Post-void residual and voiding dysfunction symptoms in women with pelvic organ prolapse before and after vaginal surgery. A multicenter cohort study | Actas Urológicas Españolas (English Edition)

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based on abnormal slow urine flow rates and abnormally high PVR&#46; The diagnosis is based on the patient&#39;s symptoms and the measurement of flowmetry and PVR&#44; and urodynamic testing with pressure-flow study is required in order to determine the cause&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Incomplete bladder emptying implies the presence of PVR volume as an initial sign and is defined as the volume of urine &#40;ml&#41; left in the bladder at the completion of micturition&#46; Although catheterization has been considered the gold standard for PVR measurement&#44; ultrasound has also been validated&#44; using the PVR volume per catheterization as a reference&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Although there is no universally accepted definition of a PVR volume that would indicate the presence of incomplete bladder emptying&#44; the significant limit established in clinical practice is a PVR of 100<span class="elsevierStyleHsp" style=""></span>ml&#46; We must keep in mind that although PVR can be considered a marker for VD&#44; it does not determine its cause&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">POP may be among the causes of VD in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Currently&#44; the diagnosis consists of a thorough study of the medical history followed by a detailed physical examination&#46; In addition&#44; other specific tests are recommended&#44; such as PVR&#44; the stress test and the study of urethral mobility assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Treatment options currently available for symptomatic POP include expectant management&#44; conservative treatment&#44; and surgical repair&#44; either through the vagina or abdomen&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the association between advanced POP and VD is accepted&#44; there is very little information regarding the impact&#44; in women intervened for POP&#44; on the symptoms suggestive of VD and PVR&#44; which makes it difficult to make a prognosis of the evolution of VD associated with POP&#46; In the context of the CIRPOP-IUE study&#44; developed by the Research Group on Pelvic Floor Dysfunctions in Women &#40;GISPEM&#44; for its initials in Spanish&#41;&#44; the impact of POP vaginal surgery on VD symptoms and PROM was analyzed&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The CIRPOP-IUE is an epidemiological&#44; longitudinal&#44; prospective cohort study&#44; in which 39 gynecology departments specialized in pelvic floor pathology from all over Spain&#44; belonging to the GISPEM&#44; participated&#46; The study protocol was approved by the ethics committee &#40;CEIC&#41; of the Hospital Cl&#237;nic i Provincial in Barcelona&#46; The approval record number is 2011&#47;7037&#46; The main objective of the study was to evaluate the frequency&#44; type&#44; and severity of LUTS in female POP patients who would undergo surgery and to determine the impact of surgical repair&#46; Additionally&#44; a subanalysis was performed to evaluate the impact of POP surgery on other urinary symptoms&#44; including VD and PVR&#46; Despite being a multicenter study including a high number of participating pelvic floor departments&#44; the recruitment period had to be prologued in order to include the number of previously planned patients&#46; A total of 345 patients were included before the extension of the recruitment period&#44; and some of the analyses and results reported to respond to different aspects of the study objectives are based on this study population&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0030" class="elsevierStylePara elsevierViewall">We consecutively included women with grade &#8805;2 symptomatic POP according to the POP-Q &#40;Pelvic Organ Prolapse Quantification&#41; classification who were to undergo surgery for vaginal prolapse and did not meet any of the exclusion criteria &#40;Annex 1&#41;&#44; who had previously given their informed consent&#46; The POP-Q system allows the classification of POP into 5 stages&#44; from 0 &#40;no POP demonstrated&#41; to 4 &#40;the most distal prolapse protrudes to at least the total vaginal length TVL-2<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; Surgery would be indicated in symptomatic patients with stage &#8805;2 POP&#46; The study consisted of a preoperative baseline visit and a follow-up visit 12 months after surgery&#46; The final sample size had 360 patients at baseline visit and 319 at follow-up visit&#44; of which 277 and 281&#44; respectively&#44; had the PVR result measured by bladder catheterization available&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was carried out following the ethical principles of the Declaration of Helsinki and the rules of the International Council for Harmonization&#46; The type of surgical procedure through vaginal route to be applied was determined by the physician&#44; based on his clinical criteria according to the routine practice in each center&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Variables collected in the study</span><p id="par0040" class="elsevierStylePara elsevierViewall">Age&#44; comorbidities and type of surgery&#44; among other variables&#44; were collected at the baseline visit&#46; Both visits included a complete pelvic examination comprised of determination of the type and stage of POP&#44; functional assessment of the pelvic floor muscles&#44; standardized stress test and measurement of PVR by ultrasound and bladder catheterization&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> The PVR measured by catheter was used for the analysis&#46; At both visits&#44; the patients completed the EPIQ &#40;Epidemiology of Prolapse and Incontinence Questionnaire&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the PFDI-20 &#40;Pelvic Floor Dysfunction Inventory&#41;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> questionnaires&#44; both validated in their Spanish version&#46; Detailed information on the administration of the questionnaires is provided in Annex 2&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">The results of the different symptoms referred through the EPIQ and the PFDI-20 were described on the sample of 360 patients&#46; The presence of symptoms suggestive of VD between both visits was descriptively compared according to the affirmative answers reported in the questionnaires&#44; and the existence of differences before and after the surgery was evaluated&#46; The correlation between symptoms of VD and incomplete emptying was studied in 345 patients&#44; evaluated by EPIQ and PFDI-20&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were stratified into 3 groups according to PVR&#58; &#8805;0 to &#60;50<span class="elsevierStyleHsp" style=""></span>ml&#59; &#8805;50 to &#8804;100<span class="elsevierStyleHsp" style=""></span>ml&#59; or &#62;100<span class="elsevierStyleHsp" style=""></span>ml&#46; Statistical analysis was performed to the variation of the PVR volume before and after surgery&#44; as well as the percentage of patients with mean values between 50 and 100 at baseline and follow-up visits&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The results were expressed as frequencies and percentages for the categorical variables and as mean and standard deviation &#40;SD&#41; for the continuous variables&#46; The Kolmogorov&#8211;Smirnov test was used to evaluate the normality of the variables&#46; The variables were analyzed with parametric or non-parametric tests depending on their distribution&#46; The categorical results were compared using the McNemar&#39;s test and the Fisher&#39;s exact test&#44; and the continuous variables were analyzed with the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#46; The results of the questionnaires were compared using the ANOVA test or the Skillings&#8211;Mack test&#46; The degree of correlation was analyzed using the Spearman&#39;s correlation coefficient &#40;rho&#41;&#46; A grade of 0&#46;05 was considered significant&#46; The statistical analyses were carried out with the programs SPSS &#40;Statistical Package for the Social Sciences&#44; version 14&#46;0&#41; and Stata software &#40;version 10&#46;0&#41;&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> present the main sociodemographic and clinical variables of the patients&#46; At the baseline visit&#44; 182 &#40;50&#46;6&#37;&#41; of the 360 patients answered yes to item 28 of the EPIQ&#44; a similar result to that obtained with the PFDI-20 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The correlation between responses to questions about difficulty urinating between the two questionnaires was moderate&#44; although significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; when assessing both&#44; VD symptoms &#40;Spearman&#39;s rho&#58; <span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;36&#41; and incomplete emptying &#40;EPIQ&#41; and VD &#40;PFDI-20&#41; &#40;Spearman&#39;s rho&#58; <span class="elsevierStyleItalic">&#961;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;57&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Data were obtained on the PVR measured by catheterization before the intervention in 277 women&#44; with a mean baseline value &#40;SD&#41; of 66&#46;4 &#40;68&#46;9&#41;<span class="elsevierStyleHsp" style=""></span>ml&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> presents the relationship between the PVR of the 3 patient groups and the VD symptom according to the EPIQ&#44; which was statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">All patients underwent surgical treatment for POP via the vaginal route &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; In relation to the subjective cure of POP one year after the intervention&#44; only 40 women affirmed to have a bulge sensation&#44; which shows a significant reduction with respect to the baseline visit &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; A similar result was obtained from PFDI-20&#44; with 290 women responding positively at the start of the study and only 39 in follow-up &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#44; giving a subjective cure rate of 86&#46;6&#37; &#40;251&#47;290&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The results of the PFDI-20 questionnaire &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and item 28 of the EPIQ &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; after performing POP surgery in isolation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>197&#41; compared to combined POP and stress urinary incontinence &#40;SUI&#41; surgery &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>118&#41;&#44; showed that surgical treatment for POP derived in a remarkable improvement in these patients&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the results of the PVR volume obtained by catheterization based on the presence or absence of VD symptoms according to EPIQ&#46; Of the 116 women with PVR &#8805;50<span class="elsevierStyleHsp" style=""></span>ml at the first visit&#44; 70 &#40;60&#46;34&#37;&#41; referred VD through EPIQ item 28 at baseline and only 18 &#40;16&#46;7&#37;&#41; at the follow-up visit &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#59; and of 42 women with PVR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml at baseline&#44; 29 &#40;69&#46;04&#37;&#41; referred VD before surgery and only 11 &#40;24&#46;4&#37;&#41; after surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">One year after undergoing surgical treatment for POP&#44; a statistically significant reduction in PVR volume measured by catheterization was observed&#46; In the cohort of patients&#44; the mean PVR volume went from 66&#46;42 at the baseline visit &#40;pre-surgery&#41; to 48&#46;33 at the follow-up visit &#40;post-surgery&#41;&#46; In the group of patients with PVR<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>ml&#44; the PVR values were 122&#46;89 and 63&#46;15 and in the patients with PVR<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml&#44; 189&#46;27 and 85&#46;17 at the baseline and follow-up visits&#44; respectively&#44; evidencing a statistically significant difference &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The present work presents the results of a subanalysis of the CIRPOP-IUE study which evaluates the presence of VD symptoms in women with grade &#8805;2 POP in the surgical waiting list through validated questionnaires&#46; Based on our results&#44; we can affirm that half of the women with POP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 gave an affirmative answer to the question <span class="elsevierStyleItalic">Do you experience difficulty emptying your bladder&#63;</span> and also have other symptoms suggestive of VD&#44; such as a feeling of incomplete emptying or the need to manually reduce POP in order to urinate&#46; In our study&#44; this symptom&#44; which is more indicative of an obstructive type of VD associated with POP&#44; was present in 25&#37; of the patients&#44; coinciding with the study by Burrows et al&#46;&#44; who report that 21&#37; of patients with POP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 require this maneuver in order to start urinating&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> According to the limited published data&#44; the overall prevalence of VD symptoms in women with symptomatic POP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 is comparable to that of women with lower-grade POP&#46; In this regard&#44; Bradley and Nygaard<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> find that 43&#37; of the women in the Women&#39;s Health Initiative &#40;WHY&#41; study&#44; who present a grade 1&#8211;2 POP&#44; report symptoms of VD&#46; Several authors have shown that there does not seem to be a correlation between POP grade and the prevalence of VD symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In our cohort of women with POP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 and treated with vaginal surgery&#44; we observed that VD symptoms are significantly reduced after surgical repair of POP&#46; One year after the intervention&#44; approximately only one in ten women reported symptoms of difficult urination and a feeling of incomplete emptying&#44; and only 1&#37; reported having to insert the lump into the vagina in order to urinate&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our study&#44; 15&#37; of the women with POP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 had a PVR volume &#62;100<span class="elsevierStyleHsp" style=""></span>ml before surgery&#59; this rate is similar to the 11&#37; reported by Lukacz et al&#46; in their study&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> but in their case&#44; only 50&#37; of the population analyzed presented symptoms of POP&#44; which would explain the lower prevalence&#46; Wong et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> in a study with similar characteristics to the latter &#40;with and without POP&#41;&#44; found a prevalence of 11&#46;4&#37; of women with PVR volume &#62;100<span class="elsevierStyleHsp" style=""></span>ml&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Twelve months after the intervention&#44; the PVR volume measured by bladder catheterization was re-evaluated and the mean PVR had significantly decreased&#46; When analyzing the changes in the mean PVR volume in the group of patients with PVR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml before the intervention&#44; it was observed that the mean residual urine volume was also significantly reduced&#44; with a mean value lower than 50&#37; of the preoperative volume&#46; In a study by Fitzgerald et al&#46; on a group of women with the same characteristics&#44; 89&#37; of them presented a PVR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml at 3 months after the intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Vaginal surgery in women with grade<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2 symptomatic POP reduces both VD symptoms and mean PVR volume&#46; These changes have been observed in women submitted to POP surgery&#44; as well as in patients with combined surgery for POP and SUI&#46; Our data on the decreased PRM after POP surgery &#40;with or without SUI correction&#41; are consistent with those of similar studies in which the PRM of all women who had a PVR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>100 before surgery was reduced to less than 100<span class="elsevierStyleHsp" style=""></span>ml after surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> However&#44; an observational study by Liang et al&#46; concludes that undergoing a concomitant anti-incontinence procedure is the only predictor of elevated post-operative PVR&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The present work has some limitations derived from its design&#44; beginning with the sample size&#44; which has not been calculated exclusively for the assessment of VD&#44; since this was not the main objective of the study&#46; In addition&#44; as it is a prospective study&#44; loss to follow-up&#44; although scarce&#44; can limit the results&#46; On the other hand&#44; results have not been analyzed by age groups&#44; which is an aspect that could affect surgery and that would constitute an interesting subject of further studies&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Among the study strengths&#44; objective data have been used for the evaluation of VD&#44; such as the mean volume of the PVR&#44; and validated questionnaires with good correlation between them have been used for the subjective evaluation&#46; However&#44; when interpreting the results&#44; it should be borne in mind that the questionnaires detect symptoms which are not an objective reality of the patient&#46; We must highlight that the present study also points out a relationship between the measurement of the mean PVR volume and the symptoms of VD reported in the EPIQ questionnaire&#44; a validated tool that can be useful to the health professional in the follow-up and evolution of the patient in usual clinical practice in our country&#46; On the other hand&#44; and in view of the scarce information available on the evolution of VD symptoms before and after POP surgery by the vaginal route&#44; this work provides relevant information on the evolution of these symptoms in women who have undergone POP surgery under routine clinical practice in our country&#46; We must add that the isolated PVR does not allow determining if the cause of VD is due to obstruction or to hypocontractile or acontractile detrusor&#46; VD does not have to be exclusively due to POP&#44; but the prevalence of bladder hypocontractility increases with age&#44; just as in POP&#46; The performance of urodynamic testing in patients with high PVR volume&#44; prior to surgery&#44; can provide relevant information when making decisions&#44; especially if the symptomatology leading to surgery is exclusively VD&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">In this cohort of patients who underwent vaginal POP surgery with 1-year follow-up&#44; an improvement in urinary dysfunction was observed&#44; both through reduced specific symptoms of VD and a lower mean residual urine volume&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">This work has been funded by <span class="elsevierStyleGrantSponsor" id="gs0000">Astellas Pharma S&#46;A&#46;</span></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">Eva Mar&#237;a Valero Fern&#225;ndez is an employee of Astellas Pharma S&#46;A&#46;</p></span></span>"
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            0 => "Prolapso de &#243;rganos p&#233;lvicos"
            1 => "Incontinencia urinaria"
            2 => "Cirug&#237;a"
            3 => "Mujer"
            4 => "Disfunci&#243;n del vaciado vesical"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">The present study evaluates the impact of vaginal surgery for pelvic organ prolapse &#40;POP&#41; on voiding dysfunction &#40;VD&#41; symptoms and post-void residual &#40;PVR&#41; one year after the intervention&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Epidemiological&#44; longitudinal&#44; prospective study&#46; Thirty-nine gynecology units included women with symptomatic POP grade 2 or higher according to the Pelvic Organ Prolapse Quantification &#40;POP-Q&#41; system&#44; who would undergo surgery for vaginal prolapse &#40;CIRPOP-IUE study&#41;&#46; Sociodemographic and clinical variables were collected before and after the intervention&#46; At both visits&#44; patients completed the &#8216;Epidemiology of Prolapse and Incontinence Questionnaire&#8217; &#40;EPIQ&#41; and &#8216;Pelvic Floor Distress Inventory&#8217; &#40;PFDI-20&#41; questionnaire&#46; PVR volume was measured by bladder catheterization immediately after spontaneous urination&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">VD symptoms were present in 50&#37; cases before the intervention&#46; PVR was measured in 277 women of which 116 &#40;41&#46;87&#37;&#41; were &#62;50<span class="elsevierStyleHsp" style=""></span>ml and 42&#47;277 &#40;15&#46;2&#37;&#41; were &#62;100<span class="elsevierStyleHsp" style=""></span>ml&#46; Objective and subjective reduction in VD symptoms was observed one year after the intervention&#46; Mean PVR volume was reduced with statistical significance&#44; from a mean &#40;SD&#41; of 66&#46;4 &#40;68&#46;9&#41;<span class="elsevierStyleHsp" style=""></span>ml to 48&#46;3 &#40;51&#46;3&#41;<span class="elsevierStyleHsp" style=""></span>ml&#46; The number of patients who reported difficulty in emptying and sensation of incomplete emptying on the EPIQ and PFDI-20 questionnaires also decreased&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">In general&#44; improved voiding functions were observed in the CIRPOP-IUE study through a decrease in specific VD symptoms and a reduction in mean PVR volume&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">El presente trabajo eval&#250;a el impacto de la cirug&#237;a vaginal del prolapso de &#243;rganos p&#233;lvicos &#40;POP&#41; en los s&#237;ntomas de disfunci&#243;n de vaciado &#40;DV&#41; y en el residuo posmiccional &#40;RPM&#41; un a&#241;o despu&#233;s de la intervenci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Estudio epidemiol&#243;gico&#44; longitudinal y prospectivo&#46; Un total de 39 unidades de ginecolog&#237;a incluyeron mujeres con POP sintom&#225;tico de grado 2 o superior seg&#250;n la clasificaci&#243;n <span class="elsevierStyleItalic">Pelvic Organ Prolapse Quantification</span> &#40;POP-Q&#41; que iban a ser sometidas a cirug&#237;a del prolapso por v&#237;a vaginal &#40;estudio CIRPOP-IUE&#41;&#46; Se recogieron variables sociodemogr&#225;ficas y cl&#237;nicas antes y despu&#233;s de la intervenci&#243;n&#46; En ambas visitas&#44; las pacientes cumplimentaron los cuestionarios <span class="elsevierStyleItalic">Epidemiology of Prolapse and Incontinence Questionnaire</span> &#40;EPIQ&#41; y <span class="elsevierStyleItalic">Pelvic Floor Distress Inventory</span> &#40;PFDI-20&#41;&#46; El RPM se midi&#243; por sondaje vesical inmediatamente despu&#233;s de una micci&#243;n espont&#225;nea&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">El 50&#37; de las mujeres refirieron s&#237;ntomas de DV antes de la intervenci&#243;n&#46; El RPM se midi&#243; en 277 mujeres de las cuales en 116 &#40;41&#44;87&#37;&#41; fue &#62;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>ml y en 42&#47;277 &#40;15&#44;2&#37;&#41; fue &#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml&#46; Un a&#241;o tras la intervenci&#243;n&#44; se observ&#243; una reducci&#243;n objetiva y subjetiva de los s&#237;ntomas de DV&#46; El RPM medio se redujo de forma estad&#237;sticamente significativa&#44; pasando de una media &#40;DE&#41; de 66&#44;4 &#40;68&#44;9&#41;<span class="elsevierStyleHsp" style=""></span>ml a 48&#44;3 &#40;51&#44;3&#41;<span class="elsevierStyleHsp" style=""></span>ml&#46; Tambi&#233;n disminuy&#243; el n&#250;mero de pacientes que reportaron dificultad de vaciado y sensaci&#243;n de vaciado incompleto en los cuestionarios EPIQ y PFDI-20&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">En general&#44; se observ&#243; una mejora de la funci&#243;n miccional tanto a trav&#233;s de la disminuci&#243;n de los s&#237;ntomas espec&#237;ficos de DV como de la reducci&#243;n del volumen medio del RPM&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objetivos"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Espu&#241;a Pons M&#44; Cassad&#243; J&#44; D&#237;ez Itza I&#44; Valero Fern&#225;ndez EM&#46; Residuo posmiccional y s&#237;ntomas de disfunci&#243;n de vaciado en mujeres con prolapso de &#243;rganos p&#233;lvicos antes y despu&#233;s de la cirug&#237;a vaginal&#46; Estudio de cohortes multic&#233;ntrico&#46; Actas Urol Esp&#46; 2021&#59;45&#58;57&#8211;63&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
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          0 => array:3 [
            "apendice" => "<p id="par0145" class="elsevierStylePara elsevierViewall">Below are the criteria for excluding patients from the study&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Patients with a previous history of POP surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Patients with a previous history of SUI surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Patients requiring abdominal POP surgery or the placement of a vaginal mesh in a posterior compartment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Patients who had exclusive indication of posterior colpoplasty for the treatment of POP&#46;</p></li></ul></p>"
            "titulo" => "Annex 1 Exclusion criteria"
            "identificador" => "sec0055"
          ]
          1 => array:3 [
            "apendice" => "<p id="par0170" class="elsevierStylePara elsevierViewall">Patients completed two questionnaires for the subjective evaluation of VD at baseline and follow-up visits&#58; the EPIQ questionnaire &#40;Epidemiology of Prolapse and Incontinence Questionnaire&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> for screening pelvic floor pathology&#44; which consists of 53 items distributed in 7 dimensions&#44; including a VD dimension of 2 items&#44; and the PFDI-20 &#40;Pelvic Floor Distress Inventory&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> which evaluates the impact of pelvic floor pathology on the patient&#39;s quality of life and consists of 20 items grouped into 3 dimensions &#40;urinary incontinence&#44; POP and anorectal dysfunction&#41;&#46; While the complete EPIQ questionnaire was filled in at the baseline visit&#44; only the 22 items related to the impact of pelvic floor dysfunction on patients&#8217; lives were answered at the follow-up visit&#46; The absence of symptom of the EPIQ question &#35;35 &#8220;<span class="elsevierStyleItalic">sensation of bulge in the vagina or something falling out of it&#8221;</span> and the response to item &#8220;d&#8221; of the PFDI-20 &#40;<span class="elsevierStyleItalic">Do you have a bulge or something falling out that you can see or feel in the vaginal area&#63;&#41;</span> were taken into account to analyze the subjective cure of POP&#46; The questions regarding voiding function that were considered for this analysis were EPIQ 28&#58; <span class="elsevierStyleItalic">Do you experience difficulty for emptying your bladder&#63;</span> and the 3 questions on the PFDI-20&#58; h- <span class="elsevierStyleItalic">Do you experience difficulty emptying your bladder&#63;&#59; i- Do you experience a feeling of incomplete bladder emptying&#63;&#59; j- Do you have to push up in the vaginal area with your fingers to start or complete urination&#63;</span></p>"
            "titulo" => "Annex 2 Administration of the EPIQ and PFDI-20 questionnaires"
            "identificador" => "sec0060"
          ]
        ]
      ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of voiding dysfunction symptoms according to the PFDI-20 questionnaire before and after surgery&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">PFDI&#58; Pelvic Floor Distress Inventory Questionnaire&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Presence of voiding dysfunction symptoms&#44; before and after surgery&#44; according to item 28 of the EPIQ questionnaire&#44; depending on the type of surgery&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparison between POP surgery in isolation and combined POP and SUI surgery in the presence of voiding dysfunction symptoms&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">EPIQ&#58; Epidemiology of Prolapse and Incontinence Questionnaire&#59; SUI&#58; stress urinary incontinence&#59; POP&#58; pelvic organ prolapse&#46;</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">POP surgery &#40;pre-post&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0033&#59; POP<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>SUI surgery &#40;pre-post&#41; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0844&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Post-void residual &#40;PVR&#41; obtained by bladder catheterization before and after surgery&#46; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; VD&#58; voiding dysfunction&#59; EPIQ&#58; Epidemiology of Prolapse and Incontinence Questionnaire&#59; SUI&#58; stress urinary incontinence&#59; UUI&#58; urge urinary incontinence&#59; PFDI&#58; Pelvic Floor Distress Inventory&#59; POP&#58; pelvic organ prolapse&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Values at baseline visit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; years&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;8 &#40;9&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pregnancy at any time&#44; &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vaginal delivery&#44; &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of births&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;7 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cesarean section&#44; &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Menopause&#44; &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidity&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urinary tract infections or cystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89 &#40;34&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;17&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81 &#40;31&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pulmonary diseases&#47;asthma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neurological diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">VD symptom &#40;EPIQ&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">182 &#40;50&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">VD symptoms &#40;PFDI-20&#41;&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Difficulty emptying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">177 &#40;49&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Feeling of incomplete emptying&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">190 &#40;52&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Need to push the lump to start urination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">89 &#40;24&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">UUI symptom &#40;EPIQ&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">138 &#40;38&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Symptom of SUI &#40;EPIQ&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">146 &#40;40&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Description of the sociodemographic and clinical characteristics of the patients at the baseline visit&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The percentages have been calculated on the total number of patients in each grade&#46; Grade 1&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>173&#46; Grade 2&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>238&#46; Grade 3&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>340&#46; Grade 4&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>123&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">POP&#58; pelvic organ prolapse&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Compartment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Baseline visit</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;9&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71 &#40;29&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">183 &#40;53&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63 &#40;51&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">334&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Middle&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;20&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110 &#40;46&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">128 &#40;37&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47 &#40;38&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">321&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posterior&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">120 &#40;69&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;23&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">219&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">173&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">238&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">340&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">123&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Classification of POP according to type and grade&#46;</p>"
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      5 => array:8 [
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        "etiqueta" => "Table 3"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">EPIQ&#58; Epidemiology of Prolapse and Incontinence Questionnaire&#59; PVR&#58; post-void residual&#46; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Volume obtained by catheterization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EPIQ voiding dysfunction</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Yes <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;0 to &#60;50<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94 &#40;67&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67 &#40;48&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">161 &#40;58&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;50 to &#8804;100<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">33 &#40;23&#46;6&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">41 &#40;29&#46;9&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">74 &#40;26&#46;7&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;100<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">13 &#40;9&#46;3&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">29 &#40;21&#46;2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">42 &#40;15&#46;2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">140 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">137 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">277 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t">188&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">115&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Pelvic floor symptoms and severity of pelvic organ prolapse in women seeking care for pelvic floor problems"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Espu&#241;a-Pons"
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                            2 => "M&#46;A&#46; Pascual"
                            3 => "P&#46; Rebollo"
                            4 => "A&#46;M&#46; Mora"
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                      "doi" => "10.1016/j.ejogrb.2014.03.050"
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                        "tituloSerie" => "Eur J Obstet Gynecol Reprod Biol"
                        "fecha" => "2014"
                        "volumen" => "177"
                        "paginaInicial" => "141"
                        "paginaFinal" => "145"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24784712"
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                  "contribucion" => array:1 [
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                      "titulo" => "An International Urogynecological Association &#40;IUGA&#41;&#47;International Continence Society &#40;ICS&#41; Joint report on the terminology for female pelvic organ prolapse &#40;POP&#41;"
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                            5 => "A&#46; Digesu"
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                    0 => array:2 [
                      "doi" => "10.1002/nau.22922"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurourol Urodyn"
                        "fecha" => "2016"
                        "volumen" => "35"
                        "paginaInicial" => "137"
                        "paginaFinal" => "168"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26749391"
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                      "titulo" => "An International Urogynecological Association &#40;IUGA&#41;&#47;International Continence Society &#40;ICS&#41; joint report on the terminology for female pelvic floor dysfunction"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Free uroflowmetry for voiding dysfunction measurement in women with pelvic organ prolapse and urinary incontinence in primary care"
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                          "etal" => false
                          "autores" => array:6 [
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                      "doi" => "10.1111/iju.12789"
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                      "titulo" => "The effect of genital prolapse on voiding"
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                          "etal" => false
                          "autores" => array:3 [
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                            2 => "S&#46;A&#46; Wein"
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                      "Libro" => array:7 [
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                        "titulo" => "Incontinence"
                        "fecha" => "2016"
                        "paginaInicial" => "2549"
                        "paginaFinal" => "2605"
                        "editorial" => "International Consultation on Incontinence"
                        "editorialLocalizacion" => "Tokio"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "How can we measure bladder volumes in women with advanced pelvic organ prolapse&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Cassad&#243;"
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