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array:23 [ "pii" => "S2173578621000536" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2021.04.007" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1357" "copyright" => "AEU" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2021;45:406-11" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S2173578621000561" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2021.04.010" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1362" "copyright" => "AEU" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Urol Esp. 2021;45:412-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Mixed epithelial and stromal tumor of the kidney" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "412" "paginaFinal" => "415" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor mixto epitelial-estromal renal" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1499 "Ancho" => 1500 "Tamanyo" => 537131 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) Voluminous cystic lesion (asterisk) dependent on the interpolar region of the left kidney (LK); (b) left partial nephrectomy and excision of the large cystic mass showing renorrhaphy with interrupted 2-0 Vicryl™ suture and Hem-o-Lock®, and application of a TachoSil® patch (white arrow); (c) tumor lesion with solid–cystic areas; (d) hematoxylin and eosin stain, 20×. A neoplastic lesion made up of epithelial and stromal components can be seen.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.E. Martínez-Corral, J.J. Núñez-Otero, V. Toucedo-Caamaño, S.M. García-Acuña, R. García-Figueiras, C. García-Freire" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M.E." "apellidos" => "Martínez-Corral" ] 1 => array:2 [ "nombre" => "J.J." "apellidos" => "Núñez-Otero" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Toucedo-Caamaño" ] 3 => array:2 [ "nombre" => "S.M." "apellidos" => "García-Acuña" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "García-Figueiras" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "García-Freire" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578621000561?idApp=UINPBA00004N" "url" => "/21735786/0000004500000005/v1_202106020937/S2173578621000561/v1_202106020937/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173578621000512" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2021.04.005" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1355" "copyright" => "AEU" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2021;45:398-405" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "398" "paginaFinal" => "405" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1205 "Ancho" => 905 "Tamanyo" => 149715 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Wound closure after placement of non-suction drainage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.U. Juan Escudero, F. Villaba Ferrer, M. Ramos de Campos, M. Fabuel Deltoro, M.J. Garcia Coret, F. Sanchez Ballester, I. Povo Martín, Y. Pallas Costa, P. Pardo Duarte, J. García Ibañez, A. Monzó Cataluña, K. Rechi Sierra, C. Juliá Romero, E. Lopez Alcina" "autores" => array:14 [ 0 => array:2 [ "nombre" => "J.U." "apellidos" => "Juan Escudero" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Villaba Ferrer" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Ramos de Campos" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Fabuel Deltoro" ] 4 => array:2 [ "nombre" => "M.J." "apellidos" => "Garcia Coret" ] 5 => array:2 [ "nombre" => "F." "apellidos" => "Sanchez Ballester" ] 6 => array:2 [ "nombre" => "I." "apellidos" => "Povo Martín" ] 7 => array:2 [ "nombre" => "Y." "apellidos" => "Pallas Costa" ] 8 => array:2 [ "nombre" => "P." "apellidos" => "Pardo Duarte" ] 9 => array:2 [ "nombre" => "J." "apellidos" => "García Ibañez" ] 10 => array:2 [ "nombre" => "A." "apellidos" => "Monzó Cataluña" ] 11 => array:2 [ "nombre" => "K." "apellidos" => "Rechi Sierra" ] 12 => array:2 [ "nombre" => "C." "apellidos" => "Juliá Romero" ] 13 => array:2 [ "nombre" => "E." "apellidos" => "Lopez Alcina" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578621000512?idApp=UINPBA00004N" "url" => "/21735786/0000004500000005/v1_202106020937/S2173578621000512/v1_202106020937/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Surgery Workshop</span>" "titulo" => "The use of ileocecal pouch with appendix as an urethral substitute in patients who are willing to have a orthotopic bladder replacement - point of technique" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "406" "paginaFinal" => "411" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Weibl, G. Ameli, C.H. Plank, W. Huebner" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Weibl" "email" => array:1 [ 0 => "pweibl@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Ameli" ] 2 => array:2 [ "nombre" => "C.H." "apellidos" => "Plank" ] 3 => array:2 [ "nombre" => "W." "apellidos" => "Huebner" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Urology, Landesklinikum Korneuburg-Teaching Hospital, Korneuburg, Austria" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bolsa ileocecal con utilización del apéndice como neouretra en pacientes dispuestos a sustitución vesical ortotópica: descripción de la técnica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4177 "Ancho" => 2083 "Tamanyo" => 1169967 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">49 yr. Old male patient with histol. Proven urothelial cancer of the bladder pT2high grade, and biopsy proven multifocal high grade UTUC.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">A)</span> Histophatological specimen en-block removal of the right kidney, ureter, bladder, prostate and membranous part of the urethra (because of the prostatic urethra involvement in conjunction with high grade urothelial cancer). <span class="elsevierStyleItalic">B)</span> Aproxx15 cm. Of the colon and 20 cm. Of the terminal ileum is used for neobladder reconstructions <span class="elsevierStyleItalic">C)</span> Configuration of the orthotopic ileo-coecal pouch with appendix as a substitute for the missing membranous urethra (white arrow-appendix). <span class="elsevierStyleItalic">D)</span> Reconstruction of the appendico-urethral anastomosis end to end with absorbable 5.0 maxon interrupted sutures (appendix-white arrow, bulbar urethra-black arrow). <span class="elsevierStyleItalic">E)</span> Postoperative cystogram<span class="elsevierStyleItalic">. F)</span> Because of the stricture recurrence in the site of the anastomosis, Memokath stent (white arrow) was placed (which made patient to be completely incontinent), therefore in the same setting was AMS 800 implanted concomitantly. <span class="elsevierStyleItalic">G)</span> Measurement of the retrograde leak point pressure (AMS 800 was activated, RLPP > 45 mm/H<span class="elsevierStyleInf">2</span>O, cuff is closed-black arrow.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urinary diversion is an essential component after radical cystectomy and has a significant impact on the quality of life. Replacement with an orthotopic ileal neobladder should be the method of first choice, although the membranous urethra with its sphincteric mechanism should be intact and free of disease. The possible use of a variety of alternative intestinal segments had broaden the horizons of the reconstructive surgery and remains as the “last resort” for unusual and specific case scenarios. The authors describe the technique of orthotopic bladder replacement with an ileocecal pouch and unaltered appendix vermiform is used as an orthotopic urethral substitute. Additional procedures with regard to the bothersome voiding symptoms and incontinence will be described as a part of multistep decision making process.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">In a small cohort of 5 patients (2 males/3 females) with muscle invasive bladder cancer (MIBC) we performed the following reconstruction. The data were collected retrospectively from our institutional database (between 2005–2018). A formal approval of the institutional review board was obtained for the analysis and description of the surgical technique. Intraoperative frozen section analysis determined positive resection margin of the bladder neck or urethra. Therefore, excision of the membranous urethra/or total urethra was performed in male and female patients respectively. The excised tissues were analyzed further intraoperatively, negative margin was obtained in all cases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">All patients were informed about the surgical procedure and realistic expectations were discussed with all the participants. For the final evaluation we included only 3 patients with sufficient follow up information and management of postoperative complications (2 male/1 female). Perioperative and postoperative risks, as well as potential complications of the procedure were discussed before the surgery. Written informed consent was obtained from all the patients. In addition, each patient was fully informed about the surgical aspects with regard to treatment of MIBC. The mean follow up was 32 months (range 20–41).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Description of the technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">The procedure was performed via an open approach under general anesthesia in a modified Lloyd-Davis position, in order to have parallel access to the perineum. A typical midline laparotomy for adequate mobilization of ascending colon was made. Sometimes, the mobilization of the colon ascendens should be more extensive up to the hepatic flexure, extension of the primary incision above the umbilicus is necessary. We have mobilized the ascending colon above the hepatic flexure laparoscopically in 1 patient where the concomitant nephroureterectomy was performed because of the UTUC (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">For the neobladder reconstructive purposes we have harvested 15 cm of cecum/accompanied by colon ascendens and 15 cm of terminal ileum. In general, the dimensions should be tailored specifically to the patient’s anatomy and body habitus.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A low pressure reservoir was achieved by antimesenteric longitudinal detubularization of terminal ileum, accompanied cecum and colon ascendens. Once the appendix was identified, the anatomy was carefully evaluated, caliber and length for a sufficient anastomosis with the bulbar part of the urethra/or complete neourethra (in female patients). The distal tip of the appendix was excised and intubated with silicon Foley CH16 catheter in order to evaluate ideal lumen. Consequently, the detubularized loops were reconstructed and sutured with running Biosyn monofilament absorbable 3.0 sutures. A simple non- antirefluxive ureteral implantation was performed thereafter with running 4.0 Maxon absorbable sutures, the right ureter was anastomosed with colon end-to-side and left ureter with ileum end-to-end respectively. Both ureters were intubated with ureteral catheter Ch 8 previously, which was fixed with vicryl rapid 5.0 suture with the neo-bladder wall extravesically.</p><p id="par0035" class="elsevierStylePara elsevierViewall">To develop the neourethra, the appendix together with its accompanying mesentery was drawn through the pelvic floor and sutured to the bulbar urethra in males or formed a complete neourethra in female patients respectively. The distal tip of appendix was spatulated and anastomosed with the proximal part of the spatulated bulbar urethra while using 4.0 vicryl rapid resorbable sutures (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In female patient’s pedicled appendix was sutured orthotopically with excised tissue margins close to labia minora.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Both ureters were intubated with ureteral Mono J catheter Ch 8, both were extracted on 9th and 10th postoperative day, followed by renal ultrasound and intravenous pyelography evaluation. Bladder Catheter was left in situ for 2 weeks and the urethrocystogram was performed. Suprapubic catheter was left in situ for 7–10 days as a rescue measure in case of urinary retention after patient’s discharge</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">There were no serious intraoperative nor early postoperative unwanted sequelae requiring invasive intervention. Generally, we perform retrograde cystogram on a 14th postoperative day, the mono J ureteral catheter is extracted on 9th and 10th postoperative day, followed by intravenous urethrography. Each patient is trained to perform a CIC.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Permanent catheter was left for 3 weeks in one male patient due to a leakage in the region of appendicourethral anastomosis. And a closed suprapubic catheter was left in situ for another 2 weeks as a safety measure. Both male patients experienced recurrent anastomotic urethral stricture 3–6 months postoperatively, consequently a Memokath stent and artificial urinary sphincter (Memokath stent Doctors & Engineers, Kvistjaard, Denmark; AMS 800 Urinary Control System™, American Medical Systems, Minnetonka, MN) was implanted resulting in normal voluntary micturition. A female patients remained socially continent during the follow up period, however performing clean intermittent catheterization (CIC) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Last but not least, in one male patient was AMS 800 implanted due to bothersome incontinence 12 months after the primary surgery. None of the patients experienced metabolic complications, probably because all of our patients were relatively young and otherwise in a good health and absence of any prior underlying metabolic or endocrine disorders.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Comments</span><p id="par0055" class="elsevierStylePara elsevierViewall">The possible use of a variety of intestinal segments has broaden the horizons of reconstructive surgery in the field of MIB. In experienced hands this knowledge helps the surgeons to deal with unusual case scenarios and patient’s wishes without compromising the final oncological outcome, however, enables to establish the „basic function per vias naturales“.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Each surgeon should be flexible, because the primary decision can be changed and evolve intraoperatively according to the body habitus, prior surgeries, postradiational changes, as well as basic anatomy of the appendix. The appendix should have adequate length with acceptable lumen, which should be at least passageable at least for the permanent catheter CH14. Therefore prior to each procedure, the surgeon should be familiar with various approaches using a wide range of techniques and bowel segments.</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is of utmost importance, to evaluate the patient’s physical function dexterity, appropriate manual functioning. Each candidate should have a satisfactory cognitive functioning, psychosocial situation and needs to be compliant and highly motivated. Surgeon has to bear in mind present neurological disorders and require specific evaluations for cases with present neurological disorders in order to define, if the condition is stable or progressive.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The use of appendix as a urethral substitute has been initially described in 1924. McGuire have initially described in detail the use of appendix as a free graft without vascular pedicle in a boy with hypospadias. The external layers were incised and removed from the underlying submucosal tissue and mucosa lining.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1980 the well-known Mitrofanoff principle was introduced as a catheterizable so called „channel stoma“.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Grunberger in 1986 reported the very first case of orthotopic bladder and urethral replacement while using coeco-appendical junction unit.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These results were reproduced and further studied in animal models and female patients as well.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> The long term results in pediatric patient population with bladder extrophy have proven, that the coeco-appendical junction may be considered and used for the continent lower urinary tract reconstruction.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Hence the fact, that the data on orthotopic neourethra reconstruction with appendix are very limited, each reconstructive surgeon should keep in mind this principle, which may be useful especially for specific complex repair case scenarios, when the urethra is compromised and the patient is still willing to have a orthotopic bladder replacement.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The presence of positive surgical margins (PSM) following radical cystectomy is a disturbing factor and is associated with poorer survival.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A negative margin status is crucial for the final „favorable “oncological outcome. For our cases with compromised bladder neck/or membranous urethra, leaving PSM after the frozen section analysis, would lead to the local/systemic spread. The complete removal of the female urethra was an absolute indication. However extirpation of the membranous urethra in male patients with negative frozen section margins and leaving the remaining urethra may pose some dilemmas. Although, the risk of local recurrence in the urethral remnant is considered to be a rare event in general.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> That is why we have indicated such a procedure in highly motivated and complaint patients.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our report has several limitations worth noting: a) small number of patients with limited follow up; b) we did not evaluate the final outcomes according to the appropriate measurable tools and validated questionnaires; and last but not least c) retrospective nature of the data collection. Nevertheless the main objective was to introduce the surgical principle of the technique, what we think we have accomplished in the light of our report.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The use of appendix with vascularized pedicle support offers the possibility of orthotopic bladder reservoir even in usually unsuitable patients, who are requesting orthotopic bladder replacement for improved body image. It allows extension of urethral resection and provides additional continence support. However, additional measures such as urethral stenting, CIC or artificial urinary sphincter implantation may be necessary for long lasting success. Although, not being a routine method for urinary diversion this technique may be used in select younger patients, without cognitive impairment, compliant and adherent to the strict follow</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they do not have conflicts of interest,</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1519042" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1377546" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1519043" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1377545" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Description of the technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Comments" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack533635" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-03" "fechaAceptado" => "2020-06-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1377546" "palabras" => array:4 [ 0 => "Bladder cancer" 1 => "Appendix" 2 => "Orthotopic bladder" 3 => "Artificial urinary sphincter" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1377545" "palabras" => array:4 [ 0 => "Cáncer de vejiga" 1 => "Apéndice" 2 => "Vejiga ortotópica" 3 => "Esfínter urinario artificial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The authors describe the technique of orthotopic bladder replacement with an ileocecal pouch and unaltered appendix used as an orthotopic urethral substitute. Additional procedures with regard to the bothersome voiding symptoms will be described.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In a small cohort of 5 patients with muscle invasive bladder cancer with tumor involvement of the bladder neck or proximal urethra (2 males/3 females) we performed the following reconstruction. A low pressure reservoir was achieved by antimesenteric longitudinal transection of terminal ileum and cecum/colon ascendens and formation of a pouch. To develop the neourethra, the appendix together with it is accompanying mesentery was drawn through the pelvic floor and sutured to the bulbar urethra in males or formed as a complete neourethra in female patients respectively.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were no intraoperative nor early postoperative unwanted sequelae. Both male patients experienced recurrent anastomotic urethral stricture, consequently a Memokath stent and artificial urinary sphincter was implanted resulting in normal voluntary micturition. All female patients remained socially continent during the follow up period, one of them performing (clean intermittent catheterization) CIC.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The technique described offers the possibility of orthotopic bladder replacement even in traditionally unsuitable, but highly motivated patients, who are requesting orthotopic bladder replacement for improved body image. It allows extension of urethral resection and provides additional continence support. However, additional measures such as urethral stenting, CIC or artificial urinary sphincter implantation may be necessary for long lasting success. Although, not being a routine method for urinary diversion this technique may be used in select patients.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Los autores describen la técnica de sustitución vesical ortotópica mediante bolsa ileocecal y apéndice inalterado como sustituto ortotópico de la uretra. Se describirán procedimientos adicionales con respecto a las molestias por síntomas de vaciado.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En una pequeña cohorte de 5 pacientes con cáncer de vejiga musculo-invasivo con afectación tumoral del cuello vesical o de la uretra proximal (2 hombres/3 mujeres) realizamos la siguiente reconstrucción. Se obtuvo un reservorio de baja presión mediante la incisión longitudinal antimesentérica del íleon terminal y el ciego/colón ascendente y la formación de una bolsa. Para desarrollar la neouretra, el apéndice y su mesenterio se extrajeron a través del suelo pélvico y se suturó a la uretra bulbar en los hombres o se formó como una neouretra completa en las mujeres respectivamente.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">No hubo secuelas indeseables intraoperatorias ni postoperatorias tempranas. Ambos pacientes masculinos experimentaron una estenosis de la anastomosis uretral recurrente, por lo que se realizó un implante de stent Memokath y un esfínter urinario artificial, resultando en una micción voluntaria normal. Todas las pacientes femeninas permanecieron socialmente continentes durante el período de seguimiento, una de ellas realizando cateterismo intermitente limpio (CIL).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La técnica descrita ofrece la posibilidad la sustitución vesical ortotópica incluso en pacientes tradicionalmente considerados como no aptos, pero muy motivados, que lo solicitan para mejorar su imagen corporal. Permite ampliar la resección uretral y proporciona un apoyo adicional a la continencia. Sin embargo, pueden ser necesarias medidas adicionales como la colocación de un stent uretral, el CIL o el implante de un esfínter urinario artificial para obtener un éxito duradero. Aunque no es un método rutinario de derivación urinaria, esta técnica puede utilizarse en pacientes seleccionados.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Weibl P, Ameli G, Plank CH, Huebner W. Bolsa ileocecal con utilización del apéndice como neouretra en pacientes dispuestos a sustitución vesical ortotópica: descripción de la técnica. Actas Urol Esp. 2021;45:406–411.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4177 "Ancho" => 2083 "Tamanyo" => 1169967 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">49 yr. Old male patient with histol. Proven urothelial cancer of the bladder pT2high grade, and biopsy proven multifocal high grade UTUC.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">A)</span> Histophatological specimen en-block removal of the right kidney, ureter, bladder, prostate and membranous part of the urethra (because of the prostatic urethra involvement in conjunction with high grade urothelial cancer). <span class="elsevierStyleItalic">B)</span> Aproxx15 cm. Of the colon and 20 cm. Of the terminal ileum is used for neobladder reconstructions <span class="elsevierStyleItalic">C)</span> Configuration of the orthotopic ileo-coecal pouch with appendix as a substitute for the missing membranous urethra (white arrow-appendix). <span class="elsevierStyleItalic">D)</span> Reconstruction of the appendico-urethral anastomosis end to end with absorbable 5.0 maxon interrupted sutures (appendix-white arrow, bulbar urethra-black arrow). <span class="elsevierStyleItalic">E)</span> Postoperative cystogram<span class="elsevierStyleItalic">. F)</span> Because of the stricture recurrence in the site of the anastomosis, Memokath stent (white arrow) was placed (which made patient to be completely incontinent), therefore in the same setting was AMS 800 implanted concomitantly. <span class="elsevierStyleItalic">G)</span> Measurement of the retrograde leak point pressure (AMS 800 was activated, RLPP > 45 mm/H<span class="elsevierStyleInf">2</span>O, cuff is closed-black arrow.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CIC: Clean intermittent catheterism; CIS carcinoma in situ; NED: no evidence of disease; TURB: transurethral resection of the bladder.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "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">Patient/Age \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">Primary histology after (second look TUR-V) \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">Final Histology \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">Postop. intervention \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">Overall follow up in our department/Clavien Dindo classification \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">Male/66 yrs \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">Multifocal pT1aG2-G3 bladder/prostatic urethra \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">Multifocal.pap. urothel. carcinoma \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">Repeated urethrotomia interna optica 2006/2007 \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">41 months \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"> \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"> \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">pT1bG2-G3N0R0 (2006) \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">Laser bladder incision 2007 \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">NED/Grade I \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"> \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"> \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"> \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">Memokath stent and AMS 800 Implantation 2008 \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"> \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"> \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"> \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"> \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">Safety pad \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"> \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">Male/51 yrs \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">Multifocal pTa/pT1G3 plus Cis of the prostatic urethra, Cis of the distal part of the right ureter, atypical histology of the right renal pelvis and proximal ureter with highly positive cytology \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">Solid pap.urothel. carcinoma \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">Memokath stent implantation 2017 \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">20 months (died due to the progression)/Grade I and IIIa \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"> \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"> \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">pT4a,N1(1/13),L1,M + b,R0 with angioinvasion of the perirenal hilum (soft tissue metastasis) (2017) \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">AMS 800 Implantation 2018 \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"> \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"> \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"> \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"> \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">Safety pad \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"> \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">Female/57 yrs \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">Multifocal Cis with invasion of the bladder neck \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">Multifocal pTisN0R0 (2008) \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">CIC \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">35 months \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"> \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"> \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"> \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">Safety pad \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">NED/None \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2608408.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics and the necessity of postoperative interventions <span class="elsevierStyleItalic">(NED-no evidence of the disease).</span></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of appendix vermiformis in the formation of a urethra in hypospadia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. 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