Laparoendoscopic radical cystectomy with orthotopic ileal neobladder through umbilical single port | Actas Urológicas Españolas (English Edition)

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Angulo, F. Cáceres, I. Arance, I. Romero, F. Ramón de Fata, P.M. Cabrera" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Angulo" "email" => array:1 [ 0 => "jangulo.hugf@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Cáceres" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Arance" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Romero" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Ramón de Fata" ] 5 => array:2 [ "nombre" => "P.M." "apellidos" => "Cabrera" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Hospital Universitario de Getafe, Fundación para la Investigación Biomédica, Servicio Madrileño de Salud, Universidad Europea de Madrid, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cistectomía radical laparoendoscópica con neovejiga íleal ortotópica a través de puerto único umbilical" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 850 "Ancho" => 1327 "Tamanyo" => 209086 ] ] "descripcion" => array:1 [ "en" => "Arrangement of the operating room, patient in Trendelenburg. Curved work instruments with dual rotation system and camera through the umbilical port and accessory trocar in the right iliac fossa." ] ] ] "textoCompleto" => "IntroductionBladder cancer is the most common of all genitourinary malignancies. Spain is one of the territories of Western Europe which has the highest incidence for this disease, especially in men.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Radical cystectomy remains the preferred therapeutic option to treat patients with muscle-invasive urothelial carcinoma of the bladder.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Radical surgical removal of the bladder must be included, within the standard limits, and the thorough exeresis of pelvic lymph nodes as well.Although the dilemma of which is the best form of urinary diversion is not closed, an orthotopic bladder substitute must also be offered, whenever possible.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> This requires that there is no tumor at the edge of the urethral resection.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Complete removal of all possible extravesical tumor extension and of the terminal ureteral segment must also be carried out.All studies support the simultaneous removal of pelvic lymph nodes. In fact, retrospective studies have demonstrated that extended lymphadenectomy is a therapeutic element that improves survival of the patients, and that the number of lymph nodes obtained means even a prognostic predictor.<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a> In this sense, pelvic lymphadenectomy performed through laparoscopic approach at the time of laparoscopic radical cystectomy has shown the same excisional benefit in terms of the number of nodes removed as conventional lymphadenectomy.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Preservation of the anterior and membranous urethra, which includes the rhabdosphincter, makes the performance of an orthotopic neobladder possible. The preservation of sensory and autonomic pelvic nerves will improve surgical outcomes, in terms of both continence and power. The best nerve sparing is achieved by deliberately leaving the seminal vesicles, with or without the prostatic capsule. However, this decision must be properly balanced with the patient, and the oncologic risk needs to be considered in every case.<a class="elsevierStyleCrossRefs" href="#bib0010">2,7</a>Both laparoscopic radical cystectomy and laparoscopic robot-assisted cystectomy are feasible alternatives.<a class="elsevierStyleCrossRefs" href="#bib0030">6,8,9</a> The current recommendation about their use remains in the hands of surgeons experienced in these techniques, also taking into account the patient's condition, the size of the tumor, and the type of diversion chosen. The possibility of performing laparoscopic or robotic intestinal neobladder is a difficult procedure of which few series are available.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> There really is important reluctance of academic centers to consider that laparoscopic and/or robotic surgery are the gold standard of care in this type of patients,<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> although in recent years, this field is progressing significantly.Possibly, the last of the advances is the performance of radical surgery for bladder cancer through single port systems, which can be coupled to the natural scar that is the navel (E-NOTES), the main embryonic natural orifice of our economy. The umbilical-approach scar is totally hidden from view, which in a few weeks makes a cosmetic impression of an ‘incisionless’ scar.Evidence acquisitionAn extensive review of the literature was performed using Medline and Embase from 1993 to 2011. The questions concerning the search were bladder cancer and laparoendoscopic surgery through single port (LESS), including radical cystectomy, pelvic lymphadenectomy, and orthotopic ileal neobladder. Year 1993 was chosen because it was the time when the first vaginal removal of an intact kidney after laparoscopic radical nephrectomy was described,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> this being the major milestone of the development of transluminal endoscopic surgery through natural orifices. In 1999, laparoscopic cholecystectomy was systematized without any incision outside the umbilicus.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In 2007, a laparoendoscopic approach was first used in Urology through the placement of a single port on the side to perform nephrectomy of a non-functioning atrophic kidney.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>The search focused on identifying all the procedures related to pelvic surgery, and more specifically, to the urinary bladder surgery, performed through LESS approach.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Only 7 articles specifically refer to this type of surgical approach for patients with bladder cancer, none of them in Spanish. Our group has extensive experience in the laparoscopic approach of bladder cancer. We have recently carried out radical cystoprostatectomy with lymphadenectomy through the navel using the Keyport system and extracorporeal ileal neobladder in a patient with muscle-invasive bladder cancer with excellent results. The updated global experience with this type of approach is, thus, described.Evidence synthesisExperience in the literatureThe first mention in the literature of patients treated by LESS radical cystectomy is the analysis of the first 100 cases of laparoendoscopic surgery performed at the Cleveland Clinic, which was published by White et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> in 2009. This description consists in carrying out a record of surgeries that can be performed successfully by LESS. Radical cystectomy represents 3% of the total indications and less than 9% of all pelvic surgeries. Other procedures performed were sacrocolpopexy, radical prostatectomy, varicocelectomy, and ureteral reimplantation. The authors noted that this type of surgery was feasible and that the complication rate did not appear increased. A better cosmetic result and less postoperative pain were the main findings of the global series.The same three patients were described by Kaouk et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> in 2010 as a specific series of LESS radical cystectomy and bilateral pelvic lymphadenectomy. They were 2 men and 1 woman. The system used was the Uni-X single port (Pnavel Systems, Brooklyn, NY) consisting of a three-light valve system that accommodates three 5-mm laparoscopic instruments, along with an insufflation port. Through this port, instruments like flexible monopolar scissors (CambridgeEndo, Framingham, MA), and a 5-mm flexible laparoscope (Olympus Surgical. Orangeburg, NY) were used. The authors stated that in no case was there locally advanced disease, and patients with previous abdominal surgery and/or radiotherapy, and patients who wanted orthotopic bladder substitution were also excluded. All the procedures were carried out using pure LESS, without need for additional port. Extraction of the specimen and performance of the ileal conduit were performed by extending the umbilical port incision to 5cm and the use of a wound protector. The mean blood loss was minimal and no patient required transfusion. The mean surgical time was 315±40min. A mean of 16±3 nodes was removed per patient. The visual analog scale for pain was 0–1 (out of 10) in the three patients. All were discharged within 1 week. Histopathological examination of the specimen revealed a stage pT2pN0 (2 patients; one with incidental prostate adenocarcinoma Gleason 3+4) and pT0pN0 (1 patient). All the patients were free of disease with a follow-up of 24–26 months. This preliminary experience heralded that the procedure was feasible in selected cases; however, none of the patients received an orthotopic neobladder (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The global record of urological LESS published by Kaouk et al.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> in 2011 includes the three cases that were conducted in the period 2007–2008<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> and other three cases performed in 2009–2010. No data are provided on the type of urinary diversion, or the operating parameters or complications obtained in the latter three cases. Indirect experience shows that the indication for LESS radical cystectomy has not grown among the authors in this contributor group. In fact, this surgery is only 0.5% of the published record and it has not shown a tendency to grow over time (p=0.83). From a global perspective, it has even been a detriment, since it was performed in 1.28% of the patients operated in 2007–2008 and in 0.35% of those operated in 2009–2010.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Very recently, several very interesting experiences from Chinese authors, who are generating renewed interest in the issue, have entered this stage of LESS radical cystectomy. It is the experience of the centers Zhujiang Hospital (Southern Medical University, Guangzhou),<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Memorial Hospital (Sun Yat-sen University, Guangzhou),<a class="elsevierStyleCrossRefs" href="#bib0110">22,23</a> and Peking University Third Hospital (Beijing).<a class="elsevierStyleCrossRef" href="#bib0120">24</a> These authors have published the description of a total of 18 new cases. The urinary derivation used was varied: cutaneous ureterostomy (2 cases), ileal conduit (3 cases), sigmoid neobladder (1 case), and ileal neobladder (12 cases) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In 4 of the 12 cases described by Lin et al., nerve sparing, which was successful in two patients (one spontaneously and another one with the aid of PDE-5 inhibitors), was conducted.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>The experience of the institutions in Guangzhou has opted for the preparation of orthotopic bladder reservoirs, mostly using an ileal segment that is performed extracorporeally. The Beijing experience, however, prefers incontinent derivations (ureterostomy or ileal loop). In these cases, the operative time is reduced significantly. The system used by all the Chinese authors has been a home-made system performed with a latex glove size 7 ½ and two compressible rings,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> or an inverted conical polycarbonate.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> These glove systems allow for a multichannel approach with three or four independent elements, since the fingers of the gloves are cut and fixed to the trocars (two 12mm and one 5mm, respectively) using a knotted suture. Thus, a 10-mm and 30° lens, along with conventional laparoscopic instruments, is used. Valves with plastic closure to allow passage of instruments through the glove fingers can also be performed. CO2 insufflation creates a tension which enables the device to be secure.Experience at our centerWe present the case of a 64-year-old male with high-grade muscle-invasive urothelial carcinoma. Radical cystectomy with orthotopic derivation was carried out through a single-port Keyport system placed in the navel with a 2.5-cm incision in the transverse direction (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We performed other surgeries at our center with this system quite satisfactorily.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> They all achieved an excellent esthetic result, and the postoperative pain was significantly lower than that of open surgery and even that of conventional laparoscopy. The transumbilical use of this system hides the surgical scar in the navel, giving the final appearance of a scar-free surgery. An auxiliary 10-mm port is placed in the right iliac fossa to facilitate the neovesicourethral anastomosis and for placement of a peritoneal drainage and bilateral urinary derivation (urinary derivation catheters) that are externalized through the same trocar.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The patient is placed in the Trendelenburg position. The surgeon takes the curved work instruments with dual rotating system (scissors in the right hand, and grasper in the left hand) while the assistant carries the camera with his left hand and the accessory trocar with his right hand (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Surgery begins with the opening of the parietal peritoneum. Then, the ureters are identified and dissected. The opening of the pouch of Douglas and dissection of the seminal case are performed. We show the dissection of the right side in detail (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Hem-o-lok ligation and right ureter section are performed. The superior vesical pedicle and vas deferens are also identified and ligated with Hem-o-lok. Hemostatic control of the seminal pedicle with 10-mm Ligasure is carried out. The same maneuver is repeated on the other side to, then, develop the space of Retzius to the prostatic apex, and hemostasis of the plexus of Santorini is performed. Finally, the urethra and the urethral rectus muscle are sectioned on the posterior plane.We proceed to perform obturator and pelvic to common iliac lymphadenectomy, showing ilioinguinal nerve. It again shows an image corresponding to the dissection of the right side (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). The lymphadenectomy specimen is removed.The intestinal loop is marked with a reference point 15cm from the ileocecal valve, which will help at the time of selection of the intestinal segment. We proceed to bagging the cystectomy specimen, which is extracted with cross-shaped minimal enlargement of the hole performed in the rectus muscle (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A). Then, the umbilical hole is also slightly extended, making a small perpendicular midline incision and disposable disc is placed to facilitate exposure of the ureters and bowel outside the navel (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B). The intestinal segment that will serve to perform the neobladder is identified. The intestine is cut and we proceed to the ileo-ileal anastomosis with mechanical sutures (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>C). Later, the intestine is detubularized and the reservoir is constructed with straight needle absorbable suture (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>D). The ureters are anastomosed to the afferent loop in isoperistaltic direction and closure of the neobladder, which acquires spherical shape leaving a distal hole that will anastomose to the urethral end, is completed.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The neobladder is introduced into the pelvic cavity to then re-enter the Keyport system, which now requires adaptation to the extended closure by means of a circular suture. Neovesicourethral anastomosis with barbed suture V-lock is carried out (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Once the anastomosis is completed, urethropexy with suture fixation to the pubic bone and traction by Hem-o-lok is performed. A drainage is placed through the accessory port, and through the same hole, both urinary derivation catheters are removed. Finally, the single port is removed and the umbilical wound is closed with Vicryl rapid 3/0 (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). The umbilical scar significantly reduces analgesic requirements. The visual analog pain scale on day 2 was 1/10. A few weeks later, the wound is almost invisible, thus, fulfilling the paradigm of ‘incision-less’ surgery. The histopathological examination showed no residual tumor in the specimen and 26 lymph nodes negative for tumor. The patient has daytime continence at three months of follow-up and training their neobladder to avoid the occasional night escape that they suffer. Additional material that illustrates the surgical technique step by step is attached.<elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia>DiscussionSingle-port surgery is the progressive result of small steps based on minor adjustments of previous techniques, the same as the tuning of an instrument is carried out with minor adjustments whose real value is difficult to define. The result is that from the sum of all these small adjustments, exquisite tuning is achieved, with no breaks or discontinuity solution in the evolutionary development of the technique.The initial impetus to promote minimally invasive surgery focused on avoiding the morbidity of laparotomy. Improvements regarding less pain, less bleeding, better recovery of intestinal motility, and decreased need for analgesics are the main achievements of the laparoscopic approach<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a> without sacrificing the results for oncological safety.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>The laparoendoscopic approach through the navel to perform radical cystectomy is the latest technical development in the field of minimally invasive surgery, because it reduces the placement of extraumbilical trocars and, most times, it allows for the final removal of the specimens, leaving a wound with significant cosmetic benefits. Furthermore, it is also possible to carry out the urinary derivation taking advantage of this approach, and even to practice orthotopic neobladder extracorporeally in a reasonable range of time.But the most important fact is that some parameters concerning the quality of the procedure such as tumor margins, the number of nodes obtained in the pelvic lymphadenectomy, and the possibility of conducting continent reservoirs are today an entirely feasible reality using a laparoendoscopic approach. If the only advantage of the procedure resided in cosmetic surgery, it might not be enough to apply this concept to the radical treatment of bladder cancer. However, the stay reduced to 6 days in a patient with orthotopic neobladder, who was discharged without any Clavien-Dindo complications, not even in the administration of analgesia, is frankly astonishing. A visual analog scale of postoperative pain 1/10 on day 2, the absence of ileus in the postoperative period, and the great satisfaction with the procedure by the patient are well worth an extended operative time of 480min.We think this type of approach is ideal for selected patients and that if these impressive results are consolidated, it will constitute an indisputable future advance in the treatment of muscle invasive bladder cancer. The reusable nature of the material used is also a strong argument in terms of hospital efficiency.There is no doubt that the experience in this type of patients is still very limited even worldwide and that more casuistry will have to be accumulated in order to acknowledge the benefits of this procedure. Today, the experience described seems comparable to the laparoscopic approach, which surely entails a high oncological efficacy. However, a closer follow-up is needed with regard to functional results and late complications.Different procedures are being developed at present with this type of single-port devices, although in many surgeries, placement of 3.5mm-gauge thin accessory ports (even less if the instrument is placed directly without the trocar) is necessary. There is no doubt that single-port surgery means a challenge of retooling, still under development. The first descriptions of its application in Urology were flank incision nephrectomy and transumbilical ureterolithectomy.<a class="elsevierStyleCrossRefs" href="#bib0080">16,29</a> Then, transumbilical nephrectomy and pyeloplasty were described.<a class="elsevierStyleCrossRefs" href="#bib0150">30,31</a> Gradually, most urological procedures have been developed using single port: adrenalectomy, nephroureterectomy, living donor nephrectomy, ureteral replacement, ureteral reimplantation, and augmentation enterocystoplasty.<a class="elsevierStyleCrossRefs" href="#bib0100">20,32–35</a> Radical prostatectomy and radical cystoprostatectomy through umbilical approach are also feasible<a class="elsevierStyleCrossRefs" href="#bib0095">19,36</a> and will soon see their indication grow.The advent of new systems with improvements provided by the applied research from the field of engineering and optics will be the key elements that will contribute to this increase. The Keyport system is an example of this development, because it incorporates dual rotation curved elements which involve greater precision, and it also prevents the external shock of the instruments thanks to the crossing inside them, which involves a mirror image. It is therefore necessary to carry out a progressive learning to compensate for the laterality change.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> The use of accessory trocars as hybrid LESS is an excellent option that also facilitates the use of this system.<a class="elsevierStyleCrossRefs" href="#bib0115">23,38</a>Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres102008" "titulo" => array:6 [ 0 => "Abstract" 1 => "Context" 2 => "Objective" 3 => "Evidence acquisition" 4 => "Evidence synthesis" 5 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec89174" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres102009" "titulo" => array:6 [ 0 => "Resumen" 1 => "Contexto" 2 => "Objetivo" 3 => "Adquisición de evidencia" 4 => "Síntesis de evidencia" 5 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec89175" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Evidence acquisition" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Evidence synthesis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Experience in the literature" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Experience at our center" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack35409" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-18" "fechaAceptado" => "2012-03-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec89174" "palabras" => array:4 [ 0 => "LESS" 1 => "KeyPort®" 2 => "Radical cystectomy" 3 => "E-NOTES" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec89175" "palabras" => array:4 [ 0 => "LESS" 1 => "KeyPort®" 2 => "Cistectomía radical" 3 => "E-NOTES" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ContextRadical cystectomy with orthotopic derivation is one of the most complex urological techniques, although laparoscopic surgery has made this procedure increasingly less invasive. ObjectiveTo provide an updated review of the single port approach to carry out radical surgery due to bladder cancer. Evidence acquisitionA comprehensive review of the literature was performed using Medline and Embase to discover the accumulated experience of the viability of carrying out laparoendoscopic radical cystectomy, pelvic lymphadenectomy and orthotopic neobladder using the LESS (laparoendoscopic single site surgery) approach. Our experience with this approach is also presented and the technique used with the reusable KeyPort® system developed by Richard Wolf is described. Evidence synthesisRadical treatment of bladder cancer is possible in men and women using a single port and even performance of ileal neobladder, as reconstructive procedure in these patients. The surgical technique, post-operative cares and result obtained in our center are described. The accumulated experience worldwide describes 25 cases of radical cystectomy performed using different single port systems, 14 of them with orthotopic intestinal neobladder. ConclusionThe KeyPort® umbilical cystectomy constitutes in our setting the least possible invasive alternative to efficiently treat muscle-invasive bladder cancer, with excellent esthetic result, minimum post-operative pain and short hospital stay. The umbilical scar decreases the analgesic requirements and it ends up being practically invisible. This supposes an important step in the development of the minimally invasive surgery for bladder cancer." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ContextoLa cistectomía radical con derivación ortotópica es una de las técnicas urológicas más complejas, aunque la cirugía laparoscópica ha hecho posible que este procedimiento sea cada vez menos invasivo. ObjetivoProporcionar una revisión actualizada acerca del abordaje a través de puerto único para llevar a cabo cirugía radical por cáncer de vejiga. Adquisición de evidenciaSe lleva a cabo una revisión exhaustiva de la literatura mediante Medline y Embase para conocer la experiencia acumulada acerca de la viabilidad de llevar a cabo cistectomía radical laparoscópica, linfadenectomía pélvica y neovejiga ortotópica mediante abordaje LESS (laparoendoscopic single site surgery). Se presenta además nuestra experiencia con este abordaje y se describe la técnica empleada con sistema KeyPort® reutilizable, desarrollado por Richard Wolf. Síntesis de evidenciaEs posible llevar a cabo el tratamiento radical del cáncer de vejiga en hombres y en mujeres a través de puerto único, e incluso la realización de neovejiga ileal como procedimiento reconstructivo en estos pacientes. Se detalla la técnica quirúrgica, los cuidados postoperatorios y el resultado obtenido en nuestro centro. La experiencia acumulada a nivel mundial describe 25 casos de cistectomía radical realizados mediante diferentes sistemas de puerto único, 14 de ellos completados con neovejiga intestinal ortotópica. ConclusiónLa cistectomía KeyPort® umbilical constituye en nuestro entorno la alternativa menos invasiva posible para tratar eficientemente el cáncer de vejiga músculo-invasivo, con excelente resultado estético, mínimo dolor postoperatorio y corta estancia hospitalaria. La cicatriz umbilical disminuye los requerimientos analgésicos y acaba siendo prácticamente invisible, por lo que supone un paso importante en el desarrollo de la cirugía mínimamente invasiva para el cáncer vesical." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Angulo JC, et al. Cistectomía radical laparoendoscópica con neovejiga íleal ortotópica a través de puerto único umbilical. Actas Urol Esp.2012;36:554–61." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 958 "Ancho" => 1301 "Tamanyo" => 260998 ] ] "descripcion" => array:1 [ "en" => "2.5-cm transverse umbilical incision (A), for placement of Keyport single-port system (B)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 850 "Ancho" => 1327 "Tamanyo" => 209086 ] ] "descripcion" => array:1 [ "en" => "Arrangement of the operating room, patient in Trendelenburg. Curved work instruments with dual rotation system and camera through the umbilical port and accessory trocar in the right iliac fossa." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1256 "Ancho" => 925 "Tamanyo" => 192170 ] ] "descripcion" => array:1 [ "en" => "Start (A) and course (B) of pelvic lymphadenectomy." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 860 "Ancho" => 1301 "Tamanyo" => 189400 ] ] "descripcion" => array:1 [ "en" => "Removal of the cystectomy specimen (A), exposure of the ureters (B), intestinal anastomosis (C), and construction of the detubularized ileal reservoir (D)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1253 "Ancho" => 926 "Tamanyo" => 198163 ] ] "descripcion" => array:1 [ "en" => "Insertion of the neobladder through the umbilical incision (A) and neovesicourethral anastomosis with V-lock barbed suture (B)." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 621 "Ancho" => 925 "Tamanyo" => 100886 ] ] "descripcion" => array:1 [ "en" => "Closure of the umbilical wound with Vicryl rapid 3/0." ] ] 6 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "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"><td 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" style="border-bottom: 2px solid black">Author (reference) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">pT (n/%) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Surgical T (min) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Bleeding (cm3) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Stay (days) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Type of urinary diversion (n/%) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Complications (n/%) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Follow-up (months) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">White et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2009 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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">pT2 (2) \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">315 \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">217 \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">6 \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">Ileal conduit (3) \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">Transfusion (1) \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">24–26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Kaouk et al.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2010 \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="" 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">pT0 (1) \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="" 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="" 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="" 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="" 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="" 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="" 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" 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">Kaouk et al.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2011 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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">NA \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">NA \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">NA \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">NA \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">NA (3) \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">NA \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">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Liu et al.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2010 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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">NA \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">570 \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">600 \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">NA \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">Sigmoid neobladder (1) \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">Transfusion (1) \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">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Huang et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2010 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \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">pT1 (4) \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">383 \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">150 \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">15.3 \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">Ileal neobladder (12) \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">Transient delirium (1) \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">16.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Lin et al.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2011 \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="" 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">pT2 (5) \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="" 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="" 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="" 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="" 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">Lymphorrhoea (2) \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="" 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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" 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="" 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="" 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">pT3 (3) \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="" 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="" 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="" 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="" 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="" 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="" 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" 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">Ma et al.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2012 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \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">pT1 (1) \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">208 \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">270 \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">19.5 \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">Cutaneous ureterostomy (2) \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">Transfusion (1) \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">4.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" 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="" 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="" 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">pT2 (3) \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="" 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="" 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="" 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">Ileal conduit (3) \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">Intestinal obstruction (1) \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="" 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" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" 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="" 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="" 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">pT3 (1) \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="" 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="" 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="" 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="" 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">Death from AMI (1) \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="" 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" 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">Present \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2012 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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">pT0 (1) \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">480 \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">400 \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">6 \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">Ileal neobladder (1) \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">None \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">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Total<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2009–2012 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \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">≤pT2 (80%) \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">208–570 \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">150–600 \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">6–19.5 \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">Non-continent diversion (36%) \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">Clavien <3 (27%) \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">3–26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" 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="" 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="" 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">pT3 (20%) \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="" 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="" 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="" 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">Continent diversion (64%) \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">Clavien >3 (9%) \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="" 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></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab184403.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "2 patients were pN1." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "The not available (NA) data were discounted of the total to calculate the overall percentage." ] ] ] "descripcion" => array:1 [ "en" => "LESS radical cystectomies published so far by different groups of authors (2009–2012)." ] ] 7 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.mp3" "ficheroTamanyo" => 5873399 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GLOBCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide. 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Statistics

Surgical technique

Laparoendoscopic radical cystectomy with orthotopic ileal neobladder through umbilical single port

Cistectomía radical laparoendoscópica con neovejiga íleal ortotópica a través de puerto único umbilical

J.C. Angulo

Corresponding author

jangulo.hugf@salud.madrid.org

Corresponding author.

, F. Cáceres, I. Arance, I. Romero, F. Ramón de Fata, P.M. Cabrera

Hospital Universitario de Getafe, Fundación para la Investigación Biomédica, Servicio Madrileño de Salud, Universidad Europea de Madrid, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bladder cancer is the most common of all genitourinary malignancies&#46; Spain is one of the territories of Western Europe which has the highest incidence for this disease&#44; especially in men&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Radical cystectomy remains the preferred therapeutic option to treat patients with muscle-invasive urothelial carcinoma of the bladder&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Radical surgical removal of the bladder must be included&#44; within the standard limits&#44; and the thorough exeresis of pelvic lymph nodes as well&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the dilemma of which is the best form of urinary diversion is not closed&#44; an orthotopic bladder substitute must also be offered&#44; whenever possible&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This requires that there is no tumor at the edge of the urethral resection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Complete removal of all possible extravesical tumor extension and of the terminal ureteral segment must also be carried out&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">All studies support the simultaneous removal of pelvic lymph nodes&#46; In fact&#44; retrospective studies have demonstrated that extended lymphadenectomy is a therapeutic element that improves survival of the patients&#44; and that the number of lymph nodes obtained means even a prognostic predictor&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> In this sense&#44; pelvic lymphadenectomy performed through laparoscopic approach at the time of laparoscopic radical cystectomy has shown the same excisional benefit in terms of the number of nodes removed as conventional lymphadenectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Preservation of the anterior and membranous urethra&#44; which includes the rhabdosphincter&#44; makes the performance of an orthotopic neobladder possible&#46; The preservation of sensory and autonomic pelvic nerves will improve surgical outcomes&#44; in terms of both continence and power&#46; The best nerve sparing is achieved by deliberately leaving the seminal vesicles&#44; with or without the prostatic capsule&#46; However&#44; this decision must be properly balanced with the patient&#44; and the oncologic risk needs to be considered in every case&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Both laparoscopic radical cystectomy and laparoscopic robot-assisted cystectomy are feasible alternatives&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a> The current recommendation about their use remains in the hands of surgeons experienced in these techniques&#44; also taking into account the patient&#39;s condition&#44; the size of the tumor&#44; and the type of diversion chosen&#46; The possibility of performing laparoscopic or robotic intestinal neobladder is a difficult procedure of which few series are available&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> There really is important reluctance of academic centers to consider that laparoscopic and&#47;or robotic surgery are the gold standard of care in this type of patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> although in recent years&#44; this field is progressing significantly&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Possibly&#44; the last of the advances is the performance of radical surgery for bladder cancer through single port systems&#44; which can be coupled to the natural scar that is the navel &#40;E-NOTES&#41;&#44; the main embryonic natural orifice of our economy&#46; The umbilical-approach scar is totally hidden from view&#44; which in a few weeks makes a cosmetic impression of an &#8216;incisionless&#8217; scar&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evidence acquisition</span><p id="par0035" class="elsevierStylePara elsevierViewall">An extensive review of the literature was performed using Medline and Embase from 1993 to 2011&#46; The questions concerning the search were bladder cancer and laparoendoscopic surgery through single port &#40;LESS&#41;&#44; including radical cystectomy&#44; pelvic lymphadenectomy&#44; and orthotopic ileal neobladder&#46; Year 1993 was chosen because it was the time when the first vaginal removal of an intact kidney after laparoscopic radical nephrectomy was described&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> this being the major milestone of the development of transluminal endoscopic surgery through natural orifices&#46; In 1999&#44; laparoscopic cholecystectomy was systematized without any incision outside the umbilicus&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In 2007&#44; a laparoendoscopic approach was first used in Urology through the placement of a single port on the side to perform nephrectomy of a non-functioning atrophic kidney&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The search focused on identifying all the procedures related to pelvic surgery&#44; and more specifically&#44; to the urinary bladder surgery&#44; performed through LESS approach&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Only 7 articles specifically refer to this type of surgical approach for patients with bladder cancer&#44; none of them in Spanish&#46; Our group has extensive experience in the laparoscopic approach of bladder cancer&#46; We have recently carried out radical cystoprostatectomy with lymphadenectomy through the navel using the Keyport system and extracorporeal ileal neobladder in a patient with muscle-invasive bladder cancer with excellent results&#46; The updated global experience with this type of approach is&#44; thus&#44; described&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Evidence synthesis</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Experience in the literature</span><p id="par0045" class="elsevierStylePara elsevierViewall">The first mention in the literature of patients treated by LESS radical cystectomy is the analysis of the first 100 cases of laparoendoscopic surgery performed at the Cleveland Clinic&#44; which was published by White et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> in 2009&#46; This description consists in carrying out a record of surgeries that can be performed successfully by LESS&#46; Radical cystectomy represents 3&#37; of the total indications and less than 9&#37; of all pelvic surgeries&#46; Other procedures performed were sacrocolpopexy&#44; radical prostatectomy&#44; varicocelectomy&#44; and ureteral reimplantation&#46; The authors noted that this type of surgery was feasible and that the complication rate did not appear increased&#46; A better cosmetic result and less postoperative pain were the main findings of the global series&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The same three patients were described by Kaouk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in 2010 as a specific series of LESS radical cystectomy and bilateral pelvic lymphadenectomy&#46; They were 2 men and 1 woman&#46; The system used was the Uni-X single port &#40;Pnavel Systems&#44; Brooklyn&#44; NY&#41; consisting of a three-light valve system that accommodates three 5-mm laparoscopic instruments&#44; along with an insufflation port&#46; Through this port&#44; instruments like flexible monopolar scissors &#40;CambridgeEndo&#44; Framingham&#44; MA&#41;&#44; and a 5-mm flexible laparoscope &#40;Olympus Surgical&#46; Orangeburg&#44; NY&#41; were used&#46; The authors stated that in no case was there locally advanced disease&#44; and patients with previous abdominal surgery and&#47;or radiotherapy&#44; and patients who wanted orthotopic bladder substitution were also excluded&#46; All the procedures were carried out using pure LESS&#44; without need for additional port&#46; Extraction of the specimen and performance of the ileal conduit were performed by extending the umbilical port incision to 5<span class="elsevierStyleHsp" style=""></span>cm and the use of a wound protector&#46; The mean blood loss was minimal and no patient required transfusion&#46; The mean surgical time was 315<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>min&#46; A mean of 16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3 nodes was removed per patient&#46; The visual analog scale for pain was 0&#8211;1 &#40;out of 10&#41; in the three patients&#46; All were discharged within 1 week&#46; Histopathological examination of the specimen revealed a stage pT2pN0 &#40;2 patients&#59; one with incidental prostate adenocarcinoma Gleason 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#41; and pT0pN0 &#40;1 patient&#41;&#46; All the patients were free of disease with a follow-up of 24&#8211;26 months&#46; This preliminary experience heralded that the procedure was feasible in selected cases&#59; however&#44; none of the patients received an orthotopic neobladder &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The global record of urological LESS published by Kaouk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> in 2011 includes the three cases that were conducted in the period 2007&#8211;2008<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> and other three cases performed in 2009&#8211;2010&#46; No data are provided on the type of urinary diversion&#44; or the operating parameters or complications obtained in the latter three cases&#46; Indirect experience shows that the indication for LESS radical cystectomy has not grown among the authors in this contributor group&#46; In fact&#44; this surgery is only 0&#46;5&#37; of the published record and it has not shown a tendency to grow over time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;83&#41;&#46; From a global perspective&#44; it has even been a detriment&#44; since it was performed in 1&#46;28&#37; of the patients operated in 2007&#8211;2008 and in 0&#46;35&#37; of those operated in 2009&#8211;2010&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Very recently&#44; several very interesting experiences from Chinese authors&#44; who are generating renewed interest in the issue&#44; have entered this stage of LESS radical cystectomy&#46; It is the experience of the centers Zhujiang Hospital &#40;Southern Medical University&#44; Guangzhou&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Memorial Hospital &#40;Sun Yat-sen University&#44; Guangzhou&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> and Peking University Third Hospital &#40;Beijing&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> These authors have published the description of a total of 18 new cases&#46; The urinary derivation used was varied&#58; cutaneous ureterostomy &#40;2 cases&#41;&#44; ileal conduit &#40;3 cases&#41;&#44; sigmoid neobladder &#40;1 case&#41;&#44; and ileal neobladder &#40;12 cases&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In 4 of the 12 cases described by Lin et al&#46;&#44; nerve sparing&#44; which was successful in two patients &#40;one spontaneously and another one with the aid of PDE-5 inhibitors&#41;&#44; was conducted&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The experience of the institutions in Guangzhou has opted for the preparation of orthotopic bladder reservoirs&#44; mostly using an ileal segment that is performed extracorporeally&#46; The Beijing experience&#44; however&#44; prefers incontinent derivations &#40;ureterostomy or ileal loop&#41;&#46; In these cases&#44; the operative time is reduced significantly&#46; The system used by all the Chinese authors has been a home-made system performed with a latex glove size 7 &#189; and two compressible rings&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> or an inverted conical polycarbonate&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> These glove systems allow for a multichannel approach with three or four independent elements&#44; since the fingers of the gloves are cut and fixed to the trocars &#40;two 12<span class="elsevierStyleHsp" style=""></span>mm and one 5<span class="elsevierStyleHsp" style=""></span>mm&#44; respectively&#41; using a knotted suture&#46; Thus&#44; a 10-mm and 30&#176; lens&#44; along with conventional laparoscopic instruments&#44; is used&#46; Valves with plastic closure to allow passage of instruments through the glove fingers can also be performed&#46; CO<span class="elsevierStyleInf">2</span> insufflation creates a tension which enables the device to be secure&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Experience at our center</span><p id="par0070" class="elsevierStylePara elsevierViewall">We present the case of a 64-year-old male with high-grade muscle-invasive urothelial carcinoma&#46; Radical cystectomy with orthotopic derivation was carried out through a single-port Keyport system placed in the navel with a 2&#46;5-cm incision in the transverse direction &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We performed other surgeries at our center with this system quite satisfactorily&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> They all achieved an excellent esthetic result&#44; and the postoperative pain was significantly lower than that of open surgery and even that of conventional laparoscopy&#46; The transumbilical use of this system hides the surgical scar in the navel&#44; giving the final appearance of a scar-free surgery&#46; An auxiliary 10-mm port is placed in the right iliac fossa to facilitate the neovesicourethral anastomosis and for placement of a peritoneal drainage and bilateral urinary derivation &#40;urinary derivation catheters&#41; that are externalized through the same trocar&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The patient is placed in the Trendelenburg position&#46; The surgeon takes the curved work instruments with dual rotating system &#40;scissors in the right hand&#44; and grasper in the left hand&#41; while the assistant carries the camera with his left hand and the accessory trocar with his right hand &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Surgery begins with the opening of the parietal peritoneum&#46; Then&#44; the ureters are identified and dissected&#46; The opening of the pouch of Douglas and dissection of the seminal case are performed&#46; We show the dissection of the right side in detail &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Hem-o-lok ligation and right ureter section are performed&#46; The superior vesical pedicle and vas deferens are also identified and ligated with Hem-o-lok&#46; Hemostatic control of the seminal pedicle with 10-mm Ligasure is carried out&#46; The same maneuver is repeated on the other side to&#44; then&#44; develop the space of Retzius to the prostatic apex&#44; and hemostasis of the plexus of Santorini is performed&#46; Finally&#44; the urethra and the urethral rectus muscle are sectioned on the posterior plane&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We proceed to perform obturator and pelvic to common iliac lymphadenectomy&#44; showing ilioinguinal nerve&#46; It again shows an image corresponding to the dissection of the right side &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46; The lymphadenectomy specimen is removed&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The intestinal loop is marked with a reference point 15<span class="elsevierStyleHsp" style=""></span>cm from the ileocecal valve&#44; which will help at the time of selection of the intestinal segment&#46; We proceed to bagging the cystectomy specimen&#44; which is extracted with cross-shaped minimal enlargement of the hole performed in the rectus muscle &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#41;&#46; Then&#44; the umbilical hole is also slightly extended&#44; making a small perpendicular midline incision and disposable disc is placed to facilitate exposure of the ureters and bowel outside the navel &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#41;&#46; The intestinal segment that will serve to perform the neobladder is identified&#46; The intestine is cut and we proceed to the ileo-ileal anastomosis with mechanical sutures &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&#46; Later&#44; the intestine is detubularized and the reservoir is constructed with straight needle absorbable suture &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>D&#41;&#46; The ureters are anastomosed to the afferent loop in isoperistaltic direction and closure of the neobladder&#44; which acquires spherical shape leaving a distal hole that will anastomose to the urethral end&#44; is completed&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The neobladder is introduced into the pelvic cavity to then re-enter the Keyport system&#44; which now requires adaptation to the extended closure by means of a circular suture&#46; Neovesicourethral anastomosis with barbed suture V-lock is carried out &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Once the anastomosis is completed&#44; urethropexy with suture fixation to the pubic bone and traction by Hem-o-lok is performed&#46; A drainage is placed through the accessory port&#44; and through the same hole&#44; both urinary derivation catheters are removed&#46; Finally&#44; the single port is removed and the umbilical wound is closed with Vicryl rapid 3&#47;0 &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46; The umbilical scar significantly reduces analgesic requirements&#46; The visual analog pain scale on day 2 was 1&#47;10&#46; A few weeks later&#44; the wound is almost invisible&#44; thus&#44; fulfilling the paradigm of &#8216;incision-less&#8217; surgery&#46; The histopathological examination showed no residual tumor in the specimen and 26 lymph nodes negative for tumor&#46; The patient has daytime continence at three months of follow-up and training their neobladder to avoid the occasional night escape that they suffer&#46; Additional material that illustrates the surgical technique step by step is attached&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Single-port surgery is the progressive result of small steps based on minor adjustments of previous techniques&#44; the same as the tuning of an instrument is carried out with minor adjustments whose real value is difficult to define&#46; The result is that from the sum of all these small adjustments&#44; exquisite tuning is achieved&#44; with no breaks or discontinuity solution in the evolutionary development of the technique&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The initial impetus to promote minimally invasive surgery focused on avoiding the morbidity of laparotomy&#46; Improvements regarding less pain&#44; less bleeding&#44; better recovery of intestinal motility&#44; and decreased need for analgesics are the main achievements of the laparoscopic approach<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> without sacrificing the results for oncological safety&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The laparoendoscopic approach through the navel to perform radical cystectomy is the latest technical development in the field of minimally invasive surgery&#44; because it reduces the placement of extraumbilical trocars and&#44; most times&#44; it allows for the final removal of the specimens&#44; leaving a wound with significant cosmetic benefits&#46; Furthermore&#44; it is also possible to carry out the urinary derivation taking advantage of this approach&#44; and even to practice orthotopic neobladder extracorporeally in a reasonable range of time&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">But the most important fact is that some parameters concerning the quality of the procedure such as tumor margins&#44; the number of nodes obtained in the pelvic lymphadenectomy&#44; and the possibility of conducting continent reservoirs are today an entirely feasible reality using a laparoendoscopic approach&#46; If the only advantage of the procedure resided in cosmetic surgery&#44; it might not be enough to apply this concept to the radical treatment of bladder cancer&#46; However&#44; the stay reduced to 6 days in a patient with orthotopic neobladder&#44; who was discharged without any Clavien-Dindo complications&#44; not even in the administration of analgesia&#44; is frankly astonishing&#46; A visual analog scale of postoperative pain 1&#47;10 on day 2&#44; the absence of ileus in the postoperative period&#44; and the great satisfaction with the procedure by the patient are well worth an extended operative time of 480<span class="elsevierStyleHsp" style=""></span>min&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">We think this type of approach is ideal for selected patients and that if these impressive results are consolidated&#44; it will constitute an indisputable future advance in the treatment of muscle invasive bladder cancer&#46; The reusable nature of the material used is also a strong argument in terms of hospital efficiency&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">There is no doubt that the experience in this type of patients is still very limited even worldwide and that more casuistry will have to be accumulated in order to acknowledge the benefits of this procedure&#46; Today&#44; the experience described seems comparable to the laparoscopic approach&#44; which surely entails a high oncological efficacy&#46; However&#44; a closer follow-up is needed with regard to functional results and late complications&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Different procedures are being developed at present with this type of single-port devices&#44; although in many surgeries&#44; placement of 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm-gauge thin accessory ports &#40;even less if the instrument is placed directly without the trocar&#41; is necessary&#46; There is no doubt that single-port surgery means a challenge of retooling&#44; still under development&#46; The first descriptions of its application in Urology were flank incision nephrectomy and transumbilical ureterolithectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;29</span></a> Then&#44; transumbilical nephrectomy and pyeloplasty were described&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a> Gradually&#44; most urological procedures have been developed using single port&#58; adrenalectomy&#44; nephroureterectomy&#44; living donor nephrectomy&#44; ureteral replacement&#44; ureteral reimplantation&#44; and augmentation enterocystoplasty&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;32&#8211;35</span></a> Radical prostatectomy and radical cystoprostatectomy through umbilical approach are also feasible<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;36</span></a> and will soon see their indication grow&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The advent of new systems with improvements provided by the applied research from the field of engineering and optics will be the key elements that will contribute to this increase&#46; The Keyport system is an example of this development&#44; because it incorporates dual rotation curved elements which involve greater precision&#44; and it also prevents the external shock of the instruments thanks to the crossing inside them&#44; which involves a mirror image&#46; It is therefore necessary to carry out a progressive learning to compensate for the laterality change&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The use of accessory trocars as hybrid LESS is an excellent option that also facilitates the use of this system&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;38</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Context</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radical cystectomy with orthotopic derivation is one of the most complex urological techniques&#44; although laparoscopic surgery has made this procedure increasingly less invasive&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To provide an updated review of the single port approach to carry out radical surgery due to bladder cancer&#46;</p> <span class="elsevierStyleSectionTitle">Evidence acquisition</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A comprehensive review of the literature was performed using Medline and Embase to discover the accumulated experience of the viability of carrying out laparoendoscopic radical cystectomy&#44; pelvic lymphadenectomy and orthotopic neobladder using the LESS &#40;<span class="elsevierStyleItalic">laparoendoscopic single site surgery</span>&#41; approach&#46; Our experience with this approach is also presented and the technique used with the reusable KeyPort<span class="elsevierStyleSup">&#174;</span> system developed by Richard Wolf is described&#46;</p> <span class="elsevierStyleSectionTitle">Evidence synthesis</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Radical treatment of bladder cancer is possible in men and women using a single port and even performance of ileal neobladder&#44; as reconstructive procedure in these patients&#46; The surgical technique&#44; post-operative cares and result obtained in our center are described&#46; The accumulated experience worldwide describes 25 cases of radical cystectomy performed using different single port systems&#44; 14 of them with orthotopic intestinal neobladder&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The KeyPort<span class="elsevierStyleSup">&#174;</span> umbilical cystectomy constitutes in our setting the least possible invasive alternative to efficiently treat muscle-invasive bladder cancer&#44; with excellent esthetic result&#44; minimum post-operative pain and short hospital stay&#46; The umbilical scar decreases the analgesic requirements and it ends up being practically invisible&#46; This supposes an important step in the development of the minimally invasive surgery for bladder cancer&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle">Contexto</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La cistectom&#237;a radical con derivaci&#243;n ortot&#243;pica es una de las t&#233;cnicas urol&#243;gicas m&#225;s complejas&#44; aunque la cirug&#237;a laparosc&#243;pica ha hecho posible que este procedimiento sea cada vez menos invasivo&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Proporcionar una revisi&#243;n actualizada acerca del abordaje a trav&#233;s de puerto &#250;nico para llevar a cabo cirug&#237;a radical por c&#225;ncer de vejiga&#46;</p> <span class="elsevierStyleSectionTitle">Adquisici&#243;n de evidencia</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se lleva a cabo una revisi&#243;n exhaustiva de la literatura mediante Medline y Embase para conocer la experiencia acumulada acerca de la viabilidad de llevar a cabo cistectom&#237;a radical laparosc&#243;pica&#44; linfadenectom&#237;a p&#233;lvica y neovejiga ortot&#243;pica mediante abordaje LESS &#40;<span class="elsevierStyleItalic">laparoendoscopic single site surgery</span>&#41;&#46; Se presenta adem&#225;s nuestra experiencia con este abordaje y se describe la t&#233;cnica empleada con sistema KeyPort<span class="elsevierStyleSup">&#174;</span> reutilizable&#44; desarrollado por Richard Wolf&#46;</p> <span class="elsevierStyleSectionTitle">S&#237;ntesis de evidencia</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Es posible llevar a cabo el tratamiento radical del c&#225;ncer de vejiga en hombres y en mujeres a trav&#233;s de puerto &#250;nico&#44; e incluso la realizaci&#243;n de neovejiga ileal como procedimiento reconstructivo en estos pacientes&#46; Se detalla la t&#233;cnica quir&#250;rgica&#44; los cuidados postoperatorios y el resultado obtenido en nuestro centro&#46; La experiencia acumulada a nivel mundial describe 25 casos de cistectom&#237;a radical realizados mediante diferentes sistemas de puerto &#250;nico&#44; 14 de ellos completados con neovejiga intestinal ortot&#243;pica&#46;</p> <span class="elsevierStyleSectionTitle">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La cistectom&#237;a KeyPort<span class="elsevierStyleSup">&#174;</span> umbilical constituye en nuestro entorno la alternativa menos invasiva posible para tratar eficientemente el c&#225;ncer de vejiga m&#250;sculo-invasivo&#44; con excelente resultado est&#233;tico&#44; m&#237;nimo dolor postoperatorio y corta estancia hospitalaria&#46; La cicatriz umbilical disminuye los requerimientos analg&#233;sicos y acaba siendo pr&#225;cticamente invisible&#44; por lo que supone un paso importante en el desarrollo de la cirug&#237;a m&#237;nimamente invasiva para el c&#225;ncer vesical&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Angulo JC&#44; et al&#46; Cistectom&#237;a radical laparoendosc&#243;pica con neovejiga &#237;leal ortot&#243;pica a trav&#233;s de puerto &#250;nico umbilical&#46; Actas Urol Esp&#46;2012&#59;36&#58;554&#8211;61&#46;</p>"
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            "apendice" => "<p id="par0155" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0045"
          ]
        ]
      ]
    ]
    "multimedia" => array:8 [
      0 => array:7 [
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          0 => array:4 [
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            "Tamanyo" => 260998
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">2&#46;5-cm transverse umbilical incision &#40;A&#41;&#44; for placement of Keyport single-port system &#40;B&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 850
            "Ancho" => 1327
            "Tamanyo" => 209086
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Arrangement of the operating room&#44; patient in Trendelenburg&#46; Curved work instruments with dual rotation system and camera through the umbilical port and accessory trocar in the right iliac fossa&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1256
            "Ancho" => 925
            "Tamanyo" => 192170
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Start &#40;A&#41; and course &#40;B&#41; of pelvic lymphadenectomy&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 860
            "Ancho" => 1301
            "Tamanyo" => 189400
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Removal of the cystectomy specimen &#40;A&#41;&#44; exposure of the ureters &#40;B&#41;&#44; intestinal anastomosis &#40;C&#41;&#44; and construction of the detubularized ileal reservoir &#40;D&#41;&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 1253
            "Ancho" => 926
            "Tamanyo" => 198163
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Insertion of the neobladder through the umbilical incision &#40;A&#41; and neovesicourethral anastomosis with V-lock barbed suture &#40;B&#41;&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 621
            "Ancho" => 925
            "Tamanyo" => 100886
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Closure of the umbilical wound with Vicryl rapid 3&#47;0&#46;</p>"
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      ]
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        "etiqueta" => "Table 1"
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        "tabla" => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Author &#40;reference&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">pT &#40;<span class="elsevierStyleItalic">n</span>&#47;&#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-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Surgical T &#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Bleeding &#40;cm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Stay &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Type of urinary diversion &#40;<span class="elsevierStyleItalic">n</span>&#47;&#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-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Complications &#40;<span class="elsevierStyleItalic">n</span>&#47;&#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-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Follow-up &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">White et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2009&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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">pT2 &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">315&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">217&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">6&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">Ileal conduit &#40;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transfusion &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#8211;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Kaouk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&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="" 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><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">pT0 &#40;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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><tr title="table-row"><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">Kaouk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2011&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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">NA&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">NA&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">NA&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">NA&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">NA &#40;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NA&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">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Liu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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">NA&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">570&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">600&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">NA&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">Sigmoid neobladder &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transfusion &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Huang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2010&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&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">pT1 &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">383&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">150&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">15&#46;3&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">Ileal neobladder &#40;12&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transient delirium &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Lin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2011&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="" 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><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">pT2 &#40;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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><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">Lymphorrhoea &#40;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="" 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><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><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">pT3 &#40;3&#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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><tr title="table-row"><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">Ma et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2012&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&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">pT1 &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">208&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">270&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">19&#46;5&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">Cutaneous ureterostomy &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transfusion &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><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">pT2 &#40;3&#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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><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">Ileal conduit &#40;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestinal obstruction &#40;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="" 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><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><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">pT3 &#40;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="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><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">Death from AMI &#40;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="" 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><tr title="table-row"><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">Present&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2012&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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">pT0 &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">480&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">400&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">6&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">Ileal neobladder &#40;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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">Total<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2009&#8211;2012&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&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">&#8804;pT2 &#40;80&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">208&#8211;570&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">150&#8211;600&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">6&#8211;19&#46;5&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">Non-continent diversion &#40;36&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clavien &#60;3 &#40;27&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8211;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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        "texto" => "<p id="par0145" class="elsevierStylePara elsevierViewall">To Mr&#46; Jos&#233; Dom&#237;nguez &#40;Departament of Photography&#44; Hospital Universitario de Getafe&#41;&#44; to Mr&#46; Jes&#250;s Arconada &#40;Grupo Taper&#44; Madrid&#41;&#44; and to Mr&#46; Stefan Guill&#233;&#44; Benjam&#237;n Seidenspinner&#44; and Juergen Steinbeck &#40;Richard Wolf GMBH&#44; Knittlingen&#44; Germany&#41; for their help and cooperation&#46;</p>"
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2012.03.009

The statistics are updated each day

Year/Month	Html	Pdf	Total

2023 March	2	2	4
2018 December	1	2	3
2018 February	13	0	13
2018 January	24	2	26
2017 December	26	1	27
2017 November	18	2	20
2017 October	20	1	21
2017 September	29	3	32
2017 August	25	1	26
2017 July	15	1	16
2017 June	37	4	41
2017 May	29	6	35
2017 April	34	2	36
2017 March	23	29	52
2017 February	34	5	39
2017 January	45	1	46
2016 December	34	5	39
2016 November	49	3	52
2016 October	85	19	104
2016 September	103	3	106
2016 August	37	2	39
2016 July	15	2	17
2016 June	24	5	29
2016 May	32	12	44
2016 April	39	6	45
2016 March	37	6	43
2016 February	31	9	40
2016 January	38	9	47
2015 December	23	8	31
2015 November	19	5	24
2015 October	26	5	31
2015 September	24	4	28
2015 August	50	5	55
2015 July	60	5	65
2015 June	36	2	38
2015 May	51	5	56
2015 April	54	7	61
2015 March	36	4	40
2015 February	32	2	34
2015 January	34	2	36
2014 December	70	10	80
2014 November	45	2	47
2014 October	57	11	68
2014 August	3	0	3
2014 July	1	0	1
2014 June	5	0	5
2014 May	6	1	7
2014 January	4	1	5
2013 December	8	8	16
2013 November	25	4	29
2013 October	28	4	32
2013 September	15	0	15
2013 July	3	1	4

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