Cost analysis of surgical treatment for pelvic organ prolapse by laparoscopic sacrocolpopexy or transvaginal mesh | Actas Urológicas Españolas (English Edition)

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Carracedo, L. López-Fando, M.D. Sánchez, M.Á. Jiménez, J.M. Gómez, I. Laso, M.Á. Rodríguez, F.J. Burgos" "autores" => array:8 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Carracedo" "email" => array:1 [ 0 => "davidcarracedocalvo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "López-Fando" ] 2 => array:2 [ "nombre" => "M.D." "apellidos" => "Sánchez" ] 3 => array:2 [ "nombre" => "M.Á." "apellidos" => "Jiménez" ] 4 => array:2 [ "nombre" => "J.M." "apellidos" => "Gómez" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Laso" ] 6 => array:2 [ "nombre" => "M.Á." "apellidos" => "Rodríguez" ] 7 => array:2 [ "nombre" => "F.J." "apellidos" => "Burgos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de costes del tratamiento del prolapso de órganos pélvicos mediante colposacropexia laparoscópica o malla transvaginal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 804 "Ancho" => 1624 "Tamanyo" => 39478 ] ] "descripcion" => array:1 [ "en" => "Box plot of the average cost per procedure." ] ] ] "textoCompleto" => "IntroductionPelvic organ prolapse (POP) is a condition caused by a weakening of the supporting structures of the pelvic organs resulting in a decrease of the pelvic organs that results in a reduction of them toward the vaginal canal.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> POP is a common pathology in middle-aged women, affecting approximately 50% of women over 50,<a class="elsevierStyleCrossRef" href="#bib0130">2</a> with an estimated global prevalence of 2.9% in women older than 20.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> Several studies in the USA show that the probability of undergoing POP surgery throughout life ranges between 12 and 19%.<a class="elsevierStyleCrossRefs" href="#bib0140">4,5</a> In the United States, an estimated 226,000 women are treated annually due to POP with a direct annual cost of approximately 1000 million dollars.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> In Europe, Subramanian et al.<a class="elsevierStyleCrossRef" href="#bib0155">7</a> studied the annual cost of surgical treatment of POP, setting an annual cost of 144.24 million € in Germany, 83.07 in France and 81.03 in England. In addition, direct costs must be added to the indirect costs resulting from the loss of productivity and wages as well as the intangible costs arising from the deterioration of the quality of life. Mestre et al.<a class="elsevierStyleCrossRef" href="#bib0160">8</a> reported in 2015 a review on the evaluation of sexual function in women with urinary incontinence and POP, objectifying that 50% of women who consult for urogynecological problems are sexually active and 60% of them refer some type of sexual dysfunction.Several risk factors are associated with the development of POP, including high parity, advanced age, obesity, hispanic race, low socioeconomic status, and less clearly the type of parity (cesarean section or vaginal delivery).<a class="elsevierStyleCrossRefs" href="#bib0135">3,9–11</a> In the current demographic reality of developed countries, with progressive aging and increased obesity, a significant increase in POP prevalence is expected. In the United States, Wu et al.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> estimate an increase in the number of women with symptomatic POP between 2010 and 2050 from 46% in the best scenario (from 3.3 to 4.9 million women) and up to 200% in the worst scenario (from 3.3 to 9.2 million women). These circumstances will lead to an increase in the demand for treatment and in the consumption of economic resources, as well as the need for a greater number of experienced professionals in the diagnosis, assessment, and treatment of POP.Currently, it is discussed what the most effective surgical treatment of POP is. There are several surgical techniques and materials used in the treatment of the same. The number of surgical procedures using transvaginal mesh (TVM) showed a constant increase until 2008 when the FDA issued the first alarm about the use of this type of materials vaginally.<a class="elsevierStyleCrossRef" href="#bib0185">13</a> Several studies<a class="elsevierStyleCrossRefs" href="#bib0190">14,15</a> have shown a change in the trend of surgical treatment of POP from this moment, and especially since 2011 after the second alarm issued by the FDA.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> It is necessary to evaluate the different surgical techniques used in the treatment of POP from the economic point of view in order to optimize the available resources.The objective of the present study is to perform a comparative study of the direct costs of the surgical treatment of the POP according to its approach by TVM or LS starting from the hypothesis that the correction of the POP by LS would present at least the same cost as the correction of the same through TVM.Material and methodsThis is a comparative retrospective analysis of the costs of the first 69 consecutive LS procedures carried out between November 2011 and June 2014 compared to the first 69 consecutive TVM procedures carried out between September 2005 and December 2008.For each procedure (LS and TVM) the direct costs derived from the treatment of the POP were determined: structural, personnel, and operating room occupation costs, anesthetics and resuscitation, hospital stay and implanted prosthetic material.Implanted prosthetic materialIn TVM procedures, the correction of the POP was performed by the implant according to the usual technique of the complete, anterior and posterior Prolift® device (Ethicon, Johnson & Johnson, New Brunswick, New Jersey, USA).In the LS procedures the mesh implanted was the preformed non-resorbable polypropylene mesh Uplift® (Neomedic International, Terrassa, Barcelona, Spain).Cost calculationFor each section, the costs were established through the data provided by the Analytical Accounting System of the Ramón y Cajal University Hospital.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the cost model established for each section in both procedures.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>As it can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, the cost for each item in both groups is different, due to the different temporal moment of both series studied, which implies that the hospital costs are different according to the temporal moment evaluated.For each section, the monetary unit in which the costs are established is the euro.Statistical analysisQuantitative variables were described by mean and standard deviation and qualitative variables by relative and absolute frequency. The mean cost for each procedure was calculated with its 95% confidence interval, as well as the minimum and maximum cost for each study group.ResultsThe mean age was similar for both groups (68.6 years for the LS group and 65.2 years for the TVM group). Regarding the occupation time of the operating room, a longer time of operating room occupation was observed in the LC group (mean of 210.2min) compared to the TVM group (145.3min). The mean hospital stay was higher in the TVM group (5.88 days) compared to the LS group (3.77 days).In 41 out of 69 patients (59.4%) of the TVM group, a suburethral sling was implanted as a treatment of SUI simultaneously with the correction of the POP. In the LS group, no patient received suburethral sling simultaneously with POP correction. The rate of intraoperative complications (13 vs. 7.2%) and complications shorter than 30 days (15.9 vs. 8.7%) was higher in the LS group, while the rate of complications greater than 30 days was higher in the TVM group (15.9 vs. 5.8%). The transfusion rate was low in both groups, requiring transfusion of blood products only one patient in the TVM group.<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the characteristics of the sample for both groups with regard to age, surgical time, time of operating room occupation, simultaneous implant of suburethral sling, intraoperative complications, early complications 30 days after the surgical operation and transfusion rate of blood products.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>As it can be observed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, the correction of the POP by LS showed a lower mean cost per procedure (€5985.7 vs. €6534.3) than correction thereof by TVM. However, the 95% confidence intervals overlap (€5613.1–6358.3 in LS vs. €6290.4–6778.3 in TVM), so the difference between both groups did not reach statistical significance.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> show the mean cost per procedure with the 95% confidence interval, as well as the maximum and minimum cost for both groups under study.DiscussionFollowing the successive alarms issued by the FDA in 2008 and 2011,<a class="elsevierStyleCrossRefs" href="#bib0185">13,16</a> there has been a change in the trend in surgical treatment of the POP. Wang et al.,<a class="elsevierStyleCrossRef" href="#bib0190">14</a> using the Medicare database, observed a progressive decrease in the use of synthetic meshes vaginally, in the repair of the POP from the year 2008 after the first alarm of the FDA<a class="elsevierStyleCrossRef" href="#bib0185">13</a> and especially from 2011 with the second alarm issued by that organism.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> Skoczylas et al.<a class="elsevierStyleCrossRef" href="#bib0195">15</a> analyze 1385 surgical procedures for POP treatment performed in a single institution between 2008 and 2011 with the objective of determining the trend in the surgical treatment of the POP and the influence of the notifications issued by the FDA. A dramatic decline in the performance of vaginal mesh procedures (slope −0.013, p=0.001) was detected, so that in 2008 TVM repair constituted 27% of the procedures, reducing to 15% after the first alarm of the FDA, 5% after the second notification, to end up constituting 2% of the procedures by the end of 2011. In the same way, they observed a significant increase in the number of native tissue correction procedures (slope 0.015, p<0.001), of the apical suspensions (slope 0.006, p=0.007) as well as minimally invasive laparoscopic colposacropexy (LC) and robotic colposacropexy procedures (slope of 0.029, p<0.001) such that at the end of the study, this last surgical technique was established as the most frequently performed surgical procedure for the treatment of the POP in this institution.In the process of choosing a surgical technique, in addition to the clinical results, it is essential to consider the cost of the procedure in order to optimize the available resources. Therefore, it is essential to evaluate the cost of the different procedures used in daily clinical practice. Several studies have evaluated the cost of the different surgical procedures used in the treatment of the POP<a class="elsevierStyleCrossRefs" href="#bib0205">17–22</a>; however, few studies have directly compared the cost of treatment by means of LS and TVM.<a class="elsevierStyleCrossRef" href="#bib0235">23</a>Maher et al.,<a class="elsevierStyleCrossRef" href="#bib0235">23</a> in a randomized study comparing costs between LS and TVM, establish a cost model for each procedure in both the public and private health systems, including clinical costs (salaries, structural, hospitalization, and consumables costs), primary costs (clinical costs and loss of productivity during the recovery period), and total costs (clinical costs, primary and derived from the need for surgical reintervention). Their results show a significantly lower mean cost per procedure in the LC group than in the TVM group in both clinical costs ($9132.7 [DS 238.9] vs. $10,215.6 [DS 213.6]), as in the primary costs ($13,957.7 [DS 279.3] vs. $16,289.2 [DS 358.3]) and in total costs ($14,295 [DS 279.3] vs. $18,288 [DS 358.3]). These authors observe that the LS group incurs a higher expenditure in relation to a longer surgical time, with the consequent higher cost in salaries and structural expenses, whereas the TVM group incurs in a higher expense in relation to the higher cost of consumables, a longer hospital stay, a greater loss of productivity secondary to a longer period of recovery after the intervention, and a higher expenditure secondary to the higher rate of reintervention.Pan et al.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> recently reported the results of a meta-analysis comparing the results of LS and robot-assisted laparoscopic colposacropexy (RALC), including the costs of both procedures. In terms of costs, three studies included in this meta-analysis compare the costs of both procedures,<a class="elsevierStyleCrossRefs" href="#bib0210">18–20</a> in all of them observing a significantly higher cost of repair through RALC compared to LS. Similarly, Judd et al.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> compared the cost of repairing the POP by means of RALC, LS and open abdominal colposacropexy (OAC), with a significantly higher cost per RALC procedure ($8508) than by LS ($7353) or OAC ($5792). In the same vein, Patel et al.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> reported a higher cost of RALC ($24,161) compared to LS ($19,308) and OAC ($13,149).The main strength of our study is to present for the first time in our public health system a comparative study of the direct cost of repairing the POP according to the approach pathway. Similarly to Maher et al.,<a class="elsevierStyleCrossRef" href="#bib0235">23</a> our data show a lower cost of POP repair through LS compared to TVM, although this difference did not reach statistical significance. In the same sense as the study by Maher et al.,<a class="elsevierStyleCrossRef" href="#bib0235">23</a> this work shows that LS repair incurs in a higher expense due to a longer surgical time, of operating room occupation and anesthesia, and the TVM group incurred in a greater cost derived from a longer hospital stay and a higher cost of the implanted prosthetic material, being therefore the results of this study consistent with the published by other authors.However, this study is not without limitations. First, the retrospective nature of the study. Secondly, changes in the costs both structural and of personnel, hospital stay or the prosthetic material implanted take place over time; for this reason, the different temporal moment of both series leads to the cost for the same section being variable in both procedures. Third, there have been changes in the hospital discharge strategy and in the treatment of SUI in patients with POP, these strategies being different in the two compared series. Since we performed the correction of the POP by LS, we adopted the strategy of initial correction of the POP in our center, and then, according to the evolution of the SUI, after the anatomical correction of the POP, treatment by suburethral sling of the SUI is carried out in those patients with de novo or persistent SUI, so the cost of treatment of this SUI is not imputed in this group of patients. Also, during the time period of the LS series, an earlier discharge strategy was implemented after the surgical procedure, which reduces the average stay in this group. These biases lead to a lower average cost per procedure in the LS group related to the absence of simultaneous correction of SUI and a shorter hospital stay and not with the surgical technique. The last limitation of this study is the absence of inclusion of the costs derived from the complications and reinterventions in both groups. Maher et al.<a class="elsevierStyleCrossRef" href="#bib0240">24</a> reported in 2011 a comparative clinical trial between TVM and LS showing a 2-year correction rate of POP by LS versus TVM (77 vs. 43%), as well as a lower rate of reintervention through LC than through TVM (5 vs. 22%), both statistically significant. Thus, as published in the literature,<a class="elsevierStyleCrossRefs" href="#bib0235">23,24</a> the imputation of these costs in the study would lead to a greater increase of the cost of repair of the POP through TVM than through LS.In spite of these limitations, this study reveals for the first time in our country that the repair of the POP by laparoscopic abdominal approach does not present a cost per procedure greater than the correction of the same by means of vaginal approach with mesh and, therefore, in addition to being a safe alternative for the treatment of POP, LC is also an efficient alternative for POP repair.ConclusionsThe correction of the POP by laparoscopic abdominal approach with LS presents, in our environment, an average cost per procedure similar to the correction of the same vaginally through TVM.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres804107" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec802355" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres804106" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec802356" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Implanted prosthetic material" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Cost calculation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-06-06" "fechaAceptado" => "2016-08-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec802355" "palabras" => array:4 [ 0 => "Pelvic organ prolapse" 1 => "Cost analysis" 2 => "Laparoscopic sacrocolpopexy" 3 => "Vaginal mesh" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec802356" "palabras" => array:4 [ 0 => "Prolapso de órganos pélvicos" 1 => "Análisis de costes" 2 => "Colposacropexia laparoscópica" 3 => "Malla transvaginal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectivesThe objective of this study is to compare direct costs of repairing pelvic organ prolapse by laparoscopic sacrocolpopexy (LS) against vaginal mesh (VM). Our hypothesis is the correction of pelvic organ prolapse by LS has a similar cost per procedure compared to VM. Material and methodsWe made a retrospective comparative analysis of medium cost per procedure of first 69 consecutive LS versus first 69 consecutive VM surgeries. We calculate direct cost for each procedure: structural outlays, personal, operating room occupation, hospital stay, perishable or inventory material and prosthetic material. Medium cost per procedure were calculated for each group, with a 95% confidence interval. ResultsLS group has a higher cost related to a longer length of surgery, higher operating room occupation and anesthesia; VM group has a higher cost due to longer hospital stay and more expensive prosthetic material. Globally, LS has a lower medium cost per procedure in comparison to VM (5985.7€±1550.8€ vs. 6534.3€±1015.5€), although it did not achieve statistical signification. ConclusionsIn our midst, pelvic organ prolapse surgical correction by LS has at least similar cost per procedure compared to VM." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivosEl objetivo del estudio es realizar un análisis comparativo de los costes directos de la reparación del prolapso de órganos pélvicos mediante colposacropexia laparoscópica (CL) o malla transvaginal (MTV). La hipótesis inicial es que la corrección del prolapso de órganos pélvicos mediante CL presentaría al menos un coste por procedimiento similar a la corrección mediante MTV. Material y métodosAnálisis retrospectivo comparativo del coste medio por procedimiento de los primeros 69 procedimientos consecutivos de CL frente a los primeros 69 procedimientos consecutivos de MTV. Para cada procedimiento, se determinaron los costes directos: gastos estructurales, personal, ocupación de quirófano, estancia hospitalaria, material fungible e inventariable y el material protésico implantado. Se determinó el coste medio por procedimiento para cada uno de los grupos, con el intervalo de confianza al 95%. ResultadosMientras que el grupo de CL incurrió en un mayor gasto en relación con un mayor tiempo quirúrgico, ocupación de quirófano y anestesia, el grupo de MTV incurrió en un mayor gasto en relación con una mayor estancia hospitalaria y un coste mayor del material protésico implantado. De forma global, si bien el grupo de CL presentó un coste medio por procedimiento menor que el grupo de MTV (5.985,7 €±1.550,8 € vs. 6.534,3 €±1.015,5 €), esta diferencia no alcanzó la significación estadística. ConclusionesEn nuestro medio, la corrección del prolapso de órganos pélvicos mediante CL presenta al menos, un coste por procedimiento similar a la corrección del mismo mediante MTV." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Carracedo D, López-Fando L, Sánchez MD, Jiménez MÁ, Gómez JM, Laso I, et al. Análisis de costes del tratamiento del prolapso de órganos pélvicos mediante colposacropexia laparoscópica o malla transvaginal. Actas Urol Esp. 2017;41:117–122." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 804 "Ancho" => 1624 "Tamanyo" => 39478 ] ] "descripcion" => array:1 [ "en" => "Box plot of the average cost per procedure." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LS, Laparoscopic sacrocolpopexy; VM, Vaginal mesh." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VM \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83.81/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70.36/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.46/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.6/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prostheses and implants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">391.47/pat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1281.21/pat \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products (rest) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.64/pat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.21/pat \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functioning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.94/pat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.91/pat \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Operating room \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">548.37/unit occupation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">517.14/unit occupation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anesthesia and resuscitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">187.27/unit occupation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">127.55/unit occupation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breakfast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.14/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.94/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lunch \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.54/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.81/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snack \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.09/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.96/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dinner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.98/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.28/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">238.41/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">184.78/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate services \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">172.94/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">180.6/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Structure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.05/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.16/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TVT/TOT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">527.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">527.51 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349886.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Cost model established for each section." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LS, Laparoscopic sacrocolpopexy; VM, Vaginal mesh." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">LS</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VM</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Min–max \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Min–max \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.6 (8.49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35–88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.2 (9.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44–85 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical time (min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">210.2 (62) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120–360 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145.3 (12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100–180 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occupation time (units) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.82 (1.42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.75–8.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.33 (0.28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.29–4.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Admission days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.77 (1.31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.88 (2.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3–16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Probing days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.73 (2.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.8 (2.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–16 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349884.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">LS</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VM</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suburet. sling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intraop. Com. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minor Com. 30 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Major Com. 30 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transfusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349887.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the sample." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LS, Laparoscopic sacrocolpopexy; VM, Vaginal mesh." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">LS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">VM \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean (SD) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">315.82 (109.60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">404.17 (144.28) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.51 (1.91) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.3 (11.53) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prostheses and implants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">391.47 (constant) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1281.21 (constant) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products (rest) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.64 (constant) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.21 (constant) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functioning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.94 (constant) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.91 (constant) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Operating room \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2643.97 (780.51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1724.14 (146.09) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anesthesia and resuscitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">812.63 (239.89) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">382.78 (32.43) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breakfast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.83 (4.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.96 (6.05) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lunch \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.48 (15.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62.53 (22.25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snack \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.88 (2.73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.31 (4.04) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dinner \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.37 (14.36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59.3 (21.16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">898.36 (311.77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1065.83 (380.47) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate services \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">651.66 (226.16) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1041.76 (371.87) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Structure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.8 (7.91) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98.98 (35.33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">321.09 (259.33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Total</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5985.7 (1550.87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6534.31 (1015.52) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">95% CI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5613.14–6358.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6290.36–6778.27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Min–max \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3990.48–11,969.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4989.48–11,234.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1349885.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Average cost per procedure of both groups." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology and prevalence of pelvic organ prolapse" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Chow" 1 => "V.L. Rodríguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Curr Op Urol" "fecha" => "2013" "volumen" => "23" "paginaInicial" => "293" "paginaFinal" => "298" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.C. Samuelsson" 1 => "F.T. Victor" 2 => "G. Tibblin" 3 => "K.F. Svärdsudd" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Am J Obstet Gynecol" "fecha" => "1999" "volumen" => "180" "paginaInicial" => "299" "paginaFinal" => "305" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9988790" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028200006373" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and trends of symptomatic pelvic floor Disorders in U.S. women" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Wu" 1 => "C.P. Vaughan" 2 => "P.S. Goode" 3 => "D.T. Redden" 4 => "K.L. Burgio" 5 => "H.E. 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Cost analysis of surgical treatment for pelvic organ prolapse by laparoscopic sacrocolpopexy or transvaginal mesh

Análisis de costes del tratamiento del prolapso de órganos pélvicos mediante colposacropexia laparoscópica o malla transvaginal

D. Carracedo

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davidcarracedocalvo@gmail.com

Corresponding author.

, L. López-Fando, M.D. Sánchez, M.Á. Jiménez, J.M. Gómez, I. Laso, M.Á. Rodríguez, F.J. Burgos

Servicio de Urología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain

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an estimated 226&#44;000 women are treated annually due to POP with a direct annual cost of approximately 1000 million dollars&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> In Europe&#44; Subramanian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> studied the annual cost of surgical treatment of POP&#44; setting an annual cost of 144&#46;24 million &#8364; in Germany&#44; 83&#46;07 in France and 81&#46;03 in England&#46; In addition&#44; direct costs must be added to the indirect costs resulting from the loss of productivity and wages as well as the intangible costs arising from the deterioration of the quality of life&#46; Mestre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> reported in 2015 a review on the evaluation of sexual function in women with urinary incontinence and POP&#44; objectifying that 50&#37; of women who consult for urogynecological problems are sexually active and 60&#37; of them refer some type of sexual dysfunction&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several risk factors are associated with the development of POP&#44; including high parity&#44; advanced age&#44; obesity&#44; hispanic race&#44; low socioeconomic status&#44; and less clearly the type of parity &#40;cesarean section or vaginal delivery&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">3&#44;9&#8211;11</span></a> In the current demographic reality of developed countries&#44; with progressive aging and increased obesity&#44; a significant increase in POP prevalence is expected&#46; In the United States&#44; Wu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> estimate an increase in the number of women with symptomatic POP between 2010 and 2050 from 46&#37; in the best scenario &#40;from 3&#46;3 to 4&#46;9 million women&#41; and up to 200&#37; in the worst scenario &#40;from 3&#46;3 to 9&#46;2 million women&#41;&#46; These circumstances will lead to an increase in the demand for treatment and in the consumption of economic resources&#44; as well as the need for a greater number of experienced professionals in the diagnosis&#44; assessment&#44; and treatment of POP&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Currently&#44; it is discussed what the most effective surgical treatment of POP is&#46; There are several surgical techniques and materials used in the treatment of the same&#46; The number of surgical procedures using transvaginal mesh &#40;TVM&#41; showed a constant increase until 2008 when the FDA issued the first alarm about the use of this type of materials vaginally&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> Several studies<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">14&#44;15</span></a> have shown a change in the trend of surgical treatment of POP from this moment&#44; and especially since 2011 after the second alarm issued by the FDA&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> It is necessary to evaluate the different surgical techniques used in the treatment of POP from the economic point of view in order to optimize the available resources&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of the present study is to perform a comparative study of the direct costs of the surgical treatment of the POP according to its approach by TVM or LS starting from the hypothesis that the correction of the POP by LS would present at least the same cost as the correction of the same through TVM&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a comparative retrospective analysis of the costs of the first 69 consecutive LS procedures carried out between November 2011 and June 2014 compared to the first 69 consecutive TVM procedures carried out between September 2005 and December 2008&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For each procedure &#40;LS and TVM&#41; the direct costs derived from the treatment of the POP were determined&#58; structural&#44; personnel&#44; and operating room occupation costs&#44; anesthetics and resuscitation&#44; hospital stay and implanted prosthetic material&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Implanted prosthetic material</span><p id="par0035" class="elsevierStylePara elsevierViewall">In TVM procedures&#44; the correction of the POP was performed by the implant according to the usual technique of the complete&#44; anterior and posterior Prolift<span class="elsevierStyleSup">&#174;</span> device &#40;Ethicon&#44; Johnson &#38; Johnson&#44; New Brunswick&#44; New Jersey&#44; USA&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the LS procedures the mesh implanted was the preformed non-resorbable polypropylene mesh Uplift<span class="elsevierStyleSup">&#174;</span> &#40;Neomedic International&#44; Terrassa&#44; Barcelona&#44; Spain&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Cost calculation</span><p id="par0045" class="elsevierStylePara elsevierViewall">For each section&#44; the costs were established through the data provided by the Analytical Accounting System of the Ram&#243;n y Cajal University Hospital&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the cost model established for each section in both procedures&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">As it can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; the cost for each item in both groups is different&#44; due to the different temporal moment of both series studied&#44; which implies that the hospital costs are different according to the temporal moment evaluated&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">For each section&#44; the monetary unit in which the costs are established is the euro&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Quantitative variables were described by mean and standard deviation and qualitative variables by relative and absolute frequency&#46; The mean cost for each procedure was calculated with its 95&#37; confidence interval&#44; as well as the minimum and maximum cost for each study group&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">The mean age was similar for both groups &#40;68&#46;6 years for the LS group and 65&#46;2 years for the TVM group&#41;&#46; Regarding the occupation time of the operating room&#44; a longer time of operating room occupation was observed in the LC group &#40;mean of 210&#46;2<span class="elsevierStyleHsp" style=""></span>min&#41; compared to the TVM group &#40;145&#46;3<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; The mean hospital stay was higher in the TVM group &#40;5&#46;88 days&#41; compared to the LS group &#40;3&#46;77 days&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In 41 out of 69 patients &#40;59&#46;4&#37;&#41; of the TVM group&#44; a suburethral sling was implanted as a treatment of SUI simultaneously with the correction of the POP&#46; In the LS group&#44; no patient received suburethral sling simultaneously with POP correction&#46; The rate of intraoperative complications &#40;13 vs&#46; 7&#46;2&#37;&#41; and complications shorter than 30 days &#40;15&#46;9 vs&#46; 8&#46;7&#37;&#41; was higher in the LS group&#44; while the rate of complications greater than 30 days was higher in the TVM group &#40;15&#46;9 vs&#46; 5&#46;8&#37;&#41;&#46; The transfusion rate was low in both groups&#44; requiring transfusion of blood products only one patient in the TVM group&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the characteristics of the sample for both groups with regard to age&#44; surgical time&#44; time of operating room occupation&#44; simultaneous implant of suburethral sling&#44; intraoperative complications&#44; early complications 30 days after the surgical operation and transfusion rate of blood products&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">As it can be observed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; the correction of the POP by LS showed a lower mean cost per procedure &#40;&#8364;5985&#46;7 vs&#46; &#8364;6534&#46;3&#41; than correction thereof by TVM&#46; However&#44; the 95&#37; confidence intervals overlap &#40;&#8364;5613&#46;1&#8211;6358&#46;3 in LS vs&#46; &#8364;6290&#46;4&#8211;6778&#46;3 in TVM&#41;&#44; so the difference between both groups did not reach statistical significance&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> show the mean cost per procedure with the 95&#37; confidence interval&#44; as well as the maximum and minimum cost for both groups under study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Following the successive alarms issued by the FDA in 2008 and 2011&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">13&#44;16</span></a> there has been a change in the trend in surgical treatment of the POP&#46; Wang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> using the Medicare database&#44; observed a progressive decrease in the use of synthetic meshes vaginally&#44; in the repair of the POP from the year 2008 after the first alarm of the FDA<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> and especially from 2011 with the second alarm issued by that organism&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> Skoczylas et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a> analyze 1385 surgical procedures for POP treatment performed in a single institution between 2008 and 2011 with the objective of determining the trend in the surgical treatment of the POP and the influence of the notifications issued by the FDA&#46; A dramatic decline in the performance of vaginal mesh procedures &#40;slope &#8722;0&#46;013&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; was detected&#44; so that in 2008 TVM repair constituted 27&#37; of the procedures&#44; reducing to 15&#37; after the first alarm of the FDA&#44; 5&#37; after the second notification&#44; to end up constituting 2&#37; of the procedures by the end of 2011&#46; In the same way&#44; they observed a significant increase in the number of native tissue correction procedures &#40;slope 0&#46;015&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; of the apical suspensions &#40;slope 0&#46;006&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41; as well as minimally invasive laparoscopic colposacropexy &#40;LC&#41; and robotic colposacropexy procedures &#40;slope of 0&#46;029&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; such that at the end of the study&#44; this last surgical technique was established as the most frequently performed surgical procedure for the treatment of the POP in this institution&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the process of choosing a surgical technique&#44; in addition to the clinical results&#44; it is essential to consider the cost of the procedure in order to optimize the available resources&#46; Therefore&#44; it is essential to evaluate the cost of the different procedures used in daily clinical practice&#46; Several studies have evaluated the cost of the different surgical procedures used in the treatment of the POP<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#8211;22</span></a>&#59; however&#44; few studies have directly compared the cost of treatment by means of LS and TVM&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Maher et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> in a randomized study comparing costs between LS and TVM&#44; establish a cost model for each procedure in both the public and private health systems&#44; including clinical costs &#40;salaries&#44; structural&#44; hospitalization&#44; and consumables costs&#41;&#44; primary costs &#40;clinical costs and loss of productivity during the recovery period&#41;&#44; and total costs &#40;clinical costs&#44; primary and derived from the need for surgical reintervention&#41;&#46; Their results show a significantly lower mean cost per procedure in the LC group than in the TVM group in both clinical costs &#40;&#36;9132&#46;7 &#91;DS 238&#46;9&#93; vs&#46; &#36;10&#44;215&#46;6 &#91;DS 213&#46;6&#93;&#41;&#44; as in the primary costs &#40;&#36;13&#44;957&#46;7 &#91;DS 279&#46;3&#93; vs&#46; &#36;16&#44;289&#46;2 &#91;DS 358&#46;3&#93;&#41; and in total costs &#40;&#36;14&#44;295 &#91;DS 279&#46;3&#93; vs&#46; &#36;18&#44;288 &#91;DS 358&#46;3&#93;&#41;&#46; These authors observe that the LS group incurs a higher expenditure in relation to a longer surgical time&#44; with the consequent higher cost in salaries and structural expenses&#44; whereas the TVM group incurs in a higher expense in relation to the higher cost of consumables&#44; a longer hospital stay&#44; a greater loss of productivity secondary to a longer period of recovery after the intervention&#44; and a higher expenditure secondary to the higher rate of reintervention&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Pan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> recently reported the results of a meta-analysis comparing the results of LS and robot-assisted laparoscopic colposacropexy &#40;RALC&#41;&#44; including the costs of both procedures&#46; In terms of costs&#44; three studies included in this meta-analysis compare the costs of both procedures&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">18&#8211;20</span></a> in all of them observing a significantly higher cost of repair through RALC compared to LS&#46; Similarly&#44; Judd et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> compared the cost of repairing the POP by means of RALC&#44; LS and open abdominal colposacropexy &#40;OAC&#41;&#44; with a significantly higher cost per RALC procedure &#40;&#36;8508&#41; than by LS &#40;&#36;7353&#41; or OAC &#40;&#36;5792&#41;&#46; In the same vein&#44; Patel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> reported a higher cost of RALC &#40;&#36;24&#44;161&#41; compared to LS &#40;&#36;19&#44;308&#41; and OAC &#40;&#36;13&#44;149&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The main strength of our study is to present for the first time in our public health system a comparative study of the direct cost of repairing the POP according to the approach pathway&#46; Similarly to Maher et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> our data show a lower cost of POP repair through LS compared to TVM&#44; although this difference did not reach statistical significance&#46; In the same sense as the study by Maher et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> this work shows that LS repair incurs in a higher expense due to a longer surgical time&#44; of operating room occupation and anesthesia&#44; and the TVM group incurred in a greater cost derived from a longer hospital stay and a higher cost of the implanted prosthetic material&#44; being therefore the results of this study consistent with the published by other authors&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">However&#44; this study is not without limitations&#46; First&#44; the retrospective nature of the study&#46; Secondly&#44; changes in the costs both structural and of personnel&#44; hospital stay or the prosthetic material implanted take place over time&#59; for this reason&#44; the different temporal moment of both series leads to the cost for the same section being variable in both procedures&#46; Third&#44; there have been changes in the hospital discharge strategy and in the treatment of SUI in patients with POP&#44; these strategies being different in the two compared series&#46; Since we performed the correction of the POP by LS&#44; we adopted the strategy of initial correction of the POP in our center&#44; and then&#44; according to the evolution of the SUI&#44; after the anatomical correction of the POP&#44; treatment by suburethral sling of the SUI is carried out in those patients with de novo or persistent SUI&#44; so the cost of treatment of this SUI is not imputed in this group of patients&#46; Also&#44; during the time period of the LS series&#44; an earlier discharge strategy was implemented after the surgical procedure&#44; which reduces the average stay in this group&#46; These biases lead to a lower average cost per procedure in the LS group related to the absence of simultaneous correction of SUI and a shorter hospital stay and not with the surgical technique&#46; The last limitation of this study is the absence of inclusion of the costs derived from the complications and reinterventions in both groups&#46; Maher et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a> reported in 2011 a comparative clinical trial between TVM and LS showing a 2-year correction rate of POP by LS versus TVM &#40;77 vs&#46; 43&#37;&#41;&#44; as well as a lower rate of reintervention through LC than through TVM &#40;5 vs&#46; 22&#37;&#41;&#44; both statistically significant&#46; Thus&#44; as published in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">23&#44;24</span></a> the imputation of these costs in the study would lead to a greater increase of the cost of repair of the POP through TVM than through LS&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In spite of these limitations&#44; this study reveals for the first time in our country that the repair of the POP by laparoscopic abdominal approach does not present a cost per procedure greater than the correction of the same by means of vaginal approach with mesh and&#44; therefore&#44; in addition to being a safe alternative for the treatment of POP&#44; LC is also an efficient alternative for POP repair&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">The correction of the POP by laparoscopic abdominal approach with LS presents&#44; in our environment&#44; an average cost per procedure similar to the correction of the same vaginally through TVM&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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    "fechaRecibido" => "2016-06-06"
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            0 => "Pelvic organ prolapse"
            1 => "Cost analysis"
            2 => "Laparoscopic sacrocolpopexy"
            3 => "Vaginal mesh"
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            0 => "Prolapso de &#243;rganos p&#233;lvicos"
            1 => "An&#225;lisis de costes"
            2 => "Colposacropexia laparosc&#243;pica"
            3 => "Malla transvaginal"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objective of this study is to compare direct costs of repairing pelvic organ prolapse by laparoscopic sacrocolpopexy &#40;LS&#41; against vaginal mesh &#40;VM&#41;&#46; Our hypothesis is the correction of pelvic organ prolapse by LS has a similar cost per procedure compared to VM&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We made a retrospective comparative analysis of medium cost per procedure of first 69 consecutive LS versus first 69 consecutive VM surgeries&#46; We calculate direct cost for each procedure&#58; structural outlays&#44; personal&#44; operating room occupation&#44; hospital stay&#44; perishable or inventory material and prosthetic material&#46; Medium cost per procedure were calculated for each group&#44; with a 95&#37; confidence interval&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">LS group has a higher cost related to a longer length of surgery&#44; higher operating room occupation and anesthesia&#59; VM group has a higher cost due to longer hospital stay and more expensive prosthetic material&#46; Globally&#44; LS has a lower medium cost per procedure in comparison to VM &#40;5985&#46;7<span class="elsevierStyleHsp" style=""></span>&#8364;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1550&#46;8<span class="elsevierStyleHsp" style=""></span>&#8364; vs&#46; 6534&#46;3<span class="elsevierStyleHsp" style=""></span>&#8364;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1015&#46;5<span class="elsevierStyleHsp" style=""></span>&#8364;&#41;&#44; although it did not achieve statistical signification&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our midst&#44; pelvic organ prolapse surgical correction by LS has at least similar cost per procedure compared to VM&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio es realizar un an&#225;lisis comparativo de los costes directos de la reparaci&#243;n del prolapso de &#243;rganos p&#233;lvicos mediante colposacropexia laparosc&#243;pica &#40;CL&#41; o malla transvaginal &#40;MTV&#41;&#46; La hip&#243;tesis inicial es que la correcci&#243;n del prolapso de &#243;rganos p&#233;lvicos mediante CL presentar&#237;a al menos un coste por procedimiento similar a la correcci&#243;n mediante MTV&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo comparativo del coste medio por procedimiento de los primeros 69 procedimientos consecutivos de CL frente a los primeros 69 procedimientos consecutivos de MTV&#46; Para cada procedimiento&#44; se determinaron los costes directos&#58; gastos estructurales&#44; personal&#44; ocupaci&#243;n de quir&#243;fano&#44; estancia hospitalaria&#44; material fungible e inventariable y el material prot&#233;sico implantado&#46; Se determin&#243; el coste medio por procedimiento para cada uno de los grupos&#44; con el intervalo de confianza al 95&#37;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mientras que el grupo de CL incurri&#243; en un mayor gasto en relaci&#243;n con un mayor tiempo quir&#250;rgico&#44; ocupaci&#243;n de quir&#243;fano y anestesia&#44; el grupo de MTV incurri&#243; en un mayor gasto en relaci&#243;n con una mayor estancia hospitalaria y un coste mayor del material prot&#233;sico implantado&#46; De forma global&#44; si bien el grupo de CL present&#243; un coste medio por procedimiento menor que el grupo de MTV &#40;5&#46;985&#44;7 &#8364;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;550&#44;8 &#8364; vs&#46; 6&#46;534&#44;3 &#8364;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;015&#44;5 &#8364;&#41;&#44; esta diferencia no alcanz&#243; la significaci&#243;n estad&#237;stica&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestro medio&#44; la correcci&#243;n del prolapso de &#243;rganos p&#233;lvicos mediante CL presenta al menos&#44; un coste por procedimiento similar a la correcci&#243;n del mismo mediante MTV&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carracedo D&#44; L&#243;pez-Fando L&#44; S&#225;nchez MD&#44; Jim&#233;nez M&#193;&#44; G&#243;mez JM&#44; Laso I&#44; et al&#46; An&#225;lisis de costes del tratamiento del prolapso de &#243;rganos p&#233;lvicos mediante colposacropexia laparosc&#243;pica o malla transvaginal&#46; Actas Urol Esp&#46; 2017&#59;41&#58;117&#8211;122&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 804
            "Ancho" => 1624
            "Tamanyo" => 39478
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Box plot of the average cost per procedure&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">LS&#44; Laparoscopic sacrocolpopexy&#59; VM&#44; Vaginal mesh&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => 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"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83&#46;81&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#46;36&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;46&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;6&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prostheses and implants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">391&#46;47&#47;pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1281&#46;21&#47;pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products &#40;rest&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;64&#47;pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;21&#47;pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;94&#47;pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;91&#47;pat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Operating room&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">548&#46;37&#47;unit occupation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">517&#46;14&#47;unit occupation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anesthesia and resuscitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">187&#46;27&#47;unit occupation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">127&#46;55&#47;unit occupation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breakfast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;14&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;94&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lunch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;54&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;81&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snack&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;09&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;96&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dinner&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;98&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;28&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">238&#46;41&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">184&#46;78&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate services&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">172&#46;94&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">180&#46;6&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Structure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;05&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;16&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TVT&#47;TOT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">527&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">527&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Cost model established for each section&#46;</p>"
        ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">LS&#44; Laparoscopic sacrocolpopexy&#59; VM&#44; Vaginal mesh&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">LS</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VM</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Min&#8211;max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;6 &#40;8&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#8211;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;2 &#40;9&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#8211;85&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">210&#46;2 &#40;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&#8211;360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">145&#46;3 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occupation time &#40;units&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;82 &#40;1&#46;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;75&#8211;8&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;33 &#40;0&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;29&#8211;4&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Admission days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;77 &#40;1&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;88 &#40;2&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#8211;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Probing days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;73 &#40;2&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;8 &#40;2&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suburet&#46; sling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intraop&#46; Com&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minor Com&#46; 30 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Major Com&#46; 30 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transfusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">VM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">315&#46;82 &#40;109&#46;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">404&#46;17 &#40;144&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;51 &#40;1&#46;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;3 &#40;11&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prostheses and implants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">391&#46;47 &#40;constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1281&#46;21 &#40;constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharmaceutical products &#40;rest&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;64 &#40;constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;21 &#40;constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Functioning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;94 &#40;constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;91 &#40;constant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Operating room&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2643&#46;97 &#40;780&#46;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1724&#46;14 &#40;146&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anesthesia and resuscitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">812&#46;63 &#40;239&#46;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">382&#46;78 &#40;32&#46;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breakfast&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;83 &#40;4&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;96 &#40;6&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lunch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#46;48 &#40;15&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&#46;53 &#40;22&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snack&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;88 &#40;2&#46;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;31 &#40;4&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dinner&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;37 &#40;14&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#46;3 &#40;21&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">898&#46;36 &#40;311&#46;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1065&#46;83 &#40;380&#46;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate services&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">651&#46;66 &#40;226&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1041&#46;76 &#40;371&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Structure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;8 &#40;7&#46;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98&#46;98 &#40;35&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TVT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">321&#46;09 &#40;259&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Total</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">5985&#46;7 &#40;1550&#46;87&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">6534&#46;31 &#40;1015&#46;52&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">5613&#46;14&#8211;6358&#46;26</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">6290&#46;36&#8211;6778&#46;27</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Min&#8211;max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">3990&#46;48&#8211;11&#44;969&#46;92</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">4989&#46;48&#8211;11&#44;234&#46;79</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
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              "identificador" => "bib0125"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and prevalence of pelvic organ prolapse"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Chow"
                            1 => "V&#46;L&#46; Rodr&#237;guez"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Curr Op Urol"
                        "fecha" => "2013"
                        "volumen" => "23"
                        "paginaInicial" => "293"
                        "paginaFinal" => "298"
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              "identificador" => "bib0130"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors"
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                          "etal" => false
                          "autores" => array:4 [
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                            1 => "F&#46;T&#46; Victor"
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                            3 => "K&#46;F&#46; Sv&#228;rdsudd"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Am J Obstet Gynecol"
                        "fecha" => "1999"
                        "volumen" => "180"
                        "paginaInicial" => "299"
                        "paginaFinal" => "305"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9988790"
                            "web" => "Medline"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and trends of symptomatic pelvic floor Disorders in U&#46;S&#46; women"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Wu"
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                            3 => "D&#46;T&#46; Redden"
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                            5 => "H&#46;E&#46; Richter"
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                        "paginaFinal" => "148"
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                      "titulo" => "Lifetime risk of undergoing surgery for pelvic organ prolapse"
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                            0 => "F&#46;J&#46; Smith"
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