Predicting the effectiveness of extracorporeal shock wave lithotripsy on urinary tract stones. Risk groups for accurate retreatment | Actas Urológicas Españolas (English Edition)

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Grupos de riesgo para precisar retratamiento" ] ] "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" => 1067 "Ancho" => 1648 "Tamanyo" => 208645 ] ] "descripcion" => array:1 [ "en" => "Measurement area (cm2) and maximum density (HU)." ] ] ] "textoCompleto" => "IntroductionExtracorporeal shock wave lithotripsy (ESWL) – from Greek lithos (stone) and Latin terere (grind) – is acoustic pulse therapy for urinary tract stones. Its use began in the early 1980s in Germany Medtech and has been generalized in the urological field thanks to Chaussy et al.<a class="elsevierStyleCrossRef" href="#bib0155">1</a> over the years. It is currently considered a non-invasive, safe and effective treatment. This effectiveness varies according to the location and size of the stone,<a class="elsevierStyleCrossRef" href="#bib0160">2</a> among other factors, which sometimes generates the need to carry out several sessions to solve the problem. This causes an impact, on the one hand, on the quality of life of the patients, who have to be treated through various procedures with their corresponding discomfort and, on the other hand, economic because of the associated costs that it entails.Computed tomography (CT) is a very complete imaging test<a class="elsevierStyleCrossRef" href="#bib0165">3</a> that has become the ‘gold standard’ for the diagnosis of renal colic or acute flank pain.<a class="elsevierStyleCrossRefs" href="#bib0170">4–6</a> It enables the diagnosis of the presence, number, size and exact location of the stone or stones that cause the symptoms, as well as any associated abdominal disease or that is responsible for the symptoms, once the urologic disease is ruled out. In addition, with this technique, different additional variables that may be important in the course of treatment, such as stone density,<a class="elsevierStyleCrossRefs" href="#bib0185">7–11</a> area or distance to the skin<a class="elsevierStyleCrossRefs" href="#bib0210">12–17</a> have been studied to date.It is, therefore, interesting to study the variables that may influence the need to carry out a retreatment after ESWL. The objective is to anticipate the effectiveness of the treatment to choose from the beginning another therapeutic approach. This would make it possible to save discomfort, time, radiation, procedures and costs derived. In other words, it is a question of identifying predictors and choosing the right candidates.<a class="elsevierStyleCrossRefs" href="#bib0240">18–20</a>Materials and methodsThis is a retrospective analytical study which includes 211 patients among all those treated by ESWL at our center between January 2010 and December 2014. The selection criterion chosen is the presence of CT scan performed at diagnosis. Follow-up concluded in June 2015, so the time ranges between 6 and 27 months.As clinical variables, we recorded sex, age, body mass index, and previous smoking history (previous or current).The multislice helical CT was made with Siemens Somaton Definition CT and Siemens Sensation 64, with milliamps (mA) adjusted according to the image window, 120 kilovolts (kV), with cuts every 5mm in its axial, coronal, and sagittal projections, without intravenous contrast and with it (0.5ml/kg). Through the image viewer Syngo Studio fastView and its tools, we manually analyzed the radiological variables (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>): stone location (upper, middle, or lower calyx, renal pelvis, proximal, middle, or distal ureter), maximum diameter in milimeters (mm), area in square centimeters (cm2), distance from the skin to the stone in centimeters (cm), maximum density in Hounsfield units (HU), thickness of adipose panicle at umbilical level (cm), presence of catheter or of dilation of the urinary tract. The distances and diameters were calculated by means of a computer rule, as well as the area that defined the contour, where the program automatically calculates the maximum and minimum density and the arithmetic mean. Most of the stones are mixed and perhaps it would be more appropriate to use the latter, but because in small lithiases the measurement of HU tends to be underestimated by the surrounding tissue, we chose the maximum density in the cross section and in the zone of largest area to be a more reproducible and more representative measurement.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>ESWL procedures were performed under sedation by the Anesthesia Service (paracetamol with or without metamizole, intravenous midazolam and remifentanyl in continuous perfusion). Siemens Lithoskop combined X-ray/shock wave C-arm system was used to locate and fragment the stone, whose evolution was periodically assessed by fluoroscopy during the procedure. As a general rule, the total energy limit applied in each procedure was 60 joules (J) for renal lithiasis or 120J for ureteral lithiasis, with a frequency of 60 and 90hertz (Hz), respectively. Tolerance was good or very good in all cases, with no incidences. In addition, we recorded the duration time in minutes (min), the number and frequency of shock waves, and the total energy delivered. At the end of the treatment, the disintegration of the stone was grouped according to whether the size of the residual fragments was smaller or greater than 4mm.Patients were performed a simple X-ray of the abdomen systematically after 15 days, sometimes repeated several times up to 3 months after the procedure.Due to the variation in the time elapsed to being free of lithiasic fragments, we defined as success in our study the lack of need for a posterior retreatment, as well as the lack of need for complementary maneuver along the follow-up.We used frequency analyses to describe the clinical-radiological characteristics, ROC curves to choose the best cut-off point in the different variables (the criterion used to establish it was that the sum of sensitivity plus specificity was maximum) and binary logistic regression models (univariate and multivariate study) to obtain those with independent influence on the need for retreatment. With the latter, we have designed a risk model that evaluates by binary logistic regression all possible combinations and allows us to choose the best possible model, that is, the one that best explains the probability of needing retreatment, with greater statistical significance than any of the influential variables individually (IBM SPSS version 20.0).ResultsA total of 211 patients (126 men, 85 women) were included; in 101 cases (47.9%), lithiases were pyelo-caliceal and in 110 they were ureteral (52.1%). In 174 patients (82.5%) the residual fragments were ≤4mm. 84 patients required retreatment (39.8%).The clinical and radiological characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Using the ROC curves of quantitative variables (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), their coordinates and their areas under the curve (AUC), we chose the best cut-off point (the one with the highest sensitivity and specificity possible).<a class="elsevierStyleCrossRef" href="#bib0255">21</a> These cut-off points are 864 HU for the maximum density of the stone, 7.5mm for the maximum diameter, 0.4cm2 for the area, and 2.67cm for the adipose panicle with the observed AUCs (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In the univariate study, the following variables are influential: maximum density >864 HU (OR: 3.41); maximum diameter 7.5mm (OR: 3.64); area >0.4cm2 (OR: 3.89); pyelo-calyceal versus ureteral location (OR: 2.99); residual fragments >4 versus ≤4mm (OR: 8.46) and thickness of the adipose panicle at the umbilical level >2.67cm (OR: 1.92).According to the multivariate study, among all influential variables, those with independent influence on the need for retreatment are the 3 listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Risk modelAfter studying all possible combinations using binary logistic regression, we chose the one that best explains the probability of needing retreatment, significantly better than any of the influential variables taken independently.The best model includes 3 risk groups according to the number of variables that they present (density>864 HU/diameter>7.5mm/pyelo-calyceal location), likely to require significantly different retreatment (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">Group 1 – low risk (0 variables): formed by 94 patients (44.6%). OR: 1; p≤0.000.</li><li class="elsevierStyleListItem" id="lsti0010">Group 2 – intermediate risk (1–2 variables): formed by 61 patients (28.9%). OR: 3.25; 95% CI: 1.56–6.75; p=0.002.</li><li class="elsevierStyleListItem" id="lsti0015">Group 3 – high risk (3 variables): formed by 56 patients (26.5%). OR: 6.49; 95% CI: 3.10–13.60; p<0.000.</li></ul><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Retreatment according to risk groupsAccording to the risk model, 19 patients from group 1 (20.2%), 30 from group 2 (49.2%), and 35 from group 3 (62.5%) required retreatment (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>DiscussionAccording to the clinical guidelines of the EAU,<a class="elsevierStyleCrossRef" href="#bib0155">1</a> depending on the size and location of the stone, there are different active treatment options equally valid, with no evidence in favor of one or the other, i.e., ESWL or ureterorenoscopy (URS)/retrograde intrarenal surgery/percutaneous nephrolithotomy.The present study focuses on the treatment of stones by means of ESWL with the aim of improving patient selection by taking more data into account. It is a retrospective analysis of the variables that themselves influence the need to receive at least one second treatment of ESWL. In addition, the complete information provided by the CT is used, which, on the other hand, is the imaging test of choice in cases of renal colic,<a class="elsevierStyleCrossRef" href="#bib0220">14</a> although it is not performed systematically in all centers.There are studies in the literature about the usefulness of CT to estimate the percentage of calcium in the stone<a class="elsevierStyleCrossRef" href="#bib0260">22</a> and to predict its composition.<a class="elsevierStyleCrossRefs" href="#bib0265">23–27</a> Also, the ratio of the density of the stone with its hardness or resistance to shock waves is known; specifically, the guidelines of the EAU point out that a possible cut-off point would be 1000 HU, and those whose density exceeds this figure are classified as extreme hardness.With regard to the skin-to-stone distance (SSD), it is logical to think that, the greater the distance, the lower the effectiveness of the shock waves of the ESWL on the objective. In fact, in studies such as that by Patel et al.,<a class="elsevierStyleCrossRef" href="#bib0215">13</a> the only independent influence factor for the rate of absence of lithiasis in their series is SSD, above even the density of the stone.Müllhaupt et al.<a class="elsevierStyleCrossRef" href="#bib0230">16</a> are in the line of Patel when confirming the influence of the SSD, which surpasses the density of the stone as predictor. They also mention the body mass index, in which, however, the results of the studies are more contradictory.<a class="elsevierStyleCrossRefs" href="#bib0220">14,15</a> It is known, for example, that obesity is a factor that has a negative influence on the effectiveness of ESWL, due to the distance that the shock waves have to travel, but it is also logical to think that it has to influence the composition of living tissues (skin, adipose tissue, aponeurosis, muscle) that are on the way from the generator to the stone, because the transmission of waves is affected by factors such as water.<a class="elsevierStyleCrossRef" href="#bib0290">28</a>To continue with the idea of existing studies, the therapeutic procedure can be further refined thanks to CT, obtaining multiple detailed patient data such as diameters (anteroposterior, transverse, diagonal) or distance from the adipose panicle. In addition, there are promising predictive options, such as dual energy computed tomography, which seems to have a greater potential to characterize the composition of the different types of stones.In our study, variables such as maximum density, area, diameter and location of the stone, the adipose panicle of the patient (with 2.67cm as the cut-off point) and the estimated residual fragments size at the end of the procedure are influential: all of them are logical and in line with what is published. Of all of them, those that influence independently are maximum density, diameter, and location. With these 3variables, which can be quickly and easily obtained with CT without waiting for the radiological report, it is possible to distribute or stratify patients according to each case (in the form of presence=1/absence=0). Thus, a score can be attributed from 0 (ureteral location, diameter smaller than 7.5mm, and maximum density lower than 864 HU) to 3 (pyelo-calicial location, diameter greater than 7.5mm, and maximum density greater than 864 HU), passing through intermediate situations according to the variables presented.In addition, the objective of this study is to obtain the variables prior to the ESWL to try to predict its effectiveness. In the cases where URS or ESWL can be chosen, the experience of the urologist, the accessibility to a treatment with ESWL, the location with the particularity of the lower calyx,<a class="elsevierStyleCrossRef" href="#bib0295">29</a> and the personal situation of each patient, among other things, are taken into account. The trend has changed in recent years: although ESWL remains widespread, the number of endoscopic treatments is increasing considerably, as described by García Galisteo et al.<a class="elsevierStyleCrossRef" href="#bib0300">30</a>There are differences between both techniques, such as invasiveness, manipulation of the urinary tract, hospitalization versus outpatient regimen, regional/general anesthesia versus sedation, having catheter or not after the procedure, solving the problem at the moment or ejecting fragments for a few days or weeks, etcetera. Therefore, with these risk groups we have more data when choosing one technique or another, individualizing with each patient. For example, in the case of a patient in group 3 (high risk of retreatment-3 variables present), an endoscopic treatment (URS/retrograde intrarenal surgery) could be chosen, given the high probability of a retreatment in case of ESWL. Otherwise, a patient in group 1 (low risk of retreatment-none of the variables present) could be informed of the low invasiveness of the ESWL procedure and the high probability of success in his particular case, with an improvement of the usual success rate, being a conditional probability.Of course, this risk model is not intended to impose a treatment over another, since the choice depends on many factors. It only tries to give more information to help in the decision making. It is necessary to deepen the studies, increasing the number of patients and trying to further limit the variables.Finally, as limitations and aspects to be revised facing future studies, we consider the possibility of studying more in detail the size, location of the stone, and to deepen in the SSD. In the case of the size, the volume is better estimator than the maximum diameter or area, so if a 3D reconstruction is available, it can be more accurate. As for the location, it would have to be considered more specifically according to the calyx or the ureteral level in which the stone is. For this, it would be advisable to increase significantly the number of patients studied. And for the SSD, which does not appear to have influence based on our study, perhaps establishing the difference of the distance according to the location of the wave generator could provide more information and have a greater protagonism, as it has been discussed in the studies mentioned.ConclusionsThe density, maximum diameter, and the pyelo-calyceal position of the stone are determining factors in the effectiveness of the treatment with ESWL. With these variables, which can be obtained before the therapeutic decision, the risk model designed enables a precise approach to choose the most appropriate treatment for each particular case.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres886506" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec872659" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres886505" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec872660" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Risk model" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Retreatment according to risk groups" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-17" "fechaAceptado" => "2016-12-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec872659" "palabras" => array:3 [ 0 => "Extracorporeal shock wave lithotripsy" 1 => "Retreatment" 2 => "Risk model" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec872660" "palabras" => array:3 [ 0 => "Litotricia extracorpórea por ondas de choque" 1 => "Retratamiento" 2 => "Modelo de riesgo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionExtracorporeal shock wave lithotripsy (ESWL) is a non-invasive, safe and effective treatment for urinary tract lithiasis. Its effectiveness varies depending on the location and size of the stones as well as other factors; several sessions are occasionally required. The objective is to attempt to predict its success or failure, when the influential variables are known beforehand. Material and methodsWe analyzed 211 patients who had had previous CT scans and were treated with ESWL between 2010 and 2014. The influential variables in requiring retreatment were studied using binary logistic regression models (univariate and multivariate analysis): maximum density, maximum diameter, area, location, disintegration and distance from the adipose panniculus. With the influential variables, a risk model was designed by assessing all possible combinations with logistic regression (version 20.0 IBM SPSS). ResultsThe independent influential variables on the need for retreatment are: maximum density >864 HU, maximum diameter >7.5mm and pyelocaliceal location. Using these variables, the best model includes 3 risk groups with a probability of requiring significantly different retreatment: group 1 – low risk (0 variables) with 20.2%; group 2 – intermediate risk (1–2 variables) with 49.2%; and group 3 – high risk (3 variables) with 62.5%. ConclusionsThe density, maximum diameter and pyelocaliceal location of the stones are determinant factors in terms of the effectiveness of treatment with ESWL. Using these variables, which can be obtained in advance of deciding on a treatment, the designed risk model provides a precise approach in choosing the most appropriate treatment for each particular case." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa litotricia extracorpórea por ondas de choque (LEOC) es un tratamiento no invasivo, seguro y efectivo para las litiasis del tracto urinario cuya efectividad varía según la localización y el tamaño del cálculo, entre otros factores; en ocasiones es necesario realizar varias sesiones. El objetivo es tratar de predecir el éxito o fracaso conociendo previamente las variables influyentes. Material y métodosAnalizamos a 211 pacientes con TAC previa entre aquellos tratados mediante LEOC entre los años 2010 y 2014. Se estudian las variables influyentes en la necesidad de retratamiento utilizando modelos de regresión logística binaria (estudio uni- y multivariado): densidad máxima, diámetro máximo, área, localización, desintegración y distancia del panículo adiposo. Con las variables influyentes se ha diseñado un modelo de riesgo valorando con regresión logística todas las posibles combinaciones (IBM SPSS versión 20.0). ResultadosLas variables de influencia independiente en la necesidad de retratamiento son: densidad máxima >864 UH, diámetro máximo >7,5mm y localización pielocalicial. Utilizando estas variables, el mejor modelo incluye 3 grupos de riesgo con probabilidades de necesitar retratamiento significativamente diferentes: grupo 1-bajo riesgo (0 variables) con 20,2%, grupo 2-riesgo intermedio (1-2 variables) con 49,2% y grupo 3-alto riesgo (3 variables) con 62,5%. ConclusionesLa densidad, el diámetro máximo y la localización pielocalicial del cálculo son factores determinantes en la efectividad del tratamiento con LEOC. Con estas variables, que se pueden obtener antes de la decisión terapéutica, el modelo de riesgo diseñado permite una aproximación precisa de cara a elegir el tratamiento más adecuado para cada caso en particular." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Hevia M, García Á, Ancizu FJ, Merino I, Velis JM, Tienza A, et al. Predicción de efectividad de litotricia extracorpórea por ondas de choque en cálculos del tracto urinario. Grupos de riesgo para precisar retratamiento. Actas Urol Esp. 2017;41:451–457." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1067 "Ancho" => 1648 "Tamanyo" => 208645 ] ] "descripcion" => array:1 [ "en" => "Measurement area (cm2) and maximum density (HU)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1888 "Ancho" => 2520 "Tamanyo" => 170443 ] ] "descripcion" => array:1 [ "en" => "ROC curves." ] ] 2 => 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:1 [ "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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \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">Median \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">Range \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 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15–86 \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">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.7–39.7 \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">Pyelo-calyceal location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 (47.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Ureteral location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">110 (52.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Distance to the panicle (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.55–6.87 \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">Previous catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (25.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Dilation of the urinary tract \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 (49.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Maximum diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3–27.6 \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">Maximum density (HU) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">937 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">123–1705 \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">Good- very good fragmentation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">174 (82.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Retreatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 (39.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497966.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and radiological characteristics." ] ] 3 => 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 [ "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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variables contrast result \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Area \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Standard error<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Asymptotic sig.<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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">Asymptotic confidence interval at 95%</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="" 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="" 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="" 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">Lower limit \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">Upper limit \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">Area (cm2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.729 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.037 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.657 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.801 \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">Maximum diameter (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.730 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.036 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.659 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.802 \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">Panicle distance (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.534 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.041 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.407 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.453 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.615 \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">Maximum density (HU) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.675 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.038 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.601 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.748 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497965.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Under the non-parametric assumption." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Null hypothesis: true area =0.5." ] ] ] "descripcion" => array:1 [ "en" => "Areas under the curve (AUC)." ] ] 4 => 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:1 [ "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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \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">OR \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">95% CI \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">p \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">Wald \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">Maximum density>864 HU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.04–3.72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.363 \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">Diameter>7.5mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.23–4.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.609 \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">Pyelo-calyceal location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.30–4.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.796 \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">Constant (−1.815) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.163 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497961.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Variables of independent influence on the need for retreatment." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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">Variables \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">OR \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">95% CI \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">p \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">Group 1 (44.6%) \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="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \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">Group 2 (28.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.56–6.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \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">Group 3 (26.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.10–13.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497960.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Risk model." ] ] 6 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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 " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Retreatment</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \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">No \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">Yes \t\t\t\t\t\t\n \t\t\t\t</th><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></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Risk groups</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low (group 1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">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">Intermediate (group 2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \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">High (group 3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">211 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1497964.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Retreatment according to the risk group." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extracorporeal shockwave lithotripsy (ESWL): a chronology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. 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Original article

Predicting the effectiveness of extracorporeal shock wave lithotripsy on urinary tract stones. Risk groups for accurate retreatment

Predicción de efectividad de litotricia extracorpórea por ondas de choque en cálculos del tracto urinario. Grupos de riesgo para precisar retratamiento

M. Heviaa,

Corresponding author

mhsuarez@unav.es

Corresponding author.

, Á. Garcíaa, F.J. Ancizua, I. Merinoa, J.M. Velisa, A. Tienzab, R. Algarrac, P. Doménecha, F. Diez-Caballeroa, D. Rosella, J.I. Pascuala, J.E. Roblesa

a Departamento de Urología, Clínica Universidad de Navarra, Pamplona, Spain

b Servicio de Urología, Hospital Universitario Son Espases, Mallorca, Spain

c Departamento de Urología, Hospital Nuestra Señora del Rosario, Madrid, Spain

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Measurement area &#40;cm<span class="elsevierStyleSup">2</span>&#41; and maximum density &#40;HU&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Extracorporeal shock wave lithotripsy &#40;ESWL&#41; &#8211; from Greek lithos &#40;stone&#41; and Latin terere &#40;grind&#41; &#8211; is acoustic pulse therapy for urinary tract stones&#46; Its use began in the early 1980s in Germany Medtech and has been generalized in the urological field thanks to Chaussy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> over the years&#46; It is currently considered a non-invasive&#44; safe and effective treatment&#46; This effectiveness varies according to the location and size of the stone&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> among other factors&#44; which sometimes generates the need to carry out several sessions to solve the problem&#46; This causes an impact&#44; on the one hand&#44; on the quality of life of the patients&#44; who have to be treated through various procedures with their corresponding discomfort and&#44; on the other hand&#44; economic because of the associated costs that it entails&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Computed tomography &#40;CT&#41; is a very complete imaging test<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> that has become the &#8216;gold standard&#8217; for the diagnosis of renal colic or acute flank pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;6</span></a> It enables the diagnosis of the presence&#44; number&#44; size and exact location of the stone or stones that cause the symptoms&#44; as well as any associated abdominal disease or that is responsible for the symptoms&#44; once the urologic disease is ruled out&#46; In addition&#44; with this technique&#44; different additional variables that may be important in the course of treatment&#44; such as stone density&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#8211;11</span></a> area or distance to the skin<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#8211;17</span></a> have been studied to date&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is&#44; therefore&#44; interesting to study the variables that may influence the need to carry out a retreatment after ESWL&#46; The objective is to anticipate the effectiveness of the treatment to choose from the beginning another therapeutic approach&#46; This would make it possible to save discomfort&#44; time&#44; radiation&#44; procedures and costs derived&#46; In other words&#44; it is a question of identifying predictors and choosing the right candidates&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">18&#8211;20</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This is a retrospective analytical study which includes 211 patients among all those treated by ESWL at our center between January 2010 and December 2014&#46; The selection criterion chosen is the presence of CT scan performed at diagnosis&#46; Follow-up concluded in June 2015&#44; so the time ranges between 6 and 27 months&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As clinical variables&#44; we recorded sex&#44; age&#44; body mass index&#44; and previous smoking history &#40;previous or current&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The multislice helical CT was made with Siemens Somaton Definition CT and Siemens Sensation 64&#44; with milliamps &#40;mA&#41; adjusted according to the image window&#44; 120 kilovolts &#40;kV&#41;&#44; with cuts every 5<span class="elsevierStyleHsp" style=""></span>mm in its axial&#44; coronal&#44; and sagittal projections&#44; without intravenous contrast and with it &#40;0&#46;5<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41;&#46; Through the image viewer Syngo Studio fastView and its tools&#44; we manually analyzed the radiological variables &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58; stone location &#40;upper&#44; middle&#44; or lower calyx&#44; renal pelvis&#44; proximal&#44; middle&#44; or distal ureter&#41;&#44; maximum diameter in milimeters &#40;mm&#41;&#44; area in square centimeters &#40;cm<span class="elsevierStyleSup">2</span>&#41;&#44; distance from the skin to the stone in centimeters &#40;cm&#41;&#44; maximum density in Hounsfield units &#40;HU&#41;&#44; thickness of adipose panicle at umbilical level &#40;cm&#41;&#44; presence of catheter or of dilation of the urinary tract&#46; The distances and diameters were calculated by means of a computer rule&#44; as well as the area that defined the contour&#44; where the program automatically calculates the maximum and minimum density and the arithmetic mean&#46; Most of the stones are mixed and perhaps it would be more appropriate to use the latter&#44; but because in small lithiases the measurement of HU tends to be underestimated by the surrounding tissue&#44; we chose the maximum density in the cross section and in the zone of largest area to be a more reproducible and more representative measurement&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">ESWL procedures were performed under sedation by the Anesthesia Service &#40;paracetamol with or without metamizole&#44; intravenous midazolam and remifentanyl in continuous perfusion&#41;&#46; Siemens Lithoskop combined X-ray&#47;shock wave C-arm system was used to locate and fragment the stone&#44; whose evolution was periodically assessed by fluoroscopy during the procedure&#46; As a general rule&#44; the total energy limit applied in each procedure was 60 joules &#40;J&#41; for renal lithiasis or 120<span class="elsevierStyleHsp" style=""></span>J for ureteral lithiasis&#44; with a frequency of 60 and 90<span class="elsevierStyleHsp" style=""></span>hertz &#40;Hz&#41;&#44; respectively&#46; Tolerance was good or very good in all cases&#44; with no incidences&#46; In addition&#44; we recorded the duration time in minutes &#40;min&#41;&#44; the number and frequency of shock waves&#44; and the total energy delivered&#46; At the end of the treatment&#44; the disintegration of the stone was grouped according to whether the size of the residual fragments was smaller or greater than 4<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients were performed a simple X-ray of the abdomen systematically after 15 days&#44; sometimes repeated several times up to 3 months after the procedure&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Due to the variation in the time elapsed to being free of lithiasic fragments&#44; we defined as success in our study the lack of need for a posterior retreatment&#44; as well as the lack of need for complementary maneuver along the follow-up&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We used frequency analyses to describe the clinical-radiological characteristics&#44; ROC curves to choose the best cut-off point in the different variables &#40;the criterion used to establish it was that the sum of sensitivity plus specificity was maximum&#41; and binary logistic regression models &#40;univariate and multivariate study&#41; to obtain those with independent influence on the need for retreatment&#46; With the latter&#44; we have designed a risk model that evaluates by binary logistic regression all possible combinations and allows us to choose the best possible model&#44; that is&#44; the one that best explains the probability of needing retreatment&#44; with greater statistical significance than any of the influential variables individually &#40;IBM SPSS version 20&#46;0&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 211 patients &#40;126 men&#44; 85 women&#41; were included&#59; in 101 cases &#40;47&#46;9&#37;&#41;&#44; lithiases were pyelo-caliceal and in 110 they were ureteral &#40;52&#46;1&#37;&#41;&#46; In 174 patients &#40;82&#46;5&#37;&#41; the residual fragments were &#8804;4<span class="elsevierStyleHsp" style=""></span>mm&#46; 84 patients required retreatment &#40;39&#46;8&#37;&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The clinical and radiological characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Using the ROC curves of quantitative variables &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; their coordinates and their areas under the curve &#40;AUC&#41;&#44; we chose the best cut-off point &#40;the one with the highest sensitivity and specificity possible&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> These cut-off points are 864 HU for the maximum density of the stone&#44; 7&#46;5<span class="elsevierStyleHsp" style=""></span>mm for the maximum diameter&#44; 0&#46;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> for the area&#44; and 2&#46;67<span class="elsevierStyleHsp" style=""></span>cm for the adipose panicle with the observed AUCs &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In the univariate study&#44; the following variables are influential&#58; maximum density &#62;864 HU &#40;OR&#58; 3&#46;41&#41;&#59; maximum diameter 7&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;OR&#58; 3&#46;64&#41;&#59; area &#62;0&#46;4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> &#40;OR&#58; 3&#46;89&#41;&#59; pyelo-calyceal versus ureteral location &#40;OR&#58; 2&#46;99&#41;&#59; residual fragments &#62;4 versus &#8804;4<span class="elsevierStyleHsp" style=""></span>mm &#40;OR&#58; 8&#46;46&#41; and thickness of the adipose panicle at the umbilical level &#62;2&#46;67<span class="elsevierStyleHsp" style=""></span>cm &#40;OR&#58; 1&#46;92&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">According to the multivariate study&#44; among all influential variables&#44; those with independent influence on the need for retreatment are the 3 listed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Risk model</span><p id="par0115" class="elsevierStylePara elsevierViewall">After studying all possible combinations using binary logistic regression&#44; we chose the one that best explains the probability of needing retreatment&#44; significantly better than any of the influential variables taken independently&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The best model includes 3 risk groups according to the number of variables that they present &#40;density<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>864 HU&#47;diameter<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#47;pyelo-calyceal location&#41;&#44; likely to require significantly different retreatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 1 &#8211; low risk &#40;0 variables&#41;</span>&#58; formed by 94 patients &#40;44&#46;6&#37;&#41;&#46; OR&#58; 1&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 2 &#8211; intermediate risk &#40;1&#8211;2 variables&#41;</span>&#58; formed by 61 patients &#40;28&#46;9&#37;&#41;&#46; OR&#58; 3&#46;25&#59; 95&#37; CI&#58; 1&#46;56&#8211;6&#46;75&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 3 &#8211; high risk &#40;3 variables&#41;</span>&#58; formed by 56 patients &#40;26&#46;5&#37;&#41;&#46; OR&#58; 6&#46;49&#59; 95&#37; CI&#58; 3&#46;10&#8211;13&#46;60&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;000&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Retreatment according to risk groups</span><p id="par0150" class="elsevierStylePara elsevierViewall">According to the risk model&#44; 19 patients from group 1 &#40;20&#46;2&#37;&#41;&#44; 30 from group 2 &#40;49&#46;2&#37;&#41;&#44; and 35 from group 3 &#40;62&#46;5&#37;&#41; required retreatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0165" class="elsevierStylePara elsevierViewall">According to the clinical guidelines of the EAU&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> depending on the size and location of the stone&#44; there are different active treatment options equally valid&#44; with no evidence in favor of one or the other&#44; i&#46;e&#46;&#44; ESWL or ureterorenoscopy &#40;URS&#41;&#47;retrograde intrarenal surgery&#47;percutaneous nephrolithotomy&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The present study focuses on the treatment of stones by means of ESWL with the aim of improving patient selection by taking more data into account&#46; It is a retrospective analysis of the variables that themselves influence the need to receive at least one second treatment of ESWL&#46; In addition&#44; the complete information provided by the CT is used&#44; which&#44; on the other hand&#44; is the imaging test of choice in cases of renal colic&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> although it is not performed systematically in all centers&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">There are studies in the literature about the usefulness of CT to estimate the percentage of calcium in the stone<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> and to predict its composition&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#8211;27</span></a> Also&#44; the ratio of the density of the stone with its hardness or resistance to shock waves is known&#59; specifically&#44; the guidelines of the EAU point out that a possible cut-off point would be 1000 HU&#44; and those whose density exceeds this figure are classified as extreme hardness&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">With regard to the skin-to-stone distance &#40;SSD&#41;&#44; it is logical to think that&#44; the greater the distance&#44; the lower the effectiveness of the shock waves of the ESWL on the objective&#46; In fact&#44; in studies such as that by Patel et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> the only independent influence factor for the rate of absence of lithiasis in their series is SSD&#44; above even the density of the stone&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">M&#252;llhaupt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> are in the line of Patel when confirming the influence of the SSD&#44; which surpasses the density of the stone as predictor&#46; They also mention the body mass index&#44; in which&#44; however&#44; the results of the studies are more contradictory&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">14&#44;15</span></a> It is known&#44; for example&#44; that obesity is a factor that has a negative influence on the effectiveness of ESWL&#44; due to the distance that the shock waves have to travel&#44; but it is also logical to think that it has to influence the composition of living tissues &#40;skin&#44; adipose tissue&#44; aponeurosis&#44; muscle&#41; that are on the way from the generator to the stone&#44; because the transmission of waves is affected by factors such as water&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">To continue with the idea of existing studies&#44; the therapeutic procedure can be further refined thanks to CT&#44; obtaining multiple detailed patient data such as diameters &#40;anteroposterior&#44; transverse&#44; diagonal&#41; or distance from the adipose panicle&#46; In addition&#44; there are promising predictive options&#44; such as dual energy computed tomography&#44; which seems to have a greater potential to characterize the composition of the different types of stones&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In our study&#44; variables such as maximum density&#44; area&#44; diameter and location of the stone&#44; the adipose panicle of the patient &#40;with 2&#46;67<span class="elsevierStyleHsp" style=""></span>cm as the cut-off point&#41; and the estimated residual fragments size at the end of the procedure are influential&#58; all of them are logical and in line with what is published&#46; Of all of them&#44; those that influence independently are maximum density&#44; diameter&#44; and location&#46; With these 3<span class="elsevierStyleHsp" style=""></span>variables&#44; which can be quickly and easily obtained with CT without waiting for the radiological report&#44; it is possible to distribute or stratify patients according to each case &#40;in the form of presence<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#47;absence<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#41;&#46; Thus&#44; a score can be attributed from 0 &#40;ureteral location&#44; diameter smaller than 7&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; and maximum density lower than 864 HU&#41; to 3 &#40;pyelo-calicial location&#44; diameter greater than 7&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; and maximum density greater than 864 HU&#41;&#44; passing through intermediate situations according to the variables presented&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In addition&#44; the objective of this study is to obtain the variables prior to the ESWL to try to predict its effectiveness&#46; In the cases where URS or ESWL can be chosen&#44; the experience of the urologist&#44; the accessibility to a treatment with ESWL&#44; the location with the particularity of the lower calyx&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> and the personal situation of each patient&#44; among other things&#44; are taken into account&#46; The trend has changed in recent years&#58; although ESWL remains widespread&#44; the number of endoscopic treatments is increasing considerably&#44; as described by Garc&#237;a Galisteo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">There are differences between both techniques&#44; such as invasiveness&#44; manipulation of the urinary tract&#44; hospitalization versus outpatient regimen&#44; regional&#47;general anesthesia versus sedation&#44; having catheter or not after the procedure&#44; solving the problem at the moment or ejecting fragments for a few days or weeks&#44; etcetera&#46; Therefore&#44; with these risk groups we have more data when choosing one technique or another&#44; individualizing with each patient&#46; For example&#44; in the case of a patient in group 3 &#40;high risk of retreatment-3 variables present&#41;&#44; an endoscopic treatment &#40;URS&#47;retrograde intrarenal surgery&#41; could be chosen&#44; given the high probability of a retreatment in case of ESWL&#46; Otherwise&#44; a patient in group 1 &#40;low risk of retreatment-none of the variables present&#41; could be informed of the low invasiveness of the ESWL procedure and the high probability of success in his particular case&#44; with an improvement of the usual success rate&#44; being a conditional probability&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Of course&#44; this risk model is not intended to impose a treatment over another&#44; since the choice depends on many factors&#46; It only tries to give more information to help in the decision making&#46; It is necessary to deepen the studies&#44; increasing the number of patients and trying to further limit the variables&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Finally&#44; as limitations and aspects to be revised facing future studies&#44; we consider the possibility of studying more in detail the size&#44; location of the stone&#44; and to deepen in the SSD&#46; In the case of the size&#44; the volume is better estimator than the maximum diameter or area&#44; so if a 3D reconstruction is available&#44; it can be more accurate&#46; As for the location&#44; it would have to be considered more specifically according to the calyx or the ureteral level in which the stone is&#46; For this&#44; it would be advisable to increase significantly the number of patients studied&#46; And for the SSD&#44; which does not appear to have influence based on our study&#44; perhaps establishing the difference of the distance according to the location of the wave generator could provide more information and have a greater protagonism&#44; as it has been discussed in the studies mentioned&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0235" class="elsevierStylePara elsevierViewall">The density&#44; maximum diameter&#44; and the pyelo-calyceal position of the stone are determining factors in the effectiveness of the treatment with ESWL&#46; With these variables&#44; which can be obtained before the therapeutic decision&#44; the risk model designed enables a precise approach to choose the most appropriate treatment for each particular case&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Risk model"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Retreatment according to risk groups"
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          "titulo" => "Discussion"
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          "identificador" => "sec0040"
          "titulo" => "Conflict of interest"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2016-10-17"
    "fechaAceptado" => "2016-12-21"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec872659"
          "palabras" => array:3 [
            0 => "Extracorporeal shock wave lithotripsy"
            1 => "Retreatment"
            2 => "Risk model"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec872660"
          "palabras" => array:3 [
            0 => "Litotricia extracorp&#243;rea por ondas de choque"
            1 => "Retratamiento"
            2 => "Modelo de riesgo"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Extracorporeal shock wave lithotripsy &#40;ESWL&#41; is a non-invasive&#44; safe and effective treatment for urinary tract lithiasis&#46; Its effectiveness varies depending on the location and size of the stones as well as other factors&#59; several sessions are occasionally required&#46; The objective is to attempt to predict its success or failure&#44; when the influential variables are known beforehand&#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 analyzed 211 patients who had had previous CT scans and were treated with ESWL between 2010 and 2014&#46; The influential variables in requiring retreatment were studied using binary logistic regression models &#40;univariate and multivariate analysis&#41;&#58; maximum density&#44; maximum diameter&#44; area&#44; location&#44; disintegration and distance from the adipose panniculus&#46; With the influential variables&#44; a risk model was designed by assessing all possible combinations with logistic regression &#40;version 20&#46;0 IBM SPSS&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The independent influential variables on the need for retreatment are&#58; maximum density &#62;864 HU&#44; maximum diameter &#62;7&#46;5<span class="elsevierStyleHsp" style=""></span>mm and pyelocaliceal location&#46; Using these variables&#44; the best model includes 3 risk groups with a probability of requiring significantly different retreatment&#58; group 1 &#8211; low risk &#40;0 variables&#41; with 20&#46;2&#37;&#59; group 2 &#8211; intermediate risk &#40;1&#8211;2 variables&#41; with 49&#46;2&#37;&#59; and group 3 &#8211; high risk &#40;3 variables&#41; with 62&#46;5&#37;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The density&#44; maximum diameter and pyelocaliceal location of the stones are determinant factors in terms of the effectiveness of treatment with ESWL&#46; Using these variables&#44; which can be obtained in advance of deciding on a treatment&#44; the designed risk model provides a precise approach in choosing the most appropriate treatment for each particular case&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La litotricia extracorp&#243;rea por ondas de choque &#40;LEOC&#41; es un tratamiento no invasivo&#44; seguro y efectivo para las litiasis del tracto urinario cuya efectividad var&#237;a seg&#250;n la localizaci&#243;n y el tama&#241;o del c&#225;lculo&#44; entre otros factores&#59; en ocasiones es necesario realizar varias sesiones&#46; El objetivo es tratar de predecir el &#233;xito o fracaso conociendo previamente las variables influyentes&#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">Analizamos a 211 pacientes con TAC previa entre aquellos tratados mediante LEOC entre los a&#241;os 2010 y 2014&#46; Se estudian las variables influyentes en la necesidad de retratamiento utilizando modelos de regresi&#243;n log&#237;stica binaria &#40;estudio uni- y multivariado&#41;&#58; densidad m&#225;xima&#44; di&#225;metro m&#225;ximo&#44; &#225;rea&#44; localizaci&#243;n&#44; desintegraci&#243;n y distancia del pan&#237;culo adiposo&#46; Con las variables influyentes se ha dise&#241;ado un modelo de riesgo valorando con regresi&#243;n log&#237;stica todas las posibles combinaciones &#40;IBM SPSS versi&#243;n 20&#46;0&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las variables de influencia independiente en la necesidad de retratamiento son&#58; densidad m&#225;xima &#62;864 UH&#44; di&#225;metro m&#225;ximo &#62;7&#44;5<span class="elsevierStyleHsp" style=""></span>mm y localizaci&#243;n pielocalicial&#46; Utilizando estas variables&#44; el mejor modelo incluye 3 grupos de riesgo con probabilidades de necesitar retratamiento significativamente diferentes&#58; grupo 1-bajo riesgo &#40;0 variables&#41; con 20&#44;2&#37;&#44; grupo 2-riesgo intermedio &#40;1-2 variables&#41; con 49&#44;2&#37; y grupo 3-alto riesgo &#40;3 variables&#41; con 62&#44;5&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La densidad&#44; el di&#225;metro m&#225;ximo y la localizaci&#243;n pielocalicial del c&#225;lculo son factores determinantes en la efectividad del tratamiento con LEOC&#46; Con estas variables&#44; que se pueden obtener antes de la decisi&#243;n terap&#233;utica&#44; el modelo de riesgo dise&#241;ado permite una aproximaci&#243;n precisa de cara a elegir el tratamiento m&#225;s adecuado para cada caso en particular&#46;</p></span>"
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            "titulo" => "Resultados"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Hevia M&#44; Garc&#237;a &#193;&#44; Ancizu FJ&#44; Merino I&#44; Velis JM&#44; Tienza A&#44; et al&#46; Predicci&#243;n de efectividad de litotricia extracorp&#243;rea por ondas de choque en c&#225;lculos del tracto urinario&#46; Grupos de riesgo para precisar retratamiento&#46; Actas Urol Esp&#46; 2017&#59;41&#58;451&#8211;457&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Measurement area &#40;cm<span class="elsevierStyleSup">2</span>&#41; and maximum density &#40;HU&#41;&#46;</p>"
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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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&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> &#40;&#37;&#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">Median&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">Range&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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#8211;86&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">BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;7&#8211;39&#46;7&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">Pyelo-calyceal location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101 &#40;47&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Ureteral location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110 &#40;52&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Distance to the panicle &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;55&#8211;6&#46;87&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">Previous catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;25&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Dilation of the urinary tract&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">104 &#40;49&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Maximum diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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;3&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;27&#46;6&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">Maximum density &#40;HU&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">937&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">123&#8211;1705&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">Good- very good fragmentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">174 &#40;82&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Retreatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;39&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Variables contrast result&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">Area&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">Standard error<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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">Asymptotic sig&#46;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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">Asymptotic confidence interval at 95&#37;</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="" 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="" 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="" 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">Lower limit&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">Upper limit&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">Area &#40;cm<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;729&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;037&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;657&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;801&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">Maximum diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;730&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;036&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;659&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;802&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">Panicle distance &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;534&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;041&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;407&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;453&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;615&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">Maximum density &#40;HU&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;675&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;038&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;601&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;748&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            1 => array:3 [
              "identificador" => "tblfn0010"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Null hypothesis&#58; true area <span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Areas under the curve &#40;AUC&#41;&#46;</p>"
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      ]
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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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&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">OR&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">95&#37; CI&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">p</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">Wald&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">Maximum density<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>864 HU&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;97&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;04&#8211;3&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;013&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;363&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">Diameter<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7&#46;5<span class="elsevierStyleHsp" style=""></span>mm&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;42&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;23&#8211;4&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;609&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">Pyelo-calyceal location&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;43&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;30&#8211;4&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&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;796&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">Constant &#40;&#8722;1&#46;815&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;163&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Variables of independent influence on the need for retreatment&#46;</p>"
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        "mostrarDisplay" => false
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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" 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">Variables&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">95&#37; CI&nbsp;\t\t\t\t\t\t\n
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                  \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">Group 1 &#40;44&#46;6&#37;&#41;&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="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Group 2 &#40;28&#46;9&#37;&#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;2&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;25&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;56&#8211;6&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002&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">Group 3 &#40;26&#46;5&#37;&#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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;49&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;10&#8211;13&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;000&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  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Retreatment</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total&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">No&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">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><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></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Risk groups</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>Low &#40;group 1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">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"><span class="elsevierStyleHsp" style=""></span>Intermediate &#40;group 2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&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>High &#40;group 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">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&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="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">211&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Retreatment according to the risk group&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Extracorporeal shockwave lithotripsy &#40;ESWL&#41;&#58; a chronology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Chaussy"
                            1 => "F&#46; Eisenberger"
                            2 => "B&#46; Forssmann"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1089/end.2007.9880"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Endourol"
                        "fecha" => "2007"
                        "volumen" => "21"
                        "paginaInicial" => "1249"
                        "paginaFinal" => "1253"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18042010"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "EAU guidelines on urolithiasis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; T&#252;rk"
                            1 => "T&#46; Knoll"
                            2 => "A&#46; Petrik"
                            3 => "K&#46; Sarica"
                            4 => "A&#46; Skolarikos"
                            5 => "M&#46; Straub"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:2 [
                        "fecha" => "2016"
                        "editorial" => "Eur Urol"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of computed tomography findings for success prediction after extracorporeal shock wave lithotripsy for urinary tract stone disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Celik"
                            1 => "O&#46; Bozkurt"
                            2 => "F&#46;G&#46; Kaya"
                            3 => "S&#46; Egriboyun"
                            4 => "O&#46; Demir"
                            5 => "M&#46; Secil"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11255-014-0857-0"
                      "Revista" => array:5 [
                        "tituloSerie" => "Int Urol Nephrol"
                        "fecha" => "2015"
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