Validation of a new artificial model for simulated training of a laparoscopic vesicourethral anastomosis | Actas Urológicas Españolas (English Edition)

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"apellidos" => "Sánchez-Margallo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Unidad de Laparoscopia, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Presidente de honor, Fundación del Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Urología, Hospital San Juan de Dios del Aljarafe, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Urología, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Dirección científica, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validación de un nuevo modelo de simulación inorgánica para la anastomosis uretrovesical laparoscópica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1413 "Ancho" => 1593 "Tamanyo" => 134675 ] ] "descripcion" => array:1 [ "en" => "Time to perform prostate resection, “task 1” and urethrovesical anastomosis, “task 2” of the E and N groups." ] ] ] "textoCompleto" => "IntroductionLaparoscopy is considered the standard surgical approach for the treatment of a wide variety of urologic diseases, mainly due to the advantages it presents for the patient.<a class="elsevierStyleCrossRefs" href="#bib0155">1,2</a> Although laparoscopic surgery (LS) is already being established, it requires a learning curve for its correct implementation.<a class="elsevierStyleCrossRef" href="#bib0165">3</a> This curve is the main limiting factor for its application.<a class="elsevierStyleCrossRefs" href="#bib0170">4,5</a>There are currently LS training programs with the objective of reducing the learning curve and surgical errors.<a class="elsevierStyleCrossRef" href="#bib0175">5</a> Given that ethical guidelines against considering experiments on animals in these programs, the development of specific laparoscopic simulators is increasing.<a class="elsevierStyleCrossRefs" href="#bib0180">6–12</a>Laparoscopic radical prostatectomy (LRP) is one of the reconstructive urologic procedures that requires more technical specialization.<a class="elsevierStyleCrossRef" href="#bib0215">13</a> Specifically, the urethrovesical anastomosis (UVA) is one of the most complex tasks of this intervention, requiring complete mastery of laparoscopic intracorporeal suturing.<a class="elsevierStyleCrossRef" href="#bib0185">7</a> At present, there are organic as well as artifial models to practice the performance of UVA with a laparoscopic approach.<a class="elsevierStyleCrossRefs" href="#bib0180">6,14</a> The organic models show satisfactory results regarding the practice of the techniques. However, it is not easy to obtain, store or preserve these models susceptible to decomposition, and their exposure at a health care environment can represent a great danger.<a class="elsevierStyleCrossRef" href="#bib0180">6</a> In order to avoid these complicated situations, we have developed a 3D realistic silicon model from real magnetic resonance images. The objective of this study is to demonstrate the validity of this model.Material and methodsThis study involved students who volunteered to attend some of the editions of the LRP monographic courses held from 2015 to 2017. All participants signed the informed consent. They were classified into 2 groups according to their previous experience in laparoscopic surgery. On the one hand, we created a group of experts (group E) with urologists who had performed more than 50 laparoscopic surgeries and, on the other hand, a group of novices (group N), including urologists who had performed 10 or less LS. Students with experience between 11 and 49 surgeries were excluded from the study.This was a 21-h course, organized as follows: simulation exercises (6h), animal model practice (12h) and theory lessons (3h). We only evaluated the UVA exercises performed on the artificial model of urethra and prostate placed on SIMULAP® (validated laparoscopy simulator, Jesus Usón Minimally Invasive Surgery Center).<a class="elsevierStyleCrossRef" href="#bib0225">15</a> The position of the surgeon was the standard clinical position on the side of the patient. The students used a 10mm rigid endoscope attached to a 3chip camera (Karl Storz S.L.) (KARL STORZ SE & Co. KG – Tuttlingen, Germany). The 11mm entry ports were arranged as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Prior to the evaluation, each student performed 10 intracorporeal suture stitches in an ex vivo pig stomach model. All students watched an explanation video of the tasks to be performed before the inorganic model practice. “Task 1” was prostate resection and “task 2” was UVA. A 20.6cm absorbable multifilament suture (Polyglycolic Novosyn violet 3/0 HS26-70cm, Braun, Braun Melsungen AG) was used for the anastomosis. The assistants were instructed to place each stitch according to the pattern indicated in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. The anastomosis was performed when they completed the indicated 8 simple interrupted stitches.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Subsequently, the participants completed an anonymous questionnaire about their demographic data and their level of experience in LS. In addition, they evaluated the didactic capacity of the organ, assessing its usefulness as a tool for the specific training of LRP.In order to demonstrat face validity, the novice participants showed their opinion about the texture, consistency, morphology and similarity between the artificial and the real organ. In the same way, the experts responded for content validation. The questionnaire on the didactic capacity of the model, as well as the validation questionnaires, were assessed by the participants according to a five-point Likert scale, in which 1 represented the value “strongly disagree” and 5 was “strongly agree”.Finally, a comparative study for the execution times of “task 1” and “task 2” between the groups was made to determine construct validity. Both tasks were recorded and subsequently evaluated independently by an expert in urological LS (with more than 50 LRP). The quality of the anastomosis was measured under the parameters described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, following the model of Jiang et al.<a class="elsevierStyleCrossRef" href="#bib0195">9</a> A value of 0, 0.5 or 1 was assigned to each parameter, establishing a maximum score of 10 points (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). A 100ml saline was injected through the Foley catheter to verify anastomotic integrity.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The statistical analysis was carried out with the statistical software SPSS 22.0 for Windows (SPSS Inc., Chicago, USA). The Kolmogorov–Smirnov test was performed to determine the normal distribution of the data. After establishing this condition, the Student's t test was performed to compare both groups. Statistical significance was established at p<0.05.ResultsDemographics and experienceOf the 42 attendees who completed the course, only 22 met the selection criteria. The students were divided into 2 groups according to their experience. There was an expert group with 10 cases (group E) and 12 novices in the second group (group N). The mean age of participants was 37.4±5.8 years.Assessment of the model's didactic capacityAll attendants evaluated the usefulness of the model as a didactic tool in a very satisfactory way, as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. All aspects achieved more than 4.5 points out of 5. The only significant difference between the scores of novices and experts was regarding the inclusion of the model in the training programs (group E=5 and group N=4.4±0.59, p=0.024).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Face and content validityRegarding face validity (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), the novices gave higher scores to “does the model faithfully reproduce the suture technique for LRP” with 4.2±0.7 points, and the question “does the placement of the organ within the simulator seem realistic”, with 4.4±0.69 points. The worst rated aspect was “the model reproduces the removal of the prostate”, with 3.4±0.96 points.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Regarding content validity, the results obtained from the E group were over 4 points for all answers. The best rated aspect was “does the model faithfully reproduce the suture technique for LRP” (4.8±0.35) and “does the placement of the organ within the simulator seem realistic” (4.8±0.35). The aspect with the lowest score was the question about “does the morphology of the prostate model correspond with reality” (4.2±0.69).On a general basis, the experts rated all the issues with higher scores than the novices ones. The aspects in which the group of novices established significantly lower scores than the group of experts were: “the texture and consistency of the model” (N group=3.7±0.84, E group=4.5±0.51); “the model reproduces the removal of the prostate” (N group=3.4±0.96, E group=4.5±0.51); “the model reproduces the suture technique for LRP” (N group=4.2±0.7, E group=4.8±0.35) and “is it important to include the prostate in the simulated prostate resection” (N group=3.6±1.05, E group=4.6±0.51). Regarding the general assessment, the novice participants gave an average score of 8.00±0.91 points and the expert group gave a 9.4±0.51 out of 10.Construct validity<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows the execution times of “task 1” and “task 2”, for both groups. There were no significant differences between groups for “task 1” (E group=1.55±0.72, N group=2.00±0.81min). However, for “task 2”, the expert group completed the simulation laparoscopic UVA significantly faster than the N group (E group=24.33±1.58min, N group=46.30±11.36min, p≤0.05).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Regarding the quality of the anastomosis according to the criteria of Jiang et al.,<a class="elsevierStyleCrossRef" href="#bib0195">9</a> a clear difference was observed between the expert and novice participants, with significantly higher scores from the expert group (N group=4.5±0.70, E group=8.70±1.20, p≤0.05).DiscussionThe knowledge of advanced maneuvers such as intracorporeal suturing is essential in laparoscopic reconstructive procedures.<a class="elsevierStyleCrossRefs" href="#bib0230">16,17</a> Various studies confirm that prior training is essential before performing surgery on the patient.<a class="elsevierStyleCrossRefs" href="#bib0210">12,16</a> There are specific materials and devices used for this objective, with physical simulators being the most frequently implemented tools for the acquisition of basic skills.<a class="elsevierStyleCrossRefs" href="#bib0175">5,6,9,10,14,18–21</a>Although there are currently different methods and models for the simulation training of the UVA in the LRP, one of the main advantages of our device is that it does not require specific preservation. Being an inorganic material, it does not need any special conditions for its use and storage. On the other hand, these simulation devices replace animals, diminishing the ethical dilemma of the use of living beings for medical teaching, in addition to reducing of the number of animals used for surgical training. Unlike pig bladders, this artificial organ presents similar anatomical morphological features to those of the human patient <a class="elsevierStyleCrossRef" href="#bib0195">9</a> providing the opportunity to develop and refine surgical skills in a more realistic way.Although some studies have reported human cadaver as the most effective model for LRP training, it has important disadvantages, such as the absence of bleeding, as well as its limited and difficult availability.<a class="elsevierStyleCrossRef" href="#bib0260">22</a> Its main advantage regards the training on dissection and resection of the prostate; there are no advantages concerning the UVA practice. For this reason, some authors, such as Huri et al.,<a class="elsevierStyleCrossRef" href="#bib0260">22</a> consider that physical simulators take the place of human cadaver for the training of UVA.Although the canine model is ideal for LRP training,<a class="elsevierStyleCrossRef" href="#bib0265">23</a> the porcine is currently the most widely used for LRP training. Eventhough there are authors such as Sabbagh et al. who did not observe statistically significant differences between these models, most studies consider the porcine as a better alternative to artificial models.<a class="elsevierStyleCrossRef" href="#bib0270">24</a> On the other hand, authors such as Perez-Duarte et al. demonstrated that previous training in an organic model decreased the operative time of laparoscopic UVA surgery subsequently performed in the live porcine model. Therefore, it is confirmed that the use of models for laparoscopic physical simulation improves the in vivo practice.<a class="elsevierStyleCrossRef" href="#bib0175">5</a>When comparing the artificial model and the porcine experimental model, the latter has some advantages over the first one, highlighting the bleeding when dissecting and cutting, similar tissue consistency and pelvis size with respect to humans. Regarding disadvantages, these are mainly availability, ethical issues and high cost.<a class="elsevierStyleCrossRef" href="#bib0235">17</a>If we compare our model with the ex vivo organs and the already existing validated artificial models, it is worth noting that ours is the only one that presents similar morphological and texture characteristics to the real one. This is because it has several distinctive features. In the first place, the silicon of our model has been used in other artificial models.<a class="elsevierStyleCrossRef" href="#bib0275">25</a> In the second place, our model is designed for its placement into the physical simulator.<a class="elsevierStyleCrossRef" href="#bib0225">15</a> The use of our artificial organ is not limited to this simulator, so this device can be used in other physical simulators.The main advantage of our device is that it does not require specific preservation conditions. Its price is around 28€, and it allows several UVA performances. However, repeated exercises are not possible for prostate resection, due to the silicon tissue having already been cut. Regarding the didactic capacity of the model, all the participants made a very positive assessment of the device. It should be noted that the group of experts presented the highest scores, with significant differences (against the N group) regarding the inclusion of this device in LRP training programs. This could be because expert surgeons, with more experience in surgical techniques, are aware of what training prior to real surgical interventions entails and know how hard it is to acquire the learning curve for this procedure. In addition, all study participants considered that the use of this device benefits the learning process of the different suture patterns for UVA.There are currently several acceptable suture patterns for UVA. Although some studies employ the continuous suture pattern, we believe that the interrupted suture of 8 stitches allows the novice urologist to learn a more accurate placement and orientation of the needle. The continuous suture model, specifically the one established by van Velthoven et al., is recommended in advanced stages of learning.<a class="elsevierStyleCrossRef" href="#bib0280">26</a>We must take into account that the use of these devices decreases the number of surgical errors in the real practice. For this reason, we consider our tool very useful to provide a more efficient route to LRP surgical proficiency on real patients.<a class="elsevierStyleCrossRef" href="#bib0285">27</a>With respect to the methodology employed in UVA, this validation has been carried out including similar studies for its analysis.<a class="elsevierStyleCrossRefs" href="#bib0195">9,14,28–30</a> In the same way as in our study, Boon et al. analize the operative time of the anastomosis, as well as the presence of leakage.<a class="elsevierStyleCrossRef" href="#bib0300">30</a>Finally, although this study has shown this artificial model as a promising tool for acquiring essential skills for the UVA performance, we must remember these limitations: the lack of bleeding and the fact that it only reproduces 2 essential steps of LRP.ConclusionIn short, this artificial model designed specifically for the implementation of UVA has shown face, content and construct validity as well as being an optimal didactic tool for learning and training prostate resection and laparoscopic UVA.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1237813" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1148991" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1237814" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1148992" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Demographics and experience" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Assessment of the model's didactic capacity" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Face and content validity" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Construct validity" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack423715" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-31" "fechaAceptado" => "2019-03-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1148991" "palabras" => array:4 [ 0 => "Laparoscopy" 1 => "Simulation" 2 => "Surgical training" 3 => "Urethrovesical anastomosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1148992" "palabras" => array:4 [ 0 => "Laparoscopia" 1 => "Simulación" 2 => "Entrenamiento quirúrgico" 3 => "Anastomosis uretrovesical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThe aim of this study is to prove the effectiveness of a low cost, artificial model for training of a laparoscopic urethrovesical anastomosis. Materials and methodsThis study included urologists who attended specialised courses on laparoscopic radical prostatectomy (LRP) held during the period 2015–2017. They were divided into 2 groups according to their previous experience in laparoscopic surgery.The tasks performed on the artificial simulator were prostate resection, “task 1”, and urethrovesical anastomosis, “task 2”. Once these exercises were completed, the study participants filled in an anonymous questionnaire regarding their demographic data and experience level in laparoscopic surgery (LS). In addition, they gave their opinions about the didactic capacity of the artificial organ and evaluated its usefulness as a tool for LRP training.To demonstrate face and content validity, the participants judged the texture, consistency, morphology and evaluated its similarity to the real organ. The assessment was made with a five-point Likert scale. ResultsThe students were divided into 2 groups: 10 experts (Group E) and 12 novices (Group N). The only significant difference between the scores of novices and experts was regarding the inclusion of this tool in the training programs (Group E=5 points versus group N=4.4±0.59, p=0.024). The experts’ group rated all the items with higher scores than the novices’ one. Regarding the general assessment of the simulation model, the novice participants gave an average score of 8.00±0.91 points out of 10, while the experts’ group granted higher scores of 9.4±0.51. ConclusionThis artificial model has shown to have an elevated face, content and construct validity, as well being an optimal didactic tool for training in the techniques of prostate resection and laparoscopic urethrovesical anastomosis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEl objetivo de este estudio es demostrar la validez de un modelo inorgánico de bajo coste para el aprendizaje y entrenamiento de la anastomosis uretrovesical laparoscópica. Materiales y métodosEn este estudio participaron alumnos que asistieron a alguna de las ediciones de los cursos monográficos sobre prostatectomía radical laparoscópica (PRL) celebrados durante el periodo de 2015 a 2017. Estos participantes se dividieron en 2 grupos de acuerdo con su experiencia previa en cirugía laparoscópica (CL).Las tareas que realizaron sobre el simulador inorgánico fueron la resección de la próstata, «tarea 1» y la anastomosis uretrovesical, «tarea 2». Una vez realizados estos ejercicios, los participantes del estudio completaron un cuestionario anónimo donde se recogieron sus datos demográficos y su nivel de experiencia en CL. Además, los asistentes realizaron una valoración de la capacidad didáctica del órgano sintético empleado, evaluando su utilidad como herramienta para la formación específica de PRL.Para demostrar la validación aparente y de contenidos los participantes mostraron su opinión acerca de la textura, la consistencia, la morfología y la similitud del órgano con el paciente real. La valoración se realizó según una escala de Likert de 5 puntos. ResultadosLos alumnos se distribuyeron en 2grupos: 10 expertos (grupo E) y 12 noveles (grupo N). La única diferencia significativa entre las puntuación de noveles y de expertos fue respecto a la inclusión de esta herramienta en los programas de formación (grupo E=5 puntos frente al grupo N=4,4 ±0,59, p=0,024). Los expertos calificaron todas las cuestiones con mayores puntaciones que los noveles. En cuanto a la valoración general del modelo inorgánico, los participantes noveles dieron una calificación media de 8,00±0,91 puntos sobre 10, siendo superada por la valoración de los participantes del grupo de expertos, que dieron una puntuación media de 9,4±0,51. ConclusiónEste modelo inorgánico ha demostrado poseer validez aparente, de contenidos y constructiva, además de ser una herramienta didáctica ideal para el aprendizaje y el entrenamiento de la resección prostática y de la anastomosis uretrovesical laparoscópica." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández-Tomé B, Díaz-Güemes I, Enciso Sanz S, Naranjo Moreno B, Correa L, Sánchez-Hurtado MA, et al. Validación de un nuevo modelo de simulación inorgánica para la anastomosis uretrovesical laparoscópica. Actas Urol Esp. 2019;43:348–354." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1174 "Ancho" => 900 "Tamanyo" => 144587 ] ] "descripcion" => array:1 [ "en" => "Artificial model placed in the SIMULAP® physical simulator where the trocars are placed: optical trocar (1), trocars to perform the resection of the prostate “task 1” (2 and 4) and trocars to perform the UVA suture “task 2” (2 and 3)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 495 "Ancho" => 950 "Tamanyo" => 23510 ] ] "descripcion" => array:1 [ "en" => "Suture pattern for the urethrovesical anastomosis. (A) Posterior side: first stitch at 5 o’clock position, second at 7 o’clock, third at 4 o’clock and fourth at 8 o’clock position. (B) Anterior side: fifth stitch at 10 o’clock, sixth at 2 o’clock, seventh at 11 o’clock and eight at 1 o’clock position." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1413 "Ancho" => 1593 "Tamanyo" => 134675 ] ] "descripcion" => array:1 [ "en" => "Time to perform prostate resection, “task 1” and urethrovesical anastomosis, “task 2” of the E and N groups." ] ] 3 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Rassweileret al.<a class="elsevierStyleCrossRef" href="#bib0210">12</a>" "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameters \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stitches \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Exact suture location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Amount of sutured tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distance between stitches \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Similar amount of engaged tissue on each side \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catheter gently and non-interruptedly indwelled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No visible space between stitches \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Square knot with 3 loops \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fixed stitch \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unripped tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Watertight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2114458.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Parameters to control the quality of anastomosis established by Jiang et al." ] ] 4 => 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: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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Didactic capacity of the model \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Novices \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Experts \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total mean \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The artificial model is useful for training in urology residency programmes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7±0.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5±0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8±0.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The artificial model is useful for surgeons to practice LRP in continuing education \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4±0.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6±0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5±0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I consider it interesting to include this model in LS training programs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4±0.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5±0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.024 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7±0.49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The artificial model is useful for learning different suture patterns for UVA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7±0.31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7±0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7±0.33 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2114459.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Questionnaire results for the didactic assessment of the artificial model." ] ] 5 => 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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Topics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Novices \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Experts \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total mean \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The artificial model has the same morpholical characteristics as the real organ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9±0.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.2±0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4±0.54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Similar texture and consistency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7±0.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5±0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1±0.75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The artificial model faithfully reproduces the removal of the prostate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.4±0.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5±0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.95±0.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The model faithfully reproduces the suture technique of LRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.2±0.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8±0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5±0.64 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The placement of the model inside the pelvis of the simulator seems realistic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4±0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8±0.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">N/A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.6±0.53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General assessment of the artificial model for LRP practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8±0.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.4±0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.7±0.84 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2114460.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results of the questionnaire for face and content validity." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Usón J. 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Original article

Validation of a new artificial model for simulated training of a laparoscopic vesicourethral anastomosis

Validación de un nuevo modelo de simulación inorgánica para la anastomosis uretrovesical laparoscópica

B. Fernández-Toméa,

Corresponding author

bfernandez@ccmijesususon.com

Corresponding author.

, I. Díaz-Güemesa, S. Enciso Sanza, B. Naranjo Morenoa, L. Correaa, M.A. Sánchez-Hurtadoa, J. Usónb, J. Bachillerc, A. Serranod, F.M. Sánchez-Margalloe

a Unidad de Laparoscopia, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain

b Presidente de honor, Fundación del Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain

c Departamento de Urología, Hospital San Juan de Dios del Aljarafe, Spain

d Departamento de Urología, Hospital Clínico San Carlos, Madrid, Spain

e Dirección científica, Centro de Cirugía de Mínima Invasión Jesús Usón, Cáceres, Spain

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the development of specific laparoscopic simulators is increasing&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Laparoscopic radical prostatectomy &#40;LRP&#41; is one of the reconstructive urologic procedures that requires more technical specialization&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> Specifically&#44; the urethrovesical anastomosis &#40;UVA&#41; is one of the most complex tasks of this intervention&#44; requiring complete mastery of laparoscopic intracorporeal suturing&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> At present&#44; there are organic as well as artifial models to practice the performance of UVA with a laparoscopic approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#44;14</span></a> The organic models show satisfactory results regarding the practice of the techniques&#46; However&#44; it is not easy to obtain&#44; store or preserve these models susceptible to decomposition&#44; and their exposure at a health care environment can represent a great danger&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> In order to avoid these complicated situations&#44; we have developed a 3D realistic silicon model from real magnetic resonance images&#46; The objective of this study is to demonstrate the validity of this model&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study involved students who volunteered to attend some of the editions of the LRP monographic courses held from 2015 to 2017&#46; All participants signed the informed consent&#46; They were classified into 2 groups according to their previous experience in laparoscopic surgery&#46; On the one hand&#44; we created a group of experts &#40;group E&#41; with urologists who had performed more than 50 laparoscopic surgeries and&#44; on the other hand&#44; a group of novices &#40;group N&#41;&#44; including urologists who had performed 10 or less LS&#46; Students with experience between 11 and 49 surgeries were excluded from the study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">This was a 21-h course&#44; organized as follows&#58; simulation exercises &#40;6<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; animal model practice &#40;12<span class="elsevierStyleHsp" style=""></span>h&#41; and theory lessons &#40;3<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; We only evaluated the UVA exercises performed on the artificial model of urethra and prostate placed on SIMULAP<span class="elsevierStyleSup">&#174;</span> &#40;validated laparoscopy simulator&#44; Jesus Us&#243;n Minimally Invasive Surgery Center&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> The position of the surgeon was the standard clinical position on the side of the patient&#46; The students used a 10<span class="elsevierStyleHsp" style=""></span>mm rigid endoscope attached to a 3<span class="elsevierStyleHsp" style=""></span>chip camera &#40;Karl Storz S&#46;L&#46;&#41; &#40;KARL STORZ SE &#38; Co&#46; KG &#8211; Tuttlingen&#44; Germany&#41;&#46; The 11<span class="elsevierStyleHsp" style=""></span>mm entry ports were arranged as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Prior to the evaluation&#44; each student performed 10 intracorporeal suture stitches in an <span class="elsevierStyleItalic">ex vivo</span> pig stomach model<span class="elsevierStyleItalic">&#46;</span> All students watched an explanation video of the tasks to be performed before the inorganic model practice&#46; <span class="elsevierStyleItalic">&#8220;Task 1&#8221;</span> was prostate resection and <span class="elsevierStyleItalic">&#8220;task 2&#8221;</span> was UVA&#46; A 20&#46;6<span class="elsevierStyleHsp" style=""></span>cm absorbable multifilament suture &#40;Polyglycolic Novosyn violet 3&#47;0 HS26-70<span class="elsevierStyleHsp" style=""></span>cm&#44; Braun&#44; Braun Melsungen AG&#41; was used for the anastomosis&#46; The assistants were instructed to place each stitch according to the pattern indicated in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The anastomosis was performed when they completed the indicated 8 simple interrupted stitches&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Subsequently&#44; the participants completed an anonymous questionnaire about their demographic data and their level of experience in LS&#46; In addition&#44; they evaluated the didactic capacity of the organ&#44; assessing its usefulness as a tool for the specific training of LRP&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In order to demonstrat face validity&#44; the novice participants showed their opinion about the texture&#44; consistency&#44; morphology and similarity between the artificial and the real organ&#46; In the same way&#44; the experts responded for content validation&#46; The questionnaire on the didactic capacity of the model&#44; as well as the validation questionnaires&#44; were assessed by the participants according to a five-point Likert scale&#44; in which 1 represented the value <span class="elsevierStyleItalic">&#8220;strongly disagree&#8221;</span> and 5 was <span class="elsevierStyleItalic">&#8220;strongly agree&#8221;</span>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally&#44; a comparative study for the execution times of &#8220;task 1&#8221; and &#8220;task 2&#8221; between the groups was made to determine construct validity&#46; Both tasks were recorded and subsequently evaluated independently by an expert in urological LS &#40;with more than 50 LRP&#41;&#46; The quality of the anastomosis was measured under the parameters described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; following the model of Jiang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> A value of 0&#44; 0&#46;5 or 1 was assigned to each parameter&#44; establishing a maximum score of 10 points &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; A 100<span class="elsevierStyleHsp" style=""></span>ml saline was injected through the Foley catheter to verify anastomotic integrity&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The statistical analysis was carried out with the statistical software SPSS 22&#46;0 for Windows &#40;SPSS Inc&#46;&#44; Chicago&#44; USA&#41;&#46; The Kolmogorov&#8211;Smirnov test was performed to determine the normal distribution of the data&#46; After establishing this condition&#44; the Student&#39;s <span class="elsevierStyleItalic">t</span> test was performed to compare both groups&#46; Statistical significance was established at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Demographics and experience</span><p id="par0055" class="elsevierStylePara elsevierViewall">Of the 42 attendees who completed the course&#44; 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<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Face and content validity</span><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding face validity &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; the novices gave higher scores to &#8220;does the model faithfully reproduce the suture technique for LRP&#8221; with 4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7 points&#44; and the question &#8220;does the placement of the organ within the simulator seem realistic&#8221;&#44; with 4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69 points&#46; The worst rated aspect was &#8220;the model reproduces the removal of the prostate&#8221;&#44; with 3&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;96 points&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding content validity&#44; the results obtained from the E group were over 4 points for all answers&#46; The best rated aspect was <span class="elsevierStyleItalic">&#8220;does the model faithfully reproduce the suture technique for LRP&#8221;</span> &#40;4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&#41; and &#8220;<span class="elsevierStyleItalic">does the placement of the organ within the simulator seem realistic&#8221;</span> &#40;4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&#41;&#46; The aspect with the lowest score was the question about &#8220;<span class="elsevierStyleItalic">does the morphology of the prostate model correspond with reality</span>&#8221; &#40;4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">On a general basis&#44; the experts rated all the issues with higher scores than the novices ones&#46; The aspects in which the group of novices established significantly lower scores than the group of experts were&#58; <span class="elsevierStyleItalic">&#8220;the texture and consistency of the model&#8221;</span> &#40;N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;84&#44; E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&#41;&#59; &#8220;<span class="elsevierStyleItalic">the model reproduces the removal of the prostate</span>&#8221; &#40;N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;96&#44; E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&#41;&#59; &#8220;<span class="elsevierStyleItalic">the model reproduces the suture technique for LRP</span>&#8221; &#40;N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#44; E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&#41; and &#8220;<span class="elsevierStyleItalic">is it important to include the prostate in the simulated prostate resection</span>&#8221; &#40;N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;05&#44; E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&#41;&#46; Regarding the general assessment&#44; the novice participants gave an average score of 8&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;91 points and the expert group gave a 9&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51 out of 10&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Construct validity</span><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the execution times of <span class="elsevierStyleItalic">&#8220;task 1&#8221;</span> and <span class="elsevierStyleItalic">&#8220;task 2&#8221;</span>&#44; for both groups&#46; There were no significant differences between groups for <span class="elsevierStyleItalic">&#8220;task 1&#8221;</span> &#40;E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;72&#44; N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;81<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; However&#44; for &#8220;task 2&#8221;&#44; the expert group completed the simulation laparoscopic UVA significantly faster than the N group &#40;E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;58<span class="elsevierStyleHsp" style=""></span>min&#44; N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>46&#46;30<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;36<span class="elsevierStyleHsp" style=""></span>min&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding the quality of the anastomosis according to the criteria of Jiang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> a clear difference was observed between the expert and novice participants&#44; with significantly higher scores from the expert group &#40;N group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;70&#44; E group<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#46;70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;20&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The knowledge of advanced maneuvers such as intracorporeal suturing is essential in laparoscopic reconstructive procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">16&#44;17</span></a> Various studies confirm that prior training is essential before performing surgery on the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">12&#44;16</span></a> There are specific materials and devices used for this objective&#44; with physical simulators being the most frequently implemented tools for the acquisition of basic skills&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;6&#44;9&#44;10&#44;14&#44;18&#8211;21</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Although there are currently different methods and models for the simulation training of the UVA in the LRP&#44; one of the main advantages of our device is that it does not require specific preservation&#46; Being an inorganic material&#44; it does not need any special conditions for its use and storage&#46; On the other hand&#44; these simulation devices replace animals&#44; diminishing the ethical dilemma of the use of living beings for medical teaching&#44; in addition to reducing of the number of animals used for surgical training&#46; Unlike pig bladders&#44; this artificial organ presents similar anatomical morphological features to those of the human patient <a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> providing the opportunity to develop and refine surgical skills in a more realistic way&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although some studies have reported human cadaver as the most effective model for LRP training&#44; it has important disadvantages&#44; such as the absence of bleeding&#44; as well as its limited and difficult availability&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Its main advantage regards the training on dissection and resection of the prostate&#59; there are no advantages concerning the UVA practice&#46; For this reason&#44; some authors&#44; such as Huri et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> consider that physical simulators take the place of human cadaver for the training of UVA&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although the canine model is ideal for LRP training&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> the porcine is currently the most widely used for LRP training&#46; Eventhough there are authors such as Sabbagh et al<span class="elsevierStyleItalic">&#46;</span> who did not observe statistically significant differences between these models&#44; most studies consider the porcine as a better alternative to artificial models&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> On the other hand&#44; authors such as Perez-Duarte et al<span class="elsevierStyleItalic">&#46;</span> demonstrated that previous training in an organic model decreased the operative time of laparoscopic UVA surgery subsequently performed in the live porcine model&#46; Therefore&#44; it is confirmed that the use of models for laparoscopic physical simulation improves the <span class="elsevierStyleItalic">in vivo</span> practice&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">When comparing the artificial model and the porcine experimental model&#44; the latter has some advantages over the first one&#44; highlighting the bleeding when dissecting and cutting&#44; similar tissue consistency and pelvis size with respect to humans&#46; Regarding disadvantages&#44; these are mainly availability&#44; ethical issues and high cost&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">If we compare our model with the <span class="elsevierStyleItalic">ex vivo</span> organs and the already existing validated artificial models&#44; it is worth noting that ours is the only one that presents similar morphological and texture characteristics to the real one&#46; This is because it has several distinctive features&#46; In the first place&#44; the silicon of our model has been used in other artificial models&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> In the second place&#44; our model is designed for its placement into the physical simulator&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> The use of our artificial organ is not limited to this simulator&#44; so this device can be used in other physical simulators&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The main advantage of our device is that it does not require specific preservation conditions&#46; Its price is around 28&#8364;&#44; and it allows several UVA performances&#46; However&#44; repeated exercises are not possible for prostate resection&#44; due to the silicon tissue having already been cut&#46; Regarding the didactic capacity of the model&#44; all the participants made a very positive assessment of the device&#46; It should be noted that the group of experts presented the highest scores&#44; with significant differences &#40;against the N group&#41; regarding the inclusion of this device in LRP training programs&#46; This could be because expert surgeons&#44; with more experience in surgical techniques&#44; are aware of what training prior to real surgical interventions entails and know how hard it is to acquire the learning curve for this procedure&#46; In addition&#44; all study participants considered that the use of this device benefits the learning process of the different suture patterns for UVA&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">There are currently several acceptable suture patterns for UVA&#46; Although some studies employ the continuous suture pattern&#44; we believe that the interrupted suture of 8 stitches allows the novice urologist to learn a more accurate placement and orientation of the needle&#46; The continuous suture model&#44; specifically the one established by van Velthoven et al&#46;&#44; is recommended in advanced stages of learning&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">We must take into account that the use of these devices decreases the number of surgical errors in the real practice&#46; For this reason&#44; we consider our tool very useful to provide a more efficient route to LRP surgical proficiency on real patients&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">With respect to the methodology employed in UVA&#44; this validation has been carried out including similar studies for its analysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9&#44;14&#44;28&#8211;30</span></a> In the same way as in our study&#44; Boon et al<span class="elsevierStyleItalic">&#46;</span> analize the operative time of the anastomosis&#44; as well as the presence of leakage&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Finally&#44; although this study has shown this artificial model as a promising tool for acquiring essential skills for the UVA performance&#44; we must remember these limitations&#58; the lack of bleeding and the fact that it only reproduces 2 essential steps of LRP&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">In short&#44; this artificial model designed specifically for the implementation of UVA has shown face&#44; content and construct validity as well as being an optimal didactic tool for learning and training prostate resection and laparoscopic UVA&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to prove the effectiveness of a low cost&#44; artificial model for training of a laparoscopic urethrovesical anastomosis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This study included urologists who attended specialised courses on laparoscopic radical prostatectomy &#40;LRP&#41; held during the period 2015&#8211;2017&#46; They were divided into 2 groups according to their previous experience in laparoscopic surgery&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The tasks performed on the artificial simulator were prostate resection&#44; <span class="elsevierStyleItalic">&#8220;task 1&#8221;</span>&#44; and urethrovesical anastomosis&#44; <span class="elsevierStyleItalic">&#8220;task 2&#8221;</span>&#46; Once these exercises were completed&#44; the study participants filled in an anonymous questionnaire regarding their demographic data and experience level in laparoscopic surgery &#40;LS&#41;&#46; In addition&#44; they gave their opinions about the didactic capacity of the artificial organ and evaluated its usefulness as a tool for LRP training&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To demonstrate face and content validity&#44; the participants judged the texture&#44; consistency&#44; morphology and evaluated its similarity to the real organ&#46; The assessment was made with a five-point Likert scale&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The students were divided into 2 groups&#58; 10 experts &#40;Group E&#41; and 12 novices &#40;Group N&#41;&#46; The only significant difference between the scores of novices and experts was regarding the inclusion of this tool in the training programs &#40;Group <span class="elsevierStyleItalic">E</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5 points versus group <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;59&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#46;024</span>&#41;&#46; The experts&#8217; group rated all the items with higher scores than the novices&#8217; one&#46; Regarding the general assessment of the simulation model&#44; the novice participants gave an average score of 8&#46;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;91 points out of 10&#44; while the experts&#8217; group granted higher scores of 9&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This artificial model has shown to have an elevated face&#44; content and construct validity&#44; as well being an optimal didactic tool for training in the techniques of prostate resection and laparoscopic urethrovesical anastomosis&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es demostrar la validez de un modelo inorg&#225;nico de bajo coste para el aprendizaje y entrenamiento de la anastomosis uretrovesical laparosc&#243;pica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este estudio participaron alumnos que asistieron a alguna de las ediciones de los cursos monogr&#225;ficos sobre prostatectom&#237;a radical laparosc&#243;pica &#40;PRL&#41; celebrados durante el periodo de 2015 a 2017&#46; Estos participantes se dividieron en 2 grupos de acuerdo con su experiencia previa en cirug&#237;a laparosc&#243;pica &#40;CL&#41;&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Las tareas que realizaron sobre el simulador inorg&#225;nico fueron la resecci&#243;n de la pr&#243;stata&#44; <span class="elsevierStyleItalic">&#171;tarea 1&#187;</span> y la anastomosis uretrovesical&#44; <span class="elsevierStyleItalic">&#171;tarea 2&#187;&#46;</span> Una vez realizados estos ejercicios&#44; los participantes del estudio completaron un cuestionario an&#243;nimo donde se recogieron sus datos demogr&#225;ficos y su nivel de experiencia en CL&#46; Adem&#225;s&#44; los asistentes realizaron una valoraci&#243;n de la capacidad did&#225;ctica del &#243;rgano sint&#233;tico empleado&#44; evaluando su utilidad como herramienta para la formaci&#243;n espec&#237;fica de PRL&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Para demostrar la validaci&#243;n aparente y de contenidos los participantes mostraron su opini&#243;n acerca de la textura&#44; la consistencia&#44; la morfolog&#237;a y la similitud del &#243;rgano con el paciente real&#46; La valoraci&#243;n se realiz&#243; seg&#250;n una escala de Likert de 5 puntos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Los alumnos se distribuyeron en 2<span class="elsevierStyleHsp" style=""></span>grupos&#58; 10 expertos &#40;grupo E&#41; y 12 noveles &#40;grupo N&#41;&#46; La &#250;nica diferencia significativa entre las puntuaci&#243;n de noveles y de expertos fue respecto a la inclusi&#243;n de esta herramienta en los programas de formaci&#243;n &#40;grupo E<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5 puntos frente al grupo N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#44;4 &#177;<span class="elsevierStyleHsp" style=""></span>0&#44;59&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#44;024</span>&#41;&#46; Los expertos calificaron todas las cuestiones con mayores puntaciones que los noveles&#46; En cuanto a la valoraci&#243;n general del modelo inorg&#225;nico&#44; los participantes noveles dieron una calificaci&#243;n media de 8&#44;00<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;91 puntos sobre 10&#44; siendo superada por la valoraci&#243;n de los participantes del grupo de expertos&#44; que dieron una puntuaci&#243;n media de 9&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;51&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Este modelo inorg&#225;nico ha demostrado poseer validez aparente&#44; de contenidos y constructiva&#44; adem&#225;s de ser una herramienta did&#225;ctica ideal para el aprendizaje y el entrenamiento de la resecci&#243;n prost&#225;tica y de la anastomosis uretrovesical laparosc&#243;pica&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez-Tom&#233; B&#44; D&#237;az-G&#252;emes I&#44; Enciso Sanz S&#44; Naranjo Moreno B&#44; Correa L&#44; S&#225;nchez-Hurtado MA&#44; et al&#46; Validaci&#243;n de un nuevo modelo de simulaci&#243;n inorg&#225;nica para la anastomosis uretrovesical laparosc&#243;pica&#46; Actas Urol Esp&#46; 2019&#59;43&#58;348&#8211;354&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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            "Tamanyo" => 144587
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Artificial model placed in the SIMULAP<span class="elsevierStyleSup">&#174;</span> physical simulator where the trocars are placed&#58; optical trocar &#40;1&#41;&#44; trocars to perform the resection of the prostate &#8220;task 1&#8221; &#40;2 and 4&#41; and trocars to perform the UVA suture &#8220;task 2&#8221; &#40;2 and 3&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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            "Tamanyo" => 23510
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Suture pattern for the urethrovesical anastomosis&#46; &#40;A&#41; Posterior side&#58; first stitch at 5 o&#8217;clock position&#44; second at 7 o&#8217;clock&#44; third at 4 o&#8217;clock and fourth at 8 o&#8217;clock position&#46; &#40;B&#41; Anterior side&#58; fifth stitch at 10 o&#8217;clock&#44; sixth at 2 o&#8217;clock&#44; seventh at 11 o&#8217;clock and eight at 1 o&#8217;clock position&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1413
            "Ancho" => 1593
            "Tamanyo" => 134675
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Time to perform prostate resection&#44; &#8220;task 1&#8221; and urethrovesical anastomosis&#44; &#8220;task 2&#8221; of the E and N groups&#46;</p>"
        ]
      ]
      3 => array:9 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Rassweileret al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a>"
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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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Stitches&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exact suture location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Amount of sutured tissue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Distance between stitches&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Similar amount of engaged tissue on each side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catheter gently and non-interruptedly indwelled&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No visible space between stitches&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Square knot with 3 loops&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fixed stitch&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unripped tissue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Watertight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Parameters to control the quality of anastomosis established by Jiang et al&#46;</p>"
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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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Didactic capacity of the model&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Novices&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Experts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The artificial model is useful for training in urology residency programmes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The artificial model is useful for surgeons to practice LRP in continuing education&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I consider it interesting to include this model in LS training programs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">0&#46;024</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The artificial model is useful for learning different suture patterns for UVA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">N&#47;A</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Topics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Novices&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Experts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The artificial model has the same morpholical characteristics as the real organ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Similar texture and consistency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The artificial model faithfully reproduces the removal of the prostate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The model faithfully reproduces the suture technique of LRP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The placement of the model inside the pelvis of the simulator seems realistic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">4&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">General assessment of the artificial model for LRP practice&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;91&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;004&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
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      "titulo" => "References"
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        0 => array:2 [
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            0 => array:3 [
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              "etiqueta" => "1"
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