Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access | Actas Urológicas Españolas (English Edition)

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Old male patient with histol. Proven urothelial cancer of the bladder pT2high grade, and biopsy proven multifocal high grade UTUC. A) Histophatological specimen en-block removal of the right kidney, ureter, bladder, prostate and membranous part of the urethra (because of the prostatic urethra involvement in conjunction with high grade urothelial cancer). B) Aproxx15 cm. Of the colon and 20 cm. Of the terminal ileum is used for neobladder reconstructions C) Configuration of the orthotopic ileo-coecal pouch with appendix as a substitute for the missing membranous urethra (white arrow-appendix). D) Reconstruction of the appendico-urethral anastomosis end to end with absorbable 5.0 maxon interrupted sutures (appendix-white arrow, bulbar urethra-black arrow). E) Postoperative cystogram. F) Because of the stricture recurrence in the site of the anastomosis, Memokath stent (white arrow) was placed (which made patient to be completely incontinent), therefore in the same setting was AMS 800 implanted concomitantly. G) Measurement of the retrograde leak point pressure (AMS 800 was activated, RLPP > 45 mm/H2O, cuff is closed-black arrow." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Weibl, G. Ameli, C.H. Plank, W. Huebner" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Weibl" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Ameli" ] 2 => array:2 [ "nombre" => "C.H." "apellidos" => "Plank" ] 3 => array:2 [ "nombre" => "W." 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"apellidos" => "Lopez Alcina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1205 "Ancho" => 905 "Tamanyo" => 149715 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Wound closure after placement of non-suction drainage." ] ] ] "textoCompleto" => "IntroductionProstate cancer is the second most frequent neoplasm in men, accounting for 15% of newly diagnosed tumors.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The increasingly widespread use of conservative management, such as active surveillance, has led to tumor stage migration in patients undergoing surgery, with more and more patients being intervened with locally advanced tumors.One of the most feared complications of this surgery is rectal injury, which can be repaired immediately if recognized intraoperatively. However, in certain cases the rectal lesion goes unnoticed, or there is wound dehiscence after its closure, producing defects that communicate the cervico-urethral anastomosis with the rectum. Another potential mechanism is thermal damage, which easily goes unnoticed during surgery and is manifested in the later postoperative period. These fistulas pose a challenge for the urologist, not so much in terms of their detection, but in terms of management.Although it is a relatively infrequent complication (1–6%)<a class="elsevierStyleCrossRefs" href="#bib0010">2–4</a> in recent years, since the widespread use of surgery and with surgical indication in tumors with increasingly advanced stages, even in metastatic stages, we have seen an increased incidence.Most scientific evidence available for its management comes from short series and usually depends on the particular skills of the surgeon. Multiple access routes have been described: transanal, transsphincteric, abdominal and perineal. Although great efforts have been made to classify them and protocolize their management,<a class="elsevierStyleCrossRef" href="#bib0025">5</a> there is no clear consensus on the most appropriate method.Posterior approaches (transsphincteric) have shown very good results in the treatment of this complex pathology; however, this route requires experience in this anatomical field and the collaboration of very experienced colorectal surgeons. On the other hand, perineal approaches have also shown to be effective in the repair of small defects, interposing muscle flaps between the suture planes,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> resulting in less complexity and good recovery in selected cases.In this paper, we will describe our experience in the treatment of rectourethral fistulas (RUF) using a different approach, perineal access and interposition of biological material.Material and methodsBetween July 2013 and February 2020, we operated on a total of five patients with a median age of 64 years (58–74), who presented with RUF after surgical treatment of prostate cancer by endoscopic extraperitoneal radical prostatectomy. None of our patients had undergone radiotherapy prior to prostatectomy. The mean pre-prostatectomy prostate-specific antigen (PSA) was 10.6 ng/mL (8–16.1 ng/mL); the mean preoperative prostate volume was 37.8 cc (16–54 cc). In the preoperative MRI, two patients had capsule rupture. The anatomopathological study of the prostatectomy specimen showed the presence of locally advanced disease (pT3a) in four of the five patients. The fistulas had a mean diameter of 4 mm (3−5 mm) and were located at a mean distance of 4 cm from the anal margin (3−5 cm) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The clinical presentation was diarrhea in three patients, fecaluria in another one, and a torpid postoperative course with acute abdomen in the fifth patient. The patients who presented diarrhea reported it one month after surgery, when they came for a check-up two or three weeks after catheter removal. The presentation of fecaluria in one patient occurred while still carrying the bladder catheter (first 12 postoperative days).The first examination after clinical suspicion was a cystography in all cases (except for the case of acute abdomen, in which a CT cystography was performed), revealing in all cases the existence of a fistulous tract at the level of the cervico-urethral anastomosis and the rectum. Similarly, all patients underwent urethrocystoscopy to evaluate the size of the orifice and its proximity to the ureteral meatus, as well as rectoscopy to measure the distance from the anal margin. In cystoscopy, three patients presented fistulous orifices of 3 mm in diameter and the other two of 4 and 5 mm. Rectoscopy was used to determine the distance of the RUF to the anal margin (DMA), finding that two fistulas were 3 cm from the anal margin, two at 4 cm and one at 5 cm (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>To complete the study, three of our patients underwent pelvic MRI to rule out associated abscess or complete dehiscence of the anastomosis with the consequent creation of a pseudocapsule, which in our case, it would have led us to reject this approach (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Description of the techniqueTo perform the procedure, the patient was placed in a forced lithotomy position and rectal washouts with normal saline were performed to check the correct preparation of the rectum and the absence of fecal or mucous material. Antibiotic prophylaxis was carried out in all cases with 2 g of amoxicillin and 200 mg of clavulanic acid and thromboembolic prophylaxis with 4,000 IU enoxaparin. The perineal and genital areas were thoroughly washed with a chlorhexidine brush and sterile chlorhexidine solution (Chloraprep®) was applied in the surgical field preparation. With the use of previous cystoscopy, a hydrophilic guide was placed through the fistulous orifice which was exposed via the transurethral route for its management, in case of small or distal fistula (only two cases). Double J ureteral catheters were only placed if the meatus was close to the defect (only one case in our series). In the other cases, a 18 Ch Foley bladder catheter was left in place to help urethral location and dissection of the fistula.Orchidopexy with interrupted silk sutures for adequate exposure of the field and transverse or semicircular incision in a downwards direction are performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The perineal body is sectioned (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and dissected posteriorly to the superficial transverse perineal muscle, creating a sufficiently wide space on both sides between the rectum and the urethra to allow placement of a speculum.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Once the fistula has been identified (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), the urethra is dissected 2 cm distal and at least 1 cm proximal to the defect (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The situation and condition of the rectum can be checked by rectoscopy and in situ rectal examination, and instillation of diluted methylene blue, if necessary. The resection and closure of the rectal defect is performed with 3−0 resorbable suture and the cervical/urethral defect with 2−0 rapid resorbable sutures in the first two patients and with resorbable unidirectional barbed sutures in the last two cases (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). The rectal defect is sutured with single-layer interrupted stitches, incorporating all layers of the rectal wall. If the anatomy and the proximity of the defect allow it, a second suture layer is carried out on the rectal wall approximating the muscular plane.<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>The watertightness of the suture is checked with infusion of intravesical saline prior to placement of the interposition mesh.Subsequently, a sharp triangular patch is taken from a biological mesh of porcine material 5 × 10 cm and 1 mm thick (lyophilized porcine dermis) and is cut out in its proximal portion to fit between the rectal wall, urethra and bladder neck (<a class="elsevierStyleCrossRefs" href="#fig0030">Figs. 6 and 7</a>). First, the mesh is fixed proximally to its deepest portion (the one we have sharpened) with a stitch, and then laterally with two 3−0 resorbable stitches, trimming the distal excess if necessary. This way, a separation layer between the rectal wall, urethra and bladder neck is created.<elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia>Finally, closure is performed in three layers, aponeurotic, subcutaneous and skin, leaving a non-suction drain away from the skin wound (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>). The skin closure is carried out with resorbable suture.<elsevierMultimedia ident="fig0040"></elsevierMultimedia>ResultsThe mean operative time was 174 min (140–210). The mean intraoperative blood loss was 70 cc (50–150).No patient presented complications in the immediate postoperative period, apart from a serous drainage from the surgical wound that took 15 days to resolve and did not correspond to urine in the biochemical analysis.Drains were maintained for 48−72 h postoperatively, depending on the output, and all patients were discharged before the fifth postoperative day.Three patients kept the bladder catheter for one month, while the other two did so for 45 and 60 days, respectively. Prior to removal of the bladder catheter, the sealing of the reconstruction was checked by cystography.The colostomy was maintained for a median of six (3−0) postoperative months, and the resolution of the defect was also checked beforehand with the use of a barium enema. Six months after surgery, a follow-up cystography was performed, which revealed resolution of the RUF in the four patients during this follow-up. After a median follow-up of 36.2 months, no patients presented recurrence symptoms.Stress urinary incontinence was observed in three of the five patients, requiring the use of at least two pads per day.DiscussionWhile both rectal injury and the dreaded event of RUF usually occur early in the learning curve,<a class="elsevierStyleCrossRefs" href="#bib0015">3,7</a> the increasing inclusion of patients with high risk disease and local volume, as well as locally advanced tumors, may increase the number of these complications once more. In our series, the incidence of these fistulas was relatively maintained over time, partly due to this fact and partly due to the incorporation of new surgeons into the learning curve.The most frequent clinical presentation is urinary leakage through the rectum, which our patients complained as diarrhea. The symptoms of pneumaturia and fecaluria are less frequent than the latter, and usually reflect the presence of larger fistulas, and should therefore be considered a sign of poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The time it can take to manifest itself can reach almost two years,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> although in our series all of them manifested almost immediately.Rivera et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> describe a staging system with five groups or stages in their study including 14 patients. Stage I-low, less than 4 cm from the anal verge and nonirradiated fistulas, stage II-high, is made up of high fistulas (more than 4 cm from anal verge), stage III-small, less than 2 cm irradiated fistula, stage IV-large, more than 2 cm irradiated fistula, and stage V-large, ischial decubitus fistulas in patients with spinal cord injury. All our fistulas were located between 3 and 5 cm from the anal margin and could therefore be classified into stages I and II. On the other hand, it is known that, in addition to the presence of fecaluria, size greater than 2 cm and a history of ionizing radiation are signs of poor prognosis<a class="elsevierStyleCrossRef" href="#bib0045">9</a>; none of these were present in our patients.As first maneuver in all cases, and as first therapeutic option in the case of small-caliber fistulas, the initial treatment is conservative, with bowel diversion and bladder catheter drain. Although there are series that report spontaneous closure in between 12–45% of RUFs with double diversion alone,<a class="elsevierStyleCrossRefs" href="#bib0035">7,10</a> our experience is that even if the bladder catheter is maintained for at least three months, the great majority of patients require surgical treatment. The factors that may favor this closure with conservative management would be a fistula of less than 5 mm in diameter and preferably a distal location. On the other hand, short or large diameter fistulas, or those located at bladder level or with a history of radiotherapy, are less likely to close after conservative treatment.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> As a general rule, if the fistula has not resolved two months after fecal and urinary diversion, it is unlikely to do so without requiring surgery.<a class="elsevierStyleCrossRefs" href="#bib0040">8,11</a>Most authors recommend performing a colostomy to keep the fistula as clean as possible,<a class="elsevierStyleCrossRefs" href="#bib0060">12–14</a> which would lead to a three-stage repair, one stage to perform the colostomy, another to correct the fistula and a third to close the colostomy at approximately two months after the fistula closure procedure. Other authors with experience in these techniques, especially when perineal approaches are involved, such as Mundy’s or Rivera’s group, do not believe that it should be performed in a routine way.<a class="elsevierStyleCrossRefs" href="#bib0025">5,8</a> This may be shown by the management variability of this infrequent entity.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Our experience tells us that avoiding the passage of feces near the fistula with bowel diversion reduces contamination of the area, on the one hand, and on the other, reduces urinary output through the fistulous tract by decreasing the pressure difference between both tracts. These two circumstances reduce the inflammatory reaction of the perineal region, which translates into easier exposure and less friability of the tissues, which improves the performance of the technique while increasing success probabilities.Many techniques have been described for the repair of RUF. The abdominal approach, reported by Turner-Warwick<a class="elsevierStyleCrossRefs" href="#bib0075">15,16</a> has the advantage of a relatively easy omental transposition, but the main disadvantage is that in certain cases, especially in obese patients, it is difficult to access such a deep area. When the patient has undergone several previous abdominal surgeries, this approach can be complex due to secondary adhesions or fibrosis. Furthermore, it is an approach with high associated morbidity and a not negligible failure rate.<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a> The laparoscopic approach, as well as the robotic, allow better exposure and easier access to these fields. Likewise, the closure of both orifices, as well as omental interposition<a class="elsevierStyleCrossRef" href="#bib0090">18</a> with the use of cystography and dissection of the posterior vesical face and the fistula itself.Although transanal advancement flap repair has given good results on limited occasions in complex fistulas,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> its use is usually restricted for small fistulas and preferably without poor prognostic factors.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> This approach only allows exposure of defects in the final portion of the rectal ampulla. It is not free of complications such as urethral stricture and urinary and fecal incontinence.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>The York Mason posterior transsphincteric approach has reported good results in the correction of the fistulous defect,<a class="elsevierStyleCrossRefs" href="#bib0105">21–23</a> with the main advantage of direct and frontal access to the fistula, which makes it more feasible. In this same work, the rate of fecal incontinence is negligible, but we know from the works described using this same approach that, although infrequent, it is not nil.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> The problem concerning this technique is that it demands the participation of experienced surgeons and that it does not allow the repair of large fistulas that require flap interposition or adequate access to the urethra to treat urethral alterations, if any.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>The perineal approach offers several advantages. First, the anatomical area is well known by urologists. On the other hand, it avoids access to the abdominal cavity, which, as mentioned above, can be very difficult in patients with multiple previous surgeries. If both urine and stool have been diverted for a reasonable period of time, inflammatory areas can be avoided. It offers easy access for the management of both orifices, and therefore easy repair. It has no complications in terms of fecal continence with a success rate close to 90–100%.<a class="elsevierStyleCrossRefs" href="#bib0030">6,16,26</a> In the case of associated urethral pathology such as concomitant urethral stricture, it allows repair by the same access route,<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> even by performing oral mucosal grafts.From our point of view, the perineal approach has a disadvantage which is the limited field of vision, especially when dealing with fistulas that are too high (trigonal fistulas). On the other hand, in certain cases it is difficult to control the ureters and there is a risk of injuring them, which is why we recommend the placement of double J catheters when the meatus is very close to the defect. Another disadvantage of this surgery is the nonnegligible rate of urethral strictures due to tissue devitalization and its manipulation during surgery. Likewise, our patients present a high rate of urinary incontinence; however, we cannot ascertain whether it was patent after the primary surgery and is a consequence of the fistula repair procedure, but we believe that both aspects might be involved in a certain way.The usefulness of the interposition of pedicled flaps between the rectal and urethral suture lines providing robustness to the closure, promoting healing and preventing recurrences, is well-known.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Although certain authors consider it necessary only in case of complex fistulas,<a class="elsevierStyleCrossRef" href="#bib0070">14</a> our experience has shown us that it provides greater certainty of success. When the abdominal approach is used, omental interposition is the most widely used.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Much of the literature reviewed uses a gracilis muscle flap,<a class="elsevierStyleCrossRefs" href="#bib0040">8,13,14,28–31</a> or even levator ani flap<a class="elsevierStyleCrossRef" href="#bib0030">6</a> when perineal approach is used. Although we know that gracilis muscle interposition has low morbidity,<a class="elsevierStyleCrossRefs" href="#bib0080">16,28</a> as mentioned above, the occurrence of urethral stricture and incontinence can be associated with this technique. Reviews on the gracilis flap technique reported 4% pain associated with its mobilization and 3% wound infections,<a class="elsevierStyleCrossRef" href="#bib0160">32</a> as well as loss of adduction strength and hypoesthesia.<a class="elsevierStyleCrossRef" href="#bib0165">33</a>A variety of tissues have been used for interposition in RUF repair, such as pedicled dartos flaps<a class="elsevierStyleCrossRefs" href="#bib0170">34,35</a> or oral mucosal grafts.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> We have also found isolated cases in the literature describing the use of porcine dermis-derived material for the repair of this type of fistulas.<a class="elsevierStyleCrossRefs" href="#bib0185">37–39</a> However, ours is the first series of patients demonstrating its reproducibility and good results.The use of meshes made of biological material is widely described in abdominal wall defect repair techniques, and our colleagues from general surgery have a great deal of experience with it. They have high success rates, and the most frequent complications are seroma and surgical wound infection.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> It was thanks to this close interdisciplinary collaboration in the repair of RUF that the idea of interposing biological material, in our case porcine dermis, arose. With this maneuver, we aimed to save mobilization of autologous tissue and improve the success rate of fistula resolution by interposing material between the two sutures.In our hands, the interposition of biological material has simplified the technique of interposition of material between sutures. The technique has obtained a good outcome, achieving fistula repair in all patients, with none of them presenting recurrence during the follow-up period. There were no complications associated with the technique, apart from seroma in two patients who did not require invasive management in any case. It is not uncommon to find wound drainage,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> but in most cases it is treated with conservative management. Urethral strictures derived from the use of gracilis described by other groups<a class="elsevierStyleCrossRef" href="#bib0070">14</a> did not appear in our series during follow-up. The mean catheter indwelling time after surgery in the series is 40 months<a class="elsevierStyleCrossRefs" href="#bib0025">5,7,8,13</a>,<a class="elsevierStyleCrossRefs" href="#bib0090">18,27,38</a> (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), which is a figure very close to the mean in our series.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>The main limitation of our study is the small number of cases due to the fortunately infrequent occurrence of this type of fistulas, and we do not have a control group with which we can compare our technique. We are aware that a refined surgical technique and sufficient experience in this type of access should lead to the success of the technique, but we believe that the interposition of material provides greater safety in the procedure.ConclusionsThe perineal approach provides the advantage of good tissue exposure and facilitates closure of both fistulous orifices. The interposition of biological material from porcine dermis presents good tolerance and provides results that are superimposable to those obtained with autologous material.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1519041" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1377543" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1519040" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1377544" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Description of the technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-15" "fechaAceptado" => "2021-01-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1377543" "palabras" => array:3 [ 0 => "Rectourethral fistulas" 1 => "Radical prostatectomy" 2 => "Biological mesh" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1377544" "palabras" => array:3 [ 0 => "Fístila retrorectal" 1 => "Prostatectomía radical" 2 => "Malla biológica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionRectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy. The development of rectourethral fistulas (URF) from rectal injuries is one of the most feared and of more complex resolution in urology. Material and methodsBetween 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material. All fistulas had a diameter of less than 6 mm at endoscopy and were less than 6 cm apart from the anal margin. ResultsThe mean age of the patients was 64 years old. All patients had a previous bowel and urinary diversion for at least 3 months. Under general anesthesia and with the patient in a forced lithotomy position, fistulorraphy and interposition of biological material of porcine origin (lyophilized porcine dermis [Permacol®]) were performed through a perineal access. Mean operative time was 174 min (140–210). Most patients were discharged on the third postoperative day. The bladder catheter was left in place for a mean of 40 days (30–60). Prior to its removal, cystography and a Gastrografin® barium enema were performed, showing resolution of the fistula in all cases. ConclusionsThe interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa lesión rectal es una complicación infrecuente de la prostatectomía radical laparoscópica extraperitoneal. El desarrollo de fístulas uretrorrectales (FUR), a partir de lesiones rectales, resulta uno de los problemas más temidos y de más compleja resolución en urología. Material y métodosEntre 2013 y 2020 hemos intervenido a un total de cinco pacientes con FUR tras prostatectomía radical endoscópica extraperitoneal, mediante un abordaje perineal utilizando la interposición de material biológico. Todas las fístulas presentaron un diámetro menor de 6 mm en la endoscopia y se encontraban a menos de 6 cm del margen anal. ResultadosLa media de edad de los pacientes fue 64 años. Todos los pacientes llevaban al menos tres meses de derivación intestinal y urinaria previas. Bajo anestesia general, y con el paciente en posición de litotomía forzada mediante un acceso perineal, se realizó fistulorrafia e interposición de material biológico de origen porcino (dermis porcina liofilizada [Permacol®, Medtronic]). La duración media de la cirugía fue de 174 min (140–210). La mayoría de los pacientes fueron dados de alta al tercer día postoperatorio. La sonda vesical se mantuvo una media de 40 días (30–60). Previa a la retirada de la misma, se realizó cistografía y enema opaco con Gastrografin®, que mostró resolución de la fístula en todos los casos. ConclusionesLa interposición de material biológico procedente de dermis porcina mediante abordaje perineal es una alternativa segura y con buenos resultados en pacientes sometidos a fistulorrafia uretrorrectal tras prostatectomía radical." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Juan Escudero JU, Villaba Ferrer F, Ramos de Campos M, Fabuel Deltoro M, Garcia Coret MJ, Sanchez Ballester F, et al. Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal. Actas Urol Esp. 2021. https://doi.org/10.1016/j.acuro.2021.01.003" ] ] "multimedia" => array:12 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 106222 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "After orchidopexy, a transverse perineal incision is made." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1722 "Ancho" => 1508 "Tamanyo" => 275859 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Exposure of the perineal muscular-fascial field." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 107925 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Exposure of the fistulous orifice at the subcervical level." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1835 "Ancho" => 1508 "Tamanyo" => 291773 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Fistula section and exposure of both orifices, urethral and rectal with sufficient margin for its closure." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 119598 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "View of the field after closure of both orifices." ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 181275 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Creation of the triangular patch." ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1663 "Ancho" => 1508 "Tamanyo" => 265597 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Deep anchorage with two stitches and superficial, with at least two other stitches." ] ] 7 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1205 "Ancho" => 905 "Tamanyo" => 149715 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Wound closure after placement of non-suction drainage." ] ] 8 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "cT: clinical stage; DAV: distance from the anal margin; rT: radiologic stage; PSA: prostate specific antigen; pT: pathological stage; SX: surgery." "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">Case \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">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">pre PSA \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">pre cT \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">rT \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">Vol \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">pre Gleason \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">SX date \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">pT \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">DAV \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">Diameter (mm) \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">SX date \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">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\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">9,2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2a \t\t\t\t\t\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">2c \t\t\t\t\t\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">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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 + 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15/2/12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><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">1/7/13 \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">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16,1 \t\t\t\t\t\t\n \t\t\t\t</td><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">3a \t\t\t\t\t\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">3a \t\t\t\t\t\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">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 + 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/7/14 \t\t\t\t\t\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">2c \t\t\t\t\t\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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14/1/15 \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">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">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">9,4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2a \t\t\t\t\t\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">2c \t\t\t\t\t\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">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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 + 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20/6/16 \t\t\t\t\t\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">3a \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><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">7/6/17 \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">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \t\t\t\t\t\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">10,4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2b \t\t\t\t\t\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">2b \t\t\t\t\t\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">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 + 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/5/19 \t\t\t\t\t\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">3a R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/12/19 \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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 \t\t\t\t\t\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">8 \t\t\t\t\t\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">1c \t\t\t\t\t\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">2c \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 + 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20/8/19 \t\t\t\t\t\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">3a R1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14/2/20 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2608404.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preoperative characteristics of the patients." ] ] 9 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "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">Case \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">Op. time \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">LOS (days) \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">Cath. time \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">Colostomy closure \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><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"> \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">min \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"> \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">days \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"> \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">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><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">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 m \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">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">210 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><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">45 \t\t\t\t\t\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">9 m \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">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">190 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><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">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 m \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">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">140 \t\t\t\t\t\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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 m \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">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 m \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2608407.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results." ] ] 10 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">[0,1–2]Rivera (5)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">[0,3–4]Ramírez (31)</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">Proposed approach \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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">I</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">< 4 cm from anal margin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">[1,0]Small size</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">[1,0]Simple</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative/Transsphincteric</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nonirradiated \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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 4 cm anal margin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nonirradiated</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transsphincteric/Transperineal</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nonirradiated \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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III</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">< 2 cm diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">[2,0]Complex</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transperineal/Abdominal</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irradiated \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 " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IV</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">> 2 cm diameter \t\t\t\t\t\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">[1,0]Large volume \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominal</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irradiated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irradiated</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">V \t\t\t\t\t\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">Large size \t\t\t\t\t\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">Abdominal \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2608405.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Fistula classification and recommended treatment." ] ] 11 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">[0,1–2]Catheter indwelling time after surgery (days)</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">Rivera et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \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">Lorente et al.<a class="elsevierStyleCrossRef" href="#bib0035">7</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \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">Mundy et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30−90 \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">Zmora et al.<a class="elsevierStyleCrossRef" href="#bib0065">13</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \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">Garza et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (suprapubic catheter) \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">Vanni et al.<a class="elsevierStyleCrossRef" href="#bib0135">27</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14−50 \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">Imperatore et al.<a class="elsevierStyleCrossRef" href="#bib0190">38</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="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 \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">Juan et al. \t\t\t\t\t\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">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2608406.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Catheterization time in the series." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review of deferred treatment with curative intent for localised prostate cancer to explore heterogeneity of definitions, thresholds and criteria and clinical effectiveness" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.M. Willemse" 1 => "T. Lam" 2 => "N. Mottet" 3 => "C. Yuan" 4 => "K. Plass" 5 => "J. Donaldson" ] ] ] ] ] "host" => array:2 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "PROSPERO" "fecha" => "2018" ] ] 1 => array:1 [ "WWW" => array:1 [ "link" => "https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018071780" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence, clinical simptoms and management of rectouretrhral fistulas after radical prostatectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Thomas" 1 => "J. Jones" 2 => "W. Jäger" 3 => "C. Hampel" 4 => "J.W. Thüroff" 5 => "R. Gilitzer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.juro.2009.10.020" "Revista" => array:7 [ "tituloSerie" => "J Urol" "fecha" => "2010" "volumen" => "183" "paginaInicial" => "608" "paginaFinal" => "612" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20018317" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0190962219325733" "estado" => "S300" "issn" => "01909622" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prostatectomía radical laparoscópica etraperitoneal: Resultados de una curva de aprendizaje después de 310 casos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O. Castillo" 1 => "M. Diaz" 2 => "M. Ivar" 3 => "A. foneron" 4 => "R. Sanchez-Salas" 5 => "G. Vitagliano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Chil Cir" "fecha" => "2009" "volumen" => "61" "paginaInicial" => "52" "paginaFinal" => "58" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The incidence and management of rectal injury associate with radical prostatectomy in a community based urology prectice" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.A. Harpster" 1 => "F.M. Romel" 2 => "P.R. Sieber" 3 => "B.A. Joseph" 4 => "A.E. Victor" 5 => "H.W. 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Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access

Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal

J.U. Juan Escuderoa,

Corresponding author

chimojuan@hotmail.com

Corresponding author.

, F. Villaba Ferrerb, M. Ramos de Camposa, M. Fabuel Deltoroa, M.J. Garcia Coretb, F. Sanchez Ballestera, I. Povo Martína, Y. Pallas Costaa, P. Pardo Duartea, J. García Ibañeza, A. Monzó Cataluñaa, K. Rechi Sierraa, C. Juliá Romeroa, E. Lopez Alcinaa

a Servicio de Urología, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

b Servicio de Cirugía General, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

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        "titulo" => "Tratamiento de las f&#237;stulas uretrorrectales tras prostatectom&#237;a radical mediante la interposici&#243;n de material biol&#243;gico v&#237;a perineal"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prostate cancer is the second most frequent neoplasm in men&#44; accounting for 15&#37; of newly diagnosed tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The increasingly widespread use of conservative management&#44; such as active surveillance&#44; has led to tumor stage migration in patients undergoing surgery&#44; with more and more patients being intervened with locally advanced tumors&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">One of the most feared complications of this surgery is rectal injury&#44; which can be repaired immediately if recognized intraoperatively&#46; However&#44; in certain cases the rectal lesion goes unnoticed&#44; or there is wound dehiscence after its closure&#44; producing defects that communicate the cervico-urethral anastomosis with the rectum&#46; Another potential mechanism is thermal damage&#44; which easily goes unnoticed during surgery and is manifested in the later postoperative period&#46; These fistulas pose a challenge for the urologist&#44; not so much in terms of their detection&#44; but in terms of management&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although it is a relatively infrequent complication &#40;1&#8211;6&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> in recent years&#44; since the widespread use of surgery and with surgical indication in tumors with increasingly advanced stages&#44; even in metastatic stages&#44; we have seen an increased incidence&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most scientific evidence available for its management comes from short series and usually depends on the particular skills of the surgeon&#46; Multiple access routes have been described&#58; transanal&#44; transsphincteric&#44; abdominal and perineal&#46; Although great efforts have been made to classify them and protocolize their management&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> there is no clear consensus on the most appropriate method&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Posterior approaches &#40;transsphincteric&#41; have shown very good results in the treatment of this complex pathology&#59; however&#44; this route requires experience in this anatomical field and the collaboration of very experienced colorectal surgeons&#46; On the other hand&#44; perineal approaches have also shown to be effective in the repair of small defects&#44; interposing muscle flaps between the suture planes&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> resulting in less complexity and good recovery in selected cases&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this paper&#44; we will describe our experience in the treatment of rectourethral fistulas &#40;RUF&#41; using a different approach&#44; perineal access and interposition of biological material&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Between July 2013 and February 2020&#44; we operated on a total of five patients with a median age of 64 years &#40;58&#8211;74&#41;&#44; who presented with RUF after surgical treatment of prostate cancer by endoscopic extraperitoneal radical prostatectomy&#46; None of our patients had undergone radiotherapy prior to prostatectomy&#46; The mean pre-prostatectomy prostate-specific antigen &#40;PSA&#41; was 10&#46;6&#8239;ng&#47;mL &#40;8&#8211;16&#46;1&#8239;ng&#47;mL&#41;&#59; the mean preoperative prostate volume was 37&#46;8&#8239;cc &#40;16&#8211;54&#8239;cc&#41;&#46; In the preoperative MRI&#44; two patients had capsule rupture&#46; The anatomopathological study of the prostatectomy specimen showed the presence of locally advanced disease &#40;pT3a&#41; in four of the five patients&#46; The fistulas had a mean diameter of 4&#8239;mm &#40;3&#8722;5&#8239;mm&#41; and were located at a mean distance of 4&#8239;cm from the anal margin &#40;3&#8722;5&#8239;cm&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical presentation was diarrhea in three patients&#44; fecaluria in another one&#44; and a torpid postoperative course with acute abdomen in the fifth patient&#46; The patients who presented diarrhea reported it one month after surgery&#44; when they came for a check-up two or three weeks after catheter removal&#46; The presentation of fecaluria in one patient occurred while still carrying the bladder catheter &#40;first 12 postoperative days&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The first examination after clinical suspicion was a cystography in all cases &#40;except for the case of acute abdomen&#44; in which a CT cystography was performed&#41;&#44; revealing in all cases the existence of a fistulous tract at the level of the cervico-urethral anastomosis and the rectum&#46; Similarly&#44; all patients underwent urethrocystoscopy to evaluate the size of the orifice and its proximity to the ureteral meatus&#44; as well as rectoscopy to measure the distance from the anal margin&#46; In cystoscopy&#44; three patients presented fistulous orifices of 3&#8239;mm in diameter and the other two of 4 and 5&#8239;mm&#46; Rectoscopy was used to determine the distance of the RUF to the anal margin &#40;DMA&#41;&#44; finding that two fistulas were 3&#8239;cm from the anal margin&#44; two at 4&#8239;cm and one at 5&#8239;cm &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">To complete the study&#44; three of our patients underwent pelvic MRI to rule out associated abscess or complete dehiscence of the anastomosis with the consequent creation of a pseudocapsule&#44; which in our case&#44; it would have led us to reject this approach &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Description of the technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">To perform the procedure&#44; the patient was placed in a forced lithotomy position and rectal washouts with normal saline were performed to check the correct preparation of the rectum and the absence of fecal or mucous material&#46; Antibiotic prophylaxis was carried out in all cases with 2&#8239;g of amoxicillin and 200&#8239;mg of clavulanic acid and thromboembolic prophylaxis with 4&#44;000 IU enoxaparin&#46; The perineal and genital areas were thoroughly washed with a chlorhexidine brush and sterile chlorhexidine solution &#40;Chloraprep&#174;&#41; was applied in the surgical field preparation&#46; With the use of previous cystoscopy&#44; a hydrophilic guide was placed through the fistulous orifice which was exposed via the transurethral route for its management&#44; in case of small or distal fistula &#40;only two cases&#41;&#46; Double J ureteral catheters were only placed if the meatus was close to the defect &#40;only one case in our series&#41;&#46; In the other cases&#44; a 18 Ch Foley bladder catheter was left in place to help urethral location and dissection of the fistula&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Orchidopexy with interrupted silk sutures for adequate exposure of the field and transverse or semicircular incision in a downwards direction are performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The perineal body is sectioned &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and dissected posteriorly to the superficial transverse perineal muscle&#44; creating a sufficiently wide space on both sides between the rectum and the urethra to allow placement of a speculum&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Once the fistula has been identified &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; the urethra is dissected 2&#8239;cm distal and at least 1&#8239;cm proximal to the defect &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The situation and condition of the rectum can be checked by rectoscopy and in situ rectal examination&#44; and instillation of diluted methylene blue&#44; if necessary&#46; The resection and closure of the rectal defect is performed with 3&#8722;0 resorbable suture and the cervical&#47;urethral defect with 2&#8722;0 rapid resorbable sutures in the first two patients and with resorbable unidirectional barbed sutures in the last two cases &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; The rectal defect is sutured with single-layer interrupted stitches&#44; incorporating all layers of the rectal wall&#46; If the anatomy and the proximity of the defect allow it&#44; a second suture layer is carried out on the rectal wall approximating the muscular plane&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The watertightness of the suture is checked with infusion of intravesical saline prior to placement of the interposition mesh&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Subsequently&#44; a sharp triangular patch is taken from a biological mesh of porcine material 5&#8239;&#215;&#8239;10&#8239;cm and 1&#8239;mm thick &#40;lyophilized porcine dermis&#41; and is cut out in its proximal portion to fit between the rectal wall&#44; urethra and bladder neck &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figs&#46; 6 and 7</a>&#41;&#46; First&#44; the mesh is fixed proximally to its deepest portion &#40;the one we have sharpened&#41; with a stitch&#44; and then laterally with two 3&#8722;0 resorbable stitches&#44; trimming the distal excess if necessary&#46; This way&#44; a separation layer between the rectal wall&#44; urethra and bladder neck is created&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Finally&#44; closure is performed in three layers&#44; aponeurotic&#44; subcutaneous and skin&#44; leaving a non-suction drain away from the skin wound &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; The skin closure is carried out with resorbable suture&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">The mean operative time was 174&#8239;min &#40;140&#8211;210&#41;&#46; The mean intraoperative blood loss was 70&#8239;cc &#40;50&#8211;150&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">No patient presented complications in the immediate postoperative period&#44; apart from a serous drainage from the surgical wound that took 15 days to resolve and did not correspond to urine in the biochemical analysis&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Drains were maintained for 48&#8722;72&#8239;h postoperatively&#44; depending on the output&#44; and all patients were discharged before the fifth postoperative day&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Three patients kept the bladder catheter for one month&#44; while the other two did so for 45 and 60 days&#44; respectively&#46; Prior to removal of the bladder catheter&#44; the sealing of the reconstruction was checked by cystography&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The colostomy was maintained for a median of six &#40;3&#8722;0&#41; postoperative months&#44; and the resolution of the defect was also checked beforehand with the use of a barium enema&#46; Six months after surgery&#44; a follow-up cystography was performed&#44; which revealed resolution of the RUF in the four patients during this follow-up&#46; After a median follow-up of 36&#46;2 months&#44; no patients presented recurrence symptoms&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Stress urinary incontinence was observed in three of the five patients&#44; requiring the use of at least two pads per day&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">While both rectal injury and the dreaded event of RUF usually occur early in the learning curve&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;7</span></a> the increasing inclusion of patients with high risk disease and local volume&#44; as well as locally advanced tumors&#44; may increase the number of these complications once more&#46; In our series&#44; the incidence of these fistulas was relatively maintained over time&#44; partly due to this fact and partly due to the incorporation of new surgeons into the learning curve&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The most frequent clinical presentation is urinary leakage through the rectum&#44; which our patients complained as diarrhea&#46; The symptoms of pneumaturia and fecaluria are less frequent than the latter&#44; and usually reflect the presence of larger fistulas&#44; and should therefore be considered a sign of poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The time it can take to manifest itself can reach almost two years&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> although in our series all of them manifested almost immediately&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Rivera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> describe a staging system with five groups or stages in their study including 14 patients&#46; Stage I-low&#44; less than 4&#8239;cm from the anal verge and nonirradiated fistulas&#44; stage II-high&#44; is made up of high fistulas &#40;more than 4&#8239;cm from anal verge&#41;&#44; stage III-small&#44; less than 2&#8239;cm irradiated fistula&#44; stage IV-large&#44; more than 2&#8239;cm irradiated fistula&#44; and stage V-large&#44; ischial decubitus fistulas in patients with spinal cord injury&#46; All our fistulas were located between 3 and 5&#8239;cm from the anal margin and could therefore be classified into stages I and II&#46; On the other hand&#44; it is known that&#44; in addition to the presence of fecaluria&#44; size greater than 2&#8239;cm and a history of ionizing radiation are signs of poor prognosis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; none of these were present in our patients&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As first maneuver in all cases&#44; and as first therapeutic option in the case of small-caliber fistulas&#44; the initial treatment is conservative&#44; with bowel diversion and bladder catheter drain&#46; Although there are series that report spontaneous closure in between 12&#8211;45&#37; of RUFs with double diversion alone&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;10</span></a> our experience is that even if the bladder catheter is maintained for at least three months&#44; the great majority of patients require surgical treatment&#46; The factors that may favor this closure with conservative management would be a fistula of less than 5&#8239;mm in diameter and preferably a distal location&#46; On the other hand&#44; short or large diameter fistulas&#44; or those located at bladder level or with a history of radiotherapy&#44; are less likely to close after conservative treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> As a general rule&#44; if the fistula has not resolved two months after fecal and urinary diversion&#44; it is unlikely to do so without requiring surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Most authors recommend performing a colostomy to keep the fistula as clean as possible&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;14</span></a> which would lead to a three-stage repair&#44; one stage to perform the colostomy&#44; another to correct the fistula and a third to close the colostomy at approximately two months after the fistula closure procedure&#46; Other authors with experience in these techniques&#44; especially when perineal approaches are involved&#44; such as Mundy&#8217;s or Rivera&#8217;s group&#44; do not believe that it should be performed in a routine way&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a> This may be shown by the management variability of this infrequent entity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Our experience tells us that avoiding the passage of feces near the fistula with bowel diversion reduces contamination of the area&#44; on the one hand&#44; and on the other&#44; reduces urinary output through the fistulous tract by decreasing the pressure difference between both tracts&#46; These two circumstances reduce the inflammatory reaction of the perineal region&#44; which translates into easier exposure and less friability of the tissues&#44; which improves the performance of the technique while increasing success probabilities&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Many techniques have been described for the repair of RUF&#46; The abdominal approach&#44; reported by Turner-Warwick<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> has the advantage of a relatively easy omental transposition&#44; but the main disadvantage is that in certain cases&#44; especially in obese patients&#44; it is difficult to access such a deep area&#46; When the patient has undergone several previous abdominal surgeries&#44; this approach can be complex due to secondary adhesions or fibrosis&#46; Furthermore&#44; it is an approach with high associated morbidity and a not negligible failure rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> The laparoscopic approach&#44; as well as the robotic&#44; allow better exposure and easier access to these fields&#46; Likewise&#44; the closure of both orifices&#44; as well as omental interposition<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> with the use of cystography and dissection of the posterior vesical face and the fistula itself&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although transanal advancement flap repair has given good results on limited occasions in complex fistulas&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> its use is usually restricted for small fistulas and preferably without poor prognostic factors&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> This approach only allows exposure of defects in the final portion of the rectal ampulla&#46; It is not free of complications such as urethral stricture and urinary and fecal incontinence&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The York Mason posterior transsphincteric approach has reported good results in the correction of the fistulous defect&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;23</span></a> with the main advantage of direct and frontal access to the fistula&#44; which makes it more feasible&#46; In this same work&#44; the rate of fecal incontinence is negligible&#44; but we know from the works described using this same approach that&#44; although infrequent&#44; it is not nil&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The problem concerning this technique is that it demands the participation of experienced surgeons and that it does not allow the repair of large fistulas that require flap interposition or adequate access to the urethra to treat urethral alterations&#44; if any&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The perineal approach offers several advantages&#46; First&#44; the anatomical area is well known by urologists&#46; On the other hand&#44; it avoids access to the abdominal cavity&#44; which&#44; as mentioned above&#44; can be very difficult in patients with multiple previous surgeries&#46; If both urine and stool have been diverted for a reasonable period of time&#44; inflammatory areas can be avoided&#46; It offers easy access for the management of both orifices&#44; and therefore easy repair&#46; It has no complications in terms of fecal continence with a success rate close to 90&#8211;100&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;16&#44;26</span></a> In the case of associated urethral pathology such as concomitant urethral stricture&#44; it allows repair by the same access route&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> even by performing oral mucosal grafts&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">From our point of view&#44; the perineal approach has a disadvantage which is the limited field of vision&#44; especially when dealing with fistulas that are too high &#40;trigonal fistulas&#41;&#46; On the other hand&#44; in certain cases it is difficult to control the ureters and there is a risk of injuring them&#44; which is why we recommend the placement of double J catheters when the meatus is very close to the defect&#46; Another disadvantage of this surgery is the nonnegligible rate of urethral strictures due to tissue devitalization and its manipulation during surgery&#46; Likewise&#44; our patients present a high rate of urinary incontinence&#59; however&#44; we cannot ascertain whether it was patent after the primary surgery and is a consequence of the fistula repair procedure&#44; but we believe that both aspects might be involved in a certain way&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The usefulness of the interposition of pedicled flaps between the rectal and urethral suture lines providing robustness to the closure&#44; promoting healing and preventing recurrences&#44; is well-known&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Although certain authors consider it necessary only in case of complex fistulas&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> our experience has shown us that it provides greater certainty of success&#46; When the abdominal approach is used&#44; omental interposition is the most widely used&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Much of the literature reviewed uses a gracilis muscle flap&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;13&#44;14&#44;28&#8211;31</span></a> or even levator ani flap<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> when perineal approach is used&#46; Although we know that gracilis muscle interposition has low morbidity&#44;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;28</span></a> as mentioned above&#44; the occurrence of urethral stricture and incontinence can be associated with this technique&#46; Reviews on the gracilis flap technique reported 4&#37; pain associated with its mobilization and 3&#37; wound infections&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> as well as loss of adduction strength and hypoesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">A variety of tissues have been used for interposition in RUF repair&#44; such as pedicled dartos flaps<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">34&#44;35</span></a> or oral mucosal grafts&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> We have also found isolated cases in the literature describing the use of porcine dermis-derived material for the repair of this type of fistulas&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37&#8211;39</span></a> However&#44; ours is the first series of patients demonstrating its reproducibility and good results&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The use of meshes made of biological material is widely described in abdominal wall defect repair techniques&#44; and our colleagues from general surgery have a great deal of experience with it&#46; They have high success rates&#44; and the most frequent complications are seroma and surgical wound infection&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> It was thanks to this close interdisciplinary collaboration in the repair of RUF that the idea of interposing biological material&#44; in our case porcine dermis&#44; arose&#46; With this maneuver&#44; we aimed to save mobilization of autologous tissue and improve the success rate of fistula resolution by interposing material between the two sutures&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In our hands&#44; the interposition of biological material has simplified the technique of interposition of material between sutures&#46; The technique has obtained a good outcome&#44; achieving fistula repair in all patients&#44; with none of them presenting recurrence during the follow-up period&#46; There were no complications associated with the technique&#44; apart from seroma in two patients who did not require invasive management in any case&#46; It is not uncommon to find wound drainage&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> but in most cases it is treated with conservative management&#46; Urethral strictures derived from the use of gracilis described by other groups<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> did not appear in our series during follow-up&#46; The mean catheter indwelling time after surgery in the series is 40 months<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;27&#44;38</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; which is a figure very close to the mean in our series&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">The main limitation of our study is the small number of cases due to the fortunately infrequent occurrence of this type of fistulas&#44; and we do not have a control group with which we can compare our technique&#46; We are aware that a refined surgical technique and sufficient experience in this type of access should lead to the success of the technique&#44; but we believe that the interposition of material provides greater safety in the procedure&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">The perineal approach provides the advantage of good tissue exposure and facilitates closure of both fistulous orifices&#46; The interposition of biological material from porcine dermis presents good tolerance and provides results that are superimposable to those obtained with autologous material&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2020-10-15"
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            0 => "Rectourethral fistulas"
            1 => "Radical prostatectomy"
            2 => "Biological mesh"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Rectal injury is a rare complication after extraperitoneal laparoscopic radical prostatectomy&#46; The development of rectourethral fistulas &#40;URF&#41; from rectal injuries is one of the most feared and of more complex resolution in urology&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Between 2013 and 2020 we have operated on a total of 5 patients with URF after extraperitoneal endoscopic radical prostatectomy through a perineal access using the interposition of biological material&#46; All fistulas had a diameter of less than 6&#8239;mm at endoscopy and were less than 6 cm apart from the anal margin&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The mean age of the patients was 64 years old&#46; All patients had a previous bowel and urinary diversion for at least 3 months&#46; Under general anesthesia and with the patient in a forced lithotomy position&#44; fistulorraphy and interposition of biological material of porcine origin &#40;lyophilized porcine dermis &#91;Permacol&#174;&#93;&#41; were performed through a perineal access&#46; Mean operative time was 174&#8239;min &#40;140&#8211;210&#41;&#46; Most patients were discharged on the third postoperative day&#46; The bladder catheter was left in place for a mean of 40 days &#40;30&#8211;60&#41;&#46; Prior to its removal&#44; cystography and a Gastrografin&#174; barium enema were performed&#44; showing resolution of the fistula in all cases&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">The interposition of biological material from porcine dermis through perineal approach is a safe alternative with good results in patients submitted to urethrorectal fistulorraphy after radical prostatectomy&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La lesi&#243;n rectal es una complicaci&#243;n infrecuente de la prostatectom&#237;a radical laparosc&#243;pica extraperitoneal&#46; El desarrollo de f&#237;stulas uretrorrectales &#40;FUR&#41;&#44; a partir de lesiones rectales&#44; resulta uno de los problemas m&#225;s temidos y de m&#225;s compleja resoluci&#243;n en urolog&#237;a&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Entre 2013 y 2020 hemos intervenido a un total de cinco pacientes con FUR tras prostatectom&#237;a radical endosc&#243;pica extraperitoneal&#44; mediante un abordaje perineal utilizando la interposici&#243;n de material biol&#243;gico&#46; Todas las f&#237;stulas presentaron un di&#225;metro menor de 6 mm en la endoscopia y se encontraban a menos de 6 cm del margen anal&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">La media de edad de los pacientes fue 64 a&#241;os&#46; Todos los pacientes llevaban al menos tres meses de derivaci&#243;n intestinal y urinaria previas&#46; Bajo anestesia general&#44; y con el paciente en posici&#243;n de litotom&#237;a forzada mediante un acceso perineal&#44; se realiz&#243; fistulorrafia e interposici&#243;n de material biol&#243;gico de origen porcino &#40;dermis porcina liofilizada &#91;Permacol&#174;&#44; Medtronic&#93;&#41;&#46; La duraci&#243;n media de la cirug&#237;a fue de 174&#8239;min &#40;140&#8211;210&#41;&#46; La mayor&#237;a de los pacientes fueron dados de alta al tercer d&#237;a postoperatorio&#46; La sonda vesical se mantuvo una media de 40 d&#237;as &#40;30&#8211;60&#41;&#46; Previa a la retirada de la misma&#44; se realiz&#243; cistograf&#237;a y enema opaco con Gastrografin&#174;&#44; que mostr&#243; resoluci&#243;n de la f&#237;stula en todos los casos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">La interposici&#243;n de material biol&#243;gico procedente de dermis porcina mediante abordaje perineal es una alternativa segura y con buenos resultados en pacientes sometidos a fistulorrafia uretrorrectal tras prostatectom&#237;a radical&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Juan Escudero JU&#44; Villaba Ferrer F&#44; Ramos de Campos M&#44; Fabuel Deltoro M&#44; Garcia Coret MJ&#44; Sanchez Ballester F&#44; et al&#46; Tratamiento de las f&#237;stulas uretrorrectales tras prostatectom&#237;a radical mediante la interposici&#243;n de material biol&#243;gico v&#237;a perineal&#46; Actas Urol Esp&#46; 2021&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.acuro.2021.01.003">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;acuro&#46;2021&#46;01&#46;003</span></p>"
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                  \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">Case&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">Age&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">pre PSA&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">pre cT&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">rT&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">Vol&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">pre Gleason&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">SX date&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">pT&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">DAV&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">Diameter &#40;mm&#41;&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">SX date&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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&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">9&#44;2&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">2a&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">2c&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#43;&#8239;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#47;2&#47;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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">1&#47;7&#47;13&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">2&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">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3a&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">3a&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">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;&#43;&#8239;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#47;7&#47;14&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">2c&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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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">14&#47;1&#47;15&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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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">9&#44;4&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">2a&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">2c&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">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#43;&#8239;4&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">20&#47;6&#47;16&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">3a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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">7&#47;6&#47;17&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">4&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">61&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">10&#44;4&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">2b&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">2b&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">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#43;&#8239;4&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">17&#47;5&#47;19&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">3a R1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#47;12&#47;19&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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&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">8&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">1c&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">2c&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8239;&#43;&#8239;4&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">20&#47;8&#47;19&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">3a R1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#47;2&#47;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2608404.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Preoperative characteristics of the patients&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "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">Case&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">Op&#46; time&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">LOS &#40;days&#41;&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">Cath&#46; time&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">Colostomy closure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><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">&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">min&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">&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">days&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">&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">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">180&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 m&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">2&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">210&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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">45&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">9 m&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">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">190&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><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">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 m&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">4&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">140&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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 m&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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2608407.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Results&#46;</p>"
        ]
      ]
      10 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0055"
            "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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#44;1&#8211;2&#93;Rivera &#40;5&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#44;3&#8211;4&#93;Ram&#237;rez &#40;31&#41;</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">Proposed approach&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 " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I</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">&#60; 4&#8239;cm from anal margin&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;1&#44;0&#93;Small size</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;1&#44;0&#93;Simple</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Conservative&#47;Transsphincteric</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nonirradiated&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 " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">II</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">&#62; 4&#8239;cm anal margin&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nonirradiated</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transsphincteric&#47;Transperineal</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nonirradiated&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 " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">III</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">&#60; 2&#8239;cm diameter&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postoperative</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#91;2&#44;0&#93;Complex</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transperineal&#47;Abdominal</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irradiated&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 " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IV</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">&#62; 2&#8239;cm diameter&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">&#91;1&#44;0&#93;Large volume&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdominal</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irradiated&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irradiated</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">V&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">Large size&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">Abdominal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2608405.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Fistula classification and recommended treatment&#46;</p>"
        ]
      ]
      11 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0060"
            "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  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#44;1&#8211;2&#93;Catheter indwelling time after surgery &#40;days&#41;</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">Rivera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&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">Lorente et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21&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">Mundy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&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="left" valign="\n
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                  \t\t\t\t">30&#8722;90&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">Zmora et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50&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">Garza et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60 &#40;suprapubic catheter&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">Vanni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14&#8722;50&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">Imperatore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
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                  \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">Juan et al&#46;&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
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                  \t\t\t\t">40&nbsp;\t\t\t\t\t\t\n
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