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Pharmacological venous thromboembolism prophylaxis in radical prostatectomy
Profilaxis farmacológica de la tromboembolia venosa en la prostatectomía radical
Sebastian Valverde-Martineza,b, Laura-Andrea Gonzalez-Rayoc, Barbara Padilla-Fernandezd, Jorge Pereira-Brunoe, Hugo Coelhof, Manuel Montesino-Semperg, Carlos Müller-Arteagah, Jose-Luis Alvarez-Ossorio-Fernandezi, Filippo Migliorinij, Maria-Begoña Garcia-Cenadork, Maria-Fernanda Lorenzo-Gomeza,k,l,
Corresponding author
mflorenzogo@yahoo.es

Corresponding author.
a Grupo de Investigación Multidisciplinar Urológico de Renal (GRUMUR), Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
b Servicio de Urología, Complejo Asistencial Universitario de Ávila, Ávila, Spain
c Universidad del Rosario, Escuela de Medicina y Ciencias de la Salud, Bogotá, Colombia
d Servicio de Urología. Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
e Servicio de Urología, Hospital Universitario Pêro da Covilhã, Covilhã, Portugal
f Servicio de Urología, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
g Servicio de Urología, Hospital Universitario Virgen del Camino, Pamplona, Spain
h Servicio de Urología, Complejo Universitario Hospitalario de Ourense, Ourense, Spain
i Servicio de Urología, Hospital Universitario Puerta del Mar, Cádiz, Spain
j Servicio de Urología, Hospital Azienda Ospedaliera Universitaria Integrata,Verona, Italy
k Departamento de Cirugía, Universidad de Salamanca, Salamanca, Spain
l Servicio de Urología, Hospital Universitario de Salamanca, Salamanca, Spain
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            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Servicio de Urolog&#237;a&#44; Hospital Universitario Virgen del Camino&#44; Pamplona&#44; Spain"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
          7 => array:3 [
            "entidad" => "Servicio de Urolog&#237;a&#44; Complejo Universitario Hospitalario de Ourense&#44; Ourense&#44; Spain"
            "etiqueta" => "h"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Servicio de Urolog&#237;a&#44; Hospital Universitario Puerta del Mar&#44; C&#225;diz&#44; Spain"
            "etiqueta" => "i"
            "identificador" => "aff0045"
          ]
          9 => array:3 [
            "entidad" => "Servicio de Urolog&#237;a&#44; Hospital Azienda Ospedaliera Universitaria Integrata&#44;Verona&#44; Italy"
            "etiqueta" => "j"
            "identificador" => "aff0050"
          ]
          10 => array:3 [
            "entidad" => "Departamento de Cirug&#237;a&#44; Universidad de Salamanca&#44; Salamanca&#44; Spain"
            "etiqueta" => "k"
            "identificador" => "aff0055"
          ]
          11 => array:3 [
            "entidad" => "Servicio de Urolog&#237;a&#44; Hospital Universitario de Salamanca&#44; Salamanca&#44; Spain"
            "etiqueta" => "l"
            "identificador" => "aff0060"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Profilaxis farmacol&#243;gica de la tromboembolia venosa en la prostatectom&#237;a radical"
      ]
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0030" class="elsevierStylePara elsevierViewall">Prostate cancer is the second most commonly diagnosed cancer in men&#44; with an estimated 1&#46;1<span class="elsevierStyleHsp" style=""></span>million diagnoses worldwide in 2012&#44; representing 15&#37; of all cancers in that year&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Most prostate cancers are organ-confined at the time of diagnosis&#46; When the life expectancy of the patient is equal to or greater than 10<span class="elsevierStyleHsp" style=""></span>years and his state of health is compatible with a general anaesthesia&#44; one of the most decisive treatments in oncological terms is radical prostatectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Radical prostatectomy is a major complex abdomen-pelvic surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The absence of standardization at the time of classifying and publishing the surgical complications of radical prostatectomy&#44; as well as the introduction of different techniques&#44; have resulted in a wide variation of types of reported complications&#44; as well as a variation in the overall incidence of the complications&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Venous thromboembolic disease &#40;VTE&#41;&#44; which includes deep vein thrombosis &#40;DVT&#41; and pulmonary thromboembolism &#40;PET&#41;&#44; are frequent complications of surgical procedures&#46; PET is one of the most common causes of non-surgical death in patients undergoing urological surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In addition to the mortality associated with PET&#44; long-term complications such as post-thrombotic syndromes lead to significant morbidity and a significant economic impact&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PET also represents the most common preventable cause of death related to hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Prior to the prophylaxis to avoid PET during abdomen&#47;pelvic surgery becoming routine&#44; the incidence of DVT was between 10 and 30&#37; and the incidence of PET&#44; between 1 and 10&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> These findings led to recommendations for routine thromboprophylaxis in patients who were going to have urological abdomen&#47;pelvic surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> With the prophylaxis of thromboembolic disease&#44; the figures for PET have decreased between 0 and 2&#46;0&#37;&#44; according to different case series&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The therapeutic options for thromboprophylaxis depend on the risk level of the patient regarding developing a venous thromboembolic event&#46; In the surgical environment the therapies to be used separately or combined are the following<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1</span><p id="par0060" class="elsevierStylePara elsevierViewall">Mechanical therapies &#40;non-pharmacological&#41;&#58;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2</span><p id="par0065" class="elsevierStylePara elsevierViewall">Starting to walk soon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3</span><p id="par0070" class="elsevierStylePara elsevierViewall">Gradual compression stockings&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">4</span><p id="par0075" class="elsevierStylePara elsevierViewall">Intermittent pneumatic compression&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">5</span><p id="par0080" class="elsevierStylePara elsevierViewall">Pharmacological agents</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">6</span><p id="par0085" class="elsevierStylePara elsevierViewall">Low doses of unfractionated heparin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">7</span><p id="par0090" class="elsevierStylePara elsevierViewall">Low molecular weight heparin</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">Pharmacological prophylaxis for venous thrombosis consists in the use of low-dose unfractionated heparin or low molecular weight heparin &#40;LMWH&#41;&#59; it should be started before anaesthetic induction&#44; as it has been proven that thrombotic phenomena begins during surgery&#46; Often these thromboembolic complications occur after hospital discharge&#44; since the risk of developing a venous thromboembolic event is almost constant during the first 4<span class="elsevierStyleHsp" style=""></span>weeks after surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6</span></a> It is therefore advisable to inform patients of the signs and symptoms that accompany these clinical events&#46; Based on the latter&#44; the general recommendation is to maintain the pharmacological prophylaxis for 4<span class="elsevierStyleHsp" style=""></span>weeks after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> What is still a matter of debate is whether this should be started the day before the intervention or the day after so as not to increase the risk of intraoperative and postoperative bleeding&#44; since the reduction of thromboembolic risk when opting for one option or the other is still unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Randomized controlled clinical trials have demonstrated the efficacy of thromboprophylaxis in reducing the incidence of venous thromboembolic events&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Some meta-analyzes in abdomen pelvic surgery by various specialities have shown that anticoagulants such as LMWH reduce the relative risk of VTE by approximately 50&#37;&#44; but also increase the relative risk of major bleeding by approximately 50&#37;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;8</span></a>&#59; therefore&#44; the administration of the VTE prophylaxis should be balanced against the risks of excessive bleeding&#44; particularly in surgical patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Various organizations &#8212; including the Spanish Association of Urology &#8212; find that the prophylaxis of thromboembolic disease is an indicator of the quality of patient care&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The existence of variations in health care lead to many questions about the quality of care&#44; including aspects of accessibility&#44; adequacy&#44; cost-effectiveness and equity&#46; These issues highlight the implications that variability in medical practice has on health policy and clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Despite the importance of PET prophylaxis after radical prostatectomy&#44; little is known about the urologists&#8217; use of prophylaxis patterns&#46; Multicentre case series have shown wide variation in the use of this prophylaxis&#44; even among high-volume institutions&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> A survey of urologists in 2004 reported that 24&#37; of US urologists used pharmacological prophylaxis&#44; compared to 100&#37; of British urologists and 50&#37; of Irish urologists&#46; There were no differences in the use of mechanical devices&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Prophylaxis guidelines for thromboembolic disease have not always been well received by urologists&#46; Some consensus&#8217;s even recommend early mobilization and mechanical therapy instead of pharmacological prophylaxis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Given the scarcity of existing data describing the prophylaxis of thromboembolic disease after prostatectomy&#44; an analysis was made of the thromboembolic disease predictors&#44; the clinical variability in the use of pharmacological prophylaxis for this disease&#44; and the results of its application among men undergoing radical prostatectomy in the 3 most widely used techniques today&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0120" class="elsevierStylePara elsevierViewall">A retrospective multicentre observational study is carried out&#46; The medical records of 610 men who underwent radical prostatectomy for organ-confined prostate cancer were reviewed in 7 hospitals in Italy&#44; Portugal and Spain&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patient selection</span><p id="par0125" class="elsevierStylePara elsevierViewall">The selection of the cohort was made taking as reference the dates from December 1&#44; 2013 to November 31&#44; 2014&#44; selecting the cases sequentially in successive and retrospective order until reaching the appropriate sample size&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The patients were treated in&#58; Salamanca University Hospital &#40;Spain&#41;&#44; P&#234;ro da Covilh&#227; University Hospital &#40;Portugal&#41;&#44; Coimbra University and Hospital Centre &#40;Portugal&#41;&#44; Virgen del Camino University Hospital in Pamplona &#40;Spain&#41;&#44; Ourense University Hospital Complex &#40;Spain&#41;&#44; Puerta del Mar University Hospital in C&#225;diz &#40;Spain&#41; and Azienda Ospedaliera Integral University of Verona Hospital &#40;Italy&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The study protocol specified that the name of the hospital would not be mentioned&#44; but rather only the hospital group level III or level IV or whether it was public or private&#47;concerted&#46; As follows&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">a&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Site 1 group&#58; general hospital level 4 public &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>153&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">b&#41;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Site 2 group&#58; general hospital level 3 public &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">c&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Site 3 group&#58; general hospital level 3 private&#47;concerted &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>53&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">d&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Site 4 group&#58; general hospital level 3 public &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">e&#41;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Sites 5 and 6 group&#58; two general hospitals level 3 public&#59; presented joint data &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>58&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">f&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Site 7 group&#58; general hospital level<span class="elsevierStyleHsp" style=""></span>4 public &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>23&#41;&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient and hospital characteristics</span><p id="par0170" class="elsevierStylePara elsevierViewall">Because the use of thromboembolic prophylaxis implies a specific risk during the procedure and for the patient&#44; and because the benefit of the reduction of venous thromboembolic events is to be weighed against the increase of intraoperative and postoperative bleeding&#44; several groups of patients were defined according to their baseline characteristics&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">On one side&#44; a definition was made of patients with a predisposition to present intraoperative and postoperative hemorrhages&#44; assessing the variables related to presenting a disease that induces hypocoagulability or treatments with anticoagulants or with platelet antiaggregants prior to surgery&#44; despite the fact that all the patients with these treatments received bridging therapy to carry out the surgical procedure&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">With regard to bleeding as a complication derived from the use of drugs for thromboembolic prophylaxis&#44; intraoperative bleeding and the need for a transfusion during hospital admission were assessed&#46; These variables were taken into account because approximately 50&#37; of major hemorrhages occur between surgery and the next morning&#44; and about 90&#37; during the first 4<span class="elsevierStyleHsp" style=""></span>days after surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">On the other side&#44; a definition was made of patients with predisposing characteristics to present a venous thromboembolic event after surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Although there are several quantitative models to estimate the risk of suffering an event&#44; in our study the risk model of venous thromboembolism was used according to the patient&#8217;s risk factors&#44; which include the variables&#58; age&#44; body mass index&#44; previous VTE in the patient or in the patient&#39;s first degree family members&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14&#44;15</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">In this study&#44; a venous thromboembolic event was defined as when the patient presented a symptomatic DVT or a PET&#46; In all cases&#44; LMWH at prophylactic dose was used as the pharmacological prophylaxis&#46; The most commonly used heparin was enoxaparin at a dose of 4000 international units &#40;IU&#41; or 40<span class="elsevierStyleHsp" style=""></span>mg&#44; regardless of patient weight&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">It is important to note that in our study all cases were indicated early ambulation at 24<span class="elsevierStyleHsp" style=""></span>h after the intervention&#44; and only 10&#37; of cases used intermittent pneumatic compression&#44; so this work mostly evaluates the pharmacological prophylaxis&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Another study group related thromboembolic events according to the different types of surgery&#58; laparoscopic&#44; open-retropubic or open-robotic prostatectomy&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The results were analyzed with descriptive and inferential statistics&#44; using Student&#39;s t&#44; chi-square&#44; Fisher&#8217;s exact test&#44; ANOVA analysis of variance &#40;with Schrieffer test for normal samples and Krystal Walls for other distributions&#41;&#46; A statistical significance was accepted for p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0210" class="elsevierStylePara elsevierViewall">The results of the study are shown in <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2&#8211;7</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0215" class="elsevierStylePara elsevierViewall">Since 2004&#44; when <span class="elsevierStyleItalic">The American College of Chest Physicians</span> presented several recommendations for the prophylaxis of VTE in patients who were going to be intervened with abdomen pelvic urological surgery&#44; the different types of prophylaxis have been adapted according to the different surgical approaches&#44; including radical prostatectomy&#46; Among these measures we have early ambulation&#44; intermittent pneumatic compression and LMWH&#46; The current recommended management is a combination of these measures&#44; regardless of the technique to be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> In our series&#44; 15 patients &#40;2&#46;5&#37;&#41; presented venous thromboembolic events&#46; Nine of them presented a severe PET that in no case caused the death of the patient&#46; Eight of the patients who presented an event did not receive pharmacological prophylaxis&#46; We observed that with respect to the pharmacological prophylaxis used in the different thromboembolic risk groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; there were differences in the low risk group but not in the intermediate and high risk groups&#59; this was probably due to the fact that this group covered 95&#37; of the cases in the series &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; However&#44; its results reflect the importance of pharmacological prophylaxis to prevent VTE&#44; because there were differences between the patients who received prophylaxis and those who did not&#46; In addition&#44; this prophylaxis was able to reduce thromboembolic events up to 6&#46;8&#37; in the study &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">However&#44; it is important to comment that in this study no other thromboembolic risk factors have been assessed&#44; and that in future studies and analysis could be made of performing pelvic lymphadenectomy&#44; the duration of the surgical procedure&#44; hereditary blood disorders such as antiphospholipid antibody syndrome&#44; factor V Leiden&#44; antithrombin&#44; and protein C or S deficiencies&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Although the variability in clinical practice is a very frequent phenomenon in our care work&#44; in this study there were few relevant differences between hospitals regarding the use of the different types of prophylaxis for the VTE&#46; When evaluating differences between the various techniques used with respect to the incidence of venous thromboembolic events&#44; no differences were observed between them &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; It is important to point out that in the case series investigated&#44; which includes patients from hospitals of different healthcare levels&#44; the indication of the prophylaxis was influenced by the &#8220;usual practice&#8221; of the urologist in regards to the type and timing of application&#46; In 15&#46;4&#37; of cases no prophylaxis was used&#44; except for early ambulation&#59; in 4&#46;1&#37; intermittent pneumatic compression was used&#59; in 84&#46;6&#37; pharmacological prophylaxis &#40;LMWH&#41; was given&#44; and only 3&#46;4&#37; received a combination of these &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Therefore&#44; although there is no obvious clinical variability among the different groups when using the various prophylactic measures&#44; there is little adherence to the clinical guidelines when only 4&#46;1&#37; of patients received the use of IPC devices&#44; and worse still is the lack of combined treatment&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">In our study&#44; 361 patients &#40;59&#46;1&#37;&#41; were given the pharmacological prophylaxis &#40;LMWH&#41; between 8 and 24<span class="elsevierStyleHsp" style=""></span>h after the surgical procedure&#44; while in the rest of the cases it was given 12<span class="elsevierStyleHsp" style=""></span>h prior to surgery&#46; As previously mentioned&#44; the ideal time to start prophylaxis is still not entirely clear&#46; The maintenance time of the pharmacological prophylaxis varied between 7 and 40<span class="elsevierStyleHsp" style=""></span>days&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Regarding the risk of hemorrhagic complications due to the use of thromboembolic pharmacological prophylaxis&#44; it has been found that the rates of intraoperative bleeding are similar and do not present differences between the groups of hemorrhagic risk&#44; nor between the patients who received or did not receive prophylaxis &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46; Similarly&#44; no differences were observed when the need for a blood transfusion was assessed in the postoperative period of the study patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">In a study on patients who underwent radical prostatectomy&#44; there was no difference in bleeding complications derived from the use of pharmacological prophylaxis &#40;LMWH&#41; for VTE&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Pharmacological prophylaxis reduces the risk of presenting a thromboembolic event in patients undergoing radical prostatectomy&#44; although this risk is not associated with the approach technique&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">There is no significant clinical variability between the different sites&#59; however&#44; there was little adherence to the recommendations of the different clinical guidelines in force in the application of thromboembolic prophylaxis&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">In patients undergoing radical prostatectomy with or without risk factors of developing a thromboembolic event&#44; a prophylactic treatment that combines early mobilization and pharmacological prophylaxis with LMWH would be indicated&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2018-09-12"
    "fechaAceptado" => "2019-04-04"
    "PalabrasClave" => array:1 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabrasclave"
          "identificador" => "xpalclavsec1209870"
          "palabras" => array:3 [
            0 => "Prostatectom&#237;a radical"
            1 => "Profilaxis tromboemb&#243;lica"
            2 => "Variabilidad cl&#237;nica"
          ]
        ]
        1 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1209871"
          "palabras" => array:3 [
            0 => "Radical prostatectomy"
            1 => "Thromboembolic prophylaxis"
            2 => "Clinical variability"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and aim</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pulmonary thromboembolism is one of the most common causes of non-surgical death in patients following urological abdominopelvic surgery&#46; Since the beginning of prophylaxis for venous thromboembolic disease&#44; episodes of deep vein thrombosis and pulmonary thromboembolism have decreased&#46; Our objective is to analyse the prognosis factors of thromboembolic disease&#44; the clinical variability in the use of pharmacological prophylaxis and the results of its application&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Retrospective multicentric study of 610 patients undergoing radical prostatectomy between December 2013 and November 2014&#44; in 7 general hospitals in Spain&#44; Italy and Portugal&#46; Patients were classified according to their baseline characteristics into thrombotic risk groups and haemorrhagic risk groups&#46; The venous thromboembolic events that occurred in the different groups were analysed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The average age was 65&#46;22 years &#40;48&#8211;78&#41;&#46; The average body mass index was 26&#46;7 and the average ASA risk 2&#46;1&#46; In all patients&#44; early mobilization began in the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; In 4&#46;1&#37; intermittent pneumatic compression was used and 84&#46;6&#37; received pharmacological prophylaxis with low molecular weight heparins&#46; Only 3&#46;4&#37; used the combination of mechanical prophylaxis with pharmacological prophylaxis&#46; We observed a decrease in the incidence of thromboembolic events in the patients who received pharmacological prophylaxis&#44; with an absolute risk reduction of 6&#46;8&#37;&#46; There was no increase in the risk of haemorrhage in the patients who received pharmacological prophylaxis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">In this study on patients undergoing radical prostatectomy&#44; there was no difference in haemorrhagic complications derived from the use of pharmacological prophylaxis for venous thromboembolic disease&#46; Pharmacological prophylaxis reduces the risk of presenting a thromboembolic event in patients undergoing radical prostatectomy&#44; although this risk is not associated with the approach technique&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and aim"
          ]
          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" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La tromboembolia pulmonar es una de las causas m&#225;s comunes de muerte no quir&#250;rgica en pacientes sometidos a cirug&#237;a urol&#243;gica abdomino-p&#233;lvica&#46; Desde el inicio de la profilaxis para la enfermedad tromboemb&#243;lica venosa los episodios de trombosis venosa profunda y tromboembolia pulmonar han descendido considerablemente&#46; Nuestro objetivo es analizar los predictores de la enfermedad tromboemb&#243;lica&#44; la variabilidad cl&#237;nica en la utilizaci&#243;n de la profilaxis farmacol&#243;gica para esta enfermedad y los resultados de su aplicaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo multic&#233;ntrico de 610 pacientes intervenidos mediante prostatectom&#237;a radical entre diciembre 2013 y noviembre de 2014&#44; en 7 hospitales generales de Espa&#241;a&#44; Italia y Portugal&#46; Se clasificaron a los pacientes seg&#250;n sus caracter&#237;sticas basales en grupos de riesgo tromb&#243;tico y grupos de riesgo hemorr&#225;gico&#46; Se evaluaron los eventos tromboemb&#243;licos venosos que se presentaron en los diferentes grupos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">La edad media fue de 65&#44;22 a&#241;os &#40;48&#8211;78&#41;&#46; El &#237;ndice de masa corporal medio de 26&#44;7 y la mediana del riesgo de ASA fue 2&#46; En todos los pacientes se inici&#243; la deambulaci&#243;n en las primeras 24 horas&#46; En 4&#46;1&#37; se utiliz&#243; compresi&#243;n neum&#225;tica intermitente y en un 84&#46;6&#37; profilaxis farmacol&#243;gica con heparinas de bajo peso molecular&#46; Solo en un 3&#46;4&#37; se utilizo la combinaci&#243;n de profilaxis mec&#225;nica con la farmacol&#243;gica&#46; Se observ&#243; disminuci&#243;n de la incidencia de eventos tromboemb&#243;licos en los pacientes que recibieron profilaxis farmacol&#243;gica&#44; con una reducci&#243;n absoluta del riesgo de 6&#46;8&#37;&#46; No se objetiv&#243; aumento del riesgo hemorr&#225;gico en los pacientes que recibieron profilaxis tromboemb&#243;lica&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">En este estudio sobre pacientes sometidos a prostatectom&#237;a radical&#44; no hubo diferencia en las complicaciones hemorr&#225;gicas derivadas del uso de profilaxis farmacol&#243;gica para la enfermedad tromboemb&#243;lica venosa&#46; La profilaxis farmacol&#243;gica reduce el riesgo de presentar un evento tromboemb&#243;lico en pacientes sometidos a prostatectom&#237;a radical&#44; si bien&#44; este riesgo no se asocia con la t&#233;cnica de abordaje&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Antecedentes y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Valverde-Martinez S&#44; Gonzalez-Rayo LA&#44; Padilla-Fernandez B&#44; Pereira-Bruno J&#44; Coelho H&#44; Montesino-Semper M&#44; et al&#46; Profilaxis farmacol&#243;gica de la tromboembolia venosa en la prostatectom&#237;a radical&#46; Med Clin &#40;Barc&#41;&#46; 2020&#59;154&#58;113&#8211;118&#46;</p>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">VTE&#58; venous thromboembolic disease&#59; BMI&#58; body mass index&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Risk</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">Low&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">No risk factors&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">1x&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">Mean&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">One of the following&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0005" class="elsevierStylePara elsevierViewall">Age &#8805;75 years</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0010" class="elsevierStylePara elsevierViewall">BMI &#8805;35<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Family history of VTE &#40;parents&#44; siblings or children&#41;</p></li></ul>&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">2x&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">Discharge&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"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">VTE background</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patient with any combination of two or more risk factors</p></li></ul>&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">3x&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Venous thromboembolic risk model according to patient risk factors&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; <span class="elsevierStyleItalic">American Society of Anesthesiologists</span> classification system to estimate the anaesthetic risk&#59; SD&#58; standard deviation&#59; BMI&#58; body mass index&#59; PSA&#58; prostate specific antigen&#59; TNM&#58; classification system of tumours&#46;</p>"
          "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">&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">Group with thromboembolic prophylaxis&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">Group without thromboembolic prophylaxis&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">n&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">516&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">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">Age &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63&#46;86 &#40;6&#46;09 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">64&#46;34 &#40;4&#46;57 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">BMI &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;73 &#40;4&#46;45 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#46;43 &#40;3&#46;68 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">ASA &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">PSA &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;19 &#40;3&#46;54 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;54 &#40;7&#46;01 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">Biopsy Gleason score &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;41 &#40;0&#46;70 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;43 &#40;1&#46;27 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">Tumour load &#40;&#37; affected cylinders&#41; &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;89 &#40;22&#46;77 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;75 &#40;22&#46;32 SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">cTNM<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Quantity&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">132&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">22&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">110&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"><span class="elsevierStyleHsp" style=""></span>Percentage&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&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;7&#37;&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">83&#46;3&#37;&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"><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">610&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">94&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">516&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"><span class="elsevierStyleHsp" style=""></span>Percentage&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;4&#37;&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">84&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            "identificador" => "at0035"
            "detalle" => "Table "
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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">Surgeries&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">Intraoperative bleeding&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">p&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">Postoperative transfusion&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">p&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"><span class="elsevierStyleItalic">Low risk</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;97&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;63&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"><span class="elsevierStyleHsp" style=""></span>No prophylaxis&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">72&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">Mean 296&#46;8 cc&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">&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">&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"><span class="elsevierStyleHsp" style=""></span>Prophylaxis&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">406&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">Mean 316&#46;4 cc&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">&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&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">&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"><span class="elsevierStyleItalic">High risk</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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">&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">&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">&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"><span class="elsevierStyleHsp" style=""></span>No prophylaxis&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">22&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">Mean 358&#46;4 cc&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&#46;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">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">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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"><span class="elsevierStyleHsp" style=""></span>Prophylaxis&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">110&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">Mean 425&#46;8 cc&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">&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">&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"><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">610&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">&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">&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">&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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Risk groups reflected in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p>"
            ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Hemorrhagic events in men who underwent radical prostatectomy according to the hemorrhagic risk groups and the use of thromboembolic pharmacological prophylaxis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:15 [
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              "identificador" => "bib0005"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "EAU-ESUR-ESTRO-SIOG Guidelines on prostate cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Mottet"
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Article information
ISSN: 23870206
Original language: English
DOI:10.1016/j.medcle.2019.04.035
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