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Comparación de los resultados perioperatorios de la cistectomía radical asistida por robot con derivación urinaria extracorpórea vs. intracorpórea
Comparison of perioperative outcomes and complications of robot assisted radical cystectomy with extracorporeal vs intracorporeal urinary diversion
A. Carrion
Autor para correspondencia
acarrionpuig@gmail.com

Autor para correspondencia.
, A. Piñero, C. Raventós, F. Lozano, F. Díaz, J. Morote
Departamento de Urología, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, España
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unos resultados oncol&#243;gicos equivalentes entre la cistectom&#237;a rob&#243;tica y la abierta<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La mayor&#237;a de estudios que comparan los resultados de la CRAR con la cistectom&#237;a abierta utilizan la derivaci&#243;n urinaria extrac&#243;rporea &#40;DUEC&#41; consider&#225;ndola una t&#233;cnica m&#225;s r&#225;pida y sencilla que la intracorp&#243;rea &#40;DUIC&#41;&#46; Sin embargo&#44; con la experiencia alcanzada en cirug&#237;a rob&#243;tica en los &#250;ltimos a&#241;os&#44; algunos autores han reportado los posibles beneficios de la derivaci&#243;n intracorp&#243;rea&#44; como son la recuperaci&#243;n m&#225;s r&#225;pida del tr&#225;nsito intestinal&#44; menor incisi&#243;n y reducci&#243;n de la p&#233;rdida de fluidos&#44; de sangre y de estenosis ureteroileales<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a>&#46; La curva de aprendizaje de la DUIC empez&#243; con el conducto ileal y&#44; posteriormente&#44; se fue adoptando progresivamente en las derivaciones ortot&#243;picas continentes&#46; Sin embargo&#44; en la actualidad existen pocos estudios que comparen directamente la eficacia y seguridad de ambos tipos de derivaciones&#44; tanto en neovejigas como en conductos ileales<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a>&#46; El objetivo de nuestro estudio fue comparar los resultados perioperatorios y complicaciones de la CRAR con DUEC vs&#46; DUIC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Poblaci&#243;n y datos del estudio</span><p id="par0015" class="elsevierStylePara elsevierViewall">Realizamos una revisi&#243;n retrospectiva&#44; de 47 pacientes recogidos prospectivamente que hab&#237;an sido sometidos a una CRAR debido a un tumor vesical entre 2015-2018 en nuestro hospital&#46; Los pacientes incluidos presentaban un TMVMI &#40;T2-T4aN0M0&#41; o un TMVNMI de alto riesgo &#40;Ta&#44; Tis&#44; T1&#41;&#44; con un seguimiento m&#237;nimo de 3 meses y con previo consentimiento informado&#46; Un caso de ureterostom&#237;a cut&#225;nea y 3 casos en los que se reconvirti&#243; a cistectom&#237;a abierta por infiltraci&#243;n de estructuras vecinas fueron excluidos del estudio&#46; Se realiz&#243; una linfadenectom&#237;a extendida &#40;LND&#41; en todos los casos&#46; No se aplic&#243; un protocolo de rehabilitaci&#243;n multimodal &#40;ERAS&#41; de manera sistem&#225;tica en los pacientes&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Se recogieron las siguientes variables&#58; edad&#44; g&#233;nero&#44; h&#225;bito tab&#225;quico&#44; &#237;ndice de masa corporal&#44; clasificaci&#243;n de la Sociedad Americana de Anestesiolog&#237;a&#44; &#237;ndice de comorbilidades de Charlson&#44; quimioterapia &#40;QT&#41; neoadyuvante&#44; tipo de derivaci&#243;n intestinal &#40;conducto ileal Bricker o neovejiga ileal&#41;&#44; tipo de derivaci&#243;n urinaria &#40;DUEC o DUIC&#41;&#44; complicaciones intraoperatorias y postoperatorias &#40;Clavien&#41;&#44; d&#237;as de &#237;leo paral&#237;tico&#44; tiempo operatorio&#44; transfusi&#243;n sangu&#237;nea&#44; estancia hospitalaria&#44; reingreso&#44; an&#225;lisis anatomopatol&#243;gico&#44; n&#250;mero de ganglios extra&#237;dos&#44; progresi&#243;n tumoral &#40;local o a distancia&#41; y supervivencia global y c&#225;ncer-espec&#237;fica&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Las complicaciones postoperatorias inclu&#237;an los primeros 30 d&#237;as tras la intervenci&#243;n y se clasificaron en menores &#40;Clavien I-II&#41; y mayores &#40;Clavien III-V&#41;&#46; Se defini&#243; estenosis ureteroileal como la necesidad de derivaci&#243;n urinaria con cat&#233;ter ureteral o sonda de nefrostom&#237;a&#44; la presencia de obstrucci&#243;n en un renograma o la dilataci&#243;n pieloureteral asociada a complicaciones &#40;empeoramiento de la funci&#243;n renal&#44; dolor c&#243;lico o infecci&#243;n&#41;&#46; El tratamiento inicial de la estenosis ureteroileal fue mediante la colocaci&#243;n de sonda de nefrostom&#237;a&#46; Posteriormente&#44; los pacientes se evaluaron para ser sometidos a un reimplante ureteral abierto vs&#46; colocaci&#243;n de cat&#233;ter uni-J permanente en funci&#243;n de sus cormorbilidades y estado basal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los tumores fueron estadiados seg&#250;n la Clasificaci&#243;n TNM de 2009<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> y su grado seg&#250;n las gu&#237;as de la WHO&#47;<span class="elsevierStyleItalic">International Society of Urological Pathology</span> de 2004<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El seguimiento se realiz&#243; a los 3&#44; 6 y 12 meses despu&#233;s de la cirug&#237;a&#44; y de forma anual posteriormente mediante exploraci&#243;n f&#237;sica&#44; an&#225;lisis de sangre y TAC toracoabdominal&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">T&#233;cnica quir&#250;rgica</span><p id="par0040" class="elsevierStylePara elsevierViewall">Todos los casos fueron realizados por el mismo cirujano y respetando los principios de la cistectom&#237;a radical abierta de acuerdo con el <span class="elsevierStyleItalic">Pasadena Consensus Panel</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a>&#46; Se realiz&#243; un abordaje transperitoneal con el robot Da Vinci<span class="elsevierStyleSup">&#174;</span> S o Xi y con uso de los 4 brazos&#46; La LND inclu&#237;a de forma sistematizada la zona obturatriz&#44; il&#237;aca interna y externa&#44; con el nervio genitofemoral y el cruce del ur&#233;ter con los vasos il&#237;acos como l&#237;mites lateral y superior&#44; respectivamente&#46; Para los conductos ileales se realiz&#243; una anastomosis tipo Bricker en la DUIC y Wallace en la DUEC&#46; Para las neovejigas se confeccion&#243; un reservorio ileal tipo Studer en la DUIC y tipo Padovana en la DUEC&#44; todas con suturas manuales&#46; En los casos de DUEC&#44; tras la confecci&#243;n del reservorio se rehac&#237;a el neumoperitoneo para realizar la anastomosis uretroneovesical&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Tanto la decisi&#243;n entre realizar un conducto ileal vs&#46; neovejiga ileal o una derivaci&#243;n urinaria extra o intracorp&#243;rea se tomaron tras una evaluaci&#243;n cuidadosa de las comorbilidades&#44; las caracter&#237;sticas del tumor&#44; los hallazgos intraoperatorios y las preferencias del paciente&#46; Los primeros casos de la serie se realizaron con DUEC y progresivamente se fue implantando la DUIC&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Objetivos del estudio</span><p id="par0050" class="elsevierStylePara elsevierViewall">El objetivo del estudio fue comparar los resultados perioperatorios y oncol&#243;gicos de la CRAR con DUEC vs&#46; DUIC&#46; El objetivo secundario fue describir la serie de los 43 primeros casos de CRAR en nuestro centro&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">An&#225;lisis estad&#237;stico</span><p id="par0055" class="elsevierStylePara elsevierViewall">Las variables continuas se presentaron con medianas y rangos&#44; y las categ&#243;ricas con frecuencias y proporciones&#46; El an&#225;lisis de Chi-cuadrado se utiliz&#243; para comparar variables categ&#243;ricas y U de Mann-Whitney para continuas&#46; Una p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#44;05 se consider&#243; como significativo&#46; Todos los an&#225;lisis se realizaron con SPSS version 20 &#40;IBM Corp&#46;&#44; Somers&#44; NY&#44; EE&#46; UU&#46;&#41;&#46;</p></span></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Un total de 43 pacientes&#44; 40 hombres &#40;93&#37;&#41; y 3 mujeres &#40;7&#37;&#41;&#44; con una mediana de edad de 65 a&#241;os &#40;rango 44-83&#41; y un seguimiento medio de 27&#44;7 meses &#40;&#177;20&#44;1&#41; fueron sometidos a una cistectom&#237;a radical asistida por robot&#46; La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> muestra las caracter&#237;sticas cl&#237;nicas y patol&#243;gicas preoperatorias de toda la serie y de los subgrupos sometidos a DUEC y DUIC&#46; Catorce pacientes &#40;32&#44;5&#37;&#41; presentaban un TMVNMI y 29 &#40;67&#44;5&#37;&#41; un TMVMI en la RTU&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Se realiz&#243; una DUEC en 22 casos &#40;51&#37;&#41; y una DUIC en 21 &#40;49&#37;&#41;&#46; Ambos grupos fueron comparables en cuanto a las caracter&#237;sticas cl&#237;nicas y preoperatorias &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Del total de pacientes con DUEC uno &#40;4&#44;5&#37;&#41; recibi&#243; QT neoadyuvante en comparaci&#243;n con 11 &#40;52&#44;4&#37;&#41; de los pacientes con DUIC &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Respecto a las 22 DUEC se realizaron 10 conductos ileales &#40;45&#44;5&#37;&#41; y 12 neovejigas &#40;54&#44;5&#37;&#41;&#44; mientras que de las 21 DUIC&#44; 14 fueron conductos ileales &#40;67&#37;&#41; y 7 neovejigas &#40;33&#37;&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Los resultados perioperatorios e histol&#243;gicos de toda la serie&#44; estratificados por el tipo de derivaci&#243;n urinaria&#44; est&#225;n reportados en la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#46; La mediana de tiempo operatorio y de estancia hospitalaria de toda la serie fueron de 360<span class="elsevierStyleHsp" style=""></span>minutos &#40;240-540&#41; y 12 d&#237;as &#40;7-73&#41;&#44; respectivamente&#46; La tasa de transfusi&#243;n sangu&#237;nea fue del 34&#37;&#46; Un total de 35 pacientes &#40;81&#44;4&#37;&#41; presentaron complicaciones postoperatorias&#44; de las cuales 10 &#40;23&#44;2&#37;&#41; fueron mayores &#40;Clavien III-V&#41;&#46; La mediana de n&#250;mero de ganglios extirpados fue de 20 &#40;5-47&#41; y la tasa de m&#225;rgenes positivos fue del 2&#44;3&#37;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">No se encontraron diferencias significativas en el tiempo operatorio&#44; las complicaciones perioperatorias&#44; la estadificaci&#243;n patol&#243;gica&#44; los m&#225;rgenes de la pieza y el n&#250;mero de ganglios extirpados entre el grupo sometido a DUEC y el DUIC&#46; En el subgrupo de DUEC la estancia hospitalaria y la tasa de ileo paral&#237;tico fueron de 13&#44;5 d&#237;as &#40;9-70&#41; y del 40&#44;9&#37;&#44; en comparaci&#243;n con 10 &#40;7-73&#41; d&#237;as&#44; y 33&#44;3&#37; en el de DUIC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;586&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;607&#41;&#46; Diez pacientes del subgrupo de DUEC &#40;45&#44;5&#37;&#41; desarrollaron estenosis ureteroileal &#40;5 conductos ileales&#44; 5 neovejigas&#41; en comparaci&#243;n con 3 de DUIC &#40;14&#44;3&#37;&#41; &#40;2 conductos ileales y una neovejiga&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#46; Del total de estenosis&#44; 9 fueron izquierdas &#40;69&#44;4&#37;&#41;&#44; una derecha &#40;7&#44;6&#37;&#41; y 3 bilaterales &#40;23&#37;&#41;&#46; Cuatro &#40;31&#37;&#41; del total de pacientes con estenosis fueron sometidos a un reimplante ureteral abierto y actualmente est&#225;n libres de estenosis&#44; y 9 &#40;69&#37;&#41; son portadores de cat&#233;ter uni J permanente&#46; Adem&#225;s&#44; de entre las neovejigas ileales&#44; las DUEC presentaron mayor tasa de estenosis uretroneovesical que las DUIC &#40;33&#44;3&#37; vs&#46; 0&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;044&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">La cistectom&#237;a radical con LND es el tratamiento est&#225;ndar para el manejo del tumor vesical no metast&#225;sico de alto riesgo&#46; El pron&#243;stico de los pacientes sometidos a cistectom&#237;a radical abierta viene determinado principalmente por la estadificaci&#243;n patol&#243;gica&#44; siendo la tasa de supervivencia libre de recurrencia del 75&#37;&#44; 60&#37; y 30&#37; en afectaci&#243;n &#243;rgano-confinada&#44; extravesical y linf&#225;tica&#44; respectivamente<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a>&#46; Con el objetivo de reducir la importante morbididad perioperatoria que supone la cistectom&#237;a radical abierta&#44; en los &#250;ltimos a&#241;os se han desarrollado t&#233;cnicas m&#237;nimamente invasivas como la cirug&#237;a rob&#243;tica&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Desde entonces&#44; estas nuevas t&#233;cnicas han tratado de respetar los principios oncol&#243;gicos de la cistectom&#237;a abierta&#44; como son evitar la manipulaci&#243;n del tumor en un ambiente de neumoperitoneo&#44; evitar la salida de orina a la cavidad abdominal o extraer la pieza embolsada&#46; Recientemente se ha publicado un estudio fase 3 multic&#233;ntrico&#44; aleatorizado&#44; que demuestra la no inferioridad de la CRAR respecto al abordaje abierto en cuanto a supervivencia libre de progresi&#243;n a 2 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a>&#46; Otros autores&#44; aunque tambi&#233;n han observado supervivencias equivalentes&#44; han reportado mayor incidencia de recidivas intraperitoneales y de la pared abdominal en pacientes sometidos a CRAR<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a>&#46; En nuestro estudio no podemos sacar conclusiones al respecto&#44; dado que no hemos comparado ambos abordajes&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En relaci&#243;n con los resultados perioperatorios&#44; la CRAR ha demostrado ser superior a la abierta en algunos estudios<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a>&#46; Parekh et al&#46; reportaron una menor p&#233;rdida estimada de sangre y una menor estancia hospitalaria en los pacientes sometidos a una t&#233;cnica rob&#243;tica&#44; aunque no encontraron diferencias significativas en cuanto a las complicaciones postoperatorias<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a>&#46; Nuestra tasa global de complicaciones &#40;menores y mayores&#41; es equiparable a la mayor&#237;a de series de cistectom&#237;a abierta y CRAR que tienen en cuenta los primeros 30 d&#237;as postoperatorios&#44; reflejando la alta morbilidad que supone esta cirug&#237;a independientemente de la t&#233;cnica<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a>&#46; Sin embargo&#44; nuestra estancia hospitalaria media&#44; y especialmente en las DUIC&#44; fue razonablemente corta teniendo en cuenta que no se aplic&#243; un protocolo de rehabilitaci&#243;n multimodal de manera sistem&#225;tica&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Algunas cr&#237;ticas al abordaje rob&#243;tico son el mayor tiempo operatorio y el mayor coste econ&#243;mico<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Nuestro tiempo operatorio medio fue de aproximadamente 6<span class="elsevierStyleHsp" style=""></span>horas&#44; y es equivalente al de otras series en que analizan los resultados del inicio de un programa de CRAR&#46; En la actualidad&#44; dado el alto volumen de procedimientos rob&#243;ticos en nuestro centro&#44; los tiempos operatorios se han reducido notablemente y suelen ser de 4<span class="elsevierStyleHsp" style=""></span>horas para la CRAR con Bricker intracorp&#243;reo&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El principal objetivo del estudio fue comparar los resultados perioperatorios de la CRAR con DUEC y con DUIC debido a la falta de trabajos que hay actualmente en la literatura&#46; Analizamos los 47 primeros casos de CRAR de nuestro centro&#44; realizados en su totalidad por el mismo cirujano y con previa experiencia en cistectom&#237;a abierta&#46; Por esta raz&#243;n&#44; creemos que nuestro estudio representa la realidad actual&#44; ya que tiene en cuenta la curva de aprendizaje y la instauraci&#243;n de un programa de cirug&#237;a vesical rob&#243;tica&#46; Ambos grupos fueron equiparables en cuanto a las caracter&#237;sticas cl&#237;nico-patol&#243;gicas preoperatorias&#44; siendo la &#250;nica diferencia que en el grupo de DUEC se administr&#243; menos QT neoadyuvante&#46; Esto es debido a que la mayor&#237;a de estos casos se realizaron al inicio de la serie&#44; cuando la QT neoadyuvante no se usaba con tanta frecuencia&#46; El antecedente de cirug&#237;a abdominop&#233;lvica previa no fue una contraindicaci&#243;n para realizar un abordaje rob&#243;tico&#44; y tambi&#233;n fue comparable entre grupos&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">El tiempo operatorio de ambas derivaciones urinarias fue equivalente&#44; y la estancia hospitalaria fue algo inferior en la DUIC&#44; aunque no de manera significativa&#46; De acuerdo con la literatura&#44; creemos que la DUIC minimiza la incisi&#243;n abdominal y la exposici&#243;n&#47;manipulaci&#243;n intestinal&#44; pudiendo as&#237; acelerar la recuperaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a>&#46; Un estudio reciente report&#243; menor p&#233;rdida sangu&#237;nea estimada en la DUIC<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; Nuestra tasa de transfusi&#243;n fue parecida entre grupos&#44; aunque no disponemos de datos completos para calcular la p&#233;rdida sangu&#237;nea estimada&#46; Aunque Lenfant et al&#46; reportaron una discreta y no significativa mayor tasa de complicaciones en la DUIC debido a la curva de aprendizaje m&#225;s compleja&#44; nosotros no encontramos diferencias en cuanto a la tasa global de complicaciones perioperatorias entre las 2 derivaciones<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a>&#46; En nuestro estudio reportamos una mayor tasa de estenosis ureteroileal en las DUEC respecto a las DUIC&#46; Esto se podr&#237;a explicar porque&#44; tal y como se ha descrito previamente&#44; la manipulaci&#243;n&#44; tracci&#243;n y disecci&#243;n del ur&#233;ter es superior en la DUEC<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a>&#46; Anderson et al&#46; no encontraron diferencias en relaci&#243;n con la tasa de estenosis ureteroileal entre la cistectom&#237;a abierta y la CRAR &#40;8&#44;5&#37; vs&#46; 12&#44;6&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;21&#41;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a>&#46; Aunque este estudio no es comparable al presente&#44; dado que incluye casos de cistectom&#237;a abierta&#44; podemos considerar nuestra tasa de estenosis en CRAR con DUEC superior a la de la literatura<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a>&#46; La mayor&#237;a de casos de estenosis en DUEC son al inicio de la serie&#44; cuando la curva de aprendizaje era inferior y se realizaba una mayor disecci&#243;n&#47;liberaci&#243;n del ur&#233;ter que en casos posteriores&#44; hecho que podr&#237;a inducir un sesgo a favor de la DUIC&#46; Aun as&#237;&#44; cabe destacar que los datos cl&#237;nico-demogr&#225;ficos de los 2 grupos comparados eran equivalentes&#44; y que nuestra tasa de estenosis ureteroileal en la DUIC fue ligeramente inferior a la de la literatura<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Por otro lado&#44; en el subgrupo de neovejigas ileales la tasa de estenosis uretroneovesical fue estad&#237;sticamente superior en la DUEC&#46; Este hecho probablemente sea debido a que la realizaci&#243;n de la anastomosis directamente con el robot minimiza la manipulaci&#243;n de la neovejiga y la uretra&#44; en comparaci&#243;n con la previa exteriorizaci&#243;n de la neovejiga en la DUEC y posterior reinicio del neumoperitoneo&#46; Sin embargo&#44; dado que nuestra serie de neovejigas es baja&#44; y dado que existe una falta de estudios que analicen este dato en la literatura&#44; no podemos sacar claras conclusiones al respecto&#46; Datos funcionales de continencia no fueron analizados en nuestro estudio&#46; Al igual que en la literatura&#44; no encontramos diferencias significativas en cuanto a supervivencia y resultados oncol&#243;gicos&#46; La menor tasa de recurrencia tumoral en la DUIC&#44; aunque no fue estad&#237;sticamente significativa&#44; podr&#237;a estar justificada por el menor tiempo de seguimiento y por la mayor utilizaci&#243;n de QT neoadyuvante&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Nuestros hallazgos sugieren que la implantaci&#243;n progresiva de un programa de CRAR con derivaci&#243;n urinaria intracorp&#243;rea es factible y segura en manos de un equipo con previa experiencia en cirug&#237;a rob&#243;tica y cistectom&#237;a abierta&#44; y en un centro terciario con alto volumen&#46; Recomendamos iniciarse con casos de CRAR con DUEC e ir realizando progresivamente cirug&#237;as con DUIC acorde a la curva de aprendizaje&#46; En nuestra experiencia el tiempo quir&#250;rgico y las complicaciones postoperatorias fueron comparables entre las 2 derivaciones&#44; pero se report&#243; un menor riesgo de desarrollar estenosis ureteroileales y uretroneovesicales en la DUIC&#46; Teniendo en cuenta que un factor muy importante en la calidad de vida de los pacientes y en las complicaciones durante su seguimiento es la presencia de alteraciones ureterales&#44; creemos justificado el uso de la derivaci&#243;n intracorp&#243;rea&#46; Sin embargo&#44; estos resultados tendr&#237;an que confirmarse con series prospectivas de m&#225;s pacientes y con mayor tiempo de seguimiento&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">El presente estudio tiene una serie de limitaciones&#46; A pesar de la recogida prospectiva de los datos el estudio es de un solo centro&#44; retrospectivo no aleatorizado&#44; y todos los procedimientos fueron realizados por un &#250;nico cirujano&#46; Por otro lado&#44; la serie de pacientes es peque&#241;a y su seguimiento corto&#46; Y finalmente&#44; no se dispone de datos de calidad de vida de los pacientes&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusiones</span><p id="par0125" class="elsevierStylePara elsevierViewall">La CRAR con derivaci&#243;n urinaria intracorp&#243;rea ofrece resultados perioperatorios y una tasa de complicaci&#243;n global comparables a la extracorp&#243;rea&#46; El uso de la derivaci&#243;n intracorp&#243;rea podr&#237;a reducir el riesgo de desarrollar estenosis ureteroileales y uretroneovesicales durante el seguimiento&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicto de intereses</span><p id="par0130" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparar los resultados perioperatorios y las complicaciones de la cistectom&#237;a radical asistida por robot &#40;CRAR&#41; con derivaci&#243;n urinaria extracorp&#243;rea &#40;DUEC&#41; vs&#46; intracorp&#243;rea &#40;DUIC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n retrospectiva de 43 pacientes sometidos a CRAR por tumor vesical entre 2015-2018 con seguimiento m&#237;nimo de 3 meses&#46; Se analiz&#243; la serie inicial de CRAR realizada por un cirujano con amplia experiencia en cistectom&#237;a radical abierta&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Cuarenta y tres pacientes&#44; 40 hombres &#40;93&#37;&#41; y 3 mujeres &#40;7&#37;&#41;&#44; con mediana de edad de 65 a&#241;os &#40;44-83&#41; y seguimiento medio de 27&#44;7 meses &#40;&#177;20&#44;1&#41; fueron sometidos a CRAR&#46; Se realiz&#243; DUEC en 22 casos &#40;51&#37;&#41;&#44; 10 conductos ileales &#40;45&#44;5&#37;&#41; y 12 neovejigas &#40;54&#44;5&#37;&#41;&#44; y DUIC en 21 &#40;49&#37;&#41;&#44; 14 conductos ileales &#40;66&#44;7&#37;&#41; y 7 neovejigas &#40;33&#44;3&#37;&#41;&#46; Las caracter&#237;sticas cl&#237;nicas y preoperatorias fueron comparables entre grupos&#46; La mediana de tiempo operatorio fue 360<span class="elsevierStyleHsp" style=""></span>minutos &#40;240-540&#41; y de estancia hospitalaria 12 d&#237;as &#40;7-73&#41;&#46; Treinta y cinco pacientes &#40;81&#37;&#41; presentaron complicaciones postoperatorias&#44; de las cuales 10 &#40;23&#37;&#41; fueron mayores&#46; No se encontraron diferencias en tiempo operatorio&#44; complicaciones perioperatorias&#44; estadificaci&#243;n patol&#243;gica&#44; m&#225;rgenes y n&#250;mero de ganglios extirpados entre DUEC y DUIC&#46; Los pacientes sometidos a DUEC presentaron mayor tasa de estenosis uretero-ileal en comparaci&#243;n con la DUIC &#40;45&#44;5&#37; vs&#46; 14&#44;3&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;026&#41;&#46; En las neovejigas la DUEC present&#243; mayor tasa de estenosis uretroneovesical que la DUIC &#40;33&#37; vs&#46; 0&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;044&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La CRAR con derivaci&#243;n urinaria intracorp&#243;rea ofrece resultados perioperatorios y complicaciones comparables a la extracorp&#243;rea&#46; La derivaci&#243;n intracorp&#243;rea podr&#237;a reducir el riesgo de desarrollar estenosis ureteroileal y uretroneovesical&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivos"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To compare perioperative outcomes and complications of robot assisted radical cystectomy &#40;RARC&#41; with extracorporeal &#40;ECUD&#41; vs&#46; intracorporeal urinary diversion &#40;ICUD&#41; for bladder cancer&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Retrospective revision of 43 patients who underwent RARC for bladder cancer between 2015-2018 with at least 3 months of follow-up&#46; The analysis included the initial series of RARC performed by one surgeon with extensive experience in open radical cystectomy&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Forty-three patients&#44; 40 men &#40;93&#37;&#41; and 3 women &#40;7&#37;&#41;&#44; with a median age of 65 years &#40;44-83&#41; and mean follow-up of 27&#46;7 months &#40;&#177;20&#46;1&#41; underwent RARC&#46; A ECUD was performed in 22 cases &#40;51&#37;&#41;&#44; of whom 10 were ileal conduits &#40;45&#46;5&#37;&#41; and 12 neobladders &#40;54&#46;5&#41;&#44; and ICUD in 21 cases &#40;49&#37;&#41;&#44; of whom 14 were ileal conduits &#40;66&#46;7&#37;&#41; and 7 neobladders &#40;33&#46;3&#37;&#41;&#46; Clinical and preoperative characteristics were similar in both groups&#46; The median operative time was 360 minutes &#40;240-540&#41; and length of hospital stay was 12 days &#40;7-73&#41;&#46; Thirty-five patients &#40;81&#37;&#41; had postoperative complications&#44; of whom 10 &#40;23&#37;&#41; were major&#46; Operative time&#44; peroperative complications&#44; pathological stage&#44; positive margins&#44; and number of lymph nodes removed did not significantly differ among groups&#46; Patients who underwent ECUD had a higher rate of uretero-ileal strictures than those with ICUD &#40;45&#46;5&#37; vs&#46; 14&#46;3&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#46;026</span>&#41;&#46; Among the neobladders&#44; the ECUD developed a higher rate of urethro-neobladder stricture than the ICUD &#40;33&#37; vs&#46; 0&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#46;044</span>&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">RARC with ICUD achieved peroperative outcomes and complication rates comparable than those with ECUD&#46; The ICUD could reduce the risk of developing uretero-ileal and urethro-neobladder strictures&#46;</p></span>"
        "secciones" => array:4 [
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          2 => array:2 [
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            "titulo" => "Results"
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            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Datos expresados en medianas &#40;rango&#41; o n &#40;&#37;&#41;&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; <span class="elsevierStyleItalic">American Society of Anesthesiologists physical classification</span>&#59; IMC&#58; &#237;ndice de masa corporal&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Toda la serie &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>43&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;a&#241;os&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hombre&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">20 &#40;90&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;95&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mujer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">IMC</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">26&#44;9 &#40;19&#44;7-32&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#44;1 &#40;22&#44;8-32&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Consumo de tabaco</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ASA</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;856&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Evisceraci&#243;n&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;9&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#205;leo paral&#237;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;37&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;40&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;607&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>F&#237;stula intestinal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;9&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;578&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fuga de orina&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5 &#40;11&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;138&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estenosis ureteroileal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;30&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;45&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;026<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Estenosis uretroneovesical &#40;neovejigas&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;044<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">D&#237;as de &#237;leo paral&#237;tico</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;1-23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#44;5 &#40;3-15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;1-23&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;588&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Histolog&#237;a del tumor vesical</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;36&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transicional puro&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35 &#40;81&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;90&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transicional micropapilar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;4&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transicional sarcomatoide&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1 &#40;2&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&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"><span class="elsevierStyleHsp" style=""></span>Leiomiosarcoma vesical&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">1 &#40;2&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0 &#40;0&#41;&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">&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>Neuroendocrino&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">1 &#40;2&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#44;5&#41;&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">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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>NESTED&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">2 &#40;4&#44;7&#41;&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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