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Evaluación del abordaje laparoscópico en la cistectomía radical desde la implantación hasta su consolidación: validación interna
Evaluation of laparoscopic approach in radical cystectomy from implementation to consolidation: Internal validation
D. Subirá-Ríos
Autor para correspondencia
ibydoc71@hotmail.com

Autor para correspondencia.
, F. Herranz-Amo, M. Moralejo-Gárate, J. Caño-Velasco, G. Bueno-Chomón, E. Rodríguez-Fernández, G. Barbas-Bernardos, C. Hernández-Fernández
Servicio de Urología, Hospital General Universitario Gregorio Marañón, Madrid, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La cistectom&#237;a radical es el tratamiento recomendado como primera opci&#243;n por las gu&#237;as cl&#237;nicas para los pacientes con tumor vesical m&#250;sculo-infiltrante &#40;T2-4 N0-x M0&#41;&#44; con tumor no m&#250;sculo-infiltrante refractarios a BCG&#44; recurrencia despu&#233;s de BCG y en los tumor no m&#250;sculo-infiltrantes no controlables endosc&#243;picamente&#46; La Asociaci&#243;n Europea de Urolog&#237;a en su gu&#237;a cl&#237;nica del a&#241;o 2017&#44; reconoce que debido a las limitaciones de los datos&#44; el acceso laparosc&#243;pico o asistido por robot se deben de considerar como procedimiento en investigaci&#243;n&#44; aunque reconocen una menor estancia hospitalaria&#44; menos transfusiones y menos complicaciones<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">La &#171;curva de aprendizaje&#187; es el periodo de tiempo durante el que un determinado procedimiento quir&#250;rgico es m&#225;s lento&#44; m&#225;s dificultoso&#44; presenta mayor n&#250;mero de complicaciones y baja eficacia&#44; debido a la inexperiencia del cirujano&#46; No est&#225; aceptada una definici&#243;n est&#225;ndar de la &#171;curva de aprendizaje&#187;&#46; Frecuentemente se define por el n&#250;mero m&#237;nimo de casos que es necesario realizar para reproducir la t&#233;cnica considerada como est&#225;ndar&#46; Obviamente dicha curva est&#225; influenciada por ciertos par&#225;metros cirujano-dependiente como&#44; experiencia en otros procedimientos &#40;abiertos y m&#237;nimamente invasivos&#41; adem&#225;s de buena actitud y confianza en s&#237; mismo<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">El objetivo de este estudio es analizar en el mismo servicio&#44; la implantaci&#243;n de un programa de cistectom&#237;a laparosc&#243;pica &#40;CRL&#41;&#44; compar&#225;ndolo con un programa consolidado y estandarizado de cistectom&#237;a abierta &#40;CRA&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todo</span><p id="par0020" class="elsevierStylePara elsevierViewall">En nuestro servicio se inici&#243; el programa de acceso laparosc&#243;pico a la cistectom&#237;a en el a&#241;o 2006 por dos staff con amplia experiencia en cirug&#237;a abierta y laparosc&#243;pica&#46; De la base de datos de cistectom&#237;as &#40;712 pacientes entre 1986-2016&#41; del servicio se han extra&#237;do los pacientes intervenidos de forma consecutiva entre 2003 y 2016&#46; Se identificaron 393 pacientes en total&#58; con abordaje abierto en 197 &#40;50&#44;1&#37;&#41; casos intervenidos entre 2003 y 2016 y 196 &#40;49&#44;9&#37;&#41; con abordaje laparosc&#243;pico entre 2006 y 2016&#46; Se seleccionaron una cohorte de CRA para compararlo con otra de CRL&#44; para ello se seleccionaron todas las CRA realizadas en un periodo contempor&#225;neo a la serie de CRL a estudio y previo al inicio del abordaje laparosc&#243;pico en la cistectom&#237;a radical&#58; 96 pacientes del periodo 2003-2005 sometidos a CRA frente 196 pacientes entre 2006-2016 solo con acceso laparosc&#243;pico&#44; en total 292 pacientes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">En todos los pacientes con abordaje laparosc&#243;pico la derivaci&#243;n urinaria se realiz&#243; de forma extracorp&#243;rea&#44; reproduciendo la cirug&#237;a abierta&#46; La linfadenectom&#237;a extendida se realiz&#243; de forma sistem&#225;tica a partir del a&#241;o 2006&#44; por tanto solo en el grupo de CRL&#46; En la CRL&#44; la parte de acceso laparosc&#243;pico&#44; fue realizado mayoritariamente por los mismos cirujanos ur&#243;logos y la derivaci&#243;n urinaria por ur&#243;logos en formaci&#243;n fundamentalmente&#46; El equipo quir&#250;rgico en la CRA fue realizada por cirujanos ur&#243;logos con experiencia en cirug&#237;a abierta y cistectom&#237;a radical&#44; junto con ur&#243;logos en formaci&#243;n en porcentajes similares &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">En ning&#250;n paciente se realiz&#243; quimioterapia neoadyuvante y en un 12&#44;5&#37; de los pacientes en el grupo de la CRA ten&#237;an radioterapia p&#233;lvica previa&#44; frente al 5&#44;1&#37; en el grupo CRL &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">El riesgo anest&#233;sico se defini&#243; seg&#250;n el sistema de clasificaci&#243;n de la American Society of Anesthesiologist &#40;ASA&#41;&#46; La patolog&#237;a previa se grad&#243; seg&#250;n la clasificaci&#243;n pron&#243;stica de Charlson<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> y posteriormente se calcul&#243; el &#237;ndice de comorbilidad mediante la suma de la puntuaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a>&#46; Las complicaciones posquir&#250;rgicas se definieron seg&#250;n la clasificaci&#243;n de Clavien-Dindo<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a>&#46; Los pacientes fueron reclasificados seg&#250;n la clasificaci&#243;n TNM de la UICC &#40;7&#46;<span class="elsevierStyleHsp" style=""></span>&#170; edici&#243;n&#41; del a&#241;o 2009<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a>&#46; Se recogieron las complicaciones acaecidas en los 60 d&#237;as posteriores a la cirug&#237;a&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se ha realizado un estudio de cohortes retrospectivo entre dos grupos de pacientes&#58; grupo 1-CRA &#40;2003-2005&#41; y grupo 2 CRL &#40;2006-20016&#41;&#44; con el objetivo de comparar la evoluci&#243;n en el tiempo de los siguientes par&#225;metros&#58; el tiempo quir&#250;rgico de la cistectom&#237;a &#40;definido como tiempo de la cistectom&#237;a<span class="elsevierStyleHsp" style=""></span>&#43; linfadenectom&#237;a y derivaci&#243;n urinaria&#41;&#44; las necesidad de transfusi&#243;n&#44; el estado de los m&#225;rgenes quir&#250;rgicos de resecci&#243;n&#44; las complicaciones postoperatorias&#44; la duraci&#243;n de la estancia hospitalaria y las recidivas&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Al analizar de forma retrospectiva los datos de las CRL&#44; observamos que la variable tiempo quir&#250;rgico define tres periodos desde el inicio de nuestra experiencia&#58; un primer periodo que representa nuestro inicio en el acceso laparosc&#243;pico en el que observamos un tiempo quir&#250;rgico variable en los casos&#44; con disminuci&#243;n del tiempo quir&#250;rgico hasta la estabilizaci&#243;n del mismo en los casos sucesivos&#59; un segundo periodo en el que observamos un tiempo quir&#250;rgico similar en todos los casos&#44; y por &#250;ltimo un periodo final en la que se observa una disminuci&#243;n importante del tiempo quir&#250;rgico &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Atendiendo a esto hemos establecido 3 grupos en nuestra cohorte de CRL&#44; definido en estos 3 periodos de tiempo&#58; periodo de implantaci&#243;n &#40;2006-09&#41; &#40;CRL-I&#41;&#44; periodo de desarrollo &#40;2010-14&#41; &#40;CRL-D&#41; y periodo de consolidaci&#243;n &#40;2015-16&#41; &#40;CRL-C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Para poder responder al objetivo planteado&#44; se comparar&#225; el grupo con solo CRA &#40;grupo control&#41; con cada uno de los subgrupos en que se ha dividido la CRL&#58; CRL-I&#40;2006-09&#41;&#44; CRL-D &#40;2010-14&#41; y CRL-C &#40;2015-16&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se ha realizado un an&#225;lisis descriptivo de las variables analizadas mediante los estad&#237;sticos habituales para las variables cuantitativas &#40;mediana y rango intercuart&#237;lico-IQR&#41; y cualitativas &#40;frecuencias absolutas y porcentajes&#41;&#46; Para el contraste de variables cualitativas se ha utilizado el test de la Chi cuadrado y para las variables num&#233;ricas el test de Anova&#46; La significaci&#243;n estad&#237;stica se consider&#243; cuando existi&#243; una p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; Todos los c&#225;lculos se han realizado con el paquete estad&#237;stico IBM&#174; SPSS&#174; statistics v-21&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas basales de los pacientes seg&#250;n el abordaje quir&#250;rgico a la cistectom&#237;a se detallan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> y seg&#250;n los periodos de tiempo definidos se detallan en la <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#46; Los pacientes con un abordaje laparosc&#243;pico presentaron unas caracter&#237;sticas distintas&#44; de forma significativa&#44; al compararlos con el grupo control &#40;CRA&#41;&#58; tumores cl&#237;nicamente m&#225;s avanzados y mayor cN<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>&#44; mayor ASA 3-4 e I&#46;Charlson &#8805;3 y mayor porcentaje de RT p&#233;lvica&#46; En cambio el tiempo entre la RTU y la cistectom&#237;a fue inferior &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Al comparar los pacientes con abordaje laparosc&#243;pico seg&#250;n los periodos predefinidos observamos un mayor porcentaje de tumores cl&#237;nicamente m&#225;s avanzados y con mayor porcentaje de RT p&#233;lvica en el &#250;ltimo periodo &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En 7 &#40;3&#44;4&#37;&#41; pacientes fue necesario la reconversi&#243;n del acceso laparosc&#243;pico a abierto&#58; tres casos en CRL-I por indicaci&#243;n anest&#233;sica debido a la intolerancia al neumoperitoneo y dos en cada uno de los otros dos periodos&#44; debido a imposibilidad t&#233;cnica laparosc&#243;pica&#46; Se produjeron 2 lesiones incidentales intraoperatorias&#58; una lesi&#243;n de la vena hipog&#225;strica en el CRL-D y una lesi&#243;n rectal en el CRL-C&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">En el grupo de CRA se realiz&#243; derivaci&#243;n transintestinal a 75 &#40;78&#44;1&#37;&#41; pacientes y en de CRL a 182 &#40;92&#44;9&#37;&#41; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; Del total de las derivaciones transintestinales en el grupo de CRA se realiz&#243; ureterostom&#237;a transileal tipo Bricker en 66 &#40;88&#37;&#41; y sustituci&#243;n vesical en 9 &#40;12&#37;&#41;&#59; en el grupo de CRL a 158 &#40;86&#44;8&#37;&#41; y 24 &#40;13&#44;2&#37;&#41; respectivamente &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;80&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Las variables intraoperatorias&#44; patol&#243;gicas y complicaciones postoperatorias seg&#250;n los periodos de tiempo previamente definidos se detallan en la <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 y 4</a> y la <a class="elsevierStyleCrossRef" href="#fig0010">figura 2</a>&#46; Se resecaron una mediana de 5 &#40;IQR 3-9&#41; ganglios en la CA y de 11 &#40;IQR 7-15&#41; en la CL&#46; Los pacientes con un abordaje laparosc&#243;pico presentaron unas caracter&#237;sticas distintas&#44; de forma significativa&#44; que los del grupo control &#40;CRA&#41;&#58; fueron realizadas pr&#225;cticamente todas por un staff&#44; m&#225;s derivaciones intestinales y menos cirug&#237;as asociadas en CRL-C&#44; estadio patol&#243;gico m&#225;s avanzado en CLR-I y CLR-C menos m&#225;rgenes quir&#250;rgicos positivos&#44; se realizaron m&#225;s linfadenectom&#237;as y se resecaron un mayor n&#250;mero de ganglios linf&#225;ticos por linfadenectom&#237;a&#44; adem&#225;s el n&#250;mero ganglio resecados aument&#243; en CRL-D con respecto al CRL-I&#40;0&#44;0001&#41;&#44; pero no entre CLR-D y CLRC &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;25&#41;&#44; mayor tiempo quir&#250;rgico en CRL-I y CRL-D&#44; menor trasfusi&#243;n intraoperatoria en los 3 periodos y postoperatoria en CRL-D y CRL-C&#44; menos complicaciones totales en CRL-D y CRL-C &#40;fundamentalmente a expensas de la disminuci&#243;n sobre todo de las infecciones de la herida quir&#250;rgica y la evisceraci&#243;n&#41; y menos complicaciones graves &#40;Clavien&#8805;3&#41; en los 3 periodos &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">La mortalidad disminuy&#243; tambi&#233;n desde el periodo de implantaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; y en el de desarrollo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41; y en el periodo de consolidaci&#243;n present&#243; una tendencia importante a la significaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;09&#41; con respecto al grupo control &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">La estancia hospitalaria disminuy&#243; desde el periodo de implantaci&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; consolid&#225;ndose esta disminuci&#243;n en los otros dos periodos de studio &#40;CRL-D p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002 y CRL-C p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;005&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">En 22 &#40;7&#44;8&#37;&#41; pacientes se observaron m&#225;rgenes quir&#250;rgicos invadidos&#44; 7 &#40;8&#37;&#41; en la CRA y 15 &#40;7&#44;7&#37;&#41; en la CRL&#44; la comparaci&#243;n de los distintos periodos de la CRL con la CRA se detalla en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Se observ&#243; recurrencia de la enfermedad en 135 &#40;46&#44;2&#37;&#41; de los pacientes&#44; 53 &#40;55&#44;2&#37;&#41; en la CRA y 82 &#40;41&#44;8&#37;&#41; en la CRL&#44; la comparaci&#243;n de los distintos periodos de la CRL con la CRA se detalla en la <a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0105" class="elsevierStylePara elsevierViewall">La implantaci&#243;n de un nuevo abordaje quir&#250;rgico resulta complejo debido a la dificultad de dise&#241;ar estudios &#40;ensayos cl&#237;nicos&#41; que permitan compararlo con el considerado como est&#225;ndar&#46; Ello explica la consideraci&#243;n en las gu&#237;as cl&#237;nicas europeas de la cistectom&#237;a m&#237;nimamente invasiva como una opci&#243;n experimental a pesar de haber pasado casi dos d&#233;cadas de la publicaci&#243;n de la cistectom&#237;a m&#237;nimamente invasiva estandarizada&#44; primero laparosc&#243;pica en el a&#241;o 2000 por Gill<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> y posteriormente rob&#243;tica<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a>&#46; Novara<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> apunta la dificultad t&#233;cnica de la cistectom&#237;a&#44; la escasez de estudios prospectivos que la avalen frente a la cistectom&#237;a abierta y las dudas surgidas en la reproductibilidad de la t&#233;cnica como causas que han dificultado la implementaci&#243;n de la cirug&#237;a m&#237;nimamente invasiva en la cistectom&#237;a radical&#46; Varios han sido los autores que durante estas dos d&#233;cadas han expresado sus dudas con respecto a la eficacia de la CRL<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;11</span></a> e incluso&#44; la seguridad oncol&#243;gica por los riesgos te&#243;ricos de diseminaci&#243;n del tumor de urotelio asociados al neumoperitoneo de la t&#233;cnica laparosc&#243;pica<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a>&#46; Todas estas dudas se ven reflejadas en la escasa implementaci&#243;n de la cistectom&#237;a m&#237;nimamente invasiva en el mundo&#58; solo un 20&#37; de todas las cistectom&#237;as realizadas en EE&#46;UU&#46; en 2016 se realizaron mediante cirug&#237;a m&#237;nimamente invasiva&#46; En Espa&#241;a en el a&#241;o 2013 solo el 10&#37; de todas las cistectom&#237;as fueron laparosc&#243;picas y rob&#243;ticas<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">La validaci&#243;n de una nueva t&#233;cnica quir&#250;rgica se basa en demostrar&#58; eficacia&#44; ventajas en morbilidad frente al est&#225;ndar y reproductibilidad de la misma&#46; Es precisamente la dificultad t&#233;cnica del abordaje laparosc&#243;pico&#44; en una cirug&#237;a ya de por s&#237; compleja como la cistectom&#237;a&#44; y por tanto su reproductibilidad frente al abordaje est&#225;ndar abierto&#44; el principal escollo para la implementaci&#243;n en muchos centros&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En el an&#225;lisis de nuestra experiencia laparosc&#243;pica hemos definido tres periodos&#58; el periodo de implantaci&#243;n &#40;CRL-I&#41;&#44; de desarrollo &#40;CRL-D&#41; y de consolidaci&#243;n &#40;CRL-C&#41; atendiendo al tiempo quir&#250;rgico observado de la cistectom&#237;a&#58; se ha considerado el per&#237;odo desarrollo cuando se observ&#243; un tiempo quir&#250;rgico estandarizado &#40;media 305<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; y el paso a la fase de consolidaci&#243;n cuando se consigui&#243; disminuir el tiempo quir&#250;rgico &#40;media 263<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; aunque sin diferencia significativa&#44; comparado con el est&#225;ndar abierto &#40;media 270<span class="elsevierStyleHsp" style=""></span>min&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Otros autores establecen el n&#250;mero caso&#47;a&#241;o como criterio en el an&#225;lisis de su experiencia&#44; sin embargo esta solo es &#250;til cuando durante el periodo de estudio existe un n&#250;mero de casos&#47;a&#241;o similar y correlativo&#46; Liss et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> hacen una revisi&#243;n de la literatura sobre cistectom&#237;as m&#237;nimamente invasivas&#44; describiendo una media de 20 casos para obtener un tiempo quir&#250;rgico menor de 6&#44;5 horas y de 30 casos para obtener una media de 20 ganglios en la linfadenectom&#237;a&#44; aunque los autores reconocen la falta de herramientas de estandarizaci&#243;n de las curvas de aprendizaje y la gran variabilidad de los estudios&#46; En nuestro caso hemos optado por el tiempo quir&#250;rgico por el hecho que el abordaje laparosc&#243;pico ha coexistido con el est&#225;ndar abierto durante a&#241;os&#44; hasta que hemos validado la t&#233;cnica&#44; por lo que el n&#250;mero de casos&#47;a&#241;o en nuestro serie es muy variable y no representa fielmente la evoluci&#243;n de la t&#233;cnica&#46; La comparaci&#243;n de esta serie laparosc&#243;pica desde su inicio en 2006&#44; se ha realizado con una serie homog&#233;nea comparable y contempor&#225;nea de cistectom&#237;a abierta&#44; que representa la t&#233;cnica est&#225;ndar y consolidada en nuestro hospital&#46; La derivaci&#243;n urinaria se ha realizado siempre de forma extracorp&#243;rea&#44; por tanto de igual manera en todos los grupos de cistectom&#237;as del estudio&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Para la validaci&#243;n de este abordaje laparosc&#243;pico en nuestro hospital hemos considerado tres aspectos a comparar con el est&#225;ndar de la cistectom&#237;a abierta&#58; evaluaci&#243;n de morbimortalidad&#44; eficacia terap&#233;utica y reproductibilidad de la t&#233;cnica&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Cuando evaluamos la morbilidad de la CRL&#44; observamos que durante el periodo inicial &#40;CRL-I&#41; el n&#250;mero total de complicaciones es similar al de la CRA y durante la fase de desarrollo &#40;CRL-D&#41; y consolidaci&#243;n &#40;CRL-C&#41; de la laparoscopia hay una reducci&#243;n significativa de las complicaciones con respecto a la CRA&#46; Sin embargo&#44; cuando analizamos los tipos de complicaciones&#44; observamos una disminuci&#243;n significativa&#44; en todas las fases de CRL&#44; de las complicaciones asociadas a la agresi&#243;n quir&#250;rgica&#44; es decir&#44; infecci&#243;n de herida&#44; abscesos&#44; y evisceraciones&#46; Tambi&#233;n observamos una menor tasa de trasfusi&#243;n intra- y postoperatoria desde el inicio de la experiencia de la CRL frente a la CRA&#46; Estos datos son coincidentes con lo publicado en la literatura<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">15&#44;16</span></a>&#46; Por otra parte&#44; tambi&#233;n desde el inicio de la experiencia de la CRL hay una disminuci&#243;n de las complicaciones graves &#40;Clavien &#8805;III&#41; a pesar de que durante los periodos de desarrollo y consolidaci&#243;n &#40;CRL-D y CRL-C&#41; de la CRL la derivaci&#243;n urinaria&#44; considerada como la causa m&#225;s frecuente de las complicaciones graves en la cistectom&#237;a radical&#44; fue realizada en m&#225;s del 90&#37; por ur&#243;logos en formaci&#243;n&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Los datos de mortalidad hay que tomarlos con cautela ya que aunque en el grupo control del estudio la mortalidad fue del 10&#37;&#44; en el conjunto de la base de datos de cistectom&#237;as abierta del servicio la mortalidad fue del 5&#37;&#46; En la serie de laparoscopia&#44; menor en n&#250;mero&#44; la tasa de mortalidad fue del 2&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;07&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Hay una disminuci&#243;n significativa de las complicaciones totales en la fase de desarrollo y consolidaci&#243;n de la CRL frente a la CRA&#44; a pesar de que los pacientes intervenidos en estos periodos presentaban mayor porcentaje de estadios localmente avanzados&#44; lo que te&#243;ricamente asociar&#237;a una mayor tasa de complicaciones y sangrado&#46; Esto refuerza la idea de que la estandarizaci&#243;n de la t&#233;cnica completa desarrollada en la fase de iniciaci&#243;n por un n&#250;mero limitado de cirujano-staff&#44; dos ur&#243;logos&#44; ha facilitado la seguridad de la t&#233;cnica y el aprendizaje&#46; La estancia hospitalaria&#44; aunque sujeta a ciertos sesgos&#44; tambi&#233;n se ha visto disminuida con respecto a la CRA y en cada per&#237;odo de la curva de aprendizaje&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En la evaluaci&#243;n de eficacia terap&#233;utica&#44; hemos considerado los criterios oncol&#243;gicos de calidad en la cistectom&#237;a radical establecidos por el Bladder Cancer Collaborative Group en 2004 &#40;19&#41;&#58; m&#225;rgenes quir&#250;rgicos &#60;<span class="elsevierStyleHsp" style=""></span>10&#37; en pT0-2 y &#60;<span class="elsevierStyleHsp" style=""></span>15&#37; en pT3-4&#44; y n&#250;mero de ganglios obtenidos en la linfadenectom&#237;a entre 10 y 14&#46; En nuestra serie de CRL obtenemos unos m&#225;rgenes quir&#250;rgicos positivos del 7&#44;7&#37; y un n&#250;mero de ganglios &#40;mediana n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41; considerados como est&#225;ndares oncol&#243;gicos en los distintos periodos de la curva de aprendizaje de la CRL&#46; No hemos observado diferencias significativas entre CRA y CRL en cuanto a m&#225;rgenes quir&#250;rgicos y recurrencias ni en el total de la serie ni en la comparaci&#243;n entre los distintos periodos&#44; lo que avala la calidad de la t&#233;cnica de la CRL&#44; desde su inicio&#46; Estos datos son superponibles a la serie m&#225;s larga de CRA publicada por Stein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">En tercer lugar y por &#250;ltimo&#44; la reproductibilidad de la t&#233;cnica de la CRL se ha hecho evidente por el hecho que al final del periodo de estudio&#44; 2010-2016&#44; el 86&#37; de las CR se realizan por este abordaje&#44; sustituyendo pr&#225;cticamente en su totalidad la CRA&#46; Adem&#225;s hemos aumentado el n&#250;mero de cirujanos que realizan esta t&#233;cnica quir&#250;rgica&#44; validando de forma interna la reproductibilidad en nuestro servicio&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Sin embargo&#44; constatamos que la curva de aprendizaje de la CRL es exigente&#59; el tiempo quir&#250;rgico fue mayor frente a la cirug&#237;a abierta durante los primeros 151 casos&#44; fases de CRL-I y CRL-D&#44; aunque hay que considerar el mayor tiempo empleado en la linfadenectom&#237;a extendida realizada desde el inicio de la CRL frente a la CRA&#46; Tras los primeros 45 casos&#44; se consigui&#243; una reducci&#243;n del tiempo quir&#250;rgico inicial&#44; hasta alcanzar una media de 300<span class="elsevierStyleHsp" style=""></span>min de duraci&#243;n de cirug&#237;a en la fase de desarrollo &#40;2010-14&#41;&#44; y ha sido solo en los dos &#250;ltimos a&#241;os &#40;2015-16&#41;&#44; periodo de consolidaci&#243;n &#40;CRL-C&#41;&#44; cuando observamos una tendencia a una disminuci&#243;n del tiempo quir&#250;rgico de la CRL frente a la cohorte de CRA &#40;270 vs&#46; 263<span class="elsevierStyleHsp" style=""></span>min media p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;40&#41;&#44; aunque probablemente no alcanza la significaci&#243;n estad&#237;stica por el n&#250;mero reducido de casos en este periodo &#40;CRL-C<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">El escaso n&#250;mero de casos&#44; especialmente en el &#250;ltimo periodo de la CRL&#44; junto al ser un estudio retrospectivo son unas de las debilidades que reducen la potencia de este estudio&#46; Adem&#225;s&#44; la extensi&#243;n de la linfadenectom&#237;a realizada entre los grupos de CRA y CRL es distinta&#44; debido a la modificaci&#243;n de los criterios de extensi&#243;n de la linfadenectom&#237;a en las gu&#237;as cl&#237;nicas a lo largo del periodo de estudio&#44; lo que indudablemente puede influir en el tiempo quir&#250;rgico&#44; los resultados oncol&#243;gicos y la morbilidad&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">En resumen en nuestro estudio observamos&#44; desde el periodo de implantaci&#243;n de la cistectom&#237;a laparosc&#243;pica &#40;CRL-I&#41; se observ&#243; una disminuci&#243;n de las transfusiones&#44; de las complicaciones y de la estancia hospitalaria&#44; a expensas de una prolongaci&#243;n del tiempo quir&#250;rgico frente a la CRA&#46; En el periodo de desarrollo &#40;CRL-D&#41; mejoraron los par&#225;metros descritos anteriormente de forma significativa y se mantuvo el tiempo quir&#250;rgico aumentado&#46; En el periodo de consolidaci&#243;n &#40;CRL-C&#41; se disminuy&#243; el tiempo quir&#250;rgico con una tendencia a un menor tiempo frente al grupo control de cirug&#237;a abierta manteni&#233;ndose las ventajas de morbilidad&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Hay una gran heterogeneidad de resultados en referencia a las curvas de aprendizaje de los distintos autores en el abordaje m&#237;nimamente invasivo de la cistectom&#237;a radical&#44; debido a los distintos criterios para definir la curva de aprendizaje y&#44; en que algunos representan la experiencia de distintos centros<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a>&#46; Algunos autores observan que su implementaci&#243;n no compromete la seguridad de los pacientes&#44; aunque no describen ventajas significativas frente a la CRA<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> y otros describen que el aumento de la experiencia mejora la calidad de la linfadenectom&#237;a y reduce el tiempo quir&#250;rgico aunque sin mejorar los resultados de la CRA<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a>&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">En base a nuestra experiencia&#44; en la implementaci&#243;n de nuevas t&#233;cnicas&#47;abordajes quir&#250;rgicos especialmente en patolog&#237;as complejas y con reducido n&#250;mero de casos&#47;a&#241;o&#44; se deber&#237;a considerar al inicio de la curva de aprendizaje&#44; limitarlo a un reducido grupo de cirujanos con experiencia quir&#250;rgica&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusi&#243;n</span><p id="par0175" class="elsevierStylePara elsevierViewall">La cistectom&#237;a laparosc&#243;pica frente a la cistectom&#237;a abierta mejora desde su implantaci&#243;n el porcentaje de transfusiones&#44; de complicaciones y la estancia hospitalaria&#44; a expensas de un mayor tiempo quir&#250;rgico&#46; En nuestra experiencia&#44; ha sido necesario una larga curva de aprendizaje para igualar e incluso observar una tendencia a un menor tiempo quir&#250;rgico del abordaje laparosc&#243;pico frente a la cistectom&#237;a abierta&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En nuestro centro&#44; la laparoscopia se ha validado como abordaje m&#237;nimamente invasivo de referencia en la cistectom&#237;a radical&#44; al obtener ventajas en morbilidad&#44; manteniendo los criterios de calidad de la cistectom&#237;a y demostrar ser reproductible tras una exigente curva de aprendizaje&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0185" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n y objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Las Guidelines de la AEU de 2017&#44; consideran el acceso laparosc&#243;pico o asistido por robot como procedimientos en investigaci&#243;n&#46; La curva de aprendizaje se define por el n&#250;mero m&#237;nimo de casos que es necesario realizar para reproducir la t&#233;cnica considerada como est&#225;ndar&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es analizar en el mismo servicio&#44; la implantaci&#243;n de un programa de cistectom&#237;a laparosc&#243;pica &#40;CRL&#41;&#44; compar&#225;ndolo con un programa consolidado y estandarizado de cistectom&#237;a abierta &#40;CRA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de cohortes retrospectivo de dos grupos de cistectom&#237;as&#58; CRL &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>196&#41; &#40;2006-2016&#41; frente a CRA &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#41; &#40;2003-2005&#41;&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Comparaci&#243;n de la evoluci&#243;n en el tiempo de los siguientes par&#225;metros&#58; tiempo quir&#250;rgico&#44; las necesidad de transfusi&#243;n&#44; el estado de los m&#225;rgenes quir&#250;rgicos de resecci&#243;n&#44; las complicaciones postoperatorias&#44; la duraci&#243;n de la estancia hospitalaria y las recidivas&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se han definido 3 periodos de tiempo para CRL&#58; implantaci&#243;n &#40;2006-09&#41; &#40;CRLI&#41;&#44; desarrollo &#40;2010-14&#41; &#40;CRL-D&#41; y consolidaci&#243;n &#40;2015-16&#41; &#40;CRL-C&#41;&#59; compar&#225;ndose cada uno de ellos con el grupo control &#40;CRA&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Para el contraste de variables cualitativas se ha utilizado el test de la Chi cuadrado y para las variables num&#233;ricas el test de Anova&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La CRL&#44; en comparaci&#243;n con la CRA&#44; present&#243; un mayor tiempo quir&#250;rgico en las fases de CRL-I y CRL-D&#44; observando una tendencia de menores tiempos operatorios que la CRA en el periodo de consolidaci&#243;n&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La CRL presenta adem&#225;s menor trasfusi&#243;n intraoperatoria en los 3 periodos y postoperatoria en CRL-D y CRL-C&#44; menos complicaciones totales en CRL-D y CRL-C&#44; menos complicaciones graves &#40;Clavien&#8805;3&#41; en las 3 fases&#59; as&#237; como una disminuci&#243;n de la mortalidad y estancia hospitalaria desde la fase de CRL-I&#44; consolid&#225;ndose esta disminuci&#243;n en los otros dos periodos de estudio&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">No hemos observado diferencias significativas entre CRA y CRL en cuanto a m&#225;rgenes quir&#250;rgicos y recurrencias ni en el total de la serie ni en la comparaci&#243;n entre los distintos periodos&#44; lo que avala la seguridad de la CRL&#44; desde su inicio&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La CRL frente a CRA mejora desde su implantaci&#243;n el porcentaje de transfusiones&#44; de complicaciones y la estancia hospitalaria&#44; con seguridad oncol&#243;gica&#44; a expensas de un mayor tiempo quir&#250;rgico en las fases de implantaci&#243;n y desarrollo&#46; Sin embargo&#44; en nuestra serie observamos una tendencia de menores tiempos quir&#250;rgicos que la CRA en el periodo de consolidaci&#243;n&#46; En nuestro servicio el abordaje laparosc&#243;pico se ha validado en el tratamiento de la cistectom&#237;a radical&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduction and objectives</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures&#46; The surgical learning curve is defined as the minimum number of cases that a surgeon has to perform in order to reproduce a technique considered as standard&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to analyze&#44; within our department&#44; the implementation of a laparoscopic radical cystectomy &#40;LRC&#41; program compared with a well consolidated and standardized open radical cystectomy &#40;ORC&#41; program&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Retrospective cohort analysis of two cystectomy groups&#58; LRC &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>196&#41; &#40;20062016&#41; vs&#46; ORC &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#41; &#40;2003-2005&#41;&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Comparison of the evolution over time of the following parameters&#58; operative time&#44; blood transfusion rates&#44; resection margins&#44; postoperative complications&#44; hospital stay and recurrence&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Three time periods have been defined for LRC&#58; implementation &#40;2006-09&#41; &#40;LRC-I&#41;&#44; development &#40;2010-14&#41; &#40;LRC-D&#41; and consolidation &#40;2015-16&#41; &#40;LRC-C&#41;&#59; comparing each of them with the control group &#40;ORC&#41;&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">When compared to ORC&#44; LRC presented longer operative times in LRC-I and LRC-D periods&#46; We observed a trend toward shorter operative time than ORC in the consolidation period &#40;LRC-C&#41;&#46;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C&#46; Overall complications in LRC-D and LRC-C were lower in LRC&#44; having fewer major complications &#40;Clavien&#8805;3&#41; in the 3 periods&#46; A decrease in mortality and hospital stay after the LRC-I phase was also observed&#46; These results were consolidated during the two last periods of the study&#46;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates&#44; neither in the total series&#44; nor in the comparison between the different periods&#46; These results endorse the oncologic safety of LRC from the beginning of the implementation process&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">When compared to ORC&#44; LRC improves perioperative transfusion rates&#44; complications and hospital stay from its implementation period&#44; maintaining oncological safety&#46; On the contrary&#44; longer operative times during implementation and development were observed&#46; However&#44; in our series&#44; we observed a trend toward shorter operative times than ORC approach in the consolidation period&#46; We have validated the laparoscopic approach for radical cystectomy in our service&#46;</p></span>"
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                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-I&#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">CRL-D &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-D&#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">CRL-C &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&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" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-C&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cirujano MIR</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Derivaci&#243;n transileal &#40;Bricker&#47;neovejiga tipo Studer&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Cirug&#237;a asociada&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;5&#44;6&#37;&#41;3 Nefrou&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estadio Patol&#243;gico&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">39 &#40;41&#44;5&#37;&#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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                  \t\t\t\t">12 &#40;26&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&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;52&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">9 &#40;9&#44;6&#37;&#41;&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;6&#44;7&#37;&#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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                  \t\t\t\t">0&#44;78&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;IQR 2-6&#41;&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">7 &#40;IQR 5-11&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;IQR 8-17&#41;&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  " align="left" valign="\n
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                  \t\t\t\t">13 &#40;IQR 11-17&#41;&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;0001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRA &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">88 &#40;91&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>cTa-T2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">88 &#40;91&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">169 &#40;86&#44;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>cT3-T4&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;5&#44;2&#37;&#41;&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">22 &#40;11&#44;2&#37;&#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">&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
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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">cN</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span>&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">Clasificaci&#243;n ASA 3-4</span>&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;1&#44;1&#37;&#41;86 &#40;91&#44;5&#37;&#41;7 &#40;7&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;31&#44;6&#37;&#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">32 &#40;34&#37;&#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">19 &#40;42&#44;2&#37;&#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">0&#44;51&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">Tiempo RTU-cistectom&#237;a &#40;mediana&#41;</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">3 &#40;IQR 3-4&#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">2 &#40;IQR 2-3&#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;IQR 2-3&#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">0&#44;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas basales de los pacientes con abordaje laparosc&#243;pico seg&#250;n los periodos de tiempo previamente definidos</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRA &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRL-I &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-I&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRL-D &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRL-C &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-C&#41;&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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad &#40;mediana&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69 &#40;IQR 60-74&#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">71 &#40;IQR 60-76&#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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                  \t\t\t\t">0&#44;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73 &#40;IQR 72-77&#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">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70 &#40;IQR 66-76&#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
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                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Var&#243;n</span>&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">88 &#40;91&#44;7&#37;&#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
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                  \t\t\t\t">52 &#40;91&#44;2&#37;&#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">0&#44;93&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">82 &#40;87&#44;2&#37;&#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">0&#44;32&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">40 &#40;88&#44;9&#37;&#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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                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estadio local &#40;cT&#41;&#58;</span><span class="elsevierStyleHsp" style=""></span>cTx<span class="elsevierStyleHsp" style=""></span>cTa-T2<span class="elsevierStyleHsp" style=""></span>cT3-T4&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">3 &#40;3&#44;1&#37;&#41;88 &#40;91&#44;7&#37;&#41;5 &#40;5&#44;2&#37;&#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  " align="left" valign="\n
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                  \t\t\t\t">057 &#40;100&#37;&#41;0&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">0&#44;08&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;1&#44;1&#37;&#41;86 &#40;91&#44;5&#37;&#41;7 &#40;7&#44;4&#37;&#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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;8&#44;9&#37;&#41;25 &#40;57&#44;8&#37;&#41;15 &#40;33&#44;3&#37;&#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
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                  \t\t\t\t">0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">cN</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></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
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                  \t\t\t\t">3 &#40;3&#44;1&#37;&#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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                  \t\t\t\t">13 &#40;22&#44;8&#37;&#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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                  \t\t\t\t">0&#44;0001&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">15 &#40;16&#37;&#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">0&#44;003&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">8 &#40;17&#44;8&#37;&#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">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Clasificaci&#243;n ASA 3-4</span>&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">16 &#40;16&#44;7&#37;&#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
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                  \t\t\t\t">19 &#40;33&#44;3&#37;&#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
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                  \t\t\t\t">0&#44;02&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">39 &#40;41&#44;5&#37;&#41;&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;0001&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;44&#44;4&#37;&#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="elsevierStyleItalic">I&#46; Charlson &#8805; 3</span>&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">3 &#40;3&#44;2&#37;&#41;&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">18 &#40;32&#44;1&#37;&#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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                  \t\t\t\t">0&#44;0001&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">Tiempo RTU-Cistectom&#237;a &#40;mediana&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">2 &#40;IQR 2-3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;IQR 2-3&#41;&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;22&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRA &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>96&#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">CRL-I &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-I&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRL-D &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-D&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRL-C &#40;N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p &#40;CRA vs&#46; CRL-C&#41;&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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">270 &#40;IQR 228-300&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">365 &#40;IQR 312-400&#41;&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;0001&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  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">263 &#40;IQR 218-300&#41;&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"><span class="elsevierStyleItalic">Transfusi&#243;n intraoperatoria</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">46 &#40;53&#44;5&#37;&#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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                  \t\t\t\t">17 &#40;30&#44;4&#37;&#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\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;16&#37;&#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">0&#44;0001&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;8&#44;9&#37;&#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">0&#44;0001&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">Complicaciones Clavien-Dindo&#58;</span><span class="elsevierStyleHsp" style=""></span>No<span class="elsevierStyleHsp" style=""></span>I<span class="elsevierStyleHsp" style=""></span>II<span class="elsevierStyleHsp" style=""></span>IIIa<span class="elsevierStyleHsp" style=""></span>IIIb<span class="elsevierStyleHsp" style=""></span>IVa<span class="elsevierStyleHsp" style=""></span>IVb&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">24 &#40;25&#37;&#41;5 &#40;5&#44;2&#37;&#41;31 &#40;32&#44;3&#37;&#41;3 &#40;3&#44;1&#37;&#41;20 &#40;20&#44;8&#37;&#41;2 &#40;2&#44;1&#37;&#41;1 &#40;1&#37;&#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">20 &#40;25&#44;1&#37;&#41;2 &#40;3&#44;5&#37;&#41;23 &#40;40&#44;4&#37;&#41;3 &#40;5&#44;3&#37;&#41;9 &#40;15&#44;9&#37;&#41;00&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&#44;15&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">46 &#40;48&#44;9&#37;&#41;8 &#40;8&#44;5&#37;&#41;24 &#40;25&#44;5&#37;&#41;4 &#40;4&#44;3&#37;&#41;6 &#40;6&#44;4&#37;&#41;2 &#40;2&#44;1&#37;&#41;2 &#40;2&#44;1&#37;&#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">0&#44;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">24 &#40;53&#44;3&#37;&#41;3 &#40;6&#44;7&#37;&#41;8 &#40;17&#44;8&#37;&#41;3 &#40;6&#44;7&#37;&#41;5 &#40;11&#44;1&#37;&#41;1 &#40;2&#44;2&#37;&#41;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;03&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">Complicaciones Clavien&#8805;III</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">36 &#40;37&#44;5&#37;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;21&#44;1&#37;&#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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16 &#40;17&#37;&#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  " align="left" valign="\n
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                  \t\t\t\t">0&#44;002&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">10 &#40;22&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;07&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">Mortalidad &#40;Clavien V&#41;</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">10 &#40;10&#44;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;2&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#44;2&#37;&#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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                  \t\t\t\t">2 &#40;2&#44;1&#37;&#41;12 &#40;12&#44;5&#37;&#41;27 &#40;28&#44;1&#37;&#41;8 &#40;8&#44;3&#37;&#41;05 &#40;5&#44;2&#37;&#41;22 &#40;22&#44;9&#37;&#41;7 &#40;7&#44;3&#37;&#41;10 &#40;10&#44;4&#37;&#41;9 &#40;9&#44;4&#37;&#41;11 &#40;11&#44;5&#37;&#41;8 &#40;8&#44;3&#37;&#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;5&#44;3&#37;&#41;5 &#40;8&#44;8&#37;&#41;8 &#40;14&#37;&#41;10 &#40;17&#44;5&#37;&#41;1 &#40;1&#44;8&#37;&#41;04 &#40;7&#37;&#41;5 &#40;5&#44;3&#37;&#41;02 &#40;3&#44;5&#37;&#41;02 &#40;3&#44;5&#37;&#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">0&#44;290&#44;480&#44;040&#44;090&#44;190&#44;080&#44;020&#44;620&#44;010&#44;170&#44;0080&#44;24&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 &#40;1&#44;1&#37;&#41;18 &#40;19&#44;1&#37;&#41;7 &#40;7&#44;4&#37;&#41;11 &#40;11&#44;7&#37;&#41;1 &#40;1&#44;1&#37;&#41;4 &#40;4&#44;3&#37;&#41;1 &#40;1&#44;1&#37;&#41;5 &#40;5&#44;3&#37;&#41;5 &#40;5&#44;3&#37;&#41;5 &#40;5&#44;3&#37;&#41;1 &#40;1&#44;1&#37;&#41;3 &#40;3&#44;2&#37;&#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">0&#44;570&#44;210&#44;00010&#44;440&#44;310&#44;760&#44;00010&#44;580&#44;190&#44;290&#44;00030&#44;13&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">07 &#40;15&#44;6&#37;&#41;2 &#40;4&#44;4&#37;&#41;4 &#40;8&#44;9&#37;&#41;1 &#40;2&#44;2&#37;&#41;2 &#40;4&#44;4&#37;&#41;5 &#40;11&#44;1&#37;&#41;01 &#40;2&#44;2&#37;&#41;1 &#40;2&#44;2&#37;&#41;01 &#40;2&#44;2&#37;&#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">0&#44;330&#44;620&#44;0010&#44;910&#44;140&#44;850&#44;100&#44;060&#44;090&#44;120&#44;020&#44;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Transfusi&#243;n postoperatoria</span>&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;41&#44;7&#37;&#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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                  \t\t\t\t">24 &#40;42&#44;1&#37;&#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
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                  \t\t\t\t">0&#44;96&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;12&#44;8&#37;&#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">0&#44;0001&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 &#40;13&#44;3&#37;&#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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;001&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">Estancia</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">15 &#40;IQR 11-28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;IQR 10-19&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;01&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">12 &#40;IQR 10-16&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;IQR 8-15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Recurrencia</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53 &#40;55&#44;2&#37;&#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">24 &#40;42&#44;1&#37;&#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">0&#44;18&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">40 &#40;42&#44;6&#37;&#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">0&#44;08&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">18 &#40;40&#37;&#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">0&#44;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0155" class="elsevierStyleSimplePara elsevierViewall">Comparaci&#243;n del grupo control CA &#40;2003-2005&#41; con el resto de los grupos de cistectom&#237;a laparosc&#243;pica</p>"
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                            4 => "V&#46; Hern&#225;ndez"
                            5 => "T&#46; Lebret"
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Información del artículo
ISSN: 02104806
Idioma original: Español
DOI:10.1016/j.acuro.2019.07.002
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos