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Original article
Changing patterns in the surgical management of renal masses
Evolución de la técnica quirúrgica en el manejo de la masa renal
A. Vilasecaa,
Corresponding author
tonivilaseca@hotmail.com

Corresponding author.
, M. Musqueraa, D.P. Nguyenb, G. Di Paolaa, L.R. Romeoa, A. Melnicka, E. García-Cruza, M.J. Ribala, J. Hugueta, A. Alcaraza
a Departamento de Urología, Hospital Clínic de Barcelona, Barcelona, Spain
b Departmento de Urología, Universidad de Berna, Berna, Switzerland
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patterns in surgical management of renal masses from 2004 to 2012&#46; Open procedures are represented in cold colors and minimally invasive procedures in warm colors&#46; The total number of procedures is indicated at the top of each column&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Due to the widespread use of and advances in medical imaging&#44; recent years have seen an increase in the overall incidence and a downward stage migration of kidney cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> Together with a better understanding of the functional advantages of nephron-sparing surgery&#44; this evolving context has led to an expansion of partial nephrectomy &#40;PN&#41; in the treatment of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">2</span></a> PN does not compromise oncological outcomes&#44;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">3&#8211;5</span></a> and it preserves renal function and quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">6&#8211;8</span></a> Furthermore&#44; there is evidence that PN decreases chronic kidney disease &#40;CKD&#41;-associated morbidity and risk of overall death&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#8211;11</span></a> International guidelines recommend PN for cT1 as well as carefully selected cT2 tumors whenever technically feasible&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">At the same time&#44; minimally invasive techniques have become popular for both RN<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;15</span></a> and PN&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> More recently&#44; new minimally invasive techniques including laparoendoscopic single-site surgery &#40;LESS&#41; and natural orifices transluminal endoscopic surgery &#40;NOTES&#41; have arisen interest&#44; with the aim to further reduce morbidity and increase cosmetic results&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> The available evidence suggests that LESS surgery for PN is associated with reduced pain and morphine requirements compared to conventional laparoscopy&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">18&#44;19</span></a> Furthermore&#44; transvaginal mixed NOTES surgery has been described as feasible&#44; safe&#44; and with excellent cosmetic results with no sexual effect in living donor nephrectomies&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In light of these recent developments&#44; there are indications that changing surgical trends have occurred in US-based academic and community hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">21&#8211;23</span></a> However&#44; a precise characterization of these changes in Europe has not been available&#46; To address this issue&#44; we offer a detailed analysis of temporal trends in the use of various surgical techniques at our academic institution over a 9-year period&#46; In addition&#44; we attempt to identify clinical factors associated with PN choice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patient population</span><p id="par0020" class="elsevierStylePara elsevierViewall">Upon Institutional Review Board approval&#44; medical records of 646 consecutive patients treated by surgery for clinically localized renal masses between January 2004 and December 2012 at our institution were reviewed&#46; The surgical techniques were&#58; open RN&#44; open PN&#44; laparoscopic RN&#44; and laparoscopic PN&#46; The laparoscopic approach included conventional as well as LESS and NOTES techniques&#46; All operations were performed by staff urologists and the choice of surgical technique followed institutional and international guidelines at the time of diagnosis&#46; Thus&#44; the decision to carry out PN or RN was based on tumor size&#44; morphology&#44; and location in preoperative imaging&#46; Imperative PN was performed in patients with anatomic or functional solitary kidneys&#44; bilateral tumors&#44; or chronic kidney disease&#46; Laparoscopy was introduced in April 2004 at our institution&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Baseline variables abstracted from our database included age&#44; gender&#44; body mass index &#40;BMI&#41;&#44; American Society of Anesthesia &#40;ASA&#41; score&#44; smoking history&#44; diabetes&#44; hypertension&#44; creatinine&#44; and estimated glomerular filtration rate &#40;eGFR&#41; using the Chronic Kidney Disease Epidemiology Collaboration &#40;CKD-EPI&#41; formula&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> tumor size&#44; and pathologic tumor stage according to the 2009 AJCC TNM classification in case of malignancy&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">The Chi-square test and the Kruskal&#8211;Wallis test were used to compare baseline characteristics of patients treated with the four surgical techniques&#46; The year of treatment was categorized by 2-year increments after 2004&#46; Yearly trends were tested using the Chi-square test for trend&#46; A simple linear regression model approximated the change in tumor size over time&#46; Adjusted odds ratios &#40;OR&#41; and 95&#37; confidence intervals &#40;CI&#41; were calculated in a logistic regression model to evaluate clinical variables predictive of PN&#44; including open and minimally invasive approaches&#46; Potential confounders included in multivariable analyses were patient age at surgery &#40;continuous&#41;&#44; gender&#44; ASA score &#40;&#8804;2 vs &#62;2 vs unknown&#41;&#44; eGFR &#40;continuous&#41;&#44; tumor size &#40;continuous&#41;&#44; and year of surgery&#46; All <span class="elsevierStyleItalic">p</span>-values are two-sided with statistical significance evaluated at the 0&#46;05 alpha level&#46; All analyses were performed using IBM SPSS Version 21&#46;0 &#40;IBM&#44; Armonk&#44; NY&#44; USA&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Baseline patient characteristics and pathologic data by surgical technique are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The distribution of ASA score was statistically different among the 4 techniques &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Specifically&#44; patients undergoing laparoscopic procedures were more likely to have ASA score &#8804;2 &#40;320&#47;497 &#40;64&#37;&#41;&#44; patients with ASA &#8804;2&#44; vs 62&#47;149 &#40;42&#37;&#41; with ASA<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Likewise&#44; patients undergoing PN were more likely to have ASA score &#8804;2 &#40;196&#47;282 &#40;70&#37;&#41;&#44; patients with ASA &#8804;2&#44; vs 186&#47;374 &#40;51&#37;&#41; with ASA<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Median eGFR also differed among the 4 groups&#44; as patients undergoing PN had higher eGFR than patients treated by RN &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Expectedly&#44; decreasing tumor size and higher proportion of low-stage disease &#40;in case of malignancy&#41; was seen in patients undergoing PN &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The annual proportion of patients undergoing PN ranged from 6&#47;29 &#40;21&#37;&#41; to 89&#47;162 &#40;55&#37;&#41; in 2011&#8211;2012 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Specifically&#44; the use of PN was constant from 2004 to 2007&#44; after which an increase is observed &#40;trend test <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The proportion of patients undergoing laparoscopic procedures &#40;RN or PN&#41; increased throughout the study&#44; representing almost all of our surgical caseload in 2011&#8211;2012 &#40;156&#47;162 &#40;96&#37;&#41; vs 5&#47;29 &#40;17&#37;&#41; in 2004&#59; 5&#46;6-fold increase&#41;&#46; The proportion of PN regardless of the surgical approach increased from 21&#37; at the beginning of the study to 55&#37; in the last period &#40;2011&#8211;2012&#41;&#44; representing a 2&#46;6-fold increase&#46; In fact&#44; laparoscopic PN was performed in 88&#47;162 &#40;54&#37;&#41; of all kidney surgeries and became the most commonly performed kidney procedure in 2011&#8211;2012&#46; Of note&#44; we began performing LESS and NOTES in March 2008&#46; The use of these techniques had increased steadily&#44; and in 2011&#8211;2012 they were performed in 19&#47;73 &#40;26&#37;&#41; of all RN cases and were shown to be feasible in 2 PN cases&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Although patient characteristics including age and comorbidities are important when electing the surgical approach&#44; the decision to perform RN or PN and to use an open or laparoscopic approach is mainly based on tumor size&#46; Therefore&#44; we analyzed the evolution of median tumor size over the study period&#46; Overall&#44; median tumor size did not significantly change from 2004 to 2012 &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Stratification by surgical technique showed that while median tumor size increased for open procedures&#44; it remained stable for laparoscopic surgeries over the years &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">On multivariable analysis adjusting for clinical variables&#44; ASA score&#44; baseline renal function&#44; and tumor size were independent predictors of PN &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Although year of surgery did not reach conventional levels of statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;1&#41;&#44; we observed increasing likelihood of undergoing PN over time &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;56&#44; 95&#37;CI<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;73&#8211;9&#46;04 in 2011&#8211;2012 vs 2004&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">In response to the evidence of oncological safety and data reporting functional advantages of nephron-sparing surgery&#44; PN is now recommended as the procedure of choice for cT1 and carefully selected cT2 renal masses by the European Association of Urology and the American Urological Association&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">12&#44;13</span></a> Initially performed in cases with absolute indications &#40;solitary kidney&#44; bilateral tumors&#44; renal function impairment&#41;&#44; PN was then offered to selected patients with small &#40;&#8804;4<span class="elsevierStyleHsp" style=""></span>cm&#41; tumors and normal contralateral kidneys&#46; More recently&#44; the indication of open PN has been extended to selected patients with larger and more complex tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">21&#44;25</span></a> This paradigm shift in the management of renal masses has been well documented in US-based studies&#46; However&#44; data stemming from European centers where laparoscopy is more used have been lacking&#46; Our results demonstrate that current international guidelines reflecting the paradigm shift in the management of renal masses have been adopted in a Spanish academic center&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the current study&#44; the percentage of patients undergoing PN increased almost 3-fold over the course of the study&#44; representing 55&#37; of all surgeries in 2011&#8211;2012&#46; These numbers are in line with those from Thompson et al&#46;&#44; who reported the Memorial Sloan Kettering Cancer Center experience from 2000 to 2007&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> At the same time&#44; in the last 2 years of our study&#44; 96&#37; of all kidney procedures were performed laparoscopically&#44; reflecting the growing adoption of minimally invasive techniques at our institution&#46; Therefore&#44; the increase in the use of PN was mainly driven by the laparoscopic approach&#46; This certainly reflects a peculiar characteristic of our institution&#46; We place an emphasis on the use of laparoscopy and all staff surgeons have a preference for minimally invasive approaches&#46; We also perform LESS and NOTES in kidney surgery&#44; and pioneer the development of the transvaginal access&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a> Although few data is available&#44; LESS and NOTES have proved to be feasible and hold the potential for achieving scarless surgery while maintaining oncologic efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> Of note&#44; we did not perform additional analyses to account for surgeon characteristics&#46; All staff surgeons at our institution are well trained in both open and laparoscopic techniques and the indications for surgery follow standardized institutional guidelines&#46; If the decision is not straightforward&#44; the case is presented internally and a consensus decision is reached&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">From North American studies&#44; it has been suggested that the popularization of laparoscopic RN may lead to a preferential use of the latter rather than PN&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">27&#44;28</span></a> In fact&#44; despite increasing use of PN&#44; RN remains by far the most commonly performed procedure in the United States&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">22&#44;23</span></a> Moreover&#44; data derived from the Surveillance Epidemiology and End Results &#40;SEER&#41; registry show that only 50&#37; of renal masses &#60;2<span class="elsevierStyleHsp" style=""></span>cm underwent PN and that 48&#37; or renal masses 2&#8211;4<span class="elsevierStyleHsp" style=""></span>cm underwent RN in 2008&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> European population-based studies are scarce&#46; Fedeli et al&#46;&#44; investigating trends in the Veneto region&#44; reported an increase in the use of PN from 22&#37; of all kidney procedures in 1999 to 31&#37; in 2007&#46; However&#44; the authors noted a greater increase in the proportion of laparoscopic RN &#40;1&#37; in 1999 vs&#46; 18&#37; in 2007&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">30</span></a> Given the potential benefits of PN&#44; the underuse of PN would represent suboptimal quality of care&#46; In light of these legitimate concerns&#44; our study shows that after the introduction of laparoscopy at our institution&#44; the use of PN steadily increased&#44; suggesting that the surgical approach did not determine the treatment algorithm among our surgeons&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We were also interested in evaluating the well-reported migration of renal cell carcinoma &#40;RCC&#41; toward smaller-sized tumors at diagnosis<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> in the context of our single institution&#46; We found that tumor size in RN and PN cases remained constant or even increased during the study period&#46; These findings are most likely due to our status as a tertiary referral center&#44; with the consequent inclusion of larger and more complex tumors&#46; Interestingly&#44; this referral bias did not preclude the expansion of minimally invasive techniques at our institution&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The main limitation of our study is that it represents the experience of a single tertiary referral center&#46; Additional studies evaluating the changing surgical trends in European academic and community settings are warranted to further reflect the landscape of kidney surgery in Europe&#46; For instance&#44; it has been suggested that patients treated at US-based teaching hospitals are more likely to undergo PN than RN&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a> Furthermore&#44; we did not provide an analysis of cost-effectiveness&#44; which may be of interest&#46; Recent studies have suggested that laparoscopic PN may be more cost-effective than open PN&#44; mainly because of shorter length of stay&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">31&#44;32</span></a> Notwithstanding these limitations&#44; our study is the first to illustrate the temporal trends in kidney cancer surgery at a European academic institution&#46; Our experience reflects current guidelines set by major urological associations<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">12&#44;13</span></a> and should encourage their further application&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0080" class="elsevierStylePara elsevierViewall">At our academic institution&#44; temporal trends in the management of renal masses have established PN as the most common surgical option&#46; Although PN has been increasingly used over the study period&#44; a parallel increase in minimally invasive approaches for RN and PN was observed&#46; Additional studies are needed to confirm our findings and further delineate the landscape of kidney surgery in Europe&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the temporal trends in surgical techniques for the management of renal masses at a single Spanish academic institution and identify factors associated with partial nephrectomy &#40;PN&#41; decision&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 646 patients were treated by surgery for clinically localized renal masses from January 2004 to December 2012 at a tertiary referral center&#46; Surgical techniques included open radical nephrectomy &#40;RN&#41;&#44; open PN&#44; laparoscopic RN&#44; and laparoscopic PN&#46; Descriptive statistics were used to compare baseline characteristics and proportions of patients treated by different surgical techniques&#46; Annual trends in the proportion of procedures performed were determined&#46; Adjusted odds ratios &#40;OR&#41; and 95&#37; confidence intervals were calculated to evaluate clinical variables predictive of PN&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">During the 9-year study period&#44; the proportion of PN relative to RN increased from 21&#37; to 55&#37;&#46; With regard to surgical approach&#44; open procedures for both RN and PN decreased gradually in favor of minimally invasive approaches &#40;83&#37; in 2004 to 4&#37; in 2011&#8211;2012&#41;&#46; While median tumor size did not significantly change over the study period&#44; laparoscopic PN became the most commonly performed kidney procedure in 2011&#8211;2012 &#40;49&#37; of all procedures&#41;&#46; Clinical variables independently predictive of partial nephrectomy were ASA score&#44; baseline renal function and tumor size &#40;all <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">At our academic institution&#44; temporal trends in the management of renal masses have established PN as the most common surgical option&#46; Although PN was increasingly used over the study period&#44; a parallel increase in minimally invasive approaches for RN and PN was seen&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir la evoluci&#243;n de la t&#233;cnica quir&#250;rgica para el manejo de las masas renales en un centro espa&#241;ol e identificar los factores asociados con la decisi&#243;n de nefrectom&#237;a parcial &#40;NP&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Un total de 646 pacientes fueron tratados quir&#250;rgicamente por tumores renales localizados entre enero de 2004 y diciembre de 2012&#46; Las t&#233;cnicas quir&#250;rgicas incluyeron la nefrectom&#237;a radical &#40;NR&#41; abierta&#44; NP abierta&#44; NR laparosc&#243;pica y NP laparosc&#243;pica&#46; Se compararon las caracter&#237;sticas basales y las proporciones de los pacientes tratados por diferentes t&#233;cnicas mediante estad&#237;sticos descriptivos y se determinaron las tendencias anuales en la proporci&#243;n de procedimientos realizados&#46; Se calcul&#243; la proporci&#243;n de probabilidades &#40;OR&#41; y los intervalos de confianza del 95&#37; para evaluar variables cl&#237;nicas predictivas de NP&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante el per&#237;odo de 9 a&#241;os&#44; la proporci&#243;n de NP aument&#243; respecto a la NR&#44; pasando del 21 al 55&#37;&#46; Los procedimientos abiertos disminuyeron gradualmente a favor de abordajes m&#237;nimamente invasivos &#40;83&#37; en 2004&#59; 4&#37; en 2011-2012&#41;&#46; Aunque el tama&#241;o tumoral medio no cambi&#243; significativamente durante el per&#237;odo de estudio&#44; la NP laparosc&#243;pica se convirti&#243; en el procedimiento m&#225;s realizado en 2011-2012 &#40;un 49&#37; de todos los procedimientos&#41;&#46; Las variables cl&#237;nicas independientemente predictivas de NP fueron puntuaci&#243;n ASA&#44; funci&#243;n renal basal y tama&#241;o tumoral &#40;todas las p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestra instituci&#243;n&#44; la evoluci&#243;n en el manejo de las masas renales ha establecido la NP como la opci&#243;n quir&#250;rgica m&#225;s frecuente&#46; Aunque la NP se utiliz&#243; cada vez m&#225;s durante el per&#237;odo de estudio&#44; se observ&#243; un aumento paralelo de los abordajes m&#237;nimamente invasivos tanto para NR como para NP&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Vilaseca A&#44; Musquera M&#44; Nguyen DP&#44; Di Paola G&#44; Romeo LR&#44; Melnick A&#44; et al&#46; Evoluci&#243;n de la t&#233;cnica quir&#250;rgica en el manejo de la masa renal&#46; Actas Urol Esp&#46; 2016&#59;40&#58;148&#8211;154&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1881
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patterns in surgical management of renal masses from 2004 to 2012&#46; Open procedures are represented in cold colors and minimally invasive procedures in warm colors&#46; The total number of procedures is indicated at the top of each column&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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            "Tamanyo" => 196632
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Scatterplot of tumor size by years&#44; &#40;A&#41; overall&#44; and &#40;B&#41; trend line stratified by surgical technique&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">IQR&#44; interquartile range&#59; ASA&#44; American Society of Anasthesiologists&#59; BMI&#44; body mass index&#59; eGFR&#44; estimated glomerular filtration rate&#59; CKD-EPI&#44; Chronic Kidney Disease Epidemiology Collaboration&#59; RCC&#44; renal cell carcinoma&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Percentages may not sum to 100&#37; due to rounding&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Open RN&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Open PN&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laparoscopic RN&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>271&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Laparoscopic PN&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>226&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male gender&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">188 &#40;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156 &#40;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age at surgery&#44; years&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;53&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;60&#8211;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65 &#40;56&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63 &#40;55&#8211;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top">ASA score&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">170 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="char" valign="top">&#60;0&#46;0001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">104 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;6 &#40;24&#46;0&#8211;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;5 &#40;25&#46;8&#8211;30&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;5 &#40;24&#46;0&#8211;29&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;8 &#40;24&#46;5&#8211;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">119 &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine&#44; mg&#47;dl&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;07 &#40;0&#46;90&#8211;1&#46;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1 &#40;0&#46;9&#8211;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;05 &#40;0&#46;84&#8211;1&#46;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;95 &#40;0&#46;81&#8211;1&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">eGFR &#40;CKD-EPI&#41;&#44; ml&#47;min per 1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68 &#40;48&#8211;93&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71 &#40;52&#8211;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72 &#40;53&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80 &#40;64&#8211;101&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;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="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tumor size&#44; mm&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80 &#40;50&#8211;110&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;23&#8211;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;35&#8211;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;20&#8211;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top">Pathology&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RCC&#44; T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156 &#40;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">171 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="char" valign="top">&#60;0&#46;0001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>RCC&#44; T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48 &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52 &#40;23&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">OR&#44; odds ratio&#59; CI&#44; confidence interval&#59; ASA&#44; American Society of Anasthesiologists&#59; eGFR&#44; estimated glomerular filtration rate&#59; CKD-EPI&#44; Chronic Kidney Disease Epidemiology Collaboration&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;03&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;40&#8211;4&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2007&#8211;2008&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;38&#8211;4&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2009&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;51&#8211;6&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2011&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;73&#8211;9&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Multivariable analysis of variables predicting partial nephrectomy&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:32 [
            0 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Renal cell cancer stage migration&#58; analysis of the National Cancer Data Base"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "C&#46;J&#46; Kane"
                            1 => "K&#46; Mallin"
                            2 => "J&#46; Ritchey"
                            3 => "M&#46;R&#46; Cooperberg"
                            4 => "P&#46;R&#46; Carroll"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/cncr.23518"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cancer"
                        "fecha" => "2008"
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                        "paginaInicial" => "78"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18491376"
                            "web" => "Medline"
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              "identificador" => "bib0170"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The expanding role of partial nephrectomy&#58; a critical analysis of indications&#44; results&#44; and complications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "K&#46; Touijer"
                            1 => "D&#46; Jacqmin"
                            2 => "L&#46;R&#46; Kavoussi"
                            3 => "F&#46; Montorsi"
                            4 => "J&#46;J&#46; Patard"
                            5 => "C&#46;G&#46; Rogers"
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                  "host" => array:1 [
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                      "Revista" => array:6 [
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            2 => array:3 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4<span class="elsevierStyleHsp" style=""></span>cm"
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                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Becker"
                            1 => "S&#46; Siemer"
                            2 => "M&#46; Hack"
                            3 => "U&#46; Humke"
                            4 => "M&#46; Ziegler"
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                          ]
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                  "host" => array:1 [
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                      "doi" => "10.1016/j.eururo.2006.03.003"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16630686"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "O&#46; Shvarts"
                            2 => "J&#46;S&#46; Lam"
                            3 => "A&#46;J&#46; Pantuck"
                            4 => "H&#46;L&#46; Kim"
                            5 => "V&#46; Ficarra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "fecha" => "2004"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15126781"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Outcome of stage T2 or greater renal cell cancer treated with partial nephrectomy"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46;H&#46; Breau"
                            1 => "P&#46;L&#46; Crispen"
                            2 => "R&#46;E&#46; Jimenez"
                            3 => "C&#46;M&#46; Lohse"
                            4 => "M&#46;L&#46; Blute"
                            5 => "B&#46;C&#46; Leibovich"
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                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.juro.2009.11.037"
                      "Revista" => array:6 [
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                        "fecha" => "2010"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic kidney disease after nephrectomy in patients with renal cortical tumours&#58; a retrospective cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46;C&#46; Huang"
                            1 => "A&#46;S&#46; Levey"
                            2 => "A&#46;M&#46; Serio"
                            3 => "M&#46; Snyder"
                            4 => "A&#46;J&#46; Vickers"
                            5 => "G&#46;V&#46; Raj"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1470-2045(06)70803-8"
                      "Revista" => array:6 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46; Scosyrev"
                            1 => "E&#46;M&#46; Messing"
                            2 => "R&#46; Sylvester"
                            3 => "S&#46; Campbell"
                            4 => "H&#46; Van Poppel"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eururo.2013.06.044"
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                        "tituloSerie" => "Eur Urol"
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ISSN: 21735786
Original language: English
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