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Review article
Urinary tract infection as the main cause of admission in cystectomized patients
La infección del tracto urinario como causa principal de ingreso en pacientes cistectomizados
P. Gayarre Abril
Corresponding author
paula17893@hotmail.com

Corresponding author.
, J. Subirá Ríos, L. Muñiz Suárez, C. Murillo Pérez, M. Ramírez Fabián, J.I. Hijazo Conejos, P. Medrano Llorente, J. García-Magariño Alonso, F.X. Elizalde Benito, G. Aleson Hornos, B. Blasco Beltrán, P. Carrera Lasfuentes
Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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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">As of today&#44; the treatment of choice for muscle-invasive bladder cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;17</span></a> is radical cystectomy with urinary diversion&#44; bilateral pelvic lymphadenectomy and neoadjuvant chemotherapy&#44; with recurrence-free survival figures of 58&#37; at 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The complications of radical cystectomy have progressively decreased over the years&#59; however&#44; the current percentage of complications is by no means negligible and up to 64&#37; of patients develop complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;23&#44;27&#44;28</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The studies available in the literature to date report series at 30&#44; 60 and 90 days as the limit to describe early or short-term complications after radical cystectomy&#44; without a clear consensus&#46; In our work&#44; we have considered follow-up at 90 days after the intervention in an attempt to record as much information as possible&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Early or short-term complications include gastrointestinal complications&#44; followed by infectious complications&#44; mainly urinary tract infections&#46; Long-term complications are stoma-related problems and chronic infections&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Urinary tract infection occurs in 20&#8211;40&#37; of patients undergoing radical cystectomy and accounts for up to 49&#37; of readmissions in cystectomized patients&#44; with more than half of the urinary tract infections occurring after removal of the ureteral catheters&#46; Urinary tract infection &#40;UTI&#41; is favored by multiple factors&#44; such as age and sex&#44; high body mass index &#40;BMI&#41;&#44; diabetes mellitus&#44; prolonged operative time and the type of urinary diversion&#44; with urinary tract infection being more prevalent in patients with continent diversions and voiding dysfunction&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;26</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objectives</span><p id="par0030" class="elsevierStylePara elsevierViewall">To assess the rate of UTI as a cause of readmission within 90 days after cystectomy&#46; To identify the most frequent germs&#44; and protective and predisposing factors of urinary tract infection in our environment&#46; Finally&#44; to know the results obtained after the implementation of the antibiotic prophylaxis protocol after ureteral catheter removal&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">Retrospective descriptive study of cystectomized patients in the Urology Department of the Hospital Cl&#237;nico Universitario Lozano Blesa from January 2012 to December 2018&#46; Since October 2017&#44; the UTI prevention protocol has been applied to all patients after catheter removal&#46; The protocol consists of the following&#58; &#8220;Prior to discharge&#44; a sample is taken from each catheter for selective urine culture&#44; and the night before catheter removal&#44; the patient takes a prophylactic antibiotic regimen at home consisting of a single 3&#8239;g dose of fosfomycin&#46; The results of the urine culture of the catheters are reviewed at consultation and in case of appearance of a fosfomycin-resistant germ&#44; a treatment regimen according to the antibiogram is indicated&#8221;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient registries were included in an Excel database&#44; where all the study variables were collected&#46; Data collection was carried out through the review of paper medical records in the Archive Service of the Hospital Cl&#237;nico Universitario&#44; and also through the electronic medical records of Salud Arag&#243;n on the intranet &#40;mainly&#41;&#44; which allowed us to register admissions in other public centers&#44; provided they were within the same autonomous community&#46; The computerized surgical protocols &#40;FileMaker pro&#41; and the electronic consultation of radical cystectomy &#40;UROCIS&#41; in FileMaker pro have been complementary sources of data collection&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study sample consisted of 153 individuals diagnosed with bladder cancer and undergoing radical cystectomy with urinary diversion under multimodal rehabilitation protocol&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Inclusion criteria&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Any patient undergoing radical cystectomy for bladder carcinoma&#44; with urinary diversion using intestinal segment&#44; during the period described&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Exclusion criteria&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Radical cystectomies non-bladder primary disease</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Radical cystectomies with cutaneous ureterostomy for diversion &#40;without manipulation of the intestinal segment&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Fosfomycin allergy&#46;</p></li></ul></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study variables</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Main variables</span><p id="par0080" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">UTI&#46; Urinary tract infection &#40;0 no&#44; 1 yes&#41; Dichotomous nominal qualitative variable&#46; UTI defined as&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Positive urine culture &#40;&#8805;105&#8239;CFU&#47;mL&#41; and symptoms of infection &#40;fever after ruling out other sources&#44; lumbar pain&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Negative or unavailable urine culture with documented symptoms compatible with a diagnosis of UTI &#40;fever without other sources&#44; lumbar pain&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Positive urine cultures without clinical findings are not considered urinary tract infection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Readmission for UTI&#46; Readmission for urinary tract infection within first 90 postoperative days &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Urinary tract infection after removal of ureteral catheters&#46; Urinary tract infection up to 7 days after removal of ureteral catheters &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">After carrying out a thorough review of the literature on the time of ureteral catheterization after radical cystectomy&#44; we found that the literature does not have homogeneous criteria to be followed&#46; Several studies refer to a lower rate of UTI with early removal of ureteral catheters&#44; which led us to propose early removal at 7 days after the intervention in our series of patients&#46; A lower number of catheter duration days was not implemented in an attempt to not underestimate results in the series&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Readmission due to UTI after removal of ureteral catheters&#46; Readmission due to UTI in up to 7 days following ureteral catheter removal within 90 days after cystectomy &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Duration of ureteral catheterization&#46; Number of days of ureteral catheterization in patients undergoing radical cystectomy&#44; until their removal in the doctor&#8217;s office&#46; Continuous quantitative variable&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Secondary variables</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Patient demographics<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Age &#40;years&#41;&#46; Age at the time of surgery&#46; Continuous quantitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Sex&#46; Sex of the patient &#40;0 male&#44; 1 female&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Personal history<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Arterial hypertension &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease &#40;COPD&#41; &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Active smoker &#40;0 no&#44; ex-smoker&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Diabetes mellitus &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">BMI&#46; Continuous quantitative variable&#46; Calculated from the patient&#8217;s weight and height&#44; following the formula&#58; BMI&#8239;&#61;&#8239;weight &#40;kg&#41;&#47;height &#40;m<span class="elsevierStyleSup">2</span>&#41;&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Medical history<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Presence or occurrence of renal hydronephrosis &#40;pre&#44; post&#44; de novo&#41; &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Precystectomy renal hydronephrosis&#8239;&#61;&#8239;patients with preoperative renal hydronephrosis ascertained by extension CT&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Postcistectomy hydronephrosis&#8239;&#61;&#8239;patients with renal hydronephrosis after intervention regardless of the existence or not of hydronephrosis prior to surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">De novo hydronephrosis&#8239;&#61;&#8239;patients with development of renal hydronephrosis after intervention who did not present it prior to surgery or appearance of hydronephrosis in the kidney contralateral to the one with ectasia&#46;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">ASA grade &#40;I&#44; II&#44; III&#44; IV&#44; V&#41;&#46; Nominal qualitative polychotomous variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Charlson index&#46; Discrete quantitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Renal failure &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Neoadjuvant chemotherapy &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Oncologic outcomes</p></li></ul></p><p id="par0230" class="elsevierStylePara elsevierViewall">Tumor stage &#40;1 localized&#44; 2 lymph node metastasis&#44; 3 visceral metastasis&#44; 4 lymph node and visceral metastasis&#41;&#46; Nominal qualitative polychotomous variable&#46;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Surgical outcomes<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Type of diversion &#40;0 Bricker&#44; 1 Studer&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">ICU stay &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">Preoperative&#44; intraoperative or postoperative transfusion requirement &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Preoperative&#58; up to one month before surgery&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Intraoperative&#58; within the first 24&#8239;h from the intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Postoperative&#58; &#62;first 24&#8239;h until hospital discharge&#46;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Laparoscopic surgery &#40;0 open&#44; 1 laparoscopic&#41;&#46; Dichotomous nominal qualitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Prehabilitation &#40;0 no&#44; 1 yes&#41;&#46; Dichotomous nominal qualitative variable&#46; Preoperative consultation&#44; which in our hospital is managed by the Department of Anesthesiology&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">Other variables<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">Operative time &#40;minutes&#41;&#46; Discrete quantitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Postoperative stay in hospital floor &#40;days&#41;&#46; Discrete quantitative variable&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Clavien-Dindo complications &#40;0 no complications&#44; 1 minor complications&#44; 2 major complications&#41;&#46; Nominal polychotomous qualitative variable&#46;</p></li></ul></p></li></ul></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0300" class="elsevierStylePara elsevierViewall">In the descriptive analysis of the information collected&#44; qualitative variables are expressed in absolute and relative frequencies&#46; Quantitative variables are reported in mean&#8239;&#177;&#8239;standard deviation or median and interquartile range&#44; depending on whether or not they follow a normal distribution&#46; To determine the normality of quantitative variables&#44; the Kolmogorov-Smirnov test was used&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">In the bivariate analysis of the data&#44; with the aim of defining the profile of patients requiring readmission for UTI after radical cystectomy&#44; the Chi-squared test or Fisher&#8217;s test was used to assess the association between qualitative variables&#46; When comparing means between 2 independent groups&#44; the Student&#96;s t test or Mann-Whitney U test was used&#44; according to the distribution of the variable&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">A series of logistic regression models were also performed to evaluate prophylaxis and catheterization time as independent factors of UTI&#44; considering the odds ratio together with their 95&#37; confidence intervals as a measure of association&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Values of p&#8239;&#60;&#8239;0&#46;05 were considered statistically significant&#46; The SPSS&#174; v22&#46;0 statistical software &#40;University of Zaragoza license&#41; was used for the entire investigation&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0320" class="elsevierStylePara elsevierViewall">We have a total of 153 patients&#44; 12 women &#40;7&#46;8&#37;&#41; and 141 men &#40;92&#46;2&#37;&#41;&#44; who were cystectomized between January 2012 and December 2018&#46; The median age of the patients is 66&#46;2&#8239;&#177;&#8239;8&#46;6 years&#44; with a range of 38&#8211;81 years&#44; and 50&#37; of the patients are 67 years or older &#40;interquartile range 61&#46;0&#8211;73&#46;0&#41;&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Of the 153 patients under study&#44; 53 &#40;34&#46;6&#37;&#41; were readmitted within the first 90 postcystectomy days&#44; 19&#46;0&#37; &#40;29&#47;153&#41; due to UTI&#44; accounting for 54&#46;7&#37; of readmissions &#40;29&#47;53&#41;&#46; Of the 29 cases readmitted for UTI&#44; 55&#46;2&#37; occurred after catheter removal &#40;16&#47;29&#41;&#44; representing 10&#46;5&#37; of all patients &#40;16&#47;153&#41;&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">In order to evaluate factors influencing UTI-related readmission at 90 days after radical cystectomy&#44; we included all patients in the study and compared the group of patients with UTI &#40;UTI Positive&#41; versus those without development of UTI &#40;UTI Negative&#41;&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">The groups are comparable in terms of the variables studied&#44; without showing statistically significant differences between them in terms of sex or age&#44; personal or medical history&#44; tumor stage&#44; surgical variables or outcomes of the surgical intervention&#46; Regarding the type of urinary diversion&#44; no statistical relationship was observed between the type of urinary diversion and the development of urinary tract infection at 90 days after cystectomy &#40;p&#8239;&#61;&#8239;0&#46;220&#41;&#59; nor between the type of urinary diversion and the occurrence of UTI after removal of ureteral catheters &#40;p&#8239;&#61;&#8239;0&#46;051&#41;&#46; The data are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0340" class="elsevierStylePara elsevierViewall">Analyzing the presence of pre- or post-intervention hydronephrosis&#44; as well as the development of de novo hydronephrosis&#44; as a factor responsible for the development of UTI at 90 days after cystectomy&#44; with a p&#8239;&#61;&#8239;0266 for pre-intervention hydronephrosis and development of UTI at 90 days and a p&#8239;&#61;&#8239;0&#46;676 for post-intervention hydronephrosis and development of UTI at 90 days&#44; statistical association between groups was ruled out&#46; Regarding the development of de novo hydronephrosis&#44; we did not obtain significant data &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0345" class="elsevierStylePara elsevierViewall">Similarly&#44; we analyzed the factors influencing readmission for UTI after catheter removal&#46; In this case&#44; the groups &#40;UTI Negative vs&#46; UTI Positive&#41; show statistically significant differences &#40;p&#8239;&#61;&#8239;0&#46;008&#41; in relation to age&#44; being lower in patients who develop UTI&#46; The sex variable shows no differences &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; In relation to personal history&#44; statistically significant differences &#40;p&#8239;&#61;&#8239;0&#46;006&#41; were observed between groups for COPD&#58; no patient with COPD presented UTI after catheter removal&#46; For the rest of the variables studied&#44; there was no statistical significance between groups&#44; as reflected in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0350" class="elsevierStylePara elsevierViewall">When analyzing the presence of hydronephrosis &#40;pre- and post-intervention&#44; and de novo hydronephrosis&#41; as a factor responsible for the development of UTI after ureteral catheter removal&#44; we found no statistically significant differences between groups &#40;p&#8239;&#61;&#8239;0&#46;394 and p&#8239;&#61;&#8239;0&#46;432&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0025">Tables 5 and 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0355" class="elsevierStylePara elsevierViewall">Of the 153 patients&#44; 13&#46;7&#37; &#40;21&#47;153&#41; had received antibiotic prophylaxis regimen before catheter removal&#46; The rate of UTI at 90 days after surgery in the group with prophylaxis is 28&#46;2&#37; &#40;5&#47;21&#41;&#44; compared to 18&#46;2&#37; of UTI in patients without prophylactic protocol &#40;p&#8239;&#61;&#8239;0&#46;553&#41;&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Of the patients receiving prophylaxis regimen&#44; 9&#46;5&#37; presented UTI after catheter removal &#40;2&#47;21&#41;&#44; compared to 10&#46;6&#37; in the group of patients without prophylaxis &#40;14&#47;132&#41;&#44; with no statistical association found between variables &#40;p&#8239;&#61;&#8239;1&#46;000&#41;&#46; There were no baseline differences between groups&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Of the total number of patients under study&#44; a urine culture was performed in 47&#46;7&#37;&#59; of these&#44; 21&#46;9&#37; were urine cultures routinely collected prior hospital discharge&#44; and the remaining 78&#46;1&#37; were urine culture extractions due to clinical signs indicative of urinary tract infection&#46; A total of 74&#46;0&#37; of the urine cultures were positive &#40;54&#47;73&#41;&#46; Of the 54 patients with positive urine cultures&#44; 77&#46;8&#37; were positive for only one germ &#40;42&#47;54&#41;&#44; 20&#46;4&#37; for 2 germs &#40;11&#47;54&#41; and 1&#46;9&#37; for 3 germs &#40;1&#47;54&#41;&#46; A total of 67 germs were identified&#44; belonging to 19 different families&#44; their distribution is described in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><p id="par0370" class="elsevierStylePara elsevierViewall">Of the 5 patients who presented UTI in the group receiving a prophylactic regimen&#44; one had no urine culture prior to catheter removal&#44; 4 had urine culture available and in 3 of them it was positive for one germ&#46; One urine culture was positive for Escherichia coli&#44; another for Enterobacter cloacae and a third for Klebsiella pneumoniae&#44; all 3 germs being sensitive to fosfomycin&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">Regarding antimicrobial spectrum and resistance&#44; Escherichia coli and Enterobacter cloacae were resistant to amoxicillin&#44; without finding resistance to fosfomycin or quinolones&#46; Klebsiella pneumoniae was sensitive to all&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">The mean catheterization time was 24&#46;5&#8239;&#177;&#8239;7&#46;3 days&#44; with a minimum stay of 8 days and a maximum of 30 days&#46; Patients readmitted for UTI at 90 days have a mean catheter time of 24&#46;3&#8239;&#177;&#8239;7&#46;3 days&#44; compared to 24&#46;5&#8239;&#177;&#8239;7&#46;4 days in patients without UTI &#40;p&#8239;&#61;&#8239;0&#46;821&#41;&#46; Something similar occurs when we analyze UTI after removal&#58; the mean catheter time is 24&#46;3&#8239;&#177;&#8239;7&#46;2 days in patients with development of UTI&#44; versus 24&#46;5&#8239;&#177;&#8239;7&#46;4 days in the group without UTI &#40;p&#8239;&#61;&#8239;0&#46;847&#41;&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">Analyzing separately the group with prophylaxis regimen we found superimposable results&#46; Catheter time in the group with prophylaxis who developed UTI at 90 days has a mean of 12&#46;0&#8239;&#177;&#8239;3&#46;9 days&#44; compared to 14&#46;0&#8239;&#177;&#8239;5&#46;7 days in the group with prophylaxis regimen without UTI &#40;p&#8239;&#61;&#8239;0&#46;495&#41;&#46; Patients with prophylaxis regimen who presented UTI after catheter removal had a mean catheter dwell time of 10&#46;0&#8239;&#177;&#8239;1&#46;4 days&#44; versus 13&#46;8&#8239;&#177;&#8239;5&#46;5 days in the group of patients with prophylaxis and without UTI after removal &#40;p&#8239;&#61;&#8239;0&#46;286&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0390" class="elsevierStylePara elsevierViewall">Complications of radical cystectomy have decreased&#59; nevertheless&#44; up to 64&#37; of patients present a complication&#44; with urinary tract infection being the second most frequent cause&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">The study by Clifford et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> reported a urinary tract infection rate of 11&#37;&#44; with an onset time of 20 days and a readmission of 52&#37;&#46; Similar figures were published in the studies by Parker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and Takada et al&#46;&#44; with UTI rates of 10&#46;3&#37; at 22&#46;5 days&#44; and figures of 43&#37; at 19 days&#44; respectively&#46; The study by Parker et al&#46; raises the possible association between UTI and catheter removal after confirming that catheter removal predisposes to the development of urinary tract infection in a significant percentage of the patients under study&#46;</p><p id="par0400" class="elsevierStylePara elsevierViewall">Of the 153 patients&#44; 53 &#40;34&#46;6&#37;&#41; were readmitted at 90 days and 29 &#40;19&#37; of the patients registered&#41; were readmitted after presenting urinary tract infection&#44; accounting for 54&#46;7&#37; of the readmissions&#46; Of those readmitted for UTI&#44; 55&#46;1&#37; developed the infection after catheter removal &#40;16&#47;29&#41;&#46;</p><p id="par0405" class="elsevierStylePara elsevierViewall">The readmission rate for UTI in our study is comparable with the data available in the literature&#46; However&#44; we must bear in mind that the design of each study is different&#58; while some studies evaluate the development of UTIs&#44; we have analyzed those that required hospital admission&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">Postcystectomy urinary tract infection is favored by multiple factors&#46; According to the study by Clifford et al&#46;&#44; a Charlson index &#62;2 correlates with higher rates of postoperative UTI&#46; In contrast&#44; other factors described as favoring &#40;diabetes mellitus&#44; age&#44; need for perioperative blood transfusion&#44; etc&#46;&#41; showed no significance&#46; Other groups have reported BMI or female sex as risk factors&#46; The study by Parker et al&#46; justifies diabetes mellitus&#44; the need for perioperative blood transfusion and the development of urinary leakage as factors associated with the onset of UTI at 90 days&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall">There is a wide diversity of opinion regarding the association between the type of urinary diversion technique employed and the rate of urinary tract infection&#46; Studies such as those by Parker et al&#46; and Van Hemelrijck et al&#46; agree on a higher rate of UTI in patients with continent urinary diversion&#46; The study by Clifford et al&#46; included a total of 1&#44;133 cystectomized patients with 72&#37; of the cohort undergoing neobladder continent diversion&#44; without observing an association between technique and UTI&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">In our study&#44; the groups are comparable in terms of the variables studied&#44; without observing statistically significant differences between them in terms of the development of UTI at 90 days after cystectomy&#46; The same variables were analyzed for UTI rates after catheter removal&#46; The groups showed statistically significant differences in terms of age&#44; with UTI occurring more frequently at a younger age&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">The association between young patients and UTI could be justified by the greater current tendency to perform continent diversion in younger patients&#46; This would support the higher incidence of infection in the patient with continent urinary diversion&#44; as indicated in the studies by Parker et al&#46; and Van Hemelrijck et al&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">In relation to history&#44; the COPD group showed significant differences in the way that patients with COPD did not present urinary tract infection after removal&#46; It is important to interpret this result with caution&#44; as it is a discrete sample that may not be representative of the population&#46; The rest of the variables analyzed did not show statistical significance between groups&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Regarding the pre- and post-intervention hydronephrosis factor and de novo hydronephrosis and the development of UTI at 90 days or UTI after removal&#44; studies in the literature are scarce and inconclusive&#46; After analyzing our data and with the results obtained&#44; we cannot demonstrate a statistical association between the existence of preoperative ectasia or postintervention ectasia and the appearance of urinary tract infection at 90 days or UTI after removal&#46; Regarding the appearance of de novo hydronephrosis&#44; the data from our series are limited&#44; and although a priori there is no statistical significance&#44; they are not conclusive and&#44; therefore&#44; we cannot extrapolate them to the general population&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">A total of 13&#46;7&#37; &#40;21&#47;153&#41; of the patients in the study received antibiotic prophylaxis&#46; In the prophylaxis group&#44; the rate of postcystectomy UTI at 90 days is 28&#46;2&#37; &#40;5&#47;21&#41;&#44; compared to 18&#46;2&#37; in patients without prophylaxis&#46; With a p&#8239;&#61;&#8239;0&#46;553&#44; the data lead us to rule out the association between prophylaxis and development of UTI at 90 days&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Of the patients with antibiotic prophylaxis&#44; 9&#46;5&#37; developed UTI after catheter removal &#40;2&#47;21&#41;&#44; compared to 10&#46;6&#37; in the group of patients without prophylaxis &#40;14&#47;132&#41;&#46; We did not find a statistical association between prophylaxis and development of UTI after removal &#40;p&#8239;&#61;&#8239;1&#46;000&#41;&#46; However&#44; there is a certain tendency towards a lower development of UTI in patients with prophylaxis&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">Different studies&#44; such as that of Clifford et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#44; identified Escherichia coli&#44; Enterococcus faecalis and Klebsiella pneumoniae as the most frequent germs in post-cystectomy urinary tract infection&#46; Parker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> also add Staphylococcus aureus and Pseudomonas aeruginosa&#46; We found similar results&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">Of the 5 patients with UTI in the prophylaxis group&#44; 4 had urine cultures and 3 of them were positive for one germ&#44; one positive for Escherichia coli&#44; another for Enterobacter cloacae and a third for Klebsiella pneumoniae&#44; all of them sensitive to fosfomycin&#44; the antimicrobial used as prophylaxis&#44; which leads us to question not the active ingredient&#44; but the prophylaxis regimen used&#44; which may be insufficient&#46;</p><p id="par0460" class="elsevierStylePara elsevierViewall">The study data rule out catheter dwell time as an independent factor responsible for UTI at 90 days or UTI after catheter removal&#44; which leads us to reconsider the premise of the <span class="elsevierStyleItalic">early removal-decrease in UTI</span> association for future studies&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Study limitations</span><p id="par0465" class="elsevierStylePara elsevierViewall">We are aware that the main weakness of the study is the small sample size available at the time of data collection&#46; A larger registry of cystectomized patients undergoing the protocol for the prevention of urinary tract infection after catheter removal would increase the power of the results of the analysis&#44; which would allow us to develop and present solid hypotheses that would help in decision-making in our patients&#44; thus minimizing morbimortality and all that this entails&#46; The latter is precisely the subject of a future thesis project&#46;</p><p id="par0470" class="elsevierStylePara elsevierViewall">The fact that this is a single-center study is another limitation to be highlighted&#46; The results of our project are biased by the characteristics of the population in our sector&#44; mostly elderly patients&#46; A multicenter study including patients with varied characteristics would eliminate this bias&#44; achieving representative results that could be extrapolated to the general population&#44; in accordance with those reported in the literature&#46;</p><p id="par0475" class="elsevierStylePara elsevierViewall">The current results encourage us to continue in this line of study and&#44; to this end&#44; to progressively increase our sample size in the service and to design and apply new preventive protocols in an attempt to reduce the rate of complications in patients undergoing radical cystectomy&#46; A larger registry of patients would provide results with less bias that could be extrapolated and more representative of the general population&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conclusions</span><p id="par0480" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">1</span><p id="par0485" class="elsevierStylePara elsevierViewall">In our series&#44; we have not identified any protective or predisposing factors for the development of UTI&#46; The type of urinary diversion used was not directly related to the infection rate&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">2</span><p id="par0490" class="elsevierStylePara elsevierViewall">UTI is responsible for 54&#46;7&#37; of readmissions&#46; Of those with UTI-related readmission&#44; 55&#46;1&#37; occurred after removal of the ureteral catheters&#46; This leads us to conclude that minimizing the rate of UTI after catheter removal will reduce the overall UTI rate in the cystectomized patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">3</span><p id="par0495" class="elsevierStylePara elsevierViewall">The most frequently isolated germs in cystectomized patients who develop urinary tract infection with positive urine culture were Enterococcus faecium and faecalis&#44; Klebsiella pneumoniae and Escherichia coli&#46; All germs isolated in the group of patients with UTI and prophylactic antibiotic regimen are sensitive to fosfomycin&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">4</span><p id="par0500" class="elsevierStylePara elsevierViewall">Despite the sensitivity to the prophylactic antimicrobial administered&#44; 3 patients developed UTI after removal&#44; which leads us to question not the active ingredient&#44; but the prophylactic regimen used&#44; which may be insufficient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">5</span><p id="par0505" class="elsevierStylePara elsevierViewall">The regression model used does not identify the ureteral catheter dwell time as an independent factor in the context of UTI at 90 days or UTI after removal&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0510" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "abst0005"
              "titulo" => "Introduction and objectives"
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            0 => "Radical cystectomy with urinary diversion"
            1 => "Urinary infection"
            2 => "Prophylactic antibiotic therapy"
            3 => "Catheter removal"
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            0 => "Cistectom&#237;a radical con derivaci&#243;n urinaria asociada"
            1 => "Infecci&#243;n urinaria"
            2 => "Antibioterapia profil&#225;ctica"
            3 => "Retirada de cat&#233;teres"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Radical cystectomy with urinary diversion associated with extended pelvic lymphadenectomy continues to be the treatment of choice in muscle invasive bladder cancer&#46; Sixty-four percent of patients submitted to this procedure present postoperative complications&#44; with urinary infection being responsible in 20&#8211;40&#37; of cases&#46; The aim of this project is to assess the rate of urinary infection as a cause of re-admission after cystectomy&#44; and to identify protective and predisposing factors for urinary infection in our environment&#46; Finally&#44; we will evaluate the outcomes after the establishment of a prophylactic antibiotic protocol after removal of ureteral catheters&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Retrospective descriptive study of cystectomized patients in the Urology Service of the Hospital Cl&#237;nico Universitario of Zaragoza&#44; from January 2012 to December 2018&#46; A urinary tract infection &#40;UTI&#41; prevention protocol after catheter removal is established for all patients since October 2017&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">UTI is responsible for 54&#46;7&#37; of readmissions&#44; with 55&#46;1&#37; of these being due to UTI after removal of ureteral catheters&#46; Of the patients who received with prophylaxis&#44; 9&#46;5&#37; presented UTIs after withdrawal&#44; compared to 10&#46;6&#37; in the group of patients without prophylaxis&#46; The patient who is re-admitted for UTI after withdrawal has a mean catheter time of 24&#46;3&#8239;&#177;&#8239;7&#46;2 days&#44; compared to 24&#46;5&#8239;&#177;&#8239;7&#46;4 days for patients in the group without UTI &#40;P&#8239;&#61;&#8239;&#46;847&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The type of urinary diversion performed is not related to the rate of urinary infection&#46; The regression model does not identify antibiotic prophylaxis&#44; nor catheter time&#44; as independent factors of UTI after catheter removal&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La cistectom&#237;a radical con derivaci&#243;n urinaria asociada a linfadenectom&#237;a p&#233;lvica ampliada contin&#250;a siendo el tratamiento de elecci&#243;n en el c&#225;ncer vesical musculoinvasivo&#46; Un 64&#37; de los pacientes presentan complicaciones postoperatorias&#44; siendo la infecci&#243;n urinaria responsable en un 20&#8211;40&#37; de los casos&#46; El objetivo del presente proyecto es valorar la tasa de infecci&#243;n urinaria como causa de reingreso tras cistectom&#237;a&#44; e identificar factores protectores y predisponentes de infecci&#243;n urinaria en nuestro medio&#46; Por &#250;ltimo&#44; conocer los resultados obtenidos al aplicar el protocolo de profilaxis antibi&#243;tica tras la retirada de los cat&#233;teres ureterales&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo de pacientes cistectomizados en el Servicio de Urolog&#237;a del Hospital Cl&#237;nico Universitario desde enero de 2012 hasta diciembre de 2018&#46; Desde octubre de 2017&#44; de forma estandarizada&#44; a todo paciente se le aplica un protocolo de prevenci&#243;n de infecci&#243;n del tracto urinario &#40;ITU&#41; tras la retirada de cat&#233;teres&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La ITU es responsable del 54&#44;7&#37; de los reingresos&#44; siendo un 55&#44;1&#37; de estos por causa de una ITU tras la retirada de los cat&#233;teres ureterales&#46; El 9&#44;5&#37; de los pacientes con profilaxis presenta ITU tras la retirada&#44; frente a un 10&#44;6&#37; en el grupo de pacientes sin profilaxis&#46; El paciente que reingresa por ITU tras la retirada tiene un tiempo de cat&#233;teres medio de 24&#44;3&#8239;&#177;&#8239;7&#44;2 d&#237;as&#44; frente a los 24&#44;5&#8239;&#177;&#8239;7&#44;4 d&#237;as en el grupo sin ITU &#40;p&#8239;&#61;&#8239;0&#44;847&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">El tipo de derivaci&#243;n urinaria empleada no guarda relaci&#243;n con la tasa de infecci&#243;n urinaria&#46; El modelo de regresi&#243;n no identifica la profilaxis antibi&#243;tica&#44; ni tampoco el tiempo de cat&#233;teres&#44; como factores independientes de ITU tras la retirada de los cat&#233;teres&#46;</p></span>"
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        "etiqueta" => "&#10032;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Please cite this article as&#58; Gayarre Abril P&#44; Subir&#225; R&#237;os J&#44; Mu&#241;iz Su&#225;rez L&#44; Murillo P&#233;rez C&#44; Ram&#237;rez Fabi&#225;n M&#44; Hijazo Conejos JI&#44; et al&#46; La infecci&#243;n del tracto urinario como causa principal de ingreso en pacientes cistectomizados&#46; Actas Urol Esp&#46; 2021&#59;45&#58;247&#8211;256&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DM&#58; diabetes mellitus&#59; COPD&#44; chronic obstructive pulmonary disease&#59; HT&#58; hypertension&#59; BMI&#44; body mass index&#59; SI&#58; surgical intervention&#59; ICU&#58; Intensive Care Unit&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data are presented as n &#40;&#37;&#41;&#44; mean&#8239;&#177;&#8239;standard deviation or median &#91;interquartile range&#93;&#46;</p>"
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