Skill and talent
Botulinum toxin in the failure of high urinary diversion closure
Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas
A. Parente
, J.M. Angulo, R.M. Romero, S. Rivas, C. Corona, A.R. Tardáguila
Corresponding author
Sección de Urología Pediátrica, Servicio de Cirugía Pediátrica, Hospital Infantil Gregorio Marañón, Madrid, Spain
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Parente, J.M. Angulo, R.M. Romero, S. Rivas, C. Corona, A.R. Tardáguila" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Parente" "email" => array:1 [ 0 => "parente80@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Angulo" ] 2 => array:2 [ "nombre" => "R.M." "apellidos" => "Romero" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Rivas" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Corona" ] 5 => array:2 [ "nombre" => "A.R." "apellidos" => "Tardáguila" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Sección de Urología Pediátrica, Servicio de Cirugía Pediátrica, Hospital Infantil Gregorio Marañón, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1854 "Ancho" => 2493 "Tamanyo" => 701918 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Videourodynamics of case 2: pre-treatment with botulinum toxin, and 6<span class="elsevierStyleHsp" style=""></span>months after the closure of the ureterostomy (1<span class="elsevierStyleHsp" style=""></span>year after BTX-A).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The urinary diversions at different levels of the urinary tract have been, for years, the treatment of choice in selected patients with pathologies involving high pressures in the upper urinary tract and that, either because of the patient's age, the underlying disease, or the child's general state, surgical correction of the problem was not possible.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Today it remains an effective, useful and necessary treatment in selected cases, although its indications have decreased and minimally invasive treatments have occupied part of its space.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The pathologies treated are as diverse as neurogenic bladder, posterior urethral valves (PUV), vesicoureteral reflux or high-grade Prune-Belly syndrome.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Some of the problems that we encountered at the time of performing definitive treatment, together with the closure of the diversion are the urodynamic changes that have occurred in these bladders {AQ: for edit}. Thus, we are faced with poorly compliant bladders, low capacities, and high opening detrusor pressure. Although these changes revert in most patients after the closure of the diversion, in those in whom it has remained opened for more years, or the underlying disease is PUV or neurogenic bladder, we found that up to 25% of the closures fail.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">So far, bladder augmentation (enterocystoplasty or other technique) was the only option that allowed for the closure of the urinary diversion in these children, with the aim to improve their quality of life without compromising renal function. The use of botulinum toxin (BT) for the bladder treatment of patients with failure to close their urinary diversion is not described, although there exist prospective studies supporting its safety and usefulness in those bladders with abnormalities implying increased pressures on the urinary system.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We propose the use of BT in two children with a single kidney with PUV to achieve permanent ureterostomy closure after a previous failure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The first patient, aged 4<span class="elsevierStyleHsp" style=""></span>years, was treated at another center with PUV neonatal endoscopic fulguration. During the follow-up, the functional absence of the right kidney with severe left ureterohydronephrosis and progressive renal failure was confirmed, so right nephrectomy and left ureterostomy were performed at 4<span class="elsevierStyleHsp" style=""></span>months of life. The postoperative development was satisfactory and renal function normalized. At 2<span class="elsevierStyleHsp" style=""></span>years of life, closure of the diversion was attempted unsuccessfully, as the patient went into renal failure with worsening of his ureterohydronephrosis. On arrival at our center, cystoscopy observing a good urethral caliber along its entire course was performed. In videourodynamics, a bladder capacity (BC) of 20<span class="elsevierStyleHsp" style=""></span>ml is observed, with a maximum detrusor pressure (MDP) of 28<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and an adaptation of 1.5<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O, with a vesicoureteral reflux to solitary left kidney and right ureteral remnant (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The second patient, aged 9<span class="elsevierStyleHsp" style=""></span>years, was treated for PUV at neonatal age due to renal failure, with ultrasound images of left renal dysplasia and right severe ureterohydronefrosis, vesicostomy being performed. Given the poor clinical, ultrasound, analytical progress, and renal gammagraphy with left renal functional cancellation, we decided to perform right ureterostomy at 2<span class="elsevierStyleHsp" style=""></span>months of life. At 2<span class="elsevierStyleHsp" style=""></span>years of life, left nephrectomy, bladder augmentation with left ureter, and closure of the urinary diversion were indicated, failing a month after surgery as the patient went into uncontrollable renal failure and severe right ureterohydronephrosis. At the time of the assessment, he showed mild renal insufficiency, with a grades II–III right single kidney hydronephrosis. In the videourodynamics, the BC was 110<span class="elsevierStyleHsp" style=""></span>ml, with a MDP of 59<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, an adaptation of 3.1<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O, and a pressure of fluid loss (PFL) of 49<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the first patient, 10<span class="elsevierStyleHsp" style=""></span>IU/kg of botulinum toxin were injected in the detrusor associating endoscopic treatment (STING) of the bilateral vesicoureteral reflux in the same procedure. Two months after the intervention, new videourodynamics, which observed an increase in bladder capacity up to 90<span class="elsevierStyleHsp" style=""></span>cc, with an adaptation of the detrusor of 2.6<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O, with no reflux into the left ureter or uninhibited contractions was performed. Thus, we indicated the closure of the ureterostomy with double J reno-vesical stent placement that was removed at 3<span class="elsevierStyleHsp" style=""></span>weeks without complications. During the follow-up after 4<span class="elsevierStyleHsp" style=""></span>years, we found no worsening in ultrasound, gammagraphic or analytical findings, currently remaining with a serum creatinine of 0.58<span class="elsevierStyleHsp" style=""></span>mg/dl. The child acquired control of the urinary sphincter at 5<span class="elsevierStyleHsp" style=""></span>years. The patient lived with IBC and antibiotic prophylaxis for 6<span class="elsevierStyleHsp" style=""></span>months until their withdrawal, and he suffered no urinary infections. Urodynamic studies performed periodically show good growth in bladder capacity with an improvement of the adaptation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). One year after the closure, the patient already had a BC of 183<span class="elsevierStyleHsp" style=""></span>ml, with an adaptation of 30.9<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O, a MDP in the filling phase of 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, and an opening detrusor pressure (ODP) of 20<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, without vesicoureteral reflux (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The urodynamic changes remain today.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The second patient began treatment regimen with anticholinergics and a detrusor injection of 300<span class="elsevierStyleHsp" style=""></span>IU of botulinum toxin-A was performed, achieving a decrease in the MDP to 28<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, with improved adaptation but with no increase in bladder capacity, so at 6<span class="elsevierStyleHsp" style=""></span>months, 300<span class="elsevierStyleHsp" style=""></span>IU of Botox<span class="elsevierStyleSup">®</span> were re-injected. A program of intermittent bladder catheterization (IBC) was started three times/day, getting 100–150<span class="elsevierStyleHsp" style=""></span>ml of urine in each probing. The control videourodynamics presented a great improvement in BC (175<span class="elsevierStyleHsp" style=""></span>ml), adaptation (27.1<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O) and ODP (18<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O), so we decided to close the ureterostomy. After the closure, the number of bladder catheterizations was sequentially reduced as there was no residue in post-void probing, currently keeping dry 1<span class="elsevierStyleHsp" style=""></span>year after the operation and with a single daily catheterization. The renal function has remained at the previous values (0.91<span class="elsevierStyleHsp" style=""></span>mg/dl), as well as ultrasound findings. The urodynamics 1<span class="elsevierStyleHsp" style=""></span>year after the closure shows a BC of 451<span class="elsevierStyleHsp" style=""></span>ml, an adaptation of 81.9<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O, a MDP of 3<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, and an ODP of 2<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Urinary diversions remain one of the treatments of choice in a variety of pathologies despite the progress in recent years of minimally invasive and endourological techniques.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Febrile urinary tract infections and increased serum creatinine levels in unweaned babies with neurogenic bladder, PUV, or severe bilateral vesicoureteral reflux are considered by many authors today as an indication for vesicostomy or bilateral ureterostomy that decompresses the upper urinary system.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Secondarily, bladders treated like this will have urodynamic changes marked by a lower bladder capacity compared to the general population, despite the improvement in distensibility that occurs especially in patients with neurogenic bladder or PUV.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There are several studies examining the reversibility of these changes after the closure of the urinary diversion.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,6</span></a> About 90% of the patients will show a rapid increase in bladder capacity, with an improvement in distensibility and opening detrusor pressure that will allow us to maintain acceptable pressures in the upper urinary system.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> This percentage will be around 100% when the diversion is due to a high-grade vesicoureteral reflux.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However, there is a group of patients whose bladders will not respond adequately to the closure, with bad adaptations and high opening detrusor pressure, causing damage to the kidney that will force us to associate other treatments or even to reopen the urinary diversion, as in the two cases presented. This is especially common in patients with neurogenic bladder and PUV, getting almost to the 25% failure rate.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,7</span></a> In addition, our patients had a high urinary diversion (ureterostomy) that was necessary to perform since the vesicostomy did not evolve appropriately, which leads us to believe that their urodynamic disorders were more severe.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Currently, we do not think that urinary diversions provide children or adolescents with an adequate quality of life, although they have done so in earlier stages of life. Therefore, the patients and their families come to us for solutions. Urinary continence is a need for them, feeling that without it they cannot feel like their classmates or friends; consequently, that is our goal as well. Although these solutions must not jeopardize the patient's urinary function, past failures should not be an obstacle to propose new options to our patients. In our cases, both children had a single kidney, so a poor progress after the ureterostomy closure was quickly reflected in its going into renal failure (monitored by the creatinine values in the blood), with the risk of not being reversible. However, both families demanded solutions to achieve continence and the disappearance of the ureterostomy. The therapeutic alternatives to the present are based on the use of anticholinergics and intermittent bladder catheterization, resorting to bladder augmentation for those cases in which these measures were not enough. The emergence of BT opens a new arsenal of treatment that can allow us to avoid enterocystoplasties and their medium- and long-term complications.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">We have not found references to the use of BT as a salvage treatment in the failures of the closures of high urinary diversions in the literature. However, it has been used for some years for the treatment of neurogenic bladder, in which it induces relaxation of the detrusor muscle through interaction at presynaptic level of cholinergic innervation, and has potential effects on the urothelial receptors.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our cases, the doses used, the puncture sites, and the solution employed are the same as those used in the neurogenic bladder, 10<span class="elsevierStyleHsp" style=""></span>IU/kg up to a maximum of 300<span class="elsevierStyleHsp" style=""></span>IU.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">BT-A has been used in many fields of medicine for years, so like other groups, we consider it a safe treatment.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> The side effects are mild and infrequent, although the production of antibodies against the toxin is described. This is more important in the cases of non-responder patients, and it may be among the possible causes of non-response. However, it seems that the current Botox<span class="elsevierStyleSup">®</span> preparation minimizes the body's immune response regarding the original one.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The closure of the urinary diversions has a failure rate, especially in patients with severe bladder and infravesical pathology, which force us to associate it with other more aggressive techniques if we want “undiversion” and, thus, to improve their quality of life. Therefore, we believe that BT could provide us with an easy, safe, reliable and little aggressive alternative for the bladder treatment of these cases.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres98378" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec85538" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres98377" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec85537" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-12-27" "fechaAceptado" => "2011-01-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec85538" "palabras" => array:3 [ 0 => "Botulinum toxin" 1 => "Urinary diversion" 2 => "Posterior urethral valves" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec85537" "palabras" => array:3 [ 0 => "Toxina botulínica" 1 => "Derivación urinaria" 2 => "Valvas de uretra posterior" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The closure of urinary diversions performed on newly born infants has a notable failure percentage in patients with bladder disease. We present the use of botulinum toxin as a useful and minimally invasive alternative to treat these patients.</p> <span class="elsevierStyleSectionTitle">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present two patients with a single kidney and with posterior urethral valves (PUV), in whom it was necessary to perform a ureterostomy due to chronic kidney disease. In both patients, the subsequent attempt to close the diversion failed. Aged 4 and 10<span class="elsevierStyleHsp" style=""></span>years respectively, they presented bladders commonly known as “dry bladders”, with a low capacity (20 and 110<span class="elsevierStyleHsp" style=""></span>ml), bad adaptation (1.5 and 3.1<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O) and high opening detrusor pressure. A 10<span class="elsevierStyleHsp" style=""></span>UI/kg botulinum toxin A puncture was applied in the detrusor on one and two occasions respectively, prior to the closure of the diversion.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Neither of the patients suffered clinical or ecographic worsening after the closure of the diversion and their kidney function continued without change with respect to the first diversion after 1 and 4<span class="elsevierStyleHsp" style=""></span>years of follow-up respectively. One year after the surgical procedure, video urodynamics showed a significant improvement in bladder capacity (451 and 250<span class="elsevierStyleHsp" style=""></span>ml), in adaptation (20.4 and 81.9<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O) and in the opening detrusor pressure.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The closure of high urinary diversions has a high failure percentage in infants with pathological high-pressure bladders. Botulinum toxin may be useful as bladder treatment prior to closure of the diversion, especially in patients with a single kidney.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El cierre de las derivaciones urinarias realizadas en la edad neonatal tiene un no despreciable porcentaje de fracasos en pacientes con patología vesical. Presentamos el uso de toxina botulínica como alternativa útil y mínimamente invasiva para el tratamiento en estos pacientes.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentamos dos pacientes monorrenos con valvas de uretra posterior (VUP) en los que fue necesario realizar ureterostomía por insuficiencia renal severa. En ambos pacientes fracasó el intento posterior de cierre de la derivación. Con 4 y 10 años de edad presentaban vejigas conocidas comúnmente como «vejigas secas», con baja capacidad (20 y 110<span class="elsevierStyleHsp" style=""></span>ml), mala acomodación (1,5 y 3,1<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O) y altas presiones de apertura del detrusor. Se realizó punción en el detrusor de toxina botulínica-A 10<span class="elsevierStyleHsp" style=""></span>UI/kg en una y dos ocasiones respectivamente previas al cierre de la derivación.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En ninguno de los pacientes hubo empeoramiento clínico ni ecográfico tras el cierre de la derivación, permaneciendo la función renal sin cambios respecto a la previa tras uno y 4 años de seguimiento, respectivamente. La videourodinámica al año de la intervención muestra una gran mejoría de la capacidad vesical (451 y 250<span class="elsevierStyleHsp" style=""></span>ml), de la acomodación (20,4 y 81,9<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O) y de la presión de apertura del detrusor.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El cierre de las derivaciones urinarias altas tiene un porcentaje de fracasos elevado en niños con vejigas patológicas con presiones elevadas. La toxina botulínica puede ser útil como tratamiento vesical previo al cierre de la derivación, especialmente en pacientes monorrenos.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Parente A, et al. Toxina botulínica en el fracaso del cierre de derivaciones urinarias altas. Actas Urol Esp. 2011;35:429–33.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1000 "Ancho" => 2507 "Tamanyo" => 154615 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Voiding cystography before and after treatment with botulinum toxin.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2743 "Ancho" => 2333 "Tamanyo" => 573313 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Urodynamics (filling phase) of case 1: pre-treatment, after the injection of botulinum toxin (BTX-A), and 6<span class="elsevierStyleHsp" style=""></span>months after the closure of ureterostomy (1<span class="elsevierStyleHsp" style=""></span>year after BTX-A).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1854 "Ancho" => 2493 "Tamanyo" => 701918 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Videourodynamics of case 2: pre-treatment with botulinum toxin, and 6<span class="elsevierStyleHsp" style=""></span>months after the closure of the ureterostomy (1<span class="elsevierStyleHsp" style=""></span>year after BTX-A).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of temporary cutaneous diversion on ultimate bladder function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V.R. 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Sarrias" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Esp Urol" "fecha" => "2002" "volumen" => "55" "paginaInicial" => "167" "paginaFinal" => "176" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12014049" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Botulinum-A toxin injection into the detrusor: a safe alternative in the treatment of children with myelomeningocele with detrusor hyperreflexia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Riccabona" 1 => "M. Koen" 2 => "M. Schindler" 3 => "B. Goedele" 4 => "A. Pycha" 5 => "L. Lusuardi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.ju.0000108892.35041.2d" "Revista" => array:7 [ "tituloSerie" => "J Urol" "fecha" => "2004" "volumen" => "171" "numero" => "2 Pt. 1" "paginaInicial" => "845" "paginaFinal" => "848" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14713840" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term botulinum toxin efficacy, safety, and immunogenicity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N.I. Mejia" 1 => "K.D. Vuong" 2 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 1 | 2 | 3 |
| 2018 February | 11 | 0 | 11 |
| 2018 January | 3 | 0 | 3 |
| 2017 December | 12 | 1 | 13 |
| 2017 November | 13 | 1 | 14 |
| 2017 October | 14 | 0 | 14 |
| 2017 September | 14 | 5 | 19 |
| 2017 August | 13 | 6 | 19 |
| 2017 July | 20 | 0 | 20 |
| 2017 June | 39 | 4 | 43 |
| 2017 May | 28 | 5 | 33 |
| 2017 April | 31 | 4 | 35 |
| 2017 March | 18 | 1 | 19 |
| 2017 February | 26 | 0 | 26 |
| 2017 January | 20 | 1 | 21 |
| 2016 December | 26 | 9 | 35 |
| 2016 November | 31 | 6 | 37 |
| 2016 October | 38 | 6 | 44 |
| 2016 September | 25 | 5 | 30 |
| 2016 August | 20 | 2 | 22 |
| 2016 July | 15 | 3 | 18 |
| 2016 June | 17 | 4 | 21 |
| 2016 May | 25 | 7 | 32 |
| 2016 April | 26 | 7 | 33 |
| 2016 March | 23 | 7 | 30 |
| 2016 February | 41 | 8 | 49 |
| 2016 January | 22 | 10 | 32 |
| 2015 December | 16 | 5 | 21 |
| 2015 November | 20 | 3 | 23 |
| 2015 October | 21 | 5 | 26 |
| 2015 September | 23 | 6 | 29 |
| 2015 August | 16 | 8 | 24 |
| 2015 July | 17 | 5 | 22 |
| 2015 June | 9 | 10 | 19 |
| 2015 May | 25 | 4 | 29 |
| 2015 April | 26 | 5 | 31 |
| 2015 March | 19 | 6 | 25 |
| 2015 February | 16 | 1 | 17 |
| 2015 January | 32 | 3 | 35 |
| 2014 December | 56 | 7 | 63 |
| 2014 November | 26 | 2 | 28 |
| 2014 October | 61 | 7 | 68 |
| 2014 September | 40 | 6 | 46 |
| 2014 August | 41 | 4 | 45 |
| 2014 July | 41 | 3 | 44 |
| 2014 June | 28 | 5 | 33 |
| 2014 May | 19 | 1 | 20 |
| 2014 April | 17 | 0 | 17 |
| 2014 March | 28 | 4 | 32 |
| 2014 February | 18 | 5 | 23 |
| 2014 January | 18 | 2 | 20 |
| 2013 December | 29 | 2 | 31 |
| 2013 November | 24 | 3 | 27 |
| 2013 October | 29 | 3 | 32 |
| 2013 September | 25 | 2 | 27 |
| 2013 August | 19 | 2 | 21 |
| 2013 July | 11 | 0 | 11 |
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