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Acute urinary retention in young adult and middle-aged males due to calculi in the urethra: A single centre experience from North India
Retención urinaria aguda en varones jóvenes y de mediana edad debida a cálculos en la uretra: una experiencia de un sólo centro del norte de India
V. Singh, R.J. Sinha
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Departamento de Urología, CSMMU (Universidad de Medicina Chhatrapati Shahuji Maharaj) (anteriormente Universidad de Medicina King George's [KGMU]), Lucknow, Uttar Pradesh, India
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Singh, R.J. Sinha" "autores" => array:2 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Singh" ] 1 => array:4 [ "nombre" => "R.J." "apellidos" => "Sinha" "email" => array:2 [ 0 => "rahuljanaksinha@rediffmail.com" 1 => "rahuljanaksinha@yahoo.co.in" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Departamento de Urología, CSMMU (Universidad de Medicina Chhatrapati Shahuji Maharaj) (anteriormente Universidad de Medicina King George's [KGMU]), Lucknow, Uttar Pradesh, India" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Retención urinaria aguda en varones jóvenes y de mediana edad debida a cálculos en la uretra: una experiencia de un sólo centro del norte de India" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Acute urinary retention (AUR) in young and middle-aged males is most commonly caused by stone/s in the urethra, and it is an uncommon urological emergency.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Other causes of AUR in this age group may be stricture of the urethra or, rarely, urinary tract infection (UTI) in the form of cystitis, prostatitis, or urethritis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Herein, we present our experience of AUR management caused by urethral calculi in young or middle-aged males. We also discuss the possible mechanism of AUR due to urethral calculi, its association with urethral stricture, and the current management of this problem. We also discuss the world literature related to this topic and share the current knowledge related to the composition of this/these stone/s and its/their possible etiologies.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">Between July 2004 and April 2011, 102 patients with AUR (caused by stone/s in the urethra) were treated at our center. These patients were in the age group of 18–40 years (mean age was 28 years). Twenty-five of these patients had a history of ureteric calculi. Renal calculi were evident in 20 patients; 10 of whom had undergone treatment by extracorporeal shock wave lithotripsy in the last 3 months. Urinary bladder calculi were present in 26 patients.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of the 102 patients, 12 were known to have stricture of the bulbar urethra and had undergone direct visual internal urethrostomy few months before. Eight patients had diabetes while five were hypertensive.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At our center, initial management of these patients starts by instilling the urethra with 2% xylocaine jelly, followed by insertion of a 16 French (F) urethral catheter to relieve the AUR. If this maneuver fails (due to impacted stones), suprapubic catheter insertion (by trocar puncture) is performed. Then, the patients are selected for immediate or delayed management of the calculus, depending on the availability of the operation theatre and/or anesthesia. Before definitive management, tests such as complete hemogram, blood sugar measurement, renal function tests, serum uric acid and calcium level measurements, urinalysis, urine culture, plain X-ray of kidney, ureter and bladder (KUB), urethra and renal, and/or ultrasonography (USG) of KUB are ordered. The location and size of the calculus are determined by X-ray and USG.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Operative procedure</span><p id="par0030" class="elsevierStylePara elsevierViewall">The definitive procedure is performed either under spinal anesthesia (preferably) or general anesthesia. The operative details are mentioned in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. For patients having comparatively smaller or a single calculus without any history of stricture of the urethra, transurethral approach is preferred. For patients with larger stones or those having a suprapubic cystostomy or history of stricture of the urethra, suprapubic approach is selected. The technique for stone fragmentation via either of the routes is based on the choice of the operating urologist (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A 24F (Wolf) nephroscope with a pneumatic lithoclast/holmium laser or a 24F mechanical lithotrite may be used through the suprapubic route. A mechanical lithotrite or nephroscope with pneumatic lithoclast/holmium laser may also be used via the transurethral approach. At the end of the procedure, stone clearance is confirmed by endoscope and/or fluoroscope. In some patients, postoperative X-ray is also performed for documentation.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">The operative procedure was uneventful in all the patients and they were given tamsulosin 0.4<span class="elsevierStyleHsp" style=""></span>mg once a day, which was continued till voiding trial was ordered following the procedure. The voiding trial was given 24–48<span class="elsevierStyleHsp" style=""></span>h after the operative procedure, and it was successful in all the patients. Antibiotics and analgesics were given to all the patients following the procedure. Complete stone removal was achieved in all the patients. In the postoperative period, UTI was observed in eight patients who underwent immediate endoscopic intervention while mild hematuria (for approximately 48<span class="elsevierStyleHsp" style=""></span>h) was seen in six patients out of the 12 who underwent suprapubic cystolitholapaxy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The average size of the stone according to measurements on plain X-ray or USG was 0.9<span class="elsevierStyleHsp" style=""></span>cm (range 0.8–3.5<span class="elsevierStyleHsp" style=""></span>cm). The serum uric acid level was raised (>7<span class="elsevierStyleHsp" style=""></span>mg %) in 16 patients, and serum calcium increased (>10.0<span class="elsevierStyleHsp" style=""></span>mg/dl) in 20 patients; nine patients overlapped between these two groups as they had raised levels of both serum calcium and uric acid. Stone analysis was performed in selected patients, and, in the majority, the composition was calcium oxalate monohydrate followed by mixed calcium oxalate and uric acid, or pure uric acid in a few. Selected patients were advised metabolic analysis for stone formation, but the majority refused due to the cost or the complexity of the procedure, or because they came from far off places and were lost to follow-up.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The origin of the calculi that are discovered in the urethra is the upper urinary tract in most of these patients. These calculi pass the ureterovesical junction and reach the urinary bladder, where they reside for a variable period of time before entering the urethra.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Most of the calculi in the urethra are trapped in the proximal membranous urethra, because this portion of the urethra is non-distensible, and the lumen here is comparatively narrow. Some of the stones may migrate distally, but they might get impacted in the bulbar or penile urethra.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">By applying gentle pressure during urethral catheterization, the stones can be pushed back into the bladder, and immediate respite from the pain of acute urinary retention is achieved.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5–7</span></a> Definitive management of stone/s can then be performed immediately or in a delayed manner as described above. Suprapubic cystolithotomy or urethrostomy were traditional open surgical methods for extraction of stone/s. The drawbacks of these methods are pain in the postoperative period, the scar, urethral fistula, or prolonged hospital stay. With the advent of endoscopic treatment e.g. intracorporeal lithotripsy or litholapaxy, stone removal has become comparatively easier, even for larger ones.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–11</span></a> The advantages of endoscopic compared to open surgery are less post-operative pain, no scar, and early discharge.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9,12–15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The presentation of stone/s in the urethra varies from irritative lower urinary tract symptoms, perineal or rectal pain, external meatal pain, pain in the urethra, interrupted urinary stream, or weak stream with dribbling, palpable urethral mass, and/or AUR.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,16,17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The incidence of AUR varies in the literature. Kamal et al. reported that 78% of their patients presented with AUR, while Amin reported the incidence as 89%.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,16</span></a> Sharfi<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported that only 22% of their patients had AUR, which is much lower than that reported above. Selli et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> did not come across any case of AUR in their 14 patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The diagnosis of stone/s in the urethra is confirmed by plain KUB X-ray with image of the urethra depicting radio-opaque shadow in approximately 98% of cases.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> USG of the bladder with concomitant scan of the urethra can diagnose suspected radiolucent stone/s. Many authors state that only 40% of the stones in the urethra can be diagnosed by USG.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The association of stone/s in the urethra with concomitant stricture of the urethra is a controversial topic. Some studies have shown that changes in the mucosa of the urethra due to inflammation lead to stricture formation. Selli et al. reported anatomical changes in the mucosa of the urethra in 56% of their patients, and a similar observation was also reported by Sharfi in a study related to stones in the posterior urethra.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We did not observe significant inflammation either in the anterior or posterior urethra in our patients, although 12 of them had had stricture of the urethra and had been treated by direct visual internal urethrostomy in a recent past. Our observation corroborates that by Kamal et al.,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> who stated that 98% of their patients did not have stricture associated with stones, and they did not observe any change in the mucosa of the urethra.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In our study, 45 patients (25 had ureteric stone/s and 20 had renal stone/s) were known cases of upper urinary tract stone/s, while 26 patients had urinary bladder stone/s. Overall, 71 patients had history of stone disease which links the origin of the stone/s in the urethra to the upper urinary tract. So, it seems that stone/s in the urethra in the majority of our patients migrated from the upper urinary tract and ultimately caused AUR.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This contradicts the common belief that calculi in the urethra of patients from developing countries are primarily bladder stones of infectious etiology.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Kamal et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in their series reported that 86% of the stones recovered from the urethra were composed of calcium oxalate, and only 2% were uric acid stones. Our observation is similar since the majority of the stones in our patients were also composed of calcium oxalate monohydrate followed by mixed calcium oxalate and uric acid, or pure uric acid in a few.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Common methods of fragmenting such stone/s through the transurethral or suprapubic route using an endoscope are mechanical lithotrite, pneumatic lithotrite, or holmium laser lithotripsy.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–15</span></a> At our centre, in the past 2 years, we have gravitated towards holmium:YAG laser lithotripsy, perhaps because of the novelty of the machine. Many times, when the stone is hard and smooth, it is difficult to hold or crush, these stones move in the bladder when the pneumatic lithotrite is used. At that point, the laser is very useful for making holes in the stone which can then be used for fragmentation with a pneumatic lithotrite.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The patients who underwent immediate endoscopic treatment for stone removal had a higher rate of UTI. Those in the delayed treatment protocol group were initially investigated properly and treated according to the antibiotic sensitivity, if their urine culture showed growth of the organisms. This could have been the reason why none of the patients in the delayed treatment protocol had postoperative UTI.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion, stones in the urethra are one of the leading causes of AUR in young and middle-aged males. Catheterization of the urethra or suprapubic trocar cystostomy followed by endoscopic management of such stone/s is the treatment of choice. The UTI is more common if the patients are taken up for immediate endoscopic treatment in comparison to delayed treatment.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres100109" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec87273" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres100108" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec87274" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Operative procedure" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-06-25" "fechaAceptado" => "2011-06-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec87273" "palabras" => array:6 [ 0 => "Urethra" 1 => "Urinary calculi" 2 => "Urinary retention" 3 => "Young adult" 4 => "Middle aged" 5 => "Male" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec87274" "palabras" => array:6 [ 0 => "Uretra" 1 => "Cálculos urinarios" 2 => "Retención urinaria" 3 => "Joven" 4 => "Mediana edad" 5 => "Varón" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present our experience of managing acute urinary retention (AUR) in young and middle-aged male due to stone/s in the urethra at a tertiary care centre.</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Between July 2004 and April 2011, 102 male patients, young and middle-aged (18–40 years), who suffered from AUR due to calculus in the urethra were managed at our center. Initial management consisted of urethral catheterization or suprapubic trocar cystostomy. Definitive management was performed immediately or after a couple of days depending upon the availability of anesthesia and/or operation theatre. Stone was fragmented by mechanical lithotrite, pneumatic lithotrite or holmium:YAG laser.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All the patients were completely free of their stone/s following the definitive procedure. Voiding trial was successful in all the cases. Postoperative urinary tract infection was observed in eight patients who had undergone immediate endoscopic management. Mild hematuria for approximately 48<span class="elsevierStyleHsp" style=""></span>h was noted in six patients who underwent suprapubic cystolithotripsy.</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Endoscopic management is currently the treatment of choice for stone/s in the urethra which may cause AUR in young and middle-aged males.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentar nuestra experiencia en el tratamiento de la retención urinaria aguda (RUA) en hombres jóvenes y de mediana edad, debido a piedra/s en la uretra en un centro de atención terciaria.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Entre julio de 2004 y abril de 2011, se trató a 102 pacientes varones jóvenes y de mediana edad (18-40 años) que presentaban RUA debido a un cálculo en la uretra en nuestro centro. El tratamiento inicial consistió en la cateterización uretral o cistostomía suprapúbica con trocar. El tratamiento definitivo se realizó inmediatamente o después de un par de días en función de la disponibilidad de la anestesia y/o quirófano. La piedra se fragmentó con litotrito mecánico, litotrito neumático u holmio: láser YAG.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Todos los pacientes quedaron totalmente libres de sus piedra/s siguiendo el procedimiento definitivo. En todos los casos se consiguió micción espontánea. La infección post-operatoria del tracto urinario se observó en 8 pacientes que habían recibido tratamiento endoscópico inmediato. Se observó hematuria leve durante aproximadamente 48 h en 6 pacientes que recibieron cistolitotricia suprapúbica.</p> <span class="elsevierStyleSectionTitle">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El tratamiento endoscópico es actualmente la elección para piedra/s en la uretra que puede/n causar RUA en varones jóvenes y de mediana edad.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Singh V, Sinha RJ. Retención urinaria aguda en varones jóvenes y de mediana edad debida a cálculos en la uretra: experiencia de un solo centro del norte de India. Actas Urol Esp.2012;36:75–8.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Operative procedure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suprapubic cystolitholapaxy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suprapubic pneumatic cystolithotripsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suprapubic holmium:YAG laser cystolithotripsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transurethral cystolitholapaxy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transurethral pneumatic cystolithotripsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transurethral holmium:YAG laser cystolithotripsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab183942.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Operative procedures for stone removal.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urinary retention in adults: diagnosis and initial management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.A. Selius" 1 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 July | 2 | 0 | 2 |
| 2018 February | 4 | 2 | 6 |
| 2018 January | 20 | 1 | 21 |
| 2017 December | 11 | 3 | 14 |
| 2017 November | 21 | 0 | 21 |
| 2017 October | 17 | 3 | 20 |
| 2017 September | 28 | 3 | 31 |
| 2017 August | 18 | 4 | 22 |
| 2017 July | 21 | 5 | 26 |
| 2017 June | 28 | 5 | 33 |
| 2017 May | 16 | 1 | 17 |
| 2017 April | 10 | 7 | 17 |
| 2017 March | 17 | 29 | 46 |
| 2017 February | 13 | 0 | 13 |
| 2017 January | 8 | 0 | 8 |
| 2016 December | 33 | 9 | 42 |
| 2016 November | 26 | 8 | 34 |
| 2016 October | 38 | 6 | 44 |
| 2016 September | 30 | 3 | 33 |
| 2016 August | 14 | 1 | 15 |
| 2016 July | 15 | 1 | 16 |
| 2016 June | 13 | 5 | 18 |
| 2016 May | 12 | 13 | 25 |
| 2016 April | 30 | 11 | 41 |
| 2016 March | 25 | 14 | 39 |
| 2016 February | 29 | 18 | 47 |
| 2016 January | 17 | 15 | 32 |
| 2015 December | 22 | 9 | 31 |
| 2015 November | 27 | 8 | 35 |
| 2015 October | 27 | 12 | 39 |
| 2015 September | 22 | 8 | 30 |
| 2015 August | 21 | 3 | 24 |
| 2015 July | 14 | 6 | 20 |
| 2015 June | 5 | 2 | 7 |
| 2015 May | 13 | 5 | 18 |
| 2015 April | 29 | 7 | 36 |
| 2015 March | 25 | 6 | 31 |
| 2015 February | 10 | 1 | 11 |
| 2015 January | 33 | 6 | 39 |
| 2014 December | 42 | 6 | 48 |
| 2014 November | 24 | 3 | 27 |
| 2014 October | 46 | 6 | 52 |
| 2014 September | 37 | 7 | 44 |
| 2014 August | 29 | 2 | 31 |
| 2014 July | 27 | 2 | 29 |
| 2014 June | 16 | 4 | 20 |
| 2014 May | 11 | 0 | 11 |
| 2014 April | 10 | 3 | 13 |
| 2014 March | 14 | 4 | 18 |
| 2014 February | 14 | 2 | 16 |
| 2014 January | 2 | 0 | 2 |
| 2013 December | 10 | 1 | 11 |
| 2013 November | 5 | 1 | 6 |
| 2013 October | 9 | 0 | 9 |
| 2013 September | 8 | 2 | 10 |
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