Flexible ureteroscopy for renal stones | Actas Urológicas Españolas (English Edition)

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Cepeda, J.H. Amón, J.A. Mainez, V. Rodríguez, D. Alonso, J.M. Martínez-Sagarra" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Cepeda" "email" => array:1 [ 0 => "marcoscepedadelgado@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.H." "apellidos" => "Amón" ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Mainez" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Rodríguez" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Alonso" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Martínez-Sagarra" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urología, Hospital Universitario Río Hortega, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la litiasis renal mediante ureteroscopia flexible" ] ] "textoCompleto" => "IntroductionIt has been over 2 decades since the first flexible ureteroscopies (FUR) were performed by Bagley.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Subsequently, Fuchs<a class="elsevierStyleCrossRef" href="#bib0010">2</a> systematized the technique and from then until now, technological advances have allowed for the treatment of renal lithiasis by FUR to be a reality.Although in the endourological era extracorporeal lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL) have been the gold standard in the treatment of renal lithiasis, FUR is now another option, as provided by the latest update of the European clinical guidelines in urolithiasis.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> This has been made possible thanks to the improvement of flexible ureteroscopes, not only in view with the advent of digital technology, but in deflection, mobility, ergonomics, and durability. These advances, coupled with the miniaturization of holmium laser fibers and the use of nitinol in the manufacture of baskets, have made it possible to report high success rates in recent series.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a>In this prospective study, we present our experience with retrograde intrarenal surgery (RIRS), analyzing its results and complications.Materials and methodsFrom June 2009 to March 2013 we treated 150 patients (83 men, 67 women) suffering from renal lithiasis by means of RIRS. The mean age was 52.3 years (r: 19–81). The lithiasis was single in 111 cases and multiple in 39, the average size being 19.12mm (r: 5–74). The inclusion criteria for this treatment included the previous failure of other endourological techniques, malformation of the urinary tract, obesity, and preference of the patient (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The demographic variables of the lithiases are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The image diagnosis was performed by means of intravenous urography (IVU) and ultrasound. A total of 39 patients (26%) were carriers of double-J at the time of surgery.Evaluation of the success rateWe define success in our series as the absence of lithiasis or residual fragments smaller than 2mm. Its immediate assessment was made by means of the endoscopic examination of the renal cavities at the end of the procedure and with plain abdominal ultrasound the day after the surgery. The final success rate was evaluated by intravenous urography and ultrasound at 3 months postoperatively.TechniqueThe patient was placed in lithotomy position under general anesthesia. We systematically used, as antibiotic prophylaxis, 2g iv amoxicillin-clavulanic. In case of allergy to beta-lactams, we switched to 400mg iv ciprofloxacin. We started the process with rigid ureteroscopy to place a guide wire to the renal cavities and perform ureteroscopy of the distal section of the ureter, making dilation under the view of this segment. Then, we collected urine from the renal cavities that we sent for bacteriological study, very useful in postsurgical infections and vital in cases of sepsis. The next step is the placement under radiological control of the ureteral access sheath. We used a 11–13 (Navigator-Boston Scientific®) or 12–14 (Flexor-Cook®) Fr sheath. It is important to leave the sheath placed in the proximal ureter at a point that allows for the deflection of the endoscope, and that at the same time makes a good washing of cavities, that is, we should not leave it in the renal pelvis or far from the ureteropelvic junction. Later, we placed a 10Fr urinary catheter to have the bladder drained during the procedure.After placing the sheath, we introduced the flexible ureteroscope and explored the renal cavities until locating the lithiasis. In approximately 95% of the procedures we used a 7.5Fr flexible fiber-optic ureteroscope (Flex X2, Storz®). In the rest of the procedures we used a 9.9Fr digital ureteroscope (URF-V, Olympus®). As irrigation system, we used a pressure pump (Olympus®) that allows us to have an adequate view at all times, by maintaining a constant flow. Working with ureteral access sheath decreases the pressure in the cavities and allows for a high flow, without increasing the pressure in excess. We tried to fragment the lithiasis without working in deflection, in order to extend the life of the endoscope, so if this is located in an unfavorable location, we mobilize it with a small basket into the pelvis or upper calyx. Lithotripsy was performed with 12W holmium laser (Calculase, Storz®) and 365 and 200μ fibers. We use the lowest caliber fiber when we are forced to work in deflection because the lithiasis cannot be moved due to its excessive size or because we are in a narrow infundibulum. In these cases, we perform in situ lithotripsy, until we achieve mobilizable fragments. To mobilize or extract fragments we used a small nitinol 1.7Fr basket. (N-Gage, Cook®); this little basket, given its small size, barely diminishes deflection to the ureteroscope and it does not decrease the irrigation during its use, so it allows us to access complex chalices with proper vision for lithiasic manipulation. We performed lithotripsy until we achieved insignificant or removable remains through the ureteral access sheath; for this, we used the tip of the laser fiber as a benchmark. Once the lithotripsy was completed, we extracted the significant remains. To finish the procedure, we placed a double J stent that we will keep for about a week. In cases of rapid procedures, with no remains and with easy sheath passage, we left a ureteral catheter for 24h.ResultsThe average patient follow-up was 15 months (r: 4–20). In 21 patients (14%) the RIRS could not be performed in a first attempt due to the impossibility of ureteral sheath uptake, so a double-J catheter was left and the intervention was deferred one week, being performed later without difficulty.The immediate success rate, evaluated endoscopically after the intervention and plain abdominal X-ray, was 85.7%. The success rate at 3 months assessed by intravenous urography and ultrasound was 91.6%.The mean operative time was 85±30.4min (r: 25–220).There were no noteworthy intraoperative complications. We found no significant change in creatinine or hemoglobin levels postoperatively. The mean postoperative hospital stay was 2.1±1.3 days (r: 1–7).In the immediate postoperative period, complications occurred in 22 patients (14.6%), although most of them were Clavien 1 and 2 (19 cases) and only 2% had Clavien 4 complications (3 cases of sepsis requiring hospitalization in the intensive care unit).In 10 patients a second operation was required to complete the treatment, so the number of procedures per patient was 1.06.There were no late complications. We observed no ureteral stenosis in any patient following the use of the ureteral access sheath.The data of results are expressed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionTechnological advances have made it possible for the RIRS to currently reach satisfactory success rates. Although European guidelines on lithiasis establish PNL as a first-line treatment for stones over 2cm, more and more groups deal with stones over 2cm with RIRS, obtaining good results in a single time.<a class="elsevierStyleCrossRefs" href="#bib0035">7–9</a> This barrier, which seemed insurmountable years ago, today is a reality. Several factors influence the increased rate of success. The improvement in vision of digital ureteroscopes makes the process easier and faster, which clearly influences the rate of success. A digital vision, combined with the systematic use of ureteral access sheath and adequate irrigation, enables us to perform lithotripsy virtually without stopping fragmentation due to vision deficit. Another important factor is the emergence of more powerful holmium lasers that make it possible to modify the parameters of frequency and energy. This allows us to adapt the lithotripsy to the lithiasic composition. Thus, we can treat sizable stones completely vaporizing them, without the need to remove fragments, reducing the surgical time. The success rate at 3 months in our series is 91.6%, slightly lower than the 93.1% reported initially,<a class="elsevierStyleCrossRef" href="#bib0050">10</a> but objectively better if we compare the average size of the lithiases treated at the start of the series with the current cases. Furthermore, if we compare our results with those published by other authors that have expanded the indications for RIRS to lithiases over 2cm, we can conclude that we have achieved similar success rates with lower rates of retreatment.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> We performed a second procedure in those patients with significant or clinically relevant remains, and in 90% of the cases they corresponded to lithiases over 2cm. To explain our results, the success rate and low morbidity, we must consider some technical aspects. All cases were performed by 2 surgeons that, working together, have jointly overcome the learning curve, which accelerates the operative time. The systematic use of the ureteral access sheath, which although in the beginning had some detractors for fear of ureteral stenosis due to ischemic damage, is currently considered essential to perform the surgery.<a class="elsevierStyleCrossRefs" href="#bib0065">13–16</a> In our series, in 21 patients (14%), we did not manage to uptake the sheath in a first attempt. In these cases, a double J catheter was placed and surgery was postponed a week.The choice of the sheath depends primarily on the flexible ureteroscope that we use, since we need to adapt it to the size of the endoscope. The sheath must have sufficient internal caliber for the endoscope to slide freely since the friction not only hinders the process but it also reduces the life of the ureteroscope. In turn, the external size greatly influences the success of the placement of the sheath. In general, the greater the sheath, the better drainage of cavities we will get and the larger lithiasic remains, but we also found more difficulty passing through the ureter. Therefore, we used an intermediate size, around 11–13 and 12–14Fr, which we consider sufficient to obtain good mobility and adequate drainage, minimizing as much as possible the ureteral invasion and the possibility of failure in the placement of the sheath. We have not detected in late controls any ureteral stenosis due to the use of sheath.Would this small initial failure rate justify the use of the previous catheterization? This issue has already been discussed and we think, in line with other authors, that prior surgical catheterization adds another surgical gesture, and also that the waiting time for surgery is not always free from the inherent morbidity to the catheter.<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>Most of the series keep a double J approximately 2 weeks after the procedure.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> In our series, we reduced the time of catheterization to a week, aware of the morbidity produced by the double J stent, although, obviously, in the cases in which it was required to perform ureteral dilatation for the uptake of the sheath, when we observed damage to the ureteral mucosa or lithiasic remains sufficient to form a lithiasic street, we were keen to keep the catheter for 4 weeks. And conversely, in short interventions, if we observed no lithiasic remains, we left an external ureteral catheter only 24h.We had no intraoperative complications and the hemoglobin and creatinine figures did not change in the immediate postoperative period. This is consistent with what is published in the literature.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> In the postoperative period, the complication rate was 14.6% (22 patients), higher than what was published in other series,<a class="elsevierStyleCrossRefs" href="#bib0105">21–24</a> but in our defense, we must say that the majority (86.3%) were Clavien 1 and 2 (febrile syndrome and hematuria) and that they occurred in the first 50 cases. We have had 3 cases of sepsis (2%) with ICU admission, resolved satisfactorily. Most complications are cases with long operating time (longer than 2h) in order to achieve an adequate resolution rate with a single procedure. We firmly believe that the complication rate decreases when using the ureteral access sheath, maintaining good vision, working at low pressure, not damaging the mucosa, and not prolonging the operating time in excess. Currently, we do not lengthen the procedure above 2h, as clearly complications increase.ConclusionThe treatment of renal lithiasis with flexible ureteroscopy obtains a high success rate with low complications. Therefore, we think that, currently, it is an effective treatment option for renal lithiasis. We need randomized studies comparing it to the PNL, in its less invasive modalities (miniperc and microperc) to accurately define its indications.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres378205" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objectives" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec357257" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres378204" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec357258" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Evaluation of the success rate" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Technique" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-24" "fechaAceptado" => "2014-03-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec357257" "palabras" => array:3 [ 0 => "Renal lithiasis" 1 => "Flexible ureteroscopy" 2 => "Retrograde intrarenal surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec357258" "palabras" => array:3 [ 0 => "Litiasis renal" 1 => "Ureteroscopia flexible" 2 => "Cirugía retrógrada intrarrenal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectivesThe objectives of this prospective study are to present our experience with retro-grade intrarenal surgery (RIRS), and to analyze its results and complications. Materials and methods150 patients with renal stones were treated with RIRS. 111 cases showed single stones whilst multiple stones were observed in 39 cases. The mean size was 19.12mm (r: 5–74). Success rate was defined as the absence of residual stones or the presence of fragments ≤2mm. ResultsIn 21 (14%) patients RIRS could not be performed on first attempt because it was impossible to place the ureteral access sheath. The immediate success rate was 85.7% and 91.6% at three months later. The average operating time was 85min (r: 25–220). Postoperative complications were observed in 22 cases (14.6%), although most of them were classified as Clavien 1 and 2 (19 cases), and only 2% (3 cases) showed Clavien 4 complications (sepsis requiring admission in the intensive care unit). 10 patients underwent a second procedure in order to complete the treatment. Thus, the number of procedures per patient was 1.06. There were nolate complications. ConclusionsThe treatment of renal stones with flexible ureteroscopy using the ureteral access sheath shows a high successful rate with a low complication rate. In order to define its indication more precisely, randomized studies comparing RIRS with minimally invasive percutaneous nephrolithotomy procedures (miniperc and microperc) would be necessary." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivosPresentamos en este trabajo prospectivo nuestra experiencia con la cirugía retró-grada intrarrenal (CRIR), analizando sus resultados y las complicaciones. Material y métodosHemos tratado 150 pacientes afectados de litiasis renal mediante CRIR. Lalitiasis fue única en 111 casos y múltiple en 39, siendo el tama¿no medio de 19,12mm (r: 5-74). Definimos éxito en nuestra serie como la ausencia de litiasis o fragmentos residuales menoresde 2mm. ResultadosEn 21 pacientes (14%) no pudo realizarse la CRIR en un primer intento por imposi-bilidad de ascenso de la vaina ureteral. La tasa de éxito inmediata fue del 85,7% y a los 3 mesesdel 91,6%. El tiempo medio operatorio fue 85min (r: 25-220). En el postoperatorio inmediatohubo complicaciones en 22 pacientes (14,6%), si bien la mayoría de ellas fueron Clavien 1 y 2(19 casos) y solo un 2% sufrió complicaciones Clavien 4 (3 casos de sepsis que precisaron ingresoen la unidad de cuidados intensivos). En 10 pacientes se precisó una segunda intervención paracompletar el tratamiento, por lo que el número de procedimientos por paciente fue de 1,06. No hubo complicaciones tardías. ConclusionesEl tratamiento de la litiasis renal mediante ureteroscopia flexible obtiene unatasa alta de éxito con bajas complicaciones. Precisamos estudios aleatorizados que la comparencon la nefrolitectomía percutánea, en sus modalidades menos invasivas (miniperc y microperc) para definir con exactitud sus indicaciones." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Cepeda M, Amón JH, Mainez JA, Rodríguez V, Alonso D, Martínez-Sagarra JM. Tratamiento de la litiasis renal mediante ureteroscopia flexible. Actas Urol Esp. 2014;38:571–575." ] ] "multimedia" => array:3 [ 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">Indications \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">N: 150 \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">Failure ESWL \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">57 (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">Residual post-PNL \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">29 (19.3%) \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">Malformation of the excretory pathway \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">13 (8.6%) \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">Obesity \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">37 (24.6%) \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">Patient preference \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">14 (9.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab575311.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Inclusion criteria." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "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">Mean size \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">19.12mm (r: 5–74) \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">Single lithiasis \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">111 \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">Lower calyx \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">37 \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">Middle calyx \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">19 \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">Upper calyx \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">27 \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">Upper calyx diverticulum \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">1 \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">Middle cáliz diverticulum \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">2 \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">Pyelic \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">15 \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">Pyelic associated to UPJ \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">8 \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">Horseshoe kidney \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">2 \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">Multiple lithiasis \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">39 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab575309.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic variables of the lithiasis." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "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=""><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">Surgical time (min) \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">85±30.4 \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">Immediate success rate \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">85.7% \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">Succes rate at 3 months \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">91.6% \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">Retreatment \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 (6.6%) \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">Procedures/patient \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">1.06 \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">Postoperative stay (days) \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">2.1±1.3 \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\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">Complications (rate) \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">14.6% \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">Clavien 1 \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 (6.6%) \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">Clavien 2 \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">9 (6%) \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">Clavien 4 \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">3 (2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab575310.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Flexible ureteropyeloscopy: diagnosis and treatment in the upper urinary tract" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.H. 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Flexible ureteroscopy for renal stones

Tratamiento de la litiasis renal mediante ureteroscopia flexible

M. Cepeda

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marcoscepedadelgado@yahoo.es

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, J.H. Amón, J.A. Mainez, V. Rodríguez, D. Alonso, J.M. Martínez-Sagarra

Servicio de Urología, Hospital Universitario Río Hortega, Valladolid, Spain

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as provided by the latest update of the European clinical guidelines in urolithiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This has been made possible thanks to the improvement of flexible ureteroscopes&#44; not only in view with the advent of digital technology&#44; but in deflection&#44; mobility&#44; ergonomics&#44; and durability&#46; These advances&#44; coupled with the miniaturization of holmium laser fibers and the use of nitinol in the manufacture of baskets&#44; have made it possible to report high success rates in recent series&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this prospective study&#44; we present our experience with retrograde intrarenal surgery &#40;RIRS&#41;&#44; analyzing its results and complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">From June 2009 to March 2013 we treated 150 patients &#40;83 men&#44; 67 women&#41; suffering from renal lithiasis by means of RIRS&#46; The mean age was 52&#46;3 years &#40;r&#58; 19&#8211;81&#41;&#46; The lithiasis was single in 111 cases and multiple in 39&#44; the average size being 19&#46;12<span class="elsevierStyleHsp" style=""></span>mm &#40;r&#58; 5&#8211;74&#41;&#46; The inclusion criteria for this treatment included the previous failure of other endourological techniques&#44; malformation of the urinary tract&#44; obesity&#44; and preference of the patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The demographic variables of the lithiases are presented in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The image diagnosis was performed by means of intravenous urography &#40;IVU&#41; and ultrasound&#46; A total of 39 patients &#40;26&#37;&#41; 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that allows us to have an adequate view at all times&#44; by maintaining a constant flow&#46; Working with ureteral access sheath decreases the pressure in the cavities and allows for a high flow&#44; without increasing the pressure in excess&#46; We tried to fragment the lithiasis without working in deflection&#44; in order to extend the life of the endoscope&#44; so if this is located in an unfavorable location&#44; we mobilize it with a small basket into the pelvis or upper calyx&#46; Lithotripsy was performed with 12<span class="elsevierStyleHsp" style=""></span>W holmium laser &#40;Calculase&#44; Storz<span class="elsevierStyleSup">&#174;</span>&#41; and 365 and 200<span class="elsevierStyleHsp" style=""></span>&#956; fibers&#46; We use the lowest caliber fiber when we are forced to work in deflection because the lithiasis cannot be moved due to its excessive size or because we are in a narrow infundibulum&#46; In these cases&#44; we perform <span class="elsevierStyleItalic">in situ</span> lithotripsy&#44; until we achieve mobilizable fragments&#46; To mobilize or extract fragments we used a small nitinol 1&#46;7<span class="elsevierStyleHsp" style=""></span>Fr basket&#46; &#40;N-Gage&#44; Cook<span class="elsevierStyleSup">&#174;</span>&#41;&#59; this little basket&#44; given its small size&#44; barely diminishes deflection to the ureteroscope and it does not decrease the irrigation during its use&#44; so it allows us to access complex chalices with proper vision for lithiasic manipulation&#46; We performed lithotripsy until we achieved insignificant or removable remains through the ureteral access sheath&#59; for this&#44; we used the tip of the laser fiber as a benchmark&#46; Once the lithotripsy was completed&#44; we extracted the significant remains&#46; To finish the procedure&#44; we placed a double J stent that we will keep for about a week&#46; In cases of rapid procedures&#44; with no remains and with easy sheath passage&#44; we left a ureteral catheter for 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The average patient follow-up was 15 months &#40;r&#58; 4&#8211;20&#41;&#46; In 21 patients &#40;14&#37;&#41; the RIRS could not be performed in a first attempt due to the impossibility of ureteral sheath uptake&#44; so a double-J catheter was left and the intervention was deferred one week&#44; being performed later without difficulty&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The immediate success rate&#44; evaluated endoscopically after the intervention and plain abdominal X-ray&#44; was 85&#46;7&#37;&#46; The success rate at 3 months assessed by intravenous urography and ultrasound was 91&#46;6&#37;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The mean operative time was 85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#46;4<span class="elsevierStyleHsp" style=""></span>min &#40;r&#58; 25&#8211;220&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">There were no noteworthy intraoperative complications&#46; We found no significant change in creatinine or hemoglobin levels postoperatively&#46; The mean postoperative hospital stay was 2&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3 days &#40;r&#58; 1&#8211;7&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the immediate postoperative period&#44; complications occurred in 22 patients &#40;14&#46;6&#37;&#41;&#44; although most of them were Clavien 1 and 2 &#40;19 cases&#41; and only 2&#37; had Clavien 4 complications &#40;3 cases of sepsis requiring hospitalization in the intensive care unit&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In 10 patients a second operation was required to complete the treatment&#44; so the number of procedures per patient was 1&#46;06&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">There were no late complications&#46; We observed no ureteral stenosis in any patient following the use of the ureteral access sheath&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The data of results are expressed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Technological advances have made it possible for the RIRS to currently reach satisfactory success rates&#46; Although European guidelines on lithiasis establish PNL as a first-line treatment for stones over 2<span class="elsevierStyleHsp" style=""></span>cm&#44; more and more groups deal with stones over 2<span class="elsevierStyleHsp" style=""></span>cm with RIRS&#44; obtaining good results in a single time&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> This barrier&#44; which seemed insurmountable years ago&#44; today is a reality&#46; Several factors influence the increased rate of success&#46; The improvement in vision of digital ureteroscopes makes the process easier and faster&#44; which clearly influences the rate of success&#46; A digital vision&#44; combined with the systematic use of ureteral access sheath and adequate irrigation&#44; enables us to perform lithotripsy virtually without stopping fragmentation due to vision deficit&#46; Another important factor is the emergence of more powerful holmium lasers that make it possible to modify the parameters of frequency and energy&#46; This allows us to adapt the lithotripsy to the lithiasic composition&#46; Thus&#44; we can treat sizable stones completely vaporizing them&#44; without the need to remove fragments&#44; reducing the surgical time&#46; The success rate at 3 months in our series is 91&#46;6&#37;&#44; slightly lower than the 93&#46;1&#37; reported initially&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> but objectively better if we compare the average size of the lithiases treated at the start of the series with the current cases&#46; Furthermore&#44; if we compare our results with those published by other authors that have expanded the indications for RIRS to lithiases over 2<span class="elsevierStyleHsp" style=""></span>cm&#44; we can conclude that we have achieved similar success rates with lower rates of retreatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> We performed a second procedure in those patients with significant or clinically relevant remains&#44; and in 90&#37; of the cases they corresponded to lithiases over 2<span class="elsevierStyleHsp" style=""></span>cm&#46; To explain our results&#44; the success rate and low morbidity&#44; we must consider some technical aspects&#46; All cases were performed by 2 surgeons that&#44; working together&#44; have jointly overcome the learning curve&#44; which accelerates the operative time&#46; The systematic use of the ureteral access sheath&#44; which although in the beginning had some detractors for fear of ureteral stenosis due to ischemic damage&#44; is currently considered essential to perform the surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;16</span></a> In our series&#44; in 21 patients &#40;14&#37;&#41;&#44; we did not manage to uptake the sheath in a first attempt&#46; In these cases&#44; a double J catheter was placed and surgery was postponed a week&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The choice of the sheath depends primarily on the flexible ureteroscope that we use&#44; since we need to adapt it to the size of the endoscope&#46; The sheath must have sufficient internal caliber for the endoscope to slide freely since the friction not only hinders the process but it also reduces the life of the ureteroscope&#46; In turn&#44; the external size greatly influences the success of the placement of the sheath&#46; In general&#44; the greater the sheath&#44; the better drainage of cavities we will get and the larger lithiasic remains&#44; but we also found more difficulty passing through the ureter&#46; Therefore&#44; we used an intermediate size&#44; around 11&#8211;13 and 12&#8211;14<span class="elsevierStyleHsp" style=""></span>Fr&#44; which we consider sufficient to obtain good mobility and adequate drainage&#44; minimizing as much as possible the ureteral invasion and the possibility of failure in the placement of the sheath&#46; We have not detected in late controls any ureteral stenosis due to the use of sheath&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Would this small initial failure rate justify the use of the previous catheterization&#63; This issue has already been discussed and we think&#44; in line with other authors&#44; that prior surgical catheterization adds another surgical gesture&#44; and also that the waiting time for surgery is not always free from the inherent morbidity to the catheter&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Most of the series keep a double J approximately 2 weeks after the procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> In our series&#44; we reduced the time of catheterization to a week&#44; aware of the morbidity produced by the double J stent&#44; although&#44; obviously&#44; in the cases in which it was required to perform ureteral dilatation for the uptake of the sheath&#44; when we observed damage to the ureteral mucosa or lithiasic remains sufficient to form a lithiasic street&#44; we were keen to keep the catheter for 4 weeks&#46; And conversely&#44; in short interventions&#44; if we observed no lithiasic remains&#44; we left an external ureteral catheter only 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">We had no intraoperative complications and the hemoglobin and creatinine figures did not change in the immediate postoperative period&#46; This is consistent with what is published in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> In the postoperative period&#44; the complication rate was 14&#46;6&#37; &#40;22 patients&#41;&#44; higher than what was published in other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#8211;24</span></a> but in our defense&#44; we must say that the majority &#40;86&#46;3&#37;&#41; were Clavien 1 and 2 &#40;febrile syndrome and hematuria&#41; and that they occurred in the first 50 cases&#46; We have had 3 cases of sepsis &#40;2&#37;&#41; with ICU admission&#44; resolved satisfactorily&#46; Most complications are cases with long operating time &#40;longer than 2<span class="elsevierStyleHsp" style=""></span>h&#41; in order to achieve an adequate resolution rate with a single procedure&#46; We firmly believe that the complication rate decreases when using the ureteral access sheath&#44; maintaining good vision&#44; working at low pressure&#44; not damaging the mucosa&#44; and not prolonging the operating time in excess&#46; Currently&#44; we do not lengthen the procedure above 2<span class="elsevierStyleHsp" style=""></span>h&#44; as clearly complications increase&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The treatment of renal lithiasis with flexible ureteroscopy obtains a high success rate with low complications&#46; Therefore&#44; we think that&#44; currently&#44; it is an effective treatment option for renal lithiasis&#46; We need randomized studies comparing it to the PNL&#44; in its less invasive modalities &#40;miniperc and microperc&#41; to accurately define its indications&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "identificador" => "xres378205"
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            0 => "Resumen"
            1 => "Objetivos"
            2 => "Material y m&#233;todos"
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            4 => "Conclusiones"
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          "identificador" => "xpalclavsec357258"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Evaluation of the success rate"
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              "titulo" => "Technique"
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          "identificador" => "sec0025"
          "titulo" => "Results"
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        7 => array:2 [
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          "titulo" => "Discussion"
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          "identificador" => "sec0035"
          "titulo" => "Conclusion"
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          "titulo" => "Conflict of interest"
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          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-02-24"
    "fechaAceptado" => "2014-03-31"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec357257"
          "palabras" => array:3 [
            0 => "Renal lithiasis"
            1 => "Flexible ureteroscopy"
            2 => "Retrograde intrarenal surgery"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec357258"
          "palabras" => array:3 [
            0 => "Litiasis renal"
            1 => "Ureteroscopia flexible"
            2 => "Cirug&#237;a retr&#243;grada intrarrenal"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The objectives of this prospective study are to present our experience with retro-grade intrarenal surgery &#40;RIRS&#41;&#44; and to analyze its results and complications&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">150 patients with renal stones were treated with RIRS&#46; 111 cases showed single stones whilst multiple stones were observed in 39 cases&#46; The mean size was 19&#46;12<span class="elsevierStyleHsp" style=""></span>mm &#40;r&#58; 5&#8211;74&#41;&#46; Success rate was defined as the absence of residual stones or the presence of fragments &#8804;2<span class="elsevierStyleHsp" style=""></span>mm&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In 21 &#40;14&#37;&#41; patients RIRS could not be performed on first attempt because it was impossible to place the ureteral access sheath&#46; The immediate success rate was 85&#46;7&#37; and 91&#46;6&#37; at three months later&#46; The average operating time was 85<span class="elsevierStyleHsp" style=""></span>min &#40;r&#58; 25&#8211;220&#41;&#46; Postoperative complications were observed in 22 cases &#40;14&#46;6&#37;&#41;&#44; although most of them were classified as Clavien 1 and 2 &#40;19 cases&#41;&#44; and only 2&#37; &#40;3 cases&#41; showed Clavien 4 complications &#40;sepsis requiring admission in the intensive care unit&#41;&#46; 10 patients underwent a second procedure in order to complete the treatment&#46; Thus&#44; the number of procedures per patient was 1&#46;06&#46; There were nolate complications&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The treatment of renal stones with flexible ureteroscopy using the ureteral access sheath shows a high successful rate with a low complication rate&#46; In order to define its indication more precisely&#44; randomized studies comparing RIRS with minimally invasive percutaneous nephrolithotomy procedures &#40;miniperc and microperc&#41; would be necessary&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos en este trabajo prospectivo nuestra experiencia con la cirug&#237;a retr&#243;-grada intrarrenal &#40;CRIR&#41;&#44; analizando sus resultados y las complicaciones&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hemos tratado 150 pacientes afectados de litiasis renal mediante CRIR&#46; Lalitiasis fue &#250;nica en 111 casos y m&#250;ltiple en 39&#44; siendo el tama¿no medio de 19&#44;12<span class="elsevierStyleHsp" style=""></span>mm &#40;r&#58; 5-74&#41;&#46; Definimos &#233;xito en nuestra serie como la ausencia de litiasis o fragmentos residuales menoresde 2<span class="elsevierStyleHsp" style=""></span>mm&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En 21 pacientes &#40;14&#37;&#41; no pudo realizarse la CRIR en un primer intento por imposi-bilidad de ascenso de la vaina ureteral&#46; La tasa de &#233;xito inmediata fue del 85&#44;7&#37; y a los 3 mesesdel 91&#44;6&#37;&#46; El tiempo medio operatorio fue 85<span class="elsevierStyleHsp" style=""></span>min &#40;r&#58; 25-220&#41;&#46; En el postoperatorio inmediatohubo complicaciones en 22 pacientes &#40;14&#44;6&#37;&#41;&#44; si bien la mayor&#237;a de ellas fueron Clavien 1 y 2&#40;19 casos&#41; y solo un 2&#37; sufri&#243; complicaciones Clavien 4 &#40;3 casos de sepsis que precisaron ingresoen la unidad de cuidados intensivos&#41;&#46; En 10 pacientes se precis&#243; una segunda intervenci&#243;n paracompletar el tratamiento&#44; por lo que el n&#250;mero de procedimientos por paciente fue de 1&#44;06&#46; No hubo complicaciones tard&#237;as&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El tratamiento de la litiasis renal mediante ureteroscopia flexible obtiene unatasa alta de &#233;xito con bajas complicaciones&#46; Precisamos estudios aleatorizados que la comparencon la nefrolitectom&#237;a percut&#225;nea&#44; en sus modalidades menos invasivas &#40;miniperc y microperc&#41; para definir con exactitud sus indicaciones&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cepeda M&#44; Am&#243;n JH&#44; Mainez JA&#44; Rodr&#237;guez V&#44; Alonso D&#44; Mart&#237;nez-Sagarra JM&#46; Tratamiento de la litiasis renal mediante ureteroscopia flexible&#46; Actas Urol Esp&#46; 2014&#59;38&#58;571&#8211;575&#46;</p>"
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                  <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
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                  \t\t\t\t" style="border-bottom: 2px solid black">Indications&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">N&#58; 150&nbsp;\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
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                  \t\t\t\t">Failure ESWL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;38&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Residual post-PNL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29 &#40;19&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Malformation of the excretory pathway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;8&#46;6&#37;&#41;&nbsp;\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">Obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37 &#40;24&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">14 &#40;9&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  <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
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mean size&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">19&#46;12<span class="elsevierStyleHsp" style=""></span>mm &#40;r&#58; 5&#8211;74&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Single lithiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">111&nbsp;\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">Lower calyx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&nbsp;\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">Middle calyx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&nbsp;\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">Upper calyx&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\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">Upper calyx diverticulum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\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">Middle c&#225;liz diverticulum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\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">Pyelic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\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">Pyelic associated to UPJ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\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">Horseshoe kidney&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\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">Multiple lithiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab575309.png"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demographic variables of the lithiasis&#46;</p>"
        ]
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                  <table border="0" frame="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Surgical time &#40;min&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Immediate success rate</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85&#46;7&#37;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Succes rate at 3 months</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;6&#37;&nbsp;\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
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                  \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
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                  \t\t\t\t">10 &#40;6&#46;6&#37;&#41;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleItalic">Procedures&#47;patient</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;06&nbsp;\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
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                  \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">2&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></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
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                  \t\t\t\t">Complications &#40;rate&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">14&#46;6&#37;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clavien 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10 &#40;6&#46;6&#37;&#41;&nbsp;\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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clavien 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;6&#37;&#41;&nbsp;\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
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                  \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">3 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Results&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Flexible ureteropyeloscopy&#58; diagnosis and treatment in the upper urinary tract"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;H&#46; Bagley"
                            1 => "J&#46;L&#46; Huffman"
                            2 => "E&#46;S&#46; Lyon"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Urol"
                        "fecha" => "1987"
                        "volumen" => "138"
                        "paginaInicial" => "280"
                        "paginaFinal" => "285"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3599238"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Retrograde intrarenal surgery for calculus disease&#58; new minimally invasive treatment approach"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;M&#46; Fuchs"
                            1 => "G&#46;J&#46; Fuchs"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Endourol"
                        "fecha" => "1990"
                        "volumen" => "4"
                        "paginaInicial" => "337"
                        "paginaFinal" => "345"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines on urolithiasis&#46; European Association of Urology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; T&#252;rk"
                            1 => "T&#46; Knoll"
                            2 => "A&#46; Petrik"
                            3 => "K&#46; Sarica"
                            4 => "C&#46; Seitz"
                            5 => "A&#46; Skolarikos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2013"
                      ]
                    ]
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                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of retrograde intrarenal surgery and mini-percutaneous nephrolithotomy in management of lower-pole renal stones with a diameter of smaller than 15<span class="elsevierStyleHsp" style=""></span>mm"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Kirac"
                            1 => "O&#46;F&#46; Bozkurt"
                            2 => "L&#46; Tunc"
                            3 => "C&#46; Guneri"
                            4 => "A&#46; Unsal"
                            5 => "H&#46; Biri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00240-013-0552-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Urolithiasis"
                        "fecha" => "2013"
                        "volumen" => "41"
                        "paginaInicial" => "241"
                        "paginaFinal" => "246"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23483226"
                            "web" => "Medline"
                          ]
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                      ]
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                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of retrograde intrarenal surgery&#44; shockwave lithotripsy&#44; and percutaneous nephrolithotomy for treatment of medium-sized radiolucent renal stones"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Resorlu"
                            1 => "A&#46; Unsal"
                            2 => "T&#46; Ziypak"
                            3 => "A&#46; Diri"
                            4 => "G&#46; Atis"
                            5 => "S&#46; Guven"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00345-012-0991-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "World J Urol"
                        "fecha" => "2013"
                        "volumen" => "31"
                        "paginaInicial" => "1581"
                        "paginaFinal" => "1586"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23179732"
                            "web" => "Medline"
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              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Micropercutaneous nephrolithotomy &#40;microperc&#41; vs retrograde intrarenal surgery for the management of small calculi&#58; a randomized controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46;B&#46; Sabnis"
                            1 => "R&#46; Ganesamoni"
                            2 => "A&#46; Doshi"
                            3 => "A&#46;P&#46; Ganpule"
                            4 => "J&#46; Jagtap"
                            5 => "M&#46;R&#46; Desai"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/bju.12164"
                      "Revista" => array:6 [
                        "tituloSerie" => "BJU Int"
                        "fecha" => "2013"
                        "volumen" => "112"
                        "paginaInicial" => "355"
                        "paginaFinal" => "361"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23826843"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Successful outcome of flexible ureteroscopy with holmium laser lithotripsy for renal stones 2<span class="elsevierStyleHsp" style=""></span>cm or greater"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Takazawa"
                            1 => "S&#46; Kitayama"
                            2 => "T&#46; Tsujii"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1442-2042.2011.02931.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Urol"
                        "fecha" => "2012"
                        "volumen" => "19"
                        "paginaInicial" => "264"
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Article information

ISSN: 21735786
Original language: English

DOI:10.1016/j.acuroe.2014.09.008

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Year/Month	Html	Pdf	Total

2023 March	1	0	1
2018 February	8	1	9
2018 January	6	2	8
2017 December	15	0	15
2017 November	10	1	11
2017 October	11	5	16
2017 September	14	2	16
2017 August	17	2	19
2017 July	17	3	20
2017 June	13	14	27
2017 May	10	1	11
2017 April	11	11	22
2017 March	15	32	47
2017 February	10	3	13
2017 January	11	2	13
2016 December	19	6	25
2016 November	23	7	30
2016 October	0	4	4
2016 September	0	2	2
2016 August	0	3	3
2016 July	0	1	1
2016 June	0	3	3
2016 May	0	3	3
2016 April	0	11	11
2016 March	0	8	8
2016 February	0	1	1
2016 January	0	2	2
2015 December	0	1	1
2015 October	1	2	3
2015 September	0	1	1
2015 August	0	1	1
2015 July	0	1	1
2015 March	0	1	1
2015 February	1	0	1
2015 January	0	2	2
2014 December	1	0	1
2014 November	0	2	2

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