Seguridad y eficacia de la uretroplastia según grupos etarios

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No existe un consenso si la mayor esperanza de vida va de la mano con las limitaciones funcionales y la discapacidad<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a>&#46; Algunos autores sugieren que los procesos de envejecimiento son modificables&#44; y que el desarrollo tecnol&#243;gico y m&#233;dico juegan un papel importante para enfrentar los desaf&#237;os del envejecimiento de la poblaci&#243;n&#44; permitiendo que las personas puedan vivir m&#225;s sin discapacidad severa<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Existe una tendencia en la pr&#225;ctica urol&#243;gica actual de ofrecer tratamientos radicales a personas de edad avanzada&#44; siendo m&#225;s importante el estado cl&#237;nico que el cronol&#243;gico&#44; y en pacientes bien motivados se ofrecen m&#225;s a menudo procedimientos como la prostatectom&#237;a radical o la cirug&#237;a conservadora de nefronas<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5-7</span></a>&#44; procedimientos que en a&#241;os anteriores se reservaban para pacientes j&#243;venes&#46; La cirug&#237;a de reconstrucci&#243;n uretral no es la excepci&#243;n&#46; Est&#225; descrito que la incidencia de la estenosis uretral aumenta constantemente con la edad&#44; presentando una incidencia del 0&#44;6&#37; a los 65 a&#241;os y hasta 1&#44;9&#37; en &#62;&#160;85 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; Este aumento es debido&#44; probablemente&#44; a que los pacientes de edad avanzada tienen un riesgo acumulativo mayor de ser sometidos a instrumentaci&#243;n urol&#243;gica &#40;resultado del tratamiento de la hiperplasia prost&#225;tica benigna o del c&#225;ncer prost&#225;tico&#41;&#44; convirtiendo a la etiolog&#237;a iatr&#243;gena en la principal en este grupo de edad<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#44;11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">La evidencia sobre los resultados de la uretroplastia en pacientes de edad avanzada es contrastante&#44; varios estudios demuestran que la edad avanzada puede ser una limitante para la realizaci&#243;n de una uretroplastia&#44; debido al mayor perfil de complicaciones o a las enfermedades cr&#243;nicas asociadas que pueden influir de manera negativa en el resultado de la cirug&#237;a&#44; siendo m&#225;s proclive en este grupo de pacientes la realizaci&#243;n de dilataciones sucesivas y la uretrotom&#237;a interna<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9&#44;12</span></a>&#46; Por otra parte existen publicaciones que demuestran que&#44; a pesar de que las dilataciones y la uretrotom&#237;a&#44; estos procedimientos han sido m&#225;s frecuentes&#59; la reconstrucci&#243;n uretral abierta se realiza con mayor frecuencia en relaci&#243;n con el pasado&#44; siendo el est&#225;ndar de tratamiento para la estenosis uretral en la actualidad<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">13&#44;14</span></a>&#46; Existen trabajos que describen que la uretroplastia es bien tolerada en el grupo de pacientes de edad avanzada&#44; y que puede ser una opci&#243;n razonable en este grupo de pacientes<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">15&#44;16</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo de esta presentaci&#243;n es analizar los resultados y las complicaciones posturetroplastia estratificando a los pacientes por edades&#46; Como objetivo secundario&#44; analizamos el impacto de la complejidad de la cirug&#237;a en cada grupo etario&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todo</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se trata de un estudio de cohortes con registro de datos retrospectivo&#44; incluyendo a todos los pacientes masculinos operados por patolog&#237;a uretral en el sector de cirug&#237;a uretral y genital reconstructiva en el Hospital Italiano de Buenos Aires entre los a&#241;os 2011 al 2018&#46; Se excluyeron los pacientes de los cuales no se obtuvo la informaci&#243;n cl&#237;nica completa&#46; Los datos fueron recabados de la historia cl&#237;nica electr&#243;nica del hospital&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A los fines del presente trabajo se dividi&#243; la poblaci&#243;n en tres grupos&#58; menores de 60 a&#241;os&#44; 60 a 79 a&#241;os y mayores de 80 a&#241;os&#46; Las variables analizadas fueron sobrevida libre de reestenosis y aparici&#243;n de complicaciones&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se defini&#243; reestenosis como todo aquel caso en el que el paciente durante el seguimiento requiri&#243; un nuevo tratamiento&#44; incluyendo dilataci&#243;n uretral&#44; tratamiento endosc&#243;pico &#40;uretrotom&#237;a interna&#41; o abierto &#40;nueva uretroplastia&#41;&#46; Las complicaciones fueron definidas como toda aquella desviaci&#243;n de la evoluci&#243;n postoperatoria normal del paciente&#44; que requiri&#243; alguna intervenci&#243;n &#40;vigilancia&#44; manejo m&#233;dico o quir&#250;rgico&#41;&#46; Se clasificaron utilizando la clasificaci&#243;n de Clavien Dindo<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> para complicaciones postoperatorias&#46; Por otra parte&#44; para los fines de este estudio&#44; las cirug&#237;as uretrales jerarquizadas como complejas fueron la uretroplastia con dos o m&#225;s injertos&#44; anastomosis ampliada&#44; la uretroplastia combinada &#40;colgajo m&#225;s injerto&#44; colgajo m&#225;s resecci&#243;n y anastomosis primaria &#91;RAP&#93;&#44; injerto m&#225;s colgajo&#44; injerto m&#225;s RAP&#41; y la cirug&#237;a por estadios&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se consignaron datos demogr&#225;ficos&#44; &#237;ndice de masa corporal &#40;IMC&#41; y antecedentes patol&#243;gicos generales de importancia &#40;tabaquismo&#44; diabetes&#44; antecedentes cardiovasculares&#44; dislipemia&#44; neumopat&#237;a&#41;&#46; La valoraci&#243;n urol&#243;gica incluy&#243; registro de procedimientos urol&#243;gicos previos &#40;dilataci&#243;n&#44; uretrotom&#237;a interna o pl&#225;stica previa&#41;&#44; etiolog&#237;a de la estenosis uretral mediante interrogatorio al paciente&#46; Todos los pacientes contaron con uretrocistograf&#237;a y cistoscop&#237;a previas a la cirug&#237;a&#44; de las cuales se consign&#243; longitud de estrechez&#44; localizaci&#243;n y cantidad de estenosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Siempre se protegieron las zonas de dec&#250;bito con adecuado acolchonamiento&#46; Adem&#225;s&#44; en todos los casos&#44; se utiliza la posici&#243;n de litotom&#237;a el menor tiempo posible &#40;por ejemplo&#44; en cirug&#237;as de uretra p&#233;ndula se realizan en dec&#250;bito dorsal&#44; y si requiere un abordaje perineal&#44; se coloca luego en posici&#243;n de litotom&#237;a&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Las cirug&#237;as fueran practicadas por dos ur&#243;logos con entrenamiento en cirug&#237;a uretral&#46; Las variables enunciadas se evaluaron como factores predictores de seguridad y efectividad&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La sonda uretral permanece en promedio durante tres semanas posterior a la cirug&#237;a&#44; y luego se realiza un control radiol&#243;gico con cistouretrograf&#237;a miccional&#46; Si no hay extravasaci&#243;n de medio de contraste se retira la sonda uretral&#46; El seguimiento es cl&#237;nico a los cuatro&#44; ocho y 12 meses&#44; y posteriormente cada seis meses&#44; hasta el tercer a&#241;o&#46; Luego se realizan controles anualmente&#46; Se realiza valoraci&#243;n cl&#237;nica&#44; uroflujometr&#237;a y urocultivo en cada consulta&#46; Se realiza una nueva cistouretrograf&#237;a o cistoscop&#237;a solo en los casos de reaparici&#243;n de s&#237;ntomas urinarios&#44; infecci&#243;n urinaria o disminuci&#243;n del flujo urinario &#40;Qmax &#60;&#160;15&#160;mL&#47;seg&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El presente trabajo fue aprobado por el Comit&#233; de &#201;tica del hospital &#40;CEPI no&#46; 4002&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lisis estad&#237;stico</span><p id="par0065" class="elsevierStylePara elsevierViewall">Las variables continuas se expresan como su media y desv&#237;o est&#225;ndar &#40;DE&#41; o mediana y rango intercuartil &#40;IQR&#41; seg&#250;n distribuci&#243;n&#46; Para su comparaci&#243;n se utiliza ANOVA o Test de Kruskall Wallis&#46; Las variables categ&#243;ricas se resumen como su valor absoluto y porcentaje&#59; para su comparaci&#243;n se emplea test de &#967;<span class="elsevierStyleSup">2</span>&#46; En todos los casos se emplea ajuste para comparaciones m&#250;ltiples por m&#233;todo de Bonferroni&#46; Los c&#225;lculos de sobrevida se realizan empleando m&#233;todo de Kaplan Meier con su intervalo de confianza al 95&#37;&#46; El an&#225;lisis univariado se realiza mediante regresi&#243;n de Cox &#40;en caso de sobrevida libre de reestenosis&#41; o log&#237;stica &#40;en caso de complicaciones&#41; introduciendo en el multivariado s&#243;lo las variables con significaci&#243;n estad&#237;stica en la regresi&#243;n univariante&#46; En los casos de regresi&#243;n de Cox se considera significativo un <span class="elsevierStyleItalic">hazard ratio</span> &#40;HR&#41; cuyo IC 95&#37; no incluya al 1&#46; En caso de regresi&#243;n log&#237;stica&#44; los mismos par&#225;metros aplican al <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41;&#46; Para todos los tests se considera significativo un p valor &#60;&#160;0&#44;05&#46; El software utilizado es el SPSS 22&#46;0&#174;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0070" class="elsevierStylePara elsevierViewall">Fueron incluidos 783 pacientes durante el periodo evaluado &#40;enero 2011-diciembre 2018&#41;&#46; De dicho n&#250;mero&#44; 375 pacientes eran menores de 60 a&#241;os&#44; 367 ten&#237;an entre 60 y 79 a&#241;os y 41 pacientes eran mayores de 80 a&#241;os&#46; Las caracter&#237;sticas demogr&#225;ficas y cl&#237;nico quir&#250;rgicas se detallan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; Se destaca mayor prevalencia de comorbilidades&#44; etiolog&#237;a iatrog&#233;nica y estenosis multifocal en los pacientes mayores a 60 a&#241;os &#40;p&#160;&#60;&#160;0&#44;0001&#59; p&#160;&#60;&#160;0&#44;05&#59; p&#160;&#60;&#160;0&#44;05&#41;&#46; Respecto a los tratamientos previos&#44; no hubo diferencias entre los distintos grupos &#40;p&#160;&#61;&#160;0&#44;741&#41;&#46; En cuanto a la longitud&#44; tampoco encontramos diferencias estad&#237;sticamente significativas &#40;p&#160;&#61;&#160;0&#44;970&#41;&#46; Por &#250;ltimo observamos que a los mayores de 80 a&#241;os se les realiz&#243; menor porcentaje de cirug&#237;as complejas &#40;p&#160;&#61;&#160;0&#44;016&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">El seguimiento promedio fue de 19 meses&#46; Se observaron reestenosis en el 13&#37; en el grupo de menores de 60 a&#241;os&#44; del 13&#37; en el grupo entre 60 a 79 a&#241;os&#44; y del 6&#44;1&#37; en los mayores de 80&#46; La sobrevida estimada a dos a&#241;os libre de reestenosis en la poblaci&#243;n menor a 60&#44; de 60 a 79 y mayor de 80 a&#241;os fue de 87&#37; &#40;IC&#160;95&#37; 81&#44;9-92&#44;1&#41;&#44; 87&#37; &#40;82&#44;3-91&#44;7&#41; y 93&#44;9&#37; &#40;IC&#160;95&#37; 85&#44;7-100&#41;&#44; respectivamente&#44; no habiendo diferencias significativas entre grupos &#40;p&#160;&#61;&#160;0&#44;368&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Para evaluar los resultados de cirug&#237;a compleja entre edades&#44; realizamos un suban&#225;lisis en los 277 pacientes a quienes se le realiz&#243; una cirug&#237;a uretral compleja&#44; no hall&#225;ndose diferencia significativas en sobrevida libre de reestenosis &#40;p&#160;&#61;&#160;0&#44;486&#41; ni en ocurrencia de complicaciones &#40;p&#160;&#61;&#160;0&#44;690&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">En el an&#225;lisis univariado&#44; el grupo etario no fue una variable predictora de reestenosis&#46; Al realizar el an&#225;lisis multivariado&#44; la realizaci&#243;n de cirug&#237;a compleja es el &#250;nico factor predictivo de recidiva&#44; aumentando el riesgo en un 60&#37; &#40;HR 1&#44;64 IC 95&#37; 1&#44;05-2&#44;56 p&#160;&#61;&#160;0&#44;029&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">La <a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a> muestra la distribuci&#243;n de complicaciones por grupo etario observ&#225;ndose que la ocurrencia de las mismas no est&#225; asociada la edad &#40;p&#160;&#61;&#160;0&#44;710&#41;&#46; Se presentaron 241 complicaciones dentro de los 30 d&#237;as postcirug&#237;a &#40;30&#44;8&#37;&#41;&#44; y se clasificaron seg&#250;n la clasificaci&#243;n de Clavien-Dindo<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a>&#46; Del total&#44; el 62&#37; corresponden a complicaciones del grupo dos o menores&#46; Ochenta y cinco pacientes &#40;10&#44;9&#37;&#41; presentaron f&#237;stula urinaria en el control radiol&#243;gico&#44; la mayor&#237;a fueron tratados con derivaci&#243;n urinaria por una semana y fueron reevaluados con un nuevo estudio radiogr&#225;fico&#46; Solamente cinco pacientes &#40;0&#44;6&#37;&#41; debieron ser reexplorados por sangrado o f&#237;stula&#46; Teniendo en cuenta solo a los pacientes a los cuales se les tom&#243; injerto oral tampoco existi&#243; diferencia en complicaciones relacionadas a la toma del injerto entre los distintos grupos &#40;p&#160;&#61;&#160;0&#44;895&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discusi&#243;n</span><p id="par0095" class="elsevierStylePara elsevierViewall">Son diversos los factores descritos que son discutibles y que sugieren que a pacientes de edad avanzada se les debe manejar de una manera particular en el &#225;mbito de la reconstrucci&#243;n uretral&#46; Genera preocupaci&#243;n el hecho de que la mayor prevalencia de comorbilidades en esta poblaci&#243;n podr&#237;a resultar en una mayor tasa de complicaciones&#46; La insuficiencia microvascular&#44; ya sea aislada por efecto del envejecimiento&#44; el tabaquismo o en pacientes diab&#233;ticos&#44; puede limitar el uso de colgajos&#44; por lo que en general se deber&#237;a prescindir de estos&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">El tabaquismo o la mala higiene bucal&#44; que tienen mayor prevalencia con el aumento de la edad&#44; podr&#237;an conducir a una fibrosis submucosa que deteriore la calidad del injerto&#46; A nivel genital existe un flujo arterial peneano disminu&#237;do&#44; lo que tambi&#233;n puede impactar negativamente al momento de utilizar injertos&#46; La posici&#243;n de litotom&#237;a tambi&#233;n puede ser una limitante&#44; al menos te&#243;rica&#44; ya que aumenta las posibilidades de complicaciones vasculares y nerviosas en los miembros inferiores&#46; Se recomienda siempre realizar acolchonamiento de las zonas de dec&#250;bito&#44; as&#237; como que el paciente permanezca el m&#237;nimo tiempo indispensable en dicha posici&#243;n&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">El trabajo presentado representa una de las series de pacientes m&#225;s extensa reportada para evaluar los resultados de la uretroplastia en pacientes de edad avanzada&#46; El tema tiene especial relevancia considerando la tendencia actual a la mayor expectativa de vida&#44; as&#237; como la inversi&#243;n de las pir&#225;mides poblacionales en diferentes pa&#237;ses<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a>&#46; Lo enunciado le proporciona al trabajo una importancia considerable para el ur&#243;logo reconstructor&#44; dado que cada vez va a ser m&#225;s frecuente la consulta de pacientes de edad avanzada en buen estado de salud&#46; Reportando la eficacia y seguridad de la uretroplastia en el adulto mayor de manera precisa&#44; contribuimos a derribar la barrera que representa la edad para tomar la decisi&#243;n de ofrecer una reparaci&#243;n abierta a un adulto mayor que as&#237; la requiera&#44; evitando con esto tratamientos repetitivos y no definitivos que afectan la calidad de vida de estos pacientes&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">De los estudios publicados previamente que relacionan la edad con la uretroplastia Schwentner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> realizaron un an&#225;lisis retrospectivo de 42 pacientes consecutivos a quienes se les practic&#243; uretroplastia con injerto dorsal de piel&#46; &#218;nicamente incluy&#243; pacientes mayores de 65 a&#241;os&#46; Report&#243; una tasa de &#233;xito global del 90&#44;5&#37; con una tasa de complicaciones del 9&#44;5&#37;&#44; concluyendo que este procedimiento es bien tolerado en este grupo de pacientes&#46; Estos resultados son similares a los presentados por nuestro grupo&#44; excepto por las complicaciones&#44; que fueron mayores en nuestro an&#225;lisis&#46; Del estudio&#44; se debe considerar la reducida cantidad de pacientes y que no se reportan las morbilidades entre ambos grupos&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Por otra parte Levy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> realizaron una revisi&#243;n retrospectiva en 11 instituciones para determinar si la edad es un predictor independiente de &#233;xito funcional y recurrencia en pacientes llevados a uretroplastia&#46; Los resultados fueron comparados entre dos cohortes &#40;&#60;&#160;60 y &#62;&#160;60 a&#241;os&#41; con un total de 322 pacientes analizados&#46; Los grupos no fueron homog&#233;neos&#44; siendo m&#225;s frecuente la diabetes&#44; hipertensi&#243;n&#44; dislipidemia&#44; enfermedad coronaria&#44; vasculopat&#237;a perif&#233;rica y el c&#225;ncer en el grupo &#62;&#160;60 a&#241;os&#46; Al realizar el an&#225;lisis multivariado&#44; no hubo diferencias en necesidad de nuevos procedimientos ni en recurrencia anat&#243;mica en ambos grupos de edad&#46; Por otro lado&#44; se encontr&#243; una diferencia estad&#237;sticamente significativa &#250;nicamente en la longitud de la estenosis&#44; concluyendo que la edad no debe ser un criterio absoluto para excluir a un paciente con necesidad de reconstrucci&#243;n uretral&#46; En nuestro estudio tampoco encontramos diferencias estratificando por grupos etarios&#46; Adem&#225;s observamos&#44; como en el citado trabajo&#44; que la longitud y tambi&#233;n la multifocalidad se comportaron como predictores de fracaso de la cirug&#237;a&#44; independientemente del grupo etario&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Santucci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> realizaron un estudio multic&#233;ntrico&#44; analizando retrospectivamente 70 casos consecutivos de uretroplastia en mayores de 64 a&#241;os&#44; siendo los procedimientos m&#225;s realizados la anastomosis primaria&#44; seguida de los colgajos fasciocut&#225;neos&#46; La etiolog&#237;a idiop&#225;tica fue la m&#225;s frecuente en un 43&#37;&#44; seguida de la traum&#225;tica&#46; Reportan una tasa final de &#233;xito general del 91&#37; con un perfil de complicaciones aceptable&#44; coincidiendo con nuestro estudio&#46; Una limitante que present&#243; esta publicaci&#243;n es que la informaci&#243;n demogr&#225;fica no fue inclu&#237;da en el an&#225;lisis&#44; lo que puede comprometer el an&#225;lisis multivariado&#46; Adem&#225;s&#44; dicho trabajo no considera un grupo de control de menores de 64 a&#241;os para comparar los resultados&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Viers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> realizaron una revisi&#243;n retrospectiva de casos de uretroplastia en un solo centro&#44; estratificando los grupos por edad &#40;&#60;&#160;50&#44; 50-59&#44; 60-69&#44; &#8805;&#160;70 a&#241;os&#41;&#44; incluyendo un total de 514 casos&#46; El estudio evidenci&#243; una tendencia a presentar mayor tasa de fracaso del tratamiento a mayor edad &#40;6&#37; vs&#46; 16&#37; vs&#46; 20&#37; vs&#46; 26&#37;&#59; p&#160;&#60;&#160;0&#44;0001&#41; y una disminuci&#243;n del periodo libre de recurrencia a mayor edad &#40;94&#37; vs&#46; 89&#37; vs&#46; 78&#37; vs&#46; 74&#37;&#59; p&#160;&#60;&#160;0&#44;0001&#41;&#44; obteniendo en el an&#225;lisis multivariado una asociaci&#243;n independiente entre mayor edad &#40;por d&#233;cada a partir de los 50 a&#241;os&#41; y riesgo de fracaso de la uretroplastia&#46; La poblaci&#243;n analizada en dicho trabajo presentaba una diferencia estad&#237;sticamente significativa en cuanto a antecedentes de radioterapia para los pacientes mayores de 70 a&#241;os&#46; En t&#233;rminos de n&#250;mero de pacientes y estratificaci&#243;n por edad&#44; este trabajo se asemeja mucho al nuestro&#46; Las diferencias observadas en t&#233;rminos de resultados pueden deberse tanto a la alta prevalencia de la radioterapia en la poblaci&#243;n mayor&#44; as&#237; como tambi&#233;n a un mayor seguimiento por parte del grupo de Viers et al&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Creemos que las fortalezas del presente trabajo son que todos los procedimientos fueron realizados por dos cirujanos reconstructivos con ardua experiencia&#44; el n&#250;mero elevado de pacientes operados&#44; el hecho de estratificar a los pacientes por edades y adem&#225;s por complejidad del procedimiento&#44; lo que nos permite detectar diferencias estad&#237;sticamente significativas en caso de existir&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Las limitaciones del presente estudio son la naturaleza retrospectiva propia del dise&#241;o&#44; que los datos obtenidos corresponden a la experiencia de un solo centro&#46; Estos hechos producen poblaciones heterog&#233;neas que solo pueden analizarse mediante m&#233;todos estad&#237;sticos espec&#237;ficos&#44; a diferencia de estudios prospectivos y controlados&#46; Por otra parte&#44; en algunos pacientes el tiempo de seguimiento fue breve debido a que&#44; al ser un centro de referencia nacional&#44; algunos pacientes contin&#250;an el seguimiento en sus ciudades de origen&#46; Un seguimiento a largo plazo es necesario para evaluar de mejor manera la eficacia de los tratamientos descritos&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusiones</span><p id="par0140" class="elsevierStylePara elsevierViewall">La uretroplastia es segura y eficaz independientemente del grupo etario&#46; No hay diferencias estad&#237;sticamente significativas en cuanto a los resultados y complicaciones comparando los diferentes grupos etarios&#46; Tampoco encontramos diferencias significativas cuando analizamos el impacto de las cirug&#237;as complejas entre los diferentes grupos etarios&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicto de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Analizar los resultados y las complicaciones posturetroplastia estratificando a los pacientes por edades&#46; Como objetivo secundario&#44; analizamos el impacto de la complejidad de la cirug&#237;a en cada grupo etario&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio de cohortes&#44; retrospectivo&#44; donde se incluy&#243; a todos los pacientes masculinos a quienes se les practic&#243; uretroplastia entre enero de 2011 y diciembre de 2018&#46; La informaci&#243;n se obtuvo de la historia cl&#237;nica electr&#243;nica&#46; Los pacientes se agruparon en menores de 60 a&#241;os&#44; de 60 a 79 a&#241;os y mayores de 80 a&#241;os&#46; Se evaluaron diferentes variables como antecedentes&#44; comorbilidades&#44; cirug&#237;as previas&#44; complejidad de la cirug&#237;a&#46; Se determin&#243; la supervivencia libre de reestenosis y las complicaciones presentadas en cada grupo&#44; seg&#250;n la clasificaci&#243;n de Clavien Dindo&#46; Se utiliz&#243; el programa SPSS&#174; para el an&#225;lisis estad&#237;stico&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron un total de 783 pacientes&#46; El seguimiento promedio fue de 19 meses&#46; La sobrevida estimada a dos a&#241;os libre de reestenosis en la poblaci&#243;n menor a 60&#44; de 60 a 79 y mayor de 80 a&#241;os fue de 87&#44; 87 y 93&#44;9&#37; &#40;IC 95&#37;&#41;&#44; respectivamente&#46; En el an&#225;lisis univariado&#44; el grupo etario no fue una variable predictora de reestenosis&#46; La realizaci&#243;n de cirug&#237;a compleja es el &#250;nico factor predictor de recidiva&#44; aumentando el riesgo en un 60&#37; &#40;HR 1&#44;64 IC 95&#37; 1&#44;05-2&#44;56 p&#160;&#61;&#160;0&#44;029&#41;&#46; Se present&#243; una tasa general de complicaciones del 30&#44;8&#37;&#44; siendo el 62&#37; Clavien menor a dos&#46; No encontramos asociaci&#243;n entre la frecuencia de las mismas y la edad&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La uretroplastia es segura y eficaz independientemente del grupo etario&#46; No hay diferencias estad&#237;sticamente significativas en cuanto a los resultados y complicaciones comparando los diferentes grupos etarios&#46; Tampoco encontramos diferencias significativas cuando analizamos el impacto de las cirug&#237;as complejas entre los diferentes grupos etarios&#46; Los datos indican que la edad&#44; como &#250;nico factor&#44; no debe ser excluyente para los pacientes que necesitan una reconstrucci&#243;n de la uretra&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To analyze the results and complications after urethroplasty based on patient age groups&#46; As secondary objective&#44; we analyzed the impact of operative complexity on each age group&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective cohort study that include male patients who underwent urethroplasty between January 2011 and December 2018&#46; Data was obtained from the patients&#8217; electronic health records&#46; Patients were grouped as follows&#58; &#60;&#160;60 years&#44; 60-79 years and &#62;&#160;80 years&#46; Variables evaluated were history&#44; comorbidities&#44; previous surgeries and operative complexity&#46; Restenosis-free survival and complications presented in each group were determined according to the Clavien-Dindo classification system&#46; The SPSS&#174; program was used for statistical analysis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 783 patients were included&#44; and the mean follow-up was 19 months&#46; The estimated 2-year restenosis-free survival in the population under 60&#44; 60-79 and over 80 years was 87&#44; 87 and 93&#46;9&#37; &#40;IC 95&#37;&#41;&#44; respectively&#46; Univariate analysis showed that the age group was not a predictor of restenosis&#46; Complex surgery is the only predictor of recurrence&#44; increasing the risk by 60&#37; &#40;HR 1&#46;64&#44; 95&#37; CI 1&#46;05-2&#46;56&#44; p&#160;&#61;&#160;0&#46;029&#41;&#46; There was an overall complication rate of 30&#46;8&#37;&#44; and 62&#37; of these were Clavien &#8804;&#160;II&#46; We found no association between the frequency of complications and age&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Urethroplasty is safe and effective regardless of age group&#46; There are no statistically significant differences in outcomes and complications shown by the age group comparison&#46; There were no significant differences when analyzing the impact of complex surgeries among the different age groups&#46; The data indicate that age alone should not be taken as an absolute exclusion criterion for patients needing urethral reconstruction&#46;</p></span>"
        "secciones" => array:4 [
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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        ]
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;17&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;074&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Uretrotom&#237;a &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">130 &#40;16&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;7&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;095&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Uretroplastia &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;17&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;074&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Estenosis m&#250;ltiple &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">36 &#40;9&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;2&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;0001</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Iatrog&#233;nica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">35 &#40;85&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Traum&#225;tica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Inflamatoria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hipospadias&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30 &#40;3&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Localizaci&#243;n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;019</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bulbar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">188 &#40;50&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19 &#40;46&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multifocal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">219 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">85 &#40;22&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">117 &#40;31&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17 &#40;41&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><a class="elsevierStyleCrossRef" href="#tblfn0010">&#42;&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">P&#233;ndula&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">P&#233;ndula&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Bulbar&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Multifocal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Posterior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">M&#225;s de una estenosis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Longitud por cm&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;96 &#40;0&#44;9-1&#44;1&#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">0&#44;236&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \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"><span class="elsevierStyleBold">1&#44;64 &#40;1&#44;1-2&#44;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;029</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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#44;64 &#40;1&#44;1-2&#44;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">0&#44;030</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Etiolog&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Iatrog&#233;nica&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">Ref&#46;&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="left" valign="\n
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                  \t\t\t\t">Ref&#46;&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflamatoria&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="left" valign="\n
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                  \t\t\t\t">1&#44;48 &#40;0&#44;7-3&#44;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;327&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traum&#225;tica&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="left" valign="\n
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                  \t\t\t\t">0&#44;53 &#40;0&#44;2-1&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;143&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Idiop&#225;tica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;39 &#40;0&#44;2-1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;051&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Hipospadias&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="left" valign="\n
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                  \t\t\t\t">0&#44;71 &#40;0&#44;2-2&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;560&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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  """
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              "imagenFichero" => array:1 [
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        "descripcion" => array:1 [
          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis univariado y multivariado</p>"
        ]
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      2 => array:8 [
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        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          0 => array:3 [
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            "detalle" => "Tabla "
            "rol" => "short"
          ]
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&#40;n&#160;&#61;&#160;783&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#60;&#160;60 a&#241;os&#40;n&#160;&#61;&#160;375&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">60-79 a&#241;os&#40;n&#160;&#61;&#160;367&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#62;&#160;80 a&#241;os&#40;n&#160;&#61;&#160;41&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hematoma &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;3&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18 &#40;4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;2&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3 &#40;7&#44;3&#41;&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">0&#44;076&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Infecci&#243;n urinaria &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">54 &#40;6&#44;9&#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">21 &#40;5&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \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">28 &#40;7&#44;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;12&#44;2&#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="left" valign="\n
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                  \t\t\t\t">0&#44;214&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Asociadas a la herida &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">51 &#40;6&#44;5&#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">25 &#40;6&#44;7&#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="left" valign="\n
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                  \t\t\t\t">22 &#40;6&#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="left" valign="\n
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                  \t\t\t\t">4 &#40;9&#44;8&#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="left" valign="\n
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                  \t\t\t\t">0&#44;643&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&#237;stula &#37;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 &#40;10&#44;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;12&#44;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;8&#44;7&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;17&#44;1&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;126&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reexploraci&#243;n por sangrado &#37;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;0&#44;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;0&#44;8&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#44;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retenci&#243;n aguda de orina &#37;&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;0&#44;9&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;3&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;1&#44;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;151&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Otras &#37;&nbsp;\t\t\t\t\t\t\n
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                  \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">15 &#40;1&#44;9&#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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;0&#44;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;3&#44;5&#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="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;341&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total &#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">241 &#40;30&#44;8&#37;&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">114 &#40;30&#44;4&#37;&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">112 &#40;30&#44;5&#37;&#41;&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">14 &#40;30&#44;6&#37;&#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="left" valign="\n
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                  \t\t\t\t">0&#44;710&nbsp;\t\t\t\t\t\t\n
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                  "contribucion" => array:1 [
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                          "etal" => false
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                            1 => "G&#46; Doblhammer"
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                  "host" => array:1 [
                    0 => array:2 [
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                0 => array:1 [
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                      "titulo" => "Should radical prostatectomy be encouraged at any age&#63; A critical non-systematic review"
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                        0 => array:2 [
                          "etal" => false
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                            4 => "G&#46; Giannarini"
                            5 => "V&#46; Ficarra"
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                        "tituloSerie" => "Minerva Urol Nefrol&#46;"
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                          0 => array:2 [
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              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "S&#46;K&#46; Bechis"
                            1 => "P&#46;R&#46; Carroll"
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                    0 => array:2 [
                      "doi" => "10.1200/JCO.2010.30.2075"
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                        "tituloSerie" => "J Clin Oncol&#46;"
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                        "paginaInicial" => "235"
                        "paginaFinal" => "241"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Small renal mass management in the elderly and the calibration of risk"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "J&#46;J&#46; Tomaszewski"
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                    0 => array:2 [
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                        "paginaFinal" => "200"
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              "etiqueta" => "8"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46;A&#46; Santucci"
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                    0 => array:2 [
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                        "tituloSerie" => "J Urol&#46;"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trends in stricture management among male Medicare beneficiaries&#58; underuse of urethroplasty&#63;"
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                        0 => array:2 [
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                            0 => "J&#46;T&#46; Anger"
                            1 => "J&#46;C&#46; Buckley"
                            2 => "R&#46;A&#46; Santucci"
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                      "doi" => "10.1016/j.urology.2010.05.055"
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                0 => array:2 [
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                    0 => array:1 [
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                          "etal" => false
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Male Urethral Stricture Disease Etiology in a Latin American Referral Center"
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              "identificador" => "bib0160"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Etiology of Urethral Stricture Disease in the 21st Century"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "N&#46; Lumen"
                            1 => "P&#46; Hoebeke"
                            2 => "P&#46; Willemsen"
                            3 => "B&#46; De Troyer"
                            4 => "R&#46; Pieters"
                            5 => "W&#46; Oosterlinck"
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                    0 => array:2 [
                      "doi" => "10.1016/j.juro.2009.05.023"
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                        "fecha" => "2009"
                        "volumen" => "182"
                        "paginaInicial" => "983"
                        "paginaFinal" => "987"
                        "link" => array:1 [
                          0 => array:2 [
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                      "titulo" => "What is the place of internal urethrotomy in the treatment of urethral stricture disease&#63;"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;M&#46; Naud&#233;"
                            1 => "C&#46;F&#46; Heyns"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ncpuro0320"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Clin Pract Urol&#46;"
                        "fecha" => "2005"
                        "volumen" => "2"
                        "paginaInicial" => "538"
                        "paginaFinal" => "545"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16474597"
                            "web" => "Medline"
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              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Population Analysis of Male Urethral Stricture Management and Urethroplasty Success in the United States"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;R&#46; Benson"
                            1 => "R&#46; Goldfarb"
                            2 => "P&#46; Kirk"
                            3 => "Y&#46; Qin"
                            4 => "T&#46; Borza"
                            5 => "T&#46;A&#46; Skolarus"
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                    0 => array:2 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Urology&#46;"
                        "fecha" => "2019"
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                        "paginaInicial" => "258"
                        "paginaFinal" => "264"
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