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Técnica quirúrgica
Estudio comparativo entre adenomectomía extraperitoneal laparoscópica y abierta
Comparative Study Between Laparoscopic Extraperitoneal and Open Adenomectomy
A. García-Segui
Autor para correspondencia
agarciasegui@gmail.com

Autor para correspondencia.
, M. Gascón-Mir
Servicio de Urología, Hospital General Mateu Orfila, Mahón, Menorca, España
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La enucleaci&#243;n prost&#225;tica con l&#225;ser Holmium obtiene resultados equivalentes a la cirug&#237;a abierta con menor morbilidad&#46; Sin embargo&#44; en los momentos actuales la disponibilidad de equipos de l&#225;ser en hospitales p&#250;blicos y comarcales es limitada&#44; debido a sus costes&#44; por lo que su uso no se ha generalizado&#46; Paralelamente&#44; los avances tecnol&#243;gicos y operativos en las t&#233;cnicas de RTUP han permitido ampliar su indicaci&#243;n en pr&#243;statas grandes&#59; sin embargo&#44; esto tambi&#233;n ha conllevado a un aumento inevitable de resecciones incompletas y de reintervenciones&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Mariano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> realizaron la primera adenomectom&#237;a laparosc&#243;pica &#40;AL&#41; en el a&#241;o 2002&#46; Este procedimiento reprodujo los pasos quir&#250;rgicos de la AR&#44; lo que permiti&#243; la extracci&#243;n completa del adenoma combinado con los beneficios de la cirug&#237;a laparosc&#243;pica&#46; Diversas variantes de la t&#233;cnica han reportado resultados satisfactorios&#44; tanto por v&#237;a laparosc&#243;pica&#44; con asistencia rob&#243;tica&#44; o mediante acceso con puerto &#250;nico<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;27</span></a>&#46; Sin embargo&#44; las publicaciones de grandes series y los estudios comparativos entre AL y cirug&#237;a abierta son escasos&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Presentamos la experiencia en nuestra instituci&#243;n con la adenomectom&#237;a laparosc&#243;pica extraperitoneal &#40;ALE&#41; con el objetivo de evaluar sus resultados compar&#225;ndolos prospectivamente con cirug&#237;a abierta convencional&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="par0020" class="elsevierStylePara elsevierViewall">Posterior a la adquisici&#243;n de experiencia en laparoscopia en Urolog&#237;a&#44; decidimos desarrollar la ALE en nuestro hospital&#46; Dise&#241;amos un estudio prospectivo comparativo entre pacientes con HPB sometidos a cirug&#237;a abierta y otros a cirug&#237;a laparosc&#243;pica&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Entre octubre de 2009 y abril de 2011 se presentaron un total de 46 pacientes con adenomas de pr&#243;stata<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleUnderline">&#62;</span><span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>cc y con indicaci&#243;n para tratamiento quir&#250;rgico&#46; A los primeros 11 pacientes se les realiz&#243; la ALE y fueron excluidos arbitrariamente del estudio comparativo&#44; por considerarlos como per&#237;odo de aprendizaje y desarrollo de la t&#233;cnica&#46; Los siguientes casos se incluyeron en el an&#225;lisis&#44; con un total de 17 pacientes que fueron sometidos a ALE y de 18 a AR&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las indicaciones para cirug&#237;a en pacientes con HPB est&#225;n bien establecidas&#58; pacientes sintom&#225;ticos refractarios al tratamiento m&#233;dico&#44; y&#47;o con presencia de complicaciones como infecciones urinarias repetidas&#44; retenci&#243;n urinaria refractaria&#44; hematuria macrosc&#243;pica refractaria&#44; litiasis vesical e insuficiencia renal provocada por la HPB<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; El estudio no requiri&#243; aprobaci&#243;n del comit&#233; de &#233;tica porque son procedimientos ya establecidos y probados&#46; En todos los pacientes se obtuvo el consentimiento informado y se les realiz&#243; la historia cl&#237;nica y examen f&#237;sico&#46; La evaluaci&#243;n cl&#237;nica incluy&#243;&#58; <span class="elsevierStyleItalic">a</span>&#41; la escala internacional de s&#237;ntomas prost&#225;ticos &#40;<span class="elsevierStyleItalic">International Prostate Symptoms Score</span> &#91;IPSS&#93;&#41;&#59; <span class="elsevierStyleItalic">b</span>&#41; la escala de calidad de vida &#40;<span class="elsevierStyleItalic">Quality of Life Score</span> &#91;QoLs&#93;&#41;&#59; <span class="elsevierStyleItalic">c</span>&#41; laboratorio&#58; PSA total y libre&#44; hemoglobina-hematocrito&#44; creatinina s&#233;rica&#59; <span class="elsevierStyleItalic">d</span>&#41; la medici&#243;n del volumen prost&#225;tico por ultrasonido p&#233;lvico o transrectal&#59; <span class="elsevierStyleItalic">e</span>&#41; la uroflujometr&#237;a &#40;Q<span class="elsevierStyleInf">m&#225;x</span>&#41;&#59; <span class="elsevierStyleItalic">f</span>&#41; la medici&#243;n del volumen residual post-miccional por ultrasonido p&#233;lvico&#59; <span class="elsevierStyleItalic">g</span>&#41; la uretrocistoscopia&#44; que se realiz&#243; solo en casos seleccionados para evaluaci&#243;n de comorbilidades&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Los datos demogr&#225;ficos y los par&#225;metros peri-operatorios y de seguimiento fueron registrados y analizados&#46; Al primer mes del postoperatorio se les realiz&#243; nuevamente el IPSS&#44; el QoLs y el Q<span class="elsevierStyleInf">m&#225;x</span>&#46; Los datos se analizaron mediante la prueba de la &#171;t&#187; Student con el programa Stata v&#46;10&#46;1 &#40;Statcorp&#44; Texas&#44; EE&#46; UU&#46;&#41;&#46; Un valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 se consider&#243; estad&#237;sticamente significativo&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">T&#233;cnica quir&#250;rgica laparosc&#243;pica</span><p id="par0040" class="elsevierStylePara elsevierViewall">Muchos pasos de la t&#233;cnica quir&#250;rgica que empleamos se han descrito previamente<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;28&#44;29</span></a>&#46; Se inicia el abordaje extraperitoneal mediante una incisi&#243;n subumbilical de 1&#44;5<span class="elsevierStyleHsp" style=""></span>cm y se diseca el espacio de Retzius con un tr&#243;car-bal&#243;n de distensi&#243;n &#40;Autosuture PDB 1000<span class="elsevierStyleSup">&#174;</span>&#47;Tyco Healthcare UK Ltd&#44; Gosport&#44; Reino Unido&#41;&#46; Se colocan 4 puertos&#46; El primer tr&#243;car de 10<span class="elsevierStyleHsp" style=""></span>mm con bal&#243;n de sello de gas &#40;Blunt Tip Trocar<span class="elsevierStyleSup">&#174;</span>Autosuture&#47;Tyco Healthcare UK Ltd&#44; Golport&#44; Reino Unido&#41; situado a nivel subumbilical para la inserci&#243;n del laparoscopio&#59; dos tr&#243;cares para el cirujano principal ubicados bilateralmente siguiendo la l&#237;nea pararectal m&#225;s caudal del ombligo&#44; el derecho de 5<span class="elsevierStyleHsp" style=""></span>mm y el izquierdo de 10<span class="elsevierStyleHsp" style=""></span>mm&#46; Un cuarto tr&#243;car de 5<span class="elsevierStyleHsp" style=""></span>mm ubicado por dentro de la espina-il&#237;aca anterosuperior derecha &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Se realiza una incisi&#243;n transversa a nivel de la uni&#243;n v&#233;sico-prost&#225;tica hasta exponer el adenoma sin necesidad de colocar puntos hemost&#225;ticos&#44; puesto que con el bistur&#237; ultras&#243;nico &#40;Ultracision<span class="elsevierStyleSup">&#174;</span> - Ethicon - Johnson &#38; Johnson&#41; se obtiene una hemostasia satisfactoria<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;13&#44;15&#44;18&#44;20&#44;21&#44;25&#44;26</span></a>&#46; En ocasiones&#44; donde se requiri&#243; mejorar la exposici&#243;n se ampli&#243; la incisi&#243;n en forma de &#171;T&#187; invertida sobre la c&#225;psula prost&#225;tica&#46; Seguidamente se realiza una incisi&#243;n transversal sobre el cuello vesical para iniciar el desarrollo del plano de disecci&#243;n&#46; El cirujano sujeta el adenoma y con tracci&#243;n en contra-sentidos sobre la gl&#225;ndula y los bordes de la c&#225;psula se van exponiendo los planos de disecci&#243;n en las distintas caras de la pr&#243;stata para ir liber&#225;ndola&#46; Acercando el laparoscopio se logra identificar con precisi&#243;n el plano de clivaje entre el adenoma y la celda&#46; La enucleaci&#243;n del adenoma se realiza casi por completo con el bistur&#237; ultras&#243;nico&#46; Se introduce por v&#237;a transuretral una buj&#237;a met&#225;lica &#40;Beniqu&#233;&#41; para identificar en el &#225;pex la uretra&#44; y bajo visi&#243;n seccionarla &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a> A y B&#41; Completada la extracci&#243;n del adenoma se constata la hemostasia del lecho prost&#225;tico aplicando el bistur&#237; ultras&#243;nico sobre las &#225;reas de sangrado o se coloca alg&#250;n punto subcapsular&#46; La trigonizaci&#243;n de la mucosa vesical se realiza mediante dos o tres puntos simples de sutura Monocryl<span class="elsevierStyleSup">&#174;</span> 2&#46;0 UR-6 2&#46;0 con el objeto de aproximar el cuello vesical hacia el labio posterior de la uretra o hacia la celda prost&#225;tica &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46; Una sonda vesical Foley de 3 v&#237;as 22<span class="elsevierStyleHsp" style=""></span>Fr es introducida v&#237;a transuretral&#46; La c&#225;psula prost&#225;tica y la vejiga se cierran mediante una l&#237;nea de sutura continua en sentido longitudinal&#46; La estanqueidad de la rafia se verifica mediante la instilaci&#243;n de 120<span class="elsevierStyleHsp" style=""></span>ml de soluci&#243;n en la vejiga&#46; Finalmente&#44; la pieza quir&#250;rgica se introduce en una endo-bolsa&#44; se morcela y se extrae a trav&#233;s de la incisi&#243;n subumbilical&#46; Se deja un drenaje de Jackson-Prat&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Un total de 6 pacientes en cada grupo llevaban sonda permanente por retenci&#243;n aguda de orina en el momento de la operaci&#243;n&#46; De las intervenciones concomitantes durante la cirug&#237;a de pr&#243;stata&#44; se realiz&#243; conjuntamente hernioplastia inguinal en dos pacientes del grupo de AR y tres en el grupo de laparoscopia&#59; tambi&#233;n en dos pacientes de cada grupo se realiz&#243; cistolitotom&#237;a&#46; Los resultados se presentan en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">En la comparaci&#243;n de los datos demogr&#225;ficos&#44; de par&#225;metros cl&#237;nicos&#44; perioperatorios y de seguimiento entre los dos grupos de pacientes no hubo diferencia en t&#233;rminos de edad&#44; volumen prost&#225;tico por ultrasonido&#44; puntuaci&#243;n del IPSS pre y postoperatoria&#44; puntuaci&#243;n del QoLs pre y postoperatoria y peso del esp&#233;cimen&#46; La mejor&#237;a en los valores de Q<span class="elsevierStyleInf">m&#225;x</span> postoperatorio fue evidente en ambos grupos&#44; pero fue mayor en el de cirug&#237;a abierta &#40;Q<span class="elsevierStyleInf">m&#225;x</span>&#58; 24&#44;4<span class="elsevierStyleHsp" style=""></span>ml&#47;s vs&#46; 19&#44;7<span class="elsevierStyleHsp" style=""></span>ml&#47;s&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;016&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El tiempo operatorio fue significativamente m&#225;s prolongado en el grupo de laparoscopia &#40;135&#46;29 vs&#46; 101&#44;2 minutos&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;022&#41;&#46; El resto de los par&#225;metros perioperatorios son m&#225;s breves en el grupo de laparoscopia&#44; obteni&#233;ndose diferencias significativas entre las siguientes variables&#58; <span class="elsevierStyleItalic">a</span>&#41; sangrado intraoperatorio &#40;250<span class="elsevierStyleHsp" style=""></span>ml vs&#46; 493&#44;3<span class="elsevierStyleHsp" style=""></span>ml&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#59; <span class="elsevierStyleItalic">b</span>&#41; tiempo de irrigaci&#243;n &#40;22&#46;2<span class="elsevierStyleHsp" style=""></span>h vs&#46; 39&#44;1<span class="elsevierStyleHsp" style=""></span>h&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;038&#41;&#59; <span class="elsevierStyleItalic">c</span>&#41; tiempo de sondaje &#40;5&#44;5 d&#237;as vs&#46; 7&#44;5 d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;030&#41;&#59; <span class="elsevierStyleItalic">d</span>&#41; estanc&#237;a hospitalaria &#40;3&#44;7 d&#237;as vs&#46; 6&#44;6 d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#46; Un paciente del grupo de laparoscopia no requiri&#243; irrigaci&#243;n&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Hubo diferencias en las complicaciones entre los dos grupos&#59; el de cirug&#237;a abierta present&#243; una mayor incidencia de complicaciones relacionadas con la pared abdominal &#40;absceso de pared en dos pacientes y seroma de la herida operatoria en otros dos&#41;&#44; mientras que en los pacientes de laparoscopia no se present&#243; este tipo de complicaci&#243;n&#46; La hemorragia intraoperatoria fue m&#225;s frecuente en el grupo de cirug&#237;a abierta&#44; donde 4 pacientes &#40;22&#44;2&#37;&#41; requirieron transfusi&#243;n&#44; mientras que en el de laparoscopia no hubo necesidad de hemoderivados&#46; Las complicaciones m&#233;dicas graves fueron escasas en ambos grupos&#59; en el de AR un paciente present&#243; infarto de miocardio que precis&#243; colocaci&#243;n de stents coronarios&#44; y otro present&#243; hematuria macrosc&#243;pica despu&#233;s de la retirada de la sonda&#44; que se resolvi&#243; con nuevo sondaje e irrigaci&#243;n&#46; En el grupo de AL un paciente sufri&#243; un edema agudo de pulm&#243;n que mejor&#243; con tratamiento m&#233;dico y otro present&#243; una f&#237;stula urinaria resuelta con la sonda mantenida durante 9 d&#237;as&#46; La infecci&#243;n urinaria se present&#243; en un paciente de cada grupo&#46; No hubo conversi&#243;n a cirug&#237;a abierta&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0070" class="elsevierStylePara elsevierViewall">A pesar de los resultados favorables reportados en las series de AL&#44; esta no ha alcanzado el impacto que logr&#243; la prostatectom&#237;a radical laparosc&#243;pica &#40;PRL&#41;&#44; porque sus dificultades t&#233;cnicas no se han justificado sobre sus beneficios&#46; La AR es un procedimiento sencillo y bien establecido&#44; con buenos resultados y morbilidad aceptable&#44; por lo que es dif&#237;cil compararla&#46; Sin embargo&#44; en la literatura cient&#237;fica han seguido apareciendo series de AL y asistida por robot realizadas principalmente en centros especializados en laparoscopia y rob&#243;tica<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;7&#44;16&#8211;21</span></a>&#46; La Asociaci&#243;n Americana de Urolog&#237;a&#44; en su &#250;ltima revisi&#243;n de las gu&#237;as cl&#237;nicas del manejo de la HPB del 2010&#44; ya considera la AL como una alternativa quir&#250;rgica<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; La Cleveland Clinic present&#243; una nueva propuesta de AL realizada por acceso con puerto &#250;nico a trav&#233;s de abordaje transvesical&#44; y m&#225;s recientemente present&#243; la combinaci&#243;n de esta t&#233;cnica de <span class="elsevierStyleItalic">single-port</span> combinada con enucleaci&#243;n bipolar endosc&#243;pica<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;30</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Los estudios comparativos entre AL y cirug&#237;a abierta<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a> se&#241;alan que ambos procedimientos son equivalentes con respecto a sus resultados funcionales&#44; y que la laparoscopia aporta beneficios en t&#233;rminos perioperatorios&#46; Sin embargo&#44; son pocas las publicaciones al respecto y con peque&#241;o n&#250;mero de pacientes&#44; siendo la serie de McCullough<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> la m&#225;s grande con 280 casos &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46; La mayor&#237;a de los estudios de AL son series de casos descriptivos no comparativos publicados en revistas indexadas o res&#250;menes de presentaciones en eventos cient&#237;ficos<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a>&#44; donde se documentan las ventajas obtenidas con el abordaje laparosc&#243;pico<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;21</span></a>&#44; muchas de las cuales son propias de la laparoscopia&#46; La mayor&#237;a de los art&#237;culos indican un sangrado bajo&#44; transfusiones ocasionales&#44; tiempos de irrigaci&#243;n y de permanencia de la sonda cortos&#44; estancia hospitalaria breve&#44; pocos requerimientos de analg&#233;sicos&#44; convalecencia corta&#44; efecto cosm&#233;tico y que adem&#225;s permite realizar procedimientos concomitantes como hernioplastia&#44; cistolitotom&#237;a&#44; diverticulectom&#237;a&#44; etc&#46; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46; El sangrado intraoperatorio en la AL es bajo por el efecto de taponamiento venoso que causa el CO<span class="elsevierStyleInf">2</span>&#44; por la cauterizaci&#243;n directa de vasos subcapsulares y por la enucleaci&#243;n meticulosa&#46; Esta ventaja hemost&#225;tica tambi&#233;n provoca una menor incidencia de sangrado postoperatorio&#44; y reduce los requerimientos de irrigaci&#243;n vesical&#59; incluso hay casos que no la han necesitado<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;20</span></a>&#46; De igual forma la incidencia de transfusiones tambi&#233;n es muy baja<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;21</span></a>&#46; Nuestros resultados son comparables con los publicados por otros autores&#44; con sangrado limitado&#44; un tiempo de irrigaci&#243;n corto&#44; sin transfusiones y un paciente no requiri&#243; irrigaci&#243;n&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">La magnificaci&#243;n laparosc&#243;pica permite una visi&#243;n notablemente superior que la obtenida en cirug&#237;a abierta<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;10&#44;12&#44;13&#44;18&#44;20</span></a>&#46; Esto garantiza una enucleaci&#243;n meticulosa con una clara identificaci&#243;n del plano de clivaje entre el adenoma y la c&#225;psula&#44; minimizando el riesgo de avulsi&#243;n de la c&#225;psula&#44; como puede ocurrir en la enucleaci&#243;n &#171;a ciegas&#187; durante la cirug&#237;a abierta&#46; Adem&#225;s permite realizar una coagulaci&#243;n selectiva de vasos sangrantes subcapsulares<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;18&#44;20</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">La introducci&#243;n del laparoscopio en la celda prost&#225;tica permite la identificaci&#243;n precisa de las estructuras anat&#243;micas que nunca se evidencian en cirug&#237;a convencional&#46; La visualizaci&#243;n de la uretra es quiz&#225;s una de las mayores ventajas de la t&#233;cnica laparosc&#243;pica&#44; pues su identificaci&#243;n garantiza un corte uretral preciso que minimiza el riesgo de da&#241;o esfinteriano y de incontinencia urinaria<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Inclusive algunos autores han reportado casos con preservaci&#243;n de la uretra prost&#225;tica para eliminar la necesidad de irrigaci&#243;n y mantener la eyaculaci&#243;n anter&#243;grada<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;15</span></a>&#46; La trigonizaci&#243;n tambi&#233;n se realiza con una calidad &#243;ptima&#44; permitiendo colocar los puntos en el labio posterior de la uretra&#46; Esto garantiza un cubrimiento m&#225;s amplio de la cara interna de la c&#225;psula prost&#225;tica&#44; lo que favorece la reepitelizaci&#243;n y la hemostasia postoperatoria&#46; Anecd&#243;ticamente tambi&#233;n se conoce que algunos autores han realizado anastomosis uretro-vesical completa&#44; aislando as&#237; el paso de la orina de la celda prost&#225;tica&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Las complicaciones inherentes a la herida quir&#250;rgica que pueden aparecer en cualquier cirug&#237;a abierta &#40;como seromas&#44; abscesos de pared&#44; eventraciones&#44; etc&#46;&#41;&#44; principalmente en pacientes portadores de sonda o con c&#225;lculos vesicales infectados&#44; no ocurren en la cirug&#237;a laparosc&#243;pica<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Las desventajas de la AL son las mismas que se han aplicado en la PRL&#58; mayor tiempo operatorio&#44; curva de aprendizaje larga y costes&#46; Los tiempos quir&#250;rgicos son siempre m&#225;s largos en los casos laparosc&#243;picos&#44; y son dependientes de la experiencia del cirujano&#46; Sin embargo&#44; las series que han aplicado la AL con la t&#233;cnica denominada &#171;dedo asistida&#187; han realizado los procedimientos m&#225;s r&#225;pidos<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12&#44;18&#44;21</span></a>&#46; Castillo et al&#46; concluyen que establecer la curva de aprendizaje en AL resulta un tema complicado y dif&#237;cil de definir<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#44; pero es obvio que requiere de entrenamiento y adquisici&#243;n de destrezas&#46; En nuestra opini&#243;n&#44; al igual que Rey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; consideramos que la AL puede formar parte de la curva de aprendizaje en PRL sin los elevados riesgos de impotencia e incontinencia&#46; No existen estudios de costes en AL&#44; pero se pueden aplicar las mismas consideraciones que se han expresado en la PRL&#44; donde los gastos perioperatorios se contraponen a la estancia breve&#44; analgesia reducida&#44; transfusiones minimizadas&#44; reincorporaci&#243;n laboral precoz y menor cantidad de irrigaci&#243;n&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Porpiglia et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;19</span></a> concluyen que la AL se reserva para centros especializados en laparoscopia&#46; A nuestro entender este es el primer art&#237;culo de AL que se realiza desde un hospital comarcal&#44; y nuestros resultados son aproximados a las series publicadas en este tipo de centros&#46; En nuestra opini&#243;n&#44; AL no es una t&#233;cnica dif&#237;cil&#44; y es menos compleja que la de PRL&#44; y aun as&#237; son muchos los hospitales no especializados en laparoscopia que realizan esta cirug&#237;a oncol&#243;gica con resultados satisfactorios&#44; y que pueden estar capacitados para realizar la AL con seguridad&#46; El creciente inter&#233;s en la laparoscopia hace que el porcentaje de ur&#243;logos entrenados en esta t&#233;cnica vaya en ascenso&#59; a diferencia de lo que ocurre con el l&#225;ser la disponibilidad de equipos de laparoscopia es generalizada&#44; por lo cual los elementos para desarrollar la AL est&#225;n presentes si existe convicci&#243;n y entusiasmo&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Las limitaciones de nuestro estudio radican en la poca cantidad de pacientes&#44; lo que imposibilita establecer conclusiones s&#243;lidas&#46; Se necesitan m&#225;s estudios prospectivos con mayor n&#250;mero de pacientes para poder definir el rol definitivo de la AL&#46; Estudios comparativos entre la AL con las t&#233;cnicas enucleaci&#243;n endosc&#243;pica no se han realizado&#44; pero puede suponerse que las ventajas de las t&#233;cnicas laparosc&#243;picas ser&#225;n menos evidentes&#46; Sin embargo&#44; mientras que la adenomectom&#237;a abierta mantenga vigencia y se siga considerando como el tratamiento de elecci&#243;n para la HPB&#44; la AL ser&#225; una alternativa razonable&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusiones</span><p id="par0110" class="elsevierStylePara elsevierViewall">ALE es un procedimiento de cierta complejidad que requiere entrenamiento&#46; Representa una alternativa factible&#44; segura y efectiva en el tratamiento quir&#250;rgico de la HPB con resultados funcionales equivalentes a la cirug&#237;a abierta y con m&#250;ltiples beneficios para el paciente&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0115" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => "Introducci&#243;n"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Pacientes y m&#233;todos"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "T&#233;cnica quir&#250;rgica laparosc&#243;pica"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Resultados"
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        7 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Discusi&#243;n"
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        8 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conclusiones"
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        9 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conflicto de intereses"
        ]
        10 => array:2 [
          "identificador" => "xack35479"
          "titulo" => "Agradecimientos"
        ]
        11 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-07-01"
    "fechaAceptado" => "2011-09-29"
    "PalabrasClave" => array:2 [
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec90109"
          "palabras" => array:3 [
            0 => "Adenomectom&#237;a laparosc&#243;pica"
            1 => "Prostatectom&#237;a simple laparosc&#243;pica"
            2 => "Hiperplasia prost&#225;tica benigna"
          ]
        ]
      ]
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec90108"
          "palabras" => array:3 [
            0 => "Laparoscopic adenomectomy"
            1 => "Simple laparoscopic prostatectomy"
            2 => "Benign prostatic hyperplasia"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A pesar del desarrollo de las t&#233;cnicas endosc&#243;picas&#44; la adenomectom&#237;a abierta sigue siendo el tratamiento de elecci&#243;n para grandes adenomas&#46; La adenomectom&#237;a laparosc&#243;pica y rob&#243;tica reporta buenos resultados en centros especializados&#46; Presentamos la experiencia en nuestra instituci&#243;n comarcal con la adenomectom&#237;a laparosc&#243;pica extraperitoneal &#40;ALE&#41; para evaluar sus resultados y compararlos prospectivamente con cirug&#237;a abierta&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cuarente y seis pacientes con hiperplasia prost&#225;tica benigna &#40;HPB&#41; &#40;pr&#243;statas<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>g&#41; con indicaci&#243;n de cirug&#237;a fueron evaluados&#46; A los primeros 11 pacientes se les realiz&#243; ALE y no fueron incluidos en la comparaci&#243;n&#46; Los siguientes casos fueron comparados&#58; 17 pacientes fueron sometidos a ALE y 18 a cirug&#237;a abierta&#46; En la t&#233;cnica extraperitoneal con 4 tr&#243;cares se realiza la enucleaci&#243;n con bistur&#237; ultras&#243;nico&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">No hubo diferencias significativas entre los grupos con respecto a la edad&#44; el volumen prost&#225;tico&#44; el uroflujo &#40;Q<span class="elsevierStyleInf">m&#225;x</span>&#41;&#44; la escala internacional de s&#237;ntomas prot&#225;ticos &#40;IPSS&#41; y la escala de calidad de vida &#40;QoLs&#41;&#46; El tiempo operatorio fue significativamente mayor en el grupo de ALE &#40;135&#44;2 vs&#46; 101&#44;2 minutos&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;022&#41;&#46; El sangrado intraoperatorio &#40;250 vs&#46; 493&#44;3<span class="elsevierStyleHsp" style=""></span>ml&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41;&#44; el tiempo de irrigaci&#243;n &#40;22&#44;2 vs&#46; 39&#44;1<span class="elsevierStyleHsp" style=""></span>horas&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;038&#41;&#44; el tiempo de permanencia de la sonda &#40;5&#44;5 vs&#46; 7&#44;5 d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;030&#41;&#44; la estancia hospitalaria &#40;3&#44;7 vs&#46; 6&#44;6 d&#237;as&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41; y la tasa de transfusiones &#40;0 vs&#46; 22&#44;2&#37;&#41; fueron significativamente menores en el grupo de laparoscopia&#46; Hubo una mayor incidencia de complicaciones hemorr&#225;gicas y de la herida quir&#250;rgica en el grupo de cirug&#237;a abierta&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ALE es una t&#233;cnica de relativa complejidad que requiere de destrezas laparosc&#243;picas&#44; pero es una alternativa factible y segura a la cirug&#237;a abierta con m&#250;ltiples beneficios&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In spite of the development of endoscopic techniques&#44; open adenomectomy continues to be the treatment of choice for large adenomas&#46; Laparoscopic and robotic adenomectomy provides good results in specialized centers&#46; The experience acquired with laparoscopic extraperitoneal adenomectomy &#40;LEA&#41; in a regional center is presented to evaluate its results and compare them prospectively with the results of open surgery&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">46 patients with benign prostatic hyperplasia &#40;BPH&#41; &#40;prostate &#62;80<span class="elsevierStyleHsp" style=""></span>g&#41; and an indication for surgery were evaluated&#46; The first 11 patients underwent LEA and were not included in the comparison&#46; Thereafter&#44; the cases were compared&#59; 17 patients underwent LEA and 18&#44; open surgery&#46; In the extraperitoneal technique with 4 trocars&#44; enucleation was performed with an ultrasonic scalpel&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">There were no significant differences between groups in age&#44; prostate volume&#44; uroflow &#40;Qmax&#41;&#44; International Prostate Symptom Score &#40;IPSS<span class="elsevierStyleBold">&#41;</span>&#44; Quality of Life scale &#40;QoLs&#41;&#46; The operation time was significantly greater in the LEA group &#40;135&#46;2 vs&#46; 101&#46;2<span class="elsevierStyleHsp" style=""></span>minutes&#44; p&#61;0&#46;022&#41;&#46; Intraoperative bleeding &#40;250 vs&#46; 493&#46;3<span class="elsevierStyleHsp" style=""></span>ml&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; irrigation time &#40;22&#46;2 vs&#46; 39&#46;1<span class="elsevierStyleHsp" style=""></span>hours&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;038&#41;&#44; catheter indwelling time &#40;5&#46;5 vs&#46; 7&#46;5 days&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;030&#41;&#44; hospital stay &#40;3&#46;7 vs&#46; 6&#46;6 days&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41; and transfusion rate &#40;0 vs&#46; 22&#46;2&#37;&#41; were significantly less in the laparoscopy group&#46; There was a greater incidence of hemorrhagic and surgical wound complications in the open surgery group&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">LEA is a relatively complex technique that requires laparoscopic skills&#44; but it is a feasible and safe alternative to open surgery and has several advantages&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Anexo A"
            "titulo" => "Material suplementario"
            "identificador" => "sec0045"
          ]
        ]
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1900
            "Ancho" => 1583
            "Tamanyo" => 189704
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Colocaci&#243;n de 4 tr&#243;cares&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figura 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2569
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            "Tamanyo" => 570891
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        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Visi&#243;n laparosc&#243;pica&#46; A&#46; La magnificaci&#243;n laparosc&#243;pica permite una visi&#243;n superior que garantiza una enucleaci&#243;n meticulosa con una clara identificaci&#243;n del plano de clivaje entre el adenoma y la c&#225;psula&#46; B&#46; La visualizaci&#243;n de la uretra es quiz&#225;s una de las ventajas de la t&#233;cnica laparosc&#243;pica&#44; pues su identificaci&#243;n garantiza un corte uretral preciso que minimiza el riesgo de da&#241;o esfinteriano y de incontinencia urinaria&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figura 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1518
            "Ancho" => 950
            "Tamanyo" => 445354
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La trigonizaci&#243;n se realiza con una calidad &#243;ptima&#44; permitiendo colocar los puntos en el labio posterior de la uretra que garantizan un cubrimiento amplio de la cara interna de la c&#225;psula prost&#225;tica&#44; favoreciendo la reepitelizaci&#243;n y la hemostasia postoperatoria&#46;</p>"
        ]
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      3 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Tabla 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">IPSS&#58; <span class="elsevierStyleItalic">International Prostatic Symptons Score&#59;</span> QoLs&#58; <span class="elsevierStyleItalic">Quality of Life score&#59;</span> Q<span class="elsevierStyleInf">m&#225;x</span>&#58; flujo m&#225;ximo&#46;</p>"
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Grupo laparosc&#243;pico</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Promedio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Rango&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Promedio&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" style="border-bottom: 2px solid black">Rango&nbsp;\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
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">68&#44;1&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">54-82&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">58-79&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">0&#44;234&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="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  " colspan="6" align="char" valign="\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"><span class="elsevierStyleHsp" style=""></span>Volumen por ultrasonido &#40;ml&#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">95&#44;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="char" valign="\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">114&#44;7&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">78-196&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">0&#44;104&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"><span class="elsevierStyleHsp" style=""></span>Peso del esp&#233;cimen &#40;g&#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="char" valign="\n
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                  \t\t\t\t">72&#44;7&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">50-101&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">82&#44;2&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">21-131&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">0&#44;250&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  " colspan="6" 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
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Preoperatorio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">25&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15-35&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\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&nbsp;\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">TO &#40;minutos&#41;&nbsp;\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">Sangrado &#40;ml&#41;&nbsp;\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">Irrigaci&#243;n &#40;horas&#41;&nbsp;\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">Sondaje &#40;d&#237;as&#41;&nbsp;\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">Estancia &#40;d&#237;as&#41;&nbsp;\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">Peso pieza &#40;g&#41;&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
                  \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">Porpiglia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>95&#44;5L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>107&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>687&#44;5L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>411&#44;6&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">NR&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;1L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44;3&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#44;8&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>88&#44;1L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#44;5&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">Baumert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>115&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>643L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>367&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>84L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#44;9&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44;8L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;1&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">NR&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">McCullough et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>184L&#61; 96&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#44;7L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>95&#44;1&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>400L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>350&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>64&#44;8L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#44;6&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44;4L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#44;7L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44;3&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">NR&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">Garcia-Segui y Gasc&#243;n-Mir&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>17&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>101&#44;2L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>135&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>493L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>250&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&#44;1L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#44;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#44;5L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;5&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44;6L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44;7&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">A<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>82&#44;2L<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>72&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Series comparativas entre cirug&#237;a abierta y adenomectom&#237;a laparosc&#243;pica</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AL&#58; adenomectom&#237;a laparosc&#243;pica&#59; NR&#58; no reportado&#59; TO&#58; tiempo operatorio&#46;</p>"
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            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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\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&nbsp;\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">Tipo de Intervenci&#243;n&nbsp;\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">TO &#40;min&#41;&nbsp;\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">Sangrado &#40;ml&#41;&nbsp;\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">Sondaje &#40;d&#237;as&#41;&nbsp;\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">Estancia &#40;d&#237;as&#41;&nbsp;\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">Transfusi&#243;n&nbsp;\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">Peso de la pieza &#40;g&#41;&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
                  \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">van Velthoven et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&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">18&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">AL&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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                            5 => "Y&#46; Niu"
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                      "titulo" => "Mamata&#46; A novel technique combining bipolar and LESS Enucleation for BPH"
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Información del artículo
ISSN: 02104806
Idioma original: Español
Datos actualizados diariamente
año/Mes Html Pdf Total
2023 Marzo 1 2 3
2021 Abril 1 0 1
2020 Octubre 2 2 4
2018 Marzo 1 0 1
2018 Febrero 10 1 11
2018 Enero 17 1 18
2017 Diciembre 16 1 17
2017 Noviembre 32 2 34
2017 Octubre 28 1 29
2017 Septiembre 28 3 31
2017 Agosto 23 2 25
2017 Julio 27 3 30
2017 Junio 52 3 55
2017 Mayo 31 3 34
2017 Abril 20 8 28
2017 Marzo 35 11 46
2017 Febrero 39 2 41
2017 Enero 20 0 20
2016 Diciembre 60 9 69
2016 Noviembre 78 8 86
2016 Octubre 78 11 89
2016 Septiembre 75 9 84
2016 Agosto 33 5 38
2016 Julio 53 2 55
2016 Junio 59 13 72
2016 Mayo 55 24 79
2016 Abril 54 9 63
2016 Marzo 64 17 81
2016 Febrero 48 9 57
2016 Enero 67 12 79
2015 Diciembre 43 7 50
2015 Noviembre 54 4 58
2015 Octubre 37 7 44
2015 Septiembre 28 3 31
2015 Agosto 60 6 66
2015 Julio 77 7 84
2015 Junio 47 5 52
2015 Mayo 43 9 52
2015 Abril 64 7 71
2015 Marzo 61 7 68
2015 Febrero 55 6 61
2015 Enero 54 6 60
2014 Diciembre 63 12 75
2014 Noviembre 63 7 70
2014 Octubre 68 8 76
2014 Septiembre 87 4 91
2014 Agosto 62 4 66
2014 Julio 80 9 89
2014 Junio 70 11 81
2014 Mayo 56 9 65
2014 Abril 32 9 41
2014 Marzo 47 6 53
2014 Febrero 26 8 34
2014 Enero 1 0 1
2013 Diciembre 10 1 11
2013 Noviembre 14 5 19
2013 Octubre 9 2 11
2013 Septiembre 3 1 4
2013 Agosto 1 2 3
2012 Febrero 1449 0 1449
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es en pt

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos