OBSTRUCCIÓN URETRAL EN GATOS
DOI:
https://doi.org/10.35172/rvz.2020.v27.531Palabras clave:
cateterismo, gato doméstico, uretraResumen
La obstrucción uretral es una condición clínica de emergencia, comúnmente vista en gatos, que puede resultar en un deterioro grave de su salud, como daño renal agudo. Esta condición puede tener causas mecánicas, anatómicas o funcionales, y presentar extrañeza, periuria y lamido excesivo de los genitales como síntomas principales. El diagnóstico se realiza con base en la historia, examen físico y de imagen, como ecografía y radiografía, y la identificación de la etiología es de suma importancia para instituir el tratamiento y reducir la recurrencia. Al diagnosticar la enfermedad, el inicio del tratamiento debe ser inmediato e intensivo, debido al riesgo de evolucionar rápidamente a la muerte. En este sentido, buscamos corregir las alteraciones hidroelectrolíticas, aportar analgesia y realizar el aclaramiento uretral, con una variación en este último procedimiento, por lo que la elección del método más adecuado puede variar según cada caso. A partir de la complejidad de su establecimiento, diagnóstico y tratamiento, este artículo de revisión tuvo como objetivo recopilar información actual y relevante relacionada con la condición de obstrucción uretral en gatos, buscando enfatizar los aspectos clínicos, quirúrgicos y etiológicos de la enfermedad, así como orientar a los médicos veterinarios en su tratamiento y prevención.
Citas
1 Trangerud C, Ottesen N, Eggertsdo AV. Causes of lower urinary tract 354 disease in Norwegian cats. J Feline Med Surg. 2011;355:410-417.
2 Segev G, Livne H, Ranen E, Lavy E. Urethral obstruction in cats: predisposing factors, clinical, clinicopathological characteristics and prognosis. J Feline Med Surg. 2011;13:101-108.
3 Saevik BK, Trangerud C, Ottesen N, Sorum H, Eggertsdottir AV. Causes of lower urinary tract disease in Norwegian cats. J Feline Med Surg. 2011;13:410–417.
4 Nevins JR, Mai W, Thomas E. Associations between ultrasound and clinical findings in 87 cats with urethral obstruction. Vet Radiol Ultrasound. 2015;56:439–447.
5 Borges NCS, Sampaio MAP, Pereira VA, Figueiredo MA, Chagas MA. Effects of castration on penile extracellular matrix morphology in domestic cats. J Feline Med Surg. 2017;215:1-6.
6 Silva TC, Barretot BM, Andradem B, De Mirandaa LS, Guimarães-Bassolia CD. Conhecimento e percepção dos médicos veterinários do hospital veterinário da UFRPE sobre a castração pediátrica. Revista de Educação Continuada em Medicina Veterinária e Zootecnia. 2016;13:72-72.
7 Defauw PA, Maele IV, Duchateau L. Risk factors and clinical presentation of cats with feline idiopathic cystitis. J Feline Med Surgery. 2011;13(12):967-975.
8 Lew-Kojrys S, Mikulska-Skupien E, Snarska A, Krystkiewicz W, Pomianowski A. Evaluation of clinical signs and causes of lower: urinary tract disease in Polish cats. Vet Med (Praha). 2017;62(7):386–393.
9 Costa FVA. Contribuição ao estudo da doença do trato urinário inferior feline. Medvep - Rev Cient Med Vet – Peq Anim Anim Est. 2009;7(23):448-463.
10 Corgozinho KB, Souza HJM, Pereira AN, Belchior C, Silva MA, Martins MCL, Damico CB. Catheter-introduced urethral trauma in cats with urethral obstruction. J Feline Med Surgery. 2007;9:481-486.
11 Lee JA, Drobatz KJ. Characterization of the Clinical Characteristics, Electrolytes, Acid-Base, and Renal Parameters in Male cats with Urethral Obstruction. J Vet Emerg Crit Care (San Antonio). 2003;13:227-233.
12 Porters N, Polis I, Moons CPH, Maele IV, Ducatelle R, Goethals K, Duchateau L, Rooster H. Relationship between age at gonadectomy and health problems in kittens adopted from shelters. Vet Rec Open, 2015;176:572-576.
13 Herron MA. The effect of prepubertal castration on the penile urethra of the cat. J Am Vet Med Assoc. 1972;160:208–211.
14 Ferreira GS, Carvalho MB, Avante MB. Características epidemiológicas, clínicas e laboratoriais de gatos com sinais de doença do trato urinário inferior. Farriers Mag. 2014;19:42-50.
15 Larsen JA. Risk of obesity in the neutered cat. J Feline Med Surgery. 2017;19:779–783.
16 Lund HS, Eggertsdóttir AV. Recurrent episodes of feline lower urinary tract disease with different causes: possible clinical implications. J Feline Med Surgery. 2019;21:590-594.
17 Hostutler RA, Chew DJ, Dibatola SP. Recent concepts in feline lower urinary tract disease. Vet Clin North Am Small Anim Pract. 2005;35:147-170.
18 Le Boedec K, Pastor ML, Lavoue R. Pseudomembranous cystitis, an unusual condition associated with feline urine outflow obstruction: four cases. J Feline Med Surgery. 201;13:588–593.
19 Siddiqui H, Nederbragt AJ, Lagesen K, Jeansson SL, Jakobsen KS. Assessing diversity of the female urine microbiota by high throughput sequencing of 16S rDNA amplicons. BMC Microbiologic. 2011;11:244-247.
20 Eggertsdóttir AV, Saevik BK, Halvorsen I, Sorum H. Occurrence of occult bacteriuria in healthy cats. J Feline Med Surgery. 2011;13:800-803.
21 Puchot ML, Cook AK, Pohlit C. Subclinical bacteriuria in cats: prevalence, findings on contemporaneous urinalyses and clinical risk factors. J Feline Med Surgery. 2017;19:1238–1244.
22 Eggertsdottir AV, Lund HS, Krontveit R, Sorum H. Bacteriuria in cats with feline lower urinary tract disease: a clinical study of 134 cases in Norway. J Feline Med Surgery. 2007;9:458–465.
23 Dorsch R, Remer C, Sauter-Louis C, Hartmann K. Feline lower urinary tract disease in a German cat population. A retrospective analysis of demographic data causes and clinical signs. Tierarztl Prax Ausg G Grosstiere Nutztiere. 2014;42:231–239.
24 Galvão ALB, Ondani AC, Frazílio FO, Guadalupe SF. Obstrução uretral em gatos machos – revisão literária. Acta Vet Brasil. 2010;4:1-6.
25 Dowers K. Nonobstructive idiopathic feline lower urinary tract disease: How to approach a puzzling disorder. 2009 [cited 2020 set 02]. Available from: < https://www.dvm360.com>.
26 Walker D. Feline urethral obstruction: a clinical refresh. Ir Vet J. 2009;62:198-202.
27 Tag TL, Thomas KD. Electrocardiographic assessment of hyperkalemia in dogs and cats. J Vet Emerg Crit Care (San Antonio), Columbus. 2008;18:61–67.
28 Hecht S. Diagnostic imaging of lower urinary tract disease. Vet Clin North Am Small Anim Pract. 2015;45:639-663.
29 Kellum JA. Acute Kidney Injury. Crit Care Med. 2008;36:141-152.
30 Fischer JR, Lane IF, Stokes J. Acute postrenal azotemia: etiology, clinicopathology, and pathophysiology. Compend Contin Educ Vet. 2009;31:520–530.
31 Neto OMV, Neto MM. Distúrbios do equilíbrio hidroeletrolítico. Revista da Faculdade de Medicina de Ribeirão Preto. 2003;36:325-337.
32 Reche-Jr A, Hagiwara MK. Semelhanças entre a doença idiopática do trato urinário inferior dos felinos e a cistite intersticial humana. Ciência Rural. 2004;34:315-321.
33 Neri AM, Machado LHA, Okamoto PTG, Filippi MG, Takahira RK, Melchert A, Lourenço MLG. Routine screening examinations in attendance of cats with obstructive lower urinary tract disease. Top Companion Anim Med. 2016;31:140-145.
34 Brabson TL, Bloch CP, Johnson JA. Correlation of gross urine color with diagnostic findings in male cats with naturally occurring urethral obstruction. J Feline Med Surgery. 2015;17:453– 457.
35 Gunn-Moore DA. Feline lower urinary tract disease. J Feline Med Surgery. 2003;5:133-138.
36 Bailiff NL, Nelson RW, Feldman EC, Westropp JL, Ling GV, Jang SS. Frequency and risk factors for urinary tract infection in cats with diabetes mellitus. J Vet Intern Med. 2006;20:850–855.
37 Gerber B, Eichenberger S, Reusch CE. Guarded log-term prognosis in male cats with urethral obstruction. J Feline Med Surgery. 2008;10:16-23.
38 Norman BC, Côté E, Barrett KA. Wide-complex tachycardia associated with severe hiperkalemya in three cats. J Feline Med Surgery. 2006;8:372-378.
39 Cunha MG, Freitas GC, Carregaro AB, Gomes K, Cunha JP, Beckmann DV, Pippi NL. Renal and cardio-respiratory effects of treatment with lactated Ringer’s solution or physiologic saline (0.9% NaCl) solution in cats with experimentally induced urethral obstruction. Am J Vet Res. 2010;71:840-846.
40 Rieser TM. Urinary tract emergencies. Vet Clin North Am Small Anim Pract. 2005;35:359-373.
41 Dorsch R, Zellner F, Schulz B, Sauter-Louis C, Hartmann K. Evaluation of meloxicam for the treatment of obstructive feline idiopathic cystitis. J Feline Med Surgery. 2016;18:925-933.
42 Westropp JL. Cats with lower urinary tract sings. Vet Focus. 2007;17(1):10-17.
43 Drebing MR, Fui Y, Mayank S, Ruth D, Elisabet D. Membrane-like structure in the urinary bladder neck of a young cat: diagnosis and treatment usin balloon dilatation and a balloonexpandable metallic stent. J Feline Med Surgery. 2017;3:232-235.
44 Leal LM, Crivelenti LZ, Cipolli VMM, Lima TB, Morato GO, Moraes PC. Uretrostomia pré-púbica após ruptura uretral em felino com doença do trato urinário inferior. Clín Vet. 2012;97:100-104.
45Balakrishnan A, Drobatz KJ. Management of urinary tract emergencies in small animals. Vet Clin North Am Small Anim Pract. 2013;43:843–867.
46 Seitz MA, Creedon JMB, Drobatz KJ. Evaluation for association between indwelling urethral catheter placement and risk of recurrent urethral obstruction in cats. J Am Vet Med Assoc. 2018;252:1509-1520.
47 Bartges JW, Kirk C, Lane IF. Update: management of calcium oxalate uroliths in dogs and cats. Vet Clin North Am Small Anim Pract. 2004;34:969–987.
48 Williams J. Surgical management of blocked cats: Which approach and when? J Feline Med Surgery. 2009;11:14-22.
49 Nye AK, Luther JK. Feline perineal urethrostomy: a review of past and present literature. Top Companion Anim Med. 2018;33:77–82.
50 Acar SA, Sarouglu M, Sadalak DJ. Prepucial urethrostomy performed using the coating technique (in Turkish). Turk J Vet Anim Sci. 2010;34:7-16.
51 Papazoglou LG, Basdani E. Perineal urethrostomy in the cat. Technique and complications. J Hellenic Vet Med Soc. 2011;62:150-160.
52 Bass M, Howard J, Gerber B, Messmer M. Retrospective study of indications for and outcome of perineal urethrostomy in cats. J Small Anim Pract. 2005;46:227-231.
53 Sousa-Filho RP, Nunes-Pinheiro DCS, Sampaio KO, Silva BCE, Cavalcanti GASA, Cunha MGMC. Clinical outcomes of 28 cats 12-24 months afer urethrostomy. J Feline Med Surgery. 2019;23:1-8.
54 Paulo NM, Silva FF, Brito GA, Damasceno AD, Brito LAB, Freitas JS, Neves PL, Akinaga MH, Barbosa LM, Cleizony MV. Reconstrução uretral com retalho autógeno de mucosa bucal após uretrostomia em cães. Acta Cirúrgica Brasileira. 2004;19:110-114.
55 Palumbo MIP, Machado LHA, Romão FG. Manejo da Insuficiência renal aguda em cães e gatos. Arq Cienc Vet Zoo UNIPAR. 2011;14:73-76.
56 Singh SK, Agarwal MM, Sharma S. Medical therapy for calculus disease. BJUI Compass. 2011;107:356-359.
57 Lotan Y, Jiménez IB, Lenoir-Wijnkoop IL, Daudon M, Molinier L, Tack I, Nuijten MJC. Increased Water Intake as a Prevention Strategy for Recurrent Urolithiasis: Major Impact of Compliance on Cost-Effectiveness. J Uro. 2013;189:935-939.
58 Forrester SD, Towell TL. Feline idiopathic cystitis. Vet Clin North Am Small Anim Pract. 2015;45:783-806.
59 Sturgess K. Dietary management of canine urolithiasis. In Practice. London. 2009;31:306-312.
60 Ruda L, Heiene R. Short- and long-term outcome after perineal urethrostomy in 86 cats with feline lower urinary tract disease. J Small Anim Pract. 2012;53:693–698.
2 Segev G, Livne H, Ranen E, Lavy E. Urethral obstruction in cats: predisposing factors, clinical, clinicopathological characteristics and prognosis. J Feline Med Surg. 2011;13:101-108.
3 Saevik BK, Trangerud C, Ottesen N, Sorum H, Eggertsdottir AV. Causes of lower urinary tract disease in Norwegian cats. J Feline Med Surg. 2011;13:410–417.
4 Nevins JR, Mai W, Thomas E. Associations between ultrasound and clinical findings in 87 cats with urethral obstruction. Vet Radiol Ultrasound. 2015;56:439–447.
5 Borges NCS, Sampaio MAP, Pereira VA, Figueiredo MA, Chagas MA. Effects of castration on penile extracellular matrix morphology in domestic cats. J Feline Med Surg. 2017;215:1-6.
6 Silva TC, Barretot BM, Andradem B, De Mirandaa LS, Guimarães-Bassolia CD. Conhecimento e percepção dos médicos veterinários do hospital veterinário da UFRPE sobre a castração pediátrica. Revista de Educação Continuada em Medicina Veterinária e Zootecnia. 2016;13:72-72.
7 Defauw PA, Maele IV, Duchateau L. Risk factors and clinical presentation of cats with feline idiopathic cystitis. J Feline Med Surgery. 2011;13(12):967-975.
8 Lew-Kojrys S, Mikulska-Skupien E, Snarska A, Krystkiewicz W, Pomianowski A. Evaluation of clinical signs and causes of lower: urinary tract disease in Polish cats. Vet Med (Praha). 2017;62(7):386–393.
9 Costa FVA. Contribuição ao estudo da doença do trato urinário inferior feline. Medvep - Rev Cient Med Vet – Peq Anim Anim Est. 2009;7(23):448-463.
10 Corgozinho KB, Souza HJM, Pereira AN, Belchior C, Silva MA, Martins MCL, Damico CB. Catheter-introduced urethral trauma in cats with urethral obstruction. J Feline Med Surgery. 2007;9:481-486.
11 Lee JA, Drobatz KJ. Characterization of the Clinical Characteristics, Electrolytes, Acid-Base, and Renal Parameters in Male cats with Urethral Obstruction. J Vet Emerg Crit Care (San Antonio). 2003;13:227-233.
12 Porters N, Polis I, Moons CPH, Maele IV, Ducatelle R, Goethals K, Duchateau L, Rooster H. Relationship between age at gonadectomy and health problems in kittens adopted from shelters. Vet Rec Open, 2015;176:572-576.
13 Herron MA. The effect of prepubertal castration on the penile urethra of the cat. J Am Vet Med Assoc. 1972;160:208–211.
14 Ferreira GS, Carvalho MB, Avante MB. Características epidemiológicas, clínicas e laboratoriais de gatos com sinais de doença do trato urinário inferior. Farriers Mag. 2014;19:42-50.
15 Larsen JA. Risk of obesity in the neutered cat. J Feline Med Surgery. 2017;19:779–783.
16 Lund HS, Eggertsdóttir AV. Recurrent episodes of feline lower urinary tract disease with different causes: possible clinical implications. J Feline Med Surgery. 2019;21:590-594.
17 Hostutler RA, Chew DJ, Dibatola SP. Recent concepts in feline lower urinary tract disease. Vet Clin North Am Small Anim Pract. 2005;35:147-170.
18 Le Boedec K, Pastor ML, Lavoue R. Pseudomembranous cystitis, an unusual condition associated with feline urine outflow obstruction: four cases. J Feline Med Surgery. 201;13:588–593.
19 Siddiqui H, Nederbragt AJ, Lagesen K, Jeansson SL, Jakobsen KS. Assessing diversity of the female urine microbiota by high throughput sequencing of 16S rDNA amplicons. BMC Microbiologic. 2011;11:244-247.
20 Eggertsdóttir AV, Saevik BK, Halvorsen I, Sorum H. Occurrence of occult bacteriuria in healthy cats. J Feline Med Surgery. 2011;13:800-803.
21 Puchot ML, Cook AK, Pohlit C. Subclinical bacteriuria in cats: prevalence, findings on contemporaneous urinalyses and clinical risk factors. J Feline Med Surgery. 2017;19:1238–1244.
22 Eggertsdottir AV, Lund HS, Krontveit R, Sorum H. Bacteriuria in cats with feline lower urinary tract disease: a clinical study of 134 cases in Norway. J Feline Med Surgery. 2007;9:458–465.
23 Dorsch R, Remer C, Sauter-Louis C, Hartmann K. Feline lower urinary tract disease in a German cat population. A retrospective analysis of demographic data causes and clinical signs. Tierarztl Prax Ausg G Grosstiere Nutztiere. 2014;42:231–239.
24 Galvão ALB, Ondani AC, Frazílio FO, Guadalupe SF. Obstrução uretral em gatos machos – revisão literária. Acta Vet Brasil. 2010;4:1-6.
25 Dowers K. Nonobstructive idiopathic feline lower urinary tract disease: How to approach a puzzling disorder. 2009 [cited 2020 set 02]. Available from: < https://www.dvm360.com>.
26 Walker D. Feline urethral obstruction: a clinical refresh. Ir Vet J. 2009;62:198-202.
27 Tag TL, Thomas KD. Electrocardiographic assessment of hyperkalemia in dogs and cats. J Vet Emerg Crit Care (San Antonio), Columbus. 2008;18:61–67.
28 Hecht S. Diagnostic imaging of lower urinary tract disease. Vet Clin North Am Small Anim Pract. 2015;45:639-663.
29 Kellum JA. Acute Kidney Injury. Crit Care Med. 2008;36:141-152.
30 Fischer JR, Lane IF, Stokes J. Acute postrenal azotemia: etiology, clinicopathology, and pathophysiology. Compend Contin Educ Vet. 2009;31:520–530.
31 Neto OMV, Neto MM. Distúrbios do equilíbrio hidroeletrolítico. Revista da Faculdade de Medicina de Ribeirão Preto. 2003;36:325-337.
32 Reche-Jr A, Hagiwara MK. Semelhanças entre a doença idiopática do trato urinário inferior dos felinos e a cistite intersticial humana. Ciência Rural. 2004;34:315-321.
33 Neri AM, Machado LHA, Okamoto PTG, Filippi MG, Takahira RK, Melchert A, Lourenço MLG. Routine screening examinations in attendance of cats with obstructive lower urinary tract disease. Top Companion Anim Med. 2016;31:140-145.
34 Brabson TL, Bloch CP, Johnson JA. Correlation of gross urine color with diagnostic findings in male cats with naturally occurring urethral obstruction. J Feline Med Surgery. 2015;17:453– 457.
35 Gunn-Moore DA. Feline lower urinary tract disease. J Feline Med Surgery. 2003;5:133-138.
36 Bailiff NL, Nelson RW, Feldman EC, Westropp JL, Ling GV, Jang SS. Frequency and risk factors for urinary tract infection in cats with diabetes mellitus. J Vet Intern Med. 2006;20:850–855.
37 Gerber B, Eichenberger S, Reusch CE. Guarded log-term prognosis in male cats with urethral obstruction. J Feline Med Surgery. 2008;10:16-23.
38 Norman BC, Côté E, Barrett KA. Wide-complex tachycardia associated with severe hiperkalemya in three cats. J Feline Med Surgery. 2006;8:372-378.
39 Cunha MG, Freitas GC, Carregaro AB, Gomes K, Cunha JP, Beckmann DV, Pippi NL. Renal and cardio-respiratory effects of treatment with lactated Ringer’s solution or physiologic saline (0.9% NaCl) solution in cats with experimentally induced urethral obstruction. Am J Vet Res. 2010;71:840-846.
40 Rieser TM. Urinary tract emergencies. Vet Clin North Am Small Anim Pract. 2005;35:359-373.
41 Dorsch R, Zellner F, Schulz B, Sauter-Louis C, Hartmann K. Evaluation of meloxicam for the treatment of obstructive feline idiopathic cystitis. J Feline Med Surgery. 2016;18:925-933.
42 Westropp JL. Cats with lower urinary tract sings. Vet Focus. 2007;17(1):10-17.
43 Drebing MR, Fui Y, Mayank S, Ruth D, Elisabet D. Membrane-like structure in the urinary bladder neck of a young cat: diagnosis and treatment usin balloon dilatation and a balloonexpandable metallic stent. J Feline Med Surgery. 2017;3:232-235.
44 Leal LM, Crivelenti LZ, Cipolli VMM, Lima TB, Morato GO, Moraes PC. Uretrostomia pré-púbica após ruptura uretral em felino com doença do trato urinário inferior. Clín Vet. 2012;97:100-104.
45Balakrishnan A, Drobatz KJ. Management of urinary tract emergencies in small animals. Vet Clin North Am Small Anim Pract. 2013;43:843–867.
46 Seitz MA, Creedon JMB, Drobatz KJ. Evaluation for association between indwelling urethral catheter placement and risk of recurrent urethral obstruction in cats. J Am Vet Med Assoc. 2018;252:1509-1520.
47 Bartges JW, Kirk C, Lane IF. Update: management of calcium oxalate uroliths in dogs and cats. Vet Clin North Am Small Anim Pract. 2004;34:969–987.
48 Williams J. Surgical management of blocked cats: Which approach and when? J Feline Med Surgery. 2009;11:14-22.
49 Nye AK, Luther JK. Feline perineal urethrostomy: a review of past and present literature. Top Companion Anim Med. 2018;33:77–82.
50 Acar SA, Sarouglu M, Sadalak DJ. Prepucial urethrostomy performed using the coating technique (in Turkish). Turk J Vet Anim Sci. 2010;34:7-16.
51 Papazoglou LG, Basdani E. Perineal urethrostomy in the cat. Technique and complications. J Hellenic Vet Med Soc. 2011;62:150-160.
52 Bass M, Howard J, Gerber B, Messmer M. Retrospective study of indications for and outcome of perineal urethrostomy in cats. J Small Anim Pract. 2005;46:227-231.
53 Sousa-Filho RP, Nunes-Pinheiro DCS, Sampaio KO, Silva BCE, Cavalcanti GASA, Cunha MGMC. Clinical outcomes of 28 cats 12-24 months afer urethrostomy. J Feline Med Surgery. 2019;23:1-8.
54 Paulo NM, Silva FF, Brito GA, Damasceno AD, Brito LAB, Freitas JS, Neves PL, Akinaga MH, Barbosa LM, Cleizony MV. Reconstrução uretral com retalho autógeno de mucosa bucal após uretrostomia em cães. Acta Cirúrgica Brasileira. 2004;19:110-114.
55 Palumbo MIP, Machado LHA, Romão FG. Manejo da Insuficiência renal aguda em cães e gatos. Arq Cienc Vet Zoo UNIPAR. 2011;14:73-76.
56 Singh SK, Agarwal MM, Sharma S. Medical therapy for calculus disease. BJUI Compass. 2011;107:356-359.
57 Lotan Y, Jiménez IB, Lenoir-Wijnkoop IL, Daudon M, Molinier L, Tack I, Nuijten MJC. Increased Water Intake as a Prevention Strategy for Recurrent Urolithiasis: Major Impact of Compliance on Cost-Effectiveness. J Uro. 2013;189:935-939.
58 Forrester SD, Towell TL. Feline idiopathic cystitis. Vet Clin North Am Small Anim Pract. 2015;45:783-806.
59 Sturgess K. Dietary management of canine urolithiasis. In Practice. London. 2009;31:306-312.
60 Ruda L, Heiene R. Short- and long-term outcome after perineal urethrostomy in 86 cats with feline lower urinary tract disease. J Small Anim Pract. 2012;53:693–698.
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2020-12-06
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de oliveira sampaio keytyanne, ALEIXO GA de S, Sousa-Filho RP de, Silva ECB da. OBSTRUCCIÓN URETRAL EN GATOS. RVZ [Internet]. 6 de diciembre de 2020 [citado 3 de diciembre de 2024];27:1-12. Disponible en: https://rvz.emnuvens.com.br/rvz/article/view/531
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