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For right-sided tumors of the renal pelvis and proximal ureter, lymphadenectomy of the hilar, paracaval, and retrocaval nodes captured 82. Lymph node involvement is reported in 12% to 25% of sufferers, though it increases with advanced stage and grade. However, the median variety of nodes eliminated and boundaries of lymphadenectomy diversified extensively in these studies (Weight and Gettman, 2011). The significance of the number of lymph nodes eliminated was addressed by Roscigno et al. For patients with muscle invasive tumors of renal pelvis, template lymphadenectomy was an impartial predictor of general survival in multivariate evaluation (Kondo et al. Several different studies explored the consequences of lymphadenectomy on survival, suggesting a possible therapeutic benefit (Brausi et al. The latter research additionally addressed the perioperative complications, citing 13% total complication rate for renal pelvis disease and 15% for ureteral illness, including 5. These numbers had been according to other studies for open and laparoscopic surgery (Abe et al. It is protected and helpful for accurate staging and appears to have prognostic and therapeutic value in patients with invasive illness (T2-T4), particularly within the setting of tumors of renal pelvis and proximal ureter. Results Multiple collection reported on sturdy correlation of end result with tumor stage and grade. The risk of tumor recurrence in a remaining ureteral stump is 30% to 75% (Babaian and Johnson, 1980; Bloom et al. Techniques similar to easy extravesical dissection and tenting up of the ureter end in an incomplete removal of the distal ureter (Strong et al. The strategies had been divided into definitive, which included any approach that resulted in excision of distal ureter with bladder mucosal cuff, and nondefinitive, which included detachment of the ureter at or above the level of detrusor. Nondefinitive management of the distal ureter was associated with a better fee of local and distal recurrence and inferior disease-specific and general survival. Complete ureterectomy with a bowel cuff should also be performed within the setting of a renal unit draining right into a urinary diversion. Chapter 99 Surgical Management of Upper Urinary Tract Urothelial Tumors 2207 Multiple sequence recommend radical nephroureterectomy as a remedy that gives optimum oncologic control (Batata et al. Although the info for open and laparoscopic cases have been pooled collectively, the bulk (77%) had open nephroureterectomy. The pT stage was evenly distributed between Ta, T1, T2, and T3, but lower than 5% of sufferers had every T0, Tcis, or T4. Around 10% of sufferers had lymph node positivity, and 16% received perioperative chemotherapy. In summary, radical nephroureterectomy provides reasonable oncologic management, with outcomes largely dependent on clinicopathological traits. It is warranted for patients with high-grade invasive organ confined or regionally superior disease (stage T1�4, N0�2, M0). Treatment selections in sufferers with compromised renal function should balance the potential curative effect of radical surgery to the morbidity related to dialysis. Segmental Ureteral Resection For purposes of this section, segmental ureterectomy primarily indicates distal ureterectomy with ureteral reimplant. Segmental resection carried out to protect renal perform in patients with compromised renal perform must not compromise oncologic efficacy for the sake of avoiding the morbidity associated with dialysis. In addition, if high-grade illness is current, many practitioners additionally do an ipsilateral pelvic lymph node dissection. Advantages to a segmental ureterectomy are the flexibility to protect renal operate whereas additionally offering a pathological specimen that may inform the need and extent of adjuvant remedy. Achieving a transparent margin and still having the flexibility to mobilize sufficient well-vascularized ureter to perform a tension-free anastomosis is paramount to the success of this procedure and the major limiting problem. A flank incision from the tip of the 12th rib supplies entry to the proximal ureter or mid-ureter. With use of an extraperitoneal strategy, the ureter is identified, mobilized, and secured with vessel loops. After regional lymphadenectomy is performed, both ends of the ureter are spatulated and anastomosed with an interrupted 4-0 Vicryl suture. The success of reconstruction is dependent upon preservation of the blood supply to the ureter and sufficient mobilization of the ureteral edges to achieve a tension-free anastomosis. If a big segment of ureter is excised, mobilization and descensus of kidney could additionally be performed to present extra size to the proximal ureter. For laparoscopic or robotic approaches, the patient can be in flank position and the trocar placement is similar as to a pyeloplasty or nephrectomy. Extreme care is taken to comply with oncologic ideas to guarantee nonviolation of tumor and acquire adverse margins. Distal Ureterectomy and Direct Neocystostomy or Ureteroneocystostomy With a Bladder Psoas Muscle Hitch or a Boari Flap. The distal ureterectomy is carried out as described within the prior part, with the exception that the whole distal ureter and bladder cuff should be excised, and the posterior cystotomy at the bladder cuff site is closed in two layers. For laparoscopic or robotic approaches, the affected person is placed in dorsolithotomy or supine and in Trendelenburg place, just like an method for prostatectomy. Ureterovesical anastomosis may be carried out utilizing an extravesical or intravesical strategy. Whether to perform a refluxing or nonrefluxing anastomosis stays a matter of debate. The advantages of a nonrefluxing anastomosis embrace a restrict of infection to the lower tract and the theoretic possibility of avoiding seeding of the higher tract. If an extravesical approach is desired, bladder detrusor muscle is incised, exposing the mucosa. An anastomosis is carried out using continuous or interrupted 3-0 polyglactin or polydioxanone sutures via the full thickness of the ureter and bladder mucosa. At the distal portion of the anastomosis, two of those sutures are handed by way of the full thickness wall of the bladder to anchor the ureter and prevent sliding out of the tunnel. The bladder detrusor is then closed on the highest of the ureter with interrupted absorbable sutures, corresponding to 2-0 polyglactin, to achieve a nonrefluxing mechanism. An incision is made on the posterolateral wall of the bladder and a 2- to 3-cm submucosal tunnel is customary. After the ureter is spatulated, the anastomosis is performed with interrupted absorbable sutures. The bladder is mobilized anteriorly and laterally, and in girls the spherical ligament is split. The contralateral superior vesical artery and whole lateral pedicle may also be divided to achieve further mobility.

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We choose to use this place for all bulbar and posterior urethral reconstructions. We find the more exaggerated place to be safe and believe it supplies unequaled access to the deep perineal buildings (Angermeier and Jordan, 1994). In addition to proper diagnosis and planning, the surgical method is essential for the general success of reconstructive surgery. In contrast to the results of extirpative surgical procedure, the results of reconstructive surgery rely upon methods that reduce tissue damage and maximize wound healing. The key elements are enough visualization, appropriate selection of suture, delicate tissue dealing with, applicable positioning, and enough retraction. Loupe magnification is utilized by nearly all surgeons performing grownup and pediatric reconstructive surgical procedure. Instruments have to be delicate as a outcome of reconstructive surgery employs small sutures and small needles. However, absorbable materials are the rule, and the caliber of sutures must be the smallest possible to align the tissue tension free. During that part, the graft survives by "drinking" vitamins from the adjoining graft host bed, and the temperature of the graft is lower than the core body temperature. The second section, inosculation, also requires about 48 hours and is the phase in which true microcirculation is reestablished in the graft. During that phase, the temperature of the graft will increase to core physique temperature. The process of take is influenced by the character of the grafted tissue and the conditions of the graft host mattress. Processes that intervene with the vascularity of the graft host bed intervene with graft take. The graft also exposes the superficial dermal (intradermal or intralaminar) plexus. In most grafts, the superficial plexus contains small but quite a few vessels, which convey favorable vascular characteristics to a split-thickness unit. After the harvest of a sheet graft, the sheet is placed on a provider that cuts systematically positioned slits within the graft. It has additionally been proposed that mesh grafts take readily because of elevated ranges of growth factors, presumably as a perform of the slits. Variable characteristics similar to color, texture, thickness, extensibility, innate pores and skin tension, and blood supply may be helpful in numerous conditions. Mucosa from different sources have been used in genitourinary reconstructive surgery with glorious results. The time period tissue switch implies the movement of tissue for purposes of reconstruction. The dermis has two layers: a superficial layer, the adventitial dermis (also known as the papillary or periadnexal dermis, relying on the anatomy), and a deep layer, the reticular dermis. Other tissues commonly transferred for genitourinary reconstruction embrace bladder and oral mucosa in addition to rectal. The bladder epithelium is the superficial layer of the bladder; the deep layer of the bladder is termed the lamina propria, with superficial and deep layers. The oral mucosa is the superficial layer of a lot of the oral cavity, which additionally has a deeper layer termed the lamina propria, once more with superficial and deep layers. All tissue has bodily traits: extensibility, inherent rigidity, and the viscoelastic properties of stress leisure and creep. The physical traits of a transferred unit are primarily a function of the helical arrangement of collagen along with the elastin cross-linkages. The collagen-elastin structure is suspended in a mucopolysaccharide matrix that influences the viscoelastic properties. The epidermal (or epithelial) layer is a covering-the barrier to the "outdoors"-and is adjacent to the superficial dermis, or superficial lamina. The deep dermis accommodates many of the lymphatics and larger collagen content material than found within the superficial dermal layer. The deep, or reticular, dermis is usually thought to account for the bodily traits of the tissue. In most circumstances, the plexus is composed of bigger vessels which are extra sparsely distributed. A full-thickness unit carries most of the lymphatics, and the bodily traits are likewise carried with the transferred tissue (Devine et al. There is a distinction between genital full-thickness pores and skin (penile and preputial pores and skin grafts) and extragenital full-thickness skin. This might be a mirrored image of the increased mass of the graft in extragenital skin grafts. The posterior auricular graft (Wolfe graft) is an exception to the rule concerning extragenital pores and skin. The postauricular pores and skin is thin and overlies the temporalis fascia and is thought to be carried on quite a few perforators. The subdermal plexus of this graft mimics the traits of the intradermal plexus, and the entire mass of the graft is more like that of the splitthickness unit. The term graft implies that tissue has been excised and transferred to a graft host mattress, where a model new blood supply develops by a process termed take. Dermal Graft the dermal graft has been used for years to increase the tunica albuginea of the corpora cavernosa. Cross-sectional diagrams (histologic appearance above, microvasculature below) of the pores and skin. The tendency of peritoneum to take readily is well documented within the literature that examines adhesion formation and within the urology literature concerning the utility of peritoneal grafts for reconstruction of the urinary tract. The literature fails to outline accurately what the surgeon can expect concerning bodily characteristics (Jordan, 1993). The proven reality that the graft has a "wet epithelial" surface is likewise thought to be a positive attribute for a lot of instances of urethral reconstructive surgery. A systematic review of the literature concerning the use of oral mucosa in the reconstruction of urethral defects associated with stricture and hypospadias/epispadias by Markiewicz et al. In that series, sixty seven patients have been described, all with follow-up exceeding 5 years and some with 10 years of follow-up. More recent research showed equal outcomes with buccal and lingular grafts (Sharma et al. Because the labial mucosal grafts are skinny, some surgeons favor that donor site for reconstruction of the fossa navicularis (Jordan, 1993). Vein Grafts As described within the urologic literature, vein grafts are maybe not true grafts in accordance with the terminology used in this chapter. The premise is that the vein survives by endothelial direct perfusion and re-establishment of vein wall blood move by perfusion of the vasa vasorum. At the present time, vein "grafts" are being extensively used for alternative of defects of the tunica albuginea of the corpora cavernosa. The pertinent factors with regard to the switch of vein patches to the corpora cavernosa and their long-term conduct have been inferred from the current vascular literature. Dermal grafts have been tried for urethral reconstruction, additionally with usually poor results.

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By 2012 six ongoing adjuvant trials were enrolling worldwide, and, as of early 2019, 4 had been reported (Table 97. However, in all of these trials sufferers receiving therapy skilled significantly larger rates of antagonistic events and there have been no variations in overall survival. More current trials are testing immunologic modulators, corresponding to check point inhibitors, in the adjuvant setting because the search for an efficacious adjuvant technique continues (see Table 97. Emerging data from phase 2 research using pazopanib, sunitinib, sorafenib, or axitinib indicate constant main tumor measurement reduction with common quantity reductions of 10% to 31% (Bindayi et al. In patients with imperative indications for nephron-sparing but in whom surgical procedure is felt to be unsafe, unfeasible, or not optimized, neoadjuvant therapy could facilitate tumor resection (Rini et al. Further potential investigation is required earlier than oncologic outcomes can be evaluated. Six ongoing, early section neoadjuvant therapy trials are investigating checkpoint inhibitors or different immunomodulatory compounds (Bindayi et al. Renal sarcoma is less widespread but extra deadly than sarcoma of some other genitourinary site, together with the prostate, bladder, and paratesticular area (Russo et al. Renal sarcoma should be suspected in any of those circumstances or in any patient with a really massive or rapidly growing renal mass (Table ninety seven. Sarcomas of the kidney, like sarcomas of some other website, are derived from mesenchymal parts and are thus free of most of the natural barriers to dissemination that confine other tumor types (Russo et al. High-grade sarcomas usually metastasize, with the lungs being a major web site of unfold, and prognosis is poor; some patients die of disease progression in a matter of months. Low-grade sarcomas are inclined to pursue a extra indolent course, although local recurrences usually require repeat resection to delay survival and reduce morbidity. In basic, an important prognostic factors for sarcomas are margin status and tumor grade. The preliminary resection is the vital thing event as a end result of that is the most effective chance for a long-term cure. This is primarily a surgical illness, and broad excision is the objective with intraoperative monitoring of margin status. Chemotherapeutic brokers historically used towards metastatic sarcomas included doxycycline and ifosfamide, and extra recently gemcitabine and docetaxel have been explored. The mixture of radiation remedy and chemotherapy, which has an established role in the adjuvant setting for the administration of sarcomas of the extremity, has not been as effective for renal or retroperitoneal sarcomas (Russo et al. Recent knowledge point out that preoperative radiation therapy may reduce the incidence of positive margins (Shah et al. Intraoperative radiation has demonstrated some profit for renal and retroperitoneal sarcomas with minimal further morbidity (Abdelfatah et al. The largest single-institution sequence of renal sarcomas embody only 15 to forty one instances and symbolize a composite experience extending for a interval of a number of years (Shirkhoda and Lewis, 1987; Wang et al. In all such collection, leiomyosarcoma is the most common histologic subtype, and in plenty of sequence, liposarcoma is the second most common entity. For retroperitoneal sarcomas, in distinction, the order is reversed with liposarcoma most typical (Karakousis et al. In this sequence of 16 patients with renal sarcomas, 15 underwent nephrectomy, often with en bloc excision of adjoining organs; 5 acquired adjuvant radiation therapy and chemotherapy without obvious profit; and 13 died within 6 months after surgery. Renal leiomyosarcoma, like different renal sarcomas, tends to displace somewhat than invade the parenchyma and is characterised by speedy growth price, frequent metastasis, and high native and systemic recurrence charges (Deyrup et al. In the Mayo Clinic series, 14 of 15 sufferers with renal leiomyosarcoma died of disease development inside four months to 5 1 2 years after surgical procedure (Frank et al. Other than leiomyosarcoma, a broad variety of histologic subtypes have been described, and almost each conceivable kind of sarcoma has been found within the kidney. Response to radiation therapy and cisplatin-based chemotherapy in an adjuvant setting has been reported and must be thought-about in patients with high-grade illness or positive margins (Belldegrun and DeKernion, 1987). Osteogenic sarcoma is a rare however distinctive type of renal sarcoma that accommodates calcium and is usually rock exhausting (Leventis et al. Extensive calcification in a large, hypovascular tumor ought to recommend the analysis. The look on plain movies can mimic a staghorn calculus, however the readily evident mass effect ought to recommend xanthogranulomatous illness or, extra hardly ever, osteogenic sarcoma. Less frequent histologic subtypes include rhabdomyosarcoma, fibrosarcoma, malignant fibrous histiocytoma, and others (see Table 97. Malignant hemangiopericytomas are notable for his or her in depth vascularity (Brescia et al. Preoperative angioembolization has been described and should simplify surgical excision (Smullens et al. The role of the urologist within the evaluation of renal lymphoma or leukemia is critical and might embrace differentiation from other renal malignant neoplasms, well timed provision of a pathologic prognosis, and preservation of renal perform (McVary, 1991). Primary renal lymphoma is uncommon, with just a few welldocumented case reviews within the literature (Ahmad et al. Hematogenous dissemination of lymphoma to the kidney is commonest and is believed to happen in 90% of instances; direct extension from retroperitoneal lymph nodes accounts for the rest. Eventually, these nodules turn into confluent, forming radiographically detectable lots. Renal lymphoma should be suspected in sufferers with huge retroperitoneal lymphadenopathy, splenomegaly, or lymphadenopathy in different areas of the body or atypical areas within the retroperitoneum. In basic, lymphomas are extra widespread in sufferers with iatrogenic immune suppression, acquired immunodeficiency syndrome, autoimmune diseases, or graft-versus-host illness, and a history of radiation remedy (McVary, 1991). These clinical associations may also enhance the index of suspicion about a prognosis of systemic lymphoma. Renal involvement associated to leukemia is more frequent in youngsters, paralleling the demographics of the disease, and is more commonly due to lymphocytic leukemia than the myelogenous varieties (Pollack et al. Leukemia sometimes entails the kidney in a diffusely infiltrative pattern and most frequently represents a late manifestation of systemic illness. If lymphoma or leukemic renal involvement is suspected, consideration must be given to percutaneous biopsy or aspiration to acquire a pathologic prognosis (Ganeshan et al. Extirpative surgical procedure must be averted if renal lymphoma and leukemia are suspected as a result of the first remedy of these processes is systemic chemotherapy with or with out radiation remedy (McVary, 1991). Nephrectomy is simply indicated in patients with severe symptoms, such as uncontrollable Chapter 97 hemorrhage. The other notable exception is the extraordinarily rare affected person with main renal lymphoma in whom a mixture of nephrectomy and systemic chemotherapy might represent optimal remedy (Garcia et al. Fourteen cases of marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue localized to the kidney have been described, with some apparently cured by surgery alone (Garcia et al. Renal lymphoma and leukemia are generally silent however could be associated with hematuria, flank pain, or progressive renal failure. Fever, weight reduction, and fatigue, the so-called B signs of lymphoma, are rather more widespread (Zomas et al. Renal failure could be because of extensive substitute of the functioning parenchyma or bilateral ureteral obstruction related to enlarged retroperitoneal lymph nodes (McVary, 1991). In actuality, renal failure in such patients is extra usually associated to medical causes, similar to hypercalcemia or urate nephropathy, which might develop during systemic remedy of advanced disease (Luciano and Brewster, 2014).

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Radiologically, renal malrotation is identified because the renal pelvis appears to come up centrally instead of its medial origin from the kidney. Some calyces are positioned medial to the renal pelvis, an indicator of rotational anomalies. Arrest or exaggeration of normal ascent of the kidneys provides rise to renal ectopia and is often related to malrotation. Despite the ureteral length being appropriate for the kidney place, the impaired drainage results in urinary stasis and elevated probabilities of an infection and stone formation. A kidney might cross the midline and fuse with the opposite kidney (crossed-fused ectopia). The ureter from the ectopic decrease kidney crosses the midline and usually inserts into the bladder in its regular place. It is often positioned low in the abdomen due to its arrest by the origin of the inferior mesenteric artery. Renal arteries give branches to the adrenal glands, renal pelves, and proximal ureters. Therefore occlusion or harm to a segmental department causes segmental renal infarction. Nevertheless, the area equipped by every segmental artery could be independently surgically resected. The anterior division supplies roughly the anterior two-thirds of the kidney, and the posterior division supplies the posterior one-third of the kidney. Typically, the anterior division divides into four anterior segmental branches: apical, upper, center, and decrease. The posterior segmental artery represents the primary and most constant branch, which separates from the renal artery before it enters the renal hilum. A small apical segmental department may originate from this posterior department, however it arises mostly from the anterior division. The posterior segmental artery from the posterior division passes posterior to the renal pelvis whereas the others move anterior to the renal pelvis. In 25% to 40% of kidneys, anatomic variations in the renal vasculature have been reported. Supernumerary renal arteries are the most typical variation, with stories of as much as 5 arteries, particularly on the left aspect. The major renal artery might manifest early branching after originating from the belly aorta and earlier than getting into the renal hilum. These prehilar arterial branches should be detected in sufferers present process evaluation for donor nephrectomy. An accent renal artery might arise from the aorta, between T11 and L4, and terminate within the kidney. Rarely, it might also originate from the iliac arteries or superior mesenteric artery. Accessory renal arteries are seen in 25% to 28% of sufferers and are considered the solely real arterial provide to a particular portion of the renal parenchyma, commonly the decrease and sometimes the higher pole of the kidney. Multiple renal arteries that arise from the aorta or iliac arteries are regularly seen in horseshoe and pelvic kidneys. There is a longitudinal avascular airplane (line of Brodel) between the posterior and anterior segmental arteries just posterior to the lateral facet of the kidney via which incision results in significantly less blood loss. However, this aircraft might have various locations that necessitate its delineation before incision either by preoperative angiography or intraoperative segmental arterial injection of methylene blue. For instance, during percutaneous access into the kidney, posterior calyces along the road of Brodel are most popular. Furthermore, throughout anatrophic nephrolithotomy (Boyce procedure), an incision is made through this avascular aircraft. These interlobar arteries progress peripherally within the cortical columns of Bertin to give the arcuate arteries at the base of the renal pyramids on the corticomedullary junction. Note the shut relationship of the interlobar arteries to the infundibuli of minor calyces. Interlobular arteries branch off the arcuate arteries and transfer radially, where they ultimately divide to kind the afferent arterioles to the glomeruli. Each afferent arteriole provides a glomerulus, one of roughly 2 million glomeruli, the place urinary filtrate leaves the arterial system and is collected within the glomerular (Bowman) capsule. Blood returns from the glomerulus through the efferent arteriole and continues as both secondary capillary networks across the urinary tubules within the cortex or descends into the renal medulla as the vasa recta. Furthermore, the interlobular veins that drain the postglomerular capillaries additionally talk freely with perinephric veins via the subcapsular venous plexus of stellate veins. The interlobular veins progress by way of the arcuate, interlobar, lobar, and segmental veins paralleling their corresponding arteries. Because the venous drainage communicates freely forming extensive collateral venous drainage of the kidney, occlusion of a segmental venous branch has little impact on venous outflow. Whereas the proper renal vein is 2 to 4 cm lengthy, the left renal vein is 6 to 10 cm. The longer left renal vein receives the left suprarenal (adrenal) vein and the left gonadal (testicular or ovarian) vein. The left renal vein additionally may obtain a lumbar vein, which could be simply avulsed throughout surgical manipulation of the Chapter 84 Surgical, Radiologic, and Endoscopic Anatomy of the Kidney and Ureter 1869. Intravenous excretory urography (A and B) displaying malrotation of the best kidney. The right renal pelvis arises centrally as a substitute of arising medially from the kidney. Calyces come up on either side of the pelvis, with some of them arising medial to the renal pelvis. Computed tomography urography (C) shows malrotation and ectopia of the right kidney. The proper kidney seems in the right pelvic region and its pelvis seems malrotated with the renal pelvis going through anteriorly with a brief ureter. Computed tomography angiography with volume-rendered three-dimensional picture (A) and axial view (B) of a horseshoe kidney showing the aberrant vasculature. Chapter 84 Inferior vena cava Right and left inferior phrenic arteries Celiac trunk Right superior suprarenal arteries Right middle suprarenal artery Right suprarenal vein Right inferior suprarenal artery Surgical, Radiologic, and Endoscopic Anatomy of the Kidney and Ureter Esophagus Left inferior phrenic vein Left superior suprarenal arteries Left middle suprarenal artery Left suprarenal vein Left inferior suprarenal artery 1869. Note that the posterior segmental artery is often the primary department of the main renal artery and it extends behind the renal pelvis. The left renal vein traverses the acute angle between the superior mesenteric artery anteriorly and the aorta posteriorly. In skinny adolescents, the left renal vein could get compressed between the superior mesenteric artery and aorta, inflicting nutcracker syndrome. In roughly 15% of the sufferers, supernumerary renal veins are seen and often are retroaortic when current on the left. Accessory renal veins are more frequent on the proper aspect, and the most typical anomaly of the left renal venous system is the circumaortic renal vein, reported in 2% to 16% of patients.

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However, with more vital perforations, termination of the process and nephrostomy drainage are advisable. Intraperitoneal extravasation is a much less frequent but probably more severe complication than retroperitoneal extravasation. In advanced circumstances of a large-volume extravasation event, air flow may turn out to be tough due to elevated stomach pressure. Intraperitoneal extravasation could additionally be treated by vigorous diuresis; alternatively, peritoneal drainage and even laparotomy could additionally be required. When a supracostal puncture is carried out, extravasation of irrigant into the pleural cavity might happen. The use of an Amplatz-type entry sheath tends to minimize extravasation into this area as a end result of intrarenal strain stays low. Fluoroscopy with use of the C-arm is often sufficient to examine for pneumothorax or hydrothorax, but if the surgeon has a high index of suspicion for a thoracic complication, a chest radiograph could also be obtained postoperatively. Should a pneumothorax or hydrothorax occur, aspiration could also be sufficient as a result of lung harm is extraordinarily uncommon. Typically, the injury is retroperitoneal; thus signs and signs of peritonitis are infrequent. If the perforation is extraperitoneal, management may be expectant, with placement of a ureteral catheter or double-J stent to decompress the collecting system and withdrawal of the nephrostomy tube from an intrarenal place to an intracolonic place to serve as a colostomy tube. The colostomy tube is left in place for a minimum of 7 days and removed after a nephrostogram or a retrograde pyelogram shows no communication between the colon and the kidney. In this section issues of anesthesia and specific points of technique and complications of ureteral stone administration are reviewed. The fundamental initiation of ureteroscopy is the development of the ureteroscope into the ureter. When the ureteral orifice is simply too slender to accommodate the ureteroscope, dilation may be accomplished with serial dilators, balloons, or even the ureteroscope. The anatomy of male patients may not permit a inflexible ureteroscope to be easily handed above the iliac vessels, however a versatile ureteroscope often could be superior over a guidewire. The whole ureter may be extra simply accessed with a rigid ureteroscope in feminine patients. Once the stone is visualized, fragmentation with the lithotrite of choice is performed, as described elsewhere in this chapter. For remedy of ureteral stones, multiple totally different units are designed to prevent stone retropulsion from the ureter into the kidney throughout lithotripsy. These antiretropulsion devices are coated extensively elsewhere in this textbook. Their total profit is seen with semirigid ureteroscopy during cases when the surgeon needs to avoid having to perform versatile nephroscopy of the kidney to retrieve a small fragment that may have traveled proximally at time of remedy of the ureteral stone. When a retrograde ureteroscopic strategy is used to deal with sufferers with intrarenal calculi, two wires are positioned initially. When an implement is present inside the working channel, simple gravity irrigation is insufficient and pressurized irrigation is required. As previously noted, placement of a ureteral entry sheath may trigger a ureteral perforation. Finally, the danger for a ureteral perforation may be elevated in the case of a prolonged ureteroscopic process, as visualization could decline due to bleeding and/or debris within the subject and surgeon fatigue could develop. Adherence to the tenets of secure ureteroscopy will decrease the chance of a ureteral perforation. When a ureteral perforation is recognized, the ureteroscopic procedure ought to be terminated and a stent placed across the harm. The threat for perforation underscores the significance of utilizing saline as an irrigant to prevent electrolyte derangements resulting from fluid extravasation. In circumstances of a severe harm, with vital extravasation of fluid, a percutaneous nephrostomy drain also may be necessary. Antibiotics should be given due to the chance for contaminated urine and abscess formation. In common, a stent ought to be left in place for approximately 4 weeks after injury. Subsequent imaging after ureteral stent removing is obligatory to consider for a proper therapeutic and enough drainage. A head-down patient position with the ipsilateral flank elevated might assist with stone and fragment visualization because fragments are inclined to migrate superiorly and are thus extra simply localized during remedy. If the stone is giant, the collecting system typically may turn into lined with fine mud and particles, which might obscure residual stones. In such circumstances, both the irrigant within the intrarenal accumulating system may be aspirated via the ureteroscope or a ureteral stent could be placed and the scenario approached in a staged style. If the lower pole infundibulum is accommodating, the most straightforward way to deal with the stone is to engage it in a nitinol basket and displace it to the renal pelvis or an upper pole calyx. Residual fragments additionally should be more prone to evacuate spontaneously from the kidney. If ureteral edema or damage is current after stone extraction, a postureteroscopy stent should be placed to prevent colic and obstruction. Multiple meta-analyses have discovered that for uncomplicated ureteroscopy, a ureteral stent could additionally be safely omitted (Assimos et al. The use of a ureteral access sheath as an adjunct to ureteroscopy was initially described as a method to simplify access to the intrarenal amassing system. It was not till more than 20 years later that the ureteral access sheath was rediscovered and refined, simplifying the deployment and security of these gadgets. The current generation of ureteral entry sheaths consists of a hydrophilic outer coating in addition to a tapered transition from obturator to sheath, which facilitates their retrograde placement. The partitions of the sheaths are designed not just for a slim profile but in addition for strength and often are reinforced so as to resist kinking. The use of an access sheath can decrease working room time because it simplifies re-entry of the ureter during repeated ureteroscope insertions. An added good factor about ureteral access sheaths is that the utilization of a sheath has been reported to maintain low intrapelvic pressures during ureteroscopy (Rehman et al. Traxer and Thomas (2013) noticed that ureteral harm can occur as a consequence of using a ureteral access sheath. Stricture the event of a postoperative ureteral stricture is likely one of the more critical issues that will occur after ureteroscopy. Approximately twenty years ago, the reported incidence of ureteral stricture after ureteroscopy was as excessive as 10%. More just lately, however, the incidence of a postoperative stricture is reported to be 3% to 6% (Assimos et al. It is probably going that the improvements in surgical know-how and approach are liable for this dramatic discount. Although the trigger of a ureteral stricture is likely multifactorial, there are specific identifiable threat components.

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Thulesius O, Angelo-Khattar M, Sabha M: the impact of ureteral distension on peristalsis: studies on human and sheep ureters, Urol Res 17:385, 1989. Thulesius O, Angelo-Khattar M: the impact of indomethacin on the motility of isolated sheep ureters, Acta Pharmacol Toxicol fifty six:298, 1985. Thulesius O, Araj G: the impact of uropathogenic bacteria on ureteral motility, Urol Res 15:273, 1987. Tomiyama Y, Hayakawa K, Shinagawa K, et al: Beta-adrenoceptor subtypes in the ureteral clean muscle of rats, rabbits and canine, Eur J Pharmacol 352:269, 1998. Tomiyama Y, Kobayashi K, Tadachi M, et al: Expressions and mechanical functions of 1 adrenoceptor subtypes in hamster ureter, Eur J Pharmacol 573:201, 2007. Tomiyama Y, Murakami M, Hayakawa K, et al: Pharmacological profile of Kul-7211, a selective beta-adrenoceptor agonist, in isolated ureteral clean muscle, J Pharmacol Sci 92:411, 2003a. Tomiyama Y, Wanajo I, Yamazaki Y, et al: Functional muscarinic cholinoceptors within the isolated canine ureter, Naunyn Schmiedebergs Arch Pharmacol 367:348, 2003b. Tsuchida S, Suzuki T: Pacemaker activity of the pelvicalyceal border recorded by an intracellular glass microelectrode, Urol Int 48:121, 1992. Tsuchida S, Yamaguchi O: A fixed electrical exercise of the renal pelvis correlated to ureteral peristalsis, Tohoku J Exp Med 121:133, 1977. Tsuchiya T, Takei N: Pressure responses and conduction of peristaltic wave in guinea-pig ureter, Jpn J Physiol forty:139, 1990. Uehara Y, Burnstock G: Demonstration of "hole junctions" between clean muscle cells, J Cell Biol 44:215, 1970. Ueno A, Kawamura T, Ogawa A, et al: Relation of spontaneous passage of ureteral calculi to measurement, Urology 10:544, 1977. Vela-Navarrete R: Percutaneous intrapelvic pressure determinations within the research of hydronephrosis, Invest Urol 8:526, 1971. Villa L, Buono R, Fossati N, et al: Effects by silodosin on the partially obstructed rat ureter in vivo and on human and rat isolated ureters, Br J Pharmacol 169:230, 2013. Wanajo I, Tomiyama Y, Yamazaki Y, et al: Pharmacological characterization of adrenoceptor subtypes mediating rest in porcine isolated ureteral clean muscle, J Urol 172:1155, 2004. Wang Y, Puri P, Hassan J, et al: Abnormal innervation and altered nerve progress factor messenger ribonucleic acid expression in ureteropelvic junction obstruction, J Urol 154:679, 1995. Washizu Y: Grouped discharges in ureter muscle, Comp Biochem Physiol 19:713, 1966. Washizu Y: Membrane potential and rigidity in guinea-pig ureter, J Pharmacol Exp Ther 158:445, 1967. Washizu Y: Ouabain on excitation contraction in guinea pig ureter, Fed Proc 27:662, 1968. Watanabe T, Miyagawa I: Characteristics of ureteral bolus in diabetic rats, Urol Res 30:185, 2002. A additional observe on the ubiquity of the Wenckebach phenomenon, Invest Urol 5:463, 1968. Yoshimura Y, Yamaguchi O: Calcium unbiased contraction of bladder smooth muscle, Int J Urol four:sixty two, 1997. Zheng Y, Xu J, Guo W, et al: the significance of Pax2 expression within the ureter epithelium of children with vesicoureteric reflux, Hum Pathol forty six:963, 2015. William T, Lisanti M: the caveolin genes: from cell biology to medication, Ann Med 584-95:2004. Yalcin S, Ertunc M, Ardicli B, et al: Ureterovesical junction obstruction causes increment in clean muscle contractility, and cholinergic and adrenergic exercise in distal ureter of rabbits, J Pediatr Surg 48:1954, 2013. Yang X, Zhang Y, Hu J: the expression of Cajal cells at the obstruction website of congenital pelviureteric junction obstruction and quantitative picture analysis, J Pediatr Surg 44:2339, 2009. Yencilek F, Erturhan S, Canguven O, et al: Does tamsulosin change the management of proximally situated ureteral stones Yerkes E, Nishimura H, Miyazaki Y, et al: Role of angiotensin in the congenital anomalies of the kidney and urinary tract within the moose and the human, Kidney Int Suppl sixty seven:575, 1998. To provide comprehensive care to the patient, urologists will must have a thorough understanding of renal physiology and pathophysiology. The goal of this chapter is to highlight the most clinically relevant aspects of these matters as they relate to urologic apply. We manage this broad subject in a clinically related style by separating renal operate into three main categories: filtration and filtrate transport, hormonal regulation, and blood move. Physiology and pathophysiology are presented together to encourage their understanding as a number of facets of one system, rather than as separate knowledge silos. Principles of physiology and pathophysiology within the kidney can direct therapeutic intervention on many ranges for the working towards urologist. In addition, the advanced handling of solutes by the kidney is a important part of sustaining homeostasis. After blood passes from the principle renal artery, it travels via smaller and smaller branching interlobar, arcuate, and interlobular arteries until it reaches the afferent arteriole. Here, passive filtration happens across the glomerular membrane, after which blood exits the glomerular equipment by way of the efferent arteriole. Plasma cystatin C is an endogenous protein that has additionally been proven to measure renal perform (Filler et al. Under some circumstances, a 24-hour collection of urine for creatinine clearance can be a helpful measure of kidney perform, however this relies on a patient being in steady state. Short-looped nephron Inner stripe Long-looped nephron After the filtrate passes the glomerular equipment into the renal tubule, solutes move out and in of the tubule. [newline]Reabsorption describes motion from tubular lumen again to the blood, and secretion indicates movement from the blood into the tubular lumen. The thin descending limb is highly water permeable, whereas the skinny and thick ascending limbs are water impermeable. The distal tubule includes first the distal convoluted tubule and the connecting tubule. After this, the collecting tubule is encountered, during which the cortical and medullary amassing tubules demonstrate barely totally different capabilities. Both deal with transport of Na+ by way of principal cells and acid hundreds via intercalated cells as well as potassium (K+) by way of both cell types. In the medullary accumulating tubule, however, tight regulated management of water and urea permeability exists, permitting for this space of the amassing tubule to concentrate urine to a a lot greater stage than plasma. In passive reabsorption, Na+ moves paracellularly into the intercellular space mediated via lively chloride (Cl-) transport that creates an electrochemical gradient, driving Na+ out of the tubular lumen into the intercellular space. An extra 25% to 35% of Na+ reabsorption happens within the thick ascending limb of the loop of Henle. This functions by Cl- being pumped across the basolateral membrane through a Cl-/K+ cotransporter. In step 1, at time zero, the fluid in the descending and ascending limbs and the interstitium is isosmotic to plasma. In step 2, NaCl is transported out of the ascending limb into the interstitium to a gradient of 200 mOsm/kg. In step three, the fluid in the descending limb equilibrates osmotically with the hyperosmotic interstitium, primarily by water movement out of the tubule.

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Terada N, Arakaki R, Okada Y, et al: Management of urethral hemangiomas associated with Klippel-Trenaunay-Weber syndrome by endoscopic sclerotherapy, Int J Urol 14(7):658�660, 2007. Clinical end result of 36 male patients with main urethral carcinoma: a single middle experience, Int J Urol 13(6):716�720, 2006. Tobisu K, Kanai Y, Sakamoto M, et al: Involvement of the anterior urethra in male sufferers with transitional cell-carcinoma of the bladder undergoing radical cystectomy with simultaneous urethrectomy, Jpn J Clin Oncol 27(6):406�409, 1997. Tobisu K, Tanaka Y, Mizutani T, et al: Transitional cell carcinoma of the urethra in men following cystectomy for bladder most cancers: multivariate analysis for risk components, J Urol 146(6):1551�1553, dialogue 1553�1554, 1991. Uchida K, Fukuta F, Ando M, et al: Female urethral hemangioma, J Urol 166(3):1008, 2001. Visser O, Adolfsson J, Rossi S, et al: Incidence and survival of rare urogenital cancers in Europe, Eur J Cancer 48(4):456�464, 2012. Yamashita T, Masuda H, Yano M, et al: Female urethral fibroepithelial polyp with stricture, J Urol 171(1):357, 2004. Yossepowitch O, Dalbagni G, Golijanin D, et al: Orthotopic urinary diversion after cystectomy for bladder cancer: implications for most cancers management and patterns of disease recurrence, J Urol 169(1):177�181, 2003. Despite rising experience in managing penile cancer over time, surgical procedure remains a cornerstone of therapy. The most essential prognostic issue is the involvement of the lymphatics situated at the inguinal area (Ornellas et al. When nodal ulceration or local pores and skin invasion is famous, surgical procedure could be carried out for symptom palliation or to keep away from demise attributable to femoral bleeding (Puras-Baez et al. They traverse the penis towards the base inside Buck fascia, draining via presymphyseal lymphatics into the nodes of the femoral triangle. This reality is crucial and guides the surgical method when considering bilateral inguinal dissection. Additionally, quick resection of clinically occult lymph node metastases is related to improved 5-year survival charges (85% vs. Nonetheless, if the tumor has unfold to the pelvic nodes, long-term survival is lower than 10% (Lapierre et al. Urethral Lymphatics Urethral lymphatic drainage runs parallel to the urethra and is located within the mucosal layer and submucosa (Spirin, 1963). This community is most dense within the area of the fossa navicularis, and these branches join the lymphatics of the glans on the prepuce. The lymphatics of the penile urethra course laterally around the corpora cavernosa to join the vessels continuing from the glans penis. Bulbar urethral drainage is extra variable and may occur along the bulbar artery towards the medial retrofemoral node or may course beneath the pubis towards the anterior bladder wall, terminating within the retrofemoral and medial exterior iliac nodes (Wood and Angermeier, 2010). The flooring of the triangle is composed of the pectineus muscle medially and the iliopsoas laterally. The location of the saphenofemoral junction is estimated to be two fingerbreadths lateral and two inferiors from the pubic tubercle. The superficial group consists of four to 25 lymph nodes which would possibly be settled in the deep membranous layer. Superficial nodes are the first to be affected and subsequently play an element in the selection of the template for the dissection. Lymphatic spread of illness follows the traditional route for penile lymphatic drainage. It is worth mentioning that only anecdotal observations suggested that penile lymphatics might drain on to the external iliac nodes (Lopes et al. The prepuce and skin of the penile shaft drain to the superficial lymphatic system. Topographic anatomy plus limits of the usual and modified inguinal lymph node dissections. The node of Cloquet is essentially the most cephalad of this deep group and is located between the femoral vein and the lacunar ligament. The exterior iliac lymph nodes receive drainage from the deep inguinal, obturator, and hypogastric groups. The blood provide to the skin of the inguinal region derives from branches of the frequent femoral artery-the superficial exterior pudendal, superficial circumflex iliac, and superficial epigastric arteries. Viability of the pores and skin flaps raised during the dissection is determined by anastomotic vessels within the superficial fatty layer of Camper fascia that course from lateral to medial alongside the pure skin strains. Because lymphatic drainage of the penis to the groin runs beneath Camper fascia, this layer can be preserved and left connected to the overlying skin when the superior and inferior skin flaps are created. Based on this anatomy, a transverse skin incision would compromise this blood provide the least, and critical skin sloughing is prevented in a majority of sufferers. The femoral nerve lies deep to the iliacus fascia and supplies motor perform to the pectineus, quadriceps femoris, and sartorius muscular tissues. In addition, this nerve provides cutaneous sensation to the anterior thigh and ought to be preserved. Some of the sensory branches of inguinal skin, nonetheless, are generally sacrificed within the regional node dissection. Crossing the medial restrict, the Saphena Magna, the great saphenous vein, is recognized. Progressive proximal dissection will lead to the fossa ovalis, also referred to as the saphenous hiatus, and identification of the accessory saphenous vein and different tributaries of the saphena. Most nodes are situated above the fascia lata, specifically medial to the saphenous-femoral junction, and could be identified by their brown or green coloration. One have to be cautious to embody all areolar tissue between the pores and skin, inguinal twine, and saphenous vein. If fluorescence is out there, minimally invasive resection can help to remove suspicious nodes. This includes all nodal and areolar tissue medial to the femoral vein and lateral to the adductor longus muscle. This resection is continued until Cloquet node (more proximal node located contained in the femoral channel) is recognized. After this resection has been accomplished, essentially the most critical buildings of femoral triangle are identified. Some specialists can discern better when the traditional node structure is changed by neoplastic tissue (Goldberg et al. The most routinely utilized method is retrograde dissection, initiating on the vertex of the femoral triangle distally and progressing towards the inguinal ligament proximally (Sotelo et al. The first important anatomic landmarks to determine are the limits of skin, Camper, and Scarpa fascia using a small incision. The lateral restrict of superficial femoral triangle is the fascia of the sartorius muscle, and the medial border is the adductor longus fascia. However, these outcomes are based mostly on a really limited number of studies (Ottenhof and Vegt, 2017; Zhang et al.

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In the retroperitoneum, the ureter is located simply lateral to the tips of the transverse processes of the lumbar vertebrae. The ureters occupy a sagittal plane that intersects the ideas of the transverse processes of those lumbar vertebrae. The ureter is arbitrarily divided into proximal (upper), middle (over the sacrum), and distal (lower) segments. However, in accordance with worldwide anatomic terminology the ureter consists of belly (from renal pelvis to iliac vessels), pelvic (from iliac vessels to the bladder), and intramural segments. The belly parts of the ureters are adherent to the retroperitoneum throughout their whole course and prolong from the renal pelvis to the pelvic brim. From the back, the floor anatomy of the ureter corresponds to a line joining a point 5 cm lateral to the L1 spinous process and the posterior superior iliac spine. The bifurcation of the frequent iliac vessels is used intraoperatively as a landmark to look for the ureter. The gonadal vessels cross the left ureter after operating parallel to it for a small distance. The inferior mesenteric artery and its terminal branch, the superior rectal artery, follow a curved course near the left ureter. Just above the entry to the pelvis, the ureter is still covered by peritoneum by advantage of the ureteral fold. This location at the pelvic brim represents one of the widespread areas of ureteral injury. Furthermore, the shut relationship of the ureter with the terminal ileum, appendix, right and left colons, and sigmoid colon makes it susceptible for encroachment of inflammatory and malignant processes, resulting in scientific presentations ranging from microhematuria to ureteral obstruction and even fistulae. The pelvic section of the ureter is roughly 15 cm long-half of its whole length. This crossover level is usually at the bifurcation of the common iliac artery into the internal and exterior iliac arteries, making this a helpful landmark for pelvic procedures. The ureter then runs downward and laterally toward the ischial backbone on the lateral pelvic wall alongside the anterior border of the greater sciatic notch, dorsally accompanied by the internal iliac artery and its visceral branches and the venous plexuses as properly. At the ischial backbone, the ureter turns medially to descend within the endopelvic fascia with branches of the hypogastric nerves. At the lateral wall of the pelvis, this part of the ureter crosses the obturator artery, vein, and nerve. In males, the vas deferens loops medially over this half whereas the ureter passes the ampulla of the vas deferens and the seminal vesicles just earlier than it enters the bladder. In females, the descending part of the pelvic segment of the ureter courses posterior to the ovary to type the posterior boundary of the ovarian fossa. The ureter then passes via the base of the broad ligament and swings in a convex curve to cross underneath the uterine vessels ("water under the bridge") in a sagittal path approximately 1. The terminal ureter runs forward, accompanied by the neurovascular bundle of the bladder and passes the anterior vaginal fornix simply before coming into the bladder. This close proximity of the ureter to the uterine vessels is the cause of ureteral accidents throughout gynecologic procedures. The Waldeyer muscle bundles of the ureter coalesce with those of the detrusor muscle of the bladder wall. Therefore reflux of urine from the bladder to the ureter is prevented throughout elevated intravesical pressure, similar to throughout micturition. When approached from the retrograde course, the ureter programs anterolaterally as it goes along the lateral pelvic wall. Then, as it crosses the pelvic brim, it angulates posteriorly to proceed as the proximal ureter. Following the 3D course of the ureter alongside a security guidewire reduces the risk for perforation, especially in patients with massive impacted stones. Radiologic Anatomy of the Ureter the ureter could presumably be delineated by excretory urography during expiration, as a outcome of it might be kinked throughout inspiration as a result of downward movement of the kidney (Friedenberg and Dunbar, 1990). Chapter 84 Surgical, Radiologic, and Endoscopic Anatomy of the Kidney and Ureter 1873. The course of the ureter and its bilateral symmetry are subject to nice variability. It may descend laterally away from the margin of the transverse processes or be displaced medial to the renal pedicle. A medially displaced right ureter may usually be seen in young black males (Adam et al. The right ureter could run medially behind the vein on the degree of third lumbar vertebra earlier than it returns to its lateral position. Similarly, crossing vessels may compress the ureter and simulate areas of stricture. Complete duplication outcomes from the development of a second ureteric bud, and the 2 ureters are inserted into the bladder individually. The partial kind outcomes from redundant duplication of the single ureteric bud by which the 2 ureters be part of collectively above the bladder to from a single stump draining into the bladder. Complete ureteral duplication with a standard or ectopic entry of the higher pole moiety is less frequent than incomplete duplication. The ureter draining the upper segment of the kidney prevalently inserts within the bladder inferior and medial to the ureter draining the decrease section of the kidney (Weigert-Meyer rule). After this, the ureter lies anterior to the vertebral body by approximately one-fourth the width of the vertebral body (Friedland et al. In aged patients with atherosclerotic vessels, ureteral narrowing at the pelvic brim at its crossing to the frequent iliac vessels may produce a posterior indentation that will appear as an extrinsic filling defect. Dilation proximal to that point may be differentiated from obstruction by the absence of pelvicalyceal dilation directly in emptying on prone or erect movies (Friedenberg and Dunbar, 1990). Medial displacement of both pelvic ureteral segments might result from retroperitoneal fibrosis or pelvic lipomatosis, or it may appear after abdominoperineal surgery. However, medial displacement and concavity of a single pelvic ureter might end result from enlarged hypogastric nodes, a bladder diverticulum, or aneurysmal dilation of the hypogastric artery. Nevertheless, this might be a traditional discovering in grownup women if solely the best ureter is affected due to the uterine tilt to the left. In older males, benign prostatic hyperplasia may result in elevation of the bladder flooring sufficient to cause the intramural phase of the ureter to curve superiorly, giving a characteristic "fish hook" or "hockey stick" look on excretory urography (Olsson, 1986). However, this phase may be uncommonly provided by branches arising from the stomach aorta or gonadal arteries. These branches method the ureters medially and divide into ascending and descending branches, forming a longitudinal anastomosis on the ureteral wall. Surgeons are educated to deal with ureters gently to avoid pointless lateral retraction and removing periureteral adventitial tissues containing the blood provide to decrease ureteral ischemia and subsequent stricture.

References

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