Miniature pyeloplasty as a minimally invasive surgery with less than....

Abdol-Mohammad Kajbafzadeh, Ali Tourchi, Behtash Ghazi Nezami,

ahshid Khakpour, Amir-Abbas Mousavian, Saman Shafaat Talab.

 Journal of Pediatric Urology  Volume 7, Issue 3 , Pages 283-288, June 2011

Abstract 

Open dismembered pyeloplasty is usually performed through flank, anterior subcostal

or posterior lumbotomy incisions. These incisions are cosmetically less acceptable and

may produce significant postoperative pain. We present the smallest incision for open

pyeloplasty, called a ‘miniature pyeloplasty’. The aim of this study was to reduce

hospital stay and postoperative pain, along with enhanced cosmetic results.

Patients and method

373 infants (mean age 4 months) with hugely dilated pelvises underwent the

miniature pyeloplasty. The exact site of incision was determined by intraoperative

renal ultrasonography and palpation. A muscle-splitting incision was made

in the most dependent part of the lower quadrant. After meticulous dissection

of the ureteropelvic junction component, the affected section was pulled out

and underwent classic dismembered pyeloplasty without renal pelvis reduction.

All children had long-duration stented anastomoses. Surgical incision size,

operative time, hospital stay, postoperative analgesic use and complication rate

were recorded.

Results

The operation was successful in all patients. The mean operative time was 53 min

(range 43–75) and patients were discharged after 18 ± 3 (mean ± SD) h. Incision size

ranged from 11 to 15 mm (mean 13). No narcotic analgesic was required postoperatively

and there were no major complications during follow up.

Conclusions

Miniature pyeloplasty is a safe and successful technique for ureteropelvic junction

obstruction that avoids long operative time with negligible postoperative pain compared

to the classic open pyeloplasty in infants. The exact incision site must be reconfirmed

intraoperatively by physical examination or renal ultrasonography.

Introduction 

Ureteropelvic junction obstruction (UPJO) remains the most common antenatally diagnosed

anomaly with an annual incidence of 0.1%. Up to 80% of children with antenatally diagnosed

 hydronephrosis due to UPJO do not require surgery [1], [2], [3]. Traditionally, open dismembered

pyeloplasty has been the main treatment of UPJO with a success rate of over 94%. This technique

 provides a widely patent, dependently positioned and well funneled UPJ [4]. The significant

dissatisfactions with this technique, such as postoperative pain due to the muscle-cutting loin

incision, long hospital stay, prolonged convalescence and remaining unsightly scars, have led

to increasing interest in minimally invasive alternative techniques such as laparoscopic and

robotic pyeloplasty [5]. The laparoscopic pyeloplasty in adults has conferred major benefits,

including shorter hospital stay, improved cosmetic results, and less postoperative pain due

to the smaller incisions. However, the benefits of laparoscopic pyeloplasty in infants and children

recede, with the higher hospital costs and no significant decrease in length of hospital stay [6], [7].

Up to now, no laparoscopic pyeloplasty series has reported shorter hospital stay compared

to their open minimally invasive counterparts [3]. Most of these series have focused on

adolescents and compared their results only within their own cohorts. In the present study,

the authors suggest that open pyeloplasty could be safely performed with miniature incisions,

with a short hospital stay, no need for narcotic usage and excellent outcomes in infants

with a hugely dilated pelvis.

The standard approach to open dismembered pyeloplasty has been through muscle-cutting

flank, anterior subcostal or posterior lumbotomy incisions, which are generally associated

with significant postoperative pain and less cosmetically appealing scars [8]. Although recently,

most pediatric urologists and surgeons have been avoiding muscle-cutting incisions in their experiences.

Large incisions are especially unfavorable in pediatric urology and can be avoided by detecting

the affected section of urinary tract with ultrasonography. Accordingly,

we developed an open dismembered pyeloplasty approach called ‘miniature pyeloplasty’,

performed through a very small incision with short hospital stay.

Patients and methods 

A total of 1154 children presented with UPJO between November 2003 and November 2008

to the Children Center of Excellence (the national referral center for pediatric urology).

Of these patients, after excluding vesicoureteral reflux (83 patients), 373 with hugely

dilated pelvises were included in our study and underwent miniature pyeloplasty (Table 1).

Most of our patients (328 infants) were detected prenatally.

The different forms of presentation are summarized in Table 2.

Table 1. Patient demographics.

No. of patients with UPJO

1154

No. of patients underwent miniature pyeloplasty

373

No. of females (%)

160 (43%)

No. of males (%)

213 (57%)

Mean age (range)/month

4 (1–18)

No. younger than 3M (%)

222 (59.5%)

No. 3–6M (%)

103 (27.6%)

No. 6–12 M (%)

21 (5.6%)

No. 12–18 M (%)

27 (7.3%)

 

Table 2. Means of presentation of UPJO.

No. (%)

Prenatal

332 (89%)

Abdominal mass

15 (4%)

Significant vomiting

10 (2.7%)

Other (urinary tract infection, hematuria)

16 (4.3%)

Total

373 (100%)

No child had previously undergone any corrective renal surgery. Preoperative diagnostic

evaluation included serum biochemical analysis, urine analysis and culture, renal function tests,

renal ultrasound, voiding cystourethrogram, renal 99mTc-DTPA scan, and magnetic resonance

 imaging in selected cases (very dilated ureter in which concomitant ureterovescial junction obstruction

was not excluded). Dimercapto-succinic scan was performed only for patients with vesicoureteral reflux.

No patient underwent duplex study or computed tomographic angiography

to explore crossing vessel at the UPJO.

Indications for surgery included severe hydronephrosis (Society for Fetal Urology grade III or IV),

recurrent urinary tract infections (UTIs), abdominal mass, declining differential renal function ([9].

Kidney microlithiasis was managed conservatively with no surgical intervention as diagnosed

incidentally. The technique was explained to parents and informed consent was obtained from them.

After induction of general anesthesia, the patient was placed in supine position and the ipsilateral

flank was slightly elevated to make a 30° angle with the operating table. Intraoperative renal

ultrasonography was performed to determine the exact site of incision, as this may change with

alterations in the size and position of the renal pelvis during hydration (Fig. 1).

An oblique incision was made in the most dependent part of the lower quadrant followed

by a muscle-splitting dissection to expose the UPJ retroperitoneally, through Gerota’s fascia.

The pliability of the skin and subcutaneous tissue in infants offers a considerable degree

of mobility and retractor positioning to avoid longer incisions. After putting a stay suture

in the ureter apex, the UPJO and renal pelvis were identified and fixed with two traction sutures (Fig. 2A).

After meticulous dissection and release of the ureter toward the pelvis, the UPJO was accessed

and pulled out from the incision for dismembered pyeloplasty. When present, crossing vessels

were dissected and preserved (35 patients). A 3-Fr Double-J® urethral stent was then placed into the ureter,

and connected and secured by 5-0 polypropylene suture to a 5-Fr feeding tube exiting from the

pelvis to facilitate stent removal without cystoscopy. Pyeloplasty was completed without renal

reduction, with watertight anastomosis using 7-0 polydioxanone interrupted sutures (Fig. 2B).

After completion of the pyeloplasty, the UPJ was returned to the retroperitoneal cavity and the fascia

and muscle layers were closed with absorbable monofilament sutures.

The operation was completed after insertion of a mini suction drain (Hemovac) through a separate stab incision (Fig. 2C).

A Foley catheter was not used during or after surgery to prevent post surgical urethral

strictures and make the patient more comfortable with this surgical procedure.

We do not administer caudal or spinal anesthesia, or subcutaneous Bupivacaine with epinephrine

before skin closure, due to the reported possible side effects in children.

Prophylactic antibiotics (third generation cephalosporin preoperatively and first generation

cephalosporin postoperatively) were given until removal of Double-J stents after 3–4 weeks.

Oral fluids and intake were started 3–4 h after complete recovery from anesthesia.

The drain was removed after 1 week. Pain management was according to the pain control

 protocol in our center. A specialized nurse using a pain score validated to patient age

assessed postoperative pain every 10 h. The Children’s and Infants’ Postoperative Pain Scale (CHIPPS)

with a total pain score ranging from 0 to 10 was used for our patients who were younger than 24 months.

When the CHIPPS score was greater than 4, patients received 15 mg/kg acetaminophen intravenously,

limited to 60 mg/kg daily. Patients were discharged when they had a CHIPPS score of 3 or less for more than 5 h,

tolerated the oral diet, and the peristaltic sounds appeared [10].

Patients were evaluated with ultrasonography after 1, 3 and 6 months.

Renal 99mTc-DTPA scan was performed after 6 months and the follow

up for clinical symptoms was continued yearly with ultrasonography studies.

PIIS1477513111000763_gr1_lrg    

Figure 1 Preoperative renal ultrasonography revealing a hugely dilated pelvis.

PIIS1477513111000763_gr2_lrg

      Figure 2 (A) Stay suture is put in the ureter apex, two traction sutures

       are fixed and the UPJ is pulled out of the incision site. (B)

      Dismembered pyeloplasty and resection of narrow ureteral part are performed. (C)

      Operation completed after insertion of mini suction drain through separate stab incision.

      The perioperative parameters including surgical incision size, operative time,

      intraoperative blood loss volume, postoperative analgesic use, hospital stay,

      complications and success rate were recorded for further evaluation.

      We defined operative time as total time from the initial incision to the final suture.

      Success was considered as complete clinical improvement (resolution of preoperative symptoms),

      improvement in drainage curve on diuretic renogram and regression in pelvic

      diameter on serial ultrasonography. Failure was defined as an increase in pyelocaliceal dilation,

      deterioration of renal function, or obstructive pattern on diuretic renal scan.

      Results 

      Miniature pyeloplasty was successful in all patients.

      Overall operative time ranged between 43 and 75 min (mean 53 min).

      Incision length ranged from 11 to 15 mm (mean 13 mm).

      No patients required narcotic analgesics in the postoperative period,

      no patients required anticholinergics for bladder spasms,

      and patients were discharged after 18 ± 3 h (mean ± SD) postoperatively (range, 14–21 h).

      Patient pain scores before discharge are summarized in Table 3.

      Twenty-seven patients (7.2%) received a single dose of acetaminophen

       and 16 patients (4.2%) received two doses of acetaminophen during the hospital stay.

      The average blood loss was 5 ml. The differential operative times,

      incision lengths and hospital stays for each age group are summarized in Table 4.

      Thirty-five children (9.3%) had crossing vessels, none of which were preoperatively identified.

      However, all of these patients underwent pyeloplasty with transpositioning

      of the accessory vessels during dismember pyeloplasty.

      Table 3. Patient pain score before discharge.

      Pain score

      No. (%)

      0

      68 (18.2%)

      1

      144 (38.6%)

      2

      101 (27.1%)

      3

      60 (16.1%)

      Table 4. Operative time, incision length and hospital stay in relation to age.

      Age

      Operative time (min)

      Incision length (mm)

      Hospital stay (h)

      Younger than 3 Ma

      51 (43–64)

      12 (11–14)

      19 (16–21)

      3–6 M

      56 (45–62)

      14 (11–14)

      17 (14–19)

      6–12 M

      60 (50–75)

      13 (13–15)

      17 (15–19)

      12–18 M

      61 (55–65)

      14 (12–15)

      18 (15–20)

      Mean (range) values are presented.

      aM = months.

      The mean anterior posterior pelvic diameter before surgery was 46.37 ± 10.00

      and the 6-month postoperative diameter was 9.58 ± 5.45 with a mean difference of 36.77 ± 11.41,

      which shows a significant (p = 0.00) 79.30% decrease in the anterior posterior pelvic diameter.

      All parents were satisfied with the cosmetic appearance of scars.

      Minor complications were observed in 30 patients,

      including asymptomatic bacteriuria (non-febrile UTI) in 16 patients,

      ureterovesical junction obstruction in 3 and mild hematuria in 11 patients.

      Since the Double J stent did not pass through the ureterovesical junction,

       two patients were managed by endoscopic endoureterotomy at the same session [11],

       and one was managed by ureteric reimplantation 3 months after pyeloplasty.

      Asymptomatic UTIs resolved after removal of the Double J and hematuria was treated conservatively.

      No serious complication such as urinoma or renal colic occurred during the postoperative follow up.

      No recurrent UPJO was encountered during the median follow up of 25 months

      (range 8–55 months) and all patients experienced complete resolution of clinical symptoms.

      Discussion 

      Open dismembered pyeloplasty is usually associated with significant postoperative

      pain and morbidity due to the muscle-cutting loin incision, aesthetic sequelae and

      long convalescence [3], [12]. The abovementioned dissatisfactions led to the development

      of minimal access alternatives in the form of endopyelotomy, laparoscopic and recently

       the robotically assisted techniques [7]. The advantage to these approaches recedes in younger patients,

      especially those who are younger than 10 years [6].

      Some authors even prohibit laparoscopic pyeloplasty in patients younger than 6 months;

      however, controlled prospective studies are needed to better assess the role of laparoscopic pyeloplasty

       in infants [13]. In the present study, the mean age of the patients at the time of surgery

      was 4 months and 60% of our patients were younger than 3 months.

      This was achieved by applying antenatal ultrasonography, which makes prenatal UPJO diagnosis possible [1].

      Recent studies have noted that open renal pediatric surgeries can be performed on a short stay

       basis with minimum postoperative pain (Table 5) [3], [8], [14], [15], [16], [17].

      Sprunger et al. reported the successful performance of major open pediatric urologic surgeries on an outpatient basis [18].

       In this regard, we chose a single oblique incision in the lower quadrant with patients treated on a short stay basis.

      The incision site was determined by physical examination and intraoperative renal ultrasonography.

       In this way, unnecessary incision length was avoided and the renal pelvis was accessed

      through a small incision (mean 13 mm) at its exact site.

      We believe that a single 10–15 mm incision is more cosmetically appealing than 3 or 4 laparoscopic port incisions

      (with total incisions usually exceeding 20 mm).

      However, although this small incision is advantageous in infants, its safe applicability in adults is not certain.

      Previous studies have suggested using a dorsal lumbotomy incision to provide the most direct exposure to the renal pelvis [8].

      However, Chamie et al. reported that dorsal lumbotomy is associated with more pain

      and anterior crossing vessels may be neglected in this approach [19].

      Table 5. Pediatric short stay pyeloplasty series.

      References

      Önol et al. [8]

      Chacko et al. [14]

      Braga et al. [3]

      Bonnard et al. [16]

      Tong et al. [17]

      Present study

      Procedure

      Dorsal Lumbotomy

      Anderson–Hynes dismembered pyeloplasty

      Laparoscopic pyeloplasty

      Dorsal Lumbotomy

      flank

      Retroperitoneal laparoscopy

      Open dismembered pyeloplasty

      Laparoscopic assisted pyeloplasty

      Open dismembered pyeloplasty

      Minature pyeloplasty

      No. pts

      54 (bilateral cases are excluded)

      74

      41

      25

      42

      22

      17

      23

      21

      373

      Mean age (years)

      5.7

      4.6

      7.9

      7.3

      8.1

      7.3

      8.6

      0.61

      0.68

      0.33

      Mean incision length (cm)

      Between 3 to 5

      Between 2 to3.5

      _

      _

      _

      _

      2

      5

      1.3

      Mean operative time (min)

      78

      Between 109 to 134

      177

      148

      144

      219

      96

      102

      95

      53

      Mean hospitalization (days)

      Less than 30

      Less than 23 hours

      2.3

      3.3

      3.6

      2.4

      5

      2.5

      5

      0.75

      % complications

      0

      _

      10

      8

      4

      15

      29

      17.3

      19.1

      7.2

      % failure

      0

      6.75

      5

      8

      2

      0

      0

      8.7

      4.2

      0

      Mean follow up(month)

      56

      _

      28

      47

      49

      24

      21

      24

      25

      Due to the less traumatic access of our incision (compared with other reported series of open pyeloplasties), there was negligible postoperative pain and no need to use narcotic analgesics in any of our patients. As Chamie et al. noted, morphine usage is correlated with greater length of hospital stay [19]. Likewise, all of our patients were discharged within 1 day of surgery, which confirms that pyeloplasty can be performed on a short stay basis. As safe surgery trumps any cost savings in our center policy, our main reason for the postoperative overnight admission was the rare possibility of post general anesthesia sleep apnea in neonates, especially in the presence of physiologic anemia. These results challenge the current trend in the literature regarding the superiority of laparoscopic approaches in terms of length of hospital stay and cosmesis [15].

      Operative time is an important issue in terms of healthcare economy, especially in developing countries [17]. Some institutions may shun procedures that are time consuming with no clear benefit for the patient. The miniature approach has a median duration of 53 min, which shows that pyeloplasty can be performed in a time-saving manner. In the study by Tong et al. the mean surgical times were 102 min for laparoscopic and 95 min for open dismembered pyeloplasty in infants [17].

      In this study, with a median follow up of 25 months, no recurrent UPJO was observed. Crossing segmental vessels were encountered in 9% of the children, who were treated successfully with no long-term failure. This confirms that the present approach does not miss crossing segmental vessels, despite perioperative or intraoperative imaging studies not being performed. This is achieved by the effective exposure of UPJ and the extended working space that allows the pinpoint exploration and reconstruction of the affected segments through a small incision.

      In this series, pelvic reduction was not performed to preserve the natural vasculature of the renal pelvis, knowing that the dilated pelvis will shrink to a great extent after the obstruction is removed [9]. As Reismann et al. postulated, reduction of the renal pelvis is unnecessary in dismembered pyeloplasty, because there are no significant differences in the renographic results between patients undergoing pelvic reduction and those who do not [20]. However, Burgu et al. noted that resolution of the anterior posterior pelvic diameter showed a significant decrease in their pelvic reduction group compared with the pelvis sparing group in the shorter term, but the difference was not significant in the long-term [21]. In our study, patients experienced a 79% decrease in pelvic diameter in a 6-month period postoperatively with no pelvic reduction during the pyeloplasty, which could suggest that pelvis reduction is unnecessary in infant pyeloplasty.

      We applied a technique for easy stent removal without further need for cystoscopy and generalized anesthesia. The reason for using externalized urethral stents during pyeloplasty is the decreased urine leakage and alignment of the anastomosis to avoid ureteral kinking in the absence of the bladder spasm [22].

      One of the main criticisms of laparascopic pyeloplasty in infants is the difficulty in suturing and intracorporeal knot tying due to the limited available space [23]. In infants, a small open incision can result in rapid convalescence and early discharge with no notable aesthetic sequalae [8]. Therefore, we believe that the potential advantages of our technique (i.e. decreased postoperative pain, short operative time and hospital stay, and enhanced cosmesis) challenge the benefits of laparoscopic and robotically assisted laparoscopic approaches in pediatrics and especially infants. In this series, due to the determination of the exact incision site with ultrasonography, and the thinness of the abdominal skin in infants, the dilated pelvis could be easily exposed through the small incision for surgical reconstruction.

      To the best of our knowledge this is the first series of miniature pyeloplasties performed in a large population. Despite the favorable mid-term results of this technique, we acknowledge the limitations of our study including the retrospective design with no control group in very young children (92.7% less than 1 year old), and this technique with short incision may not be applicable in older children. Health-related quality of life assessment in terms of hospital stay and the need for postoperative narcotics is also necessary to accurately evaluate the advantages of this technique.

      Conclusion 

      These results suggest that miniature pyeloplasty is a safe, effective and minimally invasive technique for the treatment of UPJO in young infants. In this study we showed that open pyeloplasty can be performed on a short stay basis with one night admission. The exact site of the incision should be reconfirmed by intraoperative ultrasonography and physical examination. With the introduction of this muscle-splitting oblique incision in the most dependent part of the lower quadrant, excessive incision length is avoided and an extensive working space is provided. This technique, in experienced hands, combines the advantages of minimally invasive techniques (small incision, negligible postoperative pain) with the short operative time and high success rate of an open approach. However, further controlled studies in pediatric patients are needed to accurately assess the effectiveness of miniature pyeloplasty in comparison with laparoscopic and robotically assisted approaches.

      Acknowledgement 

      We highly appreciate Mr. Majid Kajbafzadeh at the Simon Fraser University (Vancouver, Canada) for his final invaluable linguistic revision of the manuscript.

      References 

      1.  O’Flynn KJ, Gough DC, Gupta S, Lewis MA, Postlethwaite RJ. Prediction of recovery in antenatally diagnosed hydronephrosis. Br J Urol. 1993;71:478
      2.  Ulman I, Jayanthi VR, Koff SA. The long-term followup of newborns with severe unilateral hydronephrosis initially treated nonoperatively. J Urol. 2000;164:1101
      3. Braga LH, Lorenzo AJ, Bagli DJ, Mahdi M, Salle JL, Khoury AE, et al. Comparison of flank, dorsal lumbotomy and laparoscopic approaches for dismembered pyeloplasty in children older than 3 years with ureteropelvic junction obstruction. J Urol. 2010;183:306

      4. Ward AM, Kay R, Ross JH. Ureteropelvic junction obstruction in children. Unique considerations for open operative intervention. Urol Clin North Am. 1998;25:211

      5. Yanke BV, Lallas CD, Pagnani C, McGinnis DE, Bagley DH. The minimally invasive treatment of ureteropelvic junction obstruction: a review of our experience during the last decade. J Urol. 2008;180:1397

      6. Tanaka ST, Grantham JA, Thomas JC, Adams MC, Brock JW, Pope JC. A comparison of open vs laparoscopic pediatric pyeloplasty using the pediatric health information system database – do benefits of laparoscopic approach recede at younger ages?. J Urol. 2008;180:1479

      7. Eden CG. Minimally invasive treatment of ureteropelvic junction obstruction: a critical analysis of results. Eur Urol. 2007;52:983

      8. Önol FF, Akbas A, Kose O, Onol SY. Short stay pyeloplasty with transverse dorsal lumbotomy incision: our 10-year experience. Urology. 2009;74:1309

      9. Kajbafzadeh AM, Tourchi A, Bazargani S, Nezami BG. Single incision miniature pyeloplasty and ipsilateral inguinal herniorrhaphy in infants. J Urol. 2010;183:1545

      10. Buttner W, Finke W. Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies. Paediatr Anaesth. 2000;10:303

      11. Kajbafzadeh AM, Payabvash S, Salmasi AH, Arshadi H, Hashemi SM, Arabian S, et al. Endoureterotomy for treatment of primary obstructive megaureter in children. J Endourol. 2007;21:743

      12. Kumar R, Smith G. Dorsal lumbotomy incision for pediatric pyeloplasty – a good alternative. Pediatr Surg Int. 1999;15:562

      13. Tan HL. Laparoscopic Anderson–Hynes dismembered pyeloplasty in children. J Urol. 1999;162:1045

      14. Chacko JK, Koyle MA, Mingin GC, Furness PD. The minimally invasive open pyeloplasty. J Pediatr Urol. 2006;2:368

      15. Piedrahita YK, Palmer JS. Is one-day hospitalization after open pyeloplasty possible and safe?. Urology. 2006;67:181

      16. Bonnard A, Fouquet V, Carricaburu E, Aigrain Y, El-Ghoneimi A. Retroperitoneal laparoscopic versus open pyeloplasty in children. J Urol. 2005;173:1710

      17. Tong Q, Zheng L, Tang S, Zeng F, Du Z, Mei H, et al. Comparison of laparoscopic-assisted versus open dismembered pyeloplasty for ureteropelvic junction obstruction in infants: intermediate results. Urology. 2009;74:889

      18. Sprunger JK, Reese CT, Decter RM. Can standard open pediatric urological procedures be performed on an outpatient basis?. J Urol. 2001;166:1062

      19. Chamie K, Tanaka ST, Hu B, Kurzrock EA. Short stay pyeloplasty: variables affecting pain and length of stay. J Urol. 2008;179:1549

      20. Reismann M, Gratz KF, Metzelder M, Ure B, Gluer S. Excision of the dilated pelvis is not necessary in laparoscopic dismembered pyeloplasty. Eur J Pediatr Surg. 2008;18:19

      21. Burgu B, Suer E, Aydogdu O, Soygur T. Pelvic reduction during pyeloplasty for antenatal hydronephrosis: does it affect outcome in ultrasound and nuclear scan postoperatively?. Urology. 2010;76:169

      22. Braga LH, Lorenzo AJ, Farhat WA, Bagli DJ, Khoury AE, Pippi Salle JL. Outcome analysis and cost comparison between externalized pyeloureteral and standard stents in 470 consecutive open pyeloplasties. J Urol. 2008;180:1693

      23. Chen RN, Moore RG, Kavoussi LR. Laparoscopic pyeloplasty. Indications, technique, and long-term outcome. Urol Clin North Am. 1998;25:323

      © 2011 Journal of Pediatric Urology Company. Published by Elsevier Inc. All rights reserved.

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