Surgical management of BPH.pdf

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540 NATURE CLINICAL PRACTICE UROLOGY OCTOBER 2008 VOL 5 NO 10

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Surgical management of benign prostatichyperplasia: current evidenceAbdulaziz Baazeem and Mostafa M Elhilali*

Continuing Medical Education online

Medscape, LLC is pleased to provide online continuing

medical education (CME) for this journal article,

allowing clinicians the opportunity to earn CME credit.

Medscape, LLC is accredited by the Accreditation

Council for Continuing Medical Education (ACCME) to

provide CME for physicians. Medscape, LLC designates

this educational activity for a maximum of 0.75AMA PRA

Category 1 CreditsTM. Physicians should only claim credit

commensurate with the extent of their participation in the

activity. All other clinicians completing this activity will

be issued a certificate of participation. To receive credit,

please go to http://www.medscape.com/cme/ncp

and complete the post-test.

Learning objectives

Upon completion of this activity, participants should be

able to:

1 Describe the prevalence of benign prostatic hyper-

plasia (BPH) in men.

2 List the most common complications associated

with transurethral resection of the prostate (TURP).

3 Compare TURP with transurethral incision of the

prostate (TUIP).

4 Describe the holmium laser transurethral incision

with enucleation (HoLEP) procedure for BPH.

5 Compare outcomes of HoLEP with TURP.

Competing interests

MM Elhilali has declared associations with the following

companies: Laserscope and Lumenis. See the article

online for full details of the relationships. A Baazeem,

the Locum Journal Editor N Siva and the CME questions

author D Lie declared no competing interests.

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a commonurological disorder. One population-based study,published in 2001, suggests that it might affectup to 8.4% of men aged 4049 years and 33.5%of those aged 6070 years (Box 1).1In the 20th

century, open surgical management of BPHbecame popular. A relatively high-morbidityand expensive procedure, open prostatectomywas gradually replaced by transurethral resectionof the prostate (TURP) as the standard surgicaltreatment of small to medium sized BPH. Highsuccess rates, lower costs and shorter recoverytimes after TURP were among the factors con-tributing to the gradual replacement of openprostatectomy; however, TURP is associated withconsiderable complications, including the need

SUMMARY

Benign prostatic hyperplasia (BPH) is one of the most common maleurological disorders. The surgical management of BPH is evolvingat a rapid rate, with several new procedures available that challengetransurethral resection of the prostate as the standard treatment inthe surgical management of small to medium sized glands. The newprocedures aim to achieve results comparable to transurethral resectionof the prostate while minimizing morbidity and cost. In this Review, wediscuss some of the current surgical options for the treatment of BPH thatseem popular in the literature.

KEYWORDS benign prostatic hyperplasia, bipolar transurethral resection,holmium laser enucleation of the prostate, photoselective vaporization of theprostate, minimally invasive prostate surgery

A Baazeem is currently completing a Fellowship in male infertility/andrologyand laser prostatic surgery at McGill University, and MM Elhilali is Chairmanof the Department of Surgery and holds the position of Stephen JarislowskyChair in Urology at McGill University, Montreal, Quebec, Canada.

Correspondence*McGill University Faculty of Medicine, Department of Surgery, Montreal, Quebec, Canada

[email protected]

Received7 July 2008 Accepted15 August 2008

www.nature.com/clinicalpractice

doi:10.1038/ncpuro1214

REVIEW CRITERIAA PubMed search was conducted using the keywords benign prostatichyperplasia and minimally invasive surgery. Additionally, searches involvingthe specific procedures (e.g. holmium laser enucleation of prostate orHoLEP) and benign prostatic hyperplasia were also performed. RelevantEnglish articles were retrieved and reviewed. Additional articles referenced inthese papers were also retrieved for review. We did not apply any date limits. Thesearch was performed in May 2008.

CME

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OCTOBER 2008 VOL 5 NO 10 BAAZEEM AND ELHILALI NATURE CLINICAL PRACTICE UROLOGY 541


for blood transfusions in 2.04.8% of patientsand the occurrence of transurethral resection(TUR) syndrome in 01.1% of patients.2Eight-

year follow-up data on a large cohort of 23,123men who underwent TURP showed a cumulativeincidence of repeat endourological interventions

of 14.7%.3

The incidence of TUR syndromeincreases with a gland size greater than 45 g andresection times longer than 90 min.4

Over the past 15 years, numerous alterna-tive procedures have been introduced with thegoal of achieving comparable results to TURP,while minimizing morbidity and cost. Manyof these alternative procedures have not ful-filled these objectives, while a few maintain thepotential to replace TURP owing to the promis-ing results from several methodologically sound,prospective, randomized controlled trials. In this

Review, we examine the most commonly dis-cussed surgical procedures, among the currentliterature, that are used to treat BPH, with specialemphasis on original research.

TRANSURETHRAL INCISION

OF THE PROSTATE

Transurethral incision of the prostate (TUIP)involves making an incision at the 5 and 7 oclockpositions from distal to the corresponding ureteralorifice to the level of the verumontanum on theipsilateral side, extending the depth of the incisionto the surgical capsule. This procedure is usuallyperformed in patients with small prostates (


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542 NATURE CLINICAL PRACTICE UROLOGY BAAZEEM AND ELHILALI OCTOBER 2008 VOL 5 NO 10


in two other studies.13,14 In one of these twostudies, however, a significantly higher numberof patients required manual clot evacuationafter TURP compared with TUVP (19% vs0%).14Among studies that commented on post-operative serum sodium levels, none reported

statistically significant differences between thetwo techniques;1214 Dunsmuir et al.14 founda transient difference between the procedures,which corrected itself 24 h after surgery. Onerandomized study showed a significantly shortercatheterization time with TUVP,15but otherwisethere does not seem to be a difference betweenthe two techniques in terms of catheterizationtime and length of hospital stay.1214Dunsmuiret al.14 reported that a significantly largernumber of patients required recatheterizationafter bipolar TUVP compared with TURP.14

Three of these randomized trials did not showa difference between TURP and bipolar TUVPin terms of postoperative International ProstateSymptom Score (IPSS), quality of life (QOL)score, postvoid residual (PVR) urine volume ormaximum urinary flow rate (Qmax) after a meanfollow-up duration of 312 months.1214Resultsfrom the fourth study reported 1-year and 3-yearfollow-up data.15,16Although this cohorts post-operative IPSS and Qmaxvalues improved frombaseline, improvement in IPSS was substantialin the bipolar TUVP group at early follow-up.15Interestingly, at 2 and 3 years follow-up, IPSSand Qmaxvalues were significantly better in thepatients who underwent TURP, despite bothgroups having similar preoperative prostatevolumes and IPSS and Qmaxvalues.

16Moreover,significantly more patients in the TUVP groupcompared with the TURP group required secon-dary TURP after the first year (12% vs 6.6%).These long-term results raise questions aboutthe efficacy of bipolar TUVP.

Bipolar transurethral resection

of the prostate

Bipolar TURP has similar benefits to bipolarTUVP, in addition to its capability of provid-ing resected tissue that can be submitted forhistopathological assessment. Bipolar TUVP istechnically similar to conventional TURP, whichimplies a short learning curve for training sur-geons. In bipolar TURP, resectoscope loops ofvarying shapes are used, but the general conceptis essentially the same as that of conventionalTURP. Electricity runs between an active anda passive electrode, converting the irrigation

solution (i.e. normal saline) into a plasma layerwhich disintegrates tissue on contact.17Severaldevices have been assessed, some of which havebeen modified or withdrawn. A review of thetechnical differences between these devices hasbeen reported by Rassweiler and colleagues.18

Since the safety and efficacy of bipolar TURPwas first reported,19,20at least 11 randomizedtrials have assessed its use (Table 1).2131In mostof these studies, preoperative prostate volumewas around 4055 ml. Resection time wascomparable between bipolar TURP and TUVPin most studies.2224,26,27,2931 Interestingly,the largest two studies showed opposing resultson which technique resulted in better resectiontimes;21,25the group that reported shorter resec-tion times with bipolar TURP, however, did notcomment on the weight of the resected tissue,

nor did they perform postoperative TRUS orPSA assessment. A hybrid technique that usesbipolar TUVP for the median and lateral lobesand bipolar TURP for apical tissue resection andhistopathological specimen extraction was alsoreported to be faster than monopolar TURP.28None of these studies showed a difference in theweight of the resected tissue between the twotechniques, including the study that showeda shorter resection time with monopolarTURP.22,23,2527

Intraoperative blood loss is usually assessedeither by immediate (within 24 h) postoperativemeasurement of hemoglobin or hematocritlevels2226,29,30 or by other methods or tech-niques.27,31 Two studies have reported thatthe bipolar technique resulted in significantlyless blood loss than monopolar TURP.29,31In a third study, while intraoperative bloodloss was not assessed, the number of patientsrequiring blood transfusions was significantlyhigher in the monopolar TURP group thanin the bipolar TURP group.21 Additionally,five randomized, prospective studies22,2527,30reported that there was a less signigicant decline

in serum sodium levels after bipolar TURP. Eightstudies21,23,24,2730found significantly shorterpostoperative catheterization times and fivestudies revealed significantly shorter hospital stayswith bipolar TURPs compared with monopolarTURP (Table 1).

Although postoperative improvements in IPSSand QOL at 3 years were comparable betweenmonopolar and bipolar TURP in all studies,32two studies reported significant improvements inQmax1 year after bipolar TURP.

21,28Nevertheless,

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the clinical significance of these differences maybe questioned (Table 1). Postoperative urinestorage symptoms varied between the two tech-niques; the rate of postoperative urinary storagesymptoms was higher after bipolar TURP in onestudy,28whereas it was higher after monopolarTURP in two other studies.21,27Urethral stric-ture rates were significantly higher with bipolarTURP in one study,28 and they were high inanother study,22 but this was not statisticallysignificant (3 patients vs 1 patient, P>0.05). The

high ablative energy used, in addition to a largerresectoscope size (27 Fr vs 26 Fr), were proposedcauses for this difference in stricture rates.28Hoet al.22used a 26 Fr resectoscope for both bipolarTURP and TUVP procedures, and excluded anyleakage of current along the instruments sheathas a potential cause. Another study also reportedsubstantial urethral injury rates during the inser-tion of a 27 Fr resectoscope, in addition to signifi-cantly higher meatal stricture rates with thebipolar technique.21

Table 1 Prospective, randomized trials that compare monopolar TURP with bipolar TURP.

Procedure(resectoscope size)and study year

Patients(n)

Prostatevolume(ml)

Surgerytime(min)

Resectedweight(g)

Follow-upduration(months)

BaselineIPSSa/QOLa

BaselineQmax(ml/s)

Cathetertime (h)

Hospital stay(h)

Monopolar (26 Fr)24 (2008) 26 48 31.7 NR 12 20/3.6 8.7 31.9 50.6

Bipolar (27 Fr)24 (2008) 27 49 39.1 NR 12 21/3 7 23 ( P


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Bipolar enucleation of the prostate

Neill and colleagues33 compared HoLEP andbipolar enucleation of the prostate in a random-ized controlled trial. Specimen weight, post-operative catheterization time, hospital stayand the postoperative improvement in IPSS and

Qmaxat 1 year follow-up were comparable forboth HoLEP and bipolar enucleation of theprostate, whereas operative and postoperativerecovery time, as well as the need for post-operative bladder irrigation, were all lowerwith HoLEP.

LASER PROCEDURES

Several laser techniques have been assessed forthe treatment of BPH, including visual laserablation of the prostate (VLAP), interstitiallaser coagulation of the prostate, holmium laser

resection of the prostate (HoLRP) and holmiumlaser ablation of the prostate (HoLAP).3436Inthis Review, however, we will focus on a fewtechniques that have been more thoroughlyinvestigated and show the most promise forthe treatment of BPH, including HoLEP,photoselective vaporization of the prostate(PVP) and thulium laser resection of theprostate (TmLRP).

Holmium laser enucleation of the prostate

HoLEP uses the resectoscope in a similar wayto when a surgeon performs an open prostat-ectomy; that is, the surgeon uses his finger toseparate the adenoma from the surgical capsuleand achieve a truly anatomical enucleation, asdescribed by Gilling and colleagues.37In HoLEP,the adenoma is pushed into the bladder by theresectoscope and removed using a tissue mor-cellator. Normal saline is used as the irrigant tolessen the risk of TUR syndrome. HoLEP is themost extensively studied laser technique forthe treatment of BPH.

HoLEP versus monopolar TURP

At least six randomized trials from four differentinvestigator groups have compared HoLEP withmonopolar TURP (Table 2).3845One group usedthe mushroom technique (resection of devascu-larized lobes with electrocautery, using hypotonicirrigants, while still attached to the capsule by athin pedicle) instead of a tissue morcellator.39,42Mean prostate size in both studies ranged from53.5 g to 77.8 g; patients in the HoLEP grouphad significantly larger glands than patients inthe monopolar TURP group.40,43 In all trials,

procedure length was significantly shorterin the TURP group. Specimen weight afterHoLEP was significantly larger than after TURPin two trials,43,45but was larger after TURP inanother trial.41 In yet another trial, proce-dure time was comparable between both tech-

niques.42

Gupta and colleagues41

attributed thesmall specimen weight in the HoLEP and TUVPgroups to the substantial vaporization effect andthe relatively small prostate sizes in the study.In another trial, Tan and colleagues45comparedthe efficiency of the two techniques by assess-ing the mass of specimen removed per minuteof energy source used; HoLEP was significantlymore efficient than TURP, despite the longersurgery time during the HoLEP procedure.Although blood loss was significantly lowerduring HoLEP than TURP in two studies, the

clinical significance of these findings is question-able.41,42The reduction of serum sodium levelswas similar in both techniques.41,42Early post-operative dysuria was more frequent in patientsafter HoLEP in two studies.41,43 Few otherdifferences in complication rates were reportedbetween the two techniques. Catheterizationtime and hospital stay were consistently shorterin the HoLEP groups.4143,45The differences inIPSS, QOL, Qmaxand changes in sexual func-tion were generally comparable between thetwo techniques.3845

HoLEP versus open prostatectomyTwo randomized trials compared HoLEP withopen prostatectomy in patients with a meanprostate size of 113124 ml.46,47Although theweight of the removed specimen was signifi-cantly higher with open prostatectomy in bothtrials,46,47 this difference disappeared withcorrection for estimated tissue loss to vaporiza-tion.47Procedure time was significantly shorterfor open prostatectomy compared with HoLEP,and HoLEP was associated with less blood loss andtransfusion requirements as well as shorter

catheterization and hospitalization times.46,47Transient dysuria was reported during the earlypostoperative period more commonly in patientswho underwent HoLEP than in those who under-went open prostatectomy.47The two procedureswere comparable in terms of IPSS, Qmax andPVR urine volume, in addition to the incidenceof long-term complications (up to 5 years).47,48HoLEP was also found to provide significant netcost savings compared with open prostatectomyfor patients with large prostates (>70 g).49

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HoLEP has also been reported to be safe andeffective for the treatment of patients withurinary retention,50,51patients who are criti-cally ill,52and those with bleeding disorders orwho are receiving anticoagulants.53Moreover,HoLEP can be used to simultaneously treat BPHwith bladder or upper urinary tract stones.54,55

Photoselective vaporization of the prostate

PVP is performed with the potassium titanylphosphate (KTP) laser, which is selectivelyabsorbed by hemoglobin, resulting in vaporiza-tion of intracellular water in the tissue. Theprocedure can be performed using normalsaline for irrigation. Most published data usesthe 80 W KTP laser system. There is also a new,high-performance system that allows an outputpower of 120 W, with the aim of increasingvaporization efficiency. Outcome data from thisnew device is still scarce.

PVP versus TURPTwo randomized trials have compared PVPwith TURP (Table 2). In the first trial, Bouchier-Hayes56 assessed 110 patients with mean pre-operative prostate sizes of 33.5 ml in the TURPgroup and 39.4 ml in the PVP group. Proceduretime, postoperative IPSS, QOL and Qmax andsexual function outcomes were similar for bothprocedures; however, PVP showed significantly

better results in terms of blood loss, catheteriza-tion time and hospital stay. Cost analysis sug-gested that PVP was also cheaper overall thanTURP. A nonrandomized prospective trialshowed similarly favorable results for PVP.57The second randomized trial compared PVPand TURP in patients with prostates largerthan 70 ml.58Catheterization time and hospitalstay were significantly shorter after PVP thanafter TURP. Additionally, significantly fewerpatients in the PVP group required transfusions;

Table 2 Prospective, randomized trials that compare monopolar TURP to various laser procedures.

Procedureand studyyear

Patients(n)

Prostatevolume (ml)

Surgery time(min)

Resectedweight (g)

Follow-upduration(months)

BaselineIPSS/QOLa

BaselineQmax(ml/s)

Cathetertime (h)

Hospital stay(h)

TURP39 (2007) 100 49.9 73.8 37.2 36 21.4/NA 5.9 43.4 85.8

HoLEP39 (2007) 100 53.5 94.6 ( P


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however, TURP was associated with a signifi-cantly shorter operative time, a lower incidenceof early acute urinary retention and reinter-vention requirements, a substantial reductionin serum PSA level and TRUS prostate volume,as well as improvements in Qmax, PVR urine

volume and IPSS at 6 months. Nonetheless,a nonrandomized prospective trial that com-pared TURP with PVP in patients with pros-tates larger than 70 ml showed more favorableresults for PVP, including significantly smallerreductions in serum hematocrit and sodiumlevels and shorter catheterization times andhospital stays in patients who underwent thisprocedure.59 Postoperative IPSS, QOL, Qmaxand PVR urine volume and long-term compli-cations were similar between the two groups forup to 2 years, whereas the operative time was

significantly shorter and the decline in PSAwas significantly more pronounced for TURP.

PVP versus open prostatectomyAs with HoLEP, PVP showed promising resultswhen compared with open prostatectomy ina randomized controlled trial that includedpatients with prostate volumes greater than80 ml.60Despite longer procedure times, PVPwas associated with less blood loss and shortercatheterization times and hospital stays. For upto 12 months, postoperative IPSS, QOL and five-item International Index of Erectile Functionvalues, Qmax, PVR urine volume and compli-cations were comparable between PVP, openprostatectomy, except for a significantly highertransfusion rate with open prostatectomy. Thereduction in TRUS prostate size was significantlygreater in the open prostatectomy group. As withHoLEP, PVP is safe and efficacious in patientswith urinary retention,61 those who are criti-cally ill,62and patients receiving anticoagulationtreatment.63A 2006 study suggests that PVP ismore cost-effective than TURP and several mini-mally invasive BPH treatments.64Unfortunately,

HoLEP and bipolar TURP were not included inthe comparison.

Thulium laser resection of the prostate

The thulium laser has recently been introducedfor use in the management of BPH. The laser canbe used in continuous wave or pulse modes. In theonly randomized, prospective trial to have com-pared thulium laser prostate resection (TmLRP)with monopolar TURP, Xia et al.65 assessed100 patients for 12 months postoperatively

(Table 2).65 Estimated specimen weight wassimilar for the new laser and monopolar TURPtechniques after correction for the vaporizationeffect. Serum hemoglobin and sodium levels,catheterization time and hospital stay were sub-stantially reduced after TmLRP. Both techniques

had comparable IPSS, QOL and Qmaxoutcomes,as well as similar complication rates.

LAPAROSCOPIC SIMPLE PROSTATECTOMY

Laparoscopic simple prostatectomy, via eitherthe transvesical or the preperitoneal approach,has been assessed in patients with BPH.66,67Retrospective studies comparing this tech-nique with open prostatectomy showed similarimprovement parameters and complication ratesas well as reduced blood loss, catheterization timeand hospital stays and longer operation times

with the laparoscopic approach.

68,69

Blood lossand catheterization time, however, were consider-ably higher than those reported for transurethralprocedures. These findings, in addition to thesteep learning curve and with high costs, mayreduce interest in this laparoscopic approach.

ROBOTIC SIMPLE PROSTATECTOMY

Robotic simple prostatectomy has also beenassessed in patients with BPH.70In seven patients,the mean procedure time, blood loss, catheteriza-tion time, drain time and hospital stay were195 min, 381.6 ml, 7.5 days, 3.5 days and 1.33 days,respectively. The average cost was $12,093.

DISCUSSION

In recent years, most patients with symptomaticBPH are started on pharmacological therapy.This treatment option has resulted in patientspresenting at an older age with more comorbi-dities and larger prostates than usual afterunsuccessful pharmacological therapy.71Thesefactors, coupled with the relatively high mor-bidity associated with the traditional options ofintervention for BPH (i.e. open prostatectomy

and TURP), have triggered the development ofnew treatment options for patients who do notrespond to drug-based therapy or present withrefractory urinary retention.

Currently, there is sufficient data to suggest thatHoLEP has replaced open prostatectomy as thestandard surgical treatment of BPH. HoLEP isassociated with lower morbidity rates and is morecost-effective than open prostatectomy, withcomparable long-term results. Thus, it wouldseem that the only role for open prostatectomy

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at present is when there is no access to HoLEP.Unlike most of the other available options,the benefits of HoLEP have been shown to beindependent of prostate size.72

The two main criticisms of HoLEP are itshigh costs and a steep training curve. Despite

the considerable initial costs of the holmiumlaser equipment, it can also be used in the treat-ment of stones, urethral and ureteral stricturesand superficial bladder tumors.73Furthermore,holmium laser fibers can be sterilized andreused, unlike KTP fibers, which are single use;as a result, the cost of holmium laser fibers is5% of the cost of KTP fibers per patient.36Thelearning curve of HoLEP for use in patients withsmall to medium sized prostates is estimated tobe 2030 cases.36,74In a prospective assessment,Shah et al.75reported that an endourologist who

is not familiar with the procedure can achieveoutcomes comparable to experts with experienceof about 50 cases.75

PVP is emerging as a popular treatmentmodality for BPH, particularly in patients withsmall-sized and medium-sized prostates. Theprocedure has a relatively short learning curveand, like HoLEP, can be used in patients withsignificant comorbidities and those on anti-coagulation therapy. Further evidence that sup-ports the durability of PVP results is anticipated.Five-year follow-up results reported by Malekand colleagues,76 although positive, representonly 14 of their original 94 patients.76 Long-term evidence on the applicability of PVP topatients with large prostates is presently notavailable. There are concerns that this treatmentmodality may require that more patients haveto be reoperated upon in light of the limiteddegree of reduction in PSA and TRUS volumes.Prominent median lobes might also pose a largechallenge with this technique because the laserbeam leaves the side-firing fiber at a 70 angle,increasing the potential risk of bladder injury.Another concern, among others, is that ablative

methods do not leave tissue for histopathologicalassessment. Incidental detection of prostatecancer on transurethrally resected specimens isusually 5.27.4%, and has even been reported ashigh as 19%.25,77,78Although the KTP laser isnot used for stone treatment, it has been assessedfor the treatment of urethral strictures.79

Bipolar TURP also seems to be a promisingoption for treating small to medium sized pros-tates, pending long-term results. The techniquehas not yet been tested on large prostates in

prospective, randomized controlled studies.Bipolar TURP is also proposed as a safe wayof providing training in transurethral resec-tion techniques for urology residents.80Bipolarresection devices can also be applied to removingbladder tumors without the risk of perforation

owing to the obturator reflex.81

Conventional and robotic laparoscopic prostat-ectomies remain as new methods of treatingBPH that are under investigation. In our opinion,these procedures represent an exploration of thelimits of these technologies application. TUIPcan be performed as an outpatient procedure,but is reserved for small prostates (


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AcknowledgmentsDsire Lie, University

of California, Irvine, CA,

is the author of and is

solely responsible for the

content of the learning

objectives, questions and

answers of the Medscape-

accredited continuing

medical education activityassociated with this article.

Competing interestsMM Elhilali has declared

associations with the

following companies:

Laserscope and Lumenis.

See the article online for full

details of the relationships.

A Baazeem declared no

competing interests.

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