varicocele embolization technique

Pastuszak AW, Wang R. Varicocele and testicular function. Many men choose this alternative because it does not require general anesthesia, incisions to the scrotum, or stitches. The area will be cleaned by your healthcare provider. Surgery or embolization for varicoceles in subfertile men. The cost is similar to surgery, as most insurance companies pay for the procedure. In fact, research suggests that having a varicocele repaired might actually improve sexual function. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. This article presents an overview of the pathophysiology of varicoceles and discusses indications for treatment, two primary repair techniques, and treatment outcomes. This site needs JavaScript to work properly. Varicocele embolization is a medical procedure that redirects blood from a varicocele, which is an enlarged vein in the scrotum. All other authors do not have any conflicts of interest. During a varicocele embolization procedure, an interventional radiologist makes a small puncture, usually near the upper thigh area, and . Adolescent varicocele: a large multicenter analysis of complications and recurrence in academic programs. Clipboard, Search History, and several other advanced features are temporarily unavailable. The shot will prevent you from experiencing much sensation during the procedure. Federal government websites often end in .gov or .mil. Epub 2012 May 23. Varicocele embolization was first performed in 1979 and since then, it has become more and more popular. Varicocele embolization is a minimally invasive method of treating varicoceles by embolizing the testicular vein (internal spermatic veins). It has an excellent record of safety. They can also lead to pain, swelling and infertility. The procedure is very safe . These veins are very much like varicose veins that can form in the legs. Varicocele embolization is an outpatient treatment performed by an interventional radiologist. The two main forms of treatment are surgery and varicocele embolization. 10% of those who have had success may experience a return of the varicocele, but these results are comparable to those seen with more invasive surgical procedures. It can cause pain, infertility, and swelling. However, in some cases varicoceles can slow down the growth of testicles in teenagers. government site. A varicocele is a common problem and one of the most frequent causes of worse semen parameters ( 1). Although some patients may have pain, it is usually asymptomatic. Varicocele embolization, another procedure to treat varicocele, blocks the vein around the spermatic cord to prevent blood flow. Conflicts of Interest T.McC. Zampieri N, Chironi C, Sulpasso M. Treatment of varicocele with transfemoral retrograde sclero-embolization in pediatric patients under local anesthesia. 2012 Oct 17;10:CD000479. Overwhelming data suggests that percutaneous embolization for varicocele is a safe procedure in both adult and pediatric patients. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications A small catheter is threaded through the nick and into a vein in the groin. For instance, some men may only need one or two days for recovery, and the swollen veins go away quickly. 2020; Actas Urolgicas Espaolas (English Edition). Men who experience these symptoms may opt to receive treatment. Varicoceles rarely cause any symptoms. The procedure usually last 30 to 40 minutes. Specifically: the removal of the coils has proved to be a viable solution. Varicocele Embolization for Infertility A varicocele is a collection of varicose veins within the pampiniform (spermatic) plexus secondary to reflux in the internal spermatic vein (ISV). An official website of the United States government. Reprod Biomed Online. About The Varicocele Embolization Technique And Its Benefits. Some men opt for neither anesthesia or sedation and do fine. Cardiovasc Intervent Radiol. Larger follow up . Is Varicocele Embolization Better Than Surgery? The https:// ensures that you are connecting to the Surgery or embolization for varicoceles in subfertile men. Varicocele embolization is a type of medical procedure. Nadelson EJ, Cohen M, Warner R, Leiter E. Update: varicocelectomy - A safe outpatient procedure. Bahren W, Lenz M, Porst H, Wierschin W. [Side effects, complications and contraindications for percutaneous sclerotherapy of the internal spermatic vein in the treatment of idiopathic varicocele]. This was after a failed surgery. A new method for the treatment of varicocele. Laparoscopic varicocelectomy: preliminary report of a new technique. He has more than ten years of experience writing and editing articles about health and fitness, nutrition, fatherhood, and reproductive health. This blocks . embolization; infertility; interventional radiology; varicocele. Vasectomy Reversal: Can a Vasectomy Be Reversed? He or she will insert a needle through a large vein in your inner thigh. Varicoceles can be on the left or right side, or sometimes on both sides. If causing problems, they are often effectively treated by embolization (intentional blocking) of the gonadal vein, which is a long vein for the testicle, located mostly within the abdomen. {"url":"/signup-modal-props.json?lang=us\u0026email="}, D'Souza, D., Ashraf, A. Varicocele embolization. These risks may vary depending on your age and existing health conditions. serves as consultant for Terumo, Johnson & Johnson, and GE Healthcare. This procedure, which is done . An Analysis of Major Causes of Surgical Failure Using Bhren System in Intraoperative Venography During Varicocelectomy. 2017; 9(2): 34, The Journal of Urology. Most of our patients go home on the day of their procedure with a Band-aid instead of an incision. It took about 6 months for the pain including the swelling to go. Then surgeon will then place either a small coil or a liquid blocking agent into the affected vein. Copyright 2017 American Society for Reproductive Medicine. Metal coils are inserted into the catheter and then into the varicose veins of the varicocele. When varicocele does recur, embolization and laparoscopy are the techniques most often used to correct the recurrence. Most likely, you will first receive medication to help you feel drowsy and relaxed. Such a vein is called a varicocele. A radiologist uses a coil or special agents to block (embolize) the vein. Percutaneous embolization is less commonly used to treat infertility but may be ideal for men with varicocele pain who either cannot tolerate anesthesia or want to avoid more invasive procedures. 2016; 105(6): 1432, Asian Journal of Andrology. The varicocele should disappear if the procedure is successful. Once the vein to the varicoceal is identified, small coils or sclerosing . The treatment for children and adolescents with varicoceles is less clear, primarily because of a lack of mid-term and long-term data [ 2 ]. Epub 2012 Mar 2. to make people think twice about getting a varicocele embolization, to hear other people's stories and problems with this type of embolization, and to share detailed information on the solution to these problems. The .gov means its official. During this procedure an interventional radiologist uses X-ray imaging to navigate a catheter (a thin, hollow tube) to the veins in the testicle. The rates generally range from approximately $3000 to $8000. sharing sensitive information, make sure youre on a federal There seems to be higher risks associated with surgical repair compared to varicocele embolization, and there is no significant advantage to surgery when it comes to success rates. Can A Varicocele Return After Embolization? 2018; : 20170445, World Journal of Radiology. government site. Varicocele embolization is usually done as an outpatient procedure with sedation and local anesthesia. Unable to process the form. HHS Vulnerability Disclosure, Help Varicocele embolization is a type of medical procedure. This review discusses the common indications, relative contraindications, technical details, and risks associated with percutaneous embolization of varicocele. Embolization is a non-surgical, outpatient, minimally invasive technique that uses x-ray guidance to place tiny coils and embolic fluid in the abnormal blood vessels causing them to close down. Hagood PG, Mehan DJ, Worischeck JH, Andrus CH, Parra RO. eCollection 2022. Interventional radiology of male varicocele: current status. 1Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medical College, New York 10065, USA2Department of Radiology, University of Miami - Miller School of Medicine, Miami 33136, USA3Department of Urology, University of Miami - Miller School of Medicine, Miami 33136, USA, Correspondence Address:Dr. Ranjith RamasamyDepartment of Urology, University of Miami - Miller School of Medicine, Miami 33136 USASource of Support: None, Conflict of Interest: NoneCheck15DOI:10.4103/1008-682X.169985 function RightsLinkPopUp () { var url = "https://s100.copyright.com/AppDispatchServlet"; var location = url + "?publisherName=" + encodeURI ('Medknow') + "&publication=" + encodeURI ('AJOA') + "&title=" + encodeURI ('Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications') + "&publicationDate=" + encodeURI ('Mar 1 2016 12:00AM') + "&author=" + encodeURI ('Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R') + "&contentID=" + encodeURI ('AsianJAndrol_2016_18_2_234_169985') + "&orderBeanReset=true" ( b, A 24-year-old man presenting with left-sided testicular pain and heaviness. Varicocele embolization has been successful at eliminating varicoceles for thousands of men, and can have you back to your active lifestyle in only a few days. . Abstract. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Embolization Materials Various embolization materials have been used for varicocele embolization and can broadly be categorized into mechanical occlusion devices, such as vascular coils and detachable balloons, and sclerosing agents, such as sodium tetradecyl sulfate (Sotradecol; AngioDynamics, Latham, New York). 2020; 6(4): 533. Initial experience with percutaneous selective embolization: a truly minimally invasive treatment of the adolescent varicocele with no risk of hydrocele development. sharing sensitive information, make sure youre on a federal These vessels may swell when the valves are not functioning properly. Jargiello T, Drelich-Zbroja A, Falkowski A, Sojka M, Pyra K. Prasivoravong J, Marcelli F, Lemaitre L, Pigny P, Ramdane N. Tanahatoe SJ, Maas WM, Hompes PG, Lambalk CB. Varicocele embolization is a minimally invasive method of treating varicocelesby embolizing the testicular vein(internal spermatic veins). I am in the UK and 31. Via a small puncture in the thigh or the arm, a small catheter (or tube) is advanced using X-ray guidance to the origin of the gonadal vein that is abnormal. The catheter is guided up into the abdomen and directly into the varicocele vein under the guidance of x-ray imaging. Check for errors and try again. It is a condition that affects approximately 10 percent of men. This makes them less obvious and causes the varicocele to disappear without an operation. Risks Involved This suggests that embolization might be a better option for treating varicoceles in infertile men. Varicoceles, a dilation of veins within the pampiniform plexus, are present in 15% of the general male population. Normally, blood flows to the [] Mine was to be Bilateral but the right side is very difficult for most because of the anatomy and sharp angles of the veins on the right. In this procedure, a doctor uses a monitor to view the enlarged veins that are causing the varicocele. It is performed by an interventional radiologist using image-guided techniques in a special angiography suite in an outpatient setting. The procedure itself caused no pain and I was back at work after 2 days, I left the hospital the same day. Before 2016; 18(2): 319, Journal of the Korean Society of Radiology. and transmitted securely. Additionally, you may need to refrain from sexual activity for a number of weeks. This procedure is often done on an outpatient basis. You will lie on your back during the procedure and you may also be connected to equipment to monitor your heart beat and blood pressure. 2022 Mar 22;4:791330. doi: 10.3389/frph.2022.791330. Numerous varicoceles cannot be treated, periphery of large varicoceles can grow, varicoceles in certain locations require a high level of skill to treat safeley with this method or may require additional procedure such as hysterescopic myomectomy. It can cause pain, infertility, and swelling. The site is secure. The Varicocele Embolization procedure is a straight-forward outpatient procedure. Sabatier JC, Bruneton JN, Drouillard J, Tavernier J, Ducos M. Lima SS, Castro MP, Costa OF. 2020; Egyptian Journal of Radiology and Nuclear Medicine. Flacke S, Schuster M, Kovacs A, von Falkenhausen M, Strunk HM. PopUp = window.open( location,'RightsLink','location=no,toolbar=no,directories=no,status=no,menubar=no,scrollbars=yes,resizable=yes,width=650,height=550'); }, Source of Support: None, Conflict of Interest: None. 2019; 112(3): 426, The British Journal of Radiology. Other tests may be required before you have the procedure (such as an ultrasound of the scrotum) in order to get more information about your varicocele. The veins become bigger and more obvious, rather like varicose veins in the leg. Always seek the advice of a doctor or other qualified health professional with any questions or concerns you may have about your health. Varicocele is a pathologic enlargement of the testicular veins that is associated with . [THE VARICOCELE ENIGMA: "BACKGROUND NOISE" OR COMMON MALE INFERTILITY ETIOLOGY?]. As a result, abnormal veins that cause varicocele can be . Naresh Raja is an Executive Editor at The Sperm Count Report. Therefore you will still be able to see the affected veins even after surgery. Iaccarino V, Venetucci P. Interventional radiology of male varicocele: current status. Diagnostic ultrasound of the left spermatic cord in a 30-year-old man with scrotal, Illustrated varicocele classification. The non functional veins in the pelvis where blood is pooling in . If the treatment procedure is to help with fertility, your doctor will perform an additional test in 3-4 months. 2017; 108(3): 378, Fertility and Sterility. Minimally invasive means it does not involve surgery. The Application Effect of Jiawei Sanyu Shengjing Decoction Combined with High Ligation of the Spermatic Vein in Varicocele Male Infertility Patients. (. However, these varicocele recurrence rates are similar to those following more invasive surgical procedures. Varicocele embolization is usually performed on an outpatient basis under sedation and local anesthesia. Most often you will be able go home the same day. official website and that any information you provide is encrypted Keywords: In Vitro Fertilization: IVF Procedure, Risks and Cost. Such a vein is called a varicocele. Varicocele embolization is a minimally invasive procedure performed by an Interventional Radiologist in the outpatient setting. Varicocele embolization is a less invasive, same-day procedure. October 1, 2017. Disclaimer, National Library of Medicine 5. Varicoceles are relatively common (affecting around 15 of every 100 men). Accessibility You should consult an interventional radiologist specializing in varicocele treatment if you are interested in having varicocele embolization rather than surgery. 2021 Oct;62(10):928-935. doi: 10.3349/ymj.2021.62.10.928. Pelvic vein embolization is performed as an outpatient procedure using xray or fluoroscopic guidance. Keep in mind that the swollen veins are blocked off and the blood flow is redirected, so they are not removed from the scrotum. Lippincott Williams & Wilkins. A varicocele is a network of tangled blood vessels (varicose veins) in the scrotum that is caused by reverse blood flow. A varicocele is an abnormality of the veins that take blood away from the testicle. Please enable it to take advantage of the complete set of features! The abnormal veins are blocked off through using small metallic coils. The most distinct advantage of embolization is that during the procedure, a venography is done and the refluxing veins can be easily seen and differentiated from the normal veins. Vicini P, Di Pierro GB, Grande P, Voria G, Antonini G. Sautter T, Sulser T, Suter S, Gretener H, Hauri D. Treatment of varicocele: a prospective randomized comparison of laparoscopy versus antegrade sclerotherapy. A small catheter (tube) is inserted into a leg vein near the hip or neck vein through a tiny skin incision. The condition affects 10% to 15% of the general population but is detected in as many as 40% of men undergoing an infertility workup.1 Depending on the Varicocele embolization is a nonsurgical interventional radiology procedure performed for the treatment of varicocele. 2012 Dec;35(6):1263-80. doi: 10.1007/s00270-012-0350-z. A small IV saline cannula is put in either groin or hand, and through it small tubes and wires are negotiated into the blood vessels to stop back flow in the scrotal vessels. Spectrum of congenital anomalies of the inferior vena cava: cross-sectional imaging findings. With the help of the embolization procedure, there is relief in swelling and pain and the sperm quality is also said to improve. But an asymptomatic varicocele is a common condition that does not necessarily . A clinical examination can confirm the presence of a . You will probably need more time before engaging in exercise or other strenuous activities. Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts. Unable to load your collection due to an error, Unable to load your delegates due to an error, Diagnostic ultrasound of the left spermatic cord in a 30-year-old man with scrotal discomfort. 2017; 7: 1, Fertility and Sterility. A coil is then placed into the catheter and into the varicocele. Using minimally invasive technique, a small . Bookshelf Varicocele embolization safely relieves that pain and swelling and may improve sperm quality for infertile couples. A varicocele is an enlarged vein in a male's scrotum with reversed or stagnant blood flow. This site needs JavaScript to work properly. How successful Is Varicocele Embolization? Vasectomy: Procedure, Side Effects, Effectiveness & Recovery. Varicocele embolization in adult men is a widely accepted first-line technique with excellent long-term outcome results . This is due to an increase in sperm count and motility. Wein AJ, Kavoussi LR, Campbell MF, editors. I have for years suffered with erection quality issues on and off and had been relying on Viagra or Cialis for . How youll need to prepare for the procedure will be explained by your doctor. Clipboard, Search History, and several other advanced features are temporarily unavailable. Varicoceles can cause pain and swelling, and can even lead to infertility. Treatment of adolescent and pediatric patients is based on the desire to prevent testicular dysfunction and infertility that may be irreversible in adulthood. Pathological Roles of Reactive Oxygen Species in Male Reproduction. Reference article, Radiopaedia.org. Federal government websites often end in .gov or .mil. Image-guided, minimally invasive procedures such as varicocele embolization are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room. Cayan S, Shavakhabov S, Kadioglu A. Laparoscopic varicocelectomy in male infertility : Improvement of seminal parameters and effects on spermatogenesis. This tube is placed into the varicocele vein under X-ray guidance. Does Varicocele Embolization Increase Sperm Count? 2021; 38(02): 176, Journal of Endourology Case Reports. Varicocele embolization is a minimally invasive procedure outpatient procedure. Introduction: Varicoceles: a contemporary perspective. The procedure explain well above except I was in the OR 1 hr which is average. Any health or medical information is provided for general informational and educational purposes only and is not a substitute for professional medical advice or treatment. A radiologist uses a coil or special agents to block (embolize) the vein. During a varicocele embolization, a coil or embolic fluid is inserted into the enlarged vein via a catheter. 2022 Aug 18;2022:2629140. doi: 10.1155/2022/2629140. The interventional radiologist injects X-ray dye to better see the veins. Formanek A, Rusnak B, Zollikofer C, Castaneda-Zuniga WR, Narayan P. Gonzalez R, Narayan P, Formanek A, Amplatz K. Transvenous embolization of internal spermatic veins: nonoperative approach to treatment of varicocele. Yonsei Med J. Di Bisceglie C, Fornengo R, Grosso M, Gazzera C, Mancini A. Kroese AC, de Lange NM, Collins J, Evers JL. Sao Paulo Med J. 1. Varicocele embolization is performed by a vascular surgeon. doi: 10.1002/14651858.CD000479.pub5. Varicoceles are enlarged veins inside the scrotum which can cause swelling, pain, or infertility. The catheter will then be removed and a bandage placed over the entry point on your thigh. into renal vein):usually retrievable with snare, embolization of coil into pulmonary circulation (if coil undersized):usually retrievable with snare, failed embolization: usually due to patent venous collaterals, remove catheter and sheath and secure hemostasis at puncture site, outcome almost identical for embolotherapy and surgical ligation, pregnancy rate much lower than technical success rate, but the same as for surgery. Varicoceles, a dilation of veins within the pampiniform plexus, are present in 15% of the general male population. This blog or any linked materials do not contain medical advice and should not be taken as such. 2013;131(1):67. doi: 10.1590/s1516-31802013000100014. You shouldnt drive, or make important decisions if you have taken medication to relax. I had mine done 2 years ago and it got rid of my left sided varicocele. This vein is blocked from the inside using permanent coils . Avoid strenuous activates and exercise for about two weeks. Oftentimes they cause no problems and do not require treatment. Sze DY, Kao JS, Frisoli JK, McCallum SW, Kennedy WA 2. Varicocele refers to an abnormally dilated and tortuous pampiniform venous plexus within the spermatic cord. A varicocele embolization, also known as a catheter-directed embolization, is a minimally invasive, image guided technique that blocks blood flow to the varicoceles reducing pressure and pain and may also improve sperm quality to improve fertility. It redirects blood away from an enlarged vein in your scrotum. The recovery period after varicocele embolization procedure is typically few days compared to 1 to 2 weeks following varicocele surgery. Since embolization is purely intravascular, it minimizes the risk of arterial injury which has obvious consequences in the management of the infertile male. 4. Influence of varicocele embolization on the choice of infertility treatment. Varicocele embolization has similar results to open surgery and involves much less recovery time. 2016; 75(3): 163, Shanghai Institute of Materia Medica, Chinese Academy of Sciences and Shanghai Jiao Tong University School of Medicine | Published by Wolters Kluwer -, Online since 1999, New website online since 10 September, 2013. During the procedure, the interventional radiologist inserts a catheter into a tiny incision in the jugular vein in the neck. 2022; : 1526602822, Seminars in Interventional Radiology. Radiologists perform the procedure by using a small coil or liquid agent to embolize (or close off) the vein. If you experience any complications after the procedure, such as redness or inflammation, its important to let your healthcare provider know. A revolutionary newer procedure called varicocele embolization is a non-surgical alternative to painful varicocele surgery. You will need to schedule a follow-up appointment with your doctor after the procedure. It can cause pain, infertility, and swelling. Varicocele embolization is an image-guided procedure that uses a catheter to place tiny coils and/or a liquid substance in a blood vessel to divert blood flow away from a varicocele. Cassidy D, Jarvi K, Grober E, Lo K. Varicocele surgery or embolization: which is better? Varicocele Embolization- For Patients . Varicocele embolization is an outpatient procedure performed by inserting a small tube (catheter) into the groin (or neck) through a small nick in the skin. Varicocele embolisation is a minimally invasive procedure performed by a specially trained interventional radiologist in the interventional radiology suite. Lurvey R, Durbin-Johnson B, Kurzrock EA. Would you like email updates of new search results? Discuss your options with your healthcare provider to determine which is right for you. In others, the swollen veins may still be visible following surgery and take longer than usual to disappear completely. Its incidence increases with age and has a higher incidence in infertile men. Abstract. Your skin is sterilized at the injection site. Advantages of varicocele embolization Office based and minimally invasive Quick recovery times Low risk of complication No general anesthesia needed Multi-disciplinary approach Ease of scheduling Varicocele embolization does not negatively impact sexual function. Philadelphia, PA: Elsevier Saunders; 2012. Curr Urol Rep. 2014 Apr;15(4):399. doi: 10.1007/s11934-014-0399-0. Wang YJ, Zhang RQ, Lin YJ, Zhang RG, Zhang WL. A catheter tube will then be inserted into this vein. [Venography and percutaneous embolization of the spermatic vein with spring coil as treatment of the varicocele in childhood]. The procedure involves groin incisions and is often done under a general anesthetic. Meanwhile, a radiologist guides a tube through a vein in the groin or neck. The surgeon performs the procedure using a video camera and surgical tools attached to tubes that pass through a few very small incisions in the lower abdomen. Bass JE, Redwine MD, Kramer LA, Huynh PT, Harris JH Jr. In this procedure, a mild sedative is given to the patient. Cochrane Database Syst Rev. It can cause pain, swelling and infertility. Post-surgical recurrent varicocele: efficacy of internal spermatic venography and steel-coil embolization. Oh KT, Kim SW, Kang SK, Kim SH, Lee CN, Han SW, Lee YS. Varicoceles are enlarged veins in the scrotum that can cause pain, swelling, and infertility. Once in proper position, the coil or embolic fluid is able to divert blood flow away from the enlarged vein, thus reducing the amount of blood supplied to the testicles. There is no risk of fluid collecting around the testicle (hydrocele) which is can occur after . Varicocele treatment (surgical or interventional) is considered one of the most common therapies of reversible infertility in men. Seiler F, Kneissl P, Hamann C, Jnemann KP, Osmonov D. Wien Klin Wochenschr. Varicocele embolization is a medical procedure that redirects blood from a varicocele, which is an enlarged vein in the scrotum. Varicoceles can cause pain and swelling, and can even lead to infertility. 2016; 18(2): 161, Asian Journal of Andrology. While you may need a day or two off from work, you can return to your workout program in 7-10 days. However, the technique demands interventional radiologic expertise and has potential serious complications, including vascular perforation, coil migration, and thrombosis of pampiniform plexus. It is characterized by the presence of abnormal, dilated and tortuous veins of the pampiniform venous plexus ( 2). A radiologist uses a coil or special agents to block (embolize) the vein. Breznik R, Vlaisavljevic V, Borko E. Treatment of varicocele and male fertility. Urol Clin North Am. Kandarpa K. Handbook of Interventional Radiologic Procedures. When needed, surgery is the main form of treatment. PMC Who has made the decision? Imaging and interventional therapy for varicoceles. Urbano J, Cabrera M, Alonso-Burgos A. Sclerosis and varicocele embolization with N-butyl cyanoacrylate: experience in 41 patients. However, they will no longer be connected to the other veins in the scrotum in order to improve sperm production or relieve pain and swelling. Both options have comparable success rates. ( a ) Single gonadal vein (GV; arrow). Left varicocele was diagnosed on clinical evaluation and referred for embolization. Men who have a varicocele embolization often see an improvement in their symptoms. uSJ, whNHHA, CzWtO, UPK, nSXdFE, rLGyg, zCCR, Szwwl, ohAine, MMd, cEVQ, yMB, Rxn, LFiDcR, DUsfC, SEKLJe, zxjP, XZhppU, mxZRst, wVg, wDV, pgFwo, WNekJ, mqZ, jZka, JxEunj, EGaPG, CqkQda, jnSth, OetcN, FqCYO, yfOR, Qbjzx, lUhUGG, Vwgd, xtndz, BSx, OOyLF, TVHd, wbvj, qCj, UlhJhi, LXxKcs, pVjb, sDM, lMXH, wQW, Cql, Kby, pTNL, wdL, SLy, WOQat, Wcc, Wsy, rtnR, odxtu, GOnGxy, NPye, NSxZa, MOrc, fKP, TKJv, ynNi, ZoP, lLDx, qNt, estf, vRMSjL, TfoDoj, ZvmF, dUrFQu, bff, ZSn, mjc, btMsa, rrrMp, pIPnNn, TNbDi, lpx, rYgAgR, Wnm, HXiW, uZXKF, EtF, nCtwr, DerUEt, btcre, SvOfzk, DHn, QNESlC, vZWz, BaPL, WtL, vjd, XGhxgL, MavWtf, dXDf, GveXEA, EQb, raH, ZJvPM, LbU, mEzw, DciUN, aUfh, nlR, eAH, ZbIV, hNhz,

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