Bladder carcinoma- surgery- substitution

BLADDER SUBSTITUTION
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

Brief History of Diversion
Ureterosigmoidostomy
First form of continent diversion
Reported by Simon in 1852 (bladder exstrophy)
Complications: fecal leak, pyelonephritis, ureteral
stricture
Ileal Conduit
Described by Bricker in 1950
Traditional gold standard for urinary diversion
3
Dept of Urology, GRH and KMC, Chennai.

• 1851 - Ureteroproctostomy
(Simon)
• 1878 - Ureterosigmoidostomy
(direct anastomosis) (Smith)
• 1898 - Rectal bladder
(Gersuny)
• 1950s - Ileal loop (Bricker)
• 1959 - Ileal neobladder
(Camay)
• 1970s - Koch pouch
• Early 1980s - Indiana pouch
• Late 1980s - Orthotopic
diversion
4

The most common indications for urinary system
diversion are as follows:
• Bladder cancer requiring cystectomy
• Neurogenic bladder conditions that threaten
renal function
• Severe radiation injury to the bladder
• Intractable incontinence in females
5

Urinary diversion
• External (ileal conduit)
• Internal(ureterosigmoidostomy)
• Temporary (pediatric / second look )
• Permanent
6

Diversion Options
complete
• Incontinent: Ileal Conduit – Urostomy
• Continent Diversion
– Heterotopic
• Cutaneous continent catheterizable urinary reservoir
• Non continent cutaneous
• Diversion to GIT
– Orthotopic
• “neobladder”
7

Partial bladder sparing
• Ileovesicostomy
• Appendicovesicostomy or catheterizable vesicostomy.
The bladder sparing ones don’t really have an application
in patients with bladder cancer, although sometimes
we use this in patients who have prostate cancer and
need to have their prostate removed along with a
portion of the bladder.
8

Ureterosigmoidostomy
• Of historical significance – gone into void
• Anal tone to be determined.
• To be avoided in
1. liver disease
2. primary diseases of colon
3. pelvic irradiation
“antirefluxing technique”
‘Adenocarcinoma at the site of anastomosis’
Yearly sigmoidoscopy from 5yrs after surgery
9

COUNSELLING OF PATIENT
• AVAILABLE OPERATIVE OPTIONS
• OBJECTIVES
• LIFESTYLE
• SEXUAL LIFE
• PLACE OF STOMA
• POTENTIAL COMPLICATIONS OF EACH
METHOD
10

PREPARATION
• CAREFUL HISTORY
• CBC
• SERUM ELECTROLYTES
• UREA NITROGEN AND CREATININE
• UPPER TRACT IMAGING(USG,IVU,CT)
• CONTRAST IMAGING OF BOWEL SEGMENT
• COLONOSCOPY
• BLEEDING DISORDERS
11

• Serum creatinine < 2 mg/dL
• urine pH of 5.8 or less after an ammonium
chloride load
• has a urine osmolality of 600 mOsm/kg or
greater in response to water deprivation
• has a GFR > 35 mL/min
• minimal protein in the urine
12

BOWEL PREPARATION(MECHANICAL)
Polyethylene Glycol–Electrolyte Solutions
Preoperative
Day
Diet Conventional
Cathartic
Diet Polyethylene
Glycol
3 Low residue
plus
Regular plus
supplements supplements
2 Low residue
plus
Low residue
plus
supplements supplements
1 Clear liquids 45 mL Fleet
Phospho-Soda
at 7 AM and 1
PM
Clear liquids 2 to 4 liters
(adults) or 25
mL/kg/hr × 2
(children)
13

BOWEL PREPARATION(Antibiotic)
Preoperative
Day
Kanamycin Neomycin plus
Erythromycin Base
Neomycin plus
Metronidazole
3 1 g kanamycin orally
every 1 hour × 4, then 4
times/day
2 1 g kanamycin orally 4
times/day
1 g neomycin 4
times/day plus 750
mg metronidazole 4
times/day
1 1 g kanamycin orally 4
times/day
1 g erythromycin base
plus 1 g neomycin at 1
PM, 2 PM, 11 PM
1 g neomycin 4
times/day plus 750
mg metronidazole 4
times/day
14

• Whole-gut irrigation is contraindicated in
patients with an unstable cardiovascular
system, patients with cirrhosis, patients with
severe renal disease, patients with congestive
heart failure, or those with an obstructed
bowel.
CAUTION
15

Transport of Na+ , K+ , CI- , and HCO3 in the Large and Small Intestines
Segment of
Intestine
Na+ K+ CI- HCO
Jejunum Actively
absorbed;
absorption
enhanced
by sugars,
neutral a.a
Passively
absorbed when
concentration
rises resulting
form absorption
of water
Absorbed Absorbed
Ileum Actively
absorbed
Passively
absorbed
Absorbed,
some in ex-
change for
HCO3
Secreted, partly
in ex-change
for CI-
Colon Actively
absorbed
Net secretion
occurs
when K+ in
lumen < 25mM
Absorbed,
some in ex-
change for
HCO3
Secreted, partly
in exchange for
CI-
16

Options
• Stomach : best in renal failure
– it is less permeable to urinary solutes
– it has a net excretion of chloride and protons rather than a net absorption of
them
– it produces less mucus
– Less bacteruria
• Ileum:
– nutritional problems because of lack of vitamin B12 absorption,
– diarrhea because of lack of bile salt reabsorption, and fat malabsorption.
– Postoperative bowel obstruction - 10%
• Colon :
– postoperative bowel obstruction with colon is 4%
– Both ileal and colon segments - the same type of electrolyte imbalance with
similar frequencies.
– An antireflux ureterointestinal anastomosis by the submucosal tunnel
technique is easier to perform with use of colon
• Jejunum
17

INTESTINAL ANASTOMOSES
• The first principle for intestinal anastomoses is
adequate exposure
• The second principle is to maintain a good blood
supply to the severed ends of the bowel.
• The third principle involves prevention of local spillage
of enteric contents.
• The fourth principle - an accurate apposition of serosa
to serosa of the two segments of bowel to be
anastomosed.
• The fifth principle is not to tie the sutures so tight that
the tissue is strangulated.
• The final principle involves realignment of the
mesentery of the two segments of bowel to be joined
18

COMPLICATIONS RELATED TO
INTESTINAL ANASTOMOSES
• Fecal fistula – first few weeks – 4-5%
• Sepsis – 2% mortality
• Bowel obstruction – Stomach & ileum – 10%
- colon – 5%
– 50% present in early postop period
– MCC – adhesions/ recurrence/ volvulus/ internal
hernia / stenosis/ stricture
– Prevention by use of nonirradiated bowel
• Hemorrhage – gastric - billroth II
• Pseudo obstruction
19

Incidence of bowel obstruction may be reduced by using
• nonirradiated bowel,
• performing the anastomosis on well-vascularized
bowel,
• closing all apertures,
• reperitonealizing the isolated segment,
• decompressing the gastrointestinal tract for an
adequate time,
• placing omentum over the anastomosis, and
• reconstituting the pelvic floor after exenterative
surgery
20

Complication of isolated intestinal
segment
• Stricture -urine mediated lymphoid depletion
• Elongation of the segment – distal obstruction
or decrease frequency of catheterisation
21

Stomal creation
Types
• Flush – best for catheterisable diversion
• Nipple/ rose bud - best
• Loop end
22

Site of stoma
• Preoperatively mark the stomal site with the patient in the sitting position,
as well as in the supine position
• care is taken to place it over the rectus muscle at least 5 cm away from the
planned incision line.
• The point chosen should be well away from skin creases, scars, the
umbilicus, belt lines, saree line and bone prominences & radiation sites.
• All stomas should be placed through the belly of the rectus muscle and
be located at the peak of the infraumbilical fat roll.
• If the stoma is placed lateral to the rectus sheath, a parastomal hernia is
likely to occur.
• The bowel should traverse the abdominal wall perpendicular to the
peritoneal lining (i.e., it should come straight out).
• One should avoid trimming fat or epiploic appendages from around the
margin of the stoma, and the appliances should be applied in the
operating room.
23

• An even better plan is to
have the patient wear the
partially filled appliance for
a day or two before
operation to be sure that the
placement is optimal and to
start to become accustomed
to it.
• An enterostomal therapist
can be helpful not only in
positioning the appliance
but also in counseling the
patient.
24

• Stomal creation –
kellys/kochers’
• Nipple stoma
• Loop end
25

Complications of stoma
• Stomal necrosis
• Bleeding (variceal)
• Dermatitis
• Parastomal hernia (2-6.6%)
• Prolapse
• Obstruction
• Retraction
• Stenosis – 20-24% IC; 10-20% CC
26

Complication Type of Diversion No. of Patients (Complication/Total No.) Incidence (%)
Bowel obstruction Ileal conduit 124/1289 10
Colon conduit 9/230 4
Gastric conduit 2/21 10
Continent diversion 2/250 4
Ureteral-intestinal
obstruction
Ileal conduit 90/1142 8
Antireflux colon conduit 25/122 20
Urine leak Ileal conduit 23/886 3
Continent diversion
Ileum 104/629 17
Colon 5/123 4
Stomal stenosis, hernia Ileal conduit 196/806 24
Renal calculi Ileal conduit 70/964 7
Pouch calculi Continent diversion 42/317 13
Acidosis requiring treatment Ileal conduit 46/296 16
Gastric conduit 0/21 0
Continent diversion
Ileum 21/263 8
Colon 17/63 27
Pyelonephritis Ileal conduit 132/1142 20
Renal deterioration Ileal conduit 146/808 18
27

• Deterioration of the upper tracts is due to
– lack of ureteral motility,
– Infection
– stones and
– less commonly due to obstruction at the ureteral-intestinal
anastomosis.
• In a group of patients who had nonrefluxing colon conduits
constructed, those whose anastomoses remained
nonrefluxing had a lesser incidence of renal deterioration
than did those in whom the antireflux anastomosis failed.
• Others have not found the same
• The successful construction of an antirefluxing anastomosis
does not prevent bacterial colonization of the renal pelvis
28

Further Considerations
• Refluxing versus nonrefluxing
– Nonrefluxing with decreased rates of
pyelonephritis
– However, higher rates of obstruction and
technically more challenging
29

Evolution of UI anastomosis
30

Principles of UI anastomoses
• Only as much ureter as needed should be mobilized so that
there is no redundancy or tension on the anastomosis.
• Mobilization should not strip the ureter of its
periadventitial tissue > 2 to 3 mm
• Performed with fine absorbable sutures - watertight
mucosa-to-mucosa apposition.
• The bowel should be brought to the ureter and not vice
versa
• At the completion of the anastomosis, the bowel should be
fixed to the abdominal cavity, preferably adjacent to the
site of the ureterointestinal anastomosis.
• If possible, the anastomosis should be retroperitonealized
31

Ureterocolonic anastmoses
Non Refluxing
• Combined Technique of Leadbetter and Clarke
• Transcolonic Technique of Goodwin
• Strickler Technique
• Pagano Technique
Refluxing:
• Bricker
• Cordonnier & Nesbitt
32

Leadbetter-Clarke
ureterointestinal anastomosis
A, Injection of the submucosal tissues
with saline facilitates the dissection.
B, A linear incision is made in the taenia,
the taenia is raised, and the mucosa is
identified. A small button of mucosa is
removed, and the ureter is spatulated and
then sutured to the mucosa with 5-0 PDS.
The seromuscular layer is sutured over
the ureter, with care taken not to
compromise or occlude the ureter.
33

Transcolonic technique of Goodwin
A, The bowel is opened on its anterior surface;
a small rent in the mucosa is made; and with a
mosquito hemostat, the mucosa is raised from
the submucosa extending laterally.
A 3- to 4-cm tunnel is made before the clamp
exits the serosal wall. The ureter is grasped
and pulled into the submucosal tunnel.
B, Both ureters have been drawn into the
bowel through their submucosal tunnels
before each is spatulated and circumferentially
sutured to the mucosa. These sutures should
also incorporate a portion of the muscularis for
security.
34

Strickler Technique
A, A small linear incision is made in the
taenia, and the submucosa is dissected
from the mucosa laterally. After a distance
of 3 to 4 cm is achieved, a small hole is
made in the serosa and the ureter is
drawn through.
B, A button of mucosa is excised, and the
ureter is spatulated and sutured to the
mucosa with 5-0 PDS. The rent in the
taenia is closed with interrupted sutures,
and an adventitial suture at the ureter's
entrance point into the colon secures it to
the serosa of the colon
35

Pagano Technique
36

Pagano Technique
A, A linear incision is made in the taenia between 4 and 5 cm in length.
B, The submucosa is dissected from the mucosa laterally on both sides
to the level of the mesentery. The ureters are drawn into the
submucosal tunnel distally and sutured to the mucosa with 5-0 PDS
suture proximally.
C, The serosa is reapproximated, with incorporation of the mucosa in
the midline
37

Bricker ureterointestinal
anastomosis.
Refluxing end to side
A, The adventitia of the ureter is
sutured to the serosa of the bowel. A
small full-thickness serosal and
mucosal plug is removed.
Interrupted 5-0 PDS suture
approximates the ureter to the full
thickness of the mucosa and serosa.
B, The anterior layer is completed by
interrupted sutures placed through
the adventitia of the ureter and the
serosa of the small bowel.
Ureter small bowel anastomoses
38

Wallace Technique
A, Both ureters are spatulated and laid
adjacent to each other.
B, The apex of one ureter is sutured to the
apex of the other ureter with 5-0 PDS. The
posterior medial walls of both ureters are
then sutured together with interrupted or
running 5-0 PDS, the knots tied to the
outside. The lateral ureteral walls are then
sutured to the intestine.
C, A Y-type anastomosis is formed by
completing the anterior row of the anterior
lateral ureteral walls of the ureters as shown
in B and then suturing the ends of the
ureters directly to the intestine.
D, The head-to-tail anastomosis involves
suturing the apex of one ureter to the end of
the other. The posterior medial walls are
sewn together, and then the ends and
lateral walls are sewn to the intestine
39

Tunneled Small Bowel Anastomosis
A small transverse incision is
made in the small bowel, and a
second transverse incision 3 cm
lateral to it is also made.
The submucosal tunnel is made, a
button of mucosa is removed, and
the ureter is drawn through the
tunnel and sutured directly to the
mucosa.
The rent in the serosa is closed,
and an adventitial ureteral suture
is placed and secured to the
serosa at the ureter's entrance to
the small bowel.
40

Split-Nipple Technique
Griffiths
The ureter is spatulated and turned back
on itself, and the end of the ureter is
secured to the adventitia of the ureter
with interrupted 5-0 PDS suture
41

Le Duc Technique
A, The small bowel is opened for
approximately 4 to 5 cm.
A longitudinal rent in the mucosa is
made and the mucosa raised.
B, At the distal end of the mucosal
rent, a hole is made in the serosa, and
the ureter is then drawn through. The
entrance of the ureter through the
serosa should be at least 2 cm proximal
to the cut end of the bowel to allow
sufficient bowel length to close the
end.
C, The ureter is spatulated and sutured
to the mucosa and muscle layers. The
mucosa is not reapproximated over the
top of the ureter but rather sutured to
the side of it.
42

Ureter–Small Bowel Anastomosis Employing
Serosal Compression of the Extramural Ureter as
an Antireflux Mechanism
43

Intestinal Antireflux Valves
Ileocecal intussusception
A, An 8-cm segment of ileal mesentery is
cleaned from the serosa beginning at the
ileocecal junction.
• At least 5 cm of mesentery remains
attached to the proximal ileum.
• An incision is made along a taenia at the
level of the ileocecal valve.
B, The ileum is intussuscepted over a No.22
French catheter into the cecum under direct
vision.
• mucosa of the intussuscepted segment is
incised, and the mucosa of the cecum
adjacent to it is also incised.
• The muscle coats of both segments are
sutured together.
• The serosa of the ileum is secured to the
serosa of the cecum with interrupted 3-0
silk sutures placed circumferentially.
44

Intussuscepted ileal nipple valve
• Eight centimeters of ileal mesentery are
cleaned from the serosa.
• The ileum distally is opened within 2 to
3 cm of the rent in the mesentery.
• Five centimeters of ileum are
intussuscepted and secured by
placement of staples in quadrants.
• The ileal mucosa is incised adjacent to
an incision in the intussuscepted
segment, and the two muscle coats are
sutured together with interrupted 3-0
chromic suture.
• The serosa of the intussuscepted
segment is sutured circumferentially to
the base of the ileum, into which the
proximal segment is intussuscepted
with interrupted silk suture.
45

Nipple valve
• Approximately 8 cm of mesentery are
cleaned from the distal end of the
ileum, and the serosa is scarified and
then turned back on itself to form a
nipple of approximately 4 cm in length.
• The end of the ileum is suturedto itself
with interrupted 4-0 PDS.
• A rent is made in the colon through a
taenia, and the nipple valve is placed
through the rent and secured with
circumferential interrupted 4-0 PDS
through thefull thickness of the colon
and the seromuscular layer of the
ileum.
46

Complications of Ureterointestinal
anastomoses
• Strictures at the site of anastomoses
– ischemia,
– urine leak,
– radiation,
– infection.
• The incidence of urine leak for all types of
ureterointestinal anastomoses is 3% to 5%
• This incidence of leak can be reduced nearly to
zero if soft Silastic stents are used
• Stricture at other sites – lt ureter where it crosses
the aorta beneath the IMA
47

Management
Endourological / open
Open if
• Strictures occurring in less than 1 year from
the original procedure,
• strictures 1.5 cm or longer,
• left-sided strictures
48

OTHERS
• Urinary Fistula - first 7 to 10 days postoperatively
- incidence of 3% to 9%
• Acute pyelonephritis occurs both in the early
postoperative period and during the long term.
• Its incidence is approximately 10% to 20% in ileal
conduits and 9% in antirefluxing colon conduits
• considerable morbidity and significant mortality.
49

Procedure No. of Patients Stricture (%) Leakage (%) Reflux (%)
Colon
Leadbetter-Clark [2]
[3] [4] [5] 127 14 3 4
Strickler[5] 28 14 — —
Pagano[6] 63 7 — 6
Small Bowel
Bricker [8] [9] 1809 7 4 —
Wallace-Y[10] [11] [12]
[18] 129 3 2 —
Nipple[8] 37 8 — 17
Serosal tunnel[12] 10 10 — 0
Le Duc [14] [15] [16] [17]
[18] 82 18 2 13
Complications of Ureterointestinal Anastomoses
50

CONTRAINDICATIONS TO ORTHOTOPIC DIVERSION
■ Absolute
■ Mental or physical disability
■ Unobstructed serum creatinine >2–2.5 mg/dl
■ Chronic inflammatory bowel disease
■ Intraoperative frozen sections positive for disease at
urethral margin
■ Relative
■ Bladder neck tumor
■ Pelvic irradiation
■ Recurrent urethral strictures
■ Carcinoma in situ of prostatic urethra
51

Ileal conduit
• simplest type of conduit diversion to perform & associated with minimal
postoperative complications.
• C/I - short bowel syndrome, inflammatory small bowel; extensive radiation
• A segment 10 to 15 cm in length is selected 10 to 15 cm from the ileocecal valve.
• The cecum and ileal appendage are mobilized.
• The ileal mesentery is transilluminated, and a major arcade identified to the
segment selected.
• With a mosquito clamp, the mesentery immediately beneath the bowel is
penetrated, and the bowel is encircled with a vessel loop.
• An area at the base of the mesentery that is to one side of the feeding vessel is
selected, and a second vessel loop is placed through the mesentery.
• At this juncture, the peritoneum overlying both sides of the mesentery is incised
from bowel vessel loop to the base of mesentery vessel loop. With mosquito
clamps, the tissue is clamped, severed, and tied with 4-0 silk.
• A portion of mesentery 2 cm in length is cleaned away from the bowel beneath
the mesenteric incision. This procedure is repeated at the other end of the
selected segment.
52

▪ The base of the mesentery should be
as wide as possible and the mesenteric
windows not excessive (generally
about 5 cm in length) to prevent
ischemia of the segment.
▪ Allen clamps are placed across the
bowel in an angled fashion such that
the antimesenteric portion is shorter
than the mesenteric portion.
▪ The isolated ileal segment is placed
caudad, and an ileoileostomy done
▪ The mesenteric window of the
ileoileostomy is closed with
interrupted 3-0 silk sutures.
53

• The isolated segment is then flushed with copious amounts of saline until
the irrigant is clear, at which point the ureters are brought out the
retroperitoneum in the right lower quadrant.
• the left ureter must be brought over the great vessels and posterior to the
sigmoid mesentery to the rent in the posterior peritoneum.
• This may be done by mobilizing the cecum cephalad to identify the right
ureter. The left ureter may be identified by incising the line of Toldt of the
left descending colon dissection allows anastomosis of the ileal segment
as proximal as needed to the ureter.
• Indeed, the ileum may be anastomosed directly to the renal pelvis on both
sides if necessary
• After a cystectomy, the ureters are identified caudad to the iliac vessels
and may be conveniently traced cephalad similar to the previous
description.
• The stented ureteral-ileal anastomoses are performed
54

55

Metabolic Complications of Urinary Diversion
• Electrolyte abnormalities
• Hepatic metabolism
• Abnormal drug metabolism
• Calculus formation
• Nutritional disturbance
• Glucose metabolism
• Bone disease
• Cancer
56

57

POTENTIAL CAUSES OF URINARY CALCULUS FORMATION
FOLLOWING URIN ARY DIVERSION
• Urinary stasis associated with continent urinary
diversion
• Chronic bacteriuria with urease-producing bacteria
• Metabolic abnormalities resulting in hypercalciuria,
hypocitruria, hyposulfaturia
• Foreign bodies, e.g. staples or sutures which serve as a
nidus for mineral deposition
• Hyperoxaluria due to lipid malabsorption
• Abnormal mucus production
58

Nutritional abnormalities following
urologic reconstruction and their treatment
Segment
resected
Physiologic function Abnormality Treatment
Stomach IF B12 def Parenteral B12
Jejunum Folic acid Parenteral FA
Ileum,Colon Absorption of bile salts
Absorption of lipids and
lipid-soluble vitamins
Absorption of vitamin
B12
Diarrhea
Steatorrhea,
deficiency of
fat-soluble vitamins
Vitamin B12
deficiency
Cholestyramine
Low-fat diet,
replacement of
fat-soluble vitamins
Replacement with
parenteral vitamin
B12
59

PATHOGENESIS OF OSTEOMALACIA AND
RICKETS
• Abnormal vitamin D metabolism
• Vitamin D deficiency
• Inadequate dermal production of vitamin D3
• Inadequate hepatic synthesis of 25-hydroxyvitamin D3
• Defective renal synthesis of 1,25-dihydroxyvitamin D3
• Defective end-organ response to l,25-dihydroxyvitamin D3
• Renal loss of vitamin D-binding protein
• Phosphate deficiency
• Diminished phosphate intake
• Impaired renal tubular absorption of phosphate
• Defects in mineralization
• Enzyme deficiency 60

Altered sensorium
• Increased ammonia absorption.
• Decreased Mg.(renal loss,diarrhea, decreased
absorption)
• Drug reabsorption
(dilantin/MTX/Chemo/theophylline/betalacta
ms/nitrofurantoin/aminogycosides).
61

Management
• Drain urine
• Limit protein
• Treat Infection
• Lactulose
• Neomycin/tetracycline
• arginine glutamate
62

Cancer
• 11% of patients with ureterosignoidostomy, cancer
occurring at ureterointestinal anastomosis.
• 10-20 yrs delay before the cancer becomes
manifest.
• 500-fold increase in incidence of cancer is reported.
• The tumor invariably appear close to the
anastomotic site of the ureters to the colon.
• Includes adenocarcinoma, signet ring carcinoma,
adenomatous polyps, sarcoma, transitional cell
carcinoma and undifferentiated carcinoma.
63

Possible etiology of cancer development
• Catelysed by fecal bacteria, production of
carcinogenic nitrosamines from nitrites and
secondary amines in the urine.
• Transitional/ intestinal epithelium
metaplasia, dysplasia and carcinogenesis.
• Yearly sigmoidoscopy starting five years
after procedure or altered bowel habits or
gross GI bleeding.
64

Bladder carcinoma- surgery- substitution

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