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Catalina Solano
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Solano, C.; Chicaud, M.; Kutchukian, S.; Candela, L.; Corrales, M.; Panthier, F.; Doizi, S.; Traxer, O. Optimizing Outcomes in Flexible Ureteroscopy. Encyclopedia. Available online: https://encyclopedia.pub/entry/43300 (accessed on 20 August 2024).
Solano C, Chicaud M, Kutchukian S, Candela L, Corrales M, Panthier F, et al. Optimizing Outcomes in Flexible Ureteroscopy. Encyclopedia. Available at: https://encyclopedia.pub/entry/43300. Accessed August 20, 2024.
Solano, Catalina, Marie Chicaud, Stessy Kutchukian, Luigi Candela, Mariela Corrales, Frédéric Panthier, Steeve Doizi, Olivier Traxer. "Optimizing Outcomes in Flexible Ureteroscopy" Encyclopedia, https://encyclopedia.pub/entry/43300 (accessed August 20, 2024).
Solano, C., Chicaud, M., Kutchukian, S., Candela, L., Corrales, M., Panthier, F., Doizi, S., & Traxer, O. (2023, April 20). Optimizing Outcomes in Flexible Ureteroscopy. In Encyclopedia. https://encyclopedia.pub/entry/43300
Solano, Catalina, et al. "Optimizing Outcomes in Flexible Ureteroscopy." Encyclopedia. Web. 20 April, 2023.
Optimizing Outcomes in Flexible Ureteroscopy
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This entry is adapted from the peer-reviewed paper 10.3390/jcm12082815

Suction is an effective and safe technique that improves stone-free rates, reduces operative time and limits complication rates after flexible ureteroscopy (fURS). 

suction renal pressure stone-free rate

1. Introduction

Urolithiasis is a common disorder with high and increasing prevalence in industrialized countries [1]. Among the treatments, researchers found shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL). According to current guidelines, RIRS is recommended as the first or second choice for the treatment of kidney stones, regardless of the size of the stone; this includes stones larger than 2 cm [2]. Despite the benefits of using newer generation flexible ureterorenoscopes, Holmium: YAG laser lithotripsy (Ho:YAG) and Thulium fiber laser (TFL) for stone removal, it can be difficult to achieve a high success rate in removing >2 cm stones. Studies have reported stone-free rates (SFRs) ranging from 56.7% in a single procedure to 89.3% after 1.6 procedures [3].
These procedures aim to achieve a high SFR, but the presence of residual fragments (RFs) can be a problem and may lead to the need for additional interventions. The concept of clinically insignificant residual fragments (CIRFs) has been proposed, but there is currently no gold standard for managing, clearing or preventing RFs [4].
For over 25 years, suction has been utilized in endourology, often in conjunction with ultrasound and ballistic devices, to facilitate the removal of renal stones during PCNL [5]. One advantage of using a suction device during a RIRS procedure is that it can help to lower the temperature and pressure inside the kidneys, potentially reducing the risk of infection and improving surgical outcomes [6]. The specific techniques used for fragmenting or dusting stones during flexible ureteroscopy (fURS), such as a stone vacuum or steerable multi-lumen irrigation/aspiration device, vary according to the specific circumstances, such as the type of laser being used, and the surgeon’s preferences.

2. Operative Time and RP

Regarding RIRS, in the studies of Huang et al., Du et al. and Gao et al., [7][8][9] the operative time (OT) ranged from 25 to 80 min, and they all selected the same parameters in the platform: irrigation flow (IF) (PF: 50–150 mL/min), control pressure value was set at −15 to −5 mm Hg, the warning pressure value was set at 20 mm Hg, and the maximum limit value was set at 30 mm Hg. The median OT for Gao et al. was longer (75 min). Factors related to a longer surgical time in the study were multiple stones (54.19%), with 75.81% stones < 30 mm, 66.13% of complex composition and Guy Stone Score (GSS) II 33.87% [9]. For Deng et al., the OT was 24.8 ± 15.9 min, the perfusion flow was set at 100 mL/min, and the RPP control value was set at −2 mmHg. During the procedure, the IRP was controlled below 20 mm Hg, resulting in a clear operative visualization. Additionally, stone particles were effectively removed without the need for stone basketing [10].

3. Stone Free Rate

Deng et al. reported the immediate and 1st month SFR (90.0–95.6%), and 4% of patients had residual stone >4 mm, requiring subsequent SWL or other management (second ureteroscopy or medication) [10]. Similar results were reported by Huang et al. The immediate SFR was 87.5%, and the 1st month SFR was 97.4% [7]. Gao et al. found that for the patients with a GSS I, the immediate SFR was higher (87%) and the immediate SFR for GSS ≥ II was less than 80% [9]. Du et al. was the only study that reported at 100% SFR in the 1st month for ureteral stones using their modified UAS vs. 87% SFR in the control group [8].

4. Complications

All studies scored the complications according to the Clavien–Dindo classification [11]. Du et al. reported the lowest percentage of complications in the suction group; only 1.6% postoperative fever was found. None of the cases had a ureteral stricture during 6-month follow-up, and none of the patients required a secondary surgery, contrary to the control group, where 2 cases had intraoperative ureteral perforation, 3 cases had ureteral stricture and 7 cases had postoperative fever [8]. On the other hand, Deng et al. found 14% of Clavien I complications, including pain, fever, nausea/vomiting and tachycardia, and 2% Clavien II; no Clavien III–V complications were noted [10]. Gao et al. reported that the factors associated with major complications were multiple stones (5.95% vs. single: 0%, p = 0.002), big stone size (≥50 mm: 13.64% vs. other size: 1.08–5.88%, p = 0.028) and high GSS (Grade I vs. VI: 0.59–14.29%, p = 0.002) [9].
Suction ureteral access sheath (SUASs) and direct in scope suction (DISS) [7][12][13][14][15].

5. Operative Time and SFR

In a prospective cohort study, Zeng et al. evaluated the use of a modified access sheath (mUAS) for continuous flow ureteroscopic lithotripsy. The mUAS had a 12/14 Fr diameter and a bifurcated proximal segment, consisting of a straight and an oblique tube at a 45-degree angle. The oblique branch was connected to a negative pressure aspirator with a continuous mode set at 150–200 mm Hg and a flow rate of 60–80 cc/s. The process of stone fragmentation was carried out using the Holmium-YAG laser with preferred settings of 30–35 Hz/0.5–0.6 J. They reported the lowest OT (27.3 min), in contrast to the other 3 studies [13][14][15], with an immediate SFR of 97.3% and 1st month SFR 100% [12].
Zhu et al. used fURS with sUAS created by connecting a channel on the tail of the suctioning UAS to a vacuum device (KYB, China). They showed a longer OT in the sUAS group (49.7 ± 16.3 min) vs. the control group (57.0 ± 14.0 min), p < 0.001; however, the immediate SFR in the sUAS was superior (82.4% vs. 71.5%; p < 0.02) [13].
Gauhar et al. used a different suction mechanism that was directly connected to the ureteroscope (DISS), which allowed a simultaneous/alternating suction system during/after laser lithotripsy and used the endoscope as a conduit to remove fragments or dust. They mentioned a longer median OT in the DISS group [80 min] vs. the sUAS group (47.5 min), p < 0.001; this could be explained because in the DISS group, 40% of patients had multiple stones, and the median stone size was significantly higher at 22 mm (18.0–28.8 mm) vs. 13 mm in the control group (11.8–15 mm), p < 0.001. There was no significant difference in the incidence of RF between the DISS group (33.3%) and the other group (35.7% p = 0.99); nevertheless, the DISS group (33.3%) required a further RIRS [14].
Qian et al. conducted a prospective cohort with 444 patients with renal stones undergoing fURS, divided in 2 groups, sUAS and no suctioning UAS. They found in the sUAS group a lower OT (72.9 min) vs. in the group no suctioning sUAS (80.0 min), p = 0.12. The SFR in the 1st day and 1st month was higher in the sUAS group (86.4–88.9%) vs. the no suctioning sUAS group, which was 71.6–82.7%, p = 0.368 [15].

6. Complications

Zeng et al. found 1.9% fever and 0.9% complication Clavien–Dindo IIIa (false route) [12]. On the other hand, Zhu et al. reported lower total complications in the sUAS group vs. in the traditional group (24.8% vs. 11.5%, respectively; p < 0.001) [13]. The most common complications were fever (13.9% vs. 5.5%; p = 0.009) and urosepsis (6.7% vs. 1.8%), p = 0.029 [13]. Gauhar et al. reported minor complications, not fever, in DISS compared to the control with 17.8% (p = 0.05) [14]. Qiang et al. reported the incidence of postoperative fever was lower in the suctioning group (3.7% vs. 14.8%), p = 0.030, and SIRS (1.23% vs. 12.3%; p = 0.012) [15].

7. Twitter Results

The use of social media (SoMe) in urology has seen significant growth in recent years. A survey conducted among urological Twitter participants found that 44% agreed that the platform was useful for clinical decision making, and 33% had made a clinical decision after a Twitter discussion. SoMe, particularly Twitter, has become an important tool in academic and research settings [16][17][18]. It allows researchers to share their work with a broader audience, collaborate with peers and promote scientific literacy to the general public.Therefore, researchers should carefully consider the use of different types of media to maximize engagement and ensure responsible use [19].
Social media, has also played a critical role in urology by facilitating physician and patient knowledge acquisition, conference participation and mentorship. Best practices have been established to ensure responsible use, and the COVID-19 pandemic has amplified the role of SoMe in medical education [20]. The European Association of Urology (EAU) Guidelines Office has been a pioneer in using social media to disseminate their recommendations. Through campaigns for awareness days, the EAU Guidelines Office has improved engagement with different audiences, particularly through Twitter, Facebook and Instagram [21]. These findings demonstrate the potential for SoMe to raise awareness, reinforce trust with stakeholders and disseminate scientific information in the medical community [22].
The first is presented by @DrParimalGharia in pictures and video on his system for keeping a clear view and low IRP during fURS. He connects 2 syringes, one of 10 mL and one of 20 mL, to the water supply circuit, which is activated on demand to aspirate or rinse [23]. This system was also represented in drawings by @AshishRawandale, but only with one syringe [24].
@BEkidneystone presented at the World Congress of Endourology 2019 a poster about the Kalera Vacuum Aspiration Catheter (K-VAC) [25]. This second system K-VAC is a steerable catheter with an outer diameter of 13 Fr and a working length of 72 cm. At the end of the fURS, to evacuate the fragments, the ureteroscope is replaced with a K-VAC device under fluoroscopic guidance to the different calices. It is two coaxial tubes with an active deflective mechanism and also has a built-in on-demand irrigation and aspiration channel; the pressure is between 60 and 80 cmHg, and the suction is controlled with the finger of the surgeon. @PeepeeDoctor presented the first human randomized trial using K-VAC, and in conclusion, the system allows obtaining a higher ablation rate [26]. However, this technique is not done under visual control, but only under fluoroscopic control with an increase in radiation levels.
The Clearpetra Suction-Evacuation is an UAS with a connected suction system. @Abbyqianqxx and @Resistone2022, a medical device and consumables supplier, presented pictures and videos on the technique [27][28][29][30][31], a visible sUAS, in which the sheath diameter can accommodate both the guide wire and the fiber optical ureteroscope, and the procedure can be practiced under the condition of full visibility.
@MeramUrology_ presented at the 7th Istanbul Urolithiasis Days two studies comparing techniques with and without suction [32]. The suction one showed the best renal function in the first days after the operation, with fewer infectious complications and a shorter operative time. The diameter of this system is the same as a standard UAS. @Proximedsrl presented the product with two posts. In a blue test, they put the blue dye on the ureteral sheath and then connected the suction [33], after which the dye was sucked. The other video was on dusting renal stones, the technique most represented on Twitter, which appeared with excellent suction and reduced retropulsion.
In January 2020, @chuikalun1 built a self-made suction device by taking a ureteral access sheath, making a hole on the outer part and connecting a suction hose to it. Two years later, in July 2022, he shared a video of a flexible suction assess sheath: he put it on the ureteroscope, under vision control, using a ureteral access sheath and aspirated dust or used the venture effect to remove the larger fragment. The suction pressure applied to this system is not known [34].
@BioradMedisys congratulated @DocGauhar for winning the 5th Best Affordable New Technologies in the Urology Contest: BANTUC22 for Direct Scope Suction Technique [DISS] [35]. It consisted of putting an adaptor on the irrigation circuit connected to an aspiration in order to use the ureteroscope conduct to remove dust and fragments.

References

  1. Scales, C.D.; Smith, A.C.; Hanley, J.M.; Saigal, C.S. Prevalence of Kidney Stones in the United States. Eur. Urol. 2012, 62, 160–165.
  2. EAU Guidelines on Urolithiasis—INTRODUCTION—Uroweb. Uroweb—European Association of Urology. Available online: https://uroweb.org/guidelines/urolithiasis (accessed on 17 March 2023).
  3. Breda, A.; Angerri, O. Retrograde Intrarenal Surgery for Kidney Stones Larger Than 2.5 cm. Curr. Opin. Urol. 2014, 24, 179–183.
  4. Prezioso, D.; Barone, B.; Di Domenico, D.; Vitale, R. Stone residual fragments: A thorny problem. Urol. J. 2019, 86, 169–176.
  5. Haupt, G.; Pannek, J.; Herde, T.; Schulze, H.; Senge, T. The Lithovac: New Suction Device for the Swiss Lithoclast. 2009. Available online: https://www.liebertpub.com/doi/10.1089/end.1995.9.375 (accessed on 17 March 2023).
  6. Inoue, T.; Okada, S.; Hamamoto, S.; Fujisawa, M. Retrograde intrarenal surgery: Past, present, and future. Investig. Clin. Urol. 2021, 62, 121–135.
  7. Huang, J.; Xie, D.; Xiong, R.; Deng, X.; Huang, C.; Fan, D.; Peng, Z.; Qin, W.; Zeng, M.; Song, L. The Application of Suctioning Flexible Ureteroscopy with Intelligent Pressure Control in Treating Upper Urinary Tract Calculi on Patients with a Solitary Kidney. Urology 2018, 111, 44–47.
  8. Du, C.; Song, L.; Wu, X.; Deng, X.; Yang, Z.; Zhu, X.; Zhu, L.; He, J. A study on the clinical application of a patented perfusion and suctioning platform and ureteral access sheath in the treatment of large ureteral stones below L4 level. Int. Urol. Nephrol. 2019, 51, 207–213.
  9. Gao, X.; Zhang, Z.; Li, X.; Cai, W.; Zheng, B.; Lu, Y.; Zhao, H.; You, J.; Zheng, G.; Bao, W.; et al. High stone-free rate immediately after suctioning flexible ureteroscopy with Intelligent pressure-control in treating upper urinary tract calculi. BMC Urol. 2022, 22, 180.
  10. Deng, X.; Song, L.; Xie, D.; Fan, D.; Zhu, L.; Yao, L.; Wang, X.; Liu, S.; Zhang, Y.; Liao, X.; et al. A Novel Flexible Ureteroscopy with Intelligent Control of Renal Pelvic Pressure: An Initial Experience of 93 Cases. J. Endourol. 2016, 30, 1067–1072.
  11. Grosso, A.A.; Sessa, F.; Campi, R.; Viola, L.; Polverino, P.; Crisci, A.; Salvi, M.; Liatsikos, E.; Feu, O.A.; Tellini, R.; et al. Intraoperative and postoperative surgical complications after ureteroscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy: A systematic review. Minerva Urol. Nephrol. 2021, 73, 309–332.
  12. Zeng, G.; Wang, D.; Zhang, T.; Wan, S.P. Modified Access Sheath for Continuous Flow Ureteroscopic Lithotripsy: A Preliminary Report of a Novel Concept and Technique. J. Endourol. 2016, 30, 992–996.
  13. Zhu, Z.; Cui, Y.; Zeng, F.; Li, Y.; Chen, Z.; Hequn, C. Comparison of suctioning and traditional ureteral access sheath during flexible ureteroscopy in the treatment of renal stones. World J. Urol. 2019, 37, 921–929.
  14. Gauhar, V.; Somani, B.K.; Heng, C.T.; Gauhar, V.; Chew, B.H.; Sarica, K.; Teoh, J.Y.; Castellani, D.; Saleem, M.; Traxer, O. Technique, Feasibility, Utility, Limitations, and Future Perspectives of a New Technique of Applying Direct In-Scope Suction to Improve Outcomes of Retrograde Intrarenal Surgery for Stones. J. Clin. Med. 2022, 11, 5710.
  15. Qian, X.; Liu, C.; Hong, S.; Xu, J.; Qian, C.; Zhu, J.; Wang, S.; Zhang, J. Application of Suctioning Ureteral Access Sheath during Flexible Ureteroscopy for Renal Stones Decreases the Risk of Postoperative Systemic Inflammatory Response Syndrome. Int. J. Clin. Pract. 2022, 2022, e9354714.
  16. Loeb, S.; Carrick, T.; Frey, C.; Titus, T. Increasing Social Media Use in Urology: 2017 American Urological Association Survey. Eur. Urol. Focus 2020, 6, 605–608.
  17. Taylor, J.; Loeb, S. Guideline of guidelines: Social media in urology. BJU Int. 2020, 125, 379–382.
  18. Loeb, S.; Catto, J.; Kutikov, A. Social media offers unprecedented opportunities for vibrant exchange of professional ideas across continents. Eur. Urol. 2014, 66, 118–119.
  19. Klaassen, Z.; Vertosick, E.; Vickers, A.J.; Assel, M.J.; Novara, G.; Pierce, C.; Wallis, C.J.; Larcher, A.; Cooperberg, M.R.; Catto, J.W.; et al. Optimal Dissemination of Scientific Manuscripts via Social Media: A Prospective Trial Comparing Visual Abstracts Versus Key Figures in Consecutive Original Manuscripts Published in European Urology. Eur. Urol. 2022, 82, 633–636.
  20. Manning, E.; Calaway, A.; Dubin, J.M.; Loeb, S.; Sindhani, M.; Kutikov, A.; Ponsky, L.; Mishra, K.; Bukavina, L. Growth of the Twitter Presence of Academic Urology Training Programs and Its Catalysis by the COVID-19 Pandemic. Eur Urol. 2021, 80, 261–263.
  21. Pradere, B.; Esperto, F.; van Oort, I.M.; Bhatt, N.R.; Czarniecki, S.W.; van Gurp, M.; Bloemberg, J.; Darraugh, J.; Garcia-Rojo, E.; Cucchiara, V.; et al. Dissemination of the European Association of Urology Guidelines Through Social Media: Strategy, Results, and Future Developments. Eur. Urol. Focus 2022, 8, 1541–1544.
  22. Teoh, J.Y.C.; Cacciamani, G.E.; Gomez Rivas, J. Social media and misinformation in urology: What can be done? BJU Int. 2021, 128, 397.
  23. Dr Parimal Gharia . #Suction in #RIRS. Simple, Sterile, Cost Effective Easily Available 1 Litre Normal Saline Standard TUR set 10 cc & 20 cc Syringe 3 way with 10 cm & 100–150 cm Extension. Twitter. 2022. Available online: https://twitter.com/DrParimalGharia/status/1592215647651790848 (accessed on 17 March 2023).
  24. Dr Ashish Rawandale Patil . @DrParimalGharia @usi @YouthUSI @UroZedman @lkeshav1965 @DrVCMohan @drnanjappa @niteshkuro @drabhaymahajan @optionurol @RIRS_inDelhiNCR @drkarthicknagan Check This Arrangement…Surgeon Can Control the Suction or Irrigation…Maybe a Trumpet like Attachment Can Be Made…. Twitter. 2022. Available online: https://twitter.com/AshishRawandale/status/1599330521007656960 (accessed on 17 March 2023).
  25. Brian Eisner . RCT of #KALERA K-Vac Novel Stone Aspiration Device Compared to Basket Extraction after URS. K-Vac Aspiration Associated with Higher Stone Volume Removed and Improved 1 Month SFR @roger_sur @GeorgeHaleblian @DrMaheshDesai4 COI: Patent Inventor. Twitter. 2019. Available online: https://twitter.com/BEkidneystone/status/1189613179778818055 (accessed on 17 March 2023).
  26. Khurshid Ghani . Hot Off the Press—Suction Device by Kalera #URS Dr Preminger @dustcme #DUST19. Twitter. 2019. Available online: https://twitter.com/peepeeDoctor/status/1162412728000139265 (accessed on 17 March 2023).
  27. Abby Qian—Medical Device and Consumables Supplier . Two Kinds of Ureteral Access Sheath: Ureteral Access with Suction, and Standard Ureteral Access Sheath. More Details about This Product, Please Just Inbox Me or Visit Our Website. Twitter. 2022. Available online: https://twitter.com/Abbyqianqxx/status/1587351360802279424 (accessed on 17 March 2023).
  28. Shally Zhu-Medical Device and Consumables Supplier . Ureteral Access Sheath with Suction, Reduce the Intra-Luminal Pressure and Risk of Surgery, and Greatly Improve Stone Clearance Rate by Continuous Suction of Stone Fragments through the Oblique Side Port on the Sheath. Twitter. 2022. Available online: https://twitter.com/Resistone2022/status/1602234630517977089 (accessed on 17 March 2023).
  29. @ClearPetra-Well Lead . One #RIRS Case: 3.3 cm Renal Stone, with #Clearpetra Suction-Evacuation Ureteral Access Sheath 12Fr, 46cm, @LumenisU 0.5*30, and Storz XC, Solved in 40 Minutes, no Complication…#Good Vision #Low Pressure… Twitter. 2018. Available online: https://twitter.com/JustineShi_js/status/997138590734794757 (accessed on 17 March 2023).
  30. Saeed Bin Hamri @sbinhamrii]. Future Pilars of #MIS #Stone Treatment as Day Surgery: Bendable Ureteral Access Sheath #TFL +/- Suction or Venturi Effect @PETRAurogroup @OTRAXER @PEARLSendouro @DocGauhar. Twitter. 2022. Available online: https://twitter.com/sbinhamrii/status/1563208588616642560 (accessed on 17 March 2023).
  31. Resistone/Hangzhou Wuchuang . #Resistone Visible Suction-Ureteral Access Sheath the Enlarged Inner Sheath Core Can Accommodate Both the Guide Wire and the Fiber Optical Ureteroscope. And the Sheath Enters under the Condition of Full Visibility. Twitter. 2021. Available online: https://twitter.com/ElaineTong4/status/1417408297968177152 (accessed on 17 March 2023).
  32. NEU Meram Urology . Role of Suction in Ureteroscopy @LaurianDragos @ecergokhann @StefaniaFerret @drkemalsarica @elgrecocan @AliSerdarGozen @guven_selcuk @GiraySonmez @eulis_uroweb @eauesut #IUD2022. Twitter. 2022. Available online: https://twitter.com/MeramUrology_/status/1598580859573084160 (accessed on 17 March 2023).
  33. proximedsrl . RIRS with @innovexmedical UAS with Active Suction Channel: Excellent Suction of the Fragments and Probable Cancellation of the Retropulsion? @ gmilano1 Is Using a.laser 30 w #holmium by @@so_uro #rirs @EdoAgostini4. Twitter. 2022. Available online: https://twitter.com/proximedsrl/status/1501979024553304079 (accessed on 17 March 2023).
  34. Dr Chui Ka ]. My Own New Standard #RIRS 7.5 Fr Single Use fURS Suction UAS Fr 10/12 Pressure Controlled Irrigation System Dusting Mode Holmium/TFL @PusenMedical @FengGao0313 @KARLSTORZUro @SeplouMedical @quanta_system @LumenisInc. Twitter. 2022. Available online: https://twitter.com/chuikalun1/status/1564851528057626624 (accessed on 17 March 2023).
  35. Biorad Medisys Pvt. Ltd. . #BioradMedisys Congratulates @DocGauhar for Winning the 5th Best Affordable New Technologies in Urology Contest-BANTUC22 #Singapore for “Direct Scope Suction Technique (DISS) & Device for Retrograde Intrarenal Surgery (RIRS)” Using Biorad’s Patented Suction & Irrigation Device. Twitter. Available online: https://twitter.com/Bioradmed_India/status/1595347066699788288 (accessed on 17 March 2023).
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Subjects: Urology & Nephrology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Catalina Solano
,
Marie Chicaud
,
Stessy Kutchukian
,
Luigi Candela
,
Mariela Corrales
,
Frédéric Panthier
,
Steeve Doizi
,
Olivier Traxer
View Times: 355
Revisions: 2 times (View History)
Update Date: 21 Apr 2023
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