Antegrade Pyelography Research Articles

Antegrade pyelography, a survey among urologists.

Antegrade pyelography (APG) is a useful modality for imaging the upper urinary tract. Little scientific evidence exists concerning optimal pressure while performing an APG. Methods of implementation seem to vary between hospitals as no specific guideline exists. Our aim was to describe current practice patterns in pre-procedural prophylaxis, describe methods of contrast administration, and estimate rate of complications during APG as reported by urologist, in order to stimulate discussion on defining guidelines. A digital questionnaire with 16 questions concerning APG was set out among EAU members via an ESUI twitter link. Fifty urologists from different centers responded. Outcomes were use of antibiotics, used pressure in upper urinary tract, and estimated urosepsis prevalence. Percentages and confidence intervals (95% CI) were calculated. Forty-two percent (95% CI 30-56) of respondents stated that antibiotic prophylaxis was always administered. Fifty-two percent (95% CI 38-65) of urologists sometimes performed a pre-procedural culture. Seventy percent (95% CI 56-81) indicated that administration of contrast during APG was performed using a syringe. A local guideline was only used in 8% of cases (95% CI 2.8-17.9) The self-estimated average percentage of urosepsis as a result of performing an APG was mentioned to be 4% (range 0-20%). Despite a considerable risk of urosepsis, no guideline or consensus exists on how to perform APG. This is urgently needed in order to prevent complications. Low response rate is a major limitation of these findings.

Diagnosis and Management of a De Novo Urothelial Carcinoma in a Kidney Allograft: A Case Report

IntroductionFollowing renal transplantation, the incidence of malignancies is 3–5 times higher than that of healthy individuals. Among other type of cancers, the risk of urological tumors is also elevated. However, only a few cases of de novo transitional cell carcinomas occurring in renal allografts have been reported. Case reportA 63-year-old tertiary transplanted male patient was urgently hospitalized for a painless macroscopic hematuria. Ultrasonography revealed pyelectasis and a hematoma in the renal pelvis. A percutaneous nephrostomy tube was inserted. An anterograde pyelography was performed later, where a filling defect was still observable in the location of the previously reported hypoechoic mass. Contrast-enhanced ultrasonography showed enhancement of the lesion. An ultrasound-guided percutaneous biopsy was performed. The histologic evaluation revealed a high-grade transitional cell carcinoma. A whole-body staging computed tomography scan did not show signs of metastatic disease. The renal allograft was surgically removed. No disease progression was observed during the 21-month follow-up period. ConclusionsPainless hematuria and asymptomatic hydronephrosis occurring after kidney transplantation should raise the possibility of urothelial carcinoma in the kidney graft. Contrast-enhanced ultrasound should be considered as a first-line diagnostic modality because it is easily accessible and does not raise concerns about nephrotoxicity or radiation burden.

Complications and clinical utility of ultrasonographically guided pyelocentesis and antegrade pyelography in cats and dogs: 49 cases (2007-2015).

To describe the diagnostic utility and clinical safety of ultrasonographically guided percutaneous pyelocentesis and antegrade pyelography in cats and dogs. Retrospective case series. 39 cats and 10 dogs with 55 affected kidneys. Medical records were reviewed to identify cats and dogs that underwent ultrasonographically guided pyelocentesis and antegrade pyelography between June 1, 2007, and December 31, 2015. Data collected included procedure descriptions; results of diagnostic imaging, urine cytologic evaluation, and bacterial culture; and evidence of complications. Animals were assigned to the pyelocentesis group (underwent only pyelocentesis) or to the antegrade pyelography group (underwent pyelocentesis followed immediately by pyelography). The diagnostic rate for pyelography was 94% (31/33; 95% confidence interval [CI], 80.4% to 98.9%). The total, minor, and major complication rates for both treatment groups combined were 25% (95% CI, 15.8% to 38.3%), 24% (95% CI, 14.4% to 36.3%), and 2% (95% CI, 0.09% to 9.6%), respectively. Performing bacterial culture of urine obtained by pyelocentesis did not provide an advantage over performing bacterial culture of urine obtained from the lower urinary tract. Findings indicated that ultrasonographically guided pyelocentesis and antegrade pyelography were well-tolerated techniques for investigating upper urinary tract disease in cats and dogs and that pyelography had a higher diagnostic rate than previously reported; therefore, pyelography should be considered for identification of mechanical and functional ureteral patency abnormalities in cats and dogs.

Acute renal failure in a neonate due to bilateral primary obstructive megaureters

Abstract A male newborn was referred to our institute for postrenal acute renal failure with bilateral hydroureteronephrosis, electrolyte imbalance, and anuria. Voiding cystourethrography revealed no vesicoureteral reflux or posterior urethral valves. We performed bilateral percutaneous nephrostomy on the 9th post-natal day. The serum creatinine level improved to the normal range. Antegrade pyelography revealed bilateral uretero-vesical junction stenosis. Subsequently, we inserted bilateral double J urethral stents at 1 month. Bilateral ureteroneocystostomy without ureteral folding was performed at 6 months. The postoperative course was uneventful. This is the second case of postrenal acute renal failure with bilateral primary obstructive megaureters in a neonate.

Risk Factors for Primary Failure of Metallic Ureteral Stents: Experience from a Tertiary Center.

Introduction: We provide primary patency rate of metallic ureteral stents in cancer patients and investigate the factors affecting primary patency. Methods: All cancer patients who had received metallic stents for malignant ureteral obstruction between July 2009 and November 2012 in our institute were included. No patients were excluded. Patient profiles, imaging studies, and laboratory data were collected. Patient profiles included age, gender, body height, body weight, body mass index, cancer types, treatment for cancer, response to cancer treatment, methods of stent insertion, and prior ordinary stents. Imaging studies included renal ultrasonography, antegrade pyelography, CT, and MRI. Laboratory data included urinalysis, urine culture, and serum creatinine. Complications were defined according to the Clavien-Dindo classification. Primary patency was defined as a complete resolution or downgrading of hydronephrosis shown by imaging studies or success in the removal of a preexisting nephrostomy tube; otherwise the procedure was considered a primary failure. The primary endpoint was the primary patency rate of the stents. The secondary endpoints were risk factors for primary stent failure. Results: A total of 124 stents were inserted into 96 patients with malignant ureteral obstruction. There were no grade 3/4 complications. The overall primary patency rate was 87.9% (109/124). In univariate analysis, antegrade insertion (OR = 24.15, p-value = 0.0086) and urinary tract cancer (OR = 4.18, p-value = 0.0164) were significantly associated with primary failure. Those with prior ordinary stents (OR = 0.20, p-value = 0.0158) or response to cancer treatment (OR = 0.25, p-value = 0.0228) were associated with stent patency. In multivariate analysis, antegrade insertion (OR = 22.04, p-value = 0.0041) and response to cancer treatment (OR = 0.15, p-value = 0.01081) remained significant factors. Conclusions: In this large cohort of cancer patients requiring urinary diversion to preserve renal function, several factors were associated with the success rate of metallic stents.

An Enigmatic Route to the Contralateral Pelvicalyceal System on Antegrade Pyelogram.

Introduction:The authors present the rare yet enigmatic phenomenon of ‘pyelo-renal’ backflow.Case Presentation:An eight-month-old boy with multiple congenital anomalies underwent left Anderson-Hynes Pyeloplasty for pelvi-ureteric junction obstruction. Antegrade dye-study done through the nephrostomy revealed obstruction at the level of the pelvi-ureteric junction, yet the contrast was visualized in the pelvis of contralateral kidney and urinary bladder (pyelo-venous backflow) masquerading as vesicoureteric reflux. The phenomenon of ‘pyelo-renal’ backflow along with pyelo-tubular, pyelo-interstitial, pyelo-sinusal and pyelo-lymphatic backflow have been described and the respective mechanisms discussed.Conclusion:The phenomenon is known to happen in the presence of obstruction to outflow from renal pelvis thereby creating a closed compartment. Injection of contrast at a pressure above the critical limit may result in forniceal tears and back-flow of contrast into the renal tubules and beyond.

Diagnosis and treatment of coexisting ureteropelvic junction obstruction and ureterovesical junction obstruction

Objective To explore the diagnosis, treatment options and outcomes of patients with ureteropelvic junction obstruction(UPJO) and ureterovesical junction obstruction(UVJO). Methods Clinical records of 12 children with UPJO and UVJO who received treatment in Children′s Hospital of Nanjing Medical University from April 2008 to December 2015 were reviewed.Presentations included prenatal hydronephrosis and symptoms caused by urinary tract infections.Ultrasonography, intravenous pyelography, magnetic resonance imaging and renography were performed before surgery. Results Four patients underwent nephrostomy, followed by pyeloplasty and eventually, ureteroneocystostomy.Five patients underwent heterochronic pyeloplasty plus ureteroneocystostomy.Two patients received pyeloplasty only.And another patient underwent heterochronic nephrostomy plus ureteroneocystostomy.The 12 patients received a 2.0 months to 2.5 years′ follow-up.Recurrent urinary tract infection and abdominal pain were relieved after the treatment.Ultrasonography showed hydronephrosis reduced obviously after the surgery. Conclusions UVJO patients with unparallel hydronephrosis should be considered with the coexistence of UPJO.Retrograde pyelography(RPG) is recommended for the diagnosis.And the treatment includes both pyeloplasty and ureteroneocystostomy.The patients diagnosed with UPJO should be first managed with pyeloplasty or nephrostomy instead of RPG.Subsequently anterograde pyelography can be performed to decide if the patients need additional ureteroneocystostomy. Key words: Child; Hydronephrosis; Ureteropelvic junction obstruction; Ureterovesical junction obstruction; Urography

63 - Is antegrade pyelography necessary before nephrostomy removal in percutaneous nephrolithotomy?

63 - Is antegrade pyelography necessary before nephrostomy removal in percutaneous nephrolithotomy?

Post Renal Transplant Surgical Complications; MRI Standard Applications and Diagnostic Outcomes

Objective: Fast MR imaging sequences together with paramagnetic contrast agents, offer multiple advantages in the assessment of renal function. It provides cross sectional and vascular information without the risk of ionizing radiation, iodinated contrast or arterial catheterization. Post transplantation complications can be grouped as surgical or medical. Immediate surgical complications include renal artery thrombosis or stenosis, urinary leak or lymphocele. Renal allograft frequently require repeated imaging studies during the immediate post-operative period and various times thereafter, when renal function is compromised. Background: End stage renal disease is common and can result from a variety of diseases. Kidney transplantation from living-related donors offered the best prognosis. Imaging modalities that are currently used to evaluate transplanted kidneys are ultrasound (US), computed tomography (CT), scintigraphy, intravenous urography (IVU), contrast angiography, and magnetic resonance imaging (MRI). Methods: This study was conducted on 181 renal transplant recipients. Recipients were 139 males and 42 females. Their age ranged from 20 to 58 years (mean age 39 years). The patients underwent clinical assessment, Laboratory investigations, and different Radiological imaging procedures as: I- Gray scale and color Doppler ultrasonography. II- Magnetic Resonance Imaging. 3D Gd-enhanced MRA. MR Urography. Selective IA-DSA of the graft artery. III- Percutaneous catheter nephrostomy (PCN) and antegrade pyelography. IV- Radio-isotope diuretic renogram using 99m Tc-MAG3. Results: 30 renal transplants were examined by MRI in the 1st 2 weeks after renal transplantation. At the end of 1st 2 weeks, MR examinations were carried out, as basal studies (including MRI, MRA and MRU) for 98 transplants. From this group, 64 transplants were subjected to other MR examinations. After the 1st 2 weeks, 53 transplants were subjected to MR examinations for the 1st time at variable post-transplant duration. Among the studied 181 renal transplants, MR examinations detected 3 cases with graft arteries thrombosis (1.6%), 10 with graft arteries stenosis (5.5%), 6 with segmental infarctions (3.3%), 3 cases with graft intrarenal arteries pseudo-aneurysms (1.6%) and 2 cases with arterio- venous fistulae (1.1%) after graft biopsies. Conclusion: MRI is highly recommended to evaluate intra-/extra-renal graft vascular lesions, urinary obstructive syndrome, compressive collections (urinoma, lymphocele), inflammatory and tumoral lesions of the renal graft.

Ruptured Renal Pelvis Due to Obstruction by Ureterosciatic Hernia: A Rare Condition With a Rare Complication

Ureterosciatic hernia is an extremely rare condition. Here we report a case of ureterosciatic hernia presented with sudden loin pain, with contrast computed tomography and antegrade pyelogram demonstrating ureterosciatic hernia causing ureteric obstruction and renal pelvic rupture. Subsequently, laparotomy with hernia reduction and mesh repair was performed.

Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model.

To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures. Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated. All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223min (162-360). Flap tubularization suture took 31min (19-47), and proximal anastomosis took 20min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9min (7-12) and 23min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p=0.003). Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

The diagnosis and management of the urological complications of Renal Transplantation: a series of 1100 patients

Objective: To analyse the Urological Complications after Renal Transplantation and their management. Material and methods: -A retrospective analysis of 1150 consecutive live donor renal transplants was performed. The study period extended from December 1995 to December 2004. The surgical procedure for ureteral reimplantation was modified Lich anastomosis. Ultrasonography, renal scanning, antegrade pyelography, retrograde pyelography and cystography were the diagnostic tools. Results: -Overall, 68 primary urological complications (5.9%) were identified during the 15-year experience in 65 patients. The Urological Complications in our series included 35 ureteral obstruction (3.0%), 25 ureteral or bladder leaks (2.17%), 05 out flow obstruction, 02 cases of vesicoureteral reflux and 01 case of ureteral stone. Conclusion: The incidence of Urological Complications in our study is 5.9%. Early exploration of the ureteric leaks and timely intervention to obstructed kidney reduced the morbidity and improves graft su rvival. The causes of these complications and techniques for their prevention are discussed in this study.

Incidence of Adverse Contrast Reaction Following Nonintravenous Urinary Tract Imaging

Adverse reactions (ARs) to intravenous (IV) radiographic contrast range from mild urticaria to life-threatening anaphylaxis. Intraluminal contrast dye is routinely used in the urinary tract with a minimal perceived risk of AR. We used the Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida from 2007 to 2011 to identify patients who received urinary tract contrast dye for retrograde pyelography, percutaneous pyelography, retrograde/other cystogram, and ileal conduitogram. After excluding patients who had received IV contrast for other radiologic studies, ARs to contrast were identified by a composite end point of diagnoses not present on admission including shock, anaphylaxis, iatrogenic hypotension, urticaria, angioedema, laryngospasm, laryngeal edema, and/or a new diagnosis of contrast reaction. Overall, 76 174 patients were included who had undergone non-IV urinary tract imaging, 367 (0.48%) of whom developed an AR. On multivariate analysis, receipt of contrast in the lower urinary tract (odds ratio [OR]: 1.8; p=0.04) or upper urinary tract by retrograde pyelography (OR: 1.6; p=0.04) or antegrade pyelography (OR: 2.0; p=0.007) increased the risk of AR compared with control patients. The use of contrast dye in the urinary tract is associated with a low, but present risk of AR. Patient summaryWe looked at patients who underwent a urologic procedure using radiographic contrast media in the urinary tract. Although adverse reactions (ARs) may occur with the use of contrast media in the urinary tract, these reactions are experienced by a minority of patients (approximately 1 in 200). In addition, we found that an allergy to intravenous contrast does not increase a patient's risk of an AR to contrast within the urinary tract.

Laparoscopic calyceal diverticulectomy.

Calyceal diverticulum are cystic cavities within renal parenchyma lined by nonsecretory epithelium and communicating with the collecting system via a narrow channel. Usually they are asymptomatic and under one centimeter. The indications of surgical treatment are usually the symptomatic ones (hematuria, pain, infection), in most cases associated with the calculi. The development of minimally invasive approaches like laparoscopy is by displaying traditionally invasive approaches. We described a laparoscopic technique for the definitive management of a symptomatic calyceal diverticula. We presented a clinical case of a 24-year-old female who arrived to the emergency department with left flank pain and fever. The ultrasound and computed tomography (CT) showed a large upper pole renal abscess. Percutaneous abscess drainage was performed. An anterograde pyelography confirmed a large upper pole calyceal diverticulum with a narrow neck. A four trocar transperitoneal laparoscopic calyceal diverticulectomy was performed in a right lateral decubitus position. The first step was the insertion of a straight ureteral stent in the lithotomy position. A retrograde pyelography was then performed to confirm the diagnosis. After medial mobilization of the colon, the Gerota's fascia was incised and the kidney fat was removed. Kidney dissection was then performed in order to identify the upper pole diverticulum, which was then incised. The cavity was unroofed and its base was exposed revealing the small stones, which afterwards were removed. The narrow neck was identified after instillation of saline solution through the ureteral stent. We closed the neck with a 3/0 absorbable suture and confirmed the correct closure. Then the diverticulum base was fulgurated. Renal parenchyma was approximated with a continuous absorbable suture fixed by hem-o-lok clips. Afterwards, the suture was covered with a Gerota's flap. A Jackson Pratt drainage was placed. The CT on day three demonstrated the resolution of the diverticulum and no evidence of recurrent disease. The laparoscopic approach to symptomatic calyceal diverticula represents an effective minimally invasive modality for the definitive management of diverticula and the complete clearance of the lithiasis. Patient selection is mandatory. We recommend laparoscopic diverticulectomy in large diverticula, thin renal parenchyma or unsuccessful, impossible management with other approaches.

Pituitary gland adenoma with hyperprolactinemia and male erectile dysfunction – A case report

Pituitary gland adenoma with hyperprolactinemia and male erectile dysfunction – A case report

E80 Our antegrade pyelography experiences prior to nephrostomy removal in patients who underwent percutaneous nephrolithotomy

E80 Our antegrade pyelography experiences prior to nephrostomy removal in patients who underwent percutaneous nephrolithotomy

Extended Ureteral Stricture Corrected With Appendiceal Replacement in a Kidney Transplant Recipient

To present our technique of ureteral replacement with an appendicovesicostomy for the treatment of extended ureteral stricture after kidney transplantation. Ureteral stricture represents a urologic complication that may cause progressive function impairment and graft loss. Symptomatic ureteral stenosis is generally treated with a percutaneous nephrostomy and ureteral stenting. This approach may be initially effective, but often does not offer a long-term solution. A 48-year-old Caucasian man underwent kidney transplantation from a heart-beating deceased donor. The graft was transplanted to the right iliac fossa. Ureterovesical anastomosis was performed following the Lich-Gregoir technique. The postoperative period and follow-up were uneventful. Six months later the patient experienced an episode of acute pyelonephritis with hydronephrosis. A percutaneous nephrostomy was inserted, and an anterograde pyelography confirmed proximal dilatation with severe distal stenosis involving the entire ureter including the ureterovesical anastomosis. A 9 French Double-J stent was inserted antegradely and the patient was prepared for surgery. We decided therefore to use the appendix as a conduit between the proximal transplant ureter and the bladder It was interposed with an isoperistaltic orientation and anastomosed to the ureter proximally and to the bladder distally (Lich-Gregoir reimplantation) using interrupted absorbable 5/0 sutures over a 10-Fr Double-J stent. The urethral catheter was removed on day 9 postoperatively and the patient was discharged with normal parameters. At 1 year follow-up the patient remains well. The positive outcome confirms how the use of appendix as ureteral replacement is feasible and effective, allowing the salvage of the renal allograft.

Robotic-assisted partial nephrectomy for hilar and non-hilar tumors: Perioperative ouctomes

Robotic-assisted partial nephrectomy for hilar and non-hilar tumors: Perioperative ouctomes

Rare giant bladder stone with the size of an adults' fist in healthy young male

Rare giant bladder stone with the size of an adults' fist in healthy young male

MP79-17 FOLLOW UP AFTER 4 YEARS OF URETERAL STENOSIS IN TRANSPLANT KIDNEY MANAGED WITH LONG-TERM THERMO-EXPANDABLE METALLIC STENT

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-17 FOLLOW UP AFTER 4 YEARS OF URETERAL STENOSIS IN TRANSPLANT KIDNEY MANAGED WITH LONG-TERM THERMO-EXPANDABLE METALLIC STENT Helena Vila Reyes, Lluis Riera Canals, Joan Dominguez Elias, Laia Pujol Galarza, and Eladio Franco Miranda Helena Vila ReyesHelena Vila Reyes More articles by this author , Lluis Riera CanalsLluis Riera Canals More articles by this author , Joan Dominguez EliasJoan Dominguez Elias More articles by this author , Laia Pujol GalarzaLaia Pujol Galarza More articles by this author , and Eladio Franco MirandaEladio Franco Miranda More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2874AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Between 2004-2011, 773 kidney transplantations were performed in our centre. 40 patients presented ureteral stenosis as a complication (5.1%). Our first option to repair it is open surgery, performed in 27 patients. Instead of this, we choose endoscopic techniques (balloon dilatation) as an alternative in patients with high-surgical risk or with re-stenosis after surgery, with poor results. The aim of our study is to evaluate the efficacy of Memokath 051 stent in high surgical risk patients and in those in which the surgery or dilatations have failed. METHODS Prospective study over 11 patients transplanted in 2004-2011, who had ureteral stenosis with renal function repercussion. Indications for metallic stenting were: re-stenosis after surgical treatment (3 patients) and severe comorbidities contraindicating surgery (8 patients). All patients had a nephrostomy placed previously and at least 2 failed endoscopic balloon dilatations. Antegrade pyelography showed stenosis in distal ureter in 9 cases and in pyeloureteral union in 2. Follow-up after was made with serum creatinine levels, simple X-ray, ultrasonography and renal scintigraphy in some cases. RESULTS Between February 2009 and February 2012, 12 stents were placed in 11 patients through anterograde transrenal approach. Radiologic control after the procedure showed successful resolution of the stricture in all the cases. We observed 2 transitory haematuria, but there were no major immediate complications in any case. As a long term complications, we found 1 stent migration after 30 days and one patient with a new proximal stenosis after 7 months, both of them needing stent replacement. One patient had spontaneous stent migration to the bladder after 29 months, without needing a new stent because of normal renal function. Finally, one patient had severe chronic allograft dysfunction with recurrent acute pyelonephritis and we decided to perform transplantectomy. Due to their severe comorbidities, 2 patients died with functional stent in situ (after 5 and 15 months). Another 2 patients with non-obstructive chronic allograft dysfunction, were reintroduced to haemodialysis program after 7 and 18 months, and died later because of their diseases. After a mean follow-up of 52.5 months (33-69), we have 6 patients with stable renal function and without clinically significant hydronephrosis. CONCLUSIONS The management of ureteral stenosis with ureteral stent Memokath 051 is minimally invasive, safe and effective, and can be a long-term alternative to surgical treatment in selected cases. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1017 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Helena Vila Reyes More articles by this author Lluis Riera Canals More articles by this author Joan Dominguez Elias More articles by this author Laia Pujol Galarza More articles by this author Eladio Franco Miranda More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...