Intractable Hematuria Research Articles

Renal artery embolization in a case of renal cell carcinoma with intractable hematuria with acute myocardial infarction

Introduction: Renal artery embolization is a valuable treatment option for various renal tumors, both malignant and benign. The indications for this procedure include preoperative arterial embolization of large and vascular renal cell carcinoma to reduce intraoperative hemorrhagic complications, management of malignant renal tumors in patients who are not suitable candidates for surgery, treatment of symptomatic hematuria and palliative care for metastatic renal cancer. Case Report: In this case report, we present the case of a 56-year-old female with a known history of hypertension and cerebrovascular accident, who presented with complaints of hematuria and urinary retention. A diagnosis of left renal mass suggestive of renal cell carcinoma was made. The patient was planned for left radical nephrectomy and advised to discontinue aspirin for a week. However, on the morning of surgery, she experienced acute myocardial infarction and had to be hospitalized in intensive cardiac care. Aspirin was restarted, leading to recurrent severe hematuria. The patient underwent renal artery embolization, which successfully controlled the hematuria. Following cardiac stabilization, radical nephrectomy was performed three months later. The surgery and post-operative period were uneventful. Conclusion: This case study demonstrates the use of renal artery embolization as an effective modality for controlling hematuria, and temporizing management in a case of renal cell carcinoma where surgery was not immediately feasible due to a medical emergency.

Super-Selective Trans-Catheter Arterial Embolization (TAE) of the Vesical Arteries in the Management of Intractable Hematuria Secondary to Advanced Bladder and Prostate Cancers.

This article was previously presented as an abstract at the 18th UAA Congress, Seoul, October 15-17, 2020, and the abstract was published in The International Journal of Urology. It was also presented as an e-posterat the 2021 BAUS Annual Meeting on June 22, 2021. Introduction In frail patients intractable hematuria secondary to advanced pelvic malignancies is a clinical challenge. Super-selective TAE of the vesical arteries is a suitable minimally invasive option. We present our experience in this patient cohort. Patients and methods All patients who underwent TAE from January 2014 to December 2019 were included. Super-selective TAE of the superior and inferior vesical arteries was done using 300-500µ polyvinyl alcohol(PVA) particles. Demographic data, cancer stage, associated urinary system obstruction, pre-embolization palliative treatment, chemotherapy, and radiotherapy were recorded. Technical and clinical success, time to cessation of hematuria, recurrence of hematuria, and complications were recorded. Data are presented as mean ± standard deviation, and statistical significance is set at p<0.05. Results From 2014 to 2019, seven patients underwent eight procedures. The average patient's age was 60.6±10.3 years. All presented with gross hematuria, six due to locally advanced and/or metastatic bladder cancer, and one due to prostate cancer. The average time of hematuria clearance was 60 hours. The average hemoglobin levels at the time of the procedure, one month, and six months post-embolization were 9.6±1.7 g/dL, 10.6±1.5 g/dL (p<0.05), and 9.6±0.9 g/dL, respectively (p>0.05). Packed red blood cell (PRBC) requirements decreased from 7±2 units to 5±3units after the procedure (p >0.05). The patients were followed up for an average of 13.6 months and four had a recurrence at an average of four months post-embolization. Conclusion Super-selective TAE is an effective palliative method in controlling intractable hematuria. The risks of major surgery and anesthesia are omitted, and the procedure can be repeated as needed. Furthermore, post-embolization complications, using this technique, are minor and manageable.

Clinical Outcomes of Transcatheter Arterial Embolization in Patients with High-grade Gross Hematuria.

To investigate factors influencing the effectiveness and safety of super-selective embolization in patients with high-grade gross hematuria. This retrospective, single-center study included 19 consecutive cancer patients (12 men and 7 women, mean age of 72.3 years) who had undergone TAE for intractable hematuria between January 2008 and February 2024. Factors such as technical and clinical success rates, embolized vessels, embolic agents used, and complications were evaluated. This study specifically focused on patients with severe hematuria (grade 3 or above) and examined the effects of super-selective embolization, hematuria grade, and embolic agents on patient outcomes. Technical success was achieved in all 23 angiography procedures performed, with a clinical success rate of 56.5%. Clinical success was significantly correlated with hematuria grade, super-selectivity of the procedure, and type of embolic agent used. Multivariate logistic regression analysis revealed that the embolic material, specifically tris-acryl gelatin microspheres (TAGM), was an independent factor that significantly affected clinical outcomes. No major complications were reported. TAGM for supers-elective embolization in patients with massive gross hematuria is both effective and safe. However, the effectiveness of TAE may decrease in patients with severe hematuria, highlighting the need for combination therapies.

Alum instillation: A management option for intractable hemorrhagic cystitis

Intractable hemorrhagic cystitis is an uncommon but significant treatment complication of concurrent chemoradiation therapy for cervical cancer. Alum instillation is regarded as a safe and effective option for its treatment. This case presentation will discuss a patient who presented with postradiation cystitis and was treated with alum irrigation. The aim of this report is to offer alum irrigation as a management option for intractable hematuria.

Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review.

Lower urinary tract symptoms (LUTS) and hematuria are common symptoms in men with neoplasms, mainly affecting the elderly population. Prostatic arterial embolization (PAE) is a minimally invasive procedure that has shown promising results in managing LUTS and massive intractable prostatic hematuria in patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa). A few studies, however, have provided valuable insights into the durability and efficacy of PAE focusing on the long-term effectiveness, quality of life, and cancer-specific control of hemostasis and urinary symptoms. As a result of concomitant cardiovascular conditions, these patients often take anticoagulants or antithrombotics, which can worsen their hematuria and clinical status. Transurethral resection of the prostate (TURP) is considered a very high-risk procedure, even without massive bleeding, and requires discontinuation of vitamin K antagonists and antiplatelet therapies. Such patients usually have their surgery postponed, and PAE should be considered a safe alternative treatment. We aimed to report a narrative review from 1976 to June 2023 of the current state of PAE for massive and intractable hematuria, highlighting recent developments in this technique, including prospective cohort studies, and focusing on long-term outcome, safety, and complication management of patients with prostatic neoplasms who develop significant hemorrhagic symptoms. Additionally, we present a case report and a simple algorithm for treating intractable bleeding in a 92-year-old man with PCa and massive hematuria.

Selective Transarterial Embolization for Intractable Hematuria Due to Bladder Carcinomas: A Single-Center Experience.

Malignant bladder neoplasms can cause life-threatening persistent hematuria. Selective transarterial embolization is an effective way to achieve hemostasis in such patients. The purpose of our study is to share our experience in these patients and to evaluate the short- and long-term effectiveness of this procedure. Twelve male patients with intractable hematuria due to bladder carcinoma were included in the study. A total of 17 selective transarterial embolization procedures (bilateral in 5 patients) were performed in 12 patients with microspherical particles and microcoils. Complete control of bleeding was achieved in 9 patients after the procedures whereas the need for transfusion continued in 3 patients. Approximately 75% bleeding control was achieved during our average 6-month (4- to 12-month) follow-up period. After the procedure, the patients had mild complaints that lasted for a few days, such as pain (66%), fever (42%), and nausea (50%). No major complications occurred. Selective transarterial internal iliac artery embolization is a reliable method that can be used for the palliative treatment of intractable hematuria due to bladder carcinomas.

Intractable haematuria due to giant prostatic hyperplasia in a resource-challenged centre: between the devil and the deep blue sea

Intractable haematuria due to giant prostatic hyperplasia in a resource-challenged centre: between the devil and the deep blue sea

Chronic Radiation cystitis: a review of medical and surgical management

Radiation cystitis is a complication of radiation treatment given for pelvic malignancies. Radiation cystitis can present as mild symptoms of dysuria, frequency, and hematuria to severe life-threatening complications like intractable hematuria, bladder perforation and contracted non-functional urinary bladder, fistula etc. Treatment is tailored according to the severity of symptoms and available treatment modalities sequentially. Initial treatment of hematuria is intravenous fluids, blood transfusions, cystoscopy and fulguration, irrigation with intravesical agents like alum, hyperbaric oxygen therapy, angioembolisation, urinary diversion and surgery (cystectomy). Radiation cystitis is associated with short- and long-term complications in pelvic malignancies patients. Early diagnosis, follow up, treatment is crucial for decreasing morbidity and mortality in these patients. In this review article we describe the current protocol in diagnosing and managing radiation cystitis.&#x0D; Keywords Pelvis, Radiation, Hematuria, intravesical treatments, Alum, formalin

Prostatic Artery Embolization for The Treatment of Benign Prostatic Obstruction - A Retrospective Review of The Novel Experience Of 2 Tertiary Urology Centers

Background: Benign Prostatic Hyperplasia (BPH) is common in aging men with worldwide prevalence at 20-62%, while Malaysian prevalence was 39.3% (2001) and increased at 8% per decade. In surgical treatment of BPH, Trans-Urethral Resection of Prostate (TURP) remains the gold standard. Other surgical options would mostly also require general anesthesia (GA). Therefore, more Local-Anaesthesia (LA) based options should be made available for patients who are not fit or unwilling to be under GA. Those currently available LA-based procedure has shown promising results including prostatic stents and trans-urethral lifts, but have drawbacks due to being expensive, not widely available, less suitable in median lobe enlargement or may cause complications including migration, overgrowth of prostatic tissue or foreign-body related complications which may require GA for their treatment. Prostatic Artery Embolization (PAE), initially an LA-based emergency treatment option for persistent life-threatening hematuria from a bleeding BPH, now has been proven to be a safe elective treatment. In Malaysia this novel technique was first reported in 2017 for treatment of post TURP intractable hematuria. Methods and Material: We retrospectively evaluated all 13 catheter-dependent BPH patients in two tertiary urology centres treated with PAE from April 2019 until December 2021 to assess post-treatment efficacy. Results: One patient failed removal of catheter within 3 months post-procedure but 12 out of 13 patients safely got their catheter removed within 1-3 months and resulted in significant IPSS improvement. Conclusion: PAE is a safe and effective treatment option for BPH patients of the Malaysian population but needs prospective evaluation.

Safety and Efficacy of Intravesical Epinephrine Instillation in Patients with Intractable Lower Urinary Tract Hematuria – A Novel Approach

To treat intractable hematuria with intravesical instillation of epinephrine. Sixty patients were treated with intravesical instillation of epinephrine at Mackay Memorial Hospital. The control group was composed of 60 patients who were treated with standard-of-care cystoscopic electrocautery fulguration. Under general anesthesia, epinephrine-treated group were injected with 150 mL of diluted epinephrine (1:10,000) through cystoscopy, followed by bladder irrigation with 1:100,000-diluted epinephrine at the ward. Successful hemostasis was defined as hematuria resolution within 1 month post-treatment without additional invasive procedures. In the 60 patients who underwent intravesical instillation of epinephrine, radiation cystitis was the most common etiology (65.0%). Fifty-two patients (86.7%) required no additional therapy within 1 month after one course of intravesical epinephrine instillation treatment compared with 28 patients (46.7%) in the electrocautery fulguration-control group (P <.001). We observed a significant decrease in both the median length of hospitalization (P=.049) and the need for additional invasive procedures (P <.001) in the epinephrine group. In addition, cardiopulmonary monitoring of mean blood pressure, mean heart rate, and mean respiratory rate demonstrated no significant differences after epinephrine treatment. In this study, intravesical instillation of epinephrine was an innovative method of hemostasis for intractable lower urinary tract hematuria with a success rate of 86.7%, compared to 46.7% in the control group, and significantly reduced the number of additional procedures required and the length of hospitalization. It was well-tolerated by all patients, and was a safe and effective treatment modality for intractable hematuria or bladder hemorrhage.

Selective and super-selective angioembolisation for intractable haematuria of prostatic origin

Selective and super-selective angioembolisation for intractable haematuria of prostatic origin

Superselective vesical artery embolization versus intravesical formalin for intractable hematuria in patients with bladder cancer

ObjectiveIntractable hematuria is a leading critical problem occurring in patients with advanced stage bladder cancer (BCa) that are not suitable for radical cystectomy. The present study, for the first time in the literature, aimed to compare the effectiveness of intravesical formalin (IF) and superselective vesical artery embolization (SVAE) in the management of intractable and life-threatening hematuria in BCa patients. MethodsThe retrospective study included 40 BCa patients who underwent SVAE or IF treatment due to intractable hematuria after failure of other methods. Patients were divided into two groups based on the procedures administered: SVEA Group (n = 24) and IF Group (n = 16). ResultsThe success rate at first-line therapy was 50% (12/24) in SVAE Group and 82% (13/16) in IF Group (p = 0.046). Based on the success rates at first- and second-line therapies, the overall success rate in SVAE Group was 75% and this rate was similar to that of IF Group (p = 0.439). Complication rate was significantly higher in IF patients than in SVAE patients (37.5% vs. 8.3; p = 0.024), whereas duration of postoperative hospital stay was significantly longer in SVAE Group (15.8 vs. 6 days; p = 0.041). ConclusionThe advantages of IF appear to include shorter postoperative hospital stays and higher success rates at a single session, while the advantages of SVAE seem to include non-requirement of spinal/general anesthesia, easy repeatability, and low complication rates. In the management of patients with intractable hematuria, patients’ general condition, comorbidities, and anesthesia-related risks should be taken into consideration.

Embolización vesical supraselectiva versus formalina intravesical para la hematuria intratable en pacientes con cáncer de vejiga

ObjectiveIntractable hematuria is a leading critical problem occurring in patients with advanced stage bladder cancer (BCa) that are not suitable for radical cystectomy. The present study, for the first time in the literature, aimed to compare the effectiveness of intravesical formalin (IF) and superselective vesical artery embolization (SVAE) in the management of intractable and life-threatening hematuria in BCa patients. MethodsThe retrospective study included 40 BCa patients who underwent SVAE or IF treatment due to intractable hematuria after failure of other methods. Patients were divided into two groups based on the procedures administered: SVEA Group (n=24) and IF Group (n=16). ResultsThe success rate at first-line therapy was 50% (12/24) in SVAE Group and 82% (13/16) in IF Group (p=0.046). Based on the success rates at first- and second-line therapies, the overall success rate in SVAE Group was 75% and this rate was similar to that of IF Group (p=0.439). Complication rate was significantly higher in IF patients than in SVAE patients (37.5% vs. 8.3; p=0.024), whereas duration of postoperative hospital stay was significantly longer in SVAE Group (15.8 vs. 6 days; p=0.041). ConclusionThe advantages of IF appear to include shorter postoperative hospital stays and higher success rates at a single session, while the advantages of SVAE seem to include non-requirement of spinal/general anesthesia, easy repeatability, and low complication rates. In the management of patients with intractable hematuria, patients’ general condition, comorbidities, and anesthesia-related risks should be taken into consideration.

Intractable bleeding: the role of embolization in a resource-limited country

Transarterial catheter embolization is novel in Ghana, even though it has been practiced over three decades in certain parts of the world. The procedure is safer with the advent of new catheter techniques and embolic agents which place interventional radiology at the forefront of the treatment of bleeding due to myriad of indications. It is fast, safe, and minimally invasive relative to open surgery, especially when other conventional minimally invasive procedures such as endoscopic banding and sclerotherapy fail. This paper presents two cases involving pre-and post-embolization digital subtraction angiogram (DSA) of gastroduodenal artery and bilateral iliac arteries. Findings of DSA of the gastroduodenal artery and bilateral iliac arteries showed florid extravasation and extensive neovascularity. Post embolization DSA showed absent extravasation and near total devascularization. The inclusion of embolization to the management protocols of upper gastrointestinal bleeding and intractable haematuria is recommended

Endovascular Interventional Radiology of the Urogenital Tract.

Interventional radiology of the male urogenital system includes percutaneous and endovascular procedures, and these last consist mostly of transcatheter arterial embolizations. At the kidney level, arterial embolizations are performed mainly for palliative treatment of parenchymal tumors, for renal traumas and, less frequently, for arteriovenous fistulas and renal aneurysms and pseudoaneurysms. These latter may often require emergency intervention as they can cause renal or peri-renal hematomas or significant hematuria. Transcatheter arterial embolization is also an effective therapy for intractable severe bladder hematuria secondary to a number of neoplastic and inflammatory conditions in the pelvis, including unresectable bladder cancer and radiation-induced or cyclophosphamide-induced hemorrhagic cystitis. Endovascular interventional procedures for the penis are indicated for the treatment of post-traumatic priapism. In this article, we review the main endovascular radiological interventions of the male urogenital system, describing the technical aspects, results, and complications of each procedure at the various anatomical districts.

Long-term results of super-selective trans-catheter embolization of the vesical arteries for the treatment of intractable bladder haematuria

PurposeTo evaluate the feasibility, safety and long-term efficacy of super-selective trans-catheter arterial embolization for the management of intractable bladder bleeding.Materials and methodsThe records of 20 patients with intractable haematuria referred urgently for selective arterial embolization after failed conventional therapy, between 2013 and 2018, were retrospectively analyzed. Primary outcomes were technical (cessation of extravasation and/or stasis of flow within the target vessel) and clinical (bleeding control) success. Secondary outcomes included complication and re-intervention rates.ResultsTechnical success was 90% (18/20 cases), as in 2 cases, embolization was not feasible. Super-selective embolization of the vesical arteries was feasible in 15/18 cases (83.3%). Selective proximal occlusion of the anterior division of the internal iliac artery was performed in two cases (11%) and embolization of the anterior division after coil blockage of the posterior division was performed in one case (5%). Bilateral and unilateral embolization was performed in 10 and 8 cases, respectively. Peri-procedural mortality rate was 5% (1/18 patients). One possible procedure-related death occurred due to myocardial infarction ten days following non-target embolization of the buttocks and the anterior abdominal wall. Mean time follow up was 35 ± 15 months. Bleeding reoccurred in three patients (16.6%), all successfully managed (one conservatively and two with further embolization). Clinical success was 85% (17/20 cases). During follow up 11 more patients died, due to underlying conditions not related to bleeding or the procedure.ConclusionsSuper-selective angiographic embolization is feasible, safe and effective to control refractory, life threatening bladder bleeding and should be considered as a first line treatment, as to obviate the need for emergency surgery.

Transcatheter arterial embolization for intractable, nontraumatic bladder hemorrhage in cancer patients: a single-center experience and systematic review

To explore the effect of transcatheter arterial embolization (TAE) in controlling intractable, nontraumatic bladder hemorrhage in cancer patients. A literature review (PubMed and EMBASE), followed by a retrospective analysis of all cancer patients with intractable hematuria from bladder treated by TAE at our tertiary referral center. At our institution, 27 consecutive cancer patients who underwent TAE for refractory hematuria from bladder were identified. The systematic review included 13 studies published between 1981 and 2019. In our local cohort, 27 patients were treated with 100% technical success, clinical success in 88.9%, no major complications, and rebleeding rate within the first month of 7.4%. In the systematic review cohort of 201 patients, there was technical success in 99.0%, clinical success in 80.9%, major complications in 5.5%, and a rebleeding rate within the first month of 4.5%. Bilateral embolization was performed in 81.1%, and embolization levels were mostly anterior division of internal iliac artery (73.7%) and vesical artery (23.2%). TAE is effective and safe to control intractable hematuria from bladder origin in cancer patients after failure of conservative management, providing effective temporary hemostasis. For bladder hemorrhage unsuitable for surgery, TAE should be considered at an early stage. A literature review, followed by retrospective analysis of all patients with intractable hematuria from bladder treated by transcatheter arterial embolization at our tertiary referral center. Transcatheter arterial embolization is effective and safe to control intractable hematuria from bladder. The major complication rate and rebleeding within the first month are acceptable.

Superselective vesical artery embolization for intractable bladder hemorrhage related to pelvic malignancy.

Intractable bladder hemorrhage from pelvic malignancy can be potentially life-threatening and its management can be a challenging clinical problem. To evaluate safety, efficacy, and clinical outcome of superselective vesical artery embolization for the control of intractable bladder hemorrhage from pelvic malignancy. Between January 2010 and September 2018, 20 patients underwent superselective vesical artery embolization for intractable hematuria secondary to pelvic malignancy arising from or invading the bladder. Treatment details and clinical outcomes were obtained. There were 12 men and 8 women (mean age = 77 years). Bilateral embolization was performed in 10 patients and unilateral approach in 10 patients. Two patients died within four days after embolization due to underlying heart failure and systemic metastasis, respectively. The remaining 18 patients had a follow-up of >30 days. Bleeding was controlled after the first embolization in 17/18 patients and after a repeat embolization in the remaining one patient. The mean follow-up period of 18 patients was 10.6 months (range = 1-77 months). Late recurrent hemorrhage (≥ 30 days after embolization) was reported in 6 (33.3%) patients. Five of these six patients underwent repeat embolization. There were no major complications related to embolization. Palliative superselective vesical artery embolization is a feasible, effective, and safe procedure to control intractable hematuria in patients with pelvic malignancy.

Re: Superselective Vesical Artery Embolization in the Management of Intractable Hematuria Secondary to Hemorrhagic Cystitis.

Re: Superselective Vesical Artery Embolization in the Management of Intractable Hematuria Secondary to Hemorrhagic Cystitis.

MP02-10 LONG-TERM USE OF DOUBLE INTERNAL STENTS FOR EXTRINSIC MALIGNANT URETERAL OBSTRUCTION

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making I (MP02)1 Apr 2020MP02-10 LONG-TERM USE OF DOUBLE INTERNAL STENTS FOR EXTRINSIC MALIGNANT URETERAL OBSTRUCTION Ziv Savin*, Haim Herzberg, Reuven Ben David, Snir Dekalo, Ishay Mintz, Yazeed Barghouthy, Ofer Yossepowitch, and Mario Sofer Ziv Savin*Ziv Savin* More articles by this author , Haim HerzbergHaim Herzberg More articles by this author , Reuven Ben DavidReuven Ben David More articles by this author , Snir DekaloSnir Dekalo More articles by this author , Ishay MintzIshay Mintz More articles by this author , Yazeed BarghouthyYazeed Barghouthy More articles by this author , Ofer YossepowitchOfer Yossepowitch More articles by this author , and Mario SoferMario Sofer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000816.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with secondary extrinsic malignant ureteral obstruction (EMUO) seek for durable, simple and low-cost solutions of drainage. We report on long-term outcomes with double internal stents (DIS) for relief of EMUO. METHODS: DIS of 75 renal units (62 patients) presenting with EMUO were performed in 2007-2019. The procedure was done using dwelling 7 FR stents. Surveillance was performed every 3 months and stents were routinely exchanged annually. Need for permanent stents' retrieval was considered failure. Univariate and multivariate analyses were used to assess risk factors for stent failure and mortality. Kaplan-Meier estimations provided maintenance of stent patency and disease specific survival (DSS). RESULTS: Demographics and by-entry clinical data are presented in table 1. Balloon dilation was needed in 30 cases (48%). The median follow-up was 35.2 months (IQR 26.8-46.7) and the median DSS was 21 months (Range 7.1-45.5) (Figure 1). Thirty-nine patients died during the study period, 37 of them (95%) with patent stents in place. Multivariate analysis identified estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2 and balloon dilation as independent predictors for mortality (HR=2.1, 95%CI=1.1-4.2, p=0.02 and HR=2.1, 95%CI=1.1-4.1, p=0.02, respectively). Six patients (10%) had stent failure due to sepsis, creatinine elevation, or intractable hematuria. The mean time to failure was 15 months. Radiation and eGFR < 45 ml/min/1.73m2 at presentation were independent risk factors for stent failure (p=0.038 and p=0.001, respectively). Stent-related side effects including irritative symptoms and hematuria were reported by 40% of patients. CONCLUSIONS: DIS provides durable relief of EMUO for long term. It represents a simple and valuable alternative to other methods of urinary diversion, avoiding the need for external tubes and contributing to improved patients quality of life. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e15-e15 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ziv Savin* More articles by this author Haim Herzberg More articles by this author Reuven Ben David More articles by this author Snir Dekalo More articles by this author Ishay Mintz More articles by this author Yazeed Barghouthy More articles by this author Ofer Yossepowitch More articles by this author Mario Sofer More articles by this author Expand All Advertisement PDF downloadLoading ...