Bilateral Pudendal Thigh Fasciocutaneous Flap Vaginoplasty in Mayer Rokitansky Kuster Hauser Sydnrome: A Step-by-Step Approach

@#<p>The surgical management in a case of vaginal agenesis is technically challenging and requires a strong demand for expertise. The objective of this report was to record the hospital's first experience in vaginal reconstruction using Bilateral Pudendal Thigh Fasciocutaneous Flap. Presented here is a case of 23-year old, female who consulted for primary amenorrhea who plans of getting married soon. Physical examination revealed normal secondary sexual characteristics with absent vagina. Imaging revealed an absent uterus with normal ovaries and distal vagina that ends in a blind pouch. Patient underwent vaginal reconstruction with no post-operative complications. Follow-up revealed incision site infection but eventually resolved with oral and topical antibiotics. Four weeks post-operatively, good wound healing was noted, vagina was 6 centimeters in length, admits two fingers on internal examination. Overall, the authors' first neovaginoplasty using Bilateral Pudendal Thigh Fasciocutaneous Flap was a technically safe procedure with good cosmetic outcome.</p>

OHVIRA syndrome with Orofacial clefts: a rare association

Obstucted hemivagina with ipsilateral renal anomaly (OHVIRA) syndrome or Herlyn-Werner-Wunderlich syndrome (HWW) is a rare congenital anomaly consist of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. We are reporting an adolescent girl with orofacial defect who presented with lower abdominal pain. She attained menarche 3 months earlier and had a regular menstrual cycle with cyclical abdominal pain. On abdominal examination a firm, mobile tender mass extending from left iliac fossa up to umbilicus (24 weeks size) was found.  Lower border of mass could not be approached. Further evaluation with ultrasound showed enlarged uterus with collection with internal echoes and non-visualization of the left kidney. CECT showed absent left kidney and didelphys uterus with large left hematocolpometra with left complex adenexal cyst. Patient was posted for hematocolpos drainage and vaginoplasty. An unusual presentation of regular menstruation and nonspecific abdominal pain delays the diagnosis, which can lead to severe complications such as endometriosis and infertility.

How is Vaginal Function in Patients with A History of Sigmoid Vaginoplasty Surgery?

@#Introduction: Sigmoid colon vaginoplasty is a surgical procedure for the management of vaginal agenesis cases. This technique produces a neovagina that can function as a menstrual blood outlet as well as on penetration during sexual activity. Methods: A retrospective case study of vaginal agenesis, where sigmoid colon vaginoplasty surgery was performed at Dr. Sardjito Hospital Yogyakarta Indonesia in 2016-2018. The following post-surgical evaluation were assessed by observing the vaginal function to drain menstrual blood out, as well as function on penetration during sexual activity. Results: Sixteen cases of vaginal agenesis surgically performed were reported. Identification of the reproductive organs was carried out, in which 3 patients were without uterus, and 13 patients had menstrual uterine function. The length of sigmoid colon graft was around 15-20 cm. There were no complications during surgery. Post-surgical evaluation of 5 cases who have been married, all have been able to penetrate in sexual activity without meaningful complaints. All cases that had a uterus underwent regular menstrual cycles, with no dysmenorrhea. It can be said as a whole that this surgical procedure can be accepted by the patients, because it produced good vaginal function. Conclusions: Sigmoid colon vaginoplasty was a surgical procedure for congenital vaginal agenesis with satisfactory results. There were no complaints of dyspareunia or post-surgical dysmenorrhoea, resulting in a good cosmetic appearance of the external genitalia, and relatively mild complications.

Prospective study of primary amenorrhoea and its management in a rural tertiary centre

Background: Amenorrhoea (absence of menstruation) is a symptom of varied causes. It results from dysfunction of hypothalamic-pituitary ovarian axis, uterus and vagina. It is a major concern for pubertal girls and their family members. It has a major impact on the physical, mental, psychological and social life of the girl and her family. The objective of the present study was to evaluate the aetiology and management of primary amenorrhoea in young adolescent girls.Methods: It was a prospective study conducted for a period of 2 years from August 2016 to July 2018 at Rajarajeswari medical college and hospital. Patients presenting with history of amenorrhoea that is, absence of menses by the age of 13 years with no visible development of secondary sexual characteristics or by 15 years of age with the presence of normal secondary sexual characteristics were included in our study. Cases of secondary amenorrhoea were excluded. Detailed history, examination, investigations and management was documented and analysed.Results: A total of 25 patients of primary amenorrhea were studied during the study period. In our study outflow tract anomalies were the commonest cause of amenorrhoea accounting for 84%, of which imperforate hymen (32%) and Mayer Rokitansky Küster Hauser syndrome (MRKH) 36% were the two most common Mullerian anomaly causing primary amenorrhoea. Gonadal dysgenesis accounted for 12% of the cases. Amenorrhoea was the commonest complaint patients presented with accounting to 76%, followed by cyclical pain abdomen accounting for 16% of cases.Conclusions: Primary amenorrhoea is multifactorial and is of major concern among adolescent girls. Early diagnosis and intervention has an impact on the physical and psychological wellbeing of the girl.

Reporte de serie de casos: neovagina en pacientes con Síndrome Mayer-Rokitansky-Kuster-Hauser / Case series report: neovagina in patients with Mayer-Rokitansky-Kuster-Hauser Syndrome

RESUMEN INTRODUCCIÓN: La ausencia congénita de vagina es una condición poco común, algunas causas son el síndrome de Mayer-Rokitansky-Kuster-Hauser y la insensibilidad periférica a los andrógenos. Múltiples técnicas quirúrgicas y no quirúrgicas se han descrito para el manejo de esta condición, siendo el objetivo principal la creación de un canal vaginal de diámetro y longitud adecuada que permitan restaurar la función coital. El objetivo de este estudio es detallar la experiencia del procedimiento de neovagina con la técnica quirúrgica de McIndoe en pacientes con Mayer-Rokitansky-Kuster-Hauser realizados en la Unidad de Uroginecología de la Clínica Universitaria Bolivariana. METODOLOGÍA: Reporte de 5 casos de pacientes con agenesia de vagina secundarios al síndrome de Mayer-Rokitansky-Kuster-Hauser, a las cuales se les realizó neovagina con la técnica de McIndoe con algunas modificaciones en el molde para el implante de piel. RESULTADOS: Se incluyeron cinco pacientes con diagnóstico de Mayer-Rokitansky-Kuster-Hauser, todas tenían desarrollo de características sexuales secundarias, perfil hormonal normal, y un cariotipo XX. Se utilizó la técnica quirúrgica de McIndoe para la realización de la neovagina sin complicaciones intraoperatorias asociadas y con adecuada evolución posoperatoria, con una longitud vaginal entre 7-9 cm y 3 pacientes con vida sexual activa. El tiempo de estancia hospitalaria fue 7 a 9 días. CONCLUSIÓN: La técnica quirúrgica de McIndoe es una opción para restaurar la función sexual en mujeres con agenesia vaginal con resultados favorables. El tiempo para decidir su realización es electivo, sin embargo, se debe contar con madurez física y emocional para ser llevado a cabo. Las pacientes de nuestro reporte tenían una edad promedio de 18 años.

SUMMARY INTRODUCTION: The congenital absence of the vagina is an uncommon condition, some causes are the Mayer-Rokitansky-Küster-Hauser syndrome and peripheral insensitivity to androgens. Multiple surgical and non-surgical techniques have been described for the management of this condition, being the main objective the creation of a vaginal canal of adequate diameter and length to restore coital function. The objective of this study is to detail the experience of the neovagina procedure with the McIndoe surgical technique performed in patients with Mayer-Rokitansky-Küster-Hauser syndrome at the Clinica Universitaria Bolivariana. METHODOLOGY: Report of five cases of patients with vaginal agenesis secondary to the Mayer-Rokitansky-Kuster-Hauser syndrome, who underwent neovagina with the McIndoe technique and some modifications in the mold for the skin implant. RESULTS: Five patients with diagnosis of Mayer-Rokitansky-Kuster-Hauser were included, all had development of secondary sexual characteristics, normal hormonal profile, and a XX karyotype. The McIndoe surgical technique was used to perform the neovagina without associated intraoperative complications and with adequate postoperative evolution, with a vaginal length between 7-9 cm and three patients with active sexual life. The length of hospital stay was 7 to 9 days. CONCLUSION: The McIndoe surgical technique is an option to restore sexual function in women with vaginal agenesis with favorable results. The time to decide its realization is elective, however, they must have the physical and emotional maturity to be carried out. The patients in our report have an average age of 18 years.

Vaginal anatomical and functional outcomes of 49 patients with Mayer-Rokitansky-Küster-Hauser syndrome undergoing modified laparoscopic sigmoid vaginoplasty / 中国实用妇科与产科杂志

OBJECTIVE: To investigate the anatomy and sexual outcomes of patients with Mayer-Rokitansky-KüsterHauser(MRKH)syndrome undergoing modified laparoscopic sigmoid vaginoplasty.METHODS: From January 2010 to January 2017,49 MRKH syndrome patients underwent the modified laparoscopic sigmoid vaginoplasty in Guangdong Women and Children's Hospital.Analysis of the anatomy and the sexual outcomes of the neovagina was conducted.The sexual functional outcomes were assessed using the Female Sexual Function Index(FSFI)questionnaire.45 cases of similar-aged women with normal sexual life were selected as controls.RESULTS: Modified laparoscopic sigmoid vaginoplasty was successfully performed in all 49 patients.The mean operative time and intraoperative blood loss was(186±53.7)minutes and(63.8±10.6)mL respectively.The mean length and width of the neovagina at the 6-month followup examination was(12.9±1.56)cm and(3.32±0.33)cm respectively.FSFI score between the MRKH group and the control group:Desire[(4.40±0.59)vs.(4.04±0.71),P0.05],Lubrication[(4.90 ± 0.58)vs.(4.67 ± 0.79),P>0.05],Orgasm[(4.29 ± 0.70)vs.(4.20 ± 0.79),P>0.05],Satisfaction[(4.51 ± 0.82)vs.(4.45 ± 0.91),P>0.05],Comfort[(4.71 ± 0.81)vs.(4.78 ± 0.72),P>0.05],Total score[(27.08 ± 2.83)vs.(26.53 ± 2.98),P>0.05].CONCLUSION: Modified laparoscopic sigmoid vaginoplasty is an effective and safe technique for MRKH syndrome patients,which provides a nearly normal sexual function for patients with MRKH syndrome.

Laparoscopic-assisted vaginoplasty by using sigmoid colon and peritoneum for congenital complete colpatresia / 局解手术学杂志

Objective To study the desired therapeutic effect of vaginoplasty using sigmoid colon or peritoneum for entire vaginal atre-sia.Methods From May 2015 to October 2015,8 patients with complete vaginal atresia in our hospital performed vaginoplasty using sigmoid colon or peritoneum successfully.The operation methods,prognosis and therapeutic effect and quality of sexual life of two groups were com-pared and analyzed to investigate a perfect operative method and ideal nursing.Results Laparoscopic vaginoplasty using the peritoneum compared with that using sigmoid colon has advantages of shorter time of operation,less bleeding,less trauma and quicker recovery.However, artificial vagina using sigmoid colon was much more similar to a natural vagina in morphological and physiological characteristics,merely ac-companied by excessive mucus discharge during the postoperative period.At lower risk of vaginal adhesion and stenosis,laparoscopically as-sisted vaginoplasty using sigmoid colon graft also puts high technical requirements.Two patients normally developed uterus menstruate regular-ly.Four patients without uterus and 2 patients with rudimentary uterus experienced good sexual intercourse after vaginoplasty.Conclusion Patients with complete colpatresia who have normal womb should creat a patent and functional vagina until adolescence to restore its physio-logical and reproductive function.Anatomical reconstructive treatment of vaginal agenesis for patients with absent or hypoplastic uterus can be postponed till the late teens or in the adult.Both laparoscopic sigmoid vaginoplasty and peritoneal vaginoplasty achieve a minimal-invasive, cosmetic,natural lubricous, smooth artificial vagina for patient’ s sex life satisfactory.

Clinical Performance of Single-incision Laparoscopic Sigmoid Colon Vaginoplasty in Women with Congenital Absence of Vagina / 中国医科大学学报

Objective To explore the feasibility of single?incision laparoscopic sigmoid colon vaginoplasty in women with congenital absence of va?gina. Methods Clinical data of thirty?two patients with congenital absence of vagina admitted in Shengjing Hospital of China Medical University be?tween January 2008 and June 2014 was retrospectively analyzed. Nineteen patients underwent laparoscopic assisted sigmoid colon vaginoplasty,and thirteen paitiens underwent single?incision laparoscopic sigmoid colon vaginoplasty. The operation time,intraoperative blood loss,evacuation time and follow up were compared between the two groups. Results In the group of single?incision laparoscopic sigmoid colon vaginoplasty,the opera?tion time was shorter and intraoperative blood loss was less. There was no difference between two groups in evacuation time. There was no infection or leakage of anastomotic stoma of sigmoid colon,and no postoperative stenosis of the neovagina and its length was satisfied. Patients were satisfied with the quality of sexual life after the surgery. Patients underwent single?incision laparoscopic sigmoid colon vaginoplasty were all satisfied with the ap?pearance of abdomen. Conclusion The single?incision laparoscopic sigmoid colon vaginoplasty can simplify the procedure of intestinal anastomo?sis,shorten the operation time,and reduce the intraoperative blood loss. Consequently,the single?incision laparoscopic sigmoid colon vaginoplasty is effective and safe.

Cervical and vaginal agenesis report.

Cervical agenesis is a very rare condition often associated with atresia of vagina. Clinical diagnosis is usually difficult before surgery. Transverse vaginal septum or vaginal agenesis is also a rare condition that results from incomplete fusion between vaginal components of the mullerian ducts and urogenital sinus. Here we presented case of 16 years old girl who presented with primary amenorrhea and cyclical lower abdominal pain for 6 months. Abdomino-pelvic scan showed hematometra with bilateral hematosalpinx with mild free fluid in pouch of Douglas with collapsed vagina and cervix. MRI pelvis confirmed USG findings giving differential diagnosis of high vaginal septum or cervical agenesis. She was operated for cervical recanalization and vaginosplasty.

Perioperative nursing for a patient with mayer rokitansky kuster hauser combined with rectovestibullar fistula / 中国实用护理杂志

Objective To investigate the perioperative nursing experience for patients with mayer rokitansky kuster hauser (MRKH).Methods We conducted multidisciplinary care to a MRKH patient,including personalize psychological support,bowel preparation,two surgical nursing convergence and vaginal mold care during hospitalization.Results The patient discharged after clinical symptoms remission,the patient sexual life was satisfaction,no complications were found in the six months follow-up.Conclusion The key of operation success is good coordination and cooperation of multiple departments,close observation and effective nursing in the perioperation period.

Effects of different intestinal cleaning methods on bowel preparation for laparoscopic peritoneal vaginoplasty / 现代临床护理

Objective To investigate the effect of different intestinal cleaning methods on bowel preparation for laparoscopic peritoneal vaginoplasty.Methods One hundred patients undergoing laparoscopic peritoneal vaginoplasty were divided into experiment group and control group with 50 cases in each group .For bowel preparation,the experiment group was managed with oral sodium phosphate salt solution of 45 mL and the control group with oral senna leaf of 30 g in boiled water.The two groups were compared in terms of intestinal cleaning degree,adverse reactions and postoperative exhaust time.Results The incidence of adverse reactions in the former group was significantly lower than the control group.Degree of bowel cleaning satisfaction was significantly better than that of the control group and the postoperative exhaust was significantly earlier than that in the control group(P<0.05).Conclusion The method of oral sodium phosphate salt solution for bowel preparation for laparoscopic peritoneal vaginoplasty can improves the intestinal cleanliness,reduce incidence of intestinal adverse reaction and promote postoperative exhaust so that it can improve postoperative intestinal restoration of kinetic energy.

Desórdenes del desarrollo sexual y cirugía correctiva / Disorders of sexual development and corrective surgery

El desarrollo de las gónadas está determinado por los cromosomas sexuales y autosomas, estas producen hormonas que dirigen la formación de los genitales internos y externos. Los desórdenes en la diferenciación sexual se presentan cuando hay anormalidades en cromosomas, en el desarrollo gonadal o en la actividad o producción de hormonas. La presente revisión tiene como objetivo la recopilación de información que comprende los desordenes del desarrollo sexual que podrían presentar los niños al nacimiento y la posterior cirugía de corrección. Se desarrolla brevemente la anatomía normal tanto del sistema genitourinario masculino como el femenino, presentando las similitudes y diferencias. La sexualidad de las personas está determinada por el sexo cromosómico, sexo gonadal, sexo genital y sexo social, con base en estos determinantes se establece el procedimiento quirúrgico más adecuado. La investigación se enfoca en la cirugía de feminización, en la cual, se efectúa una reducción de clítoris, separación de vagina y uretra; además de una vaginoplastía. Actualmente, los resultados de la cirugía correctiva son los más óptimos, sin embargo, gran cantidad de estudios indica que no todas las personas que se someten a ellas están satisfechas con los resultados obtenidos refiriéndose a función sexual.

Gonadal development is determined by sexual chromosomes and autosomes, which produce hormones that direct the formation of internal and external genitals. Disorders in sexual differentiation appear when abnormalities in chromosomes, gonadal development or activity or production of hormones are present. This investigation is a review of research about disorders in sexual development present in children at birth and the following correction surgery. Also, it includes information concerning the normal anatomy of male and female genitourinary system, showing similarities and differences between them. People’s sexuality is determined by the chromosome sex, gonadal sex, genital sex and social sex. Based on these factors, physicians can determine the best surgical procedure for the patient. This investigation is focused on feminization surgery, in which a reduction of clitoris is done. After this, a separation of the vagina and urethra is also performed to then finalize with a vaginoplasty. Nowadays, the results of the correction surgery are the best that can be done, however, several studies indicate that not all patients are fulfilled with the results.

Simplificando a neovaginoplastia na síndrome de Mayer-Rokitansky-Küster-Hauser / Simplifying vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome

Embora sua descrição diste da primeira metade do século XIX, talvez pela sua raridade, o tratamento da Síndrome de Mayer-Rokitansky-Küster-Hauser (MRKH) ainda hoje constitui um desafio. Neste artigo, após breve revisão teórica das características da síndrome, discutimos as técnicas propostas para criação de uma neovagina. Apresentamos a seguir um relato de caso de paciente de 39 anos submetida à Neovaginoplastia de Creatsas, que, pela sua simplicidade, rapidez de recuperação, baixa morbidade e excelentes resultados iniciais, parece ser a opção ideal para as pacientes brasileiras.

Although its description dates from the first half of the 19th century, the treatment of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome remains a challenge, perhaps because of its rarity. In this paper, after a brief theoretical review of the characteristics of the syndrome, the proposed techniques for creating a neovagina are discussed. Then we report the case of a 39-year-old patient submitted to Creatsas neovaginoplasty, which owing to its simplicity, fast recovery, low morbidity and excellent early results, seems to be the ideal choice for Brazilian patients.

Six cases of laparoscopic assisted neovaginoplasty using pelvic peritoneal flap in MRKH syndrome / 대한산부인과학회지

Vaginal agenesis is rare gynecologic condition, and the most common etiology is Mayer-Rokitansky-Kster-Hauser (MRKH) syndrome, characterized by the absence of uterus and vagina and presence of normal ovaries and tubes. In such patients, the evaluation for associated malformations as well as careful non-surgical and surgical approach are essential. The neovaginoplasty is an important issue for these patients in regard of functional and psychological standpoint. There are many options available for creation of neovagina. We report six cases of laparoscopic assisted neovaginoplasty using pelvic peritoneal flap.

The influence on the quality of marital and life in the congenital absence of vagina patients with operation by psychological intervention / 中国基层医药

Objective To explore the influence on the quality of marital and life of the congenital absence of vagina patients with operation by psychological intervention.Methods The congenital absente of vagina patients were divided into psycholOgical intervened group(n=18,all cases were treated with the cognitive and behaviour therapy)and without intervened group(n=11).Before and after treatment the scores of the nottingham health poofity(NHP)were used in the two groups.After treatment the Olson's enrich questionary were tested also.Results The scores of NHP and Olson of psychological intervened group were significantly superior to those without intervened group(P＜0.05 or P＜0 01).Conclusion The cogntive and behaviour theraopy before operation is good for the quality of marital and life in congenital absence of vagina patients.

A case of transverse vaginal septum with modified Garcia technique / 대한산부인과학회지

The incidence of all transverse vaginal septum is 1:2,100 - 1:72,000. The transverse vaginal septum is a developmental defect of vagina which may be fused incompletely between the Mullerian duct component and the urogenital sinus component of vagina. Serious complications may be hematocolpos, hematometra and hematosalpinx. Simple surgical excision or simple incision have been developed to treat congenital transverse vaginal septa, but also caused common complications such as secondary tissue contracture. Garcia technique using eight vaginal mucosa flaps was developed to avoid common complication of secondary vaginal stenosis. Here, we present a case of contracted transverse vaginal septum who has been performed a simple incision 13 years ago, successfully performed the modified Garcia technique without serious postoperative complication.

Laparoscopic peritoneal vaginoplasty for congenital absence of vagina / 第三军医大学学报

Objective To investigate the possibility and efficacy of laparoscopic peritoneal vaginoplasty for the treatment of congenital absence of vagina. Methods A total of 4 patients with congenital absence of vagina underwent laparoscopic peritoneal vaginoplasty. Results Operations were performed successfully in the 4 cases. The mean operative time was 114 min (range: 90-160 min), and the mean postoperative hospital stay was 5.4 d (range: 5-6 d). There was no complication in all patients. Conclusion Laparoscopic peritoneal vaginoplasty is a safe, minimally invasive, and reliable method for the treatment of congenital absence of vagina.

Neovaginoplasty Using Sigmoid Colon in Patient with Male Pseudo-hermaphroditism / 대한비뇨기과학회지

Gender assignment is the most important step in treating a child with ambiguous genitalia. Once an appropriate sex assignment has been made, the next critical step is the performance of a reconstructive procedure in a timely fashion. The aim of vaginoplasty should be the creation of a neovagina that will have a satisfying appearance, function and feeling, with a low rate of morbidity. Different forms of vaginal reconstruction have been described, and include the use of split-thickness or full-thickness grafts, amnion, peritoneum or bowel. Of these, vaginal reconstruction, with isolated bowel segments, provides a cosmetic, self-lubricating neovagina, with low rates of failure and revision, and without the need for routine dilation. Sigmoid vaginoplasty especially seems to have a clear advantage, with an excellent surgical success rate, and low complication rates. We report our initial experience of a neovaginoplasty, using sigmoid colon, in a 10-year old patient with an incomplete form of androgen insensitivity syndrome (Reifenstein syndrome).

Laparoscopy-assisted Sigmoid Colon Vaginoplasty:Report of 27 Cases / 中国微创外科杂志

Objective To study the surgical techniques and effects of laparoscopy-assisted sigmoid colon vaginoplasty.MethodsClinical data of 27 patients,who underwent laparoscopy-assisted sigmoid colon vaginoplasty at Beijing Anzhen Hospital between June 2006 and June 2007,were retrospectively analyzed.A 15-cm segment of pedicled sigmoid colon was isolated using an ultrasound knife.The distal end of the segment was pulled into the vaginal space in the cul-de-sac of Douglas under a laparoscopic vision as the neovagina.The continuity of the intestinal tract(end-to-end bowel anastomosis) was restored using a circular mechanical suture through the rectum.ResultsThe surgery was successfully completed in all the cases,no intra-operative complication occurred.The mean blood loss and operation time was 82 ml(50-180 ml) and 168 min(120-246 ml) respectively.One patient developed incomplete intestinal obstruction 16 days after the operation,and was cured by conservative treatment.Follow-up was available in 21 patients for 14-20 months.Five patients had no sexual partner during the follow-up,while the other 16 patients were satisfied with their sexual lives after the surgeries.ConclusionLaparoscopic vaginal reconstruction using a sigmoid colon segment is satisfying for cosmetic,functional,and anatomic results.

Clinical analysis of 73 cases of laparoscopic vaginoplasty of peritoneum / 中国微创外科杂志

9 cm in 66 cases and 8 cm in 4 cases.A vaginal speculum was inserted smoothly,showing a pinky,wet,and normal-tensioned vaginal mucous membrane.Of 44 cases with intercourse experience,there were 43 cases with satisfactory sexual life and 1 case with a complaint of too short vagina(vaginal length,8 cm).Conclusions Laparoscopic vaginoplasty of peritoneum has advantages of minimal invasion,simplicity of performance,and rapid recovery.The appearance and functions of "artificial vagina" after surgery are similar to those of normal vagina.