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Abstract

Objective:

This study evaluates surgical outcomes in benign prostatic hyperplasia (BPH) patients undergoing transurethral enucleation using various holmium laser (HoLEP) settings and/or bipolar devices (BipoLEP).

Design:

This study was retrospective.

Methods:

We retrospectively analyzed 158 BPH patients treated surgically, categorized by method: BipoLEP (n = 28), HoLEP with short pulse (HoLEP-SP, n = 26), HoLEP with long pulse and low energy (HoLEP-LP/LE, n = 29), HoLEP with long pulse and high energy (HoLEP-LP/HE, n = 26), HoLEP using Moses technology (HoLEP-Mo, n = 19), and a combination of HoLEP and BipoLEP (HoLEP-mix, n = 30). We assessed enucleation, morcellation, coagulation, and overall operation efficiency, along with complications at immediate, 2-week, and 3-month postoperative intervals.

Results:

The HoLEP-LP/LE group exhibited the highest overall operation efficiency (p < 0.05). The BipoLEP and HoLEP-SP groups had lower enucleation efficiency (p < 0.05). HoLEP-LP/LE and BipoLEP showed superior coagulation efficiency (p < 0.05). Excluding hard nodule cases, the HoLEP-mix group had reduced morcellation efficiency compared to HoLEP-LP/LE (p < 0.05). Complication rates did not significantly differ between groups (p > 0.05).

Conclusion:

The HoLEP-LP/LE procedure demonstrated superior performance in enucleation, morcellation, coagulation, and overall operation efficiency. Complication rates were comparable across all groups. BipoLEP, while less efficient in enucleation than some HoLEP settings, proved effective and safe. In addition, the Moses technology may offer enhanced bleeding control.

Keywords

bipolar transurethral enucleation endoscopic enucleation of prostate holmium lasers laser therapy prostatic hyperplasia

Introduction

Lower urinary tract symptoms/benign prostate hyperplasia (LUTS/BPH) commonly affect older men.¹ The anatomical endoscopic enucleation of the prostate (AEEP) technique, introduced two decades ago, offers significant advantages, mirroring the extraction principles of open prostatectomy and transurethral resection of the prostate (TURP) with radical resection.^2,3 Furthermore, AEEP’s efficacy and safety in long-term follow-up are comparable to TURP.^3–5

AEEP utilizes various energy sources.¹ Among these, holmium laser enucleation of the prostate (HoLEP) employs a holmium laser, while bipolar enucleation (BipoLEP) uses a bipolar device. In addition, a combined technique involving a holmium laser for enucleation and a bipolar device for coagulation, followed by prostatic adenoma removal via morcellator, exists. Previous comparisons between HoLEP and BipoLEP indicate HoLEP’s superiority in terms of operation duration, catheterization, and bladder irrigation times.⁶ However, these studies did not investigate outcomes based on the energy or pulse duration in HoLEP.

The versatility of a holmium laser in frequency, energy, and pulse duration settings,⁷ including short pulse, long pulse, and the Moses function for pulse modulation, suggests potential for enhanced BPH treatment efficiency.^8–11 Nonetheless, the effects of varying holmium laser settings on surgical outcomes in BPH patients remain unreported. Therefore, this study evaluated surgical outcomes in benign prostatic hyperplasia (BPH) patients undergoing transurethral enucleation using various holmium laser (HoLEP) settings and/or bipolar device (BipoLEP).

Materials and methods

Patients and study groups

This retrospective review encompassed 158 BPH patients operated on by two surgeons (SYC and SJO) from January 2019 to July 2023 (IRB No.: 1812-124-997 & 0810-027-260). From 3421 enucleation cases, the most recent 3-year span was selected to account for the surgeons’ learning curves. Patients diagnosed with BPH were included, excluding those with neurogenic bladder, bladder stone, prostate or bladder cancer, urinary tract infections, and malformations. All specimens from the patients in this study were free of prostate cancer. However, patients with minimal LUTS contribution from conditions like transient ischemic attacks or diabetes were included. Fifteen patients (9.5%) were taking anticoagulants, and all of them stopped their therapy 4–7 days before surgery after consulting with either a cardiologist or a neurologist. After surgery, the patients consulted a cardiologist or neurologist and resumed anticoagulant therapy. Preoperative assessments included the international prostate symptom score (IPSS), IPSS-quality of life (IPSS-QoL), uroflowmetry (UFM) with post-void residual (PVR) volume, transrectal ultrasonography (TRUS), and urodynamic studies, the latter omitted for patients with urinary retention.

Patient groups were categorized based on surgical method: BipoLEP (effect level 2 for cutting and level 3 for coagulation, n = 28), HoLEP with short pulse (HoLEP-SP, 2 J with 30–40 Hz, n = 26), HoLEP with long pulse and low energy (HoLEP-LP/LE, 2 J with 20 Hz, n = 29), HoLEP with long pulse and high energy (HoLEP-LP/HE, 2 J with 30–40 Hz, n = 26), HoLEP with Moses technology (HoLEP-Mo, 2 J with 30–40 Hz, n = 19), and a combination of HoLEP and BipoLEP (HoLEP-mix, n = 30).

Surgical techniques

The HoLEP and BipoLEP methods are well established.^12,13 The choice of procedure was determined by the availability of medical equipment and the surgeon’s preference. Current guidelines do not provide specific criteria for selecting energy sources based on the condition of the prostates. Given that both surgeons were proficient in performing HoLEP and BipoLEP, they did not feel compelled to favor one method over the other. However, when a patient expressed a strong preference for laser treatment, HoLEP was employed. The HoLEP-mix technique, combining holmium laser enucleation with bipolar device coagulation, obviated the need for urethral sheath changes post-enucleation for prostate fossa coagulation. Surgeons did not need to change the outer sheath to use the bipolar device to coagulate the enucleation plane right after the enucleation procedure with a holmium laser only. In cases of hematuria postoperatively, despite thorough coagulation, Foley catheter traction was considered, with the balloon size tailored to the prostate’s dimensions: 30 mL for prostates smaller than 80 mL, and 50 mL for those 80 mL or larger. Hematuria is a term that can be defined in various ways and is often subjective, making it challenging to settle on a single definition. However, in the study published in Urology (2021 Feb; 148:32-36), hematuria was specifically defined as a score of 3 or higher on a severity scale.¹⁴

Patients were admitted 1 day before surgery to prepare for the surgical procedure. In most cases, the Foley catheter was removed the day after surgery, allowing the patient to be discharged. However, if there were concerns about potential surgical site damage during the operation or other reasonable medical considerations, the Foley catheter was left in place and removed during an outpatient visit 1–2 weeks later. Irrigation was performed immediately after surgery through a 3-way 18Fr Foley catheter. The protocol involved assessing the urine color every 4 h, and if the urine appeared clear, irrigation was reduced or stopped. On the morning following surgery, irrigation was discontinued, and the urine color was evaluated to determine if the Foley catheter could be removed. After removal of the Foley catheter, if the patient presented with severe hematuria, such as cherry wine mixed with blood, the catheter was reinserted, and irrigation was resumed.

Clinical parameters

Baseline characteristics including IPSS scores, Qmax, voiding volume, PVR, prostate-specific antigen levels, total prostate volume (TPV), transition zone volume (TZV), and urodynamic parameters were analyzed. Bladder voiding efficiency was calculated as (voided volume)/(voided volume + PVR) × 100.¹⁵ Detrusor overactivity was defined based on involuntary contraction during filling cystometry.¹⁶

Total operation efficiency was determined by dividing the TPV by the overall operation time. In addition, enucleation efficiency, morcellation efficiency, coagulation efficiency, and total operation efficiency were evaluated. Enucleation efficiency was calculated by dividing the TPV by the enucleation time, morcellation efficiency by dividing the TPV by the morcellation time, and coagulation efficiency by dividing the TPV by the coagulation time. Complications, such as emergency room (ER) visits, hematuria, transfusion, and transurethral coagulation, were assessed immediately post-surgery, as well as at 2-week and 3-month follow-up.

Statistical analysis

Data are presented as mean, standard deviation, and percentage. One-way analysis of variance (ANOVA), Welch’s ANOVA, and Fisher’s exact test were employed for quantitative and qualitative variables, respectively, using SPSS version 27.0 (IBM Corp., Armonk, NY, USA). A p-value <0.05 was considered statistically significant.

Results

Baseline characteristics

We performed a total of 970 cases from January 2019 to July 2023. Of these, 158 patients had complete records of energy, pulse, and power, and did not have prostate or bladder cancer. Among the six surgical methods evaluated, the incidence of hypertension was notably higher in the BipoLEP, HoLEP-SP, and HoLEP-mix groups (p < 0.05). The TPV and TZV were significantly smaller in the HoLEP-SP group (p < 0.05). In addition, the Qmax, IPSS storage score, and QoL score were significantly lower in both the BipoLEP and HoLEP-SP groups (p < 0.05; Table 1).

Table 1.

Baseline characteristics of patients.

Group	BipoLEP (n = 28)	HoLEP-SP (n = 26)	HoLEP-LP/LE (n = 29)	HoLEP-LP/HE (n = 26)	HoLEP-Mo (n = 19)	HoLEP-mix (n = 30)	p-value
Age, year	73.57 ± 7.31	69.08 ± 9.72	69.07 ± 7.20	71.31 ± 6.79	71.53 ± 6.69	71.87 ± 8.11	0.229
Body mass index, kg/m²	23.47 ± 3.16	25.39 ± 2.91	24.66 ± 2.69	23.46 ± 5.61	24.99 ± 2.90	25.05 ± 3.15	0.200
Preoperative medications for LUTS
Anticoagulant medication	0 (0.00%)	0 (0.00%)	4 (13.79%)	4 (15.38%)	1 (7.14%)	6 (20.00%)	0.052
Alpha blocker	1 (3.57%)	3 (11.54%)	22 (75.86%)	23 (88.46%)	6 (42.86%)	26 (86.67%)	0.001
Anticholinergic drug	1 (3.57%)	0 (0.00%)	1 (3.45%)	1 (3.86)	0 (0.00%)	1 (3.33%)	0.917
5α-reductase inhibitors	1 (3.57%)	0 (0.00%)	12 (41.38%)	14 (53.85%)	3 (21.43%)	12 (40.00%)	0.001
Previous medical history
Diabetes	4 (14.29%)	6 (23.08%)	5 (17.24%)	5 (19.23%)	6 (31.58%)	5 (17.24%)	0.758
Hypertension	15 (53.57%)	13 (50.00%)	5 (17.24%)	3 (11.54%)	6 (31.58%)	12 (41.38%)	0.003
Cerebrovascular disease	3 (10.71%)	3 (11.54%)	1 (3.45%)	1 (3.85%)	0 (0.00%)	0 (0.00%)	0.229
PSA, ng/mL*	6.58 ± 7.93	5.38 ± 5.10	4.29 ± 3.67	5.22 ± 3.55	6.08 ± 6.41	6.11 ± 5.59	0.694
Total prostate volume, mL	80.62 ± 35.24	69.06 ± 29.25	76.37 ± 33.29	98.31 ± 32.40	89.56 ± 25.41	86.79 ± 37.45	0.037
Transition zone volume, mL	48.11 ± 28.65	39.31 ± 22.82	46.97 ± 25.05	64.54 ± 26.92	58.59 ± 22.85	47.80 ± 20.99	0.013
Qmax, mL/s	7.59 ± 4.97	8.58 ± 4.09	13.28 ± 6.00	10.62 ± 5.94	10.07 ± 4.95	11.51 ± 6.45	0.018
Voiding volume, mL	144.02 ± 119.41	160.18 ± 92.07	218.27 ± 136.55	167.76 ± 110.94	136.06 ± 75.67	177.91 ± 84.92	0.121
PVR, mL*	96.48 ± 135.77	89.78 ± 109.48	116.03 ± 186.19	88.20 ± 61.98	124.35 ± 84.89	91.17 ± 69.45	0.881
BVE, %*	67.56 ± 30.33	69.67 ± 18.76	71.68 ± 22.62	63.64 ± 19.83	56.34 ± 23.67	68.05 ± 18.34	0.163
MCC, mL*	326.00 ± 176.81	275.67 ± 166.18	268.54 ± 148.47	279.68 ± 127.71	291.29 ± 153.16	243.27 ± 122.54	0.571
Volume of first desire to void on urodynamics, mL	169.47 ± 95.69	156.33 ± 106.06	134.36 ± 77.86	159.12 ± 67.86	172.71 ± 77.20	147.03 ± 63.15	0.566
BOO index*	49.44 ± 31.47	51.67 ± 20.32	54.68 ± 30.30	73.20 ± 30.59	63.59 ± 30.34	52.10 ± 27.97	0.074
BCI*	94.50 ± 29.76	106.50 ± 24.14	102.02 ± 27.64	119.68 ± 30.49	108.88 ± 22.70	102.93 ± 24.05	0.069
Detrusor overactivity	12 (70.59%)	5 (83.33%)	27 (96.43%)	21 (84.00%)	13 (76.47%)	29 (96.67%)	0.059
Subtotal storage symptom score on IPSS	5.64 ± 4.77	5.08 ± 4.73	8.55 ± 3.36	7.19 ± 3.51	9.00 ± 4.94	7.23 ± 3.32	0.006
Subtotal voiding symptom score on IPSS	6.21 ± 5.71	7.08 ± 6.42	9.90 ± 4.39	7.23 ± 4.84	8.47 ± 4.96	8.27 ± 4.79	0.137
Total IPSS	14.64 ± 11.79	14.08 ± 12.50	21.69 ± 7.61	17.15 ± 8.82	20.00 ± 10.76	18.13 ± 9.16	0.054
QoL index*	1.29 ± 1.88	2.58 ± 2.08	3.93 ± 1.36	4.00 ± 1.39	3.93 ± 1.91	4.20 ± 1.13	0.001

Bold values indicate statistically significant.

All variables are presented as mean ± standard deviation or number of patients (%). *p < 0.05: comparison in variables between groups using one-way analysis of variance or chi-squared test as indicated.

BCI, bladder contractility index; BOO index, bladder outlet obstruction index; BVE, bladder voiding efficiency; MCC, maximum cystometric capacity; PSA, prostate-specific antigen; PVR, post-void residual volume; QoL, quality of life.

BipoLEP means BipoLEP. HoLEP-SP means HoLEP with a short pulse. HoLEP-LP/LE means HoLEP with a long pulse & low energy. HoLEP-LP/HE means HoLEP with a long pulse & high energy. HoLEP-Mo means HoLEP with Moses. HoLEP-mix means mixed HoLEP and BipoLEP.

Intraoperative outcomes

The total operation efficiency was significantly higher in the HoLEP-LP/LE group compared to the BipoLEP, HoLEP-SP, HoLEP-Mo, and HoLEP-mix groups (p < 0.05). The HoLEP-LP/LE and HoLEP-LP/HE groups exhibited similar total operation efficiencies (Table 2). Enucleation efficiency was notably lower in the BipoLEP and HoLEP-SP groups compared to the HoLEP-LP/LE group (p < 0.05). The other groups, including HoLEP-LP/HE, HoLEP-Mo, and HoLEP-mix, showed no significant differences in comparison to other groups. Coagulation efficiency was significantly greater in the HoLEP-LP/LE and BipoLEP groups than in the HoLEP-SP, HoLEP-LP/HE, and HoLEP-Mo groups (p < 0.05), with the HoLEP-LP/LE and BipoLEP groups demonstrating similar coagulation efficiencies. When cases with hard nodules were excluded, the morcellation efficiency in the HoLEP-mix group was lower than in the HoLEP-LP/LE group (p < 0.05). The remaining groups (BipoLEP, HoLEP-SP, HoLEP-LP/HE, and HoLEP-Mo) showed no significant differences. However, the presence of hard nodules resulted in lower morcellation efficiency in the HoLEP-mix and BipoLEP groups compared to the other groups. In the BipoLEP group, two patients (7.1%) had hard nodules, thus the morcellation time was more than twice that of other cases. Post-surgery, no urethral Foley catheter traction was necessary in any of the cases.

Table 2.

Intraoperative parameters.

Variable	Group	Mean	SD	p-Value	Scheffe
Total prostate volume/Enucleation time, mL/min	BipoLEP (n = 28)	2.31	1.09	0.001	HoLEP-LP/LE > HoLEP-LP/HE, HoLEP-Mo, HoLEP-mix > BipoLEP and HoLEP-SP
[Enucleation efficiency]	HoLEP-SP (n = 26)	2.62	2.48
	HoLEP-LP/LE (n = 29)	4.15	1.66
	HoLEP-LP/HE (n = 26)	3.31	0.98
	HoLEP-Mo (n = 19)	2.91	1.00
	HoLEP-mix (n = 30)	3.25	1.35
Total prostate volume/Morcellation time, mL/min	BipoLEP (n = 28)	8.71	4.94	0.014	HoLEP-LP/LE > BipoLEP, HoLEP-SP, HoLEP LP/HE, HoLEP-Mo > HoLEP-mix
[Morcellation efficiency]	HoLEP-SP (n = 26)	6.66	4.10
	HoLEP-LP/LE (n = 29)	10.70	7.64
	HoLEP-LP/HE (n = 26)	6.46	4.70
	HoLEP-Mo (n = 19)	8.06	5.07
	HoLEP-mix (n = 30)	4.42	1.96
Total prostate volume/coagulation time, mL/min	BipoLEP (n = 28)	10.82	8.99	0.001	HoLEP-LP/LE, BipoLEP > HoLEP-SP, HoLEP-LP/HE, and HoLEP-Mo, and HoLEP mx
[Coagulation efficiency]	HoLEP-SP (n = 26)	6.69	4.47
	HoLEP-LP/LE (n = 29)	16.63	11.72
	HoLEP-LP/HE (n = 26)	8.21	3.72
	HoLEP-Mo (n = 19)	8.43	4.19
	HoLEP-mix (n = 30)	9.09	5.84
Total prostate volume/operation time, mL/min	BipoLEP (n = 28)	1.06	0.55	0.001	HoLEP-LP/LE > BipoLEP, HoLEP-SP, HoLEP-LP/HE, HoLEP-Mo, and HoLEP-mix
[Operation efficiency]	HoLEP-SP (n = 26)	1.05	0.47
	HoLEP-LP/LE (n = 29)	2.03	1.11
	HoLEP-LP/HE (n = 26)	1.45	0.65
	HoLEP-Mo (n = 19)	1.30	0.54
	HoLEP-mix (n = 30)	1.24	0.45

Bold values indicate statistically significant.

p < 0.05, comparison in variables between groups using one-way analysis of variance and Welch’s ANOVA.

Complications

No significant differences were observed in complication rates between the groups (p > 0.05) (Table 3). Among the 28 patients who underwent BipoLEP, two (7.1%) experienced acute urinary retention (AUR) and visited the ER: one with urethral discomfort and another with clot retention. In these cases, there was no active bleeding. The first patient had a urethral Foley catheter inserted and maintained for an additional 8 days, while the second patient received bladder irrigation without the need for a long-standing indwelling Foley catheter.

Table 3.

Complications data.

complication-related ER visit	BipoLEP(n = 28)	HoLEP-SP(n = 26)	HoLEP-LP/HE(n = 26)	HoLEP-mix(n = 30)
ER visit for AUR* right after surgery	2 (7.1%)	2 (7.7%)	0	0
ER visit for hematuria & TUC* after 2 weeks postoperatively	0	0	0	1 (3.3%)
ER visit for hematuria after 1 month postoperatively	0	0	1 (3.8%)	0

All variables are presented as a number of patients (%). There were no cases requiring transfusion after surgery.

AUR, acute urinary retention; TUC, transurethral coagulation.

Among the 26 HoLEP-SP patients, two (7.7%) visited the ER with AUR. This included a patient with Parkinson’s disease who went to the ER on the discharge day and required a Foley catheter for 7 days and another patient who went to the ER on the seventh day post-surgery, requiring a Foley catheter for nine more days due to clot retention. In the HoLEP-LP/HE group, one of the 26 patients (3.8%) visited the ER for hematuria 1 month after surgery and underwent transurethral coagulation. This patient was successfully trialed without a catheter and discharged catheter-free. Among the 30 HoLEP-mix patients, one (3.3%) visited the ER 2 weeks post-surgery for hematuria and received bladder irrigation before being discharged without a catheter.

Discussion

With technological advancements, AEEP is now feasible using various types of lasers. Among the different surgical methods for BPH, HoLEP, the first to adopt the enucleation method, is considered a new gold standard, serving as an alternative to TURP.^17–20 The procedure can be performed with multiple pulse powers and frequencies within a holmium laser.²¹ Recently, the introduction of Moses technology has marked a new generation of holmium laser procedures, known as MoLEP.^9,21 In addition, given the high initial setup cost of holmium lasers, BipoLEP was introduced as a cost-effective alternative.¹³

In our study, BipoLEP was conducted using an effect level of 2 for cutting and level 3 for coagulation. HoLEP-SP utilized 2 J at 30–40 Hz. HoLEP-LP/LE operated at 2 J with 20 Hz, while HoLEP-LP/HE used 2 J with 30–40 Hz. HoLEP-Mo was performed at 2 J with 30–40 Hz. This study found that the total operation time was highest in the HoLEP-LP/LE group among the six surgical procedures evaluated. This outcome contrasts with other studies that have indicated an increase in enucleation efficiency and improved hemostasis with higher laser power.²² However, other research has shown that low-power HoLEP can be as effective, if not more so, than high-power HoLEP.^10,23 The feasibility of low-power HoLEP is supported by evidence that the minimum operational energy level for a holmium laser is 1.4 J at a frequency of 10 Hz, suggesting that a low-power setting is adequate for performing HoLEP with proper surgical techniques.²⁴ Furthermore, one study highlighted that in AEEP, the efficacy and safety are more reliant on the surgeon’s technique than on the laser power.²⁵ The authors believe that a continuously fired laser, utilizing a long pulse and low energy, can facilitate rapid enucleation plane creation and simultaneous coagulation without causing excessive incision or bleeding. A low-power laser, generating weaker shockwaves and lower temperatures than a high-power laser, is safer for patients²⁶ and offers cost-effectiveness, especially for less experienced surgeons.^24,25

Our study revealed that both BipoLEP and HoLEP-SP had low enucleation efficiencies. In the case of BipoLEP, the outcomes were consistent with other RCT studies comparing BipoLEP and HoLEP.^6,27 This suggests that the BipoLEP surgeon in our study performed enucleation and coagulation concurrently as much as possible, resulting in a significantly longer enucleation time for BipoLEP in this study. By contrast, HoLEP-SP required more time for enucleation and bleeding control, despite smaller prostate sizes, ultimately leading to lower enucleation efficiency than other modalities.²⁸

Previous research indicated that morcellation efficiency decreases when the TZV exceeds 32 mL.²⁹ However, our study found no correlation between TPV or TZV and morcellation efficiency. The influence of the TZV remains a topic of debate. In addition, the presence of hard nodules decreased morcellation efficiency in the BipoLEP group, suggesting that HoLEP might facilitate easier incisions on enucleated prostate nodules. Therefore, focusing on educational courses that teach techniques for making deep incisions on enucleated nodules using BipoLEP could accelerate morcellation in cases with hard nodules.

Our study observed no complications such as ER visits, bleeding, hematuria, transfusion, or transurethral coagulation following surgery in the HoLEP-LP/LE or HoLEP-Mo groups. However, other groups reported 3.3%–7.7% ER visits due to hematuria, urinary retention, or urethral discomfort. Notably, no hematuria complications were reported in the HoLEP-Mo group. This might be attributed to the Moses technology’s ability to deliver laser pulse energy precisely to the target with dual peaks, effectively enhancing hemostasis.³⁰ Another study also suggested that the Moses function could reduce total operation time by improving hemostasis during enucleation compared to regular mode holmium laser pulses.⁹

A limitation of our study is its single-center, retrospective nature. One of the limitations of our study is that we did not include the analysis of total operation efficiency, enucleation efficiency, morcellation efficiency, and coagulation efficiency using enucleated tissue weight instead of TPV. The small number of patients could introduce bias, making it challenging to generalize the results. In addition, the follow-up period post-surgery was limited to 3 months.

Conclusion

The total operation efficiency was significantly higher in the HoLEP-LP/LE group. Both HoLEP-LP/LE and BipoLEP groups demonstrated significantly higher coagulation efficiency. BipoLEP exhibited good efficacy and safety, comparable to other HoLEP procedures. There were no significant differences in complication rates between the groups. The MOSES technology might offer a favorable safety profile, particularly in terms of postoperative hematuria complications. This study might show holmium laser enucleation with long pulse mode can be performed efficiently with acceptable safety without any high-power laser. Comparison between long pulse mode and other modulated pulse modes should be further investigated regarding many other factors.

Footnotes

Acknowledgements

This study was supported by Seoul National University Hospital under project number 3020230370.

Declarations

ORCID iDs

Hyun Ju Jeong

Steffi Kar Kei Yuen

Sung Yong Cho

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