Prospective comparison of two methods for correct ureteral stent placement in pediatric laparoscopic pyeloplasty.

INTRODUCTION: Ureteral stent placement during laparoscopic pyeloplasty is a common procedure in pediatric patients. Although an apparently safe maneuver, ascending placement of the stent can lead to complex removal or repositioning reinterventions. OBJECTIVE: In this study we compare two methods for intraoperative verification of correct positioning. STUDY DESIGN: Prospective observational study collecting data on laparoscopic pyeloplasties in pediatric patients in our center over three years. We carried out descriptive and univariate comparative analyses. Data were compared between ultrasound and reflux visualized by the catheter after intraoperative salineinjection into the bladder through the urethral catheter. We recorded time to catheter visualization in both ultrasonography and in reflux from the start of bladder instillation, as well as bladder volume at the time of placement verification with each method. RESULTS: Data were collected from 20 patients (15 male and 5 female) with a median age of 48 months. Pyeloplasty was successful in 100% of the sample (as observed by ultrasound and MAG-3), while one patient had postoperative leak requiring nephrostomy placement. Correct distal positioning of the ureteral stent could be verified by intraoperative ultrasound and reflux in all cases. Using reflux, the bladder volume needed to verify correct positioning exceeded the age-related maximum in half the cohort, while on ultrasound, the stent was visualized in the bladder without reaching the maximum bladder capacity for age in any case (p = 0.02 comparing percentages). Likewise, mean time to verification was lower with ultrasound than with reflux (61.8 s versus 115 s), but without these differences reaching statistical significance (p = 0.14). DISCUSSION: The present study is the first to compare two methods to verify the correct positioning of the ureteral stent in laparoscopic pyeloplasties in pediatric patients. Our results show that both intraoperative ultrasound and visualization of reflux are useful methods, although ultrasound requires a lower volume of saline instilled through the bladder catheter for verification. This work can be very useful for the daily clinical practice of urologists and pediatric surgeons. CONCLUSIONS: Both intraoperative ultrasound and visualization of reflux are useful methods to verify the correct positioning of the ureteral stent in laparoscopic pyeloplasty of pediatric patients. With ultrasound, a smaller volume is required to check for reflux. Although ultrasound is faster for verification, there are no differences in procedural times.

Response to "Outcomes of infants undergoing laparoscopic pyeloplasty: A single-center experience".

Although studies such as that of Erol et al. can raise doubts to a pediatric urologist about whether or not to carry out a laparoscopic approach in a pyeloplasty in infants, especially due to the percentage of complications, meta-analyses such as the one mentioned reinforce the safety and good results of the laparoscopic approach in these patients. The laparoscopic approach provides potential benefits over open surgery, such as better visualization of polar vessels, less aggressive dissection of periureteral tissues, or smaller scars. Although many open pyeloplasty incisions can be made small, they will never be smaller than those with 3 or 5 mm ports. Thus, any urologist or pediatric surgeon with experience in laparoscopic surgery has sufficient data at their disposal to be confident in the reproducibility and safety of laparoscopic surgery for pyeloplasties in infants. It is appreciated that works such as that of Erol et al. help minimally invasive techniques expand within pediatric urology.

Metabolic analysis using HR-MAS in prostate tissue for prostate cancer diagnosis.

INTRODUCTION: In this study we used nuclear magnetic resonance spectroscopy in prostate tissue to provide new data on potential biomarkers of prostate cancer in patients eligible for prostate biopsy. MATERIAL AND METHODS: Core needle prostate tissue samples were obtained. After acquiring all the spectra using a Bruker Avance III DRX 600 spectrometer, tissue samples were subjected to routine histology to confirm presence or absence of prostate cancer. Univariate and multivariate analyses with metabolic and clinical variables were performed to predict the occurrence of prostate cancer. RESULTS: A total of 201 patients, were included in the study. Of all cores subjected to high-resolution magic angle spinning (HR-MAS) followed by standard histological study, 56 (27.8%) tested positive for carcinoma. According to HR-MAS probe analysis, metabolic pathways such as glycolysis, the Krebs cycle, and the metabolism of different amino acids were associated with presence of prostate cancer. Metabolites detected in tissue such as citrate or glycerol-3-phosphocholine, together with prostate volume and suspicious rectal examination, formed a predictive model for prostate cancer in tissue with an area under the curve of 0.87, a specificity of 94%, a positive predictive value of 80% and a negative predictive value of 84%. CONCLUSIONS: Metabolomics using HR-MAS analysis can uncover a specific metabolic fingerprint of prostate cancer in prostate tissue, using a tissue core obtained by transrectal biopsy. This specific fingerprint is based on levels of citrate, glycerol-3-phosphocholine, glycine, carnitine, and 0-phosphocholine. Several clinical variables, such as suspicious digital rectal examination and prostate volume, combined with these metabolites, form a predictive model to diagnose prostate cancer that has shown encouraging results.

Comparison between open and minimally invasive pyeloplasty in infants: A systematic review and meta-analysis.

INTRODUCTION: Ureteropelvic junction obstruction (UPJO) is the most common cause of congenital hydronephrosis. Techniques such as laparoscopic pyeloplasty (LP) have gained in popularity over recent years. Although some retrospective studies have compared minimally invasive reconstructive techniques with open surgery for treatment of UPJO in infants, results remain controversial due to the small sample size in most of these studies. OBJECTIVE: To verify whether the benefits of minimally invasive pyeloplasty (MIP) observed in adults and children over 2 years of age also apply to infants. METHODS: A systematic review of the literature was performed according to PRISMA recommendations. We searched databases of MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. We excluded studies in which patient cohorts were outside the age range between 1 and 23 months of age (infants). Studies should evaluate at least one of the following outcomes: average hospital stay, operative time, follow-up time, complications, post-surgical catheter use, success rate and reintervention rate. The quality of the evidence was assessed with the ROBINS-I tool. RESULTS: In total, 13 studies were selected. 3494 patients were included in the meta-analysis, of whom 3054 underwent OP, while the remaining 440 were part of the group undergoing MIP. The mean difference in hospital days was -1.16 lower the MIP group (95 % CI; -1.78, -0.53; p = 0.0003). Also, our analysis showed a significantly shorter surgical time in the group who underwent OP, with a mean operative time of 119.92 min, compared to 137.63 min in the MIP group (95 % CI; -31.76, -6.27; p = 0.003). No statistically significant between-group differences were found respect to follow-up time, complications, post-surgical catheter use, success rate and reintervention rate. CONCLUSION: This systematic review with meta-analysis has shown that laparoscopic/robotic pyeloplasty in infants is a safe technique with similar success rates to open surgery. Nonetheless, randomized clinical trials with longer follow-up are needed to consolidate these results with more robust scientific evidence.

Single-Use Versus Reusable Cystoscope for Ureteral Stent Removal: A Comparative Study of Perceived Pain and Procedure Times.

INTRODUCTION: The aim of this study was to compare the IsirisTM cystoscope with a common reusable flexible cystoscope in terms of patient perceived pain and endoscopy time in the ureteral stent removal setting. MATERIALS AND METHODS: A non-randomized prospective study comparing the IsirisTM single-use cystoscope with a reusable flexible cystoscope. A visual analogue scale (VAS) was used for pain assessment and endoscopy time was recorded in seconds. Univariate and multivariate analyses were performed to assess the correlation between endoscope type and clinical variables with VAS score and endoscopy time. RESULTS: A total of 85 patients were included in the study: 53 in the disposable cystoscope group and 32 in the reusable cystoscope group. Ureteral stent extraction was successful in all cases. The mean VAS score was similar between groups (single-use group was 2.09 +/- 2.53 vs 2.53 +/- 2.14 in the reusable cystoscope group) (p = 0.13). Same was observed endoscopy time (74.92 +/- 74.45 s. in the single-use group vs 98.87 +/- 153.33 s. in the reusable group) (p = 0.07). Age (coefficient ß = -0.36, p < 0.04) and body mass index (BMI) (coefficient ß = -0.22, p < 0.02) were inversely correlated with perceived pain during ureteral stent removal, measured by VAS score. CONCLUSIONS: Ureteral catheter removal with a flexible cystoscope is a well-tolerated procedure in patients. Older age and high BMI are associated with better intervention tolerance. Use of a single-use flexible cystoscope is comparable to that of a common flexible cystoscope in terms of pain and endoscopy time.

Renal Cyst after Heminephrectomy in a Pediatric Patient: Complication or Normality?

INTRODUCTION: In this work, we present two cases of heminephrectomies with postoperative findings of cystic lesions in the bed of the excised renal segment. MATERIAL AND METHODS: Description of the clinical cases, therapeutic management and description of the ultrasound findings. A review of the published cases was carried out. RESULTS: We present a case of open heminephrectomy due to atrophy of the upper hemirrenal in a case of ureterocele, and another case with bilateral lower heminephrectomy in a case of vesicoureteral reflux disease. In the first case, the cystic lesion disappeared during follow-up, while in the second, the cysts remained stable. In none of the cases published in the literature was it necessary to perform any intervention to resolve the cysts. CONCLUSIONS: The appearance of cystic lesions in the heminephrectomy bed in pediatric patients is a radiological finding that occurs frequently. Due to its favorable evolution, without the need for additional procedures for its resolution, we do not consider the presence of these lesions as a complication after heminephrectomy.

Microbladder due to Granulomatous Cystitis Secondary to BCG Treatment.

INTRODUCTION: Intravesical immunotherapy with bacillus Calmette-Guerin (BCG) is considered as the standard treatment for non-muscle invasive bladder cancer with high risk of recurrence and progression. OBJECTIVE: To report a case of granulomatous cystitis in a patient receiving BCG intravesical therapy for urothelial carcinoma. MATERIAL AND METHODS: A 63-year-old man underwent BCG treatment for a bladder tumor with pathological diagnosis of T1G3 urothelial carcinoma. Five months later, trans urethral resection (TUR) of bladder was performed for an erythematous lesion, with results of post-BCG cystitis. Two years later, the patient presented with hematuria and with suspicious findings in the cystoscopy (extensive fibrin-covered and calcified lesions in the bladder) and a bladder TUR was done. RESULTS: The histopathological study showed granulomatous cystitis with necrosis and the presence of BAAR compatible with post-BCG origin. In the mycobacterial culture, M. bovis grew, and treatment was initiated. A cystography was performed on suspicion of a microbladder on CT with secondary vesicoureteral reflux, confirmed in this test. It was decided to perform a radical cystectomy. Histopathology reported post-BCG granulomatous cystitis and prostatitis. CONCLUSIONS: After BCG treatment, if symptoms or images are suggestive of granulomatous cystitis, a study of mycobacterial infection should be started to avoid the development of complications, such as the microbladder as in the case we present.

Early Ultrasound after Endoscopic Puncture of Ureterocele: Signs that Show Surgical Treatment Success.

INTRODUCTION: We show the ability of early ultrasound after surgery to show the success of endoscopic puncture of the ureterocele. METHOD: Description of the clinical cases, therapeutic management and description of the ultrasound findings. RESULTS: We present two infants aged 1 and 4 months who underwent endoscopic puncture of ectopic ureteroceles during a period of 3 months at our institution. The first case was operated urgently for urinary sepsis, while the second was punctured to preserve renal function. In both cases, ultrasound was performed two hours after surgery, and the ultrasound findings were recorded. In both patients, the ureterocele was considered resolved one year after the puncture. CONCLUSIONS: Findings such as puncture notch, flap-like collapse of the walls, decrease in ureterohydronephrosis, or disappearance of debris in the upper tract, are ultrasound signs that are visualized in the immediate postoperative period of endoscopic puncture of the ureterocele. Thus, early ultrasound is useful for early monitoring of endoscopic treatment of ureterocele.

[The use of urokinase in urinary catheter obstructed by clots.] / El uso de urocinasa en catéteres urinarios obstruidos por coágulos.

OBJECTIVE: The objective of thisstudy is to review three cases using urokinase in patientswith urinary catheter obstructed by clots, aswell to carry out a review of the published literature. METHODS: It was done a review of three casesfrom 2019 to 2020 who required urokinase due tourinary catheters obstructed by clots in our department.In addition, a reference search was performedin Pubmed. RESULTS: The first case was a woman with metastaticbreast carcinoma who required nephrostomyplacement. The second case was a renal trauma thatrequired bladder catheterization. The third case wasa male with a benign ureteric obstruction who requirednephrostomy placement due to sepsis. After instillationswith urokinase, the first two cases respondedadequately, while the third was unsuccessful. CONCLUSIONS: Urokinase may be an effectiveand well-tolerated therapy in the treatment of coagulatedurinary catheters that does not respond toother measures.

OBJETIVO: Reportar tres casos acercadel uso de la urocinasa en pacientes portadores decatéteres urinarios obstruidos por coágulos y realizaruna revisión de la literatura publicada. MATERIAL Y MÉTODOS: Revisión de casos quehan precisado de urocinasa en nuestro servicio de2019 a 2020 en relación a pacientes con catéteresurinarios obstruidos por coágulos. Además, se realizóbúsqueda de referencias en Pubmed. RESULTADOS: El primer caso fue una mujer concarcinoma de mama metástasico que precisó colocaciónde nefrostomías. El segundo fue un paciente pediátricocon traumatismo renal que requirió sondajevesical. El último enfermo fue un varón con obstrucciónbenigna de uréter que precisó de nefrostomía porsepsis. Tras instilaciones con urocinasa, los dos primerospacientes respondieron adecuadamente, mientrasque no hubo éxito en el tercero. CONCLUSIONES: La urocinasa puede ser unaterapia eficaz y bien tolerada en el tratamiento decatéteres urinarios coagulados que no responden aotras medidas.

Retrograde endoureterotomy as a treatment option for impacted calculus in the ureterointestinal junction.

INTRODUCTION: In patients with a history of radical cystectomy and with intestinal diversion, urolithiasis in the upper urinary tract is a frequent event. MATERIAL AND METHODS: We describe for the first time a case of retrograde endoureterotomy used to treat a calculus proximal to the ureterointestinal junction. RESULTS: This technique is of interest when antegrade access is not possible. In our example, after passing the guidewire percutaneously, and externalize it through the stoma, the left meatus was reached with a resectoscope inserted through the ileal duct. After the use of a balloon to prevent migration of the calculus, a retrograde endoureterotomy was performed with a Collins knife and the stone removed. The patient's progress was satisfactory. CONCLUSION: Endoscopic management of calculi in patients with intestinal diversion can be performed with different approaches. We recommend retrograde endoureterotomy as a feasible treatment option for the removal of impacted calculi at the ureterointestinal junction.

Endoureterotomy with the Lovaco technique for treatment of ureterointestinal strictures: outcomes in an experienced center and factors associated with procedural success or failure.

INTRODUCTION: The study aimed to present the outcomes of an endoureterotomy series using the Lovaco technique for the treatment of ureterointestinal strictures. Factors influencing the success or failure of this technique were also determined. MATERIALS AND METHODS: Data were collected from all endoureterotomies for ureterointestinal strictures performed in a single-center between 2017 and 2020. Clinical variables and characteristics of the stricture were recorded in each case, and success was defined as the complete resolution of ureterohydronephrosis. Univariate analysis was used to correlate the variables recorded with procedural success or failure. RESULTS: A total of 25 patients were recruited: 16 with strictures on the left side, 5 on the right, and 4 bilateral. With the first endoureterotomy, 52% of the cases (13 patients) were resolved, and in patients undergoing a second intervention 64% success (16 patients) was achieved. Infectious complications occurred in 23.3% of surgeries. Stricture length, poor renal function, and left side involvement were associated with endoureterotomy failure. CONCLUSIONS: Endoureterotomy with the Lovaco technique is a useful method in the setting of ureterointestinal strictures, achieving complete resolution of the obstruction in more than 60% of cases. Factors that can negatively affect the success of the procedure include stricture length, poor renal function, and left side involvement.

[Pediatric ureteral ectopia: Solutions for several issues.] / Ectopia ureteral en paciente pediátrico: diferentes soluciones para diferentes problemas.

OBJECTIVE: The treatment of the ectopic ureter in the pediatric patient must be individualized in each caseMETHOD: Description of clinical cases, therapeutic management and evolution of patients. RESULTS: We present four pediatric patients with ectopic ureters who underwent surgery. We describe a case of laparoscopic nephroureterectomy, one of laparoscopic uretero-ureterostomy, one of bilateral ureteral reimplantation and another of unilateral reimplantation. The discussion about the diagnosis and different surgical treatments of each case is deepened. CONCLUSIONS: We present four cases of pediatric patients with ectopic ureters, treated by different surgeries. We present how was the preoperative diagnosis and the importance of individualizing the surgical treatment in eachc ase. Aspects recently described in the context of ureteralectopy, such as diagnostic evaluation by MRI or the role of minimally invasive techniques in treatment, should be taken into account in its management.

OBJETIVO: El tratamiento del uréter ectópico en el paciente pediátrico debe individualizarse en cada caso.MÉTODO: Descripción de los casos clínicos, manejo terapéutico y evolución de los pacientes. RESULTADOS: Presentamos cuatro pacientes pediátricos con uréteres ectópicos sometidos a cirugía. Se describe un caso de nefroureterectomía laparoscópica, uno de uretero-ureterostomía laparoscópica, uno de reimplante ureteral bilateral y otro de reimplante unilateral. Se profundiza en la discusión sobre el diagnóstico y diferentes tratamientos quirúrgicos de cada caso. CONCLUSIONES: Presentamos cuatro casos de pacientes pediátricos con uréteres ectópicos, tratados mediante diferentes cirugías. Exponemos cómo fue el diagnóstico preoperatorio y la importancia de individualizar el tratamiento quirúrgico en cada caso. Aspectos descritos recientemente en el contexto de la ectopia ureteral, como la evaluación diagnóstica mediante RMN o el papel de las técnicas mínimamente invasivas en el tratamiento, deben tenerse en cuenta en su manejo.

Endoscopic treatment of intraluminal ureteral suture with holmium laser.

Although reconstructive surgery is the most accepted treatment for ureteral injury, there are reports of cases where endourologic treatment led to correct resolution of the problem. We present the case of a female patient aged 72-year-old who was previously underwent sacralcolpopexy because of anterior vaginal compartment prolapse. The patient underwent surgery to remove the mesh, due to the pain she had had since it was placed. A mid-line laparotomy was performed removing completely the mesh. At 48 hours after intervention, the patient started feeling an intense pain in the left renal fossa that was not relieved with anti-inflammatories and morphic drugs. In the diagnostic ureteroscopy, it was found iatrogenic suture of the ureter. Due to the availability of holmium laser, an endoureterotomy was performed in the 12h central position on the tip, with laser parameters of 1J-10Hz. A 6F ureteral stent was maintained for one month. During follow-up, the patient remained asymptomatic and without dilation of the left system on imaging tests. Although we accept that open reconstruction is the gold standard treatment for ureteral trauma, we describe holmium laser endoureterotomy as a promising technique to consider in the event of ureteral intraluminal ligation.

[Penile Cancer: A case for non-lymph node disease following a negative sentinel node exploration.] / Cáncer de pene: afectación extranodal en paciente con ganglio centinela negativo.

OBJECTIVE: To describe the case of a patient with subcutaneous inguinal recurrence of penile cancer without lymph node involvement. METHODS: Description of a clinical case and review of the literature on the subject. RESULTS: We present the case of a 72-year-old man with penile cancer and extranodal inguinal extension that affected subcutaneous cell tissue, with a history of negative sentinel lymph node and subsequently without invasion of the regional lymph nodes in lymphadenectomy after chemotherapy. The patient presented disease progression despite multimodal treatment. CONCLUSION: Extranodal inguinal involvement in penile cancer may occur despite a history of negative sentinel lymph node. The evolution of the patient we presented was disastrous despite the multimodal treatment carried out.

OBJETIVO: Describir el caso de un paciente con recurrencia inguinal subcutánea de cáncer de pene sin afectación ganglionar. MÉTODOS: Descripción de un caso clínico y revisión de la literatura sobre el tema. RESULTADOS: Presentamos el caso de un hombre de 72 años con cáncer de pene y extensión inguinal extranodal que afectó al tejido celular subcutáneo, con antecedente de ganglio centinelal negativo y posteriormente sin invasión de los ganglios linfáticos regionales en linfadenectomía tras quimioterapia. El paciente presentó progresión de enfermedad a pesar de un tratamiento multimodal. CONCLUSIÓN: La afectación extraganglionar inguinal en cáncer de pene puede producirse a pesar de un antecedente de ganglio centinela negativo para neoplasia. La evolución del paciente que presentamos fue nefasta a pesar del tratamiento multimodal llevado a cabo.

Endoscopic Treatment of Complete Ureterointestinal Stenosis Without Antegrade Ureteroscopy.

Background: Ureterointestinal stenosis is a frequent complication after radical cystectomy, occurring in up to 10%-12% of cases. Endoscopic treatment of complete stenosis has been described through double access, with antegrade flexible ureteroscopy and simultaneous retrograde endoscopy through the intestinal diversion. We present a case of endoscopic treatment without use of antegrade ureteroscopy. Case Presentation: A 52-year-old man underwent surgery for peritoneal carcinomatosis secondary to mucinous adenocarcinoma. Ileocecal resection, omentectomy, sigmoidectomy, rectal resection, cystoprostatectomy, and ileal duct were performed. He had a complicated postoperative period because of enterocutaneous fistulas, peritonitis, and secondary intention wall closure, needing multiple surgeries. Four months later, he was diagnosed with left ureteroinestinal stenosis, for which endoscopic management was the chosen treatment. Intraoperative diagnosis was complete stenosis. To locate the stenosis, methylene blue was instilled using a percutaneous ureteral catheter. With a resectoscope inserted through the ileal duct, the stenosis was observed and opened using cold knife and Collins knife. The stenosis was resolved satisfactorily. Conclusion: Endoscopic management of complete ureterointestinal stenosis is a viable treatment option. Although stenosis localization has previously been described with two endoscopes using transillumination, we demonstrate another localization technique using methylene blue.

Erectile dysfunction: Prevalence and its relationship with lower urinary tract symptoms. / Disfunción eréctil: prevalencia y su relación con los síntomas del tracto urinario inferior.

BACKGROUND AND OBJECTIVE: The objective was to determine the prevalence of erectile dysfunction in men over 40 years of age and their relationship with frequent pathologies in Primary Care. PATIENTS AND METHODS: Three hundred two men (40-79 years) were included. Anthropometric medical history, habits and parameters were determined. They were given the international prostate symptomatology questionnaire (IPSS), the male sexual health questionnaire (SHIM) and the Goldberg test for anxiety and depression. The prevalence of erectile dysfunction was determined and the relationship of the different variables obtained by univariate and multivariate analysis was studied. RESULTS: The prevalence of erectile dysfunction was 36%. Older patients, smokers, with abdominal obesity, hypertensive, diabetic, at risk of depression or with voiding symptoms had lower scores on the sexual health questionnaire. According to the multivariate analysis, the risk of suffering from erectile dysfunction increased with age, if the person was diabetic, or if there was voiding symptomatology. CONCLUSION: Age, diabetes mellitus and the presence of voiding symptoms are factors associated with erectile dysfunction in the field of Primary Care.

Dislodgement in Long-Term Patients with Nephrostomy Tube: Risk Factors and Comparative Analysis Between Two Catheter Designs.

Objective: To determine possible risk factors for accidental nephrostomy tube dislodgement and compare two different tube types in this context in patients with chronic catheters. Materials and Methods: We conducted a retrospective study of long-term patients with nephrostomy tube. We performed a comparative analysis, studying the possible variables that were related to catheter dislodgement. In addition, a subanalysis was also carried out comparing different catheter designs (Pigtail and Foley) in case this could be related to the dislodgement. Results: Two hundred five cases were collected. A total of 51.2% of cases had a pigtail nephrostomy and 48.8% Foley type, and accidental dislodgement occurred in 26.3% of cases. In multivariate analysis, we observed that first time nephrostomy tube placement entailed higher risk of accidental dislodgement than successive placements (odds ratio [OR] 1.95, confidence interval [CI] 1.01-3.74, p = 0.04). In the pigtail-type catheter patient subgroup, tubes placed by a resident were more prone to accidental dislodgement than those placed by an attending physician (OR 3.39, CI 1.29-8.91, p = 0.01), while first episode cases were more likely to have become dislodged than in a subsequent event (OR 3.17, CI 1.17-8.57, p = 0.02). In addition, the mean (in days) until nephrostomy tube dislodgement in cases where this occurred was 20.32 ± 3.52 for pigtail and 60.92 ± 5.15 for Foley (p < 0.01 in Kaplan-Meier's test). Conclusion: Nephrostomy tube displacement in long-term patients is a common problem. Some factors associated with the catheter could increase the risk of involuntary displacement, such as being a first event or being inserted by less experienced resident doctors. In addition, pigtail type nephrostomies tend toward accidental dislodgement earlier than Foley ones.