obstetric trauma surgery art and science

VHWWLQJVWDQGDUGVE\HYLGHQFHEDVHGSUDFWLFH

comprehensive training manual

based on

ILQGLQJVDQGRXWFRPH REVWHWULFILVWXODWUDXPDUHFRQVWUXFWLYHSURFHGXUHV

SRVWJUDGXDWHWUDLQLQJ GRFWRUVQXUVHVDQGRWKHUSHUVRQV

the one and only risk factor of obstetric poor obstetric care due to a failed system

all the rest is political blah blah blah deliberate lies and fake news

NHHVZDDOGLMN REVWHWULFWUDXPDVXUJHU\ DUWDQGVFLHQFH

VHULHVRIWH[WERRNVHDFKZLWKDVSHFLILFWRSLF

VHWWLQJHYLGHQFHEDVHGVWDQGDUGV

WKLVVHULHVKDVEHHQGHYHORSHGIRUVHWWLQJHYLGHQFHEDVHGVWDQGDUGVLQWKHWUDLQLQJDQG PDQDJHPHQWRIWKHREVWHWULFWUDXPDLQDOOLWVIRUPVLQWKHGHYHORSLQJDVZHOODVLQWKH LQGXVWULDOL]HGZRUOG

WKHQDPHRIWKHVHULHVKDVEHHQFKDQJHGIURPREVWHWULFILVWXOD WRREVWHWULFWUDXPD VXUJHU\VLQFHWKHILVWXODLVRQO\RQHDVSHFWRIWKHFRPSOH[REVWHWULFWUDXPD

WKRXJKDV\VWHPDWLFDSSURDFKLVEHLQJIROORZHGWKLVVHHPVWREHDXWRSLDVLQFHWKH PDWHULDOLVWRRH[WHQVLYHDQGLWZRXOGWDNHWRRORQJ

HDFKWLPHDVSHFLILFWRSLFKDVEHHQILQDOL]HGLWZLOOEHSXEOLVKHGDVDVHSDUDWHHQWLW\ZLWK ODWHURQDQXSGDWHLIQHHGHG

WKHQVRPHZKHUHDORQJWKHOLQHDFRPSUHKHQVLYHVXPPDU\ZLOOEHSURGXFHGLQRUGHUWR KDYHDUHSUHVHQWDWLYHRYHUYLHZ

WKH HPSKDVLV LV SODFHG RQ WKH IXQFWLRQDO DQDWRP\ RI SHOYLV SHOYLV IORRU DQG SHOYLV RUJDQ V WKHIHPDOHXULQHDQGVWRROFRQWLQHQFHPHFKDQLVPVWKHPHFKDQLVPRIDFWLRQ DQGWKHSULQFLSOHVRIUHFRQVWUXFWLYHDQGVHSWLFVXUJHU\

IRUWUDLQLQJUHDVRQVLWZLOOIROORZDVWHSE\VWHSDSSURDFKDQGUHSHWLWLRQWRJHWKHUZLWK VFKHPDWLFGUDZLQJVDQGSKRWRJUDSKV

WKHZKROHVHULHVLVEDVHGRQNHHVDUFKLYHVRIREVWHWULFWUDXPDZLWKVRIDU  UHFRQVWUXFWLYH DQG FRQVHUYDWLYH SURFHGXUHV LQ  SDWLHQWV ZLWK D UDUH ³FRPSOHWH´GRFXPHQWDWLRQRIHDFKSURFHGXUHDQGUHVXOWVDVWRKHDOLQJDQGFRQWLQHQFH E\HOHFWURQLFUHSRUWVZLWKSDUDPHWHUVRYHUSUHLQWUDSRVWRSHUDWLYHGLJLWDO SKRWRJUDSKVDQGDFRPSUHKHQVLYHGDWDEDVHDVSHUVRQDOH[SHULHQFHRYHUD\HDU SHULRGIURPXSWLOOQRZ

DVVXFKLWLVFRQVLGHUHGWREHDIXOOVFLHQWLILFHYLGHQFHEDVHGUHSRUWWKRXJKLWKDVQRW IROORZHGWKH³\RXSHHUPHLSHHU\RX´GRFWULQH

LWLVDOVRQRWIROORZLQJWKHVWULFWSURWRFRORIWKHLQWHUQDWLRQDOVFLHQWLILFMRXUQDOVRUWKHVR FDOOHGHVWDEOLVKHGWKHRULHVVLQFHRQO\GHDGILVKIROORZWKHIORZRIWKHULYHUDQGVWULFW SURWRFROVNLOODQ\FUHDWLYLW\WKHPHVVDJHLVQRWLQWKHIRUPDW

VLQFHLWLVWKHOLIHZRUNRIWKHDXWKRULWLVZULWWHQLQKLVRZQZRUGVDQGLQKLVRZQVW\OH

ZULWLQJWKLQJVGRZQKHOSVWKHDXWKRULQRUJDQL]LQJKLVRZQXQGHUVWDQGLQJDQGLGHDV IRUHZRUG

ZKHQWKHDXWKRUVWDUWHGKLVREVWHWULFWUDXPDVXUJHU\LQKHVRRQUHDOL]HGWKHUHZDV DQHHGIRUWUDLQLQJRWKHUVEXWWKHUHZDVQRWUDLQLQJPDQXDODYDLODEOH

GXULQJWKHWUDLQLQJLWWXUQHGRXWWKDWWKHDQDWRPLFNQRZOHGJHRIWKHWUDLQHHVUDQJHGIURP ³QRQH[LVWLQJ´WRSRRUWKHVDPHDVZKHQWKHDXWKRUVWDUWHGKLPVHOI

DQGWKDWWKHSK\VLFDOH[DPLQDWLRQRIWKHSDWLHQWVXUJLFDOVNLOOVDQGWLVVXHKDQGOLQJE\WKH WUDLQHHVZHUHEHORZVWDQGDUGVLPSO\EHFDXVHWKHVHWKLQJVDUHQRWLQWHJUDWHGZLWKLQWKHLU FXUULFXOXP

VLQFHOHDUQLQJDWULFNLVQRWVXIILFLHQWDQGWKHREVWHWULFILVWXODKDVWREHKDQGOHG ZLWKLQWKHFRQWH[WRIWKHFRPSOH[REVWHWULFWUDXPDZKHUHE\WKHILVWXODLVFORVHG GXULQJWKHSURFHVVRIUHFRQVWUXFWLQJWKHIXQFWLRQDOSHOYLVDQDWRP\

LQMDQXDU\DZULWWHQUDWKHUEDVLFPDQXDOZDVSURGXFHGE\WKHDXWKRUDVDKDQGRXW WR WKH WUDLQHHV ZKLFK ZDV FRQWLQXRXVO\ XSGDWHG LQ OLQH ZLWK WKH DXWKRU¶V LQFUHDVLQJ LQVLJKWLQWRWKHWKHRUHWLFDOEDFNJURXQGDQGWKHUHOHYDQWVXUJLFDOVROXWLRQV

DQGRYHUDOOWKRVH\HDUVRIVXUJHU\DQGWUDLQLQJLWUHVXOWHGLQWRWKLVIXOO\HYLGHQFH EDVHGHGLWLRQLQRUGHUWRH[SODLQILUVWWKHVFLHQFHDQGWKHQWKHDUWLQRUGHUWRKHOSRWKHU VXUJHRQVLQDV\VWHPDWLFVXUJLFDODSSURDFK

DVSUHVHQWHGQRZDVRQHWH[WERRNRXWRIWKHVHULHVREVWHWULFWUDXPDVXUJHU\ DUWDQGVFLHQFH

WKHPDQXDOGHDOVZLWKWKHEDVLFVRIIXQFWLRQDOSHOYLVDQDWRP\DQGSK\VLRORJ\GHVFULEHV WKHHQRUPRXVYDULHW\RIWKHREVWHWULFWUDXPDSUHVHQWVDVFLHQWLILFFODVVLILFDWLRQDQG RXWOLQHVWKHSULQFLSOHVRIWKHFRQVHUYDWLYHDQGUHFRQVWUXFWLYHVXUJHU\PDQDJHPHQWDV EDVHGXSRQDYHU\SHUVRQDOHYLGHQFHEDVHGH[SHULHQFH

WKHFRQWHQWVSUHVHQWWKHPLQLPXPWKHRUHWLFDOUHTXLUHPHQWVEHIRUHSUDFWLFDO WUDLQLQJLVVWDUWHG

WKHDXWKRU DSULO

3 table of contents

IRUHZRUG 

LQWURGXFWLRQ LQWURGXFWLRQ  ZKDWLVQHHGHG  HVVHQWLDOVYYIUYI  WKHREVWHWULFILVWXODDFRPSOH[WUDXPD  HVVHQWLDOVSHOYLVDQDWRP\ 

FRPSOH[REVWHWULFWUDXPD PHFKDQLVPREVWHWULFWUDXPD  FRPSOH[REVWHWULFWUDXPD  REVWHWULFQHXURORJLFWUDXPD  REVWHWULFWUDXPDHQGRSHOYLFGLDSKUDJP  XURJHQLWDODQGGLJHVWLYHSURODSVH  KLVWRU\WDNLQJ 

PDQDJHPHQWRIWKHREVWHWULFXULQHILVWXOD PDQDJHPHQWYYI  FODVVLILFDWLRQRIYYI  VXUJLFDOSULQFLSOHVYYIUHSDU  LPPHGLDWHPDQDJHPHQW  FDWKHWHUSURWRFRO  ILVWXODVIRUEHJLQQHUV  SRVWSDUWXPOHDNLQJXULQHZLWKRXWILVWXOD  SRVWUHSDLULQFRQWLQHQFH  WRWDOXWHUXVSURODSVH  PDQDJHPHQW RIWKHREVWHWULFVWRROILVWXOD PDQDJHPHQWUYI  FODVVLILFDWLRQRIUYI  VXUJLFDO SULQFLSOHVUYI UHSDLU  VSKLQFWHUDQLUXSWXUH  VWRROIODWXVLQFRQWLQHQFHZLWKRXWVSKLQFWHUDQLUXSWXUH 

JHQHUDOPDQDJHPHQWGRFXPHQWDWLRQHWF LPSRUWDQFHRUDOIOXLGV  SRVWRSHUDWLYHLQVWUXFWLRQV  HFODPSVLD  HTXLSPHQW DQG LQVWUXPHQWV  DQHVWKHVLD  EODGGHUVWRQHV  GRFXPHQWDWLRQ 

LUUHSDLUDEOHILVWXODVLQFRQWLQHQFHEDKDQ\D LUUHSDLUDEOHILVWXODVFKDUDFWHULVWLFVSURWRFRO  NHHVQHRYDJLQDUHFRQVWUXFWLRQ 

SUHYHQWLRQ SULPDU\  VHFRQGDU\ 

WUDLQLQJ FXUULFXOXP WUDLQLQJFXUULFXOXP IRU GRFWRUV  JXLGHOLQHVWUDLQLQJ  WRSLFUHODWHGZRUNVKRSV 

DEEUHYLDWLRQV

LQWURGXFWLRQ

WKHFRPSOH[REVWHWULFWUDXPDFRQWLQXHVWREHDFKDOOHQJHWRVXUJHRQVDOORYHU WKHZRUOGLQWKHGHYHORSLQJDQGLQWKHLQGXVWULDOL]HGFRXQWULHV

LQWKHLQGXVWULDOL]HGZRUOGLWLVWKHXULQHDQGVWRROLQFRQWLQHQFHZLWKSURODSVHZKLOVWLQWKH GHYHORSLQJZRUOGDOVRWKHVHWRJHWKHUZLWKWKHREVWHWULFILVWXOD

WKHSUREOHPLVWKDWWKHIXQFWLRQDOSHOYLVDQDWRP\LVKLJKO\FRPSOLFDWHGWKH PHFKDQLVPVRIDFWLRQDUHQRWZHOOXQGHUVWRRGDQGWKHUHTXLUHGUHFRQVWUXFWLYHVXUJHU\ VNLOOVDUHQRWRSWLPDO

IRUDV\VWHPDWLFSXUSRVHILUVWWKHDQDWRP\WKHIXQFWLRQDODQDWRP\DQGWKHXULQHDQG VWRROFRQWLQHQFHPHFKDQLVPVKDYHWREHVWXGLHGDVEDVLFVFLHQFH

WKHQWKHPHFKDQLVPRIDFWLRQRIWKHREVWHWULFWUDXPDZLOOEHH[SODLQHGLQUHODWLRQWRWKH GLIIHUHQWGHIHFWVUHVSRQVLEOHIRUORVVRIWKHIXQFWLRQDODQDWRP\

IROORZHGE\DQH[WHQVLYHHVVD\DERXWWKHREVWHWULFILVWXODDVEHLQJRQO\RQHDVSHFWRI WKHHQRUPRXVYDULHW\RIWKHREVWHWULFWUDXPD

EDVHGXSRQWKHDPRXQWRITXDQWLWDWLYHDQGTXDOLWDWLYHWLVVXHORVVRIWKHFRQWLQHQFH PHFKDQLVPVDQHYLGHQFHEDVHGVFLHQWLILFFODVVLILFDWLRQIRUXULQHDQGIRUVWRROILVWXODVLV SUHVHQWHG

WKHLPPHGLDWHPDQDJHPHQWLVKLJKOLJKWHG

ODVWO\WKHVXUJLFDOSULQFLSOHVIRUWKHGLIIHUHQWW\SHVDUHRXWOLQHGVSHFLILFVWHSE\VWHS VXUJLFDOWHFKQLTXHVZLOOEHSUHVHQWHGLQGLIIHUHQWERRNV

DFWXDOO\RQO\LIWKHVXUJHRQPDVWHUVWKHDUW VFLHQFHRIWKHREVWHWULFWUDXPDDQG UHFRQVWUXFWLYHVXUJHU\ V KHZLOOEHDEOHWRGHDOFRQILGHQWO\ZLWKWKLVFRQGLWLRQ

UHFRQVWUXFWLYHVXUJHU\PHDQVRQHRQO\UHFRQVWUXFWVWKHIXQFWLRQDODQDWRP\QRWKLQJ PRUHDQGQRWKLQJOHVVDQ\WKLQJWKDWLVQRWLQOLQHZLWKWKHIXQFWLRQDODQDWRP\ZLOORQO\ PDNHWKLQJVZRUVHWRROLWWOHLVKDUPIXOEXWWRRPXFKLVKDUPIXODVZHOO

WKHSKLORVRSK\RIUHFRQVWUXFWLYHVXUJHU\LVWKDWRQFHWKHIXQFWLRQDODQDWRP\KDVEHHQ UHVWRUHGXQGHUSK\VLRORJLFVWUHVVWKHQRUPDOSK\VLRORJ\ZLOOEHHQVXUHG

LWLVJRRGWRNHHSLQPLQGWKDWWKHVXUJHRQFDQQRWKHDOWKHUROHRIWKHVXUJHRQLVWR UHVWRUHWKHIXQFWLRQDODQDWRP\E\EULQJLQJWKHULJKWW\SHRIWLVVXHWRJHWKHUWRWKHEHVWRI KLVNQRZOHGJHVNLOOVH[SHULHQFHDQGFRQVFLHQFHDQGWKHQOHDYHLWWRWKHHQRUPRXV UHJHQHUDWLYHSRZHURIQDWXUHIRUKHDOLQJ

WKHDXWKRU DSULO

7 what is needed before a start is made

RQHKDVWRPDVWHUWKHFRPSOLFDWHGIXQFWLRQDODQDWRP\RIWKHSHOYLVWKHSHOYLVRUJDQV DQGWKHSHOYLVIORRU

RQH KDV WR XQGHUVWDQG WKH IXQFWLRQDO DQDWRP\ DV LQWHUDFWLRQ EHWZHHQ WKH GLIIHUHQW VWUXFWXUHVLQRUGHU

WR XQGHUVWDQG WKH SK\VLRORJ\ RI WKH XULQH DQG VWRRO FRQWLQHQFH PHFKDQLVPV LQ WKH IHPDOH

RQHPXVWEHDEOHWRLGHQWLI\WKHLQGLYLGXDOVWUXFWXUHVRIWKHIXQFWLRQDODQDWRP\LQWKH OLYLQJIHPDOH

ZKLFKLVGLIIHUHQWIURPWKHSRVWPRUWHPDQDWRP\LQWKHGHDG

RQHKDVWRVWXG\DQGXQGHUVWDQGWKHPHFKDQLVPRIDFWLRQRIWKHREVWHWULFWUDXPDZKDW LWGRHVWRWKHIXQFWLRQDODQDWRP\RIWKHLQGLYLGXDOVWUXFWXUHVDQGPDVWHUWKHHQRUPRXV YDULHW\RIOHVLRQV

RQHPXVWEHDEOHWRLGHQWLI\DQGDVVHVVWKHLQGLYLGXDOREVWHWULFWUDXPDGHIHFWVLQWKH OLYLQJIHPDOH

RQHPXVWVWXG\XQGHUVWDQGDQGPDVWHUWKHPHFKDQLVPVRIDFWLRQRIXULQHDQGVWRRO LQFRQWLQHQFHDQGRISURODSVHLQWKHIHPDOH

WKHQRQHPXVWPDNHDSODQRIDFWLRQKRZWRUHFRQVWUXFWWKHIXQFWLRQDODQDWRP\DV FXVWRPL]HGWRWKHLQGLYLGXDOILQGLQJVDQGQHHGV

RQH PXVW PDVWHU WKH SULQFLSOHV RI JHQHUDO J\QHFRORJLF XURORJLF FRORUHFWDO DQG UHFRQVWUXFWLYHVXUJHU\DQGVLQFHWKHYDJLQDLVQHYHUVWHULOHDOVRWKHSULQFLSOHVRIVHSWLF VXUJHU\

RQHPXVWXQGHUVWDQGDQGUHVSHFWWKHQDWXUDOWLVVXHIRUFHVLQVLGHWKHKXPDQERG\

RQHPXVWPDVWHUWKHSK\VLRORJLFKHDOLQJSURFHVVHVLQRUGHUWRSURPRWHWKHHQRUPRXV QDWXUDOKHDOLQJSRWHQWLDORIWKHKXPDQERG\

SUHIHUDEO\RQHXQGHUJRHVDSUDFWLFDOWUDLQLQJZLWKDVWHSE\VWHSDSSURDFKZKHUHWKH EDVLFVNLOOVDUHGHPRQVWUDWHGLQRUGHUWROHDUQWKHVHVNLOOV

WKRXJKWKHVNLOOVFDQEHGHPRQVWUDWHGDQGEHSUDFWLFHGVWHSE\VWHSXQGHUVWULFWVXSHU YLVLRQWKHUHLVQRDXWRPDWLFWUDQVIHURIWKHVHVNLOOVDQGWKHXOWLPDWHUHVSRQVLELOLW\IRUDQ\ VXUJHU\UHVWVXSRQWKHSHUIRUPLQJVXUJHRQ

WKHGHFLVLYHIDFWRULQVXUJHU\LVWKHVXUJHRQ

8 HVVHQWLDOVYYIUYI

YYI YHVLFRYDJLQDO ILVWXOD DQ DEQRUPDO FRQQHFWLRQ EHWZHHQ WKH EODGGHU DQG WKH YDJLQDDXULQHILVWXOD

UYI UHFWRYDJLQDOILVWXODDQDEQRUPDOFRQQHFWLRQEHWZHHQWKHUHFWXPDQGWKHYDJLQD DVWRROILVWXOD

FDXVHV D SUHVVXUHQHFURVLVGXHWRREVWUXFWHGODERUWKHREVWHWULFILVWXOD E VXUJHU\K\VWHUHFWRP\FROSRUUKDSK\FHVDUHDQVHFWLRQ F PDOLJQDQF\ G UDGLDWLRQ H WUDXPD I FRQJHQLWDOPDOIRUPDWLRQ J LQIHFWLRQ

PDLQFDXVHLVSURORQJHGREVWUXFWHGODERU WKRXJKWKHREVWHWULFILVWXODKDVGLVDSSHDUHGIURPWKHLQGXVWULDOL]HGZRUOGLWLVVWLOO YHU\ SUHYDOHQW LQ WKH GHYHORSLQJ ZRUOG DQG DFFRXQWV IRU RYHU  RI DOO WKH ILVWXODVZRUOGZLGH

V\PSWRPV YYI FRQWLQXRXVOHDNLQJRIXULQHWKUXWKHYDJLQDKRXUVDGD\ZKLFKFDQQRW EHVWRSSHGRUFOHDQHG UYI LQWHUPLWWHQW SDVVLQJ RI VWRROV IURP WKH YDJLQD ZKLFK FDQ EH VWRSSHG XQOHVVGLDUUKHD DQGFOHDQHG

VRFLDODFFHSWDQFH WKHUHIRUHWKHSDWLHQWZLWKDYYILVVRFLDOO\IDUOHVVDFFHSWDEOHWKDQWKHSDWLHQW ZLWKDUYI

VRFLDOPHGLFDODQGPHQWDOLPSOLFDWLRQV LQDIULFDLWPHDQVWKDWWKHYYISDWLHQWLVRVWUDFL]HGIURPKHURZQFRPPXQLW\DQG KDVWROLYHDVDQRXWFDVWZLWKSURJUHVVLYHGRZQJUDGLQJPHGLFDOO\VRFLDOO\DQG PHQWDOO\

LQFLGHQFH  SHU WKRXVDQG GHOLYHULHV ZKHUH WKHUH LV QR HDV\ DFFHVV WR IXQFWLRQLQJ REVWHWULFFDUHGXHWRDIDLOHGV\VWHP

SUHYDOHQFH DPLQLPXPRIYYISDWLHQWVZRUOGZLGHDZDLWLQJVXUJHU\RIZKRPDW OHDVWDUHLQ$IULFD

WUHDWPHQW PDLQO\VXUJHU\E\GLIIHUHQWRSHUDWLRQWHFKQLTXHV

SURJQRVLVDIWHUVXFFHVVIXOUHSDLU PHGLFDOO\ JRRG VRFLDOO\ JRRG PHQWDOO\ JRRG

 9 9 the obstetric : a complex trauma

LQFLGHQFHRIREVWHWULFILVWXOD DPLQLPXPRISHUWKRXVDQGGHOLYHULHVZKHQWKHPRWKHUVXUYLYHVLQVLWXDWLRQV ZKHUHWKHUHLVQRHDV\DFFHVVWRDIXQFWLRQLQJREVWHWULFVHUYLFHWKLVPHDQVIRU DIULFDDQDQQXDOLQFLGHQFHRIVRPHWRQHZILVWXODSDWLHQWV WKHUHLVQRUHODWLRQWRUDFHWULEHUHOLJLRQFXOWXUHHDUO\PDUULDJHRUDQ\WKLQJHOVH H[FHSWIRUHDUO\LQWHUYHQWLRQE\FVZLWKLQKRXUVIURPWKHPRPHQWREVWUXFWHG ODERUKDVGHYHORSHG

SUHYDOHQFHRIREVWHWULFILVWXOD LQDIULFDDPLQLPXPRIILVWXODSDWLHQWVDZDLWLQJVXUJHU\

FDXVHRIREVWHWULFILVWXOD REVWUXFWHGODERU SUHVVXUHQHFURVLV DQGRUFHVDUHDQVHFWLRQDQGRUSULPLWLYH REVWHWULFSUDFWLFHV

PHFKDQLVPRIDFWLRQLQREVWUXFWHGODERU WKHIHWDOKHDGLVWRRELJRUOLHVSUHVHQWVDEQRUPDOO\DQGJHWVVWXFNLQVLGHWKHELUWK FDQDOWKHQWKHVRIWWLVVXHVDUHFRPSUHVVHGEHWZHHQWKHKDUGIHWDOVNXOODQGWKH KDUGPDWHUQDOSHOYLFERQHVLIWKLVLVQRWUHOLHYHGZLWKLQKRXUVE\FHVDUHDQ VHFWLRQWLVVXHQHFURVLV QREORRGVXSSO\ RFFXUVDQGDILVWXODGHYHORSV

ZKLFKVWUXFWXUHVDUHDWULVN WKHDQWHULRUYDJLQDZDOOSXERFHUYLFDOIDVFLDEODGGHUXUHWKUDDUHPRUHDWULVNWKDQ WKHSRVWHULRUYDJLQDZDOOSUHUHFWDOIDVFLDUHFWXPDOVRWKHODWHUDOYDJLQDSHOYLV ZDOOV OHYDWRUDQLPXVFOHV FHUYL[XWHUXVDQGGHHSHUSHOYLFVWUXFWXUHV QHUYHV OLJDPHQWVSHULRVWHWF DUHDWULVN

LVRODWHGYYI WKLVLVWKHUXOHRIWKHSDWLHQWV

FRPELQDWLRQYYIUYI WKHYYILVFRPELQHGZLWKUYILQVRPHRIWKHSDWLHQWV

LVRODWHGUYI YHU\VHOGRPH[FHSWIRUVSKLQFWHUDQLUXSWXUHZLWKGLVWDODQRUHFWXPWUDXPD

LQWUDSHOYLFYDJLQDOOHVLRQVGXHWRREVWUXFWHGODERU DOZD\VWLVVXHORVVRISRVWHULRUXUHWKUDEODGGHUDQGRUDQWHULRUUHFWXP DOZD\VWLVVXHORVVRISXERFHUYLFDOPXVFXORIDVFLDDQGRUSUHUHFWDOIDVFLD DOZD\VWLVVXHORVVRIDQWHULRUDQGRUSRVWHULRUYDJLQDZDOO YDJLQDVWULFWXUHYDJLQDVWHQRVLVYDJLQDVKRUWHQLQJDQGHYHQYDJLQDDWUHVLD WLVVXHORVVRISXERFRFF\JHXVREWXUDWRFRFF\JHXVDQG LVFKLR FRFF\JHXVPXVFOHV UHVXOWLQJLQEDUHSXELFERQHVZLWKORVVRISHULRVWDQGV\PSK\VLVFDUWLODJH WUDXPDWRDUFXVWHQGLQHXVIDVFLDHDQGDUFXVWHQGLQHXVRIOHYDWRUDQLPXVFOHV ZLWKHYHQWLVVXHORVVRILQWHUQDOREWXUDWRUPXVFOHDQGREWXUDWRUPHPEUDQH WLVVXHORVVRIEURDGFDUGLQDODQGVDFURXWHULQHOLJDPHQWV WLVVXHORVVRIFHUYL[XWHUXVWRWDOORVVLVVHOGRP HQGRPHWULXPWUDXPDZLWKVHFRQGDU\DPHQRUUKHD WUDXPDWRLQWHUQDODQGH[WHUQDOVSKLQFWHUDQLPXVFOHVDQGSHULQHDOERG\ WLVVXHORVVRIODELDPLQRUD

10 QHXURORJLFOHVLRQVGXHWRREVWUXFWHGODERU SHURQHXVQHUYHSDOV\GXHWRFRPSUHVVLRQRIWKHVFLDWLFQHUYH DQHVWKHVLDRIWKHYDJLQDXSWRZHHNV VSKLQFWHUDQLSDOV\ZLWKVWRROIODWXVLQFRQWLQHQFH VDGGOHDQHVWKHVLD

QHXURORJLFOHVLRQVGXHWRHFODPSVLD PHQWDOFRQIXVLRQVSRQWDQHRXVKHDOLQJ VWURNHGXHWRK\SHUWHQVLRQVHOGRP WUDQVLHQWEOLQGQHVVVSRQWDQHRXVKHDOLQJ

ORFDOH[WUDYDJLQDOOHVLRQVGXHWRSURORQJHGREVWUXFWHGODERU SUHVVXUHVRUHVRYHUVDFUXPWURFKDQWHUPDMRUKHHODQGVFDSXOD WLVVXHORVVRIODELDPDMRUD "LQIHFWLRXVJDQJUHQH" 

V\VWHPLFOHVLRQVGXHWRWKHHQRUPRXVWUDXPDRISURORQJHGREVWUXFWHGODERU SRRUJHQHUDOKHDOWKDQGHYHQFDFKH[LD VHYHUHDQHPLD VHFRQGDU\DPHQRUUKHDGXHWRH[FHVVLYHEORRGORVV VKHHKDQV\QGURPH 

OHVLRQVGXHWRFRQWLQXRXVXULQHOHDNDJH DPPRQLDGHUPDWLWLVDURXQGWKHYXOYD wet clothes with offensive odor

LQLWVextreme formWKHZRPDQHQGVXSZLWKDcloacaDQGempty IRUZKLFK QRWKLQJFDQEHGRQHVKHLVcrippled for lifeSK\VLFDOO\PHQWDOO\HPRWLRQDOO\DQG VRFLDOO\DQGVKHZLOOEHnever again a normal woman

WKHenormous trauma of prolonged obstructed labor LVVXFKWKDWRYHURIWKHLQIDQWVGLHLQVLGHWKHPRWKHUWKHQWKHKHDG LWV ODUJHVWFLUFXPIHUHQFH VKULQNVDQGWKHPRWKHUPD\EHDEOHWRSXVKWKHGHDGFKLOG RXW PDQ\WLPHVWKHPRWKHUGLHVDVZHOOLQWKHSURFHVV""KRZRIWHQ"" LIWKHPRWKHUVXUYLYHVLWLVIRUWKHSUL]HRIDGHDGFKLOGDQGDQREVWHWULFILVWXOD DQGWKHQ«WKHUHDOWURXEOHVWDUWV prevention of the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prevention of the woman from becoming an outcast WKLV LV YHU\ ZHOO IHDVLEOH HYHQ XQGHU SULPLWLYH FRQGLWLRQV E\WKHimmediate management by catheter and/or early closure

11

IXQFWLRQDOSHOYLVDQDWRP\ HVVHQWLDOV

WUXHSHOYLVFDYLW\ DFRQILQHGVSDFHIRUWKHGLVWDORXWOHWRUJDQVRIWKHXULQDU\WUDFWDQWHULRUO\WKHJHQLWDO WUDFWLQWKHPLGGOHDQGWKHGLJHVWLYHWUDFWSRVWHULRUO\ZLWKK\GURVWDWLFDQGFRPSUHVVLRQ SUHVVXUHQRUPDOO\LQDFRQWLQHQWZD\DQGGLYLGHGLQWR DQWHULRUSUHBVXESHULWRQHDOFRPSDUWPHQW IRUWKHGLVWDOHQGSDUWVRIWKHXULQDU\WUDFWSHOYLFXUHWHUVEODGGHUDQGXUHWKUD PHGLDQVXESHULWRQHDOFRPSDUWPHQW IRUWKH DOVRGLVWDOHQGSDUWVRI JHQLWDOWUDFWXWHUXVDGQH[DFHUYL[DQGYDJLQD SRVWHULRUUHWURBVXESHULWRQHDOFRPSDUWPHQW IRUWKHGLVWDOHQGSDUWVRIWKHGLJHVWLYHWUDFWUHFWXPDQRUHFWXPDQGVSKLQFWHUDQL

HQFORVHGE\ SDULHWDOSHOYLVIDVFLDFRYHULQJSHOYLVZDOOIORRUPXVFOHV DQG SDULHWDOSHULWRQHXP DVFRQQHFWHGWRHDFKRWKHUE\ WHODXURJHQLWDOLVZLWKFRUSXVLQWUDSHOYLQXPDQGHQGRSHOYLFGLDSKUDJP

FRUSXVLQWUDSHOYLQXPDVG\QDPLFPDWUL[ FRQQHFWLYHWLVVXHRUJDQRISHOYLVFRQVLVWVRIDFRKHVLYHPL[WXUHRIFROODJHQIRUVWUHQJWK HODVWLQIRUSDVVLYHHODVWLFLW\DQGSODVWLFLW\DQGPRVWO\VPRRWKPXVFOHILEHUVIRUG\QDPLF DFWLYHQRQIDWLJXHWRQXVLQDORRVHGHQVHRUFRQGHQVHGIRUPDV DG\QDPLFPDWUL[LQWRZKLFKWKHRUJDQVDQGWKHLUVXSSO\DUHHPEHGGHGDQGVXVSHQGHG FRQQHFWHGWRWKHSHOYLVZDOODQGHDFKRWKHUE\KLJKO\VSHFLDOL]HGVWUXFWXUHV SURWHFWLQJWKHRUJDQVDQGWKHLUVXSSO\DJDLQVWWUDXPDDQGVWDELOL]LQJVHFXULQJWKHPLQ WKHLUYDULDEOHDQDWRPLFSRVLWLRQ DVFRRUGLQDWHGE\WKHDXWRQRPLFQHUYRXVV\VWHP FRQVLGHUHGWREHDIOXLGXPVLQFHQRVKDUSGHPDUFDWLRQVEHWZHHQWKHDUFKDLFPDWUL[DQG LWVVSHFLDOL]HGVWUXFWXUHV

HQGRSHOYLFGLDSKUDJP KLJKO\VSHFLDOL]HGVWUXFWXUHRIFRUSXVLQWUDSHOYLQXPIURPV\PSK\VLVDQWHULRUO\WRVDFUXP SRVWHULRUO\DVFRQQHFWHGWRLWVELODWHUDODUFXVWHQGLHQXVIDVFLDHZLWKFHUYL[DVFHQWUXP WHQGLQHXPLQWUDSHOYLQXPVLQFHDOOPXVFXORIDVFLDVWUXFWXUHVDUHFRQQHFWHGWRLW DVILUVWOLQHRIFRXQWHUDFWLQJLQWUDDEGRPLQDOK\GURVWDWLFSUHVVXUHDQG VXSSRUWLQJWKHXURJHQLWDOFRQWLQHQFHPHFKDQLVPVLQWKHLUDQDWRPLFSRVLWLRQDQG SUHYHQWLQJKHUQLDWLRQRIWKHXULQDU\WUDFWJHQLWDOWUDFWLQWUDSHULWRQHDOFRQWHQWVDQGGLVWDO GLJHVWLYHWUDFWLQWRWKH]HURSUHVVXUHYDJLQD

SHOYLVIORRUDVRQHIXQFWLRQDOXQLWDVSDUWRIDEGRPLQRSHOYLFZDOO OHYDWRUDQLPXVFOHVFRQQHFWHGILUPO\WRWKHSHULQHXPRXWOHWGLDSKUDJPYLDSHULQHDOERG\ DQGH[WHUQDOVSKLQFWHUDQLPXVFOHVXSSRUWLQJDQGUHLQIRUFLQJHDFKRWKHU OHYDWRUDQLPXVFOHVDV³SHOYLVGLDSKUDJP´KLJKO\RYHUUDWHGZLWKGLUHFWDFWLRQRQVWRRO FRQWLQHQFHPHFKDQLVPDQGRQO\LQGLUHFWDFWLRQRQXULQHFRQWLQHQFHPHFKDQLVP SHULQHXPRXWOHWGLDSKUDJPLQWRZKLFKWKHHQGRXWOHWRUJDQVZLWKWKHLUVWULDWHGVSKLQFWHU PHFKDQLVPVDUHDQFKRUHGDQGVXSSRUWLQJGLUHFWO\DQGWKHXULQHDQGVWRROFRQWLQHQFH PHFKDQLVPV

24  12 IHPDOHXULQHFRQWLQHQFHPHFKDQLVP  RYHULQWRWDOFP EODGGHUQHFNXYMXQFWLRQDQGZKROHXUHWKUD VXSSRUWHGE\WKHHQGRSHOYLFGLDSKUDJP WKHUHLVDQLQWHUQDOVPRRWKPXVFOHVSKLQFWHUDQGDQH[WHUQDOVWULDWHGUKDEGRVSKLQFWHU ZLWKZDVKHUHIIHFWE\WKHPXFRVDDQGVXEPXFRXVYDVFXODUSOH[XV FRQWLQHQFHSRWHQWLDORYHULWVZKROHOHQJWK

IHPDOHJHQLWDOFRQWLQHQFHPHFKDQLVP RYHULQWRWDOFP ZLWKFHUYL[DVLQWHUQDOVPRRWKPXVFOHVSKLQFWHUDVDQFKRUHGLQWRHQGRSHOYLFGLDSKUDJP

IHPDOHVWRROFRQWLQHQFHPHFKDQLVP  RYHULQWRWDOFP DQRUHFWXPDQGH[WHUQDOVSKLQFWHUDQL DQFKRUHGZLWKLQSHULQHXPRXWOHWGLDSKUDJP WKHUHLVDQLQWHUQDOVPRRWKPXVFOHVSKLQFWHUDQGDQH[WHUQDOVWULDWHGVSKLQFWHUDQL PXVFOHZLWKZDVKHUHIIHFWE\PXFRVDDQGVXEPXFRXVYDVFXODUSOH[XV

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

SHOYLVIORRUPXVFOHH[HUFLVHV KDYHDSRVLWLYHHIIHFWXSRQWKHXULQHDQGFRQWLQHQFHPHFKDQLVPVLQFH WKHSHULQHXPRXWOHWGLDSKUDJPFRQWULEXWHVWRWKHXULQHDQGVWRROFRQWLQHQFHPHFKDQLVP E\IXUWKHUVWDELOL]LQJWKHRXWOHWSDUWV WKHOHYDWRUDQLPXVFOHVFRQWULEXWHGLUHFWO\WRWKHVWRROFRQWLQHQFHPHFKDQLVPWRZKLFK WKH\DUHDQDWRPLFDOO\FRQQHFWHGEXWRQO\LQGLUHFWO\WRWKHXULQHFRQWLQHQFHPHFKDQLVP ZLWKQRDQDWRPLFFRQQHFWLRQZKDWVRHYHU ZLWKVLPXOWDQHRXVUHIOH[FRQWUDFWLRQRIWKHH[WHUQDOVWULDWHGPXVFOHVSKLQFWHUV ZLWKLQFUHDVHLQWRQXVRIVPRRWKPXVFOHILEHUVRIWKHHQGRSHOYLFGLDSKUDJPE\UHIOH[ DFWLRQE\WKHV\PSDWKHWLFSDUWRIWKHDXWRQRPLFQHUYRXVV\VWHP

REVWHWULFWUDXPD GXHWRK\GURVWDWLFSUHVVXUHGLODWDWLRQRIELUWKFDQDO LQ GLUHFWFXWWLQJWKUXVKHDULQJDQG FRPSUHVVLRQDQGLQSURORQJHGREVWUXFWHGODERUGXHWRSUHVVXUHQHFURVLV UHVXOWLQJLQDQHQRUPRXVYDULHW\RIGHIHFWVIURPPLQLPDOWRH[WHQVLYH

SHOYLVRUJDQSURODSVH KHUQLDWLRQRIDGMDFHQWKLJK HU SUHVVXUHRUJDQVLQWRWKH]HURSUHVVXUHYDJLQDDQGWKHQ IXUWKHUSURODSVHWKUXWKHYDJLQDGUDJJLQJYDJLQDZDOOZLWKWKHPDVLQWXVVXVFHSWLRQ GXHWRGHIHFWVZLWKLQWKHVHSDUDWLQJDQGVXSSRUWLQJHQGRSHOYLFGLDSKUDJPVWUXFWXUHVRI WKHFRUSXVLQWUDSHOYLQXPEHWZHHQWKHVHRUJDQVDQGWKHYDJLQD OHYDWRUDQLPXVFOHVDQGSHULQHXPRXWOHWGLDSKUDJPGRQRWSOD\DUROHLQWKLVSURFHVV VLQFHWKHUHLVQRDQDWRPLFFRQWDFWEHWZHHQWKRVHRUJDQVDQGWKHVHVWUXFWXUHV

UHFRQVWUXFWLYHVXUJHU\ WKHVFLHQFHLVWRLGHQWLI\WKHVSHFLILFGHIHFWVZKLOVWWKHDUWLVWRUHFRQVWUXFWWKHIXQFWLRQDO DQDWRP\XVLQJWKHDYDLODEOHDXWRORJRXVVWUXFWXUHV

 13 25

FRPSOH[REVWHWULFWUDXPD

PHFKDQLVPREVWHWULFWUDXPD

FRPSOH[REVWHWULFWUDXPD

REVWHWULFQHXURORJLFWUDXPD

REVWHWULFWUDXPDHQGRSHOYLFGLDSKUDJP

XURJHQLWDODQGGLJHVWLYHSURODSVH

KLVWRU\WDNLQJ

 mechanism of obstetric trauma

REVWHWULFVFRQVWLWXWHVDOZD\VDPDMRUFKDOOHQJHWRDOOSHOYLVRUJDQVZLWKWKHLUGLIIHUHQW VWUXFWXUHVDQGWKHUHDUHVHYHUDOPHFKDQLVPVE\ZKLFKWKHLQWUDSHOYLFRUJDQVPD\EH DIIHFWHGZKLFKZLOOLQIOXHQFHWKHIXQFWLRQDOSHOYLVDQDWRP\LQRQHZD\RUWKHRWKHU

firstE\KRUPRQDOIORRGLQJ

secondE\FRQWLQXRXVO\LQFUHDVLQJK\GURVWDWLFSUHVVXUHGXHWRSUHJQDQWXWHUXV

thirdE\GLODWDWLRQRIFHUYL[ZLWKRSHQLQJXSRIHQGRSHOYLFGLDSKUDJP

fourthE\GLUHFWRULQGLUHFWFXWWLQJWKUXRIWKHKHDGWKUXWKHFHUYL[WKUXWKHJDSEHWZHHQ WKHSXERUHFWDOLVOHGJHVDQGWKUXWKHRSHQLQJZLWKLQWKHSHOYLVRXWOHWGLDSKUDJP

fifth E\VKHDULQJIRUFHVGXULQJDFWXDOFKLOGELUWKZKHQWKHKHDGSDVVHVWKUXWKHFHUYL[ WKUXWKHYDJLQDWKUXWKHJDSEHWZHHQWKHOHYDWRUDQLOHGJHVDQGWKUXWKHRSHQLQJLQWKH SHOYLVRXWOHWGLDSKUDJP

sixthE\FRPSUHVVLRQRIWKHVRIWWLVVXHVEHWZHHQWKHKDUGIHWDOVNXOODQGWKHKDUGERQ\ PDWHUQDOSHOYLV

seventhLDWURJHQLFE\LQWHUYHQWLRQE\KHDOWKZRUNHUV

eighthHFODPSVLD

LKRUPRQDOIORRGLQJ DOOWKHWLVVXHVZLOOILUVW³K\SHUWURSK\´WRZLWKVWDQGWKHLQFUHDVHGK\GURVWDWLFSUHVVXUHDQG ODWHURQZLOOVRIWHQDVSUHSDUDWLRQIRUFKLOGELUWKDQGZLOOLQYROXWHGXULQJWKHSXHUSHULXP

LLK\GURVWDWLFSUHVVXUH VLQFHWKHIHWXVDQGWKHXWHUXVZLOOJURZVORZO\WKHUHLVDFRQWLQXRXVO\LQFUHDVLQJK\GUR VWDWLFSUHVVXUHZKLFKPD\WUDXPDWL]HWKHHQGRSHOYLFGLDSKUDJPGHVSLWH³K\SHUWURSK\´ LQWKHLQYROXWLRQSKDVHGHIHFWVPD\EHUHVROYHGVSRQWDQHRXVO\WKRXJKVPDOOGHIHFWV PD\UHPDLQ ZLWKVXEVHTXHQWSUHJQDQFLHVGHOLYHULHVWKHVHUHPDLQLQJGHIHFWVPD\EHFRPHODUJHUXS WRDSRLQWZKHUHWKHVXSSRUWRIWKHXULQDU\FRQWLQHQFHPHFKDQLVPEHFRPHVLQVXIILFLHQW DQGRUWKHVHFXULQJVWDELOL]DWLRQRIWKHRUJDQVEHFRPHGHIHFWLYH

LLLFHUYL[GLODWDWLRQZLWKRSHQLQJRIHQGRSHOYLFGLDSKUDJP GXULQJWKHILUVWVWDJHRIODERUWKHFHUYL[ZLOOHIIDFHDQGWKHHQGRSHOYLFGLDSKUDJPZLOO RSHQXSZLWKSRVVLEOHWUDXPDWRWKHFHUYL[DQFKRULQJLQWRWKLVGLDSKUDJP ZKHQWKHKHDGSDVVHVWKUXWKLVRSHQLQJLWPD\IXUWKHUVWUHWFKWUDXPDWL]HWKHWLVVXHV HLWKHUEOXQWO\RUVKDUSO\

LYFXWWKUXWUDXPD ZKHQWKHSDVVLQJRIWKHKHDGWKUXWKHELUWKFDQDOJRHVWRRTXLFNRUZKHQWKHELUWKFDQDO LVQRWIXOO\GLODWHGDQGWKHWLVVXHVKDYHQRWWLPHWRVWUHWFKWKHKHDGPD\FXWWKUXWKH WLVVXHVHLWKHUEOXQWO\RUVKDUSO\DV

28 EOXQWFXWWKUX LQFRPELQDWLRQZLWKVWUHWFKLQJWKHELODWHUDOOHGJHVRIWKHSXEUHFWDOLVPXVFOHVPD\EH WUDXPDWL]HG LQFRPELQDWLRQZLWKVWUHWFKLQJWKHSHOYLVRXWOHWGLDSKUDJPPD\EHWUDXPDWL]HGUHVXOWLQJ LQDZLGHLQWURLWXV VKDUSFXWWKUX ZKHQWKHFHUYL[LVQRWIXOO\GLODWHGWKHKHDGPD\IXUWKHUWUDXPDWL]HWKHFHUYL[DQGLWV DQFKRULQJLQWRWKHHQGRSHOYLFGLDSKUDJP ZKHQWKHSHOYLVRXWOHWLVWRRVWLIIWKHKHDGPD\FXWWKUXWKHSHULQHXPVSKLQFWHUDQLDQG UHFWXPUHVXOWLQJLQWKHFRPSOH[VSKLQFWHUDQLUXSWXUH

YVKLIWLQJVKHDULQJ ZKHQWKHKHDGRIWKHLQIDQWSDVVHVWKUXWKHELUWKFDQDODOZD\VVKHDULQJZLOOWDNHSODFHLQ PLQRURUPDMRUIRUP EHWZHHQWKHKHDGDQGWKHYDJLQDZDOO EHWZHHQWKHYDJLQDZDOODQGWKHHQGRSHOYLFGLDSKUDJP EHWZHHQWKHHQGRSHOYLFGLDSKUDJPDQGLWVDWWDFKPHQWWRWKHSXELVERQHDQGREWXUDWRU LQWHUQXVPXVFOHIDVFLDDQG EHWZHHQWKHDUFXVWHQGLQHXVRIWKHOHYDWRUDQLPXVFOHVDQGWKHREWXUDWRULQWHUQXV PXVFOHIDVFLD

YLFRPSUHVVLRQWUDXPD ZKHQWKHKHDGSDVVHVWKUXWKHYDJLQDWKHUHZLOOEHFRPSUHVVLRQRIWKHVRIWWLVVXHV EHWZHHQWKHKDUGIHWDOVNXOODQGWKHKDUGPDWHUQDOERQ\SHOYLV QRUPDOO\WKLVLVQRWDSUREOHPGXULQJSK\VLRORJLFFKLOGELUWKEXWZKHQREVWUXFWHGODERU GHYHORSVZKLFKLVQRWUHOLHYHGLQWLPHSUHVVXUHQHFURVLVZLOOGHYHORSLQDQHQGOHVV YDULHW\IURPPLQLPDOWRH[WHQVLYHDQDWRPLFWLVVXHORVVZLWKILVWXODGHYHORSPHQW

YLLLDWURJHQLFWUDXPD DGGLWLRQDOWUDXPDE\HSLVLRWRP\E\YDFXXPE\IRUFHSVE\LQWHUQDOYHUVLRQDQGSRGDO H[WUDFWLRQE\FUDQLRWRP\RUE\FHVDUHDQVHFWLRQ

YLLLHFODPSVLD PD\FDXVHGHDWKVWURNHPHQWDOFRQIXVLRQWUDQVLWLRQDOEOLQGQHVV

GLVFXVVLRQ WKHUHDUHDOZD\VWLVVXHFKDQJHVDQGWLVVXHWUDXPDGXULQJSUHJQDQF\DQGFKLOGELUWK HYHQLQSK\VLRORJLFSUHJQDQF\ODERU QRUPDOO\ WKHVH FKDQJHVWUDXPD ZLOO EH UHVROYHG GXULQJ WKH LQYROXWLRQ SHULRG RI WKH SXHUSHULXPWKRXJKVPDOOGHIHFWVPD\UHPDLQ UHSHDWSUHJQDQFLHVGHOLYHULHVZLOOUHSHDWHGO\DGGWRWKHVHVPDOOGHIHFWVDQGPD\UHVXOW LQUHDOSDWKRORJLFGHIHFWV KRZHYHUZKHQODERUEHFRPHVREVWUXFWHGDQGWKLVLVQRWUHOLHYHGLQWLPHE\DFWLYHLQWHU YHQWLRQSUHVVXUHQHFURVLVZLOOGHYHORSUHVXOWLQJLQDQHQGOHVVYDULHW\RIDQDWRPLFWLVVXH ORVVZLWKGHYDVWDWLQJFRQVHTXHQFHVIRUWKHZRPDQDIIHFWHG

FRQFOXVLRQ WKHREVWHWULFILVWXODLVPRUHWKDQRQO\DILVWXODDQGKDVWREHKDQGOHGZLWKLQWKHFRQWH[W RIWKHFRPSOH[REVWHWULFWUDXPD

29

complex obstetric trauma

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

PHFKDQLVPRIDFWLRQLQREVWUXFWHGODERU WKHIHWDOKHDGLVWRRELJRUOLHVRUSUHVHQWVDEQRUPDOO\DQGJHWVVWXFNLQVLGHWKHELUWK FDQDOWKHQWKHVRIWWLVVXHVDUHFRPSUHVVHGEHWZHHQWKHKDUGIHWDOVNXOODQGWKHKDUG PDWHUQDOSHOYLFERQHVLIWKLVLVQRWUHOLHYHGZLWKLQKRXUVE\FHVDUHDQVHFWLRQWLVVXH QHFURVLV QREORRGVXSSO\ RFFXUVDQGDILVWXODGHYHORSV WKHHQRUPRXVWUDXPD RISURORQJHGREVWUXFWHGODERULVVXFKWKDWRYHURIWKHLQIDQWV GLHLQVLGHWKHPRWKHUWKHQWKHKHDG LWVODUJHVWFLUFXPIHUHQFH VKULQNVDQGWKHPRWKHU PD\EHDEOHWRSXVKWKHGHDGFKLOGRXWPDQ\WLPHVWKHPRWKHUGLHVDVZHOOLQWKH SURFHVVWKRXJKLWLVQRWSRVVLEOHWRJLYHILJXUHV LIWKHPRWKHUVXUYLYHVLWLVIRUWKHSUL]HRIDGHDGFKLOGDQGDQREVWHWULFILVWXODDQG WKHQWKHUHDOWURXEOHVWDUWV WRXQGHUVWDQGZKDWLVKDSSHQLQJLWLVJRRGWRUHDOL]HWKDWWKHPD[LPXPSUHVVXUHRIWKH VRIWWLVVXHVZLWKLQWKHPDWHUQDOSHOYLVLVDJDLQVWWKHV\PSK\VLVDQWHULRUO\DJDLQVWWKH DUFXVWHQGLQXHVIDVFLDHDQGDUFXVWHQGLQHXVRIWKHOHYDWRUDQLPXVFOHVELODWHUDOO\DQG DJDLQVWWKHVDFUXPSRVWHULRUO\

34 table: complex obstetric trauma

001 LQWUDSHOYLFYDJLQDOOHVLRQVGXHWRSUHVVXUHQHFURVLV

002 YXOYDOHVLRQVGXHWRSUHVVXUHQHFURVLVQHFURWL]LQJLQIHFWLRQ

003 ORFDOH[WUDYDJLQDOOHVLRQVGXHWRLPPRELOL]DWLRQRUQHXURORJLFWUDXPD

004 QHXURORJLFOHVLRQVGXHWRLQWUDSHOYLFFRPSUHVVLRQ

005 QHXURORJLFOHVLRQVGXHWRHFODPSVLD

006 V\VWHPLFOHVLRQVGXHWRHQRUPRXVWUDXPDRISURORQJHGREVWUXFWHGODERU

007 V\VWHPLFOHVLRQVGXHWREORRGORVV

008 ILVWXODDPHQRUUKHD

009 OHVLRQVGXHWRFRQWLQXRXVXULQHOHDNDJH

010 OHVLRQVGXHWRUHVWULFWLRQRIRUDOIOXLGLQWDNH

011 VH[FRQGLWLRQRILQIDQWERUQ

012 VRFLDOLPSOLFDWLRQV

001LQWUDSHOYLFYDJLQDOOHVLRQVGXHWRSUHVVXUHQHFURVLV WKHDQWHULRUYDJLQDZDOOSXERFHUYLFDOIDVFLDDQGEODGGHUXUHWKUDDUHPRUHDWULVNWKDQ WKHSRVWHULRUYDJLQDZDOODQGUHFWXPDOVRWKHODWHUDOYDJLQDZDOOVDUFLWHQGLQHLOHYDWRU DQLPXVFOHVFHUYL[XWHUXVDQGGHHSHUSHOYLVVWUXFWXUHV QHUYHVOLJDPHQWVEORRGYHV VHOVSHULRVWHWF DUHDWULVN WKHUHIRUH DQ LVRODWHG YHVLFRYDJLQDO ILVWXOD vvf  LV IRXQG LQ  RI WKH SDWLHQWV D FRPELQDWLRQRIYYIZLWKUHFWRYDJLQDOILVWXOD rvf LQZKLOVWDQLVRODWHGUYILV XQFRPPRQH[FHSWIRUVSKLQFWHUDQLUXSWXUHZLWKGLVWDODQRUHFWXPWUDXPD LQFDVHRIYYIWKHUHLVDOZD\VWLVVXHORVVRIWKHXUHWKUDDQGRUEODGGHUSXERFHUYLFDO PXVFXORIDVFLDDQGDQWHULRUYDJLQDZDOODQGRUFHUYL[DQGRUXWHUXV WKHUHPD\EHDXUHWKURYDJLQDOILVWXODDYHVLFRYDJLQDOILVWXODDYHVLFRFHUYLFDOILVWXODRUD YHVLFRXWHULQHILVWXODHLWKHULVRODWHGRULQFRPELQDWLRQZLWKHDFKRWKHUDQGWKHUHPD\EH PXOWLSOHILVWXODV LIWKHWUDXPDWL]HGXUHWKUDLVWRWDOO\GLVUXSWHGIURPWKHWUDXPDWL]HGEODGGHU QHFN WKHUH LVDFLUFXPIHUHQWLDOILVWXODRUDXUHWKURYHVLFRYDJLQDOILVWXODZLWKDFLUFXPIHUHQWLDOGHIHFW ZKLFKLVFRPPRQ XUHWKUD EORFN RI WKH SUR[LPDOXUHWKUD RSHQLQJLVIUHTXHQWO\ IRXQGLQ FLUFXPIHUHQWLDO ILVWXODVVLQFHWKHWUDXPDWL]HGXUHWKUDKHDOVZLWKVFDUULQJDQGREOLWHUDWLRQ LQWKHYHVLFRFHUYLFDODQGYHVLFRXWHULQHILVWXODVWKHUHPD\EH DGGLWLRQDO WUDXPDGXHWR UXSWXUHGXWHUXVZLWKUXSWXUHGEODGGHUDQGRUWUDXPDGXHWRFHVDUHDQVHFWLRQ

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ureter fistulas and other exceptional urine fistulas HVSHFLDOO\LIDFDHVDUHDQVHFWLRQKDVEHHQSHUIRUPHGDQGWKHZRPDQLVOHDNLQJXULQH WRJHWKHUZLWKVSRQWDQHRXVPLFWXULWLRQWKHUHPD\EHDXUHWHUILVWXODDVZHOO H[FHSWLRQDOO\ILVWXODVEHWZHHQWKHXULQDU\WUDFWDQGERZHOVPD\GHYHORSRUEHWZHHQWKH EODGGHUDQGWKHVNLQ urine stress incontinence LPPHGLDWHSRVWSDUWXPXULQHVWUHVVLQFRQWLQHQFHLVFRPPRQZLWKRUZLWKRXWDYLVLEOH WUDXPDWRWKHDQWHULRUYDJLQDZDOORYHUWKHXUHWKURYHVLFDOMXQFWLRQRUDVWKHVSRQWDQH RXVKHDOLQJSKDVHRIDQDWRQLFEODGGHU QRUPDOO\WKLVPD\KHDOVSRQWDQHRXVO\E\VKRUWWHUPFDWKHWHUWUHDWPHQWIROORZHGE\VWULFW EODGGHUGULOO KRZHYHUDIWHUPRQWKVQRVSRQWDQHRXVKHDOLQJFDQEHH[SHFWHGDQGDQLQFRQWL QHQFHRSHUDWLRQLVLQGLFDWHG atonic bladder WKHVLJQVDUHRYHUIORZLQFRQWLQHQFHVXSUDSXELFPDVVDQWHULRUYDJLQDZDOOEXOJLQJLQWR WKHYDJLQDDQGLQFUHDVHGORQJLWXGLQDOEODGGHUGLDPHWHUZLWKRUZLWKRXWYLVLEOHWUDXPDWR WKHDQWHULRUYDJLQDZDOO WKRXJKWKHUHPD\EHDQHXURJHQLFFRPSRQHQWWREHWHVWHGE\WKHDQDOVSKLQFWHUUHIOH[ LWLVSUREDEO\FDXVHGE\H[WUHPHRYHUVWUHWFKLQJRIWKHGHWUXVRUPXVFOHILEHUVUHVXOWLQJLQ ³EUHDNLQJ´RIWKHILEHUVVRWKDWWKHGHWUXVRUPXVFOHFDQQRWFRQWUDFWDQ\ORQJHU VSRQWDQHRXVKHDOLQJYLDXULQHVWUHVVLQFRQWLQHQFHLVWKHQRUPZKLFKFDQEHSURPRWHG E\FDWKHWHUWUHDWPHQWIRUZHHNVIROORZHGE\EODGGHUGULOOKRZHYHUGXUDWLRQRIXSWR \HDUVZDVHQFRXQWHUHGZKLFKFRXOGEHFXUHGE\FDWKHWHUWUHDWPHQWIRUZN stricture of urethrovesical junction WKLVPD\GHYHORSLIWKHUHKDVEHHQDVXEILVWXORXVWUDXPDWRWKHDQWHULRUYDJLQDZDOO EODGGHU QHFNDQG SUR[LPDOXUHWKUD UHVXOWLQJ LQ VFDUULQJ RI DQWHULRU YDJLQD ZDOODQG XUHWKURYHVLFDOMXQFWLRQGXULQJWKHKHDOLQJSURFHVVGLODWDWLRQDQGFDWKHWHUWUHDWPHQWDUH LQGLFDWHG anterior wall QRUPDOO\WKHWUDXPDWRWKHDQWHULRUYDJLQDZDOOLVODUJHUWKDQWKHWUDXPDWRWKHXQGHU O\LQJPXVFXORIDVFLDDQGEODGGHUXUHWKUDDVIRXQGLQIUHVKREVWHWULFWUDXPD KRZHYHUWKHDQWHULRUYDJLQDZDOOKHDOVIDVWHUWKDQWKHIDVFLDDQGEODGGHU LQFDVHRIUYIWKHUHLVDOZD\VWLVVXHORVVRIWKHUHFWXPSUHUHFWDOIDVFLDDQGSRVWHULRU YDJLQDZDOODQGWKHUHPD\EHPXOWLSOHILVWXODV LQVSKLQFWHUDQLUXSWXUHWKHUHLVDOZD\VWUDXPD ZLWKRUZLWKRXWWLVVXHORVV WRWKHLQWHU QDODQGH[WHUQDODQDOVSKLQFWHUVDQRUHFWXPSUHUHFWDOIDVFLDDQGSHULQHDOERG\ LQSUR[LPDOUHFWRYDJLQDOILVWXODVWKHUHLVRIWHQD VHYHUH UHFWXPVWULFWXUHDWWKHGLVWDO SDUWZKLFKKDVWREHGLVUXSWHGGXULQJWKHUHSDLURWKHUZLVHWKHUHSDLUZLOOEORZRXW LIWKHWUDXPDWL]HGUHFWXPLVFRPSOHWHO\GLVUXSWHGIURPWKHWUDXPDWL]HGVLJPRLGWKHUHLVD FLUFXPIHUHQWLDOILVWXODRUDUHFWRYDJLQDOILVWXODZLWKFLUFXPIHUHQWLDOGHIHFWZKLFKLVQRWVR FRPPRQ FRPSOHWHFORVXUHRIWKHGLVWDOORRSZLWKWKHUHFWXPDVDEOLQGVDFLVSRVVLEOHLQWKHFLU FXPIHUHQWLDOILVWXODV LQIUHTXHQWO\WKHWUDXPDLVVRH[WHQVLYHWKDWWKHILVWXODEHFRPHVLQRSHUDEOH

36 WKHUHLVDVWURQJWHQGHQF\IRUVPDOOPHGLDQSUR[LPDOILVWXODVWRKHDOVSRQWDQHRXVO\LI WKHUHLVQRUHFWXPVWULFWXUHZLWKRXWIORZREVWUXFWLRQ WKHUHIRUHWKHLQFLGHQFHRIUHFWRYDJLQDOILVWXODLVIDUKLJKHUWKDQDVVXPHG sphincter ani rupture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posterior vagina wall DOVRWKHWUDXPDWRWKHSRVWHULRUYDJLQDZDOOLVODUJHUWKDQWKHWUDXPDWRWKHXQGHUO\LQJ SUHUHFWDOIDVFLDDQGUHFWXPDVQRWHGLQIUHVKREVWHWULFILVWXODV and WKHUHPD\EHWLVVXHORVVRIWKHFHUYL[DQG VXE WRWDOORVVLVIUHTXHQWO\HQFRXQWHUHGVR WKDWDOVRWKHFDQDOFDQQRWEHLGHQWLILHGHYHQWKRXJKWKHSDWLHQWLVPHQVWUXDWLQJ LIWKHUHLVWRWDOREOLWHUDWLRQRIWKHFHUYLFDOFDQDOVHFRQGDU\DPHQRUUKHDZLWKRUZLWKRXW FU\SWRPHQRUUKHDLVIRXQG WUDXPDWRDQGWLVVXHORVVRIWKHHQGRPHWULXPPD\OHDGWRV\QHFKLDDQGVHFRQGDU\ DPHQRUUKHD WKRXJK VXE WRWDO ORVV RI WKH XWHUXV LV YHU\ UDUH WKLV LVGLIIHUHQW IURP VHFRQGDU\DPHQRUUKHDGXHWRH[FHVVLYHEORRGORVV VKHHKDQV\QGURPH  levator ani musculature WKHUHPD\EHYDULDEOHDPRXQWVRIWLVVXHORVVRIWKHSXERFRFF\JHXVREWXUDWRFRFF\JHXV DQG LVFKLR FRFF\JHXVPXVFOHVDORQJWKHDUFXVWHQGLQHXVRIOHYDWRUDQLPXVFOH LWLVWKHFHSKDODGSDUWRIWKHVHPXVFOHVZLWKLWVRULJLQWKHDUFXVWHQGLQHXVRIWKHOHYDWRU DQLPXVFOHVatlamZKLFKLVDIIHFWHGZKLOVWWKHFDXGDGSDUWZLWKLWVLQVHUWLRQLQWROHYDWRU SODWHDQGFRFF\[LVVWLOOLQWDFW WKLVLVDOZD\VIRXQGLQWKHFLUFXPIHUHQWLDOILVWXODVDQGPD\IUHTXHQWO\OHDGWRDYDJLQD VWULFWXUHPRVWO\RIWKHSRVWHULRUDQGODWHUDOYDJLQDZDOOVEXWDOVRFLUFXODUDWWKHGLVWDO HGJHRIWLVVXHORVVDWWKHMXQFWLRQZLWKWUDXPDWL]HGWLVVXHZKLFKKDV³KHDOHGRII´ZLWK VFDUULQJDQGGLVWDOYDJLQDVWHQRVLV LIWKHUHLVPDMRUORVVRIWKHOHYDWRUDQLPXVFOHUHVXOWLQJLQEDUHERQHVLWGRHVQRWPDNH VHQVHWRLQVWUXFWSDWLHQWVLQWKHXVHRISHOYLVIORRUPXVFOHH[HUFLVHVLILQFRQWLQHQFH obturator internus muscle and obturator membrane LQIUHTXHQWO\WLVVXHORVVRIWKHREWXUDWRULQWHUQXVPXVFOHREWXUDWRUPHPEUDQHLVVXFK WKDWWKHREWXUDWRUIRUDPHQLV³HPSW\´DQGDILQJHUFDQEHSDVVHGWKURXJKWKLVIRUDPHQ IURPWKHLQVLGHWRWKHRXWVLGHWKLVPD\LQWHUIHUHZLWKH[RURWDWLRQDQGDEGXFWLRQRIWKH KLSMRLQWDQGXSSHUOHJ piriformis muscle WKHRUHWLFDOO\WKHUHPD\EHWUDXPDWRWKHSLULIRUPLVPXVFOHZKLFKPD\LQWHUIHUHZLWKH[R UDWLRQRIWKHKLSMRLQWDVZHOO perineal body LQVSKLQFWHUDQLUXSWXUHWKHUHLVGLVUXSWLRQRISHULQHDOERG\DVZHOO bulbospongiosus muscles LIWKHSHULQHDOERG\KDVEHHQGLVUXSWHGWKHSRVWHULRUXQLRQRIWKHEXOERVSRQJLRVXV PXVFOHVLVGLVUXSWHGDVZHOOVLQFHWKHPXVFOHVUDGLDWHLQWRWKHSHULQHDOERG\

37 transversus perinei muscles LIWKHSHULQHDOERG\KDVEHHQGLVUXSWHGWKHXQLRQRIWKHWUDQVYHUVXVSHULQHLPXVFOHVLV GLVUXSWHGDVZHOOVLQFHWKH\UDGLDWHLQWRWKHSHULQHDOERG\ pubis bones and pubis symphysis LIWKHUHLVPDMRUWLVVXHORVVRIWKHOHYDWRUDQLPXVFOH LQWHUQDOREWXUDWRUPXVFOH WKLV UHVXOWVLQEDUHSXELVERQHVZLWKORVVRISXELVERQHSHULRVWDQGSXELVV\PSK\VLVFDUWL ODJHWKRXJKVRPHWLPHVWKHUHLVVXEWRWDOORVVRIWKHSXELVV\PSK\VLVFDUWLODJHFRPSOHWH V\PSK\VLRO\VLVZLWKGHKLVFHQFHGLVORFDWLRQKDVneverEHHQHQFRXQWHUHG pubocervical musculofascia WKHUHLVDOZD\VWLVVXHORVVRIWKHSXERFHUYLFDOIDVFLDLQYYIZKLFKPD\EHFRPELQHGZLWK ORVVRIRWKHULQWUDSHOYLFFRQQHFWLYHWLVVXHVDQGOLJDPHQWVLQWKHFLUFXPIHUHQWLDOILVWXODV WKHSDUDXUHWKUDDUFXVWHQGLQHXVIDVFLDHatfKDVEHHQORVWELODWHUDOO\DVZHOO WKHDQWHULRUSDUWRIWKHSXERFHUYLFDOIDVFLDWRJHWKHUZLWKLWVELODWHUDOFRQQHFWLRQWRWKH SDUDXUHWKUDDUFXVWHQGLQHXVIDVFLDHVHFXUHVVWDELOL]HVWKHXUHWKUDLQLWVDQDWRPLFSRVL WLRQVRWKDWWKHXUHWKUDFDQH[HUWLWVSK\VLRORJLFFRQWLQHQFHFORVLQJDFWLRQ WKLVPHFKDQLVPKDVWREHFKHFNHGIRUV\VWHPDWLFDOO\DQGLIGHIHFWLYHUHSDLUHGZLWKJUHDW FDUHLQRUGHUWRSUHYHQWSRVWUHSDLUXULQHLQWULQVLFVWUHVVLQFRQWLQHQFH arcus tendineus fasciae atf and arcus tendineus of levator ani muscle atlam WUDXPDWRWKHDUFXVWHQGLQHXVIDVFLDH DWI DQGWRWKHDUFXVWHQGLQHXVRIWKHOHYDWRUDQL PXVFXODWXUH DWODP DUHIUHTXHQWO\IRXQGVLQFHWKLVLVH[DFWO\DORQJWKHSHOYLVLQOHW ZKHUHWKHSUHVVXUHLVEHLQJH[HUWHGGXULQJSURORQJHGREVWUXFWHGODERU LQH[WHQVLYHWUDXPDERWKDUFLWHQGLQHLPD\EHWRWDOO\ORVWIURPSDUDXUHWKUDOO\XSWRWKH LVFKLXPVSLQHVLIWKLVLVIRXQGLWLVDOZD\VLQFRPELQDWLRQZLWKPDMRUORVVRIWKHSXERFHU YLFDOPXVFXORIDVFLDZLWKWLVVXHORVVRIWKHSXERFRFF\JHXVREWXUDWRFRFF\JHXVDQGRU LVFKLR FRFF\JHXVPXVFOHV pubourethral ligaments IUHTXHQWO\WKHUHLVWLVVXHORVVRIWKHLQWHUPHGLDWHDQGSRVWHULRUSXERXUHWKUDOOLJDPHQWV ZKLOVWORVVRIWKHDQWHULRUSXERXUHWKUDOOLJDPHQWVLVVHOGRPLIWKHUHLVDFLUFXPIHUHQWLDO ILVWXODLWPD\EHWRWDO broad, cardinal and sacrouterine ligaments LQH[WHQVLYHILVWXODVZLWKDFLUFXPIHUHQWLDOGHIHFWWKHUHPD\EHWUDXPDWRWKHEURDG FDUGLQDODQGVDFURXWHULQHOLJDPHQWVUHVXOWLQJLQSURODSVHRIFHUYL[DQGXWHUXV KHUHWKHUHLVPDMRUWLVVXHORVVRIWKHSHOYLVFRQQHFWLYHWLVVXHFRPELQHGZLWKPDMRUORVV RIWKHHQGRSHOYLFGLDSKUDJPUHVXOWLQJLQDQHPSW\SHOYLV RQWKHRWKHUKDQGWUDXPDDWWKHSRVWHULRULQOHWPD\OHDGWRVFDUULQJZLWKSUR[LPDOIL[D WLRQRIWKHFHUYL[RQWRLWVVXUURXQGLQJVHVSHFLDOO\DIWHUFHVDUHDQVHFWLRQDQGWKHQRQ FRXJKWKHFHUYL[PRYHVparadoxicallyFHSKDODGWRZDUGVLQWRWKHDEGRPLQDOFDYLW\WKLV PHFKDQLVPPD\EHUHVSRQVLEOHIRUEUHDNGRZQDIWHUILVWXODUHSDLU sacrospinous and sacrotuberous ligaments LIWKHSUHVVXUHLVH[HUWHGDWWKHSRVWHULRUSDUWRIWKHSHOYLVRXWOHWWKHVDFURVSLQRXV OLJDPHQWPD\EHWUDXPDWL]HGPRVWO\DWLWVMXQFWLRQZLWKWKHLVFKLXPVSLQHWKHRUHWLFDOO\ DOVRWKHVDFURWXEHURXVOLJDPHQWPD\EHWUDXPDWL]HG vascular and lymphatic tissue LQWKHXUHWKURYHVLFRYDJLQDOILVWXODVZLWKFLUFXPIHUHQWLDOGHIHFWWKHUHLVWUDXPDWRDQG ORVVRIWKHSUHYHVLFDOYDVFXODUSOH[XVDQGPDMRUKHPRUUKDJHLVQRWHQFRXQWHUHGDWFLU FXPIHUHQWLDOGLVVHFWLRQRIWKHEODGGHUIURPWKHV\PSK\VLVWKHUHPXVWEHWUDXPDWR RWKHUYDVFXODUVWUXFWXUHVDQGWRWKHO\PSKDWLFWLVVXHVDVZHOO vagina stricture, stenosis, shortening and atresia WLVVXHORVVWRJHWKHUZLWKWUDXPDRIWKHLQWUDSHOYLFVRIWWLVVXHVPD\³KHDORII´E\YDU\LQJ GHJUHHVRIVFDUULQJUHVXOWLQJLQYDU\LQJGHJUHHVRIYDJLQDVWULFWXUHYDJLQDVWHQRVLV YDJLQDVKRUWHQLQJRUHYHQYDJLQDDWUHVLD

38 empty pelvis with bare bones LIWKHUHLV VXE WRWDOORVVRIWKHLQWUDSHOYLFVRIWWLVVXHVWKHUHLVQRWLVVXHOHIWWR³KHDO´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intrapelvic sciatic/peroneal nerve trauma resulting in foot drop WKHVFLDWLFQHUYHRULWVOXPERVDFUDOSOH[XVPD\EHFRPSUHVVHGEHWZHHQWKHKDUGIHWDO VNXOODQGERQ\PDWHUQDOSHOYLVUHVXOWLQJLQPLQRUWRWRWDOIXQFWLRQORVVRIWKHSHURQHXV QHUYHEHLQJSDUWRIWKHLQWUDSHOYLFVFLDWLFQHUYH WKHLQFLGHQFHRISHURQHXVQHUYHWUDXPDLQWKHREVWHWULFILVWXODLVKLJKVLQFHVLJQVRILW DUHIRXQGLQRYHURIWKHSDWLHQWVZKRSUHVHQWZLWKLQPRQWKVDIWHUFKLOGELUWKDQG WKHUHIRUHLWVKRXOGEHSDUWRIWKHURXWLQHH[DPLQDWLRQ VLQFHZHFDQQRWLQIOXHQFHQHUYHKHDOLQJZHFDQRQO\ZDLWIRUVSRQWDQHRXVUHFRYHU\RU LPSURYHPHQWZKLFKPD\WDNHXSWR\HDUVDQGRFFXUVLQRYHURIWKHSDWLHQWV WKHUHPD\EHWUDXPDWRWKHRWKHUSDUWVRIWKHVFLDWLFQHUYHDVZHOOWKRXJKWKLVKDVQRW EHHQV\VWHPDWLFDOO\H[DPLQHG pudendal nerve/sacral plexus trauma WKHVDFUDOSOH[XVPD\EHFRPSUHVVHGEHWZHHQWKHKDUGIHWDOVNXOODQGPDWHUQDOERQ\ SHOYLVUHVXOWLQJLQaDWRQLFEODGGHUZLWKRYHUIORZLQFRQWLQHQFHZLWKOHDNLQJXULQHb PLQRURUPDMRUVWUHVVLQFRQWLQHQFHZLWKOHDNLQJXULQHc.VSKLQFWHUDQLSDUDO\VLVZLWK VWRROIODWXVLQFRQWLQHQFHdXQLELODWHUDOVDGGOHDQHVWKHVLDRIYXOYDSHULQHXPEXWWRFNV DQGHYHQWXDOO\XOFHUDWLRQGXHWRDQHVWKHVLD WKHUHIRUHURXWLQHH[DPLQDWLRQRIWKHREVWHWULFILVWXODSDWLHQWVVKRXOGLQFOXGHPHDVXULQJ EODGGHUFDSDFLW\ELODWHUDOWHVWLQJRIDQDOVSKLQFWHUUHIOH[DQGLIWKLVLVQHJDWLYHVHQVLWL YLW\WHVWLQJRIYXOYDSHULQHXPEXWWRFNVIRUVDGGOHDQHVWKHVLD WKRXJKVDFUDOSOH[XVWUDXPDLVUHJXODUO\HQFRXQWHUHGLPPHGLDWHO\IROORZLQJREVWUXFWHG ODERUXVXDOO\LWKHDOVVSRQWDQHRXVO\DQGPRVWSDWLHQWVKDYHQRFRPSODLQWVDIWHU ZHHNVKRZHYHUUDUHO\SDWLHQWVDUHHQFRXQWHUHGZKRKDYHWKHFRPELQDWLRQRIDOOWKHVH OHVLRQVORQJHUWKDQ\HDUVDQGWKHQZHKDYHQRWKLQJWRRIIHU anesthesia of the vagina WKLVLVPRUHRUOHVVDSK\VLRORJLFSKHQRPHQRQGXULQJDIWHUFKLOGELUWKDQGODVWVVRPH ZHHNVDIWHUZDUGVSUREDEO\GXHWRWUDXPDWRWKHDOUHDG\VSDUVHQHUYHHQGLQJVLQWKH YDJLQDZDOOV WKLVH[SODLQVZK\LQDVHOHFWHGJURXSRISDWLHQWVSULPDU\VXWXULQJFDQEHSHUIRUPHGZLWK H[FHOOHQWUHVXOWV 

39 005 QHXURORJLFOHVLRQVGXHWRHFODPSVLD mental confusion WKLVLVHQFRXQWHUHGUHJXODUO\DQGQRUPDOO\KHDOVZLWKLQPRQWKV stroke (cerebrovascular accident) WKRXJKDFWXDOO\QRWFDXVHGE\REVWUXFWHGODERUteenageSDWLHQWVZHUHWUHDWHGZKR SUHVHQWHGZLWKDQREVWHWULFILVWXODDQGKDGH[SHULHQFHGDVWURNHGXHWRK\SHUWHQVLRQ HFODPSVLD GXULQJREVWUXFWHGODERUUHVXOWLQJLQIDVFLDOLVSDUHVLVZLWKVOXUUHGVSHHFKDQG FRQWUDODWHUDOSDUHVLVRIWKHOLPEVWKHLUUHFRYHU\ZDVYHU\VORZDQGLQFRPSOHWH transient blindness D\HDUROGJLUOZDVWUHDWHGE\FDWKHWHUDWGD\VSRVWSDUWXPZLWKDQREVWHWULFXULQH ILVWXODDQGVHYHUHO\LPSDLUHGYLVLRQGXHWRHFODPSVLDZKLFKUHFRYHUHGVSRQWDQHRXVO\ RYHUWKHZHHNVRIWUHDWPHQWWKLVVHHPVWREHQRWXQFRPPRQLQ\RXQJSDWLHQWVZLWK HFODPSVLDLQQRUWKHUQQLJHULD

006V\VWHPLFOHVLRQVGXHWRSURORQJHGREVWUXFWHGODERU SRRUJHQHUDOKHDOWKDQGHYHQFDFKH[LDPD\EHHQFRXQWHUHGZKLFKLVGXHWRWKHDPRXQW RI HQHUJ\ FRQVXPHG IURP ZKLFK VRPH SDWLHQWV HYHQ GLH SRVW SDUWXP KLJKSURWHLQ DOLPHQWDWLRQLVQHFHVVDU\

007V\VWHPLFOHVLRQVGXHWRH[FHVVLYHEORRGORVV VHYHUHDQHPLDLVIUHTXHQWO\IRXQGDQGWKHQRUDORUV\VWHPLFKHPDWLQLFVRUHYHQEORRG WUDQVIXVLRQVDUHLQGLFDWHGSDWLHQWVPD\GLHIURPWKLVDVZHOOSRVWSDUWXP LIWKHUHKDVEHHQH[FHVVLYHEORRGORVVVHFRQGDU\DPHQRUUKHDPD\GHYHORS VKHHKDQ V\QGURPH 

008ILVWXODDPHQRUUKHD ILVWXODUHODWHGVHFRQGDU\DPHQRUUKHDHLWKHUGXHWRORFDOHQGRPHWULXPWUDXPDREOLWH UDWLRQRIFHUYL[FDQDORUHQGRFULQRORJLFDOO\LVIRXQGLQRQO\RIWKHSDWLHQWVLIWKH ILVWXODGXUDWLRQLVRQH\HDURUORQJHU FU\SWRPHQRUUKHDPD\EHIRXQGLIWKHUHLVWRWDOREOLWHUDWLRQRIWKHFHUYL[FDQDO

009OHVLRQVGXHWRFRQWLQXRXVXULQHOHDNDJH LQDOPRVWDOOSDWLHQWVDPPRQLDGHUPDWLWLVDURXQGWKHYXOYDGHYHORSVGXHWRWKHFRQWLQX RXVOHDNLQJRIXULQHLQVRPHSDWLHQWVLWPD\EHYHU\DJJUHVVLYHDQGLIORQJVWDQGLQJLW PD\EHOHDWKHUOLNH FDXVDOWUHDWPHQWLVE\FORVXUHRIWKHILVWXODDQGLIQHFHVVDU\WUHDWPHQWRIWKHSRVWUHSDLU LQFRQWLQHQFH

010OHVLRQVGXHWRUHVWULFWLRQRIRUDOIOXLGLQWDNH LIWKHXULQHOHDNDJHODVWVIRUVRPHWLPHWKHZRPDQUHVWULFWVKHUIOXLGLQWDNHZKLFKPD\ UHVXOWLQUHSHDWDVFHQGLQJXULQDU\WUDFWLQIHFWLRQVZLWKLQWKHHQGDVKUXQNHQEODGGHUDQG VKHPD\DOVRGHYHORSVWRQHVLQWKHEODGGHUDQGRUYDJLQDDVZHOOWKHRIIHQVLYHRGRU EHFRPHVZRUVHZKLOVWXURVHSVLVLVUDUH DVFHQGLQJXULQDU\WUDFWLQIHFWLRQVPD\OHDGWRK\GURXUHWHUVDQGK\GURQHSKURVWKRXJK WKLVLVDUDUHILQGLQJGXULQJRSHUDWLRQDQGWRLPSDLUHGNLGQH\IXQFWLRQ WKHUHIRUHLWLVRIXWPRVWLPSRUWDQFHWRUHKDELOLWDWHWKHSDWLHQWLQDEXQGDQWGULQNLQJRWKHU ZLVHQRWKLQJFDQEHGRQHIRUKHU

40 011VH[FRQGLWLRQRIWKHLQIDQWERUQPDOHIHPDOHUDWLR WKHmale:femaleVH[UDWLRLV2:1ZKLFKFDQRQO\EHSDUWLDOO\H[SODLQHGE\WKHKHDYLHU ZHLJKWRIWKHPDOHLQIDQWHYHQLIFRPELQHGZLWKWKHQDWXUDOSK\VLRORJLFUDWLRRIPDOH DJDLQVWIHPDOHOLYHLQIDQWVDWELUWK KRZHYHUWKHUHPXVWEHDQRWKHUPHFKDQLVPLQYROYHGZKLFKFRQWLQXHVWRHOXGHWKH DXWKRUVLQFHKHGHVFULEHGWKLVUDWLRLQ SKGWKHVLV  WKHWUDXPDRIREVWUXFWHGODERULVVXFKWKDWRIWKHLQIDQWVGLHLQVLGHWKHPRWKHURU LPPHGLDWHO\XSRQELUWK

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

GLVFXVVLRQ WKHUHLVDQLPPHQVHYDULHW\QRWRQO\RIWKHWUDXPDWRWKHEODGGHUDQGRUUHFWXPOHDGLQJ WRDILVWXODEXWDOVRRIWKHDGGLWLRQDOWUDXPDWRRWKHULQWUDSHOYLFVWUXFWXUHVVXFKDVFRQ QHFWLYHWLVVXHOLJDPHQWVPXVFOHVEORRGYHVVHOVO\PSKDWLFYHVVHOVDQGWKHYDJLQD ZDOOVDQGRIWKHVXUJLFDOWUDXPDIURPSUHYLRXVUHSDLUV WKHRUHWLFDOO\WKHWUDXPDRISURORQJHGREVWUXFWHGODERUPD\UHVXOWLQWLVVXHORVVUDQJLQJ IURPRQHFHOOWR VXE WRWDOORVVRIDOOWKHLQWUDSHOYLFVRIWWLVVXHV WKHUHDUHLQWUDSHOYLFYDJLQDOORFDOH[WUDYDJLQDOQHXURORJLFXULQHLQGXFHGDQGV\VWHPLF OHVLRQVLQDQLPPHQVHYDULHW\HLWKHULVRODWHGRULQWRWDOFRPELQDWLRQ WKHUHDUHQRLGHQWLFDOILVWXODVDQGHDFKILVWXODFRQVWLWXWHVDXQLTXHHQWLW\LQQHHGRILWV RZQFXVWRPL]HGDSSURDFK WKRXJKWKHPHGLFDODVSHFWVRIWKHREVWHWULFILVWXODDUHDOUHDG\KHDUWEUHDNLQJWKHIDU UHDFKLQJVRFLDOLPSOLFDWLRQVFRQVWLWXWHDGLVDVWHUHVSHFLDOO\FRQVLGHULQJWKHIDFWWKDWLQ QRUWKHUQQLJHULDRIWKHSDWLHQWVDUH\RXQJHUWKDQ\HDUVDQGKDYHWKHLUZKROH DGROHVFHQWDQGDGXOWOLIHLQIURQWRIWKHPRIWKHSDWLHQWVDUHHYHQ\RXQJHUWKDQ \HDUV LQRUGHUWRSODQDQGH[HFXWHUHFRQVWUXFWLYHREVWHWULFILVWXODVXUJHU\LWLVRIXWPRVWLPSRU WDQFHWRH[DPLQHWKHSDWLHQWV\VWHPDWLFDOO\DQGWRDVVHVVDOOWKHGLIIHUHQWOHVLRQVSUH DQGLQWUDRSHUDWLYHO\VSHFLDODWWHQWLRQKDVWREHJLYHQWRWKHLQYROYHPHQWRIWKHXULQH FRQWLQHQFHFORVLQJPHFKDQLVPVLQFHFORVXUHRIWKHILVWXODLVRQO\HIIHFWLYHLIWKHSDWLHQW EHFRPHVFRQWLQHQWDVZHOO

41 FRQFOXVLRQ

WKHREVWHWULFILVWXODFRQVWLWXWHVDFRPSOH[WUDXPDZLWKDQLPPHQVHYDULHW\WKHRUHWLFDOO\ IURPRQHFHOOORVVWRWRWDOORVVRIWKHGLIIHUHQWLQWUDSHOYLFVWUXFWXUHVLQFRPELQDWLRQZLWK ORFDO H[WUDYDJLQDO OHVLRQV QHXURORJLF OHVLRQV XULQH LQGXFHG OHVLRQV DQG V\VWHPLF OHVLRQVZLWKIDUUHDFKLQJVRFLDOLPSOLFDWLRQVDPHGLFDOFDODPLW\DQGVRFLDOGLVDVWHU

WKHUHIRUHWKHUHSDLURIDQREVWHWULFILVWXODPD\EH³VLPSOH´GLIILFXOWKLJKO\FRPSOLFDWHGRU HYHQLPSRVVLEOHDQGUHTXLUHVWKRURXJKWKHRUHWLFDONQRZOHGJHRIDQGDPSOHSUDFWLFDO H[SHULHQFHLQWKHREVWHWULFILVWXODDQGSURIRXQGXQGHUVWDQGLQJRIWKHXULQHFRQWLQHQFH FORVLQJPHFKDQLVPDQGSHOYLF IORRU DQDWRP\LQWKHIHPDOHWRJHWKHUZLWKH[SHUWVXUJL FDOVNLOOV

DFWXDOO\WKHUHDUHQRVLPSOHUHSDLUVLWRQO\PD\ORRN³VLPSOH´LQWKHKDQGVRIWKHIHZ KLJKO\H[SHULHQFHGILVWXODVXUJHRQV

WKRXJKQRUPDOO\VRPHWKLQJFDQEHGRQHLQLWVH[WUHPHIRUPWKHZRPDQHQGVXSZLWKD FORDFDLQDQHPSW\SHOYLVIRUZKLFKQRWKLQJFDQEHGRQHDQGVKHLVFULSSOHGIRUOLIH SK\VLFDOO\VRFLDOO\HPRWLRQDOO\DQGPHQWDOO\DQGVKHZLOOQHYHUDJDLQEHDQRUPDO ZRPDQ

to learn a trick is not enough

one needs full understanding of the anatomy and physiology

one has to know exactly what has been lost

only then

with expert surgical skills

one may be able to handle the obstetric fistula

with care

to full satisfaction of

the patient and the surgeon

42 QHXURORJLFWUDXPDGXHWRREVWUXFWHGODERU

, LQWUDSHOYLFSHURQHXVQHUYHWUDXPDZLWKIRRWGURS

WKHVFLDWLFQHUYHRULWVOXPERVDFUDOSOH[XVPD\EHFRPSUHVVHGEHWZHHQWKHKDUGIHWDO VNXOODQGERQ\PDWHUQDOSHOYLVUHVXOWLQJLQPLQRUWRWRWDOIXQFWLRQORVVRIWKHSHURQHXV QHUYHEHLQJSDUWRIWKHLQWUDSHOYLFVFLDWLFQHUYH

VLQFHWKHSHURQHXVQHUYHLVVHUYLQJWKHPPWLELDOLVDQWHULRUH[WHQVRUKDOOXFLVORQJXV H[WHQVRUKDOOXFLVEUHYLVH[WHQVRUGLJLWRUXPORQJXVH[WHQVRUGLJLWRUXPEUHYLVSHURQHXV ORQJXVSHURQHXVEUHYLVDQGSHURQHXVWHUWLXVWKLVZLOOUHVXOWLQ SDUWLDO DWURSK\RIWKHVH PXVFOHVZLWKZHDNQHVVRUORVVRIGRUVLIOH[LRQDQGHYHUVLRQRIWKHIRRW

LQLWVH[WUHPHIRUPWKHIRRWLVLQLQYHUVLRQSODQWLIOH[LRQDQGLIORQJVWDQGLQJWKHVROHXV JDVWURFQHPLXVPXVFOHVZLWKDFKLOOHVWHQGRQZLOOVKRUWHQDQGFRQWUDFWHVSHFLDOO\ZKHQ WKH SDWLHQW LV LPPRELOL]HG LQ WKH HQG LW ZLOO EHFRPH D IL[HG LQYHUVLRQSODQWLIOH[LRQ FRQWUDFWXUHRIWKHDQNOHLIQRWKLQJLVGRQH

WKHLQFLGHQFHRISHURQHXVQHUYHWUDXPDLQWKHREVWHWULFILVWXODLVKLJKVLQFHVLJQVRILW DUHIRXQGLQVRPHRIWKHSDWLHQWVZKRSUHVHQWZLWKLQPRQWKVDIWHUFKLOGELUWKDQG WKHUHIRUHLWVKRXOGEHSDUWRIWKHURXWLQHH[DPLQDWLRQ

WKHGHJUHHRIWUDXPDLVHVWLPDWHGE\YROXQWDU\PXVFOHWHVWLQJYPWDFFRUGLQJWRWKH PHGLFDOUHVHDUFKFRXQFLORUPUFVFDOHZKHUHE\ JUDGH QRIXQFWLRQZKDWVRHYHU JUDGH RQO\DPXVFOHWZLWFK JUDGH PLQLPDOPRYHPHQW DFWLYHGRUVLIOH[LRQRIWRHV  JUDGH DFWLYHKDOIUDQJHGRUVLIOH[LRQRIIRRWLIJUDYLW\LVHOLPLQDWHG JUDGH DFWLYHIXOOUDQJHGRUVLIOH[LRQRIIRRWZLWKPLQRUPXVFOHZHDNQHVV JUDGH QRUPDO WKHJDLWLVVHYHUHO\DIIHFWHGLQJUDGHV  ZKLFKZLOOSURGXFHWKHW\SLFDOIRRWGURS ZDONLQJ

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

SUREDEO\WKHUHLVDQHVWKHVLDRIWKHDQWHURODWHUDODQGGRUVRODWHUDODVSHFWVRIWKHORZHU OHJDQGIRRWDVZHOOEXWZHKDYHQRWEHHQWHVWLQJWKLVE\VHQVLWLYLW\WHVWLQJVWVLQFHZH GRQRWHQFRXQWHUXOFHUDWLRQRIWKHVHDUHDV

 31 43 ,, VDFUDOSOH[XVWUDXPD

WKHVDFUDOSOH[XVPD\EHFRPSUHVVHGEHWZHHQWKHKDUGIHWDOVNXOODQGPDWHUQDOERQ\ SHOYLVUHVXOWLQJLQ

D DWRQLFEODGGHUZLWKRYHUIORZLQFRQWLQHQFHZLWKOHDNLQJXULQH

E PLQRURUPDMRUVWUHVVLQFRQWLQHQFHZLWKOHDNLQJXULQH

F H[WHUQDOVSKLQFWHUDQLSDUDO\VLVZLWKVWRROIODWXVLQFRQWLQHQFH

G VDGGOHDQHVWKHVLDRIYXOYDSHULQHXPEXWWRFNVXOFHUDWLRQGXHWRDQHVWKHVLD

WKHUHIRUHURXWLQHH[DPLQDWLRQRIWKHREVWHWULFILVWXODSDWLHQWVVKRXOGLQFOXGHPHDVXULQJ EODGGHU FDSDFLW\ ELODWHUDO WHVWLQJ RI DQDO VSKLQFWHU UHIOH[ DQG LI WKLV LV QHJDWLYH VHQVLWLYLW\WHVWLQJVWRIYXOYDSHULQHXPEXWWRFNVIRUVDGGOHDQHVWKHVLD

WKRXJKVDFUDOSOH[XVWUDXPDLVUHJXODUO\HQFRXQWHUHGLPPHGLDWHO\IROORZLQJREVWUXFWHG ODERUXVXDOO\LWKHDOVVSRQWDQHRXVO\DQGPRVWSDWLHQWVKDYHQRFRPSODLQWVDIWHU ZHHNV

KRZHYHUUDUHO\SDWLHQWVDUHHQFRXQWHUHGZKRKDYHWKHFRPELQDWLRQRIDOOWKHVHOHVLRQV ORQJHUWKDQ\HDUVDQGWKHQZHKDYHQRWKLQJWRRIIHU

,,, DQHVWKHVLDRIWKHYDJLQD

WKLVLVPRUHRUOHVVDSK\VLRORJLFSURFHVVGXULQJFKLOGELUWKDQGODVWVVRPHZHHNV DIWHUZDUGVSUREDEO\GXHWRWUDXPDWRWKHVSDUVHQHUYHHQGLQJVLQWKHYDJLQDZDOOV

WKLVH[SODLQVZK\LQDVHOHFWHGJURXSRISDWLHQWVSULPDU\VXWXULQJFDQEHSHUIRUPHGZLWK H[FHOOHQWUHVXOWV

,9 SRVW HFODPSVLDV\QGURPHPHQWDOFRQIXVLRQWUDQVLHQWEOLQGQHVVVWURNH

PHQWDOFRQIXVLRQDQGWUDQVLHQWEOLQGQHVVDUHHQFRXQWHUHGUHJXODUO\DQGLWPD\WDNH PRQWKVRUVRPHWLPHVORQJHUWRKHDOFRPSOHWHO\ WKRXJKDFWXDOO\QRWFDXVHGE\REVWUXFWHGODERUWHHQDJHSDWLHQWVZHUHWUHDWHGZKR KDGDQREVWHWULFILVWXODDQGKDGH[SHULHQFHGDVWURNHGXHWRK\SHUWHQVLRQ HFODPSVLD  GXULQJREVWUXFWHGODERUUHVXOWLQJLQIDFLDOLVSDUHVLVZLWKVOXUUHGVSHHFKDQGFRQWUDODWHUDO SDUDO\VLVRIWKHOLPEVWKHLUUHFRYHU\ZDVYHU\VORZDQGLQFRPSOHWH

WKHFRPSOH[WUDXPDRIWKHREVWHWULFILVWXOD

PRELOL]HWKHREVWHWULFILVWXODSDWLHQWLPPHGLDWHO\VLQFH ZDONLQJZLOOVWUHWFKWKHDIIHFWHGPXVFOHV DQGVWUHQJWKHQPXVFOHSRZHU

ZKHUHLVWKHUHVHDUFKLQWRHFODPSVLD

44  32 endopelvic diaphragm trauma

LQWURGXFWLRQ

WKHHQGRSHOYLFGLDSKUDJPDVSDUWRIWKHFRUSXVLQWUDSHOYLQXPRUFRQQHFWLYHWLVVXHERG\ RIWKHWHODXURJHQLWDOLVLVDQLPSRUWDQWG\QDPLFVWUXFWXUHDVFRQWUROOHGE\WKHDXWRQRPLF QHUYRXVV\VWHPYLDDFRPSOH[PHFKDQLVPRIUHIOH[DFWLRQ

VHFXULQJWKHRUJDQVLQWKHLUDQDWRPLFSRVLWLRQDQGDVVXFKFRQWULEXWLQJWRWKHGLIIHUHQW FRQWLQHQFHPHFKDQLVPV

HQGRSHOYLFGLDSKUDJP

IURPWKHSXELVERQHERGLHVDQWHULRUO\WRWKHVDFUXPSRVWHULRUO\DQGFLUFXPIHUHQWLDOO\ FRQQHFWHGWRWKHSHOYLVZDOOOLNHWKHVNLQRIDGUXPRUWUDPSROLQH

LWFRQVWLWXWHVDUHDOGLDSKUDJPZLWKWKHFHUYL[DVLWVFHQWHUZLWKDVPDOODQWHULRUPHGLDQ RSHQLQJIRUWKHXUHWKUDDQGDODUJHUSRVWHULRUPHGLDQRSHQLQJIRUWKHUHFWXP

DQGLVGLYLGHGLQWRWKHIROORZLQJPDLQO\VPRRWKPXVFOHFRPSRQHQWV pubovesical/posterior pubourethral ligaments (= muscles) pubocervical musculofascia arcus tendineus fasciae = atf cervix cardinal ligaments and broad ligaments sacrouterine ligaments = rectouterinus muscles rectovaginal fascia

PHFKDQLVPRISDWKRSK\VLRORJLFDFWLRQ

GXHWRGRZQZDUGLQWUDDEGRPLQDOSUHVVXUHE\WKHSUHJQDQWXWHUXVWKHORQJLWXGLQDOILEHUV RIWKHSXERFHUYLFDOPXVFXORIDVFLDHQGRSHOYLFGLDSKUDJPPD\VSOLWLQWKHPLGOLQH

GXULQJFKLOGELUWKLWVHOIWKHSUHVVXUHFKDQJHVIURPGRZQZDUGWRXSZDUGDQGVHPLFLUFXODU FRPSUHVVLRQDQGVKHDULQJRFFXUDWZKHUHWKHHQGRSHOYLFGLDSKUDJPSXERFHUYLFDOPXV FXORIDVFLDLVDWWDFKHGWRSXELVERQHVDQGDWI

LQSURORQJHGREVWUXFWHGODERUSUHVVXUHQHFURVLVPD\GHYHORSDQGOHDGWRDQDWRPLF WLVVXHORVVDWDQ\ORFDWLRQZLWKLQWKHHQGRSHOYLFGLDSKUDJP

WKHQWKHUHPD\EHGLUHFWWUDXPD SHQHWUDWLRQVXUJHU\ DQGWUDXPDGXHWRLQIHFWLRQ

45 GHIHFWVZLWKLQWKHHQGRSHOYLFGLDSKUDJP

WKHUHDUHWZRW\SHVRIGHIHFWVYL]GHIHFWVZLWKRXWDQGGHIHFWVZLWKDQDWRPLFWLVVXH

GHIHFWVZLWKRXWDQDWRPLFWLVVXHORVV

anterior defects ZLWKZHDNHQLQJRIWKHXULQHFRQWLQHQFHVXSSRUW E\WKLVPHFKDQLVPJHQXLQHRUSRVWUHSDLULQWULQVLFVWUHVVLQFRQWLQHQFHGHYHORSV

median longitudinal defects GHSHQGLQJXSRQLWVORFDWLRQWKHSRVWHULRUXUHWKUDEODGGHUEDVHPD\KHUQLDWHWKUXWKLV GHIHFWLQWRWKH]HURSUHVVXUHYDJLQDDQGHYHQWXDOO\SURODSVHWRWKHRXWVLGH

central defect WKHFHUYL[XWHUXVZLOOKHUQLDWHWKUXWKLVGHIHFWLQWRWKHYDJLQDDQGWKHQPD\SURODSVH XQRSSRVHGWRWKHRXWVLGHWKUXWKHKHUQLDSURQHRSHQLQJLQWKHSHOYLVIORRUGUDJJLQJWKH DQWHULRUYDJLQDZDOOZLWKLWOLNHLQWXVVXVFHSWLRQ

apical defect WKLVZLOOUHVXOWLQKHUQLDWLRQRIWKHLQWUDSHULWRQHDOFRQWHQWVLQWRWKH]HURSUHVVXUHYDJLQD

posterior defects WKLVZLOOUHVXOWLQKHUQLDWLRQRIWKHUHFWXPLQWRWKH]HURSUHVVXUHYDJLQDHVSHFLDOO\ZKHQ FRPELQHGZLWKSHULQHDOERG\GHIHFWV

lateral defects at atf WKLVZLOOUHVXOWLQORVVRIWRQXVRIWKHHQGRSHOYLFGLDSKUDJPUHVXOWLQJLQDQLQFUHDVHLQWKH FDXGDGFHSKDODGPRYHPHQWVEXWQRWLQKHUQLDWLRQSURODSVHRIDQRUJDQWKUXWKLVGHIHFW

lateral defects of the fascia sheath in between the atf and atlam WKLVZLOOUHVXOWLQPHGLDOGLVSODFHPHQWRIWKHDWIZLWKORVVRIWRQXVDQGK\SHUPRELOLW\RI WKHLQWUDSHOYLFXURJHQLWDOGLDSKUDJPEXWQRWLQKHUQLDWLRQSURODSVHRIDQRUJDQWKUXWKLV GHIHFW

other location GXHWRSHQHWUDWLQJWUDXPDRUIRUFHSVGHOLYHU\RUYDFXXPGHOLYHU\

GHIHFWVZLWKDQDWRPLFWLVVXHORVV

WKHH[WHQWDQGORFDWLRQRISUHVVXUHQHFURVLVOHVLRQVLQSURORQJHGREVWUXFWHGODERUPD\ EHIURPPLQLPDOWRH[WHQVLYHDQGIURPRQHORFDWLRQWRWKHRWKHULQDQHQGOHVVYDULDWLRQ ZKLFKPDNHVWKHREVWHWULFWUDXPDVRLQWULJXLQJ

circular punched out defects WKHVDPHVL]HDVWKHILVWXODRU VOLJKWO\ ELJJHUWKDQWKHILVWXOD

transverse curved defects ELJJHUWKDQWKHILVWXODZKHUHE\WKHILVWXODLVVRPHZKHUHZLWKLQWKLVGHIHFW quartercircular defects

46 ZLWKSDUWLDORUWRWDODQDWRPLFORVVRIDWIDQGDWODPDQGSRVVLEOHSDUWLDOORVVRIOHYDWRUDQL PXVFOHVREWXUDWRULQWHUQXVPXVFOHVDQGREWXUDWRUPHPEUDQH ZLWKILVWXODIRUPDWLRQDQGSRVVLEOHRSHQLQJRIWKHSDUDYHVLFDOVSDFHV semicircular defects ZLWKSDUWLDORUWRWDODQDWRPLFWLVVXHORVVRIDWIDQGDWODPDQGZLWKSDUWLDOWLVVXHORVVRI WKHOHYDWRUDQLPXVFOHVREWXUDWRULQWHUQXVPXVFOHVDQGREWXUDWRUPHPEUDQHHYHQWXDOO\ ZLWKEDUHERQHV ZLWKILVWXODIRUPDWLRQDQGRSHQLQJRIWKHSDUDYHVLFDOVSDFH

(sub)total pubocervical musculofascia loss UHJXODUO\ VXE WRWDOIDVFLDORVVZLWKH[WHQVLYHILVWXODIRUPDWLRQDQGDQWHULRUYDJLQDZDOO ORVVDQGWRWDOORVVRIDWIDQGDWODPDQG SDUWLDOH[WHQVLYH ORVVRIOHYDWRUDQLPXVFOHV REWXUDWRULQWHUQXVPXVFOHVDQGREWXUDWRUPHPEUDQHVLVIRXQGZLWKEDUHERQHVLQDVR FDOOHGempty pelvisZLWKFRPSOHWHO\RSHQSDUDYHVLFDOVSDFH

(sub)total endopelvic diaphragm loss IURPWLPHWRWLPH VXE WRWDOORVVRIWKHZKROHGLDSKUDJPPD\EHIRXQGZLWKH[WHQVLYH VRIWWLVVXHORVVUHVXOWLQJLQH[WHQVLYHXULQHVWRROILVWXODVDVFORDFD IRUWKHVHXQIRUWXQDWHZRPHQQRWKLQJFDQEHGRQHVXUJLFDOO\VSHDNLQJ

KRZHYHUDQDWRPLFWLVVXHORVVPD\DOVREHIRXQG

GXHWRsurgeryZKHUHE\WLVVXHLVH[FLVHG

RUGXHWRnecrotizing infectionsOLNHSRVWPHDVOHVQRPDYDJLQDH

UHFRQVWUXFWLYHVXUJHU\

LWLVLPSRUWDQWILUVWWRLGHQWLI\WKHUHDO H[WHQWRIWKH GHIHFW V DQGWKHQUHFRQVWUXFWWKH IXQFWLRQDODQDWRP\PHWLFXORXVO\XVLQJDXWRORJRXVVWUXFWXUHVVRWKDWQRUPDOSK\VLRORJ\ ZLOOEHHQVXUHGZKLOVW

VSHFLDODWWHQWLRQVKRXOGEHSDLGWRPDNHVXUHWKDWWKHSXERFHUYLFDOPXVFXORIDVFLDLV SURSHUO\ UH IL[HGWRWKHSDUDHXRSXELVERQHVDQGELODWHUDODWIDQGWKDWWKHFHUYL[LV SURSHUO\ UH DQFKRUHGZLWKLQWKHHQGRSHOYLFGLDSKUDJP

GLVFXVVLRQ

WKHREVWHWULFILVWXODLVRQO\SDUWRIDFRPSOH[REVWHWULFWUDXPDDQGRQO\E\UHSDLULQJDOO GHIHFWVLQRUGHUWRUHFRQVWUXFWWKHIXQFWLRQDOSHOYLVDQDWRP\EHWWHUSRVWUHSDLUUHVXOWVDUH HQVXUHGHVSHFLDOO\DVWRSRVWUHSDLUFRQWLQHQFH

47 urogenital and digestive prolapse mechanism of action

DVEDVHGRQLQWUDRSHUDWLYHILQGLQJV

introduction

VLQFHWKHYDJLQDLVDORZRU]HURSUHVVXUHRUJDQWKHYDJLQDFDQQRWKHUQLDWHLQWRLWV DGMDFHQWRUJDQVZLWKKLJK HU SUHVVXUHZKLOVWWKHVHKLJKSUHVVXUHRUJDQVFDQHDVLO\ KHUQLDWHLQWRWKHYDJLQDRQFHGHIHFWVGHYHORSZLWKLQWKHVHSDUDWLQJDQGVXSSRUWLQJ FRUSXVLQWUDSHOYLQXPVWUXFWXUHVLQEHWZHHQWKHVHRUJDQVDQGYDJLQD

RQFHWKHRUJDQVKHUQLDWHLQWRWKHYDJLQDWKH\FDQIXUWKHUSURODSVHXQRSSRVHGWRWKH RXWVLGHZKLOVWGUDJJLQJWKHYDJLQD ZDOO ZLWKLW

WKHGLVWDOHQGRUJDQVRIWKHXULQDU\WUDFWJHQLWDOWUDFWDQGGLJHVWLYHWUDFWWRJHWKHUZLWK WKHLUUHVSHFWLYHDQDWRPLFFRQWLQHQFHPHFKDQLVPDUHDQFKRUHGLQWRWKHSHULQHXPRXWOHW GLDSKUDJP

VRWKHVHHQGRUJDQVFDQRQO\SURODSVHWRWKHRXWVLGHE\NLQGRILQWXVVXVFHSWLRQIRU LQVWDQFHOLNHWRWDOFHUYL[XWHUXVSURODSVHWKUXWKHLQWURLWXV

WKHSHOYLVIORRUZLWKLWVODUJHKHUQLDSURQHRSHQLQJVFDQQHLWKHUSUHYHQWQRUVWRSWKLV SURFHVV

WKHZLGHUWKHSHOYLVWKHZLGHUWKHVSDQLQEHWZHHQLWVVLGHZDOOVDQGWKHPRUHFKDQFHRI GHYHORSLQJSURODSVH

FRQVLGHULQJDSXELFDUFK LQGLFDWLRQRISHOYLVZLGWK RIƒDVQRUPDODVFRUUHVSRQGLQJ ZLWKDQRUPDOZLGWKSHOYLV

DSXELFDUFKRIƒVHHPVWREHWKHFULWLFDOSRLQW

LQDOPRVWDOOWKHSDWLHQWVWKHDXWKRURSHUDWHGIRUVRPHNLQGRISURODSVHKHIRXQGDSXELF DUFKRI!ƒVLQFHKHVWDUWHGPHDVXULQJWKLVDUFK

WKLVZDVDOVRIRXQGLQSDWLHQWVZLWKJHQXLQHLQWULQVLFVWUHVVLQFRQWLQHQFHDQGLQSDWLHQWV ZLWKREVWHWULFDQWHULRUVSKLQFWHUDQLUXSWXUH

SURODSVH

KHUQLDWLRQRIWKHSRVWHULRUXUHWKUDLQWRWKHYDJLQDWKUXDPHGLDQGHIHFWZLWKLQWKHXUH WKURYDJLQDOIDVFLDDVPRVWDQWHULRUSDUWRIWKHHQGRSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJP

KHUQLDWLRQRIWKHSRVWHULRUEODGGHULQWRWKHYDJLQDWKUXDPHGLDQGHIHFWZLWKLQWKHSXER FHUYLFDOIDVFLDDVDQWHULRUSDUWRIWKHHQGRSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJP

48 cervix/uterus prolapse KHUQLDWLRQRIWKHFHUYL[XWHUXVLQWRWKHYDJLQDWKUXDFHQWUDOGHIHFWLQWKHHQGRSHOYLFXUR JHQLWRGLJHVWLYHGLDSKUDJP KHUQLDWLRQRILQWUDSHULWRQHDOFRQWHQWV LOHXP WKUXDGHIHFWZLWKLQWKHUHFWRYDJLQDOIDVFLD LQEHWZHHQWKHVDFURXWHULQHOLJDPHQWVDVPRVWSRVWHULRUSDUWRIWKHHQGRSHOYLFXUR JHQLWRGLJHVWLYHGLDSKUDJP KHUQLDWLRQRIWKHDQWHULRUUHFWXPWKUXDPHGLDQGHIHFWZLWKLQWKHUHFWRYDJLQDOIDVFLDDQG SHULQHDOERG\

WKHVHSURODSVHVPD\RFFXULVRODWHGRUFRPELQHGLQDQ\FRPELQDWLRQ prolapseWKUXDQXV LQWXVVXVFHSWLRQRIWKHUHFWXPWKUXDGHIHFWLYHDQDWRPLFVWRROFRQWLQHQFHPHFKDQLVP urethra caruncle LQWXVVXFHSWLRQRIXUHWKUDPXFRVDWKUXH[WHUQDOXUHWKUDRSHQLQJ

PHFKDQLVPRIDFWLRQ

WKHLQWDFWHQGRSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJPZLWKLWVVSHFLDOL]HGVWUXFWXUHVVWDEL OL]HVVHFXUHVWKHEODGGHUDQGXUHWKUDDQGWKHFHUYL[LQWKHLUYDULDEOHDQDWRPLFSRVLWLRQ DQGSUHYHQWVWKHLQWUDSHULWRQHDOFRQWHQWVIURPKHUQLDWLQJLQWRWKHYDJLQD

H[FHSWIRUWKHGLVWDOXUHWKURYDJLQDOIDVFLDZKHUHWKHILEHUVVHHPWREHWUDQVYHUVHWKH ILEHUVRIWKHSXERFHUYLFDOPXVFXORIDVFLDVHHPWREHORQJLWXGLQDO

WKHLUZHDNHVWSRLQWLVLQWKHPLGOLQH ZKHUHWKHVSDQLVWKHEURDGHVWDQGWKHSUHVVXUH WKHKLJKHVW ZKHUHGXHWRK\GURVWDWLFSUHVVXUHWKHORQJLWXGLQDOILEHUVPD\VWDUWWRGLYLGH VSOLWZKHUHE\WKHVHILEHUVUHWUDFW EL ODWHUDOO\DQGPHGLDQGHIHFW V ZLOOGHYHORS

WKHQGHSHQGLQJXSRQWKHSRVLWLRQRIWKHGHIHFWWKHSRVWHULRUXUHWKUDEODGGHUEDVH FHUYL[DQGRULQWUDSHULWRQHDOFRQWHQWV LOHXP KHUQLDWHWKUXWKLVGHIHFWLQWRWKH]HUR SUHVVXUHYDJLQDDVXUHWKURFHOHF\VWRFHOHFHUYL[SURODSVHRUHQWHURFHOH

LIQRWFRUUHFWHGWKHKHUQLDWHGRUJDQVPD\SURODSVHXQRSSRVHGWRWKHRXWVLGHWKUXWKH YDJLQDWKUXRSHQLQJVZLWKLQWKHSHOYLVIORRUGUDJJLQJWKHDQWHULRUYDJLQDZDOOZLWKWKHP E\LQWXVVXVFHSWLRQ

WKHPHFKDQLVPRIUHFWRFHOHLVDELWGLIIHUHQWVLQFHK\GURVWDWLFSUHVVXUHLVQRWLQYROYHG EXWLWLVE\REVWHWULFRURWKHUWUDXPDFDXVLQJDPHGLDQGHIHFWZLWKLQWKHUHFWRYDJLQDO IDVFLDDQGSHULQHDOERG\

WKHQWKHKLJKSUHVVXUH DQWHULRU UHFWXP ZDOO ZLOOKHUQLDWHWKUXWKLVGHIHFWLQWRWKH]HUR SUHVVXUHYDJLQDDQGPD\IXUWKHUSURODSVHXQRSSRVHGWRWKHRXWVLGHWKUXWKHRSHQLQJ LQWRWKHSHOYLVIORRUGUDJJLQJWKHSRVWHULRUYDJLQDZDOOZLWKLWE\LQWXVVXVFHSWLRQ

49 GLVFXVVLRQ

LWLVFUXFLDOWRXQGHUVWDQGWKDWWKHPHFKDQLVPRIDFWLRQLVE\GHIHFWVZLWKLQWKHPXVFXOR IDVFLDVWUXFWXUHVRIWKHFRUSXVLQWUDSHOYLQXPEHWZHHQWKHKLJK HU SUHVVXUHDGMDFHQW RUJDQVDQGWKH]HURSUHVVXUHYDJLQD

DQGDVVXFKWKHRUJDQVZLOOILUVWKHUQLDWHLQWRWKHYDJLQDRQO\DWDODWHUVWDJHWKH\PD\ VOLGHWKUXWKHYDJLQDDQGSURODSVHXQRSSRVHGWKUXWKHKHUQLDSURQHRSHQLQJ V LQWKH SHOYLVIORRUWRWKHRXWVLGHGUDJJLQJWKHYDJLQD ZDOO ZLWKWKHPDVLQWXVVXVFHSWLRQ

WKHVDPHDVZLWKILVWXODVZKHUHE\XULQHDQGRUVWRROZLOOOHDNIURPWKHKLJKSUHVVXUH EODGGHUUHVSHFWLYHO\KLJKSUHVVXUHUHFWXPILUVWLQWRWKH]HURSUHVVXUHYDJLQDDQGWKHQ IXUWKHUOHDNWKUXWKHYDJLQDWRWKHRXWVLGH

WKHQRWLRQWKDWWKHOHYDWRUDQLPXVFOHVSOD\DPDMRUUROHLQSUHYHQWLRQLILQWDFWDQGZHOO IXQFWLRQLQJDQGLQPHFKDQLVPRISURODSVHLIZHDNFDQQRWEHFRQILUPHG

WRWKHDXWKRULWORRNVIDUIHWFKHGVLQFHWKHUHLVQRZKHUHGLUHFWFRQWDFWEHWZHHQWKHVH RUJDQV ZDOO DQGWKHOHYDWRUDQLPXVFOHVQRWHYHQZKHQKHUQLDWHGSURODSVHG

FRQVLGHUWKHWXEHOLNHFRQILJXUDWLRQRIWKHSHOYLVVSDFHDQGDOOWKHGLIIHUHQWLQWUDSHOYLF VWUXFWXUHVEHWZHHQWKHSHOYLVIORRUDQGWKHRUJDQV

E\ZKDWPHFKDQLVPZRXOGWKHDFWLRQRIWKHOHYDWRUDQLPXVFOHVFRQWULEXWH

WKHGLDPHWHUUHFWDEHWZHHQWKHXQGHUVLGHRIV\PSK\VLVDQGWLSRIFRFF\[LVFP DQGWKHOHYDWRUDQLPXVFOHVDUHIXVHGDVOHYDWRUSODWHDWPLQLPDOO\FPIURPV\PSK\VLV DQG IL[HG WR FRFF\[DQRFRFF\JHDO OLJDPHQW DQG WKH GLVWDQFH IURP LVFKLDO VSLQH WR FRFF\[LVPLQLPDOO\FP

VRDWQRSRLQWLWLVSRVVLEOHWKDWWKHSRVWHULRUXQLRQRIWKHOHYDWRUDQLPXVFOHVFDQFRPH LQWRGLUHFWFRQWDFWZLWKWKHSRVWHULRUEODGGHUZDOOWKHFHUYL[WKHLQWUDSHULWRQHDOFRQWHQWV RUWKHDQWHULRUUHFWXPZDOOE\FRQWUDFWLRQRUDQ\WKLQJSK\VLRORJLF

LIWKHUHLVQRFRQWDFWKRZFDQWKHOHYDWRUPXVFOHVQRZSUHYHQWWKHGHYHORSPHQWRI GHIHFWVZLWKLQWKHPXVFXORIDVFLDVWUXFWXUHVEHWZHHQWKHRUJDQVDQGWKHYDJLQD

SURODSVHLVQRWWKUXWKHOHYDWRUDQLPXVFOHVDQGRWKHUSHOYLVIORRUVWUXFWXUHVEXWWKHSUR ODSVHLVWKUXGHIHFWVLQWKHHQGRSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJPGXHWRZKLFKWKH EODGGHUDQGRUFHUYL[DQGRULQWUDSHULWRQHDOFRQWHQWVDUHQRORQJHUVXSSRUWHGDQGVWDUW WRGHVFHQGKHUQLDWH

LIWKHUHLVKHUQLDWLRQWKHKHUQLDWHGRUJDQZLOOVOLGHXQRSSRVHGWKUXWKHYDJLQDGUDJJLQJ WKHYDJLQD ZDOO ZLWKLWDQGPD\SURODSVHWRWKHRXWVLGH

WKLVSURFHVVDOVRFDQQHLWKHUEHSUHYHQWHGQRUVWRSSHGE\WKHOHYDWRUDQLPXVFOHVRU RWKHUSHOYLVIORRUVWUXFWXUHVHLWKHUUHOD[HGRUFRQWUDFWHG

VLQFHWKHHQGRSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJPLVDOVRVXSSRUWLQJWKHIHPDOHDQDWR PLFXULQHFRQWLQHQFHPHFKDQLVPSURODSVHPD\EHDFFRPSDQLHGE\XULQHLQFRQWLQHQFHLI WKHGHIHFWUHVXOWVLQORVVRIVXSSRUW

50

KLVWRU\WDNLQJLQREVWHWULFILVWXODSDWLHQWV

KRZPDQ\GHOLYHULHV

KRZPDQ\DUHDOLYH

KRZORQJOHDNLQJXULQHVWRROV GD\VPRQWKV\HDUV

DIWHUZKLFKGHOLYHU\GLGLWVWDUW

ZKHQGLGLWVWDUWIROORZLQJODERU LPPHGLDWHO\RUKRZPDQ\GD\VODWHU

KRZPDQ\GD\VLQODERU

ZKHUHGLG\RXGHOLYHU DWKRPHRULQKRVSLWDO

FHVDUHDQVHFWLRQ \HVQR

VH[RILQIDQW ER\RUJLUO

FRQGLWLRQRILQIDQW VWLOOERUQDOLYHDQGGLHGODWHURUDOLYH

HFODPSVLD \HVQR

KRZORQJPDUULHG PRQWKV\HDUV

ZKHUHGLGPHQVWUXDWLRQVWDUW DWSDUHQWV RUDWKXVEDQG VKRPH

OLYLQJZLWKKXVEDQGRQVDPHFRPSRXQG\HVQR

VWLOOPHQVWUXDWLQJ \HVQR

IRRWGURS \HVQR

ZKLFKVLGH ULJKWDQGRUOHIW

IRUKRZORQJ PRQWKV\HDUV

OHDNLQJVWRROVDVZHOO \HVQR

KRZPDQ\WLPHVRSHUDWHG

JUDGLQJRIIRRWGURSDFFRUGLQJWRPHGLFDOUHVHDUFKFRXQFLORUPUFVFDOH  QRIXQFWLRQZKDWVRHYHU  RQO\DPXVFOHWZLWFK  PLQLPDOPRYHPHQW DFWLYHGRUVLIOH[LRQRIWRHV   DFWLYHKDOIUDQJHPRYHPHQWLIJUDYLW\LVHOLPLQDWHG  DFWLYHIXOOUDQJHPRYHPHQWZLWKRQO\VOLJKWPXVFOHZHDNQHVV  QRUPDO

 45 57

PDQDJHPHQWREVWHWULFXULQHILVWXOD

PDQDJHPHQWYYI

FODVVLILFDWLRQYYI

VXUJLFDOSULQFLSOHV

LPPHGLDWHPDQDJHPHQW

FDWKHWHUSURWRFRO

ILVWXODVIRUEHJLQQHUV

SRVWSDUWXPOHDNLQJZLWKRXWILVWXOD

SRVWUHSDLULQFRQWLQHQFH

WRWDOFHUYL[XWHUXVSURODSVH SUHLQWUDDQGSRVWRSHUDWLYHPDQDJHPHQWRIYYI

WKHILVWXODLVFORVHGGXULQJWKHVXUJLFDOSURFHVVRI UHFRQVWUXFWLQJ WKHIXQFWLRQDOSHOYLVDQDWRP\

WKHEHWWHUWKHRUJDQL]DWLRQRIWKHSUHRSHUDWLYHSUHSDUDWLRQRIWKHRSHUDWLRQWKHDWHU DQGRIWKHSRVWRSHUDWLYHFDUHWKHEHWWHUWKHRXWFRPHRIILVWXODVXUJHU\LQWHUPVRI FORVXUHDQGFRQWLQHQFHDQGWKHEHWWHUWKHFKDQFHRIPHGLFDOSK\VLFDOPHQWDODQG VRFLDOUHKDELOLWDWLRQ KRZHYHULWFDQQRWEHVWUHVVHGHQRXJKWKDWWKHZHDNHVWSRLQWRIILVWXODVXUJHU\LQWKH GHYHORSLQJZRUOGLVWKHSRRUQXUVLQJFDUH

ILUVWYLVLWRISDWLHQW H[WHQVLYHKLVWRU\ FOLQLFDOFKHFNXSZLWKYDJLQDOH[DPLQDWLRQ VSHFLDODWWHQWLRQWRRWKHUOHVLRQVGXHWRREVWUXFWHGODERUXOFHUVIRRWGURSHWF

SUHRSHUDWLYHSUHSDUDWLRQ RUDOKHPDWLQLFVDQGKLJKSURWHLQGLHWQRDQWLELRWLFV KLJKRUDOIOXLGLQWDNHRIDWOHDVWOLWHUVSHUGD\DOUHDG\SUHRSHUDWLYHO\ IXOOPRELOL]DWLRQLIQHHGHGZLWKVWLFN

ODERUDWRU\EORRGEDQNDQG;UD\V +E+WDQGVHUXPFUHDWLQLQH DEORRGEDQNLVFRPSOLFDWHG ;UD\VDUHQRWLQGLFDWHG

H[DPLQDWLRQ QRUPDOYDJLQDOH[DPLQDWLRQDWILUVWYLVLWDQGGD\EHIRUHRSHUDWLRQ HXD H[DPLQDWLRQXQGHUDQHVWKHVLD LVXWWHUO\QRQVHQVHLILWLVQRWIROORZHGXSLP PHGLDWHO\E\VXUJHU\LQWKHVDPHVHVVLRQ

WLPLQJRIILVWXODPDQDJHPHQW WKHPDQDJHPHQWKDVWRVWDUWWKHPRPHQWWKHOHDNLQJRIXULQHLVPDQLIHVW LIQRKHDOLQJE\FDWKHWHUWKHQIRUHDUO\FORVXUHDVVRRQDVZRXQGVDUHFOHDQ

HTXLSPHQW DZHOOIXQFWLRQLQJK\GUDXOLFRSHUDWLQJWDEOHZLWKƒLQFOLQDWLRQLVDPXVW

VSHFLDOVXUJLFDOLQVWUXPHQWV VHOIUHWDLQLQJ ZHLJKWHG DXYDUG VSHFXOXP ORQJ YDJLQDO LQVWUXPHQWV VKDUSO\ FXUYHGWKRUHNVFLVVRUVVKDUSGHVFKDPSVDQHXU\VPQHHGOH

VXWXULQJPDWHULDOV SRO\JO\FROLFDFLGDQGQ\ORQH[SHQVLYHDWUDXPDWLFVXWXULQJPDWHULDOVDUHQRWUH TXLUHG

DQHVWKHVLD VSLQDODQHVWKHVLDZLWKDORQJDFWLQJDJHQWHJK\SHUEDULFEXSLYDFDLQH

60  48 PDQSRZHU RQO\WKHVXUJHRQDQGRQHLQVWUXPHQWDWLQJRSHUDWLRQWKHDWHUQXUVH RQHUHWUDFWRULQVLGHWKHYDJLQDLVDOUHDG\DFURZG

RSHUDWLRQURXWH WKHYDJLQDLQW\SH,WKURXJKW\SH,,%EILVWXODVH[FHSWLRQDOO\DQGIRUW\SH,,,ILVWXODV RWKHUURXWHVPD\EHQHFHVVDU\

SRVLWLRQRQWKHRSHUDWLRQWDEOH H[DJJHUDWHGOLWKRWRP\SRVLWLRQZLWKWKHOHJVIOH[HGDQGVOLJKWO\DEGXFWHGLQWKH OHJKROGHUV

DFFHVVLELOLW\ E\PHGLDQXQLRUELODWHUDOHSLVLRWRPLHV

H[DPLQDWLRQXQGHUDQHVWKHVLD WKLVLVGRQHE\DQ\VXUJHRQIRUZKDWHYHUVXUJHU\DWWKHEHJLQQLQJRIDQ\RSH UDWLRQWKHILVWXODLVFODVVLILHGDQGDILQDOGHFLVLRQWDNHQKRZWRWDFNOHWKLVVSHFLILF ILVWXOD

FODVVLILFDWLRQRIILVWXODVDFFRUGLQJWRDQDWRPLFSK\VLRORJLFORFDWLRQ SKGWKHVLV  , QRWLQYROYLQJWKHFORVLQJPHFKDQLVP ,, LQYROYLQJWKHFORVLQJPHFKDQLVP $ZLWKRXW VXE WRWDOXUHWKUDLQYROYHPHQW DZLWKRXWFLUFXPIHUHQWLDOGHIHFW EZLWKFLUFXPIHUHQWLDOGHIHFW %ZLWK VXE WRWDOXUHWKUDLQYROYHPHQW DZLWKRXWFLUFXPIHUHQWLDOGHIHFW EZLWKFLUFXPIHUHQWLDOGHIHFW ,,, PLVFHOODQHRXVHJXUHWHUDQGRWKHUH[FHSWLRQDOILVWXODV

WKLVFODVVLILFDWLRQLVEDVHGRQWKHTXDQWLWDWLYHDQGTXDOLWDWLYHDPRXQWRIWLVVXHORVVRIWKH XULQHFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH, LQWDFWFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH,,$D PLQRULQYROYHPHQWRIFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH,,$E PRGHUDWHWRPDMRULQYROYHPHQWRIFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH,,%D PDMRULQYROYHPHQWRIFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH,,%E H[WHQVLYHLQYROYHPHQWRIFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH,,, LQWDFWFRQWLQHQFHFORVLQJPHFKDQLVP

DQGWKHQWKHUHLVSRVWSDUWXPXULQHLQFRQWLQHQFHZLWKRXWDILVWXOD

WKHRSHUDWLRQLQRUGHUWRFORVHWKHILVWXODDQGWRUHVWRUHFRQWLQHQFHEHFRPHVSURJUHV VLYHO\PRUHFRPSOLFDWHGIURPW\SH,WKUXW\SH,,%EZKLOVWWKHSURJQRVLVDVWRFORVXUHDQG FRQWLQHQFHZRUVHQVSURJUHVVLYHO\WKHVDPHDSSOLHVIURPVPDOOWKUXH[WHQVLYH W\SH,,,ILVWXODVDUHDFODVVRILWVRZQ

 49 61 VXUJLFDOREMHFWLYHV FORVHWKHILVWXOD PDNHWKHSDWLHQWFRQWLQHQW SUHVHUYHVXIILFLHQWYDJLQDGHSWKOHQJWKIRUVH[XDOLQWHUFRXUVH

RSHUDWLRQ PHWLFXORXVZDWHUWLJKWFORVXUHRIEODGGHUXUHWKUDZKLOVWRQO\DGDSWDWLRQRU KDOIRSHQFORVXUHRIDQWHULRUYDJLQDZDOO W\SH, RQO\FORVXUH W\SH,,$D FORVXUHDQGVRPHWKLQJKDVWREHGRQHDERXWFRQWLQHQFH W\SH,,$E FLUFXPIHUHQWLDOUHSDLUE\HQGWRHQGYHVLFRXUHWKURVWRP\ W\SH,,%D UHSDLU XUHWKUDUHFRQVWUXFWLRQZLWKIXQFWLRQDOXUHWKUDWLVVXH W\SH,,%E FLUFXPIHUHQWLDOUHSDLU XUHWKUDUHFRQVWUXFWLRQZLWKRWKHUWLVVXH VFDUWLVVXHSDUDXUHWKUDWLVVXHRUEODGGHU RIWHQLQWZRVWDJHV W\SH,,, XUHWHUUHLPSODQWDWLRQRUVRPHWKLQJHOVH

SXERFHUYLFDOPXVFXORIDVFLDHQGRSHOYLFGLDSKUDJP DQ\GHIHFWKDVWREHUHSDLUHGPHWLFXORXVO\DQGLIQHFHVVDU\LWKDVWREH UH IL[HG WRWKHSDUDXUHWKUDDUFXVWHQGLQHXVIDVFLDH

WKHPDUWLXVILEURIDWW\SDGJUDIWRUDQ\RWKHUNLQGRIJUDIWLQJ GRHVQRWFRQWULEXWHHLWKHUWRFORVXUHRUWRFRQWLQHQFHPRUHVXUJLFDOWUDXPD

LQGZHOOLQJEODGGHUFDWKHWHUIRUPLQLPXPSHULRGRIZHHNV IROH\FDWKHWHUFKRUQHODWRQFK

SRVWRSHUDWLYHIOXLGLQWDNH DWOHDVWOLWHUVSHUGD\LQRUGHUWRJHWJRRGXULQHIORZZLWKXULQHRXWSXWRI PLQLPDOO\POSHUKU

YDJLQDSDFN QRURXWLQHYDJLQDSDFNJRRGFKHFNRQKHPRVWDVLV

DQWLELRWLFV RQO\RQVWULFWLQGLFDWLRQVHJSQHXPRQLD WKHLQGLVFULPLQDWHXVHRIDQWLELRWLFVRQO\OHDGVWRPXOWLUHVLVWDQFH

PRELOL]DWLRQ IXOOPRELOL]DWLRQWKHPRUQLQJIROORZLQJVXUJHU\

PDLQSRVWRSHUDWLYHSUREOHPZKHQWKHILVWXODLVFORVHG LQWULQVLFVWUHVVDQGRUXUJHLQFRQWLQHQFH VRDOUHDG\DWILUVWDWWHPSWPDNHVXUHWKHULJKWWHFKQLTXHLVSHUIRUPHG

SRVWRSHUDWLYHLQWULQVLFVWUHVVLQFRQWLQHQFH XUHWKUDOL]DWLRQDQGPXVFXORIDVFLDUHSDLUUHIL[DWLRQ

SRVWRSHUDWLYHXUJHLQFRQWLQHQFH RQO\VWULFWEODGGHUGULOO

XUHWKURYHVLFDOMXQFWLRQ RUXY VWULFWXUHZLWKRYHUIORZ GDLO\JHQWOHGLODWDWLRQIRUZHHNVHYHQWXDOO\FRPELQHGZLWKXUHWKURWRP\

62  50 VRFLDOUHKDELOLWDWLRQ RQO\E\VXFFHVVIXOUHSDLUWKHQLWWDNHVSODFHVSRQWDQHRXVO\

IXWXUHVXEVHTXHQWSUHJQDQFLHVGHOLYHULHV UHJXODUDQWHQDWDOFDUHZLWKGHOLYHU\LQKRVSLWDOE\HOHFWLYHFHVDUHDQVHFWLRQVLQFH ODERUDVVLVWDQFHPRQLWRULQJLVYHU\SRRULQPRVWLQVWDQFHV

UHVLGXDOILVWXODV WKHVDPHWHFKQLTXHDVLILWZHUHWKHILUVWDWWHPSW

G\HWHVWZLWKJHQWLDQYLROHW ZKHQHYHULQGRXEW ILVWXOD"LQFRQWLQHQFH"ZKLFKW\SHRILQFRQWLQHQFH" LQVWLOO POJHQWLDQYLROHWLQWRWKHEODGGHUXQGHUWKHPRWWRWKHG\HQROLH KRZHYHULWLVWURXEOHVRPHDQGXQUHOLDEOHLQWKHLPPHGLDWHSRVWRSHUDWLYHSHULRG

GRQRWZDVWHWLPHHQHUJ\DQGPRQH\RQWKLQJVZKLFKPDNHQRVHQVHVXFKDVHXD ILUVWWUHDWLQJWKHXULQHGHUPDWLWLVLQWUDYHQRXVS\HORJUDSK\XULQHH[DPLQDWLRQZDLWLQJ PRQWKVDIWHUGHOLYHU\EHIRUHVXUJHU\HWF

FRQFHQWUDWHRQWKHPRVWLPSRUWDQWWKLQJ FORVHWKHILVWXOD

 51 63

NHHVFODVVLILFDWLRQRIXULQHILVWXODV DVEDVHGRQWLVVXHORVVRSHUDWLRQWHFKQLTXHDQGRXWFRPH ZLWKVSHFLDOUHJDUGWRFRQWLQHQFHPHFKDQLVP

LQWURGXFWLRQ ,QRUGHUWRGHYLVHDQGH[HFXWHWKHILVWXODUHSDLUDFFRUGLQJWRWKHSULQFLSOHVRIUHFRQVWUXF WLYHVXUJHU\DQGWRFRPSDUHWKHUHVXOWVDQGGLIIHUHQWRSHUDWLRQWHFKQLTXHVLWLVLPSRUWDQW WRKDYHDVFLHQWLILFFODVVLILFDWLRQZKLFKPDNHVVHQVH

EDVHGRQDUHWURVSHFWLYHDQDO\VLVLQFRQVHFXWLYHSDWLHQWVDVFLHQWLILFFODVVLILFDWLRQ ZDVGHYHORSHGDQGUHFRPPHQGHGLQDSKGWKHVLVLQXQLYHUVLW\RIXWUHFKW

WKLVFODVVLILFDWLRQKDVEHHQXVHGSURVSHFWLYHO\DQGUHILQHGE\WKHDXWKRULQRYHU SHUVRQDO ILVWXOD UHSDLUV DQGUHODWHGRSHUDWLRQVGXULQJD\HDUSHULRGRI VXUJLFDO  PDQDJHPHQWRIWKHREVWHWULFILVWXODPDLQO\LQQLJHULDEXWDOVRLQEXUNLQDIDVRHWKLRSLD NHQ\DQLJHUWDQ]DQLDXJDQGDDQGSDNLVWDQIURPXSWLOOWRGD\

ULJKWIURPWKHEHJLQQLQJWKHZKROHPDQDJHPHQWKDVEHHQSDLQVWDNLQJO\GRFXPHQWHGE\ FRPSXWHUL]HGRSHUDWLRQUHSRUWVLQFOXGLQJKLVWRU\DQGVFKHPDWLFGUDZLQJVFRPSOHWHZLWK LQWHUPHGLDWHDQGILQDOSRVWRSHUDWLYHFKHFNXSVDVHYLGHQFHEDVHGUHVXOWVWRVXSSRUWWKH FRQWLQXRXVSURVSHFWLYHUHVHDUFK

FODVVLILFDWLRQ WKHIROORZLQJFODVVLILFDWLRQLVSUHVHQWHGDFFRUGLQJWRWKHDQDWRPLFSK\VLRORJLFORFDWLRQ ZLWKFRQVHTXHQFHVIRURSHUDWLRQWHFKQLTXHDQGSURJQRVLVVHHILJVDQGWDEOH,

W\SH, ILVWXODVQRWLQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVP W\SH,, ILVWXODVLQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVPDQG W\SH,,, PLVFHOODQHRXV

ILJXUHVDQG

66 52 WDEOH, FODVVLILFDWLRQRIILVWXODVDFFRUGLQJWRDQDWRPLFSK\VLRORJLFORFDWLRQ

W\SH, ILVWXODVQRWLQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH,, ILVWXODVLQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVP $ZLWKRXW VXE WRWDOXUHWKUDLQYROYHPHQW DZLWKRXWFLUFXPIHUHQWLDOGHIHFW EZLWKFLUFXPIHUHQWLDOGHIHFW %ZLWK VXE WRWDOXUHWKUDLQYROYHPHQW DZLWKRXWFLUFXPIHUHQWLDOGHIHFW EZLWKFLUFXPIHUHQWLDOGHIHFW

W\SH,,, PLVFHOODQHRXVHJXUHWHUILVWXODVDQGRWKHUH[FHSWLRQDOILVWXODV

WKLVFODVVLILFDWLRQLVEDVHGRQWKHSURJUHVVLYHTXDQWLWDWLYHDQGTXDOLWDWLYHDPRXQWRI WLVVXHORVVRIWKHXULQHFRQWLQHQFHFORVLQJPHFKDQLVP WKHWUDQVLWLRQIURPW\SH,LQWRW\SH,,ILVWXODVLVDWFPZKLOVWWKHWUDQVLWLRQIURPW\SH,,$ LQWRW\SH,,%ILVWXODVLVDWFPIURPWKHH[WHUQDOXUHWKUDRSHQLQJ

DJUDGLQJRILQYROYHPHQWRIWKHXULQHFRQWLQHQFHPHFKDQLVPRIWKHGLIIHUHQWW\SHVLV SUHVHQWHGLQWDEOH,,

WDEOH,, LQYROYHPHQWRIFRQWLQHQFHPHFKDQLVPDFFRUGLQJWRW\SH

W\SH LQYROYHPHQWRIFRQWLQHQFHPHFKDQLVP

W\SH, QRQH

W\SH,,$D PLQRUWRPRGHUDWH

W\SH,,$E PRGHUDWHWRPDMRU

W\SH,,%D PDMRU

W\SH,,%E H[WHQVLYH

W\SH,,, QRQH

LQW\SH,ILVWXODVWKHUHLVRQO\WLVVXHORVVRIWKHEODGGHUSXERFHUYLFDOPXVFXORIDVFLD DV SDUWRIHQGRSHOYLFGLDSKUDJP HSG DQGDQWHULRUYDJLQDZDOO DYZ DQGRUFHUYL[DQG RUXWHUXVZLWKDQLQWDFWFRQWLQHQFHFORVLQJPHFKDQLVP WKHUHPD\EHPDMRUWLVVXHORVVZLWKDOVRWUDXPDWRWKHVDFURVSLQRXVOLJDPHQW LVFKLR  FRFF\JHXVPXVFOHVDQGSULULIRUPLVPXVFOHV KRZHYHUWKHXUHWKUDXUHWKURYHVLFDOMXQFWLRQDQGDQWHULRUSDUWRIWKHSXERFHUYLFDOPXV FXORIDVFLDWRJHWKHUZLWKLWVFRQQHFWLRQWRWKHSDUDXUHWKUDSXELVERQHVDQGWKHDUFXV WHQGLQHXVIDVFLDHDUHVWLOOLQWDFW

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

LQW\SH,,%DILVWXODVWKHUHLVPDMRUWLVVXHORVVRIWKHXUHWKUDDQGWLVVXHORVVRIWKHXUH WKURYHVLFDOMXQFWLRQWULJRQDOULQJGHWUXVRUORRSVEODGGHUSXERFHUYLFDOPXVFXORIDVFLD DQG DQWHULRU YDJLQD ZDOO DQG FHUYL[ DQGRU XWHUXV  ZLWK PDMRU LQYROYHPHQW RI WKH FRQWLQHQFHFORVLQJPHFKDQLVP WKRXJKWKHUHLVWLVVXHORVVRIWKHDQWHULRUSDUWRIWKHSXERFHUYLFDOPXVFXORIDVFLDWKHDWI DWODPDQGOHYDWRUDQLPXVFXODWXUHDUHLQWDFWWKRXJKWKHFRQQHFWLRQRIWKHPXVFXORIDVFLD RQWRWKHLPPHGLDWHSDUDXUHWKUDSXELVERQHVPD\EHORVW

LQW\SH,,%EILVWXODVWKHUHLV VXE WRWDOFLUFXPIHUHQWLDOWLVVXHORVVRIWKHXUHWKUDXUHWKUR YHVLFDOMXQFWLRQWULJRQDOULQJEODGGHUQHFNGHWUXVRUORRSVDQGWLVVXHORVVRIWKHLQWHUPH GLDWHDQGSRVWHULRUSXERXUHWKUDOOLJDPHQWVSXERFHUYLFDOPXVFXORIDVFLDDQWHULRUYDJLQD ZDOO DQGFHUYL[DQGRUXWHUXV DWIDWODPSXERFRFF\JHXVREWXUDWRFRFF\JHXVPXVFOHV DOVRWKHUHPD\EHHYHQWUDXPDWRWKHREWXUDWRULQWHUQXVPXVFOHVREWXUDWRUPHPEUDQH DQGFRFF\JHXVPXVFOHVZLWKHYHQWXDOORVVRISXELVERQHSHULRVWDQGSXELVV\PSK\VLV FDUWLODJHZLWKH[WHQVLYHLQYROYHPHQWRIWKHFRQWLQHQFHFORVLQJPHFKDQLVP

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

WKHW\SH,,,ILVWXODVDUHDFODVVRILWVRZQHJXUHWHUILVWXODVRUILVWXODVEHWZHHQWKH EODGGHUDQGERZHOVRUEHWZHHQWKHEODGGHUDQGVNLQ

DQDGGLWLRQDOVXEFODVVLILFDWLRQLVSUHVHQWHGDFFRUGLQJWRWKHILVWXODVL]HVPDOOPHGLXP ODUJHDQGH[WHQVLYHVHHWDEOH,,,

WDEOH,,, VXEFODVVLILFDWLRQRIILVWXODVDFFRUGLQJWRVL]H

VPDOO FP

PHGLXPFP

ODUJHFP

H[WHQVLYH!FP

UHVXOWV WKHRSHUDWLRQWHFKQLTXHEHFRPHVSURJUHVVLYHO\FRPSOLFDWHGIURPW\SH,WKUXW\SH,,%E ZKLOVWWKHUHVXOWVDVWRFORVXUHDQGFRQWLQHQFHEHFRPHZRUVHWKHVDPHDSSOLHVWRWKH ILVWXODVL]HIURPVPDOOWRH[WHQVLYH

 55 69 FRPPHQWV

WKLVFODVVLILFDWLRQLVEDVHGRQWKHTXDOLWDWLYHDQGTXDQWLWDWLYHDPRXQWRIWLVVXHORVVRIWKH XULQHFRQWLQHQFHPHFKDQLVPLQWKHIHPDOH

VRIDULWLVWKHRQO\FODVVLILFDWLRQZLWKD VROLGVFLHQWLILFEDFNJURXQG FOHDURSHUDWLRQWHFKQLTXHSULQFLSOHVIRUHDFKW\SHDQG SUHGLFWLRQRIRXWFRPHLQWHUPVRIFORVXUHDQGFRQWLQHQFH

WKHRWKHUFODVVLILFDWLRQVDUHHLWKHUEDVHGRQWKHVXEMHFWLYHRSLQLRQRIWKHVXUJHRQOLNH VLPSOHFRPSOH[HDV\GLIILFXOWHWFRUDUHDPRGLILFDWLRQRIZKDWKDVEHHQSUHVHQWHGE\ WKHDXWKRULQWKLVERRN

RIFRXUVHZLWKLQHDFKW\SHWHQVKXQGUHGVRUWKRXVDQGVRIVXEW\SHVFDQEHPDGHEXW WKDWZRXOGPDNHWKHVHQVHRIFODVVLILFDWLRQXQZRUNDEOH

WKHVHDUHRQO\JXLGHOLQHVDQGWKHDSSURDFKKDVWREHFXVWRPL]HGVLQFHHDFKILVWXOD FRQVWLWXWHVLWVRZQXQLTXHHQWLW\

QRWRQO\WKHILVWXODKDVWREHFODVVLILHGEXWDOOWKHOHVLRQVGHIHFWVKDYHWREHREMHFWLYHO\ GHVFULEHGGRFXPHQWHGLQZULWLQJWREHFRPSOHWHO\WUDQVSDUHQW

WKHFODVVLILFDWLRQDVWRW\SHLVIDUPRUHLPSRUWDQWDQGGHFLVLYHWKDQWKHDGGLWLRQDOVXE FODVVLILFDWLRQDVWRVL]HZKLOVWPRVWRIW\SH,,$EW\SH,,%DDQGW\SH,,%EILVWXODVDUH DOUHDG\ODUJHRUH[WHQVLYH

ZLWKWKLVFODVVLILFDWLRQLWLVSRVVLEOHWRSODQDQGH[HFXWHWKHILVWXODUHSDLUDFFRUGLQJWRWKH SULQFLSOHVRIUHFRQVWUXFWLYHVXUJHU\DQGWRFRPSDUHWKHUHVXOWVDQGRSHUDWLRQWHFKQLTXHV LQDVFLHQWLILFZD\

KRZHYHUVLQFHWKHYDULHW\LVVRLPPHQVHDQGWKHUHDUHQRVKDUSGHPDUFDWLRQVEXWIOXLG WUDQVLWLRQVEHWZHHQWKHGLIIHUHQWW\SHVWKLVFODVVLILFDWLRQVKRXOGEHXVHGDVDFRPSUH KHQVLYHJXLGHOLQHVLQFH

HDFKILVWXODFRQVWLWXWHVDVHSDUDWHXQLTXHHQWLW\DQGQHHGVLWVRZQVSHFLILFFXVWRPL]HG DSSURDFKDQGWKDWLVH[DFWO\ZKDWPDNHVREVWHWULFILVWXODVXUJHU\VRLQWULJXLQJDQG FKDOOHQJLQJVLQFHWKHUHDUHQRLGHQWLFDOREVWHWULFILVWXODV

YDJLQDVWULFWXUHVVFDUULQJVWHQRVLVDQGRUSUHYLRXVUHSDLU V  DUHQRSDUWRIDFODVVLILFDWLRQLWRQO\PD\PDNHWKHRSHUDWLRQPRUHFRPSOLFDWHG

DQGWKHQWKHUHLVSRVWSDUWXPXULQHLQFRQWLQHQFHZLWKRXWDILVWXOD

70  56

surgical principles for vesicovaginal fistulas

introduction WKHPDLQREMHFWLYHVRIDQ\YYIUHSDLUDUHa)WRFORVHWKHILVWXODb)WRPDNHWKHSDWLHQW FRQWLQHQWDQGc)WRSUHVHUYHRUWRSURYLGHKHUZLWKVRPHWKLQJIRUVH[XDOLQWHUFRXUVH ,IWKHVHWKUHHREMHFWLYHVKDYHEHHQDFKLHYHGWKHSDWLHQWZLOOEHUHKDELOLWDWHGFRPSOHWHO\ LQWRKHURZQVRFLHW\WKLVZLOOWDNHSODFHVSRQWDQHRXVO\ZLWKRXWIXUWKHUPHDVXUHV manpower ILVWXODVXUJHU\LVDRQHPDQMREDQGDOOWKHRSHUDWLRQVDUHSHUIRUPHGE\WKHVXUJHRQ DQGRQHDVVLVWDQWZKRLVGRLQJWKHLQVWUXPHQWDWLRQRQHUHWUDFWRULQVLGHWKHYDJLQDLV DOUHDG\DFURZG instruments QRUPDO ORQJ YDJLQDOVXUJHU\LQVWUXPHQWVDUHQHHGHGWRJHWKHUZLWKWKHIROORZLQJVSHFLDO LQVWUXPHQWVD DQDXYDUGZHLJKWHGVSHFXOXPIRUNHHSLQJWKHYDJLQDRSHQE ORQJDOOLV FODPSVIRUSLFNLQJXSWKHYDJLQDRUEODGGHUHGJHVF DSDLURIVKDUSO\FXUYHGWKRUHN VFLVVRUVIRUGLVVHFWLQJWKHDQWHULRUYDJLQDZDOOIURPWKHSXERFHUYLFDOPXVFXORIDVFLD EODGGHUDQGG DVKDUSGHVFKDPSVDQHXU\VPQHHGOHIRUIL[DWLRQRIWKHSXERFHUYLFDO PXVFXORIDVFLDRQWRLWVDUFXVWHQGLQHXVIDVFLDH EHVLGHVDFRPSOHWHZHOOIXQFWLRQLQJK\GUDXOLFRSHUDWLRQWDEOHLVRIXWPRVWLPSRUWDQFH DQGDPXVW suturing materials QRUPDOUHDEVRUEDEOHSRO\JO\FROLFDFLGVL]HDQGDQGQRQDEVRUEDEOHQ\ORQVXWXUHV VL]HDQGDUHQHHGHGZLWKDVWURQJVPDOOFXUYHGQHHGOH

SULQFLSOHVRIVXUJLFDOWHFKQLTXH V  WKHYDJLQDODSSURDFKLVWKHURXWHRIFKRLFHZLWKRUZLWKRXWXQLODWHUDOPHGLDQRUELODWHUDO HSLVLRWRPLHV VSLQDO DQHVWKHVLD LV WKH DQHVWKHVLD RI FKRLFH DQG WKH H[DJJHUDWHG  OLWKRWRP\SRVLWLRQLVWKHSRVLWLRQRIFKRLFHIRUW\SH,WKUXW\SH,,%EILVWXODVKRZHYHUW\SH ,,,ILVWXODVPD\QHHGDGLIIHUHQWDSSURDFK

000 VSLQDODQHVWKHVLDZLWKORQJDFWLQJDJHQW

001 WKHSDWLHQWLVSODFHGLQWKHH[DJJHUDWHGOLWKRWRP\SRVLWLRQZLWKWKHOHJVIOH[HGDQG VOLJKWO\DEGXFWHGLQVWLUUXSVDQGKHUEXWWRFNVRYHUWKHHQGRIWKHRSHUDWLRQWDEOHWKLVLV WKHSRVLWLRQRIFKRLFH

002 D FDUHIXO LQVSHFWLRQ DQG V\VWHPDWLF H[DPLQDWLRQ XQGHU DQHVWKHVLD  RI WKH ZKROH REVWHWULFWUDXPDDQGRIWKHILVWXODDVWRVL]HORFDWLRQDQGWH[WXUHRIWKHILVWXODLQUHODWLRQ WR SUHVXPHG H[WHUQDOXUHWKUDRSHQLQJDQGFHUYL[RUYDJLQDYDXOWDVWRWKHFRQGLWLRQRI WKHYDJLQDVXFKDVVWULFWXUHVWHQRVLVRUHYHQDWUHVLDLIWKHUHLVDUHFWRYDJLQDOILVWXODDV ZHOOLIWKHILVWXODLVDFFHVVLEOHLIWKHUHLVDFLUFXPIHUHQWLDOGHIHFWHWF

79 003 EDVHGXSRQWKLVH[DPLQDWLRQWKHILVWXODLVFODVVLILHGDQGWKHVXUJHRQPDNHVXSKLV GHILQLWHSODQRIDFWLRQKRZWRKDQGOHWKLVVSHFLILFILVWXODDVLWVRZQXQLTXHHQWLW\

004 WKHODELDPLQRUDDUHVXWXUHGRQWRWKHLQVLGHRIWKHXSSHUOHJVWRNHHSWKHYDJLQDRSHQ ODWHUDOO\

005 LQRUGHUWRLPSURYHWKHDFFHVVLELOLW\DXQLRUELODWHUDOHSLVLRWRP\LVSHUIRUPHGDW DQGRUR FORFNRUDVPDOOPHGLDQHSLVLRWRP\DWR FORFN

006 WKHQDQDXYDUGVHOIUHWDLQLQJZHLJKWHGVSHFXOXPLVSODFHGLQVLGHWKHYDJLQDZLWKXQGHU QHDWKDJDX]HFRYHULQJWKHDQXVWRNHHSWKHYDJLQDRSHQSRVWHULRUO\QRPRUHVSHFXOD

007 LIQHFHVVDU\DVLQILVWXODVQHDUWKHFHUYL[DQHIIRUWLVPDGHWRLGHQWLI\DQGFDWKHWHUL]H WKHXUHWHUVIRUFP

008 DSK\VLRORJLFWUDQVYHUVHFXUYHGLQFLVLRQLVPDGHZLWKLQWKHUXJDIROGVRIWKHDQWHULRU YDJLQDZDOOWKUXWKHILVWXODWKHQDFLUFXPIHUHQWLDOLQFLVLRQLVPDGHDWWKHILVWXODHGJH

009 WKHDQWHULRUYDJLQDZDOOLVGLVVHFWHGVKDUSO\IURPWKHSXERFHUYLFDOPXVFXORIDVFD ZLWK DGKHUHQWEODGGHUDQGRUXUHWKUD XVLQJWKHVKDUSO\FXUYHGWKRUHNVFLVVRUVLQRUGHUWR H[HFXWHDtension-free UHSDLUDLPIRUDMXVWVXIILFLHQWGLVVHFWLRQ

010 WKHGHIHFWZLWKLQWKHSXERFHUYLFDOPXVFXORIDVFLDLVFORVHGZLWKLQWKHSURFHVVFORVXUHRI WKHEODGGHUXUHWKUDZLWKDVLQJOHOD\HURILQWHUUXSWHGLQYHUWLQJSRO\JO\FROLFDFLGRU VXWXUHVDVHFRQGOD\HULVQRWQHFHVVDU\DQGDFWXDOO\ZRXOGEHKDUPIXO

011 FORVXUHLVIURPODWHUDOO\WRZDUGVWKHPLGOLQHRWKHUZLVHLWPD\EHYHU\GLIILFXOWWRFORVH WKHODWHUDODQJOHVDQGFRUQHUFRUQHUILVWXODVPD\GHYHORS

012 JRRGELWHVDUHWDNHQWRJHWEURDGDGDSWDWLRQRIWKHUDZSXERFHUYLFDOPXVFXORIDVFLD ZLWKDGKHUHQWEODGGHUDQGRUXUHWKUDPXVFXODWXUH 

013 FDUHLVWDNHQRQO\WRDGDSWWKHWLVVXHVDQGQRWWRDSSO\WHQVLRQRQWKHVXWXUHVDVWKHQ WKH\PD\FXWWKURXJKUHPHPEHUVXWXUHVFDQQRWKHDORQO\DGDSW  014 WKH SULQFLSOHV RI UHFRQVWUXFWLYHVXUJHU\ DQG FRPPRQVHQVHGLFWDWH WKHGLUHFWLRQRI FORVXUHORQJLWXGLQDOWUDQVYHUVHRUREOLTXHPRVWRIWKHWLPHDWUDQVYHUVHFORVXUHLVWKH PRVWORJLFDODVLWSUHVHQWVLWVHOIWKLVZD\DQGLVLQOLQHZLWKWKHQDWXUDOWLVVXHIRUFHV ZKLOVWORQJLWXGLQDOFORVXUHVHHPVWREHDJDLQVWWKHOLQHVRIWHQVLRQ

80 015 FDUHLVWDNHQQRWWRJRWKURXJKWKHEODGGHUPXFRVDDVWKHRUHWLFDOO\WKLVPLJKWOHDGWR VWRQHIRUPDWLRQEXWRQFHLQDZKLOHWKLVFDQQRWEHSUHYHQWHG

016 cave GRQRWFXWWKHVXWXUHVWRRVKRUWVLQFHWKHQWKHNQRW V ZLOOVOLSDQGORRVHQXS

017 ZLWKXULQHRUZDWHULQVLGHWKHEODGGHUDVNSDWLHQWWRFRXJKDQGORRNLIWKHUHLVOHDNDJH WKUXVXWXUHOLQH FORVXUHQRWFRPSOHWH DQGRUXULQHFRPLQJRXWWKUXHXR VWUHVVLQFRQ WLQHQFH 

018 QRQHHGWRFKHFNZLWKG\HIDUPRUHLPSRUWDQWLVWRPDNHVXUHWKHWLVVXHDUHLQYHUWHG DQGEURDGO\DGDSWHGDQGWKDWWKHUHLVQRSLHFHRIEODGGHUPXFRVDVWLFNLQJRXWZKLFKZLOO LQWHUIHUHQHJDWLYHO\ZLWKKHDOLQJ

019 WU\WRJHWDQLPSUHVVLRQRIWKHEODGGHUFDSDFLW\E\PHDVXULQJWKHORQJLWXGLQDOEODGGHU GLDPHWHUE\PHDVXULQJWKHGLVWDQFHHXRWREODGGHUZDOO HXREZ E\FDOLEUDWHGPHWDO VRXQGWKHQLQVHUWIROH\FDWKHWHUDQGGHWHUPLQHXUHWKUDOHQJWKE\PHDVXULQJGLVWDQFH HXRWREDOORRQ HXRE  HXREZPLQXVHXRE ORQJLWXGLQDOEODGGHUGLDPHWHU LQFP 

020 LQVHUWIROH\FKEDOORRQLWDQGFKHFNIRUXULQHGUDLQDJHWKUXFDWKHWHU LIXULQHLVGUDLQLQJWKLVPHDQVWKLQJVa) WKHFDWKHWHULVLQVLGHEODGGHUb)DWOHDVWRQH XUHWHULVGUDLQLQJLQWRWKHEODGGHUDQGc) WKHSDWLHQWLVQRWLQVKRFN LIQRGUDLQLQJRIXULQHFKHFNIRUWKHFDXVHDQGFRUUHFWLW

021 WKHDQWHULRUYDJLQDZDOOLVDGDSWHGZLWKLQWHUUXSWHGHYHUWLQJ LVLQYHUWLQJLQWRWKHYDJLQD  QRQDEVRUEDEOHRUUHVRUEDEOHVXWXUHVZKHUHE\KHPRVWDVLVLVVHFXUHGPRVWRIWKHWLPH DWUDQVYHUVHFORVXUHVHHPVWREHWKHPRVWORJLFDO WKHDQWHULRUYDJLQDZDOOLVRQO\DGDSWHGRUKDOIFORVHGWRDOORZIUHHVSRQWDQHRXVHYDFX DWLRQRIVPDOOEORRGFORWVWLVVXHGHEULVDQGEDFWHULDDFFRUGLQJWRWKHSULQFLSOHVRIVHSWLF VXUJHU\VLQFHWKHYDJLQDLVQHYHUVWHULOH

022 LIHSLVLRWRPLHVKDYHEHHQSHUIRUPHGWKH\DUHDGDSWHG

023 WKHYDJLQDLVSDFNHGWLJKWO\ZLWKJDX]H VRDNHGLQDQWLVHSWLFRUQRW WRKHOSKHPRVWDVLV

024 LIWKHSDWLHQWLVLQJRRGFRQGLWLRQZLWKJRRGXULQHIORZVKHLVWUDQVIHUUHGWRWKHSRVW RSHUDWLYHZDUG cave ,IWKHUHLVQRXULQHIORZQRWHYHQDIWHUDWWHPSWVDWIRUFHGGLXUHVLVWKLVLVDQLQGLFDWLRQ WKDWERWKXUHWHUVKDYHEHHQWUDXPDWL]HGDQGWKHZKROHUHSDLUKDVWREHXQGRQH

81 LQtype I fistulasWKLVLVWKHVWUDLJKWIRUZDUGSURFHGXUHWKRXJKLQWKHYHVLFRFHUYLFR YDJLQDOILVWXODVDQGYHVLFRXWHURYDJLQDOILVWXODVWKHEODGGHUKDVWREHGLVVHFWHGIURPWKH FHUYL[DQGRUXWHUXVRQFHWKHILVWXODKDVKHDOHGWKHSDWLHQWZLOOEHFRQWLQHQWDVZHOO VLQFH WKH FRQWLQHQFHFORVLQJ PHFKDQLVP LV QRW LQYROYHG XQOHVV VKH ZDV DOUHDG\ LQFRQWLQHQWEHIRUHVKHGHYHORSHGWKHILVWXODLWKDVWKHEHVWFKDQFHRIKHDOLQJDQG FRQWLQHQFH

LQWKHtype II fistulasDOVRVRPHWKLQJKDVWREHGRQHDERXW UHLQIRUFLQJ WKHFRQWLQHQFH FORVLQJPHFKDQLVPSUHIHUDEO\GXULQJWKHUHSDLURUODWHULIWKHSDWLHQWGHYHORSVLQFRQWL QHQFHWKHFLUFXPIHUHQWLDOILVWXODVQHHGDFLUFXPIHUHQWLDOGLVVHFWLRQDGYDQFHPHQWRIWKH EODGGHUDQGFLUFXPIHUHQWLDOUHSDLUE\DQHQGWRHQGYHVLFRXUHWKURVWRP\

LQtype IIAa fistulasWKHDQWHULRUYDJLQDZDOOLVGLVVHFWHGIURPWKHEODGGHUDQGXUHWKUD DQGDQHIIRUWPDGHWRUHVWRUHWKHXUHWKURYHVLFDOMXQFWLRQZKLOVWFDUHKDVWREHWDNHQWR UHSDLUWKHSXERFHUYLFDOPXVFXORIDVFLDIRUJRRGXUHWKUDVXSSRUWLIWKHUHLVDWUDQVYHUVH GHIHFWLQWKHIDVFLDRULILWLVORRVHLWVKRXOGEHIL[HGDVZHOORQWRWKHSDUDXUHWKUDV\P SK\VLVLQWDFWDWIVLQFHWKHFRQWLQHQFHFORVLQJPHFKDQLVPLVLQYROYHGWKHUHLVDVOLJKW FKDQFHWKHSDWLHQWZLOOEHFRPHLQFRQWLQHQWDIWHUVXFFHVVIXOFORVXUHGHSHQGLQJXSRQWKH DPRXQWRIWLVVXHORVV

LQtype IIAb fistulasWKHUHLVWRWDOGLVUXSWLRQRIWKHWUDXPDWL]HGXUHWKUDIURPWKHEODGGHU QHFN LQRUGHUWRSHUIRUPDFRPSOHWH FLUFXPIHUHQWLDO UHVWRUDWLRQRIWKHXUHWKURYHVLFDO MXQFWLRQLWLVQHFHVVDU\WRGLVVHFWWKHEODGGHUFLUFXPIHUHQWLDOO\IURPWKHDQWHULRUYDJLQD ZDOOSXELVERQHVDQGSRVWHULRUSXELVV\PSK\VLVDQGLIQHFHVVDU\DOVRIURPWKHDQWHULRU DEGRPLQDOZDOOWKHQWKHEODGGHULVDGYDQFHGDQGWKHDQWHULRUDQGDQWHURODWHUDOEODGGHU ZDOOVDUHDQFKRUHGRQWRWKHFDXGDGSRVWHULRUV\PSK\VLVDQGGLVWDODQWHULRUXUHWKUDE\ SRO\JO\FROLFDFLGVXWXUHVZKLOVWWKHRSHUDWLRQLVIXUWKHUFRPSOHWHGDVDQHQGWRHQG YHVLFRXUHWKURVWRP\IROORZHGE\ELODWHUDOUHIL[DWLRQRIWKHSXERFHUYLFDOPXVFXORIDVFLD RQWRWKHSDUDXUHWKUDOV\PSK\VLVZKHUHWKHORVWDWIXVHGWREHVLQFHWKHUHLVFLUFXPIHU HQWLDOWLVVXHORVVFLUFXPIHUHQWLDOGLVVHFWLRQDQGFLUFXPIHUHQWLDOUHSDLUWKHFORVXUHUDWH DQGWKHFRQWLQHQFHUDWHDUHVOLJKWO\ZRUVHWKDQLQW\SH,,$DILVWXODV

LQtype IIB fistulas SDUWRI WKHXUHWKUDKDVWREHUHFRQVWUXFWHG LQDGGLWLRQWREODGGHU FORVXUHLQODUJHILVWXODV SUHIHUDEO\GXULQJWKHILUVWUHSDLURULIWKDWLVQRWSRVVLEOHDVD VHFRQGVWDJHVLQFHWKHPRVWLPSRUWDQWSDUWRIWKHFRQWLQHQFHFORVLQJPHFKDQLVPLV VLWXDWHGLQWKHXUHWKUDWKHFKDQFHRIEHFRPLQJLQFRQWLQHQWDIWHUVXFFHVVIXOFORVXUHLV KLJKHUWKDQLQW\SH,,$ILVWXODV

LQtype IIBa fistulasWKHXUHWKUDLVUHFRQVWUXFWHGORQJLWXGLQDOO\E\DVLQJOHOD\HURILQWHU UXSWHGSRO\JO\FROLFDFLGXUHWKUDWLVVXHKDVUHWUDFWHGELODWHUDOO\DQGWKLV SDUD XUHWKUD WLVVXHLVXVHGIRUWKHUHFRQVWUXFWLRQWKHQWKHSXERFHUYLFDOPXVFXORIDVFLDKDVWREH IL[HGWRWKHSDUDXUHWKUDV\PSK\VLVDQGWKHLQWDFWSDUDXUHWKUDDWIDQGWKHQHRXUHWKUD FRYHUHGE\DIODSIURPWKHDQWHULRUYDJLQDZDOORUIURPWKHODELDWKHUHIRUHWKHFORVXUH UDWHLVVOLJKWO\ZRUVHWKDQLQW\SH,,$ILVWXODVDVZHOODVWKHFRQWLQHQFHUDWHKRZHYHU IXQFWLRQDOXUHWKUDWLVVXHLVXVHGIRUWKHUHFRQVWUXFWLRQ

LQtype IIBb fistulasWKHUHLVRIWHQH[WHQVLYHWLVVXHORVVZLWK VXE WRWDOWLVVXHORVVRIWKH XUHWKUDWKHUHIRUHWKHXUHWKUDLVUHFRQVWUXFWHGIURPQRQXUHWKUDWLVVXHHLWKHUE\SDUD XUHWKUDWLVVXHLIDYDLODEOHRUE\VFDUWLVVXHRUE\EODGGHUWLVVXHDVZHOOWKHEODGGHUKDV WREHGLVVHFWHGFLUFXPIHUHQWLDOO\DQGDQFKRUHGWRWKHFDXGDGSRVWHULRUSXELFV\PSK\VLV ZLWKDQHQGWRHQGDQDVWRPRVLVRQWRWKHQHRXUHWKUDDQGWKHQWKHSXERFHUYLFDOPXVFX ORIDVFLDKDVWREHUHIL[HGWRWKHSDUDXUHWKUD³DUFXVWHQGLQHXVIDVFLDH´DQGWKHZKROH UHSDLUFRYHUHGE\DIODSIURPWKHDQWHULRUYDJLQDZDOORUODELDPDQ\WLPHVDtwo-stage

82 DSSURDFKLVQHFHVVDU\DVILUVWVWDJHWKHEODGGHULVDGYDQFHGDQGDQFKRUHGFDXGDOO\ RQWRWKHSXELFV\PSK\VLVLQWRWKHVXSSRVHG³H[WHUQDOXUHWKUDRSHQLQJ´DQGDVVHFRQG VWDJHWKHXUHWKUDLVUHFRQVWUXFWHGVRPHWLPHVWKHILUVWVWDJHHQVXUHVDOUHDG\IXOOXULQH FRQWLQHQFHWKHUHLVDIDLUFKDQFHRIEUHDNGRZQDQGFKDQFHRIGHYHORSLQJ LQWULQVLFVWUHVVLQFRQWLQHQFHLIWKHUHSDLUKDVEHHQVXFFHVVIXO fistula size LQSULQFLSOHWKHUHLVSURJUHVVLYHO\PRUHWLVVXHORVVLQILVWXODVIURPVPDOOWKUXH[WHQVLYH KRZHYHUWKHUHDUHH[WHQVLYHILVWXODVZKLFKKDYHEHFRPHVPDOOGXHWRVFDUULQJDQGWKLV VKRXOGEHWDNHQLQWRDFFRXQWVRWKHUHDUHH[WHQVLYHVPDOOILVWXODV GLVVHFWLRQEHFRPHVSURJUHVVLYHO\PRUHH[WHQVLYHWKHRSHUDWLRQSURJUHVVLYHO\PRUH FRPSOLFDWHGDQGWKHUHVXOWVSURJUHVVLYHO\ZRUVHIURPVPDOOWKUXH[WHQVLYH cave PLQXWHILVWXODVXSWRFPDUHYHU\WURXEOHVRPHHYHQIRUH[SHUWV type III fistulasDUHDFODVVRILWVRZQDQGQHHGWKHLURZQVSHFLILFDSSURDFKHJXUHWHU LPSODQWDWLRQLQWRWKHEODGGHU

classification + operation technique + results classifcation LQYROYHPHQWRIFRQWLQHQFHPHFKDQLVPIRUWKHGLIIHUHQWW\SHVLVSUHVHQWHGLQWDEOH, operation principles WKHRSHUDWLRQSULQFLSOHVIRUWKHGLIIHUHQWW\SHVDUHVXPPDUL]HGLQWDEOH,, results WKHHYLGHQFHEDVHGUHVXOWVIRUWKHGLIIHUHQWW\SHVDUHSUHVHQWHGLQWDEOH,,,

WDEOH,

LQYROYHPHQWFRQWLQHQFHFORVLQJPHFKDQLVP

W\SH LQYROYHPHQWFRQWLQHQFHPHFKDQLVP

W\SH, none

W\SH,,$D minor to moderate

W\SH,,$E moderate to major

W\SH,,%D major

W\SH,,%E extensive

W\SH,,, none

83 WDEOH,,

RSHUDWLRQSULQFLSOHV

type bladder/urethra pubocervical fascia ant vagina wall direction of closure closure

W\SH, DQ\DFFRUGLQJWR FORVXUH DGDSWDWLRQ FRPPRQVHQVH

W\SH,,$D WUDQVYHUVH WUDQVYHUVHUHSDLU WUDQVYHUVH IL[DWLRQ  DGDSWDWLRQ

W\SH,,$E FLUFXPIHUHQWLDO UHIL[DWLRQ WUDQVYHUVH HQGWRHQG  WRDWI DGDSWDWLRQ

W\SH,,%D ORQJLWXGLQDO  UHIL[DWLRQ IODS WUDQVYHUVH  WRDWI XUHWKUDWLVVXH

W\SH,,%E ORQJLWXGLQDO UHIL[DWLRQ IODS  FLUFXPIHUHQWLDO WRDWI QRQXUHWKUDWLVVXH

WDEOH,,,

UHVXOWV

UHVXOWVDVWRILVWXODW\SHLQFRQVHFXWLYHHDUO\FORVXUHSDWLHQWV  

type number healed first attempt final healing incontinent

W\SH,          

W\SH,,$D          

W\SH,,$E          

W\SH,,%D          

W\SH,,%E          

WKHUHVXOWVDVWRfistula healingDWILUVWDWWHPSWDFFRUGLQJWRILVWXODW\SHGHFOLQHGSUR JUHVVLYHO\IURPW\SH,WKUXW\SH,,%EILVWXODVWKHVDPHFRXOGEHGHPRQVWUDWHGIRUWKH ILVWXODVL]HIURPVPDOOWKUXH[WHQVLYH

WKHcontinence rateRIWKHKHDOHGILVWXODVGHFOLQHGSURJUHVVLYHO\IURPW\SH,WKUXW\SH ,,%EWKHVDPHFRXOGEHGHPRQVWUDWHGIRUILVWXODVL]HIURPVPDOOWKUXH[WHQVLYH

84

LPPHGLDWHPDQDJHPHQWRIIUHVKREVWHWULFILVWXODV E\FDWKHWHUDQGRUHDUO\FORVXUH DFFRUGLQJWREDVLFVXUJLFDOSULQFLSOHV ZLWKSUHYHQWLRQRIWKHZRPDQIURPEHFRPLQJDQRXWFDVW

FDWKHWHU DQ\ZRPDQZKRVWDUWVOHDNLQJXULQHIROORZLQJFKLOGELUWKVKRXOGKDYHDQLQGZHOOLQJ EODGGHUFDWKHWHUZKDWHYHUWKHFDXVH ILVWXODVWUHVVLQFRQWLQHQFHRURYHUIORZLQFRQWLQHQFH DWRQLFEODGGHU  E\LQVHUWLQJDIROH\FDWKHWHUFKIRUDPLQLPXPRIZHHNVDWOHDVWRI WKHILVWXODVZLOOKHDODVZHOODVVWUHVVRYHUIORZLQFRQWLQHQFH

QRDQWLELRWLFV VLQFHWKHILVWXODLVFDXVHGE\SUHVVXUHQHFURVLVDQGQRWE\LQIHFWLRQV\VWHPLF DQWLELRWLFVDUHQRWLQGLFDWHGURXWLQHO\MXVWDVLQEXUQZRXQGV WKHUPDOQHFURVLV  DQGEHGVRUHV DOVRSUHVVXUHQHFURVLV  RQO\RQVSHFLILFLQGLFDWLRQVXFKDVSXHUSHUDOVHSVLVRUSQHXPRQLDDQWLELRWLFV KDYHWREHJLYHQ

RUDOIOXLGLQWDNH DPLQLPXPRIOLWHUVSHUGD\LQRUGHUWRSURGXFHDWOHDVWPORI XULQHSHUKUWRNHHSWKHFDWKHWHURSHQDQGWRSUHYHQWDVFHQGLQJXULQDU\WUDFW LQIHFWLRQ

RUDOKHPDWLQLFV IHUVRODWHDQGIROLFDFLG

KLJKSURWHLQGLHW WRVSHHGXSUHFRYHU\IURPWKHHQRUPRXVWUDXPDRISURORQJHGREVWUXFWHGODERU

VORXJKQHFURVLVRIODUJHUILVWXODV GHEULGHPHQWRIWKHVORXJKDVVRRQDVSRVVLEOHOLNHLQRWKHUW\SHVRISUHVVXUH QHFURVLV EHGVRUHV RUWKHUPDOQHFURVLV EXUQZRXQGV WKLVLVVRXQGVXUJLFDO SUDFWLFH IROORZHGE\UHJXODUWKRURXJKLQWUDYDJLQDOFOHDQLQJRIWKHYDJLQDZRXQGE\WKH SDWLHQWKHUVHOIXVLQJZDWHUGHWHUJHQW

HDUO\FORVXUH DVVRRQDVWKHILVWXODHGJHLVFOHDQDQHDUO\FORVXUHLVSHUIRUPHGXQOHVVWKH ILVWXODKDVKHDOHGDOUHDG\E\FDWKHWHUWKLVLVDOVRVRXQGVXUJLFDOSUDFWLFHDVLW IDOOVZLWKLQWKHWLPHRIWKHSK\VLRORJLFZRXQGKHDOLQJSURFHVVHV

DGYDQWDJHV H[FHOOHQWVXFFHVVUDWHDVWRFORVXUHDQGWRFRQWLQHQFHDQGWKXVSUHYHQWLRQRI WKH ZRPDQJLUO IURP EHFRPLQJ DQ RXWFDVW ZLWK SURJUHVVLYH GRZQJUDGLQJ PHGLFDOO\VRFLDOO\DQGPHQWDOO\

WKHVRRQHUWKLVPDQDJHPHQWLVVWDUWHGWKHEHWWHUWKHFKDQFHRI FRPSOHWHFXUH

 71 89 NHHVSURWRFROFDWKHWHUWUHDWPHQW LPPHGLDWHPDQDJHPHQWREVWHWULFILVWXOD

HYLGHQFHEDVHGSUDFWLFHUHYHDOHGWKDWFDWKHWHUWUHDWPHQWZLWKLQPRQWKVDIWHUGHOLYHU\ PD\SURPRWHWKHVSRQWDQHRXVKHDOLQJRIXULQHILVWXODVLQRIWKHSDWLHQWV LIWKHLQWHUYDOLVORQJHUWKDQPRQWKVWKDWFKDQFHZLOOEHFRPH YHU\ ORZWKRXJKVWLOO SRVVLEOH

WKHUHDUHWZRGLIIHUHQWSURWRFROVIRUWZRGLIIHUHQWVLWXDWLRQV DVHWWLQJVZLWKRXWDQG EVHWWLQJZLWKUHDOILVWXODH[SHUWLVHLQFOXGLQJVXUJHU\

SURWRFRO, LIQRUHDOILVWXODH[SHUWLVHDYDLODEOH

DQ\SDWLHQWZKRLVOHDNLQJXULQHDQGUHSRUWVZLWKLQPRQWKVVLQFHGHOLYHU\

QRLQWUDYDJLQDOH[DPLQDWLRQ

FKHFNRQWKHRXWVLGHLIUHDOO\XULQHIURPYDJLQD

GRQRWZDVWHYDOXDEOHWLPHVLQFHWKHHDUOLHUDFDWKHWHULVLQVHUWHGWKHEHWWHUWKHUHVXOWV

LQVHUWIROH\FDWKHWHUFK RUDQ\RWKHUVL]HDYDLODEOH LPPHGLDWHO\IRUZHHNV

KLJKRUDOIOXLGLQWDNHRIOLWHUVSHUGD\ZDWHUWHDVRXS

HQVXUHIUHHXULQHGUDLQDJHSUHIHUDEO\RSHQLQWRSRW

LQVWUXFWSDWLHQWQRWWREORFNWKHFDWKHWHU E\VLWWLQJRUO\LQJXSRQLWRURWKHUZLVH 

DWWHQGWRKHURWKHUQHHGV

QRURXWLQHDQWLELRWLFVVLQFHLWLVSUHVVXUHQHFURVLV

DQWLELRWLFVRQO\RQLQGLFDWLRQHJSXHUSHUDOVHSVLV

LPPHGLDWHPRELOL]DWLRQRISDWLHQWLIQHFHVVDU\ZLWKVWLFN

RUDOKHPDWLQLFVOLNHIHUVRODWHDQGIROLFDFLGLIQHFHVVDU\V\VWHPLFOLNHLURQGH[WUDQ

KLJKSURWHLQGLHW

FKHFNIRUFRXSOHRIGD\VLISDWLHQWLVIROORZLQJLQVWUXFWLRQV

DQGFKHFNLIXULQHLVIROORZLQJFDWKHWHU

90  72 XULQHVKRXOGEHFOHDUDQGZLWKRXWFRORUOLNHFOHDQZDWHU

LIVRVKHFDQEHWUHDWHGRQDQRXWSDWLHQWEDVHZLWKRQFHDZHHNUHSRUWLQJFKHFNLQJDQG LQVWUXFWLRQV

LIXULQHLVQRWIROORZLQJFDWKHWHUFKHFNLILWLVLQSODFHDQGRUEORFNHG

LIQRWLQSODFHLQVHUWLWWKHULJKWZD\

LIEORFNHGIOXVKRUFKDQJHWKHFDWKHWHU

LIFDWKHWHULVLQSODFHDQGQRWEORFNHGDQGQRWGUDLQLQJDWDOOUHPRYHFDWKHWHUDQGUHIHU SDWLHQWWRDUHDOYYIFHQWHU

LIWKHSDWLHQWVOHDNVOLWWOHLWVWLOOFDQKHDODVORQJDVWKHFDWKHWHULVIXQFWLRQLQJZHOO

UHPRYHFDWKHWHUDIWHUZHHNVDQGLQVWUXFWKHUDJDLQDERXWKLJKRUDOIOXLGLQWDNHDQG UHJXODUO\SDVVLQJXULQHHYHU\WRPLQXWHV

DQGDVNFKHFNWKHGD\DIWHUFDWKHWHUUHPRYDOLIVKHLVGU\RUVWLOOOHDNLQJ

LIVKHLVGU\H[FHOOHQWVLQFHKHDOHGE\FDWKHWHU

LIOHDNLQJOLWWOHLQVWUXFWKHUDERXWRUDOIOXLGVDQGUHJXODUSDVVLQJXULQHDQGFKHFNRQH PRQWKODWHULIGU\ILQHLIVWLOOOHDNLQJDIWHURQHPRQWKUHIHUWRYYIFHQWHU

LIVWLOOOHDNLQJSOHQW\UHIHUVWUDLJKWDZD\WRYYIFHQWHU

SURWRFRO,, LIUHDOILVWXODH[SHUWLVHDYDLODEOHLQFOXGLQJVXUJHU\

UHDOH[SHUWLVHPHDQVWKHGRFWRUKDVDPSOHILVWXODVXUJHU\H[SHULHQFHDQGIDFLOLWLHVDUH DYDLODEOHIRUILVWXODVXUJHU\

DQ\SDWLHQWZKRLVOHDNLQJXULQHDQGUHSRUWVZLWKLQPRQWKVIROORZLQJGHOLYHU\

LISRVVLEOHSHUIRUPJHQWOHYDJLQDH[DPLQDWLRQWRDVVHVVWKHREVWHWULFWUDXPD

LQVHUWIROH\FKFDWKHWHUIRUZHHNV

DQGIROORZWKHVDPHSURWRFROZLWKWKHIROORZLQJDGGLWLRQV

H[DPLQHRQFHDZHHNYDJLQDOO\WRDVVHVVSURVSHFWVRIKHDOLQJRUVXUJHU\

LILWVHHPVKHDOLQJOHDYHFDWKHWHULQVLWXDQGFRQWLQXHSURWRFRO

LIGHILQLWHO\QRWKHDOLQJUHPRYHFDWKHWHUDQGSUHSDUHIRUHDUO\FORVXUH

WKHQLIQHFHVVDU\SHUIRUPGHEULGHPHQWRIVORXJK

 73 91 DQGLQVWUXFWSDWLHQWDERXWVLW]EDWKVZLWKGHWHUJHQWDGHWHUJHQWOLNHRPRRUDULHOLVIUHHO\ DYDLODEOHLQWKHPDUNHWFKHDSDQGKLJKO\HIIHFWLYHDQGVXSHULRUWRH[SHQVLYHDQWLVHS WLFVVRLXVHLWIRUPHP\VHOIDVZHOO

DVVRRQDVZRXQGFOHDQSHUIRUPHDUO\FORVXUH

PRELOL]HSDWLHQWDWDOOWLPHV

DWWHQGWRWKHRWKHUQHHGVRIWKHSDWLHQW

GLVFXVVLRQ WKLVWUHDWPHQWUHJLPHQLVEDVHGRQDSHUVRQDOH[SHULHQFHLQRYHUILVWXODSDWLHQWV RXWRIZKRP NDQRDQGNDWVLQD ZHUHWUHDWHGZLWKLQGD\VDIWHUODERUHLWKHUE\ FDWKHWHURUE\FDWKHWHUIROORZHGE\RSHUDWLRQRUVWUDLJKWDZD\E\RSHUDWLRQ

LWLVWKHEHJLQQLQJRIDQLPPHGLDWHDFWLYHPDQDJHPHQWRIDQ\ZRPDQZKRVWDUWVOHDNLQJ XULQHDIWHUFKLOGELUWK

LIQRWVXFFHVVIXOVKHKDVWREHUHIHUUHGWRDYYIFHQWHUIRUIXUWKHUVXUJLFDOPDQDJHPHQW

LIXSRQYDJLQDOH[DPLQDWLRQWKHILVWXODLVWRRELJRUWKHEDOORRQLVLQVLGHWKHILVWXODWKH FDWKHWHUVKRXOGEHUHPRYHGDQGWKHSDWLHQWUHIHUUHGWRDILVWXODVXUJHRQ

WKHLQGZHOOLQJIROH\FDWKHWHUZLOOGHFRPSUHVVWKHEODGGHUVRWKDWWKHZRXQGHGJHVDUH FRPLQJWRJHWKHUDQGVWD\WRJHWKHUDWOHDVWLQWKHVPDOOHUILVWXODV

WKHLPSRUWDQFHRIDKLJKRUDOIOXLGLQWDNHFDQQRWEHVWUHVVHGHQRXJKWKHFRQVHTXHQW KLJKXULQHRXWSXWZLOOSUHYHQWEORFNDJHRIWKHFDWKHWHUDQGZLOOSUHYHQWDQ\DVFHQGLQJ XULQDU\WUDFWLQIHFWLRQ

LIWKHXULQHLVQRWFOHDUDQGFRORUOHVVDQGRGRUOHVVOLNHZDWHUVKHLVQRWGULQNLQJHQRXJK

WKHLQGLVFULPLQDWHXVHRIDQWLELRWLFVLQQHFURWLFOHVLRQVLVPDOSUDFWLFHDQGOHDGVWR PXOWLUHVLVWDQFH

LIWKHOHDNLQJH[WHQGVEH\RQGPWKDIWHUFKLOGELUWKQRWKLQJFDQEHH[SHFWHGDQ\PRUH IURPFDWKHWHUL]DWLRQ

FRQFOXVLRQ DQ\ZRPDQZKRVWDUWVOHDNLQJXULQHSRVWSDUWXPVKRXOGKDYHDQLQGZHOOLQJEODGGHU FDWKHWHUIRUDSHULRGRIDWOHDVWZHHNVDQGWKHQVKHKDVWRWDNHOLWHUVRIRUDO IOXLGVDGD\WRSURGXFHDPLQLPXPRIOLWHUVRIXULQHSHUKRXUV

LIE\PDVVFDPSDLJQWKLVUHJLPHQZRXOGEHLQVWDOOHGDOORYHUWKHGHYHORSLQJZRUOGLWZLOO SUHYHQWKHDOWKHREVWHWULFILVWXODLQDWOHDVWRIWKHSDWLHQWVDQGWKDWLVPRUHWKDQ DOOILVWXODVXUJHRQVFRPELQHGDUHRSHUDWLQJDWWKHPRPHQWIRUDIUDFWLRQRIWKHFRVWV KRZHYHUWKHSDWLHQWKDVWREHLQVWUXFWHGDQGPRQLWRUHGYHU\FDUHIXOO\

WKRXJKWKHREVWHWULFILVWXODZLOOUHPDLQDPDMRUSXEOLFKHDOWKSUREOHPIRUDWOHDVWDQRWKHU \HDUVFRPLQJLPPHGLDWHEODGGHUFDWKHWHUL]DWLRQZLOOKDYHDPDMRULPSDFW

92  74

ILVWXODVIRUEHJLQQHUV

REMHFWLYHFKDUDFWHULVWLFVE\NHHV

LQWURGXFWLRQ GXHWRYRFDOVWDWHPHQWVE\YHUEDOVXUJHRQVLQWKHLQGXVWULDOL]HGZRUOGDQGSROLWLFDO VWDWHPHQWVE\WKHPDMRUDLGRUJDQL]DWLRQVWKHUHLVDORWRIPLVXQGHUVWDQGLQJDERXW REVWHWULF ILVWXOD VXUJHU\ DQG WUDLQLQJ VXFK DV WKH SDWLHQW FDQ EH FXUHG E\ D VLPSOH RSHUDWLRQDQGEHJLQQHUVQHHGUDSLGKDQGVRQWUDLQLQJIRUDVKRUWSHULRG

KRZHYHUWKHUHDUHQRVLPSOHILVWXODVFRQVLGHULQJWKHFRPSOH[WUDXPDRIWKHREVWHWULF ILVWXODDQGWKHHQRUPRXVYDULHW\LQWLVVXHORVVLWRQO\PD\ORRNVLPSOHLQWKHKDQGVRI WKHIHZH[SHULHQFHGILVWXODVXUJHRQV

VWLOORQHKDVWRVWDUWVRPHZKHUHDQGWKHUHDUHIHZYHVLFRYDJLQDOILVWXODVVXLWDEOHIRU EHJLQQHUVDVEDVHGRQREMHFWLYHILQGLQJVDVWRVL]HORFDWLRQWLVVXHTXDOLW\PRELOLW\RI ILVWXODWLVVXHFHUYL[ ZLGWK RI SXELF DUFK GHSWK RI YDJLQD FRQFRPLWDQW UHFWRYDJLQDO ILVWXODVSKLQFWHUDQLUXSWXUHSUHYLRXVUHSDLUVHWFDOOWKHFKDUDFWHULVWLFVRIDVPDOOW\SH ,,$DILVWXODDUHRXWOLQHGLQRUGHUWRKHOSWUDLQHUVDQGWUDLQHHV

REMHFWLYHFULWHULD EDVHGXSRQDQH[WHQVLYHH[SHULHQFHLQPRUHWKDQFRQVHUYDWLYHDQGVXUJLFDO SURFHGXUHVZLWKH[FHOOHQWHYLGHQFHEDVHGUHVXOWVLQFORVXUHRIWKHILVWXODDIWHURQHRU PRUHRSHUDWLRQVLQPRUHWKDQZLWKVHYHUHLQFRQWLQHQFHLQRQO\WKHUHDUH VRPHILVWXODVZKLFKDUHVXLWDEOHIRUEHJLQQHUVWKHREMHFWLYHFKDUDFWHULVWLFVRIZKLFKDUH RXWOLQHGLQWDEOH,ZLWKGUDZLQJVLQILJDQG

WDEOH,

FKDUDFWHULVWLFVRIILVWXODVIRUEHJLQQHUV

VL]H FP ORFDWLRQ PLGOLQH GLVWDQFHIURPHXRFP FODVVLILFDWLRQ VPDOOW\SH,,$D UXJDIROGV LQWDFW PRELOLW\ JRRGPRELOLW\RIILVWXODWLVVXHVDQGFHUYL[ SXELFDUFK ! ƒ YDJLQDGHSWK ! FP SUHYLRXVRSHUDWLRQ QRFRQWUDLQGLFDWLRQDVORQJDVQRPDMRUVFDUULQJ UHFWRYDJLQDOILVWXOD QRFRQWUDLQGLFDWLRQ QRVHYHUHREHVLW\ REHVLW\PDNHVDQ\RSHUDWLRQFRPSOLFDWHG

94  76

FKDUDFWHULVWLFVFKHFNOLVW

VL]H ILVWXODV FPDUHGLIILFXOWWRKDQGOHDQGQHHGVSHFLDOLQVLJKWDQGRSHUDWLRQSULQFLSOHV

ORFDWLRQ ILVWXODVQRWLQWKHPLGOLQHDUHGLIILFXOWWRKDQGOHVLQFHLQVWUXPHQWKDQGOLQJDQGWLVVXH KDQGOLQJLVFRPSOLFDWHG

GLVWDQFHIURPHXR DQ\SUR[LPDOILVWXODLVGLIILFXOW LQVWUXPHQWKDQGOLQJ DQGLILWLVWRRGLVWDOWKHGHOLFDWH XUHWKUD PDLQFRQWLQHQFHVWUXFWXUH PD\EHWUDXPDWL]HG

FODVVLILFDWLRQ VPDOOW\SH,,$DILVWXODVZKHUH,,PHDQVLQYROYLQJWKHXULQHFRQWLQHQFHPHFKDQLVP$QR VXE WRWDOXUHWKUDLQYROYHPHQWDQGDQRFLUFXPIHUHQWLDOGHIHFW

UXJDIROGV ZKHQWKHUXJDIROGVDUHQRWLQWDFWWKHUHLVIDUPRUHWUDXPDWKDQDQWLFLSDWHGDWILUVWVLJKW DQGRQHKDVWRGHWHUPLQHH[DFWO\WKHDPRXQWRIWLVVXHORVV

PRELOLW\ LI PRELOLW\ LV SRRU WKHQ PRELOL]DWLRQ RI WLVVXH DQG WHQVLRQIUHH FORVXUH PD\ EH FRP SURPLVHGRUHYHQLPSRVVLEOHHYHQDIWHUFORVXUHWKHUHPD\EHWUDFWLRQXSRQWKHUHSDLU VXFKDVZKHQDUHWUDFWHGFHUYL[ DIWHUFHVDUHDQVHFWLRQ LVSXOOLQJRQWKHUHSDLUZKHQWKH SDWLHQWLVFRXJKLQJ

SXELFDUFK LIWKHSXELFDUFKLV ƒWKHQDFFHVVPD\EHSRRUZKLFKZRXOGPDNHWKHRSHUDWLRQ PRUHFRPSOLFDWHG

YDJLQDGHSWK LIWKHYDJLQDGHSWKLV FPWKHUHLVDOUHDG\VXEVWDQWLDOWLVVXHORVV

SUHYLRXVRSHUDWLRQ LIRSHUDWHGE\H[SHUWVXUJHRQWKHUHLVDOPRVWQRVFDUWLVVXHKRZHYHULIRSHUDWHGE\D VXUJHRQZLWKRXWH[SHUWLVHWKHUHPD\EHH[FHVVLYHVFDUWLVVXHDQGPXWLODWLRQ

UHFWRYDJLQDOILVWXOD DUHFWRYDJLQDOILVWXODGRHVQRWLQWHUIHUHZLWKWKHRSHUDWLRQWHFKQLTXHRUKHDOLQJDVSKLQF WHUDQLUXSWXUHPDNHVWKHDFFHVVHYHQEHWWHU KRZHYHUEHJLQQHUVVKRXOGQRWFRPELQHWKHYYIDQGUYILQRQHVHVVLRQEXWFRQFHQWUDWH WRWDOO\RQRQHDWDWLPH

VHYHUHREHVLW\ VHYHUHREHVLW\PDNHVDQ\RSHUDWLRQFRPSOLFDWHGLIVRWKHSDWLHQWVKRXOGORVHZHLJKW GUDVWLFDOO\ILUVWEHIRUHVKHFDQEHRSHUDWHG

DIWHUH[DFWH[DPLQDWLRQE\WKLVFKHFNOLVWWKHVXUJHRQVKRXOGDVNKLPVHOILIKHLVDEOHWR FRQWLQXHRULILWLVEHWWHUWRUHIHUWKHSDWLHQWWRDPRUHH[SHULHQFHGVXUJHRQ

 79 97 SUHRSHUDWLYHSUHSDUDWLRQ

WKHQRUPDOSUHRSHUDWLYHSUHSDUDWLRQVKRXOGEHIROORZHGOLNHLQ DQ\RWKHURSHUDWLRQ VSHFLDOIRUWKHYYILVDEXQGDQWSUHRSHUDWLYHRUDOIOXLGLQWDNHXQWLOWKHVSLQDODQHVWKHVLD ZKLFKZLOOFOHDQWKHILVWXODEODGGHUDQGXULQHDQGK\GUDWHWKHSDWLHQWVRWKDWVSLQDO DQHVWKHVLDEHFRPHVVDIHXUHWHUVFDQEHLGHQWLILHGDQGWKHRFFXUUHQFHRIFDWKHWHU EORFNDJHLVPLQLPDODQGWRHQVXUHSDWLHQWFRPSOLDQFH

RSHUDWLRQWHFKQLTXH

XQGHUVSLQDODQHVWKHVLDDQGLQWKH H[DJJHUDWHG OLWKRWRP\SRVLWLRQDSURSHUH[DPLQD WLRQLVSHUIRUPHGZKHUHE\WKHDERYHQDPHGFKHFNOLVWLVIROORZHGWKHQWKHVXUJHRQ VKRXOGDVNKLPVHOILIKHLVDEOHWRKDQGOHWKLVILVWXODFRPSHWHQWO\ DOLEHUDOXVHVKRXOGEHPDGHRIHSLVLRWRP\WRLPSURYHWKHDFFHVVWRWKHRSHUDWLRQILHOG DQLQFLVLRQLVPDGHDWWKHILVWXODHGJHZLWKELODWHUDOWUDQVYHUVHH[WHQVLRQWKHQPLQLPDO VKDUSGLVVHFWLRQRIWKHDQWHULRUYDJLQDZDOOIURPWKHSXERFHUYLFDOPXVFXORIDVFLD ZLWK DGKHUHQWEODGGHUXUHWKUD LGHQWLILFDWLRQRIWKHSXERFHUYLFDOIDVFLDDWUDQVYHUVHFORVXUH RIWKHSXERFHUYLFDOIDVFLD ZLWKDGKHUHQWEODGGHUXUHWKUD LVPDGHE\DVLQJOHOD\HURI LQYHUWLQJSRO\JO\FROLFDFLGWKHSDWLHQWLVDVNHGWRFRXJK ZLWKXULQHLQWKHEODGGHU WR FKHFNIRUXULQHOHDNDJHWKUXVXWXUHOLQHRUXULQHWKUXHXR DIROH\FDWKHWHUFKLVLQVHUWHGDQGLWLVFKHFNHGLIXULQHIORZVWKUXWKHFDWKHWHUZKLFK PHDQVWKLQJVFDWKHWHULVLQWKHEODGGHUDWOHDVWRQHXUHWHULVIXQFWLRQLQJDQGWKH SDWLHQWLVQRWLQVKRFN WKHEODGGHUFDSDFLW\LVHVWLPDWHGDQGWKHXUHWKUDOHQJWKLVPHDVXUHGLQFP WKHDQWHULRUYDJLQDZDOOLVRQO\DGDSWHGZLWK[HYHUWLQJ QRQ DEVRUEDEOHVXWXUHV DFFRUGLQJWRWKHSULQFLSOHVRIVHSWLFVXUJHU\ WKHHSLVLRWRP\LVFORVHGDQGVHFXUHFKHFNPDGHRIWKHKHPRVWDVLVDVURXWLQHDYDJLQD SDFNLVQRWLQVHUWHGXQOHVVWKHUHVKRXOGEHGLIIXVHRR]LQJZKLFKFDQQRWEHFRQWUROOHG RWKHUZLVH DQ HOHFWURQLF RSHUDWLRQUHSRUWLVZULWWHQLPPHGLDWHO\DIWHUILQLVKLQJWKHUHSDLUFRPSULV LQJDOOWKHUHOHYDQWSDUDPHWHUVDOVRLQFOXGLQJDGUDZLQJRIWKHILVWXOD

SRVWRSHUDWLYHFDUH

LQWHQVLYHFDUHLVQRUPDOO\RQO\IRUKRXUVZLWKOLEHUDOXVHRIDQDOJHVLFGUXJVQR PRUSKLQHRUPRUSKLQHGHULYDWLYHVVLQFHWKHVHLQWHUIHUHZLWKEUHDWKLQJ WKHIROORZLQJPRUQLQJWKHSDWLHQWVKDYHWREHPRELOL]HGOLNHDIWHUDQ\RWKHURSHUDWLRQ EHVLGHVJRRGIRUWKHLUJHQHUDOKHDOWKLWLVDOVRJRRGIRUSUHYHQWLRQRUWUHDWPHQWRIFRQ WUDFWXUHV DEXQGDQWIOXLGLQWDNHIRUDVORQJDVWKHUHLVIROH\FDWKHWHULQVHUWHGZKLFKLVOHIWLQIRUD PLQLPXPSHULRGRIGD\VLIQRQDEVRUEDEOHVXWXUHVKDYHEHHQXVHGIRUDGDSWDWLRQRI WKHDQWHULRUYDJLQDZDOOWKHVHDUHUHPRYHGZHHNDIWHUFDWKHWHUUHPRYDO XSRQFDWKHWHUUHPRYDOWKHSDWLHQWVLVLQVWUXFWHGWRFRQWLQXHDEXQGDQWRUDOIOXLGLQWDNH DQGWRXULQDWHIUHTXHQWO\WRUHIUDLQIURPVH[IRUPRQWKVWRFRPHIRUUHJXODUIROORZ XSXSWLOOPRQWKVSRVWRSHUDWLYHO\WRUHSRUWZKHQPRQWKSUHJQDQWDQGWRJRLPPHGL DWHO\ZKHQODERUSDLQVVWDUWWRDKRVSLWDODWVXEVHTXHQWGHOLYHULHV GXULQJWKHUHFRYHU\SKDVHDOOWKHSDWLHQWVDUHDWWHQGLQJUHKDELOLWDWLRQFRXUVHVLQVSHFLDO FHQWHUVOLNHOLWHUDF\FODVVPDNLQJVRDSVHZLQJHWF

98  80 HYLGHQFHEDVHGUHVXOWV

RXWRISDWLHQWVRSHUDWHGGXULQJWKHSHULRGLQNDWVLQDNDQR]DULDDQG QJXUXZKHUHWKHUHDUHUHOLDEOHIROORZXSGDWDRQO\  IXOILOOHGWKHDERYH RXWOLQHGFULWHULD WKHHYLGHQFHEDVHGSRVWRSHUDWLYHUHVXOWVKDYHEHHQDQDO\]HGLQWDEOH,,

WDEOH,, UHVXOWVLQSDWLHQWVRSHUDWHGGXULQJWKHSHULRG

KHDOHGILUVWDWWHPSW    KHDOHGVHFRQGDWWHPSW  ZKLOVWGLGQRWUHSRUWIRUDQRWKHUUHSDLU SRVWUHSDLUFRQWLQHQFHVXUJHU\  DOOWRWDOO\FRQWLQHQW KHDOHGILQDORXWFRPH    SHUVLVWHQWLQFRQWLQHQFHRQO\   KRZHYHUWKH\GLGQRWUHSRUWIRULQFRQWLQHQFHVXUJHU\ PRUWDOLW\    QDWLYHPHGLFLQHFHUHEURVSLQDOPHQLQJLWLV

GLVFXVVLRQ

DVDVWDUWWKHEHJLQQHUVKRXOGVWLFNWRWKHVHSULQFLSOHVLQRUGHUWRJHWJRRGUHVXOWVPRUH H[SHULHQFHDQGDV\VWHPDWLFDSSURDFK

RQFH V KHKDVSHUIRUPHGVRPHUHSDLUVZLWKJRRGUHVXOW V KHQRZFDQH[SDQG KHUKLVUHFRQVWUXFWLYHVXUJHU\WRRWKHUW\SH,,$DDQGW\SH,ILVWXODV

KDYLQJSHUIRUPHGVRPHUHSDLUVZLWKJRRGUHVXOWV V KHQRZFDQVWDUWZLWKVPDOO W\SH,,$EILVWXODV

VLQFHW\SH,,%DDQGHYHQPRUHVRW\SH,,%EILVWXODVDUHYHU\FRPSOLFDWHG V KHVKRXOG VWDUWKDQGOLQJWKHVHW\SHVRQO\LI V KHLVYHU\FRQILGHQWZLWKW\SH,,,$DDQG,,$E

QELIDWDQ\SRLQWGXULQJRSHUDWLRQLWEHFRPHVWRRFRPSOLFDWHGSOHDVHWHUPLQDWHWKH RSHUDWLRQDQGUHIHUWKHSDWLHQWWKDWLVEHWWHUWKDQWRFRQWLQXHDQGPDNHLUUHSDLUDEOH GDPDJH   UHPHPEHU\RXDUHQRWWKHRQHZKRFDXVHGWKHILVWXOD

ILUVWHGLWLRQ GHFHPEHU

ILQDOHGLWLRQ IHEUXDU\

 81 99 SRVWSDUWXPXULQHLQFRQWLQHQFH REVWHWULFWUDXPDZLWK RXW DQDWRPLFWLVVXHORVV

LQWURGXFWLRQ

WKHUHLVDOVRXULQHOHDNDJHGXHWRREVWHWULFWUDXPDKRZHYHUZLWKRXWWLVVXHORVVDQGWKH REVWHWULFWUDXPDVXUJHRQKDVWREHIDPLOLDUZLWKWKLV

WKHQWKHUHLVREMHFWLYHVWUHVVXUJHLQFRQWLQHQFHFRPELQHGZLWKDVPDOOPLQXWHILVWXOD

VRWKHILUVWSULRULW\LVWRLGHQWLI\WKHFDXVHRIWKHXULQHLQFRQWLQHQFH

DQGWKHVHFRQGLVWRSURPRWHVSRQWDQHRXVKHDOLQJE\LQGZHOOLQJEODGGHUFDWKHWHURULI WKDWLVQRWVXFFHVVIXOE\PHWLFXORXVUHSDLURIWKHGHIHFWVLISRVVLEOHZKLOVWKLJKRUDOIOXLG LQWDNHLVDPXVW

SRVWSDUWXPLQWULQVLFLQFRQWLQHQFH

DVGXHWRPHGLDQGHIHFWVZLWKLQWKHHQGRSHOYLFGLDSKUDJPRUDQRYHUVWUHWFKHGORRVH HQGRSHOYLFGLDSKUDJPVRWKDWWKHVXSSRUWRIWKHSRVWHULRUEODGGHUXYMXQFWLRQXUHWKUDLV LQVXIILFLHQWDQGWKHVHVWUXFWXUHVZLOOURWDWHEDFNZDUGIURPWKHV\PSK\VLVZLWKIXQQHOLQJ RISUR[LPDOPLGRUZKROHXUHWKUDDQGGHFUHDVHLQRXWIORZUHVLVWDQFH HTXLYDOHQWWRWK SRZHURIUDGLXVRIXUHWKUDGLDPHWHU 

VSRQWDQHRXVKHDOLQJLVSRVVLEOHEXWWKHIROORZLQJLVEHWWHU LPPHGLDWHFDWKHWHUWUHDWPHQWIRUZHHNVPD\SURPRWHVSRQWDQHRXVKHDOLQJIROORZHG E\SHOYLVIORRUH[HUFLVHVLIQRFXUHREWDLQHGWKHUHVSRQVLEOHORQJLWXGLQDOPHGLDQGHIHFW ZLWKLQWKHHQGRSHOYLFGLDSKUDJPKDVWREHUHSDLUHG

SRVWSDUWXPK\SRWRQLFEODGGHUZLWKRYHUIORZLQFRQWLQHQFH

SUREDEO\ GXH WR SK\VLFDO EUHDNDJHWUDXPD RI VPRRWK PXVFOH ILEHUV RI WKH GHWUXVRU PXVFOHGXHWRRYHUVWUHWFKLQJILOOLQJRIWKHEODGGHUGXULQJGHOLYHU\VLQFHXUHWKUDEORFNHG E\WKHLQIDQWKHDG

VSRQWDQHRXVKHDOLQJLVSRVVLEOHYLDJHQXLQHLQWULQVLFLQFRQWLQHQFHRULQWHUPLWWHQWVHOI FDWKHWHUL]DWLRQKRZHYHUWKHEODGGHUUHPDLQVIXOORULVILOOLQJXSDJDLQDIWHUHDFKVHOI FDWKHWHUL]DWLRQLQWHUIHULQJZLWKWKHSK\VLRORJLFKHDOLQJSURFHVVHV

WKHIROORZLQJPDNHVPRUHVHQVH LPPHGLDWHEODGGHUFDWKHWHUIRUZHHNVZLWKFRPSOHWHGHFRPSUHVVLRQRIWKHEODGGHU DWDOOWLPHVLQRUGHUIRUWKHVPRRWKPXVFOHILEHUVWRKHDO

100  82 XYVWULFWXUHZLWKRYHUIORZLQFRQWLQHQFHDQGG\VXULD

WKLVPD\EHGXHWRVFDUULQJDIWHUVXEILVWXODWUDXPDDQGVLQFHLWPD\EHWKHFDXVHRUWKH VHTXHODPLQXWHILVWXODKDVWREHH[FOXGHGE\DG\HWHVW

DQGQHHGV UHSHDW JUDGXDOGLODWDWLRQZLWKLQGZHOOLQJFDWKHWHUIRUZHHNVDQGKLJKRUDO IOXLGLQWDNH

LIQRFXUHREWDLQHGDVXUJLFDOUHYLVLRQRIWKHXYMXQFWLRQLVQHHGHGZLWKH[FLVLRQRIDOO VFDUWLVVXHDQGUHDQDVWRPRVLVRIEODGGHUQHFNWRSUR[LPDOXUHWKUDRUEXFFDOPXFRVD SODVW\

QHXURORJLFLQFRQWLQHQFH

WKLVLVWKHRUHWLFDOO\SRVVLEOHWKRXJKGLIILFXOWWRGLDJQRVHDQGVHHPVLQIUHTXHQW

REVWHWULFILVWXODVFRPELQHGZLWKVWUHVVXUJHLQFRQWLQHQFH

HVSHFLDOO\DIWHUILVWXODUHSDLUZLWKPLQXWHVPDOOUHVLGXDOILVWXODVYLVLEOHDQGQRQYLVLEOHDW GLUHFWLQVSHFWLRQZKHUHE\WKHVFDUULQJIXQFWLRQVOLNHHFWRSLFSDFHPDNHUDQGSUHYHQWV SK\VLRORJLFIXQFWLRQLQJRIWKHFRQWLQHQFHPHFKDQLVP DQGDG\HWHVWLVQHFHVVDU\WRGHPRQVWUDWHRUH[FOXGHWKHILVWXOD DQG DIUHTXHQWILQGLQJDVFRPELQHGZLWKXUHWHUILVWXODVW\SH,,,

RQFHWKHILVWXODKDVKHDOHGRUWKHXUHWHUKDVEHHQVXFFHVVIXOO\UHLPSODQWHGQRUPDOO\ WKHLQFRQWLQHQFHZLOOKHDODVZHOO

SRVWUHSDLUSRVWGHOLYHU\LQFRQWLQHQFH

LQSDWLHQWVZKRKDGDVXFFHVVIXOUHSDLUZLWKIXOOFRQWLQHQFHDQGZKRVWDUWHGWROHDN DJDLQZLWKRXWDILVWXODIROORZLQJDVXEVHTXHQWGHOLYHU\VHHQH[WFKDSWHU

ZLWKLQWKHILUVWPRQWKVDIWHUGHOLYHU\WKHSDWLHQWVPD\EHQHILWIURPLQGZHOOLQJFDWKHWHU IRUZHHNVDQGKLJKRUDOIOXLGLQWDNHKRZHYHUPRVWRIWKHPZLOOQRWEHFXUHG

DIWHUDQHZRUUHVLGXDOILVWXODKDVEHHQH[FOXGHGE\DG\HWHVWLQFRQWLQHQFHVXUJHU\ZLOO EH QHFHVVDU\ ZKHUHE\ DQ HIIRUW KDV WR EH PDGH WR LGHQWLI\ DQG WKHQ UHSDLU DOO WKH UHVSRQVLEOHGHIHFWVZLWKLQWKHHQGRSHOYLFGLDSKUDJPDQGLWVVXVSHQVLRQIURPLQVHUWLRQ LQWRWKHSHOYLVZDOO

 83 101 SRVWUHSDLUXULQHLQFRQWLQHQFH RSHUDWLRQVXFFHVVIXOSDWLHQWVWLOOOHDNLQJ

PDLQSUREOHP WKRXJKFORVXUHRIWKHILVWXODLVSRVVLEOHLQRYHURIWKHSDWLHQWVWKHRFFXUUHQFHRI SHUVLVWLQJSRVWUHSDLUXULQHLQFRQWLQHQFHORQJHUWKDQPRQWKVDIWHUUHSDLULVWKHODUJHVW PDMRUSUREOHPLQYYIVXUJHU\ZKLFKKDVQRW\HWEHHQIXOO\VROYHG VRDOUHDG\DWILUVWDWWHPSWDQHIIRUWVKRXOGEHPDGHWRUHVWRUHFRQWLQHQFHDVZHOO

UHVSRQVLEOHIDFWRUV VHHEDVLFVFLHQFHFKDSWHUPHFKDQLVPRIXULQHLQFRQWLQHQFHLQWKHIHPDOH

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

YLVXDOFRQILUPDWLRQ XULQHORVVWKUXWKHH[WHUQDOXUHWKUDRSHQLQJ HXRPXVWEHFRQILUPHGREMHFWLYHO\E\WKH VXUJHRQZLWK RXW FRXJKLQJLIQRXULQHORVVWKUXHXRWKHUHPD\VWLOOEHDILVWXOD

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

VXUJLFDOPDQDJHPHQW VLQFHDPLQXWHILVWXODZLOODFWDVSDFHPDNHUZLWKREMHFWLYHXULQHORVVWKUXHXRZLWK RXW  FRXJKLQJWKLVKDVWREHH[FOXGHGE\DG\HWHVW E\XSWRDWOHDVWPO XQGHUVSLQDO DQHVWKHVLDEHIRUHWKHVXUJHU\LVVWDUWHGE\FORVXUHRIWKHPLQXWHILVWXODQRUPDOO\WKH LQFRQWLQHQFHZLOOGLVDSSHDU LIQRILVWXODGHWHFWHGLGHQWLI\WKHGHIHFW V UHVSRQVLEOHIRUWKHLQFRQWLQHQFHOLNHXUHWKUD WRRVKRUWDQGRUWRRRSHQDQGRUPHGLDQRUWUDQVYHUVHGHIHFWVLQWKHSXRFHUYLFDOPXVFX ORIDVFLDDVSDUWRIWKHLQWUDSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJPRULWVIL[DWLRQRQWRDWI

LUUHSDLUDEOHLQFRQWLQHQFH VWLOOWKHUHUHPDLQSDWLHQWVZLWKLUUHSDLUDEOHLQFRQWLQHQFHVHHVSHFLDOFKDSWHU

102  84

LUUHSDLUDEOHLQFRQWLQHQFHVXUJHU\EDKDQ\D DGYDQFHGOHYHO

WKRXJKSURJUHVVKDVEHHQPDGHLQSUHYHQWLQJDQGWUHDWLQJSRVWUHSDLULQFRQWLQHQFH LUUHSDLUDEOHLQFRQWLQHQFHVWLOOFRQWLQXHVWREHWKHPDMRUFKDOOHQJHZKLFKKDVQRW\HWEHHQ VROYHG

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³GLDUUKHLF´E\PL[LQJWKHGLVWDOVWRROZLWKXULQH DQG ODVWO\ PDQ\ SDWLHQWV DUH YHU\ XQKDSS\ ZLWK LW HVSHFLDOO\ WKH QLJKWO\VRLOLQJDQG ³VKLWWLQJOLNHDFKLFNHQ´

XUHWHURVLJPRLGRVWRP\ IDUOHVVFRPSOLFDWHGDQGIDUOHVVWUDXPDWL]LQJKRZHYHUZLWKVDPHRXWFRPH

PLWURIDQRIISULQFLSOH WKLVVHHPVWREHDEHWWHURSWLRQVLQFHQRWVRFRPSOLFDWHGDQGXULQHVWRUDJHVWD\VLQVLGH WKHEODGGHUDVSK\VLRORJLFUHVHUYRLU KRZHYHUODWHVWHQRVLVRIDSSHQGL[VNLQRSHQLQJPD\GHYHORSDQGLWQHHGVJRRGSDWLHQW FRPSOLDQFHVLQFHWLPHVGDLO\VHOIFDWKHWHUL]DWLRQWRHPSW\WKHEODGGHUFRPSOHWHO\ RWKHUZLVHVWRQHIRUPDWLRQPD\EHWKHUHVXOW

VXUJHU\IRUVHYHUHYDJLQDVWHQRVLV EDKDQ\D NHHVQHRYDJLQD

QHHGVVHULRXVSDWLHQWFRPSOLDQFHVLQFHQHZO\FUHDWHGYDJLQDKDVWREHNHSWRSHQ

VLJPRLGQHRYDJLQD WKLVLVDQHVWDEOLVKHGSURFHGXUHKRZHYHULWLVFRPSOLFDWHGZLWKJUDYHFRPSOLFDWLRQV QHHGVJHQHUDODQHVWKHVLDDQGUHTXLUHVDPSOHH[SHULHQFHLQFRORUHFWDODQGUHFRQVWUXF WLYHSHOYLVVXUJHU\

FUHDWLRQRINHHVQHRYDJLQDXVLQJWKHYDJLQDURXWH WKHDXWKRUKDVGHYHORSHGDVDIHWHFKQLFEDVHGRQWKHIXQFWLRQDOSHOYLVDQDWRP\ZLWK JRRGUHVXOWV KRZHYHULWUHTXLUHVH[DFWWKHRUHWLFDQGSUDFWLFDODQDWRPLFNQRZOHGJHDQGDGYDQFHG OHYHOVXUJLFDOVNLOOV

 86 105 total cervix prolapse

NHHSLQJSURFUHDWLRQLQWDFW

LQWURGXFWLRQ VLQFHZHGHDOZLWKWKHREVWHWULFWUDXPDLQDOOLWVIRUPVPDQ\SDWLHQWVFRPHIRUZDUGZLWK WRWDOƒFHUYL[SURODSVH WKHLQFLGHQFHDQGSUHYDOHQFHDUHXQNQRZQEXWLWPXVWEHHTXDORUHYHQVXUSDVVLQJWKDW RIWKHREVWHWULFILVWXOD WKHUHDUHW\SHVDQGPHFKDQLVPV

type I ZLGHSXELFDUFK!ƒ SHOYLVLQOHWWRREURDG VLQFHWKHGLVWDQFHLVWRRZLGHDQGWKH DEGRPLQDOSUHVVXUHWRRPXFKIRUWKHFHUYL[RUGXULQJODERUWKHFHUYL[FRPHVWRRPXFK GRZQDQGWKHFHUYL[XWHUXVSXOORQWRWKHHQGRSHOYLFGLDSKUDJPVDFURXWHULQHOLJDPHQWV DQGFDUGLQDOOLJDPHQWVGUDJJLQJWKHVHVWUXFWXUHVGRZQDQGRXWVLGHWKHYXOYD VLQFHWKHEODGGHUXUHWKUDDUHDQWHULRUO\DGKHUHQWWRWKHV\PSK\VLVDEGRPLQDOZDOOWKH SRVWHULRUEODGGHULVGUDJJHGZLWKLWVLQFHLWLVDGKHUHQWWRWKHHQGRSHOYLFGLDSKUDJPZLWK DQLQFUHDVHLQEODGGHUFDSDFLW\ ORQJLWXGLQDOGLDPHWHU!FP  GXULQJWKLVSURFHVVWKHXUHWKURYHVLFDOMXQFWLRQDQGSUR[LPDOXUHWKUDRSHQXS YHVLFD OL]DWLRQ ZLWKDGHFUHDVHLQXUHWKUDOHQJWKZKLOVWWKHFRQWLQHQFHSRWHQWLDOZLWKLQWKH XUHWKUDVKLIWVGLVWDOO\WRZDUGVWKHH[WHUQDOXUHWKUDRSHQLQJZLWKQDUURZLQJRIWKHGLVWDO XUHWKUDDQGH[WHUQDORSHQLQJ QRUPDOO\WKHSDWLHQWLVIXOO\FRQWLQHQWHYHQZLWKDUHPDLQLQJXUHWKUDOHQJWKRIRQO\ FPHYHQDIWHUUHGXFWLRQRIWKHSURODSVHVLQFHWKHDQWHULRUSXERFHUYLFDOPXVFXORIDVFLDLV LQWDFWZLWKDQLQWDFWIL[DWLRQRQWRWKHSDUDXUHWKUDODUFXVWHQGLQHXVIDVFLDH WKLVLVWKHW\SHFRPPRQO\VHHQLQWKHLQGXVWULDOL]HGZRUOGZKHUHDJHLQJSURFHVVHVSOD\ DUROHDVZHOO LQWKHGHYHORSLQJZRUOGLWPD\EHVHHQDOVRLQ\RXQJJLUOVRI\HDUVDIWHURQO\RQH GHOLYHU\

type II QDUURZQRUPDOSXELFDUFKLQDVVRFLDWLRQZLWKH[WHQVLYHREVWHWULFWLVVXHWUDXPDFLUFXP IHUHQWLDOILVWXODZKHUHE\DPDMRUSDUWRIWKHHQGRSHOYLFGLDSKUDJP ZLWKFDUGLQDODQG VDFURXWHULQHOLJDPHQWV KDVEHHQORVWRUVHULRXVO\GDPDJHGE\SUHVVXUHQHFURVLVGXHWR REVWUXFWHGODERU

RSHUDWLRQWHFKQLTXH WRWDOO\LQOLQHZLWKWKHIXQFWLRQDOSHOYLVDQDWRP\

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

106 WKHQZLWKRXWIXUWKHUGLVVHFWLRQWZRWKLFNQRQDEVRUEDEOHQ\ORQVXWXUHVDUHSODFHG WKUXWKHVXSUDVSLQRXVSDUWRIWKHLVFKLXPERQHSHULRVWDQGREWXUDWRULQWHUQXVPXVFOH IURQWDOO\IURP ZKHUHWKHSDUDPHWULXPLVDWWDFKHGWRWKHSHOYLVZDOO

DQGWKHQWKUXWKHSRVWHULRUFHUYL[ZLWKWKHILUVWVXWXUHDQGWKUXWKHDQWHULRUFHUYL[ ZLWK DGKHUHQWSXERFHUYLFDOPXVFXORIDVFLDHQGRSHOYLFGLDSKUDJP ZLWKWKHVHFRQGVXWXUH

DIWHUEULQJLQJWKHFHUYL[LQWRFRQWDFWZLWKWKHREWXUDWRULQWHUQXVPXVFOHWKHVHVXWXUHV DUHWLHGZLWKRXWDORRVHORRS

VRWKDWWKHFHUYL[ ZLWKDGKHUHQWHQGRSHOYLFGLDSKUDJP FRPHVLQWRGLUHFWEURDGFRQWDFW ZLWKWKHREWXUDWRULQWHUQXVPXVFOH

WKHXULQHLVFKHFNHGIRUEORRGZKLFKZRXOGPHDQWKHEODGGHUKDVEHHQWUDXPDWL]HGEXW VLQFHHYHU\WKLQJLVSHUIRUPHGXQGHUGLUHFWYLVLRQWKLVKDVQRWKDSSHQHGVRIDU

WKHDQWHULRUYDJLQDZDOOLVOHIWRSHQLQFORVHFRQWDFWZLWKWKHODWHUDOVLGH

WKHQWKHIL[DWLRQLVFKHFNHGWKHDPRXQWRIHOHYDWLRQDWWKH/VLGHHVWLPDWHGDQGDJDLQ WKHXUHWKUDOHQJWKPHDVXUHGDOVRWKHSDWLHQWLVDVNHGWRFRXJKLQRUGHUWRFKHFNLIWKHUH LV XULQH LQFRQWLQHQFH D FDUHIXO FKHFN XSRQ KHPRVWDVLV LV PDGH DQG WKH SDWLHQW WUDQVIHUUHGWRWKHZDUG

WKHQRQDEVRUEDOHVXWXUHVDUHUHPRYHGPRQWKVDIWHURSHUDWLRQWKRXJKWKH\FRXOG UHPDLQIDUORQJHUVLQFHWKH\DUHPRQRILODPHQWQ\ORQ remarks WKHIL[DWLRQLVSHUIRUPHGRQO\XQLODWHUDOO\WRNHHSWKHRSHUDWLRQWRWKHPLQLPXPDVZHOO RQO\DODUJHFHUYL[FRXOGEHIL[HGELODWHUDOO\WKLVZD\VLQFHRWKHUZLVHWKHFHUYL[ZRXOG WHDURXWLILWVKRXOGIDLORULIWKHSDWLHQWLVQRWVDWLVILHGZLWKWKHUHVXOWWKHRWKHUVLGHFDQ EHIL[HGDWDVHSDUDWHVHVVLRQ

LWGRHVQRWPDNHVHQVHWRSHUIRUPDK\VWHUHFWRP\VLQFHLWFRPSOLFDWHVWKHRSHUDWLRQ XQQHFHVVDULO\DQDGGLWLRQDOVXUJLFDOWUDXPDDVZHOOWKH\RXQJSDWLHQWVZRXOGOLNHWR KDYHPRUHFKLOGUHQDQGWKHHOGHUO\SDWLHQWVRQO\ZDQWWKHFHUYL[WREHLQVLGH

QRUPDOO\DWWKHHQGRIWKHRSHUDWLRQWKHUHLVQRVLJQRIXULQHLQFRQWLQHQFHWKHXUHWKUD OHQJWKKDVLQFUHDVHGE\DWOHDVWFP UHXUHWKUDOL]DWLRQ VLQFHWKHHQGRSHOYLFGLD SKUDJP DGKHUHQWWRWKHFHUYL[ KDVEHHQWLJKWHQHGE\LWVIL[DWLRQRQWRLVFKLXPERQH SHULRVWREWXUDWRULQWHUQXVPXVFOH

DVZHOOWKHUHLVQRORQJHUPDMRUF\VWRFHOHWKRXJKWKHUHPD\EHVRPHURWDWLRQDOGHVFHQW RQWKHVLGHRSSRVLWHWRWKHIL[DWLRQ conclusion WKLVLVDYHU\SURPLVLQJWHFKQLTXHDOVRLQWKHLQGXVWULDOL]HGZRUOGDQGKDVEHFRPHWKH VWDQGDUGRSHUDWLRQ

107

PDQDJHPHQWRIWKHVWRROILVWXOD

PDQDJHPHQWUYI

FODVVLILFDWLRQRIUYI

VXUJLFDOSULQFLSOHVRIUYIUHSDLU

VSKLQFWHUDQLUXSWXUH

VWRROVIODWXVLQFRQWLQHQFHZLWKRXWVSKLQFWHUDQLUXSWXUH



SUHLQWUDDQGSRVWRSHUDWLYHPDQDJHPHQWRIUYI

WKHEHWWHUWKHRUJDQL]DWLRQRIWKHSUHRSHUDWLYHSUHSDUDWLRQRIWKHRSHUDWLRQWKHDWHU DQGRIWKHSRVWRSHUDWLYHFDUHWKHEHWWHUWKHRXWFRPHRIILVWXODVXUJHU\DQGWKHEHWWHU WKHFKDQFHRIVRFLDOUHKDELOLWDWLRQ KRZHYHULWFDQQRWEHVWUHVVHGHQRXJKWKDWWKHZHDNHVWSRLQWRIILVWXODVXUJHU\LQWKH GHYHORSLQJZRUOGLVWKHSRRUQXUVLQJFDUH

SUHRSHUDWLYHSUHSDUDWLRQ RUDOKHPDWLQLFVDQGKLJKSURWHLQGLHWQRDQWLELRWLFV

ODERUDWRU\ +E+W

;UD\VDUH QRWUHFRPPHQGHG

H[DPLQDWLRQ QRUPDOYDJLQDOH[DPLQDWLRQDWILUVWYLVLWDQGWKHGD\EHIRUHVXUJHU\ HXD H[DPLQDWLRQXQGHUDQHVWKHVLD LVXWWHUO\QRQVHQVHLILWLVQRWIROORZHGXS LPPHGLDWHO\E\VXUJHU\LQWKHVDPHVHVVLRQ

DQHVWKHVLD VSLQDODQHVWKHVLDZLWKDORQJDFWLQJDJHQWHJK\SHUEDULFEXSLYDFDLQH

PDQSRZHU RQO\WKHVXUJHRQDQGRQHLQWUXPHQWDWLQJRSHUDWLRQWKHDWHUQXUVH RQHUHWUDFWRULQVLGHWKHYDJLQDLVDOUHDG\DFURZG

VSHFLDOLQVWUXPHQWV VHOIUHWDLQLQJ ZHLJKWHG DXYDUG VSHFXOXP ORQJ YDJLQDO LQVWUXPHQWV VKDUSO\ FXUYHGWKRUHNVFLVVRUVVKDUSGHVFKDPSVDQHXU\VPQHHGOH

VXWXULQJPDWHULDOV SRO\JO\FROLF DFLG DQG Q\ORQ H[SHQVLYH DWUDXPDWLF VXWXULQJ PDWHULDOV DUH QRW UHTXLUHG

RSHUDWLRQURXWH WKHYDJLQDLQW\SH,WKURXJKW\SH,,EILVWXODVH[FHSWLRQDOO\DVLQW\SH,FDQG,,, ILVWXODVRWKHUURXWHVPD\EHQHFHVVDU\

SRVLWLRQRQWKHRSHUDWLRQWDEOH H[DJJHUDWHGOLWKRWRP\SRVLWLRQZLWKWKHOHJVIOH[HGDQGVOLJKWO\DEGXFWHGLQWKH OHJKROGHUV

DFFHVVLELOLW\ E\PHGLDQXQLRUELODWHUDOHSLVLRWRPLHV

 91 111 H[DPLQDWLRQXQGHUDQHVWKHVLD WKLV LV GRQH E\ DQ\ VXUJHRQ IRU ZKDWHYHU VXUJHU\ DW WKH EHJLQQLQJ RI DQ\ RSHUDWLRQWKHILVWXODLVFODVVLILHGDQGDILQDOGHFLVLRQWDNHQKRZWRWDFNOHWKLV VSHFLILFILVWXOD

FODVVLILFDWLRQRIILVWXODVDFFRUGLQJWRDQDWRPLFSK\VLRORJLFORFDWLRQ , SUR[LPDOILVWXODV D ZLWKRXWUHFWXPVWULFWXUH E ZLWKUHFWXPVWULFWXUH F ZLWKFLUFXPIHUHQWLDOGHIHFW  YHU\VHOGRP ,, GLVWDOILVWXODV D ZLWKRXWVSKLQFWHUDQLLQYROYHPHQW E ZLWKVSKLQFWHUDQLLQYROYHPHQW ,,, PLVFHOODQHRXVHJLOHRXWHULQHILVWXODVDIWHULQVWUXPHQWDODERUWLRQ

IXUWKHUFODVVLILFDWLRQDVWRVL]H VPDOO  FP PHGLXP FP ODUJH  FP H[WHQVLYH !FP

RSHUDWLRQ DLUWLJKWFORVXUHRIUHFWXPZKLOVWKDOIRSHQDGDSWDWLRQRUHYHQQRFORVXUH DWDOORISRVWHULRUYDJLQDZDOO SULQFLSOHVRIVHSWLFVXUJHU\  W\SH,D WUDQVYHUVHFORVXUHRIUHFWXP W\SH,E ZLWKGLVUXSWLRQRIUHFWXPVWULFWXUH W\SH,F DEGRPLQR YDJLQDO DSSURDFK ZLWK HQGWRHQG DQDVWRPRVLVFROR VWRP\

W\SH,,D WUDQVYHUVHRUORQJLWXGLQDOFORVXUHRIUHFWXPFRPPRQVHQVH W\SH,,E ZLWKVSKLQFWHUDQLSHULQHDOERG\UHFRQVWUXFWLRQ

W\SH,,, GHSHQGLQJXSRQWKHVLWXDWLRQ

YDJLQDSDFN QRURXWLQHYDJLQDSDFNJRRGFKHFNRQKHPRVWDVLV

SHULRSHUDWLYHDQWLELRWLFV QRURXWLQHRQO\LQFRPSOLFDWHGUHSDLUVHJGLVUXSWLRQRIUHFWXPVWULFWXUH WLQLGD]ROHJSHURVDQGRQHVKRWRIEURDGVSHFWUXPDQWLELRWLFVLPDWEHJLQQLQJ RIDQHVWKHVLDRSHUDWLRQ

FRORVWRP\ WKLVLVQRWFXUDWLYHEXWDKHOSRQO\LILWFDQEHJXDUDQWHHGWKDWZHHNVDIWHU FRORVWRP\WKHUYILVUHSDLUHGDQGWKDWZHHNVDIWHUVXFFHVVIXOUHSDLUWKHFR ORVWRP\LVFORVHG

QRVROLGIRRGSRVWRSHUDWLYHO\IRUGD\V LQRUGHUWRKDYHVRIWDQGOHVVEXON\VWRROV

OD[DWLYHVOLNHOLTXLGSDUDIILQSRVWRSHUDWLYHO\IRUGD\V QRVWUDLQLQJRQGHIHFDWLRQ

112  92 QRDQWLELRWLFVSUHDQGSRVWRSHUDWLYHO\ RQO\RQVWULFWLQGLFDWLRQHJSQHXPRQLD

QRVLW]EDWKVSRVWRSHUDWLYH\ VSHFLILFDOO\ZKHQWKHVSKLQFWHUDQLKDVEHHQUHSDLUHG

SURJQRVLVDVWRFORVXUH WKHUHLVQRUHODWLRQWRW\SHRIILVWXODDQGVXFFHVVDWFORVXUH

VRFLDOUHKDELOLWDWLRQ E\VXFFHVVIXOUHSDLULWZLOOWDNHSODFHVSRQWDQHRXVO\

IXWXUHVXEVHTXHQWSUHJQDQFLHVGHOLYHULHV UHJXODUDQWHQDWDOFDUHZLWKGHOLYHU\LQKRVSLWDO

VSKLQFWHUDQLUXSWXUHZLWKORQJLWXGLQDODQRUHFWXPWUDXPDDQGSHULQHXPWHDU PLQLPDOGLVVHFWLRQORQJLWXGLQDOGLVWDODQRUHFWXPFORVXUHZLWKPHWLFXORXVDLUWLJKW DGDSWDWLRQRILQWHUQDOVSKLQFWHUE\GRXEOHOD\HURILQYHUWLQJSRO\JO\FROLFDFLGHQG WRHQGH[WHUQDOVSKLQFWHUDQLUHSDLUDQGSHULQHDOERG\UHSDLUOHDYLQJSRVWHULRU YDJLQDZDOODQGSHULQHXPRSHQVHHWH[WERRNREVWHWULFWUDXPDVXUJHU\DUWDQG VFLHQFHVSKLQFWHUDQLUXSWXUH

QEWKHUHFWXPLVYHU\GHOLFDWHDQGQHHGVWREHKDQGOHGZLWKFDUHDVZHOOWKHUHLVDOZD\V FRQWDPLQDWLRQVRWKHSULQFLSOHVRIVHSWLFVXUJHU\KDYHWREHDSSOLHGVWULFWO\DQGPDQ\ WLPHVWKHSRVWHULRUYDJLQDZDOOLVMXVWOHIWFRPSOHWHO\RSHQZKLOVWWKHUHSDLULWVHOIVKRXOG EHDLUWLJKW

GRQRWZDVWHWLPHHQHUJ\DQGPRQH\RQWKLQJVZKLFKPDNHQRVHQVHVXFKDVHXD ZDLWLQJPRQWKVDIWHUGHOLYHU\EHIRUHVXUJHU\HWF

FRQFHQWUDWHRQWKHPRVWLPSRUWDQWWKLQJ FORVHWKHILVWXOD

 93 113 NHHVFODVVLILFDWLRQRIVWRROILVWXODV DVEDVHGRQWLVVXHORVVFRQWLQHQFHPHFKDQLVPDQGRSHUDWLRQWHFKQLTXH ZLWKRXWFRQVHTXHQFHVIRUSURJQRVLV

LQWURGXFWLRQ ,QRUGHUWRGHYLVHDQGH[HFXWHWKHILVWXODUHSDLUDFFRUGLQJWRWKHSULQFLSOHVRIUHFRQVWUXF WLYHVXUJHU\DQGWRFRPSDUHWKHUHVXOWVDQGGLIIHUHQWRSHUDWLRQWHFKQLTXHVLWLVLPSRUWDQW WRKDYHDVFLHQWLILFFODVVLILFDWLRQZKLFKPDNHVVHQVH

WKHDXWKRUGHYLVHGDFODVVLILFDWLRQIRUWKHREVWHWULFVWRROILVWXODVFRQIRUPWKHJXLGHOLQHV RIWKHXULQHILVWXODFODVVLILFDWLRQ

WKLVFODVVLILFDWLRQKDVEHHQXVHGSURVSHFWLYHO\DQGUHILQHGE\WKHDXWKRULQRYHU SHUVRQDO ILVWXOD UHSDLUV DQGUHODWHGRSHUDWLRQVGXULQJD\HDUSHULRGRI VXUJLFDO  PDQDJHPHQWRIWKHREVWHWULFILVWXODPDLQO\LQQLJHULDEXWDOVRLQEXUNLQDIDVRHWKLRSLD NHQ\DQLJHUSDNLVWDQXJDQGDDQGWDQ]DQLDIURPXSWLOOWRGD\

ULJKWIURPWKHEHJLQQLQJWKHZKROHPDQDJHPHQWKDVEHHQSDLQVWDNLQJO\GRFXPHQWHGE\ FRPSXWHUL]HGRSHUDWLRQUHSRUWVLQFOXGLQJKLVWRU\DQGVFKHPDWLFGUDZLQJVFRPSOHWHZLWK LQWHUPHGLDWHDQGILQDOSRVWRSHUDWLYHFKHFNXSVDVHYLGHQFHEDVHGUHVXOWVWRVXSSRUWWKH FRQWLQXRXVSURVSHFWLYHUHVHDUFK

FODVVLILFDWLRQ WKHIROORZLQJFODVVLILFDWLRQLVSUHVHQWHGDFFRUGLQJWRWKHDQDWRPLFSK\VLRORJLFORFDWLRQ ZLWKFRQVHTXHQFHVIRURSHUDWLRQWHFKQLTXHRQO\VHHILJVDQGWDEOH,

W\SH, ILVWXODVQRWLQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVP W\SH,, ILVWXODVLQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVP W\SH,,, PLVFHOODQHRXV

ILJXUHVDQG

114 94 WDEOH, FODVVLILFDWLRQRIILVWXODVDFFRUGLQJWRDQDWRPLFSK\VLRORJLFORFDWLRQ

W\SH, QRWLQYROYLQJFRQWLQHQFHPHFKDQLVP SUR[LPDOILVWXODV DZLWKRXWUHFWXPVWULFWXUH EZLWKUHFWXPVWULFWXUH FZLWKFLUFXPIHUHQWLDOGHIHFW

W\SH,, LQYROYLQJFRQWLQHQFHPHFKDQLVP GLVWDOILVWXODV DZLWKRXWVSKLQFWHUDQLLQYROYHPHQW EZLWKVSKLQFWHUDQLLQYROYHPHQW

W\SH,,, PLVFHOODQHRXVHJLOHRXWHULQHILVWXODVDIWHULQVWUXPHQWDODERUWLRQ

DQGWKHQWKHUHLVSRVWSDUWXPVWRROIODWXVLQFRQWLQHQFHZLWKRXWDILVWXOD

WKLVFODVVLILFDWLRQLVEDVHGRQWKHSURJUHVVLYHTXDQWLWDWLYHDQGTXDOLWDWLYHDPRXQWRI WLVVXHORVVDQGRQLQYROYHPHQWRIWKHVWRROFRQWLQHQFHFORVLQJPHFKDQLVP

WKHWUDQVLWLRQIURPW\SH,LQWRW\SH,,ILVWXODVLVDWFPIURPWKHDQXVZKLOVWIRUW\SH, ILVWXODVDUHFWXPVWULFWXUHRUFLUFXPIHUHQWLDOGHIHFWKDVWREHORRNHGIRU

DJUDGLQJRILQYROYHPHQWRIWKHVWRROFRQWLQHQFHPHFKDQLVPRIWKHGLIIHUHQWW\SHVLV SUHVHQWHGLQWDEOH,,

WDEOH,, LQYROYHPHQWRIFRQWLQHQFHPHFKDQLVPDFFRUGLQJWRW\SH

W\SH LQYROYHPHQWRIFRQWLQHQFHPHFKDQLVP

W\SH,D QRQH

W\SH,E QRQH

W\SH,F QRQH

W\SH,,D IURPPLQLPXPXSWRPDMRU

W\SH,,E H[WHQVLYH

W\SH,,, QRQH

 95 115 RSHUDWLRQSULQFLSOHV

WKHRSHUDWLRQSULQFLSOHVIRUHDFKW\SHDUHSUHVHQWHGLQWDEOH,,,

WDEOH,,, RSHUDWLRQSULQFLSOHVIRUHDFKW\SH

W\SH UHFWXPFORVXUH VSHFLDO SRVWYDJLQDZDOO GLUHFWLRQ  PHDVXUHV RQO\DGDSWDWLRQ

W\SH,D WUDQVYHUVH FROSRWRP\  WUDQVYHUVH

W\SH,E WUDQVYHUVH  GLVUXSWLRQ WUDQVYHUVH VWULFWXUH

W\SH,F FLUFXPIHUHQWLDO GLVUXSWLRQ  WUDQVYHUVH HQGWRHQG  VWULFWXUH  KLJKO\FRPSOLFDWHG

W\SH,,D FRPPRQVHQVH SHULQHDOERG\  KDOIRSHQ WUDQVYHUVHRU ORQJLWXGLQDO

W\SH,,E ORQJLWXGLQDO  VSKLQFWHUDQL OHIWRSHQ  SHULQHDOERG\ LQWHQWLRQDOO\

W\SH,,, VSHFLDOFODVVRILWVRZQWKDWQHHGVWKHLURZQVSHFLILFDSSURDFK

WKRXJKWKHFODVVLILFDWLRQDVWRW\SHLVWKHPRVWLPSRUWDQWDQDGGLWLRQDOVXEFODVVLILFDWLRQ FDQEHPDGHWRWKHVL]HVPDOOPHGLXPODUJHDQGH[WHQVLYHVHHWDEOH,,,

WDEOH,,, VXEFODVVLILFDWLRQRIILVWXODVDFFRUGLQJWRVL]H

VPDOO FP PHGLXPFP ODUJHFP H[WHQVLYH!FP

UHVXOWV

SRVWUHSDLULQFRQWLQHQFHLVQRWDPDMRUSUREOHPWKRXJKLWPD\RFFXULQW\SH,,EILVWXODV ZKLOVWWKHW\SH,FILVWXODVKDYHWKHZRUVWUHVXOWVDVWRFORVXUHDQGPD\QHHGDFRPELQHG DEGRPLQRYDJLQDODSSURDFKIXUWKHUQRFOHDUUHODWLRQWRW\SH

116  96 FRPPHQWV

WKLVFODVVLILFDWLRQLVEDVHGRQWKHTXDOLWDWLYHDQGTXDQWLWDWLYHDPRXQWRIWLVVXHORVVDQG RQWKHLQYROYHPHQWRIWKHVWRROFRQWLQHQFHPHFKDQLVPLQWKHIHPDOH

VRIDULWLVWKHRQO\FODVVLILFDWLRQZLWKD VROLGVFLHQWLILFEDFNJURXQG FOHDURSHUDWLRQWHFKQLTXHSULQFLSOHVIRUHDFKW\SHDQG KRZHYHUQRSUHGLFWLRQRIRXWFRPHLQWHUPVRIFORVXUH

QRWRQO\WKHILVWXODKDVWREHFODVVLILHGEXWDOOWKHOHVLRQVGHIHFWVKDYHWREHREMHFWLYHO\ GHVFULEHGGRFXPHQWHGLQZULWLQJWREHFRPSOHWHO\WUDQVSDUHQW

WKHFODVVLILFDWLRQDVWRW\SHLVIDUPRUHLPSRUWDQWDQGGHFLVLYHWKDQWKHDGGLWLRQDOVXE FODVVLILFDWLRQDVWRVL]H

ZLWKWKLVFODVVLILFDWLRQLWLVSRVVLEOHWRSODQDQGH[HFXWHWKHILVWXODUHSDLUDFFRUGLQJWRWKH SULQFLSOHVRIUHFRQVWUXFWLYHVXUJHU\DQGWRFRPSDUHWKHUHVXOWVDQGRSHUDWLRQWHFKQLTXHV LQDVFLHQWLILFZD\

KRZHYHUVLQFHWKHYDULHW\LVVRLPPHQVHDQGWKHUHDUHQRVKDUSGHPDUFDWLRQVEXWIOXLG WUDQVLWLRQVEHWZHHQWKHGLIIHUHQWW\SHVWKLVFODVVLILFDWLRQVKRXOGEHXVHGDVDFRPSUH KHQVLYHJXLGHOLQHVLQFH

HDFKILVWXODFRQVWLWXWHVDVHSDUDWHXQLTXHHQWLW\DQGQHHGVLWVRZQVSHFLILFFXVWRPL]HG DSSURDFKDQGWKDWLVH[DFWO\ZKDWPDNHVREVWHWULFILVWXODVXUJHU\VRLQWULJXLQJDQG FKDOOHQJLQJVLQFHWKHUHDUHQRLGHQWLFDOREVWHWULFILVWXODV

YDJLQDVWULFWXUHVVFDUULQJVWHQRVLVDQGRUSUHYLRXVUHSDLU V  DUHQRSDUWRIDFODVVLILFDWLRQLWRQO\PD\PDNHWKHRSHUDWLRQPRUHFRPSOLFDWHG

DQGWKHQWKHUHLVSRVWSDUWXPVWRROLQFRQWLQHQFHZLWKRXWDILVWXOD

QE WKRXJKWKHUHFWRYDJLQDOILVWXODVPD\ORRNVLPSOHWKH\DUHHYHQPRUHFRPSOLFDWHGWR KDQGOHWKDQYHVLFRYDJLQDOILVWXODVDQGWKHSULQFLSOHVRIVHSWLFVXUJHU\KDYHWREHDSSOLHG VLQFHWKHUHLVDOZD\VVRPHNLQGRIVWRROIODWXVFRQWDPLQDWLRQ

 97 117

VXUJLFDOSULQFLSOHVIRUUHFWRYDJLQDOILVWXODV

WKHEHWWHUWKHRUJDQL]DWLRQRIWKHSUHRSHUDWLYHSUHSDUDWLRQRIWKHRSHUDWLRQWKHDWHU DQGRIWKHSRVWRSHUDWLYHFDUHWKHEHWWHUWKHRXWFRPHRIILVWXODVXUJHU\LQWHUPVRI FORVXUHDQGFRQWLQHQFHDQGWKHEHWWHUWKHFKDQFHRIPHGLFDOSK\VLFDOPHQWDODQG VRFLDOUHKDELOLWDWLRQ KRZHYHULWFDQQRWEHVWUHVVHGHQRXJKWKDWWKHZHDNHVWSRLQWRIILVWXODVXUJHU\LQWKH GHYHORSLQJZRUOGLVWKHSRRUQXUVLQJFDUH

JHQHUDORSHUDWLRQSULQFLSOHV WKHYDJLQDODSSURDFKLVWKHURXWHRIFKRLFHZLWKZLWKRXWHSLVLRWRPLHVVSLQDODQHVWKHVLD LVWKHDQHVWKHVLDRIFKRLFHDQGWKH H[DJJHUDWHG OLWKRWRP\SRVLWLRQLVWKHSRVLWLRQRI FKRLFHW\SH,FDQGW\SH,,,ILVWXODVPD\QHHGDGLIIHUHQWDSSURDFK

WKHRSHUDWLRQSULQFLSOHVIRUHDFKW\SHDUHSUHVHQWHGLQWDEOHV,,,

WDEOH, RSHUDWLRQSULQFLSOHV

UYIW\SH,D QRWLQYROYLQJFRQWLQHQFHFORVLQJPHFKDQLVP WUDQVYHUVHUHFWXPFORVXUHZLWKSYZDGDSWDWLRQFKHFNIRUUHFWXPVWULFWXUH

UYIW\SH,E QRWLQYROYLQJFRQWLQHQFHFORVLQJPHFKDQLVPUHFWXPVWULFWXUH ILUVWEOXQWVKDUSGLVUXSWLRQRIUHFWXPVWULFWXUHWKHQWKHVDPHDVW\SH,D

UYIW\SH,F QRWLQYROYLQJFRQWLQHQFHFORVLQJPHFKDQLVPFLUFXPIHUHQWLDOGHIHFW LISRVVLEOHDQGVDIHFLUFXPIHUHQWLDOHQGWRHQGUHFWRUHFWRVWRP\ LIQRWSRVVLEOHRUQRWVDIHFLUFXPIHUHQWLDOUHFWXPUHSDLU LIGLIILFXOWDFRPELQHGDEGRPLQRYDJLQDOSURFHGXUHPD\EHUHTXLUHG WKHVHDUHWKHPRVWGLIILFXOWWRUHSDLUZLWKWKHZRUVWSURJQRVLV

UYIW\SH,,D LQYROYLQJWKHFRQWLQHQFHFORVLQJPHFKDQLVP WUDQVYHUVHRUORQJLWXGLQDOUHFWXPFORVXUHGHSHQGLQJRQFRPPRQVHQVH

UYIW\SH,,E PDMRULQYROYHPHQWRIFRQWLQHQFHFORVLQJPHFKDQLVP ORQJLWXGLQDODQRUHFWXPFORVXUHHQGWRHQGVSKLQFWHUDQLUHFRQVWUXFWLRQDQGSHULQHDO ERG\UHSDLU  IRUVWHSE\VWHSUHFRQVWUXFWLRQVHHWH[WERRN

UYIW\SH,,, PD\QHHGDQDEGRPLQDODSSURDFK DFWLRQDFFRUGLQJWRZKDWLVQHHGHG

122 102 WDEOH,, RSHUDWLRQSULQFLSOHVIRUHDFKW\SH

W\SH UHFWXPFORVXUH VSHFLDO SRVWYDJLQDZDOO GLUHFWLRQ  PHDVXUHV RQO\DGDSWDWLRQ

W\SH,D WUDQVYHUVH FROSRWRP\  WUDQVYHUVH

W\SH,E WUDQVYHUVH  GLVUXSWLRQ WUDQVYHUVH VWULFWXUH

W\SH,F FLUFXPIHUHQWLDO GLVUXSWLRQ  WUDQVYHUVH HQGWRHQG  VWULFWXUH  KLJKO\FRPSOLFDWHG

W\SH,,D FRPPRQVHQVH SHULQHDOERG\  KDOIRSHQ WUDQVYHUVHRU ORQJLWXGLQDO

W\SH,,E ORQJLWXGLQDO  VSKLQFWHUDQL OHIWRSHQ  SHULQHDOERG\ LQWHQWLRQDOO\

W\SH,,, VSHFLDOFODVVRILWVRZQWKDWQHHGVWKHLURZQVSHFLILFDSSURDFK

FRPPHQWV WKHVHDUHRQO\JXLGHOLQHVDQGWKHDSSURDFKKDVWREHFXVWRPL]HGVLQFHHDFKILVWXOD FRQVWLWXWHVLWVRZQXQLTXHHQWLW\

WKHUHLVQRUHODWLRQEHWZHHQILVWXODW\SHDQGRXWFRPHRQO\WKDWW\SH,FILVWXODVDUHWKH PRVWGLIILFXOWZLWKWKHZRUVWRXWFRPHDVWRKHDOLQJZKLOVW

W\SH,,EILVWXODVQHHGWKRURXJKWKHRUHWLFSUDFWLFDONQRZOHGJHRIWKHVWRROFRQWLQHQFH PHFKDQLVPRWKHUZLVHWKHUHVXOWVZLOOEHSRRU

103 123 FRPSOH[WUDXPDRIVSKLQFWHUDQLUXSWXUHW\SH,,E VWHSE\VWHSUHFRQVWUXFWLRQ

VKRUWRXWOLQHIURPWH[WERRN REVWHWULFWUDXPDVXUJHU\VSKLQFWHUDQLUXSWXUH

LQWURGXFWLRQ

WKHPDMRUSUREOHPLVWKDWLWORRNVVRVLPSOHWKDWHYHQWKHPRVWLQH[SHULHQFHGGRFWRURU QXUVHGHDOLQJZLWKREVWHWULFVWKLQNV V KHFDQKDQGOHLWMXVWDFRXSOHRIVXWXUHVWRFORVH WKHYLVLEOHWHDUZLWKRXWSD\LQJDWWHQWLRQWRWKHGLIIHUHQWLQGLYLGXDODQDWRPLFGHIHFWV

SDUWLDOO\WREODPHIRUWKLVLVWKHWHUPUGRIWKGHJUHHSHULQHXPWHDUZKLFKSODFHVWKH HPSKDVLVZURQJO\RQWKHSHULQHXP

KRZHYHUDFRXSOHRIVXWXUHVWRFORVHWKHYLVLEOHJDSDUHFHUWDLQO\QRWVXIILFLHQWDQGWKH VXUJLFDOUHFRQVWUXFWLRQUHTXLUHVDPSOHWKHRUHWLFDODQGSUDFWLFDONQRZOHGJHRIWKHDQDO FRQWLQHQFH PHFKDQLVP LQ WKH IHPDOH FRPELQHG ZLWK H[SHUW VNLOOV LQ UHFRQVWUXFWLYH VXUJHU\RIWKHDQRUHFWXPVSKLQFWHUDQLPXVFOHDQGSHULQHDOERG\DFFRUGLQJWRH[DFW DVVHVVPHQWLGHQWLILFDWLRQ RI DOO WKH LQGLYLGXDO OHVLRQV ZKLOVW WKH SULQFLSOHV RI VHSWLF VXUJHU\KDYHWREHDSSOLHGVLQFHWKHUHLVDOZD\VKHDY\VWRROFRQWDPLQDWLRQ

QRUPDOO\ WKHUH LV QR WLVVXH ORVV VLQFH LW LV D FXWWKUX WUDXPD KRZHYHU VLQFH PRVW UHIHUUHGSDWLHQWVKDYHEHHQDWWHPSWHGDWOHDVWRQFHE\LQH[SHULHQFHGVXUJHRQVWKHUH PD\EH H[WHQVLYH DGGLWLRQDOVXUJLFDOWUDXPDZLWKDQDWRPLFWLVVXHORVV

WKH DLP LV WR DFKLHYH D ODVWLQJ H[FHOOHQW DQDWRPLFFRVPHWLF DQG SK\VLRORJLF UHVXOW HYHU\WKLQJ VKRXOG ORRN QRUPDOILQH DQG IXQFWLRQ QRUPDOO\ ZLWK FRPSOHWH VWRROIODWXV FRQWLQHQFHDQGKHDOWK\VH[OLIH

SUHRSHUDWLYHFDUH

SUHSDUDWLRQ SUHSDUDWLRQRIWKHSDWLHQWE\FOLQLFDOFKHFNRIJHQHUDOKHDOWKDQG DQ HPLD

WLPLQJRIRSHUDWLRQ WLPLQJRIRSHUDWLRQDVVRRQDVWKHZRXQGVDUHFOHDQWKHSDWLHQWVLVFRQVLGHUHGWREH VXLWDEOHIRURSHUDWLRQXQOHVVKHUJHQHUDOFRQGLWLRQGRHVQRWSHUPLWLW LIRYHUWLQIHFWLRQVLW]EDWKVZLWKZDWHUDQGDGHWHUJHQWOLNHRPR FKHDSDQGDYDLODEOHDQG KLJKO\HIIHFWLYH WLPHVGDLO\IRUPLQXWHVXQWLOZRXQGLVFOHDQ

QRVLJPRLGRVWRP\ WKLVZRXOGPHDQDPLQLPXPRIWKUHHRSHUDWLRQV

QRSUHLQWUDDQGRUSRVWRSHUDWLYHDQWLELRWLFV OHDNLQJXPEUHOOD WKRXJKWKHRSHUDWLRQVLWHLVDOZD\VKHDYLO\FRQWDPLQDWHGURXWLQHDQWLELRWLFVDUHQRW JLYHQWKH\ZLOORQO\FRQWULEXWHWRPXOWLUHVLVWDQFH

124 104 FRPSOH[VSKLQFWHUDQLDQRUHFWXPSHULQHDOERG\WUDXPD

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

FDYHLIWKHUHLVDQ\WKLQJWKDWZRXOGHQGDQJHUWKHUHSDLUHJPDMRUWLVVXHORVVGXHWR SUHVVXUHQHFURVLVWKHRSHUDWLRQLVHQGHGDVDILUVWVWDJHDQGWKHUHFRQVWUXFWLRQRIWKH H[WHUQDOVSKLQFWHUSRVWSRQHGDVDVHFRQGVWDJH

 WKHVWULDWHGPXVFOHH[WHUQDOVSKLQFWHUHQGVDUHLGHQWLILHGDQGZLWKRXWDQ\IXUWKHU GLVVHFWLRQ WKH DOUHDG\ IUHVKHQHG VSKLQFWHU HQGV DUH XQLWHG LQ DQ HQGWRHQG PDQQHUE\VHSDUDWHSRO\JO\FROLFDFLGVXWXUHV VXSHUILFLDOGHHSDQGVXEFXWD QHRXVSDUW PDNLQJVXUHWKHH[WHUQDOVSKLQFWHULVUHDOO\SLFNHGXSE\SXOOLQJRQWR WKHVXWXUHVEHIRUHW\LQJ

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

FDYHLILWGRHVQRWORRNQRUPDORQLQVSHFWLRQWKHQVRPHWKLQJZHQWZURQJDQGWKHUHSDLU LVQRWDOULJKWDQGWKLVKDVWREHFRUUHFWHG

 WKH SRVWHULRU YDJLQD ZDOO DQG DGDSWHG SHULQHXP DUH OHIW LQWHQWLRQDOO\ RSHQ DFFRUGLQJWRWKHSULQFLSOHVRIVHSWLFVXUJHU\VLQFHWKHYDJLQDDQGWKHSHULQHXP DUHDOZD\VFRQWDPLQDWHGDQGWKXVHQVXULQJIUHHGUDLQDJHRIEDFWHULDZRXQG IOXLGGHEULVDQGVPDOOEORRGFORWV  LQVHUWLRQRILQGZHOOLQJIROH\FDWKHWHUFKIRUVRPHGD\V  DIWHUFDUHIXOFKHFNXSRQKHPRVWDVLVDQGJHQHUDOFRQGLWLRQWKHSDWLHQWLVWUDQV IHUUHGWRWKHSRVWRSHUDWLYHZDUG  ZULWHLPPHGLDWHO\GHWDLOHGRSHUDWLRQUHSRUWZLWKDOOWKHUHOHYDQWGDWDLQFOXGLQJ WLVVXHTXDOLW\DQGSUHGLFWLRQRIKHDOLQJDVWRFORVXUHDQGFRQWLQHQFH

UHPDUNV WKHDUWLVWRUHFRQVWUXFWWKHVWRROFRQWLQHQFHPHFKDQLVPVWHSE\VWHSZKHUHE\VORZO\EXW YHU\YLVLEOHDIWHUHDFKVWHSWKHQRUPDOIXQFWLRQDODQDWRP\LVEHLQJUHVWRUHGDQGWKH DQWHULRU DQXVFRPHVWROLHVHFXUHGLQLWVDQDWRPLFGLVWDOSRVLWLRQRXWVLGHWKHYDJLQD DQGVOLJKWO\SURWUXGLQJHYHU\WKLQJVKRXOGORRNQRUPDO LILWGRHVQRWORRNQRUPDOVRPHWKLQJZHQWLVZURQJDQGQHHGVWREHFRUUHFWHGDQGWKLV VKRXOGEHGRFXPHQWHGLQWKHRSHUDWLRQUHSRUW

WLSV IRUVSKLQFWHUDQLUHFRQVWUXFWLRQDQGSHULQHDOERG\UHFRQVWUXFWLRQZRUNLQJZLWKQHHGOH KROGHUVZLOOIDFLOLWDWHWKHLQVWUXPHQWDWLRQDQGDVVXFKWKHRSHUDWLRQWKHVHFRQGQHHGOH KROGHUZLOOLPPHGLDWHO\SLFNXSWKHWLSRIWKHQHHGOHZKHQLWFRPHVRXWRIWKHWLVVXHVRLW FDQQRWVOLSEDFNDSUREOHPZLWKRQHQHHGOHKROGHUDQGVXUJLFDOIRUFHSV VRPHWLPHVIRUSODFLQJWKHVSKLQFWHUDQLRUSHULQHDOERG\VXWXUHVLWLVHDVLHUWRFRPHRXW WKUXWKHVNLQZLWKWKHQHHGOHDQGWKHQJREDFNDJDLQWKHPRVWLPSRUWDQWWKLQJLVWR DGDSWWKHWLVVXHVDVVPRRWKO\DVSRVVLEOH IRUSHULQHDOERG\UHFRQVWUXFWLRQDELJJHUQHHGOHLVXVHGVLQFHGHHSELWHVDUHWDNHQ

SRVWRSHUDWLYHLQVWUXFWLRQV QRVROLGIRRGIRUGD\VDQGDVWRROVRIWHQHUOLNHOLTXLGSDUDIILQIRUGD\VDOVROLEHUDO XVHRIDQDOJHWLFV

DIWHUHDFKERZHOPRYHPHQWWKHSHULQHXPDQXVKDYHWREHFOHDQHGFDUHIXOO\E\ZDWHU DQGWKHQFRPSOHWHO\GULHG

VLW]EDWKVDUHFRQWUDLQGLFDWHGXQOHVVLWVKRXOGEHFRPHVHSWLFVLQFHWKLVZLOOVRIWHQWKH UHSDLUHGWLVVXHVXWXUHVDQGEUHDNGRZQLQIHFWLRQPD\EHPRUHIUHTXHQWQRUPDOO\WKH OHVVRQHGRHVDERXWDQRSHUDWLRQZRXQGWKHEHWWHULWKHDOV

126 106 GLVFXVVLRQ

WKH SUHVHQWHG WHFKQLTXH LV D PLQLPXPLQYDVLYH VWUDLJKWIRUZDUG DSSURDFK ZLWK WKH REMHFWLYHWRUHFRQVWUXFWRQO\WKHDIIHFWHGLQGLYLGXDOVWUXFWXUHVXQGHUWKHSKLORVRSK\WKDW LQVXUJHU\RQO\WKHQHFHVVDU\KDVWREHGRQHQRWKLQJPRUHEXWDOVRQRWKLQJOHVV

KRZHYHUWKLVKDVWREHGRQHYHU\ZHOOZLWKPHWLFXORXVDWWHQWLRQWRGHWDLOWKHMRERID VXUJHRQLVWREULQJWLVVXHVWRJHWKHULQVXFKDZD\WKDWWKH\ZLOOXQLWHFRPSOHWHO\DQGWKDW DIWHUKHDOLQJWKHQRUPDOIXQFWLRQDODQDWRP\DQGSK\VLRORJ\ZLOOEHUHVWRUHG

WKHVHSULQFLSOHVQHYHUFKDQJHWKRXJKWKHUHPD\EHFXVWRPL]DWLRQWRWKHLQGLYLGXDO ILQGLQJVLQWKHLQGLYLGXDOSDWLHQW

WKHILUVWLQWHUUXSWHGOD\HULVIRUEULQJLQJWKHWLVVXHVWRJHWKHUDQGIRUVHFXULW\VKRXOGWKH FRQWLQXRXVVXWXUHEUHDNWKHVHFRQGFRQWLQXRXVOD\HULVIRUDLUWLJKWFORVXUHDQGIRU FRPSOHWHDSSUR[LPDWLRQRIWKHLQWHUQDOVSKLQFWHU

LIDWWKHHQGRIWKLVVWDJHWKHLQQHUULQJRIWKHH[WHUQDOVSKLQFWHUDQLLVQRWDGDSWHGLW PHDQVWKHUHUHPDLQVDGHIHFWLQWKHGLVWDOSDUWRIWKHLQWHUQDOVSKLQFWHUZKLFKPD\OHDG WRLQFRPSOHWHDQDOFRQWLQHQFHWKHDQRFXWDQHRXVMXQFWLRQLVXVHGDVODQGPDUN

WKHH[WHUQDOVSKLQFWHULVUHFRQVWUXFWHGDVWKHVHFRQGSKDVHRIWKHUHFRQVWUXFWLRQE\ XQLWLQJWKHIUHVKHQHGHQGLQJVLQDQHQGWRHQGIDVKLRQZLWKRXWVHSDUDWHGLVVHFWLRQ PRELOL]DWLRQRIWKHVSKLQFWHUNHHSLQJWKHVXUJLFDOWUDXPDWRWKHPLQLPXPWKLVZLOOUHVWRUH WKHQRUPDODQDWRP\DWRWDORIVXWXUHVDUHXVHGIRUWKHGLIIHUHQWSDUWVILUVWWKH VXSHUILFLDOSDUWWKHQE\SXOOLQJRQWKLVVXWXUHWKHGHHSSDUWDQGWKHVXEFXWDQHRXVSDUW DVODVW

WKHSHULQHDOERG\LVUHSDLUHGDVWKHWKLUGSKDVHRIWKHUHFRQVWUXFWLRQLQRUGHUWRUHVWRUH WKHQRUPDODQDWRP\DQGFRVPHWLFVKDSHRIWKHYXOYDSHULQHXPDQGDVVXSSRUWIRUWKH DQDOFRQWLQHQFHPHFKDQLVP

E\UHFRQVWUXFWLRQRIWKHSHULQHDOERG\DOVRWKHEXOOERVSRQJLRVXVDQGWUDQVYHUVXVSHULQHL PXVFOHV ZKLFKUDGLDWHLQWRWKHSHULQHDOERG\ ZLOOEHUHXQLWHG

WKHSRVWHULRUYDJLQDZDOODQGDGDSWHGSHULQHXPDUHOHIWRSHQLQWHQWLRQDOO\VLQFHWKH GLVWDO YDJLQDDQGSHULQHXPDUHDOZD\VKHDYLO\FRQWDPLQDWHGLQRUGHUIRUGUDLQDJHDQG VSRQWDQHRXV HYDFXDWLRQ RI WLVVXH GHEULV EDFWHULD DQG VPDOO EORRG FORWV RQFH WKH DQR UHFWXPDKLJKSUHVVXUHRUJDQKDVKHDOHGWKHYDJLQDD]HURRUORZSUHVVXUH RUJDQZLOODOZD\VKHDO

FRQFOXVLRQ

WKLVHYLGHQFHEDVHGRSHUDWLRQWHFKQLTXHLVKLJKO\HIIHFWLYHVLQFHWKHQRUPDOIXQFWLRQDO DQDWRP\LVUHFRQVWUXFWHGDQGZLWKLWWKHUHVXOWLQJSK\VLRORJ\UHVWRUHG

LWLVH[DFWO\WKHRSSRVLWHRIWKHPHFKDQLVPRIDFWLRQRIUXSWXUHDQGWKHVWUXFWXUHVZKLFK ZHUHUXSWXUHGODVWDUHWKHILUVWWREHUHSDLUHG

LWLVUHFRPPHQGHGDVVWDQGDUG VXUJLFDO PDQDJHPHQWRIWKHFRPSOH[VSKLQFWHUDQL UXSWXUHWUDXPDLQDOOLWVIRUPVLQWKHGHYHORSLQJDQGLQWKHLQGXVWULDOL]HGZRUOG

107 127        

    



SRVWSDUWXPREVWHWULFVWRROIODWXVLQFRQWLQHQFH ZLWKRXWVSKLQFWHUDQLUXSWXUH DVEDVHGRQ RYHUSDWLHQWV

LQWURGXFWLRQ

PDQ\SDWLHQWVFRPSODLQRIVWRROIODWXVLQFRQWLQHQFHLPPHGLDWHO\DIWHUFKLOGELUWKDQGWKH ILUVWWKLQJLVWRHVWDEOLVKZKHWKHULWLVIRUVXUJLFDOUHFRQVWUXFWLRQRUQRWDQGZKHWKHULWZLOO KHDOVSRQWDQHRXVO\RUQRW KHUHRQO\WKHQRQVXUJLFDOFRQGLWLRQVZLOOEHPHQWLRQHG

REVWHWULFLQFRQWLQHQFHGXHWRWUDXPDRIVXSSRUW

RSHQSHULQHXPUXSWXUHRSHQHSLVLRWRP\ZLWKVWRRODQGRUIODWXVLQFRQWLQHQFH WKRXJKLWSUREDEO\ZLOOKHDOVSRQWDQHRXVO\VRPHWKLQJFDQEHGRQHEXWRQO\LIWKHZRXQG LVFOHDQLIQRWFOHDQVSHHGLWXSE\VLW]EDWKV DVVRRQDVZRXQGLVFOHDQRQHRUWZRGHHSDGDSWDWLRQVXWXUHVLQRQHJRWKUXVNLQDQG XQGHUO\LQJ WLVVXH DUH SHUIRUPHG DV KDOIRSHQ FORVXUH DFFRUGLQJ WR VHSWLF VXUJHU\ SULQFLSOHVOHDYHWKHUHVWRSHQ

REVWHWULFLQFRQWLQHQFHGXHWRSRVWHULRUYDJLQDZDOOQHFURVLV

GLVWDORUWRWDOSRVWHULRUYDJLQDZDOOQHFURVLVRUDOUHDG\LQKHDOLQJSKDVH SDWLHQWV SUHVHQW ZLWK VWRROIODWXV LQFRQWLQHQFH LPPHGLDWHO\ SRVW SDUWXP DQG GLVWDO SRVWHULRUYDJLQDQHFURVLVZLWKRXWDILVWXOD WKHPHFKDQLVPLVWKDWWKHLQHUWQRQIXQFWLRQLQJGHDGQHFURWLFWLVVXHZLWKLQQHUYDWLRQORVV LVLQWHUIHULQJZLWKWKHVPRRWKIXQFWLRQLQJRIWKHVWRROFRQWLQHQFHPHFKDQLVPWKHUHDUH WZR SRVVLELOLWLHV HLWKHU IXOO WKLFNQHVV RU QRW IXOO WKLFNQHVV QHFURVLV WKLV FDQQRW EH HVWDEOLVKHGLPPHGLDWHO\DIWHUFKLOGELUWKRQO\UHWURVSHFWLYHO\

QHFURVLVLVIXOOWKLFNQHVV WKHQHFURVLVLVIXOOWKLFNQHVVDQGWKHSDWLHQWZLOOGHYHORSUXSWXUHILVWXODZLWKLQDFRXSOHRI GD\VDQGWKHQLWEHFRPHVDVXUJLFDOFRQGLWLRQVHHSUHYLRXVFKDSWHU

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

114 133 REVWHWULFQHXURJHQLFVWRROIODWXVLQFRQWLQHQFH

QRYLVLEOHWUDXPDWRDQXVSHULQHXPSRVWHULRUYDJLQDZDOO FRQVLGHULQJWKHGLIIHUHQWLQQHUYDWLRQRIWKHLQWHUQDOVSKLQFWHUDQGH[WHUQDOVSKLQFWHUWKHUH DUHDQXPEHURISRVVLELOLWLHVWKRXJKIRUERWKORFDOWUDXPDDQGSOH[XVWUDXPDHLWKHU LVRODWHGRUFRPELQHGRUDOOFRPELQHGDUHSRVVLEOH

WKHV\PSDWKHWLFDQGSDUDV\PSDWKHWLFQHUYRXVV\VWHPLVLQQHUYDWLQJWKHLQWHUQDOVPRRWK PXVFOHVSKLQFWHUIRULWVIXQFWLRQQRFOLQLFDOWHVWLVDYDLODEOH

WKHSXGHQGDOQHUYHLVLQQHUYDWLQJWKHH[WHUQDOVWULDWHGVSKLQFWHUDQLPXVFOHWRWHVWLWV IXQFWLRQWKHDQDOUHIOH[LVXVHG

WKH LQWHQVLW\ RI WKH WUDXPD PD\ EHVOLJKWPRGHUDWHRUH[WHQVLYHUHVXOWLQJLQVOLJKW PRGHUDWHRUHYHQWRWDOORVVRIIXQFWLRQ

WKHJRRGWKLQJLVWKDWQRUPDOO\WKHUHLVVSRQWDQHRXVKHDOLQJZLWKIXOOUHFRYHU\ILUVWWKH SDWLHQWEHFRPHVFRQWLQHQWIRUVWRRODQGODWHURQDOVRIRUIODWXV

IRUVFLHQWLILFUHDVRQVWKHIROORZLQJSRVVLELOLWLHVPD\EHWKHFDXVHHLWKHULVRODWHGRULQ DQ\NLQGRIFRPELQDWLRQ

LQWHUQDOVSKLQFWHUSDUHVLV ORFDOWUDXPDWRDXWRQRPLFQHUYRXVV\VWHPDWLQWHUQDOVSKLQFWHUOHYHO WUDXPDWRQHUYHGXULQJLWVFRXUVH SHOYLFSOH[XVWUDXPD

H[WHUQDOVSKLQFWHUSDUHVLV ORFDOWUDXPDWRSXGHQGDOQHUYHDWVSKLQFWHUOHYHO WUDXPDWRSXGHQGDOQHUYHGXULQJLWVFRXUVH VDFUDOSOH[XVWUDXPD

FRPELQDWLRQRILQWHUQDOVSKLQFWHUH[WHUQDOVSKLQFWHUSDUHVLV LQZKDWHYHUFRPELQDWLRQ

QRQREVWHWULFQHXURJHQLFLQFRQWLQHQFH

DFWXDOO\WKLVWRSLFGRHVQRWEHORQJLQWKLVPDQXVFULSWEXWDVKRUWRXWOLQHZLOOEHJLYHQWR FRPSOHWHWKHRYHUDOOYLHZWKHUHDUHPDQ\SRVVLELOLWLHVDQGFDUHIXOKLVWRU\WDNLQJDQG H[DPLQDWLRQLVQHFHVVDU\VLQFHSDWLHQWVDUHQRWFRPLQJRXWE\WKHPVHOYHV WKHVHFRQGLWLRQVDUHQRWEHLQJGRFXPHQWHGRUPDQDJHGE\WKHDXWKRU VSLQDELILGDRYHUWRURFFXOW LIWKLVLVWKHFDXVHQRUPDOO\WKHSDWLHQWLVDOUHDG\VWRROIODWXVLQFRQWLQHQWVLQFHVKHZDV ERUQHEXWQRWDOODIIHFWHGSHUVRQVDUHLQFRQWLQHQW RQHSDWLHQWZLWKYLVLEOHVDFUDOPHQLQJRFHOHFODLPHGWREHWRWDOO\VWRROIODWXVFRQWLQHQW XQWLOVKHGHOLYHUHG VRLQVSHFWWKHEDFNVLGHDQGORRNIRUVFDUVRISUHYLRXVRSHUDWLRQDVZHOO VHQLOHLQFRQWLQHQFH XQIRUWXQDWHO\WKLVKDSSHQVUDWKHUIUHTXHQWO\ WKRXJKLQWKHGHYHORSLQJZRUOGWKHUHLVQRWUHDWPHQWIRUWKLVW\SHRILQFRQWLQHQFHWKHVH SDWLHQWVPD\VWLOOEHQHILWIURPVWULFWSHUVRQDOK\JLHQHDQG

134 115 VWULFWSURSHUVWRROWUDLQLQJ VHWDWLPHIRUDFWLYHGHIHFDWLRQ LIWKHQHHGLVIHOWRUQRW LQWKHPRUQLQJDIWHUEUHDNIDVW JDVWURDQDOUHIOH[ DQGFRQWLQXHWKLVSUDFWLFHHYHU\GD\VRWKDWDQGWKHPLQG EUDLQ DQG WKHERG\LVSURJUDPPHGDQGDIWHUVRPHWLPHDQGFRQWLQXLQJWKLVWUDLQLQJGHIHFDWLRQZLOO EHUHJXODWHGPRUHRUOHVV RQHIDWKHUZKRFRQVXOWHGPHIRUZLWKKLV\UROGVRQZLWKVSLQDELILGDDQGVWRROIODWXV LQFRQWLQHQFHUHSRUWHGPWKODWHUWRPHSHUVRQDOO\WKDWWKHSUREOHPKDGEHHQVROYHG

GLVFXVVLRQ

WKHYDULHW\RISRVWSDUWXPVWRROIODWXVLQFRQWLQHQFHLVODUJHDQGWKHILUVWWKLQJZKLFKKDVWR EHHVWDEOLVKHGLVZKHWKHUWKLVFRQVWLWXWHVDVXUJLFDORUDQRQVXUJLFDOFRQGLWLRQ

LILQFRQWLQHQFHGXHWRSRVWHULRUYDJLQDZDOOQHFURVLVZDLWIRUEUHDNGRZQRUFRPSOHWH VSRQWDQHRXVKHDOLQJQRPDQXDORULQVWUXPHQWDOH[DPLQDWLRQ

WKHPRUHVSHFLILFWKHKLVWRU\WDNLQJWKHPRUHIUHTXHQWRQHILQGVREVWHWULFQHXURJHQLF VWRROIODWXVLQFRQWLQHQFHWKHUHDOLQFLGHQFHLVQRWNQRZQWKRXJKLWPXVWEHKLJK

QRUPDOO\WKLVFRQGLWLRQKHDOVVSRQWDQHRXVO\DQGFRPSOHWHO\ZLWKLQPRQWKVDQGHYHQ IDUTXLFNHU

LILWGRHVQRWKHDOVSRQWDQHRXVO\DFDUHIXOH[DPLQDWLRQLVSHUIRUPHGWRILQGRXWZKDWLV ZURQJDQGWKHQDFWLRQWDNHQDFFRUGLQJO\"UKDSK\RIZKROHFRQWLQHQFHPHFKDQLVP"DV ODVWUHVRUW

LQSDWLHQWVZLWKQRQREVWHWULFQHXURJHQLFVWRROIODWXVLQFRQWLQHQFHVWULFWSHUVRQDOK\JLHQH ZLWKVWRROWUDLQLQJPD\EHRIEHQHILW

116 135

JHQHUDOPDQDJHPHQW

LPSRUWDQFHRUDOIOXLGV

SRVWRSHUDWLYHLQVWUXFWLRQV

HFODPSVLD

HTXLSPHQWDQGLQVWUXPHQWV

DQHVWKHVLD

EODGGHUVWRQHV

GRFXPHQWDWLRQ LPSRUWDQFHRIKLJKRUDOIOXLGLQWDNH

WKHSDWLHQWVDUHKLJKO\LQWHOOLJHQWDQGQRWLFHWKDWZKHQWKH\GULQNSOHQW\WKH\ZLOOOHDN SOHQW\DQGZKHQWKH\GULQNOLWWOHWKH\ZLOOOHDNOLWWOH

VRDIWHUVRPHWLPHEXWHVSHFLDOO\ZKHQWKH\KDYHHLWKHUORQJVWDQGLQJILVWXODRUORQJ VWDQGLQJ SRVWUHSDLU XULQHVWUHVVLQFRQWLQHQFHPRVWRIWKHPZLOOUHVWULFWWKHLURUDOIOXLG LQWDNHWRWKHPLQLPXP

KRZHYHUWKDWLVRQHRIWKHZRUVWWKLQJVWKDWFDQKDSSHQVLQFHXULQHRXWSXWZLOOEH PLQLPDODQGWKHXULQHFRQFHQWUDWHGUHVXOWLQJLQ DUHFXUUHQWXULQDU\WUDFWLQIHFWLRQVZLWKLQWKHHQGDVKUXQNHQEODGGHU ELQIHFWLRXVK\GURXUHWHUVZLWKK\GURQHSKURV FVWRQHIRUPDWLRQ GVHYHUHXULQHGHUPDWLWLV HRIIHQVLYHRGRU I PRUHVRFLDORXWFDVW JWKH\JLYHXSKRSHVLQFHLWLVGLIILFXOWWRJHWFXUHG

WRRSHUDWHWKHSDWLHQWVLQWKLVVWDJHLVDVVRFLDWHGZLWKSUREOHPVDQGEDGUHVXOWVVXFKDV KLJKSHUFHQWDJHRIEUHDNGRZQF\VWLWLV89VWULFWXUHHWF

WKHUHIRUHLWLVRIXWPRVWLPSRUWDQFHWRUHKDELOLWDWHWKHSDWLHQWWRVWDUWGULQNLQJDQG DEXQGDQWGULQNLQJDOUHDG\EHIRUHDQ\UHSDLULVXQGHUWDNHQ

WKH\KDYHWRXQGHUVWDQGWKDWWKH\ILUVWKDYHWROHDNPRUHEHIRUHWKH\FDQEHFXUHGDQG WKLVUHTXLUHVSDWLHQWFRPSOLDQFH

XOWLPDWHO\WKHSDWLHQWLVUHVSRQVLEOHIRUKHURZQKHDOWKDQGQRWWKHVXUJHRQLWLVQRW SRVVLEOHWRFXUHDQXQFRRSHUDWLYHSDWLHQW

VRWKHILUVWWKLQJLQWKHPDQDJHPHQWRIWKHREVWHWULFILVWXODLVWRH[SODLQDQGLQVWUXFWWKH SDWLHQWWRGULQNDWOHDVWOLWHUVSHUGD\DQGPDNHKHUXQGHUVWDQGWKDWLIVKHLVQRW GULQNLQJWKHUHZLOOEHQRRSHUDWLRQ

WKLVZLOODOVRKHOSLQWKHSDWLHQWFRPSO\LQJWRGULQNSRVWRSHUDWLYHO\VLQFHVKHLVDOUHDG\ XVHGWRLWDQGGXULQJRSHUDWLRQLWPLJKWKHOSLQLGHQWLI\LQJWKHXUHWHUV

LWLVHDV\WRFKHFNDVRQHRQO\QHHGVWKHSDWLHQWWRVWDQGIRUDFRXSOHRIPLQXWHVDQGLI QROHDNDJHWHOOKHUWRFRPHEDFNLIGULQNLQJ

LWZLOOVHOHFWWKHFRRSHUDWLYHSDWLHQWVIURPWKHXQFRRSHUDWLYHSDWLHQWVLIWKHSDWLHQWLV XQFRRSHUDWLYHGRQRWRSHUDWHLWLVDVNLQJIRUWURXEOH

WKHRUHWLFDOO\WKHUHLVDPLQLPDOULVNRIGHYHORSLQJK\SRQDWUHPLDZKHQWKHSDWLHQWLVQRW HDWLQJVRRQWKHRSHUDWLRQGD\VRPHVDOWPD\EHDGGHGWRWKHZDWHU

\RXZDQWWREHGU\\RXKDYHWRFRPSO\

138 118 SRVWRSHUDWLYHLQVWUXFWLRQVDQGIROORZXS

SRVWRSHUDWLYHZDUG

FKHFNEORRGSUHVVXUHDQGSXOVHHYHU\PLQIRUKRXUV

LIKLVWRU\RIHFODPSVLDDGPLQLVWHUPJYDOLXPLPWKHDIWHUQRRQRIRSHUDWLRQ

OLEHUDOXVHRIDQDOJHWLFV

LIQRXULQHRQRSHUDWLRQGD\VWDUWLYIOXLGVZLWKODVL[LYDQGFDOOWKHGRFWRU

HQFRXUDJHRUDOIOXLGLQWDNHDWOHDVWOLWHUVSHUGD\

LIQRWGULQNLQJYRPLWLQJRUORZXULQHRXWSXWVWDUWLYIOXLGV

IHHGLQJDVVRRQDVSDWLHQWIHHOVOLNHLW

FKHFNFDWKHWHUGUDLQDJHDQGLIEORFNHGIOXVKLWRUFKDQJHLW

XULQHVKRXOGEHDWOHDVWPOSHUKRXUVDQGFRPSOHWHO\FOHDU

IXOOPRELOL]DWLRQWKHPRUQLQJIROORZLQJVXUJHU\

QRDQWLELRWLFVXQOHVVVSHFLILFDOO\RUGHUHG

IHUVRODWHDQGIROLFDFLGWDEOHWRGVHDFK

LILQGLFDWHGLURQGH[WUDQLP

UHPRYHSDFNDIWHUGD\FDUHIXOO\RWKHUZLVHWKHSDWLHQWZLOOVWDUWEOHHGLQJ

LIIHYHUGHYHORSVJLYHDQWLPDODULDOVDVZHOODQGGRWKHQHFHVVDU\

HSLVLRWRP\VXWXUHVWREHUHPRYHGDIWHUGD\V

FDWKHWHUWREHUHPRYHGDIWHUZHHNVLQWKHRSHUDWLRQWKHDWUH

DIWHUUHPRYDORIWKHFDWKHWHUWKHSDWLHQWLVGLVFKDUJHGIURPWKHSRVWRSHUDWLYHZDUGEDFN WRWKHKRVWHOVKHKDVWREHLQVWUXFWHGWRFRQWLQXHGULQNLQJDQGWRSDVVXULQHHYHU\ PLQXWHV

QRQDEVRUEDEOHLQWUDYDJLQDOVXWXUHVWREHUHPRYHGZHHNDIWHUFDWKHWHUUHPRYDOWKDWLV DOVRWKHILUVWSRVWRSHUDWLYHLQWUDYDJLQDOH[DPLQDWLRQ

DGGLWLRQDOO\IRUUYI QRVROLGIRRGIRUGD\V OD[DWLYHVOLNHOLTXLGSDUDIILQIRUGD\V QRVLW]EDWKVXQOHVVZRXQGEHFRPHVVHSWLF DIWHUGHIHFDWLRQFOHDQVHDQXVSHULQHXPZLWKZDWHUVRDSDQGZLSHGU\DQGNHHSGU\

119 139 SRVWRSHUDWLYHIROORZXS

QRQDEVRUEDEOHLQWUDYDJLQDOVXWXUHVWREHUHPRYHGZHHNDIWHUFDWKHWHUUHPRYDO

WKHQZHHNVODWHUFKHFNXS

WKHQPRQWKODWHUFKHFNXS

WKHQPRQWKVODWHUFKHFNXS

WKHQPRQWKVODWHUODVWFKHFNXSSDWLHQWFDQUHVXPHVH[XDODFWLYLWLHV

DWHDFKFKHFNXSSOHDVHDVNIRUWKHIROORZLQJDQGGRQRWIRUJHWKHDOWKHGXFDWLRQ

OHDNLQJ\HVQR IRUUYISDVVLQJVWRROVIODWXVSHUYDJLQDP

LQFRQWLQHQFH\HVQR IRUUYIVWRROIODWXVFRQWLQHQFH

QRUPDOPLFWLRQ\HVQR IRUUYIQRUPDOGHIHFDWLRQ

WKHQH[DPLQHDQGFKHFNIRUWKHIROORZLQJ

KHDOHG\HVQR IRUUYISHULQHDOERG\VSKLQFWHUDQL

HOHYDWLRQJRRGPRGHUDWHSRRU

VWUHVV LQFRQWLQHQFH\HVQR

LIUHSRUWLQJZLWKSUHJQDQF\IROORZLQJ VXFFHVVIXO UHSDLUJLYHKHDOWKHGXFDWLRQDQGVHW GDWHIRUHOHFWLYHFHVDUHDQVHFWLRQ

ZKDWHYHU\RXGRZULWHLWGRZQIRUGRFXPHQWDWLRQ

140 120 HFODPSVLD YHUVXVK\SRQDWUHPLD 

ZLWKLQRQHZHHNZHVDZDSDWLHQWZKRILWWHGZKLOVWLQOLQHIRUILUVWH[DPLQDWLRQDSDWLHQW ZKRVWDUWHGWRILWZKLOVWLQOLQHIRURSHUDWLRQDSDWLHQWZKRILWWHGWKHGD\DIWHUDQLQGZHO OLQJEODGGHUFDWKHWHUKDGEHHQLQVHUWHGDQGDSDWLHQWZKRILWWHGWKHHYHQLQJQLJKWDIWHU RSHUDWLRQDOOSDWLHQWVUHFRYHUHGXQHYHQWIXOO\

WKHPRWKHURIWKHODVWSDWLHQWWROGXVLWLVH[DFWO\WKHVDPHDVZKDWKDSSHQHGEHIRUH ZKHQVKHGHOLYHUHG

WKHQWKHSLHFHVRIWKHSX]]OHIHOOLQWRSODFHDQGLFDQQRWXQGHUVWDQGZK\LWWRRNVRORQJ

SUHLQWUDDQGSRVWSDUWXPHFODPSVLD

WKLVDJDLQFRQILUPVKRZVHULRXVHFODPSVLDLVLQWKHGHYHORSLQJZRUOGQRWRQO\LQSULPL JUDYLGDH SDUDH EXWDOVRLQPXOWLJUDYLGDH SDUDH SUHLQWUDDQGSRVWSDUWXPXSWR PRQWKVDIWHUGHOLYHU\

WKHPHFKDQLVPSRVWRSHUDWLYHO\VHHPVWREHDEORRGSUHVVXUHUHERXQGHIIHFWGXULQJRU DIWHUWKHZHDULQJRXWRIVSLQDODQHVWKHVLD

SUHYLRXVO\ZHKDGWKRXJKWWKDWWKHILWWLQJPLJKWKDYHEHHQGXHWRK\SRQDWUHPLDVLQFHWKH SDWLHQWVKDYHWRGULQNSOHQW\ SKGWKHVLV WKRXJKWKHUHLVDVOLJKWWKHRUHWLFDOSRVVL ELOLW\LWLVSUDFWLFDOO\DOPRVWLPSRVVLEOHWRGHYHORSWKLVE\RUDOIOXLGVRQO\

KRZHYHUVLQFHLIDPLOLDUL]HGP\VHOIZLWKHFODPSVLDWKLVVHHPVWREHWKHH[SODQDWLRQIRU WKLVSKHQRPHQRQRIVRIDUXQH[SODLQHGILWWLQJ

WKRXJKLDOZD\VWKRXJKWWKDWHFODPSVLDZDVRQO\KDSSHQLQJLQSULPLJUDYLGDH SDUDH  DQGRQO\SUHDQGLQWUDSDUWXPQRZWRP\VXUSULVHLKDYHEHHQWROGE\P\VWDIIWKDWWKH\ VHHLWLQDQ\JUDYLGLW\SDULW\ZLWKGHYDVWDWLQJHIIHFWVRQPRWKHUDQGFKLOGEHLQJDPDMRU FDXVHRIPDWHUQDODQGSHULQDWDOLQIDQWPRUWDOLW\

IURPWKDWPRPHQWRQZDUGVZHVWDUWHGWRDVNDQ\SDWLHQWV\VWHPDWLFDOO\DERXWWKHRFFXU UHQFHRIHFODPSVLDDQGLIVKHKDVH[SHULHQFHGLWVKHLVJLYHQPJGLD]HSDPLPDVD VLQJOHGRVHWKHDIWHUQRRQDIWHURSHUDWLRQ

LIWKLVVKRXOGQRWEHVXIILFLHQWZHDOZD\VFDQLQFUHDVHWKHGRVHRUORRNIRURWKHUZD\VWR SUHYHQWLWEXWVLQFHZHVWDUWHGZLWKWKLVUHJLPHQZHKDYHQRWHQFRXQWHUHGLWDQ\PRUH

LIWKHSDWLHQWVKRXOGGHYHORSILWWLQJSRVWRSHUDWLYHO\PDJQHVLXPVXOIDWHKDVWREHJLYHQ DVWKHVXSHULRUGUXJRIFKRLFH

WKHUHIRUHZHZRXOGOLNHWRVWUHVVDQGUHFRPPHQGWKHIROORZLQJ

SOHDVHDVNZKHQWDNLQJWKHKLVWRU\DOVRDERXWWKHRFFXUUHQFHRIHFODPSVLDDQGLIWKH SDWLHQWRUKHUUHODWLYH V FRQILUPWKLVDGPLQLVWHUPJYDOLXPRUDOO\RULPDVDVLQJOH GRVHWKHDIWHUQRRQRIWKHRSHUDWLRQ

121 141 HTXLSPHQWDQGLQVWUXPHQWV

RSHUDWLQJWDEOH DZHOOIXQFWLRQLQJK\GUDXOLFRSHUDWLQJWDEOHFRPSOHWHZLWKVKRXOGHUVXSSRUWVDQG OHJKROGHUVDQGDQLQFOLQDWLRQSRVVLELOLW\RIDWOHDVWƒLVDPXVW

DXWRFODYHDQGVWHULOL]HU HLWKHURQHOHFWULFLW\RURQJDV

RSHUDWLQJOLJKWV WKHEHVWLVDPXOWLSOHEXOEV\VWHPZLWKWKHSRVVLELOLW\RIIRFXVLQJ

VWDQGE\JHQHUDWRU WKLVLVDPXVWDVPRVWRIWKHWLPHWKHPDLQHOHFWULFLW\VXSSO\DQGRUWKHKRVSLWDO JHQHUDWRUDUHIDXOW\

VXWXULQJPDWHULDOV DEVRUEDEOHSRO\JO\FROLFDFLGDQGQRQDEVRUEDEOHQ\ORQVXWXUHV ORRVHVXWXULQJQHHGOHVIURP$&8),50 *D*DQG*D

LQVWUXPHQWVSHUVHW  DWOHDVWFPORQJ QXPEHU

 WUROOH\IRUSODFHPHQWRILQVWUXPHQWV WZR

VSRQJHIRUFHSVIRUGLVLQIHFWLQJRSHUDWLRQDUHD WZR

EDFNKDXVRSHUDWLRQGUHVVLQJFODPSV VL[

 VHOIUHWDLQLQJZHLJKWHGDXYDUGVSHFXOXP RQH

SDLURIVKDUSO\FXUYHGWKRUHNVFLVVRUV  RQH

SDLURIVOLJKWO\FXUYHGORQJGLVVHFWLQJVFLVVRUV RQH

 SDLURIFXUYHGVFLVVRUVWRFXWVXWXUHV WZR

VKDUSGHVFKDPSVDQHXU\VPQHHGOH RQH

VOHQGHUDOOLVFODPSV IRXU

PRVTXLWRDUWHU\IRUFHSV  FPORQJFXUYHG WHQ

ORQJVOHQGHUDUWHU\IRUFHSV FPORQJFXUYHG IRXU

142 122 VOHQGHUQHHGOHKROGHU WZR

UREXVWQHHGOHKROGHU RQH

VOHQGHUVFDOSHOKROGHUIRUEODGHVQR RQH

VFDOSHOEODGHVQR WZR

VOHQGHUWRRWKHGWLVVXHIRUFHSV RQH

FDOLEUDWHGXSWRFPXWHULQHVRXQG RQH

 VHWRIPHWDOGLODWRUVIURP+WKUX+ RQH

SODVWLFEODGGHUIOXVKLQJV\ULQJHRIDWOHDVWPO RQH

PHWDONLGQH\ERZOV WZR

RSHUDWLRQGUHVVLQJWRZHOV IRXU

 PHWDOUXOHUVFDOH FP RQH

PHWDODQJOHPHDVXUH SXELFDUFK RQH

IRUJRRGIXQFWLRQLQJDQGVPRRWKRSHUDWLRQSURJUDPDWOHDVWWZRWRWKUHHIXOOVHWVDUH QHHGHG

LIWKHUHLVQRHOHFWULFLW\SODFHWKHRSHUDWLQJWDEOHQHDUDZLQGRZDQGXVHQDWXUDOOLJKW

QDWXUDOOLJKWLVWKHEHVW

KRZHYHUSHRSOHDUHEOLQGHGE\WHFKQRORJ\ LQVWHDGRIXVLQJFRPPRQVHQVH HQGLQJXSZLWKSRRUOLJKW

VXIIHULQJLQWKHSUHVHQFHRIDEXQGDQFH

123 143 DQHVWKHVLDLQREVWHWULFILVWXODUHSDLU

LQWURGXFWLRQ LQGHYHORSLQJFRXQWULHVWKHUHDUHPDQ\SUREOHPVZLWKWKHDQHVWKHVLDGXHWRODFNRI SHUVRQQHOWUDLQLQJHTXLSPHQWPDWHULDOVGUXJVDQGPRQH\RIWHQWKHVXUJHRQKLPVHOILV UHVSRQVLEOHIRUWKHDQHVWKHVLD UHJLRQDODQHVWKHVLDGRHVQRWUHTXLUHVSHFLDOHTXLSPHQWLVHDV\WROHDUQGRHVQRWQHHG LQWHQVLYHLQWUDDQGRUSRVWRSHUDWLYHPRQLWRULQJLVDVHIIHFWLYHDVJHQHUDODQHVWKHVLD GRHVQRWUHTXLUHHOHFWULFLW\DQGLVVDIHDQGFKHDS WKHUHIRUHVSLQDODQHVWKHVLDZLWKDORQJDFWLQJDJHQWVXFKDVEXSLYDFDLQHVHHPVWREH WKHPHWKRGRIFKRLFH

PHWKRGV QRSUHPHGLFDWLRQLVJLYHQLQRUGHUQRWWRORZHUWKHEORRGSUHVVXUHDOUHDG\EHIRUHWKH DQHVWKHVLDLVVWDUWHG WKHEORRGSUHVVXUHLVPHDVXUHGEHIRUHVWDUWLQJZLWKWKHSDWLHQWO\LQJRQKHUEDFNRQWKH RSHUDWLRQ WDEOH ZKLFK VKRXOG EH VOLJKWO\ HOHYDWHG DW WKH KHDG HQG WKH SDWLHQW LV LQVWUXFWHGWRVLWRQWKHRSHUDWLRQWDEOHZLWKWKHOHJVVWUDLJKWDQGWKHQWREHQGIRUZDUG KROGLQJERWKIHHWZLWKKHUKDQGVWKHSDWLHQW VORZHUEDFNLVGLVLQIHFWHGZLWKDQDQWLVHSWLF DJHQW D VSLQDO QHHGOH * LV LQWURGXFHG EHWZHHQ WKH OXPEDU YHUWHEUD VSLQRXV SURFHVVHV//WKURXJKWKH\HOORZOLJDPHQWWKHQWXUQHGƒLQRUGHUQRWWRSLHUFHEXW WRGLYLGHVSOLWWKHILEHUVRIWKHGXUDOVDFDQGLQVHUWHGLQWRWKHGXUDOVDFWRFKHFNLIWKH QHHGOH LV UHDOO\ LQVLGH WKH GXUDO VDF WKH QHHGOH LV WXUQHG EDFN ƒ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

FRPSOLFDWLRQV WKHUHDUHRQO\WKUHHPDMRUFRPSOLFDWLRQVYL]WRWDOVSLQDOEORFNVKRFNDQGSRVWVSLQDO PHQLQJLWLV WRWDOVSLQDOEORFNQHHGVLQWXEDWLRQDQGDUWLILFLDOYHQWLODWLRQXQWLOWKHGUXJHIIHFWKDVZRUQ RXWVKRFNQHHGVLQWUDYHQRXVIOXLGVIDVWDQGSRVWVSLQDOPHQLQJLWLVQHHGVDQWLELRWLFV

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

FRQFOXVLRQ EHFDXVHLWLVVLPSOHHIIHFWLYHVDIHDQGFKHDSVSLQDODQHVWKHVLDZLWKDORQJDFWLQJ DJHQWVXFKDVEXSLYDFDLQHLVWKHDQHVWKHVLDRIFKRLFHLQGHYHORSLQJFRXQWULHVIRU RSHUDWLRQVRIWKHORZHUKDOIRIWKHERG\LQFOXGLQJREVWHWULFILVWXODVXUJHU\

UHPDUNV QRZDGD\VLQDOOWKHYYIUHSDLUFHQWHUVWKHDQHVWKHVLDLVEHLQJGHDOWZLWKE\VSHFLDOL]HG DQHVWKHWLFQXUVHV VRWKHVXUJHRQFDQFRQFHQWUDWHIXOO\XSRQKLVUHFRQVWUXFWLYHVXUJHU\

125 145

bladder stones

LQWURGXFWLRQ LQGHDOLQJZLWKXULQHILVWXODVEODGGHUVWRQHVDUHDIUHTXHQWILQGLQJHLWKHULQFRPELQDWLRQ ZLWKDILVWXODLQFRPELQDWLRQZLWKSRVWUHSDLULQFRQWLQHQFHRULQFRPELQDWLRQZLWKXUJH LQFRQWLQHQFHZLWKRXWDILVWXOD VRREVWHWULFILVWXODVXUJHRQVKDYHWREHIDPLOLDUZLWKLWVPDQDJHPHQW

EODGGHUVWRQHZLWKILVWXOD URXWLQH FKHFN ZLWK PHWDO VRXQG EHIRUH WKH RSHUDWLRQ LV VWDUWHG ZLOO GHPRQVWUDWH D EODGGHUVWRQHDQGWKLVVWRQHKDVWREHUHPRYHGEHIRUHWKHILVWXODLVFORVHG QRUPDOO\ WKH VWRQH LV ELJJHU WKDQ WKH ILVWXOD DQG D SK\VLRORJLF WUDQVYHUVH FXUYHG LQFLVLRQLVPDGHWKUXWKHILVWXODGLVVHFWLRQWKHEODGGHULVRSHQHGIXUWKHUE\WUDQVYHUVH LQFLVLRQ WKH VWRQH LQ WRWR RU LQ SLHFHV  LV UHPRYHG DQG WKH EODGGHU IOXVKHG ZLWK DEXQGDQWIOXLGWRIOXVKRXWDQ\GHEULVXQWLOFOHDQ DQGWKHQWKHUHDUHVHYHUDOSRVVLELOLWLHV no sign of infection  FOHDUXULQH SURFHHGZLWKWKHIXOOUHSDLUDVKDVEHHQRXWOLQHGGLVVHFWLRQRIDYZFORVXUHRIHQGR SHOYLFGLDSKUDJP ZLWKDGKHUHQWEODGGHU FDWKHWHUDYZDGDSWDWLRQ some signs of infection FORXG\XULQH SURFHHGZLWKWKHUHSDLURQO\LWLVWKHQHLWKHULQYHUWLQJFORVXUHRIWKHEODGGHUZLWKDSSUR[L PDWLRQRIWKHDYZZLWKHYDFXDWLRQRIGHEULVLQWRYDJLQDVRQRDEVFHVVIRUPDWLRQRU EURDGDGDSWDWLRQRIDYZRQO\VRHYDFXDWLRQLQWREODGGHUVRQRDEVFHVVIRUPDWLRQ signs of overt infection  XULQHZLWKSXV ZLWKRXWIXUWKHUGLVVHFWLRQRQO\DSSUR[LPDWLRQRIDYZE\HYHUWLQJLQWHUUXSWHGVXWXUHV overt urosepsis SK\VLRORJLF WUDQVYHUVH FXUYHG LQFLVLRQ LQ RQH JR WKUX DYZHQGRSHOYLF GLDSKUDJP EODGGHUUHPRYHWKHVWRQHDQGWKHQRQO\DSSUR[LPDWLRQRIDYZE\VXWXUHV RQO\LIVLJQVRIJHQHUDOL]HGVHSVLVDQWLELRWLFVDUHLQGLFDWHGWKRXJKDFWXDOO\QRUPDOO\ DEXQGDQWRUDOIOXLGLQWDNHLVVXIILFLHQW VXUSULVLQJO\PRVWRIWKHVHILVWXODVGRKHDOZLWKRXWDQ\SUREOHP

EODGGHUVWRQHZLWKSRVWUHSDLUXULQHLQFRQWLQHQFH SK\VLRORJLFLQFLVLRQWKUXRSHUDWLRQVFDUGLVVHFWLRQRSHQLQJEODGGHUUHPRYDORIVWRQH WUDQVYHUVHFORVXUHRIHQGRSHOYLFGLDSKUDJP ZLWKDGKHUHQWEODGGHUXUHWKUD LGHQWLI\LQJ WKHFDXVHRISRVWUHSDLULQFRQWLQHQFHDQGWKHQ³DQDWRPLF´UHFRQVWUXFWLRQRIHQGRSHOYLF GLDSKUDJPZLWKLWVTXDUWHUFLUFXODUIL[DWLRQWRSHOYLVZDOOFDWKHWHUDYZDGDWDWLRQ IRULQIHFWLRQXURVHSVLVHWFVHHDERYH

EODGGHUVWRQHZLWKXUJHLQFRQWLQHQFH RSHQLQJEODGGHUE\SK\VLRORJLFDQWHULRUYDJLQDZDOOLQFLVLRQDWFPIURPHXRVWRQH UHPRYDOIOXVKLQJEODGGHUDQGFORVXUHZKLOVWOHDYLQJIROH\FDWKHWHUIRUGD\V IRULQIHFWLRQXURVHSVLVHWFVHHDERYH

VXSUDSXELFYHUVXVYDJLQDODSSURDFK RYHUWKH\HDUWKHDXWKRUFKDQJHGIURPDVXSUDSXELFWRDYDJLQDODSSURDFKZKLFKLVIDU OHVVWUDXPDWLFFRVPHWLFDOO\VXSHULRUZLWKH[FHOOHQWUHVXOWVHVSHFLDOO\WKHSRVWRSHUDWLYH ZRXQGLQIHFWLRQUDWHLVIDUOHVVLIWKHULJKWRSHUDWLRQSULQFLSOHVDUHEHLQJDSSOLHG

147 GRFXPHQWDWLRQ

WKHLPSRUWDQFHRISURSHUV\VWHPDWLFGRFXPHQWDWLRQFDQQRWEHRYHUVWUHVVHGHQRXJKLQ RUGHUWRHYDOXDWHWKHUHVXOWVFRPSDUHWKHPZLWKRWKHUFHQWHUVDQGIRUUHVHDUFKDQGDQ HIIRUWVKRXOGEHPDGHWRZULWHHYHU\WKLQJGRZQ

WKHGRFXPHQWDWLRQVKRXOGFRQWDLQWKHIROORZLQJLQIRUPDWLRQ

SURSHUSDWLHQWKLVWRU\

SURSHUILVWXODKLVWRU\

VH[DQGFRQGLWLRQRILQIDQW

VRFLDOVWDWXVRISDWLHQW

FODVVLILFDWLRQRIILVWXOD

VL]HRIILVWXODLQFP

GURSIRRW\HVRUQRDQGLI\HVPUFJUDGH

RWKHUOHVLRQVGXHWRREVWUXFWHGODERU

SXELFDUFKDQGDSGLDPHWHURIWKHPDWHUQDOSHOYLV

DQDOUHIOH[

GHWDLOHGRSHUDWLRQUHSRUW

W\SHRIDQHVWKHVLD

SRVWRSHUDWLYHFKHFNXSV

KHDOHGRUQRW

LIKHDOHGFRQWLQHQWRUQRW

ILQDOUHVXOW KHDOHGZLWKZLWKRXWFRQWLQHQFH FRQWLQHQFHUDWHRIKHDOHGILVWXODVRQO\DQGQRWRIWRWDOQXPEHU QRWKHDOHG

DOOWKHVHGDWDDUHWREHSXWLQWRDODUJHGDWDEDVHDQGIURPWLPHWRWLPHDQHYDOXDWLRQKDV WREHPDGHWRGUDZVRPHFRQFOXVLRQVDERXWLQFLGHQFHSUHYDOHQFHLQDFHUWDLQDUHDWR DQDO\VHWKHUHVXOWVDQGWRDXGLWWKHSURMHFW

DQGWRSXEOLVKDERXWKLVRZQSHUVRQDOHYLGHQFHEDVHGH[SHULHQFH

148 126

W\SH,,$EXULQHUHSDLU

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ƒDUSRVELODWHUDOSUR[LPDODWIDWO  LOFBLVFP ORVV SDUDXUHWKUD LQWDFW  FHUYL[ IL[HGQRW PRYLQJ [ FP VHPLFLUFXODUSUR[LPDOIDVFLDGHIHFW³RSHUDWHG´[ DEXWKNXMDQD HXRIFPIFFPDEDXFPLYFP FPNJ RSHUDWLRQ XUHWHU5FLUFXPXYYIUHSDLUTXDUWHUFLUFXODUIDVFLDUHSDLUUHIL[DWLRQ GXUDWLRQPLQKHDOLQJ FRQWLQHQFH DQHVWKHVLD VSLQDOE\DQHVWKHWLFVWDII

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±TXDOLW\XUHWKUDBHXRLQDQDWRPLFSRVLWLRQ WKHSUREOHP VHYHUHPXWLODWLRQEODGGHUUHDOO\WUDXPDWL]HG  QRWOHDNLQJDWDOOFDWKUHPRYHGEODGGHUGULOO  QRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ LQVSKHDOHGJRRGHOHYDWLRQQRVWUHVVLQFRQWLQHQFH  LGHP  QRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ KHDOHGQRVWUHVV

FP

150 128 FDWKHWHUWUHDWPHQW ILVWXODZLWKK\SRWRQLFEODGGHU

NDWVLQD FDWK DQWHULRUWUDXPD

KVJ NDWVLQD  IHPDOH \U 

GLDJQRVLV 39, DOLYH FPQHFURWLFXUHWKURYHVLFRYDJLQDOILVWXODW\SH,,$DDW PLGOLQHOHDNLQJXULQHIRUGD\VWKDWVWDUWHGLPPHGLDWHO\IROORZLQJODVW REVWUXFWHGODERUIRUGD\LQKRVSLWDOVEIHPDOHPDUULHG\UDJRSUH PHQDUFKHPWKODWHU QRWOLYLQJZLWKKXVEDQGQRPHQVWUXDWLRQGURSIRRW 5 JUDGH   DQG / JUDGH   QR UYI QR \DQNDQ JLVKLUL QR HFODPSVLD QRUPDODSGLDPHWHUSXELFDUFKƒDUSRV HXRIFPIFFPFP

 VXSUDSXELFPDVVDYZEXOJLQJLQWRYDJLQDIROH\FKIUHHXULQHIORZ HXREZFPSRRUDQWHULRUHOHYDWLRQHXREFP LQFUHDVHGEODGGHUFDSDFLW\ ORQJLWXGLQDOGLDPHWHU FPDWRQLF EODGGHU  SRRUSRVLWLRQRIXYMXQFWLRQDJDLQVWFDXGDGWKLUGRIV\PSK\VLV QRUPDOZLGWKFPJRRG±TXDOLW\XUHWKUDBHXRLQDQDWRPLFSRVLWLRQ

 QRWOHDNLQJDWDOO KHDOHG OHDYHFDWKIRUPRUHZN DWRQLFEODG   QRWOHDNLQJDWDOO FDWKUHPRYHG EODGGHUGULOO  QRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ ,QVSKHDOHGJRRGHOHYDWLRQQRVWUHVVLQFRQWLQHQFH  LGHP  QRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ KHDOHGQRVWUHVV

 DPHQRUUKHDIRUPWK QRWOHDNLQJDWDOO LQVWUXFWLRQV

FP

129 151 W\SH,,DVWRROW\SH,,%DXULQHILVWXOD

SW NDWVLQD  UYI SW VHYHUHLDWURJHQLFPXWLODWLRQ YYI

PXP NDWVLQD  IHPDOH \U 

VXUJHRQ NHHVZDDOGLMN DVVLVWDQW NDELUODZDO GLDJQRVLV 3, DOLYH FPXUHWKURYHVLFRYDJLQDOILVWXODW\SH,,%DFP VFDUUHGGLVWDOUHFWRYDJLQDOILVWXODW\SH,,DOHDNLQJXULQHSDVVLQJVWRROVSY IRU\UZKLFKVWDUWHGLPPHGLDWHO\IROORZLQJREVWUXFWHGODERUIRUGD\LQ KRVSLWDOVEPDOHPDUULHG\UDJRSUH PHQDUFKH\UODWHU QRWOLYLQJZLWK KXVEDQGQRPHQVWUXDWLRQELODWHUDOIRRWGURSIRUPWK5 JUDGH DQG/ JUDGH   QR \DQNDQ JLVKLUL HFODPSVLD \HV QRUPDO DS GLDPHWHUZLGH SXELFDUFKƒDUSRVFHUYL[PRELOHFPSFIDVFLDGHIHFWPXWLODWHG[ SULY FOLQBIXQWXD  ZKHUHE\ SYZ VXWXUHG WR DYZ YDJLQD QRZ RSHQ ZLWK GLVWDOVWHQRVLVDIWHUILUVWVWDJHRSHQLQJXS HXRIFPIFFPDIFPLYFP FP RSHUDWLRQ XYYIUHSDLUDQGUYIUHSDLU GRFXPHQWDWLRQUYIUHSDLU GXUDWLRQ PLQ KHDOLQJERWK FRQWLQHQFHXBVB DQHVWKHVLD VSLQDO//ZLWKPOEXSLYDFDLQH

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±TXDOLW\XUHWKUDBHXRLQDQDWRPLFSRVLWLRQ LQFLVLRQDURXQGUYIVKDUSGLVVHFWLRQH[FLVLRQRIVFDUWLVVXHWHQVLRQIUHHORQJLWXGLQDO DQRUHFWXPFORVXUHRYHUFPE\GRXEOHOD\HURILQYHUWLQJLQWHUUXSWHGFRQWLQXRXVVHUDILW FKHFNRQKHPRVWDVLVHSLFORVXUHSDFNIRUGD\VWRNHHSGLVWDOYDJLQDRSHQ  QRWOHDNLQJDWDOOVWRROVRNFDWKUHPRYHG EODGGHUGULOO  VWRROVRNQRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ LQVSERWKKHDOHGJRRGHOHYDWLRQQRVWUHVVLQFRQWLQHQFH

55 SUHDQHVWKHVLDPP+J     SRVWRSHUDWLRQ FP

152 130 SRVWSDUWXPWRWDOJHQXLQHLQFRQWLQHQFH

SW NDWVLQD YYI KRXUJODVVXUHWKUDBHXRDQWHULRUSDUWLDOLQWUDRSHUDWLYHGRFXPHQWDWLRQ

KV]G NDWVLQD  IHPDOH \U 

VXUJHRQ NHHVZDDOGLMN DVVLVWDQW NDELUODZDO GLDJQRVLV 3, DOLYH WRWDOXULQHLQWULQVLFBVWUHVVLQFRQWLQHQFH,,,OHDNLQJRIXULQH ZKLOVWO\LQJVLWWLQJVWDQGLQJZDONLQJ QRVSRQWDQHRXVPLFWLRQIRU GD\VZKLFKVWDUWHGLPPHGLDWHO\IROORZLQJREVWUXFWHGODERUIRUGD\V LQKRVSLWDOVEPDOHPDUULHG\UDJRSRVW PHQDUFKH\UHDUOLHU VWLOOZLWK KXVEDQGQRPHQVWUXDWLRQQR KR GURSIRRW7 JUDGH DQG/ JUDGH  QRUYIQR\DQNDQJLVKLULHFODPSVLD\HVQRUPDODSGLDPHWHUZLGHSXELF DUFKqDUSRVFHUYL[PRELOHLQDQDWRPLFSRVLWLRQQRSURODSVH HXRFFP  ZLGHRSHQKRXUJODVVXUHWKUDBHXR REHVLW\ HXREZFPSRRUHOHYDWLRQHXREFP LYFP FP RSHUDWLRQ VRWDXUHWKUDOL]DWLRQE\ORQJLWXGLQDOIDVFLDUHSDLUHXRUKDSK\ GXUDWLRQPLQKHDOLQJ FRQWLQHQFH DQHVWKHVLD VSLQDO//ZLWKPOEXSLYDFDLQHE\DQHVWKHWLFVWDII

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±TXDOLW\XUHWKUDBHXRLQDQDWRPLFSRVLWLRQ  QRWOHDNLQJDWDOO FDWKUHPRYHG EODGGHUGULOO  QRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ LQVSKHDOHGJRRGHOHYDWLRQQRVWUHVVLQFRQWLQHQFH LGHP  QRWOHDNLQJDWDOOQRLQFRQWLQHQFHQRUPDOPLFWLRQ KHDOHGQRVWUHVV

KRXUJODVVXUHWKUDBHXR

153

LQFXUDEOHILVWXODVLQFRQWLQHQFH

EDKDQ\D

SURWRFROLQFXUDEOHILVWXODVLQFRQWLQHQFH

NHHVQHRYDJLQD

1 LQFXUDEOHILVWXODSDWLHQWVNHHVSURWRFRO FKDUDFWHULVWLFVDQGKRZWREHKDYH

LQWURGXFWLRQ KRZFDSDEOHWKHVXUJHRQPD\EHWKHUHDUHDOZD\VSDWLHQWVLQZKRPWKHWUDXPDLVULJKW IURPWKHEHJLQQLQJRUKDVEHFRPHGXULQJVXUJLFDOLQWHUYHQWLRQ V LQFXUDEOH

ZKDWLVLQFXUDEOH LQFXUDEOHPHDQVWKDW HLWKHU WKHVXUJHRQLVQRORQJHUDEOHWRRSHUDWHDQ\PRUH RU WKHSDWLHQWZLOOQRWEHQHILWDQ\PRUHIURPDQRSHUDWLRQ RU WKHRSHUDWLRQZRXOGHQGDQJHUKHUKHDOWKDQGRUKHUOLIH

ZKRZLOOHQFRXQWHULW IRU WKH LQH[SHULHQFHG VXUJHRQ LW FRPHV DW DQ HDUO\ VWDJH DQG IRU WKH H[SHULHQFHG VXUJHRQLWFRPHVDWDODWHUVWDJH KRZHYHUDQ\VXUJHRQZKDWHYHUKLVH[SHULHQFHDQGVNLOOVZLOOHQFRXQWHUSDWLHQWVZKR DUHEH\RQGUHSDLU

FKDUDFWHULVWLFV DEVROXWH YDOLGIRUDQ\VXUJHRQZKDWHYHUKLVH[SHULHQFH QRWLVVXHOHIWWRUHFRQVWUXFWOLNH VXE WRWDOEODGGHUXUHWKUDORVV HYHU\WKLQJILEURWLFIL[HGVRWKHWLVVXHFDQQRWEHPRELOL]HG UHODWLYH GHSHQGLQJXSRQWKHVXUJHRQ¶VH[SHULHQFH VHYHUHYDJLQDVWHQRVLV VHYHUHPXWLODWLRQ HLWKHUREVWHWULFRULDWURJHQLFRUFRPELQHG H[WHQVLYHREVWHWULFWUDXPDOLNHLQW\SH,,%E UHSDLU³SRVVLEOH´ZLWKSUHGLFWDEOHUHVXOWLQJLQFRQWLQHQFHLIFORVHG WRWDOSRVW,,$E,,%ELQWULQVLFLQFRQWLQHQFH SURFHGXUHZKLFKZRXOGWDNHPRUHWKDQKRXUV VHYHUHREHVLW\ZLWKILVWXODGHHSLQVLGH ROGDJHZLWKORQJODVWLQJXULQHOHDNLQJ

DHWLRORJ\ PLQRULW\GXHWRH[WHQVLYHREVWHWULFWUDXPDDQGRUSURFHGXUHVE\H[SHULHQFHGILVWXOD VXUJHRQV PDMRULW\GXHWRPXWLODWLQJSURFHGXUHVE\ LQ H[SHULHQFHG ILVWXOD VXUJHRQVZKRGRQRW XQGHUVWDQGWKHREVWHWULFWUDXPDDQGRUSHOYLVDQDWRP\GXHWRODFNRIWUDLQLQJDQGRUVHOI DUURJDQFH

156 133 SHULOVRIREVWHWULFILVWXODVXUJH\ WKHVXUJLFDOPDQDJHPHQWRIWKHREVWHWULFILVWXODVXUJHU\ZLOOEULQJGRZQDQ\VXUJHRQ IURPZKDWHYHUEDFNJURXQGWUDLQLQJUDFHRUFRXQWU\GRZQWRWKHHDUWKZLWKERWKIHHW SODQWHGVROLGO\RQWKHJURXQGVLQFHDQ\ERG\ HYHQWKHEOLQG FDQVHH RUVPHOO WKHPLV IRUWXQHVKRZHYHUPXFKWKHVXUJHRQLVERDVWLQJDERXWKLVSHUIRUPDQFH DQG WKHQHYHQLQKLJKO\FRPSHWHQWKDQGVRSHUDWLRQVXFFHVVIXOSDWLHQWOHDNLQJ

PDLQSUREOHP QRWWKHILVWXODLWVHOIVLQFHFORVXUHUDWHLVXSWREXWKRZWRHQVXUHVHFXUHVRFLDO FRQWLQHQFHLQRUGHUIRUKHUWROLYHD³QRUPDO´OLIHZKDWHYHUWKDWPD\EH

KRZWREHKDYHLQRUGHUWRSUHYHQWLDWURJHQLFPXWLODWLRQ DQ\VXUJHRQZKDWHYHUKLVH[SHULHQFHVKRXOGDVNKLPKHUVHOI DZLOOWKHSDWLHQWEHQHILWIURPP\VXUJHU\ EFDQLKDQGOHLWVDIHO\ FKRZGRLREWDLQTXDOLW\LQP\VXUJHU\ GFDQLKDQGOHLWP\VHOIRUGRLUHIHUWRDPRUHFRPSHWHQWVXUJHRQ HLVLWQRWVKDPHIXOWRGRVRPHWKLQJLNQRZGHHSLQVLGHLFDQQRWKDQGOH

ZKRKRZWRGHWHUPLQHLQFXUDEOH WKHPRVWH[SHULHQFHGILVWXODVXUJHRQLQDFHUWDLQDUHDLVWKHRQHZKRVKRXOGGHWHUPLQH ³LQFXUDEOH´ KRZHYHUVLQFHWKHREVWHWULFDQGRUVXUJLFDOWUDXPDLVVRFRPSOH[WKLVFDQRQO\EHGRQH E\DQH[DPLQDWLRQXQGHU VSLQDO DQHVWKHVLDDQG WKHQWKHVXUJHRQVKRXOGSURFHHGLISRVVLEOHRUVWRSLIUHDOO\LQFXUDEOHDQG GRFXPHQWZKDWLVIRXQGIRUKLPVHOIDQGRWKHUV

KRZWREHKDYHLILQFXUDEOH WKHVLWXDWLRQKDVWREHH[SODLQHGWRWKHSDWLHQWV DQGKHUUHODWLYHV LQVRIDUDVVKHLV DEOHWRXQGHUVWDQGLW VKHKDVWREHLQVWUXFWHGLQSHUVRQDOK\JLHQHDQGGULQNLQJ VKHKDVWREHWDXJKWVNLOOVWRORRNDIWHUKHUVHOI VKHKDVWRFRPHRQFHD\HDUIRUFKHFNXSDQGWRVHHLIQHZWHFKQLTXHVKDYHEHFRPH DYDLODEOH GRQRWORFNKHUXSLQDILVWXODULXPQRWHYHQLQDJROGHQSULVRQVLQFHXOWLPDWHO\WKH SDWLHQWKHUVHOILVUHVSRQVLEOHIRUKHURZQOLIH

LVLQFXUDEOHLQFXUDEOHIRUHYHU LQFXUDEOHGRHVQRWDVDUXOHPHDQLQFXUDEOHIRUHYHUVLQFH WKHUHVSRQVLEOHVXUJHRQPD\JDLQWKHDGGLWLRQDOH[SHUWLVH QHZLQVLJKWVZLWKQHZWHFKQLTXHVPD\EHFRPHDYDLODEOHZLWKWLPH DQRWKHUVXUJHRQPD\KDYHWKHQHFHVVDU\H[SHUWLVH

134 157 SHUVRQDOH[SHULHQFH DIWHURYHUUHSDLUVWKHDXWKRUVWLOOIDFHVLQFXUDEOHSDWLHQWVLQZLWKDQXS ZDUG WUHQG VLQFH PRUH DQG PRUH SDWLHQWV DUH UHIHUUHG WR KLP DQG PRUH DQG PRUH LQH[SHULHQFHG³VXUJHRQV´RSHUDWH LQWKHYHU\EHJLQQLQJWKHSDWLHQWVZHUHWROGWRFRPHEDFNDIWHU\HDUDQGZLWKPRUH H[SHULHQFHPRVWRIWKHPZHUHRSHUDWHGVXFFHVVIXOO\ QRZZHDUHLQWKHSURFHVVRIUHYLHZLQJWKHPDOORQHE\RQHWRH[HFXWHWKHILQDOODVW UHVRUWDVVHVVPHQWRISRVVLELOLWLHV ZLWKSURPLVLQJUHVXOWVVLQFHZHGHYHORSHGQHZWHFKQLTXHVIRUSRVWUHSDLULQFRQWLQHQFH

XSZDUGWUHQGRILQFXUDELOLW\ VLQFHREVWHWULFILVWXODEHFDPHDOORIDVXGGHQVH[\DURXQGWKH\HDUPRUHGRFWRUV DQGPRUHRUJDQL]DWLRQVEHFDPHLQWHUHVWHG KRZHYHUWKH\DUHLQWHUHVWHGPRUHLQTXDQWLW\WKDQLQTXDOLW\IRUVKRUWWHUPVKRZRIILQ RUGHUWRUDLVHIXQGVKRZFDQRQHWUDLQGRFWRUVVXUJLFDOO\LQRQO\SDWLHQWV WKLVUHVXOWHGLQDQLQFUHDVHRILOOWUDLQHG³VXUJHRQV´ZLWKPXWLODWLQJWHFKQLTXHVWKDQNVWR WKHDUURJDQWLQWHUIHUHQFHE\SHRSOHZKRDUHRQO\LQWHUHVWHGLQSROLWLFDOUKHWRULF

FRQFOXVLRQ

VLQFHILVWXODVXUJHU\LVKLJKO\FRPSOLFDWHGWKHPDMRULW\DUHWKHUHVXOWRISRRUVXUJHU\E\ LQFRPSHWHQW DQGDUURJDQW VXUJHRQVRQH³UHSDLU´FDQVSRLOWKHSDWLHQW¶VOLIHIRUHYHU

DQ\VXUJHRQVKRXOGNQRZKLVOLPLWVDQGUHVWULFWVKLPKHUVHOIWRWKLQJV V KHLVVXUH V KH FDQKDQGOH

WRRPDQ\GRFWRUVDUHSRRUO\WUDLQHGDQGDVVXFKGRQRWKDYHWKHVOLJKWHVWFOXHDERXWWKH REVWHWULFILVWXODDQGSHOYLVDQDWRP\WKH\DUHRQO\WU\LQJWRFRS\DWULFN

ZHVKRXOGDOODLPDWTXDOLW\DQGQRWDWTXDQWLW\

KDOINQRZOHGJHLVH[WUHPHO\GDQJHURXV RQHUHSDLUE\DQLQFRPSHWHQWVXUJHRQ PD\FKDQJHWKHSURVSHFWRIWKHILVWXOD IURPRSHUDEOHLQWRLQRSHUDEOH ZLWKGHYDVWDWLQJOLIHORQJFRQVHTXHQFHV IRUWKHSDWLHQW

158 135 kees neovagina reconstruction

VWHSE\VWHSSXUHYDJLQDORSHUDWLRQWHFKQLF XQGHUVSLQDODQHVWKHVLD aLQH[DJJHUDWHGOLWKRWRP\SRVLWLRQ b LIQHHGHG EL ODWHUDOHSLVLRWRP\IRUJRRGH[SRVXUH c LQGZHOOLQJIROH\EODGGHUFDWKHWHUIRUHPSW\LQJEODGGHUDQGDVRULHQWDWLRQGXULQJ WXQQHOFUHDWLRQGLVVHFWLRQ d WUDQVYHUVHLQFLVLRQ³YDJLQDYDXOW´LIFHUYL[SUHVHQWDV³SRVWHULRUFROSRWRP\´ e VKDUSEOXQWFUHDWLRQRIWXQQHOXSWRSDULHWDOSHULWRQHXPWKHPRVWGLIILFXOWSDUW f WUDQVYHUVHRSHQLQJRIDEGRPHQDVSRVWHULRUFROSRWRP\ g VKDUSEOXQW WUDQVYHUVH ZLGHQLQJ RI FROSRWRP\ XS WR LVFKLXP VSLQHV LQ RUGHU WR SUHYHQWQHRYDJLQDVWULFWXUH h LGHQWLI\LQJFHUYL[LISUHVHQWDQG UH SRVLWLRQLQJFHUYL[LQWRQHRYDJLQD i VXWXULQJWKHSRVWHULRUFROSRWRP\SHULWRQHXPRQWRZKDWLVOHIWRISRVWHULRUYDJLQDZDOO E\SRO\JO\FROLFDFLG j VXWXULQJWKHDQWHULRUFROSRWRP\SHULWRQHXPELODWHUDOO\IURPFHUYL[ VRRSHQLQJLQWR QHRYDJLQD RQWRZKDWLVOHIWRIDQWHULRUYDJLQDZDOOE\SRO\JO\FROLFDFLG k LGHQWLI\LQJXWHUXVDQGVXWXULQJ SRVWHURW ODWHUDOXWHUXVSHULWRQHXP VHURVD ELODWHUDOO\ RQWRVDFURXWHULQHOLJDPHQWVE\SRO\JO\FROLFDFLGFORVLQJWKHVSDFHEHWZHHQWKHXWHUXV XSWRFPSUR[LPDOO\IURPLVWKPXV DQGODWHUDOSHOYLVZDOO l VXWXULQJSRVWHULRUXWHUXVSHULWRQHXP VHURVD DWFPSUR[LPDOO\IURPLVWKPXVRQWR DQWHULRUUHFWXPVHURVDDWFPIURPDQXVE\SRO\JO\FROLFDFLGFORVLQJWKHDEGRPHQ LQVXFKDZD\WKDWWKHSUR[LPDOUHFWXPZLOOEHWKHQHRYDJLQDYDXOW m FORVXUHRIHSLVLRWRPLHV nOHDYHLQGZHOOLQJIROH\FDWKHWHUIRUFRXSOHRIGD\V o GHHSYDJLQDSDFNXSWRQHRYDJLQDYDXOWIRUGD\VWKHQUHQHZSDFNIRUGD\VXSWR GD\VDQGIXUWKHUNHHSLQJYDJLQDRSHQE\VLOLFRQHYDJLQDGLODWRU p WRVWDUWVH[XDOLQWHUFRXUVHZHHNVDIWHURSHUDWLRQ

LQFRQJHQLWDOPD\HUURNLWDQVN\NVWHUKDXVHUV\QGURPHWKHSRVWHULRUEODGGHU VHURVDSHULWRQHXPLVXVHGLQVWHDGRIWKHXWHUXVVHURVDSHULWRQHXP

159 GLVFXVVLRQ

WKHSURFHGXUHLVVWUDLJKWIRUZDUGVDIHDQGJLYHVJRRGUHVXOWVDQGLVQRZWKHSURFHGXUH RIFKRLFHE\WKHDXWKRUDQGOHVVWUDXPDWLFDQGIDUIDVWHUWKDQDQ\RWKHUSURFHGXUH

WKHPRVWGLIILFXOWSDUWLVWKHGLVVHFWLRQFUHDWLRQRIDWXQQHOZLWKLQWKHILEURVLVXSWRWKH SDULHWDOSHULWRQHXPZKHUHE\HLWKHUWKHEODGGHURUWKHUHFWXPPD\EHWUDXPDWL]HGWREH UHSDLUHGLPPHGLDWHO\

WKLVQHRYDJLQDLVIDUPRUHWKDQRQO\GRXJODVSRXFKDQGUHDFKHVXSWRWKHVLJPRLG UHFWXPMXQFWLRQZKHUHE\WKHDQWHULRUSUR[LPDOUHFWXPZDOOZLOOEHFRPHWKHQHRYDJLQD YDXOW

VLQFHWKHFHUYL[LVRSHQLQJLQWRWKHQHRYDJLQDLWLVSRVVLEOHIRUWKHZRPDQWREHFRPH SUHJQDQWVLQFHWKHIL[DWLRQLVDWFPWRLVWKPXVWKHIXQGXVFDQJURZLQWRWKHDEGR PHQZLWKRXWFRPSURPLVLQJWKHUHFWXPFHVDUHDQVHFWLRQLVUHFRPPHQGHG

WKHQHRYDJLQDLVWRWDOO\LQOLQHZLWKWKHIXQFWLRQDOSHOYLVDQDWRP\ZKHUHE\WKHLQWUDSHOYLF XURJHQLWRGLJHVWLYHGLDSKUDJPLVNHSWLQWDFWDQGHYHQPD\EHUHLQIRUFHGE\SDUWRIWKH SRVWHULRUXWHUXVLVWKPXVVXSSRUWLQJWKHXULQHFRQWLQHQFHPHFKDQLVPDQGSUHYHQWLQJ XURJHQLWDOSURODSVH

SDWLHQWFRPSOLDQFHLVWKHPDMRUFKDOOHQJHVLQFHDWWKHVOLJKWHVWLQFRQYHQLHQFHWKH\ VWRSZLWKWKHSRVWRSHUDWLYHLQVWUXFWLRQVVLOLFRQHYDJLQDGLODWRUIRUDWOHDVWPRQWKVRU HYHQORQJHUDQGUHJXODUVH[XDOLQWHUFRXUVHDIWHUZRXQGKHDOLQJ

LWGLIIHUVIURPRWKHUWHFKQLFVDVGHVFULEHG

firstSXUHYDJLQDOSURFHGXUH second QRLQFLVLRQGLVVHFWLRQDQGWKHQSXOOLQJRISHULWRQHXPXSWRYXOYD third VHSDUDWHELODWHUDOVXWXULQJRISRVWHURODWHUDOXWHUXVVHURVDRQWRVDFURXWHULQHOLJD PHQWV fourth DQWHULRUSUR[LPDOUHFWXPZDOODVYDXOWLQVWHDGRI RQO\ FLUFXPIHUHQWLDOO\FORVHG SHULWRQHXP fifth VKDUSEOXQWWUDQVYHUVHGLVVHFWLRQRIFROSRWRP\XSWRLVFKLXPVSLQHVLQRUGHUWRSUH YHQWVWULFWXUHRIQHRYDJLQD sixth VXWXULQJDQWHULRUFROSRWRP\SHULWRQHXPELODWHUDOO\IURPWKHFHUYL[ VRRSHQLQJLQWR QHRYDJLQD RQWRZKDWLVOHIWRIDQWHULRUYDJLQDZDOO seventhVXWXULQJSRVWHULRUFROSRWRP\SHULWRQHXPRQWRZKDWLVOHIWRISRVWHULRUYDJLQD ZDOO eighth QHRYDJLQDOLQHGE\RULJLQDOYDJLQDPXFRVDRULJLQDOSDULHWDOSHULWRQHXPRISHOYLV DQGRULJLQDOYLVFHUDOSHULWRQHXPRIRUJDQVDQGVRWRWDOO\ ninthLQOLQHZLWKWKHIXQFWLRQDOSHOYLVDQDWRP\

KRZHYHUWKHDXWKRUFRXOGQRWILQGVWHSE\VWHSGHVFULSWLRQVRIWKHRWKHUWHFKQLFVRQO\ VRPHJHQHUDOSULQFLSOHVLIWKH\H[LVWDQGLIQHFHVVDU\WKHDXWKRUZLOODGDSWKLVFODLPV DQGFRPPHQWVDFFRUGLQJO\

160 REVWHWULFEDKDQ\D J\QDWUHVLD ¿EURVLVVFDUWLVVXH

SODQHRIGLVVHFWLRQ DIWHUGLVVHFWLRQ IUHHLQJGHEORFNLQJRIFHUYL[

HQGWRHQGFROSRSHULWRQHRVWRP\ HQGWRHQGFROSRSHULWRQHRVWRP\ DQWHULRUDQDVWRPRVLVSRLQWV DQWHULRUDQDVWRPRVLV HQGWRHQGFROSRSHULWRQHRVWRP\ HQGWRHQGFROSRSHULWRQHRVWRP\ SRVWHULRUDQDVWRPRVLVSRLQWV DQDVWRPRVLVFRPSOHWHG

SRLQWRIVXWXULQJSRVWHULRUXWHUXVPXVFXODULVVHURVD UHFRQVWUXFWLRQFRPSOHWHG RQWRDQWHULRUUHFWXPPXVFXODULVVHURVD

QRUPDOYDJLQD NHHVQHRYDJLQD H[WHQGHGUHFWRXWHULQHSRXFK SUHYHQWLRQ

ZK\LVQRERG\LQWHUHVWHG

H[FHSWIRUWKHILVWXODVXUJHRQV

WKLVPDQXDOZRXOGQRWEHFRPSOHWHZLWKRXWDIHZZRUGVDERXWSUHYHQWLRQ WKHUHDUHWZRW\SHVRISUHYHQWLRQ primary prevention WRSUHYHQWWKHILVWXODIURPRFFXUULQJLQWKHILUVWSODFH no SURJUHVVZKDWVRHYHU nobody interested secondary prevention WRSUHYHQWWKHZRPDQIURPWKHPHGLFDOVRFLDODQGPHQWDOFRQVHTXHQFHV excellent SURJUHVV   E\WKHILVWXODVXUJHRQV

the one and only risk factor in obstetric fistulas

poor obstetric care due to a failed system

all the rest is public relation blah blah blah pure lies and fake news for fundraising blaming others for your own failure SULPDU\SUHYHQWLRQ

SUHYHQWLRQRIWKHREVWHWULFILVWXODIURPRFFXUULQJ

E\

HVWDEOLVKLQJQHWZRUNRIIXQFWLRQLQJREVWHWULFXQLWV ZLWKKLJKTXDOLW\FDUH

OHVVRQOHDUQHGIURPKLVWRU\

SOLJKWRI ZKROHVRFLHW\SROLWLFLDQVJRYHUQPHQWVDQG PDMRUDLGRUJDQL]DWLRQV

LQWURGXFWLRQ WKHREVWHWULFILVWXODLVWKHRQO\PDMRUSXEOLFKHDOWKSUREOHPZKHUHWKHSUHYHQWLRQ DQGWKHWUHDWPHQWLVE\KLJKTXDOLW\FDUHDQGVXUJHU\E\UHDOSURIHVVLRQDOV

OHVVRQOHDUQHGIURPKLVWRU\ WKHREVWHWULFILVWXODGLVDSSHDUHGIURPWKHLQGXVWULDOL]HGZRUOGRYHUDSHULRGRI\HDUV E\HVWDEOLVKLQJTXDOLW\FDUHREVWHWULFFDUHVRWKDW

ODERUZDVSUHYHQWHGIURPEHFRPLQJREVWUXFWHGE\WLPHO\LQWHUYHQWLRQE\KLJKO\WUDLQHG DQGVNLOOHGSURIHVVLRQDOVZLWKLQIXQFWLRQLQJREVWHWULFXQLWV

LIVHOGRPDQREVWHWULFILVWXODGHYHORSVLWLVGXHWRFHVDUHDQVHFWLRQDQGQRWWRSURORQJHG REVWUXFWHGODERU

WKHRQO\VROXWLRQLV

WRHVWDEOLVKDQHWZRUNRIIXQFWLRQLQJREVWHWULFXQLWV

WRWUDLQSURIHVVLRQDOV

KRZHYHUWKLVZLOOWDNHWLPHDQGPRQH\

DQG

SHRSOHZLWKFRPSDVVLRQDQGVWDPLQD

164 145 ZK\LVQRERG\LQWHUHVWHG PDNLQJWKHILUVWVWHS

QHLWKHUWKHIHPDOHVQRUWKHPDOHVQRUWKHWUDGLWLRQDOOHDGHUVQRUWKHUHOLJLRXVOHDGHUV QRUWKHSROLWLFLDQVQRUWKHLQWHUQDWLRQDOPDMRUDLGRUJDQL]DWLRQV DQGODVWO\QRUHYHQWKHREVWHWULFILVWXODYLFWLPV

WREODPHIRUWKLVDUHWKHGHOLEHUDWHOLHVDQGIDNHQHZVE\WKHPDMRUDLGRUJDQL ]DWLRQVZKRDUHPRUHLQWHUHVWHGLQSROLWLFDOYHUEDOUKHWRULFDQGIDPLO\SODQQLQJWKDQLQ WKHIDWHRIWKHZRPHQDQGPL[XSVHYHUDOREMHFWLYHVDQGDEXVHWKHVXIIHULQJRIWKH REVWHWULFILVWXODYLFWLPVIRUWKHLURZQDUURJDQW³VXSHULRULW\´FRPSOH[

LIRQHLVUHDOO\LQWHUHVWHGLQWKHREVWHWULFILVWXODGRVRPHWKLQJDERXWLW

LI\RXZDQQDZRUN««ZRUN«GRQ¶WWDON

DQG«GRQ¶WOLHGHOLEHUDWHO\

ELJJHVWGHOLEHUDWHOLH

HDUO\PDUULDJH HDUO\PDUULDJHKDVQRWKLQJZKDWVRHYHUWRGRZLWKWKHREVWHWULFILVWXOD WKRXJKWKHUHDUHVWLOORYHUWHHQDJHGHOLYHULHVD\HDULQWKHXVDQRWDVLQJOH ILVWXODKDVEHHQUHSRUWHG

IDNHQHZV

UDSHLQGXFHGILVWXODV WKHSODFHWRGREDVHOLQHUHVHDUFKDUHWKHDPHULFDQSULVRQVZKHUHUDSHLQDOOLWVIRUPV LVUDPSDQWKRZHYHUQRWDVLQJOHILVWXODRUVSKLQFWHUDQLUXSWXUHUHSRUWHG

JHQGHUEDVHGYLROHQFH JRHVRXWIURPERWKSDUWLHVIURPIHPDOHVDQGIURPPDOHVVWXG\LWLQQHZ\RUN

IHPDOHFLUFXPFLVLRQ ZKDWDERXWPDOHFLUFXPFLVLRQDQGZKDWDERXW

UHGXFWLRQODELDPLQRUDH[FLVLRQQLSSOHODELDFOLWRULVSLHUFLQJWDWWRRLQJ³FRVPHWLF´EUHDVW VXUJHU\SODVWLFPDWVLQVLGHWKHYDJLQDEXWWRFNLPSODQWVERWR[IDFHOLIWLQJDQGODVWEXW QRWOHDVWWKHLQGLVFULPLQDWHXVHRIDQWLELRWLFVF\WRVWDWLFVDQGRWKHUGUXJVZKLFKFDXVH WKHGHDWKRIKXQGUHGWKRXVDQGVRISHRSOHD\HDUZRUOGZLGH

LVWKHILQDQFLDOJUHHGRIWKHVXUJHRQVLQXVDHXRSHODXGDEOHDQGWKHVXUYLYDORIWKH WUDGLWLRQDOKHDOWKZRUNHUVWREHVWRSSHG

ZKDWDK\SRFULV\WKHRQH\RXFDOOSULPLWLYHDQGWKHRWKHUFRVPHWLF

146 165 VHFRQGDU\SUHYHQWLRQ

SUHYHQWLRQRIWKHILVWXODZRPDQIURPEHFRPLQJDQRXWFDVW E\ WKHLPPHGLDWHPDQDJHPHQW

DVGHYHORSHGE\WKHDXWKRUNHHVGXULQJ DMRJ

SOLJKWRIWKHREVWHWULFWUDXPDVXUJHRQV

XQWLOLWZDVFRPPRQGRXEOHPDOSUDFWLFHDVJROGHQVWDQGDUG

ILUVWWRVHQGDZD\DQ\ZRPDQZKRGHYHORSHGDQREVWHWULFILVWXOD DQGDVVXFKQHHGHG LPPHGLDWHDWWHQWLRQ DQGWHOOKHUWRFRPHEDFNDIWHUPRQWKVDQG

VHFRQGSUHVFULELQJKHDY\GRVHVRIDQWLELRWLFV XVHOHVVLQWKHREVWHWULFILVWXOD 

WKHUDWLRQDOHZDV DDQ\UHSDLUZLWKLQWKHILUVWPRQWKVLVGRRPHGWRIDLO ELIWKHDQWLELRWLFVGRQRWKHOSWKH\ZLOOQRWKDUP

KRZHYHUWKH VXUJLFDO PDQDJHPHQWKDVWRVWDUWWKHPRPHQWWKHOHDNLQJRIXULQHLV PDQLIHVWDQGWKHLQGLVFULPLQDWHSUHVFULSWLRQRIDQWLELRWLFV XVHOHVVLQWKHREVWHWULF ILVWXOD ZLOORQO\FRQWULEXWHWRWKHGHYHORSPHQWRIPXOWLUHVLVWDQFH YHU\KDUPIXO 

WKHWKHRUHWLF DQGQRZHYLGHQFHEDVHG UDWLRQDOHZDVDQGVWLOOLV FWRSURPRWHWKHQDWXUDOKHDOLQJSURFHVVHV GKLJKRUDOIOXLGLQWDNHWRSURPRWHFOHDQVLQJDQGWRSUHYHQWDVFHQGLQJLQIHFWLRQ

IURPWKHDXWKRUVWDUWHGDV\VWHPDWLF VXUJLFDO PDQDJHPHQWRIWKHIUHVK REVWHWULFILVWXODVZLWKLQWKHILUVWGD\VE\

LQFKURQRORJLFRUGHU

ILUVWE\FDWKHWHUWUHDWPHQWRIZHHNVKLJKRUDOIOXLGLQWDNH WKLVUHVXOWHGLQDJRRGHYLGHQFHEDVHGSHUFHQWDJHRIKHDOLQJ

WKHQE\DGDSWDWLRQVXWXUHVDQGFDWKHWHUWUHDWPHQW WKLVUHVXOWHGLQDEHWWHUHYLGHQFHEDVHGSHUFHQWDJH

166 147 WKHQE\IUHVKHQLQJDYZDGDSWDWLRQVXWXUHVDQGFDWKHWHUWUHDWPHQW WKLVUHVXOWHGLQDEHWWHUHYLGHQFHEDVHGSHUFHQWDJH

WKHQE\IUHVKHQLQJPLQLPDOQHHGOHGLVVHFWLRQDYZDGDSWDWLRQDQGFDWKHWHUWUHDWPHQW WKLVUHVXOWHGLQDEHWWHUHYLGHQFHEDVHGSHUFHQWDJH

WKHQE\IUHVKHQLQJPLQLPDOQHHGOHGLVVHFWLRQEODGGHUXUHWKUDFORVXUHDYZDGDSWD WLRQDQGFDWKHWHUWUHDWPHQW WKLVUHVXOWHGLQDEHWWHUHYLGHQFHEDVHGSHUFHQWDJH

DWDFHUWDLQSRLQWGXULQJWKLVPDQDJHPHQW

DIXOOUHSDLUZDVFDUULHGRXWZLWKLQFLVLRQPLQLPDOGLVVHFWLRQEODGGHUXUHWKUDFORVXUH DYZDGDSWDWLRQDQGFDWKHWHUWUHDWPHQW ZLWKH[FHOOHQWUHVXOWV

DIWHUDILQDODQDO\VLVRIWKHHYLGHQFHEDVHGUHVXOWVWKHLPPHGLDWHPDQDJHPHQW E\FDWKHWHUDQGRUHDUO\FORVXUHZDVDORJLFDOFRQVHTXHQFH

ZKHQWKHDXWKRUVWDUWHGWRUHSRUWDERXWWKLVKHZDVPHWZLWKYHU\KRVWLOHUHVSRQVHV VLQFHDJDLQVWWKHFRQVHQVXV IURPWKHSURIHVVLRQDOVEXWHVSHFLDOO\IURPWKHYHU\ YRFDODQGVWHDOLQJYHUEDO³VXUJHRQV´LQWKHXVDDQGXN ZKHUHWKHXUJHWRILUVWVWHDODQG WKHQSXEOLVKH[WHQVLYHO\DERXWWKHREVWHWULFILVWXODH[FHHGVWKHLU]HURSHUIRUPDQFH 

DVZHOOVLQFHDWWKDWWLPHWKHPDMRULW\RIILVWXODVXUJHRQVZHUHPLVVLRQDULHVVRPHRI WKHPXVHGWKHVXIIHULQJRIWKHREVWHWULFILVWXODYLFWLPVIRUFKULVWLDQL]DWLRQZKHUHWKH SDWLHQWVDUHFRHUFHGWRDWWHQGWKHPDVVHVDQGDSSURDFKHGWRFRQYHUWWKXVWKHFKDQJH WRLPPHGLDWHPDQDJHPHQWZRXOGQRWFRQWULEXWHWRWKLVVWUDWHJ\

GXWFKSURYHUEVXUJHRQVZLWKVRIWKDQGVPDNHVWLQNLQJZRXQGV

148 167

REVWHWULFWUDXPDVXUJHU\ WUDLQLQJJXLGHOLQHV

WUDLQLQJFXUULFXOXPIRUGRFWRUV

WUDLQLQJJXLGHOLQHV QHHGIRUWUDLQLQJ WUDLQLQJFRXUVHDQGWUDLQHHV WUDLQLQJFXUULFXOXP WUDLQLQJPRGXOH WUDLQLQJFHQWHU UHSDLUFHQWHU UHKDELOLWDWLRQFHQWHU QDWLRQZLGHVHUYLFH REVWHWULFILVWXODWRXULVP WUDLQLQJLQGXVWULDOL]HGZRUOG WUDLQLQJQRQGRFWRUVRUHYHQQRQPHGLFDOSHUVRQV

WRSLFUHODWHGZRUNVKRSV

ILUVWHGLWLRQ QRYHPEHU

QGHGLWLRQ DSULO SUHSDUHGIRUXQISDPHHWLQJLQQLDPH\

UGHGLWLRQ DXJXVW SUHSDUHGIRUILJRPHHWLQJLQGDUHVVDODDP

WKHGLWLRQ PD\ SUHSDUHGIRUWUDLQLQJPDQXDO

WKHGLWLRQ RFWREHU DGDSWHGIRUWRSLFUHODWHGZRUNVKRSV IRUHZRUG

VRIDUWKHWUDLQLQJRIVXUJHRQVLQWKHPDQDJHPHQWRIWKHREVWHWULFWUDXPDVXUJHU\KDV EHHQDIDLOXUH

WKLVKDVEHHQGXHWRWKHIDFWWKDWWKHPDMRURUJDQL]DWLRQVKDYHQRWEHHQIROORZLQJWKH UHFRPPHQGDWLRQVRIWKHIHZUHDOH[SHUWWUDLQHUVGXHWRWKHW\SLFDODUURJDQFHRISHRSOH ZLWKPRQH\ZKRWKLQNWKH\NQRZLWEHWWHUWKDQWKHH[SHUWV

UHVXOWLQJLQVKRUWWHUPWUDLQLQJSURJUDPVZLWKLPPHGLDWHKDQGVRQ³WUDLQLQJ´RIRWKHUZLVH SRRUO\WUDLQHGGRFWRUVZKRWKHQZHUHUHFUXLWHGLPPHGLDWHO\WRWUDLQWKHEHJLQQHUV

WKHEOLQGWHDFKLQJWKHODPHKRZWRFURVVWKHURDG

UHVXOWLQJLQWHUPVOLNHVLPSOHILVWXODVWKRXJKLKDYHQHYHUVHHQDVLPSOHILVWXOD GXULQJP\ZKROHFDUHHU

QHJOHFWLQJWKHZDUQLQJWKDWREVWHWULFWUDXPDVXUJHU\RYHUWKHZKROHZRUOGEHORQJVWR WKHPRVWFRPSOLFDWHGVXUJHU\

WKHZHDNHVWSRLQWLVQRNQRZOHGJHRIWKHDQDWRP\FRPELQHG ZLWKSRRUVXUJLFDOVNLOOV

ZKLOVWDQGWKHRUJDQL]DWLRQVDQGWKH³VXUJHRQV´DUHRQO\LQWHUHVWHGLQQXPEHUVEXW QRERG\LQWKHHYLGHQFHEDVHGUHVXOWV SRVLWLYHGHSHQGLQJXSRQKRZSRRUWKH VXUJHRQ KRZHYHU

DQRQWUHDWHGSDWLHQWLVEHWWHURIIWKDQDPXWLODWHGSDWLHQW

RQHRIWKHVLGHHIIHFWVLVWKDWVLQFHWKHSDWLHQWVDUHPRUHLQWHOOLJHQW KLJKO\ WKDQWKH RUJDQL]DWLRQVWKH\RQO\FRPHIRUZDUGLIWKHUHVXOWVDUHJRRG

UHVXOWLQJLQWKH³GHFUHDVHLQQXPEHUV´ ZKLFKWKHDXWKRUGHILQLWHO\FDQQRWFRQILUP DFWXDOO\LWLVWKHRSSRVLWHVLQFHPRUHGHOLYHULHVZLWKRXWFRQFRPLWDQWLPSURYHPHQWRIWKH REVWHWULFFDUH 

WKHUHIRUHWKHDXWKRUDGDSWHGKLVRULJLQDOJXLGHOLQHV ZKLFKKDYHEHHQQHJOHFWHGVR IDU HVSHFLDOO\WRLPSURYHWKHNQRZKRZRIWKHWUDLQHUVE\RUJDQL]LQJ

VSHFLDOWRSLFUHODWHGGD\ZRUNVKRSVIRUH[SHULHQFHGVXUJHRQV QRWWKHYHUEDORQHV 

KRSLQJWKDWWKLVWLPHVRPHERG\LVOLVWHQLQJYHU\GRXEWIXO

WKHDXWKRU RFWREHU

170 151 training curriculum for doctors RQ VXUJLFDO PDQDJHPHQWRIYHVLFRYDJLQDODQGUHFWRYDJLQDOILVWXODV

LQWHUYLHZ SHUVRQDOLQWURGXFWLRQ SURIHVVLRQDOHYDOXDWLRQRIWKHWUDLQHH SXUSRVHRIWUDLQLQJ WHUPVRIWUDLQLQJ LVRIVILJRUFRJWUDLQLQJPDQXDO KDQGLQJRXWWHDFKLQJPDWHULDOV ORJERRN

LQWURGXFWLRQ GHILQLWLRQVDQGWHUPLQRORJ\ PHFKDQLVPRIDFWLRQ FRPELQDWLRQYYIUYI PHGLFDOFRQVHTXHQFHV VRFLDOFRQVHTXHQFHV LQFLGHQFH SUHYDOHQFH SXEOLFKHDOWKSUREOHP KLVWRU\OLWHUDWXUHUHYLHZ

DQDWRP\RIIHPDOHSHOYLV ERQHV SHOYLFIORRUDQDWRP\ DUFXVWHQGLQHXVIDVFLDH SXERFHUYLFDOIDVFLD DUFXVWHQGLQHXVRIOHYDWRUDQLPXVFOH OHYDWRUDQLPXVFOH SXERFRFF\JHXVPXVFOH LOLRFRFF\JHXVPXVFOH LVFKLR FRFF\JHXVPXVFOH LQWHUQDOREWXUDWRUPXVFOH SLULIRUPLVPXVFOH VDFURWXEHUDOOLJDPHQWV VDFURVSLQRXVOLJDPHQWV VDFURXWHULQHOLJDPHQWV JUHDWHUVFLDWLFIRUDPHQ OHVVHUVFLDWLFIRUDPHQ EORRGVXSSO\ LQQHUYDWLRQ

152 171 SK\VLRORJ\RISHOYLFIORRUVWUXFWXUHV DVEDVHGRQWKHIXQFWLRQDODQDWRP\ IXQFWLRQRIOHYDWRUDQLPXVFOHV SHOYLVIORRUPXVFOHVH[HUFLVHV

XULQHFRQWLQHQFHPHFKDQLVPLQWKHIHPDOH ZKROHXUHWKUDEODGGHUQHFNFP DQDWRP\RIXUHWKUD FUXFLDOUROHRISXERFHUYLFDOIDVFLDDVVWDELOL]LQJIDFWRU

VWRROFRQWLQHQFHPHFKDQLVPLQWKHIHPDOH LQWHUQDOVSKLQFWHU DQRUHFWXPFP H[WHUQDOVSKLQFWHU VSKLQFWHUDQL SHULQHDOERG\DVVWDELOL]LQJIDFWRU

FDXVHVRIYYIUYI REVWHWULF SUHVVXUHQHFURVLV VXUJLFDO WUDXPDGXULQJODERU WUDXPDWLF VXUJHU\RURWKHU FKHPLFDO LQIHFWLRXV FDQFHU UDGLDWLRQ FRQJHQLWDO

FRPSOH[WUDXPDRIWKHREVWHWULFILVWXOD LQWUDYDJLQDOOHVLRQVGXHWRSUHVVXUHQHFURVLV YXOYDOHVLRQVGXHWRSUHVVXUHQHFURVLV ORFDOH[WUDYDJLQDOOHVLRQVGXHWRLPPRELOL]DWLRQRUQHXURORJLFWUDXPD QHXURORJLFOHVLRQVGXHWRLQWUDSHOYLFFRPSUHVVLRQ QHXURORJLFOHVLRQVGXHWRHFODPSVLD V\VWHPLFOHVLRQVGXHWRHQRUPRXVWUDXPDRISURORQJHGREVWUXFWHGODERU V\VWHPLFOHVLRQVGXHWREORRGORVV OHVLRQVGXHWRFRQWLQXRXVXULQHOHDNDJH OHVLRQVGXHWRUHVWULFWLRQRIRUDOIOXLGLQWDNH VH[FRQGLWLRQRILQIDQWERUQ

FODVVLILFDWLRQ DFFRUGLQJWRORFDWLRQ PRVWLPSRUWDQW DFFRUGLQJWRVL]H  DGGLWLRQDO

FRQVHTXHQFHVRIFODVVLILFDWLRQ RSHUDWLRQWHFKQLFSULQFLSOHV KHDOLQJDVWRFORVXUH KHDOLQJDVWRFRQWLQHQFH

172 153 KLVWRU\WDNLQJ SDULW\ KRZPDQ\DOLYH GXUDWLRQRIOHDNDJH RQVHWRIOHDNDJH KRPHKRVSLWDOGHOLYHU\ VH[FRQGLWLRQRILQIDQW PHQVWUXDWLRQ VRFLDOVWDWXV \DQNDQJLVKLUL HFODPSVLD

FOLQLFDOH[DPLQDWLRQ JHQHUDOKHDOWKVWDWXVQXWULWLRQDQHPLD YDJLQDOH[DPLQDWLRQZLWKRXWDQHVWKHVLD DQDOUHIOH[ LIQHJDWLYHFKHFNIRUVDGGOHDQHVWKHVLD SHURQHDOQHUYHWUDXPDJUDGLQJRIGURSIRRW DFFHVVLELOLW\ YDJLQDVWHQRVLV XULQHGHUPDWLWLV EHGVRUHV DWRQLFEODGGHU SHOLPLQDU\FODVVLILFDWLRQ FDQ\RXKDQGOHLWRUQRW LI\RXDUHQRWVXUHUHIHUSDWLHQWWRVRPHERG\PRUHH[SHULHQFHG

VXUJLFDOFODVVLILFDWLRQZLWKUHJDUGVWRRSHUDWLRQWHFKQLFQHHGHG EDVHGRQDQDWRPLFSK\VLRORJLFORFDWLRQ W\SH, W\SH,,$D W\SH,,$E W\SH,,%D W\SH,,%E W\SH,,,

ODERUDWRU\LQYHVWLJDWLRQ KHPRJORELQDQGVHUXPFUHDWLQLQHLISRVVLEOH

[UD\LQYHVWLJDWLRQ QRQH

H[DPLQDWLRQXQGHUDQHVWKHVLD HXD DVVHSDUDWHSURFHGXUH XWWHUO\QRQVHQVHRQO\DPRQH\PDNHUIRUSHRSOHZKRFDQQRWKDQGOHYYI

154 173 LPPHGLDWHPDQDJHPHQWRIIUHVKREVWHWULFILVWXODV FDWKHWHU GHEULGHPHQW FOHDQLQJ HDUO\FORVXUH KHPDWLQLFV KLJKSURWHLQGLHW LPPHGLDWHPRELOL]DWLRQ

SUHRSHUDWLYHSUHSDUDWLRQ KLJKSURWHLQGLHW KHPDWLQLFV SHUVRQDOK\JLHQH HQHPD VKDYLQJ

HTXLSPHQWLQVWUXPHQWVPDWHULDOV RSHUDWLQJWDEOH QRUPDOYDJLQDOLQVWUXPHQWV VSHFLDOLQVWUXPHQWVVKDUSO\FXUYHGVFLVVRUVDQHXU\VPQHHGOH SRO\JO\FROLFDFLG QRQDEVRUEDEOHVXWXUHV QHHGOHV

DQHVWKHVLD VSLQDODQHVWKHVLD ORQJDFWLQJEXSLYDFDLQH OHYHORIVSLQDOWDEQRUPDOORZKLJK VLWWLQJSRVLWLRQ KHDGIOH[HGDQWHULRUO\WKRUD[DOZD\VHOHYDWHG PDMRUFRPSOLFDWLRQV PLQRUFRPSOLFDWLRQV EORRGSUHVVXUHEHIRUHGXULQJDIWHURSHUDWLRQ

SRVLWLRQRQRSHUDWLQJWDEOH H[DJJHUDWHGOLWKRWRP\SRVLWLRQ QHYHUNQHHHOERZSRVLWLRQ OHJKROGHUVDQGVKRXOGHUVXSSRUW

PDQSRZHU VXUJHRQ LQVWUXPHQWDWLQJWKHDWHUQXUVH QRDVVLVWDQW V WKHYDJLQDLVDRQHPDQSODFH DVVLVWDQWVDUHUHVWULFWLQJWKHVXUJHRQLQPDQHXYHULQJKLVLQVWUXPHQWV

174 155 URXWHRIRSHUDWLRQ H[FOXVLYHO\WKHYDJLQD QE DEGRPLQDO DSSURDFK VNLQ VXEFXWLV IDVFLD PXVFOHV IDVFLD SHULWRQHXP DEGRPHQSHULWRQHXPEODGGHUDQGWKHQRQHLVLQWKHYDJLQDVRZK\GRQRWVWDUW WKHUHLPPHGLDWHO\""ZKDWDWUDXPDZDVWHRIHQHUJ\

DFFHVVLELOLW\ VXWXULQJODELDPLQRUDWRLQQHUWKLJKV HSLVLRWRPLHVLIQHFHVVDU\ ZHLJKWHG$89$5'VSHFXOXP QRUHWUDFWRUVRQHLQVWUXPHQWLQVLGHWKHYDJLQDLVDOUHDG\DFURZGDQGPRUHDUH KLQGHULQJWKHVXUJHRQLQPDQHXYHULQJKLVLQVWUXPHQWV

DVVHVVPHQWRQRSHUDWLQJWDEOHXQGHUDQHVWKHVLD SHOYLVSXELFDUFK$3GLDPHWHUJHQHUDOL]HGFRQWUDFWLRQHWF VL]HRIILVWXODLQFP ORFDWLRQRIILVWXODPLGOLQHULJKWOHIW GLVWDQFHIURPH[WHUQDOXUHWKUDRSHQLQJWRILVWXODLQFP GLVWDQFHIURPILVWXODWRFHUYL[YDJLQDYDXOWLQFP FLUFXPIHUHQWLDOGHIHFW\HVQR VFDUWLVVXHWH[WXUHPRELOLW\ GHILQLWHFODVVLILFDWLRQ PDNHXS\RXUPLQGZKDWWRGRH[DFWO\ PDNH\RXUVHOIFRPIRUWDEOHFKHFNHYHU\WKLQJEHIRUH\RXVWDUWRSHUDWLQJ

RSHUDWLRQWHFKQLF FKHFNIRUXUHWHUV LQFLVLRQ VKDUSPLQLPDOGLVVHFWLRQPRELOL]DWLRQ EODGGHUXUHWKUDFORVXUHWUDQVYHUVHORQJLWXGLQDO VWDWLFEODGGHUFDSDFLW\ )2/(<FDWKHWHUDQGIL[DWLRQ XUHWKUDOHQJWK HOHYDWLRQRIEODGGHUQHFN YDJLQDZDOODGDSWDWLRQ HSLVLRWRP\FORVXUH QRURXWLQHYDJLQDSDFN FKHFNXULQHIORZ FKHFNEORRGSUHVVXUH GHWDLOHGRSHUDWLRQUHSRUW

SRVWRSHUDWLYHFDUH FKHFNIRUYLWDOVLJQVIRUKU KLJK RUDO IOXLGLQWDNH IHHGLQJDVVRRQDVSDWLHQWIHHOVOLNHLW LIKLVWRU\RIHFODPSVLDPJYDOLXP GLD]HSDP LPRQRSHUDWLRQDIWHUQRRQ

156 175 UHJXODUFKHFNRIFDWKHWHU LPPHGLDWHPRELOL]DWLRQ XULQHRXWSXWFRORUOHVVOLNHFOHDUZDWHU QRURXWLQHXVHRIDQWLELRWLFV DQWLELRWLFVRQO\RQLQGLFDWLRQJHQHUDOL]HGVHSVLVSQHXPRQLD KHPDWLQLFV SHUVRQDOK\JLHQH FDUHIXOUHPRYHRIHYHQWXDOSDFNGD\DIWHURSHUDWLRQ

VXUJLFDODIWHUFDUH UHPRYDORIHSLVLRWRP\VXWXUHVDIWHUGD\V LQGZHOOLQJFDWKHWHUIRUDWOHDVWZN LIQHFHVVDU\ HDUO\FORVXUH ZNUHVS DWRQLFEODGGHU ZN FDWKHWHUUHPRYDOLQRSHUDWLRQWKHDWHUZNODWHU KLJKRUDOIOXLGLQWDNHDQGIUHTXHQWSDVVLQJRIXULQH UHPRYDORIQRQDEVRUEDEOHYDJLQDVXWXUHZNDIWHUFDWKHWHUUHPRYDO DVNIRUOHDNLQJLQFRQWLQHQFHDQGVSRQWDQHRXVPLFWLRQ FKHFNIRUKHDOLQJHOHYDWLRQDQGVWUHVVXUJHLQFRQWLQHQFH EODGGHUGULOOIRULQFRQWLQHQFH

SRVWRSHUDWLYHFKHFNXSV UHJXODUO\XSWRPWK QRVH[XDOLQWHUFRXUVHGXULQJWKLVSHULRG FRQWLQXHGULQNLQJDQGIUHTXHQWSDVVLQJRIXULQH DVNIRUOHDNLQJLQFRQWLQHQFHDQGVSRQWDQHRXVPLFWLRQ FKHFNIRUKHDOLQJHOHYDWLRQDQGVWUHVVXUJHLQFRQWLQHQFH LILQGRXEWG\HWHVW WKHG\HQROLH

SDWLHQWFRXQVHOOLQJ WRFRPHEDFNDWVXEVHTXHQWSUHJQDQFLHVDWPWKDPHQRUUKHD WRDWWHQGDQWHQDWDOFDUHUHJXODUO\ IHUVRODWHDQGIROLFDFLG WRGHOLYHULQKRVSLWDOE\HOHFWLYHFHVDUHDQVHFWLRQ SDWLHQWFDUGZLWKZULWWHQLQVWUXFWLRQVRSHUDWLRQUHSRUW

GRFXPHQWDWLRQ H[WUHPHO\LPSRUWDQWIRUPRQLWRULQJSURJUDP KLVWRU\ GHWDLOHGRSHUDWLRQUHSRUW FKHFNXSV HYDOXDWLRQUHSRUWV

176 157 SUHYHQWLRQ QRUHODWLRQWRWULEHUHOLJLRQFXOWXUHHDUO\PDUULDJHRUDQ\WKLQJHOVHH[FHSWIRU HDUO\LQWHUYHQWLRQE\FHVDUHDQVHFWLRQ FV ZLWKLQKRXUV RQO\ E\ HVWDEOLVKLQJ D IXQFWLRQLQJ QHWZRUNRI REVWHWULF XQLWV WKURXJKRXW $IULFD ZKHUH HPHUJHQF\ FHVDUHDQ VHFWLRQ FDQ EH SHUIRUPHG ZLWKLQKRXUVRIODERUEHFRPLQJREVWUXFWHG GHWHFWLRQ RI SUREOHP SDWLHQWV DW DQWHQDWDO FDUH SHOYLF DVVHVVPHQW  WKHQ KRVSLWDOGHOLYHU\ LGHQWLI\LQJSUREOHPVE\SDUWRJUDPWKHQHDUO\UHIHUUDOIRUFV

WKHHPSKDVLVLVSODFHGRQKRZWRPDQDJHYYIUYIXQGHUDIULFDQFRQGLWLRQV

KDYLQJ ILQLVKHG WKLV FRXUVH WKH FDQGLGDWH PXVW KDYH DPSOH XQGHUVWDQGLQJ RI WKH FRPSOH[WUDXPDRIWKHREVWHWULFILVWXODWKHREVWHWULFILVWXODDVDPDMRUSXEOLFKHDOWK SUREOHPDVZHOODV V KHPXVWEHDEOHWRGHFLGHZKLFKILVWXODV V KHFDQKDQGOHZLWK FRQILGHQFHDQGZKLFKQRW

FHUWLILFDWH RQO\FHUWLILFDWHRIDWWHQGDQFHZLOOEHLVVXHG

ILUVWHGLWLRQ GHFHPEHU

ODVWHGLWLRQ PD\

158 177 training guidelines

the obstetric fistula as a major public health problem the need for training

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

WKHEHVWZHFDQDLPIRUDWWKHPRPHQWLVWRVSUHDGWKHH[SHUWLVHKRZWRPDQDJHWKH REVWHWULFILVWXODFRQILGHQWO\ZLWKLQWKHVFDUFHUHVRXUFHVRIGHYHORSLQJ$IULFDDQGRQFH DYDLODEOHWRNHHSWKLVH[SHUWLVHZKHUHLWLVQHHGHGIRUDVORQJDVQHHGHG IRUVXVWDLQDELOLW\UHDVRQVWKHPDQDJHPHQWRIWKHREVWHWULFILVWXODKDVWREHVLPSOH VDIHHIIHFWLYHIHDVLEOHDIIRUGDEOHDQGSD\DEOH KRZHYHUWKHUHDUHRQO\WUDLQLQJFHQWHUVLQWKHZRUOGZKHUHV\VWHPDWLFDOO\GRFWRUV QXUVHVDQGRWKHUKHDOWKSHUVRQQHODUHWUDLQHGLQWKHPDQDJHPHQWRIWKHREVWHWULFILVWXOD

VLQFHPDQSRZHUH[SHUWLVHIDFLOLWLHVHTXLSPHQWWUDLQLQJPDWHULDOVDQGILQDQFHVDUH VFDUFHLWZLOOWDNHVRPHWLPHEHIRUHDQLPSDFWFDQEHH[SHFWHG

VRPHLGHDVRQKRZWRSURFHHGDUHSUHVHQWHGLQVHSDUDWHFKDSWHUV

obstetric fistula training and trainees training curriculum training module obstetric fistula training center obstetric fistula repair centers obstetric fistula rehabilitation nation-wide obstetric fistula service obstetric fistula tourism training of industrialized world training of non-doctors

EHVLGHV WKLV WKH REVWHWULFILVWXODKDVWREHLQWHJUDWHGZLWKLQWKHJRYHUQPHQWKHDOWK V\VWHPDVDPDMRUSXEOLFKHDOWKSUREOHPZLWKDQDWLRQDOSURJUDPDOVR LQWHU QDWLRQDO GRQRUDJHQFLHVKDYHWREHLQYROYHG

178 REVWHWULFILVWXODWUDLQLQJDQGWUDLQHHV

LQWURGXFWLRQ LQRUGHUWRFRSHZLWKWKHLQFUHDVLQJQXPEHURIREVWHWULFILVWXODSDWLHQWVLQWKHGHYHORSLQJ ZRUOGLWLVLPSRUWDQWWRWUDLQVXIILFLHQWGRFWRUVQXUVHVDQGRWKHUSHUVRQQHO WKHGRFWRUWUDLQHHVQHHGDWOHDVWUHSDLUVXQGHUVWULFWVXSHUYLVLRQIURPSODFLQJWKH SDWLHQWRQWKHRSHUDWLQJWDEOHXQWLOWKHYHU\HQGRIWKHRSHUDWLRQ IXWXUHWUDLQHUVQHHGSHUVRQDOH[SRVXUHWRWKHFRPSOLFDWHGDQGGLIILFXOWILVWXODVLQRUGHUWR WUDLQRWKHUGRFWRUVLQWKHQREOHDUWRIILVWXODVXUJHU\WKH\KDYHWREHFRPHFRPSOHWHO\ IDPLOLDUZLWKDOONLQGVRIILVWXODVDQGDOONLQGVRIRSHUDWLRQV IRUQXUVHVDQGRWKHUKHDOWKSHUVRQQHOLWLVVXIILFLHQWWRKDYHDQLQWHQVLYHH[SRVXUHWRWKH REVWHWULFILVWXODFRPELQHGZLWKSUDFWLFDODQGWKHRUHWLFDOOHVVRQV

GLIIHUHQWWUDLQLQJFRXUVHV D WUDLQLQJFRXUVHIRUGRFWRUVZLWKRXWH[SHULHQFHLQILVWXODVXUJHU\ E WUDLQLQJFRXUVHIRUFRQVXOWDQWVZLWKRXWH[SHULHQFHLQILVWXODVXUJHU\ F IROORZXSDGYDQFHGWUDLQLQJFRXUVHVLQREVWHWULFILVWXODVXUJHU\ G WUDLQLQJFRXUVHIRUIXWXUHGRFWRUWUDLQHUVZLWKVXIILFLHQWH[SHULHQFH H WUDLQLQJFRXUVHIRURSHUDWLRQWKHDWHUQXUVHV I WUDLQLQJFRXUVHIRUSUHDQGSRVWRSHUDWLYHQXUVHV J WUDLQLQJFRXUVHIRUDQHVWKHVLDQXUVHV K WUDLQLQJFRXUVHIRUIXWXUHQXUVHWUDLQHUVZLWKVXIILFLHQWH[SHULHQFH L UHIUHVKHUFRXUVHVIRUQXUVHV M WUDLQLQJFRXUVHIRUVXSSRUWLQJVWDIIDQGRWKHU KHDOWK SHUVRQQHO N WUDLQLQJFRXUVHIRUGRFWRUVDQGVWDIIIURPWKHLQGXVWULDOL]HGZRUOG

UHTXLUHPHQWVRIGRFWRUV DWUDLQHHPXVWKDYHDVXUJLFDOH[SHULHQFHRIDWOHDVW\HDUVLQRUGHUWROHDUQWKHEDVLFV RIREVWHWULFILVWXODVXUJHU\ 6 KHGRHVQRWQHHGWREHDFRQVXOWDQWEXW V KHPXVWEH LQWHUHVWHGLQWKHZRUNDQGQRWLQWKHPRQH\RIWKHWUDLQLQJFRXUVH

UHTXLUHPHQWVRIIXWXUHWUDLQHUV WREHFRPHDIXWXUHWUDLQHULQSULQFLSOHWKHWUDLQHHVKRXOGEHDFRQVXOWDQWDQGKDYH DOUHDG\DSHUVRQDOH[SHULHQFHRIDWOHDVWUHSDLUVDQGKHPXVWEHSUHSDUHGWR EHFRPHDIXOOWLPHILVWXODVXUJHRQ

UHTXLUHPHQWVRIQXUVHVPLGZLYHVRUDQ\ERG\HOVH DWUDLQHHPXVWEHZRUNLQJZLWKREVWHWULFILVWXODSDWLHQWVDQGEHZLOOLQJWRFRQWLQXHWRGR WKLVVREHIRUHDWWHQGLQJDQ\WUDLQHHVKRXOGEHVFUHHQHGZHOOE\KLV KHU HPSOR\HUDQG E\WKHVSRQVRULQJDJHQF\

GXUDWLRQRIWUDLQLQJ IRUGRFWRUVZLWKRXWRUZLWKORZH[SHULHQFHLQILVWXODVXUJHU\DSHULRGRIPRQWKVZLOO EHVXIILFLHQWLIWKHUHDUHHQRXJKSDWLHQWVIRUWKHPWRRSHUDWHXSRQDIWHUSHUVRQDO UHSDLUVWKH\FDQEHWUDLQHGDJDLQIRUPRQWK IRUQXUVHVDQGRWKHU KHDOWK SHUVRQQHODSHULRGRIPRQWKZLOOEHVXIILFLHQWLIWKHUHDUH HQRXJKSDWLHQWVDYDLODEOH IRUIXWXUHWUDLQHUVWKHEHVWZRXOGEHDQLQLWLDOSHULRGRIPRQWKWKHQDJDLQZHHNV DIWHUVRPHPRQWKDQGLIQHFHVVDU\DJDLQZHHNVDIWHUPRQWKV

163 179 WUDLQLQJFXUULFXOXPIRUGRFWRUVDQGQXUVHV

WKHSUREOHPLVWKDWILVWXODVXUJHU\ORRNVVRVLPSOHVRHYHU\ERG\LQYROYHGLQJ\QHFRORJ\ LVDILVWXODVXUJHRQDQGWXUQVRXWWREHVRGLIILFXOW DQRWKHUSUREOHPLVWKDWVXUJHU\FDQQRWEHOHDUQHGIURPDWH[WERRNRUDWKHRUHWLFDO OHFWXUHRUDZRUNVKRSEXWRQO\E\SHUIRUPLQJWKHVXUJHU\RQHVHOIXQGHUVXSHUYLVLRQ RIDQH[SHUWILVWXODVXUJHRQLQDVXIILFLHQWQXPEHURISDWLHQWV KRZHYHUEHIRUHVWDUWLQJZLWKWKH VXUJLFDO PDQDJHPHQWWKHWUDLQHHPXVWOHDUQDQG XQGHUVWDQGILUVWWKHPHFKDQLVPRIREVWUXFWHGODERUWKHFRPSOH[WUDXPDRIWKHREVWHWULF ILVWXODWKHFRPSOH[DQDWRP\RIWKHSHOYLVDQGLQWUDSHOYLFRUJDQVDQGWKHLUGLIIHUHQW WLVVXHVPXVFOHVOLJDPHQWVHWFDQGWKHWKHRUHWLFDOVROXWLRQV RQFHWKHGRFWRUWUDLQHHPDVWHUVDOOWKHWKHRUHWLFDODVSHFWVKLVSUDFWLFDOWUDLQLQJFDQVWDUW DQGVWHSE\VWHSKHKDVWREHWDXJKWWKH VXUJLFDO PDQDJHPHQWRIWKHREVWHWULFWUDXPD WKRXJKWKHQXUVHWUDLQHHGRHVQRWSHUIRUPWKHVXUJHU\ V KHPXVWEHIDPLOLDUZLWKDOOWKH VXUJLFDOWHFKQLTXHVDQGDOOWKHRWKHUWKHRUHWLFDODQGSUDFWLFDODVSHFWV

FRPSOH[REVWHWULFWUDXPD WKHHQRUPRXVYDULHW\RIWKHREVWHWULFILVWXODDQGRWKHULQWUDYDJLQDOLQWUDSHOYLFH[WUD YDJLQDODQGV\VWHPLFOHVLRQVGXHWRREVWUXFWHGODERU

DQDWRP\RIWKHSHOYLV WKHSHOYLFERQHVWKHLQWUDSHOYLFRUJDQVDQGWKHLUUHODWLRQ

XULQHVWRROFRQWLQHQFHPHFKDQLVPLQWKHIHPDOH DQDWRP\SK\VLRORJ\RIFRQWLQHQFH

KLVWRU\WDNLQJ SDULW\GXUDWLRQRIOHDNDJHSUHYLRXVUHSDLUVHWF

H[DPLQDWLRQRIREVWHWULFILVWXODSDWLHQWV LQVSHFWLRQYDJLQDOH[DPLQDWLRQDQGH[DPLQDWLRQRIRWKHUOHVLRQV

FODVVLILFDWLRQRIWKHREVWHWULFILVWXOD EDVHG RQ WKH TXDQWLWDWLYH DQG TXDOLWDWLYH DPRXQW RI WLVVXH ORVV RI WKH FRQWLQHQFHB FORVLQJPHFKDQLVPZLWKFRQVHTXHQFHVIRUWKHRSHUDWLRQWHFKQLTXHDQGSURJQRVLV

LPPHGLDWHPDQDJHPHQWRIWKHREVWHWULFILVWXOD E\FDWKHWHUDQGRUHDUO\FORVXUH

SUHRSHUDWLYHSUHSDUDWLRQ ODERUDWRU\KLJKRUDOIOXLGLQWDNHK\JLHQH

VSLQDODQHVWKHVLD WHFKQLTXHPRQLWRULQJDQGFRPSOLFDWLRQV

VXUJLFDOWHFKQLTXHV EDVLFWHFKQLTXHVIRUWKHGLIIHUHQWILVWXODW\SHVDQGWKHLUDGMXVWPHQWIRUWKDWVSHFLILFILVWXOD  RWKHUWHFKQLTXHVIRUVWUHVVLQFRQWLQHQFHEODGGHUVWRQHYDJLQDDWUHVLDHWF

KDQGOLQJRIVXUJLFDOLQVWUXPHQWV WKLVLVGLIILFXOWLQVLGHWKHYDJLQDDQGQHHGVH[SHUWFRDFKLQJ

180 164 LQWUDRSHUDWLYHFRPSOLFDWLRQV XUHWHUVKHPRUUKDJHVWRROFRQWDPLQDWLRQHWF

SRVWRSHUDWLYHFDUH FDWKHWHUPDQDJHPHQWKLJKRUDOIOXLGLQWDNHHWF

LPPHGLDWHSRVWRSHUDWLYHFRPSOLFDWLRQV DQXULDEORFNHGFDWKHWHUVHFRQGDU\KHPRUUKDJH

FRQWLQHQFHPHFKDQLVPLQWKHIHPDOH WKHRUHWLFDODVSHFWVZLWKSUDFWLFDO FRQVHUYDWLYHDQGVXUJLFDO FRQVHTXHQFHV

PDQDJHPHQWRIORQJWHUPVHTXHODH XUHWKUDVWULFWXUHEODGGHUVWRQHYDJLQDDWUHVLDVHFRQGDU\DPHQRUUKHD

SRVWUHSDLUWRWDOXULQHLQWULQVLFBVWUHVVLQFRQWLQHQFH EODGGHUGULOOXUHWKUDOL]DWLRQBIDVFLRFROSRVXVSHQVLRQ

KRZWRVHWXSDYYIUHSDLUFHQWHU LQDQH[LVWLQJKRVSLWDO

KRZWRVHWXSDYYIWUDLQLQJFHQWHU LQDQH[LVWLQJ99)UHSDLUFHQWHU

FRXQVHOLQJ SHUVRQDO K\JLHQH ZKHQ WR VWDUW VH[XDO LQWHUFRXUVH VXEVHTXHQW SUHJQDQFLHV DQG GHOLYHULHV

GHSHQGLQJ XSRQ WKHLU WKHRUHWLFDO NQRZOHGJH WKHLU VXUJLFDO VNLOOVDQGWKHLUVXUJLFDO H[SHULHQFHLWLVFOHDUWKDWWKHWUDLQLQJRIHDFKGRFWRULVKLJKO\LQGLYLGXDO

VLQFHLWWDNHV\HDUVWREHFRPHDFRQVXOWDQWVXUJHRQLWLVDOVRFOHDUWKDWLWWDNHVD ORQJWLPHEHIRUHRQHPDVWHUVWKHQREOHDUWRIREVWHWULFWUDXPDVXUJHU\

GXULQJWKHLUWUDLQLQJFRXUVHWKHGRFWRUWUDLQHHVFDQRQO\EHWDXJKWWKHEDVLFSULQFLSOHVRI REVWHWULF ILVWXOD VXUJHU\ WKHQ ZLWK XSV DQG GRZQV WKH\ KDYH WR JDWKHU WKHLU RZQ H[SHUWLVHE\KDUGZRUN

WUDLQLQJLVDFRQWLQXRXVOLIHORQJSURFHVVZKLFKQHYHUVWRSV

165 181 WUDLQLQJPRGXOH HYLGHQFHEDVHGDVSUDFWLFHGLQWKHQDWLRQDOYYISURMHFWQLJHULD

ILUVW VHOHFWLRQRIDQREVWHWULFWUDXPDPDQDJHPHQWWHDPFRQVLVWLQJRIDGRFWRUDQRSHUD WLRQWKHDWUHQXUVHDQDQHVWKHVLDQXUVHDQGWZRSUHDQGSRVWRSHUDWLYHQXUVHVZKRDUH LQWHUHVWHGDQGZLOOLQJWRSURYLGHDVHUYLFHIRUWKHREVWHWULFILVWXODSDWLHQWV

VHFRQG WUDLQLQJRIWKHFRPSOHWHWHDPLQDQHVWDEOLVKHGREVWHWULFWUDXPDWUDLQLQJFHQWHUZLWK DKLJKWXUQRYHURISDWLHQWVDQGDKLJKQXPEHURIUHSDLUV IRUWKHGRFWRUZHHNVLQLWLDOO\ IRUWKHQXUVHVZHHNV

WKLUG RUJDQL]LQJDGD\ZRUNVKRSWRRSHUDWHDODUJHQXPEHURISDWLHQWVLQFRPELQDWLRQZLWK OHFWXUHVDVFRIDFLOLWDWHGE\WKHFRQVXOWDQWWUDLQHUWHDPIRUDGYRFDF\BSXEOLFLW\WKDW VRPHWKLQJFDQEHGRQHDQGWRVWDUWWKHREVWHWULFILVWXODVHUYLFHLQWKDWDUHD

IRXUWK WKHWHDPVWDUWVZRUNLQJRQLWVRZQZLWKWKHVLPSOHILVWXODVZKLFKWKH\PXVWEHDEOHWR KDQGOHWKHPVHOYHVFRQILGHQWO\DIWHUWKHLULQLWLDOWUDLQLQJ

ILIWK WKHFRQVXOWDQWWUDLQHUWHDPFRPHIURPWLPHWRWLPHIRURQWKHMREWUDLQLQJDQGWR KDQGOHWKHPRUHFRPSOLFDWHGILVWXODVDQGWRVHOHFWPRUHVWDIIIRUWUDLQLQJ

VL[WK DIWHU  SHUVRQDO UHSDLUV WKH GRFWRU VKRXOG FRPH IRU DGYDQFHG WUDLQLQJ WR WKH REVWHWULFILVWXODWUDLQLQJFHQWHUIRUZHHNVLQRUGHUWRERRVWKLVH[SHUWLVH

VHYHQWK WKHGRFWRUFRQWLQXHVKLVRZQVXUJLFDOSURJUDPDQGWKHFRQVXOWDQWWUDLQHUWHDPFRPHV IURPWLPHWRWLPHIRUIXUWKHURQWKHMREWUDLQLQJWRDVVHVVWKHVHUYLFHDQGWRKDQGOHWKH GLIILFXOWILVWXODV

HLJKW DWDQ\WLPHWKHGRFWRUFRPHVIXUWKHUWUDLQLQJRIZHHNVZKHQHYHUKHWKLQNVKHQHHGV PRUHWUDLQLQJ

QLQWK DIWHUUHSDLUVDQGLIIHDVLEOHDQGLIWKHUHLVDQHHGWKHGRFWRUVKRXOGFRPHWRWKH WUDLQLQJFHQWHUIRUIXUWKHUDGYDQFHGWUDLQLQJWREHFRPHDIXWXUHWUDLQHU

WHQWK DWDQ\WLPHEH V KHDGRFWRURUDOUHDG\DWUDLQHUZKHQHYHUWKHUHLVDQHHG V KH VKRXOGDSSHDODQGFRPHIRUIXUWKHUWUDLQLQJWRWKHHVWDEOLVKHGWUDLQLQJFHQWHU

ZRUNVKRSVKDYHORZYDOXHIRUWKHLQLWLDOWUDLQLQJEXWKLJKYDOXHIRU PRUH H[SHULHQFHG ILVWXODVXUJHRQVRQVSHFLILFWRSLFVVXFKDVSRVWUHSDLULQFRQWLQHQFHDQGGHILQLWHO\YDOXHLQ DGYRFDF\DQGKHOSLQJODUJHQXPEHUVRISDWLHQWVZLWKLQDVKRUWWLPH

182 166 REVWHWULFWUDXPDWUDLQLQJFHQWHU

LQWURGXFWLRQ LQRUGHUWRFRSHZLWKWKHLQFUHDVLQJQXPEHURIREVWHWULFILVWXODSDWLHQWVLQWKHGHYHORSLQJ ZRUOGLWLVLPSRUWDQWWRKDYHIXQFWLRQLQJWUDLQLQJFHQWHUVZKHUHSUHVHQWDQGIXWXUH JHQHUDWLRQVRIVXUJHRQVFDQEHLQVWUXFWHGLQWKH VXUJLFDO PDQDJHPHQWRIWKHREVWHWULF ILVWXODWKHYDULHW\RITXDOLWDWLYHDQGTXDQWLWDWLYHOHVLRQVRIWKHREVWHWULFILVWXODLVVXFK WKDWWKH\FDQRQO\EHWDXJKWWKHEDVLFVVLQFHLWLVKDQGZRUNWKHWUDLQHHVQHHGDWOHDVW UHSDLUVXQGHUVWULFWVXSHUYLVLRQIROORZLQJWKHLUWUDLQLQJWKH\VWLOOFDQRSHUDWHFRQILGHQWO\ RQO\WKH³VLPSOH´ILVWXODVKRZHYHURQO\RIWKHILVWXODVDUHILWIRUWKHWUDLQHHVWKH UHVWLVWRRFRPSOLFDWHGRUWRRGLIILFXOW IRUQXUVHVDQGRWKHUKHDOWKSHUVRQQHOLWLVVXIILFLHQWWRKDYHDQLQWHQVLYHH[SRVXUHWRWKH REVWHWULFILVWXODFRPELQHGZLWKSUDFWLFDODQGWKHRUHWLFDOOHVVRQV IROORZLQJDVLPSOHFDOFXODWLRQPRGHOWKHIROORZLQJFDQEHGHPRQVWUDWHG

UHTXLUHPHQWVRIWKHWUDLQHU IRUDWUDLQHUWRSHUIRUPZHOOKHQHHGVVXIILFLHQWH[SHULHQFHFRQVLGHULQJWKHYDULHW\DQG WKHGLIILFXOW\JUDGHRIREVWHWULFILVWXODVXUJHU\LHDPLQLPXPRIUHSDLUVRWKHU ZLVHLWZRXOGEHWKHEOLQGWHDFKLQJWKHODPHKRZWRFURVVWKHURDG LQSULQFLSOHWKHWUDLQHUPXVWEHDFRQVXOWDQWLQRUGHUWRKDYHVXIILFLHQWDXWKRULW\ZLWKLQWKH LQVWLWXWLRQZLWKLQWKHVHWXSRIWKH JRYHUQPHQW KHDOWKFDUHDQGZLWKLQWKHUHJLRQIURP ZKLFKWKHWUDLQHHVDUHFRPLQJ

UHTXLUHPHQWVRIVXSSRUWLQJVWDII VLQFHLWLVWHDPZRUNWKDWFRXQWVDOVRKLVVXSSRUWLQJVWDIIVKRXOGEHRIKLJKTXDOLW\LQ RUGHUWRWHDFKWKHWUDLQHHVEHLWDGRFWRURUDQXUVHRUDQ\ERG\HOVHWKHSUHRSHUDWLYH FDUHWKHDQHVWKHVLDWKHSRVWRSHUDWLYHFDUHDQGWKHSDWLHQWFRXQVHOLQJ

UHTXLUHPHQWVRIWKHWUDLQLQJFHQWHU IRUDWUDLQLQJFHQWHUWRIXQFWLRQZHOOWKHUHPXVWEHVXIILFLHQWRSHUDWLRQVDWOHDVW ILVWXODUHSDLUVD\HDULHRSHUDWLRQVSHUZHHNZLWKOHVVWKDQUHSDLUVLWZLOOEH GLIILFXOWWRVXVWDLQDFRQWLQXRXVGDLO\LQWHQVLYHWUDLQLQJWHDFKLQJSURJUDP ZLWKUHSDLUVD\HDUWKHUHDUHRQO\RSHUDWLRQVDYDLODEOHIRUWKHWUDLQHHVRURQO\ UHSDLUDZHHN WKLVZRXOGPHDQWKDWWKHFHQWHUFDQRQO\KDQGOHWUDLQHHVD\HDUDQGWKDWRQO\ WUDLQHHFDQEHWDXJKWDWWKHVDPHWLPH GXULQJDWUDLQLQJSHULRGRIPRQWKVDWUDLQHHZLOOEHSUHVHQWDWRQO\UHSDLUVRXWRI ZKLFKKHFDQSHUIRUPUHSDLUVKLPVHOI KRZHYHUVRPHZLOOEHOXFN\DQGVRPHQRWVLQFHWKHSDWLHQWVDUHQRWFRPLQJHYHQO\ GLVWULEXWHGRYHUWKHZKROH\HDUWKHVDPHDSSOLHVWRWKHSDWLHQWVZLWKDILVWXODZKLFKFDQ EHKDQGOHGE\DWUDLQHH LQSULQFLSOHWKHFHQWHUVKRXOGEHDJRYHUQPHQWRZQHGRUDJRYHUQPHQWUHFRJQL]HG WUDLQLQJFHQWHUZKHUHJRYHUQPHQWPLVVLRQDQGHYHQSULYDWHGRFWRUVDQGQXUVHVFDQ DWWHQGWKHSRVWJUDGXDWHFRXUVHV

RQWKHMREWUDLQLQJRIUHVLGHQWVRURWKHUGRFWRUVLQWHDFKLQJRURWKHUKRVSLWDOV WKLVWDNHVDORQJWLPHDQGLVRQO\SRVVLEOHLIWKHWUDLQHUKDVVXIILFLHQWH[SHULHQFHDQGWKH QXPEHURISDWLHQWVLVHQRXJKDVH[SODLQHGDOUHDG\ LWZRXOGEHEHWWHUWRDVVLJQWKHUHVLGHQWVWRDUHDOREVWHWULFILVWXODUHSDLURUWUDLQLQJ FHQWHUIRUPRQWKVIRUDQLQWHQVLYHH[SRVXUHWRWKHREVWHWULFILVWXOD

167 183 REVWHWULFWUDXPDUHSDLUFHQWHU

WKLVVKRXOGEHDVHSDUDWHXQLWZLWKDVHSDUDWHKRVWHODVHSDUDWHZDUGDQGDVHSDUDWH RSHUDWLQJWKHDWHUZLWKVHSDUDWHVWDIIIRUSUHLQWUDDQGSRVWRSHUDWLYHFDUH

LQWKHEHJLQQLQJLWFDQEHLQWHJUDWHGZLWKLQDQH[LVWLQJKRVSLWDODQGWKHQRQHIL[HGGD\D ZHHNKDVWREHDIXOOILVWXODRSHUDWLQJGD\ QRRWKHURSHUDWLRQVQHLWKHUSODQQHGQRU HPHUJHQF\ EXWLIWKHQXPEHURIRSHUDWLRQVDUHPRUHWKDQD\HDUDVSHFLILFYYI FHQWHUVKRXOGEHEXLOW

DVLWLVDILVWXODUHSDLUFHQWHULWVKRXOGFRQFHQWUDWHRQWKHVXUJHU\RQO\RWKHUZLVHWKH SURIHVVLRQDOVXUJHRQDQGKLVSURIHVVLRQDOPHGLFDOVWDIIDUHZDVWLQJWKHLUWLPHDVXUJHRQ DQGKLVPHGLFDOVWDIIDUHQRWVRFLDOZRUNHUV

WRSUHYHQWFRQIOLFWRILQWHUHVWWKHKRVWDODQQH[UHKDELOLWDWLRQFHQWHUVKRXOGEHVLWXDWHG RXWVLGHWKHKRVSLWDOSUHPLVHVEXWLQWKHQHLJKERUKRRG

RQFHWKHVXUJLFDOMREKDVEHHQILQLVKHGRWKHUSURIHVVLRQDOVRFLDOVWDIIKDYHWRWDNHRYHU WKHUHKDELOLWDWLRQ

DQHIIRUWKDVWREHPDGHWRNHHSWKLQJVVLPSOHZLWKVWUDLJKWIRUZDUGSUHLQWUDDQGSRVW RSHUDWLYHJXLGHOLQHV

WKHRQHWKLQJWKDWFDQQRWEHFRPSURPLVHGLVDKLJKTXDOLW\RSHUDWLQJWDEOHH[FHSWIRU VKDUSO\FXUYHG7+25(.VFLVVRUVDQGVKDUS'(6&+$036DQHXU\VPQHHGOHQRVSHFLDO LQVWUXPHQWVDUHQHHGHG

VSLQDODQHVWKHVLDLVVDIHVLPSOHHIIHFWLYHDQGFKHDSVLQFHLWGRHVQRWQHHGH[SHQVLYH HTXLSPHQW

IRU ODERUDWRU\ LQYHVWLJDWLRQV +E DQG VHUXP FUHDWLQLQH ZRXOG EH DGYLVDEOH XULQH LQYHVWLJDWLRQLVXQUHOLDEOH

[UD\VDUHQRWUHTXLUHGHYHQLIWKH[LYSZRXOGVKRZDEQRUPDOLWLHVWKLVGRHVQRWPHDQ WKDWWKHSDWLHQWFDQQRWEHRSHUDWHG

SK\VLRWKHUDS\LVVRPHWKLQJIRUWKHUHKDELOLWDWLRQFHQWHUEXWRQO\LIIL[HGFRQWUDFWXUHV KDYHGHYHORSHGLPPHGLDWHPRELOL]DWLRQLVWKHEHVWWRSUHYHQWWKHP

WKHWUHDWPHQWRIREVWHWULFILVWXODVVKRXOGEHIUHHRIFKDUJHEXWWKHSDWLHQWVKRXOGEHDU VRPHRIWKHFRVWV

LQRUGHUWREULQJWKHVHUYLFHWRZDUGVWKHSDWLHQWVLWLVEHWWHUWRKDYHPXOWLSOHVPDOO FHQWHUVWKDQRQHODUJHFHQWHULQDFRXQWU\HVSHFLDOO\VLQFHWKHDFWLRQUDGLXVRIDQ REVWHWULFILVWXODUHSDLUFHQWHULVNPLQSODQQLQJDQDWLRQZLGHVHUYLFHWKLVVKRXOG EHWDNHQLQWRDFFRXQW

184 168 REVWHWULFWUDXPDUHKDELOLWDWLRQFHQWHU

UHKDELOLWDWLRQPHDQVSUHSDUHKHOSWKHSDWLHQWWRWDNHIXOOFRQWURORIKLVKHUOLIHDQG GRHVQRWPHDQPDNHWKHSDWLHQWVGHSHQGLQJXSRQWKHVHUYLFHGHSULYLQJWKHPRIWKHLU RZQUHVSRQVLELOLWLHVWKDWLVWKHZURQJDSSURDFKDQGKDVQRWKLQJWRGRZLWKUHKDELOLWDWLRQ

WKHEHVWUHKDELOLWDWLRQLVDVXFFHVVIXOUHSDLUWKHQLWZLOOWDNHSODFHVSRQWDQHRXVO\

RQO\WKH³LQFXUDEOHV´ DIWHUPXOWLSOHUHSDLUVZKLFKGLGQRWVWRSWKHFRQWLQXRXVXULQH OHDNLQJEHLWDUHVLGXDOILVWXODRUWRWDOSRVWUHSDLUXULQHLQFRQWLQHQFH QHHGYRFDWLRQDO WUDLQLQJLQRUGHUWRHDUQWKHLURZQOLYLQJWKRXJKIRUWKHVHXQIRUWXQDWHJLUOVZRPHQOLIH KDVHQGHGVRPHZD\VRPHKRZWKH\KDYHWRFRQWLQXH

WKLVLVQRWDMREIRUWKHSURIHVVLRQDOVXUJHRQDQGKLVSURIHVVLRQDOPHGLFDOVWDIIEXWIRU RWKHUVRFLDOSURIHVVLRQDOVXQIRUWXQDWHO\WKHVRFLDOSURIHVVLRQDOVDUHQRWRUQRW\HW LQWHUHVWHG

WKHEHVWZRXOGEHDKRVWHODQQH[UHKDELOLWDWLRQFHQWHULQWKHQHLJKERXUKRRGRIDILVWXOD UHSDLUFHQWHUZKHUHWKHVRFLDOZRUNHUVFRXOGGRWKHLUMREWKLVFHQWHUKDVWREHRXWVLGH WKHKRVSLWDORWKHUZLVHWKHUHZLOOEHDQHJDWLYHLPSDFWXSRQWKHIXQFWLRQLQJRIWKHILVWXOD UHSDLUFHQWHU

ZKDWKDSSHQVLIWKHUHLVQRVHSDUDWLRQRIKRVSLWDODQGUHKDELOLWDWLRQVHUYLFHVLVWKH IROORZLQJVLQFHWKHZRPHQKDYHWRVXUYLYHPDOHVFRPHDWQLJKWDQGYLVLWWKHPLQWKH FHQWHU IRUVRPHPDOHVWKHVPHOORIXULQHVHHPVWREHDQDSKURGLVLDFDVZHOOWKH ZRPHQ DUH KLJKO\ DWWUDFWLYH  VRPH RI WKHP ILJKW RYHU RQH ZRPDQ DQG PDOHV DQG IHPDOHVILJKWWKHVWDIILIWKH\DUHWU\LQJWRSUHYHQWWKHPIURPHQWHULQJWKHFRPSRXQGDQG EUHDNWKHZDOOLIWKHJDWHLVFORVHGPDQ\WLPHVWKHSROLFHKDVWRLQWHUYHQHKRZHYHULI WKHSROLFHLVDVNHGWRSUHYHQWWKLVIURPKDSSHQLQJWKH\WDNHWKHSDWLHQWVDVJLUOIULHQGV DQGLWLVHYHQPRUHGLIILFXOWWRUHYHUVHWKLV

DVZHOOWKHROGSDWLHQWVDUHLQVWUXFWLQJWKHQHZSDWLHQWVLQDOOW\SHVRIEHKDYLRUZKLFKLV QRWLQOLQHZLWKWKHKRVSLWDOLQVWUXFWLRQVWKH\KDYHWKHLURZQLGHDVDERXWWKHSUHDQG SRVWRSHUDWLYHPDQDJHPHQWDQGVRPHRIWKHPHYHQVHOOQDWLYHPHGLFLQHWRWKHQHZSD WLHQWVZLWKWHUULEOHFRQVHTXHQFHVWKH\FODLPWKHEHVWIRRGDQGWKHEHVWSODFHVLQWKH KRVWHOIRUZKLFKWKH\EHIULHQGWKHPDOHVWDIIRIWKHKRVSLWDORUEULEHWKHIHPDOHVWDII

WKDWLVDOOILQHLQWKHVWUXJJOHIRUVXUYLYDODQGHYHU\ERG\LVIUHHLQGRLQJZKDW V KHKDVWR GREXWIRUVPRRWKUXQQLQJRIKRVSLWDOVHUYLFHVVXFKDVREVWHWULFILVWXODVXUJHU\LWLVQRW LGHDO

WKHKRVWHOBUHKDELOLWDWLRQFHQWHUKDVWREHLQWKHQHLJKERXUKRRGRIWKHILVWXODUHSDLUFHQWHU IRUTXLFNFRPPXQLFDWLRQDQGVPRRWKFRRSHUDWLRQ

WRDYRLGFRQIOLFWRILQWHUHVWWKHILVWXODUHSDLUFHQWHUKDVWRFRPHXQGHUWKH0LQLVWU\RI +HDOWKDQGWKHKRVWHODQQH[UHKDELOLWDWLRQFHQWHUXQGHUWKH0LQLVWU\RI6RFLDO:HOIDUH KRZHYHUWKHUHPXVWEHJRRGFRRSHUDWLRQ

KRZHYHUGRQRWFRQYHUWWKHVHUHKDELOLWDWLRQFHQWHUVLQWRILVWXODULDVLQFHDQ\ERG\PXVW WDNHWKHIXOOUHVSRQVLELOLWLHVRIKLVKHURZQOLIH

169 185 QDWLRQZLGHREVWHWULFILVWXODVHUYLFH

DQ\FRXQWU\ZLWKDKLJKSUHYDOHQFHRIWKHREVWHWULFILVWXODVKRXOGPDNHDQHIIRUWWR RUJDQL]HDQGH[HFXWHDQDWLRQZLGHIHDVLEOHDQGVXVWDLQDEOHREVWHWULFILVWXODVHUYLFH HVSHFLDOO\VLQFHLWZLOOWDNHDQRWKHUFHQWXU\WRSUHYHQWLWIURPRFFXUULQJ

LQRUGHUWREULQJWKHVHUYLFHWRZDUGVWKHSDWLHQWV DQGQRWWKHRWKHUZD\URXQG DQG WDNLQJLQWRDFFRXQWWKHDFWLRQUDGLXVRIDQREVWHWULFILVWXODFHQWHURINPWKH IROORZLQJLVVXJJHVWHGWRFUHDWHDQDWLRQZLGHQHWZRUNRIIXQFWLRQLQJFHQWHUV RQH ELJ UHIHUUDO FHQWHU IRU WKH ZKROH FRXQWU\ ZKHUH SDWLHQWV KDYH WR WUDYHO ORQJ GLVWDQFHVWKHDZDUHQHVVWKDWVRPHWKLQJFDQEHGRQHLVORZDQGWKHUHIHUUDOV\VWHPLV QRWIXQFWLRQLQJ LVQRWWKHLGHDOVHWXS

QDWLRQDOPDVWHUSODQZLWKQDWLRQDOSURJUDP GHYHORSHGDQGFRRUGLQDWHGE\WKHQDWLRQDOPLQLVWU\RIKHDOWKZLWKLWVRZQEXGJHW

UHJLRQDOPDVWHUSODQZLWKUHJLRQDOSURJUDP GHYHORSHGDQGH[HFXWHGE\WKHUHJLRQDOPLQLVWU\RIKHDOWKZLWKLWVRZQEXGJHW

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

UHJLRQDOREVWHWULFILVWXODUHSDLUFHQWHUV HDFKUHJLRQEHLWVWDWHSURYLQFHRUGpSDUWPHQWQHHGVLWVRZQREVWHWULFILVWXODUHSDLU FHQWHUSUHIHUDEO\LQWKHFDSLWDORIWKHUHJLRQ WKLVUHSDLUFHQWHUVKRXOGEHDQLQGHSHQGHQWREVWHWULFILVWXODKRVSLWDOZKHUHRQO\99) DQG59)UHSDLUVDQGUHODWHGRSHUDWLRQVDUHSHUIRUPHGVRQRLQWHUIHUHQFHE\RWKHUVIRU J\QDHFRORJLFRSHUDWLRQVRUHPHUJHQF\RSHUDWLRQVVXFKDVFDHVDUHDQVHFWLRQ

LQFHQWLYHVIRUWKHSHUVRQQHO VLQFHWKHUHLVQRPRQH\WREHPDGHLQWKHPDQDJHPHQWRIWKHREVWHWULFILVWXODVRPHKRZ WKHKLJKO\TXDOLILHGDQGHGXFDWHGSHUVRQQHOKDYHWREHFRPSHQVDWHGILQDQFLDOO\DQGLQ FDUHHUSODQQLQJRWKHUZLVHWKH\ZLOOOHDYH

VWHSE\VWHSLPSOHPHQWDWLRQ WKLQJVFDQQRWEHFKDQJHGRYHUQLJKWEXWDQHIIRUWKDVWREHPDGHVRWKDWZLWKLQ\HDUV HDFKFRXQWU\KDVLWVRZQIXQFWLRQLQJVHUYLFHLQSODFHDQGWKHQVXVWDLQLW

WUDLQLQJFXUULFXOXPIRUUHVLGHQWVLQREVWHWULFVDQGJ\QHFRORJ\ DFWXDOO\HDFKDQGHYHU\J\QHFRORJLVWVKRXOGKDYHDPSOHNQRZOHGJHRIWKHREVWHWULF ILVWXODDQGEHDEOHWRSHUIRUPWKHVLPSOHUHSDLUVDVWKDWLVKLVMREKRZHYHUGXULQJWKHLU WUDLQLQJWKH\KDYHQRWEHHQH[SRVHGVXIILFLHQWO\DQGQRZLWLVWRRODWH WKHUHIRUHLWZRXOGEHEHWWHUIRUWKHSUHVHQWDQGIXWXUHUHVLGHQWVWRKDYHDQLQWHQVLYH H[SRVXUH WR WKH REVWHWULF ILVWXOD RI  PRQWKV LQ HLWKHU D UHSDLU RU D WUDLQLQJ FHQWHU LQVWHDGRIH[SRVXUHWRXURORJ\DQGWKHLURIILFLDOFXUULFXOXPVKRXOGEHDGMXVWHG

186 170 obstetric fistula tourism RUDVDKDXVDSURYHUEVD\V the king in one country is a beggar in another UHSRUWDPHULFDQVXJHRQV¶YLVLWWRVRNRWRIURPWKUX

IRUSROLWLFDOUHDVRQVDQGEHFDXVHWKHUHZDVDORWRIPRQH\WREHVKDUHGORFDOO\DPRQJVW WKHRUJDQL]HUVWKHXVXDOWKLQJLQDIULFDDWHDPRIDPHULFDQVXUJHRQV J\QHFRORJ\VXU JHU\SODVWLFVXUJHU\DQHVWKHVLD IURPDXQLYHUVLW\WHDFKLQJKRVSLWDOFDPHWRPDU\DPD DEDFKDKRVSLWDOWRSHUIRUPREVWHWULFILVWXODVXUJHU\

WKRXJKLQWKHLURZQVXUURXQGLQJVWKH\DUHH[SHUWVWKHLUH[SHULHQFHLQREVWHWULFILVWXOD VXUJHU\ZDV]HURVLPSO\EHFDXVHWKHUHDUHQRREVWHWULFILVWXODVLQDPHULFD

WKHFKLHIFRQVXOWDQWILVWXODVXUJHRQRIIHUHGWRKHOSDQGZDVZLOOLQJWRWUDLQWKHPEXWWKH\ ZHUHVRDUURJDQWWKDWWKH\UHIXVHGWRWDONWRKLPVLQFHWKH\NQHZLWDOO

VRWKH\WHDPHGXSZLWKVRPHQLJHULDQGRFWRUVZKRGLGQRWKDYHWKHVOLJKWHVWFOXHDV ZHOOLQWRWDOWKH\ZHUHQLQHGUHGUEGUKGUNGUNGUEGUJGUYDQGGUE

WRVKRZRIIWKH\VWDUWHGZLWKWKHPRVWFRPSOLFDWHGSDWLHQWVZKRKDGEHHQRSHUDWHG DOUHDG\RQFHRUHYHQPRUHWLPHV

WKH\ZRUNHGLQWZRWHDPVIURPDPXSWRPLGQLJKWVLQFHRSHUDWLRQWLPHJRWRXWRI KDQGIURPDPLQLPXPRIKRXUVXSWRKRXUV

RQWKHYHU\ILUVWGD\RQHSDWLHQWGLHGLPPHGLDWHO\DIWHUZDUGVDQGKHUQDPHZDVQRW HQWHUHG LQ WKH RSHUDWLRQ UHJLVWHU ZKLOVW DOO WKH GRFXPHQWV GLVDSSHDUHG DPHULFDQ OLWLJDWLRQ 

DIWHUGD\VWKHUHVLGHQWGRFWRUVZKRFDPHWR³DGPLUH´WKHLUVXUJLFDOVNLOOVZDONHGRXW RQWKHPWKRXJKLQDSROLWHKDXVDZD\

DIWHU  GD\V WKH UHPDLQLQJ SDWLHQWV UHIXVHG WR EH RSHUDWHG VLQFH WKH\ DUH KLJKO\ LQWHOOLJHQWDQGQRWLFHGWKDWQRQHRIWKHRSHUDWHGSDWLHQWVZHUHRNEXWVWDUWHGWROHDN DOUHDG\DIWHUGD\VDVZHOOVRPHRIWKHVWDIIDGYLVHGWKHPVR

VRWKHODVWWZRGD\VRQO\GHVSHUDWHSDWLHQWDGD\FDPHIRUZDUGWREHRSHUDWHG

WKH\ZHUHRQO\LQWHUHVWHGLQWKHVXUJHU\DQGGLGQRWHYHQERWKHUDERXWSRVWRSHUDWLYH FDUHDQGIROORZXSDQGOHIWWKHPHVVIRUWKHFKLHIFRQVXOWDQWDQGKLVWHDPWREHVRUWHG RXW

WKHµUHVXOW¶RIWKHLUDUURJDQFHDQGREVWHWULFILVWXODDQDOSKDEHWLVPLVWKHIROORZLQJ

WRWDOQXPEHURISDWLHQWVRSHUDWHG SDWLHQWV

RXWFRPH HDUO\EUHDNGRZQBOHDNLQJ SDWLHQWV QRWOHDNLQJ XUHWHURVLJPRLGRVWRP\  SDWLHQW SRVWRSHUDWLYHPRUWDOLW\ SDWLHQW

LWLVOHIWWRWKHUHDGHUWRGUDZKLVKHURZQFRQFOXVLRQVDERXWWKHYDOXHRIREVWHWULF ILVWXODWRXULVP

171 187 OLVWRIREVWHWULFILVWXODSDWLHQWVRSHUDWHGIURPWKUX

SDWLHQWVQDPHWRZQ RSGDWH DSSURDFK RXWFRPH

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

DIWHUORQJGHOLEHUDWLRQVWKHDXWKRUGHFLGHGWRFRPHRXWZLWKWKLVGHWDLOHGUHSRUWDERXW REVWHWULFILVWXODWRXULVPVLQFHWKLVKDVEHHQUHSHDWHGVHYHUDOWLPHVE\RWKHUVDQGLW VHHPVWKDWVRPHJURXSVRUJDQL]DWLRQVDUHSODQQLQJWRPDNHWKHVDPHPLVWDNHVRPH HYHQWKLQNRILQYROYLQJWKHWRXULVWVLQWUDLQLQJ

KRZHYHUQHLWKHUWKHSDWLHQWVQRUWKHWRXULVWVDUHKHOSHGE\VXFKDQH[HUFLVH

LWLVODXGDEOHWRKHOSWKHVHSRRUSDWLHQWVEXWWKHQPDNHVXUHRQHLVWUDLQHGSURSHUO\E\ H[SHUWILVWXODVXUJHRQVZKRDUHKLJKO\ZLOOLQJWRGRVR

188 172 WUDLQLQJGRFWRUVDQGVWDIIIURPWKHLQGXVWULDOL]HGZRUOG ZKLOVWHGXFDWLQJWKHRUJDQL]DWLRQV

WKHUHDUHPDQ\GRFWRUVQXUVHVDQGRWKHUSHUVRQVLQWKHLQGXVWULDOL]HGZRUOGZKRDUH YHU\PXFKZLOOLQJWRKHOSWKHREVWHWULFILVWXODSDWLHQWVLQWKHGHYHORSLQJZRUOGIRUWKLV WKH\DUHYROXQWHHULQJWRVSHQGWKHLURZQPRQH\ H[SHQVLYHDLUWUDYHOOLQJDFFRPPR GDWLRQIHHGLQJQRLQFRPH WKHLUWLPHDQGWKHLUH[SHUWLVHKRZHYHUQRH[SHULHQFHZLWK WKHREVWHWULFILVWXOD

WKHUHDUHRUJDQL]DWLRQVLQWKHLQGXVWULDOL]HGZRUOGZLOOLQJWRVSRQVRULQLWLDWLYHVWKDWZLOO FRQWULEXWH WR WKH PDQDJHPHQW RI WKH REVWHWULF ILVWXOD SDWLHQWV E\ VHQGLQJ WHDPV WR RSHUDWHWKHPWKLQNLQJWKDWDQH[SHUWVXUJHRQLQHXURSHDVLDDXVWUDOLDRUXQLWHGVWDWHVLV DOVRDQH[SHUWILVWXODVXUJHRQLQDIULFDKRZHYHUWKH\DUHZURQJ

LW ZRXOG EH ULGLFXORXV QRW WR PDNH XVH RI JRRGZLOOLQJ LQGLYLGXDOV DQG JRRGZLOOLQJ RUJDQL]DWLRQV VR ZH KDYH WR HGXFDWH WKH RUJDQL]DWLRQV DQG ZH KDYH WR WUDLQWKH YROXQWHHUVXUJHRQVDQGVWDIILQWKH VXUJLFDO PDQDJHPHQWRIWKHREVWHWULFILVWXOD XQGHUUDWKHUSULPLWLYHFRQGLWLRQVLQDQDIULFDQKRVSLWDO

FULWHULDIRUGRFWRUVDQGVWDII WKH\PXVWKDYHEHHQZRUNLQJLQDGHYHORSLQJFRXQWU\IRUVRPH\HDUVDQGZLOOLQJWR VSHQGUHJXODUWLPH RQFHRUWZLFHD\HDUVRPHZHHNV LQWKHIXWXUHLQDGHYHORSLQJ FRXQWU\RWKHUZLVHLWLVDZDVWHRIYDOXDEOHWLPHE\WKHH[SHUWILVWXODVXUJHRQ

LQQLJHULDWKHIROORZLQJSURFHGXUHLVXVHG

ILUVW LQLWLDOYLVLWRIZHHNV WHDFKLQJWKHFRPSOH[WUDXPDRIWKHREVWHWULFILVWXODLQVSHFWLRQDQGH[DPLQDWLRQRIWKH REVWHWULFILVWXODSDWLHQWVDQGWKHLUOHVLRQVVSLQDODQHVWKHVLDDQGVRPHSHUVRQDOYDJLQDO UHSDLUVGHSHQGLQJXSRQKRZORQJWKH\VWD\ VLQFHPRVWRIWKHPDUHDOUHDG\H[SHUWVXUJHRQVWKH\GRQRWQHHGWKHLQWHQVLYHFRDFKLQJ RILQVWUXPHQWKDQGOLQJ DWWKHHQGWKH\DOOVD\WKH\QHYHUNQHZDQGQHYHUUHDOL]HGKRZFRPSOLFDWHGWKHVXUJLFDO PDQDJHPHQWRIDQGKRZH[WHQVLYHWKHREVWHWULFILVWXODWUDXPDLV

VHFRQG DIWHUWKHLUYLVLWWKH\NQRZZKLFKILVWXODVWKH\FDQKDQGOHWKHPVHOYHVDQGZKLFKQRWDQG QRZWKH\FDQVWDUWZLWKWKHLUVXUJHU\LQRUGHUWRJDWKHUWKHLURZQH[SHUWLVH

WKLUG IROORZXSYLVLWRIZHHNV DIWHUVRPHUHSDLUVWKH\FRPHEDFNWRGLVFXVVWKHLUH[SHULHQFHDQGWRXSJUDGHWKHLU VNLOOVLIWKH\IHHOWKH\QHHGLW

IRXUWK WKH\FRQWLQXHWKHLUZRUNDOVRRSHUDWLQJWKHPRUHFRPSOLFDWHGILVWXODVDQGDWDQ\WLPH WKH\FDQFRPHEDFNLIWKHUHLVDQHHGIRUDGYDQFHGOHYHOILVWXODVXUJHU\

ILIWK IROORZXSYLVLWIRUVSHFLILFSUREOHPV

173 189 VXUJLFDOWUDLQLQJRIQRQGRFWRUVRUHYHQQRQPHGLFDOSHUVRQV GLVFULPLQDWLRQDQGK\SRFULV\

WKHUHLVDGHEDWHRYHUWKHWUDLQLQJRIFOLQLFDODVVLVWDQWVRUHYHQQRQPHGLFDOSHUVRQV

ILUVWGRQRWVWDUWDSUDFWLFHLQDIULFDZKLFKRQHQHYHUZRXOGDFFHSWLQHXURSHRUWKHXVD DUHDIULFDQVQRWKXPDQEHLQJVZKRGHVHUYHWKHEHVW

WKHQ REVWHWULF ILVWXOD VXUJHU\ LV WKH PRVW GLIILFXOW DQG FRPSOLFDWHG VXUJHU\ L HYHU HQFRXQWHUHGLQP\OLIHVRLWQHHGVWKHULJKWHGXFDWLRQWREHFRPHDGRFWRUWKHULJKW VXUJLFDO WUDLQLQJ WR EHFRPH D VSHFLDOLVW DQG WKHQ WKH ULJKW SRVWJUDGXDWH WUDLQLQJ WR EHFRPHDILVWXODVXUJHRQ

WKLVUHIOHFWVLQWKHVWDWHPHQWE\VRPHRUJDQL]DWLRQVWKDWDSURJUDPPHLVVXFFHVVIXOLI FORVXUHUDWHFDQEHDFKLHYHG

KRZHYHUZKDWNLQGRISKLORVRSK\DQGVXUJHU\LVWKDWZHVKRXOGDLPDW

OHDUQLQJ D WULFN LV QRW VXIILFLHQW RQH QHHGV IXOO XQGHUVWDQGLQJ RI WKH FRPSOLFDWHG DQDWRP\DQGSK\VLRORJ\RIWKHSHOYLVSHOYLVIORRUXULQHVWRROFRQWLQHQFHPHFKDQLVPLQ WKHIHPDOHHWFHWFRQHKDVWRNQRZH[DFWO\ZKDWKDVEHHQORVWGXHWRSUHVVXUHQHFURVLV KRZ WR SHUIRUP UHFRQVWUXFWLYH VXUJHU\ LI WKH QRUPDO IXQFWLRQDO DQDWRP\ DQG SDWKRSK\VLRORJ\DUHQRWNQRZQ

RQO\WKHQZLWKH[SHUWVXUJLFDOVNLOOVRQHPD\EHDEOHWRKDQGOHWKHREVWHWULFILVWXODZLWK FDUHWRIXOOVDWLVIDFWLRQRIWKHSDWLHQWDQGWKHVXUJHRQ

LIDQRQGRFWRULVDWWHQGLQJDSRVWJUDGXDWHVXUJLFDOFRXUVH V KHZLOOJHWDOLFHQFHWR SHUIRUPVXUJLFDOPDOSUDFWLFH

ZK\QRWVSRQVRUWKLVQRQGRFWRUWREHFRPHDUHDOGRFWRUILUVWDQGWKHQRQO\LI V KHKDV DFKLHYHGWKLVVHQGKLPKHUIRUSRVWJUDGXDWHWUDLQLQJLQWKHQREOHDUWRIREVWHWULFILVWXOD VXUJLFDO PDQDJHPHQWVDPHSUDFWLFHDVLQWKHLQGXVWULDOL]HGZRUOG

GLVFULPLQDWLRQZKDWLVJRRGIRUDIULFDLVQRWJRRGHQRXJKIRUHXURSHXVD

ODVWO\WKHSHRSOHZKRSURSDJDWHWKLVSUDFWLFHDUHQRWEHOLHYLQJLQLWWKHPVHOYHVDVLKDYH QHYHUVHHQDQRQGRFWRUDQGRUQRQPHGLFDO³ILVWXODVXUJHRQ´EHHQDSSRLQWHGDVFKLHI PHGLFDOGLUHFWRURIWKHLUKRVSLWDO ZLWKDOOWKHILQDQFLDOEHQHILWV 

V KHFDQEHWUXVWHGZLWKWKHUHVSRQVLELOLW\RILQYDVLYHVXUJHU\DQGLWLVJRRGIRUIXQG UDLVLQJEXW V KHFDQQRWEHWUXVWHGZLWKWKHDGPLQLVWUDWLYHILQDQFLDOUHVSRQVLELOLW\RI FKLHIPHGLFDOGLUHFWRU  ZKDWDK\SRFULV\

190 174 WRSLFUHODWHGGD\ZRUNVKRSV IRU H[SHULHQFHGREVWHWULFWUDXPDVXUJHRQV

LQRUGHUWRLPSURYHWKHTXDOLW\RIWKHGLIILFXOWREVWHWULFWUDXPDUHFRQVWUXFWLYHVXUJHU\VR WKDWDQGWKHSDWLHQWDQGWKHVXUJHRQDUHVDWLVILHG

LWLVLPSRUWDQWWRXSJUDGHWKHNQRZOHGJHRIH[SHULHQFHGVXUJHRQVWUDLQHUVDERXWWKH FRPSOLFDWHGSHOYLVDQDWRP\DQGWKHHYHQPRUHFRPSOLFDWHGIXQFWLRQDOSHOYLVDQDWRP\ LQWKHIHPDOH

LQRUGHUWRGHYHORSHIIHFWLYHLQQRYDWLYHUHFRQVWUXFWLYHVXUJHU\SULQFLSOHVDQGWHFKQLTXHV

WKLVFDQRQO\EHGRQHLQSUDFWLFDOLQWHQVLYHZRUNDQGWDONVKRSVZLWKDOLPLWHGQXPEHU RISDUWLFLSDQWV

ZKHUHRQHWRSLFRUWZRWRSLFVDUHGHDOWZLWK

IXOO\WUDQVSDUHQWGD\WRSLFUHODWHGSUDFWLFDOWKHRUHWLFZRUNVKRSV ZLWKHYLGHQFHEDVHGIROORZXS

YHQXH UHDOILVWXODFHQWHUZLWKJRRGQXPEHURISDWLHQWVDQGZLWKZHOOWUDLQHGSHUVRQHOFHUWDLQO\ QRWDXQLYHUVLW\RUWHDFKLQJKRVSLWDOFHQWHUZLWKRQO\SDWLHQWVD\HDU

QXPEHURISDWLHQWV DPLQLPXPRISDWLHQWVZLWKWKHWRSLFUHODWHGREVWHWULFWUDXPDZLWKZLWKRXWRWKHU REVWHWULFWUDXPDSDWLHQWVWREHRSHUDWHGKRZHYHULQWRWDOSDWLHQW

FRDFKHV WKHILVWXODVXUJHRQLFWKHILVWXODFHQWHUWRJHWKHUZLWKKHDGFRDFK

SDUWLFLSDQWV PD[LPXPRIUHDOWUDLQHUH[SHUWVVRQRWSROLWLFDOWUDLQHUVZKRKDYHQRWJRWWKHVOLJKWHVW FOXHDERXWVXUJHU\DQGDERXWWUDLQLQJ

HPSKDVLV TXDOLW\LQVWHDGRITXDQWLW\

GD\WRGD\SURJUDP VWDUWLQJKULQWKHPRUQLQJZLWKKLJKTXDOLW\UHFRQVWUXFWLYHVXUJHU\ZLWKVWHSE\VWHS GHPRQVWUDWLRQ RI WKH WHFKQLTXH ZLWK SUHVXUJHU\ GLVFXVVLRQ DQG SRVWVXUJHU\ TXHVWLRQVDQGDQVZHUV IURPKULQWKHDIWHUQRRQWKHRUHWLFOHFWXUHVE\DOOWKHSDUWLFLSDQWVZKRKDYHWRGR WKHLUSUHZRUNVKRSKRPHZRUN

175 191 SUDFWLFDOWRSLFVWREHDGGUHVVHG

FRQWLQHQWREVWHWULFXULQHILVWXODVXUJHU\

FRQWLQHQWREVWHWULFFLUFXPIHUHQWLDOILVWXODVXUJHU\

FRQWLQHQWXUHWKUDUHFRQVWUXFWLRQ

FRQWLQHQWFLUFXPIHUHQWLDOXUHWKUDUHFRQVWUXFWLRQ

FRQWLQHQWJHQXLQHLQWULQVLFXULQHLQFRQWLQHQFHVXUJHU\

FRQWLQHQWSRVWUHSDLUVXUJHU\

IXQFWLRQDOEDKDQ\DVXUJHU\

SURJHQHUDWLRQXWHUXVVSDULQJSURODSVHVXUJHU\

LPPHGLDWHPDQDJHPHQW

XUHWHULFILVWXODV

FRQWLQHQWXULQDU\GLYHUVLRQV

HWFHWF

WKHRUHWLFWRSLFV

WKHSHOYLVDQDWRP\

WKHIXQFWLRQDODQDWRP\

WKHFRQQHFWLYHWLVVXHERG\RISHOYLV

WKHLQWUDSHOYLFXURJHQLWRGLJHVWLYHGLDSKUDJP

WKHXULQHFRQWLQHQFHPHFKDQLVP

WKHVWRROFRQWLQHQFHPHFKDQLVP

WKHXULQHLQFRQWLQHQFHPHFKDQLVPIDFWRUV

WKHK\SRWRQLFEODGGHU

JHQXLQHLQWULQVLFLQFRQWLQHQFH

SRVWUHSDLUXULQHLQFRQWLQHQFH

WKHVWRROLQFRQWLQHQFHPHFKDQLVPIDFWRUV

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

 177 193 abbreviations

YYI  YHVLFRYDJQDOILVWXOD UYI  UHFWRYDJLQDOILVWXOD XYYI  XUHWKURYHVLFRYDJLQDOILVWXOD YFYI  YHVLFRFHUYLFRYDJLQDOILVWXOD YXYI  YHVLFRXWHURYDJLQDOILVWXOD

F[  FHUYL[ DYZ  DQWHULRUYDJLQDZDOO SYZ  SRVWHULRUYDJLQDZDOO SFPI  SXERFHUYLFDOPXVFXORIDVFLD DWI  DUFXVWHQGLQHXVIDVFLDH DWODP  DUFXVWHQGLQHXVRIOHYDWRUDQLPXVFOH ODP  OHYDWRUDQLPXVFOH SFP  SXEFRFF\JHXVPXVFOH RFP  REWXUDWRFRFF\JHXVPXVFOH LVFP  LVFKLR FRFF\JHXVPXVFOH LRP  REWXUDWRULQWHUQXVPXVFOH SP  SLULIRUPLVPXVFOH VXO  VDFURXWHULQHOLJDPHQW EO  EURDGOLJDPHQW FO  FDUGLQDOOLJDPHQW HSG  HQGRSHOYLFGLDSKUDJP

FK  FKDUULqUH J  JDXJH K  KHJDU

S  SDULW\ VE  VWLOOERUQ FV  FHVDUHDQVHFWLRQ VWK  VXEWRWDOK\VWHUHFWRP\ WDK  WRWDODEGRPLQDOK\VWHUHFWRP\ WYK  WRWDOYDJLQDOK\VWHUHFWRP\

194 HXR  H[WHUQDOXUHWKUDRSHQLQJ LXR  LQWHUQDOXUHWKUDRSHQLQJ XY MXQFWLRQ   XUHWKURYHVLFDO MXQFWLRQ 

HXRI  GLVWDQFHEHWZHHQHXRDQGILVWXOD IF  GLVWDQFHEHWZHHQILVWXODDQGFHUYL[ IY  GLVWDQFHEHWZHHQILVWXODDQGYDJLQDYDXOW HXRE  GLVWDQFHEHWZHHQHXRDQGFDWKHWHUEDOORRQ HXREZ  GLVWDQFHEHWZHHQHXRDQGEODGGHUZDOO IXQGXV  DI  GLVWDQFHEHWZHHQDQXVDQG UHFWRYDJLQDO ILVWXOD LY  GLVWDQFHEHWZHHQLQWURLWXVDQGYDJLQDYDXOWYDJLQDOHQJWK

SD  SXELFDUFK DS  DQWHULRUWRSRVWHULRUSHOYLVGLDPHWHU DU  DQDOUHIOH[

JP  JDVWURFQHPLXVPXVFOH VP  VROHXVPXVFOH DW  DFKLOOHVWHQGRQ

PLQ  PLQXWH KU  KRXU ZN  ZHHN PWK  PRQWK \U  \HDU

5  ULJKW /  OHIW

EODGGHUFDSDFLW\E\ORQJLWXGLQDOGLDPHWHU HXREZPLQXVHXRE  VPDOO    FP PRGHUDWH  FP QRUPDO  FP WUDQVLWLRQDO  FP LQFUHDVHG  !FP

195 QRUPDOSHOYLVPHDVXUHPHQWV

YDJLQDOHQJWK FP

HXRF   FP

DQDWRPLFXULQHFRQWLQHQFHPHFKDQLVP  FP

DQDWRPLFVWRROFRQWLQHQFHPHFKDQLVP  FP

XUHWKUDOHQJWK FP

ORQJLWXGLQDOEODGGHUGLDPHWHU HXREZPLQXVHXRE  FP

DQRUHFWXP  FP

V\PSK\VLV  FPEURDG D[LVLQFOLQDWLRQ ƒDVWRKRUL]RQWDOLQWKHXSULJKWSRVLWLRQ

SXELFDUFK ƒ

DWI FP LQFOLQDWLRQ ƒDVWRKRUL]RQWDOIURPSXELVERQHWRLVFKLXPVSLQH

DWODP FP LQFOLQDWLRQ ƒDVWRKRUL]RQWDOIURPSXELVERQHWRLVFKLXPVSLQH

DQJOHEHWZHHQV\PSK\VLVDQGDWIDWODPƒ

LQWHULVFKLXPVSLQHGLVWDQFH FP

LQWHULVFKLXPWXEHURVLW\GLVWDQFH  FP

SHOYLVLQOHWSODQH LQFOLQDWLRQƒWRKRUL]RQWDOIURPVXSHULRUV\PSK\VLVHGJHWR SURPRQWRU\LQWKHXSULJKWSRVLWLRQ

SHOYLVRXWOHW ƒWRKRUL]RQWDOIURPLQIHULRUV\PSK\VLVWRWLSRIFRFF\[LQWKH XSULJKWSRVLWLRQ

DQWHULRUWULDQJOHSHOYLVRXWOHWIURPLQIHULRUV\PSK\VLVWRLVFKLXPWXEHURVLW\LQRQHSODQH ZLWKWRƒLQFOLQDWLRQWRKRUL]RQWDOLQXSULJKWSRVLWLRQ

SRVWHULRUWULDQJOHSHOYLVRXWOHWIURPLVFKLXPWXEHURVLW\WRWLSRIFRFF\[LQRQHSODQHZLWK ƒLQFOLQDWLRQDVWRKRUL]RQWDOLQXSULJKWSRVLWLRQ

SHOYLVRXWOHWVXUIDFHVTFP

JDSEHWZHHQSXERUHFWDOLVHGJHV VTFP

GLDPHWHUUHFWDIURPLQIHULRUV\PSK\VLVXSWRWLSRIFRFF\[FPXSWRFP GXULQJGHOLYHU\

196 180