Surg Radiol Anat
DOI 10.1007/s00276-014-1336-0
Original Article
Denonvilliers’ fascia revisited
Ji Hyun Kim · Yusuke Kinugasa · Si Eun Hwang ·
Gen Murakami · Jose Francisco Rodríguez‑Vázquez ·
Baik Hwan Cho 
Received: 16 January 2014 / Accepted: 20 June 2014
© Springer-Verlag France 2014
Abstract  Although several studies have reported that
the peritoneum does not contribute to the formation of a
fascia between the urogenital organs and rectum, Denon-
villiers’ fascia (DF), a fascia between the mesorectum and
prostate (or vagina) in adults, is believed to be a remnant
of the peritoneum. Remnants of the peritoneum, however,
were reportedly difficult to detect in other fusion fasciae
of the abdominopelvic region in mid-term fetuses. To
examine morphological changes of the pelvic cul-de-sac
of the peritoneum, we examined 18 male and 6 female
embryos and fetuses. A typical cul-de-sac was observed
J. H. Kim  a tension-induced structure rather than a fusion fascia.
Department of Anatomy, Chonbuk National University Medical
School, Jeonju, Korea
Y. Kinugasa 
Division of Colorectal Cancer, Sizuoka Cancer Institute, Susono
City, Sizuoka, Japan
S. E. Hwang 
Department of Surgery, Daejeon Sun Hospital, Daejeon, Korea
G. Murakami 
Division of Internal Medicine, Iwamizawa Kojin-kai Hospital,
Iwamizawa, Japan
J. F. Rodríguez‑Vázquez  Denonvilliers’ fascia (DF), originally termed “aponévrose
Institute of Embryology, Complutense Universidad, Madrid,
Spain
B. H. Cho 
Department of Surgery, Chonbuk National University Medical
School, Jeonju, Korea
B. H. Cho (*) 
Biomedical Research Institute, Chonbuk National University
Hospital, Deokjin‑gu, Jeonju, Korea
e-mail: chobh@jbnu.ac.kr
only at 7 weeks, whereas, at later stages, the peritoneal
cavity did not extend inferiorly to the level of the pros-
tatic colliculus or the corresponding structure in females.
The cul-de-sac had completely disappeared in front of
the rectum at 8 weeks and homogeneous and loose mes-
enchymal tissue was present in front of the rectum at the
level of the colliculus at 12–16 weeks. We found no evi-
dence that linearly arranged mesenchymal cells developed
into a definite fascia. Therefore, the development of the
DF in later stages of fetal development may result from
the mechanical stress on the increased volumes of the
mesorectum, seminal vesicle, prostate and vagina and/
or enlarged rectum. Therefore, we considered the DF as
Fasciae around the viscera seemed to be classified into (1)
a fusion fascia, (2) a migration fascia and (3) a tension-
induced fascia although the second and third types are
likely to be overlapped.
Keywords  Denonvilliers’ fascia · Peritoneum ·
Cul-de-sac · Rectum · Prostate · Vagina
Introduction
prostatopéritonéale”, was first described in 1838 [2, 6].
This structure is nearly always present between the pros-
tate or vagina and the fatty tissue around the rectum, i.e.,
the mesorectum [14, 17, 18, 36]. DF is also sometimes
referred to as the rectovesical septum, prostatorectal fascia,
rectogenital fascia, or rectovaginal septum [26, 27, 33]. In
contrast to the male DF, the histological architecture of the
rectovaginal septum has been described in detail [25, 37].
DF in elderly women is often fragmented and unclear; thus,
13

the distal parts of the pelvic plexus extend freely from the
paracolpium to the mesorectum.
The actual DF is regarded as the “anterior layer of the
DF”, whereas the “posterior layer of the DF” corresponds
to the fascia propria of the rectum [30, 32]. Several recent
anatomic studies have also used the term “anterior layer”
for the actual DF [36, 37]. To date, however, no embryologi-
cal studies have reported that the fascia propria of the rec-
tum is derived from the pelvic cul-de-sac of the peritoneum
(i.e., an inferior protrusion of the peritoneal cavity in front of
the embryonic rectum). For simplicity, we use the term DF
to describe a definite membranous structure in front of the
mesorectum in both genders. Loose fatty tissue of the meso-
rectum between the fascia propria and DF contains abundant
blood vessels and nerves that supply the rectum. Several
hypotheses have been formulated to determine the embryo-
logical origin of the DF. In one hypothesis, peritoneal fusion
occurs, giving rise to the DF [3, 30]. In a second hypothesis,
fusion occurs but does not give rise to the DF because no
remnant of the peritoneum remains in fetuses [34]. In a third
hypothesis, fusion does not occur and the DF does not origi-
nate from the pelvic cul-de-sac of the peritoneum [29].
A detailed morphometric analysis of the topographical
relationship between the cul-de-sac and other landmark
structures in the pelvis clearly demonstrated that the peri-
toneal cul-de-sac disappears during the fetal stage, with
smooth muscles derived from the longitudinal muscle layer
of the rectum later appearing behind the rectum [29]. This
finding suggested that the presence of aberrant smooth
muscles may erroneously suggest the presence of a fascia-
like structure in fetuses. Smooth muscles in fetuses actu-
ally originate from the longitudinal muscle layer of the rec-
tum as well as from the bladder, and migrate and disperse
around these structures to form smooth muscle tissues
embedded in the pelvic floor [1, 9, 16]. The histology of
the actual peritoneal fusion behind the duodenum has been
compared with the artifactual fusion at the edge of the pel-
vic cul-de-sac [29].
The retroduodenal or retropancreatic fascia (i.e., the
fascia of Treitz) has been famous for a fusion fascia of the
peritoneum rather than the DF. The retroduodenal fascia
provides a classical plane in abdominal surgery during ret-
ropancreatic mobilization of the pancreatic head and duo-
denum (i.e., the Kocher maneuver). After rotation of the
midgut mesentery, however, a remnant of the secondary
fusion of the peritoneum becomes unclear at the mid-term
fetuses [4, 35]. Likewise, following secondary attachment
of the mesocolon transversum to the pancreas and duode-
num, the fused peritoneal layer is changed into irregularly
arrayed fibrous tissues [10]. Therefore, it may be difficult
to determine whether or not the so called fusion fascia cor-
responds to a true remnant of the fused peritoneum. In con-
trast to the concept of fusion fascia, our group has applied
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Surg Radiol Anat
another concept of fasciae, the “migration fascia” [8] to
many fascial structures of the human body based on fetal
histology [5, 12, 13, 15, 21–23]. The term “migration fas-
cia” is used due to the upward migration of the fetal kid-
ney, but it essentially indicates mechanical stress- or ten-
sion-inducing fascial formation. This study was designed
to re-examine morphological changes in the pelvic cul-
de-sac of the peritoneum in human embryos and fetuses at
7–16 weeks of gestation.
Materials and methods
The study was performed in accordance with the provi-
sions of the Declaration of Helsinki 1995 (as revised
in Edinburgh 2000). Eighteen paraffin-embedded male
embryos and fetuses at an estimated gestational age (GA)
of 7–16 weeks [crown rump length (CRL) 20.5–115 mm]
were examined, including four embryos of GA 7 weeks
(CRL 20.5–23 mm), five fetuses of GA 9–10 weeks (CRL
36–56 mm) and nine fetuses of GA 12–16 weeks (CRL 80–
130 mm). For comparison, six female embryos and fetuses
were examined, two of GA 8 weeks (CRL 36 and 39 mm)
and four of GA 12–14 weeks (CRL 62–95 mm). All fetuses
and embryos were part of the large collection kept at the
embryology Institute of the Universidad Complutense,
Madrid, being the products of urgent abortions, miscar-
riages or ectopic pregnancies managed at the Department
of Obstetrics of the University. Approval for the study was
granted by the ethics committee of the university.
The donated fetuses were fixed in 10 % v/v formalin
solution for more than 3 months. After division into the
head and neck, thorax, abdomen and pelvis, and the four
extremities, the abdominopelvic specimens from the eight
larger fetuses (GA 12–15 weeks) were decalcified by incu-
bation at room temperature for 3–5 days in Plank-Rychlo
solution (AlCl2/6H2O, 7.0 w/v %; HCl 3.6; HCOOH 4.6).
After routine procedures for paraffin-embedded histology,
7-µm-thick horizontal sections of the entire abdomen and
pelvis were prepared serially from the nine earlier speci-
mens, with sections of similar thickness prepared at 50 µm
intervals from the nine later specimens. The sectional planes
were horizontal (two specimens of GA 7 weeks; three of
GA 9 weeks; and five of GA 12–15 weeks), frontal (two
of GA 10 weeks; two of GA 13 weeks) or sagittal (two of
GA 7 weeks; two of GA 15–16 weeks). The sections were
stained with hematoxylin and eosin (HE) or azan stain.
Results
In earlier-stage specimens, the urogenital sinus did not dif-
ferentiate into the bladder and urethra. Likewise, Műllerian
Surg Radiol Anat
Fig. 1  Sagittal sections showing the bottom of the peritoneal cavity.
a (7 weeks) displays the cul-de-sac of the peritoneum (stars) reach-
ing a level inferior to the future prostate (PR). The future urethra
(UR) and bladder are not differentiated from the urogenital sinus,
b (14 weeks) and c (16 weeks) exhibit the bottom of the peritoneal
and Wolffian ducts did not differentiate into the vas def-
erens, prostate, seminal vesicles and vagina. The prostatic
colliculus and the corresponding structure in females are
derived from complexes of the Műllerian and Wolffian
ducts [31]. However, for easy comparison between stages
or with adult morphology, we used terms of adult anatomy:
the bladder and/or urethra for the urogenital sinus; and the
vas deferens, prostate and vagina for the Műllerian and
Wolffian ducts.
cavity in the superior side of the developing prostate. No fascia is evi-
dent behind the rectum (R). Scale bars in each panel, 1 mm. CO coc-
cyx, EAS external anal sphincter, PB pubis, R rectum, S sacrum, VAS
vas deferens
The pelvic cul-de-sac of the peritoneum extended
below the level of the future prostatic colliculus, reaching
the level of the second or third sacral vertebra at 7 weeks
(Fig.  1). This lowermost part of the peritoneal cavity sur-
rounded the anterior half of the rectum. Behind the rec-
tum, a mesentery-like structure attached to the presacral
loose mesenchymal tissue (Fig. 2). The cul-de-sac was a
U-shaped cavity sandwiching the rectum. The developing
pelvic nerve plexus was thicker than the cul-de-sac and
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 Surg Radiol Anat

extended along the anteroposterior axis of the pelvis near the primitive levator ani muscle. Because the nerve plexus
the rectum and urogenital sinus. The lower end of the cul- was penetrated by and intermingled with abundant veins,
de-sac was located in the superior side of the inferior end of spongy tissues were located on the immediately lateral side

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 Surg Radiol Anat
◂ Fig. 2  Horizontal sections of a 7-week embryo. a The most superior
section in this figure, displays the future vas deferens (VAS) merging
either the future urethra (UR) or urogenital sinus. Intervals between
a–b, b–c and c–d are 0.1 mm. The cul-de-sac of the peritoneum
(stars) surrounding the anterior half of the rectum (R) provides a
mesentery-like structure (arrowheads in a) at the posterior side of d,
the most inferior section in this figure, the cul-de-sac disappears and,
instead, nerves and veins occupy in the space alongside the rectum.
a–d were prepared at the same magnification (scale bar in a 1 mm).
e (Scale bar 0.1 mm), a higher magnification view of the central part
of c, exhibits numerous veins intermingling with nerves near the peri-
toneum. The peritoneum is slightly thicker than endothelium of the
veins. IS ischium (developing bone), PN sacral roots of the pudendal
nerve, S sacrum
of the cul-de-sac (Fig. 2e). Although the amount of mate-
rial was limited, we observed no histologic evidence sug-
gesting that peritoneal fusion occurred at the edge of the
cul-de-sac.
In the other specimens, of GA later than 7 weeks, the
peritoneal cavity was not seen in the level behind the pro-
static colliculus (Figs. 1b, c, 3, 4). Moreover, covering by
the lowermost part of the peritoneal cavity was limited to
the anterior aspect of the rectum; it did not extend to the
lateral aspect (Figs. 3a, 4a). Thus, the typical U-shaped
cul-de-sac was most likely to disappear at GA 8 weeks.
At GA 9–10 weeks, the future prostate faced the bottom
of the peritoneal cavity and, even at the level of the future
prostatic colliculus under the bottom of the peritoneum,
the prostate and rectum were connected tightly (Fig. 3c).
This connection was invaded by the developing pelvic
autonomic plexus. At GA 12–16 weeks, homogeneous
and loose mesenchymal tissue was present in front of the
rectum at the level of the colliculus. Although this tissue
contained no fascial structures (Figs. 4, 5), we observed an
artifactual space with/without artifactual banding of col-
lagen fibers (Fig. 4c) and short but linear arrangements of
mesenchymal cells possibly due to a type of knife mark
(Fig. 4d). The artifactual space was similar to a cyst, except
for the absence of lining cells. Because the urethra and rec-
tum were not straight along the supero-inferior axis, frontal
sections also demonstrated mesenchymal tissue between
the colliculus or prostate and the rectum (Fig. 5). Frontal
sections elongated the space for the DF (Fig. 5b–d) and
emphasized the homogeneous structure. The longitudinal
smooth muscles of the rectum extended upward and later-
ally toward the mesenchymal tissue (Fig. 5a).
A junction between the urethra (urogenital sinus) and
the descending vagina formed a colliculus-like structure
(Fig. 6). Thus, the morphology in females was very similar
to that in males, including the prostatic colliculus. We pre-
viously described this colliculus-like structure in females
[20]. Similar to the developing prostate, the inferior end of
the vagina faced the cul-de-sac at GA 7 weeks (Fig. 6a).
The mesenchymal tissue between the vagina and rectum
initially contained a connecting band running along the
anteroposterior axis (Fig. 6b, c), but, as the size of the fetus
increased, the mesenchymal tissue became more homoge-
neous (Fig. 6d).
In specimens of both genders of GA >10 weeks, the
smooth muscles of the bladder neck surface (i.e., the fetal
detrusor apron [9]) extended posterolaterally to connect
with a fascial structure (Fig. 3b). At GA 10 weeks, the pre-
sacral fascia (Fig. 4a, b) as well as the fascia pelvis parieta-
lis (Fig. 4e) appeared. The latter fascia was much thicker
along the obturator internus muscle (i.e., above the arcus
tendineus levator ani) than along the levator ani (Fig. 5c, d).
Discussion
This study has shown that, after the disappearance of the
cul-de-sac of the peritoneum in front of the rectum at and
around GA 8 weeks, the space between the rectum and
prostate (or vagina) was filled with homogeneous loose
tissue [29, 34]. We observed many morphologic character-
istics similar to a peritoneal cyst [30] or a remnant of the
peritoneum, including intermingling among the developing
nerve plexus, the thin veins and the artifactual space with
or without artifactual banding of collagen fibers. However,
we found no evidence that linearly arranged mesenchymal
cells developed into a definite fascia, although we did not
examine late-stage fetuses. Likewise, we found no evidence
of peritoneal fusion at the edge or end of the cul-de-sac.
Rather, the sac seemed to move or regress upward. There-
fore, our results support the third hypothesis, that fusion
does not occur and the DF does not originate from the pel-
vic cul-de-sac of the peritoneum [29]. A definite DF was
shown to be present behind the seminal vesicles in a fetus
of CRL 191 mm (GA 24 weeks) [7]. Since the fascia pro-
pria of the rectum is also established at a late stage [1],
fetal development of the DF may occur in late-stage fetuses
in combination with formation of the fascia propria of the
rectum (Fig. 7).
Mechanical stress may be eliminated as a cause of fascia
during DF development, although the DF has been reported
to be formed by condensation of mesenchymal tissue after
absorption of the cul-de-sac [34]. The concept of “migra-
tion fascia” postulates that the upward migration of the fetal
kidney results in mechanical stress or tension around it,
with the stress inducing linear condensation of mesenchy-
mal tissues producing collagen fibers for the future renal
fascia [8]. In the musculoskeletal system, site-dependent
configurations of collagen fibers are dependent on the direc-
tion and strength of mechanical stress [11, 19]. In human
fetal development, mechanical stress originates from early
developed striated muscles to provide fascial structures,
as typified in the prevertebral lamina of the deep cervical
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Fig. 3  Horizontal sections of a 10-week fetus. a The most superior
section in this figure, displays the ureter (UT) passing through walls
of the bladder (B). Note the anteriorly restricted covering of the peri-
toneum (stars). Thus, a mesentery-like structure behind the rectum is
not evident (cf, see Fig. 2a, b). Intervals between panels are 0.9 mm
(a–b), 0.6 mm (b–c) and 1.1 mm (c–d), respectively, b includes the
bottom of the peritoneal cavity (star). From the anterior aspect of the
neck of the bladder (B neck), smooth muscles extend posterolaterally
fascia and other cervical fasciae [22, 23]. Rapidly growing
tissues or organs are another major source of mechanical
stress. These structures compress the surrounding mesen-
chymal tissues into a linear orientation, providing a fascial
structure around them, as typified by the renal fasciae [21].
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Surg Radiol Anat
to connect with a fascial structure (arrows). In the inferior side of the
bottom (c), the urethral wall (UR) is connected with the rectum (R)
by a dense mesenchymal tissue (arrowheads). In the more inferior
levels (d), a homogeneous loose tissue is present between the ure-
thra and rectum. All panels were prepared at the same magnification
(scale bar in a, 1 mm). LA levator ani, PB pubis, PR future prostate,
VAS vas deferens
In short, early developed, relatively hard structures tend to
accompany fascial structures. Fusion fasciae from the mes-
entery of the colon around the kidney also seem to contrib-
ute to fascia formation (i.e., the lateroconal fascia [21]).
The ureteral sheath and the hypogastric fascia are likely
Surg Radiol Anat
Fig. 4  Horizontal sections of a 12-week fetus. a The most superior sec-
tion in this figure, displays the ureter (UT) joining the bladder (B). The
vas deferens (VAS) is located in the immediately anterior side of the peri-
toneal cavity (stars). Intervals between panels are 1.2 mm (a–b), 0.1 mm
(b–c), 1.4 mm (c–d) and 1.5 mm (d–e), respectively. b includes the bot-
tom of the peritoneal cavity. In the inferior side of the bottom, there is
an artifactual space due to histological procedure (asterisks) and it is dif-
ferent from nearby veins with endothelial lining (c). In the more inferior
levels (d, e), it is difficult to find fascial structures between the prostatic
colliculus or urethra (UR) and the rectum (R). Multiple, short and linear
arrangements of mesenchymal cells (arrows in d) appeared to be a kind
of knife mark (artifact). There are primitive forms of the presacral fascia
(arrows in a, b) as well as the fascia pelvis parietalis (arrows in e). Scale
bars in each panel, 1 mm. PB pubis, PR future prostate, S sacrum
13

Fig. 5  Frontal sections of a 14-week fetus. a, d corresponds to the
most posterior (anterior) side of the figure. Intervals between panels
are 2.5 mm (a–b), 1.2 mm (b–c) and 0.5 mm (c–d), respectively. a
(Scale bar in a, 1 mm) includes outward extensions of longitudinal
smooth muscles (arrows) of the rectum (R). In b–d, a space between
the prostate (PR) or urethra (UR) and the rectum is emphasized by
to be formed by mechanical stress between the ureter or
hypogastric nerve and other prevertebral tissues [15]. In
the fetal head, rapidly developing fatty tissue masses seem
to play a major role in fascia formation, with the regressed
Reichert’s cartilage especially contributing to the formation
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Surg Radiol Anat
elongated views due to frontal sections: it is filled with a homoge-
neous loose tissue. The fascia pelvis parietalis is much thicker along
the obturator internus muscle (arrowheads in c, d) than that along
the levator ani muscle (arrows in c). B bladder, LA, levator ani mus-
cle, IC, ischiocavernosus muscle, OI Obturator internus muscle, UA
umbilical artery, UT ureter, VAS vas deferens
of tensor-vascular-styloid and prestyloid fasciae [5, 12, 13].
Overall, migration of a structure covered by the fascia is
not usually required in fetuses. Therefore, with an excep-
tion (i.e., fasciae around the kidney), the term “migration
fascia” seems unsuitable; “tension-induced fascia” may be
Surg Radiol Anat
Fig. 6  Horizontal sections of four female fetuses. All panels dis-
play a level including the inferior end of the vagina (scale bar in each
panel, 1 mm). At the level, the cul-de-sac is seen in a (8 weeks), but
not in b (12 weeks), c (13 weeks) and d (14 weeks). In a and b, a
colliculus-like structure is evident at the merging between the ure-
thra (UR) and vagina (VAG). A mesenchymal condensation is seen
better. Fasciae around the viscera seemed to be classified
into (1) a fusion fascia, (2) a migration fascia and (3) a ten-
sion-induced fascia although the second and third types are
likely to be overlapped. Tension-induced fasciae are charac-
terized by inter-individual differences because morphology
is dependent on slight differences in topographical anatomy.
In the rectovaginal septum, i.e., the female DF, elastic
fibers are regularly arrayed, with transverse and horizontal
directed fibers suggesting tensions caused by sexual behav-
ior and vaginal delivery [25]. No information is yet availa-
ble, however, on composite fibers and their direction in male
connecting between the vagina and rectum (R) in panels B and C
(arrows), while the space is filled with a homogeneous loose tissue in
d. Scale bar in each panel, 1 mm. LA levator ani muscle, OI obturator
internus muscle, PB pubis, UA umbilical artery, UT ureter, VAS vas
deferens
DF. Gender differences in the fibrous architecture of the
endopelvic fascia (fascia pelvis parietalis or fascia diaphrag-
matis pelvis superior) have been observed [9]. Likewise,
in the DF, the composition as well as the direction of fib-
ers is likely to show gender differences. Moreover, because
DF morphology seems to depend on mechanical stress, we
hypothesized that individual variations in DF architecture,
such as fragmentary fibrous tissue, multilaminar thin fas-
ciae or solid monolayer fasciae, are likely to occur in the
pelvic floor of elderly individuals due to benign prostatic
hyperplasia and vaginal delivery (Fig. 7). Actually, we had
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 Surg Radiol Anat

Fig. 7  Hypothetical processes
of fetal development and
postnatal changes of Denonvil-
liers’ fascia. At 7 weeks, the
cul-de-sac (stars) of the perito-
neal cavity (PC) is between the
rectum (R) and the urethra (UR)
and vas deferens (VAS). At and
around 15 weeks, the cul-de-sac
disappears and a homogene-
ous mesenchymal tissue fills
a space (asterisks) in front
of the rectum. The presacral
fascia is formed at this stage. In
later stages, mechanical stress
makes Denonvilliers’ fascia
as well as the fascia propria
of the rectum (dotted lines). A
tube-like loose connective tissue
space (i.e., the mesorectum;
asterisks) appears around the
fascia propria: it is delineated
anteriorly by Denonvilliers’
fascia and posteriorly by the
presacral fascia. In the postnatal
life, depending on direction and
strength of mechanical stress
from the surrounding structures,
the fetal Denonvilliers’ fascia is
changed into (1) a solid mon-
olayer, (2) multilayer structure
or, (3) a fragmentary, unclear
fibrous tissue. This scheme can
be adapted to Denonvilliers’
fascia in females when the vas
and prostate are replaced by the
vagina. The adult variations are
based on our unpublished data.
B bladder, PR prostate

a histological data of the DF in 30 adult males: (1) the DF
usually took a multilayer configuration, but (2) it was often
fragmented into short pieces, i.e., unclear, or composed of a
very thick leaf and the other thin leaves, i.e., a pseudo mon-
olayer, depending on the sites (data, submitted now). An
extension of the DF to the anterior side of the seminal vesi-
cles [28] seems also to be one of the individual variations.
Detailed histological studies using specimens from older
individuals are necessary to understand DF morphology by
routine magnetic resonance imaging.
Acknowledgments  We are grateful to the families for agreeing
to the fetuses and embryos donations for research and education on
human anatomy without any economical benefit. This study was
supported by a grant (0620220-1) from the National R&D Program
for Cancer Control, Ministry of Health & Welfare, Republic of Korea.
Conflict of interest The authors declare that they have no conflict
of interest.
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