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My strategy to deal with sub-meatal urethral stricture

Based on my analysis here, here and here, I’ve currently decided the following course of action:

Step 1: Continue intra-urethral injection of aloe vera. Supplement with sesame seed oil when received. Keep a record (here – private)

Step 2: Continue monitoring urine flow (here – private). Closely track any changing trend in the flow rate.

Step 3: Get 2-3 independent opinions during October 2017 and work out how you will get the big surgery done: by whom, when, and where. Make sure that the person you choose for the surgery has extensive training AND experience in exactly this type of surgery. Can’t take risks with botched up surgery.

Step 4: As and when the stricture recurs (it will almost certainly do so – unless the aloe vera/sesame treatment actually works) , implement the surgery plan.

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Dealing with sub-meatal urethral stricture: meatoplasty and dilation (related: fossa navicularis strictures)

Note: my surgery was for Rigid Cystoscopy and Optical Urethrotomy (direct visual internal urethrotomy – DVIU).

WHAT MY SURGEON SHOULD HAVE DONE TO PREVENT THIS COMPLICATION

When urethral strictures are identified at the time of catheter placement for another surgical procedure, assessment of the need for catheterization should be made. [Source: Male Urethral Stricture: American Urological Association Guideline] [Sanjeev: Although my surgeon admits he felt something blocking the catheter, it was obviously not big enough to cause alarm – the catheter did get inserted. Alternatively, it is possible the surgeon is not experienced enough with these kinds of rare complications. He would presumably have learnt something from his experience. There is no doubt that accidents will occur during surgery. Expecting perfection in life is a foolish thing.]

Urethral strictures may be dilated in this setting to allow catheter insertion, and dilation over a guidewire is recommended to prevent false passage formation or rectal injury. Alternatively, DVIU may be performed, particularly if the stricture is too dense to be adequately dilated. SP cystotomy may also be performed to provide urinary drainage at the time of surgery if these initial maneuvers are unsuccessful, or when subse¬quent definitive treatment for urethral stricture is planned in the near future. [Source: Male Urethral Stricture: American Urological Association Guideline]

In my view, given the HUGE risk of catheters causing severe injury, it is crucial that the urether of men is fully tested and checked independently BEFORE surgery, so any issues can be identified and fixed in advance of the surgery.

URETHROTOMY IS GUARANTEED TO FAIL

After 1 urethrotomy Pansadoro and Emiliozzi found a 5-year stricture-free survival rate of 6%, which closely matched our 5-year stricture-free survival rate of 7%. Treatment eventually failed in all 7% of the patients by 79 months. [Source] – i.e. 100 PER CENT RECURRENCE WITHIN FIVE YEARS, WITH MOST RECURRING WITHIN 3-6 MONTHS.

The stricture-free rate after the first urethrotomy was 8% with a median time to recurrence of 7 months. For the second urethrotomy stricture-free rate was 6% with a median time to recurrence of 9 months. For the third urethrotomy stricture-free rate was 9% with a median time to recurrence of 3 months. For procedures 4 and 5 stricture-free rate was 0% with a median time to recurrence of 20 and 8 months, respectively. [Source]

RECOMMENDATION: NO MORE THAN ONE URETHROTOMY

“During the last 30 years urethroplasty has improved in efficacy and safety, while urethrotomy is increasingly considered neither cost-efficient nor effective in the long term. Urethroplasty is reported to have lifetime success rates ranging from 75% to 100%. Repeat and unsuccessful urethrotomies impose costs to the patients in the form of lost wages, unnecessary health care expenditures, decreased quality of life and unnecessary anesthesia. The fact that urethrotomy has a low success rate is a strong argument for opting for the more effective urethroplasty instead of a less effective urethrotomy.” [Source]

NOTE: THIS ISSUE IS NOT STENOSIS!

It is hard to get information on this issue from the internet. First thing to note is that it is quite different to meatal stenosis, which is a narrowing of the opening (this is how it looks). “Meatal stenosis is a common complication of circumcision.” Curing stenosis is relatively easy and is done through a surgical procedure called meatotomy during which the meatus is crushed with a straight mosquito hemostat and then divided with fine-tipped scissors. (here is a video of how it is done]

WHAT A MEATAL (or fossa navicularis) STRICTURE LOOKS LIKE?

What it looks like – picture.

Causes

It appears this issue was very common with prostatectomies in the past (Some Common Complications After Prostatectomy, J. Cosbie Ross and L. F. Tinckler, The British Medical Journal, Vol. 2, No. 5153 (Oct. 10, 1959). The issue still occurs in around 2 per cent of the patients.

Male Urethral Stricture: American Urological Association Guideline (2017)

Male Urethral Stricture: American Urological Association Guideline (full guideline needs online journal access) says that uncomplicated urethral stricture confined to the meatus or fossa navicularis should be treated with simple dilation or meatotomy, with or without guidewire placement.

However, urethroplasty is needed for to patients with recurrent meatal or fossa navi­cularis strictures. Meatal and fossa navicularis strictures refractory (i.e. stubborn to) to endoscopic procedures are unlikely to respond to further endoscopic treatments (e.g. Urethrotomy).

Patients who opt for repeat endoscopic treatments or intermittent self-dilation in lieu of more definitive treatment, such as ure­throplasty should be advised that success of a sub­sequent reconstructive procedure may be lower when following a plan of repeated endoscopic surgery and/ or intermittent self-dilation. Similar to other types of stricture, exact delineation of length and etiology is important for guiding treatment.

Dilation is a bad idea. In my case, when the stricture recurs, I should undergo urethroplasty (or whatever the term is called).

TREATMENT OPTION 1: DILATION [not recommended]

Pictures of Dilation of the Urethral Meatal Stricture

INTERMITTENT SELF MEATAL DILATATION – AN INFORMATION LEAFLET, January 2017

What are the Treatments for Meatal Stricture / Meatal Stenosis? [Sanjeev: these are quite different things]

  • Intermittent self meatal dilatation – In some men it is possible that the narrowing of your urethra may re-occur. To reduce this risk you may be taught how to perform intermittent self meatal dilatation. [Sanjeev: it appears it will recur in almost all cases, and instead, aggravate things.]

What is Meatal Dilatation? Meatal Dilatation is a procedure which involves you passing a short catheter into the end of your urethra. The catheter is passed beyond the narrow section and this helps to keep the urethra open.

What Are The Alternatives?

  • Meatal dilatation – If your urethra is not too narrow, it can be dilated or stretched in theatre under local anaesthetic or a general anaesthetic (when you are put completely to sleep) using catheters (soft, hollow plastic tubes) which are graduated in size.
  • Meatotomy – A small operation to stretch or cut through the narrow tissue in your urethra may be necessary. This is called a ‘meatotomy’. Occasionally an additional procedure called circumcision (removal of the foreskin) may be necessary if repeated infections and inflammation (balanitis) at the tip of the penis has resulted in a tight foreskin. [Sanjeev: this is – as described – ONLY meant for a stenosis; not applicable in my case]

What are the risks of Meatal Dilatation?

  • Pain. At first it may be a little painful or uncomfortable to pass the catheter, especially if you have had recent surgery. This, however, should improve with time and most men are able to tolerate the procedure with little discomfort.
  • Bleeding. You may see a little blood on the end of the catheter after performing the procedure or experience a little bleeding from the urethra. This is nothing to worry about and should soon stop. If the bleeding becomes heavy and prolonged then contact your healthcare professional. [Sanjeev: actually bleeding is a BAD thing during dilation, as it will simply aggravate scarring]
  • Infection. It is important to wash your hands and penis before performing meatal dilatation so that no bugs are passed up into the bladder. However, if you experience pain or burning when passing urine, notice that your urine is cloudy or smelly or, especially, if you start to feel unwell (i.e. high temperature, abdominal pain or flu like symptoms), contact your GP or healthcare professional immediately as you may have a urine infection.
  • Recurrent Stricture If you notice a reduction in your flow of urine or if it becomes difficult to pass the catheter into the urethra, it may be because the narrowing has re-occurred. If this happens seek advice from you healthcare professional. [Sanjeev: This is STUPID. The advice should be provided upfront, including discussion of all risks]

General Advice

  • For how long and how often should I perform Meatal Dilatation? As everyone is different, a personalised regime will be agreed between yourself and your healthcare professional as to how often and for how long you should perform the procedure.

Dilatation catheters
These are usually sterile hydrophilic coated single use catheters with NO drainage eyes. They are used for keeping the urethra patent in patients with strictures or who have had surgery to the urethra. Dilatation catheters will not drain the bladder. Shorter length meatal dilators are available for men who need only to dilate the meatus to avoid meatal stenosis, or to dilate a sub-meatal stricture. If the stricture is higher in the urethra then a full length dilatation catheter (40cm) will be needed. [Source: Trust Guideline for the Management of Teaching Clean Intermittent Self-catheterisation (CISC)]

DILATION IS NOT A GREAT IDEA

Treatment approach to pre-TURP urethral strictures:

– Meatal/sub-meatal stricuture: Do a formal meatotomy instead of excess dilation

Source: Common Urologic Problems: Benign Prostatic Hyperplasia By Sujata Patwardhan

 

CAN DILATION WORK IN SOME CASES? – UNLIKELY

It is said in the Male Urethral Stricture: American Urological Association Guideline that stricture recurrence is significantly lower among patients performing self-catheterization. Data suggests that performing self-catheterization for greater than four months after DVIU reduced recurrence rates compared to performing self-catheterization for less than three months. [Sanjeev: I find this hard to believe – given the study which showed that RECURRENCE IS GUARANTEED WITH DVIU – see this study].

TREATMENT OPTION 2: MEATOPLASTY/ URETHROPLASTY

Note that this is different from the ear meatoplasty! And note that is is not meatotomy, although some doctors use the terms interchangeably.

The surgical technique of Meatoplasty is generally suggested in patients with meatal urethral stricturesThere are three basic types of Meatoplasty [Source] This is perhaps the best description.

  • Meatoplasty using skin flapUsing this technique, the urethral meatus is augmented using a penile skin flap (figure 1).

  • Meatoplasty with oral mucosal graft. Using this technique, the urethral meatus is augmented by a transplant of an oral graft (figure 2).

  • Meatoplasty with skin graft. Using this technique, the urethral meatus  is augmented by a transplant of a skin graft.

Jordan Flap Meatoplasty – a lot of details here.

DETAILS – IN A PAPER: Meatoplasty using double buccal mucosal graft technique – Apul Goel, Anuj Goel, Diwakar Dalela, Satya N. Sankhwar, International Urology and Nephrology, December 2009, Volume 41, Issue 4, pp 885–887

Glanular/meatal stricture can be seen as an isolated problem or as part of more extensive urethral stricture disease. Various treatment options are available, including penile flap and buccal mucosa, for the treatment of stricture at this location

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Uttarbasti – a medicinal oil-based treatment of urethral stricture

What is it?

See: http://urethralstricture-cure-in-ayurved.com/  (Uttarbasti is introduction of Sesame oil + Honey + Rock salt into urethra). Basically a glass syringe 40ml is used for this purpose.

Alternative (see this), “Medicated oil or decoction is introduced into the urinary bladder with the help of a rubber catheter through the urethral opening under aseptic conditions.”

A further ayurvedic doctor uses “disposable feeding tube no. 9“. This post claims that INFANT FEEDING TUBE can be used. [This Hindi blog post also describes its results – but no proof is offered]

Note that the size of a metus is around 0.3 inches (this study).

Video below:

Papers that claim that uttarbasti works:

K. Rajeshwar Reddy’s study

This seems to be a tolerable quality paper: Clinical evaluation of Apamarga-Ksharataila Uttarabasti in the management of urethral stricture

Even though this study is published by a shoddy journal (An international quarterly journal of research in ayurveda), it is featured on the website of the US National Library of Medicine, National Institutes of Health. That doesn’t make it a good study, but perhaps its results can be considered – with a pinch of salt.

In the present study, total 60 patients of urethral stricture were divided into two groups and treated with Uttarabasti (Group A) and urethral dilatation (Group B). The symptoms like obstructed urine flow, straining, dribbling and prolongation of micturation were assessed before and after treatment. The results of the study were significant on all the parameters.

Basically, uttarbasti works in the short term as well as dilation but has SIGNIFICANTLY fewer rates of recurrence.

But note that patients selected for this study had “mild to moderate” stricture. No one had a severe stricture.

Rajendra H Amilkanthwar’s work

Rajendra H Amilkanthwar is probably the most prominent ayurvedic doctor to make this claim. He got a clinical trial approved by the US government in 2007 but DID NOT COMPLETE IT. His claims (which clearly did not qualify the stringent requirements of the US government) are published in a paper: Role of uttarbasti in management of mutra marga sankoch (urethral stricture) – Rajendra H Amilkanthawar

Interestingly, he claims that his research has been uploaded on the US government website, which seems to be false:
The author is working as a assistant professor in the subject of Shalyatantra (Surgery in Ayurveda) from last twenty years in Govt. Ayurvedic Colleges in Maharashtra state. He has previously worked at Nagpur & Osmanabad and currently working at Govt. Ayurved College, Nanded in Maharashtra, India.
He is involved in the field of research since 1992. He is working in the field of urology applying the innovative techniques from Ayurveda – the traditional health science of India. With special interest in Urethral Stricture, he has treated over 1500 patients from India and abroad. He has got immense success with the procedure of Uttarbasti in the condition of urethral stricture. Over 95 % patients have been cured.
Research work was accepted by NISCAIR and published in Indian Journal of Traditional Knowledge (IPC Int.Cl7 : A61K35/78; A61K25/00; A61P13/02; A61P13/00.
The work has been conducted under the scheme of Research Fellowship for Teachers, sponsored by Maharashtra University of Health Science, Nashik. The work has been successfully completed and uploaded on clinical trials.gov, an official website of National Institute of Health of US. [Sanjeev: this claim is false, since no completed work has been uploaded]
Research work presented in MASICON surgeons’ conference and many national and international conferences. [Source]

A further case study:

Case report: “Management of urethral stricture with Uttara Basti”  by Dr. T.S. Dudhamal, Dr. S.K. Gupta, Prof. C. Bhuyan

This one takes a single case and is not robust. It also does not undertake longer term follow up.

Further:

A case study here that is very sketchy, refers to some ayurvedic medicines and has no formal documentation.

Further:

Pre and post procedural urethrography was carried out in all patients. Findings of urethrography revealed increase in the caliber of urethral lumen. Pre and post procedural urine flow rate was recorded. Pre procedural average urine flow rate was 30-50ml/10sec while after completion it improved up to 140-160ml/10sec. No post procedural complications, delayed complications and adverse effects were observed. [Source]

See this.

In this webpage, two self-declared auyurvedic doctors say that uttarbasti can reduce symptoms but won’t cure them. Plus Uttarbasti has HIGH RISK OF INFECTION.

Centres that claim to use this method to treat patients:

http://www.cureurethralstricture.com/uttarbasti.html

Most of the patients require ten sittings which are usually done on alternate days. 

Total duration of treatment is approximately 20 days.

Sunil Kahlekar

A doctor sunil kahalekar cured a patient who reported this on youtube.

This patient wrote a blog post on in which Sunil was cited.


His details.

INJECTING OILS OR OTHER THINGS INTO THE PENIS TIP

Uttarbasti involves injecting oil + honey into the urethtra through the penis tip.

Likewise here is a person who has injected hydrogen peroxide into his penis tip [You’ll need to find a 4 to cc syringe,…a plastic one preferred, so you can easily round off the sharp EDGE of it’s output,..so that when you insert it into your urethra/end of penis or in women the other part. You dilute the 3% Hydro to 1.5% via tap water. From that solution in a small cup, or premixed as 1.5%, in an old Hydrogen Peroxide container.
Draw into your syringe at least 2 CC’s of this 1.5%,…and after urinating inject this amount into your Urethra, up into and past the Prostate, or if  you figure the infection is below, in or above the rostate,..simply feel for what will be instant relief, as the 1.5% starts to bubble away at the infection. Hold the tip of the Syringe SEALED in the end of the Penis/womens part,.. and keep it sealed against the syringe tip, by clamping the end of the penis closed, clsing the emptied end of the syringe as the Urethra plug. Hold this dilute solution of Peroxide in your Urethra for 25 to 35 seconds,..and then removing the plug/syringe, as you will have a sensation of peeing, as part of the infection fluids and 1.5% hydrogen peroxide are expelled. Repeat this twice in the morning”

Further:

There is a claim made by someone (a patent) that a herbal mixture can cure strictures.

Homeopathic treatment

While on this subject, there seems to be some claims on the internet that homeopathy has reduced the need for dilation: https://hubpages.com/health/Homeopathy-Safe-Natural-Cure-For-Urethral-Strictures

  • but a couple of patients admitted it didn’t work; and finally had to undergo the plasty operation.

Aloe vera for urethral stricture

I’ve had superb results with aloe vera and have used it virtually everywhere – including for an anal fissure (which medicine could not cure). I have also applied aloe vera AND honey directly into my eye and it had only a positive effect (although in my case this was unnecessary since the cause was unrelated to the eyes: it had to do with cheek muscles).

Aloe Meatal Catheterhttp://hunterurology.com/products/5-aloe-meatal-catheter– Clearly someone has already got the idea of using aloe vera as a coating for urinary stricture.

Note that there is a medicine alprostadil that is inserted into the meatus: See this (including diagrams). This video shows how it is done.

Overall it is evident that if done safely and with elimination of bacterial contamination, insertion of a small object into the meatus is safe.

 

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Stem cell treatment for post-prostate cancer surgery incontinence – but note there are potential severe risks associated with it

This is an amazing advance in science – BUT THERE IS A RISK THAT STEM CELL THERAPY MIGHT MULTIPLY ANY RESIDUAL CANCER CELLS THAT ARE LEFT BEHIND AFTER SURGERY.

“Decades ago, researchers discovered that a particular type of stem cell — mesenchymal stem cells — in bone marrow could generate new bone, cartilage, and fat. In 2001 researchers discovered that mesenchymal cells are even more plentiful in body fat…. Injured and inflamed cells send out an SOS signal; new stem cells pick it up. “The stem cells are so smart, all you have to do is turn them loose,” he offers. “They float around to different areas of the body and fix them.”…you’ll find a significant number of unhappy people who’ve paid thousands of dollars at clinics and have not seen any results. ?” [Source]

“Stem cells are able to be derived from a number of sources: embryonic stems cells (ESCs) and mesenchymal stem cells (MSCs) , which include: placental or amniotic fluid stem cells (AFPSCs), muscle-derived stem cells (MDSC) , adipose-derived stem cells (ADSC) , bone-marrow-derived stem cells, and even urinary-derived stem cells (USC).” [Urinary Continence and Sexual Function After Robotic Radical Prostatectomy]

Human trials in stress urinary incontinence have been ongoing for a number of years. Carr et al. reported on a patient population of 38 women with stress urinary incontinence who underwent muscle-derived stem cell injections into the sphincter. The women were also offered a second injection 3 months later. Ninety percent of the treated women had over a 50 % decrease in pad weight and only 50 % reported leaks. Adverse events were essentially absent [ 38 ].

Gotoh treated 11 men with persistent stress urinary incontinence 1 year after prostate surgery and demonstrated a 60 % decrease in urinary leakage volume on pads weighed by the patients. One of the 11 achieved complete return of urinary control. Functional urethral leak and urethral closing pressures were also increased compared to pretreatment levels. No adverse events were reported [39 ].

Currently, there is a large multicenter ongoing trial phase 3 trial in the United States with muscle-derived stem cells in women with stress urinary incontinence and a phase 1, 2 trial using muscle-derived stem cell in postpros-tatectomy incontinence (ClinicalTrials.gov Identifier: NCT01893138 and NCT02291432).

Although stem cells derived from any source are not yet ready for clinical use in men with stress urinary incontinence after radical retropubic prostatectomy, the future appears to hold promise. Nonetheless, ethical and regulatory issues remain of concern and may present hurdles to widespread clinical adoption [40 ].

The early ethical concerns surrounding the use of fetal embryonic stem cells have by and large been resolved by the development of so many other sources for multipotent stem cells. Nonetheless, the recent classification of stem cells as a “drug” places them under the purview of the FDA and now regulatory hurdles may enhance or impede the science and usefulness of these agents.

Finally, the fears of the development of secondary cancers or causing early recurrences/failures of cancers if stems cells are released into the operative field to and in early functional recovery are very real. Well-structured trials need to be carried out to address these questions and the questions of which (if any) of the currently available products might be best used in men undergoing prostatectomy. Nonetheless, the future of stem cells use in our patients undergoing prostatectomy appears bright.  [Urinary Continence and Sexual Function After Robotic Radical Prostatectomy]

Stem cells have been found to fix this issue by regenerating relevant tissue – THIS DOCTOR DOES IT. (Michell Kaye).

Male Incontinence and Cell Surgical Network is using Stromal Vascular Fraction with adipose derived adult mesenchymal stem cells to treat post prostatectomy incontinence. The SVF and a small amount of condensed fat matrix is injected with a telescope directly into a deficient sphincter under local anesthetic. Based on experience from Nagoya University, Japan where Stromal Vascular Fraction has been used successfully for male incontinence, we believe that the external sphincter may be regenerated to some extent to provide bladder control. can provide access to the same technology through our investigatory protocol. [Source]

“In the past five years, the number of U.S. stem cell clinics has mushroomed from 25 to 570, according to a recent report published in the journal Cell Stem Cell…. the costly procedures are still unapproved by the FDA, leaving an open gate for medical charlatans and hucksters.” [Source – including analysis]

“the FDA warns that stem cells can migrate to the wrong site or turn into tumors.” [source]

CLINICAL TRIALS IN AUSTRALIA

http://www.stemcellsaustralia.edu.au/About-Stem-Cells/trials-in-australia.aspx

PAPERS/REPORTS

Stem Cell Injections Ease Incontinence (2007) [“Endoscopic injections of human umbilical cord blood stem cells may be a safe treatment option for women with stress urinary incontinence (SUI), according to findings presented here at the American Urological Association annual meeting.”]

Stem Cell Therapy for Incontinence: Where Are We Now? (2011) What is the Realistic Potential?
Charuspong Dissaranan, Michelle A. Cruz, Bruna M. Couri, Howard B. Goldman, and Margot S. Damaser [” the future of this therapy looks promising”]

Stem Cells Treatment for the Local Urinary Incontinence After a Radical Prostate Cancer Surgery (2012) – clinical trial.

Stem cell injection successfully treats urinary incontinence (2012) [“The procedure means that today, she can do her strenuous morning exercises of standing broad jumps and stride jumps without having to wear heavy pads to absorb leakage.”

Stem Cell Therapy for Male Urinary Incontinence – Giberti C. · Gallo F. · Schenone M. · Cortese P. · Ninotta G. [“Regarding animal studies, bone marrow-, muscle- and adipose-derived stem cells have been widely studied, showing regeneration of the urethral sphincter and recovery of the damaged pelvic nerves. With regard to human studies, only four papers are available in the literature using muscle- and adipose-derived stem cells which reported a significant improvement in sphincteric function and incontinence with no severe side effects.”]

Pilot Study of Adipose Stem Cells in the Treatment of Urinary Incontinence (2014) [“ASC injection is a viable treatment strategy for female urinary incontinence.”]

Stem Cells May Ease Urinary Incontinence, Study Says (2014) [The study is published online in the July issue of the journal Stem Cells Translational Medicine.]

The potential role of stem cells in the treatment of urinary incontinence (2015) Christine Tran and Margot S. Damas [“Early clinical trials using stem cells for the treatment of stress urinary incontinence in both male and female patients have also achieved promising functional results with minimal adverse effects.”]

Stem Cell Therapy for Treatment of Stress Urinary Incontinence: The Current Status and Challenges
(2016) Shukui Zhou,1 Kaile Zhang,1 Anthony Atala,2 Oula Khoury,2 Sean V. Murphy,2 Weixin Zhao,2 and Qiang Fu1[“stem cell transplantation as a therapy for SUI has great promise”]

VIDEOS

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Policy issues identified after my experience with prostate surgery

I’ll pursue these after I’m better:

  1. There needs to be an independent body that tracks progress of continence and erectile function of surgeons. [“The NHS – who make surgeons report their success rates these days – regard success after RP as using 1 pad or less per day by 12 months post-op.” – Source]

2. Patients need to be given a copy of the video after robotic prostate surgery. It is clear that doctors get a copy of their surgery video record: “I asked my doctor if he understands why some people have more severe incontinence problems and he said there is some correlation with age and fitness but that he’s reviewed the videos and records from his past surgeries and tried to correlate them with the outcomes but he still doesn’t understand the variations in outcome.” [Source]. This does imply, thought, that providing the video to an untrained patient might not do the patient any good. If even experts can’t use the videos to predict continence outcomes then it is unlikely that giving the videos to the patients will help.

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