Section 2. Mid-Urethral Sling Induced Sexual Dysfunction

From Leaking Urethra to Damaged Prostate

Most women who undergo a mid-urethral sling (MUS) placement will see an improve sexual function, but 1 in 11 women will suffer a decrease in sexual pleasure after the procedure.

Midurethal sling: Better sex for most women; but 1 in 11 suffers more?

One in 11 suffers more.

So, to better understand the reason for this unwanted result (of decreased sexual pleasure in 1 in 11 women who undergo MUS), Guadet et al. performed mid-urethral slings on cadavers and then sectioned the area to visualize the affected tissue. They reported their results in the Journal of Sexual Medicine in 2018 as follows:

“MUS placement interrupts tissue with glandular, vascular, and neuronal structures within the periurethral space adjacent to the anterior vaginal wall. Disruption of the prostatic glandular tissue and neurovascular structures may be a root cause of orgasmic dysfunction and diminished sexual satisfaction evident in women following MUS implantation.

Recovering Function (or Preventing Dysfunction) in Regards to MUS

Considering the previous description, to correct or prevent the problem, where would you inject a material which increases blood flow, grows nerves and collagen, improves the health of glandular tissue, and has never been reported to form a granuloma or neoplasia?

Also, consider that the material you will inject is aqueous, so it will hydrodissect along the tissue planes, taking the path of least resistance as if you were hydrodissecting with saline. This means you would not need multiple injections since you could use the pressure gradient generated by your syringe to spread the material.

Now, look at the following diagram, the same one we used to describe (in Section 1) what could be the best of the currently published options for the placement of the needle for the injection of PRP for the treatment of stress urinary incontinence (the O-Shot® procedure).

Then take another look at the photograph of the placement of the needle for the O-Shot® procedure:

Now you can see that our O-Shot® procedure is designed to repair exactly where these brilliant investigators documented that the neurovascular damage from a MUS occurs. (Application for further training in the O-Shot® procedure can be found at (click), this description does not constitute training or license to use the name “O-Shot,” which is protected by the US Patent & Trademark office for license to only those approved by the Cellular Medicine Association.

My Third Female-Ejaculation Experience, Which Leads to the O-Shot® Procedure

In 1984, while in medical school, one of our professors said to the class, “I do not want anyone to finish at this medical school and still think that female ejaculation is not a real phenomenon.”

Then, he showed us a video of a woman masturbating until she ejaculated.

Watching the video, I thought, “Looks like an interesting party trick; but of what practical benefit does that serve except the knowledge that the female body can ejaculate.”

Years later, a lover demonstrated to me that she could bring herself to masturbation with ejaculation. I still found the phenomenon interesting but not warranting much attention.

Then, it happened.

While I was making love to a woman, she unexpectedly ejaculated for the first time; and, unlike what I had witnessed with the previous two demonstrations (ejaculation while masturbating) when she ejaculated during our lovemaking, not only could I almost feel the deep, soul-shattering depth of her orgasm, but also her demeanor afterward reflected that of a man after ejaculation with calmness, satisfied bliss, and a wanting to connect with me emotionally like I had never witnessed with this woman—perhaps with any woman.

Finally, I took notice.

Up until then, the female orgasms that I had witnessed were associated with women showing varying degrees of pleasure during the orgasm, followed by increased energy and increased hunger for more sex and more orgasms. But, observing my third female ejaculation, the woman afterward showed calmness and peace and greatly decreased energy and complete satisfaction; more importantly, she seemed to drop invisible walls and swing open a wide path from her soul to mine.

I concede that my description of female ejaculation does not provide a scientific-objective explanation of what happened; but hopefully, you will forgive the description when you consider that when I find world-renowned experts in female sexuality and ask them to describe it to me in scientific-objective words, what happens when a woman experiences an orgasm of any kind, I can see their frustration as they give what we both know to be a relatively superficial answer to a profoundly important phenomenon.

So, since there is no good scientific explanation of the frequent orgasms of usual lovemaking (in comparison with a soul-shaking orgasm where the woman sobs, ejaculates and melts her soul into yours), I hope that you will pardon my use of a subjective description where no objective measure exists. Something happens to more easily facilitate a soul connection between a woman and her lover (and maybe even her GOD) when she experiences an ejaculatory orgasm.

After experiencing for the first time this phenomenon of female ejaculatory orgasm during lovemaking, I decided to pay more attention; I began reading all the popular books, the textbooks, and the research that I could find regarding female ejaculation. And, I began learning more about my lover (and subsequent lovers) about how to reproduce and enhance the experience of the female ejaculatory orgasm.

William Osler once told his medical students that if he asked them how long it takes for the fingernail to grow one length, most of them would not give it a second thought; some of them would read about it; and a few of them would grab a silver nitrate stick, make a mark on their proximal thumbnail with the stick, and then measure how long it took for the mark to grow to the end of the finger.

It was in the spirit of the third medical student described by Dr. Olser that I read the books and the research for the next ten-plus years and then took that reading to the bedroom. Over more than a decade, I developed my own ideas about female ejaculation. I even published an online course for men about how to help their female lover to a complete and profound ejaculatory orgasm and have helped thousands of couples with that course.

I tell you about my interest in female ejaculation for only one purpose: to show you that the study of female ejaculation combined with my work providing hormone replacement and menopausal care for over 3,000 women is what set the stage for me to design the O-Shot® procedure.

Then, in early 2010, I was first introduced to the idea of PRP and its possibilities for cosmetic use in the face. Because the stage was set, one of the ideas that occurred to me regarding PRP was to inject it near the distal urethra in the area of the Skene’s glands (female prostate) to see if it would enhance the female ejaculatory orgasm. During this time, I had already developed the P-Shot® and injected my own corpus cavernosi (penis) multiple times, so it seemed reasonable also to inject the female corpus cavernosi and periurethral area as well.

The best I can tell, I was the first to inject (2010) the female periurethral area with PRP.

First, I injected my lover; I had taught her to have an ejaculatory orgasm and wanted to see if things would improve. Afterward, her ejaculatory orgasms grew consistently higher on the Richter scale.

I thought maybe her results were just a placebo effect. Then, knowing that PRP has been shown in multiple studies to remodel scar tissue into a more healthy state, I injected a woman’s periurethral and clitoral area who had been physically abused by her x-husband—leaving her with severe dyspareunia and anorgasmia even after seeing multiple gynecologists.

So, she received the second O-Shot® procedure.

Afterward, not only did her dyspareunia resolve, but also she reported to me that she was able to start running again because her urinary incontinence went away.

I thought, “Why didn’t I think of that?!”

In the process of injecting in the area of the Skene’s glands (or female prostate), I had inadvertently chosen a place that would help urinary incontinence and improve the nerves associated with sexual function and micturition.

Since then, we (members of the Cellular Medicine Association) have found that injecting more proximal to the bladder does not affect the entire urethra as significantly with resultantly less improvement for both urinary incontinence and for sex.

So, my process of designing the place to put the PRP to improve ejaculatory orgasm inadvertently resulted in placing the PRP where it would best help those suffering from urinary incontinence or with sexual dysfunction after a sling.


  • Most women see an improvement in sexual function after a mid-urethral sling.
  • One in 11 women sees a decrease in sexual function after a sling.
  • Cadaver studies showed that the nerves, Skene’s glands, and blood flow disrupted by the placement of a MUS lie exactly where the PRP is placed when doing the O-Shot® procedure.
  • PRP is aqueous and therefore requires a minimum of injection points if the needle lumen is put into the proper tissue plane to affect best the tissue that needs repair.
  • Meticulous placement of the PRP for improvement of sex after MUS placement is critical to the success of the procedure.
  • Reading this report does not qualify anyone to do an O-Shot® procedure; many critical nuances are beyond the scope of this report.
  • Application for training in the O-Shot® procedure can be found at


  1. Jang HC, Jeon JH, Kim DY. Changes in Sexual Function after the Midurethral Sling Procedure for Stress Urinary Incontinence: Long-term Follow-up. Int Neurourol J. 2010;14(3):170. doi:10.5213/inj.2010.14.3.170
  2. Gaudet D, Clohosey DG, Hannan JL, et al. 249 Midurethral sling placement disrupts periurethral neurovascular and glandular structures near anterior vaginal wall: Potential role in female sexual dysfunction. The Journal of Sexual Medicine. 2018;15(7):S221-S222. doi:10.1016/j.jsxm.2018.04.214
  3. Runels C. A Pilot Study of the Effect of Localized Injections of Autologous Platelet Rich Plasma (PRP) for the Treatment of Female Sexual Dysfunction. J Women’s Health Care. 2014;03(04). doi:10.4172/2167-0420.1000169
  4. Gaudet D, Clohosey DG, Hannan JL, et al. 249 Midurethral sling placement disrupts periurethral neurovascular and glandular structures near anterior vaginal wall: Potential role in female sexual dysfunction. The Journal of Sexual Medicine. 2018;15(7):S221-S222. doi:10.1016/j.jsxm.2018.04.214
  5. Rodriguez FD, Camacho A, Bordes SJ, Gardner B, Levin RJ, Tubbs RS. Female ejaculation: An update on anatomy, history, and controversies. Clin Anat. 2021;34(1):103-107. doi:10.1002/ca.23654
  6. Pollen JJ, Dreilinger A. Immunohistochemical identification of prostatic acid phosphatase and prostate specific antigen in female periurethral glands.
    Urology. 1984;23(3):303-304. doi:10.1016/S0090-4295(84)90053-0
  7. Korda JB, Goldstein SW, Sommer F. SEXUAL MEDICINE HISTORY: The History of Female Ejaculation. The Journal of Sexual Medicine. 2010;7(5):1965-1975. doi:10.1111/j.1743-6109.2010.01720.x
  8. Tomalty D, Giovannetti O, Hannan J, et al. Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction. Sexual Medicine Reviews. 2022;0(0). doi:10.1016/j.sxmr.2021.12.002
  9. Dietrich W, Susani M, Stifter L, Haitel A. The Human Female Prostate—Immunohistochemical Study with Prostate‐Specific Antigen, Prostate‐Specific Alkaline Phosphatase, and Androgen Receptor and 3‐D Remodeling. The Journal of Sexual Medicine. 2011;8(10):2816-2821. doi:10.1111/j.1743-6109.2011.02408.x
  10. Zavia M. Ultrastructure of the normal adult human female prostate gland (Skene’s gland). :12.
  11. Alves R, Grimalt R. A Review of Platelet-Rich Plasma: History, Biology, Mechanism of Action, and Classification. Skin Appendage Disord. 2018;4(1):18-24. doi:10.1159/000477353
  12. Gawdat H, El-Hadidy YA, Allam RSHM, Abdelkader HA. Autologous platelet-rich plasma “fluid” versus “gel” form in combination with fractional CO2 laser in the treatment of atrophic acne scars: a split-face randomized clinical trial. Journal of Dermatological Treatment. 2022;0(ja):1-31. doi:10.1080/09546634.2022.2067816
  13. Charles-de-Sá L, Gontijo-de-Amorim NF, Takiya CM, et al. Effect of Use of Platelet-Rich Plasma (PRP) in Skin with Intrinsic Aging Process. Aesthet Surg J. 2018;38(3):321-328. doi:10.1093/asj/sjx137
  14. Eichler C, Üner J, Thangarajah F, et al. Platelet-rich plasma (PRP) in oncological patients: long-term oncological outcome analysis of the treatment of subcutaneous venous access device scars in 89 breast cancer patients. Arch Gynecol Obstet. Published online April 4, 2022. doi:10.1007/s00404-022-06416-4
  15. Number 5 SV 24. Platelet-Rich Plasma (PRP): Current Applications in Dermatology. Accessed August 26, 2021.
  16. Sánchez M, Anitua E, Delgado D, et al. Platelet-rich plasma, a source of autologous growth factors and biomimetic scaffold for peripheral nerve regeneration. Expert Opinion on Biological Therapy. 2017;17(2):197-212. doi:10.1080/14712598.2017.1259409

PRP for Improved Sexual Function. International Society for Cosmetogynecology

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Dr. Marco Pelosi III: Our next speaker is probably best described as the Michael Jordan of platelet rich plasma, Dr. Charles Runels from Alabama, that pioneered the O-Shot® [Orgasm Shot®], the Vampire [Face]lift®, the P-Shot® [Priapus Shot®], and he's taken all the abuse and he's given the world some very, very useful procedures for everyone. He's going to talk about the studies he did and the studies done in platelet rich plasma in regards to sexual function. Dr. Runels, it's a pleasure to have you here.

Dr. Runels: Thank you for having me.

I'm going to go through a whirlwind look at research that's been done where people have used PRP to help with sex. Much of the research has been done by the people in our group, and I've described many of them in this room who have done this research. It's a for-profit organization, but we pay for research, we pay for education, we pay for marketing for our providers. Just to echo what you just heard, sex is much more than about just having fun. Rainer Maria Rilke said it's just so correlated to the creative experience that it's affecting how we do our work, how you do your presentation, and how - of course - relationships and families.

I want to echo that sentiment, and remind us that back in 1980, if you look in 'Urology' - this was 'Urology' 1980 - the most common cause for erectile dysfunction was thought to be 85% psychogenic. Here's a quote from 'Urology' where urologists were encouraged to become counselors, because most of erectile dysfunction was thought to be psychogenic. Of course, I'm echoing the penis stuff because if you take a penis and shrink it and unzip it, that becomes a clitoris. I'm thinking most of the research will eventually apply to that. Certainly, our attitude is applying because we're back in the ... We're not, I'm preaching to the choir, but many of our colleagues are back in the 1980's and saying the main thing we have for sexuality for women is counseling.

My thinking that perhaps, as you guys do, some of the pathology that applies to the penis may apply to the clitoris, and maybe some of these women are suffering from actual genital histopathology, not just psychogenic problems. We have this one FDA approved drug now for female sexual dysfunction that's a psych drug, flibanserin. It's a useful drug, but obviously, we need much more and maybe we should think in terms of systems, like we do for the rest of the body.

Into play is platelet rich plasma. Obviously, this is not a new idea. This is from, this month, over 9,000 papers indexed in PubMed about platelet rich plasma. Our orthopedic colleagues, our dentist, our facial plastic surgeons have worked with this, and all we have to do is take their ideas and then hopefully people in this room will extend what I'm about to show you and just take those ideas and adapt them to the genital space. Here's some of the growth factors we know about. There are many more. They have these effects. These are good things for the genitalia. Down-regulating autoimmune response, proliferation of fibroblasts, new angiogenesis, the adipocytes enlarge and multiply - think labia majora, collagen production, neurogenesis and maybe some glandular function.

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There's never, in all those 9,000 papers, I still cannot find one serious side effect. No granulomas, no serious infection. PRP is what your body makes to heal when you do your surgeries and help prevent infection. Obviously, there are always certain things that can happen, bruising and such, but if you have a serious life-threatening complication from PRP, you will have the first recorded in all of that 9,000 plus papers. That's a nice thing.

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We have commercially available methods for preparing it, within 5 or 10 minutes of the bedside, and the devices are FDA approved. So you guys don't get confused, obviously the FDA does not approve your procedures. That's a doctor business. They don't approve blood that belongs to you, just like your spit and your saliva and your skin. They tried, at one time, to control eggs and the gynecologists said, "Hell no." So they don't control eggs and they don't control blood, but you should use an FDA approved device if you do this [approved for preparation of PRP to go back into the body].

Here's some of the ideas about down-regulating autoimmune response. We have split-scalp studies showing that PRP helps alopecia areata better than triamcinolone. More hair growth that comes in thicker. Here's rat studies looking at rheumatoid arthritis. What do we have in the genital space? We have lichens sclerosus. We did some before and after pictures where you use stem cells mixed with PRP, and before and after pictures show improvement. Of course, that's two variables because you have stem cells and you have the PRP.

We took the same idea and just used PRP. Andrew Goldstein worked with me on this, and we had two blinded dermatopathologists. The protocol was biopsy, PRP, wait six weeks later, another PRP injection, and then six weeks after that, another biopsy. Two blinded dermatopathologists out of George Washington University did not know the before or the after. We showed statistical improvement in both the histology and symptomatology. Here's our histology. You can see obviously, that's the same magnification and we're showing decreased hyperkeratosis. That's obviously healthier tissue. A layperson could tell that's better. Of course if you look at the gross pictures, lady on the left as you guys know, she has pain wearing her blue jeans. The lady on the right is back to making love to her husband. They've invited me into their close Facebook groups and I saw a post a few months ago. Quote says, "I was sitting next to my husband, whom I love, last night. I was afraid to hold his hand because I was afraid he would become aroused and I'm bleeding and hurting today." That's what you guys are helping.

We published that in 'Lower Genital Tract Disease'. We extended it because it worked. We published this past January in the journal of the American Academy of Dermatology. You have some science to go do this now.

One of our providers, Kathleen Posey, who's a gynecologist out of New Orleans, took this idea and then she said, "Let's do some dissection in the office", and she presented this in Argentina, published it in the same journal 'Lower Genital Tract Disease'. Here's one of her patients, where you can introduce [inaudible 00:06:44]. It had been 12 years since she had had sexual intercourse, penis and vagina intercourse, with her loving husband ... 12 years. She was being followed by a dermatologist on high dose clobetasol. Kathleen dissected it out in the office and then injected PRP ... 8 weeks later, she's having comfortable sex with her husband. She's now 3 years out. She's had to be treated with PRP, not repeat surgery ... PRP now, 2 other times a year apart to maintain that result. She now has a series of 60 or so patients that she's now going to publish with similar results, where she's dissecting out - as you guys know how to do - treating the [inaudible 00:07:27], but then following that with PRP injections to help the healing and decease the autoimmune response.

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That same doctor, Casabona, repeated his study with lichen sclerosus in men [BXO], and showed with just PRP alone ... This study of 45 men with repeat treatments ... It is cumulative, 2 to 10 treatments, the same thing. All of them stopped their steroids. None of them started back. Only one went on to have circumcision.

Peyronie's disease, another autoimmune disease ... This came out this month out of Wake Forest, where they took men and they followed their results with Peyronie's disease. Not only did their Peyronie's improve statistically, but they also improved their erectile dysfunction by 5 on that scale of 5 to 25 that the urologists use. For some reason, thankfully, they threw in one woman just for good measure, and showed that it helped her incontinence. They just tucked that in as an aftermath.

Ronald Virag, as you guys know as the legendary vascular surgeon who was first to present the idea of intracavernosal injections for erectile dysfunction, out of Paris. His big thing now is PRP for Peyronie's. He just published a study where he showed that this is comparing PRP with Xiapex, which is a $50,000 series of injections, FDA approved version of collagenase. He showed that PRP works better with few side effects. There's a risk of about 1 in 30, that actually go from a bent pencil to a fractured pencil and a limp noodle. You don't see that with PRP. You see the side effect is the erectile function improves. He showed the same thing, actually, in his studies that erectile dysfunction improves by an average of about 7 on that 5 to 25 point scale.

Let's think about the [inaudible 00:09:29] literature. Look at this, there's so much of this out there. This is looking at post-operative adhesions, lots of studies looking at scarring with microneedling and PRP. This is a split-face study comparing PRP with microneedling verus PRP ... Excuse me, microneedling with saline or Vitamin C serum and split-faced studies in PRP wins. Dr. Sclafani did some studies in the cosmetic space looking at increased collagen production and fibroblast activity, and never a neoplasia documented. People worry about that. This is not indiscriminate blindness blind growth. You don't worry about carcinogenesis when you do surgery and it's the same PRP that's causing healing. There's actually some helpful immune processes that go on, that you could argue actually might help prevent cancer. I'm not going to make that argument but it might need to be made one day.

If you look further, here's a wound healing study looking at reepithelialized exposed bone and tendon of the foot and ankle. When I took that and applied, this is a hypertrophic scar that was a year old from cortisone, and then using PRP and Juvederm or HA filler, this is a few days later, a month later, and that's a year later. Now, take that and think, "How could I use that in the genitourinary space?" Doing that anecdotally, we have many of the members of our group are seeing help with episiotomy scars or dyspareunia, pelvic foreplay instead of injecting that pelvic floor tenderness with triamcinolone. Physiatrist for the past ten years has been using PRP, your sports medicine doctors. Now, when you palpate it, consider injecting with PRP instead. Dyspareunia from mesh and that unknown dyspareunia, we're seeing this is where we need you guys to help extend the research. The science is there that it should help and it seems to be helping. Not 100%, but about 80% in people with dyspareunia.

Here is a look at a gentleman who did ... He took the mesh out and then he patched the hole with a gel form of PRP and showed benefit. We're finding anecdotally - no one's done this study yet, here's another one for you to pick up ... I'm giving you low hanging fruit. We're seeing anecdotally that if you inject in the distribution of the pudendal nerve, which seems to be inflamed in some women with mesh pain, that their pain will frequently go from 9 out of 10 down to 1 or 2 out of 10, without even taking the mesh out. Just another place where we need some research done.

Here, we have rat studies looking at inflammation. Let's think about this one. Here's a rat study where they modeled cystitis and we are seeing in chronic interstitial cystitis without even infiltrating the bladder, just infiltrating in the periurethral space, some of our women are getting better. I've had two separate urologists call me and say, "Charles, I can't believe it. I was doing this and expecting not this to happen. I have these patients now who have had chronic interstitial cystitis pain for years, and it's gone." Not 1005 but finding out who's going to respond and who's not and why, there's a lot of variables that need to be thought about that you guys will hopefully do the research.

Here's a study that came out in the 'Journal of Sexual Medicine', where a guy took ... the [inaudible 00:12:51] men who have an erection of 3 inches or less and then he treated them with PRP, combined with a pump, and showed that if you repeated it every time you did it, it grew by about 7 millimeters. I've always thought if I could give you a guarantee half an inch to an inch with anything, I'd get my picture on a postage stamp. I don't have that yet, but I can tell you that we're seeing about 60% of the time we do this procedure, men will see some sort of growth.

If you look at the neovascular space, there was a study out of Southern California that was published in the 'Journal of Sexual Medicine' where they transferred adipocyte stem cells to the penis of diabetic rats. They showed new endothelial cell growth and increased nitric oxide activity in the dorsal nerve. Would that be helpful in the clitoris? Probably, but the interesting thing is the adipocyte-derived stem cells were attacked and they died. The postulate was the improvement was from the growth factors.

I have seen what [inaudible 00:13:52] have seen in that when you inject this in the penis, erectile function goes up on the average of about 5 to 7 per injection. Think about nerve repair. We have rat studies modeling prostrate surgery, showing that the nerves improved with PRP and so we have, again, another clear place where we need studies if you add this now to the usual protocol for rehabilitating the penis post-prostate surgery ... would you see benefit? We have seen that in some of our patients who are a year or two out who failed the rehabilitation part of that. Would that help your patients who have, say, numbness and decreased function from riding their bikes too much, or trauma? I don't know, but it's worth thinking about and publishing research about.

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In thinking about where to put this, where we do our O-Shot, when we do PRP to the anterior vaginal wall, we're putting it as distal from the bladder as possible. We found that it works better. We're essentially making a liquid sling. Think infiltrating and getting ready to put in the mesh. That's what we're doing. Very simple, only we're using a material that has never caused a granuloma ever. Doing that, frequently our patients will have their incontinence go away that day from the actual liquid and as it's replaced with new tissue, it never recurs. Usually, you'll have to repeat the procedure at a year or two out depending on the etiology. Sometimes it lasts longer.

The interesting idea is what might be happening with those [inaudible 00:15:21]. They become more active, and does that help with sexual function? The other place we put it is in the actual corpus cavernosum of the clitoris. We use [inaudible 00:15:29] ultrasound visualization and see it flow down into the body of the clitoris by the pubic ramus and the wave form goes to what you see in a flaccid penis to what you see in an erect penis.

That's my time, almost done. Just 30 more seconds. Here's a pilot study we did where we showed that in women with female sexual distress, that it dropped by an average of 10 and female sexual function went up by 5 when you do what I just showed you. Here's a study that Dr. Neto, who may be here, published where he looked at incontinence and sexual function down in Brazil and showed that 94% of the people loved it. The question here is how would you combine it with your energy source? It works great in the face if you do laser and follow it with PRP ... better results, faster healing. Is it going to ... We need people to help us work out the algorithms. Not everybody has laxity, but when you have something, when do you use which treatment and when do you combine it with PRP? We need those answers, because I don't have them yet. This is possible helps.

I am done. Thank you very much for having me. I put all these references at that website, if you want to go download them. Thank you. You guys have a wonderful conference.

Dr. Marco Pelosi III: Thank you Charles. Beautiful

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