MOHD NAQIB MOHD SABRIMohamad Zulfadhli Bin Ahmad Sobri22024-03-30T21:38:002024-03-30T21:38:00PT9MLibreOffice/6.1.5.2$Linux_X86_64 LibreOffice_project/10$Build-216.00000falsefalsefalsefalse 0 0 0 0 true false false false false false false false true true true true true false true false false true true false 303044 true true false true false false true true true false true true false false 1 true false true true false true false false 0 0 false false true true false true false false true true false false true 303044 true true true false false high-resolution true true true true true true false true false true true false false true false 0 TIJ 2024 V4.N1 The Interventionalist Journal https://theinterventionalists.com 28 The Interventionalist Journal https://theinterventionalists.com 0 TIJ 2024 V4.N1 The Interventionalist Journal https://theinterventionalists.com 0 0 0 THE EFFICACY OF REZUM WATER VAPOR THERAPY AMONG MALAYSIAN MEN WITH LOWER URINARY TRACT SYMPTOMS ASSOCIATED WITH BENIGN PROSTATIC HYPERPLASIA F.Y. Lee1, K.A. Mohd Ghani1*, A. Nurdin2,3, C. L. K. Siang1, N. Ibrahim4, S. A. Muhamad Jamil4, A. Sabri1, A.H. Jasmani1, M.H. Mohd Rosli1, M.F. Md Ibrahim1 1Department of Urology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia2Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia3Laboratory of UPM-MAKNA Cancer Research (CANRES), Institute of Bioscience, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia4School of Mathematical Sciences, College of Computing, Informatics and Media, Universiti Teknologi MARA, Shah Alam, Selangor, Malaysia *Corresponding author: Khairul Asri Mohd Ghani, Department of Urology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia. Email: khairulasri@upm.edu.my DOI: https://doi.org/10.32896/tij.v4n1.9-20 Submitted: 16.02.2024 Accepted: 29.03.2024 Published: 31.03.2024 ABSTRACT: Purpose: This study investigates the efficacy and safety of Rezǔm water vapor in the management of Malaysian men with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). Material and methods: A total of 60 men with symptoms of moderate to severe BPH were enrolled in pilot studies at Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia. All patients were treated with transurethral delivery of water vapor. International Prostate Symptom Score (IPSS), quality of life (QoL), peak urinary flow (Qmax), postvoid residual, and International Index of Erectile Function (IIEF-5) were evaluated at 1 week and 1, 3, and 6-months post-treatment. Safety was also assessed. Results and discussion: The mean age of our study population was 64.57 ± 9.37 years old with mean prostate volume of 59.98 ± 22.06 cc. Our findings revealed statistically significant improvements throughout the 6 months of follow-up for IPSS score (17.45 ± 6.10 score to 7.53 ± 4.28), the QoL scores (3.52 ± 1.19 to 1.53 ± 0.70) and the urinary flow rate, Qmax (9.74 ± 3.39 mL/s to 17.40 ± 5.92 mL/s). There was no significant difference (p>0.05) was observed in sexual function (IIEF-5 scores) when compared to preoperatively. No adverse events (AEs) related to endoscopic instrumentations were observed. Two cases of urinary retention were classified as procedure-related AE.Conclusion: The Rezǔm water vapor therapy is safe and provides effective relief of symptoms and it should be considered as one of the treatment options in patients with LUTs associated with BPH especially for patients who are keen to preserve sexual function as part of the added benefit in this treatment modality. Keywords: Benign prostatic hyperplasia, lower urinary tract symptoms, water vapor therapy INTRODUCTION Recently, a total of 94.0 million men aged 40 years and older were diagnosed with benign prostatic hyperplasia (BPH) in 2019 with a 70.5% increment as compared to prevalence in the year 2000. BPH is a urological disease that is characterized by the benign enlargement of the prostate gland due to the unregulated proliferation of stromal and epithelial cells within the transitional zone of the prostate (1). These changes, along with the inflammation, fibrosis, and alteration in the smooth muscle function, lead to the obstruction of the urethra (2,3). Chronic obstruction of the bladder outflow associated with BPH leads to lower urinary tract symptoms (LUTs) such as voiding dysfunction and storage symptoms, and these greatly affect the quality of life of the patients. Long-term untreated BPH conditions will lead to other possible complications such as chronic urinary retention, haematuria, bladder dysfunction, bladder stones, and kidney damage (4,5). Medications such as 5-alpha-reductase inhibitors (5α-RIs) and phosphodiesterase-5 inhibitors are among the commonly prescribed drugs to reduce the tension on the urethra outflow and relax the muscle in the prostate. However, there is a growing concern that long-term use of these medications has neurocognitive implications that lead to an increased risk of diseases such as dementia and depression (6,7). Longer exposure to 5α-RIs such as finasteride also has been shown to increase the risk of persistent erectile dysfunction and is associated with worsening sexual function (8,9). In addition to drug intervention, a variety of promising surgical alternatives and minimally invasive therapies (MISTs) are currently available to treat BPH. Among them are transurethral resection of the prostate (TURP) and prostatic urethral lift (UroLift®). Despite the improvement in BPH treatment, TURP remained the gold standard in treating BPH surgically by removing a section of the prostate gland to release the blockage using a resectoscope inserted through the urethra. However, the TURP procedure was reported to be associated with a risk of perioperative bleeding requiring transfusion and complications which include urinary tract infection, erectile dysfunction, retrograde ejaculation, transurethral resection syndrome, urinary incontinence, and urethral stricture (10,11). Alternatively, UroLift® therapy is considered a minimally invasive approach for treating BPH by permanently placing a non-absorbable suture consisting of a nitinol capsular tab, urethral endpiece, and adjustable non-absorbable filament to mechanically lift and hold the enlarged prostate tissue which will allow the widening of the urethra and subsequently increase urinary outflow (12). A recent study revealed that the patients treated using UroLift® therapy significantly improved the International Prostate Symptoms Score (IPSS) and increased their quality of life (QoL) as compared with TURP, suggesting that UroLift® therapy is an effective treatment for BPH patients with or without obstructive median lobes (OMLs) (13). This procedure works for men with a small- to intermediate-size prostate without the presence of median lobe obstruction, but not for individuals with a larger-sized prostate (>100 mL) (14). Despite the effectiveness of this method in providing rapid and durable relief of LUTs and preserving sexual function, several complications have been reported such as an encrusted implant, migration of implant into the bladder, and up to 13.5% of the patients received retreatment with additional implant and TURP or laser ablation after 5 years follow-up (15). Due to the TURP- and UroLift®-related complications, clinicians have considered offering Rezǔm water vapor thermal therapy to men with LUTs associated with BPH for the benefit of improving their QoL. It is a MIST medical procedure that delivers sterile water vapor to the targeted transition zone of prostate tissue and disperses into the interstitial space of the prostate The condensation process of the water vapour within the transition zone releases the stored thermal energy and causes denaturation of the cell membrane which leads to a reduction in the volume of prostatic tissue, and subsequently improves the LUTs symptoms (15). Multiple clinical trial studies have suggested that Rezǔm is clinically effective in treating LUTs due to BPH with significant clinical improvement in IPSS, Qmax, and QOL while retaining their sexual functions (16-18). A recent randomized clinical trials study revealed that Rezǔm water vapour therapy significantly reduced the IPSS compared with UroLift® after 3 years of follow-up, suggesting that Rezǔm therapy provides a greater improvement in symptom relief (19). This technique, however, remains relatively novel in the local context as this treatment approach has never been used yet in Malaysia. All previous studies focused on the application of Rezǔm water vapor therapy among the Caucasian population. Hence, this study aims to evaluate the efficacy and safety of Rezǔm water vapor in the management of Malaysian men with LUTS associated with BPH. METHODOLOGY Study Protocol From July 2021 to December 2022, 60 patients with symptomatic benign prostatic hyperplasia (BPH) were enrolled in this study. The study was performed following the ethical approval obtained from the Ethics Committee for Research involving Human Subjects of University Putra Malaysia (JKEUPM) (JKEUPM-2022-286). This study was conducted at Urology Clinic, Hospital Sultan Abdul Aziz Shah (HSAAS), UPM, Serdang, Selangor, Malaysia. Patients were considered eligible for this study if they met the following criteria: aged over 40 years, clinically indicated for surgical intervention with moderate to severe international prostate symptom score (IPSS), intolerable pharmaceutical side effect, desire of the patient to avoid taking daily medication, prostate volume 30 g and above, failure of medical therapy to sufficiently ameliorate bothersome lower urinary tract symptoms (LUTs) and large median lobe causing benign prostatic obstruction (BPO). However, patients with the following criteria were excluded from this study: patients who have active urinary tract infection (UTI) by culture, evidence of bacterial prostatitis or symptoms of epididymitis, presence of penile implant or urinary sphincter implant, presence of urethral stricture or bladder neck contracture, any cognitive disorder that interferes with or precludes direct and accurate communication with the study investigator, neurogenic bladder or sphincter abnormalities and presence of prostate or bladder cancer. Patients who fulfilled the recruitment criteria and agreed to participate in this study were given a briefing about the study protocol by the investigator and the patient was then asked to sign the Informed Consent Form once they were agreeable. Patients will be informed that they are allowed to withdraw from this study at any point without obligation to explain the cause. During the outpatient review, the following tests were conducted: basic blood investigation for pre-operative assessment, urine FEME, urine culture and sensitivity, uroflowmetry and post-void residual volume (PVR), and flexible cystoscopy under local anaesthesia to assess the urethra, prostate, and bladder. Following that, patients were admitted at least a day before the procedure. On the day of admission, the patients were asked to answer a set of questionnaires. On the day of surgery, the patient underwent the procedure as per protocol with prophylactic antibiotics given during induction. The number of treatments required by the patient is based on the surgeon’s assessment intraoperatively. After completion of the procedure, a 16F Foley’s catheter was inserted and kept for 5-7 days up to the discretion of the surgeon. Two consultant urologists who had undergone training for the procedure performed the surgery. The duration of the surgery and any immediate post-operative complications were observed and documented. The patient was discharged on the following day with the following treatment: oral antibiotic for a week, oral analgesia (NSAID and paracetamol as needed), Foley’s catheter, BPH medications for 1 month until review, and the antiplatelet or anticoagulant will be resumed if the patient is on before the procedure. The patient will be reviewed during the catheter removal, at 1 month, 3 months, and 6 months to assess patient progress with uroflowmetry and the questionnaires as mentioned. Thermal treatment procedures The operative procedure for water vapor thermal therapy was performed as previously reported under general anesthesia (4). Water vapor thermal therapy uses the principles of convective heat transfer to the cell membrane of the targeted tissue in the prostate leading to instant cell death. This system comprises of radiofrequency generator with a single-use transurethral delivery device which was incorporated into a 4mm 30-degree cystoscopy lens. The radiofrequency current is then applied to an inductive coil heater producing thermal energy in the form of water vapor (steam). This water vapor was delivered through a retractable needle via emitter holes in the transurethral device that is injected into the transitional zone of the prostate which rapidly and uniformly disperses through the tissue interstices leading to cell necrosis and subsequently increases the luminal diameter of the urethra. Study clinical assessment For the primary outcome measures, the subjects were assessed for the mean improvement in the voiding symptoms using the standardized questionnaire of International Prostate Symptom Score (IPSS). The IPSS questionnaire consists of a total of seven questions related to BPH symptoms. The secondary outcome was also measured in this study by assessing the subject’s quality of life associated with voiding symptoms, erectile and ejaculatory functions using the IPSS-QoL score, and International Index of Erectile Function -5 (IIEF-5), respectively. The obtained IPSS-QoL score was categorised into seven categories which include delighted, pleased, mostly satisfied, mixed, mostly dissatisfied, unhappy, and terrible. The IIEF-5 questionnaire consists of five questions and the total scores were categorized into severe erectile dysfunction (1-7 scores), moderate erectile dysfunction (8-11 scores), mild-moderate erectile dysfunction (12-16 scores), mild erectile dysfunction (17-21 scores), and no erectile dysfunction (22-25 scores). The urine flow rate and post-void residual urine volume (PVR) were also assessed using the uroflowmetry and transabdominal sonography of the bladder, respectively. These outcomes were measured in the standardised protocol by the qualified and trained urologist before the procedure (baseline) and follow-up assessment at 1,3 and 6 months after the procedure. Statistical analysis The obtained data were analysed using Statistical Package for the Social Sciences (SPSS) version 27. A paired-t test was used to determine the significant difference between the baseline and follow-up assessments. The obtained data were presented as mean ± standard deviation (SD) with a p-value less than 0.05 was considered significant. RESULTS AND DISCUSSION This study was designed to evaluate the effectiveness of water vapor thermal therapy of the prostate among Malaysian men with lower urinary tract symptoms (LUTs) associated with benign prostatic hyperplasia (BPH). A total of 60 patients presented with BPH with a mean age of 64.57 ± 9.37 years old were enrolled in this study. The majority were Malay ethnicity (83.4%), Chinese (10%), and Indian (6.6%). The mean prostate volume of the patients evaluated was 59.98 ± 22.06 cc. Out of that, 10 patients had prostate volume of >80cc. The majority (83.30%) of them received general/regional anesthesia during the procedure. The results in this study demonstrate that the Rezum therapy is an effective treatment option for LUTs secondary to BPH. Our findings outline an improvement in the mean of urinary flow rate (Qmax) throughout the 6 months of follow-up after Rezǔm water vapor treatment from 9.74 ± 3.39 mL/s to 17.40 ± 5.92 mL/s (p<0.01) (Table 1), indicating that the urine flows increased from 70.92 ± 79.39 % to 86.04 ± 70.78 % and 95.72 ± 80.62 % after 1 month, 3 months and 6 months of follow-up, respectively. A significant improvement in Qmax was observed in patients after 3 months (p<0.022) and 6 months (p<0.009) of follow-up as compared with 1-month follow-up. However, no further significant improvement in Qmax was observed after 6 months (p=0.146) of follow-up as compared with 3 months of follow-up. Our findings also revealed a significant improvement in the IPSS score of the patients from 17.45 ± 6.10 score to 7.53 ± 4.28 score after 6 months of follow-up, indicating that the IPSS score was significantly improved from 27.94 ± 47.05% to 54.07 ± 27.25% after 6 months of follow up with a significant improvement was observed after 3 (p<0.008) and 6 (p<0.001) months of follow up as compared with 1 month follow up. A significant improvement in IPPS score was also observed after 6 months (p<0.001) of follow-up as compared with 3 months of follow-up (Table 1). In line with the IPSS score, the QoL scores significantly reduced from 3.52 ± 1.19 to 1.53 ± 0.70 after 6 months of follow-up, indicating that the QoL among the patients is significantly increased after being subjected to water vapor thermal therapy. At 6 months of follow-up, most of the patients (93.7%) are satisfied with their QoL after undergoing Rezum water vapor thermal therapy. (Figure 1). From our findings, 41.7% of the patients (n=25) were categorized as having good PVR values. Intervention with water vapor thermal therapy among these patients significantly reduced the PVR value from 123.40 ± 65.34 mL to 40.92 ± 71.37 mL after 6 months of follow-up as compared to the pre-operative value. However, no significant difference (p>0.05) was observed in the reduction of the PVR value in different months of follow-up. No significant difference (p>0.05) was observed in the IIEF-5 scores after 1, 3, and 6 months of follow-up as compared with pre-operative IIEF-5 scores (Table 1; Figure 2). The safety of the Rezum therapy was confirmed in this study. Two patients (3.3%) had failed trial of void at 1 week due to suspected urinary tract infection (UTI) and successful removal of catheter thereafter the infection was treated. There were 7 patients (11.7%) reported to have light hematuria post procedure, however not requiring bladder irrigation. Most of the adverse events reported were classified as Clavien Dindo Grade I. Majority of the patients reported to have irritative symptoms which includes urinary frequency, urgency, and dysuria, which were transient and self-limiting for 4-6 weeks. In our study appeared that the sexual function was not adversely affected by the treatment. This is an added benefit to individuals who had significant LUTs symptoms secondary to BPH and who want to have voiding symptom resolution and preserve sexual function. Rezum therapy is a minimally invasive procedure suitable for patients who are at high risk for general/regional anaesthesia and unsuitable for prolonged operative time. In this cohort of patients, we have a total of 10 patients (16.7%) who underwent this procedure under IV sedation. Most patients reported the maximal pain was during the delivery of steam into the prostatic tissue with a mean pain score reported 4. The procedure performed in this group of patients was uneventful. Based on the small number of our patients being performed under local anaesthesia suggest that it is reasonable to perform this procedure under local anaesthesia. It has been reported in the previous study that Rezum therapy can be done under IV sedation without local anaesthetic prostatic block as it has no significant effect on patient-reported pain (20). The minimally invasive nature of this procedure coupled with its favourable safety profile makes it an attractive alternative for individuals seeking relief from BPH-related symptoms. CONCLUSION In conclusion, the results of this study suggest that Rezum water vapor therapy represents a promising therapeutic option for men with lower urinary tract symptoms associated with BPH, offering a minimally invasive and effective approach to improving their quality of life. Continued research and long-term studies will be crucial in further establishing the role of Rezum therapy in the comprehensive management of benign prostatic hyperplasia. LIMITATIONS The sample size of our cohort was small, hence we were not able to draw a conclusion that represents Malaysian populations. This study also had a short follow-up period which is crucial in assessing the sustainability of treatment effects and any delayed adverse events. Given the specific demographic of Malaysian men, cultural and ethnic factors may influence treatment outcomes differently than in other populations. Acknowledging and addressing these limitations in future research can contribute to a more robust understanding of the efficacy of Rezum Water Vapor Therapy among Malaysian men with lower urinary tract symptoms associated with BPH. CONFLICTS OF INTEREST The authors have declared no conflicts of interest. FUNDING This study was supported by Boston Scientific Medical Device (Malaysia) Sdn. Bhd. REFERENCE Auffenberg GB, Helfand BT, McVary KT. Established medical therapy for benign prostatic hyperplasia. Urol Clin North Am. 2009 Nov;36(4):443-59, v-vi. doi: 10.1016/j.ucl.2009.07.004. PMID: 19942044. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol 2011; 185: 1793–803. Bushman W. Etiology, epidemiology, and natural history of benign prostatic hyperplasia. Urol Clin North Am 2009; 36: 403–15. Dixon C, Cedano ER, Pacik D, Vit V, Varga G, Wagrell L, Tornblom M, Mynderse L, Larson T. Efficacy and Safety of Rezūm System Water Vapor Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. Urology. 2015 Nov;86(5):1042-7. doi: 10.1016/j.urology.2015.05.046. Epub 2015 Jul 26. PMID: 26216644. Fusco F, Creta M, De Nunzio C, et al. Progressive bladder remodeling due to bladder outlet obstruction: a systematic review of morphological and molecular evidences in humans. BMC Urol 2018; 18: 15. Speakman MJ, Cheng X. Management of the complications of BPH/BOO. Indian J Urol. 2014 Apr;30(2):208-13. doi: 10.4103/0970-1591.127856. PMID: 24744522; PMCID: PMC3989825. Welk B, McArthur E, Ordon M, Morrow SA, Hayward J, Dixon S. The risk of dementia with the use of 5 alpha reductase inhibitors. J Neurol Sci. 2017 Aug 15;379:109-111. doi: 10.1016/j.jns.2017.05.064. Epub 2017 May 31. PMID: 28716218. Pietrzyk B, Olszanecka-Glinianowicz M, Owczarek A, Gabryelewicz T, Almgren-Rachtan Kiguradze T, Temps WH, Yarnold PR, Cashy J, Brannigan RE, Nardone B, Micali G, West DP, Belknap SM. Persistent erectile dysfunction in men exposed to the 5α-reductase inhibitors, finasteride, or dutasteride. PeerJ. 2017 Mar 9;5:e3020. doi: 10.7717/peerj.3020. PMID: 28289563; PMCID: PMC5346286. Fwu CW, Eggers PW, Kirkali Z, McVary KT, Burrows PK, Kusek JW. Change in sexual function in men with lower urinary tract symptoms/benign prostatic hyperplasia associated with long-term treatment with doxazosin, finasteride and combined therapy. J Urol. 2014 Jun;191(6):1828-34. doi: 10.1016/j.juro.2013.12.014. Epub 2013 Dec 14. PMID: 24342143. Reich O, Gratzke C, Bachmann A, Seitz M, Schlenker B, Hermanek P, Lack N, Stief CG; Urology Section of the Bavarian Working Group for Quality Assurance. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol. 2008 Jul;180(1):246-9. doi: 10.1016/j.juro.2008.03.058. Epub 2008 May 21. PMID: 18499179. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention. Eur Urol. 2006 Nov;50(5):969-79; discussion 980. doi: 10.1016/j.eururo.2005.12.042. Epub 2006 Jan 30. PMID: 16469429. Bardoli AD, Taylor WSJ, Mahmalji W. Can the UroLift prostatic implant device treat the symptoms of benign prostatic hypertrophy, avoid sexual dysfunction and reduce hospital TURP waiting times? A single centre, single surgeon experience and review of the literature. Aging Male. 2017 Sep;20(3):192-197. doi: 10.1080/13685538.2017.1336531. Epub 2017 Jun 13. PMID: 28609136. Eure G, Rukstalis D, Roehrborn C. Prostatic Urethral Lift for Obstructive Median Lobes: Consistent Results Across Controlled Trial and Real-World Settings. J Endourol. 2023 Jan;37(1):50-59. doi: 10.1089/end.2022.0324. Epub 2022 Sep 9. PMID: 35876440; PMCID: PMC9810349. Pushkaran A, Stainer V, Muir G, Shergill IS. Urolift - minimally invasive surgical BPH management. Expert Rev Med Devices. 2017 Mar;14(3):223-228. doi: 10.1080/17434440.2017.1296762. Epub 2017 Mar 8. PMID: 28270016. Roehrborn CG, Barkin J, Gange SN, Shore ND, Giddens JL, Bolton DM, Cowan BE, Cantwell AL, McVary KT, Te AE, Gholami SS, Moseley WG, Chin PT, Dowling WT, Freedman SJ, Incze PF, Coffield KS, Herron S, Rashid P, Rukstalis DB. Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol. 2017 Jun;24(3):8802-8813. PMID: 28646935. Dixon CM, Rijo Cedano E, Mynderse LA, Larson TR. Transurethral convective water vapor as a treatment for lower urinary tract symptomatology due to benign prostatic hyperplasia using the Rezūm(®) system: evaluation of acute ablative capabilities in the human prostate. Res Rep Urol. 2015 Jan 30;7:13-8. doi: 10.2147/RRU.S74040. PMID: 25674555; PMCID: PMC4321608. McVary KT, Gange SN, Gittelman MC, Goldberg KA, Patel K, Shore ND, Levin RM, Rousseau M, Beahrs JR, Kaminetsky J, Cowan BE, Cantrill CH, Mynderse LA, Ulchaker JC, Larson TR, Dixon CM, Roehrborn CG. Minimally Invasive Prostate Convective Water Vapor Energy Ablation: A Multicenter, Randomized, Controlled Study for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia. J Urol. 2016 May;195(5):1529-1538. doi: 10.1016/j.juro.2015.10.181. Epub 2015 Nov 22. PMID: 26614889. Mynderse LA, Hanson D, Robb RA, Pacik D, Vit V, Varga G, Wagrell L, Tornblom M, Cedano ER, Woodrum DA, Dixon CM, Larson TR. Rezūm System Water Vapor Treatment for Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: Validation of Convective Thermal Energy Transfer and Characterization With Magnetic Resonance Imaging and 3-Dimensional Renderings. Urology. 2015 Jul;86(1):122-7. doi: 10.1016/j.urology.2015.03.021. Epub 2015 May 16. PMID: 25987496. Elterman D, Shepherd S, Saadat SH, Alshak MN, Bhojani N, Zorn KC, Rijo E, Misrai V, Lajkosz K, Chughtai B. Prostatic urethral lift (UroLift) versus convective water vapor ablation (Rezum) for minimally invasive treatment of BPH: a comparison of improvements and durability in 3-year clinical outcomes. Can J Urol. 2021 Oct;28(5):10824-10833. PMID: 34657655. Leigh Gilpin, David Zekan, Bryce Baugh,Apexa Patel, Stacie A Deslich, Samuel Deem, Ryan Fitzwater, Joshua Lohri, James Tierney, Nathan E Hale. Evaluating the Efficacy of Employing Local Anesthetic Prostatic Blocks During Rezum Procedure. Cureus. 2022 Sep; 14(9): e29598. doi: 10.7759/cureus.29598. PMID: 36321018 TABLE LEGENDS: Table 1: Paired outcomes measures after Rezum water vapor thermal therapy through 6 months. Outcome measure Baseline 1 month 3 months 6 months Peak urinary flow rate (Qmax) Qmax (mL/s) ǂ 9.74 ± 3.39 15.09 ± 5.35 16.65 ± 5.36 17.40 ± 5.92 N (paired value) 60 60 60 60 P value 0.001 0.001 0.001 Number of patients with clinically significant improvement 52 (86.7%) 57 (95.0%) 56 (93.3%) Change (%) 70.92 ± 79.39 86.04 ± 70.78 95.72 ± 80.62 International Prostate Symptom Score (IPSS) IPSS score ǂǂ 17.45 ± 6.10 11.58 ± 6.90 9.40 ± 5.01 7.53 ± 4.28 N (paired value) 60 60 60 60 P value 0.001 0.001 0.001 Number of patients with clinically significant improvement 45 (86.7%) 57 (95.0%) 57 (95.0%) Change (%) - 27.94 ± 47.05 - 43.37 ± 28.84 - 54.07 ± 27.25 Quality of life (QoL) QoL score ǂǂ 3.52 ± 1.19 2.37 ± 1.21 1.83 ± 0.85 1.53 ± 0.70 N (paired value) 60 60 60 60 P value 0.001 0.001 0.001 Post Void Residual (PVR) PVR value ǂǂ 123.40 ± 65.34 38.68 ± 29.04 55.48 ± 67.53 40.92 ± 71.37 N (paired value) 25 25 25 25 P value 0.001 0.001 0.001 Number of patients with clinically significant improvement 21 (84.0%) 17 (68.0%) 20 (80.0%) Change (%) - 59.0 ± 43.21 - 50.47 ± 75.03 - 68.06 ± 38.10 International Index of Erectile Function-5 (IIEF-5 IIEF score ǂǂ 14.26 ± 4.98 14.47 ± 4.87 14.53 ± 4.98 14.68 ± 4.61 N (paired value) 53 53 53 53 Outcome measure Baseline 1 month 3 months 6 months Peak urinary flow rate (Qmax) Qmax (mL/s) ǂ 9.74 ± 3.39 15.09 ± 5.35 16.65 ± 5.36 17.40 ± 5.92 N (paired value) 60 60 60 60 P value 0.001 0.001 0.001 Number of patients with clinically significant improvement 52 (86.7%) 57 (95.0%) 56 (93.3%) Change (%) 70.92 ± 79.39 86.04 ± 70.78 95.72 ± 80.62 International Prostate Symptom Score (IPSS) IPSS score ǂǂ 17.45 ± 6.10 11.58 ± 6.90 9.40 ± 5.01 7.53 ± 4.28 N (paired value) 60 60 60 60 P value 0.001 0.001 0.001 Number of patients with clinically significant improvement 45 (86.7%) 57 (95.0%) 57 (95.0%) Change (%) - 27.94 ± 47.05 - 43.37 ± 28.84 - 54.07 ± 27.25 Quality of life (QoL) QoL score ǂǂ 3.52 ± 1.19 2.37 ± 1.21 1.83 ± 0.85 1.53 ± 0.70 N (paired value) 60 60 60 60 P value 0.001 0.001 0.001 Post Void Residual (PVR) PVR value ǂǂ 123.40 ± 65.34 38.68 ± 29.04 55.48 ± 67.53 40.92 ± 71.37 N (paired value) 25 25 25 25 P value 0.001 0.001 0.001 Number of patients with clinically significant improvement 21 (84.0%) 17 (68.0%) 20 (80.0%) Change (%) - 59.0 ± 43.21 - 50.47 ± 75.03 - 68.06 ± 38.10 International Index of Erectile Function-5 (IIEF-5) IIEF score ǂǂ 14.26 ± 4.98 14.47 ± 4.87 14.53 ± 4.98 14.68 ± 4.61 N (paired value) 53 53 53 53 P value 0.589 0.593 0.380 Values are presented as mean ± standard deviation (SD). The p-value is calculated based on the comparison of the value after follow-up with the value obtained from pre-operative or baseline. ǂ Increase indicates improvement. ǂǂ Decrease indicates improvement. % changes were calculated based on the following formula = [ (post-operative - pre-operative) ÷ pre-operative] x 100. The p-value is calculated based on the comparison of the value with the baseline. FIGURE LEGENDS: iVBORw0KGgoAAAANSUhEUgAABCAAAAI2CAMAAAC2bQnrAAAAAXNSR0IArs4c6QAAAARnQU1B AACxjwv8YQUAAAEyUExURQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAzzABmzDPMzDPM/1FRUWxsbKOjo9nZ2f9mmf+ZzP/M/0YF WisAAABadFJOUwAECAoOExUZGh0gISQoKywvNjc5Ojw+QkVHSUxNUFJUWFldYGFiZGhrbXN0 d3l8gIGDhIaHiImMjZCSlJiZnZ6foqarrq+ys7i7v8DFzM3S1dfa3+Hi5+70+c4WhlIAAAAJ cEhZcwAAFxEAABcRAcom8z8AAD5USURBVHhe7Z0Pe9vGla8JKmuXoaNEbRlFTtOoumXVOGnk jbpbrnOj1EmluLItVYm2FLH3b+/u9/8K95wzZ4DBAJSgAUgNiN/7PLYGwGAAEjgvBwNgZgAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAABi4yh1+ElnAgA2mvHchPzFFk0kh/N08QWn ykAQAPSPmYb8EaWTs/SAjCGuKAFBANA7htcm4m8e0cSM6xFkiVOzrArKqikAwMYzcWRAsuCp WbrYMTMqgCAA6A/J944LJqkIYmquN6qBIADoD+N5unjz5baZmGWCWH6NAUEA0B9IBswlKyI5 M1UHmlfdTMlAEAD0BttEmaYHBUFIk2UllFVTAIAe8OSQn4RY7IgtIAgAgMceKeIUggCrI03/ RxmcS11hPCcnoA0CrIxWBUEn4RI0A2ibKVcaZkYQejOjGhwEEAIE0W3k+WqqOpgHpcQT1eAg gBBaFsR/VIJzs3Wm6YlcTYzn5AQ8SQlWBQTRSbhdUtobJtIsOZWJ2S1XGBAECGKdgqCasJI9 A5gjby+bprZLryk+W1Ri9zxNF/s6IZTzJocn5o++EH285K3obsHvcl5uD3ZfyxeZnC2Wv81p oPyaAqA+661BsCLoLOa4fumfzGNzs44j3JeBLsqYqBOm6c3Pzrxbe37e4bl92lBDaHTuC6iL JIdvyY2vP8kml/cHYYAgQAjrFQRHP//MZTVkB72bXyUIe6NfGc+NICjrxdZxKhWEDC/v8Nr4 w3kh2s7qFxAECGFNgvizyWAFwe8f+hfMNrLLlxhe0I+uUyOIygeDinlJCZKX5ubNeJOSnHoA BAFCWJMgtMBMEBzGXpN7MbILFBZxGbUFIY8JEIUXoimLXqP0CAgChPBAgpBGNqlCjF6lqbS0 mcjmHBLgcpEt7JtFyYt08UxinLnY4pnEka7BBbIMCoKgCVNP0WeIaGVTkejfRQZ9PZoCoD4P JQiOc05N5oud0TVXJjSytZFxeE41jEQf/eFFX53RGvzLX6pB6BqUtyQIqjhI2nsYmf70rgoB QYAQHkoQ3AhB8Uwz6CddbuBrZOsf85NPi23Qpwcc5bRySRC6RnHKQKVIVkcQnEcvOHoFBAFC eGBBUMRKbOcvLZs/+YRTuaBwv58gyAumocPO1DxUhNmLHgFBgBAeVhD6y05xqw0NNpbzCUcQ JrzvIQhdPZ+ZC4L/9AoIAoTwsG0QHLgG1wn8J7vE4Ow6796CoKxGEF4bRDa/R9B3rCkA6vNQ giABkAHcaNa0/XOe3nAjpTwTUVBAiCB4czzTaAeCAKAmDyQI/kmnGOVots2F1gwa4AkFvH16 uKCAewiC0ioCWsjbUU9QEZy1V0AQIIQHEgQnNGIlhCcf28i2AT49FTcIBQUsEwQV5Qsia6Tk uWZzMk1FmHpMj4AgQAgPIwiuQEiISlvl9mB8kkV2JoPbBHE0fkazVRBc2A9be1ySJwiWhnEJ 5eXt6QvRuM0JQD3WKwgKaW5VGFFIm/5OOIQJjmx+3onCVv+Y+Wl69XLbzCOFmDoC+0BWGBzT X64QcKlp+qZQjIFMoLIovBBNK6g3+gN9Q5oCoD5rEoQMKm0CmXnzxbuyArH3Nk1FAlQxoNDW P07em0c6T5zBDRfn6SV5gasKBAvgYJ5eHfAaix27voHy2KT7QjQetQagHmsShGa4B7khmvzY 25e1CpA2souQ3kBfpKYAqE+sgpim3MowGIzOGwmCrkfKq+N1bwBqEqkg8k5dZnofIpCK3mHQ YQwAdYm1BjFLL/gd8Mef8eCTTdAu53I2o8u5ewNBgBCibYPYfcXNjVd5a2Yo2mltxmZ0Wntv IAgQQsuCWIZmAA8GDgIIAYLoCTgIIIRWBQHiBYIAIUAQPQGCACFAED0BggAhQBA9AYIAIUAQ PQGCACFAED0BggAhQBA9AYIAIbQqCDoJl6AZwIOBgwBCgCB6Ag4CCKFlQWgBHlpe3sXD1Xef aBcxQR0zyJrFVzKzNy5G5/J+d0/fuFgOfWOaAqA+6xTEYLBHkX2xNdilP5eP7KCaIXBvc64g 7Dubo3PtYKan72wuB4IAIaxJEH82GbibOO6shasAZticQEFQZcQVhHbxwHqwPVD1s9eH5UAQ IIQ1CUILtILgjmcXO60JQvuNSr7/hq89tAupXvYbtRwIAoTwcIJI91sTRN7zJHejr4Kg0jUF CAgChBBFDWL0Kk1fSxvC48O3tMR0RylXDCfvfCcXD1mOwe45rVoQBJVj+67maxerhT72Xb0c CAKE8DCC4DjOR+aczBc7o2vue3Iyv3yUzLTbeh7FIjmcc5TnObjucJA8/9YVRD76RUEQlBNV iAwIAoTwIILguxj0RwVBQU1C4EGvuGJxlF0+mGGwJpTOc3BS18wFQUaxJnAF0cfxs5YDQYAQ 1i8I5s3LD3SKBEFCkP+pgnAwX+xzYKsguOPahC4xnByU5Kg3g2wZSCtZz9euIIxLgCE7BgDc gwepQShGEKbawJGvkU0pezFhxsJycmiS05kgqJhlgshrGb0HggAhPLwg+H8DR/5g94fPVRAs gzS93HZzmFWKgiARLBNENh/Qt6cpAOoThyBEDczobLFDlxgmsJNjlkLheQmbhCDuCwQBQohD ELYxkWL6lNsgbGDv8qORp04OXGKEAkGAEB5eENzgKAE++ZjDXxopeZpbJwdciTh1cnCSXeEK gtZaJoh8W70HggAhRCAIEkJ6sz0Yn0h4n7IlJOBnbALKc+TksLc4WBBWCiwNRwpZmrLamgmA IEAQ6xUEv82Z/drL25wcwhTgbIBHYoz05tf0H2eS4TnH8qBUlkOSR4Pdb3la2yXYBDZJ4khP 1UCUtq4AEAQIYk2C+IkXc/QKJm75194YYu9tmr7kB6kn8/Rkiy4rRCLPt2n+4kTCPcsxGBzM 08ud6dXXn2ajdpJXpKogfmHM1QcetXahr0VTANRnTYLQDCsif1nLQS5OgAWCACFshCAS87p3 EbzuXQCCACFshCCotlCqQqDDmCIQBAhhMwSRdTmXgS7nPCAIEMKGCCLvtFZBp7UeEAQIYVME Ae4AggAhQBA9AYIAIbQsiGVoBvBg4CCAECCInoCDAEJoVRAgXiAIEAIE0RMgCBACBNETIAgQ AgTREyAIEAIE0RMgCBACBNETIAgQQquCoJNwCZoBPBg4CLHyRxMiHjoe/oOzTkFwz3FE1kuD diBzR7dP0q9MUM8O07T0whb3grvYr1hAyIa8V0DNKx48MujVASU6/IYHfTZNgbjgGKhAlz40 LQvif1WSlcdj7mXdNEgHUHkHdFVMWB7cM909BWHWo415603Tm5/JaBvVBR77gjAviarISBUd fkeUPoCmQFxURk3fBKEVJtMpnFYZJlcUwbd26jKec1Ze6X6CMOuVBUFzLraO0zdlcxjIBAVB mD4lpGah+93dXiZo/zUF4gKCoE+rBQ7/9gdKa1/Tx7+5QxCja3HJvQWh65UvMawAqi8xSoLQ jqpmJ1tUddD97mw/VRBErEAQriB+TlIwlxXjv75/uyD4lztEEHa9Mn4Nwcdbbrq6HP4zp7lQ FgTtTHXZsQNBxAoE4QpCmgAk3KdHHHQqCG48vPxEkvxjffLOd48oWpmLLRGEqeebiTyIbd7B 4PHhWzLPM5pn12P9yJZsJl6VZ0lRsgvc+Pja9ERFO7DYKQqC8mtdh+DROmSdrvaVTZ9ZUyAu IAhXEI9kEBwKseS7R7kg6Ld6my4MOALH84ut5JBHw+DFeQ2C2zf5wiCZ3WSdy+V5J/PLR4mO umXX08bNPJOtIdhWz8l8sTO6lvoMLTlInn9bEIQz3IYRhFQdKGcnqxAQRKxAEAVByO84hdjk VCJZBEEJimwTejNzqV8SBC+WWJ7l8ZnlNb/vNv6L6+UF2gy6wGxVFlOSdoTnO4JwBuySdYzL ujpeFwQRKxBEQRAcpRxix/sSyRJ1MloWL5CA5QG1eGBOL9BZArR8+BdzUcLkeQ/mCxnUs1IQ NpMnCJqS/0k7ZtOcNRcEbc+5BzuxE8Yl3QOCiBUIoigIjt/Fjk1xsGnAmvhmfyzkeSQv0HkJ xzInlTyvYDL46zmZKJkLQlsVaN6+Ju1yA+VyBDGTDASVnufpEBBErEAQRUHw73R6xHFuBaER TYKgiORgTVN+PskXhPxNvs+D1slL7P7weaUgnEwFQfD/hiO7hYIgqJhcEJPsuqIwu0PQ59QU iAsIwhMEiSC9eaWRXBLEgEf8l5QX6CZ+f17o3T7LOxidLXa0AH+9PFNJEFJsnnOpIIbX2WWF O7tL0FegKRAXEIQnCPlJt2KwlxgU0Vl48j1P+sUuCYJnyByHPO+pNUxpPZupLAitFtx1iZGc iR+G/0b/Uel5ng5B34CmQFxAEJ4gOA4lgjmSJfLoooPik2afmsZE/s2vEESxEZGyZXk5wqWR siwIp8CiILg0McDkY06yKwqCoDKtIGayl4ncP6HSZaprQBCx0klBVHH3C6g1BUEBKnGYCYIS JmApAmccqZTjSBYfjZ85giAD6G++IcvLWcUSVhDOenmBniCotPRmezCmixZK8gJerk4gzP4Q NFswOvH2oSvQ/msKxMXGCOLuXb5TEHspvzRNoScxdkDzF/L4pPOg1IxvSo75uSa5FKG//FyT icnkzP6mG7K8HPLpza+5PG3mzNfLC5S3NdkgWiAZwOSU5NFg91ueNi4iSAWSZpEIkpNsYbTR MWj/NQXiopOC0N10aSSIn3ixiTQKr/HfKUzt77LE295b7XFh8Hyb0osTueY/Ty9NW6U1xKRY u8/zTubpyRZdSIhAiutlmcQiFPR5gbzVl+YeyMGc1pleff3puzLJUH7OZLIzsg941Bq0CwTR 3qd1H4JYPeZlrSLmWqWDQBCxAkG08mnllQpucFwfdK1SuprA696gZSCIVj4tX/tze+I6KXcP gw5jQNtAEK0J4nmhiXINmC7nctDlHGgdCKKVT5u8yB5LWCOm09oMdFoLWgeCiOfT9hgIIlYg CAiiAe89/dM3X3/6gU6FA0HECgQBQYTy3iuKa8Prho6gIjQF4qJXgliGZgD3YfRCvz1Dsb30 vlABmgJxAUEQmgHcg73sEU5lIY+aBkLrawrERY8EAVpkj0L68sunHzxh3nv6OV9tNHiIE4KI FQgCBDChCkPxnmpCVYrw98QgiFiBIMD9GV6flh+5SGbhz3FCELECQYD7M6185SM5C77IgCBi BYIA9yb5XfUti9HvQx/lhCBiBYIAD8sRySFDeuYAEdEjQeg5WIEs1q6Zslqydhmzz6m7XoKS bluKV+D6nsTjY1rE3b50+EWJ1QJBRA0EQWgGHmAz61BBeniSF7A4+u+8uOb+4lxB6JuW2uHT zXaXX7VcLRBE1PRKEP+zkqzDW9Prm96rm1xRbNtOa+8WBNU3XEFozwzj19sDHrWX+4PrbmcN t/P4Sd4PXjD0FWkKxAUEQYLQdYd/+4OJZeb4N1YQNS4xfEHY3p6e8yzuppYL7Wx3T7eQ8BWU O8BgIBBErEAQriB+Tqe76ddh/Nf3M0HUoSiIQn+RLAjWBVVQwp8kihPpoptpqj4qQlMgLiAI VxA/4xNeLiem0r00n/fSjHCkbZi28/rB6FWa0vUDs3tOcwqCIBVoPYQZzxfPJNHVLqeXow25 RPATEAYqQVMgLiAIVxCPWAMcxcl3j6wgZKAKOv+5CZMWjedf0czJfLEzupbKBgXJQfL8W1cQ VEoWMI8P5zz0BUM5N6sKkZxdfvGUOXzbsAoBQcQKBFEQhLRTUhRPzNh6ctrzPI53lsfp4Jhj nJZRFUFG2KEk5eI8uSCyUa+0/pEuZJIKcCoWXUabJc1QZMVUGNkxAJEBQRQEIZVmimLSQEkQ HPeLz+XpBspFc6Z8sUFJjnpalgmCrsxNQwaTUA1CGzaMSzaA4Y/m1e7h9cuP5HXOpy9Qg9hQ IIiiIFgLix2bKgqC54gFuG1OBJHua5LTmSBohVwQlJvvc3IeWj+vZXQZ+tAyuBhrUZEvKBwq QVMgLiCIoiDknD/iMbLKgpAqBEc+zzEc2YWuIGhNVxDiE65l+PO7S3LMwwc6X0TTh8CoCE2B uIAgPEFIM+UrOvsrBMEpnpXPyZK3CcI2Wm6OIOSzcGNtYvqdeyn1iQZkxwBEBgThCYJ/7sUC FYLgWdz8yHO0ubHGJYasp02bm3GJwZAa5GHy5MOnHzTVAwQRLxCEJwgOdRvOviCOP6Ukz7PX GpOPOcmucAVB0jCCGM8Xn/DfiVlGJUqBG8LevFE3lAUgiFiBIHxBkA9sOHuCOD4Se1BarkO2 BzwaJyU5OwsiqzWQNOS+Jud+uT0YXW/abU7D6Lz5tYUCQcQKBEGC0HcI91L5RZTHGwaDAzpp pQLAD0rRnOSYqgXDc5pLubgpU+sMlDwa7H7L06aeISaQJHuE0QsO8oWIYmNIPmurUYW+JE2B uIAgSBCy2EQzRfD473TS84+/sM81CTKEzPgtuYKg6N97a7p5IA7m6eXO9OrrT7O3GqnOYaoK nCt9Y19l2rxHrbmaZW54NoS+Jk2BuIAgrCDapPCyloW0YasYmwPf8DSebAQEESsQxCoEkejr 3gU26nXvx4dv3rz5gutMrbRVQhCxAkGsQhBUWyhVITaqwxgdV0vUMDpvbj4IIlYgiJUIwnY5 l7NRXc7Z1tfsbo25nRsOlaQpEBcQxGoEYTutzdikTmv56TC6wnjzxt63HZ83rB1BELECQaxI EJvM8Ed7c3P870YMyZcQxGYCQUAQ96YsiKZAELECQUAQ94afJddLjJZuzEAQsQJBQBD3x2uk bA6VpCkQF70SxDI0A6iN3uZs7ckvHIRYgSAIzQDqkxy+0gelWgEHIVZ6JAgQLxBErEAQIAIg iFiBIMC9ST6svneRfBR6TwOCiBUIAtyfWXXj5DS4PxwIIlYgCIveustOfe0R4o77eNJbxC1t +bJcnkOuMwSwQ0X23fM0XexXl5NvJ8N92HtKn6PFh73H86oXOPfCe4+hndcUiAsIIocH18ue /OGO5u7oL2nC8tCB+ZZzbAKXI7jeTUFTbDn7NL2RsUOXlKPbyXBfFyP57bf6uti03E/M6EXN z1cFfShNgbjokSAktirRDOIEW2WYXFGI3vqc4HjOWXmlWwODaiL3EoQptpyd5lxsHadvlpWj 27G4b5dzYVRoiy+c82BArz99olODwZPfUe0m+AIDgogXCIL4s8kw/NsfaEJP8+Pf3CGIkRnN v64g6G+tH3Attpz9rnKKgnC7rBHx8VSLXdYkVGERrt5wt3pMk77naHVNgbjolSD+XyXZyTn8 289JCuayYvzX928XhP4q1xdEPWyxZe4qp7jc6fQu+f7LfF+ryw7hgAp1aNatFBWgKRAXEIQr CLnGl3CfHnGoqiC4dfDSdIkyouTJO989onBkLrZEEJzXTjhRSustdkzgSg4u2RaQJwaPD+lH ePGM17DFsp0K2blknpWVMxi9olq+aWVwtqNQ9qzCfywriRla7Tb3sa1EEIuGXddSEZoCcQFB uIJ4xLcyOIaS7x7lgqBf422q+XNYjucXW8nhXCM+r0Fw+ybX/JPZTd6RFIXsQfL8W1OiNmZm BeQlTeaXj/iaXiLaFutnl9Kccmitxc7oWqo7he0Y6HOIRYjpSVYo52yvCkHs/kle6vz6I50O pi+C+CN90DJ6ifvQVO8cBEHfgclAgpAfaoqhyalElQiCEhS7JrbMmBkTisSiIHixBOssD0DK Qevzcg5czZcVkCW4eyYZkUfC2ys2357NoQvMTsni4nYMdugeWvevW1mh7A0uLz6yY7DhcMBV oEsfGN0ZH40wl/4KgsOQY+h4X6JKBCEj4/ACicj0YpvrF34kc5jT8uFf8qq2WYNXKQhCC8hL Opgv9jl0qwVhc3mCoCn5n6xU3I7AHTaYO7Tj1zQvEwQlTKUoNrJjsOFEHW6tRtt6WL8gOJYW OzbF0aQRaSKYgjFdyANHXiTzEg5WThpMzaAisE0BeUmCWb1UrJOrUI4WTvP2ve0IlMkIYsjj lGeFciLLExXZMdhwIIh2Wb8g+Ic4PeI4t4LQ6CJBUMxxNKYyVIwXyeZv8r353WbsgkJg5wXk JRG7P3xeLQgnV6Ec/t9w5G1HoFKMIGivLbwwmx8btH+a2mwgiHZ5AEFwSN3w7y6HakkQA3P/ n1JeJJsA/bnTk7UXuHYyKyBLDEZnix0tvlRsnqskCNlqaTtCJgIIIi4giHZ5AEHIb7YVg73E oJDN4o/vedJFf0kQPEPmKFyQE7h5SGsBbkmn1j/lYrPsJUFwEYS3HYEWLxNElicqaP80tdlA EO3yAILgQJMQ5VBlQfBFBwUgzT41rYX8o14hiEIrIUPTHMOFwM4K+CEriQNcGikrBOFsr1gO Fy75Jx972xGoTLemYAvlhHyk6IAgIgCCUCN4eIKgCJRAywRBCRORFGMzDkXKcSSLj8bPbMAS FOP6o26gaS6IA5eC1Qa2LSBLcEFiiUwQTrH59jxBcNXgZnswpmua4nYMZm8tXKhM+rsYDRBE BEAQagSP7OTcS+VxYfPsweCA5psR5ZwHpWZ813HMDy5xSHNg8oNLJuiSM/dXm6AoPRrsfkv5 6K/mywrIEhzx6c2veWu0uldsvj15W5My2O1R4Santx0DmcAmiUwQJBHHGxFBu66pzQaCaJc1 CeInXsy/yRI/479THFIoGTig9t6m6ZXI4/k2pc1zxcPz9NK0VVpDTPzq+8Gcskyvvv703Sxf VkBe0mSenmzRdYTRS7HYLJdohKI+3x7v1EtzE8TZjkLZzT4JmSBafdSa2D3nApPnDUfmhCCi AIJQI3i09mmdhyAeHOdlrRxzrdIebFHZzHHTYiGICIAg1AgebXxaeWeCWxRjgS5VyhcTLb7u zUidSwRh+rBoAAQRARCEGsGjjU/LF/fcYBgPFb3DtNhhDJOcLb54+isZnHN47VzQhABBRAAE oUbwaEsQz4tNlA+N2+Wc0GaXc4wM4Wvu/Jhm1Aa0J4io35eEIFqmM4JIXhQePIgCt9NapsVO awVxg324LBpBGCGU0KUPDQTRLp0RRB9Jzi62RRD8rGfDxo32QrhyiOaITmg9X11i2TsIQo3g Ec2n7RqTNL16m5ouKaNpg4AggoEg1Age0XzariEPdRmaXl9REZpqCgQRDAShRvCI5tN2Cbmi yAzRuP2FytBUUyCIYCAINYJHNJ+2O4zl9RRi9xWF9lXz1k8IIgIgCDWCRzSftjvM9AGp1oAg IgCCUCN4RPNpOwO/GNLua+MQRARAEMvQDKAmwx9/+/RdfUbK4KZDaO8gQBDBQBDL0AygJsMf f/nkyZP3/vYB/W/4LKIHpVQKLhGd0Hq+usSyd30XBGgN0xmFCwRRCwiiXSCIODF9Z7hAELWA INplnbtsu4hZ7EgjXKFLJka6ammtOwXzooTp/oVb/Np+UWLFlKoQEEQtIIh2We8uS/8n5g3I 8fVpKWDtqJhtoK9a2jg7av1VyxWTHKra0isenLNxZ9lUkKaaAkEE03dBmBO6Cs3Av+f27t1x +dlArle0JAjtmcHUVMzPb8udNawB987FWLqFCCc/CE2BIIKBIJahvQWsTRC2u6eJ+4pTy909 rZ7hD7kU3HQIdBA01RQIIhgI4j8ryU7OtQlCO4x0B+qT4hv229ZhIIgIgCDUCB5LBSFNiEfJ C/WCCIJ7hnkmOR4fvk1N2uQ7rpqSCSqU180uIWhCqg60cPHmy6zbp7a7nF4neFCqHhBEuzxw DYKbJf+V/hlDcJB/Je8v8i/9ZH75KJmZjhA43+JgsFcxtUtlcvNjMtPmT8IOWqH3TWzPcNxt nUnFz4cf0Uf68GnGi4Zuo69BU02BIIKBINQIHtnJWRIEK4EqDSQFni1TBzrFf444pjkyeAnJ gOdRiBenKIu8DD3Lg5+0whNSniBDbrA32C9dQMSY7z8BQdQCgmiXCARBMygcrCDol1+nDuYL GVHTCoLrBKZCUZxiT/DMv2jBMifrP+GJ3C40k7R5u/XI4U+oQ4JZIIhaQBDtEoEgKNSdekI+ JWj1wCqBJmn94pTmcQbVoeWZIIg92qrUHGjzDcNsXbD0TLtKBgRRCwiiXeIWxO4Pn5cEQYuK U2bSvWFBm3EFkYnBnx8x4znt6fB68fobw6t4ur2HIIKBINQIHoGCGJ0tdugS405ByN+fOz3Q l0Sgdz07JAhBxsVQ8KBUPSCIdnkwQZhh9G4TBGU+5TYITxDlSwwp1r0/QcuLIuBx++SPEUVX SH6hMiXcdAgQRARAEGoEj+zk5EtrDVHTpniLIMw9Ck8QVY2UJuFGftZIOU1lmHAyA2dnQdj6 S4dIfvGkhZ2GICIAglAjeOQnJ8W+/rYfyy/+LYLgasEpW8IKQm9Y0HrFKcK/f0nCsLc5xQgT ow8/W0fgfmsXb142swQEEQEQhBrBIz85E37+8ZPB4PEL+UmXR54oZrUGwFMndoqjO735Nf1H huCJxVdb+qBUcYpIzlQ7CplAyqeS+Cmp3dfmSSkyj3Mh0iH4azOOCwaCiAAIQo3gkaY/aQ7t xn3x0kSsNB6kpxzHpIHi1GAypwsECg1bgzjam+tD2MUpZlK8dKAMoo5EHtZ+TUYSOvyo9SR6 QVTxACP6QhDtsiZBaIZgRAma9qcY5yEIQW9bFKHVvGwdYtpFQTzAWQ5BtEv3BcF3KMwtEYdE X/cu0LnXvV2iv82pQxy4PMRZDkG0S/cFwQ0L4+Iw/ERF7zDd6zDGJfq3OVUKLg9xlkMQ7dIR QWhjplKYYkE8LzRRCtrlXE7HupzzgSDqAUG0SzcEYZov7VVDcYr7jyj7gRsoi9WKTnVam/yL v7MQRD0giHbpSA2ib5R1AEHUA4JoFwgiSty3MAxopKwHBNEuEESUDK/TBfd2nxH/g1IqBZeH OO4QRLtAEFHC92k8IIhaQBDtAkFECQQRCgTRLhBElEAQoUAQ7dKyIJahGUBNSBDa+GCBIOoB QbQLBBEluIsRCgTRLh3c5T6A5yBCgSDaBYKIknIHc9F3OadScIEgPCAIECsQRARAELei71Ao lS9QGKY8lp7kdl7qXj7lkb+EkfyOe4vv1EsYK4O+ME01BYIIpu+CoJNwCbJ4/Pdnpkfqm0eD 5LPlguDwp+jnnLkEilP8PucSQWSvcXI/bVckh46/xtkS9iA0B4IIBoJYhvQ9NuYe4lQQg8FB E0EUp1yyXh+olIUZkrPbHUEsY/SK/Gc+oPnKmOU94tBCTTUFgggGgvivStyTMxPELcglxq1K WCqIrCspCplstO9OdyW1hKkIgfv4ZaQfT6Jamgwt1FRTIIhgIAg1god7ctYRhCFIELYzSsqQ X8PQRPd6s75dabbKYD4Yfx3MLV8sLdVUUyCIYCAINYKHe3Lyueycx1xR5k7peYwL+p0fny/2 5dyn6BcJ7J6nC2lkrJhy11dovulqin5S8x6oOtidNX0JlQK0zE64cYW+KPmUE+ezLgGCiAAI Qo3gsVwQk/liZ3Qtv/UU0hfvkxvIEib6OeflJwNnLIziFAeQs75gB8Tg5U6loXsDYtC3cZvT hv/M/7NK+dtwBy5eBgQRARCEGsFjqSDoDKcTfCZnOYXE5dfvnJEgNPr1jzOaVmnKXV+gQsQE ZITF9/TPjLzH3siydAL+fHe3m/CXwT6kr2Hx5stiF5w+EEQEQBBqBI+lgqA4phN8Ks0FFNsU 3JP5gY1+/cMLKFYqp9z1GYoYk2TbPEpMXoIiqFvNlMMff/v03cLj1VWPWqst+WtgvF56i9By TTUFgggGglAjeLgnpysI/QU0FwAUzTrfEwQtpgVVU4X1GZotguAFVGWw67AgMil1guGPv3zy 5Ml7f/uA/jd8VvEB6POx9/hjGuxdzwpoqaaaAkEEA0GoETzck5PPZnuu52c2hXH2c2/jWv/c IojC+gzXtVkQmpk9IWXa+d2Bvg2PCkFM8k/15JCbdqs+5JFZ3ZAPgRgOBBEMBKFG8KAzU3OU BaGhHSyIbH3GikCrFlmZ3RPExAS0Q4UgZoVPv6dNlh4QBATRgAcXhNu+uFQQtKBqqrA+QzOM CKgwXuAIoiK+ooZ2vUj5A0w8H1R/SggCgmjAgwqCo0ACevLxLYKgBcum3PUZqjkYQdAPMBdG yyWGKHS07M6QyDUDc8UdSlXE/vDa/0yVQxYrVJCmmgJBBANBqBE83JOzIAiuSN9sD2RozUpB UHhT0HP+8hRlcdcXqBBpr1RTzHJfFH9su4F756LUo1RyJl/X8N/MJMPjGGuyBAQRARCEGsHD PTn3aEJfoiIooAkRBiX1rUsdepMlQPF9YIK8OGVH53TWF8gEXM3QOgP9Z25v0HWJ3ufoFMMf cim4aWEmMkhm9MGmqXneYzw3H74K+po01RQIIhgIQo3gkV/7UsgK5oed2Hubpi/to9YmjE2e 08Hwxy/ee0FZeTEFiDtls+TrK6QRrSokx5THPoTdvUet74ScJ9A3ye4UW0xu+ZSUVVNNgSCC gSDUCB5r/LSVl+EUQct/WmNn9PTp09yAFr64Evjjcj3qcnuw67yUUoKyaKopEEQwEIQawWON n5ZqIuWLiQ6/7r3LL2RRPcF7BMrWxEw1KjmketTi9SdmWTWUVVNNgSCCgSDUCB7r/LQVvcN0 uMMYeyFhm1bCoSI01RQIIhgIQo3gsdZPm3U5Z+lwl3N5RSFvtQmEitBUUyCIYCAINYLHej9t 3mmtocOd1s7SxXffMK/ktdUmQBARAEGoETyi+bQdIznLLyymDZtRIIgIgCDUCB7RfNqOcdfr 3vcBgogACEKN4BHNp+0Y7gidGJuzHhBEu0AQEZOcXX765Amnnuye4xKjFkvO3SpkLIa1AkGo ETwgiEDyu5yN73NSCZpqysYIYv17B0GoETyi+bRdQx9AZ5o+6kVFaKopnRSE7qbLA+wdBLEM zQDuSWaIxo+CUhmaagoEEQwEsQzNAO7N7iv6+m5/iroW7R0ECCKYvgsCxAsE4QNB1AGC6AkQ hA8EUQcIoidAED4QRB0giJ4AQfhAEHWAIHoCBOEDQdQBgugJEIQPBFEHCKInQBA+EEQdIIie AEH4QBB1gCB6AgThA0HUAYLoCRsoiD/SZ6pAz1cXCCIYCCJi3P4gmkKRo6mmRCMI44MSer66 QBDBQBARM7z2u7sPhyJHU02JSBB6vrpAEO0CQUTM8Pry/OqgnS53IQgfCKIOEETEcD+UyfHc GVowHAjCB4KoAwQRP7vnl3jduwIIYg1AEPEzepWmi6aDe0AQPhBEHSCI2NHROdP09Qc6Jwgq QFNNgSCCgSBAmwx/3Mn0cPnJe6+aVCOoCE01BYIIBoIAbTK8NnKg2oO0U47OwkcZpUI01RQI IhgIArSJFUR2G2N4Hdx5LQThA0HUAYKIGCOIk3d1cnCcpjehVQgIwgeCqAMEETEkiMVJXmVg X0AQORDEGoAgImZ4fek+I8WDZASPrwVB+EAQdYAgIsZ/WSv5MPyZSgjCB4KoAwTREyAIn8gF UcX6hxuGIGKG38UwJMcNx+6FIEp0UBAPEIIQRMTkghgMrzG6t89mC0L30gWCAJbkw6dPn/7q 75/S/8JnTYfvhSB8IIg6QBCRcjCXOmVO8A1OA5WgqaZAEMFAEKA1Rtlz1gbUIHwgiDUAQUTL 0L6nZdjX2YFQCZpqCgQRDAQBWmR4nV69URr3KgVB+EAQdYAgImb8783aHVwgCB8Iog4QRMx8 2KzdwQWC8IEg6gBBdATnmYggIAgfCKIOEESkfPiRPgyhvMBtTh8IYg1AEHEyS9NTeb87A4Lw gSDWAAQRJabrBwjiViCINQBBRAl3/XCx1X1BVNHaK4kQxBqAIOJkPF/sUD1i8fobw6v5xgii tfMIglgDEETEuB3GNH0mor3AvI8g/rMMBOEBQYBAkl/kz0G46RAgCB8Iog4QREfo5nMQKgUX CMIDggD3xn0CwtDN5yBUCi4QhAcEAe5N4f6FAYLwgSDWAAQRJRBEDSCINQBBRAkEUQMIYg1A EFHiPAFh6OhzECoFFwjCA4IA98YfMgfPQVQAQawBCKInQBA+EEQdIIhukHykiVAgCB8Iog4Q ROQkT4T3rzvZaa1KwQWC8IAgQDB7+egYnez2XqXgAkF4QBAglIlxg4C7GD4QxBqAICKGe4XI QA3CB4JYAxBExLiPS1369z3vCRWhqaZAEMFAEKBNhtwyOZXWyb1uDv+vUnCBIDwgCBCIvOI9 /PGAk6Unp+4JBOEDQdQBgoiY5Pud0Z92punl7391np7qzEAgCB8Iog4QRMxMF2l68U+mJQJ3 MXwgiDUAQcQMt1LePDI3OyEIHwhiDUAQUTOZ86XFlAWBSwwfCGINQBBxkzzh/0d/+uYTmQwH gvCBIOoAQfQECMIHgqgDBNETIAgfCKIOEERHQIcxJSCINQBBRMzw1ZsM3MUoAUGsAQgiYgpd 10IQPhDEGoAgIgaCuBUIYg1AEBEDQdwKBLEGIIiIGV6f6MB7h/OLj9AfhAcEsQYgiIhJ/iWT wiRFn5Q+EMQagCC6wfAaPUr5QBBrAIKIGGeM7xdogygBQawBCCJi0Eh5KxDEGoAgIqYgCFxi +EAQawCCiBhXEAt0OecDQawBCCJinDG+v3hX54UCQfhAEHWAICKmcU+1DhCEDwRRBwiiJ0AQ PhBEHSCIqHn84dOPml5cGCAIHwiiDhBEvCSHOnTvSQuOCBLEH832ffR8demkIKr4sxa+EiAI 0B7jfGTvBY+dQ8hIOmFQKZq6B2brJfR8ddkYQaz0LIcgQGtMcj8QZuS99QtCD77L5ghCd9MF gvCAICLFqT8I8q5Wg37nqAhN3QMIol0gCNAWM7bCFT8G8eotJ+VJ62n489YQhA8EUQcIIk6o AvH6A00PBu+dy0XGeB4kiCMWjOUnnVkLCKJdIAjQEtNU2yWVvfRia28e9kIGBAFBBANBREly 5o+0J8PvaVvlPYEgIIhgIIgoKT9kLY2WDd7YorU1dQ8giHaBIEA7lO9nypudQRUIAwThA0HU AYKIkmpBnDboEgKC8IEg6gBBREly5vdRO0kXzzQZBAThA0HUAYKIk5l3vyI5e4gu5yCIdoEg QEtM08ttTTKj89S/rXFPIAgfCKIOEESccJPD60+fSPrJr15ReD/EuBgQRLtAEKAtzHMPOQ37 rIUgSkAQdYAgIiU5M2JQmvZZC0GUgCDqAEHESsEQjf0AQZSAIOoAQURLcmzkQLx0GyzDoFI0 dQ8giHaBIECbPD58Q3F91YIeIIgyEEQdIIieAEH4QBB1gCB6AgThA0HUAYLoCRCEDwRRBwii J0AQPhBEHSCIngBB+EAQdYAgegIE4QNB1AGC6AkQhA8EUQcIoidAED4QRB0giJ4AQfhAEHWA IHoCBOEDQdQBgugJEIQPBFEHCKInQBA+EEQdIIieAEH4QBB1gCB6AgThA0HUAYLoCRCEDwRR BwiiJ0AQPhBEHSCIngBB+EAQdYAgegIE4QNB1AGC6AkQhA8EUQcIoidAED4QRB0giJ4AQfhA EHWAIHoCBOEDQdQBgugJEIQPBFEHCKInQBA+EEQdIIieAEH4QBB1gCB6AgThA0HUAYLoCRCE DwRRBwiiJ0AQPhBEHSCIngBB+EAQdYAgegIE4QNB1AGC6AkQhA8EUQcIoidAED4QRB0giJ4A QfhAEHWAIHoCBOEDQdQBgugJEIQPBFEHCKInQBA+EEQdIIieAEH4QBB1gCB6AgThA0HUAYLo CRCEDwRRBwiiJ0AQPhBEHSCIngBB+EAQdYAgegIE4QNB1AGC6AkQhA8EUQcIoidAED4QRB0g iJ4AQfhAEHWAIHoCBOEDQdQBgugJEIQPBFEHCKInQBA+EEQdIIieAEH4QBB1gCB6AgThA0HU AYLoCRCEDwRRBwiiJ9wliD9Shgr04LtsuCCq+LNusSkbLogq2vrqwIqhY6WpaszhLKEH36WH gmhrl3soiAfYZRDCXYdqNdGmUnCJXRC6my4QhEfcuwxCgCB8IIg6QBA9AYLwgSDqAEH0BAjC B4KoAwTREyAIHwiiDhBET4AgfCCIOkAQPQGC8IEg6gBB9AQIwgeCqAME0RMgCB8Iog4QRE+A IHwgiDpAED0BgvCBIOoAQfQECMIHgqgDBNETui2IJe+a6m66xLLLq9ljLXyNQBA9gU5OTVWz xmir4o63gjWXj+6mSyyC0D300b10gSBABNDJqalqHlgQd5xHafofZSIXhO6lCwQBYuWuGFxj tP1XGQjCA4IA6wWC8IEg6gBB9AQIwgeCqAME0RMgCB8Iog4QRE+AIHwgiDpAED0BgvCBIOoA QfQECMIHgqgDBNETIAgfCKIOEERPgCB8IIg6QBA9AYLwgSDqAEH0BAjCB4KoAwTREyAIHwjC YzUvoFaBATvjgw6LpqqBIITIBVFFa9Gm5fnobro03eXVig6EcNdRgSCEDgqitWhb45esWwTx cNeJBEEIkQtC99IFggBtAEH4QBAeEESfgSB8IAgPCGJzSQ7n6eKLLZ2qAoLwgSA8IIiNJTlL Dwbj+cUthoAgfCAIDwhiY5ml5AayxKlOVwBB+EAQHhDEpjK8FjXM0sWOmVEBBOEDQXhAEJvK JBVBTNP0yMyoAILwgSA8IIhNZZYJYvk1BgThA0F4QBAbSnJmqg4kiOXNlBCEDwThAUFsKI4g bh6ZWWUgCB8IwgOC2FCG1/UEAQC4J/9N46fL3C2If/zjH//3f+snBgDUZhMEcXcbBAniH/9H PzEAoDabIAi+i8GC0JsZAADgQFUH86CUeAIAABzqPEkJAOgrU2l8mOEKAwBQJjlb3PU2JwCg t9zdHwQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAFgbU+1wL02vvvtE562c aXq5tM/tNhid72sqnPGcvpPVd8v1+Ji283Jbp4JZ095akt+9mi/vNr0Wa95jEMweHamLrcEu /Vlt2DITjlw+N1Z4aozO07SZIMxeag/hK0XCJE1vmhhifXurJMf0c9KkR4G17zFoAHeVz/3L 8Lm66n5mxvOVC4L10FAQZi/tEAKrZPx6e5DMaH8bdAC2vr1V6PAtDjQdxNr3GDTBCoK7zF9x T5ajaxO5K7zESL7/hn+UmwhC93IdJ/Bz/hr4iw8XxBr31kB+aFThWf8eg0a4gmgUWHfCNYeV bsAwafY57F6u7QTmLz54f9e+t7ShZj8ja99j0AxXEItfsiUutsbnCz6Go1dpSpXgArtUhb/k 5kw+0OkRXY4unpklNreYxpbx+PCtzaHtoRfvy4qSi08RLoe3X7WxIOwZqJj9TF6k6cmWXICc mPneB+EMfL7avdySE5jm2o+3MsZzZxMt7a2s+c53K6inlYZciX6PQTOsIPg40qGnE0BCmGZN 5oud0XXx92JK9UuqI/Kh5lYmuhjd0zPGyZ2XMZlfPuKLbMnBW+DINc1TWY1lfM2br9pYGHYz Ft7cV6KjIzlXZef9D/Kv9M8ssavz92JWcwtrnceH8/TC8WIre8u9FieHTW80VMHb8b6PyPcY NEQFwXcxOFApmi+/fueM0nQkRRjuD4aZR78CdFB5RZrQGrKbOyuD/tFJQdnlwLunBp0qPMln zPBHskLVxgKxm7Hw5khktFPp1Q7vreqQNpV/EPoxy5dke5ke2LmrgrdGu5fvbyt7a77HyQrC jfZh8T39o9qCJfI9Bg2RA0W8efkBT/Jx3qff8wM+uhS/08IlJy2VeXw4eUUOcJpnzoUsd17G wZzO/Um1IDgbz5/yqVG1sUDsZiy6OdoLLpw2xBv1PwidpDTLP4Epi85dGdwLudkzQyt7y3+2 B8kKKuxUsqkT5l9K5HsMGqKHz0JHSqJZagbmGOfRlp8LlEcnOAdVD93cWRkGmikB4AuCp49M BaJqY6HYzVjync5P4KoPYpb4e6lzV4jc56QtGVrZW/qzmrEP+DhpyHdkj0FT+EAVBWGmeL4h OxXswTXngh5hc4gLubMymN0fPjenjn9qyNl2sTXhrFUbC8VuxqKbK5zAVR/k1hN4lWjUGVrZ Wy6RfurbaPItopsxR644L9I9Bk3hA7VMEHQAGTrOBB3qquNuDrGTuyCI0dliR08d/9Qw5R6c FWa1gN2MRcvWvQg8gVcK7Ub24dvZW37YUb/1VuE45l11fwLi3mPQFD5QywShv2t0nM3B43l0 cM1B1SPMU+amVfYrmJ8+dDac2lPHPzVM4uqvnLOwekPsZiy6ucIJzPP8D6Kn6pITeJXQJrMd bmtv+S5ja19pDh1aLvQuQUS0x6AhfKCqBMEpievJxzIp0DxzUOlA6hHWc8bNnZXBPzjSSCmL vFODoII0VbWxQOxmLLq5wglc9UF0ydITuH3G84W8IDdxNtHG3kpbH/8ktx9utF98aGmHsrIj 32PQED5QlYKgI84P1Y71wReBji4dVMpDh5hXpONpJFDInZXBJ8MpZ8gEcTR+Zk8NM4fPGaJq Y4HYM9CimyuewP4HyU5Vfy917kqgsvlNztG1d5uz8d7OOM5oFs1pGTqYvF8zc0SFyPcYNITf 5syPNh9T+6IEJTlsdcrgPP/CR3jx1ZZ9UMrJnZXBWdKbX9N/vAU2BWfgB2f0lyJ/8KFqY2HQ KZee5sazmzugnaCzlX6lbvjTeg/yUAbaA968u5ekK527EtiKjPP1t7O3M75nOF7JY0cU3/KI TK602PcYNIGjSTAHXI5e9gO897bcVwHPu5KX+eQngPRiHxS2ud0yJvP0ZIuqjiYEhufppWnp lDOGl+exUbWx+yNKYrJTTTdnPug+nY8akNkH0QzZksJe5vlXAe9D+sa9u9fO3j7fpvzuw0wt knAPFs4z8fHvMXgYRBCaBgCAAhAEAGApEAQAYCna9gQAACVMK5PTmg0AAAAAAAAAAAAAAAAA AAAAAAAAECfJ4Yk+6cAUXihajqzBT1fePnbWMTofBKDTDM+5f0AO+JtH/hvht8BPV5IgeL1b nsIena9+mGAAwMoYXsvr0vy6BSe44wKnU5nl6PsZdwjCFg8A6CLJmXmEmrt24FDmv7WqEPYF rruG553U8w0AIEKm2t+KK4hab13UfcOT8uElDgC6CYWveU3TCoLjXmoQzli87nir2cC7RhDa Vmn+2FFbeYV8fN6ZKggA0DUmNqStILgNgpXhjcVrx1vNB97VGoRtq6Q/+aitTjbp6g5VCAA6 CSnARK8RRGI7nuTJfCzebLxVqilQSiZVEM6fwqitNpsoR/4CADoGRbS2SHJsC5cyfkNxLF7S iBlvlYxBNpCBd8uCIDVwRhKEk01sgWZKALoIxbUjCJLB4xcpD/CuUKDLYvor462aegVP7lcI wiyhQtxsIgixDACgY1DwFgVhahLmqiMfi1dmppfbrAHD0W2CcLO52wAAdIqyIKS2wJcE7li8 Ax1v9UOjAeEOQdhsEAQAnYVC2RcE38agBIV1PhYvIeOtvqLItw2Odwgib5ekkqRgAEDHIC1U 1yB4MhuLNx9vdabGmHx8myC4rdJmE0GgkRKATpLd5uQI59hmM9AsimpnLN5svFWpXpiBd28T hJMNtzkB6C4UvRTXBBuBZMCPTNqAz8fizcdbJaHwApKAjpVR/EOLeZmTTaSBB6UA6CQkAv55 Zz0ob754lxcUxuJ1xlvlgVp54F2zxmnxj3hB1rDZCDxqDUBnsS9rrQxSkKmjAAA6R6Kve68M vO4NQIdZcY8u6DAGgE5jupxbEehyDoCOkxzK7ciVgE5rAQAAAAAAAAAAAAAAAAAAAACgLfi9 dmXx2ryAEsp4nt7/TnELd5fl1VvnSfZjeV0GANAG/AoqPwj++HCepi9DYmsiwamvyN+PvflF k+fTnC3nghi9yPsTBQA0hN8+lTdF+G3Um/vH6/A6WBDT9LTJr71uWT5BLgiqQ+DNOADaIhOE XG/c+6UREoMJx/tfYkybvcKWbdkXRLYAANCUXBDSQc49O77iikNgNE6adaKTb9kXRNOSAQAZ uSAkKV3d1MZ2vhUA6ahJBcLZckkQ5A68PgtAKziC4G40KdSkJkG/wbxEahSS2OeutfiHWUY0 Nl1lmU60iH1Z1fxuJ7z8Sl5Q4195KpH7+r30xUMXNBLVmmdwME8XX23R2uavLFpeUr5lFURy PE+zN3Jt2QCAhviCICMM+dd5f8DjFosgJDr3NeM0vdjmODVVDQlOTozYKiwISkiH4BKtsuZL Ls6vmvAScx2Q/Hda+hUXRFszIjAXOreXlG1ZUl/JerbeQB+kSe0EAGDRuGfkZ5nTPI+il1st JVR5+s0RLb7Yov8oDFkl2ZI8TGkdDXyTzcylDHk2C2WwypCHMU62WDGLN1/xFmTdO0rKi5Ql B+42nMIBAE3guFoiiEwDHMI0f0qXGJw8kiWyUjFMjVQ4NvkyhefzXCoiU02G5tOkLNSyWAy8 6I6SilumlLMNuw4AoCEcXnUEoQGXvEgvd6SFsFIQHN38g88hakui5VlJGbRAKgaELV23qoK4 qySdzlPONnid4uYAAEFweLmC4MDSUC0IgqaV0YubQ7tSMUzNeOc2rPlvOXgVWnC7IO4qSafz lCcI/UwAgCZweGkwcYi5oVotiL25jGhcLQh2jA1rvkAoB6/B1g+YakHcVVJxy8VtQBAAtASH lwYTRyrHog3VSkHw8KSypFIQ9vfe/i0Hr0ILbhfEXSXpdJ6CIABoHw4vE0wcmXnwLREEz5MR jasFYWsGNkTLwavQgtsFcVdJOp2nnG3wOsXNAQCC4PAyguAIM0GrocqR6wvCLMoEYYPbXYfL 4AsEG/TF4FUon1RWTDLLmwvirpKKWy5ugwVhlgEAGsHhJbHOUaVvc3LwnQ726H8TchqChKll yCNUmSBOB9ODLLypFI5uCmtxja5psrlQhjsEcUdJxS0Xt8FSUaEBABog/UFwIO6e89NKOpMC jPiG/l1QcMqzjqaWIWGYXv6GM9jfd1kmT1Ly29s0R55/lPA3PtnKhZLBS0wM29KlhBMt8hkt uL2kbMuy5AddwiqRyoRIBQDQBAl3w+L17/MIHpMtXsu9Co40Dj0bcsmLdPHFFr85Yd584Eci yCuS1eThtyIKb1CkF6wAP2Zp0/J7b/P8E/uB5pnAlyrF7SXplqu2QWXz+gCArkKBXaxTtAcV XZQRAKBrUFVhRe0EVJ1BCwQAHadhj1JLoQoELjAA6DxT785GS8zgBwA2gYa9WlcyOkOv1gBs Bi2Mi+GDcTEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACAwWDw/wExcRk2N6C0 ugAAAABJRU5ErkJggg== A group of colorful bars Description automatically generated Figure 1: Quality of Life (QoL) of the patients after being subjected to water vapor thermal therapy with 6 months of follow-up. iVBORw0KGgoAAAANSUhEUgAABKQAAAJVCAMAAADX491kAAAAAXNSR0IArs4c6QAAAARnQU1B AACxjwv8YQUAAAEdUExURQAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAzzDPM//9mmf+ZzP/M/2lwCbcAAABZdFJOUwAECAoOFRkaHSAh JCgrLC82Nzk6PD5AQkVHSUxNUFJUWFldYGJkaGttb3N0d3l8gIGDhIaHiImMjZCSlJmdnp+g oqarr7KzuLu/wMXMzdLV19rf4eLn7vT5meTHJQAAAAlwSFlzAAAXEQAAFxEByibzPwAAMbRJ REFUeF7t3Q1729aZoGGCilyGjhN1ll1V7qZRtapmNnEjb5S2il2l61SKI8tSlVFLE7M78/9/ xr7vOQcgPg5EggJ0APK5rysWCIIfEIgnIASCAwAAAAAAAGBtjKexcb0lF6KjaTx7oUMA0A2n tlHxsQxHF/GBVMv0CgC6YHhnG/VhWy6c6vaUlOrcXgcAwU0yQZJg6aXTeLZjRwBAYNHfMj2a xCZSh/a9HwCEN57Gs6uvn9kLp2mkeL8HoBskSOpGMxVd2E0oGceucwCdkOw2j+ODXKTMbvTB 4Nhdafy7GQUAj+zpkR4pNdsxxSJSADpoTzJ1TqQAdNZ4Kl2q2iclgXJDABDIoW48ndpIuT/y pYgUgODMZ2FkE8oezGlalSJSAII5jM/MO7vxVLpUccQ5kQIQiu4rN/ufJmZX+aG5cFo4lpNI AQhGz4Fw82yw+84cdB5dzDxnQSBSAIKJjt7H8ezd5+lFz/mkiBSATiNSADqNSAHoNCIFoNOI FIBOI1IAOo1IAeg0IgWg04gUgE4jUgA6jUgB6DQiBaDTiBSATiNSADqNSAHoNCIFoNOIFIBO I1IAOo1IAeg0IgWg04gUgE4jUgA6jUgB6DQiBaDTiBSATiNSADqNSAHoNCIFoNOIFIBOI1IA Oo1IAeg0IgWg04gUgE4jUgA6jUgB6DQiBaDTiBSATiNSADqNSAHoNCIFoNOIFIBOI1IAOo1I Aeg0IgWg04gUgE4jUgA6jUgB6DQiBaDTiBSATiNSADqNSAHoNCIFoNOIFLCQrCYV3ARoEb9m YCEbJB83weitDL/7fPBy241Y2Xhq79g6HwwO3WAcX339zE20WWTW3RCACnH8X17J2jOZnm0N or1p/OHBkbKZmu3IwCeXGimbqeutwe5lHL/Z0hEbhkgBCy2I1Hhq45T8fJjowkVqEJ2aSGm1 JFKD4Z39uWmIFLDQgkjJps6xGZg0G6nB+Mz86yI1mMjqarK1WYgUsNCCSJ3KanSj+4uiHxqM 1P72YPidjkgjpZtSLl+bhEgBCy0RqTh+J5mSsAjdjS6XtDbiOK2MG2+vuN4aX87251Onkkil O+HTSJkH2rxNKZlpNwSgwoJI6dsw9camZjKd7YzupDMmRtqh8Z1GJh1vanP9qW1PZqzlIjX+ RzlSbhf6hpGZdkMAKiyI1OBEEyXMlpE0RbZ2TvUfzYvurRr+LA3KjNdI3bz+6EI3pzJjLRup 0UW6f2seKa1hE7u9+kVm2g0BqLAoUunBTLpBZHejH5phiZFG5VATVBgvm1iT6UFurGW2vwSR cmSm3RCACgsjNRi9MmGRDSJtjMmOvtGzm1JmQyo33sWrMNZiS6pAZtoNAaiwOFJJpj5s65/g LImPBud6a6KJyY3XfVImO7mxlo0U+6RSMtNuCECFBZH6ve2GxsRGKg2O2fY5uNCtpNz4XKTm UxsuUvx1L0GkgIUWROrE7U+SmthIzUOil25/0sLkxuciVchOEik9nCH6o0yVRiq5ZsMQKWCh BZE6dW/BJCISHAmQKcnkNzpO36HZTaXs+DRShalVNkUTDVgaKR0oFG0TEClgoUWRis9McYbm cCezd/uZ+0iL3boyQ9nx80jlp1aZSI3utG9JpPQKd6uNQqSAhRZGKr75TJJyadsiF7U8bpfS /BCozHi9RXp9OtbSJsUHMvDkaGr+5qcbYzL1SBplY7hhZPbdEIAKC/dJRXvvZfPn7GNzcaAX 3NHnsqmUvHWbj9dNIuEOOshNbROVkttqoqyrF+7+N4zMuhsCUGFBpNAqIgUsRKRCIlLAQkQq JCIFLESkQiJSwEJEKiQiBSxEpEIiUsBCRCokIgUsRKRCIlLAQrKaVHAToEX8moGFbJB83ARo Eb9mAJ1GpAB0GpEC0GlECkCnESkAnUakAHQakQLQaUQKQKcRKQCdRqQAdBqRAtBpRApApxEp AJ1GpIDFZD3xc9ejRfyagcVskTzc9WgRv2ZgsTj+Tx+79kxsr47NlMJ957D7guIs8/XEmW9U X0X+K47P04cTV1+nX4S8TmTO3BCAKvdGajDY1XBcb9kLwzu5MP9u9byTOpGaeDonNFPm/j+5 1EjZTMmj717G8Rv3JNYJkQIWWxAp06Vk02lyKxFJilUkPVk6UuOpP1LRRRLB6NRESqulD6hP o+qBe4xIAYstitTf/yBrkgmGbCz9rplIje587xjFPFKD8Zn5N3lAfePpnsUaIVLAYgsj9cvk Ldhg/NOnjURKy3N/pPa3B8PvdEQaKd2UcvlaI61H6lt5hAp/dZP0RvW89G5WUM/CSP1CwmF3 nR8ep80YmN1EN5+bQR2e7aSRGr2N43fPbHFk6vHlTIr05Oi9VOZLvV73M5lr5pMmkki9TGo3 f8BTucnabUrJPLmhlpjfdAU3SW+4p+3jpsCaWhipbX2npfmJftieN+Mw/vBM3rXZeMXxQfTy exepyXS2M7ozWz0Slmu78TWZ3mxHcjHd0WS2pDKTWi5S43+UI6Vpc31cH62vX3H8/yr0MVLu qRcRqXW3OFJm37lEZXI+b4YMSG8kHDJehmWcTqWRstecmhxJlW5ef3QRX8t/0rNkW0vvRSOV ndSykRpd2E0yoZPaNCWpXCtEqgYitbEWR8psxEhITvbnzZD8yEaUXCHj7b86SiMil8w1un0k o6RGk+nB4GAq7/mkM7lIZSe1zDtEQaQaQqSwBpaIlJZitpMMaTN0s0n6YqqjYdF3fZIciYi7 JBckQ65bCRlpeuQilZvUYkuqYUQKa2CJSJktouNDCUrSDJcZCYfEywbLRcq8NzRknNzOFkbt /vhVPlK5SS0bKfZJNYZIYQ0sEymzFfNW+rJcpNLmZCI1upjtmMllOBOpdFLLRYq/7jWFSGEN LBMpbUcaJ/2pfZHMmC65d22ZSKUtmUdKbnhum2YvJJEqZCeJ1L4+6B8zD5hes16IVA1EamMt EynzXkuyMm+G5EfCJKOlMjKsrbGR0ksmJpPfZCKliTE7zrORyk1qZVM00TtNH1AHCkVbA0Sq BiK1sZaKlGz0mJ3W2WZIpKQyEhtpj16pkZK+yKX4wzP7qZY0UiYxaYH00vH4y9ykViZSozvd PEseUK+wd7VWiFQNRGpjLYjUXnygP9zBTAeyVs3MYebZgzmlRceD3e/lOlcuYZomgzf607yz iz/8Vv7RBGlxkq0uN+Rok8wDPjmamo0t3YSTuxjJLc7Wr1FEqg4itbHujZRu65itpfE/JS5a DEPzsfc+jm9NwKRd0/hm5/D29Rcf6yW95k3ysRg78WAylchEJ24zaXgp0+tAMqllEpWSSdMH jK9emLteNzJnbqglRAprYMGWFNpEpGogUhuLSAVEpGogUhuLSAVEpGogUhuLSAVEpGrYiEit 0UmzGjyXGZG63yfP//yX11985i41TJaXG2oJkeoZuxJ7uSl6wz1tLzfJsojUPT55636pcfyu jU7J/bqhlhCpnonj/+vXx+XlnnpJ7XkhUpVGr2yfnJvmv1VL7tUNtYRI9QyR8rEroIe7fnPt 5Q7bEjN3WFhz5E7dUEuIVM8QKR+7/nm46zfWnvwObr5+/tlT9cnzr/SdnznAvkGt/5qJVM8Q KSxvIhtO+Q/iRLJpZQ6fbw6RqoFI9QuRatvw7rz8WcHoNPM5wyYQqRqIVL8QqbYdes+5EF00 +4aPSNVApPqFSLUs+r3/T3mjf230XAxEqgYi1S9Eaj0QqRqIVL8QqfVApGogUv1CpNYDkaqB SPULkXpMT562dcY9IlUDkeoXIvVoohM98Hz2opWTFxOpGohUvxCpx+LOgdzS10DI/bqhlhCp niFSqG1+mvWmPxKj5G7dUEuIVM8QKdQVXdy8eK6O3rexKUWkaiBS/UKk2uZ2lduvHcwPNYhI 1UCk+oVItWz4sz0ty/Duza/NaRCev2JLKjAi1S9EqmXRhfsyUvv9pYp9UoERqX5pLlJ2BfRx E2yo6MR+f6n57mVlv4q5YXK/bqglRKpniJSHXQN93AQbazyNv5GNqcieQ/hNG0cg6G/fDbWE SPUMkfKoWvL2fuzXrM/f6bg/yO/rkGxamO9Fd1ea4ezplqpvW1S66QryX9F+nj124Orr1U5O LnkypzWPfvX8s1YSpb/9ll96RKpniJTH/ZEaDHZ15U/2GZv3PjN9F6RNkPyMZURaoZNiaSpu 61G66T0mFWfH1Kdk7v+TS42UzZQ8+u7lyttBe9PmT2ueI8/QDbWESPUMkfJYFCm7T8Z1YXIr ITDVcZHSa7ObSvnSVNzWo3TTauNpRaT02HAbwejUREqfoz6gPo2qB15gdNnS+zyHSNVApPrl ESP19z/ImmRWetng+V0aGvN2b1GkKm5btnykRndV5xmfR2owPjP/Jg+obzzds6gr+rfKrb8m EKkaiFS/PGakfinrul1Rxz99WgjNokjdd9uspSOl4VkQqf3twfA7HZFGSp/lyqmRe7EHI7SB SNVApPrlMSP1C/2IrSnR4XGy3uvP7Nu93UupgCdSvtuaqeObz3XIXsjcdPQ2jt89s8WRqceX M0nSk6P3Upkv5WqZTpm7SSZNJJF6mTyH+QPqwU4rbkrJ/Z608bWgljwvN9QSItUzRMpjcaS2 9d2SJiT6YTtd790ecxcpacdB9PL7cqS8tz2MPzyTd22mXYWbTqazndGd2eqRsFzbja/J9GY7 kouaGb0TuyWVmdRykRr/oxwpbZsdquHJ0dXV1Qv9eEx7+8+JVA1Eql8eNVJaIi3D5Hy+3rs6 2R8yVkbqcClSntvKT8mNdENjk7+pverU5EiqdPP6o4v4Wv6Tx5Dp3RQ2UtlJLRup0UX6HHRa m6YklXW47y82eRpdujtqmjyAG2oJkeoZIuWxRKTMhojE4GR/vt7nIiXXu6yUIuW5rUxmN770 NvmbyiVzlW4fySjJ0WR6MDiYyns+6UwuUtlJLfMOUTQTKb2J5R5ulrw/bZLcvRtqCZHqGSLl sUykdG2f7SRDpUhpHWRYu1GOVOm27pY2OvmbuktyQcJQSJ6M1B7pnWg1cpNaOqqxLSm9M3m3 d3VlIyp3dlnvDpZDpGogUv3yuJEyWzXHhxIFb6TcsD9Spdu6zEg3JDr5m+olS8bJ7Wxh1O6P X+UjlZvUspFqaJ/U8OdkCy25v+jr3Lw1Q56XG2oJkeoZIuWxVKTMlshb14gFkbLvk8y7MO9t F0QqbU4mUqOL2Y6dPhepdFLLRaqZv+6VI9UKeV5uqCVEqmeIlMdSkdL136zv3kjptdWRKt5W byKZsRPnb6pXpS2ZR0pueO6ilotUITtJpPb1Qf+YfbLJNTXITWbu7Z57Fq2QX40bagmR6hki 5bFUpDQipg3eSGlPNBi2NBn+28rUcksZq7fJ31QumZhMfpOJlCbG7DjPRio3qZVN0UTvNH2y OlAo2kK2tco8XEvk7t1QS4hUzxApj+UiJTEy/fFHSlZovVZLk9te8d9WfsotJTK69udvqmX4 8Mx+qiWNlElMUiC9cDz+Mj+plYnU6E43z5IH1CvsXdXhDkHQ59oeuX831BIi1TNEymNRpPZi cxyjOyDpQNYq87d4PZhTxrgfEpTjwe73xXW64ra5gznzN5VLwjRNBu155jSE8Yffyj+SIA1O en0yaGmTzAM+OZqaAOomnNzFSG6yygdboqO37mDO9sgzdEMtIVI9Q6Q87o+UfdMja/z4n7KN omu9sW+CEJ+7HxKgaXyzc3j7+ovMOl11W4nX+zi+TY7hzt9Ur3qTfCzGbmwNJvrpuejEbiYN L+0ZM+eTWvapJGTS9AHjtkvzAPLs3FBLiFTPECmP+yOFdhGpGohUvxCplkW/8r9BjH69whvH akSqBiLVL0Sqbaf+HeaHZvdaY4hUDUSqX4hU28bTZKdZ1p7782FTiFQNRKpfiFTrDst/Ehy9 yv3xsgFEqgYi1S9EqnV6Bqt3Xzx1lwaDp7+/NH/IbBSRqoFI9QuRal90IglRt1fv3VDj5xGW +3RDLSFSPUOkPOza5+Mm2GAHuWOv7PnvmiX36oZaQqR6hkh52PXPx02wyZ4kG1Ni1sbXMcj9 uqGWEKmeIVKobffP5mQIr3/tLjeLSNVApAL61vyf2uuvbpIiIrUeZBG7oZYQqZ7paqRsj/zc JEVEaj1UL+GGEKme6W6k/rNC5RMjUuuBSNVApAIiUhuLSNVApAIiUhuLSNVApAIiUhuLSNVA pAIiUhuLSNVApAIiUhuLSNVApAIiUhuLSNVApAIiUhuLSNVApAIiUhuLSNVApAIiUhuLSNVA pAIKHClZUSq4CTba7qV+t1/0Ur8wsHmt/5KJVM8QKS8bJB83wSbTb+8zX0B60vCJg63Wf8lE qmeIlFfVfa3Tol+V+YJTE6nx1HxRacOIVA1EKqAOR8p+C/H86wfc1wLL+nqo32BuvjbYXWmG 5996nv9G4fPsFwp/nX7tcNdFF7MXz//HP3SmhndNn99cya/DDbWESPUMkfK6L1KDwa7G5tqd lHJ4JxfMtzppg6ROYxmRFuwkGyk7iZn2k0vzBQaaKbmj3cs4ftPCSS7bMPxZnv/w73ZLKjtv TQkaqSpVJzEL7Z5IVerqvFQiUl73R8p0STed1ORWwmOK5SKl12Y3s7IrcnThIjWITjVSehO9 rd4mqV7HmT6Zf2RmNiZSYdeGaqtEqqvzUolIeS2I1N//IIvavdU5+V0SKft2b8lIDcZn+k9y W30P2cZ7p+ZFF9fPTKR086+NsLa+Ft0XKbeciwKvDdXuiZR76iWdnZdKRMprUaR+KXGxsRn/ 9GkaKWuZSO1vD4bfyeU0UnojV6+uk57evo/tN1qt3T4pt5yLAq8N1YhUQB2P1C8kNrZEh8dJ aPRn9u2ebGnMdioi9dKNSyM1OG1plW+ezoPTSlblft1QS4hUzxApr0WR2ta3Z1qf6IftNDRu j7mLlOTpIHr5vTdSY/PHMTGPlEzuhjovrVQ7m35yx26oJUSqZ4iU18JIaYl01/nkPP+WLY2U jJWROlyO1OgiGTePVFK97hv9+fX/eivP9vZFO00lUjUQqYC6Himz5SNvz072KyIl1+u7N3kX V4yU6nGkdBZafaLyi3BDLSFSPUOkvBZHSvMy20mGSpHSVVmG/TvOe70lpbNnn3JLiFQNRCqg zkfK7Ok+PpQQeSPlhv2R6vc+qdP4m1afJ5GqgUgF1P1ImU2ftzsrRarXf90b/zPdXx79sYVc EakaiFRA3Y+U9sYExhupe9/umeOkzBqe3ja5og/GPybnaEm3CJtEpGogUgF1P1LmDZp+NMYb Kd0y0g2jikipiVyf3lYH+rEhNXx7Jc91dqVa2YtGpGogUgH1IFISI7OO+iMl7wb1Wo1UZgMp E6nRnUyb3FbHm/voPp29FJEKjEgF1OlI7cUH+uPUbvscyFo10zdAejCnbh3ZH7IpdTzY/V5X ZX3fZ2mUzI2fHE3tyV1i/bzfSBp11o9GEalOIVIBdThSusfcvNEze5A1M8a+CVB87n5IvKbx zc7h7esvPnZ3ahOVMp+Zca5epBN1HZHqEiIVUKe3pDba8O6bp4kjIhUYkQqISHVV9rADDkEI jUgFRKQ2FpGqgUgFRKQ6bfT8+fO2zspOpGogUgERqQ7Tc3KKmfkbZ02jt3F8m9ww+UtC7ugL ueyGWkKkeoZIeRGpe8z/KDk/tmJZ7rZ66mShnwVSufuRy26oJUSqZ4iUl113fNwEGyxzIEXt D/KktzXfYpEczZD/G6GMcEMtIVI9Q6S87Mrj4ybYYKfx7Ie/qLfT2p/kOT3bGoz0zaK5oX4w qKz1XzKR6hkihXqii/mbs8OaH+UZ/m/9VzenNE/R37wbYkSqBiIVEJHqKvvBRSs7vDz9oKKG TmI183x1M5GqgUgFRKS6ynyDsbPaqVo0UrpPyu1EvylkikjVQKQCIlJdFV3cfPH0qQ493b1c 6cwNwztzzMH8Q4D5QxlkhBtqCZHqGSKFmuZHIKxyDIKYzP8q+PRI/9yX/yOhjHBDLSFSPUOk UJO+W3NWOwXWaa5te243ekru1w21hEj1DJFCXWmlVmvUpHDgwniaP1BK7tgNtYRI9QyRQn27 +uWg75IzndczvCu27ZBIrYxIBUSk1lR0YRo1/M5eVONpkq1j3T5L/Lsd1zwi1TNECo/q1AQp OjXnTranTB5Pk31URKqu/kXqW7d4a3FPvajDkarknnoJkWrU3tWX9ucKp2VP/jQ42zGHIJhi TdJ3e0Sqrv5Fyi3detxTLyJS8Jvv6D70fvbuPvb88ELvQc+BcPNssPsufzSnjHVDLSFSIVWu 2f1bLPdFyj31oiYXi1mRvNwEG0za4iI1vDMnM1heehIE+9m9o/eySVXa/y7XuqGWEKmQiJRf /Xmxa5KPm2Bz6bs0tw+p/Ie6JrT+SyZSIREpv/rzEsf/4dXZF+vjGf6cfoplkj92oCFEqgYi FRCR6qr5mQ9G7iucG0akaiBSARGproours2O7icn03a+Gp5I1UCkAupwpOyJuc0ftuwH+X2f sp3vIlbnmU/les6g1C+TOJ5dvbczs9IHjBeQu3VDLSFSIREpv/rzcu+WVGQyZf+wNb47r9iY 0EyZj/d/cmmKppmSDQ/9ppU3LWx/PJ7MB4zbeLcnv/uWX3pEKiQi5Vd/Xu5/u2c2k9z5RU5y pxnJ0HXZThOdaqT0RvruKD2GsbeiV6ZQ5dPVNUPu2A21hEiFRKT86s/Lgkj9oG/z7GbEEpEa jPUbnJJImQMaax8F2S2fvJWZuT1oJ7VEqgYiFVC3I3VmtqVMchZGan/bfpo2jZRuSrl6wYNI 1UCkAup4pOznO3S3sYuU7mq6yR07nUTqpdtvk0bK7Hnv+aaU+uQzN9AwIlUDkQqo65Gyf+Pb TyJ1GH94NrrL/bHLRSr9roJ5pNwu9J6KfvX8+a+3zOys9D3rCxGpGohUQJ2PlDZII2QiJWus bBpJfDKfZbORGl0kfwGbR0q3wlr5u9jj2J3KJqPOjd1SbByRqoFIBdT5SNljpD5sm0jJZpVs REmkMu/iTMXMJPby2kRKtw3tzN228q5V7tgNtYRIhUSk/OrPyxKRshsT5xop95lbiU+mPeu6 JRVdyOai2SW3v+L37i1ApGogUgH1IFJ2TdV3PNofu+Zm3v/YSK3fPin97J7ZipStqNW+wXgB IlUDkQqoD5EyO88XRWrt/rqn32Csc6DbguOfWmgtkaqBSAXUi0glHdINC4mUbCGV3u6Z46QG 0R/tn8NMpJIr+up0Zj64p38j0DOVN45I1UCkAupFpLROJjdVO86TFk1kfBopHejvhpR9/vYY scNW9qwRqRqIVED9iJSssKZDst7KSiupymxZZCI1upNrk0jp+P7ukVLjy3j2pZmRGW/3AiNS AXU5UtHpLD22fGI75DmY02xw6NGOT46m7s1gfLM9GEmjVviWlQ1CpGogUgF1OFJam/nOJ/ex mL33+olbM2jY90SJ2Y65kXH14mM3Dbzkd+SGWkKkQiJSfvXn5f63e2gTkaqBSAVEpDYWkaqB SAVEpDYWkaqBSAVEpDYWkaqBSAUUPFJV3ARoTeu/ZCIVEpHyqz8vNkg+bgK0pvVfMpEKiUj5 kZY+IVI1EKmAiNTGaipS3+qGr597xZQQqfYRKT8i1ScSETf0MLZHXu4VU0Kk2kek/IhUI4Zv r0Tr32wqEXFDD7NGa0M1IhUQkeqe4V1LXweaR6RqIFIBEanuGd49ykmPiVQNRCogItU9Qz3j zJOnibY+J02kaiBSARGp7tETB0e7r+z5HWavP29p5xSRqoFIBUSkuif52oW9aUtfC2oRqRqI VEBEqnvS74Y5TM7up+dubxyRqoFIBUSkuieN1Pif7tztnf5KKyLlR6SaQqS6J01SOrDXxp/7 iFQNRCogItU95itB84hUYEQqICLVPUSqe4hUQESqe4hU9xCpgIhU9xCp7iFSARGp7hne3f4l b0qkAiNSARGp7tEjzvPG/yBSYRGpgIhU95SPiuI4qdCIVEBEqnuifykeX14e0wAiVQORCohI bSwiVQORCohIddzw1dW718/bOAcekaqBSAVEpLon+rP+Re+75B1edMIhCMERqYCIVPcM7+LZ i+xOqEMiFRqRCohIdc/wbpY/BiG6IFKBEamAiFT3mNMH50yIVGBEKiAi1T3m9MFmv5TxeouD OYMjUgERqe6xh24+2XsvGbl9od/DwMGcoRGpgIhU9yRJik7jc7v/nEiFRqQCIlLdkyaJ0wd3 BpEKiEh1T5qkdIAd56ERqYCIVPdwPqnuIVIBEanuIVLdQ6QCIlLdQ6S6h0gFRKS6h0iF8q39 bXu5p15EpNpHpLpHIvWDO5DTekukHofNkZ976kVEqn1Eqns4fXAo67Q2sFj8iFQjykdFcZzU 4yBSfiwWFBCpUIiUH4sFBUQqFCLlx2JBwfBu3w0lOOL8cRApPxYLCjgEIRQi5cdiQQGRCoVI +bFYUECkQiFSfiwWFBCpUIiUH4sFBRKpd+5Yc4sjzh8JkfJjsaCAI85DIVJ+LBYUcJxUKETK j8WCAiIVCpHyY7GggEiFQqT8WCwo4IjzUIiUH4sFBRyCEAqR8mOxoIBIhUKk/FgsKCBSoRAp PxYLCohUKETKj8WCAo44D4VI+bFYUMAR56EQKT8WCwo4TioUIuXHYkFB9C9bbihRHtMAIlVC pPxYLAiDSJUQKT8WC8IgUiVEyo/FgjCIVAmR8mOxIAwiVUKk/FgsCINIlRApPxYLwiBSJUTK j8WCMIhUCZHyY7EgDCJVQqT8WCwIg0iVECk/FgvCIFIlRMqPxYIwiFQJkfJjsSAMIlVCpPxY LAiDSJUQKT8WC8IgUiVEyo/FgjCIVAmR8mOxIAwiVUKk/FgsCINIlRApPxYLwiBSJUTKj8WC MIhUCZHyY7EgDCJVQqT8WCwIg0iVECk/FgvCIFIlRMqPxYIwiFQJkfJjsSAMIlVCpPxYLAiD SJUQKT8WC8IgUiVEyo/FgjCIVAmR8mOxIAwiVUKk/FgsCINIlRApPxYLwiBSJUTKj8WCMIhU CZHyY7EgDCJVQqT8WCwIg0iVECk/FgvCIFIlRMqPxYIwiFQJkfJjsSAMIlVCpPxYLAiDSJUQ KT8WC8IgUiVEyo/FgjCIVAmR8mOxIAwiVUKk/FgsCINIlRApPxYLwtjcSH0rs17BPfWSrq4N 98wKkfIiUn0iL2M39DD9WxvsOuzlnnpJV9cG97S93FMvIlLoDXkZu6GH6WOk/suvj5FyT72E SPkRqT4hUiVEyo9IIQwiVUKk/IgUwiBSJUTKj0ghDCJVQqT8iBTCIFIlRMqPSCEMIlVCpPyI FMIgUiVEyo9IIQwiVUKk/IgUwiBSJUTKj0ghDCJVQqT8iBTCIFIlRMqPSCEMIlVCpPyIFMIg UiVEyo9IIYx6kVqnExc9VqSq/NU9jwYQKT8itR5kbXFDy7Crl597xRQRqSrueTSASPkRqfVQ b2VZp7XhsSL1H35EqiYitbGIVAmR8iNSCINIlRApPyKFMIhUCZHyI1IIg0iVECk/IoUwiFQJ kfIjUgiDSJUQKT8ihTCIVAmR8iNSCINIlRApPyKFMIhUCZHyI1IIg0iVECk/IoUwiFQJkfIj UgiDSJUQKT8ihTCIVAmR8iNSCINIlRApPyKFMLoZqSoNniiOSFVYYbE0ulyqNLxYqjzGrKAe WSxuaBnB1wb3PJpApPxWWSxNLpcqjxSpx5gV1FNvqTzW2uBW5CIi5Rd4sTS7XKr0b7GgIUSq hEj5ESmEQaRKiJQfkUIYRKqESPkRKYRBpEqIlB+RQhhEqoRI+REphEGkSoiUH5FCGESqhEj5 ESmEQaRKiJQfkUIYRKqESPkRKYRBpEqIlB+RQhhEqoRI+REphEGkSoiUH5FCGESqhEj5ESmE QaRKiJTf40TqW3lFVnBPvYRIrTlZ9m5oGUTKj0g1xvbIyz31EiK15mTZu6FlECk/ItWYNVos aAiRKiFSfkQKYRCpEiLlR6QQBpEqIVJ+RAphEKkSIuVHpBAGkSohUn5ECmEQqRIi5UekEAaR KiFSfkQKYRCpEiLlR6QQBpEqIVJ+RAphEKkSIuVHpBAGkSohUn5ECmEQqRIi5UekEAaRKiFS fkQKYRCpEiLlR6QQBpEqIVJ+RAphEKkSIuVHpBAGkSohUn5ECmEQqRIi5UekEAaRKiFSfkQK YRCpEiLlR6QQBpEqIVJ+RAphEKkSIuVHpNC26Ggaz15suUsJIlVCpPyIFFoWXcQHg/H0ulAp IlVCpPyIFFp2GkufpFTn7rJDpEqIlB+RQruGdyZPp/Fsx45wiFQJkfIjUmjXJDaROozjYzvC IVIlRMqPSKFdp2mk8u/3iFQJkfIjUmhVdGE3oSRS+V3nRKqESPkRKbQqE6kP23aURaRKiJQf kUKrhnfVkQJQ0/906w+aUxmp//5/3G8dwNKIVPMq90kNjt1vHcDSiFQLTm2k3B/5AKBjZBPK HsxpWgUAHVN1xDkAdMOh2Rl1yrs9AN0UXcx8Z0EAgI7wn08KAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAoO3UlT4/j2h8/duNYdxje507E/mtHlvhta3Xgqv6yA5xd8ciJP4M0zd2lloWcjFf3+ 7TR/dv7aOjMvaMmeLOHrrcGu/Gg/HRONhL6mQrykRpdx/LBI2afvvvoiDLNCxvGHh1SqA7OR iE7kf48POYNHh+YFrdGvm9FzUemrv+1zUo2n4SKliXpgpOzTT76fJ4jxu2eD6FRm5AGnOOzA bCTkpTA7cMMr6dC8oD1JpPRrZ1o+A/HozkYixNu96G9/0W2Qh0TKPf2ga8RL/cXpolo9Ul2Y DUca9aBNwi7NC1qUjdSD1uGFdAuq1QdYYPKwGUyefvg1QhfVyjPSndnQp/Cw/y12aF7Qpmyk Zv9NS3W9Nb6c6bIfvY1jeXuRsyvvmm50F7u+QOLjE7nRl/aaZGpTu+Q+nhy9T6Zw++ivPzU3 NFPpS0vvRx/f92DNSl7Sjp2B6FUcn22ZN4NndnxhDnUCXQGSp79l1ggZm8z34xtPM4/d0GyY W370w6Nu4Za+hq3H84I2JZHS5S8vGXnhmIzIqMl0tjO6y/+/7lC2z2UbW18iurdydjDYc6+0 zNTz+5hMb7Z1F4qZQh9BI2F3c6ZbbuM7fXjfgzUsefyEPo9vTCuPzYvfzFVxDv8k/9lrkpvr L8zeLHtnj+fJ0TS+ztS8kdnQc+RHRw/9M1s9+gwKv8Lezgta5SKlf93TWEhRbl5/dCHD8gow 0cr+z86Ok/+DyYtBbygX3HuP7NTpfch/8mKSyc0LJvuSkpeYXtRX2vBnKZPvwZqWPH5Cn4dU Vp5tfLujs+FaLc9hPofyf+j5NenTjw+SsY9On4Y87/mMNDIb9jc/edQVW57d7G/yn2w1JXo7 L2iVWcDi6s1nelFfH/uyXXOgrwppyGFut4Fca8bpy0BvqJGRcfY1lE49v4+DqaxNE3+kdDId f6gvKd+DNS15/IR7HvL09FHlGeizKc6hvOplVHGNkEnc2Men37thn7LVyGzoj2eD6FHfIslj 2u3s+e+xt/OCVrnFnpAlbIpitpDsa2O+Ys9fQzKNu6BTyOZ1dur0PiwZaVapYqT08rHdkPI9 WOOSx0/M52a+Rvjm0F5TfPpubAjmGAR5ClYjsyE/Hvsbh3SZu+z0fl7QLl3A+UjZSzreSl9C yYvCvobcK8O+NHJTp/ehdn/8yr7kii8p8yq93propL4Ha1zy+An3PHJrhG8O710jgnDrt9XI bOg9yoZNq3+4KHBPwL4K8uN6Ny9oly7gqkjJglfy+hDyEvG9XuxLIzN1LlKji9mOe8kVX1L2 fg8ucqPalDx+wj2oe3orrhFhyPNLf13NzIYe+u2W0yPRluhMZP+X1td5Qbt0AVdFyv3fWl4f dqHrOHlR2BeDe2XoJftH4PT/7fOXnbyKzpOXXPElZQduf9IpczdvS/L4Cfc8cmuEjivOoXvt V6wRQchzSeekqdnQv/O3vxAy5GWiD7coUr2YF7RKF7AvUjpk2jL5jbloyDj7YpAXgHtluNda dur0PvR/lmbHubmq8JISckduyPdgTUseP+GeR26N8M2hu6ZyjXhE4+nMfAx8knnsJmbD7GXW DZDHXLHlGevLRJ5q+qi9nRe0ShewN1LyStEPLYzdAXWGvCrkxSDTyEtDbyivAxui3NTpfeiL 6FwnSCN1PP4yeUnZMfpaE74Ha1rykk6455FfI4pzmL72i0/fjX1c8qB6BoTRXeEQhAfPxqmu 0TJKxjwaeWHoMz61rw6jt/OCVulZEOavEn0tJB+sk0FNh7tkZY6r01fG7Jut5GDOzNTpfegk 8Yffyj/6CFornUAPyHP/l5sfGOV7sIbJazg+n+c4eR4H8uzk5S//6/2gv4bCkYMygTw1fV7Z py8tdWMfl7ZcZRZYM7Nxqn+1Hz/yAZDSGHM43jy4/Z0XtEdXXMO+UMxST7c39t6Xz1yk427N B9fN/74kcclHNJKps/cxmcZnW7LpbVeq4WV8Y/e+m1eaXj9f23wP1iDTS5W+dt3zsL+BfXmB u3U/nUM3QXpN7unPp39U+uTiq+zf15uZjZfPZPrsYZWPItJzY2U+C9XneUEXmUi5YQDoHCIF oNOIFIBOc/swAaCT7N7KzF9mAAAAAAAAAAAAAAAAAKBfoqMzdySUyn2ktZq5hR6Ffv93FJ9w AmoADzS81HNEa3Q+bBfP5nIPPQpdIqW3u+cTM6PLx/+adQBrZXhnzmiiH8/TAT2NUebEeNXc 5/kWRCq5ewBYTXRhP+6ip4bSnOjPpTalkg8d3/92T6u3VPMAwOvQnRouG6mlPqW37JkRZDo+ 9AdgVZIQe3qDJFLaHrMl9eTovQy5U3GOLuP47CM97f3orTvBoo2U239uf0Sv0m6lk+kpXnnD B2BVkyQrSaR0n5RmazK134ttEjaeXm9FR3oq6cl0tjO6M6dzdfuk5j/+JP+5u5tPZk5bzKYU gBVJhmxBbKSi5ETmevFY+2K2guyXKEw+bMsWkwyZiy5SmR+yKSW30j1QmclM9sxPAKhNquL2 kmtfjBvzbW+Dg+nMfI2ei5R+K0f0w7ZUS4p0qDcqR0rypBNKpDKTmWKx6xzAaqQtmUhJkJ68 iuOZ+YYYJbExV8vPePZiy21f6cV9T6TsNXIn2clMpEzpAKA2CUg+UnaLyr4D3P3xKxcpMzK+ eaYpso7vi1R2suxjAEBN5UiZrSZ9eza6mO3I2z17tX6VtQz/yqbIWBCpZDIiBeABJCfFSOmf 92RA0nKuw0lfdi9l/FupT7ITfEGk5vvK5Z7MHQNAbZIm/5aUXjQ7zvXqSA+Q0o0p/eZYM/3k N/dFSvefJ5OZSLHjHMCK0kMQtDLaF62TjJKyxOc6bGJzqttFMsWx2cx6NhifFeuUj1RmMg5B APAQUhBpi9AqSZD00PIkOvGH38o/WqlTPQJhrAdzStT0CgmR+y6+/A+5Wq/LTGbCxcGcAFYk MdLNHE2Uc/XiY71iMo3PtuQtntmSevls7308O9M3bTIQv3GndpEu5X+YNplbJJMJPhYD4AGS Dxi3RjJot9UAYAWRO1VLazhVC4AHafmsdJz0DsAD2dMHt4TTBwN4sOjIHCrQCr6IAQAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA9MBhnLj6eqVvpz+Ml/7i +dW/Wno8lSd47C7wNdLAZtFMXW8Ndi/j+E2tlX+yL/9oPtJ63G94ebNKBu3D3GUeZnS5dBcB 9J9mRiI1GEoH9OeyxtN6kRrefVglLfZh9MnNH2bFuwLQS0mkBhPZpDq345Ywuou1Hku/3Ysu 7PQ1uYfJR0qeap2cAui1NFIagtmOHbmQ3qpWdA7jVbZ+kocpREourlI8AH2URmpwajal9LIE QS9IVmQDSK8eX86kCk+O3kvHvpRJ3f7260/txEL3ad18LgP29tGrXFU0K7qVNr/ybGswkpu4 XekVt04eZstESsaaBxenKyUPQB/NI+V2obud1FIpEwL5aVp0vTWZ3mxHcjGpjW7MJHu0ZUPp mbw100Ed9Sf5z17hyHtJc0mv/EbDFx+bHtmxlbdOHkYjZW9mt6DkqbIpBWyIeaR0p5R0yb21 kg4kkbp5/dFFfC3/yXg3OlsPmVguSrpsOnSUbPbI1PZuDbkXUxW9cnagF+PbnWSa6ltnHyY+ mN+nPNXld58B6LUlIiWdmEwPBgdTec8nE3kiJRPZm0g6dJTcoYyyd6skL3Z3l5te7kUvu8eo vnX5Yex9yvj5nQNYa0tEyvx0ZLTmJV+PeXrKtzdkXHWk7rl1IVLpfcr4+Z0DWGvzSEkCdKgQ hNwW0e6PX/ki5S7Z9BSDomSC6kjdc+v8w8zvM70/AGtPO2ArJDlK3nD5IzW6mO24vOTrcU9m rDQq7koiBWBZ2gFTId0trWt+IQjzSMmU50le8vXQf+WSvUkxKErG2ai4K3ORuufW90RqfucA 1loaKR3QP5m5ICT7otJIacTMjvNypHQi25DylphRb8f5/Nb3RCrZvAOw5pJIpX/f14Eft/bs XvRMpEzEks0tvXA8/jKph1yUf2VSKYovUu6qikhV37rwMOl9yu21pwA2gKz4+vG7kdTnzG6c 6Jg4vppHyn46T0MRf/it/CN90Vjp9XrspeaicDimjJLb2aAYUhW9LrnyQO5EinQi0+gGVuWt sw9zlrlPeYqmeQDWnQ2SunrxsRs3OJjGtwd6zcwcbylMESZTyVh0YraBBsPL+GbHbOnYSu29 j+VGMuBGSU/s1pIlhdOp3JX2Uffn01TeOvcw8+n5WAyAhq32AeMKkjyzXQYATZFNsubeoHGq FgCNa/BMdZz0DkALVjx9cBmnDwbQitW/iCGPL2IAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA0IjB4P8DnzyjwQz5J3MAAAAASUVORK5CYII= A group of colored bars Description automatically generated Figure 2: International Index of Erectile Function-5 (IIEF-5) of the patients after being subjected to water vapor thermal therapy with 6 months of follow-up.