 Need for a prospective study. If we can achieve the same superior results from our study incorporating the ALS packing strategy, we should be able to assess cost- effectiveness of using the ALS packing vs. standard approach as has been discussed in previous trials, but has not been systematically studied. In fact there are insufficient numbers of patients studies to even perform a meta-analysis. We feel that it is critical to prove the cost-effectiveness of the new strategy in order for it to be used in a widespread fashion. 