Host

Good evening and welcome to our webinar on exploring effective male urology treatments. I’ll be your host this evening and our expert presenter is Mr Steve Garnett, Consultant Urological Surgeon.

This evening, we'll do a short presentation and that'll be followed by a Q and A session, you can ask questions throughout at the bottom of your screen using the Q and A icon and we will answer at the end. You can do this with or without giving your name, just note this session is being recorded so if you do provide your name then other people can see that. The good thing about providing your name is that if we don't have enough time to answer all your questions, we can then contact you afterwards with the answers. I will now hand over to Mr Garnett, thank you.

Mr Steve Garnett

Thank you.

Good evening, everyone. Thank you for joining us this evening.

So, we're just going to talk a little bit about prostate treatments but also a little bit about some some of the other Urology treatments we offer here at Benenden Hospital.

So, I've been a a Consultant Urologist here at Benenden for quite a while now, I think 2009 I started here and before that in East Sussex, which is my NHS base in Eastbourne. I do a lot of prostate type surgery as well as general urology and prostate cancer surgery.

So, we're going to talk about enlarged prostates, what that means and some of the treatment options. There is a little bit about testicular problems and erectile dysfunction, and we'll come on to that at the end. So, the the Crux of what we're talking about really is prostate enlargement, which is a normal process in in men as we get older so unfortunately the older you get the more likely it is that your prostate will be enlarged, and that process actually starts at a relatively young age. It probably starts in the thirties and increases over time and what does that actually mean. Well this diagram here really gets to the sort of the number of the matter the prostate is a gland here that sits just underneath the bladder and this is the bladder which is essentially a muscular sack that holds the urine and the urine is obviously made in the kidneys and comes down to the bladder and when you pee you pee out actually through the urethra which runs through the prostate and when you're a younger man and the prostate's fine you get a good flow of urine because there's no blockage to the way out from the bladder and as men get older and the prostate enlarges it doesn't just grow outwards it grows inwards as well and blocks the urethra and causes a restriction in flow. This can make it more difficult to pee, the the flow of urine gets slower, and it can be difficult to start peeing and it can be difficult to completely empty the bladder. These give the typical sort of prostate symptoms that many men get which can include getting up a lot at night having to pee more often, having to rush to the toilet, that type of thing.

So, there are a number of different treatments out there for prostate enlargement but I particularly wanted to talk about this evening is the UroLift® system, which is a relatively new treatment it's been around a little while now we've been doing it Benenden for quite a few years but it has a number of advantages over some of the more established or longer term treatments which are a bit more invasive. The UroLift® can be thought of as an alternative to drug treatment, medical treatment or in some cases more invasive surgery such as TURP or TURP surgery, which is very commonly done operation for enlarged prostate. What the UroLift® offers is a quick symptom relief with a better side effect profile, fewer complications or side effects than bigger surgery and good symptom relief, it's better or more effective than tablets it doesn't have any impact on sexual function which is a big plus as some other treatments do and people can get back to normal activity and work and whatever they want to do very quickly. What do we actually do when we're doing a UroLift® procedure? Well, we're putting little implants into the prostate to open it up, so rather than cutting anything away or destroying anything we're simply pulling the prostate open using a telescope which goes into the bladder. We're firing these little implants through on either side and rather than the prostate coming together and blocking the way out the sides or the lobes of the prostate are pulled apart to create a nice channel through which you can pass your urine. What what does the UroLift® implant actually look like? It's actually a little bit of a metal, it looks like a treasury tag doesn't it? That's what everyone says to me, but it's a little metallic implant with a bit of stitch material between the two ends and that is tensioned to pull the prostate open. What does that look like? Well, when we look into the bladder before a UroLift® you can see in the lower left picture the two lobes of the prostate, this is a camera inside the urethra inside the water pipe trying to look into the bladder and you can see the lobes of the prostate on each side are actually meeting in the middle and there's no easy passage through to the bladder. In the middle picture there, you'll see that the UroLift® implants have been placed and those lobes have been pulled apart so that opening there is the way in and out of the bladder so there's no prostate tissue causing a blockage in and out of the bladder.

The final sort of pictures here on the right hand side above and below just showing that the important structures which are the the dorsal vein and the neurovascular structures which are the nerves that run to and from the penis, these are well away from where we're placing these implants which is why these implants don't cause any impact on sexual function.

Okay, it's probably easiest to actually show you a video to describe how this works in in real life because it's always a little bit difficult on these inanimate pictures and things so I'm going to play a video which does have some American voice over you'll just have to deal with that. I'll come back to you, so we'll hopefully play this and this this this animation kind of shows you exactly what's happening when the UroLift® implants are placed.

[UroLift® video plays]

Okay, if I move on. Right, okay. So hopefully that gives you a better understanding of what actually is being done physically to the prostate and the lobes of the prostate during the UroLift® procedure and shows you you know very much in in visually exactly how this treatment opens opens up the channel out of the out of the bladder allowing allowing men to pee better. Once this has been placed and by relieving that blockage it actually takes pressure off the bladder which means a lot of the other symptoms that men get which we refer to as irritative symptoms so that's a feeling wanting to go a lot or maybe getting up at night they they tend to settle down as well once the blockage has been treated.

Now, I said earlier that the UroLift® was a relatively new treatment but the actual the studies started back 12 years ago now on on the sort of originally I'm looking at the safety and feasibility of this and it started in the USA and in Australia and the first of all studies published on this were were 10 years ago now and a major study was 2013, this so-called lift study which I'll talk about a little bit which was a really important study to show that this was effective and safe and and lasted so there have now been a lot of studies done showing the effectiveness of this and the safety of this and in fact got a positive NICE appraisal for the NHS nine years ago now or eight years ago and nearly nine years ago and was then widely adopted as a as a measure in the UK in 2016. Unfortunately, although it was you know accepted it hasn't been easy to for many NHS hospitals to to adopt new new system, so although it's in theory available, it can be difficult to actually get to have this in NHS hospitals. In terms of sort of studies that have been done I won't go into too much detail about the studies but this is an important study which is worth talking about a little bit because it was a rare thing in in surgical studies because it involved what's called a sham and lots of studies it can be difficult in surgical studies to prove that a treatment works because it's fairly obvious you've had an operation but in this study they actually did a sham operation which involved putting a telescope in into a patient and making a noise which sounded like the UroLift® was being deployed and so neither the patient which is the subject or the people assessing them afterwards knew if they'd had the UroLift® or not so it was to try and really give what we call a double-blind assessment and it was a very well-constructed study done both in the USA Australia and a couple of centres in Canada. This goes back some time now, but it was a very important study that that actually showed that the uplift worked very well and was durable and lasted and if we look at the results and there have been quite a few longer-term follow-up studies now going up to four and five years showing that actually symptoms improve very rapidly. This number here refers to something called the international prostate symptom score and that sort of an indication of how bad someone's symptoms are and if they're hot they have a very high number they have bad symptoms and the number dropped down very rapidly and has remained low up to four years and that's a very you know impressive result in terms of persistent symptom improvement and now five-year results have been presented and again have shown prolonged and persistent improvement in symptoms with a low re-treatment rate so a few people do need further treatment and that's important to note but it is it is low foreign importantly in in the studies that have been done they've been very little in the way of serious more prolonged side effects. Stinging and burning after passing urine and most people will get a bit of that for the first 10 days to two weeks after a procedure but it settles down very quickly and they've been very few more serious problems and no sexual problems at all and actually it's been very low retreatment rates compared to other treatments for the prostate. If you look at the UroLift® 13% of people needed something further doing after five years which is which is a pretty low figure overall and importantly people are able to get back to their activity very quickly. This is five days was the average sort of return to the normal activity which if you compare to bigger operations is very very quick, so for people who are working or got things they need to be doing it's a very good procedure allowing you to return to your normal activity very quickly and doesn't restrict you from doing things for very long and this is sort of comparing the UroLift® with more major surgery. TURP or transurethral resection of the prostate is a good operation it's been done for a long time there's and is what we always compare new treatments to and UroLift® compares very well in terms of overall satisfaction because of the very low side effect profile.

I think this is a nice summary slide what this is trying to show is the positive things about the positive things about each treatment versus the side effects and what you can see in this is that you get a good positive improvement in symptoms with the UroLift® which is not quite as good as the bigger operations but when you look at the side effects or complication profiles of the bigger operations and compare it to UroLift® it fares much much better so very few side effects which are generally mild versus more serious side effects with bigger operations. I think what's really interesting about this slide for me anyway as a doctor we often tend to think not think so much about the side effects of of the drugs that we give patients but actually a lot of people with prostate symptoms are put on various drugs particularly drugs which are called alpha blocker drugs and they're very effective at improving urinary symptoms a bit but they all have quite serious side effects so tiredness and I see a lot of men in my clinic who just say the medicines do help a bit but I feel tired, I feel awful, I don't feel like my normal self, I get a bit of dizziness, get some sexual side effects and really I don't want to keep taking these tablets, they're they're ruining my quality of life. Often doctors don't think so much about that, we tend to think about operations and the effect of operations, but I think it's really important to remember that medicines do have side effects and so UroLift® can be a good option rather than take continuing to take tablets for a long period of time and this is sort of looking at where does UroLift® fit in. I think that these are the alpha blockers I was talking about, and I think UroLift® is a good option actually, we often think of it as an alternative to to more major surgery but it's actually a good alternative to taking medicines for a long period of time. Really anyone who has prostate symptoms can be considered for a UroLift®, there are some sort of people with very large prostates who aren't suitable and some prostate shapes that aren't don't do quite so well with UroLift®  and we need to do some tests to look into that but from the starting point anyone who has urinary symptoms could potentially have a UroLift® and there have been further studies looking at the UroLift® in the real world so that means outside these sort of tightly confined studies and this shows again good ongoing reduction in symptoms and improvements and this has continued to show large numbers of patients now with ongoing good results.

This always raises a few eyebrows, but this slide is kind of a visual representation of what a lot of men find that they're struggling with and when they when they come to see either their GP or a urologist to talk about their urinary problems. I think that most of the men I see will will recognize this pictures as as when we're young men or boys we have the competition to see who gets over the five bar gate and we can all pee well up high and then as we get a bit older it comes down to here and then unfortunately if the prostate really enlarges we can end up worrying about splashing our toes when we're at the urinal and it and that's really exactly what we're talking about when we're talking about the obstruction to the flow from an enlarged prostate.

One of the first things that you'll have done if you come to see a urologist to talk about your urinary symptoms is something called a flow test and that is a more scientific way of trying to judge what your flow is actually like. You'll come along to clinic and we will ask you to pee into a bowl like here on the right which is connected to a something called a flow meter or a flow machine and that will give us a graphic representation of your flow and it will look like this and a normal flow in a younger man is a very fast flow getting up to 20 mils per second or more and once once you've finished peeing it stops very quickly and that's it but what we see in men with prostate enlargement that's blocking the way out of the bladder it's a slow flow it goes on its prolonged it might stop and then start again stop and start and you might have a bit of dribbling towards the end and that's that's something that we we want to see to know that the prostate is causing a blockage and that's a simple non-invasive test that can be done at some GP practices and certainly all urology clinics.

In summary, the UroLift® is a good minimally invasive treatment for enlarged prostates causing obstructive symptoms. It rapidly causes symptom improvement; it improves prostate symptoms very significantly and increases the flow very quickly and most of all the improvement is there within two weeks of treatment and it has mild symptoms that are usually nearly all gone by a couple of weeks. There's no impact on sexual function. We generally do it under a short general anaesthetic because I find that most men find it a little uncomfortable under local anaesthesia but it can be done under local anaesthetic, it's been shown to have long lasting results up to five years and there's lots of studies around the world now showing that this is a reliable treatment, so it's a good treatment option for many men with prostate enlarged who either don't like the medicines they're on or don't want to have more invasive treatments.

I'm going to move on just to talk very quickly a little bit about other Urological or men's health problems that we see. In terms of what we see a lot in the clinic is testicular lumps or scrotal lumps and swellings. These are usually something called hydrocele or epididymal cyst and what this diagram is showing you is that this is the testicle here but it's not uncommon that men get sort of painless enlargement around the testicle and that is actually usually fluid and that's called a hydrocele and in most cases there's no serious cause for that, it's just a again something that can happen in manners as we get older and you can get a collection of fluid around the testicle that causes swelling and obviously that can be worrying but usually it's very easy to diagnose that. This is a simple hydrocele and nothing worrying, occasionally men can get epididymal cysts which is this structure here, which runs along the side and the top of the testicle. Again, this can cause a lump next to the testicle which can be worrying and certainly any any lumps or in increase in size in the testicles should always be investigated and checked out, but they're nearly always not worrying in men over the age of 60. Younger men sometimes it can be serious causes but that that is obviously something that can be looked at very easily and very quickly by your doctor so if there is a testicular swelling like a hydrocele or epididymal cyst, that's causing enlargement usually it doesn't cause too much in the way of pain but what most men say to me is this this swelling gets in the way when they're trying to do their activities, particularly if they like cycling or you know playing sports or things like that it's and it can be unsightly, particularly in in trousers and things. A lot of men do come to see me to seek treatment for this and this can usually be sorted out by a relatively small straightforward operation which can be performed here at Benenden as a day case procedure.

We do obviously see a complete range of men's health problems, including erection problems and again this is not an uncommon problem in men and it's usually due to narrowing of the blood vessels that carry the blood to the penis. It's the same actually process that's associated with heart disease because that is also narrowing of the blood vessels, there can be some hormone problems and there can be some medicines often people have put on medicines for high blood pressure which can actually cause problems with erectile dysfunction so there are a number of things that can be looked at to improve erections. Obviously, again these things can be discussed with your doctor but if if you're not getting anywhere then there are a number of treatments that can be offered usually starting with tablets here at Benenden that we can offer to help with erection problems.

Flow obstruction really just is talking about what we've just been talking about with the UroLift® but if it gets very severe and gets to the point that the prostate is causing a complete blockage and that's called acute retention of urine when when someone can't pass urine at all and the bladder's very full obviously that's usually very uncomfortable and painful we can all all know and sympathize with what it's like when you're desperate to pee and you can't that can cause further damage and problems with the kidneys and things like that and usually requires an urgent procedure to pass a catheter to drain that off and then we can look at various treatment options to try and get rid of the catheter and remove the underlying problem which is usually prostate enlargement and obviously we've talked about UroLift® which is one treatment for that as is more invasive surgeries such as TURP surgery which cause out the prostate and that may be more appropriate if you've unfortunately got to the point of needing a catheter in.

I think what I'm going to do is stop there at this point in terms of what I'm saying about urological problems and hopefully a few questions have come through and I'm happy to take questions and and talk through that if if anyone's got any.

Host

Thank you, we do have some questions. I think there's a three-part question from Ian so I will start off with the first section. They have an enlarged prostate; I would like to ask why it works fine during the day but not at night?

Mr Steve Garnett

Yes, a lot of a lot of men asked me that and they do say look it's not too bad during the day but night-time it's it's really awful. I think there's several factors in that Ian. I think that often men within large prostates don't empty their bladders very well and during the day particularly when you're up and about and doing things or if you sat down watching TV or you tend to be a bit distracted and not so much aware that there is a a lot of urine left in your bladder but at night time when you're lying down and you're not doing anything other than trying to sleep and also in a in a lying down position you are more aware of that urine that's left behind in your bladder and it can make you feel like you want to pee a lot. Also, if your bladder gets very full men with prostate problems typically do find it more difficult to pee so the bladder is a muscle and all muscles work best at a certain sort of range of movement and if the bladder gets very full and overly stretched then the muscle doesn't work so well so the flow will be worse then and finally there are a number of other factors that influence why people have problems at night so some people actually it's not related to their to their prostate but they may make more urine than they should do at night and then feel that they constantly need to pee so that's a slightly different problem but just because you've got an enlarged prostate doesn't mean that you don't have or can't have that problem as well.

Host

Okay, stage two is what anaesthetic is generally used for UroLift®?

Mr Steve Garnett

So, we generally use a short general anaesthetic, it can be done under sedation but to be honest with you there isn't actually much difference between a short light general anaesthetic and a a heavy sedation and it's usually easier just to do a short general anaesthetic, but it can be done under sedation and local anaesthetic.

Host

Okay and can UroLift® ever be reversed if a different treatment is needed in future?

Mr Steve Garnett

Yes, it is, as as I indicated several men will have UroLift® and then go on to need further treatment and you can still have further treatment such as trp or laser surgery and that can be done after a UroLift® and the internal implants are removed during that procedure.

Host

Okay, thank you We have a few hands raised and it's best if you type the questions via the Q and A icon if you do have a question or even in the chat icon.

We have a question from Stephen currently suffering incredible pain passing urine and still undiagnosed and has an enlarged prostate well that's been mentioned. You say we were a UroLift® lasts five years, what happens after that?

Mr Steve Garnett

So I'm not saying UroLift® wears off after five years I'm just saying that the studies that have been done up to now have only gone for five years so you you may well be fine for more than five years and you may not have you may not ever need further treatment but with any new treatment obviously it takes time to find out what the long-term effects are and that's the the difficulty for new treatments is that we don't know long long term what what happens but as I've just sort of indicated you can have further treatments and it may be that in five six seven years you need further treatment such as another UroLift® or another treatment but that those are all options. What I what I would just say on on on your question and and referring to your symptoms actually although you know enlarged prostate does cause a lot of symptoms it's not usually painful to pass urine so if you've got pain I'd be a little bit worried that you might have a urine infection or another problem such as inflammation in the prostate rather than simply just prostate enlargement because that doesn't usually cause pain.

Host

Okay, thank you. Michael asked what tests are needed to determine suitability for UroLift®?

Mr Steve Garnett

So, you'd need to come up for a consultation and an examination and do a flow test. We'd ask you to complete a symptom questionnaire which gives us a sort of idea of how bad your symptoms are and then in most cases you would need a camera examination of the prostate and bladder just to check that the prostate shape is suitable for the UroLift® because a small number of men do have what we call a middle lobe or a lump of prostate in the middle rather than at the sides and obviously if the urine if it's pulling the sides apart to create a better flow if you had a big lump of prostate in the middle that that wouldn't be such an effective treatment.

Host

Thank you, another attendee has asked if we check for cancer as part of the tests for UroLift®?

Mr Steve Garnett

Yeah, so it's part of the test for the UroLift® I either when you come out to see us all often your GP beforehand would do a blood test a PSA test on the prostate and then we'd examine you and the combination of that gives us a very good idea of the likelihood of any prostate cancer. Obviously if there are any concerns about cancer then further tests would be done and we wouldn't do a UroLift® before we were happy that that that prostate cancer was not an issue.

Host

Thank you. Relating to cancer, Thomas said he had prostate cancer, and his prostate was removed General in 2016. He now has all the symptoms of prostate cancer again and passing urine with slow flow as you described and many times at night any thoughts on the reason for this?

Mr Steve Garnett

Yeah, I mean there could be a number of things there, I mean clearly, I don't know exactly what treatment you had but if you if you had an operation to fully remove your prostate for prostate cancer then obviously the prostate itself won't be causing any blockage. What can happen in that situation is you can get narrowing down of where the bladder is joined onto your urethra your water pipe and that that that kind of scarring that sometimes happens after that type of surgery can mimic the same symptoms as prostate enlargement but again by blocking the way out of the bladder so some further tests may be needed there to work out exactly what's going on.

Host

Thank you. Christopher mentions says that one slide mentioned being catheter free after one month, can you expand on this and how long are you in hospital?

Mr Steve Garnett

So that slide was referring to people in one study who had the UroLift® when they already had a catheter in so that that's that's a slightly different scenario. Most people who have UroLift® do not have a catheter in before or after the procedure, we don't routinely put a catheter in. This is a day case of operational procedure, so people come in and go home the same day, there's not usually there's no need to stay in hospital. A small number of people can occasionally have trouble peeing after so we always keep a close eye on you after the procedure to make sure you're peeing okay, occasionally people do need a catheter putting in so I can't give you a hundred percent guarantee, but most people do not need a catheter.

Host

Okay, thank you. Can you self-refer for this process or is it by the GP?

Mr Steve Garnett

You can self-refer for as a private patient at Benenden Hospital, I think the details are on the slide in front of you.

Host

Thank you. Michael says he has a dwelling catheter in place at present and is awaiting a TURP procedure with the NHS, however it has a long waiting list if he was to come to Benenden for a consultation can you deal with the catheter in place?

Mr Steve Garnett

Yeah, I mean it's difficult to get into too many details you know obviously I can't give you a consultation right here and now, but we see plenty of patients with catheters in and that's something we can deal with at Benenden and talk to about the various treatment options. It may be that a TURP is the best operation for you and that is also something we can provide here at Benenden Hospital so I’d be very happy to see you and talk through the options and yes, we can certainly treat you with a catheter in.

Host

Thank you, final question I have now is is it common for testicular non-cancerous lumps to return after treatment?

Mr Steve Garnett

It does depend of course which what treatment you've had and what lump you're talking about but it's not common. I wouldn't say it's common for certainly hydroceles if they're effectively operated on it's not common for them to recur, they can you can get it on the other side that's possible and epididymal cysts sometimes you can grow another cyst so I wouldn't say it's common, but it happens occasionally.

Host

Okay, suddenly we do have a couple more questions I think we have time to fit these in. Stephen says he's currently prescribed the tamuse that you referred to earlier, do you believe this is an acceptable long-term option for prostate issues?

Mr Steve Garnett

So, it has been used long term in many men and and yes look it does appear to be safe as a long-term medication it's really a question of whether you're happy taking it long term. If you're taking it and getting good Improvement in your symptoms and are not getting side effects then it's a good option for you and it's safe but if you're taking it and it's not doing enough you've still got symptoms that bother you or you're taking it and you're getting side effects like dizziness, tiredness, stuffy nose, sometimes people get also men can get ejaculation problems on that medicine, if you've got that or occasionally erection problems as well if you get any side effects like that and you want to get off the tablet then the UroLift® is potentially an option for you.

Host

Thank you, okay Richard says he was diagnosed as having a BPE in January 2021 by yourself, he thinks at the stage now where he would like to discuss UroLift®, should he book in a consultation with you?

Mr Steve Garnett

Again, BPE is benign prostate enlargement. So yes, it sounds like you should come back and see me again.

Host

Thank you. A couple more. Ian says he takes a finasteride and has been told and told it's also proven to reduce prostate cancer risk by 25%. Can you comment on your knowledge of this?

Mr Steve Garnett

I would not actually say I'm comfortable to accept that. Finasteride is a useful medication, it works to reduce the conversion of testosterone to a more active form of testosterone so it's a hormonal type of drug and it works by that hormonal effect, it works to slowly shrink the prostate down. By doing that it also has effects on the PSA level and also obviously by shrinking the prostate it can improve urinary symptoms, it's not it's because it's a hormonal drug it's not a quick acting drug and you do have to take it for quite a while to get an improvement but it is it is a useful and effective drug it does have side effects and a number of men can get erection problems on that and also a number of men can get breast tenderness as well so it's not for everyone but it is it is a good drug and it's the only drug that actually reduces the prostate size. In terms of reducing prostate cancer that that's quite a contentious issue what it does do is reduce the PSA level and it may reduce the detection of what we would call not significant prostate cancers whether it has any impact on actual development of prostate cancer I think is a little bit less clear to be honest.

Host

Okay, this is our last question we're going to take. If someone had a UroLift® procedure three years ago and symptoms are returning, does it mean the system is breaking down or is further treatment required?

Mr Steve Garnett

I think it's probably more likely that the prostate has grown further and you know as as outlined in the in the sort of study slides and things there is a retreatment rate a small number of men every year will find that that their symptoms have got worse after any treatment for the prostate enlargement including urine and also including more major surgery so the prostate can still continue to grow and if that gets to a point where the symptoms are getting worse then it is possible that you may need further treatment. What I would say which is worth bearing in mind is you know if you have a relatively minor treatment a small treatment like UroLift® that's done as a day case that has relatively few side effects then actually if you did need to have it done again after three four five years that may not be the end of the world it's clearly a personal decision and something you need to think about but some men would prefer to do that and some men would prefer to have a bigger treatment with more side effects but a slightly lower risk of needing something doing again in the future. It's a balance that you must consider.

Host

Great, thank you.

Well, thank you very much for everyone typing in your questions, it's great to have a good conversation at the end. If there are any more questions coming up and you haven't asked yours so, please just let us know your name and we can answer those. If you’d like a consultation with Mr Garnett, the details are on the screen there and we are offering 50% off your consultation if you're booked by the 5th of January, you just need to quote the webinar on the subject line.

At the end of this, a survey will pop up and we'd really appreciate it if you could complete the survey, it gives us feedback on the webinar process, the booking the bookings areas onto the zoom webinar and for Steve as well it would be great to give some feedback for him.

Our next webinar is actually this Wednesday it's on ear, nose and throat symptoms and it's with Mr hone and that's at 6.30pm as well. If you'd like to register for that you're very welcome to via our website. In January we also have webinars on weight loss, orthopaedics, and gynaecology, so take a look out for our future events for your friends and family. Now, just to say thank you very much Mr Garnett for your time and your information this evening, thank you very much everyone for joining us, we hope it's helpful. Thank you to my team for supporting this and have a nice evening everyone. Thank you, goodbye.