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Um Yeah, sure that can you see the first light? Yes, I can see. Ok, thank you. Um uh Good afternoon, good evening, good morning. Wherever you are. Uh welcome to the Zoom Academic Meeting of the Department of Pediatric Surgery in East London, South Africa. Uh Today we have a very unusual talk about antenatal and postnatal investigations and management of non malignant ovarian pathology in Children by Doctor Noom Gola. Doctor Kola is um she is um a consultant gynecologist and a gynecological oncologist and head of Clinical Unit at Hospital in East London. She is also a senior lecturer at the Walter Suu University. She did her M BC HB from the Water SUSU University in 2005, did her internship and community service in Umtata in the Nelson Mandela Hospital. She qualified as a specialist gynecologist in 2015 and a gynecological oncologist. At, in 2021 she enjoys m supervision and has special interest in cervical cancer prevention. And she is the principal investigator for the cervical cancer screening and treatment algorithm since a trial at Fair Hospital. So, uh we uh I welcome you do, I will stop share and then you can start sharing. Uh Thank you pro for that well, warm welcome. And uh also for the opportunity to present in, in your meeting. Um Let me just, you just need to share your presentation again. Yes. OK. Can you all see? Yeah. OK. Thank you. Uh again, for, for the opportunity to, to present this talk. It was uh quite uh not that usual for me as well and, and, and quite interesting. II learned a lot. Um I mean, uh since we first spoke, the topic evolved a bit and uh I hope uh in the talk, I'll be able to cover the pressing part for, for, for this uh group to, to learn from. So the the talk is uh antenatal and postnatal investigation and management of non malignant ovarian pathology. So as an overview, I just went over um ovarian pathology in pediatric population. And then later on, we'll talk about ovarian pathology and management in infancy and also in. So uh ovarian pathology in pediatrics, the most common pathology is ovarian cyst and uh the the most common cause of abdominal masses in Children and in pregnancy. Uh they do, OK. And they affect one in, in 2500 pregnancies. They usually diagnosed in the third trimester. And uh ovarian cancers are also um um occur in 3 to 8% of adolescents that uh repo that have an adnexal mass. And they also account for 1 to 2% of all childhood cancers. But for the purpose of this talk, we won't be talking about malignancies. So, ovarian masses in pediatric, uh they have um um a typical distribution where there are more cases reported within the first year of life. And again, uh around the age of 12, there's another peak and again, at the age of 16 years. So just talking briefly about uh the ovary, I've put the picture there just to, for us to orientate ourselves with the anatomy and the attachments uh of the ovary on the uterus and on the pelvic side wall uh through the suspensory ligament there. But of important is to note that the size of the ovary increases gradually from fetal life and it reaches the peak size at the age of 20 years and then thereafter, it reduces in size. So at about two years, it's about seven point mils in volume and at 20 years, it's between six and seven mils. And then at menopause, it's around 2.8 mils in volume. So the non ovarian uh pathology that are common in Children. I've decided to talk about these three ovarian functional ovarian cyst, ovarian torsion and uh mature cystic teratoma. Also noting that uh in um in the reproductive age or after a, there are also endometriomas and also in girls that are sexually active. You can also get tubo ovarian abscesses as a result of P ID. So the functional uh cyst they uh occur in a normal menstrual cycle. The two cysts that you would get it a follicular cyst and the corpus luteal cyst. The follicular cyst occur when the ovum is not released as a result of excessive FSH or LH Z and then uh a copper luteal cyst. They are derived from the copper luteum and they usually three centimeters in size. They don't usually grow bigger than that and most of the time they're asymptomatic and you do get these physiological cyst in the prenatal setting. And uh in the prenatal setting, they occur as a result of a fetal gonadotropins, maternal hormones and placental hormones. Uh Sorry, I don't know what I've done. Can you hear me? Yes. So we can hear you just uh presentation seems to be stuck on this slide. Yeah. Ok. Let me try that. Ok. Yeah. Let me just use that. Ok. So, so the next pathology to look at is ovarian torsion which occurs as a result of the ovary and ovarian mass rotating uh around its uh supportive structures causing an obstruction in the venous uh lymphatic and arterial flow. And eventually this can lead to an infarct or infarction of the, of the ovary. Uh It usually involves the ovary and the tube, especially when you've got an adnexal mass. And 15% of all ovarian torsion uh occur in pediatric patients and in pediatrics, uh ovarian torsion uh has a bimodal distribution and uh 16% of cases occur at infancy and uh 52% of cases uh in premen girls. So, in ovarian torsion, the symptoms can be acute, uh unilateral severe or abdominal pains, which could be associated with nausea and vomiting, uh and fever. And in infants, they might uh present with an abdominal mass and uh feeding intolerance. So, the next pathology that we'll go through uh is a mature cystic teratoma. It is the most common ovarian neoplasm in females below the age of 20 years. It's usually asymptomatic, uh, mostly diagnosed, uh, as an incidental finding even in adult, uh, in older females, that's, it's usually the case or they usually come, uh, already torted patients may present with abdominal pains or a sensation of abdominal fullness. And the common complications include torsion, uh, or rupture or infection. And really, you might get a encephalitis or hemolytic anemia. Um, the investigations that, uh, we do for, uh, these, uh, ovarian or these ovarian masses or ovarian pathology. Uh, I didn't dwell on the blood test because, uh, I mean tumor markers is when you suspect if there is a malignancy. Uh, if you've got a simple ovarian cyst, even in our setting, we don't routinely do tumor markers in young patients except for when you are dealing with an elderly patient. Uh, you might have to do some blood tests if you are planning surgery or if you suspect an infective cause. But, uh, your most important investigation when you are dealing with an adnexal mess uh is uh imaging. Uh the most commonly used will be ultrasound uh and then MRI in a perinatal period and in a pediatric setting and also CT scans. So you um the, the use for your imaging is you want to make or confirm the diagnosis or, or localize the ovarian mass. You want to assess if is this mass a benign or you suspect a non benign pathology, you want to exclude a cyst accident. And if you suspect a malignancy, this image, this imaging are going to use uh assist you in staging. So, looking at an ultrasound, uh it is the most useful diagnostic tool and for the diagnosis of ovarian cyst, it has a 94% sensitivity, 98 specificity in a pediatric setting, it's easy to perform and cost effective. It, it is helpful in differentiating between benign and malignant lesion. And uh mostly you are going to be doing a transabdominal scan and uh there is no room for a transvaginal scan, not unless the patient is sexually active and agrees to have a a transvaginal scan. So, on the ultrasound, what you are looking uh for, you are looking for features uh that are going to make you uh make a decision on whether are you dealing with a benign or a malignant uh mess. So, uh in obs and Gynae, we use the IOTA classification where they have a certain patterns for the b patterns for a benign tumor and M patterns for the malignant tumor. So, if your, if your mass or is uh your cyst is unilocular, it has um no solid component or at least the largest is uh less than seven millimeters. There is presence of acoustic shadows or it's a smooth multilocular cyst which is less than 100 millimeters. And also if there is no uh blood flow in the mass um uh itself, and then if you have features like that, you suspect that you are mostly dealing with a with a benign tumor. And on the other hand, if you have a solid tumor, uh ascitis papillary projections, more than four multiloculated cyst and uh a vascular lesion. So a strong uh blood flow within the tumor itself. And then in that case, you suspect that you are dealing with a malignancy. So uh also just uh to emphasize the features that you are looking for on the scan. When you are your ultrasound, when you are assessing your images, you are looking at the consistency of your lesion, the size the composition is it, are you suspecting caution that they papillary projections? And if you are, you are having a picture of a cystic mass which is about 8 to 10 centimeters or less, which is homogeneous, uh with no papillary projections, then you know that you are dealing with a, with an, with a benign lesion. So uh what uh we're just going to go through a few slides where we're looking at the pictures that we'll find uh on ultrasound. So your functional cyst, it's going to be a picture similar to that one we've got there. It's usually unilocular cyst, thin wall. Um And uh it could be, I mean, it's usually more than three centimeters, but it doesn't uh uh exits 10 milli 10 centimeters. And if it's a corpus luteal cyst, it will be thick walled, there will be peripheral blood flow or what we know as a ring of fire and there will be presence of internal hemorrhage or there could uh there could be no internal hemorrhage. So on the ultrasound, when you suspect a torsion, uh what do you find? You would find an enlarged uh ovary, usually the ovarian volume will be three times than uh bigger than the expected uh volume according to age. And if you don't have a chart to look at the age, you compare it to the contralateral side, which is something that you should be doing anyways. And that will tell you if the other ovary is, is enlarged, you would uh if there is medicalization of the ovary or deviation of the uterus of the mid line, that will also make you suspect that you are dealing with a torsion. If you've got a whirlpool sign, it's actually, it will be confirming that you are dealing with a torsion and the coexistence of a, a adnexal mass uh with or without uh the flow of Doppler that can also uh confirm that you are probably dealing with it. If there is no Doppler flow around the mess, then you would even suspect that you are dealing with an infected uh ovarian uh mess or ovary. So I've also just gone through the ultrasound features of a mature cystic teratoma. Um teratomas have got quite um a variety of pictures that you get on an ultrasound. You can get a picture similar to this one we've got on the screen which shows a cystic mass with a RTA nodule or dermoid nodule. You can also get a complete different picture where you are seeing a a fat fluid levels that is called a dermoid mesh or you would get a, a picture of a uh ground glass appearance which is typical of a dermoid. But if you are, if it's a teratoma, it usually has uh punctate calcifications. So the next uh imaging modality to look at uh in in the pediatric population is an MRI and its biggest class is the fact that it has uh no radiation exposure. And it also gives a good assessment of the whole pelvis and and and abdomen with excellent tissue contrast. The issue with it is that it's expensive and it's not always uh available. Uh So we use MRI most of the time secondary to ultrasound, if we suspect a malignancy or we are unsure of the findings on ultrasound in the prenatal setting, it might have a slightly more benefits because it also offers you an opportunity to assess the whole fetus for other congenital malformations. It is able to distinguish fat from hemorrhage and it can pick up infection, infection and necrosis. And it will also assist in staging. If you are dealing with the malignancy, the CT scan, uh it's also done secondary to an ultrasound. Although you might find that in a pri in an emergency setting, it could be the primary um imaging modality that is performed. And also, despite the radiation exposure concerns, it still remains the most useful diagnostic tool. There's better access to CT than MRI. And it will give you additional information to ultrasound if you require additional information. So, uh in summary, just a management of uh ovarian masses or pathology in, in Children, we will look at infants and, and and in utero in the next few slides. But in Children, a multidisciplinary team is necessary for management of these cases. And the goal for your management is to remove the pathology or treat the patho pathology. But the main, the other main goal is to preserve fertility, especially when you are dealing with a benign disease indications. For surgery will be an acute abdomen uh with a suspicion for torsion, persistent uh ovarian cyst larger than four centimeters if you suspect a malignancy. And in these cases, laparoscopy is preferred uh over laparotomy. And also for the reason that we are wanting to preserve fertility. A cystectomy is a preferred uh over or Omy. In fact, you aim to do a cystectomy and who performs surgery uh, in younger, uh, patients younger than adolescents. Uh, and preteens. I mean, it's, it's, it's the pe surgeons are responsible for the management of these patients and, uh for, for obvious reasons and in all the patients, uh, I mean, I'm, I read one paper where they, they, they were trying to answer this question and the conclusion which I liked it says whoever can perform minimally invasive surgery and achieve fertility preservation can, can, can, can do the surgery. And I think that is, is probably a fair, fair argument. And uh so management uh options for, for patients with uh different ovarian pathologies, the cyst uh can be managed conservatively uh assist uh between the size of 3 to 5 centimeters can be observed rescanned after three months. And um and then uh if it persists, you can decide on surgery. If it's bigger than that size, you can decide on surgery. But I just want to say also this is I'm in a pediatric group of patients. It's a wide range of age of people that are growing different. I'm I'm not sure how the pediatric surgeons if they will be comfortable observing an ovarian cyst of four centimeters in a two year old. So I want to say as much as uh this is the information that I got, but it might uh, it, I mean, it, you will need to individualized cases as well. Uh, ovarian torsion, uh, you would, uh, detort the ovary and perform Opex, which, uh, has been found that it doesn't prevent a recurrence of torsion. But, uh, at the setting where you are finding a torted ovary, you don't really have much options after unt toting it and also just some reassurance if you find an ovary that has torted and, um, seems to be, uh, getting infarcted with a blue black uh area. It's, there are reports that these ovaries once un toed, they can still, um, uh, have a normal ovarian function. So not unless there is a ova necrosis, the ovary can still be functional and then in mature cystic teratoma, uh smaller ones uh can be observed although they are less likely to regress. But the one reassuring thing about them is that they grow very slowly. One paper was even mentioning, uh, that they grow at a rate of 1.8 centimeters per, per year. If you are dealing with a larger cystic teratoma, you have to consider surgery. So I didn't complete, uh, that line consider surgery because they are high risk. They are high risk of toting. And uh, so all these benign tumors, I mean, they, they are most likely going to, to. So torsion becomes the, the main complication, unlike in the malignant um, cases where they are less likely to tort. Also the two other pathologies that I mentioned before that I didn't cover in this talk, endometriomas and, and, and, and Tuva abscesses, they are also less likely to, to. So it's only the benign that are most likely to taught. So um this is a flow diagram on the, the II got it from the talk uh on um they did a review of the management of cysts in the pediatric population. Uh just looking at the differences, I think the take home message here is that smaller cysts, you can um you can uh rescan and, and observe. But for larger cysts, you have to offer definitive management and everything in between. You probably have, you have to individualize. So uh looking at uh ovarian management of ovarian cyst in infants. So this uh paper is this, this was a, this was a paper from Canada. They did a retrospective review of patients in uh in the first year of life with ova with ovarian masses. 28 of uh the 40 cases that they had were managed surgically. The criteria is not outlined. And also the fact that this is a retrospective uh review. It, it's uh I mean there were different reasons why surgery was, was performed and 12 cases were observed and in these uh observed cases, they did serial scans, I think every two weeks and out of the 12 1 had um aspiration of the of the, of the cyst percutaneous aspiration of the cyst. So, when you look at the, uh, different groups of patients. So, most of, uh, in fact, these patients, some of them were diagnosed prenatally, uh, with this ovarian cyst and some were diagnosed postnatally. And, uh, the gestational age, um, at birth was the ones that were diagnosed prenatally was around 38 weeks and 34 weeks for the ones that were diagnosed postnatally. But, uh, what I want us to look at is the once at, at, at surgery, 18 of the patients, uh, 18, out of 19 of the patients that were diagnosed prenatally, had a surgery and the ones that were diagnosed post postnatally, about 10 of them had surgery and then 50% almost 50% of them were not, uh, were not operated on. So the outcomes of the Children that were surgically managed, they, when they opened them, these surgeries were performed, uh, after delivery, 96% of the cases showed signs of torsion intra op. 21% of them ended up with oophorectomies. Only 14 had, uh, ovary sparing surgery, which it is equal to four Children and 65% of them were reported to have, uh, the ovary was reported to have auto amputated at the time they were opened for, for surgery. So, um, just, uh, so the, the, one of the things that it was, um, I noted is the fact that the patients that were not surgically managed, they needed a, a longer length of follow up, which was almost five times more than the ones that were surgically managed, which is uh the down um size of um uh conservative management is that these patients need to come repeatedly of which uh in our setting, uh It could be, this could be problematic. But uh anyway, this is the, on the other side is that these patients need to be uh reviewed frequently and be assessed with serial scans. But the authors uh at the end, they do uh recommend observation and uh aspiration of per uh whether it can be done percutaneously or laparoscopically for, for these patients. So, uh management of ovarian cyst in utero, uh the in utero therapy aims to prevent or correct congenital anomalies in fetuses and it prevents their severe consequences on later fetal development. So, to be able to offer in utero therapy, you need to have a good imaging. And uh when it comes to ultrasound, you, uh at the time of the surgery, you will need real time ultrasound. So you need to have a fetomaternal specialist or a uh a level three scanner uh in, in, in, in South Africa. And uh also an MRI is an important uh imaging modality that you need in your unit to be able to offer fetal therapy. So, multidisciplinary teams are, are necessary where a fetal or pediatric surgeon, a fetal maternal specialist or at least a level three scanner and neonatologist and an anesthetist. Uh are important uh members of the, of the team. So looking at the management of ovarian cyst in utero, uh they uh I looked at these papers that were looking mainly uh on uh on imaging. They are 20 years apart. But uh both of them, they found uh ultrasound to be the most useful tool in diagnosing um Ovarian cyst uh in utero and uh therefore influencing management. So uh with the letter paper, they even do make a conclusion that as much as MRI can give you additional information, but it's not going to change your decision uh in terms of management that we have made using the information from the ultrasound. So ultrasound still remains the most uh important diagnostic tool uh in diagnosing uh ovarian cyst in fetuses. So uh just uh also reporting on the management of uh ovarian cyst in fetuses. I looked at uh this review, uh it's um paper from Japan. Uh In fact, the, the reason why I added this paper on the presentation is purely for, for, for, for this slide. So if you look uh at the, when they did the review, they found out um they've had patients that they've managed in their center who had a simple cyst and complex cyst and how they manage this patient. They noted that it actually evolved uh over the years where uh if there was a complex cyst, uh a patient will receive uh expected management until delivery. Uh But with um simple cyst, uh sorry, with simple cyst, they noticed that a there was a shift in the way that these patients were managed. Before 2018, all the patients who were diagnosed with simple cyst in pregnancy, uh uh they would receive expected management. And after 2018, people started thinking now that we probably don't need to manage everyone. The same way that uh fetuses that were found with cysts that were more than 40 millimeters were offered uh intrauterine uh aspirations and the ones that were less than 40 millimeters were offered expected management. And this was a retrospective review. So, out of the patients that they had uh with the, the simple cyst, uh we're just going to look at the ones uh that had a cyst that were more than 40 millimeters. So at the end, there were 15 of them, of which 11 had expected management and four had intra run aspiration. And if you can, if you look at those that had uh aspiration, two of them, post delivery needed to be operated and two of them were observed and these are the results for the 11 that had expected management. Three of them developed complex cyst and were therefore operated, of which two of them had uh necrosis and actually one ended up being observed. And then in the rest of the eight patients, five were operated and three were observed. So the one the last uh article we're going to look at is uh this publication in the journal of ultrasound in obstetrics and gynecology. They actually did a randomized um a controlled trial. So this is a prospective study where they compared in utero aspiration versus expected management for anechoic uh fetal ovarian. So they recruited 65 so sorry, 66 participants and five declined and that and they had 61 of which 34 had in uh aspiration and 27 had expert and management. And um as the characteristics of the participants were quite similar, the maternal age was the same, the age of diagnosis was around 34 weeks for both groups. And uh the distribution of cysts was also quite similar. Cysts that were less than five centimeters were 24 in the in utero group and uh 19 in the expectant group and the cyst between eight and five and eight centimeters, nine and eight and greater than eight centimeters were one and zero in the expectant group. Uh So, uh looking at the, at the results uh postnatal or postdelivery uh intervention in the group of participants that had in uh aspiration, seven required neonatal intervention compared to 10 in the expected management. And uh in utero evolution of cysts were 16 in the aspirated group and five in the expected management. And uh I mean, I think the biggest uh result to look at is the oophorectomy, which was one in the aspiration group and six in the expected management. So, uh I mean, I think this is the the biggest uh achievement uh with this um randomized trial, which is going to be the last study to look at. So having looked at this, my conclusion is that the management of ovarian pathology in pediatrics need a mental disciplinary approach. Uh All the patients, I think there are several management approach that we're probably quite familiar with and uh in infancy and in utero, especially in utero, I think uh looking at the, the, the last um paper that we looked at in our setting, it is probably uh it's giving a challenge to us to probably consider uh our practice and uh and, and, and, and, and also to note that um cyst drainage is, is, is probably uh an, an, an, an, an option for management of these patients. Thank you. Uh Yes, thank you, doctor me. So that was really an excellent talk. Um uh We have one question which ii will come to. Uh but I just want to thank you for highlighting that as far as possible. Ovarian preservation should be uh tried or attempted in cases of uh ovarian or tubo ovarian torsion. I just would like you to uh clarify uh or, or just elaborate a little bit on the Whirlpool sign uh for ovarian torsion uh on ultrasound, I think for the junior uh colleagues here. So just please explain about Whirlpool sign. Oh, ok. So the, the Whirlpool sign is because the ovary is twisting uh around uh its uh its structures and therefore taking with it the, the, the blood vessels. So your, your, your artery and the and the vein. So if you put a, a color Doppler, but e even in a black and white, you are probably because there's also going to be edema around. So it's the, the blood flow and, and, and, and the edema around uh or of the fluid collection around the ovary, they will give that um Whirlpool sign. So that is the, that is what is, is, is, is, is causing the whirlpool sign. It's the, the, the, the vessels that rotate uh around or the edema around that ovary. Yes. Thank you. We see a similar sign in mild rotation with world. So I just wanted the juniors to know about it. There is a also testicular torsion as well. Yes. Correct. Yes. Yes. So a any torsion of the vessels which will change the, the relative position, we'll give you a sign. Uh Thank you. Uh There is a question by Doctor C Botu who is a pediatric surgeon. Um I think she's asking about that Canadian study. What age did the babies with prenatal diagnosis of surgery? And was that included in the study? Mhm. The ones that have said, I think it's, it's within uh the neonatal period. Uh II could be mistaken. I don't remember but it's, I think it's within uh the 28 days of, of, of life. Oh, wait, not the Canadian study. Yes, I think so. Give me, I'm, I'm, I'm, I'm, I'm confusing it with the, with the, with the French one, the last one that I spoke about. So I think that was up to 10 weeks in the Canadian study. Ok. Ok. Thank you. Um, all senior colleagues from South Africa and outside are attending. So I'm just going to ask some of them to give their uh comments. I see Doctor Ellen Map who is a senior pediatric surgeon in Johannesburg. She is attending. So Ellen, any comments, any experience about uh these things? Um, good afternoon everyone. Yeah. Well, I think she commented on how to live like an uh I think she said a child uh with a big size, an apparent big size cyst. I mean, we do leave the neonates um, as long as it's not symptomatic and it's less than five centimeters. We do observe and watch and they do regress like I can think of a, a number of them, maybe two or three which regressed. Uh Actually one of them, the parents were against any intervention, although it was centimeters that was in December last year, but now it has regressed um over time. So as long as it's simple and you don't see features that are too suspicious. Yeah, you can, you can wait and watch. That's what I would say. Mm. Yes, thank. Thank you. Yeah, please come in. No, no, I'm saying. Thank you for that. I mean, it's like if you are working in a territory that's not yours, you like as, as much as the literature is saying that. But I was like, mm, I'm not sure if the you guys actually do that for. So it, it's, it's, it's, it's reassuring. Thank you for that comment. Yes, I, and, and you nicely showed uh the difference in the benign and the malignant types of ovarian cyst. So I think those are something which uh we need to think uh while deciding whether it is benign and malignant and obviously ones which look benign and are symptomatic. They can be left alone and small ones. Uh Next, I would like to ask uh Professor Chaudhury, he may have joined a little bit late. Professor Chaudhury is a senior pediatric surgeon in Pakistan. So Professor Chaudhury, any experience, any comments, not sure whether he's able to hear me. I also saw uh Professor Roma Bko. I hope she's still here. Uh Professor Olle is a senior pediatric surgeon from a co so Roma if you are still here. Yes, please come down here. So I don't know if you understand me well, but we have some case diagnosis at birth one day after birth. So we it's so big big cyst. So we need to operate them. But I think so it's uh it can be helpful to have um to do, do function of this uh of this system? Oh, you mean like aspiration? Aspiration? Yes. Yes. Yes. Yes. Yes, you can hear. Yes. Ok. Ok. Thank you for this. Uh a nice uh it's a nice presentation. Yes. Yes. Thank you. Thank you. Um I saw doctor Nikola Masha, but I don't think she is in the meeting. Um So I will, I think the last comment I'll ask is doctor man who is a senior consultant, pediatric surgeon in our department uh to make comments. All right, thanks. Thank you, Doctor NGO. That was really a good presentation. I think it was good for the pediatric surgeons. It's something we don't discuss um frequently. And as you said, we are responsible for the surgery uh and management of these patients. I just have a, a question uh out of interest. Does your institution, can you do cryopreservation of ovarian tissue at your institution for bilateral disease? They showed that she works with us at prayer hospital. Oh, ok. Yeah, the question is still value but she, she was, I thought she was the uh no, I and II don't think in the, in the public sector there is, I mean in, in, in the Western Cape, I think they still use the, the, the private labs for, for, for, for that. Uh I'm not sure if anyone does it in the public sector in South Africa. Ok. Well, that's interesting because um II guess it's more important than the malignant disease. But um bilateral disease. I think we need to think about that in the Children to the fertility. But thank you for the talk. It was really good. Thank you. No, excellent. Uh I think uh if there are no other questions. Uh no. So I would like you to give a final take home message um And then we can conclude our talk. Yes. Um Thank you for no. Uh Thank you for the opportunity to, to talk about this. And I think for me, the main thing was to actually uh firstly, I mean, the torsion in pediatrics, it, it, it was uh something completely different to what I know in obstetrics in Ghana. We don't have normal ovaries toting, we have an ovary with a cyst that taught. So uh that was, that was quite interesting, but also just the management of, of ovarian cyst as the other pro was saying, I think the emphasis that now we can uh I mean, if the cyst is simple and benign, there is no problem in aspirating it. And also if the aspiration is done early, then you are going to, you're more likely to preserve fertility and prevent an uh future or, and, and, and as a sort of like um not future as in, in a long time, but an an an oophorectomy that can come as a result of that ovary being touted. So I think an aspiration uh allows an um a simpler way of managing these patients and it will even be nicer if we could do it uh in uh utero because we can see if we do that there are better outcomes. And of course, I mean, in terms of the data, it was not a lot that I provided, but it's also a challenge that uh we can actually do more trials uh to look at these um uh interventions and which one will be the best. So again, thank you for the opportunity. Uh Yes, I would just like to uh say that uh we will certainly um involve you uh people if we need any assistance. Uh We usually manage Children up to 12 years of age. But if you come across any child between 12 and 18 years of age, uh please feel free to contact one of us and we will try our best. My younger colleagues have, have very decent laparoscopic skills. So, if you have uh a a child between 12 and 18 years of age, they will be most willing to, to come and be with you and assist you for the laparoscopic uh uh approach for such a patient. And uh thank you again. And uh our last meeting will be on the 12th of December same time and we will have a talk by doctor Yako Yun who is a pedia uh orthopedic surgeon with special interest in oncology and he will be talking about uh malignant bone tumors in Children. So thank you all. Um I will upload the video recording of this talk on the youtube channel uh shortly this evening. Thank you all. Bye-bye. Thank you.