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and okay, so that's that's live I ever want. Um, I can see that there's a good number of people already here, but, um, we'll give it until two minutes past 8 p.m. u k. Time. And then we can go ahead and start, so I'll just give it another three minutes. Right. Okay, so I think we'll go ahead and start. So welcome, everyone again to one of the mind the believe urology, Siris Sessions. Today's topic is going to be about flank pain on green or colic. So I'm going to go ahead and handover just now. Teo, Doctor, half you. Who's gonna be talking about this subject? Thank you, Doctor. The area I'm Dr Copies in Georgia On the physical set, these are particles presentation blank piece. It's a very good topic on, uh, I've tried to coverage as injured. That mean, what, 5 to 60 minutes? Uh, we'll see how so Logical complaints with which patient presents it could be cracked rise for either being on. It could be any change in the act of situation. They could be some changes in that was a peer in off the urine, the any change or function or appearance off mean gyn kill you. Or sometimes it's a standing symptoms being associated with any. You know, tract abnormalities are either really because off inflammation or infection. So what happens with inflammation infection is that that keeps keeps a little capsule. URGENT organs like prostate epididymis and kidneys. Whenever there is inflammation off these organs that no supplies off the capsule, they are stimulated. And that's what this pain. So what happens that inflammation within a capsule on as organ is limited by the capsule? When I didn't planes and observe structure on the capsule off the order that causes pain, so being is really into nutrition. 40 Most of the biological abnormalities tumors as as the not cause much inflammation. Tumors don't causing pain unless there are way once stage, when the massive tumor is so enlarged. That exertion correction on the patches pointed at that strange on the human scores, right flapping is one of the most commonly any presentation on, but most of us have just seen a patient flank pain and flapping has a way brought differential diagnosis, the cramping off. The logical origin is classically located in the 50 nature cost of what your hunger. I just need the second string. It's muscle hand be the three on. Patients have this classic sign off. They're they're holding their black. It looks like they're holding the cramp, describing to describe the pain or plan, which is mostly for it on variation. Off pain is really on the upper abdomen, but it can radiate words. The umbilicus or the coins sustenance and minutes to the evening causes off flanking from Georgia Perspective. The most common cause off Lamping is Rena, or military obstruction caused by you know you carry a stone. If there is no obstruction, the stone could still be there. And what was any pain from there? Lots of cases. I'm sure you guys have gone through where there are stones in the kidneys on. Patients are asymptomatic when they're only found incidental finding so a stone itself doesn't cause it being. And it's one of the obstruction. Now what which happens when a stone causes blockage, very becomes the source of pain on real and military obstruction caused. The other pathology is like blood clots or population. A chlor necrosis seen diabetic patients or obstruction caused by a tumor of the upper tract called transitions of carcinoma, or congenital of normal is like albuterol attention, obstruction or congenital or actually, and it strictures or any external compression by tumors or tubal close is, or any inflammatory process off abdomen on. All of these, as there's any inflammation or infection of the kidney could also present as real quick. Yeah. Oh, thank you. Other rare causes off Manti mean our trauma off the kidney for real infection. Second floor the trauma or from one body processes you retire. It stunts insert before any cause than patients with congenital normal it easily into physical therapy plus and other problems off upper trip There are lots of nausea. Logical causes were patients also present with black pain on? Uh, sometimes that's difficult to differentiate. Whether mean is logical or non Georgia in origin. And besides shows that common president in quadrant off complaints off patient patients who called gold God Stones policy started their stomach ulcer, you know, can have Spain invites upper part or the central. A report dreams. Patients no and get can be present in other with renal colic or appendicitis. Inflammatory bulges it is on constipation are other sources of can female, especially public pathologies. It can mimic the renal, colic person and pain. What is our had? Complained me to disease to the pregnancy evidence is our portion. Interestingly, the pain off renal origin is often associated with gastrointestinal symptoms as well, so that that makes it a little more confusing. Drool out being off your logical origin or it's in any contract on because that wasn't peeing The reason that a real pain causes gas and descent symptoms. It's because of the moment of supply on which results in reflex stimulation of the city. I can't go on as well as when they're severe inflammation off the kidney or the literature that can also irritate surrounding structures on That could also be to guess you understand symptoms to differentiate pain flapping weather's real ah jiggle or non Georgia because one of the most start difference is that you guys would appreciate would be that patients who have trouble opening pathology on patient really library. Still, because any movement causes paratonia medication and that aggravates that thing, there is the pain. That's the logical origin patients with multiple just sit still, the regal in training. They walk around the building clank and more from side to side. So that's one of the major differences back, you know, drugged on the origin, then real college. Any flank me just calls for our renal or retired cause it's called renal colic on it really weighs acute and squats because we discussed earlier obstruction on the tractor stood up. The pain that patient describes is It's your anyways, sudden in onset on severe on the patient's often described it as a dull and aching pain. Some, some patients describe it as a sharp pain is real, but that's really more with retired Stone than with a little bit. Yeah, the pain, as I described over here, any organ that's bone through the capsule when it distends it causes pain. So the any obstruction in the part of the U. N. From kidney at a future to be J. Any obstruction that level, resulting in this tension off the capsule of the kidney. So that would be the pain in the plant and the other source of the pain. The biggest there is any obstruction in the ureter and ureter. Causing hyper very styles is to get over that obstruction than that beads off pain felt have to do it. This classic renal colic is really seen either stone present Fridays or any clothes. Our population, of course, is so any acute obstruction off the kidney or later, but let you call it and can also sometimes indicate the location off the stone has shown in Vegas. Parts off the upper tract are three eights and president slightly differently. Sometimes that's not always a rule, but it can sometimes help, too. The location that isn't real quality were the strong with, except on further diagnosis. So a pretty unitary obstruction pain degree. It's to the exit little plastic or lady in three minutes. That's interesting thing opportunity. You expect the pain to be a little higher, but actually the being off the upper uterus son's really are in the region of the groin and testicles. And that's because the testicles have the same enough supply as a regulator. So from L1. That's why I came off the upper neuter. It's really it's a plastic pillow, the media Terek obstruction. It's It's tractor to the McBurney's point, and some plans mimic appendicitis on the right side, and direct flight is on the left side. And then there is Lord Little obstruction. And it is when the soreness almost hand into the bladder on what we refer to the recycle your chart stones on the purchases. Lots off those I call irritability and patients have associated symptoms of frequency urgency on there, so probably good for and men between. It's the tip of the Penis and the referral. The back of Genesis Off Stone formation, which is one of the most common cause of flank pain, is a very complex pocket on their wages. Various truly is to describe the process off how a stone it's formed, but no single to me has achieved. Why do acceptance on because of the? And I think that the exclaimed, They're not in the spring. All the information's there on the extreme part of this one. Formation processes. The most talented things are Nucleation Terry and crystal inhibitor teary. The penetration to it's just that stones are getting it from crystals or foreign bodies and more wrist supersaturated urine. So the human past, um, supersaturated for the stone before, and any crystals or irons on that are in higher concentration. They have a gate and give us a point of origin. Were other signs aggregate wrong, then on the form a stone. So But I think that this to can't explain this. Why patients gets only one kidney and or the other kidney, and why some patients to have a super saturated hearing still not for make any sense, then this is jelly off. Question three trains that someone's actually forming the accents off inhibitors extra information like magnesia, surfeit, medication, secret, piriform straight and other trace Snapples. But then again, there are patients who have no levels of insulin hitters on. This will go on from so one incident and contrast, or patients who have very high level of these inhibitors and the state form stones. So these are the contrast in claims that they want now explain completely for the horses. Three. Then there are a lot around two third of the patients who are people you can find a metabolic caused those fishing off the PSA information, but then they're one side of the stations new form stones. But they're no metabolic. A moment then, um, the soul composition. The most woman stones are judging off the late songs on the the second comments want hydroxyapatite the flu shot. Andreas Stones are most amount Asian pathogenic sounds uric. It's just a wide system. Other hypertensive, very it's It's one of the most common cause off, So information on, um, it's one of the most common. Normally, even if I write on a metabolic work up of patients with stones, huh, really caused by thing? You need hepatitis articulate. Normally, geez, it's it's getting Just buy this type one type two factory type one is absorbed it purposefully aware there is in her ability off on a patch to increase calcium absorption from the gut. Bruce Lee soup increased stretch in excretion, and there are two types off. Absorb the hepatitis A. We actually, one is where they start dependent on the others were straight independent. So the one we're start dependencies were restricting the culture to less than one stream or 1000 brands barely would be crazy, but it's the extra information and Onley this small degree off patients who required limiting their attention. In big. There's a wider mean it's in general population that anyone that kidney stone should decrease. Then there's a real hepatitis Syria, due to the fancy clothes off really off the tension on, uh, then and 33 is do the result of her Percocet area because of the increased the mineralization of the bones, which results in okay. Hyper exit area is the second call because off getting catching stones, hybrids reason or present a recessive disorder off. The ultimate goal is, um, it needs to increase the situation off Asian off the weight and such informational attention oxidants stones. There were positive time with his genetic abnormality, and patients are not able to make people. It's on oxalate properly, the other is, and Terry, which is the most common one on. But it happens in patients who have a smaller good on there, have completely reliable about disease or unity both on syndromes, and they're more trouble. Uh huh. Absorbed, you know, tension. Uh huh. So what happens is that whenever there is to decrease amount of tension or increase more of oxalate, so kitchen and oxalate it binds into the courage and become slim absorbable. But when one either when there is an increased oxalate, that's contrary culture. There is an increased production of oxalate, which is a type of movie. The other ones, they're hyper you know Syria. It's been excessive writing off the Arendse. It's only 10% of the patient form stones have. Hi, you're running. It's the formalities on Go on the 40% off the occasions informers have This is Mom. It's also a good rated by Lord. You're in a volume on the beach. High positive proteinuria is sent me a bigger off on renal stones. So the degrees off secrete the during a great stone formation in the patients citrate, as is an inhibitor of the some information. So most of the medicine that helps in the profile access to prevent future formation of kidney stones have citrate in them. Um, the strong varieties and we'll discuss instrumental bottle of normal is just people in there some sort varieties air important, like the tension eso the gimmick up 80 to 85% off union stones that we see the cause is off tension in play. It's very typical close in prison. Your attention on the she requested oxalate and decreased citrate with inhibitor. And again there are one third of the patients weren't having on that body. Image is in the form of a white stone is one of the most important thing from your logical point of view that these are very high mortality. Patients who have a staghorn stone or strike origin has a 50% more dean. Five years there are treated. The stones are forms off McNish in a morning and forced it. They are one of those times because they don't cause an obstruction on their painless on are often incidentally, found scanning patients for other causes of patients can. For the repeated you native contraction sound on. So I just want on. These are the ones that have formed by organisms like patients who have infection with protease of the non school been insured caps that out So by the current plasma patients have a very high pH because these organisms later you're getting pneumonia. Patients have very high pH know for more than 7.49 basis, or hydroxyzine, which inhibits curious on that. The pollen is that it's not well tolerated, and it's not uncommon for the treatment. Most acrophobia treatment for patients is complete clearance off stones and or just stress from the kidney on then putting the patients and fluid intake and San transom electric antibodies on Tobi. It's frequent infection. It's a business through Whitestone against Appreciate How you define calluses off the kidney. Understand the newer kisses stone, although they're rare. But these are one of the stones that are not visible on X ray on. Sometimes I'm not visible on author was some off the treatment modalities to the stations the street on Actually, technology. Um, again, these songs are formed in Patients have basic pH off less than five point part, so the treatment is needing even imprisoned urine output and and using the pH for about 66 or 6.51 of the good things about these stones is that this can be resolved without any intervention by this commune. Eyes in the urine and it's expected. It's estimated that one centimeter apart mental song can be resolved. No, no, some of the writings off to give it extra. So even the the storm of the same composition should have it shits and sizes. You can't always describe which time it was just then. These are some career stones on 16 stones on. These are going to do a metabolic abnormalities on the body. Cystinuria recessive, normally genetic part. It's needs to be. Stones are three of stones, right sentence on the imports. Contented efficiency off enzymes, stones occurring patients. Not all the patients or enzyme deficiency Fortifications see treatment again to, uh, preservation. So any patient presents flank same the 100 your your history and it's an injection. The most important to ask patient with Pantene in regards of history's any association off the pain. Any other symptoms, like Dog had mostly are damaging our patients, having any associating that. Normally it's like they they have people or other symptoms, like being aggravated by any activity thing, about most commonly in a place to people in patients who do not have any obvious cause off. The pathology, like their imaging, is all normal. The bloods are normal but still having pains in those patients, very people to retype knows what the cause of the pain is and the keep present in a minute in the most, um, Korben in those patients is really musculoskeletal pains, and muscle started me on the back upper back pain with very hard to differentiate from real quality because next heart's into their presentation. The only thing missing is that you don't have much of the gastrointestinal symptoms on, uh, the patients can often get their pain with the physical activity that lifting or walking around that corrects their thing. So expect their pain is aggravated or have any association with physical activity and their blood's under. Other investigations are mama than you can give them some muscle relaxants and energy. Six and rapid into being treating your hospital the most common vested a shins be due for a new patient present with the flank pain and suspected really call It would be our baseline. The seriously You know how the globe anus and water white cell count is. If they're having any signs off increasing planetary markers his white cell count on, then when's want to make sure that pretty normal and there's no drop in the park and the adult place Anomalous Well, crp mean we need to know if there is an inflammatory process going on in flexion. I, in our meeting with me, are planning for any intervention with patients. I don't get this one off the most useful and open overlooked investigation assessing the patient between a college and whenever I'm on was in and have to see patients on suspicious and statement the talking doctors are from or get to the urine. And this This has a major, uh, problem with the managing patients and defining whether this patient, because this is one of the North earliest noninvasive test that you do to rule out with doing the flanking is from reading or non renal in origin, like really more so patients with the black man who did you bring that they have infection to be like carrots for the site positive Or if they have Sloan, there would be humanitarian microscopic hematuria so interesting the 80% of the patients reached 90% of the patients will have any stones will show up with microscopic hematuria on there on their surgeons have turned it on the 10 20 person so on the tendon from the person patients off your article have pain can present with out my material. So it's a very good, different Jiating test on you know the cause in early presentations of patients, and then we can do a urine culture to see for any infection. Are the patient symptoms, then the image in bridges, August on scan and CT be X ray. I would most probably see Just stand that throughout any military are kidney stones running or urinary tract of normality is Then we have a stone available form other spontaneous passes by the patient or form Sergi. We contend it from the border for analysis. Just see what the cause of this So the most important estimation in urology as you have most of your rear arteries city, you plain on the good things about this meeting morality. Is that this Mark meeting front? Trust me. And both situation and almost all stones are visualized. 99% of the sense our visualized by city KGB, the radium stones, like being a stone are and some other drug stones that are more visible on CD baby. But that's where you going here, and you can see the kidneys on the way home. You can assess whether the stones high partners of the stone, which is a no, you're on the cities name we call constant units on, but this can help us to be controlled with me. So what's what? Treatment modalities? Thinking also to the patient. I will discuss it later in the next life. So this is one of the, uh on depends on the CT to see if you can appreciate luck. Tell me, retiring stone. Uh, you just on. It's causing some distention in the can should system if you compared to the other side, that's right side. So this is what has a smooth giving patients treatment Options like station three is not septic. You should have. It is not set. Begins is really functions are good. You can have Yes. Ludicrous secret medicine outpatient morning with the treatments. If you're septic with need to put in from the back of his foster me are, the other option is to start this patient, but okay, other investigations are I would be or it started turning this cardiogram or intravenous you a graph in some countries, um, think about this test with that tells us that function as well as an actual me off the Children ease and it's actually two different on average it on this IV, you know, and any of the upper tracts any defects in the tracks on the downside of this is that with the choirs ever a stint operator to get you and problems like medical Barca creation or there was an ideas are lots of Strattera years. They could really affect the quality of the stands. This us We appreciate it, Um, on the left side on that there is normal kidneys and and you just and you can appreciate the bladder as well. But on the left side, on the right side, you see that there is marked hybrid, Of course, is off the left kidney. And there is you appreciate a strong in the future as well. And then there is no contrast going into the ureter on the left side. Other investigations that are you are, you know, number intending? Well, when trees like mostly evening 100 please our weapons and directed ultrasonography where we don't have the technology to do that distant for a patient there after guess is almost comparable to IVP. And sometimes it can. Yeah, so the mattered off doing this is that we get X ray. This one has to be visible on the x ray, and then you you're directed ultrasonography to assist the kidney, and this long it's very much operator dependent on it doesn't give us as much natural details of the surrounding structures and the kidneys as we get from secrets, other investigations, a picture of it, part of time on MRI and listen to their feet. The memory is doing pregnancy. They want to avoid radiations and rest. Integrate feels very done, too. I appreciate the functions of the kidneys and to compare with functions in the fitness. So the most, uh, common treatment options we offered to patients that small kidney or your carrots once is observations. So any patient who has a stone off less than five millimeters have more than 50% chance of spontaneous passage within six weeks. Kind. And once the strong side scores above five millimeter, the chances off between persons wantonness the decreases were here We have the neck trepidation, which is the medical expense of therapy, which is where we get a little blocked gradually. Cancer seen and sometimes on, say, help with the pain. And patients are able to pass stones so matter if it's only indicated for patients who have a stone larger than five millimeters. Because it's more than admitted, it hasn't to be off much helping those patients and any strong that's more than one centimeter. Is your quality very quiet, some kind of intervention patients are marching, but the past times more than one centimeter. So your macula piece for this one's off sides of spite of the mutual one centimeter. Any patient you off the conservative treatment or MetroPCS should monitored for six weeks, and it still have persistent symptoms and haven't processed front. And they definitely it's intervention on the stone site had the presentation or supportive apart. That's chances of presents. Want to lower? You tell extra ones. Have you guessed, has more chances or spontaneous that suggests, compared to a permit hasn't discussed are the very, very case. It's stones. Handsome sons are the ones that can be resolved by denies in the urine are by either by a while or incurring motives. Going matters are no longer a huge sitting on the the method that we used to reserve the stones in his and traumatic patients. Stuart Stones and the Solution Trapeze have been quiet with movies resolution, and yes, it's great. But most often, given the size of the stone, it's mostly intervention needed to completely off this one and the antibiotic Screaming Islam Week. Most perfect in Instant Boston. It's one off the procedure that undertaking patients who have who have your sepsis on, uh, or may not be good for me. Intervention internist. Easier so it's mostly are temporary diversion on to relieve the obstruction on in the patient. Have a definite treatment for the cause of the structures on unicorn obstruction, which is often related. Your pregnancy and the hepatitis the frost means production. Is that as it's done in the local anesthesia, then patients who have any infection or perinephric food collections are abscess or, you know, months on the 10 people back with the forced to me, um, gain in patients where you try to stand them on to a nutraceutical. Your sister Snoopy, too. Very tricky part in the field on. Then we have the ocean stuck it in fast for them on it. Has that wanted off offering a tract, too? Oh, upper tract. Where for future treatment? Off the problems, like a patient. Have a few just stone that we want to appeasing. They drawn. If you doing across to me, the person that one step of the businesses, all right, then they're speaking. They touched that and then cases off for a physical or it's or traumatic injuries movements, inflammation, other causes that so obstruction off the upper tract in the hospitals. A good option, then. This is one of the non invasive treatment modality that we can offer to patients. Um, it's, um, indication. With an upper you take stone or renal stone. Or in some cases, your ureter experience also discreetly mobility it smarts together for majoritarian since before reacher near the bones. But for the lower uterine stones and expensive treatment modality, patient has to be asymptomatic because that we can offer the sleeping deceptive patient. That's when the sun fragment is stopped. Poison bacteremia and those patients, um, the teacher one off the norm in recent treatment modalities. But the downside is that for patients may don't have the body heartedness that's acquired for the Pepsi or sometimes a bitch on this more than the victim, it off label on some patients may require more than one session, too company to get rid of their so on on one of the complications that can happen. Most commonly, exactly large assumes patients to do the rib series that multiple fragments of the stones wants to go down. They get stuck in the lower part of the ureters got strained. Slows it okay. And that their stations meeting intervention. Yours chart for you. Just copy. It's one of the most common away off. Being with the uterine stone still stays. So what you do is prosecuting work. Watch a part into the bladder. And so they're into the ureter. There were on fire, and then we break the stone There. Different modalities on off making the stone in the patients and they're different instruments or going in the tube as well. Some or reject some more flexible on. They have the means apart. Whether the original are flexible but mostly for nor gator, median stones appear. You tried stones sometimes use credit system. Richard, stop Part of your parents want you sound good medicine to lose track of you, then the modality off breaking the stones. There are different modalities and a half benefits, and pros and cons like the dramatically capacity is most widely of a level, and it's the most cheapest option. It's very good treatment options quicker for stones in the lower ureter. But as the sleep goes in the upper huge or majority the which gets ready, people break things without pushing them back into that. So things faces like to do laser lithotripsy rays. There is very minimal prevention of this one back in. Okay, okay on, then the other treatment options, then offer to patients is retrograde or integrate standing again. It's a completely mega toe. Bypass the obstruction it's acquired to peaches or double just stand Or be just unsure, for it is to quiets. One question is, is a picnic on the other quite ships in the bladder and bypasses any obstruction around, Be richer or with your job? Uh huh. A huge on your carrots stand with candidates are antegrade where we do it through our purpose. Tennis boot on there, sent then was from the kidney into the bladder. Or we do it to reach a great look for the samples from the bladder into the kidney. The good thing about entyvio it's tempting is that extra can be done with the local anesthesia on, but triggers thinking often requires Germans teeth. Okay, so then other management option. That's most of the days for the nurse on kind, large radar for the Stones and is perfectly honest. After the Talk Me way, make a track form the back off the plant below. The sometimes, you know, the dried shape at level approach it sometimes about drugs, depending on which part of the kidney being born in toe. And we're going to break the stone. Ongoing. They're different modalities, others ultrasonic little critter. There's no magic little class on the laser, and that will do. Is New Technologies that kind of thing, which has combined? I heard the sound as a little bit. I just on the devices together. Good echo and faster. So strong that division, so reasonable as a done too plant into quite very enthusiastic. The common risks associated with the procedure is sepsis and hemorrhage on extra visitation off Roger Political system. No, it's the patient. Accepts is there's a mortality from Subsys Trouble for Peace World Regis. No patients that infection explosive. This is just open stone. Surgery is almost non existent now because of the bruise, more baby, more beauty and the availability off the lesson Recent. Fortunately, procedures indications are very, very dark. Storm burden on have marks in the prep any more stones of the kidney isn't having infection, and they should have some symptoms related. Need a promotion that. Thank you. All right. Thank you very much. Stuff that I use. That was a really sure presentation. Um, would anyone like Teo pop any questions and chatterbox? Um, I'll just give you guys a couple of minutes in case anyone wants to ask anything. So dot office. Someone has asked if you could please go back to the slide on renal colic. Pain. Radiation, please. Okay, this way. Hey, extended The stone slow kitchen can be predicted. Form the radiation off the pain. So patients the flat pain and have three meals or retired colic. If the pains were getting two testicles are crying on the most like me to have her baby carrots songs. And I, most of you have seen patients who presently blanking, radiated the groin was a present complaint of the patients. And then on the later you find all the construction seven uterine Korpi, just one. And the cause is because they have, uh, because the pain with Mr Testes. And since she's had percent enough supply as a producer. So that's why being from the upper military rhino testing on then majoritarian so on referred to go Matt Bernie's point. And it's still simulate being off the pen beside Ear's on the right side. And the left side may be completely screwed diverticulitis or constipation and your uterine stones, in which there is very high chance that patient to be the process next continuously. No, there are symptoms off like patients often present with an associate of symptoms of frequency, urgency and other war. You need back sentence and men patients may complain in the we retry and sometimes people great, you know, mine on. But there was just one more question. Dean has asked, What is the use of taking the plain X ray after a C T K U B? Yeah, so this is open on is a very good question is often asked burning by the junior doctors. So the rational off during an X ray after cities to assess that, whether that stone is radio opaque or radio use it. So as we discussed that some of the stones are really picked, all of the attention containing stones, already epics and known catchin stones like sister instruments are America's instance. They're really loosened. So when we are can give three different treatments. Two patients we want to know whether the patient can have X ray based treatment options like little drips in. So if we are taping that we might offer patient little tipsy, really regard the shock waves off the little strips machine, there's an extra technology we need to make sure that the stream is visible on the extra plane and sitting. Actually do X ray on you gave me in patients with City on. Then again, Then you you were not planning to give patients a little bit. See option. The other rational off doing an extra activities morning to the stone because Cytic eighties has a lot of radiation and sometimes stones off. A mediator or a producer are not really good visited that you have good visibility on the ultra sensitive and they often get missed. So if they're visible on the X ray, we can just monitor the patient on a follow up X ray after four or five weeks off with other conservative management or giving them on metrop and follow Justin absolutely, and that results of radiation consider perfect. Thank you very much. Start like he's. I don't think that the moment we have any more questions, so if we could just move to the very last slide. That's okay. So, yeah, Thank you again for everyone for joining us again for one of our sessions. And if we could just keep that last slide open, um, feel free to go ahead and use the QR code. Just something screen. Now, you can use that for feedback on Get yourself a certificate. If you happen to remember any of the questions later on, do you send us an email on the address provided on will Be happy to answer those questions. Um, do course on. But please make sure to join this next time. My next session is going to be about lower your new tract symptoms and benign prostatic hyperplasia. So thank you all again on day. I have a fast, happy, festive period, and I'll see you next week. Thank you very much. Yeah,