Jan Chaseley

Good evening, everyone, and welcome to our webinar on enlarged prostate treatment. My name is Jan, and I'm a Nurse Specialist at Benenden Hospital. Our expert presenter tonight is Consultant Urology Surgeon, Mr Steve Garnett. This presentation will be followed by a question-and-answer session. If you'd like to ask a question during or after the presentation, please do so by using the Q & A icon, which is at the bottom of your screen. This can be done with or without leaving your name. Please note that this session is being recorded if you do provide your name. If you would like to book your consultation, we will provide contact details at the end of this session.

I'll now hand it over to Mr Steve Garnett, and you'll hear from me again shortly.

Mr Steve Garnett

Okay, thank you, Jan. Thank you everyone for joining this presentation this evening I hope you find it useful so yes, I’m Steve Garnett one of the Urologists at Benenden and obviously Jan is one of our Nurse Specialist's and helps us look after our prostate patients. So what we're going to talk about a little this evening is about prostate enlargement itself what causes it what symptoms people get from that how we diagnose this and various treatment options but in particular this evening we're going to be focusing on Aquablation® a little bit more which is a new robotic procedure which has recently been introduced at Benenden hospital we'll also talk a little bit about other treatments such as UroLift® and TURP surgery and there'll be some time for some questions at the end so very briefly don't need to spend too long on me but I’ve been doing prostate surgery at Benenden for you know 15 years or so now and I was fully trained in the UK and also spent a bit of time in Germany and I’ve been practicing in the NHS in east Sussex since 2012. In fact, before that, in 2008, I started but became the lead for the urology department in 2012. So in terms of prostate enlargement what we're really talking about and focusing on tonight is benign prostate enlargement which is also called BPE also used to be called BPH or benign prostatic hyperplasia and these terms are really trying to distinguish that from enlargement of the prostate due to prostate cancer and in fact BPE is much more common and most people with prostate symptoms will have benign prostate enlargement and this particularly affects men as we get older particularly from the age of 50 and increasingly more so as we get older such that by the time men in their 80s nearly 90 percent of them will have a degree of benign prostate enlargement causing variables symptoms so in the UK it's thought that at least three million men have urinary symptoms associated with benign prostate enlargement so this is just a little diagram that explains a little bit you know shows you a bit more vividly really what we're talking about so you can see on the left that the prostate here is situated underneath the bladder and there's a nice open  channel or water pipe technically we call this the urethra which runs through the prostate and it's nice and open in this normal situation but when the prostate gets enlarged it doesn't just grow outwards it grows inwards and it compresses the urethra so you can very easily see why in that situation men would have reduced flow and difficulty passing urine and that has knock-on effects on the bladder and it indicates a little bit here but the bladder wall becomes thickened and then the bladder itself works differently and less effectively and that can lead on to not being able to empty the bladder completely and then also wanting to go to the toilet more often what we call frequency and getting up a lot at night so why do why do men get this well it's clearly linked to testosterone stimulates growth in the prostate but exactly why or what that what causes that stimulation we don't really know and it may simply be you know the accumulative effects of testosterone over time but it's clearly has some genetic factors to that as well because not everyone will get this and in fact not everyone who gets benign prostate enlargement will get particular symptoms in terms of symptoms  as you saw in that diagram, the prostate is normally quite a small gland situated just underneath the bladder and deep in the pelvis between the bladder and the penis, and as the prostate gets enlarged, it blocks the way out, squeezing and compressing the urethra, and that can cause, as I said, difficulty starting to pass urine, going more often, poor flow, difficulty emptying the bladder, and getting up more at night.

Over time that can lead also to another symptom of urinary urgency of having to rush to the toilet so in terms of if any of those are ringing bells or you're worried about prostate enlargement what can you do well you can see your GP and in the first place many GPs are able to assess your symptoms using things like symptom questionnaires and asking exactly what sort of problems you're guessing but if you're referred on to the hospital you might get further tests such as assessment of the prostate size in particular something called a flow rate which is when we get men to basically pee into a machine which is like a big funnel that measures how well you're passing urine and you know urologists get a bit obsessed by these flow rates because they're actually very useful at telling us how much or what degree of obstruction you're getting from your prostate how bad your degree of blockage is and can actually also indicate what treatment might be best for you and we usually come find that with a quick scan of your bladder afterwards because as this process progresses men generally find it more difficult to empty their bladder so there's this concept of bladder failure when the bladder stops being able to squeeze all the urine out and you leave more and more urine behind and eventually if that's not treated you can end up to the point where you can't pass urine at all and that's called retention of urine so in terms of treatment if the symptoms are very mild you may not need any treatments you may simply want reassurance that there isn't anything more serious going on you may be able to manage these early symptoms with lifestyle changes like reducing caffeine thinking about how much you drink and when that type of thing but if the symptoms are more bothersome more severe in the first place   there are medical treatments that can help relax a prostate or reduce the size of the prostate but leading on from that if that's not enough or you don't want to take tablets or you're getting side effects from tablets then there are procedures that can be done on the prostate to relieve these problems so we're going to talk firstly about Aquablation® which is this new robotic procedure that uses high pressure water jets to ablate the prostate there is the most commonly performed standard operation which is the TURP or trans urethra section of prostate which we also do at Benenden and the UroLift® procedure which is another relatively new procedure which is minimally invasive that allows us to improve symptoms without any cutting or destruction of prostate tissue and this can be done as a day case so Aquablation® is a fairly new minimally invasive robotic assisted procedure and that means that it's actually well it's whilst it's controlled by the surgeon or me     It's the robot that actually directs the water jets, according to the plan that I've set out based on the information I gather, that starts the procedure, and it uses a high-pressure and high-velocity water jet to remove or destroy this excess prostate tissue or ablate it, and by doing that, it relieves the pressure on the urethra and opens up that urethral channel to allow a good flow. So, it's performed under general anaesthesia because it's important that there's no movement once you're in position, but there are no cuts or incisions at all.

We've recently started doing this at Bellington Hospital. This is a quick picture of the team and some of the equipment in the theatre. This is, you know, a pretty major investment for a private hospital, and there aren't that many centres performing this across the UK because the robotic equipment is expensive. So, this is, you know, a major and very exciting development for Bellington Hospital. So to talk a little bit more about what actually happens in essence at the start of the procedure an ultrasound probe is placed that allows us to very accurately in real time image the prostate and by doing that we can use the ultrasound to plan the treatment so what we then do is precisely target and remove the excess process prostate tissue using this high pressure water but we're using the ultrasound to map out the prostate and then plan and essentially map a plan onto the real-time ultrasound of how much prostate we want to remove and in actual fact that allows us to be very precise and we then send that information to the robot which controls the water jet to remove exactly the right amount of prostate tissue and protect sensitive areas particularly those that can be involved in sexual function so the other part of the procedure is a camera and waterjet pro which is placed in down the urethra and into the bladder through the prostate and then the robot controls that and we slowly pull back the well the robot slowly pulls back the water jets to ablate the prostate tissue through the prostate under real-time imaging with the ultrasound and we're usually doing that with a one night stay in hospital and you would have a catheter in for that one night so this is just a little video to try and explain a bit better than my words as to what's happening so what this is showing you is that the hand piece that goes down the urethra is in place and the image in the bottom right is the ultrasound we've already mapped out how much prostate we want to remove and as the procedure starts the robot controls this powerful water jet and the little picture in the corner there you could see it as it looks like down the telescope but in the graphic there you can see the water jet where it was very precisely delineate how deep we want this to go and just using that high pressure it ablates the prostate tissue according to the map which is the green dotted line that we've set out and at the end here there's the area that is particularly involved in ejaculation and we can very carefully and safely just a blank tissue at the side and save the ducts and factors that are involved in ejaculation so this is why this procedure is associated with fewer side effects in terms of sexual function and there's no associated risk of erection problems and much lower risk of ejaculatory problems so yeah so it doesn't affect sexual function  these are the benefits.    Really, Aquablation® doesn't affect sexual function; it does appear to have a reduced recovery time and very little post-procedure pain or discomfort, and people do seem to recover quicker than standard operations. Because it's robotic, it would be very precise in the amount of prostate and which bits of prostate we want to remove and destroy, and that allows us to, as I said, preserve essentially the ejaculatory ducts that are involved in ejaculation.

In terms of side effects all operations or procedures can have side effects particularly when we're doing this type of thing there's always a small risk of infection so it would give you antibiotics if you're having this procedure and often people will have some blood in the urine for a few days up to a couple of weeks afterwards but these symptoms are usually quite mild and resolved fairly quickly often in the first couple of weeks patients do notice passing little bits of debris if you like from the procedure that's painless but you may notice little flecks in the urine for the first couple of weeks so it's a suitable for men with bothersome urinary symptoms due to enlarged prostate and it's actually suitable unlike some other procedures it's suitable for pretty much all prostate shapes and most prostate sizes it's not ideal for very some men have very small prostates but still have symptoms     it's not ideal for that but otherwise it's suitable for most people as long as you don't have particular other conditions that predispose you to bleeding the other sort of more commonly done procedure certainly nationally is the TURP or transurethral resection of prostate that's a procedure that's been done for over 40 years now so it's very well-known and you know the side effects and risks of this procedure are very well documented and you often read a lot about the side effects of TURP but actually it's a very effective operation and we know that it works well and doing this procedure again a camera is put down the water pipe the urethra and an image put onto a screen and by using that image we can cut away or scrape away the inside of the prostate using electrical energy to cut through the prostate and little chips or small pieces of this cut away bit by bit to create a nice open cavity and it's as I say  it's a very effective and good operation, but it does have well-recognized side effects, particularly on sexual function, so most men having this operation will suffer ejaculatory dysfunction, and the number that will get erection problems are also very small, but there is a small risk of incontinence.  It's rare, but it can happen. the other procedure we do a lot of at Benenden Hospital is the UroLift® procedure now this is perhaps the least invasive of all the treatments we have currently for prostate enlargement and it's been around a little while now and it's a proven minimum invasive treatment that I think fits or sits well between people who don't want to keep taking medicine but don't want to have a more invasive procedure and in this procedure as you can see here in the little diagram little implants a place that pull the prostate open now some people you know liken these to treasury tags but essentially these are little metallic implants that are fired through the prostate and then the prostate is compressed and tensioned to be pulled open as you can see in that picture so this improves the flow and improves the bladder emptying and improves the symptoms and as there's no cutting or no destruction of prostate tissue it does have fewer side effects and doesn't have any ejaculatory effects and doesn't cause any problems with erections and that all sounds great but it's not suitable for everyone and I would also say that it is a slightly smaller procedure and it has a less dramatic impact on symptoms so it's an it's a good option but it doesn't create such an improvement in flow or symptoms as some as the other treatment and the jury's a little bit out on quite how long it lasts we don't know if people are going to are more likely to need further treatment it says on here local anaesthetic procedure but actually we generally do this under a short general anaesthetic because it is a little bit uncomfortable to do it under local anaesthetic so I’m going to show another little video here to just again make it a little bit easier to understand how this works and what this involves   now this does start off with an American voiceover and I’m going to try and cancel that because it's a bit grating I’m blocked really there we go so this is a sort of schematic representation of the prostate and that's a telescope going through the prostate down the urethra and this is how we fire the implants through the prostate we'll just come out now through the prostate to the outer capsule of the prostate and then tension that back to compress the prostate and pull the inner part of the prostate away from the urethra or open up the urethra by doing that and generally depends on the prostate size but generally we're putting in about four of these implants to fully open the prostate so as you can see there's absolutely no cutting so there's no risk of damaging other structures with this but as I said you do get a less dramatic improvement in flow.

There we go, and that's the view that we would see looking down the cystoscope or the telescope into the bladder.

So I’m going to stop talking there that's a brief overview of the three main procedures that we do for prostate enlargement each has their pros and cons and I think what's what I feel is really important as a doctor and treating patients with these type of problems is to really identify what it is that you as a patient want in terms of outcomes and work out what procedure is going to be right for you as I say they're not all suitable for every patient and the UroLift® in particular is limited a little bit on prostate shape so that does affect who would be suitable for it but I will at this point stop and hand back to jan and if we've got any questions I’d be very happy to take them at this stage.

Jan Chaseley

Lovely, and thank you for that really interesting presentation, Mr Garnett. Yes, and we do have a few questions.

One of them I think you have possibly already answered in the presentation, but it's how long does the application surgery take to stay overnight?

Mr Steve Garnett

Yeah so the Aquablation® procedure takes about an hour that's actually more to do with setting everything up because we have to get the robotic arm in exactly the right position and get the ultrasound image or all precise and get everything in line and that and that's really what takes the time the actual ablation parts of it or the actual kind of operating on the prostate bit really only takes about 10 minutes or so but there's a lot of setting up and checking and making sure we've got everything in the right place and making sure the images are perfect and then planning the treatment so that's what takes the time some places some hospitals are doing this as a day case but you will need a catheter in overnight and I’d prefer personally and what we tend to do at Benenden is to say if you're going to have a catheter in overnight we think it's better that you stay in the hospital overnight and then have the catheter out in the morning I know other places send people home with a catheter and then bring them back a day or two days or three days later but I think it's nicer to get the catheter out as soon as possible and feel secure that whilst you've got the catheter in if you've got any problems you're being well looked after.

Jan Chaseley

Thank you, and also slightly on the same question, can it be done under spinal anaesthesia?

Mr Steve Garnett

The thing about the acrobatic ablation is that it's really, really important that there's no movement, and the problem with the spinal ablation is that, you know, the patient undergoing the procedure may start coughing or breathing more heavily, so we do really only do it under general anaesthesia, certainly at this time, because we can control that, so we can, if need be, control your breathing. We certainly won't be coughing or anything once, or under a general anaesthesia, so that's really important because we don't want you to suddenly move while we're in the middle of the water jet ablation.

Jan Chaseley

What percentage of men may suffer from retrograde ejaculation following Aquablation®, according to the figures for a standard TURP, or are there other ways of doing that kind of laser nucleation of the prostate in those procedures?

Mr Steve Garnett

About two-thirds of men will get retrograde ejaculation. The documented figures with Aquablation® are around 11, 10, and 11 percent. It may actually be lower for full-on retrograde ejaculation, but I think it's best to think of it around 10, so it's much lower, but there isn't an absolute guarantee about it.

Jan Chaseley

Thank you. Are all the procedures a permanent solution, or can symptoms return?

Mr Steve Garnett

Whatever you have done to the prostate there is a risk of symptoms returning now it seems to be that the more prostate tissue you remove or destroy the less chance there is of symptoms returning over time so if you take these sort of standard TURP operation we know that 80 percent of men at 10 years after the operation are still happy and haven't needed anything else doing or to turn that round 20 have needed something else doing so that's one in five with the UroLift® we know that that figure of 80 percent and 20 is there at five years so it does look like the UroLift® is a smaller procedure with fewer side effects but probably more likely that you will need something else doing but you could argue that if it's a small day case procedure with few side effects does it matter so much if you need it repeating after a few years so that's a personal thing I think you need to consider with the Aquablation® because it's new we don't have long-term results there are some five-year results out which it looked very good if anything slightly better than TURP but we don't have tenure results yet for Aquablation® but I would expect people to get very good lasting results from the Aquablation® because we are removing a lot of prostate.

Jan Chaseley

Thank you, and do all of these options mean no more tangelo sin? Yes, the idea would be to stop your medication. Yes, thank you. Someone's just got a query. I'm 76. Would that be a problem?

Mr Steve Garnett

Well, you're too young. No, age is not an issue; it's just fitness. You know what's going to be appropriate for you; it's really fitness for general anaesthesia or other, you know, spinal if you're having a TURP, so it's not age; it's just how well you are.

Jan Chaseley

Thank you. Do these procedures have any impact on the subsequent likelihood of developing prostate cancer?

Mr Steve Garnett

No, there's nothing to suggest any of these procedures have any impact on developing prostate cancer, either by preventing it or causing it. So when you're doing these procedures, what you're doing is generally what we call the what's called the transition zone of the prostate, which is kind of the central part of the prostate, and we're not removing the whole prostate, which is a much bigger operation with which is done for cancer, which has other side effects, but in fact it's the outer bit, the peripheral zone, where prostate cancer tends to happen, so this procedure is not a cancer treatment, but it does not increase the risk of prostate cancer.

Jan Chaseley

Thank you if I've had a UroLift® procedure and then needed something more comprehensive. Are the UroLift® pins removed, and if so, how?

Mr Steve Garnett

Yes, they just come out well, as you can see from the UroLift® picture that I showed you or the video as well. There are two clips on the UroLift®: one on the outer parts, what we call the capsule of the prostate, and one on the inner bit, and that's what we call the urethral end plate. That urethral bit is removed during TURP or Aquablation®, and those internal metal clips come out. The bit that is on the outside of the prostate is not. It's not possible to remove those that would stay there, but essentially, you can go on and have further treatment without any problem, and those internal clips are removed.

Jan Chaseley

Thank you, and is the UroLift® day treatment?

Mr Steve Garnett

With so the UroLift®  is done as a day case procedure there is a small risk of so with most people having a UroLift® don't need a catheter being put in after the procedure but sometimes people can get a bit of bleeding a little bit of blood in the urethra or may find it difficult to pee because the prostate can swell up a little bit straight away after the procedure so there's a small risk of needing a catheter and again if that happens at Benenden we generally say if we put a catheter in stay in overnight and have the catheter out the next day you could technically go home with a catheter in and come back later if that happens but for the majority of patients the UroLift® is done as a day case with no catheter.

Jan Chaseley

Thank you. With Aquablation®, how do you determine how much tissue needs to be removed?

Mr Steve Garnett

So that's what I'm saying about the beginning of the procedure: we're accurately mapping out the prostate in its different sort of dimensions, and once we've accurately mapped out the prostate, we use the computer program to draw a treatment plan onto the image of the prostate so we can see exactly how much prostate tissue we want to remove, how deep to go in which part of the prostate, which parts to save, and essentially withdrawing or mapping a plan onto the computer system that the robot then follows.

Jan Chaseley

Okay, and a patient here says he has been seen elsewhere and is recommended to have a small resection with the accumulation as a viable alternative?

Mr Steve Garnett

Potentially, it is difficult to answer specific questions because it does depend a bit on the size of your prostate, but it also depends on what your consultant means when they say small resections. I don't really know exactly what that means it's a little bit imprecise but potentially you would be suitable for accumulation yes but I would really need to see you and get a bit more detail yeah and how different is Aquablation® to the whole lab treatment so hold up I haven't really talked about that's a laser procedure which is similar more I think it's better to think of the whole app is like the TURP so the whole lip uses laser hold up stands for transurethral resection of the prostate and essentially that's using laser energy to core out the prostate whereas the TURP is using electrical energy to core out the prostate so it's what you use to cut through the prostate but both of those procedures are cutting through the prostate to remove prostate tissue and both of them have similar side effects in terms of retrograde ejaculation and incontinence so the Aquablation® is the only procedure that allows this more accurate real-time ultrasound imaging of the prostate and then mapping a treatment onto that and it's also the treatment with the lowest rates of sexual dysfunction so it's I would say that the whole episode is a very good treatment but it's more similar to the TURP than Aquablation®.

Jan Chaseley

Thank you. Does diabetes have any impact on prostates?

Mr Steve Garnett

Diabetes has a big impact on bladder function, but it doesn't specifically affect the size of your prostate. It can affect your symptoms to a large degree, so people with diabetes can get nerve-related problems through the diabetes, and that can affect bladder function, so that can have a big role in the symptoms but not so much directly on the prostate itself.

Jan Chaseley

Thank you. Is a higher-than-normal PSA a sign of an enlarged prostate that may not be cancer-related?

Mr Steve Garnett

Yes, absolutely. An enlarged prostate will mean that the bigger you'll have, the more PSA you will tend to make. So, if you've got a slightly high PSA, that's called a high PSA. That's related to a value that's considered normal for your age, but if you've got a particularly large prostate, you will make more PSA. So, what we prefer to look at rather than simply just PSA level on its own is what we call PSA density, which is a way of taking into account the size of the prostate because if you've got a large benign prostate, you will have a slightly high PSA, and that doesn't mean that that PSA level doesn't relate to prostate cancer. In that situation, it relates to having a large prostate. I think it's very likely that it is your next option. You know again, we need a few sorts of tests and assessments, but really, depending on the sort of symptoms, you've really been on maximum medical treatment for quite a long time, and if it's still despite that, you've got problems, then I would think you need to look at surgery. Yes.

Jan Chaseley

Thank you, and I'm sorry, I'm just scrolling through.

Is it common to get a stricture after a simple catheterization?

Mr Steve Garnett

I understand your anxiety because obviously the there are lots of different circumstances in which catheters are used and how they're placed so a straightforward catheterization is very unlikely to cause a stricture however if there was difficulty placing the catheter if there was trauma caused during the catheter placement then that could lead to structuring stretching is what happens when you get scarring in the urethra and the urethra becomes tight and narrowed and you get problems passing urine because of that scarring in the urethra now as I say it's uncommon after simple catheterization but it's possible it's also possible after infections and it's also possible after instruments being passed down the urethra.

Jan Chaseley

How much discomfort do patients find in the pre-op investigations? I.e., the insertion of a camera

Mr Steve Garnett

I'm assuming someone's maybe talking about a flexible cystoscopy. Yeah so one of the commonly used investigations prior to these procedures is called a flexible cystoscopy that's a local anaesthetic insertion of a camera down the urethra to look at the prostate and the bladder in more detail I would say that a lot of well most men who you mention this to go a bit white and don't like the sound of it at all and get very worried which I completely understand it does sound like it's going to be an unpleasant procedure but what I would say is my experience particularly at Benenden is that it's done in a very professional and quick and competent way and nearly everyone who we've done it on turns around and says that wasn't half as bad as I was expecting and it really is a very quick procedure it takes really less than five minutes usually and I do find quite a few patients come to us having had bad experiences elsewhere and actually say that was so much better than it was last time and I think it depends you know quite a lot on the experience of the team doing it and sometimes in the NHS these procedures can be left to some of the more junior doctors and I think it is better to have it done by someone more experienced.

Jan Chaseley

Thank you, and from this presentation, is the Aquablation® version a better option than the resume?

Mr Steve Garnett

I think we didn't mention I don't talk about resume. What's called "well steam" is steam treatment of the prostate. I would say resume is a better comparison for the UroLift® procedure, so Aquablation®, the robotic procedure I was talking about, is a much more powerful and effective treatment. resume  during the resume treatment a camera is placed down the urethra and through this a needle is placed directly into the prostate and steam is injected into the prostate and by doing this you can destroy prostate tissue but it's much a much smaller effect than the Aquablation® and if it's much more limited in size of the prostate and it's much more limited in the size of the effect or the improvement in symptoms so it is a smaller procedure and that's the advantage of it but everyone has a catheter afterwards usually for four or five days and quite a lot of patients need multiple treatments so they may have half the prostate treated sent home with a catheter have the catheter out after four or five days then come back in four weeks and have the procedure repeated on the other side or the other half of the prostate so it's a smaller procedure but I think a bit less effective and not really a direct comparison with the Aquablation®.

Jan Chaseley

Thank you. Is the procedure appropriate to assist with erectile dysfunction? 

Mr Steve Garnett

None of these procedures are designed to help with erections, and you should seek other treatment if that's your primary concern. These are not designed and don't help improve erections. Having pyronine's disease has no impact on success, so we haven't really got time to go into pyronine's disease in depth, but this is a condition that affects erections. No, that should not make any difference to having any of these procedures.

Jan Chaseley

Lovely, thank you. With UroLift®, does the presence of the pins affect having future MRI scans?

Mr Steve Garnett

Yes, they affect it in that when you've got these metallic implants in your prostate, if you have an MRI scan, you'll get a little bit of blurring of the MRI images for about two millimetres around each of the internal clips, so you can certainly have an MRI. You just need to let them know that you've got UroLift® implants. You can have an MRI, or some people ask me if it won't set off airport scanners. You can have an MRI, but you just need to let them know that you've got the clips in. It does cause a little bit of blurring around the internal clips, but that should not affect the usefulness of the MRI.

Jan Chaseley

Thank you, and this question: all of these options obviously will relieve symptoms of BPE, but does that make it harder to monitor or pick up prostate cancer at a later stage?

Mr Steve Garnett

No, I mean so basically, when you're removing prostate tissue, so Aquablation® TURP holds it, you are removing benign prostate enlargement, so you would expect in patients who've had these procedures for the PSA to go down, so in fact, it can make it easier to monitor for prostate cancer because the PSA should go down; it should be much more within the normal range than it was when you had a large prostate with the UroLift® after you've recovered from, you know, the first couple of months after the procedure, it has no impact on the PSA, and as I said, it has a slight impact on MRI scans, but not in a way that would make it more difficult to check for or monitor for prostate cancer.

Jan Chaseley

There's a couple of other questions, basically from patients who've maybe had previous procedures wondering if activation is suitable now, and I think the answer to that is probably that you would need to review each patient on an individual basis too.

Mr Steve Garnett

Yeah, I mean, it depends on what procedure and when, and I think in that situation we usually need to do a few more tests, but the starting point would be essentially no. Just because you had a previous procedure does not mean that you cannot have something else, be it Aquablation® or UroLift®, but I would have to let you know that on an individual basis.

Jan Chaseley

You could just move to the last slide for me. Mr Garnett?

Mr Steve Garnett

Hang on; yes, that was that one. Oh yes, sorry, there you go.

Jan Chaseley

Thank you very much for attending this webinar. I'm sorry if we didn't answer all of your questions, but if you've probably provided your name, we will answer via email. As a thank you for joining this session, we are offering the value of your consultation refunded upon booking and a callback from your dedicated private patient advisor. You will also receive an email tomorrow with a recording of this session and further information. You will also receive updates if you would like to discuss or book a consultation. Our Private Patients team can take your call up until eight o'clock tonight or between 8 a.m. and 6 p.m. Monday through Friday using the number on the screen.

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Our next webinar is on hip replacement surgery, and you can visit the Benenden Hospital website to sign up. On behalf of Mr Garnett and the expert team here at Benenden, I'd like to say thank you for joining us tonight, and I hope that we will hear from you very soon. Thank you very much. Good-bye.