Episode 92: Fundamentals - Discussing Pelvic Radiation Disease with Lisa Durrant

Join us as we discuss the impact of Pelvic Radiation Disease & the late effects of radiotherapy in the pelvis.

We re always trying to get he best result for our patients and to cure cancer but we need to take time to deal with the impact of radiotherapy side effects in our patients.

We are talking radiotherapy for pelvic cancers; bladder, prostate, gynaecological and rectal cancers.
Lisa is a consultant radiographer pioneering support for patients with late effects of radiotherapy. She leads her radiotherapy late effects service at Musgrove Park hospital in Taunton.

In this first of 2 parts we discuss;
🔎 What is Pelvic radiation Disease
🔎 When are effects 'Late Effects' from radiotherapy
🔎 Strategies for dealing with bladder and bowel side effects

A must listen for anyone who is delivering pelvic radiotherapy and a useful tool for patients receiving radiotherapy to the pelvis.

Enjoy!!

Transcript

Simply Oncology Podcast Recording pelvic late effects-20251215_113514-Meeting Recording

December 15, 2025, 11:35AM

50m 59s

 Welcome back to another Simply Oncology podcast episode. Mike. Today we're talking about radiotherapy, late effects and we'll probably be focusing a bit more on pelvic radiotherapy, late effects and who have we got. Mike, John, we have the wonderful Lisa Durant who is a.
 Therapeutic radiographer in Taunton and who leads up the late effect service there and has been a pioneer actually for the late effect service in the Southwest. Lisa, welcome.

 Lisa Durrant   1:56
 Thank you. Thank you for inviting me to come along.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   1:59
 And I think pertinent to point out that radiographers have really LED this concept of a late effect service. So and Lisa, actually there's a good hop on point, what is.
 Radio or what are radiotherapy LED effects and how do they differ from our standard radiotherapy side effects?
Lisa Durrant   2:24
 So we're going to concentrate mainly on pelvic late effects today, if that's all right.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   2:27
 That suits me, because I treat pelvic malignancy. So this is if nobody else listens and that's a very real risk, at least there'll be one listener and that will be me.
Lisa Durrant   2:29
 Yeah, I'll touch.
 Good. This is good. So the pelvic radiation Disease Association has actually got a really good definition of late effects. So they say it's one or more ongoing symptoms of very variable complexity that may affect people who have previously had radiotherapy to the pelvic region to treat their cancer.
 Symptoms arise as damage from damage to internal organs or skin, and they're defined as starting three or more months after radiotherapy is finishing, and some may start even many decades after that. So it's a whole host.
 Of different symptoms that arise, some are radiating normal tissues while you're doing radiotherapy to the pelvis.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   3:23
 And is that is that just a continuation of some of those side effects that people might be experiencing during radiotherapy or is it something completely different?
Lisa Durrant   3:31
 We think it's something completely different. So when people are having their radiotherapy, a lot of the side effects are due to inflammatory processes or damage to tissues with a high turnover rate. So that's why we've seen things like skin changes and desquamation and diarrhoea with late effects. It's a slightly different aetiology.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   3:44
 Mm-hmm.
 Mm-hmm.
Lisa Durrant   3:50
 And we think it's due to fibrosis changes in vasculature. So ischemic tissues and damage to tissues over long term. So there might be loss of stem cells or loss of progenitor cells. So that tissues can't repair themselves further down the line. So with true late effects, we see changes in structure.
 And function and quite often they can be permanent and progressive.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   4:14
 So our early side effects are inflammatory and that's easy to visualise if you think about where an area is being treated. All of that can be inflamed and our late side effects are that kind of end stage vascular change that leads to fibrosis.
Lisa Durrant   4:20
 None.
 That's right, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   4:32
 I'm being very clear again for anyone who might not be have a radiotherapy slant is the key thing is it's the X-ray beams, the photons, the things that are treating the cancer have to go through from the outside of your body to the tumour, which is usually deep inside of you and then out the other side. They don't just stop inside of you. And so it's basically any tissues.
 That have been around where the cancer was that are at risk, is that right, Lisa?
Lisa Durrant   4:55
 Yeah, that's absolutely right. So radiotherapy treatment just uses very high energy X-rays in most cases. So the beam goes in one side and out the other. So even though the treatment's very carefully tailored to the bit we, we want to irradiate or treat the cancer. Normal tissues can also receive quite a substantial dose.
 And gradually, over time, that can cause late effects. I think the other thing that's worth thinking about at this point of time as well is with some of these treatments. We actually treat quite a large volume of a patient. So if you imagine a cervical cancer patient, if you think your cervix is probably quite small.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   5:29
 Hmm.
Lisa Durrant   5:29
 Whereas in patients we actually treat the whole of their pelvis and sometimes all the way up their abdomen to get some of their nodal groups in as well. So even though the tumour might be quite small, we end up treating large volumes of patients to make sure we treat different nodal groups. We also treat quite a lot of prophylactic treatment.
 So we include a lot of the nodal groups as well, don't we? So some of the treatments are quite large and therefore some of the normal tissues treated are perhaps bits that you wouldn't expect to be treated.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   5:51
 Mm-hmm.
 And when we think about late effects, how big a problem is this? This is a kind of scenario where I'm going to feel during this whole episode like a villain, because I'm a, you know, if this was an A help group, I would be putting my hand up and saying my name is John Mcgreen and I'm a radiotherapy late effect.
 Causer. No, absolutely. And so were you. Yeah, absolutely. Because I treat prostate cancer. But I also treat gynae cancer. So I do a lot of pelvic radiotherapy. How big a problem is it if we think about those two groups, prostate and maybe other kind of ****. Maybe. Yeah. ****, rectal, bladder.
 Cancer malignancies. And then we think of gyn as a slightly separate group. Is that fair?
Lisa Durrant   6:45
 It's. Yeah, that's absolutely fair. And actually it's a really, really difficult question to answer and that's because we haven't really traditionally gathered this data, have we? And the data tells it tells different stories depending on what you look at. So with a lot of the trial data, we might.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   6:56
 Hmm.
Lisa Durrant   7:03
 Follow patients up and we might grade their toxicities and get an idea. So say with prostate cancer patients we might look at grade two and above toxicities and for some of those. So if we look at some of the new prostate cancer treatments, so perhaps they've compared standard fractionation to hyper fractionation.
 And some of those report, I guess between 2 and 3% for bowel and bladder changes. But actually then if you look at what patients have reported in the national Prostate Cancer audit, actually patients are reporting perhaps between 5 and 10%. So it's a bit different.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   7:40
 OK.
 None.
Lisa Durrant   7:42
 And actually then if we look at perhaps some of the RCR consent forms, so there's the consent forms are really good now for radiotherapy and they they're very detailed about some of the late effects on there. And if you look at it.
 The numbers that they use again it tells a different story. So it's actually really, really difficult to say.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   8:03
 And not helped by the fact that when we treat people, we often put them on APSA tracker and they only really come back into the service if they have severe side effects. So there might be a huge group of people that we don't really know about having kind of grade 2.
Lisa Durrant   8:15
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   8:22
 21 top side effects that that's for the rest of their lives, which is, yeah. And because we're not looking, we're not seeing it.
Lisa Durrant   8:25
 Definitely.
 And it's really difficult to know where to look, isn't it? Because these patients like with the prostate cancer patients are discharged immediately after radiotherapy and they go on to a tracker which literally cheques to see whether they've got disease or not. It's not asking any other questions, is it?
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   8:46
 No.
Lisa Durrant   8:47
 And we know that patients perhaps go back to their GP, but don't get the answers they need. And actually we've got quite a lot of this information from the gynae cancer patients. So when the Joes trust the Cervical Cancer Trust was around, they had a great document where they'd asked people about their late effects.
 And actually what they told their GP, and there were lots of things that people didn't tell their GP. So it's, as I say, it's really difficult to kind of stitch it all together. Obviously in my practise, I think everyone's got late effects because they're the only patients I see. There's there are lots of people out there who don't get late effects, but I think.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   9:16
 Yeah, yeah.
Lisa Durrant   9:22
 As you pointed out quite rightly there some of the ones that we think are quite mild are actually quite troublesome for patients. I know there's a big push now, especially with the new, with the new consent forms to actually start tracking what people have. There isn't actually a way for people to report this. So if you think if you have a medication incident.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   9:27
 Hmm.
Lisa Durrant   9:41
 There's the yellow card that you can send in, but there isn't a way or a mechanism for looking at people's acute side effects or late side effects. So I'm hoping that there's going to be a push to start doing that and the new advancing safer radiotherapy document came out recently and that's asking for that.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   9:43
 Mm-hmm.
Lisa Durrant   10:14
 Absolutely.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   10:15
 To a service because there's not enough bricks and mortar or people to keep those appointments going. And.
Lisa Durrant   10:22
 I agree. But who? I guess, whose role is it, though? So as clinical oncologists, you're there to manage people with cancer, but actually these people don't have cancer anymore. So people then get referred back into services that perhaps aren't really relevant.
 So a lot of these patients, they don't need to come back into cancer services, they need all the other services, don't they around it. So then might be.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   10:43
 But yes, it's that issue of survivorship, isn't it? You're right. Lisa's. Yeah. Yeah. So, but this is where you come in. Yeah, because you have a late effect. Do you know it's a very valid point because people do get referred back with radiotherapy, side effects, maybe 10 years down the line. No evidence of cancer. But because we have an inverted commas caused.
Lisa Durrant   10:46
 Yeah.
 That's right.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   11:03
 The problem the patients come back to us, but you you're very right. We're not always the best people for that because our focus is treatment of cancer, not late radiation disease. So let's think about some people who do focus on that and they look a lot like you. So why don't you tell us about that?
Lisa Durrant   11:22
 So we started with a service in Taunton. I think it started in 2014 and it came out of a single prostate cancer patient who complained, basically said, who's going to look after me now. So the service was originally set up by a radiographer called Karen Morgan.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   11:22
 None.
Lisa Durrant   11:38
 Who did a bit of steering work and thinking about perhaps what these what these patients need and over time and the service has grown. So although we see the majority of our patients are actually pelvic cancer patients, but actually we see patients from all sites, all diagnosis some of the many, many decades.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   11:56
 Mm-hmm.
Lisa Durrant   11:58
 After they've had their radiotherapy and so potentially a very big group of patients. But the problem with just having one radiographer seeing all those patients you, you can't be an expert in everything. And suddenly unlike with clinical oncologist, when you perhaps specialised in prostate or.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   12:12
 Hmm.
Lisa Durrant   12:18
 Realising head and neck it's not a particularly safe or effective service for one person to be trying to do everything. So what we needed was more people doing it and the other thing we needed was people within different radiotherapy centres because.
 If a person and have had this or a person for Truro was referred up to the Taunton late effect service, and actually what they really needed was a colonoscopy to start with, I've got no idea how to do that down in Truro. So we need people within their own centres to make those links.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   12:42
 Mm-hmm.
 Mm-hmm.
Lisa Durrant   12:49
 To work out what those pathways are, these patients effectively need pretty much every service within healthcare apart from oncology. So someone has to go out and make the connections with the gastroenterology team, the pain team, you name it, absolutely everything, which is quite a big job to start with, but actually what we've done.
 Now is we've managed to build, I guess deliver a service model where we've got a radiographer in in centres around the Southwest and we can work together as a team now. So someone on the team can have a special interest in perhaps prostate cancer patients. Someone else could have a special interest in knowledge in Gianni cancer patients so.
 Suddenly we can work together as a team to deliver that expertise and also working as a region we've suddenly found there's loads of really good services in the southwest that we can refer our patients into that we didn't have access to before. So having a kind of radiographer based service.
 So we understand the treatment that's been delivered to people. We understand which tissues have been irradiated and which tissues potentially could have later bets. But then we've worked to work out what the pathways are that we need to refer the patients into.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   13:49
 Mm-hmm.
Lisa Durrant   14:00
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   14:00
 And if we think about you, those main issues that happen that are probably common between gyne and prostate cancer or other pelvic cancers, you know, bowel issues, I think we have to talk about bladder issues. We have to talk about and then sexual function after treatment, I think.
 I think it's fair to say those three are the big three, maybe bone as well, bone health as well, bone thinning.
Lisa Durrant   14:28
 And pain, we were amazed at how many patients come back reporting pain. It was really high.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   14:33
 OK, well, well, let's put pain in that list then. Let's look at bowel function as a late effect, because people would get a new version of normal, don't they? After I know patients hate that phrase, but a new version of normal.
Lisa Durrant   14:42
 Play song.
 I know.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   14:51
 After radiotherapy to the pelvis.
Lisa Durrant   14:53
 Yeah, they do. They do. And a lot of patients actually tell us that they feel well before they've had their radiotherapy. So they might have been picked up on screening or actually not had any huge symptoms. But you know further down the line when things aren't going so well, it's quite challenging for patients.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   15:02
 Hmm.
Lisa Durrant   15:08
 So with barrel side effects, quite often part of the barrel is in the high dose field and we see changes over time. So a lot of patients we see have simple well it sounds simple but simple things like they're opening their bowels more often, their stalls are very loose.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   15:14
 Mm-hmm.
Lisa Durrant   15:26
 They're producing loads of bowel gas.
 Lots of things that can actually be managed quite simply. Simple things like sitting on the toilet properly, making sure you've got enough fibre in your dart, and you're drinking enough fluid, perhaps using the loperamide or Imodium in small doses quite regularly could really, really help, and that can literally turn someone around for being unable to leave the house because.
 Concerned about their bowel function to being able to go out?
 Yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   15:54
 Could you tell me or my how to sit on the toilet properly because I've not heard that phrase before.
Lisa Durrant   15:58
 ****.
 Surely, surely you have so countries that don't have nice toilets like us, but have a hole in the floor really don't have the same problems as us. So sitting on the toilet property with your feet up so that your knees are higher than your hips.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   16:02
 Yeah.
 Have you?
 Knees up.
 It's key.
Lisa Durrant   16:18
 Means it's much better to evacuate your bowel that way. So it just makes it a much more effective way of emptying your bowel than sitting on an acid.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   16:26
 Well, I think I know what I'm asking for Christmas, we're designed to be squatters, aren't we? You know, squatting down. That's, that's OK. Well, every day's a school day. I'll take that.
Lisa Durrant   16:30
 We are designed to be Scottish.
 There was a great little BBC clip about sitting on the toilet properly that I send out to patients. It's very informative, so there is some information on the Internet, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   16:37
 But.
 I will thank you for that.
 Yeah.
Lisa Durrant   16:47
 With other bowel issues they can, they can obviously be much more complex. So we see patients that develop bleeding from their bottom and this is because the lining of the bowel becomes quite a scheming cough to radiotherapy and it almost tries to repair itself by growing lots of.
 For blood vessels to try and bring oxygen and nutrients in, and they're really fragile and they bleed really easily. And if you look at them on a colonoscopy or a flexi sigmoidoscopy, they look really insignificant. But you can you can lose a lot of blood for these tiny blood vessels.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   17:20
 Hmm.
Lisa Durrant   17:22
 So again managing that, so it might be that just softening up someone's stores and making sure they're not straining can really make a difference. Sometimes we use sequel Fate, which I'm sure some people.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   17:35
 Oh, circular. Fair enemies. Yeah, yeah.
Lisa Durrant   17:37
 Sucralfate enemas, which actually work really, really effectively, but also they need to be seen by the colorectal team or the Gastro team, because we need a proper diagnosis just to check there's nothing else going on and they can have those vessels cauterising, but in various ways to stop the bleeding but for patients.
 It's hugely worrying. It's hugely worrying to suddenly start bleeding from your bottom. They're not sure whether they've got cancer again, so explaining to people showing them their plan and explaining to people that actually this is a consequence and if they can put up with the bleeding and their blood counts are fine. Sometimes it's better just to do nothing.
 But for people to understand that can really, really help. And then the other thing with bowel is you could get a malabsorption syndromes. So especially with large field gyne treatments, so you terminal ilium is where bile acid salts are reabsorbed.
 And if they're not reabsorbed, it gives you really, really chronic diarrhoea and loose doors, parts of your bowel are important for absorbing vitamins. So vitamin B12, so these patients perhaps have problems with fatigue further down the line. So the kind of structure and the function of the bowel.
 Can change after radiotherapy and we have had patients who their life has improved by actually going and having a stoma having part of that that bowel removed. We still see people though perhaps who've got a rectal stump left who still have problems passing blood, passing mucus.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   19:12
 So I think a clear message there is having good links with your gastroenterology team and working well with them. Quick question, steroid enemies, do we ever use those?
Lisa Durrant   19:27
 We tend to use steroids very sparingly because for some of these patients it's a long term condition and we don't really want people using it for a long, long period of time.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   19:31
 Mm-hmm.
 Yeah.
 Another question, argon treatment argon laser are we for or against this?
Lisa Durrant   19:47
 It depends who you ask. For some patients it works really well. From what I understand, it can actually do damage to the bowel. So after radiotherapy, the ability of tissues to repair themselves is diminished. So actually you can end up with.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   19:49
 Yeah.
 Right.
 Thank you.
Lisa Durrant   20:20
 Things are changing, yeah.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   20:20
 Thank you.
 So bowel really important. I think the key thing is you know, they're the reason we're look, we're trying to report these and trying to find them is there are actual things that we can do and I think that's the big message, isn't it? Is that you need to report it. So we know there's a problem. So we can do something about it. Bladder is another big organ that gets in the way of things.
Lisa Durrant   20:38
 Yeah.
 Yeah, especially with prostate patients and the kind of the important bit of the bladder is the bit at the bottom. So you to choose the muscle and the trigonal the mechanism so that you can actually go for a week. So further down the line, people develop problems with.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   20:43
 Talk us through bladder.
 Hmm.
 Mm-hmm.
Lisa Durrant   21:00
 Storage and problems avoiding.
 Some of them are really difficult to manage because we just have the kind of traditional tools in a way, don't we? So medications to try and calm your bladder down, making sure people are drinking enough fluid, not having really concentrated urine, it's going to irritate your bladder.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   21:14
 Mm-hmm.
 Yeah.
Lisa Durrant   21:21
 But a bit like the bowel, you can also cause changes to the lining of the bladder. So again, we get people who are bleeding from their bladder and that again can be quite difficult to manage. People get repeated infections. It's almost like the inside of your bladder can become a bit denuded.
 They get what I think are repeated infections, or they can have symptoms like they've got an infection, but actually they haven't got bacteria in there.
 You can have your bladder relined, so the stuff they use, you know, pump your face up or whatever they can do it to the inside of your bladder lining as well and that works really, really well.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   21:50
 Yes.
 Is that the hyaluronic acid? Yeah.
Lisa Durrant   22:02
 Yeah, you will. Yeah, that sort of stuff. Yeah. And it works really well and actually some centres are getting to the situation now where patients can do it themselves. They can do the installations themselves at home, which is, which is really, really good.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   22:13
 Aye.
 Well, that's a game changer. Now, I must admit, our urologists work really well with us, with the IL. You're so all my day. Sorry. I know it is really hard to say. I wouldn't want to say that over and over again like you. Red lorry, yellow lorry. But you have seen my own patients benefit dramatically with that.
Lisa Durrant   22:17
 Yeah, yeah.
 Yeah.
 Yeah.
 Yeah. Yeah. I think some of the things that are offered to patients, so we tend to discuss some of our patients here at the euro gyne meeting, which is great because there's people from urology, colorectal, there's all the surgeons there, but they're very reticent to do things to these patients because of the problems with healing.
 Afterwards, so perhaps for some of the female patients where you know previously they might have put a tape in, although they wouldn't do that now or you know some of the procedures they won't offer them to these patients anymore because of the risks afterwards there is.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   22:54
 Mm-hmm.
Lisa Durrant   23:10
 Bulkamid which you can use to bulk up the end of the urethral opening if people have got a bit of stress incontinence and sometimes they'll offer that.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   23:19
 Talk me through this bulk amid.
Lisa Durrant   23:21
 Bulk amid. Yeah. So the stuff that used to plump people's lips up, they just use it to bulk up the end of the urethra, which can really help with female patients with a bit of incontinence.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   23:30
 You're.
 Interesting. So you get. What's it called when you get a little filler? Pout. Trout. What is it? Trout pout. So, trout pout for the end of the event. You read through that, you pay through. OK.
Lisa Durrant   23:38
 That's right, yeah.
 Yeah, but it, I mean it's quite obviously a simple and fairly conservative treatment. So that can work quite well for patients with more complex problems. So perhaps patients who are bleeding from their bladder.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   23:48
 Hmm.
Lisa Durrant   23:59
 We have had patients that we sent for hyperbaric oxygen therapy down in Plymouth.
ROWE, Michael (ROYAL CORNWALL HOSPITALS NHS TRUST)   24:02
 Oh yes, I'm glad we've hit this nerve because that's something we have to talk about. Yeah, yeah. But we'll let you finish your .1 of the one of the A&E, one of the A&E consultants has talked to me about that and whether we use the service because we've got one in Plymouth, haven't we? I've sent people up for it, but yeah.
Lisa Durrant   24:10
 OK.
 And that's where we refer. Yeah, we refer from around the region down to Plymouth. They've been absolutely brilliant and there's some patients, it's worked really, really well when we haven't really got many options left. There is a specialist guy who works at guys in London and he runs the National Radiation Cystitis Clinic.
 So he's really helpful. So sometimes we refer complex patients on to him for some it's Ramesh, the Rai Raja, I've probably said his name wrong and I apologise. But he's absolutely amazing.