Welcome, everyone. My name is Reitan Ribeiro. I'm a gynecologist at the Erasto Garnet Hospital and co-chair of the Surgical Education Workgroup of the IGCS Education Committee. So I would like to welcome you today for the Surgical Film Festival on Challenging Gyne-Oncology Surgery. We have an incredible panel of surgeons today that will be sharing their expertise and we are thrilled to have them. Before we get started, I want to mention a few housekeeping items. There will be ample time for discussion today, so we encourage you to submit your questions via the Q&A feature at the bottom of your screen. We will do our best to address as many questions as possible. A recording of this webinar will be available at the IGCS Educational 360 Learning at the portal. Now it's my honor to introduce my co-chair and co-moderator, Dr. Carrie Langstroth of Mayo Clinic. Thank you, Dr. Langstroth, for joining me and I will hand it off to you to introduce our speakers. Thank you, Dr. Ribeiro. It's my honor to introduce today's speakers. Joining us today are Dr. Raj Naik of Queen Elizabeth Hospital and Northern Gynecologic Oncology Center in the United Kingdom, who will be presenting sidewall disease recurrences. And we also have Dr. David Atala of St. Joseph University in Lebanon, who will present his placenta procreata film. I will conclude the film festival on special considerations in patients with a history of prior transplant. Without further ado, to kick off today's film festival, I invite Dr. Raj Naik. Thank you for joining us this morning or today. Okay, thanks, Carrie. And thanks, everyone, for joining us today. To try and keep to time, I'm going to move straight on with my presentation. Ashley, very kindly, is going to be coordinating my slides. My talk will be on LEA and LEPRA for pelvic sidewall recurrences. And it's an edited surgical video. And I've edited it intentionally to try and bring out the educational aspects of the actual operation. And you'll see, hopefully, that it's a relatively straightforward operation to carry out. It's a step-by-step procedure. And I'll be going through each of the steps during this presentation today. So, Ashley, can we go to the next slide? I have no conflicts of interest related to this presentation. Next slide, please. Of course, it's not possible to do the presentation without acknowledging the contribution by Michael Hochul. He, as you know, achieved the IGCS Lifetime Achievement Award for last year. And to quote a famous scholar, Oscar Wilde, imitation is the sincerest form of flattery that mediocrity can pay to greatness. And this procedure that I'm going to show today I learnt from Michael by attending his training course at Leipzig School. Next slide, please. So, I'm going to classify LEA as separate from LEPRA. And I know others have their own means and methods of classification. LEA, as described by Michael, is a laterally extended endopelvic resection. It's excision of the endopelvic fascia, which is the connective tissue network that envelops the pelvic viscera. It also involves removing the obturator muscle and also the internal iliac artery and vein. LEPRA, in fact, is more radical as a procedure as it involves the above, but also removal of either the nerves or the bones or the major blood vessels. Next slide, please. So, these are the steps I'm going to go through. I won't present them on this slide to try and keep to time, but you'll see that it is a step by step procedure. And we're going to go through each of the steps now as we go through the video presentation. Next slide, please. This is what we hope to achieve anatomically at the end of this LEA procedure, where you have isolation of the external iliac artery and vein. The internal iliac artery and veins have been excised and are part of the surgical specimen. And all you should see are the obturator nerve, the sciatic nerve and the lumbosacral plexus and the bony pelvis. All other structures on that side wall should form part of the en bloc specimen. Next slide, please. So, the case I'm going to present is a young lady. She originally presented elsewhere with a stage 1b2 adenosclerosis cancer of the cervix. She had a radical hysterectomy and bilateral pelvic nerve dissection, but unfortunately recurred very shortly afterwards with a central pelvic recurrence, which was treated with radical chemotherapy. Unfortunately, she progressed during this chemo radiotherapy treatment. And when she presented to us, the MRI scan confirmed that there was a central recurrence that was extending to the right pelvic side wall and involving the right obturator muscle. The preoperative PET CT scan showed no evidence of metastatic spread. And as I say, she was then referred to us for consideration of the LEA procedure. Next slide, please. This is the MRI scan showing the central recurrence extending to the right pelvic side wall and involving the obturator muscle. Next slide, please. And this is the PET CT scan showing no evidence of metastatic spread. Next slide, please. And can we click next to start the video? So, step one involves excision of the lower parotid lymph nodes, and this is then sent for frozen section analysis. And the purpose of this really is many people would consider involvement of the lower parotid lymph nodes as a relative contraindication to continuing with the LEA procedure. Next slide, please. Can you try the next slide again, please, Ashley? And this is histology confirming no evidence of metastatic spread in the lower parotid lymph nodes. Next slide, please. And the next step would be to mobilize the ureter and also the common iliac artery. You can see on this video that it's actually a sharp dissection rather than a blunt dissection. This is a result of the significant fibrosis and scarring as a result of the previous pelvic node dissection, radical hysterectomy, but also the chemoradiotherapy, which, as you can imagine, does cause considerable scarring and fibrosis. So, it's clearly a sharp dissection of the ureter and also the common iliac vessels. And the purpose of dissecting the common iliac artery is with the option of then clamping the common iliac artery should you run into significant hemorrhage when subsequently carrying out the pelvic dissection. Next slide, please. So, step one is isolate the common iliac artery. Next slide. And keep some vascular clamps handy in case you run into severe hemorrhage within the pelvis. Next slide, please. And the next video sequence is of mobilizing and isolating the external iliac artery and vein. As you can see, I'm struggling here a little bit as a result of the fibrosis and scarring. And it's really to demonstrate that it's not the kind of surgery you would normally expect to carry out in a lady that hasn't previously had radical surgery or previous chemoradiotherapy. So, you will see here the external iliac artery has been isolated. The next step would be to demonstrate and isolate the internal iliac artery. And as you can see there's quite significant fibrosis, it's currently stuck to the obturator nerve which is what's being dissected away. And then once the internal iliac artery has been isolated, it's then ligated and cut. You can see here the internal iliac artery being ligated and then cut. This then gives access to the internal iliac vein, which is then also ligated and cut. These vessels will form part of the specimen in order to achieve the R0 excision. That is the internal iliac vein also ligated. So, to demonstrate what we've just carried out there, we've dissected the external iliac vessels, next slide please, and ligated and cut both the internal iliac artery and vein. Next slide please. So we then continue the dissection of the internal iliac vessels, and once we've got access to the lateral pelvic sidewall, it's at this point that we then cut the ureter, and you'll see that she's had a stenting of this right ureter as a result of the pelvic recurrence extending to the right sidewall, causing a ureteric obstruction. This then allows access to the sciatic nerve, which you can see on your screen now. Next slide please. So what you see there was the external iliac artery isolated, the internal iliac vessels cut, the sciatic nerve coming into play. Next slide please. And the objective then is, as the sciatic nerve is not going to be excised during this procedure, to dissect the obturator muscle off and away from that sciatic nerve, and we're then going to dissect through that obturator muscle in this direction. So my method is initially to cut through the obturator muscle, and then to use a haemostatic instrument to try and address the perforating veins that travel through the obturator muscle and towards the bony pelvic sidewall. So, that's the illustration demonstrated here. We cut through the obturator muscle to give us access more openly towards the sciatic nerve and the lumbosacral plexus. Obviously, the areas to be concerned about would be the perforating vessels, which are addressed using the haemostatic instruments. Next slide, please. So, the next step would be to continue dissection laterally by excising more of the muscle away from the sciatic nerve. That is the sciatic nerve in the centre of the screen there. That gives you access to the lumbosacral plexus, which lies inferiorly, which are then also dissected off the obturator muscle. And the rest of the operation is a relatively straightforward exenteration. We open up the presacral space. The intention is to carry out a complete exenteration with removal of the bladder and rectum. We then use a haematic instrument to dissect through the levator muscles to give access to the penia and similarly anteriorly in front of the bladder and the cave of rexius. The procedure is then completed with a peroneal approach with complete excision of the vagina and rectum. And here we're just excising the rectum of the anterior surface of the sacrum with the specimen extracted through the peroneal incision as an en bloc specimen. Next slide please. So these are illustrations of the specimen. And next slide. And as I say, this is the anatomy of the pelvic sidewall on completion of the procedure. Next slide please. And next slide please. And next slide. And next slide. And next slide. And again. So the purpose of this clearly is to achieve R0 excision. And as we demonstrated preoperatively, there was involvement of the obturator muscle, which therefore needed to be excised. And as you can see, the histology of this particular case I presented, there was a good 6mm surgical margin from the tumour itself. Next slide please. And next slide. And this is the histology confirming complete excision of the tumour with a clear surgical margin. Next slide please. And this is the lady who made a good recovery 6 weeks following the procedure. Next slide. So this is another case. This is a left-sided layer. I'm going to quickly show you this because it demonstrates the anatomy a little bit better. And what you can see is the external iliac artery and vein that's been completely isolated and dissected. Underneath the external iliac vein is the obturator nerve. And below that is the sciatic nerve. And below that is the lumbosacral plexus. And you'll see in a moment that one of the branches of that lumbosacral plexus had to be sacrificed as part of the surgical specimen. So that's the obturator nerve there. And below it the sciatic nerve. And below that the lumbosacral plexus. All of the structures on that side wall have been removed. And this is the same left pelvic side wall magnified using a laparoscopic lens. And as you can see the arteries are fully exposed as are the nerves and the bony pelvic side wall. So, the steps are, step one, lower pelvic node dissection, next slide please. Isolation of the common iliac artery in case you need to clamp the main vessel into the pelvis in case you run into problems of severe hemorrhage, next slide. Isolation of the external iliac artery and vein, next slide please. Isolation of the internal iliac artery, next slide please. Ligation of the internal iliac artery and excision, next slide please. Similarly with the internal iliac vein, next slide please. And next slide please. Identification and dissection of the sciatic nerve, next slide please. Identification and excision of the obturator muscle which will also form part of the specimen and then dealing with the perforating veins and then completion of the exenteration through the cava vex rexius, next slide please. Presacral space, next slide please. And completion with an AP approach, next slide please. And as I mentioned earlier, these would be the anatomical structures you should find at the end of the procedure, next slide please. So that's a LIA procedure, LEPRA as I've mentioned already is a more radical procedure, it's what I've just presented but in addition excision of nerves or bone or major blood vessels, next slide please. We combined our series of that LEPRA procedure with Giovanni Scambi in Rome and David Cibulet in Prague and that formed part of this Gynaecologic Oncology publication, next slide please. And as you can see, there were a significant number of cases within that series involving excision of the nerves or major blood vessels or bony pelvis, next slide please. In terms of technique, nerve excision is straightforward, you literally just cut it but obviously you'd need to counsel the patient considerably regards post-operative rehabilitation and physiotherapy, next slide please. Regards excision of bone, this would involve involvement of an orthopaedic surgeon and considerable reconstructive methods of regaining the stability of the pelvis during this surgical procedure, next slide please. And there are various techniques that are available in order to achieve this, next slide please and next slide please. Similarly with major blood vessels and particularly the external iliac artery, there are various reconstructive techniques including crossover vessels, next slide please or use of vessel grafts, next slide please. In terms of extreme cases, there's the hemipelvectomy or the hindquarter amputation where there's removal of all of the structures on that hemipelvis, clearly this would involve significant reconstruction rehabilitation, next slide please. This really is to show that there are prostheses available for these extremely rare procedures, next slide please and next slide please and you can just start that video and you can see there'll be months and months and months of rehabilitation involved with such radical extreme operations, next slide please. So really in conclusion in terms of take home messages, the procedure is an ethically demanding topic, just because you can operate doesn't mean you should, case selection is critical, there is need for a multi-surgical disciplinary involvement, there has to be MDT support and compliance with international guidance, case selection as I mentioned already is critical as is preoperative patient counselling and there has to be significant consideration of quality of life, reconstruction, rehabilitation and of course centralisation to national centres of excellence, thank you very much. Thank you Dr Naiki, what a wonderful presentation, we really loved it, we will now open for discussion so just a reminder to all that you may submit questions through the bottom of your screen at the Q&A feature, so just one question for you to warm up, do you think after a PET-CT you still have to do the pyroarthritic dissection? Yeah I think so because the PET-CT scan isn't going to pick up micro metastases and that's only going to be possible through histological assessment and I think it's useful information to know whether the lower pyroarthritic nodes are involved, I wouldn't call it an absolute contraindication but it's one of the factors you need to take into consideration when determining case selection. Clearly if it's an elderly lady, it's a large tumour, let's say with plenty of comorbidities and she's got positive pyroarthritic nodes, then maybe that would be your threshold for abandoning the procedure, whereas in a young lady who's otherwise fit and healthy and has very very little alternative options available, then you might still want to continue and go ahead with the Lear procedure despite the knowledge that she's got microscopically positive lower pyroarthritic lymph nodes. Great, and would you consider a pelvic lymphadenectomy in case of patients who didn't have it because before, how do you decide to do or not to do a pelvic lymph node section? Yeah, if she's not had it before then absolutely I would do a full pelvic lymphadenectomy as part of my surgical excisional procedure in that there is some therapeutic benefit in removing microscopically involved pelvic lymph nodes, so to leave it behind really makes no sense, especially when one's being quite radical on that pelvic side wall. So if it's a Lear on the right and a standard exenteration on the left, but had she not had her pelvic lymph node dissection previously, I would carry out a pelvic lymph node dissection on that left side. So we have a question from Roger and he's asking, what are your most frequent indications for hemipervectomy in gyne cancers, in gyne cases? Most common indication for? Hemipervectomy. Oh, I see. To be honest, I've never actually performed one. Yeah, I only ever had one lady, very young, she was a very strong, brave lady, she's ex-army and she met the criteria for a hemipelvectomy. When I discovered the implications post-operatively of what she would need to go through in terms of rehabilitation, she declined the operation. Yeah, it's very hard to indicate, but I'm quite sure that all of us have some patients we may have think about it, at least. So anyway, so for the sake of time, I just want to thank you again for this wonderful discussion. I want to invite Dr. David Attala to present his film on placenta percreta. Dr. Attala, please proceed. Thank you. Thank you for the invitation. I'm very happy here to speak about this dreadful situation and it has been demonstrated that the presence of gynecologists, oncologists since the beginning of the procedure, since the management of this case is a prognostic factor. So in our department, we are a reference center for placenta accreta spectrum as cesarean section in our country is very high, it's around 60%. And with this referral center, we try to develop our own technique in order to tackle these problems correctly in order to minimize blood loss and to do it stepwise. Here we are describing our technique in six consecutive steps, and I'll show you two other films where there are some special situation where we needed to remove a patch of the bladder and with some incidental happening. And when using this technique with this incident, you can tackle the problem correctly and save patient's life. Thank you and please start scrolling. It is a professionally edited film and please start the film. Placenta percreta poses significant challenges in obstetric care, necessitating a meticulous surgical approach. Our presentation outlines a comprehensive stepwise guide for radical management of placenta percreta and minimization of complications. In the initial step, a longitudinal uterine fundal incision is made for the delivery of the baby. Closure of the uterus with vicryl zero hepatic needle running sutures, followed by an extension of the laparotomy to the pubic bone. The second crucial step involves the opening of the retroperitoneum, especially lateral to the adnexo ligaments, a crucial move when the placenta fills the pelvis. Given the young age of these patients, the conservation of ovaries becomes imperative. The uterovarian ligaments are ligated as close as possible to the uterus with double or even triple ligation sutures due to engorged vessels in the infundibulopelvic region. Vigilance against bleeding is emphasized as these vessels can be highly congested, potentially leading to massive bleeding, particularly with the infundibulopelvic vessel injury. Moving to the third step, both external iliac and hypogastric arteries are thoroughly identified. The obliterated umbilical artery is dissected. And the uterine artery is identified. Ureters are dissected distally until reaching the uterine arteries, which are clipped using hemolock. Uterine veins are exposed and clipped as well. The subsequent step involves the dissection and unroofing of both ureters, freeing them from their crossing with uterine arteries. This technique's safety lies in preventing ureteral lesions and maintaining an acceptable level of blood loss. In the fourth step, a rectovaginal space dissection is performed. A vaginal incision is carried out with a flat retractor placed in the posterior vaginal fornix. By elevating the uterus with both fingers in the posterior cul-de-sac incision allows us to avoid pulling on the uterus upwards and risking the rupturing of the placenta. By this way, the dissected ureters are automatically brought down, eliminating concerns about ureteral lesions when retroperitoneal and paravesical spaces are dissected and the uterus is approached posteriorly. The fifth step involves bladder dissection and incision of the anterior fornix. The bladder is filled to aid in identifying its separate site, followed by cautious dissection with the bowie knife. The bladder-vaginal interface is then exposed after bringing down the bladder. Achieving an anterior vaginal incision involves placing the operator's index and middle fingers through the posterior incision and poking into the anterior cul-de-sac. For the sixth step, clamps are placed alongside the lateral cervical tissue after verifying ureter distance and hysterectomy is performed with no morbidity. Additionally, two cases are discussed where the placenta invaded the bladder, necessitating the excision of a bladder patch. In certain instances, accidental placental rupture occurs. For example, in this specific case, the resident mistakenly pulled upward on the uterus instead of lifting it through the posterior cul-de-sac incision. In this patient, all spaces were dissected except for the anterior part. In the face of this massive bleeding, we promptly open the bladder to contain the ruptured placenta slash uterus within the surgeon's hands. Following this, the remaining bladder was dissected and the anterior vaginal wall was opened, guided by the two fingers inserted through the posterior vaginal wall opening. In conclusion, this technique allows us to accomplish a total hysterectomy with minimal morbidity and nearly absent ureteral risk, emphasizing the importance of a systematic and careful surgical approach in placenta pacreata cases. Dr. Attalla, thank you very much for that great presentation. My heart rate went up just with that second, that last final video watching that placenta rupture and seeing all that bleeding. I think these are always challenging cases. One of the things we always discuss here is use of ureteral stents. Are you a proponent or in specific cases or? Since the beginning of my experience, you know, I'm trained as a gynecologist oncologist in my training. I've never done that. I developed this technique with time and patients were referred to me and applied the GYN oncology principles. As you can see here, it's like a radical hysterectomy, but at the beginning I started to put stents and I started to put sort of intra uterine, intra uterine artery balloon and inflating it just after the delivering of the baby. But by using this technique, it's useless because you can see the ureter you dissected. And many times you have the invasion, as you can see, as you saw in the second cases, the invasion of the bladder. And it's a little bit tricky. There was a patient in Lebanon in another institution. They tried to put a stent. They punctured the placenta and the patient bled to death and they couldn't save it. So that's the importance of trying to prepare everything before dissecting the bladder from the placenta. Because if it happens to have this accident like we had here, the patient and nothing is prepared, the patient either have a lot of morbidity or the patient can die. So preparing all the spaces, like you can see it's in five minutes, it was contained and we maintained the hemostasis of the patient. Yeah. Yeah. I really like your posterior entry technique because I think you're right. Like the tendency is to pull kind of midline and you can rupture that. So that was, is that something you came up with or how did that posterior? You know, it is something that I used to do in difficult pelvic surgeries when sometimes I don't have access to the interior part or sometimes I don't have to access to the posterior part. I put the valve inside of the, I always operate on my patients with the Allen's Therapy position up in legs and always to have, it's a principle that I had from my, my, my, my mentors. And you know, previously, you know, all mentors that used to, to operate in a double-équipe position, that's what you call in France, double-équipe position. And it's a principles coming from, from very old surgeons in the forties and the fifties in order to have better access. And yes, we did. I described the first, I was the first to describe this technique in 2013 in a letter to the editor in the Scandinavian Journal. And then I published the first cases and I've done a lot of conferences on that. That's great. Great. And then one final question and that specifically, you know, in those patients like that last one where you had, or the second to last one, where you had a lot of bladder involvement, are you, how are you reconstructing? Are you just, most of the time, can you do a simple cystotomy? Are you doing ureteroneos? Exactly. I try to remove as less as I can from the bladder. And I, I studied my, hopefully it will be published soon. I studied my patients on, on that, that were operated, that had the partial cystectomy. And really luckily all these patients didn't have any problem in, in their bladder for, in the compliance of the bladder, they, they, they didn't any, it was really, there was no incident on, on the, the, the maturation function of, in these patients. That's great. I try to remove as little as I can. Oh, very good. That's great discussion. And just to, in the essence of time, we'll go ahead and move forward. Thank you so much for joining us today for this presentation. I really appreciated it. So I will be presenting our last presentation here. So I'll go ahead and share. I need to switch my display. Making sure you're seeing the right film now. Yes. So I'm Carrie Langstrand. I'm a gynecologic oncologist at the Mayo Clinic in Rochester, Minnesota, and I'm going to be talking about considerations when proceeding with hysterectomy after a transplant. So when, I know when I had my first patient that had had a prior renal transplant proceeding to hysterectomy, I had a lot of questions, you know, where, where is the transplant organ? Where's the vascular anastomosis specific to the kidney? Where's, what's the course of the ureter? There's also concern about adhesions from the prior surgical intervention, whether or not they went trans-abdominally, or did they have a retroperitoneal approach to their transplant? And then there's additional considerations such as their immunosuppression status and their knee, their risk for wound healing and infection, and the underlying medical conditions that that patient has that either led to the transplant or resulted from the transplant. And then finally, what the indication is for surgery. Are you proceeding for endometrial cancer, an ovarian cancer? Do you need to have a pelvic node dissection or a periordic node dissection? So the, the most common transplant that we encounter as gynecologic oncologists is the kidney transplant. The kidney is most typically placed in the iliac fossa on the right or the left with vascular, vascular anastomosis to the external iliac arteries and vein. And then the ureter takes a abnormal course, you know, they'll have to, usually the native ureters will be present. And then in the transplanted kidney, that ureter will had sort of lateral and anterior almost in that preperitoneal space that we could encounter if we did a fan and steel incision or even sometimes a midline abdominal incision. There are rare instances where the kidney is placed intraperitoneally, but those are most often if they've had a failure for a retroperitoneal placement. So this is most often retroperitoneal. Often we won't even see this in our surgical approach. A pancreatic transplant is something else we might encounter. These are also placed over the iliac vessels with anastomosis to the external and, or external iliac artery and vein. They also will harvest a portion of the jejunum, and this then will be anastomosed to the terminal ilium. This picture here shows the tail of the pancreas kind of going off to the side, but I've seen the pancreas laying over the pelvic rim as well. And some pancreatic transplants are also placed in the upper abdomen with vascular anastomosis to the splenic artery or to mesenteric vessels, but we can also see these in the pelvis. So the biggest thing we need to know when we are proceeding after a transplant is the location of the pelvic organ and the anatomy. So this is a CT scan of a patient with a right renal transplant. So you can see the psoas muscle here. Here is the kidney, and the anastomosis to the vessels is kind of right in this location. And then her ureter comes down, and it kind of, there was the anastomosis, or the ureter goes here and then kind of kinks back up and then goes back into the bladder more superiorly. So something, you know, really we need to identify, and I'm just going to show one more video here to share a different screen. So this is a video of the completion of a transplant done here at Mayo, and this is an open approach. Here is the bladder, and here is the ureter and the kidney. So it's, again, kind of in that pre-peritoneal space. And as they let this go and show the retractors there, you can see that that ureter kind of is sitting right in that pre-pubertal space almost for us. So something that we could easily encounter when we do a, when we're doing a fan and steel incision or a midline incision. The pancreas transplants can be a little more variable. This is a case of a patient who had a 1A2 adenocarcinoma of the cervix, and she'd had two prior pancreatic transplants that were failed. And so what you can see in this CT scan is just some calcification over the pelvic brim where her residual pancreas lives. It's sort of here. But really, sometimes when you're scanning these patients preoperatively, you may just see sort of an amorphous pancreas sitting there at the pelvic brim, and it's really hard to understand what that anatomy will look like when you get into the abdomen. So I have a video here I'll share. This is that same patient with a pancreas transplant. Unfortunately, I don't have a kidney transplant patient, but going into this patient's surgery, we knew that we wanted to do a lymphadenectomy. So we planned for sentinel nodes, but discussed that if we needed to do full pelvic nodes, we may have difficulty with anatomy. And again, if we were to do periordic nodes, we'd also have to consider the anatomy. So here, she didn't have any adhesions, likely from her immune suppression. This is commonly where you would see a kidney, is sitting here on psoas muscle. What you can see for her is just this residual pancreas, sort of calcified nodule here that I really wanted to remove, but I was working with a transplant surgeon, and he told me to leave that be. But that's really kind of all we saw. We then proceeded to remove her fallopian tubes, as we were planning to remove those with the uterus. So we just separate these adhesions, and this is, again, really minimal adhesions, which is fairly common in our transplant patients. So then we moved to do the retroperitoneal approach, and open up our perivascular and periorectal spaces to identify our nodes. You can see that she really, again, doesn't have much for an abnormal anatomy in the retroperitoneal space. It opens sort of like a patient that had never had surgery. We did inject with ICG, so we were able to follow her channels very well, but you can imagine that in patients that have had prior retroperitoneal surgery, you may not always see that open as nicely or map as nicely. So for her, we just opened the space and identified the node there, elevate that from the external iliac artery and vein, then for excision. And for her, you know, we counseled about, you know, if we can't get in safely, what should be our plan, and, you know, I had transplant surgery available to help if we really needed to do a full periortic or pelvic lymphadenectomy based on the pathology that we found. The similar story on the left side, we opened the retroperitoneal space, and again, found very few adhesions, maybe a little bit stickier than normal, because she did have a transplant on this side as well, or an attempted transplant. And you can see the channels on the left opened real nicely, and you can see the green even just with white light. So just developing the space a little more and finding ureter. And we see just mainly a bunch of channels here, and we opened paravesical space a little bit more to just make sure there wasn't a lymph node in that space, and follow those channels up to the external iliac artery there. So again, taking down some peritoneal adhesions and identifying the lymph node for removal. These lymph nodes were then placed in laparoscopic bags and brought out through the umbilical incision. So again, open real nicely, which, you know, hopefully you will see, but if you had a kidney transplant, it might not be as friendly. And then this patient desired a repeat pancreas transplant, so we closed the retroperitoneum over the retroperitoneal space to prevent adhesions to make her future surgery easier. And again, if you had a kidney, it would be sort of sitting lateral over psoas with the anastomosis in this space. And with your kidney dissection, you may have some difficulty getting your sentinel nodes to map or to do a full pelvic node dissection due to adhesions. And this was just the completed surgery, so closure of both peritoneal spaces. This is her residual pancreas, so would have been sitting here kind of with the tail out lateral. Oops, I didn't want to stop share here. Sorry about that. So finally, just in summary, some considerations, you know, minimally invasive and open surgery are feasible in patients that have had prior transplant. It's really important to review the operative note from that transplant so that you are aware of the location of that organ. Review imaging studies that you have available and review their anatomy. Discuss the possibility of limitations to your nodal dissection or have help from transplant surgery if you feel you really need to do those nodes. Consider ureteral stent placement or ICG for easier identification of a ureter from a transplant and involve your transplant team when possible. So thank you, that is all I have. Wonderful. Thank you, Kerry, for this beautiful presentation. Again, we are going to open for discussion, so you can send your questions through the Q&A feature. And I have a couple of questions to warm up. Does the immunosuppression change your perioperative care? Do you make any changes in your routine for those patients? I do not make any changes. We continue with our usual cefazolin, our third-generation cephalosporin for antibiotic prophylaxis. But no, I don't do anything different pre-op, and we don't continue antibiotics post-operatively either. Great, and do you think this vascular dissection that those patients may have done can change the lymphatic drainage? Do you think it's still you can do safely, just send a lymph node, or do you consider to do a pelvic lymphadenectomy in such cases? Yeah, I think that's a good question. I don't know that we have data to help us one way or the other on that. You know, I think we've all had patients that haven't mapped, and I kind of, you know, think that if their lymphatics have been disrupted, that they're not going to map normally, and then you won't identify your sentinel node. So I think if you identify one, I kind of think those are true. But again, we don't have any data or series to really guide us in that. So then I think it really becomes that discussion of why are we doing the lymph nodes? Is it prognostic or therapeutic? And having a good discussion with the patient about their feelings about removing those nodes. Great. I know it's not so common in transplant patients, but patients with urinary disease, sometimes they have used catheters for a long period, and do you expect sometimes to have more fibrosis? I know the ureter is not so important in these cases, but anyway, sometimes you do expect to find some changes because of the long-term use of catheters. How do you deal? Do you have any suggestions to these situations? Yeah, I haven't seen that preoperatively as much, but I know, you know, one of my partners has had a post-op ureteral bladder stricture or ureteral stricture due to their surgical intervention with the hysterectomy. So, you know, I think you just have to really be cautious around the bladder and, you know, use your usual anatomical considerations and approach. Yeah. Good. Good. So thank you again, Karen. So that's all we have for today. Thank you all for attending, and I would also like to thank our experts presenting and my co-chair, Dr. Langstroth. The recording of today's sessions will be available at the IGCS Educational 360 Learning Portal next week. Be on the lookout for assessing information next week on the IGCS website. It's membership renewal season, so it's time to take a look and see if you need to do it. And we encourage you to take a look on the news and continue to access our educational portal, like today's webinar and other member benefits for you all. So if you are not an IGCS member, please visit igcs.org to learn more about how to become a member. We wish you all to continue healthy and safe. Stay well. Bye.

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