Good morning, everyone. Welcome to our session today. My name is Afshin Bahadur. I'm a gynecologic oncologist in San Diego, California, in the United States. I would like to welcome you to today's webinar, Identification of Sentinel Lymph Nodes During Endometrial Cancer Surgery, which is in part supported by Intuitive Surgical. IGS is committed to providing meaningful opportunities to our industry colleagues to gain exposure to our gynecologic oncology community through a unique year-long educational engagement program. This platform provides a level of strategic engagement and exposure needed to educate and inform gynecologic oncology professionals on current and future to optimize patient care both locally and globally. Before we get started, I want to mention a few housekeeping items. We encourage you to submit questions via the Q&A, and following the presentation, we will have time for questions and answers. We will do our best to answer all your questions. This is a very exciting topic, and I'm sure there will be a lot of questions. I'll try to consolidate and make sure we hit the main points. Also, a recording of this webinar will be available on IGCS Education 360 Learning Portal within one week. So let's meet our esteemed speakers. It is wonderful to be joined today by our esteemed presenters, Drs. Gustavo Gitman and Dr. Enrique Falconer. Thank you, gentlemen, both, for joining us today. If you would please introduce yourselves. Dr. Gitman, if you would like to go first. Hello. I'm not seeing my camera, but it's okay. Thanks for the introduction. Are you hearing me, Bahadur? Yes, we can hear you, sir. Perfect. Yeah. My name is Gustavo Gitman. I'm from Rio de Janeiro, Brazil. I'm an oncologist from the National Cancer Institute Brazil and America's Medical City. First, I'd like to thank the IGCS organization, especially Ashley for the hard work behind the scenes, and Bahadur and Falconer for joining me for this meeting. Are you sharing my screen? I think that you have to stop. Let's do the introductions first, if you don't mind, Gustavo, and then we'll get to your presentation in just a minute. Thank you so much. Perfect. So thank you for that introduction. Dr. Falconer, would you please introduce yourself? Yes, certainly. Good morning or good afternoon, wherever you are. Thank you very much for this kind presentation and invitation to present some of my thoughts on how we deal with central lymph nodes in gynecological oncology. It's always hard to be second, especially with a renowned expert as Dr. Gitman. So I'll try to do my best, and I guess we'll be hearing about the fundamentals first, and I'll be second with some troubleshooting. Thank you, Henrik. We are fortunate to have presenters from different parts of the world, along with participants. This is very exciting and such an incredible opportunity to be a part of, and I'm very excited personally myself. So let's go ahead and start. Dr. Gitman, if you could please begin your presentation, and your slides should be coming up in just a second. I'm going to share. There you go. You got it. Okay. Perfect. Again, thanks for the invitation. We'll talk with a very special topic. The problem is since 2014, already published, most of the service still not doing the sentinel node, but we're trying to improve this. Our mission is to identification the sentinel node bilateral. It's not just one side, but our main goal is to identification the sentinel bilateral. The map of our mission is already published by the NCCN 2014, lead by Agurustu, and is well known, is published in NCCN, and you have to follow these to achieve a low rate of a false negative rate. We have two big weapons to fight with these nodes, is the blue and the green. The film trial already show better for the green, better results for bilateral detection, 7%, 8% to 31%, a significant difference between both. It's easy to do the ICG, but who don't have around the world the ICG can use just a blue and you can do it well with just a blue. We are going to focus in a small time in the ICG. ICG is 97% sensitivity and negative predictive value is 99%. Our agenda is going to see the ICG features, the best concentration, where to inject and in the local, the time to start the dissection, something about anatomy, especially in situations that the folklore is going to follow these two. Just a little background, endometrial cancer is the most common in developed countries, not in Brazil, but still using a sentinel node there, here, with a protocol. Since 1998, endometrial cancer, 2013, 2014, NCCN was up to date for sentinel nodes. Sentinel node may increase the detection of sentinel node metastasis and ICG green is most useful for doing that. Some features that is important because most of us use, but don't know well about the ICG. ICG is a well-known science, I think in 1959, it started with ophthalmologic surgery. Sentinel green is a water soluble, pH is 6.5 when put in water. Intravenous injection, rapidly bound with the albumin and a protein. ICG contain sodium iodine, have to take care with allergens with people or patients that have allergens with that. It's unstable, after you put water inside, it's unstable, you must within six hours and completely extract by the liver. The new drug application for FDA approved for use with a cervical injection in 2018, first it was intravenous, then after started for the cervix. The dilution they suggest is 25 milligrams with ICG plus 20 water to achieve 1.5 milligrams per ml. The recommendation for injections is 1.5 milligrams, it's that 1 ml deep and superficial with a total of 5 milligrams of ICG at 3 and 9 o'clock deep and superficial. Just review the features and the concentration should be 1.5, but the other service use difference from 0.5 to 5 milligrams, but they suggest 1.25. The injections we use here in Rio, 2.2 gauze spinel needle. The local still use 3 and 9, sometimes you put more points. And time to start the session is very hard to see, but there's no consensus in the literature, but about 10 minutes enough to start your dissection. About anatomy is very important part. We usually open all the vascular space, we really like in the green row, you pull the brown ligament and push out the ureter from the uterine artery here. And you're going to start here, your dissection between the ureter and the internal liquid, go down to the uterine artery and then after start the paravesical space. I changed during the time after, before that I started with the paravesical and then go to paruretal, but most of the sentinel nodes come this side and we start now at paruretal space. This is a very important part, we really need to find your landmarks, recover the anatomy, open the vascular space, then just start your surgery to be secure and not break the channels. This is a very, if I can choose one sentence, this look for the channels, the channels, not for the nodes. The channels is the most important part of starting to looking for the sentinel node. You have to look for the channels, then follow them and achieve for the nodes. Maybe you have a false negative or a wrong node. This is an educational video that I'm going to film because the time is just to show you different parts. This is a very important part of the sentinel node that sometimes they not go to the so common places and go to different places like a pre-surgical. Like this video you can show here, like you show the anatomy part. You're going to see the internal artery there and you're going to see the channels between both and you're going to follow for the pre-surgical and you're going to see the sentinel node. This is an important part to not break the nodes. Here is more a little dangerous because the liquid vein is there and the nodes are just a little side by there, but you can do it easy. These are very nice features of the sentinel nodes, because sometimes you have two vials, two ways for two channels directly from the parametric or from the uterus and then you have two sentinel nodes. It's not necessary to have just one. Maybe you can have one or two or more, but have to be to follow the channels directly from the uterus to the channel. If you have like this one, probably you have two channel, two sentinel nodes and you have to take out the two nodes and send for uptestation showing that there are two nodes in the same site. Because of that, it's very important to not break the channels before you follow them until you achieve the sentinel node. Here is the obturator nerve and you can take it, take one and after take the second sentinel node in the same site. Like I showed you the pre-circle, it's another one you are seeing in the heteroperitoneal space, nothing showing, no channels there. Probably it's being negative, but you go inside the peritoneal in the middle part and you can see the channel follow the cervicals through the middle part until to the pre-circle. Then you go directly to the pre-circle. Then you go behind the common right iliac and take the sentinel node. If you don't do the sentinel node, probably go to the obturator fossa in this case and take the lymph nodes in the obturator fossa and probably it may become negative and the positive nodes are there. Because of that, the importance of the sentinel node that we are more precise surgery than take all the nodes out. The brush effect, I always talk with my fellows about the brush effect. The brush effect is very nice. We learned this with the time that you can dirty your grasper and mimetize some kind of sentinel nodes and just take out, if you don't take care, just take out some fat. You know there is a dye, a green dye and maybe can spread from the peritoneal and you dirty your grasper and you dirty your tissue and take it out. Another thing is a paintball effect. A paintball effect, I call this when you inject in the peritoneal, it's like a splash, something like that and you see a mess there in the peritoneal, but don't give up. Don't give up to start looking for your sentinel node. Open the head of the peritoneal, follow the steps, open the vascular space, try to not dirty your grasper in that and you're going to see that behind the retroperitoneal, you can see in many cases, still you can do the sentinel node. Don't give up. Maybe have a mess in the peritoneal, but if you count with count open like that, you see a mess in the peritoneal, but behind in the retroperitoneal, just open. Take care to not make rows in the peritoneal, to not spread the green, the dye to the retroperitoneal and follow the technique to achieve them. Sorry about the sound. This is a very important effect, the sallow, like with albumin, the green, join with albumin and sallow the channels. In a few patients, it's easy to see the channel and the lymph node, but in obese patients, all of them will be right and maybe you have empty pocket. Empty pocket when you take out just fat or some tissue without a sentinel node. If you have any doubt, it's better to send for the pathology, not for the pathology. Just to have certain that you have lymph node tissue in your tissue that you are sending for after ultrastaging. Then you can see how now broken the channel, then spread the ICG, but have to care the channels, maybe right as a sentinel node and you have to be more confused. Obesity. Obesity is another important. Most of the patients with endometrial cancer have a high body mass and ICG green is better to do than blue because you have deep about 1.5 centimeters in the tissue. It's better to visualize the green. Sometimes the blue is not so easy to see in the obese patients. But again, it's difficult sometimes to look for and to find the sentinel node. Sometimes you think to stop here and maybe you can take this like a sentinel node, but it's not the sentinel node. You have to follow the channel again. If you follow the channel, you're going to go inside the uterotor fossa there behind the iliac vein and you're going to achieve and to see the really sentinel node and achieve a really good result. You can follow there until the uterotor nerve. There's going to be a right fossa, then you're going to take out the sentinel node. The blockage channel is a lot pitiful that you have already published by my colleagues. Here you can see a channel here, a sentinel node, but between them we have a large node. If you follow the map, the algorithm, you have to take out any large nodes instead of other guy nodes. You have to take out any large nodes and to take out and you can see there is a positive node, but it's not a sentinel node. It's obvious that you have any large nodes. You have to forget the sentinel nodes and take out these nodes too. My take-home message is inject ICG slowly. The inject part is the most important, one of the most important, and who have to inject is the most experienced surgeons in the room with the technique. You have to respect your learning curve. Open always the vascular space and look for the landmarks and the structures. Don't break the channels. You have to take a lot of care to not break the channels. If you follow the channels, you're probably going to see where is the sentinel node. Again, we would like to thank you and after we can ask some questions and answers. Thank you again. Thank you so much for that excellent presentation. I love your last slide with the take-home messages. I also like the fact that you mentioned that if you are unsure about the fact that when you take a piece of lymphatic tissue and you're not sure whether it's a node or not, to send it to pathology to have them to confirm that there's a lymph node there because it can be sometimes challenging to distinguish a bunch of, a bundle of lymphatics and it may look as though it's a node, but actually on your final pathology, you'd be surprised that they did not find a lymph node there. So you would try to avoid finding yourself in that situation. Excellent presentation. Thank you so much. We will now go ahead and move on to Dr. Falconer and have him present his slides and certainly the questions are coming in. We will have opportunity to answer those questions at the end of the presentation. Right. Thank you very much, Dr. Bador and Dr. Gitman. Wonderful presentation. Again, it's always hard to be second, but, you know, it's repetition is never something that's bad for us in teaching and learning. So Dr. Gitman has already covered some of the troubleshooting, but I'll just give some thoughts on this as well. So when we talk about troubleshooting in central lymph nodes in gynecological oncology, we typically talk about failed mapping that could be on both sides or one side. We have something that Dr. Gitman already touched upon, the empty packets, and we have some other issues as well. Just want to draw your attention to this publication. This was a large multinational collaboration a couple of years ago where we tried to find a consensus for how to perform central lymph nodes in endometrial cancer. So experts around the world were gathered to create a common platform. We sent out questionnaires and tried to reach consensus for the various steps in central lymph node biopsy for endometrial cancer. And then we published this competence assessment tool in the International Journal. I think it's a wonderful tool and something that could be used for both teaching and research in endometrial cancer. So don't forget, I showed you this, but this is obviously what you want to see. So we inject the ICG in the cervix. We want to see this, we want to see bilateral mapping. So we see the green passing through the upper pathways, running through the parametrias on both right and left side. So this is what we refer to the upper pathway, running through the parametrium. But we can also see here something different here. We can see the lower pathway. So this is a different pathway. And these two pathways, the upper and the lower, are divided by the ureter. So you can see here the lower pathway and the upper pathway. These two pathways are distinctly separate from each other. And we have seen from the literature that the drainage from the uterus and from the cervix is complex. So we have the infundibular pelvic ligaments with ovarian vessels, draining in the upper periortic region. We have the lower pathway, running close to the rectum and draining in the lower periortic region. And we have the most common one, the upper pericervical pathway, running through the parametrias and draining typically in the obturator or around the external iliacs. So when we analyze the results from central lymph nodes, which of these routes are most important? Well, clearly the upper, but also I think it's important to stress that we do find metastases along the lower pathway. So in this particular study, one fifth of the patients with positive nodes also had metastases along the lower pathway. So when we map along the lower pathway, we'll see different pattern. So here you can see the upper pathway here, and then we have the presacral from the lower pathway. It's tempting to think that this is a central lymph node running from the right side, but you can see no afferent vessels coming up here. So this is crossover, crossover from left to right. So the vessels originate from the left side and they cross over to the right side. So if we wanna find a central here, we need to do what Dr. Geetman just showed you. We need to follow the vessels. So we shouldn't take just any node. We need to make certain that this is the first node in the chain. So just going deeper down here along the promontory to find what is actually the central lymph node from in this particular case, the lower pathway. So here it is deep down. This is the central lymph node and not the first one. So the presacral area is a lot more complex and it requires more experience clearly to identify the correct nodes. Failed mapping, that's what we fear, of course, because failed mapping will pose some difficulties for us in staging. So we see that it's more common in endometric cancer than in cervical cancer, and that's clearly because of the different pathology and the different patient characteristics. So as you all know, endometric cancer patients, they tend to be older. They have a higher BMI. They're more prone to have cardiovascular disease, which may affect lymphatic vessels as well. Cervical pathology, previous colonization, cervical amputation, strictures, all these things might have an impact on your mapping. Obesity, previous surgery with adhesions, advanced age, and of course, if you don't use the correct injection technique. And I think one of the things that also was shown in the last presentation is the present of metastatic disease, which is something that's causing some issues sometimes when we find them. So from the literature, we know that bilateral mapping ranges from something like 70, 75% all the way up to 95% from the largest trials of central lymph node mapping in endometric cancer. What's interesting when we look at some of the largest studies on this is that in the FIERS trial, the first proof of concept for central lymph nodes by ICG, we can see that the bilateral mapping was quite poor with just about 50% of the patients in this trial that had bilateral mapping. Whereas in a more recent trial, the FREC trial from Sweden, the bilateral mapping was 94%. And an interesting detail here is that the amount of ICG was 2.5 times higher. So maybe the amount of ICG matters when it comes to mapping. Let's see if I can do this. And this is just, of course, when we see vessels like this, it's clear that mapping will be affected. Learning curve, obviously a learning curve will have an impact on the rate of bilateral mapping. There's been a few publications on this and it appears to have that the learning curve flattens out after about 40 to 50 cases. So obviously adhering to the correct anatomical principles, the right technique and being trained properly are crucial factors for achieving a high rate of bilateral mapping. So we cannot expect our fellows to have the same rate of mapping as we have among experts surgeons. We just need to train our surgeons properly. There are different types of central lymph nodes. We have what we call referred to as type one, which is the classic green. So we have an afferent lymphatic vessels ending up in a green node. That's a type one. The type two was what Dr. Geepman just showed you. We have a lymphatic vessel ending up in a node that hasn't taken up the green. And of course we have what we always have, the suspicious nodes, macrometastases. All these types of nodes need to be taken into account when we do our central lymph node mapping. So here are a few examples. We have here a clear example of a vessel. We see an afferent vessel running through here on the right side through the parametrium. It's a clear green vessel, but it ends up in a node without any uptake. You can see that this node is a roundly shaped. This is a macrometastasis. The hypothesis is that once the nodes become metastatic, they're just filled up with tumor and they cannot take up the green anymore. So it's really important that when we find afferent vessels, we need to take the closest node to that because that might actually be a metastasis. Same thing here, we do the mapping here. Opening up the paravertebral space here on the left side, trying to find the green afferent vessels. We see no mapping down here. Continued opening up the paravesical spaces as well, trying to find some of the afferent vessels, but again, no signs of mapping. And what we see here is that, again, we have macrometastasis. So every time we have failed mapping, it's utterly important to look for, do we have macrometastasis that might be an explanation for the failed mapping? Because at the end of the day, this is what we want to find. We want to find the patients with the metastasis. So what do we do when we have failed mapping? We should, in my opinion, start with reinjection. This is some data from the SHREC trial from Sweden when we had, after the first injection, we had a bilateral mapping rate of 83%, but after reinjection of ICG, a bilateral mapping rate of 94%. So we increased the bilateral mapping by 11%. So again, going back to the principles of central lymph node, don't disrupt the channels. Try to dissect the spaces first. Try to maintain the vessels, because if you don't have your mapping, you can reinject if you have maintained lymphatic channels. If it fails, we have two options. Either we do a site-specific lymphadenectomy, which is recommended by most guidelines, but it's also been proposed that we could do anatomical-based mapping. What is that? Well, from previous studies, we know that the most common localizations of central lymph nodes are around the iliac vessels, the obturator. There's where we find 90% of all the central lymph nodes. So it's feasible to do a mapping based on the anatomy. The point here is that we can maintain the benefits of ultrastaging when we only take away two or three nodes instead of doing a complete site-specific lymphadenectomy. Also, of course, associated with less morbidity. It needs to be shown in prospective studies, but I think it's interesting to just take the nodes that we think might represent the central lymph nodes when we fail our mapping. This might be especially important in women with low grade endometrial cancer to avoid unnecessary morbidity. So Dr. Geithner also touched upon the empty package. That's the same thing we want to avoid. Why? We don't want to end up having our pathology report with no central lymph nodes, but of course we can't go back to repeat the central lymph nodes. We have to take the patient back to theater perhaps and do a full lymphadenectomy. It correlates with learning curve. There's been a couple of publications on this as well. So learning curve, frozen section, or pathology, just to make sure that we have a node. And we should use our technique correctly. Again, try to maintain the vessels. So my fellow here is dissecting here, opening up the spaces. We can see the afferent vessels running through the parametrium. So my fellow here is things that this might represent the central lymph node. You can see here, the node is here, but just by shifting the camera in parallel, you can see that this big thing here that might represent the central lymph node actually is just an enlarged vessel. So just by a parallel shift with the camera, we can make sure that this wasn't a node, was in fact a vessel, and we can move on with the dissection. We can also use built-in technology. This is the most recent optics from the DaVinci platform using a sensitive mode. So here you see a very busy pattern of lymphatic vessels. It's difficult here to distinguish which are the vessels, which are the nodes. So by just increasing the contrast here, the contrast level, we can easier identify the vessels from the nodes by switching over to a sensitive mode here, increasing the contrast to see the vessels and separating the central lymph nodes. So we're just being helped by technology here, and we should use it correctly. Central lymph nodes is typically referred to something that's fairly simple. Once you've done your 30, 40 first cases, you're past the learning curve, but I think it's important to keep in mind that also central lymph node mapping might be associated with some issues apart from failed mapping that can obviously be dangerous for patients. We're still doing retroperitoneal dissection here, so we need to be careful. So this is a surgery from Karolinska. It's a clear mistake from the beginning because this surgeon here is continuing the dissection despite having poor exposure. So he cleans the camera, takes the camera in. I think you probably have noticed something already. Continues doing the mapping, opening up the retroperitoneal space. The surgeon hasn't noticed anything yet. Opening up the parorectal space, trying to find the green, and all of a sudden, there's some blood. The surgeon is not aware what has happened still. Thinks it's some peritoneal vessels. Here you can see the green. More blood coming. Still not understanding what's happening here. Still trying to continue with the dissection, to open up, doing some random diathermia. And now he realizes that during the first division of the round ligament, he accidentally cut the external vein, which obviously can be easily sutured. So central lymph node mapping can be harmful, of course, for patients, and we can damage critical organs. This is even worse. Another case, the surgeon doing central lymph node mapping. Another mistake, pushing your scissors too deep into the vein instead of lifting up the peritoneum. This case here, you can't rescue, so we need to do an emergency undocking. So again, central lymph node mapping is typically something that's feasible, fairly easy once you're trained, but we need to keep in mind that things can go wrong, and we need to be properly trained. And just going back to training, this is from Karolinska, my institution in Stockholm. This is what happened after the implementation of central lymph nodes. And you can see here that the proportion of patients that undergo pelvic and pelvic lymphadenectomy for endometric cancer has decreased dramatically since we introduced central lymph nodes. Same thing, of course, for vulva cancer, cervical cancer. So the question is, how do we train our fellows in the lymphadenectomy, and how do we maintain our own skills? I think this probably is a subject for another webinar, but I think it's important that it's something that we need to keep in mind. So thank you very much for the attention. Just want to acknowledge my friend, Nico Bissari, for some help with the images. Thank you very much for listening. Fantastic presentation, Henrik. Thank you so much. This was great. I learned a lot from both of your presentations. We have some questions we're gonna get to in just a second. Henrik, I like the fact that you show in your video that you do an initial survey before you start opening the peritoneum, obviously not only to look for any evidence of extra uterine disease at the onset of the sentinel mapping but also to make sure that you actually see channels on both sides. And I appreciate the fact that you mentioned the sensitive mode. For those who are not familiar with the sensitive mode, can you please comment real quick on what the sensitive mode is and how do you achieve that? Right. So I think, I mean, it goes back to being structured in your mapping. So if you start out with just exposing everything in the pelvis and you see that you have bilateral mapping, you know that you'll find the nodes. With the sensitive mode, you can have some extra help, especially in difficult cases, if you have patients with obesity, previous surgery, fibrosis. So we can just switch from two different modes within the same camera to something that's called sensitive mode, which will increase your contrast level. And it makes the ICG become clear and the background noise from white becomes lowered. So it's gonna help you to see your channels. It's gonna help you to see your nodes, especially in tricky cases. I've had some help, you know, especially in obese patients. I don't know what your experience is. Have you been using it as well? So, yeah, when you are alluding to the sensitive mode, you're obviously talking about the plus scope that is available on the newer generation XI model of the da Vinci system. So you have to have the plus scope in order for you to be able to flip back and forth from a regular firefly mode to the sensitive mode, right? Is that what you- That's correct. Yeah, actually my experience has been the same and I wanna hear Gustavo's response to that also, especially in situations where at first glance, when you're in the firefly mode, you don't see bilateral channels appearing in the posterior cul-de-sac along the pelvic sidewalls before you even open the peritoneum. So flipping in and out of sensitive mode can be very helpful, but especially in those patients who have a significant body fat content in the retroperitoneum where the channels get obliterated by the surrounding fat. And so having the sensitive mode available will really help you or enhance the ICG effects and actually find a channel that otherwise would not have showed up in the firefly mode. Gustavo, what are your thoughts on that? Yes, when I start the surgery and don't have the both channels, I prefer to start where the channels were and have time and give time, maybe for the channels to be, to complete with ICG in the other side before I start. If not, maybe we're going to slowly open the spaces and trying to find out the channels that are with ICG. If not, we're like Falconer do, we inject this after 20 or 30 minutes. Another thing, when you don't have a special, like a scope plus, maybe your next side, what you can do, you can put the light, the normal light a little down and you can maybe change for the firefly mode. You can, because not all the IXI in the world have the plus, but you can range the light, put the light, the normal light a little down in the touch pad, and maybe you can put the pens more high or low, the firefly mode, and you can try to see if you can see something. Is that all that I do? And that's an excellent remark. Thank you for that. It was actually on my list of things to also ask you about, about if, let's just say for some reason, you don't have the plus scope and you have the regular scope, as some may have, it's good to be aware that you can adjust the levels of both the ICG in the firefly mode of your panel, along with the ambient lights to kind of balance that off. And you can, if you have an overwhelming fluorescence, when you first get in, like you showed, you can dial down on the ICG, right? And the Firefly mode, and you can see perhaps that your actual important node or channel may show up better. So it's important for everyone to be aware of the fact that you can change your settings on your panel. And I would encourage everyone to practice with it. I have other questions to ask you, but I want to get to the questions. You both had mentioned about finding the gross, the macroscopic or the grossly involved disease first. Can you please briefly tell us in terms of your technique of opening the retroperitoneum, how would you go about obviously not only making sure you get the mapping, but not to miss the node? And you both touched on it, but this is a question and let us know if you have any additional feedback on that. Can I go first? Yes, go ahead. First as possible, you have to do a nice MRI or image before, this is very important. But in a surgical technique, I always open the round ligament, push, pull the round ligaments to the middle and starting to see like the first thing that I looking for is the ureter. We look in the ureter and starting to open the space between the ureter and the internally and open this space then go and see the uterine artery through the uterine artery, then go to the front from the vesicle space, part of vesicle space and see with your grasper, touching the fat tissue to see if you have any, because it's very, very nice how Falcona do the surgery, how you feel nice with the technology because you do surgeries in a black and white without tattoos, you feel more comfortable with the time. And when you put your grasper with the tissue trying to see, it's not the best, okay? But if you have very large nodes, probably going to see this. I think what we sometimes see among our fellows is that you open up the peritoneum and then you go directly for the green. You're so keen on, you know, just seeing the green, you want to go for the green. So what we tell our fellows is that you need to do the same thing over and over again. Be structured, open up the spaces, have your ureter lateralized, visualize the nerve, see the peritoneum and see the channels coming in. You should be seeing a node if you see a vessel. At the end of that vessel, there should be a node. And when you open up the spaces, you will also see if you have metastatic disease, if you have bulky disease. If you just go for the green, you might miss things around. So be structured, try to do the same thing over again, visualize everything, have nice exposure. If you don't have that, you typically end up having more issues with bleedings, you get nervous about the ureter, you get nervous about the nerves. So try to be structured, try to do the same thing, same steps every, every time. Excellent, thank you, gentlemen. When I was watching, Henrik, your complication videos, it was like watching a horror movie and I knew what was about to happen and I literally would close my eyes because I knew exactly what was gonna happen. You know, can you please make a comment? When I noticed that those particular surgeons make the initial incision on the peritoneum to enter the retroperitoneum, in your opinion, what was the mistake that was made right off the bat? And obviously there was a deeper application of the monopolar, but there was also, I thought that was a mistake in how the peritoneal incision was made. You're absolutely right. I think the first video shows that, you know, what we see that some surgeons, they're so fast. They wanna open up the spaces immediately and obviously you need to have everything in order. So you have to have exposure. So what happened in the first case is that, you know, the gas, the evaporated gas from the diathermia caused, you know, he couldn't see what was happening. So he accidentally hit the vein during the transection of the round ligament. And the thing that's interesting here from this video, he didn't notice. So he proceeded, obviously he was lucky because the incision was quite small. We have the patients in trend. We have an increased intramuscular pressure. They normally don't have this massive hemorrhages, but it is a mistake and he should have waited until the camera was cleared before proceeding. Second case, you have to be sure that you have a space between the peritoneum and the vessels when you open it up. If you dig in your scissors, you don't know what's gonna happen. You might have patients with anatomical deviations and that's a particularly bad case because we had to do emergency undocking and laparotomy. So again, it's a standard procedure and just keeping to the principles of anatomy and safe surgery. Excellent, thank you. Making that peritoneal incision kind of linearly down, you show and you're both of you showing great part of that where you actually create a triangle when the round ligament is on top, your IP ligament is medial and your external iliacs are lateral, you have this triangle. And I think making that incision, this is what I tell my residents is to make that incision linear down to avoid both vascular structures. And then that's what we do. We do both vascular structures and then dissecting the retroperitoneum. So I thought that was a really excellent video to show that. We're getting... Yes, go ahead. Well, I think that the thin patients is not the big problem because you really see the vessels and you can go lateral. When you have obese patients, what I do, I push, I pull the round ligament up, quite the abdominal part open, very lateral, then go like a parallel to the vessels, very lateral, and see, you see the psoas muscle. Then you go, then you got to start medial. If you go directly medial, maybe happen what Falkorner show, you can go directly to the vessels. This is, I think, the problem. We have a question from our participants. Please address this quickly because the answer can be very long. Why is the cervix the organ of injection and not the endometrium and endometrial cancer sentinel mapping? Who wants to take that one first? I think this is the... Every time that you inject in the cervix, we do all these questions. You already saw in the main papers. If you see all the endometrial cancers, you have to about 2% or 3% of isolated paraortic nodes. And you're going to, maybe you're going to miss these 2% or 3%. There are other ones, maybe you have first the cervical injection, go to the pelvic, you're going to be positive, then go to the parotic, not to skip metastasis. I think is that you're going to, maybe you're going to miss 2% or 3%, and it's much easier to do that. If you have to go to the scope and go there, and most of the nodes go to the pelvic, like Falkorner show in the three ways of the most them go to rectory. If you inject in the fundus, probably you're going to miss more nodes in the pelvic and going to achieve more false negative in the paroartic. I think that you always, we don't want to inject in both, but the sentinel nodes are going to miss 2% or 3% maybe. Henry, do you have any comments on that? Yeah. I mean, this is all about anatomy. Anatomy and not disease. I mean, just because the disease arises from the metrium doesn't mean that, I mean, we still have the drainage of the uterus. We know that the lymphatic drainage from the uterus runs through the parametrias, runs through the eye polygons. It doesn't matter what kind of disease you have. You could have cervical cancer, you have endometrial cancer. We see that the mapping and the sensitivity of sentinel lymph nodes appears to be identical between these two diseases. So it doesn't appear to have, I mean, we've been trying to do all the fundal injections or with a hysteroscopic injection, and it turns out that cervical injection is superior. And it's just because of the anatomy. It's about a drainage, a lymphatic drainage. There's the- And it's easily accessible, of course. Right. And there's been plenty of literature published on this in terms of mapping the uterus that has demonstrated that there may be some minimal increase in your detection rate if you inject the fundus, but that minimal difference was not significant to routinely require, as you both mentioned. In terms of high-grade cancers, would you do any kind of preoperative imaging just in case you have an isolated periodic gross node or any other evidence of disease? How do you use preoperative imaging in your sentinel node mapping as part of the preoperative workup? If it's possible, I always use MRI, but you know that maybe have a false negative if the sentinel is less than one centimeters and have a very high false negative for myocardial metastasis or low disease. And for a high volume, for a high grade, I use like a Pamela Sonoma from MD Anderson published before that we will use for all the cases. We believe that if you don't have a large nodes, maybe it could be treated with a chemo. Right. And we always do a CT scan on all our patients, regardless of if it's low grade or high grade. So just to rule out distant disease or bulky disease before we do our staging. So, and we've been seeing from, especially from cervical cancer that the PET-CT doesn't add anything in terms of sensitivity. So I think currently the best, I mean, MRI is good, but then you've probably been missing some of your upper abdominal disease. So in my opinion, a CT scan should be enough at least to rule out distant disease and bulky disease. Because then we have a clearly a different scenario if you have bulky disease. Perhaps the bulking depending on the patient's age and comorbidity and so forth, but then we have a different situation. Fantastic. Thank you. One more question. This is again, going back to the historical way of identifying sentinel nodes with regards to technetium-99. Is this still practiced in your geographic area or your institutions using technetium-99 for sentinel node mapping in endometrial cancer? No, no, no. When you don't have a green, you just use a blue dye. The technetium is very, I did some cases inject inside the room 24 hours before the surgery, but have to put the patients in a gynecology position, don't have in a nuclear medicine, sometimes tables to do that. It's very difficult. And I think they have a good learning curve, maybe with blue, it's okay to do that. For obese patients, more difficult to find, but I do not use a technetium. No, I agree. I mean, we know from the film trial, from the memorial, that ICG is superior to blue dye and technetium is technically more challenging. It's more expensive. It has worse sensitivity. I think pretty much all meta-analysis on the various traces showed that ICG is superior in terms of sensitivity, ease of use. I think there are no indications left to do technetium, but if that's what you have and you have experience with it, sure, it's better than doing a full lymphadenectomy at least. And that's a great point because not every location or every geographics may have access to some of the technologies we're discussing today. And technetium-99 sort of being the OG or the sort of the original way of mapping sentinel nodes, if you have experience with it, success with it, and that's the technology you have access to, I think that's important to acknowledge. Fortunately, you both have stayed on time and we have a lot of great discussion questions. I have a question for both of you. Yes, go ahead. I think that who didn't start to do the sentinel node and don't have ICG, you can start using the blue dye just to making your learning curve. It's not opposite for you to do the lymphadenectomy. If you do the lymphadenectomy, okay, start doing the sentinel node with blue if you don't have ICG, trying to find the channels, trying to find the nodes, then if you don't think that you are in a good way, do the lymphadenectomy, but starting on your learning curve. Right, and by blue, you're talking about isosulfan blue? Yes, or methane blue. Methane blue, also. But we use like a patent blue here in Rio, patent blue. I think it's the same. Sure. Both of you, if you could, maybe, Enrique, you can answer first. How many times would you say it's reasonable to re-inject to try to maximize your mapping? How many times have you done it? And if you feel that there is a sort of a magic number that has achieved the highest percentage of success rate? It's a good question. I think there's only one prospective trial exploring re-injection, and that was done once. Re-injection is something, it's gonna take another 10, 15 minutes to re-inject, depending on your setup with the patient. You know, you have to go down between the legs again, perhaps take out your manipulator. It's, you know, it's a bit of work. It's still worth it, but, you know, to go back twice, I don't know. I've actually never done it. Gustavo, have you re-injected more than once? I just re-injected once. If not works, I go to the lymphadenectomy. I don't think, if you are re-injecting looking, already looking the uterus, the parametrium, in the right side, doing the right volume, if not working, probably is not working the second, the third, and the fourth. So I just re-inject one, and if it works, okay, if not, go to the lymphadenectomy. So I just wanna stress that- Yes, go ahead, please, Henry. Yeah, yeah, sorry. I mean, I just wanna stress that if we don't get bilateral mapping, if we have a low-grade tumor, we will not be doing a site-specific lymphadenectomy. Why? Well, we didn't assess lymph nodes in these patients at all, you know, a couple of years ago. So we have extended lymph node assessment by including low grades as well. Should we be imposing more morbidity? I don't think we should. So we could instead do anatomical sampling so we could still take, you know, the first node we think might represent the central lymph nodes. You typically see them. After some time, when you've trained for a while, you see nodes that there is, you know, in those typical positions. We can take these few nodes out, have the benefit of ultra-staging, avoiding a full site-specific lymphadenectomy for this category of patients. Obviously, for the high-risk, we'll do a full lymphadenectomy. So I'm actually guilty of injecting up to three times. Oh, really? To be honest with you, I think three out of four times I've been successful. The same people are injecting or changing? No, it's me. So, you know, I think you both can testify to the fact that sometimes you have such difficult anatomy reaching the cervix. I agree. Or maybe the cervix is so distorted, your initial injection just doesn't feel right. Maybe there's no resistance. It just goes in too easily. Maybe the patient's cervical anatomy just said, you know what, you walk away from your first injection thinking that it just didn't feel right. And once you gain enough experience and you build a learning curve, that initial impression translates to your observation of not having a sentinel channel. So in those patients particularly, I do make the effort of re-injecting again, because I just didn't feel like I got a really good injection. And I've been re-injected up to three times and I've been successful, I would say three out of four times after the third injection. And again, your point about the low-grade versus high-grade, I think that the more you feel that having a sentinel node is important, the more you're likely to try to pursue it rather than exposing the patient to the additional morbidity of doing a full lymphadenectomy. So I think you just kind of case-by-case basis decide that. What are your thoughts on that? No, I think you're absolutely right. I think it's really interesting to hear that you have that experience with doing re-injections. Yeah, and again, I mean, our patients with endometriic cancer, they might be frail, obese, comorbidity, cardiovascular disease. It's a balance. How much morbidity should we be adding to these patients with normally pretty good prognosis, especially for the low-grade? So I absolutely agree. I mean, we should be making efforts to avoid that extra morbidity and try to get that sentinel lymph node, especially if we plan for it. And there was a question that just came up from that comment, how much would you inject and would you re-inject the same location? I try not to go exactly at the same spot, maybe go up a millimeter or two, either more lateral or a little bit higher, maybe half a cc more, I think is good. You don't have to inject the entire one cc because then you see the entire field turn green once you've injected three times. Well, again, we're... Yes, go ahead, please. It's a very nice point. This is a very nice point, how much you inject. Depends, okay, the size of the cervix too. You have to feel that you are completely injected. Depends of your learning curve. If you have a small cervix, it's different if you have a large cervix. You have to have some learning curve to know how you feel your pressure, your injections, it's difficult. Excellent. Well, gentlemen, it's been an absolute honor for me to participate in this event with both of you. Thank you so much for the time you spent to prepare your slides and to give us your time to present. It has been such a great experience. So this is the end of our presentation. I would like to thank all the attending participants for your questions. I would like to thank Intuitive Surgical for partially sponsoring this event and giving us the opportunity to discuss this technology. As mentioned before, the recording of today's sessions will be available on the IGCS Education 360 Learning Portal within about a week. So please go to igcs.org to get that information and relook at the presentation. Thank you all for joining us today. Have a wonderful rest of the day, evening. And again, it's been an honor. Thank you. Bye. Thank you so much. Thank you. Thank you, Ferdinand-Marie.

sentinel lymph nodes

endometrial cancer surgery

webinar

Dr. Afshin Bahadur

Dr. Gustavo Gitman

Dr. Enrique Falconer

indocyanine green (ICG)

lymphatic channels

preoperative imaging

patient care