All right, we are right at 8 o'clock, so we will go ahead and get started. I am Keri Langstrad. I'm a gynecologic oncologist at the Mayo Clinic in Rochester, Minnesota, and I'm very happy to be here, and I'd like to welcome you all to our Surgical Film Festival on Radical Hysterectomy. We have an incredible panel of surgeons who will be sharing their expertise with us on radical hysterectomy and on anatomy. We are thrilled to have you all with us today. Before we get started, I just wanted 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 that you will see at the bottom of your screen. We will do our best to address as many of those questions as possible, and a recording of this webinar will be available on the new IGCS Education 360 Learning Portal next week. Unfortunately, my co-chair, Dr. Reytan Ribeiro, has been taken away this morning to the OR and will not be able to join us, so we will go ahead and get started here. It is my honor to introduce today's first speaker, or today's speakers. Today joining us is Dr. Javier Macrina of Mayo Clinic Arizona in the United States, Dr. David Cibula of Charles University and General University Hospital in Czech Republic, Yukio Sonoda of Memorial Sloan Kettering Center in the United States, and finally, Professor Shingo Fujii at Kyoto University in Japan. Thank you all for providing your expertise and knowledge with us today. Without further ado, to kick off today's film festival, I invite Dr. Javier Macrina to present Pelvic Anatomy. Dr. Macrina, you may begin by sharing your screen and then go ahead. Thank you so much. All right. Good morning, everybody. Carrie, thank you so much for the introduction and invitation to participate in this surgical film webinar, which obviously is a very interesting subject. We are located in Arizona, and we have two seasons during the year, the one that is warm and the one that is super warm. These are my disclosures, and these are my objectives. I was asked to talk about pelvic anatomy, and I thought that I could direct the anatomy that I will discuss with you as it pertains to more radical hysterectomy, particularly the autonomic nerves, but I will address the vessels as I see in my simple mind as a surgeon for the branching of the hypogastric artery, the autonomic nerves, and for this, I want to thank Dr. Fujii because I did learn the dissection during the radical hysterectomy from him, and particularly the splenic as it pertains to the perimetral resection, and then obviously the sacral nerves, because sometimes we reach into that area, and then finally I'll finish with just a little ureteral artery. So the branching of the hypogastric artery, I always think about three branches, the anterior, the lateral, posterior. There are 47 variations based on an article from 1948 on cadaver dissection, and they tell you you never know what an artery is until you finish it till the end. So we are on the right side of the pelvis, this is what I consider the anterior, with a medial umbilical ligament, here's an artery somewhere in here, and this could be the inferior vesicle, middle vesicle, and you know the superior vesicle comes from the medial umbilical ligament. Then we follow and we see that there is a lateral one, which is either the internal cladendal most of the times, the inferior gluteal some of the times, or a branch that gives both, and this kind gives you the upper inter-artery, so be aware that this can change, and then as you go more proximal, you find the largest and widest 7 millimeters superior gluteal. So think about anterior, lateral, and posterior. I'm going to show you this in another patient, again, hypogastric, anterior, ureter, inter-artery some here in the fat, right there, and then as we turn it, we find the lateral one right here, and as we go higher, you will find the superior gluteal artery. So think about this, and this, like I said before, the lateral is inferior gluteal, internal cladendal, they both start with an I. Superior gluteal, 7 millimeters, the only muscle branch. So if you're going to do a hypogastric artery ligation, make sure you do it distal to the superior gluteal artery, otherwise you may produce intermittent claudication, and it's about 2.5 centimeters from the bifurcation of the common iliac, and it exits the pelvis between lumbosacral trunk and sacral nerve one. So the pelvic autonomic nerves, this is the world classification for pelvic autonomic nerves. You have the superior hypogastric plexus, divides between right and left, and as it goes into the pelvis, and at the level of S2, S3, with the bottom at S4, is called the inferior gluteal. This is superior hypogastric plexus right and left, inferior hypogastric plexus right and left. Now the surgeons, as we know, we change things, and in some articles you will see that this is called hypogastric nerves, and this is called pelvic plexus. Sometimes it looks like a nerve, sometimes this looks like a large plexus, but the pelvic plexus by the world classification is all the plexuses in the pelvis, but it's all referring to the same thing. This is sympathetic. Now the inferior plexus has also parasympathetic, and it comes with those three branches of the anterior portion of S2, S3, and S4, called the splenic nerves. I'd rather call them anterior branches of the sacral roots, one, two, and three, or sacral nerves one, two, and three. Splenic, why is splenic? Splagnos means in Greek viscera. So it means having to do with the viscera, parasympathetic. So remember, if you sacrifice those, you are outchanging the innervation that they are on the viscera, particularly vagina, rectum, bladder, but also sigmoid, and also colon too. So on the next one, we're going to repeat this, superior hypogastric plexus, parasympathetic, pelvic splenic nerves, inferior hypogastric plexus, sympathetic, and parasympathetic. Where can we find the superior utero-sacral ligament? This is the easiest place to find the superior hypogastric ligament, which I'm going to show you in the next couple of slides. Here they are. Ureter, two or three centimeters below the ureter, you will find them right there, right below the peritoneum, easy to find, easy to discover. So in this case, you'll see that it's a plexus. So we'll call it the inferior hypogastric plexus. Now we go to the right one, and it looks more like a hypogastric nerve. We've taken the peritoneum for endometriosis. And as you can see, it's below the ureter, two or three centimeters. So again, easy to identify. Now we go to the sphagnics. That's a little more difficult to identify, but you'll find in the dorsal aspect, dorsal and lateral aspect of the pararectal fossa, and those are parasympathetic, and you want to preserve those. In a conventional radical hysterectomy, barometrectomy, we resect those to the pelvic floor. So we are going to destroy or take off some of the sphagnic nerves. If we do a nervous sparing, we are going to preserve the vast majority of them or entirely all of them. So you will not have problems with bladder constipation. So we are on the right side. This is the deep ureter right there. These are sphagnics right there. Pararectal space. And this is the, we used the deep uterine bay as the segment. That's where we stop our dissection. On the next patient, we are dividing the paramecium on the right side. As I'm going down pararectal fossa, you see the sphagnic nerves right here. Look that if I continue dividing this past the vein, I will sacrifice those sphagnic nerves up here. You see, we stop right here because otherwise we would divide the sphagnic nerves in that area. In a cadaver, we have finished here a nervous sparing hysterectomy. We can cut it from here, but we preserved the distal part of the paramecium. Paravesical, pararectal. We go in the pararectal space. We go past the lower part of the paramecium we preserved. And here are the beautiful sphagnic nerves. Very well seen. You will not see that on a patient on a radical hysterectomy. You don't need to, but you can see that if I divide this, I will divide them as they go from here to the pelvic viscera. So remember this inner bay pelvic viscera. All right. So the question is up here, we preserve this. All right. So what happens when we have this? We go to the side. I'm sorry. Inferior haplogastric plexus sympathetic parasympathetic has the further nerves to bladder, vagina and rectum, but also reserve sensory nerves information from bladder, vagina and rectum. So here it is on the left side, pelvic exploding nerves and inferior haplogastric plexus right there. We go to the left utero-sacral ligament. You dissect them. You cut the utero-sacral ligament, but you preserve the inferior haplogastric plexus. And I'm sure you will see some videos on my colleagues up here as they come up. Now, inferior haplogastric plexus, how do you preserve the fibers that go up to the here on the posterior vascular ligament? That's where you're going to find the further nerves from the inferior haplogastric plexus. Again, we go to the cadaver. We find up here the superior haplogastric plexus right there. You can see that ureter is right there on the left. We follow it. It joins the splenic nerves from here, right there, next to the utero-sacral ligament. And from here goes to bladder, vagina and rectum. And we can find those when you dissect the posterior vascular ligament and you dissect them and you start finding them right here, right there. So they're always going to be there if you look for them. If you keep dissecting more, in this case, you can find more as they appear here. And you'll see in the next two seconds, right there, okay, those could be divided completely if I cut the posterior vascular ligament. Now, at the end of a radical hysterectomy, this is why I want to see. I want to see that I preserve the superior haplogastric plexus. I want to see that I preserve the splenic nerves joining the superior haplogastric plexus in this case. Here they are. So that's inferior haplogastric plexus preserved. And then I want to see the different nerves of the inferior haplogastric plexus. They follow all the way to vagina and bladder, as you will see up here, right there. And they are very different from patient to patient. Sometimes they're thick, sometimes they're thinner. But I want to see those, if ferret, vaginal cap is still open, but I want to see they go all the way that I preserve them. If I need to cut more vagina, I can move those down up here. So the question is, well, if I preserve this, how much dorsal parametrium left? Well, we did a study on 22 cadavers, and this measures 2.2 centimeters. And from the urinary artery to here, it's 5.6. So we leave about 40% of the lateral parametrium. We also decided to take out how much of the lateral parametrium is remaining on a radical, his C1 or C2. So after the surgery was done, then we took from measure from the origin of the hypogastric artery to the levator muscles, from the hypogastric artery posterior to the sacrum. And we found 44 specimens, that the mean length is 8.8 centimeters, and the width is 2.2 centimeters. So this is the parametrium that we leave because when we do a radical hysterectomy, we do it flash with the hypogastric artery. When we say control nerves, you've seen this. This is the hypogastric nerve. That's the medial aspect to find the sacral roots. You go lateral to the hypogastric artery, and you find sacral roots. Sacral root one, sacral root two, sacral root three. So in the case you need it during the case, they're very easy. Most likely, you will do a lateral approach. You will go lateral to the external arteries, medial to the psoas muscle, and you will find lumbosacral trunk. That's the lateral sacral parametrium, S1 right here, and superior gluteal artery in between those two. In the cadaver, interesting, the lumbosacral trunk here was not fixed. It was separate. So the L5, L4 were separated. But again, S1 would be here and superior gluteal artery again in between both of them. And that would be S1 exiting the pelvis through the greater sciatic notch, beginning of the sciatic nerve. Parametrial ureter, I'll leave this with you, an occasional time that I want to share with you, but I was able to dissect it and find the parametrial ureter with a beautiful ureter artery coming from the urinary artery and another branch coming here through the tunnel. Parametrial ureter is 3.5 or 3.2 centimeters long. These are ureter arteries, which is not something you don't see every day. Terry, again, thank you so much for having me. I thought that you guys took a few ideas from this. This is my email. You can reach me anytime if you have any questions and we'll answer questions now. Thank you. Thank you, Dr. Magrina. That was an amazing review of anatomy. And as always, I've learned some tips and tricks. For those people that are just young in their career or starting to do more of these nerve-sparing rad hits, what advice would you give them for helping them identify this anatomy? Is it spending more time in the anatomy lab? Is it finding a mentor? What would you recommend? Yeah, I definitely would go with a mentor that knows this. Sometimes you'll see people that say, here's where the nerves are, and they don't show them to you. Well, I want to see them. I always said I want to see them. And so I was able, Dr. Fujii showed me those enough times that it finally stuck in my mind, and I went over them time and time and time and time and over again until I finally was able to do it. And then cadaver dissections, Kerry, is where you really spend the time that you want to. You can do dissections in the cadaver you're going to do in a patient doing a radical hysterectomy. So that's where you really learn it. But my advice is don't get desperate, but just be persistent. If you quit, you'll be the loser. You will never get it. So it's just repetition, repetition, repetition. And then it finally one day says, I understand it now. It always seems so clear in the cadaver and then you're in the OR. So, well, thank you so much for your presentation. We really appreciate it. It was excellent. And now I'd like to invite Dr. David Sabula. I'm sorry, Dr. Sabula, I didn't get to meet you earlier, so I'm sorry if I'm mispronouncing your name. But he will be speaking about the surgical technique of radical hysterectomy. So thank you so much for being here. Kerry, thank you for the invitation. And I'm sorry for the inconvenience. I'm sitting at the outboard. My flight was more than two hours delayed. So I had a quiet place in the hotel for me, but unfortunately I have to stop here. So there is a background noise. I'm sorry for that. It's annoying. I know that. Well, thank you so much. Can you hear me? Okay. So once again, thank you for the invitation. I'm really very honored and pleased to be in one session together with Javier and Shingo and with Raitan and other colleagues. And I will, I know it's a film festival, but I'd like to, there will be films, but I'd like to tackle certain topics which I consider currently quite important for the future of radical hysterectomy in our field. So starting with a fundamental question, what defines radical hysterectomy? And I know that, you know, the audience here is quite advanced, so I'm sure that we are all aware that it's the parametrial resection, but this is what I wanted to highlight in my talk, that there are a lot of aspects which defines our procedure and we always should have a plan in advance. So this is, in my opinion, the full description of the procedure, what's going to be our surgical approach, what's the plan for the procedure on the adnexa, what's going to be the type of lymph node assessment, whether any type of intraoperative assessment will be there, sentinel lymph nodes or partial cervix resection or tissue from a sample from trachelectomy, and what will be the next step if there is a frozen section in case of negative and in case of positive, what type of procedure, radical hysterectomy, radical parametrectomy, radical trachelectomy, what type of parametrectomy, so have a plan according to the risk factors, and then also vaginal resection. And this is one aspect which I'd like to a little bit talk about it, because in the historical classification systems, usually the type of vaginectomy or the extent of vaginectomy was linked to the radicality of the hysterectomy, but these are very different aspects, or rather the extent is decided based on different parameters. So on the left side, it's an intracervical or is to make large tumors, so obviously the type of radical hysterectomy, at least in my hands, will be more extended, but there is no need to resect bigger part of the vagina. On the right side, though, there is a very small tumor, so type B radical hysterectomy is, in my opinion, again, satisfactory, but there is a reason to extend the resection of the vagina. Dr. Sabula. Anything wrong, Carrie? Yeah, yeah, we can't, your slides aren't advancing. I'm sorry, I tried to join earlier and say that, but we're not seeing your slides advance. Really? Well, I see them advancing, so what can be wrong? Maybe go to presenter mode, because we're not seeing the presenter mode either. Okay. What about now? Now we're seeing the slides and see if it will advance there. And now I... Yes, perfect. Okay. And can you see it in the presentation mode? Yes. Good, good. So now, once again, I try to demonstrate two different situations and the extent of the vaginal resection and emphasize that in the description, if there is any reason why to do bigger vaginal resection, it should be also part of the description of the procedure. And the whole situation, as already Javier nicely demonstrated, is that the parametria is a complex structure, which lies on each side of the cervix and has three parts. After blunt dissection, it's running ventrally, dorsally, and laterally. And also, the extent of our resection can be defined at least in two planes, in horizontal plane from the cervix towards the pelvic sidewall, but also vertically or deeply to the parametria. So it's a complex situation. And on short videos, I'd like to demonstrate how different can be the radicality of our resection. In some institutions, you may have performed just one type, which fits to all, one type of radical hysterectomy. And then you always do the same dissection, the same procedure. But after more extensive dissection in the pelvis, each part of the parametria is really a massive structure. So this is a short video on the lateral parametria in type B, just immediately to the urethra in type C1, just to the level of vaginal or deep parametrial vein. And in type C2, it can be really complete resection of the lateral parametrium. You see here, it's the open rectal space and paravesical space. And this is the lateral parametrium. So the difference here is really substantial. Now on the ventral parametria in type B radical hysterectomy, where the urethra is our resection margin, it's not possible to resect ventral parametria because urethra has not been dissected. If this resection is just partial resection of the ventral parametria, but it can be even complete. So really a massive resection ventrally. Of course, without the urethra, you obviously recognize that I'm also holding the urethra. So this is not correct. And dorsally, it's a little bit more complex situation. But here, in type B resection, it's a part of the dorsal parametria. If we want to spare hypogastric nerves, the nerves should be dissected from the uterus sacral ligament or dorsal parametrium, or there can be a complete resection again, going deeply to the pelvis. So my aim was just to show that the extent of the resection can differ substantially. Concerning the classification, which I consider very important because without it, we can hardly understand each other. There are different classification systems across the world. Which is okay. But in my opinion, we should be able to compare them to say, you know, what I do is similar to, I don't know, type C2, type C1, and to know what we are doing, what's the plan, and which type of radical hysterectomy we use in certain patients with a certain combination of risk factors. Ketele-Moro classification has been quite extensively used in the literature in the last decade. And I think it's for good reasons. One is that it separately defines the extent of the resection for each part of the parametrium. And second one is that it tries to use a stable anatomical landmarks whenever it is possible, like the vaginal vein, internal iliac vein, bladder, ureter. I fully acknowledge that it's not completely possible. And in some steps, it's still vaguely defined like one half or two thirds of, which often relies on the extent of the dissection. But it's really separate the radicality on all three parts of the radical history. These pictures are very old, but I like them because they separate these three parts of the parametrium. They simplify the whole thing. There is only horizontal aspect, not the vertical aspect. But just to have some impression, what's the difference between ventrally, on the ventral parametrium, type B, type C1, type C2 radical hysterectomy. Laterally, type B, very little resection, and type C1, C2 going laterally to the pelvic side wall. Very different radicality in between C1 and C2 vertically, trying to spare the nerves, which are located in the deep half of the lateral parametrium. And a dorsal resection, which can also be very, very different. Coming to another topic, which I consider very important, and this is the access to the parametria. Because some people can say, ventral parametrium, we don't see it. We don't have it if we do radical hysterectomy. Or lateral parametrium, you say it's a massive structure. But what we see, it's just a tiny structure, which is medial to the urethra. So everything depends on the extent of the dissection. Radical hysterectomy is about opening spaces and dissection of the pelvic landmarks. There are two aspects, pelvic spaces opening and dissection of the distal urethra. And I have two situations on both sides of the uterus, just to demonstrate how significant is the dissection, I mean previous dissection, for the radicality of the hysterectomy. So here on the left side, what was done was that urethra was obviously dissected from the cervix, from the vagina, but it remained fixed to the ventral parametrium and to the lateral parametrium. So for me, it's type B, radical hysterectomy. Parabasical space was not open. Lateral parietal space was not open. So after this type of dissection, what I can resect is just this part of the dorsal parametria. No part of the ventral parametria, because there is urethra and this part of the lateral parametria. This is what we can resect after this type of dissection. While on the other side of the uterus, there was a really complete exposure and dissection of parabasical space, pararectal space, medial pararectal space. Here we can see this is a bladder wall, and it was also dissected from the rectum. And here on the lateral parametrium, we put a clamp really medially to the internal iliac vessel. So this is how now the potential radicality is demonstrated by these clamps. Urethra, and it's a little bit more dissection. Urethra was just dissected from the ventral parametrium and from the lateral parametrium. Spaces were widely open, and you see that the radicality, the extent of the radicality is huge. It's much, much bigger than on the left side. And the reason for that is that we allowed it by the way how we dissected spaces and structures in the pelvis. And then a little bit provocative final part of my talk, which is a little bit prediction to the future. And I'm sorry for that. People can disbelieve with me. But I think that the reason for resecting parametria has been changed in the past 10, 15 years. And this was due to a much more precise preoperative assessment or clinical staging of our patients. The radical hysterectomy was developed to achieve three margins, to resect the whole tumor because using just physical examination of patient, the proportion of patients who were scheduled for surgery for one big stage cervical cancer, so no parametrial involvement who had parametrial involvement based on the final histology was pretty high because of inaccuracy of physical examination. And if you look to the older literature, you even find certain proportion of patients with positive parametrial margins. So there were really big inaccuracies in preoperative assessment. This is one of the favorites. I'm sorry I selected this one just by chance. And you see that 130 patients were scheduled between 95 to 2,004 in one institution and for one B stage, so tumor in the cervix, but 12% of patients had parametrial involvement and 16% of patients had positive margins. And this has changed or should change. These are data from our SENTICS trial, which has been just finished recently. It was a prospective study on sentinel lymph node and cervical cancer, 600 patients prospectively enrolled in almost 50 sites in 17 countries. And what is important for our purpose is that either MRI or expert ultrasound were mandatory. For preoperative assessment. And you see here that out of 600 patients, only less than 2% of patients had positive parametria. And all these positive parametria are positive in terms of one or two millimeters. So something what is questionable, whether it's really invasion into the parametria, because as we know, there is no, you know, margin between the stroma and the parametria. And only less than 2% with positive vaginal margins and 0% with positive parametrial margins. So this is something what's why we see recently results showing that infertile despairing, simple colonization or simple trachelectomy have equal survival as radical trachelectomy. And why we expect that the SHAPE trial will be a positive trial. So very likely it will show us that simple trachelectomy actually is a safe procedure for tumors below two centimeters, because there is very little risk in these patients that there will be any extent to the parametria. At the same time, I strongly believe that there is still a good reason for parametrectomy in bigger tumors. And it's not a continuous invasion of the tumor to the parametria, which as I said, by using MRI or good expert ultrasound can be excluded in 98% of cases. But those are lymphatic metastases, because in the parametria, there are indeed lymph nodes and there are indeed small lymph nodes, which lies between the cervix and central lymph node or pelvic lymph node as we know them. So in bigger tumors with the increased risk of positive parametrial, of positive lymph nodes, there is a reason indeed for performing radical or will be performing radical hysterectomy if we want to avoid further radiotherapy after our surgery. But this is in the future evolution, which we can expect because already in very, very low risk patients nowadays, according to recommendations, we do simple hysterectomy. It can be expected after the SHAPE trial this year or next year, simple hysterectomy will be an adequate procedure even in tumors less than two centimeters. On the other side, higher risk tumors are generally agreed that they should be referred for primary chemoradiation. So, you know, the space or the opportunity for radical hysterectomy has been shrinking and will be shrinking. And in my opinion, there will be a need for radical hysterectomy with good resection of the parametria, because the risk will not be the invasion, continuous invasion into the parametria, but positive metastases, which are distant, which are separated from the cervix in lymphatic channels or in the lymph nodes in the current. That's my talk. I'm sorry for being provocative. I'm very sorry for the background noise. I know how annoying it is. We all hate these sounds of the airport. I hope that the quality of the signal was okay. And thank you for your attention. And I'm ready to answer questions if there are any. Great, thank you so much for your presentation. We were aiming to not be provocative, but I really liked your provocative questions. And I think you're really thinking about all the important things for our patients and for their outcomes, not only oncologic, but also their morbidity and mortality from the surgery. So very interesting questions there. And there's a question in our Q and A asking about talking about the length of the parametria when we perform radhyst. So they state, I think the resectable length of anterior leaf of the vesicle uterine ligament is shorter than that of the posterior leaf. If we perform a radhyst for stage 2B cervix cancer with adeno or neuroendocrine cancer, what should we cautious to avoid or how should we avoid getting a positive margin? 2B. 2B, you mean? 2B, well, first of all, I know that it's only in some institutions, they jump for surgery and in 2B stage. And in majority of institutions, these patients are referred for primary chemoradiation. And in general, positive parametria are considered high risk factors. So it's like positive lymph nodes. And the thing is that if we have these high risk factors, I'm afraid that nobody is gutsy enough to do just a radical hysterectomy and not to send the patients for the adjuvant radiotherapy. And so if we know in advance that the patient will be sent, then the question is why to do a radical hysterectomy? Because at the end, the risk of morbidity, the risk of complications is definitely higher. It's not just the risk of fistulas, but it's also that each type of the treatment generates a different type of morbidity. So it cannot be at the end, the win-win situation can be only worse. And we have no data showing that radical plus adjuvant would be better than primary chemoradiation, even in large tumors, even in adenocarcinoma. I'm not saying that technically it's not possible, of course it is. And then if there is any reason, I remember that I operated a lady who previously had pelvic radiotherapy for Hodgkin lymphoma, and she had initial 2B stage of cervical cancer. So for her, this was the only option with curative intent. So we did a radical hysterectomy, full lymphadenectomy, and then she is without signs of disease, thanks God, for many, many years. So she is probably cured. And well, we at that case really adopted our radicality. So the tumor was on one side, so we performed side-adopted radicality. No reason why to be so extensive on one side where there was no tumor, and we were very extensive on that side with the tumor. So you save some nerves for the rectum, for the bladder. And then again, for each and every radical hysterectomy, it's important to have a plan. Start with the appropriate dissection to get an excess and then to do the resection. The resection itself is an easy part. It's just, you know, cutting, but the dissection is a central part of radical hysterectomy. Yeah, and in regards to the dissection, and I had the same question, you know, dissecting the ventral perimetrial around that ureter is always difficult. Do you have any tips and tricks, you know, thinking about those two videos on the two sides, I think really demonstrates how you have to be cautious, but how, do you have any tips or tricks for that? Well, what I would say to that, well, maybe two aspects. One is nerve-sparing intention. I have a simple trick or a simple message. Be aware that the nerves, the major nerves, hypogastric nerves, run below the ureter. So whenever you are dorsally, laterally to the cervix, ventrally, think about it, that below the ureter, there are nerves. So if you want to spend, to spare the nerves, don't touch the tissue, which is just running below the ureter. And then the second aspect is that actually to really resect this ventral perimetrium, it's a very delicate part of the surgery because of the risk of fistulas. And it's not the fistula from the injury that you would cut the ureter, and, or that you would, you know, injure it somehow by your thermal dissection, but it's because it's chemo. So typically these fistulas appear after, a week after the surgery, because simply the length of the ureter, which is without good blood supply is too long. And the most sensitive, the most vulnerable is the very distant part of the ureter before it's entering the bladder. So here, you know, at this step, we really need to be very cautious and consider what radicality we really want and need to achieve. And would you, this is another sort of philosophical and provocative question. If on frozen section, you had a positive note, would you proceed with radical hysterectomy or would you abort that procedure? Yeah, this was one of the questions which we were unable to answer when we did the first European guidelines. And we had a lot of discussions about that. So after that, I initiated the ABRAX trial, which was presented and published recently. And of course, to do a prospective trial on that would be for decades. So we tried to collect as much possible data as possible. And we collected retrospectively data from the patients, but what is important exactly with this situation, because usually in the literature, what they did, they mixed patients with intraoperatively positive lymph nodes and postoperatively, which is different situation. So we collected data from intraoperatively positive lymph nodes. And what I expected is that there might be benefit from removing the uterus, at least in adenocarcinomas or big tumors. This is what we think might be less sensitive to radiotherapy. And we didn't find any signal for better survival or for better out. So it was relatively large, large retrospective cohorts. And the final conclusion was that we did not find in any sample, any signal for better prognosis. So yes, now it's our practice. It's also in the ESCO guidelines that if we find intraoperatively positive lymph nodes, we quit. We don't, we abandon and we refer the patient. And the patient must be, of course, informed about it in advance to know that there is a such possibility not to be completely surprised. Yeah. There's a couple more questions here that, are you okay with a couple more? Do you have time? Yeah, okay. So at imaging, can we consider the proximal parametria to be, is medial to the ureter and the distal parametria is lateral to the ureter? Well, this is terminology, this semantic question. Well, I don't recognize proximal and distal parametria. Proximal and distal parametria. It makes sense, of course, for the surgery, for the surgical procedure, but in the diagnostics, as we know, you know, before dissection, without dissection, ureter is attached to the, you know, it's very close, it's very near to the cervix and it lies on the vagina. So without dissection, there is almost no, nothing there between the cervix and the ureter. Okay, thank you. And we meant to say earlier that we've, we wanted to steer away from controversy, but be provocative here. So here's another question for you about trials. So do you think it's difficult to stand, or do you think that the difficulty in standardizing radical hysterectomy across sites can also interfere with surgical trials and the results that we've seen? Well, definitely. Definitely, that's a weakness of each and every surgical trial. It's to some extent, you know, unavoidable. I had one lecture about the assessment of radicality. And what I showed was that after the resection, I identified all three parts of the parametria by stitches. But then once you cut it and remove it from, you will never recognize, you know, that there is one piece of the tissue. So you can also, you know, pull it out, extend it, or so many times people, if they show, you know, their parametria, the majority of it's just peritoneum. It's the dorsal peritoneum. It's not the parametria. So to really standardize the radicality is very difficult. And if you allow me to be even more provocative, then I'm quite critical even to any randomized trials which compare something, what is skill-driven? Because none of us is equally trained. In robotics and open surgery. So you randomize patients, but these patients are either treated at institutions with better experience with radical and robotic or laparoscopy or open surgery. So the other procedure is simply inferior. It's really very tricky because it's not like in chemotherapy that you give a drug A or B. It's not radiotherapy that you increase the dose and the robots do it. It's, you know, I know that if you see, you know, if I'm mostly open surgeon, so if you randomize in my hands, patient into robotic surgery, it will be a lousy procedure. You don't need to randomize. So that's very difficult aspect for all surgical trials. Great, thank you so much, David. That was a very interesting talk. And I loved your approach to the different parts, the critical parts of the robot or the radical hysterectomy, so. Thank you, Carrie. Thank you. So next I'm pleased to welcome Dr. Yukio Sonoda, who will be presenting surgical approach to cervical cancer and consider nerve-sparing radical hysterectomies. Thank you so much for being here. Please go ahead. Thanks, Dr. Langstad for the invitation and it's an honor to be on such a distinguished panel of surgeons, so thanks once again. So I wanna just recognize Aaron Price, one of our fellows who really put together this video and I'll go ahead and present it. Let me share it. Can you see that? In today's video, we will review the surgical approach to cervical cancer. No. With a focus on nerve-sparing radical hysterectomies. Now we can. The FIGO staging for cervical cancer was updated. Early stage cervical cancer includes stages 1A and 1B. 1A includes microscopic invasive disease and 1B includes disease with greater than five millimeter depth invasion limited to the cervix, but now mangroscopic. In 2018, stage 1B was divided into three categories, less than two centimeters at greatest diameter, between two to four centimeters and greater than four centimeters. While radical hysterectomy is often the surgical route of choice for early stage cervical cancer, simple hysterectomy can be utilized in patients with 1A1 disease without LBI and radical trachelectomy for fertility conserving purposes can be considered in an early stage disease. The pelvic autonomic system is made up of the superior and inferior hypogastric plexuses. It is important to note that performing a nerve-sparing radical hysterectomy does not detract from the radicality of the procedure, but rather describes the technique employed to carefully dissect and preserve the autonomic nerves of the pelvis. Radicality rather is determined by the resection of the ventral, dorsal and lateral parametria. This anatomic nomenclature is crucial in learning the steps in performing radical hysterectomy. The 2017 data on classification of radical hysterectomy describes type A through D radical hysterectomies. Type C1 is the most commonly performed radical hysterectomy for early stage cervical cancer. This patient is a 75-year-old with post-menopausal bleeding for a few months. She initially presented to multiple urologists with concern for hematuria. She ultimately underwent a cervical biopsy that demonstrated cervical adenocarcinoma, HPV-associated. On exam, preoperative imaging. She was noted to have a three and a half centimeter cervical tumor with no other suspicious findings or adenopathy, giving her a radiographic vivo stage of at least 1B2. On exam, the cervix had a two centimeter friable endocervical tumor dilating the cervical os, surrounded by a rim of grossly normal appearing cervix. With the patient in lithotomy position, the procedure is begun by creating an abdominal incision to allow access to the pelvis and pelvic sidewalls. In this case, a maillard incision is performed and the pelvis is exposed with a book-walter retractor. One consideration for an abdominal radical hysterectomy is use of a laparoscopic vessel sealing device since this allows for more fine dissection and coagulation of small vessels, which you will see throughout this video. We begin by evaluating the lymph nodes and central lymph node biopsy is performed. The retroperitoneal spaces on the left are exposed and the central lymph node is identified. The cervix has previously been injected with endocyanidin green solution at the three and nine o'clock positions superficially. And a handheld near infrared light source camera is being used to identify the central lymph node, which in this case is located at the hypogastric chain. The node is subsequently removed and the procedure is repeated on the contralateral side. For tumors greater than two centimeters, sentinel node mapping is more often unsuccessful. And so side-specific pelvic lymph node dissection should be completed when mapping is unsuccessful. Next, the paravesical and pararectal spaces are developed. Here you can see the ureter passing along the medial leaf of the broad ligament. Two centimeters below that, you can see the hypogastric nerve plexus, which will be spared in this type of nerve-sparing radical hysterectomy. And here now being squeezed by the forceps, the deep uterine vein. Next, the branches of the hypogastric artery are dissected and the uterine artery is isolated at its origin of the hypogastric artery. This is ligated and divided at this location. The ureter tunnels between the anterior fascial bundles of the broad ligament and the so-called fascial tunnel. This is carefully opened. The anterior roof of this tunnel is clamped with Clark clamps and ligated and divided. Next, the ureter tunnel is separated from the anterior fascial bundles of the broad ligament. The ureter tunnel is separated from the anterior fascial Care is taken not to ligate the hypogastric nerves, which lie about two to three centimeters dorsal to the ureter and the medial leaf of the broad ligament. Anterior paracervical tissue is dissected and the bladder is fully mobilized off the vagina and cervix. The uterus sacral ligaments are now dissected and divided. The uterus is moved forward and a peritoneal reflection of the cul-de-sac is now incised. The rectovaginal space is opened and developed. Curved sepal and clamps are then used to ligate the uterus sacral ligaments and release the dorsal perimetria bilaterally. Careful attention is paid to the path of the ureter and the hypogastric nerves below. Previously the hypogastric nerves coursed two centimeters below the ureter, but now Care is taken to identify the hypogastric nerves again because the landmark of two centimeters below the ureter no longer applies after ureterolysis. With the uterus sacral ligaments dissected bilaterally, a Wertheim clamp is placed on the vagina below the cervix. This important step isolates the cervical tumor from the peritoneum. Zeppelin clamps are placed below the Wertheim clamp and the vagina is divided between the Wertheim clamp and Zeppelin clamps. The vagina is then closed with interrupted serovicral sutures, and the procedure is completed. This is the specimen once the procedure is completed, showing the uterus, bilateral adnexa, bilateral parametria, cervix with cervical tumor, and vaginal margin. When performing radical hysterectomy through a minimally invasive route for cervical cancer, the most important consideration is containment of the cervical tumor before vaginotomy, especially to avoid peritoneal spread of cervical cancer cells. In this case, we demonstrate use of the robotic stapling device, which is similar to use of the orthotic clamp in abdominal surgery. The stapler is placed across the area of where vaginotomy will be made, taking care to avoid the contralateral ureter and bladder. Usually a second fire of the stapler is needed. This allows for containment of the cervical tumor. Then the staple line is resected from the vagina, which provides an additional surgical margin for the case. The specimen is then retrieved vaginally with no concern for peritoneal or vaginal spread of cancer cells, and the vagina is closed with a running suture in the normal fashion. Additionally, vaginal closure can be performed with a clamp placed proximally to prevent tumor cell spillage, and colpotomy performed distally, as shown in this footage. Radical hysterectomy is not just one type of surgery, but rather includes a spectrum of types of resections that balance curative effect with adverse postoperative consequences. Considerations for radical hysterectomy include review of the updated radical hysterectomy classification system, dissection and identification of key artificial spaces of the pelvis, and use of a laparoscopic vessel sealing device during open surgery. Importantly, sentinel lymph node mapping can be utilized in early stage cervical cancer with side-specific pelvic lymph node dissection performed for unsuccessful mapping, and use of a Wertheim clamp or minimally invasive stapling device to prevent spill of cervical cancer cells and prepare to nail it is crucial. Thank you. So once again, thanks to Erin, our fellow who really put this video together of how we do things here in New York. Excellent video. Thank you so much. There was one question about staging. If you have a patient that has just a parametral lymph node involved, would you stage that as a 3C1 or where would you stage that? Yeah, I would put it in as a 3C1. A lot of times we pick these up on sentinel node mapping and take them out separately too and label them as a parametral node. Great. One of the questions I've had about the nerve sparing, and I'm interested to hear Dr. Fujii's talk as well, or Professor Fujii's talk, do you easily identify those nerves on all of the patients that you operate on or are there patients that you find it's really difficult and challenging to identify those hypogastric and pelvic splanchnic nerves? For me, I think it depends on the body habitus of the patient. Sometimes they're tough to see in some cases and you rely on your anatomy and knowing where the vessels are and what levels to stay at. Certainly doing vaginal surgery, it's tougher to see some of these structures. Now the landscape has changed with our approaches to different, doing radical hysterectomies, but certainly with the robot, it was helpful too with the visualization. Great. Then I'm interested to hear what your thoughts are on Dr. Sabula's comments about becoming less radical. Do you think that there are going to be less and less opportunities for us to perform radical hysterectomies? Unfortunately, probably that's how things are moving. That's how the trend has been in many different cancers, breast surgery, whatnot. I think for the good of the patient, probably not for the good of the trainees, but probably less rad hysterectomies performed. It's good to have access to some of the leaders and have these types of webinars so that our fellows and people who are fresh out of training might still have some exposure. Just really, I've been practicing for a while. It's really great to listen to some of these fantastic surgeons as well. It has been. Great. Thank you so much for joining us this morning, Yukio, and thank you for your wonderful presentation. Thank you. Our final presentation will be Professor Shingo Fujii and his film on neurovascular anatomy of the paracervical and upper vaginal area for radical hysterectomy. Thank you so much for joining us today, Professor Fujii. Thank you very much for inviting me to this IGCS surgical video session. Many people talked about the anatomy of the paracervical upper vaginal area for radical hysterectomy. However, this description or this talk is a little bit very complicated and difficult to understand. Today, I'd like to focus on the anatomy of this area using my video. The neurovascular anatomy of the paracervical and upper vaginal area has been considered that it is very complicated. In this video, I'd like to show the surgical steps of this area and would like to reveal that the structure of this area is not complicated but rather simple. After the development of the paravagical and paralectal spaces, the deep uterine vein is isolated and divided. In this case, beneath the deep uterine vein, a small vein and the pelvic splanchnic nerve are appreciated. From the rectal side wall of the paralectal space, the hypogastric nerve is isolated and the vessel tape is applied for a marker. Hypogastric nerve is separated close to the level of the uterine cervix. Picking up the cut ends of both the uterine artery and the superficial uterine vein, these vessels are separated from the surface of the ureter. If the separation of these vessels may be completed, the ventral layer of the vesicle of the uterine ligament is appreciated. The connective tissues in the ventral layer of the vesicle of the uterine ligament are separated. Then, a pair of blood vessels running over the ureter, from the cervix to the ulnar bladder, are observed. These vessels are divided. By this step, the majority tissues in the fentral layer of the vesicular uterine ligament are separated. In the cranial portion of the ureter, a vein between the ureter and the cervix is usually observed, and it is divided. By this step, the ureter becomes separable from the dorsal layer of the vesicular uterine ligament, and is able to rotate the location toward the inguinal side. The rotation of the ureter toward the inguinal side reveals the full figure of the dorsal layer of the vesicular uterine ligament. And its medial side, a loose connective tissue area is observed. It is the entrance of the paravaginal space, called Okabayashi paravaginal space. In the lateral side of the lower cervix and upper vagina, paracorpium containing vaginal blood vessels is observed. This means that Okabayashi paravaginal space is a border between the dorsal layer of the vesicular uterine ligament and the paracorpium. The cranial traction of the cut end of the deep uterine vein reveals a relationship between a small vein to the internal lidiac vein, and a vesical vein from the ulnar bladder. The small vein is divided, and the separation of the adipose tissue reveals that the vesical vein is draining into the deep uterine vein. This vesical vein is divided. Another vein from the ulnar bladder is also confirmed to drain into the deep uterine vein. This vesical vein is also divided. By this procedure, the ureter with the ulnar bladder becomes completely free from the uterus. In the dorsal side of this vesical vein, the pelvic sphagnum nerve and its branch to the ulnar bladder is appreciated. The remaining connective tissue is divided. Then, the hypogastric nerve is separated close to the level of the uterine cervix. Lifting up the cut end of the deep uterine vein, the vein is completely separated from the lateral cervix. By this step, the full figure of the inferior hypogastric plexus composed by the hypogastric nerve, pelvic sphagnum nerve, uterine branch, and bladder branch is appreciated. On the bladder side of the inferior hypogastric plexus, a loose connective tissue space is appreciated between the vaginal blood vessels and the bladder branch. From this space, the uterine branch is isolated from the lateral cervix. The uterine branch is divided. Then the lecto-vaginal ligament between upper vagina and the lectum is divided, not damaging the remaining inferior hypogastric plexus. Only the pericorpium, including the vagina blood vessels, is clamped. After ligation of the vaginal side of the paracorpium, the right side of the uterus is ready to remove. Our video shows that after the separation of the ventral layer of the vesicular uterine ligament, the rotation of the ureter towards the inguinal side reveals the dorsal layer of the vesicular uterine ligament. In the medial side of the dorsal layer of the vesicular uterine ligament, a loose connectivity space is recognized. This is Okabayashi paravaginal space. Okabayashi paravaginal space is recognized as the border of the paracorpium vaginal blood vessels with bladder branch and the dorsal layer of the vesicular uterine ligament. The dorsal layer of the vesicular uterine ligament contains only a couple of vesicular veins draining into the deep uterine vein. Lifting up the cut end of the deep uterine vein, the inferior hypogastric plexus is revealed. From the loose space between the vaginal blood vessels and the bladder branch, the uterine branch is isolated and divided. After the division of the electrovaginal ligament, selecting the most suitable length of the vaginal cuff, the vaginal blood vessels are clumped and divided. This illustration is showing the figure after the removal of the uterus. I would like to say through this video that the anatomy of the parasympathetic vaginal area is not complicated, but it is quite simple. Thank you very much for your kind attention. I can't, I cannot, I can't. Hear me? Yeah, yeah. Sorry about that. Thank you so much for that wonderful talk. It was great to see those videos. Makes it look very simple. And if I have a couple of questions here that might be good for the whole panel to weigh on. Yeah, one comment first, the best lecture on surgical anatomy of a radical hysterectomy that can be heard. So thank you so much, Dr. Fuji, that was related to your video. So the first question is, nerve sparing rad hysterectomy are quite difficult even for those of us that have been practicing for a while. And it's even more difficult than for fellows who are just finishing up fellowship. Does anybody or have any ideas on how you could certify fellows when they graduate that they can be independent or do you have any recommendations of the number of cases they should do before being considered independent? If the young doctor would like to do the nerve sparing radical hysterectomy, at first they should do the surgery. Surgical steps is from the abdominal side to the dorsal side, from the surface to the bottom, just the connective tissue in the lateral pelvic side, such as the paraplegical space and the paralectal space, and just dividing, not digging deeply into the deep area, just from the surface to the bottom. If you may separate the connective tissue, then you can see every kind of anatomy, like the uterine artery and superficial uterine vein, and then you can see the deep uterine vein. And if you may divide only the deep uterine vein, you can see beneath such kind of vein, you can appreciate the pelvic splenic nerve. And hypogastric nerve is also, that is easy to find if you can develop clearly the paralectal space. In the rectal side wall, you can see the hypogastric nerve running two centimeters below, or two or three centimeters below the ureter. That is easily, you can see the nerve bundle, and that is separable. So try to find like that, and step by step, if you may do the surgery, radical hysterectomy is not difficult. That is very, very simple. But if you may dig into the deep area and try to separate and try to cramp and divide, then it makes everything very difficult. Just step by step from the surface to the bottom, if you may do the surgery, that is quite simple. I just did such kind of surgery, and that is the result of this kind of video. And particularly in the area of the ureter that is running into the uterine bladder, that part looks like very complicated. But if you may divide the uterine artery and the superficial uterine vein, and you may separate from the surface of the ureter, that is very, sometimes the superficial uterine vein is draining, coming from the urinary bladder and needed to separate such kind of veins. But if you may divide and separate every kind of such kind of things, then you need not dig the ureter tunnel. You need not to do such kind of thing, just to separate along the ureter. You just separate the connective tissue, then you will find only one pair of blood vessels and to divide like that, then you can completely separate the ventral area of the vesicular uterine ligament. And then the ureter is, I think, can rotate and laterally. And when you rotate the ureter laterally, at that time, I showed some kind of vein is running. If we may divide that one, then you can separate the ureter completely to the inguinal side. And then many people says lateral, parametrium, or like that. But that is, if you may divide the deep uterine vein, and then the lateral parametrium is just decomposed by the connective tissue and the vein that is draining into from, that is coming from the urinary bladder to the deep uterine vein. So without the division of such kind of things, the vesicular vein and division of the vesicular vein is very important to separate the ureter and the urinary bladder from the uterus. So, and then you may see the lateral side of the parasympathetic, vesicular space. And particularly, if you may remove the adipose tissue, then you will find the nerves. So if you can do this kind of step-by-step surgery, not so difficult, but if you skip some kind of things and clamp, clamp, clamp like that, then every kind of thing becomes very difficult and very complicated. And some people say that the, I call the deep uterine vein, but some people say anatomically that is a vaginal vein, but uterus is a very important organ for the pregnancy. And at the time of the venous return from the uterus is very important. That is, I think the mainstream is the deep uterine vein, but people ignore like that of things and they say that that is a vaginal vein. And that is anatomically, this is described like that, but physiologically, deep uterine vein is very important. The deep uterine vein is attached and running from the cervix. So the most important thing is if young people can do this surgery step-by-step from the surface to the bottom. And the other thing is the stretch, the organ, between the organ and the organ, stretch and the connective tissue and in the center of the connective tissue, just to divide. Then every kind of things comes out and it becomes very easy. So I recommend the many, I'm opening my medical academy and I'm teaching some kind of surgical technique like that. In such kind of space, I am always saying that from the surface to the bottom, if you can do the surgery step-by-step, then every kind of thing, the periphery is not so complicated in the organ. Yeah, I think that's a good point. Your last video that you showed was, I think demonstrating that just going, sort of layer by layer to identify all those structures. So it really becomes the foundation of your anatomy knowledge and then the knowing what steps are critical and going slow. I think that's a good point. And there's a question about lymphadenectomy and when should we do level one, two, three lymphadenectomy separately or in total? Yes, I usually do the lymphadenectomy at first and do the totally every kind of, every kind of, so the unblock, a dissection, I do. My practice hasn't been to separate them and it doesn't sound like you separate them by level either. Yes, yes. But if we can do the centenary lymph node, at that time, the technique itself is some kind of, omit that one. But if the, I live with advanced case, I usually do the lymphadenectomy and I think the radical hysterectomy and lymphadenectomy itself is not so complicated and difficult. And the two, I think, not the two invasive surgery. If you can do this surgery very kindly and step-by-step, it is not so dangerous surgery. I'd agree. There is, somebody missed the demonstration of the yabuki space. Is it necessary to develop it in order to dissect the ventral parametria? And I think I can tell you that the yabuki space is, in Japan, that is also the controversial in Japan because the yabuki space is, he found such kind of space in the cardiovascular like that. Not that during his surgery, he found such kind of space. I'm, from our discussion or talk with the yabuki, I feel like that. And that is the okabashi paravaginal space is the safe and good space. But yabuki would like to try to preserve the nerve fiber around the ureter to the urinary bladder. That usually have to separate when we do the laryngoplastyctomy. But he would like to preserve such kind of nerve and then he tried to open such kind of space. So if you may open such kind of space and do the surgery, that becomes a very close to the Werzheim method. That is my opinion. And I do not open such kind of space and I cannot agree with his opinion. And his surgical anatomy is too complicated. Well, great. Well, thank you so much, Dr. Fujii. This is all we have time for today. So today's recording, just a reminder, will be available next week on the IGCS Education 360 Learning Portal and be on the lookout for accessing information or how to access that information next week on an IGCS website. And I just wanna thank all of our presenters for this excellent film festival. I certainly learned a lot and I'm grateful to all of you for your time. And please join IGCS in Seoul, South Korea for the 2023 Annual Global Meeting in November, 2023. The dates are November 5th through 7th. As a reminder, the oral abstracts and surgical film submissions are due May 8th and visit the igcsmeeting.com website for more information. We wish you all continued health and safety and stay well. And thank you again to all of our presenters this morning. Have a great day. Thank you very much. Thank you.

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