I don't know, you may all have to reclick something if it says it's being recorded. I don't know if you got a pop up. Looks like we got it. Okay. All right, I'm going to start it now, Vance. Good morning, everyone. We're going to wait just a few more minutes while we're getting a few more participants to join and get started shortly. Welcome, everyone. My name is Vance Broach, I'm a gynecologic oncologist at Memorial Sloan Kettering Cancer Center in the United States, and I'd like to welcome everyone to today's surgical education webinar dedicated to ultra radical surgical procedures. We are thrilled to have you with us today. I wanted to mention a few housekeeping items relevant to the zoom platform that we're using for this festival. First, please adjust your screen to full screen mode in the top right corner of your screen and adjust your view settings to fit to window. And second, the quality and the clarity of the video presentations are linked directly to the speed of your internet connection, high speed and wired connections are best for you in these videos. If the quality of your video stream is poor at any time during the presentations today, this webinar will also be available to view on the IGCS education portal, and we'll post it in a timely fashion after the webinar is complete. We have an incredible panel of surgeons who will be sharing their expertise, performing ultra radical procedures for gynecologic cancers. There will be ample time for discussion today, so we encourage you to submit questions through the q amp a feature at the bottom of your screen and we'll do our best to address as many questions as possible throughout the course of the webinar. I'd like to acknowledge everyone who submitted a film for consideration for through our submission process, and we received numerous incredible submissions and look forward to including a submission option for future film festivals as well. Now it is my honor to introduce Dr. Raytan Ribeiro who's the co chair of the surgical education work group of the IGCS education committee, and he and I will be co moderating today's session, and I'd like to turn it over to him to introduce our speakers. Thank you. Thank you Dr. Bruch. I'm very happy to be here be part of the IGCS education committee. We have an incredible session planned for you today, focus on ultra radical procedures. Now it's my honor to introduce you today's speakers. Joining us are David Sibula from Charles University and General Hospital in Czech Republic, Cara Long, Raj, and Kimberly DeSources from Memorial Sloan Kettering Cancer Center in the USA, Mario Leite, also from the Memorial Sloan Kettering Cancer Center in the USA, Hussein Alhaj from center, Oscar Lambert in France, and Payan Kashi from John Hopkins University School of Medicine in USA. Thank you all for joining us today. It's an honor to have you here. And without further ado, I would like to kick off today's film festival and invite Professor David Sibula to present his film on lateral extended endopelvic resections. Professor Sibula, you can share your screen. Thank you. Thank you very much for your kind introduction. Can you see it now. Yes, we can see it but it's not. So first of all, I'm really grateful to IGCS and educational committee for for having me for for inviting me it's really honor to share a little bit of my experience with this procedure, which has different titles in the, in the literature, it's called Lear it's called leper. Well, recently I've been, I've been collaborating on an article about it, and I was surprised how, how, you know, non uniformly, this, this terminology is used so so in some institutions, it's used, even in a very cranial resections if there is a section of the source source muscle. While I believe that the principles of the procedure is slightly different so so let me know I know it's a surgical festival but but but but let me just show a few introductory slides. First of all, I'd like to talk about the procedure and not mentioned, Michael heckle German surgeon gynecologist who was a pioneer of this of this technique and published already decades ago, a large series of of cases. So let me just go through swiftly and mentioned a few aspects which I consider important. First of all, is a definition so so so what makes it different from traditional pelvic exoneration as, as we, as we know it. The definition as we understand it means that it includes a section of the structures which lies on the lateral pelvic pelvic sidewall. There are many structures it's quite complicated anatomy. Some surgeons who did, even if they just resect part of the source muscle in in our practice, we use the near terminology, only if we need to resect internal iliac vessels, and a adjacent structures. So what are the structures there which can be resected. So definitely it's internal iliac vessels, more eventually it's up to radio facial operator muscle and nerve and vessels. And then closely, it's coaxial muscle, it's side nerve so lumbosacral plexus the branches of the major nerve in the, in the pelvis and cranial part of the periformis muscle and cranially it can also be the source, the source muscle. Now I now I'd like to share with you a short set movies from the cadavers, because to make a film, a good surgical film in the pelvis, it's not easy because it's simply around the corner, it's, it's, it's 9090 degree angle so so so our ability to resect internal structures is very limited, and without very good knowledge of anatomy, it's impossible to do this, this, this procedures and that's why, for this reason I believe the cadaver lesson can be can be helpful. So here we see the, the heavy pelvis. It's eventually it's, it's synthesis dorsally sacral bone. Here we see external iliac vessels and dorsally, we already see the branches of lumbosacral plexus and detached internal iliac vessels so if we want to resect these structures internal iliac vessel must be part of this. This is a strong and firm fascia of the obturator muscle, and the obturator, and the obturator muscle itself with the obturator nerve and vessels have been already already removed. This is one of the key structures, which I'd like to highlight a little bit more because especially in patients with the recurrence of cervical cancer. It's often attached at this level, where is his kill spine. And also, according to my experience, if there is an attachment to the pelvic cycle, it's mostly in this spot of the pelvic anatomy because eventually, there is a strong barrier of the fascia dorsally, there is a nerve, which is very lately be being infiltrated and medially, there is a place for the tumor to invade into these into these structures below the obturator muscle together and following the nerve. So, why this area of anatomy, I consider very crucial for the procedure. Here, we remove sacral muscle, which is attached to do is kill spine. As you can see now, the dental vessels and so called our channel. This is the area of high risk of all the bleeding, and this step of these attaching the muscle can be very crucial for the achievement of complete cycle reduction. This is these are branches of lumbosacral plexus of siding nerve, and the massive performance muscle, which is running out of, of the pelvis here. Very briefly, what are, what's the, the aim, why to do such a such a complicated not easy procedure. Well to overcome one of the classical contraindications or limitations of pelvic exoneration, which is the attachment to the, to the pelvic pelvic sidewall. I would say that the procedure can overcome a massive infiltration of a, of a pelvic sidewall, but it rather can help us to achieve what is the, the, the ultimate goal of such procedure, and this is to achieve really free surgical budgets. The only possibility is to do such a demanding procedure for us, but especially for the patient, and then to see after a few months, a local recurrence in the same spot, which shows us that we were not enough radical in our, in our surgery. In many cases, even if it's seemingly is center pelvic recurrence, and the devil is in the detail, and the detail is this tiny attachment to the pelvic sidewall in these places where the technique of Lear can help us to completely remove the tumor. So those are the guidelines and those are European guidelines from Prague from the Czech Republic in the, in the guidelines the Lear procedure is mentioned as a possibility as an option for for recurrent tumor and cervical cancer, but to know the technique can be helpful in in many other recurrent especially recurrent tumors, even as, as I mentioned, if it's seemingly is located centrally in the palace. So, as I mentioned, the importance of the, of the, of the, the region of the, of the skill is skill spine. This is this part of the, of the, of the skill is skill bone I tried to explain why according to my experience. This is a very crucial area for the surgery of our current tumors especially recurrent cervical cervical cancer. If we add muscles, this is, this is the region and I'd like to share with you the technique. If, if we found it, how to avoid and how to expose this, this, this field. So, so the crucial and the key step is to remove operator muscle, and to get access into into the ball. Now, if we do it, this this this skill spine, this this distal part of the bone can be quite easily resected without very little risk to do any harm because we now preserve all the vessels around, around the ball. So if we do it now again this is the, the operator fascia, both parts of the operator muscle. In fact, this is the skill spine, which is only a small part of the bone is removed. We have access, obviously, to lumbosacral plexus to put in the vessels to gluteal inferior vessels, and we can achieve free margins. In many cases, which otherwise wouldn't be wouldn't be possible to to operate. One, one case, it was a young lady who was treated for for vaginal cancer which was located proximally in the proximal vagina by by definitive radiotherapy she recovered after 23 months as a first pelvic recurrence. She was primarily treated in another hospital so they started with polyamory chemotherapy, not surprisingly the tumor progressed on on chemotherapy. So she was referred to us, while always symptomatic on MRI scan, we can see a massive and obviously fixed pelvic recurrence infiltrating the operator muscle. And this is a complex procedure we did more than just the leader but I will focus on the, on the leader procedure so this is from the abdominal approach. And this is a tumor which was hidden because it was really fixed and and deeply infiltrating pelvic pelvic sidewall. On the right side. This is already a situation after detachment ventrally of the bladder, of course we accepted you rather, which was involved, as soon as both organs were uninvolved. And this is the important step of the whole procedure which I would like to highlight and this is the opening of operator fascia, because if the tumor infiltrate operator of the whole procedure, which I would like to highlight. And this is the opening of obturator fascia, because if the tumor infiltrate obturator fascia, it feels like it infiltrates the bone. It's totally fixed in as a stone-like infiltration, but while we open the fascia, only rarely it infiltrates deeply beyond it. So here we see the normal obturator muscle, which was interrupted. And then we gain access to the bone, to the ischial spine. And we have a good collaboration with orthopedists, who now resets the bone, which is, however, at this stage, not a complicated procedure. And what helps us is this picture, is to receive this one. So now we see that normally with the bone, we would see only this part of the sciatic nerve branches. Well, after the bone was resected, we got an access to the whole longitudinal lumbosacral plexus. So in this very fixed tumor, we got an access to much deeper structures. We resected in this patient, majority of lumbosacral plexus, so of our sciatic nerve as well. She was informed about it. We planned it. It was not unplanned. So it allows us to resect the tumor completely in this region. And this is the final picture with almost complete resection of the nerve as well. This is the final specimen. And just finally, it's not easy to film Lear as such, because usually we perform it on tumors, which are very much fixed into the lateral pelvic side wall after previous radiation in the majority of cases. So usually what we see is that surgeons show a lot of procedures around, and then a magical step and it's done. But the magical step to detachment from the pelvic side wall, it is the most difficult part of it. I just want to refer to our article at the International Journal where the whole video of the Lear is available. And also those who are interested in this field, more films from my department are available on this free access web portal surgery4u.eu. Thank you for your attention. Thank you, Dr. Sigula. Now we will open up for discussion. A reminder to all that you may submit your questions at the bottom of the screen, there's a Q&A question. And I was going to ask if there is a limit for Lear. It seems we are overcoming our limits. But I also like to address that you mentioned about selection. And I would like to know if there's any clinical feature that you use for deciding. Like Professor Heckel, you say that bilateral hydrolysis is a contraindication for the procedure. Do you agree with that? Or do you agree that the patient must have some other dysfunctions associated? And do you feel like there is a limit for Lear if the patients agree to do it? And what's the limit? When do you say, okay, this is too much and we are not going for it? Yeah, thank you, Raison. Obviously, it's an always very difficult decision. Well, I always take it very seriously. It always requires long discussions with the patient and with the family. And concerning the limits, like technical limits, well, actually, our main technical limit is the complete removal. So this must be our aim. So what I always say is it doesn't make sense to do such a procedure and to leave one millimeter of tumor behind, because obviously, in a few months, you will have recurrence. And everything what you will bring to the patient is just suffering, nothing more. So it's a technical limit, it's the removal. I didn't argue here for doing such a procedure in cases with massively infiltrating pelvic bones, or no, these cases, unfortunately, are not good candidates for radical surgery. But I would rather argue for this technique to achieve in more patients with recurrent tumors complete removal. Because in many cases, especially after previous radiotherapy, we don't have any technique how to recognize where is the tumor and where is the proliferation fibrosis and where starts the bone, it's just a guess. So in such cases, we simply should go one layer beyond it. And to really achieve the free margins, this is a very helpful, well, helpful techniques. Otherwise, what are the parameters or aspects which we take into consideration while discussing the case and discussing with the patients, there are many, including status of the patient, age, but also support from the family. And especially if this patient will require some more procedures like sciatic nerve resection with inevitable consequences. Great. So do we have time for Q&A or do we have to move forward? I think let's try to answer a couple of questions and then if we don't get to every one of them, perhaps we can answer them, you know, not live. Okay, I'd be grateful. Professor Silva, do you think I or IT can replace some exenterative procedures or not? It's a very good question. Well, this is of course difficult to solve this puzzle, whether these intraoperative radiotherapy techniques can replace removal of the tumor because we will never have any prospective studies or there will never be a randomization of the patients. Definitely it can help to overcome some limitations, but as a surgeon, still I feel like our role, if we go for such a really super radical procedure, should be complete removal of the tube. Do you think, do you consider a pelvic exenteration earlier for patients with PFS less than six months or do you have a different number for it or? Yeah, definitely PFS is one of the sign of biological behavior of the tumor, especially if previous treatment was performed radically and accordingly. Well, yes, definitely, you know, in those who were cured very soon after the primary treatment, like less than six months are not good candidate. Having said that, it's a very difficult ethical issue. If you have the lady 35 years old, who were cured soon after primary radiotherapy and according to, you know, everything you have available, there are no distant mass and you see that there is a technical possibility to remove the tumor, you will probably go for it. Great, and Dr. Sergei Skoura is asking if you will do frozen section, how do you define free margin during surgery? No, we don't do that. Well, maybe in a very specific situations like vaginal margins or, but on the pelvic side wall, it's very difficult, you know, to define the surgical margin and then to send it for frozen section. And usually, you know, surgical line is very long. So it's also, yeah, it's difficult to define it. What I would rather highlight is a need to very carefully prepare for such a procedure and to very carefully read preoperative imaging with your radiologist to be prepared technically for what you are going to do. Great. I think in the interest of time, even though there's still some wonderful questions, just to try to stay on schedule, I think we're going to have to press in with our next presenter. Dr. Simula, there are a few questions in the Q&A feature. If you'd like, perhaps you can get on there and try to respond to some of those. But at this point, I just want to thank you again for such a wonderful discussion and such a wonderful presentation. And I'd like to invite Drs. Kara Long and Kimberly DeSources to present their film Evaluating Vascular Bypass in Resection of Gynecologic Cancer. I just need the ability to share my screen. So Simula, if you could stop sharing, then we can- Oh, sorry. It's fine. It's my fault, okay? Sorry, I didn't know that. Just wanted to say good morning and thank you so much to the organizers of this for having Dr. DeSources and myself present our video. Thank you for the opportunity to present our surgical film entitled Radical Retroperitoneal Unblocked Resection of Malarian Carcinoma. This is a case of a 41-year-old who initially presented with new onset right-sided lower back pain. MRI spine demonstrated a retroperitoneal mass measuring 2.9 centimeters. CT guided core biopsy of the mass was consistent with moderately differentiated adenocarcinoma. The tumor was ERPR positive and immunohistochemical staining was consistent with malarian origin. The tumor abutted the right ureter, third portion of the duodenum and the aorta. It compressed the inferior vena cava and encased the right common iliac artery. Uterus and adnexa were radiologically normal. The mass initially decreased and stabilized in size after platinum-based chemotherapy. Given the isolated persistent disease, decision was made to proceed with chemo radiation followed by endocrine ablation. The residual mass remained stable in size without significant FDG avidity for seven months. 14 months after initial diagnosis, the patient was found to have on imaging. PET-CT showed a single site of disease now with increased size and FDG avidity. MRI showed a 3.5 centimeter mass now invading and obliterating the distal inferior vena cava and proximal bilateral common iliac veins. The tumor also invaded the duodenum, right psoas muscle and right ureter. After extensive counseling, decision was made to proceed with surgical excision of the lesion with a multidisciplinary surgical team. Interoperative findings included a three centimeter tumor that was fibrotic and densely adherent to the retroperitoneum. The small bowel was packed to the left to facilitate a right-sided transperitoneal approach. An incision of the peritoneum covering the upper part of the right common iliac artery was made and carried above the aortic bifurcation. The proximal infernal aorta is dissected, isolated and tagged using a vessel loop. The right external iliac artery was tagged in a similar fashion. We then turned to the resection of the involved duodenum. The Coker maneuver was performed to allow for visualization of the duodenum and surrounding structures. The ampulla was palpated and noted to be freed from the intended staple line. The third portion of the duodenum proximal to the tumor was transected. The distal duodenum was resected from the pancreas and its mesentery and left attached to the tumor. Similarly, the uninvolved jejunum distal to the tumor was identified and transected and freed from surrounding structures. We then returned to the retroperitoneal dissection. The tumor was carefully dissected off of the anterior aorta proximally and the right external iliac artery distally. The remaining right iliac vessels and a small portion of the ureter were noted to be involved with the tumor. The distal right ureter was identified and tagged. The ureter was transected just distal to the tumor. The proximal right ureter was also isolated, ligated, and transected in a similar fashion. The tumor was dissected off of the psoas muscle laterally. We obtained circumferential vascular control of the arteries proximal and distal to the tumor. The arteries were encircled with vessel loops to allow for later vascular clamping. We then obtained circumferential control of the vena cava above the mass as well as the common iliac veins below the mass using Rommel-Turner kits. The patient was systemically anticoagulated with 5,000 units of unfractionated heparin. The proximal aorta, distal right external iliac artery, and left common iliac artery were secured using vascular clamps. The remainder of the tumor was dissected off of the aorta and the left common iliac artery. Here, you can see the clamped aorta and left common iliac artery completely free of tumor, the secured proximal inferior vena cava, the tumor in the resected duodenum, and the secured bilateral common iliac veins. The proximal right common iliac artery was transected at the bifurcation of the aorta. A cryopreserved femoral vein allograft was prepared using manufacturer's instructions. The graft was anastomosed to the aorta at the origin of the right common iliac artery using 5-O polypropylene suture in an end-to-end fashion. We released the clamps, and the proximal anastomosis was noted to be hemostatic. We clamped the inferior vena cava proximally and distally to the transection margin above the tumor, divided it, and overstowed the stump of the vena cava with 5-O polypropylene suture in a block stitch. In a similar fashion, we divided the right external and internal iliac arteries beyond their origins. We transected and secured the bilateral common iliac veins. After dividing its final attachment to the psoas muscle, the specimen was taken off of the field. We found that the inferior vena cava was completely occluded. The lumen had been chronically obliterated by tumor, so decision was made not to reconstruct the vein. The femoral vein allograft was anastomosed to the right external iliac artery in an end-to-end fashion after spatulating the artery. For ureteral reconstruction, a 20 centimeter jejunal interposition from the prior resection was used. An anastomosis was created from the ureteropelvic junction to the posterior aspect of the jejunum proximally and the dome of the bladder distally. A double J ureteral stent was placed. Finally, the remaining jejunum was brought up and a hand-sewn, two-layer, side-to-side duodenal jejunostomy was performed. The patient tolerated the procedure well with no major postoperative complications. Final pathology was consistent with a poorly differentiated malarian adenocarcinoma with treatment-related changes. Uterus and bilateral adnexa were benign. A poly hotspot mutation was noted on targeted next-generation sequencing. The mass is thought to be a primary malarian carcinoma in a retroperitoneal malarian remnant. Margins on the resection were negative unless the patient received no adjuvant therapy. Four months post-procedure, she has no evidence of disease, no lower extremity swelling on exam, and continues to do well. We hope you enjoyed this video. Okay, thank you so much for such a tremendous video and a wonderful presentation. We'll go ahead and open this up for discussion. And while questions are coming in from the Q&A section, a question that I have is, this seems like a very much a one-off surgery, very unique and specific to this patient. And I think counseling patients when you're doing ultra-radical procedures is always challenging because talking to them about expected outcomes and side effects can be a challenge for things that are rare. So can you just walk us through a little bit of the conversation that you had with the patient beforehand and what expected sort of side effects and secondary events you discussed? I'm happy to take that. So this is a patient that I had been taking care of since she was first diagnosed as kind of an additional opinion. She got most of her care at a local center. And I think it's important to note that we didn't choose surgery as the first kind of line. She got chemo, didn't respond. Then she had persistent disease and we did choose to do chemo radiation first. I think when you're dealing with such a high risk surgical procedure, it's important to consider therapies that may be less morbid when you have those options. Now, when the disease progressed, that's really when we realized that we were very limited in what good options she had left. And we readdressed surgery as a potentially curative procedure. And at that point, she and I were much more willing to take on the risks. And she was thoroughly counseled on everything and met with all members of the surgical team. Great, thanks so much. Yeah, the video highlighted the vascular reconstruction, which was impressive, but also there was a pretty tremendous amount of bowel and urinary reconstruction that went on as well. And was the decision to use the jejunal interposition for the urinary reconstruction, was that something that was planned or was that sort of something that sort of fell in your lap as the tumor came out and you realized that that might've been the best way to do that reconstruction? I'll let Dr. DeSources answer that. She was... Based on preoperative imaging, we knew there wasn't a significant amount of the ureter involved, but I think it kind of, when we had done the duodenal resection, that was kind of the first time that we had thought that that would maybe be a good idea. And then we had, at the end of our dissection, we had to just make sure that the bowel wouldn't be on tension. If we used additional jejunum for our interposition, there wouldn't be tension when we had to do our duodenal jejunostomy. And because that worked out, it worked out that it was able to be used for the ureteral reconstruction. You know, there's a lot of reports of ileal interpositions to repair a ureter in this situation. And we really, there was only about a centimeter or two of the proximal ureter to work with, but in using a portion of the jejunum, she only had one small bowel anastomosis as opposed to two. Gotcha. Some questions from the chat. The first was just the decision to not replace the IVC. That was based on the fact that it just, you noticed that intraoperatively, it was sort of obliterated by the tumor. So the question is, how did you replace the IVC? You didn't, you know, in terms of long-term consequences of not performing that step, how is she doing? So she has, I mean, this was only about four and a half months ago, but she, and we prophylactically had her meet with our specialist in lymphedema, because thought that may be one of the major side effects of having basically no IVC, but she has had no lower extremity swelling or heaviness or doesn't have any complaints of that. And typically the literature for this, since this is a really rare case, comes from patients who have chronic IVC occlusions, either from IVC filters or from chronic clots. And usually if it's a slow indolent event, their body overcompensates with collaterals over time and they do pretty well. For her, we don't know exactly the timeline when she completely stopped having blood flow through her IVC, but in working with our vascular team and her prolonged course, it seemed as though she had kind of this more indolent obstruction, which is evidenced by the fact that she is doing so well. Right. Last question that we'll take before we move on from the audience, the transplant surgery has advocated for these types of unblocker section for well-differentiated tumors. And this, you know, it was not known this was a poorly differentiated tumor until the post-op histology was more moderately differentiated at the outset. So is this extensive OR for just local control, justified for all histologies or what do you, what do you think about that? I'm asking you to predict the future, I think. I mean, I think when you're, when you're facing kind of this radical procedure for a gynecologic cancer, these are case by case decisions. I don't think there's any, you know, kind of generalized criteria that we can use. We only had core biopsies of the mass preoperatively. So our analysis of, our pathologic analysis was a little limited. But I think for this patient, you know, hindsight is 20, 20, and it does seem like this was a primary site of a malarian carcinoma in a malarian remnant. She had no, she never had any disease in any other site and still does not. So I think it's just a unique situation. Well, that's a great discussion, but we have to move on. So thank you both for the outstanding presentation. Next, please welcome Dr. Mario Leiteio presenting robotics integration with endoscopic double barotraumatic colostomy. Thank you, Dr. Leiteio, you can share your screen. All right. Thanks everybody. After that video, I don't know if it's even worth showing this one. This is like nothing compared to that. Wow. Congratulations guys. Thank you for inviting me to be a part of this. As always, I'm happy to do this and share our thoughts. And I mean, totally enjoyed the videos so far and definitely hearing from Dr. Sabula was outstanding and Dr. Sources and Dr. Long. So, all right. So hopefully everybody can see my screen here. So I'm gonna show, you know, here a robotically assisted exonerations. This lady's had multiple prior recurrences of revolver cancer in the setting of lichen sclerosis. I'm just gonna go back for a second, just to show you. And she had received prior radiation. She was 72 years old, had received prior radiation and had yet another recurrence here, as you can see on the posterior left vulva extending to the right side and abutting the anal canal. After obviously the usual extensive discussions, we discussed an exonerative procedure because this was really a procedure where the mass is externally like this. We felt that an MIS approach would be something feasible to try. And she was willing to undergo this approach with us and fully understand the possible need for doing laparotomy. She already had a prior usual vectomy with a flap from the right leg. So this is, we've adopted the usual position. We keep trying to keep things as simple as possible in doing these procedures, especially in something relatively newer and less common. And it's a standard pelvic setup for us for robotic procedure. I used to do robotic arms on the right. And you can see here, we're entering the pararectal space. The ureter is up to the right side. Again, I like to use two arms on my right hand for the robot one on the left. And on the right, I usually have a progress all the way lateral, the scissors in my right hand there, and then a Marilyn bipolar. Once we dissected the pararectal space, we identified her uterine vessels and took them somewhat midway between the origin and the uterus itself. You can see the ureter freely dissected. Let me continue that section down. You can see here, easy, you can get down to the pelvic floor. The levator muscles are just came in view there. I'll fast forward a little bit, just for time's sake. Again, after that part, we then started dissect the bladder down from the symphysis. You can see the bony structures there coming in view, the pubic rami there, the symphysis. We have the bladder in hand here with the left hand. We'll get to that in a minute. With the left hand, we're getting clearly into the space thoracis, and you can see here, the bladder's here. There's the edge of the bladder. And again, this fortunately came down nice and easy. Most of the radiation was mostly of vulvar folks, but she has received some pelvic radiation also. And we continue the bladder dissection there, and you get the idea there. So we continue this circumferentially. Here, we're taking the bladder further down. Once the bladder is free, the uterus is pulled up. We're just mobilizing the rectal sigmoid here, the upper rectum or lower sigmoid, just complete mobilization so that we can then identify an area for transsection of the rectum. This is the retrorectal space here. Nice thing about this platform is that it allows for really great visualization in these spaces and steadiness of motion and no shaking. And it really is a nice way to approach a complex procedure like this, in my opinion. But of course, this is typically done via open, and that's also acceptable. And I know there are folks who do this with standard laparoscopic instrumentation without the use of this platform, but this really was a near-blowless procedure throughout, and with some great visualization in deep pelvic spaces. During exoneration, an open procedure, as you can imagine, is somewhat difficult, especially when you get to underneath the symphysis, but, you know, that can also be overcome. At this point, we decide to transect the ureter. Found the spot that we want to transect it. We clipped it and then cut the ureter, which is obvious there. And of course, all these things were done on both sides. So although we're sewing one side, there's no reason to show the other side as the steps are the same on both sides. We then continue our dissection downwards towards the pelvic brim. The para-rectal space has already been developed. You can see the pelvic floor in the distance. Again, just simple bipolar and monopolar energy was all that was needed. We're just taking the middle rectal vessels there. And again, no fancy instrumentation was needed other than the fancy robot, but otherwise, we were able to do this entire procedure without vessel sealer, and we're just using bipolar and monopolar instrumentation. You can see here, continued dissection of the rectum, posteriorly down to the levators. Now we're touching the coccyx. There's the retro-rectal space, sacral hollow. There, what we had done is we created actually a space here, which we had just saw here. We were able to find the coccyx and mark and create a defect just anterior to the coccyx that would guide us from our perineal phase when we started the perineal phase. We continue circumferentially around the bladder here anteriorly. And it's just a sequential continuation of dissection spaces around all the pelvic organs, which again, can be done with these two instruments here throughout. And here, now we're getting into the levator muscle area. Some muscle fibers are being cut now. And this is the other side which we will pass because it's the same steps on the other side. So this rectum has been fully mobilized anteriorly. You're coming through the pelvic levators. And here we now have one of our partners, Dr. Broach actually was doing the perineal phase and had started to do the perineal incision. And now we could sort of connect and actually see and meet in the middle. And this was really helpful in sort of deciding where to come through. At this point, we just started this, after most of that dissection was done, we just came more proximal on the rectum, transected it with a robotic stapler. And at this point, we're working together with someone from below. At this point, we're below the elevators. This is on the right side. Now we've got connected. We've met, East and West have met there in the middle. From that point, it was just working together again to finish the resection circumferentially and again, this is an area where with an open approach, it's very difficult to get to this point open and see well enough. And here you can see the visualization how close you can be and really work together from both below and above. We use the air seal device, which helps us to be able to have these defects and not lose our pneumoperitoneum, which has also been a huge advantage for these cases. Otherwise, with standard insufflation, there would be a lot of loss of pneumoperitoneum making it near impossible to continue this procedure in this fashion with the hole at the perineum. And then you can imagine just work circumferentially again to finish this resection. The specimen was then, once it was all free, it was just pulled out from below. And again, at this point, even the air seal can't maintain that much and we were able enough to do enough to at least get the specimen out. Plastic surgeons then did their reconstruction and we decided to then do a double barrel wet colostomy. So instead of doing separate, just as a quick dimension of double barrel wet colostomy, instead of having separate diversions, both a urinary and a colostomy, this reduces the number of bowel resections needed and actually reduced the operative time by almost two hours by doing a modification of the old Brundrig colostomy, which was a wet end colostomy, which had a lot of problems and we stopped doing. This is a modification where you actually create a loop end colostomy and the distal limb, which is looped, is where the urinary connection goes and then the stool comes out through the proximal limb onto the same bag. And so then you get a bag with wet stool, but the streams actually do not connect within the stoma itself. So identify the ureters on both sides. Spatulate the ureter. I mean, I'm sorry, cut the ureter, something that I have to clean fresh edges. We then spatulate the ureter there, as you can see. I like to use this little tag suture to help manipulate the ureter, so to avoid actually having to grab the ureter multiple times with the instruments. It also helps to manipulate the ureter much easier. You then create a colotomy and that way you feel it would sit in the distal end of the transected colon. And this becomes a routine ureteral colonic anastomosis where you're using four orichal sutures on an RV1 needle. And the costa from the ureter to the bowel. You want to do interrupted sutures. You don't want to put too many sutures here either as that can actually cause stricturing and necrosis if you put too many sutures and you continue the anastomosis around. So unfortunately you do the back flap first so that you can see. Once you attach that posterior aspect of the ureteral colonic anastomosis, you pass a double J ureteral stent. This is an eight and a half French 24 centimeter stent that we're placing. You place the proximal end retrograde. And then you also then place the distal end into the colon. Then you finish your anastomosis. And then obviously you do that on the other side. And here you can see the last sutures with the ureteral colonic anastomosis there for the left ureter to the colon. And then you repeat the obviously the connection for the other side, which is essentially just repeating the same steps for the contralateral ovary there. Again, the callotomy being created, the anastomosis start after ureter spatulate, the same exact steps just on the other ureter. You do the sort of one side of the ureter away from your camera, and then you pass the stent and then you finish your anastomosis. And at this point, once this is done, the plastic surgeons did their procedure. And then we came back to pull the stoma up through one of the trocar sites. And here you can see here's a stoma through one of the old trocar sites with a bridge to help the stoma stay up. The ureteral stents pulled out and just a sort of bridging maloncot drain just to keep the ureteral limb of the stoma open and patent. Then we place the drain into the pelvis. So that's all I got. Thank you. Hope you enjoyed it. Great, great video, Professor Leiteo. So we are going to open up for discussion with the audience so you can send me your questions. And how do you usually follow up those patients regarding the urinary function? Because do you feel they have more complications compared to the classic bricker reconstruction or something like that? Because some people they think that this patient may have more infection and loses function. So actually, you know, this is actually has been published a long time ago from urology group doing a double barrel. It's a double barrel. Remember, it's not the old Brunswick colostomy where you cut it and you put the ureters proximal to where the stoma would be made. So at that point you would have true stool and urine flowing together before they got exited the body. So yes, those were associated with high rates of ascending infections and all kinds of other problems. This now imagine instead of having two separate whole, two separate bowel over sections with separation, you're just looping the bowel. And so really it's a double barrel colostomy. You don't have mixing within the abdomen of stool and urine. It's all mixes once it gets into the bag. So we've actually looked at ours, Dr. Brooks looked at our outcomes so far and it does not seem to be an increased risk of infection or complications with this as compared to the many separate diversions we've done. This has also been published by other urology groups elsewhere and other colleagues in gynecology. It does not seem to be to date an increased risk of infection by doing this. What it has been shown is that decreases the surgery time by an hour and a half to two hours and it avoids multiple bowel over sections and re-anastomosis. So we do think there is some value to doing it this way. And it's also just one bag as opposed to potentially two bags or one bag and self-catheterizing some other time. So, and most folks have one bag and are self-catheterizing urinary system, often say, well, I could have just had two bags. I'm used to one bag. Now I have to wake up in the middle of the night to self-catheterize and all those things. So that's why we think there's some value to it. And Dr. Brooks is on obviously and he can also give some of his thoughts on this. But we have been doing this more frequently. The challenge we've had is actually finding a bag system that works well enough for now, a mixed stool and urine. And we're actually trying to create a bag with a filtering system in it so that it actually filters out the two components for easier management. So we've been able to work with our stoma team to get to a place where we can find bag systems that work for patients. Yeah, I agree. I also have this feeling that it's much easier to take care of these patients than with patient with two stoma. So I agree with that. So do you use frozen section to evaluate margins during resection? No, we don't. It's just, it's a big specimen. It's like exactly where you do the margin. You'll wait an hour for frozen section on such a big resection, right? So we don't. We basically see where the tumor is and we go for as wide as we can since we're doing such a huge resection. We try to get a good four or five centimeters of clinical margin actually on the perineum or have a plastic surgery reconstruction coming in. So we don't get frozens. I think I don't never, I've never really heard of doing frozens that much for these procedures. I think you can. It's just so add additional time. So we don't, is that right or wrong? I'm not sure, but we usually don't do frozen sections unless you're concerned, unless you're close somewhere and it's just anatomically impossible to do more or you want to avoid doing more, but routinely we don't do frozen sections on our extended procedures. Great. So a question from the audience, Dr. Deshleng. I hope I'm doing it right. How long did it take you to do the whole procedure? Oh, yeah. Well, plastic surgery came in and that took about another two and a half hours. I think our, the whole start to end was approximately seven and a half to eight hours. I'd have to go back and look exactly, but yeah, you know, our part, our resection part was about two hours. The double bowel colostomy pulling it up another hour and a half, two hours also. So that's four hours in the, you know, the plastic surgeons and then another three hours or so. Vance, that's about what I remember. I have to look back to see. Resection was probably the shortest part of it, actually. It was the wet colostomy and the reconstruction that was longer. Yeah. So Dr. Bernardini is asking, have you moved to double wet colostomy for the bowel colostomy for all your exenterations now? So I can't speak to everybody in our practice. I personally do. I think if someone's going to get a total exenteration, I do give them the, we do go over the options, but I feel that I kind of recommend doing the double bowel wet colostomy in those situations. Yeah. Obviously if you're doing an anterior or posterior, then that's different. But I think for a total, I like this approach and that is what I am offering as my recommended approach, but I can't speak for the whole MSK group. I'm not sure that everyone has moved over to the double bowel wet colostomy and some are still sticking with the separate diversions. I mean, we still have to gather more information. There are still concerns, I guess, and this is all going to be retrospective. No one's ever going to do a randomized trial comparing these two. We just don't have enough case to ever meaningfully come up with information. So yes, I have. Okay, you have. Good. So Dr. Rene is asking, what has been your experience with electrolyte disturbances with the double wet colostomy? We haven't had an issue with electrolyte disturbances at all. I mean, it's really, again, no different from any other diversion that you would have. So I haven't noticed any electrolyte disturbances of note. We've had an anastomotic leak. You can get a stricture. So we've seen the typical things we see with these diversions, but not at a higher rate. And it seems to be the same, at least in our early publication, our early look at this, we haven't published yet, and also looking through what has been published by others. It does not seem to result in any, it's got complications, of course, but they seem to be the same as with the two separate diversions. Okay, and any concerns about the empty pelvis syndrome and do you have any tips to prevent it? So, yeah, you know, obviously that's, yeah, of course, you know, we always try to do, so our approach here has been, and we try doing fillers and all kinds of things in the pelvis. What we usually do when we do a total exoneration is we have our plastic surgeons come in and do a flat closure. So even if they're not getting a new vagina, we do feel that the empty pelvis can cause some problems. And some of the problems are like herniations down the perineum and actually fistulas to the perineum, which we've seen. So we feel like putting a myocutaneous flap is optimal. Obviously, if they're doing neo-vagina, that takes care of the empty pelvis syndrome. And then those who don't want a vaginal reconstruction, we still will do, as you saw in that case, a vertical rectus abdominis flap. That's our preferred flap by our plastic surgery team. There's obviously other flaps that can be done, but that is, and it's usually a very generous, as you saw, big muscular flap that gets placed down into the pelvis. So that's how we try to address that completely empty pelvis syndrome. All right. Thank you so much, Dr. Luteau, for a really tremendous presentation and outstanding discussion. Really so appreciative. We're going to go ahead and move on to our next- You're welcome. We're going to go ahead and move on to our next presenter, Dr. Hossein Ahlaj from France, who's going to be presenting his video evaluating complete abdominal peritonectomy. And let me... Hello. Thank you all for giving me the chance to be part of today's film festival. So I will be presenting today the total parietal peritonectomy. We start by performing a Xifu pubic skin incision. This is followed by incising the linea alba. And here care should be taken not to incise the peritoneum. So as we incise the linea alba, we expose the pre-peritoneal fat. And at this point, we hold the edges of the aponeurosis with two kosher clamps. And traction must be maintained by the assistant. This traction is important to expose the dissection plane. So the parietal peritoneum is dissected here from the posterior sheath of the rectus abdominus muscle. It is important to carry out the dissection in the right place. And it incises neither the peritoneum nor to dissect the aponeurosis. The dissection of the peritoneum from the aponeurosis layer is sometimes easy to perform, but sometimes due to the carcinomatosis and the associated inflammation, it could be difficult and it could be performed with either electrocortis or with scalpel. Once the plane is dissected, blood dissection can be performed. But when arriving to the ultrate line, the delineated posterior sheath of the rectus abdominus Is it still playing the video? Okay. So we go from the deep aspect to the superficial aspect because this way we can expose the dissection plane easier. And here we are continuing the dissection towards the pubis. The next step after we finish the lateral dissection is to go to the bladder dissection. So the dome of the bladder is held with atriomatic clamps such as heart-shaped clamps. And then the peritoneum is stripped away from the bladder. This part might be challenging as well due to important casinomatosis to overcome this difficulty. We can start dissecting laterally on both sides and then go back to dissecting the dome of the bladder. Or we can fill the bladder with saline water to better visualize the dissection plane. And as we see, traction is always important to show the dissection plane. So finishing with the bladder dissection, we move back to the paracolyte gutters. And here the dissection is usually easy and can be performed bluntly because the connections between the peritoneum and the underlying fat is very loose. And lateral dissection here should be performed on both sides until visualizing the ureters. As we can see here, the ureter and the psoas muscle. And we should also, we can see here the ureter moving. And we see the gonadal vessels just beneath the ureter. When moving upwards, care must be taken as well not to embark the transversus muscle. Here the peritoneum is as well adherent to the transversus muscle. So when this is the case, we perform a blunt dissection and we can also go from the deep, the posterior dissection anteriorly. Once this is performed, we usually put the LHC retractor to enhance the fetus position. And then we put the retractors. And as with all supramusocral surgery, we'll put the patient in a reverse slender position with a lateral tilt to the side opposite of the site operated. And the strong detraction of the costal merging here increases the exposure. Peritonectomy of the left dome, as we see here, is only difficult when, because of the presence of the spleen. And in case of splenic invasion, a monoblock resection is preferred or a primary splenectomy is preferred to avoid important hemorrhage during peritonectomy. The peritoneum here is separated from the underlying muscle with either a mounted pad or electrocortis. We think that the mounted pad is very effective because it preserves the muscles and does not traumatize the abdominal branch of the phrenic nerve. However, electrocortis is less hemorrhaging but should be avoided near the cardiac area. Here we are seeing the peritoneum being separated gradually. And you can see the liver on the left and the spleen on the right side of the screen. The peritoneal separation is easy in the muscular part, but becomes more difficult as we approach the pancreatic part or the phrenic part of the diaphragm. Once we finish with the left side, here we can see also the subdiaphragmatic vessels that we should avoid as well. Once we finish with the left side, we move to the right upper quadrant. Here we can see the spleen that's being dissected. And this is the right upper quadrant. So here we are starting laterally. We can see the prerenal fatty tissue and the adrenal gland on the lower side of the screen. And we can see the blood dissection that we perform and the liver on the upper side of the screen. So here we can resect easily the triangular ligaments. And as we go upwards, we should pay extra attention here because as we go to the coronary ligaments, we get closer to the vena cava and to the hepatic vessels. So here the dissection should be very cautious not to injure those vessels. And this is a view of the whole peritoneum. And once we finish the peritonectomy, we open the peritoneum, and then we expose the abdomen, the tumor. And the liver afterwards, after all the extraperitoneal dissection has been performed. Okay, thank you so much for a really tremendous video. What an incredible operation and a beautiful video that you put together. We're going to open up for questions now. One question that I had is, you know, when you're performing these peritonectomies, how are you certain that there's no unresectable disease on the small bowel sclerosa or elsewhere before you start the peritonectomy? So what we usually do is we do the laparoscopy, the diagnostic laparoscopy, a week or 10 days before the laparotomy. So we schedule both the laparoscopy, diagnostic laparoscopy, and the laparotomy. If the diagnostic laparoscopy shows that the disease is resectable, then we keep the scheduled laparotomy and we already know what is to be resected and if the patient is completely resectable or not. It sounds great. Yeah, I mean, I think we all struggle with, you know, wanting to make sure that we get a complete growth section when we're doing these ovarian cancer surgeries and so it sounds like a great strategy. One question from the audience is, what technology did you use to make the film? And I agree that the quality was fantastic. Well, we have cameras in the ceiling and we used as well the laparoscopic camera. Oh, the laparoscopic camera, got it, okay. Yeah. Another question from the audience, how about argon plasma coagulation to control bleeding during the peritonectomy? Is that acceptable in the upper quadrants or near the heart? Yeah, it is acceptable, but the thing is that there are not much studies about the effect of, it's only, it's, I think it's every team's habits and, but yeah, it is acceptable and it doesn't cause as much damage. Okay. And then maybe one more question from the audience, why do you prefer not to open the peritoneum in the midline at the beginning? And is this because you think it's easier to not do that? It is actually, we think it's easier to do this this way before opening it, but sometimes honestly we cannot, it doesn't work every time. Sometimes we just open the peritoneum and then we do the exact same thing, but with the peritoneum open. Okay. Thank you for your very informative presentation, Dr. El-Hajj. Our final film presenter today will be Dr. Payan Kashy from Johns Hopkins University School of Medicine. He'll be presenting in robotic assisted pelvic exoneration in a radiated field. Dr. Kashy, you can start. Thank you very much. I'm going to share my screen. And there we go. Good morning, everyone. And I'm delighted to be here presenting robotic assisted pelvic exonerations in a radiated field. And I have no disclosure. Everybody in this audience pretty much knows about why we're doing pelvic exonerations. I just wanted to go over a few kind of overall indications in gynecologic surgery or gynecologic malignancy. There are different types of exonerations, anterior, posterior and total, particularly in cervical cancer patients. It's done either for patients who have central recurrence or for palliations or persistent fistula. In our patients that we're presenting today, all three of them had advanced cervical disease or cervical cancer, have gone through chemo radiations, and they had fistulas. So what do we use? I mean, the answer to this is very obvious. I mean, we have improved visualizations, decreased blood loss, and improved pain postoperatively. And as you can see in these videos, the visualizations is great. And through smaller incisions, we can perform all the detailed of a very extensive ultraradical surgery. And mostly here, we're going to talk about the kind of present the cases that we have today here. The three patients had all advanced cervical cancer. Their median age are very similar. Their BMI are similar as well. Two of them had vesicovaginal fistula, and our third patient had the vesicovaginal, ureterovaginal, and rectovaginal fistulas. We're going to talk about the surgical metrics. And essentially, if you look at this, surgical metrics that, you know, operative time that we included, the robotic time is not that long. You can perform the operation kind of efficiently and get what you need to get done. And our EBL is between 4 and 800, and that's including the reconstructive phase of the procedure. And we kind of input the complications that some of the patients had postoperatively. So robotic setups is something that we, it depends on what kind of robotic system you use. Here, I'm showing a robotic XI system, you know, whether you use the XI system or SI system. Essentially, from the pubic symphysis, 20 to 22 centimeters above the pubic symphysis, you can make your incisions. Here, we prefer to make the incisions kind of in a midline and a vertical fashion. So if we had to convert to open or for the reconstructive phase, if you're not comfortable doing a robotic reconstructive ilioconduit or creating colostomy, you could kind of extend the incision and patients will have less incision. Whether you go from the right or left is kind of depends on your, again, robotic platform, your room, and how you're comfortable with the system that your hospital uses. So in surgical approaches, obviously, in this patient's had palliative surgery and the survey that you usually do to see if the patients are a good candidate for completion of this operation may not be feasible. In that, you may not be able to get into a retroperitoneal spaces the way that usually you would and one would and see the pararectal and paravesical spaces. And so there are some modifications to the way you perform this operations. So essentially, if we had to break down the general aspects of this operations, the surgery could be in two phases of anterior and posterior phase. You identify the ureter, you create the vascular exposures necessary, controlling the bleeding is also very important in early stages of the operations. The bladder dissections also is not similar to what you would see. The planes are not as clear, it's mostly fibrosed. And then the transsection of the urethra and a colpotomy. And if you had to do a posterior exent, then you could kind of continue going through that route. So here, you would see in our, I have some pictures for you guys before the video. So in this patient, you could see the pelvic anatomy is apparently normal, but you could see all the fibrosis all around. That is a result. Here on the right side of the patient one, we could see kind of clear margins and clear retroperitoneal space. Similarly, of a patient without radiations, we could identify the uterine artery. And in the contralateral side, you could see a major fibrosis. So to remedy this and overcome getting through the kind of safely through the retroperitoneum, we identified the external iliac, we went really high and made the incisions on the lateral side. We choose the kind of a lateral to medial approach and carefully dissected through the fibrosis, but kind of stayed in a kind of a medial side within the fibrosis to avoid unnecessary injuries. Here you can see as a result of radiation, in this patient number two, the uterine artery kind of sheared off with a gentle touch. We were able to identify kind of the uterine artery at its origin and carefully kind of coagulate and ligate the right uterine artery in this patient. On this patient, this is our third patient who is very fibrous. This is by far the worst fibrosis of the three patients. We weren't able to find access to retroperitoneal space safely. So instead, we kind of went to the traditional route and started coagulating and transecting through the left round ligament and then work our way kind of towards the midline. On the right side of the same patient, if you look, there was a cavernous defect. This is a result of her fistula. You can see it's highlighted in green. So again, to stay safe, we started from coagulating and transecting our IP ligament and then finding our way down towards the lower part of the pelvis. When it comes to the bladder, there are planes that are pretty clear and we can kind of transect through those planes. But then there is an issue with countertractions. As you can see, the bladder is kind of defined here in this picture, but there are not kind of clear pictures around this dissection. So what we did is that we made a kind of a semicircular U-shaped incisions around the bladder and then artificially created these pedicles that we could then cut and coagulate with using bipolar and monopolar device. And in most cases, we had no problem kind of getting these dissections down. Again, not having the countertraction is an issue with regards to dissecting the bladder. At the level of urethra, I think the key that we want to reiterate here is that whether the patient is diverted or not, we use the urinary catheter or folic catheter and that kind of allowed us to delineate the urethra. And there was no, because the patient had fistulas, there was no kind of adhesions and the planes were kind of clear down to the vaginal cuff. And the kind of the vagina was delineated using a sponge stick. Obviously, we didn't use any manipulator and we were able to circumferentially then remove the specimen. To get the kind of isolate the ureters, in the first patient, as you can see, we were able to kind of identify the ureter and retroperitoneum, isolated with suture ligature and cut it off. And then inferiorly to the ureteral cut, then we're able to get the uterus sacral ligaments and continue on to kind of dissect towards the lower part of the pelvis. Patient number two and three, there was significant fibrosis. So the ureter lysis was found to be very challenging. So in this case, you could see that there was a thin layer of the peritoneum or parietal peritoneum over the ureter that was carefully kind of peeled off the ureter and transected. And this allowed us to visualize the ureter. So here, instead of doing the suture ligature, we were able to kind of go all the way down to the level of the uterus sacral ligament and transect the ureter off in that layer. And then after we removed the specimen, we came back to dissect off the ureters and perform the ureter lysis in the retroperitoneal space. I'm sorry. I don't know what happened. Back to the video. I'm sorry. So I'm going to back up a little bit. So here, the other area that is very challenging is creating a rectovaginal space. In the rectovaginal space, we were able to cut through behind the vagina. We found that we were too high. We came down lower in the lower part of the rectovaginal space. And we used the EEA sizer, and that kind of allowed us to delineate the space and dissect off the bowel in the right plane. In this patient, you can see that there is a defect here posteriorly. Again, we were able to amputate the cervix off the vaginal cuff, and then we were able to remove the specimen. And then here, you can see the rectovaginal fistula. We used the EEA sizer again in this space to be able to delineate the kind of lesion and be able to dissect off the vaginal cuff and close it in a very tension-free fashion. So the closure is very important in terms of we used the V-lock, but we wanted to kind of have a tension-free closure. So we kind of used the suture line in whatever directions that we could take, whether it's vertical or horizontal, and it would be tension-free closure. And basically, that's the final results. And basically, we want to say that robotic surgery for palliative care in a radiated field is acceptable, with acceptable loss and equitable postoperative morbidity. However, it's based on the surgeon's experience and comfort level. And I'd also like to acknowledge the attending surgeon, Dr. Gard, and Dr. Dubell, for allowing me to present here today. And that's it. I'm happy to answer any questions you might have. Thank you, Dr. Kashi. It's a great film. So let's open up for discussion. A question is, how do you decide between trying just a diversion, like a breaker for urinary fistula or just a colostomy, or before doing a pelvic incineration? Where is this line? When do you choose to go for it? When do you choose to just go for a stoma before trying something more extensive? What's extensive surgery? I think in most patients who have extensive palliations, or radiations, for that say, for a better word, in these patients, it's really hard to reconstruct or repair these fistulas. Obviously, the patient's age, whether they're cured of their disease or they have recurrence, all of those comes into play when you make these decisions. In these two of the three patients, or all three patients who had vesicovascular fistula, it persisted and it didn't respond. And we couldn't, obviously, with all that fibrosis, we weren't able to do a reconstructive procedure. The patient has to be very committed to this, knowing that it's very extensive operations and your bodily function is permanently altered. That's usually the algorithm. It's very case-to-case. You see a patient's age and what stage of disease they had, and if their fistula persists and it doesn't respond to treatment, then you would take this route. In patients like with urinary fistula, do you sometimes consider just doing a breaker and leaving the fistula, or do you always remove the area? Again, I think it's very kind of patient-dependent. If they have a massive, I mean, they have a lot of symptoms that they can't live with, they have lots of infections and issues relating to quality of life, for sure, I mean, you can consider. Again, the choice of going through this route is a difficult choice because you're taking out so much of the tissue and rerouting their bladder or the bowel. Great. We have a question from the audience. What's your opinion about IORT for surgical margin positivity? Surgically positive margin, you said? For these patients, obviously, I think the intraoperative RT is possible. Oftentimes, in these cases that we did, they were all palliative. I think if you find a sign of the disease, that's a kind of a hard stop if it's not resectable. It all depends on the institution you're at and whether they have the capability of allowing the intraoperative radiation during surgery. Yeah. Also, sometimes I think that it's still a little bit hard to decide where to irradiate also, right? I mean, obviously, if there is a specific margin, but if you're doing just for palliation, I don't know. And the challenge of this is that actually knowing the correct patient is knowing that the patient does not have extensive disease to the pelvic sidewall. As you could see, the dissections and the planes are completely kind of destroyed. And so not having right plane of dissections makes you prone to having major vascular injuries. And the risk kind of outweighs the benefit of what you're trying to do here. Great. So there is another question. Do you perform frozen section for suspicious lymph nodes? I guess they are asking in like cases for when you are looking for not for palliation, for... So again, this is like a very good question. For a radical hysterectomy, I mean, the operation starts with if you have positive lymph nodes, you abort, right? And that's kind of the sign that you don't continue with the surgery. In these cases, finding the space to get into, if you preoperative imaging is not showing enlarged lymph nodes, you won't even explore the option of getting the lymph nodes out. Again, it's just going through the unchartered territory of causing more damage than doing patients good. So in terms of lymph node, frozen section for lymph nodes, the opinion of pathologists about sending frozens for lymph nodes are varied, especially now that you've seen that there is a level of like micro metastases or isolated tumor cells. They feel like they can't accurately... I mean, most very expert pathologists feel like if there's an obvious disease, they can tell, but then the full study of saying something as positive or negative is kind of in question in those cases because they can't do the ultra staging and really look at all the samples kind of closely. Great. Thank you so much for such a tremendous video and a wonderful discussion. And really to all of our presenters today, thank you so much. It was really a wonderful discussion. I'd also like to thank very much the IGCS staff who've made this possible today. Megan Anderson and Mandy Hanson in particular do an enormous amount of work to make these possible. And so we really are so grateful to them, as well as the leadership of the IGCS with Mary Eichen and Rithu and Angurta. We're really grateful to have these opportunities. I'd like to thank also everybody for attending. We had a wonderful turnout. And remember, this is all going to be available on the IGCS educational website. So please go ahead and check back probably by midweek next week. The recorded talks will be available for you. And as we have done over the last year and a half, we plan to continue the surgical education offerings, including more opportunities for our membership to submit films for presentation. The dates of the next sessions will be made available as soon as they're scheduled. And so please stay tuned for that. We certainly wish you all continued health and safety and look forward to seeing you again soon. Bye-bye.

robotically assisted exonerative procedure

recurrent vulvar cancer

minimally invasive approach

robotic arms

dissections

transections

pelvic exonerative procedure

advanced cervical cancer

fibrosis

radiation damage

ureters

rectovaginal space

surgical planning