Preserving Fertility in Gynecologic Cancer: A Breakthrough with Uterine Transposition
Previously Recorded -Friday, April 11th at 1:30 PM ET
Join John P. Diaz, M.D. and Jean-Marie Stephan, M.D., for an in-depth discussion on uterine transposition, a pioneering procedure designed to preserve fertility in patients undergoing cancer treatment. This webinar explored the clinical approach, surgical techniques, and patient outcomes of this groundbreaking case. Learn how this innovation is transforming gynecologic cancer care and expanding reproductive options for patients.
Chief of Gynecologic Oncology
Miami Cancer Institute
Gynecologic Oncologist
Miami Cancer Institute
Good afternoon everyone and welcome to Baptist Health Cancer Care's webinar series. I'm Doctor John Diaz, chief of gynecologic oncology and medical director for robotic surgery, and I'm joined today with Doctor Jean Marie Stan, gynecologic oncologist, and we're gonna be discussing preserving fertility and gynecologic cancers a breakthrough with uterine transposition. Cancer cases in the United States have remained the same from 2021 until 2025. We're gonna talk in a little bit about a uh American Cancer Society figure and facts report that was issued in 205 that has both good and bad news, and we'll be discussing them uh next. The cancers we deal with are mainly gynecologic cancers, uh, uterine cancer, cervical cancer, vaginal cancer, ovarian cancer, and vular cancer. And so what's been reported is we've seen a shift in cancer burden. There are more women being diagnosed with cancers and at a younger age, Dr. Fan, have you seen this in your practice and why do you think we're seeing this? I have seen this in my practice, you know, I mentioned earlier the good news. The good news is that cancer rates on the whole have been decreasing steadily through time for most cancers. That doesn't apply to uterine cancer. We'll get into that. Um, there, there's no answer, one answer that explains why more women are getting cancer and more younger patients are, are getting cancer. There's been some theories around this. Some theories suggest that um Patients who in the 1960s have had some sort of environmental exposure that and we're still feeling the ripple effect up until now there's also the obesity pandemic there is uh exposure to uh microplastics. There's exposure to ultra processed food, increased alcohol consumption, uh, consumption, um, and smoking, but there's a lot of research trying to delineate exactly why we're seeing younger patients in my clinic. Uh, every week we see somebody that is younger than 40 year old with cancer, and that wasn't the case, you know, 10 years ago. For the first time, John. The uh, since this report was issued, this is the first time that women. Under the age of 50, have higher cancer rates than their male counterparts, and I mentioned earlier cancer rates decreasing, however, the only category where it's not decreasing is in young patients. These young patients have had higher cancer nowadays than they did 10 years ago. Yeah, and I'm seeing the same thing in my practice, and this poses a problem. I mean, the treatment for G1 cancers is usually a hysterectomy or pelvic radiation, which in patients who have completed their childbearing, you know, doesn't impact the fertility. But in these young patients when they're faced with this new diagnosis, it now adds another dimension that we need to address when trying to deal with their cancer, but also seeing what we can do about their other quality of life issues, particularly fertility. And so when you look here, you know, women have been delayed childbearing now for some time. Back in 1971, the average age at which a woman had her first delivery was 21 years of age. Fast forward to now and it's almost up to 28 years at time of first delivery. So that's a big jump in just three decades. And when you look here, These are the changes that we've seen. So Doan, you wanna go through this chart with us. Uh, we've seen that, uh, more and more. The birth age by mother in the United States has been increasing steadily over time, similar to what you showed in the prior slides from the 1970s until 2023. More and more women are delaying childbearing and first conception whether it's due to, uh, you know, wanting to become a doctor, getting educated, uh, change in culture, change in religion, so more and more this has been put on a back burner until they finish what their priorities is and then have uh children. In higher age groups 35, which we used to consider old but which is now uh very uh traditional to see patients trying to get pregnant at that age and you look at these numbers women between the ages of 30 and 34 account for about 1.2 million births, uh, last year in the United States and so this becomes a problem or a challenge for us. Uh, we first encountered this with cervical cancer again, the traditional treatment for cervical cancer is what's called a radical hysterectomy. And you see that outlined here in green, we remove the uterus with the cervix to treat the cervical cancer. But as we saw with women delaying childbearing. This wasn't acceptable to them, and they pushed us to come up with something better for them and so we did so we developed a brand new surgery and this was spirited by Doctor Degent in France and adopted in the US what's called the radical tracheolectomy. So the idea here was we were gonna remove the cervix, which is where the cervical cancer is, and preserve the uterus so that they could carry a pregnancy in the future. Now, when we first started doing this, people thought we were crazy, right? And these were the steps that we developed for our abdominal technique, and so you see here is the uterus. You develop it just like you would a radical hysterectomy. But then we move on to the trachelectomy portions. This is where we remove the cervix with the margins with the cancer, and that's the specimen you see here and that blue hue is because this is when we also start to do central lymph nodes, so we would inject with this blue dye and you see we leave behind the uterus. We then would reconnect the uterus to the vagina, preserving fertility and preserving her ability to get pregnant. Because we remove part of the cervix and part of the cervix does is keep the uterus closed to prevent preterm deliveries, we'd put a cirlage in to help prevent that. Um, but when we're done with the procedure, you know, this new cervix or a new vagina looks just like a normal cervix and vagina. One thing I wanna add here is that there's a, there's a very slow timeline in fertility preserving surgery. Um, you mentioned Doctor Darjean 1990s when this was uh done prior to that, the concept of fertility preserving surgery was basically nonexistent and even from the 1990s until the mid. 2010s, no real progress was made in that uh there was no guidelines, uh, SGO NCCN guidelines started mentioning for preserving surgery in 2010-2011, which I think we're gonna talk about a little bit later and, and that has to do with. Us initially focusing on cancer outcomes, but then we were pushed by the reality of younger cancer patients also pushed by women demanding more than cancer outcomes, demanding better quality of life and the ability to have kids, right? And we've seen that both with your approach to breast cancer, these radical morbid. Mastectomies to now lumpectomies and so you're right, so there really wasn't a lot of traction. This is my paper, uh, which we published in 2008. We were the first to compare a radical tracheolectomy to the traditional radical hysterectomy approach in women with cervical cancer, and we demonstrated that in fact, yes, this approach was oncologically safe. And you see here the survival curves that there was no difference between a radical trachelectomy or radical hysterectomy approach again disease specific survival the lines overlap and to your point is, in fact this paper that was used to change the guidelines for NCCN from an experimental procedure. To now standard of care, uh, and to your point this is 2008 and these guidelines weren't updated until about three or four years later on the NCN guidelines. So we've been dealing with this issue of women being diagnosed with cancers where they still want to preserve the fertility, um, and we continue to get pushed, uh, in this realm and so. There's been a new or renewed push for even improved outcomes in patients beyond GAN cancers, and it really has forced us to think outside the box and that's really what all this is, you know, think outside of what we have traditionally thought and taught and listen to what our patients are asking for us, which is, to your point, great oncologic outcomes. A great quality of life afterwards and in some cases fertility and so take us a little bit through this. Uh, so what the point of this whole, uh, webinar is to discuss this breakthrough procedure called uterine transposition as you mentioned, uh, very rare procedure initially first report in 2017 done in Brazil by Doctor Ribira. To date, less than 20 cases in the world reported. So, uh, and so out of these 20 patients, uh, that have been reported in the literature, the first big case series was done in, uh, Brazil. 8 women, uh, who underwent who were who had some sort of pelvic cancer. Most of them were anal cancers and requiring pelvic radiation. So the instead of just doing the radiation and as we, you know, telling the audience, the radiation will damage both ovaries if they're in the radiation field, but also damage the uterus's ability to carry a pregnancy. Uh, so perform that procedure which we'll discuss and show you a video about to elevate the uterus outside the radiation feed. In this case, series 6 out of 8 cases, uh, managed to preserve the uterus and preserve the function of the uterus, resume normal menses, normal hormone levels post treatment, and no significant surgical complications. Uh, that's all good, but does it translate into pregnancies and fertility, and that's what we'll talk about, um, coming next, yeah, and just the thought, and when, when I've talked to colleagues about this, G oncologists and those who are not, you know, we partner with our fellow colorectal surgeons who identify a lot of these patients for us. Just the thought of moving the uterus, uh, they look at you and are you crazy? Uh, so it's such a novel concept. Um, and it's really changed maybe the way that we can help some of these women to preserve the fertility. So tell us a little bit about exactly the end outcome is this is great that we can do the surgery, but are we seeing what we want, which is, are we seeing live baby births? Right, so in fertility preserving surgery, it, it, the goal is to eventually, uh, preserve fertility to get pregnant. It's hard to measure this outcome because a lot of these patients, including in the vaginal tracheolectomy or the tracheolectomy patients. Out of 100 patients, only about 1/3 attempt pregnancy. So in this. A specific scenario here for uterine transposition, we have out of less than 20 patients, we have a report of 5 patients who have attempted pregnancy and then 3 live uh deliveries. So 3 out of 5 were able to carry a pregnancy and deliver a healthy baby. Two of them went preterm at 36 weeks, term being 37 weeks, and one of them went to term at 38 weeks. Uh, all the babies were healthy with the follow up, not showing any, any developmental delay or problems. Mothers were also healthy discharged posts of the one in both cases, and these women would need cesarean sections. These women do need cesarean sections correct. And so this is the report of the first live birth from uh a patient who underwent a uterine transposition, um, then received her pelvic radiation for treatment of her anal cancer, was able to spontaneously conceive, so without the use of, uh, a specialist, uh, delivered her baby at 36 weeks, uh, and now a year later we have, you know, again a healthy baby boy with no evidence of any sequela. And a healthy mom who's cancer free. That's correct. That that was the first baby uh reported and that was in Brazil. Uh, there's been a lot of effort in the United States as well. Memorial Sloan Kettering, and we're part of the alliance has the biggest case series on that. They've done, uh, about 88 surgeries, uterine transposition, and in December 2020, uh, the first live baby following a uterine transposition was, uh, reported. As of 2025, Memorial Stone Kettering has done eight of those transposition procedures. Yeah, and our relationship with the Alliance has been helpful, uh, in this, you know, and so. This has been our experience, uh, so talk us through what we've been able to do here at Miami Cancer Institute. So so far we've done two procedures at the Miami Cancer Institute. Uh, both young women, uh, 28 years old, was one of my patients. How old was your patient? was 32, 32. Both of them, uh, desiring, uh, fertility. Uh, both surgeries, both the transposition as well as the reposition completed successfully with good ovarian function and good menstrual regular mens is returning. Pregnancy outcomes are pending, obviously this is very, very recent within the past year that we've done these two surgeries. To my knowledge, the first in the southeast United States and the second following Memorial stone, yeah. And I think we should be very proud of this work, uh, and it's really, uh, incredible, uh, you know that we've taken this on and so you know we've done these procedures utilizing the robotic platform obviously we use every day so we understand robotics is but a lot of our times our patients and even some of the physicians don't fully understand so this is the robotic platform. So as the surgeon you sit there comfortably like we're doing today at the console where you control the robotic instruments you see there that's the actual robotic platform with those arms it kind of looks like an octopus and those arms then have the robotic instruments enter the body through small 8 millimeter incisions where we can perform these complex surgeries that we're controlling the robotic platform. And so Baptist Health is actually the leading robotic center in the South of the United States. This is the latest robotic technology. This is the DB-5 platform released in March of 2024. We have 5 of these platforms throughout our system for a total of 29 robotic platforms, one of the largest robotic centers in the country, uh, and we do some of the most complex robotic surgeries anywhere in the world. I'm very proud of this, and these were the technologies actually that we utilize, uh, at least I use the UDV-5 for my case, uh, and so again we continue to push the envelope with robotics to ensure the best outcomes for our patients. And so this is a case, this is my patient. uh my patient was diagnosed with a vaginal cancer, a very rare cancer, particularly in someone this young on the left hand side there, that red and pink and yellow picture that's a PET scan, uh, so that helps us identify. Where the cancer is, we get this light up and see the arrow points that small yellow ball there in the vagina. That's the vaginal cancer itself. On the right you see the MRI and so this gives a better definition. You see the anatomy is better there and again pointing out that vaginal cancer and it's just located in a tough spot where you can't really resect it. Behind it is the rectum, so to try and get a negative surgical margin. You know, we were concerned about damaging the rectum and so the traditional treatment for this would have been relation therapy to basically what you see there, which would have included the vagina, the uterus, the tubes and the ovaries, which is effective cancer treatment, we would have cured her cancer. But to your point earlier, it would have resulted in infertility for this patient. This was not an option that was acceptable to her. And so, as you know, we discussed this case on our tumor board. Uh, we talked with our friends around the country and the world actually. I spoke with our colleagues at Sloan Ketter and I spoke to Doctor Brera in Brazil and presented the case, and they all said, John, what about union transposition? And to your point, novel surgery, this was the first case we're getting ready for this in our institution and thankfully we had a patient that um believed in us, trusted us and gave us the opportunity to do something like this and so. This is an animation. Maybe you can talk us through what the surgery actually entails, right? So this is a video showing the uterus connected to the vagina, the ovaries on the side. The surgery entails disconnecting the uterus from where it's anatomically located, lifting it way up in the upper abdomen while maintaining the blood supply. What you see on the sides is one of the blood supplies to the uterus which maintains perfusion, allows the uterus and the ovaries to stay alive while disconnected. That area that we're seeing right now that lit up, that's where the radiation field is. It's essential, John, to keep this about 2 centimeters higher than the radiation field to minimize the dose of radiation. The cases of failure of uterine function that were mentioned in the case reports were cases where the uterus was kept lower than that and received some of the radiation resulting in necrosis and the uterus, not preserving its function. Uh, we will have a video of, uh, actually how this happens in surgery and we'll describe it. It, it's a pretty we had to think outside the box, but technically this procedure when I performed it was surprisingly easy because we do all these steps during a regular hysterectomy and we'll kind of talk about this a little bit further, yeah, and I think what gave me confidence in doing this was this is the same blood supply that we learned through trachelectomy. That we knew would be enough to sustain a uterus and sustain a pregnancy. And so again, we started our experience with tracheolectomy 15 years ago. That was the concern, right? We're taking the main blood supply to the uterus, uterine arteries. Would this other blood supply be enough? And so we have experience with that through our trachealectomy experience that we're all comfortable doing and so. Talk us through this is the first stage of the procedure, Doctor Zafon, where we're now going to release the uterus for transposition. So talk us through what's going on here, right, so this is a 2 minute video, so I, I'll kind of explain a little bit what we're doing here for the audience. So right now those steps are exactly the same steps we would do during a regular hysterectomy. We're opening up the retroperitoneum to and then isolating the blood supply of the ovaries. We call this the ovarian vessels of the IP ligament. Essential to keep these intact because this is what's gonna uh keep the uterus alive throughout this whole procedure. So right now we're just opening the, the broad ligament. Making sure we're not damaging any vital structures, getting the ureters away out of the way, those steps, John, are exactly what we do in a regular hysterectomy. uh, and so for those in the audience that aren't familiar about the surgery, what are the instruments that you're using here for this procedure? Uh, this is a bipolar. This is a uni monopolar scissor, and on the, on the right side of the screen, this is just a regular grasper. Uh, so monopolar energy, bipolar energy, very, very typical to any surgery that we do. What we're gonna see here on, uh, on the screen, this is what we're, we're gonna hold right now with the bipolar device. Those are the uterine vessels, and, uh, it's one of the ways the uterine gets, uh, the uterus gets perfused, but during this procedure, we will have to sacrifice. those vessels similar to what we would do in a radical trachelectomy, to your point, and we know that the uterus and the cervix survived that. Now we'll have a very cool video, uh, towards the end of this video, we'll have a very cool image showing and proving that this organ remains transfused. And that's kind of what's neat about robotic surgery, that we could actually see it real and um live that the uterus is perfused using that technology. I use ICG in a lot of uh my cases, and this is a perfect application of ICG and so to your point, these are the same steps that we do for a hysterectomy, you know, uh, here we're taking our urinal arteries a little bit lower and so now we've put a sponge and a stick or we can also use a cylinder into the vagina to help delineate where that cervix and vagina point is and so we're gonna now release the entire uterus and cervix from the vagina as you see there, that's the inside of the vagina we've now released everything. We're gonna close our vagina which is a barb suture that we use again, these are the same steps we do every day for hysterectomy. So the steps are the same. It's just to your point, thinking, thinking outside the box. So take us through what's going on here. This, this would be where we start thinking outside the box. So instead of finishing the surgery by cutting those two, arteries on the side and doing a hysterectomy, we've pulled the uterus all the way from the pelvis to the upper abdomen. Where we're gonna now suture it to the abdominal wall, but again, very important to know where is the site of radiation so we can go above that, about 2 centimeters above that. Right now we're switching the round ligaments to the abdominal wall and we're gonna do that on both sides so that we can suspend the uterus above. So that's one side, and we're gonna do the other side right now. We're gonna also suspend the ovaries on both sides so we can keep them away from the intraabdominal organs and away from the fields of uh of radiation. Very carefully, we will make sure that the blood supply is not twisted so that the ovaries are perfused. I mentioned earlier ICG. ICG is just uh something we inject that will emit green energy under infrared light and then the robot allows us to go under infrared. It works very, very quickly and wherever there's blood, you're gonna see that organ turn green and it's a very cool picture here. We're gonna see the ovaries start to turn green and that's where the blood supply is coming from. That's where the blood supply is coming from and then we're gonna start seeing the uterus as well as the tip of the cervix turn green. Uh, towards the end, I mean that tells you and proves that this organ is gonna survive and is well profused. Yeah, that's very encouraging. Uh, again, for those at home, we've now flipped the robot 180 degrees so we're now looking up at the abdomen as you said, uh, and at least in our case, you know, I left the cervix in situ I gave the patient a medication called Depoloron, uh, to suppress her menstruation. When it was originally described, uh, they would bring it out through the umbilicus and the patients would measure the umbilicus. I thought it was a little messy, so I start through this, but certainly both techniques are acceptable, um, to, to your point, and uh, when you do, when you look at the literature, those 20 cases or so that were done. There's no actual standard of care yet because it's such a novel technique. So there was one prepubescent patient that didn't need anything, so they left their, the cervix inside the abdomen because she doesn't menstruate. There's several that had the cervix brought up through the umbilicus, and they had menstruation through umbilicus, which is what I did with my patient. And she resumed men um she resumed menstruation through her umbilicus, which again, like you said, people, when you say that to people, they, they look at you like you're crazy, but that's, um, that's kind of what. Happens you put the cervix through the umbilicus. They have periods through the umbilicus until you, uh, bring it back. And then to your point, there's also several cases described just like this one that you showed where the uterus and the cervix are left intraabdominal, but you do have to suppress the ovaries so that people don't menstruate intraabdominally. So after my patient completed her radiation successfully, we then returned to the operating room, uh, and so this again is a robotic procedure in my right hands I have the uh robotic scissors with energy and the bipolar device. What we're doing here is we're just releasing some of the adhesions, uh, which can happen, you know, being careful obviously to maintain the blood supply to go through all this. We don't wanna injure that infiniteelvic ligament. So just releasing all these adhesions from the anterior abdominal wall, which is how this was held in place, uh, you'll find sometimes you'll get a little bit of, um, almost a membrane that forms around the cervix and so you'll see in a moment we're gonna excise that, and so that's that membrane I talked about, we're gonna excise that. And so as you're doing this, you just wanna be careful, take your time, identify your normal anatomy and so once the uterus is completely released we're then gonna now mobilize it back down into the pelvis and again you might have to release some adhesions to get that like any anathemosis that we do bowel ostomosis, whatnot, you wanna make sure that it's under no tension and the blood supply has not been compromised so the uterus has now been moved back into the pelvis you see here. Right? Nice pink, healthy uterus. We're not gonna come in with a sponges stick again in the vagina. We're gonna make our incision there, what we call our culpotomy to now open our vagina so we can again introduce now the cervix back into its normal position. And so you wanna make this wide enough you can get a snug fit, but you wanna be sure to bring the cervix into the vagina when it heals, uh, it looks like a normal cervix and also they can continue to have their routine cervical cancer screening. And so that's my assistant who's gonna gently grab and we're gonna make a snug fit here of the cervix around the vagina. We then use that same barb suture to bring the vagina back to the cervix. I just wanna bring a little bit higher up, so again that cervix sticks snugly within the vagina. And you wanna be careful to avoid those lateral areas. So as we saw in the previous video, that's where the rement of the uterine artery runs, and that's the blood supply to that cervix. We wanna make sure that we maintain that. So most of my suture is gonna be anteriorly and posteriorly with care to avoid the lateral areas, make sure we don't damage any of that blood supply. These are all techniques we've used in the past. I mean, this is what we, similar to what we do in a radical tracheolectomy when we reattach the uterus. Similar techniques, uh, just thinking outside the box and giving the, the patients this opportunity to get pregnant spontaneously. Uh, this surgery is done at the same time as patients usually, so when they're done with the radiation and at the same time they're getting the surgery that they need for their other cancers. In my case my patient had anal cancer, so following radiation and chemotherapy, we went back and I did this part where I reattached the uterus and the colorectal uh surgeon using the same robotic, uh, platform, the same incisions that we had. Uh, did the surgery removing the colon, uh, where the cancer was, so the patient undergoes one surgery to achieve both goals. Yeah. And so if you work away here around the vagina, we're gonna again just carefully suture that vagina into place. You can see now it looks like a normal healthy uterus. When again use that ICG green, you can see the green coming from the lateral components, that's where it's going through the IP. A nice green, beautiful uterus telling us that to this point we have good perfusion and so at least at the completion of the procedure, we had a successful uh reastomosis of that. Uh, and again, you look at this and you think, why did I think of this before? Yeah. Uh, so it was great. So, uh, these are some pictures of my patient, uh, that's Doctor Mara La Teo from Masloan Kettering. He's my friend and mentor, and again, our Sloan Ketter Alliance, I think helped to, uh, motivate us, uh, to presume with this. Uh, that's a picture of my patient when she completed her treatment and her surgery to ringing the bell with our whole team, including our radiation oncology team, uh, Doctor Yoni Weiss, who's a fantastic oncologist, and you really need a multi-disciplinary team when you're gonna do these kinds of things. It needs to be done at a specialized center, and she, she was grateful. Uh, and that's us at a Panthers game for hockey fights Cancer night, um, and she's really been a huge advocate of, uh, sharing her story, uh, and we talk about cancer survivors, and we don't, we don't like that term. We say cancer thrivers, right? And we don't wanna survive, we wanna thrive. We're given the opportunity to thrive to maintain her fertility, uh. When she reached out to me once, uh, menstruation, uh, happened, she sent me a text message. I think I don't know if I was happier than she was when I got that text message, um, but our patients really become like our families. We probably text every other day, uh, and it's just a wonderful story an inspiration that she shares with other young cancer patients again these are things that, you know, women in their 20s or 30s shouldn't be facing a cancer diagnosis. Much less now the decision of fertility and family planning. These are things that they're in the middle of their busy day, and we're thrusting these very important decisions upon them and so, and so she's been great to advocate for other young patients and I'm grateful for her. So that's Fong, what are some of the take home messages from today? Take a message from today is listen to what patient wants, uh, focus on treating cancer but also focus on preserving fertility when possible. We have techniques, we have the expertise at the Baptist, we have uh. The thinking and the the the technical ability to deliver fertility preserving surgery specifically uterine transposition has appeared to be safe, feasible with good oncological outcomes, good fertility outcomes for selected patients, uh, and then we're gonna continue to push the envelope and like you said, you know, we, we, my patient and her family were extremely grateful we were able to offer that. And um I think we need to continue providing this to our patients and just force the point that we don't have to settle for just cancer outcomes we need to focus on on bigger issues as well, absolutely. And so we, if we have time we're getting some questions uh through the text message. So Doctor Zafan, one of the questions we got are what are preoperative patient characteristics that would make someone a candidate for you in transposition? Well, it depends a little bit on what cancer we're talking about. Uh, so the cancers that uh would be amenable for uterine transposition would be anal cancer, would be vaginal cancers such as yours, vular cancer. Maybe down the line, even certain cervical cancers that are small that we could do a tracheolectomy on and then move the uterus out of the way. Um, so, any cancer that's in the pelvis that will that will be cured with radiation. Is a cancer that we can offer uterine transposition on. Obviously the patient has to be young and uh fertile and desire fertility, and there's some uterine characteristics too, right? You saw my video that was a uterus, right? So sometimes women may have some things that make that more challenging. So traditionally we've asked for small uteruses that don't have a lot of fibroids. It's really not an absolute contraindication could potentially do about making the time, but also the uterus has to. Be amenable to this. That's correct because I mean if it's a very big uterus, no matter how, how you move it, it will still be within the radiation field to a certain extent and I think excited that we were the first to perform this procedure for vaginal cancer. To your point, most of it's described have been for rectal, uh, anal colorectal cancers, a few cervical cancer in Brazil, it's a little bit more outside the box, uh, so we're the first to do it for vaginal cancer. I think that that's a great tip to us. So another question that comes in is, will IVF, so in vitro fertilization, be needed after this? And so, you know, you touched upon this. Uh, one of the important things again when you're doing this is you need a multidisciplinary team. So all of my patients were considering fertility preservation, be it trachollectomy, be it endometrial cancer, hormone therapy, all of them I involve. A fertility expert because you know we need their input, not that they would necessarily need fertility assistance, but it's part of that multidisciplinary team. We wanna make sure that we have everyone involved, the patients are doing something a little bit unusual, make sure that all the counseling information they can to make decisions so you don't necessarily require IVF to get pregnant, to your point, many of the initial. Uh, pregnancies were spontaneous, the 3 pregnancies that were, uh, reported and the 3 deliveries that were reported were all spontaneous, no IVF. If I agree with you, I involved, um, a reproductive endocrinologist in the care of my patients. We did, uh, egg retrieval before the surgery just in case. She didn't end up hopefully she won't end up needing any of that, but it's essential to have a multidisciplinary approach. The other question that came in was how do we collaborate with the oncologists and as we said before, you know, all of these cases are discussed at our multi-disciplinary team of which are G oncologists, obviously us and our colleagues are part of, but also our R on college. They played an instrumental role in this in mapping out the operation field. So we do where we gotta go and to see, you know, if this is feasible. And so they're an integral part of our team. They're part of our division, uh, and we're very fortunate to work some very talented region oncologist, but yeah, this needs to be done in a multi- setting with a very specialized center that has the expertise. Uh, the courage, and now the experience to do these kinds of things one other way to help our colleagues from radiation oncology, we, we know where the radiation fields are, but we also help them by delineating where the where we end up transposing the organs, so. By placing clips that they can see when they do their scans so we can clip the ovaries so they can know where the ovaries are and better uh administer the radiation to try and minimize that radiation so it's a it's a we both have to kind of help each other understand a little bit because it's an unusual scenario. Absolutely. So one of the question, what are some of the surgical risks or complications that are unique to this transposition and what about the learning curve for the surgeons? The in the reported cases, like, as I said, less than 20 cases, there wasn't any real complications with the transposition or with the reposition. There were failed cases, so there were two cases where the uterus did not survive, whether that was a surgical technique that was inadequate, whether that was the uterus was exposed to the radiation during the radiation, um, course, it is a little bit unclear. And in terms of oncologic outcomes, we wanna make sure that this is safe. So out of these 20 patients that where the surgery was done, there was only one patient that had a recurrence. Those numbers are, are very encouraging. So in terms of surgery complications, um, there's not really different complication if it's done properly. That leads me to the next part here. Uh, there's a learning curve in everything we do, but as I mentioned earlier, going into that surgery, um, and I'm sure you were the same. I was pretty comfortable with the surgery and with the technique knowing that we've done it in radical tracheolectomies. We know the uterus can get perfused and we do hysterectomies, uh, very commonly, and it's all the same steps. So there is a learning curve, uh, but within limits we know that the surgery is safe and so far in the 20 cases reported no bad surgical outcomes. Yeah, I think you need to counsel your patients, right, and be honest, listen, this is a new technique, but to your point, the steps aren't hard and so I've had several colleagues around the country reach out to me. To ask me about the procedure, and the first thing I tell them, you know, these are well trained G1 oncologists is the steps aren't hard. It's just thinking outside the box, that's a challenging part, um. So one question we get is does this procedure in any way compromise libidos sexual intercourse or the sex rate of conception? So remember libido, uh, is really related more to hormone and so the idea again is we're preserving the ovaries, the blood supply, and so we're not compromising hormones, so it shouldn't have a negative effect again we have a small series. sexual intercourse is an interesting one and when you look at the data from trachelectomies, um, and. Cancer in general GYA cancer generals, there's a huge amount of anxiety, uh, following a cancer diagnosis and sexual activity, uh, and in those patients that we successfully perform treatment for GN cancers, there's a lot of anxiety that comes with intercourse and so not unique to this particular procedure, but we know that happens with our patients and so we have a very, uh, healthy sexual health clinic, uh, for which we can refer these patients, but it's not uncommon after a GAN cancer diagnosis. For women to have anxiety with sex, and so that's not an uncommon thing and not so unique to this procedure. That's correct. And, and that's even without surgery, a lot of these patients uh will have some sexual uh. Changes unrelated to surgery but related to the cancer diagnosis itself, the chemotherapy, uh, the, the stress it causes to their life on a daily basis, to their relationship with their with their spouse, so not related to the surgery itself, but definitely like you said, we refer a lot of these patients to the sexual health clinic, yeah. What are the implications of early findings like preserving menstruation, hormone function post treatment for overall endocrine health? So again, I, I think that's a soft marker for us, right? The fact that menstruation has returned that tells again that the entire axis is working. Um, if something should happen where that's not occurring, you have to look to see is this something mechanical scar tissue from the surgery, is this something from, uh, an ovarian standpoint, or is this something higher up pituitary, some of the axis, so you have to work through those things, uh, as they come along, but certainly the fact that your patient has resumed menstruation and so is mine is an encouraging fact that yes things are working, uh, and now we have to wait to see, you know, when they attempt pregnancy, uh, what that success will be correct. So our last question is, are there any clinical trials we'll be exploring how these new surgical procedures occur, uh, Doctor Zafan? Uh, there's no clinical trials about uterine transposition at this point, uh, and it's hard, you know, clinical trials require a large number of patients and, uh, as you, as you just heard, this is, uh, a pretty rare procedure for two reasons one. It requires a very young patient that is uh still interested in fertility to have cancer, but also uh requires this patient to be close to a center such as ours that can provide this procedure. So to go ahead and uh build a trial and collect all these patients will take a long time. So I think we need to extrapolate on the safety from this procedures from, from other things we've done in the past like the tracheectomies, like the ovarian transposition. As well as built on the experience of others, we, you know, we're encouraged to do this because it was done in Brazil and there's 8 cases reported because Memorial Stone Kettering pioneered it in the United States and there's 8 cases reported and because the recurrence rate was not high was similar to what it would be without these procedures so I don't think clinical trials with large numbers are. Anytime anywhere close, I'm not sure what you think about that. Yeah, I think unlikely, as you know, uh, we have a robust clinical trials portfolio and we currently have two surgical trials open, but they're difficult to do. And to your point, in GN cancers we saw the numbers at the start of the presentation. Uh, while it's what we do every day, we also have to remember there are only about 100,000 GN cancers a year in the entire state. So a clinical trial for such a unique situation, I think is unlikely. And so to your point, I think we have to rely on expertise, uh, and that's where we're gonna develop this. So Doctor Fan, I wanna thank you for joining us today and sharing your expertise, uh, really an amazing talk. I wanna thank all of you that joined us, uh, from home, uh, for this, you know, we're really proud of the work that we're doing here at Bath's Health Cancer Care. Uh, we continue to innovate. Uh, we continue to be the leaders, uh, in South Florida, and we're grateful for you to spending the afternoon with us to learn a little bit about a very unique technique, uh, but they may have a significant impact on patients' lives in the future. So thank you and have a wonderful rest of your Friday.
