Chapters Transcript Video Uterine Transposition Welcome to the Baptist Health Doc to Doc podcast. A conversation for physicians by physicians providing insight on the latest in medical practice, research, technology and innovation in health care on the Doc to Doc podcast. Certain cancers though treatable have required women to forego their dreams of having Children. Naturally. The radiation treatment for the pelvis which can save their lives can also damage tissue of the uterus and make it difficult to bear Children. But now there's surgical technique called uterine transposition. This surgery allows women who have been diagnosed with cancers in the pelvis and will require radiation treatment to preserve their ability to have their own biological Children. Recently, Baptist Health Mamie Cancer Institute was the first cancer center in the southeast region to conduct a successful uterine transmission surgery on a rectal cancer patient. Hello, I'm Doctor John Diaz, chief of Gynecological oncology at Baptist Health Mammy Cancer Institute. And joining today is my friend and partner, Doctor Jean Marie Stan, a board certified Gynecological oncologist at Baptist Health Mammy Cancer Institute. So, Jean Marie, what is uterine transposition? What's this new procedure that we've developed uterine transposition is a procedure where we're able to detach the uterus from its attachment to the vagina. And it's anatomical location in the pelvis, lift it up to the upper abdomen where we will reattach it to the abdominal wall. Therefore, lifting it outside the radiation field, allowing the patient who's gonna require radiation to the pelvis to receive radiation without the uterus and the ovaries being exposed to that radiation. And it's amazing. This reminds me a lot of what we've seen The evolution in surgical oncology. We started very radical surgery for breast cancer. We did these huge resections and massive lymph node resections and they had good oncologic outcomes. But the impact on women was devastating and it was the patient that kind of forced us to find surgeries that would have the same oncologic outcomes but be less morbid. And we saw this 15 years ago with radical troms, we were able to remove the cervical cancer, but we could preserve the fertility. And once again, we're being challenged by patients to kind of find a better way to treat them. So who would be a good candidate for this procedure? Just to your point? Quickly, I I agree 100% with, with what you said. I think at some level as surgical oncologist, we first focus on cancer care and cancer outcome and we wanna cure patients and we kind of forget or put as a second goal, the quality of life, post cancer, especially for our patients are mostly uh women and a lot of them are young women. So we have moved on from just focusing on cancer care. And like you said, our patients have challenged us to think about life after cancer and how we can allow them to have good quality of life specifically when it pertains to uterine transposition, allowing them to have a family and basically biological Children. So, um what was your question again? So I was saying, who's a good candidate, who's a good candidate for uterine transposition? Right? So any any young woman who has cancer in the Pelvis and that could include cervical cancer, uh uh vaginal cancer, rectal cancer. Uh The patient that was uh the first patient that we did this procedure on at the Miami Cancer Institute was a rectal cancer patient. So young woman with cancer in the Pelvis, who's uh who's part of her treatment is gonna be radiation therapy to the palace. So it's essentially this procedure was first described in 2017 by a Brazilian surgical oncologist, but it really hasn't caught on. Um I went to New York to go observe the procedure in one of our patients. We came back and sure after that, you performed the first procedure and we have a video of what the procedure is like if you wanna talk us through kind of some of the steps in doing this. I was a little bit surprised. It's not too different than what we do every day. For a hysterectomy. Right. I, I think, you know, when I performed this procedure a few, a few months ago, the first thing that came to my mind following the procedure is why have I not done this so many times before I was? Because how simple it was. Exactly. Technically, it is not very challenging. Like you said, you can see on the video, basically, the 80% of the first steps are exactly the same steps as a hysterectomy. Uh some minor differences are in a hysterectomy. You, well, major differences I would say are preservation of blood supply to the uterus because we want this uterus to be and the ovaries to be viable. So short of preserving the blood supply to the uterus, the steps are exactly the same up until the level of uh what we call the corpo of you, which is detaching the cervix from the vagina. And that, uh that is the first, you know, about 80% of what we do in a, in a regular hysterectomy and a simple hysterectomy. Now, the difference becomes lifting the uterus and the ovaries to the upper abdomen and then attaching them to the abdominal wall in an anatomical way that preserves that blood supply from being tors and maintains viability to the tissue. Uh When I was performing the procedure, I found that to be the most technically difficult part of the procedure. Um I see that you've, um, you know, in your video you've used IC G green, which I found to be very helpful to allow me to know that this uh uterus was viable. Is that something you saw as well? Yeah. You know, we first uh started doing these fertility spray and radical trom is about 15 years ago and there was a concern if you're taking or sacrificing your arteries, is this uterus or preserving, still gonna be viable? And so we had done some initial evaluation using green about 15 years ago. And I think we've become more comfortable now using that technique when we do our bowel resections to kind of confirm we have good healthy flow. And so that's something that we did here uh with this first patient where we give the IC G green and make sure that we see good flow. Um We're still learning, right? So I get an ultrasound after this procedure just to document flow a few weeks later. Uh I sent my patient home with Lovenox, uh anything to just try and prevent clots. I don't know if we need to do this or not. Um But it seems reasonable to really preserve that blood supply. Um In my case for my patient, we had started her on Depo Lupron a medication that we give as you know, to kind of shut down the ovaries so that they're not menstruating. I kept the cervix within the uterus. I know you brought the cervix up throughout the umbilicus. So when they menstruate, uh we wouldn't have spillage to abdominal cavity. But I think IC G is a great another technique for us to just confirm what we're seeing anatomically that yes, the IP ligaments are patent and we're having good flow. Yeah, absolutely. Like you said, we're still learning uh as I was preparing for that case, um there's not a lot to look at, there's not a lot that's described in the literature. So it was, it was a question to me as well. But what do I do? Is it better to leave the uterus and the cervix intraabdominally and then shut down the ovaries with Lupron or uh bring out the cervix via the umbilicus like a, like a colostomy. So I decided to do it that way and actually placed a co a colostomy bag on my patient. She menstruated the first, um, you know, within the first month after the surgery and then she started on chemotherapy which automatically shut down her menstruation, she's done with chemotherapy and is in the process of getting radiation to the pelvis and then her ovaries kicked back in and she had another period through her umbilicus. So I think that's a viable option. What you did is also a viable option. But over time, the more we do these, the more we have, we offer these to our patients, I think we learn what works, what doesn't and what we're doing that is not entirely necessary, similar to maybe, uh, Lovenox. So it's my patient, you know, understandably nervous, a young woman with, uh, cancer had this really unique surgery. First time we've done this, uh, I went to the, er, at one point or Sam from abdominal discomfort and I got a call from the, er, physician that she has a mass in her abdomen. I said that's her uterus actually moved it up there. Um, so I had some interval imaging between taking her back. Um We just took her back a few weeks ago and we have the video from the uh reanastomosis of the uterus back into the pelvis. And so, you know, as you would expect, we had some scar tissue, um you can see here just kind of releasing that you kind of have to re orientate yourself when you get in there and remember that you've kind of ligaments up to the abdomen at first you're looking um Also, there's like a pseudo membrane that forms over the cervix as you're taking this down. Uh So you'll see a little bit, we kind of uh release that pseudomembrane, but essentially, it's just releasing the adhesions that you put there on purpose to tag the uterus up, then bringing the uterus back down into the pelvis and then doing a re anastomosis to the vagina, kind of like we do with our trachelectomy. So, again, these are techniques that we're very comfortable doing. And as you said earlier, after you do it, why didn't I think of this before? But I think it's a great um opportunity to offer this to our patients. Um in the US. Maura and Kin has the largest series of patients and they've only done seven of these in about three years. So it's really a select group of women who can benefit from this. Um But certainly it's something we can offer our patients. We've now done two just in the last three months uh between you and I, and so I think we're well on our way to offer this to our patients here in South Florida, collaborating with our colorectal team. Most of these patients are rectal cancer patients. In fact, in Sloan Kettering's group, uh six of the seven were rectal cancers. The last one, it was my vaginal cancer patient. So, um so as you can see here, we kind of bring the cervix now back into the vagina. And I'm very curious as to why you sutured the cervix about a centimeter or so in the vagina rather than end to end. And so with our troms as you've done these before, and it's more of an end to end, we sometimes get that stenosis and it can become a little bit difficult. And it's not uncommon with our trachy patients, we have to go back and kind of dilate that cervix. So I want to leave a little bit of a lip of the cervix, kind of the natural way where the cervix protrudes into the vagina and hopefully limit any kind of cervical stenosis. And we just saw her uh in the office actually, this week, the cervix looks great. Plenty of accommodation there in the vagina looked like she had like a normal cervix like three weeks post op. So, you know, care here, obviously, you're gonna start anteriorly, you want to avoid the lateral components, which is where you have the remnant of that. You dont art. That's the blood supply that um So once we finished the top, we then went to the backside and completed a there, uh Yeah, using a barbed suture uh just to kind of make the procedure a little bit faster enough to tie these knots. Um But again, pretty straightforward, like you said, when you're done, done about thought about this before the, the techniques are we've all used in different surgeries in different circumstances. But uh I think thinking about this, it's a little bit out of out of the box. I mean, even though we've, we've had those techniques mastered when I scheduled that first case, um I had to kind of sit and put them all together into one surgery, right? And then, and then imagine the procedure before you go into it. Oh, I see. Green, green, which demonstrates the flow of the uterus. The uterus is nice and green. Um Yeah, it's a beautiful picture. And again, we saw her now, three weeks later and she's doing fantastic. Yeah. So patients are gonna, I'm sorry, go ahead. I was saying who's not a candidate for this because now we're, you know, starting to publicize this. Uh I said our colleagues in colorectal are understanding this is a possibility for many of their patients. So in your mind, who's someone that maybe is not an ideal candidate for this? Well, similar to IVF, I would in vitro fertilization, you have patients that are candidate patients who are not candidate. We have to be a little bit realistic when it comes to cancer, preserving surgeries, similar to tracheotomies. Uh Classically, we've offered these to patients who are of good reproductive age with good ovarian reserve. 40 is the cut off that we use in cervical cancer. So I would venture to say that is sort of a cut off. I mean, it's not an absolute contraindication, but we're doing this to preserve fertility in somebody that wants to get pregnant naturally. So if you're starting off with low chances of getting pregnant naturally, maybe going through the procedure is not for you. Uh Anybody who has uterine cancer obviously is not a candidate. And uh short of that, I think all our young patients who want to have families. I think it's amazing that we can now offer this procedure to them. Even my patient, you mentioned yours. My patient is a 29 year old uh who also had the, you know, has had never heard of this procedure was the first one to get it uh in Miami or in Florida for that matter. Uh And every time I see her, she's so grateful that we were able to offer her that procedure, her, her family, her sister, her mother, and then imagine how, how much we're gonna be able to help patients who are in a similar situation. And the other thing I think about is, you know, what are those challenges we sometimes get into the pelvis. You know, uh today, I did a patient who had a huge fibroid uterus. So I think that might be a relative complication. You have to be able to move this uterus and now suspend it up to the abdomen. The last thing you want us to go through all this and have those sutures fail. So I think anything with a large uterine size may pose a problem as we're selecting patients. I might, I might have endometriosis may be a little bit of a challenge. I mean, for sure. And I agree, I mean, if you, if the pelvis is frozen, it's going to be hard. But I think I think these patients who we do this procedure on are gonna require c sections going forward in their deliveries. Uh So I don't foresee, you know, not so distant future us doing, for example, a myomectomy prior to this procedure doing a myomectomy closing the uterus, then proceeding with the with the rest of the transposition. Um, I don't know that that is very much far fetched. What do you think? Yeah, I don't disagree with you. You know, as we start to see who these patients are that are candidates you alluded to this earlier, I think it's important and we've done this with our fertility patients to go troms or some sort of um hormone treatment for endometrial cancer. You know, to get our colleagues in reproductive endocrinology and fertility involved early in the process. You know, I think it's important to partner with them and we're fortunate that the mai can just to have a robust group of re I that we work with. But it really is a multidisciplinary approach. This is not just the surgery, this is co ordination with their colorectal surgeons because they're gonna need a colorectal section. In the future of these are rectal cancer patients, they're medical oncologists um and are reproductive endocrinologists. And so really, it's a multi disc team. I think that has to be involved with these patient care. Yeah, I agree. That takes me back to something you mentioned earlier when we started, you said, you know, this was done first in 2017 and it hasn't caught up. And I think, I think we have to take responsibility a little bit in that where we have to promote this a little bit more to our colleagues who see these patients, the colorectal surgeon that I worked with on my patient as well as the medical oncologist had never heard of that procedure before. Did not know it was an option. And I think the more we talk about it, the more we educate ourselves, educate the patients, educate, you know, the other specialties, we will find that these patients are actually there, but they're not, they've not been offered the procedure and not necessarily with our, our institute, even patients from outside Miami Cancer Institute will not know that will now know that we do this procedure and we'll seek it. But we just have to make sure that people are aware and other doctors are aware as well that we can offer this now. Well, that's what we're doing today, right? We're educating our colleagues. Um Many obgyns have no idea. I know that many have reached out to you after they saw your video. Um I think it's a great thing that we're being able to offer this, you know, and it's kind of for me living through this. The second time we went and saw this 15 years ago with the trachy. Uh Everyone thought it was crazy. What are you doing? Leaving behind the uterus and someone has cervical cancer. Um And now we didn't even think twice about it. It makes so much sense and so kind of like this technique. So the first time I saw it, I said this isn't that hard, you know, I can do this. I would say though that like you, I took post up MRI S to MRI S and looking at those images. It is, it is kind of a crazy idea, but then it works and it offers these patients a new chance of life and having a family and it's amazing. And so how are you judging success um for your patients. So obviously, the first success is, hey, the surgery is done well. She's obviously going through her treatment. Now. Um What are you looking for as you move forward again, for success in your patient? Ultimately, we're doing this surgery for a very clear reason, right? These patients want to have a family and biological Children. So to me, obviously, you want a successful surgery and all complications, healthy patient. But to me, success will translate into a live birth. And granted there's a lot of factors that play into that. But I think just like any other fertility preserving surgery, success should be judged based on the ability to have kids and actually have kids and deliver them. Yeah, absolutely. Actually, I was with Mario um when the first live baby from Sloan Ket was born and he got the text from the patient. Uh We actually at SGO we said text and, and that's ultimately right. I mean, success is measured as we go through the first stage of the surgery, the second procedure is successful, they've completed their cancer treatment, they start menstruating again. That's a big step that things are moving in the right direction. Um But yeah, I agree with you that when you get that picture messages or notifications that my patients who I did a trom on have delivered. I mean, this is when you say, OK, you know what this was all worth it. Yeah, absolutely. So where do we go from here with our program? How do we continue to expand, how do we get the message out there, get more patients to benefit from the skill set that we bring education, education, education. Um I mean, just between you and I now, so it's two out of uh our five partners. Next. So we, we're the, the entire organization knows that we do this. Now, this has within Baptist, this was pretty big, right? I mean, I, I, like you said, I've had colleagues from Ojos who've reached out medical oncologist, colorectal. So within Baptist, I think we've done a good job of uh putting that out there saying, hey, we have this new option. Next step is doing what we're doing today, relaying that to other physicians even outside our uh institution and saying this is an option for these young women and do not ignore it. This is something we can do that we have done already. We've done it twice, both of hopefully, uh so far successful, there's a proven track record and I think that, you know, we have to build on that. I'm not sure if there's any, you know, short of uh educating and you know, promoting awareness, there's something more that we can do. What do you think? I think we're doing it and exactly what you said, you know, speaking to those patients are gonna see these patients. So most of these patients are gonna be those younger women with rectal colon cancer. So, you know, I had a vaginal cancer patient. There's some gon cancer patients that might benefit from. But I think the, you look at the data, the majority of the women in these series are these rectal cancer colon cancer patients. So we need to get out there and discuss this with our colorectal surgeons, our G I medical oncologist, make sure they understand that in select women, this may be an option for them. Uh And this is a huge option in that prior to this, we maybe transposed the ovaries. Um so they could preserve ovarian function and maybe even they could preserve their own eggs and have a genetic child. Uh But now this is the ability for them to have, you know, their own child naturally and within their uterus. So I agree with you educating and let them know and you know, work and develop our program here. Important to mention that when we were doing tracheotomies for cervical cancer, we were worried about oncological outcomes a little bit. Uh Are we affecting the oncological outcome in these situations right? Now, when we're operating for rectal cancer. For example, we're not interfering with oncological outcomes at all. We're just basically moving something out of the way, allowing complete cancer care and just putting it back where it belongs. So I think patients and providers should feel very comfortable referring their patients for us to be able to do this procedure. Yeah, I would agree. So the goal of this surgical innovation is to provide women light in their cancer tunnel, Right? Uterine transition has emerged an active tool for tid preservation in women with pelvic malignancies that require ration therapy. And in the past few years, there's been an increase in young women being diagnosed with colorectal and galic cancer. So the advent decent techniques is allowing them to now pursue their starting of a family or continue their family after successful completion of their cancer treatments. So doctors f thanks for joining me today and Doctor Doc. It was a pleasure. Thank you John and thank you for having us to find out more about the topics covered on the Dock to Doc podcast. Please visit physician resources dot Baptist health.net. Created by
