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Uterine Cancer: Recent Surgical Advances

Nov 23 | 2:30 PM

Gynecological cancers are among the most frequent cancers in women, and as a result, they constitute a major public health concern. In underdeveloped nations such as India, most women report at advanced stages due to a lack of cancer awareness, varied histology, and a lack of effective screening facilities, negatively influencing prognosis and clinical outcomes. Robotic surgery has become the go-to treatment for endometrial cancer because of advancements in minimally invasive surgery. Join us as Dr. Rohit Ranade discusses uterine cancer surgical therapy, including the use of robotic surgery.

[Music] good evening everyone this is dr rishali from netflix and i welcome you for yet another amazing session today we have with us dr rohit ranade he is a gynac oncologist with an experience of over more than 12 years he is only the second indian to be awarded the mch in ghani oncology his area of expertise includes robotics in gynecological malignancies aggressive cytoreductive surgeries and advanced laparoscopy so doctor with ranades over to you we can start now okay good evening to everyone and thank you brushali for the kind invite and the entire team of netflix for supporting this and managing to happen so the topic of discussion today is recent advances in the treatment of uterine cancers in essentially uh why you must ask the question why you trying cancer now we all know that uh cervical cancer uh is the second most common malignancy in india uh in the in the in india but in the rural india it is the commonest cancer so but what we are seeing that the trend which is there is the you the incidence of endometrial cancer is increasing um as the time progresses and it is the commonest malignancy in the western world but as you know the trend is what was where what was in west about 20 25 30 years comes to india now so that's why we are seeing more and more increase in the incidence of endometrial cancer or uterine cancer in the indian continent as well now yeah if you ask me the statistics roughly it's around 14 000 new cases in uh 2018 as per the global can statistics it has increased to about 16 000 in the 2020 uh statistics now globocan is the organization attached to the who which gives the cancer statistics every two years now uh most of the cases of endometrial cancer are associated with obesity diabetes and hypertension and as we know that all three of them are on an increase in our country as well as in the indian subcontinent so hence uh this is uh so we are seeing more and more increase in the endometrial cancer also usually there are type 1 and type 2 cancers there are two types primarily if you look at it they are essentially somebody cancers which are good prognosis that is the fire survival is quite great especially in stage 1 cancers so that's why it's important that we know the management of such cancers is done correctly now now if for every cancer before we decide the management we should know what is the what is the imaging modality of choice should we do an ultrasound should we do a ct scan or should we do an mri or should we do a pet scan so is there some guideline for this now previously there was no guideline for this but now there's a clear-cut guideline that mri should be the imaging modality of choice for these patients mri has got an excellent soft tissue imaging quality the depth of myometrial invasion is accuracy is about 75 to 80 percent the the prediction of cervical stromal invasion is around 80 to 85 percent as far as the nodes are concerned it is about 60 now why this is important is because depending on the depth of myometrial invasion and all these other parameters we need to decide whether we need to do a lymph node dissection or not so previously in all cases we would do a lymph node dissection but now oncology is moving from one size fits all to a tailored form of treatment so it's like individualized and it's no longer one size fits all also in centers where frozen section is available there is definitely a role of frozen section for these patients so according to guidelines it is either you do an mri or if your center has a frozen section you can utilize that for planning the management of these patients this is just the diagram or some of the radiological pictures you can see there is a tumor inside i'm sorry i don't have a pointer but you can see that in the sagittal section you can see a tumor inside there is hardly any myometrial invasion which can be seen or at the max it is less than 50 so as an imaging modality mr is excellent as as compared to ct scan or a pet scan now is there any evidence for this this was one paper which i was fortunate enough to write and publish in the annals of oncology so this was a part of my thesis during my mch in tata memorial center so we looked at whether pre-operative mri or intraoperative frozen section was better in the surgical management of early stage endometrial cancer so this was what was a result so as a single modality so as a single modality uh the sensitivity though of both mri and frozen section is better but as a single modality frozen section is much more specific as compared to the mri also the accuracy of the frozen section was much better than the mri as the false negative rate was much less in the frozen section also the false positivity rate was much less so as a single investigation if you just have the luxury of doing only one investigation and frozen section is available then you should go in for frozen section but then the negative predictive value of both was also quite good so you can even in centers where frozen is not available you can go for an mri also now so what has changed in the management now if you look at the standard of care for early stage endometrial cancer it is doing a hysterectomy with a sulfingophorectomy with a lymphadenectomy with or without peritoneal cytology so this is what we used to do uh when when we were all doing open surgeries but we look at whether minimal access surgery can be can be used for these patients now in today's oncology you cannot offer a treatment because you like it or because you feel that it is good anything that you offer in today's world has to be supplemented by evidence and evidence is always in the form of either a phase three randomized controlled trials or meta-analysis now if you ask me this is one of the cancers where there is significant evidence to offer minimal access surgery that is either a laparoscopic surgery or a robotic surgery for these sorts these type of endometrial cancer patients with endometrial cancer there are as close to eight randomized control trials and two recent meta-analysis which have said that minimal access surgery is as equal to open surgery for these patients now why do we want to do minimal access surgery that is either laparoscopy or robotic surgery for these patients now we estimate that because of minimal access there will be less blood loss there will be better post-operative pain scores now if you ask me as a surgeon what is the one single thing which makes a difference between a laparoscopy or a robotic surgery versus an open surgery it is the pain the post operative patient is much more comfortable with the mis as compared to the open surgery now there is always an earlier return of bowel function there is reduced or equivalent operating times so initially when you are in your learning curve your operating times are going to be longer but when you as as as you pass your learning curve things are going to be better and your team gets used to it you are going to have as equivalent operating times as that of open source now all of these means that your patient is going to stay less in the hospital and going to be discharged early so they can go back and resume their normal activities and because the blood loss is less also there is reduction in the blood transfusion rates now so if all these advantages are there in laparoscopy why what is the added advantage of robotics over lapros copy now if you ask me one single advantage it is better instrumental or ergonomics or seven degrees of freedom known as endobrist technology now for those who are little familiar with the laparoscopy when you are doing laparoscopy the instrument moves either anteriorly posteriorly or sideways so it is only four degrees of freedom but robotic it is seven degrees of freedom it is as if you are putting your hand into the peritoneal cavity and the you can move it in whatever direction you want so the precision of the instruments is much better and so it the all of these things allows you to do complex surgeries more better also the robotic camera has a three-dimensional vision with a better magnification tremors are abolished in the robotic surgery there is abolition of the fulcrum effect of laparoscopy most important practical point and i think people who are com who are used to doing laparoscopy will agree with me the surgeon controls the camera and the three arms in a laparoscopy you need to depend on your way on your cameraman to show you properly he is like your eyes if if the cameraman doesn't show you properly you are not going to be able to see and perform the surgery that everything is totally abolished in robotic it is the camera is under your control um i will be showing you a video of robotic surgery so you will realize uh how the instrument and everything works now all of this means that there is a lesser learning curve and an easier transition from an open surgeon to a minimal access surgeon and obviously you can incorporate the firefly technology into that which is essential for sentinel node dissection i'll be talking about it a little later and can we have the video playing please yes sir welcome to the video showing the how the robotic system is so as you can see in the video this is the robotic arm so these are the arms which go into the patient this is the port placement so the port placement is a little different from what you have for a standard laparoscopic system so this process is called as docking where you fix the robot to the patient this is uh it's important that your team is aware of all of that and the surgeon you can see sits comfortably away from the patient this is the image which the operating team sees in the theater and you can see that the surgeon is moving he's sitting comfortably moving the master controllers and when the master controllers move the instruments move very very sophisticatedly inside the patient the cautery settings are in the control of the surgeon and the instruments move with very good excellent precision so you can see the this is the depicting both the video both the movements and the these are the master control surgeons sees a three-dimensional vision in the console but you also need a good assistant team for that yeah so this is just the picture of this you can see that this is the patient card which these are the arms which go into the patient there is a screen where the assistants can see and you can see these are the long instruments which go inside the patient's abdomen and will help you to do surgery this is again the same picture depicting the same so these are the arms which are docked into the patient remember the assistant teams is just a two-dimensional vision while the operating surgeon sees a three-dimensional vision in the console now so these are just some of the images of the patients these are taken with their permission so this was one lady from who traveled all the way from tanzania weighing more than 100 kgs for she was suffering from endometrial cancer we operated on her this is her on the fourth day this lady roamed all along bangalore did a lot of shopping on her fourth day after surgery and she is there she is seen on the fifth day in my opd ready to fly back to tanzania no amount of open surgery even by the best surgeon in the world can have such a dramatic recovery which robotic surgery or minimal access surgery can offer this is another lady weighing again more than 100 kgs he was around 126 kgs she initially she could not manage to fit on our operating table so we had to use a special bariatric table for her she's suffering from endometrial cancer this is her on the sixth day ready to fly back to tanzania to sudan and so the recovery especially in obese patients is obviously fantastic now so as there are some you can say advantages of the robot we should also know what are the drawbacks of robotics primarily it is still a very costly tool primarily because the patent is still owned by one company but there are a lot of other companies also coming up in the market and we hope that in the next three to four years there will be lot of systems coming in the market and then the cost will definitely come down uh initially you saw that there is a longer operating time because there is a process called as docking talking means that you connect the robot to the patient now initially when we started the docking time was around 30 minutes to 40 minutes but now with practice and when the whole all the team gets used to it it is down to about two and a half to three minutes now you have seen in the video that the space required in the ot is much larger as compared to a standard laparoscopic suit that is something which is a problem now another practical point which some of you will definitely appreciate is once you talk the patient that is you give head low and dock the patient you can't change the operating table even by 5 degrees now this can be a problem in patients where who have some respiratory compromise or especially in obese patients where you want to reduce the head low let the anesthetics take a better control and then again give hello this is a little you can say this is a little difficult especially in the standard systems but now the company is coming up with an integrated ot table where the table is integrated with the system where you can change the position of the ot table during surgery as well again you saw that the camera movements are a little slow so as of now it is feasible only for surgery in one quarter for example if you want to do something in the pelvis and then again do something in the upper abdomen robotic is not a good tool again in thinner individuals especially some women are really thin and especially with cervical cancer there are clashing of the ports especially in patients with lesser bmi that is because see the ports are all need to be kept in the straight line that is a that is a drawback of the system but in laparoscopy you could triangulate the pores so port clashing is not seen in the robotic system in the laparoscopic system but it is seen in especially in thin individuals with the robotic system this is just the diagram depicting the steep head low and then the difficulty in the changing the position once the patient is talked because you need to undock for that now i was talking about that there was lot of evidence for endometrial cancer now this is one of the largest randomized trials which was done for endometrial cancer so this looked at the gog lab2 study this looked at around 2600 women with early stage endometrial cancer and they were randomly assigned either to laparotomy or laparoscopy for surgery the surgery done what was a hysterectomy with a sulfingophorectomy with a pelvic and a periodic lymphadenectomy and a peritoneal cytology it looked mainly at end points where mortality morbidity hospital stay and conversion to laparotomy now in this trial there was a 26 percent conversion to la uh to laparotomy because mainly because of the higher bmi and difficulties with the lymphadenectomy now this if you if you use the robot this conversion goes down to less than two percent that is something that is the advantage of robotics over laparoscopy there was a operating time was longer in the laparoscopy arm but obviously the shorter there was shorter shorter hospital stay and obviously the adverse events were much less and the laparoscopy group so this trial said that the laparoscopic surgical staging for uterine cancer is feasible and in terms of short-term outcomes it is as equal to open surgery and there are definitely fewer complications and a shorter hospital stay for the laparoscopy calm this was another trial looking at improved surgical safety the latest trial this was done in australia and this uh said that with laparoscopy you can definitely reduce the mean length of the hospital state see it has dropped down from five days to two days and the blood loss is also less and the uh the adverse events were also less so so this was another paper which looked mainly at the utility of robotics in obese patients so all of the patients in this subgroup were more had bmi more than 35 more than 35 to 37 so in this the rate of lymphadenectomy and the mean number of nodes were similar in both the groups but the mean operating time was significantly longer in the robotic arm but the mean estimated blood loss the incidence of blood transfusion the length of hospital stay wound complications were significantly lower in the robotic group now we come to the second the newer advance in endometrial cancer which is a sentinel node now what is a sentinel node so the sentinel node is the first draining node now see as a rule for oncology whenever you need to do the resection of the primary tumor you also need to reset the draining lymphatics now doing a full lymph node dissection has some drawbacks one is it increases the surgical time there can be some associated complications associated with the lymph node dissection like injury to the vessel injury to the nerves and other things but more importantly there can also be some delayed side effects or a delayed uh adverse events like for example development of lymphedema development of lymphocyst or development of lymphoid now for all practical purposes we know that when one the limb once the lymphoedema appears it is very difficult to treat it and and there is no credible treatment that we offer the it is sometimes it is so unfortunate that the patient gets cured of cancer but she he or she succumbs to some complications related to the lymphoedema like uh like lymph like a development of infections and other things so then came the concept of sentinel node so the sentinel node is the first draining node from the target organ that is it is the first node where the cancer cells grow from the target organ and the hypothesis is that if you can target like if you can detect the sentinel node and excise the sentinel node and then send it for examination and if that is negative then the concept that the cancer cells have not progressed beyond the sentinel node so in that case if you do if you are able to find out the exact sentinel node and take it out then a full lymph node dissection can be avoided now in endometrial cancer it is either the observatory node or the internal electrode which is the most commonly detected sentinel node now it's very important that you need to do a combination of gamma probe plus a blue dye or the robotic system comes with a firefly with an icg dye so either of these two techniques you can use for sentinel node now it's important that when the sentinel node is when you are planning to do sentinel node and ultra staging is must so your pathologist should be able to do ultra staging normally when they take sections the sections are taken at 3 mm in ultra staging they are taken at 1 mm so your laboratory pathology laboratory should be equipped to do ultra staging if you are planning to start a sentinel node program so this is the dye so the dye is basically injected into the cervix and then this this is seen in the gamma camera you can see that the die has taken up so that is a node which has taken up you can excise the node send it for examination if that is negative then you don't need to do a full systematic lymph node dissection this is another sentinel node uh scene so this these are just the pictures of some sentinel node which are which are seen so most commonly is the internal or the obturator but it could be anything like x nylag or even sometimes it can be directly be a periodic node also so this is the excised sentinel node and then it is sent for examination you can see that you can see the entire lymphatic channel and this is the sentinel node which is seen which is which is an external act node so you can beautifully see the full uh uh lymphatic channel which is seen uh in this in this picture so this yeah this picture it is more clear you can see that the lymphatic channel entirely comes and then splits into two and then it goes into the external act node which is probably the sentinel node for this pressure now is there any evidence to offer sentinel node to patient so because as i told you anything that we offer in today's world has to be supplemented by evidence so there is a large randomized multi-centric prospective cohort study known as the fire study this study was mainly conducted at centers in uh in in u.s so in this the sentinel nodes uh identified with an icg dye using the robotic system have a high degree of diagnostic accuracy in detecting endometrial cancer metastasis and can safely replace lymphadenectomy in the in staging of endometrial cancer and the false negative rate is only three percent so it's important that once uh so you can offer sentinel node to these patients but it's very important that you validate all your own studies so everybody will not be able to do sentinel node from day one so you need to start doing some cases at least the recommended guideline is to do at least 25 cases where you can do the sentinel node also and do a full lymph node dissection also and check your accuracy rates before offering sentinel node to all patients that is something which is very very important now is there something different in the adjuvant therapy which we are offering to patients for endometrial cancer definitely previously we were offering these high risk patients high-risk endometrial cancer patients only radiation but now there is definite evidence to offer them combination of chemotherapy plus radiation versus radiation only there is a large multi-centric trial called as the portec 3 study which has definitely showed that there is a disease-free survival advantage for women when they are offered a combination of chemotherapy and radiotherapy versus radiotherapy only but again there is no overall survival benefit in data uh now there was there was a lot of concern especially this is important for younger women whether we should give them hormone replacement therapy post endometrial cancer treatment so initially there was lot of you can say reluctance to give because we thought that they are all estrogen sensitive tumors and so the chances of recurrence could increase but now there is a large double-blinded randomized control trial from mskcc which has says said that the hormone replacement therapy and endometrial cancer is safe and you especially in type 1 endometrial cancer and early stage that is stage 1 or stage 2 and it can definitely be offered to patients so i think i have tried to cover most of the recent advances in endometrial cancer at the end i just have a small video about 7 minutes of a robotic radical hysterectomy that will it will help you to appreciate how the camera movements occur and how the robotic instruments move uh and then i would be happy to take any questions so can we play the video please yes sir this is a video demonstrating the uh radical hysterectomy uh this is for a endometrial cancer with the involvement of the cervix so you can see that after the robot is docked so the first step is the dissection of the bladder now this was a lady who had the previous three scissoring sections uh that's why the bladder dissection was a little difficult but the but the magnification of the robotic system allows you to go very close and to do this dissection with great precision so this is uh so we always mobilize the sigmoid in all the cases and this is the uh spaces so there are uh parabola cycle and apparently there are total six vascular spaces in the female pelvis uh which we can utilize to our uh benefit actually god has been quite phenomenal and kind that he has given us six vascular spaces which we surgeons pelvic surgeons can use to our advantage so this is the ureter being dissected you can see the ureter which is held up with the force bipolar and so this is the monopolar which is detecting the ureter so the so radical hysterectomy you need to dissect out the ureter completely so this is the uterine artery being clamped at its origin so it's important that you clamp the uterine artery at its origin so as because you need to get a good margin for a radical hysterectomy uh this is again the same dissection which is continued and along with the uterine artery you also need to take a good amount of parametrium also so as to achieve a good clearance now in oncology it is important that you not only exercise the tumor but also as a rule you should exercise the margin also along with it because you need to account for the the i mean for the tumor spread as well so this is a round ligament being cut this is the standard part of all these spectomy but just that for when you're doing for cancer we tend to go a little more radical radical or lateral you can say this is the anterior paramaterial cut being taken so with the bladder being pushed uh away nicely and then you can see that when we are doing this the and you can see the ureter in the floor so this is the ureter which is there in the floor and then i am using the fenestrated bipolar to sort of uh develop a plane between the ureter and the parametrium because i need to take the anterior parametrium to my side so this is called as the tunnel of varadems so this is basically a very very vascular area and dissection of this is important it is particularly challenging in a laparoscopic surgery but the good control which is there with the robotic system better camera dynamics better vision and allows you a much better control of this area when doing it through the robotic system now there was this uh there was a node which was enlarged on the right side so as a as a policy we exercise the node first and send it for frozen section so accordingly it was done and then you can see that i have already developed the parabola cycle and the paragraph two spaces on the right side so the same exercise is continued on the right side where we dissect the ureter so it's important that when you're dissecting the ureter you need to leave a good amount of tissue with that ureter because the as you know the vascularity of the ureter travels along its own whole length so it's important to preserve that because you don't need because if you don't preserve the vascularity then there are good chances of delayed fistula occurring so you can see this is the internal artery you can see the uterine artery uh uterine vein in the floor uh so you sorry the internet like vein in the floor so that's it's important that you first demarcate the structures which you want to preserve at any cost and now once the uterine artery is clipped so that is what is clipped uh as close to the its origin of the internal vessels and then we take the entire tissue along with the uterine artery to the specimen side so that is why so in fact radical hysterectomy is a very skilled procedure where you have to save the ureter you have to save the rectum you have to save the bladder and at the same time take a good margin this is again the anterior parametric dissection or the eutectic tunnel dissection being done you can see that the ureter is right going into the tunnel and we need to open up the tunnel fully so as to take all the tissue to the specimen side so there are that side the margin is very very important this is more important when you are doing surgery for a cervical cancer because cervical cancer tends to spread more laterally as compared to anterior posteriorly so that is where the recurrences are very common and so as a surgically that is important so this is a complete ureter being detected uh because you need to take margins laterally now this is the uh posterior space being developed you can see that is the infundable pelvic vessels which are being uh coagulated uh there and then uh what you can do is you can extend the same cut down because you need to take a good amount of uterine ligaments also so that is like the ventral parameter so it's now not called utero sacral but it is dorsal lateral and ventral parametric so this is in fact this is a ventral parametrium which is uh it's important to take that then so that's so you can go very slowly with the robotic monopolar and buzz all of that this area especially the anterior pyramidal area is very challenging to do uh it is quite vascular and usually so that's why and they're mainly it is mainly venous bleeding so and because of neovascularization because of the cancer it is going to have lot of new vessels and unnamed vessels so you just need to be a little careful and be a slow in that so the same exercise being done on the right side where you are sort of cutting the uterus accruals uh and again as i told you that this area is here so as an alternative you can also do this using the ligature or you can also use thunderbeat or ncl or harmonic whatever you are comfortable with so this is the final uh this one being dissected further so that uh so as to get uh help us to get a good vaginal cuff because you need to get some vaginal cuff so as to get a good margin on this so this is the same thing so i am just again dissecting the ureter more further because you need to some margin to suture that as well so this is the complete call for me being completed with the monopolar itself and then the specimen is excised from the vagina so that is how it looks after you so then we start with the pelvic note dissection this clip has a very edited version of the pelvic nodes so uh because of the lack of time so it's the this is so you can see that with the robot i am able to go very close uh to the external act vessels uh as far as possible and that actually uh with the camera precision the vision is absolutely clear mind you this video is in a two-dimensional but as a surgeon what i see is a three-dimensional picture so you can see that it is the pubic rami you can see the white glistening bone and then below that is the tendon of the observatory internals and then you can see the operator nerve so which is our lateral which is our uh lower limit of this section so you take all the tissues of the obturator vein sorry operator nerve so that is what is important and then you can see the internal artery this is the observatory the same exercise is done on the right side where uh the same thing that you are detecting first you have to demarcate the vessel so it's always a vessel first approach uh so first you have to demarcate the external artery and take the nodes over it this will enable you to get a good clearance again that's the vein down there and see how your vascular control is excellent with the system so you can see that stability with which the cam which the with which the movements are occurring and the way by which you can tease out the tissues and uh get a good clearance and at the same time safety is also quite here because see all of this this area is quite vascular and it can have it can give rise to significant hemorrhage if you injure any vessel most of the times the bleeding is venous so uh that is what is it so this is how the specimens are being exercised delivered from the vagina and then the vaginal cuff is done by the standard method uh so we you normally use a three zero v lock switches but you can also use a white grid uh it's just that a v lock saves time because you don't have to put a knot so we tend to use vlog but it's all you can use white grill as well then the suture cutting is done and this is how the final picture looks like you can see both the ureters nicely dissected from the pelvic brim i thank you for a patient hearing that's the end of my presentation thank you thank you so much sir it was an amazing presentation the video was amazing uh we'll turn over to some of the questions now there's uh dr vishnu pratap singh is asking how can we give hormone therapy in endometrial cancer please elaborate okay so basically hormonal therapy is uh rarely used in early stage endometrial cancer there are two situations where you can use hormone hormone hormonal therapy one is uh it is used as a treatment of metastatic erpr positive endometrial cancer when they are not fit for standard chemotherapy so that is one role of giving uh hormone replacement uh i mean hormonal therapy so was this question about hormone replacement therapy or was it uh for hormone therapy hormone therapy yeah so hormone therapy is only given in metastatic recurrent setting so there is there is some evidence to suggest that it increases the disease free survival so the next question is by dr bharti how long after die injection should we view the uh the frozen section yeah uh yeah right so basically she wants to ask so basically the dye should be injected and you should be able to open the space in less than five minutes or even as less as one to two minutes because the diet travels very fast so what what some people do is they already dock the robot and open the spaces and keep and then inject the dye but what we do as a routine is we keep everything ready uh dock the robot inject the dye and then open the space so you have to open it as early as possible because if you if you if you open it late then the dye spreads everywhere and then you are not going to be able to detect the exact sentinel so that is why i said that the learning curve is very important it's not that tomorrow you can start doing sentinel node and you can immediately start offering to its patient so that is why there is some learning curve so you need to do you need to validate or your own technique what is better for you so that's roughly is around 20 to 25 cases next question is from dr sambit can generate apologist to radical hysterectomy uh yeah that that's a very difficult question uh to answer but if you are adequately trained uh you can do a radical stretch there is no contraindication that a general general gynecologist can't do a radical hysterectomy but you should definitely be adequately trained that is something which is very important because it is a high stakes operation uh it is it is it is a treatment of choice for early stage cervical cancer the best surgery or the best chance that the lady has to be cancer free is the first surgery so that is something which you have to do with with the good amount of precision with minimal complications and with excellent oncological clearance okay so we have one raise and request dr vishnu pratap singh i would be accepting your request now how many types of treatment we can give in endometrial cancer and which one is based so basically see it depends upon what stage the patient is in so early stage that is stage one to stage two it is always primary surgery yes so sir if it's in first it's and if it's in fourth stage which one is the best so first stage yeah the first day first stage and the second stage the treatment of choice is surgery in fourth stage uh the patient can only be offered either a palliative chemotherapy or uh it can be offered hormonal therapy thank you sir yes but obviously survival on the stage yes so stage four the fire survival is around 20 25 to 30 percent okay so it's the cbr yes okay thank you sir thank you what was the etiological cost to endometrial prolapse and fibronites and can you tell the difference between endometrial adenoma and fiber [Music] endometrial prolapse so is he asking about uterine prolapse uh sir it's written the etiological cause for endometrial prolapse so basically if he's if he's talking about uterine prolapse so that means that a weakness it is mainly because of the weakness of the muscles so that can occur in postmenopausal women when the estrogen is not there in the body frequent risk factors include frequent childbirths obstetric trauma or most of the times it can be genetic disorders like marfan syndrome or where there is connective tissue laxity so these are some ecological reasons now fibroids uh it can there can be multiple reasons the commonest uh is idiot i mean idiopathic we don't know about why 50 percent of cases of women get fibroids but other common causes include hyper estrogenism uh where the estrogen all the conditions which lead to excessive estrogen in the body so that is what can cause fibroids and he's asking a difference between endometrial adenoma and fibroids now fibroid is basically uh now fibroids can be at three places they can be either be in the myometrium which is the commonest uh with a smooth muscle uh consisting of smooth muscle tissues so this one will teach you get hard now so it's called ferroids yeah i mean there is nothing like hard fibroid can be soft as well but you need to see specific it's basically a tumor developing in the smooth muscle now the smooth muscle can be in the uterine myometrium or it can be in the serosa as well well adenoma is mainly like a polyp it is mainly like an endometrial polyp so that mainly occurs in the endometrial lining i hope dr d prasad this answers your question in case uh if you have some other question or you wanted to ask something else you can raise your hand so we can get you on stage uh so there's another question in stage one surgery uh chemo yes or no yeah so basically stage one uh surgery is always the main mainstay of the treatment now depending on the histopathology report uh what type of cancer the patient may need uh chemo or chemo or radiation well there are many comments that it was an excellent presentation and they really enjoyed the video i think so that's about it uh thank you so much sir it was an amazing presentation i'm sure our audience also loved it i would like to thank dr utranade for this amazing session and thank you to the audience as well thank you thank you i thank ali and the team of mediflex nivedita and devanchi for coordinating and arranging this it was a pleasure and thank you for the audience for joining thank you so much

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