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Hi, everyone. Thank you all for joining us today. I'm Sino. I'm one of the social media leads at softer and today is going to be our last session on Gynae. We have a who's a second year medical student at the University of Buckingham, taking us through the anatomy of the pelvic floor. And then I have Bless, who's going to take us through. Bless who's a third year student who's going to take us through hysterectomies and malignancies. After on, uh, we will, at the end of the session, we will be releasing feedback forms. So if you fill those in, you'll be able to get your attendance certificates and you'll also get discount codes to teach me surgery and pass the MRC S. These are all the sponsors by the way and thank you so much to them for allowing this to happen. And if you guys have any questions, feel free to pop them in the chart, I will try to answer them as we go to the session. Otherwise we'll address them at the end of the session as well. Um Now without any further ado, I'm gonna pass it on to a girl. Thank you? Um, hi, I'm Monica and I'm just going to start talking about the anatomy of the pelvic floor. These are the learning objectives and I'm just carrying forward from what has been covered in the previous sessions. So let's start with the anatomical position of the uterus. Now, as we know, the uterus is located in the pelvic cavity and it lines, uh, it lies between the bladder and the rectum. It's connected to the ovaries to its sides that is laterally and to the vagina distally. Now, talking about the position of the uterus with respect to the bladder and the rectum. The uterus line lies behind and slightly above the bladder, which means it is postero superior to the bladder and it lies in front of the rectum, which means it is anterior to the rectum. Now, in between these organs, there are certain spaces that are lined by the peritoneum, which is a thin membrane that lines the abdominal cavity and some parts of the pelvic cavity. The uter vesical pouch, also known as the Vesico uterine pouch is a small space in the female pelvis and it lies between the anterior wall of the uterus and the posterior wall of the bladder. The rectal uterine pouch similarly lies between the rectum and the uterus. Can anyone guess what the clinical significance of these spaces might be? You can let us know in the chat. Can you let me know if there are any responses there are any so far you guys, if anyone can engage with this, it would be really helpful. Oh, we have one, it says fluid can collect there. Um That's right. So the clinical significance of this is that it's a common site for fluid accumulation such as during ascites. But it can also be involved in a variety of other pathological processes such as during infection or endometriosis. For example, the uro vesical pouch especially is very relevant and s and tiny because it can be in uh involved in like pelvic inflammatory disease and endometriosis. And also during certain surgical procedures such as C section. In which case, it can be like clinically significant to access the space for ACL moving on to the bony features of the pelvis. The pelvis is made of the innominate bones, the sacrum and the cosi talking a bit more about the sacrum. Um It's a triangular bone and it lies at the base of the spine. It's between the two iliac bones and the joint between the sacrum and the ileum is known as the sacroiliac joint, as you can see here. Um It plays an important role in providing stability to the hip and it transfers weight from the upper body into the lower body. Um The sacrum consists of five fused vertebrae, the S one to the S five and it forms the back part of the pelvis. Uh It also provides attachment points for ligaments and muscles of pelvis and the low, lower back moving on to the cozy, which you can see here. It's also known as the tail bone and is a smaller triangular bone uh made between it consists of 3 to 5 fused vertebrae. And although these number of segments can vary between, it serves as an attachment point for ligaments and muscles involved in the pelvic floor. It provides some support and protection to the organs in the pelvic cavity, moving on to the innominate bones. They are made of the ileum which you can see in green, the ischium which is in APG sort of color and the pubis, which is the purple part that you can see here. The ileum is the widest and the largest part of the innominate bones. It is made of the body and the ring and it has an internal and an external surface and an iliac crest. It also has other features which you can see in this diagram. Um such as the posterior superior iliac spine, the anterior superior iliac spine. Similarly, the posterior inferior iliac spines. These are important sites for muscle and ligament attachment as well. Moving on to the ischial. It is the postero inferior part of the inno bones. It is made of the ischial body, the superior and inferior ischial ramus. It also has escu tuberosities and ECU spine and greater and lesser spatic nodules that you can see in the title as well. Talking about the pubis. It is the most anterior part it's made of the pubic body and the superior and inferior pubic uh ride that you can see in this diagram. Now, the pelvis in itself has a pelvic inlet, a pelvic cavity and a pelvic outlet. Talking about the greater pelvis. It's also known as the false pelvis because it lies above the pelvic inlet and it's surrounded by the superior pelvic girdle. It houses the inferior parts of the abdominal organs, the lesser pelvis. On the other hand, is known as the true pelvis because in itself, it is the pelvic cavity. It lies between the pelvic inlet and the pelvic outlet. It's surrounded by the inferior pelvic girdle and it houses most of all pelvic cera. Now, the major vasa of the female pelvis mainly includes the bladder, the ovary, the uterus, the fallopian tubes, the cervix, the vagina, and the rectum. What you see here is the pelvic floor muscle. And we're gonna be talking a bit more in detail about that. The main function of the pelvic floor generally is to support the abdominal pelvic organs. And it also contributes to urinary and fecal continence. It's form of three components, majorly, the Vater aai, the coss and the fascia, which are the covering of these muscles. The leva ana is a broad sheet of muscles and it's formed of three muscles, which is the puborectalis, the red muscle that you can see here. The pubic acis, the one in green and the ileo acis. Now I've made a table here that speaks a bit more in detail about the function and the blood supply and innovation to these muscles. But overall, this helps in providing support to the pelvic organs. And as I mentioned, um fecal and urinary continence, strengthening, the pelvic floor muscles usually helps to alleviate symptoms in pelvic organ prolapse, moving on to the pelvic walls. The anterior wall is formed by the posterior surface of the pubic synthesis. The pubic rami and the body of the pubic bones and the posterior wall. As you can see here is formed by the sacrum, the cozy, the piriformis muscle and the pelvic fascia. Finally, I'm going to be talking a bit about the external female genitalia. The external female genitalia comprises of mons pubis, which I don't think is labeled in this diagram, but it is a subcutaneous fat pad and it's located anterior to the pubic synthesis. It is formed by the fusion of the labia majora that you can see here. The Libya majority of themselves are two hairbearing external skin folds. The labia Minora. On the other hand, are two hairless skin folds that lie within the labia majora. They fuse anteriorly to form the hood of the clitoris and they extend posteriorly on either side of the vaginal opening. The clitoris is located under the clitoral hood and it's not just a small part that you can see here, it extends behind and is a much larger organ than is visible in the external part. Um It is formed by the erectile corpora cavernosa tissue and it becomes engaged with blood during sexual stimulation. The vestibule is the area that is covered by the labia Minora. It contains the openings of the vagina and urethral openings. The Bartholin's glands are these small glands and they have openings next on either side of the vaginal opening, they secrete lubricating mucus during sexual stimulation. Now, the perinium is the area of skin between the vaginal opening and the anal opening and it contains muscles and connective tissue that support the pelvic floor. That's all that I'm talking about in today's session. If you guys have any questions, please let us know and I'll be handing over to Blessin now. Ok. Let me, we can, they see the slides. Yeah, we can see the slides. All right. Uh Hi guys. My name is Bless. Um And I'm gonna present to you with Hysterectomy and malignancies. So, our learning objectives, as mentioned, we have hysterectomies. We have to discuss, uh we can't see the slides anymore. Can you share your screen, please? Yeah, we can see it now. Thank you. Oh, interesting. Ok. Right. So, well, now, can you see the slides? Yeah, we can see the Hysterectomy Volume tractors. All right. All right. So we're gonna discuss how hysterectomies are classified first. So we're gonna talk about the types of hysterectomy to simply put Hysterectomy is an operation to remove the uterus. And it is the second most common female uh surgery after cesarean section or commonly called AC section and Hysterectomy as mentioned over here is most often done as a first line treatment for cancer, but it's the last line treatment for everything else. And when, I mean, by everything else, I mean, uh diseases or conditions like endometriosis or adenomyosis. And depending on that, we have three types of hysterectomies. And also it depends on whether you, whether the surgeon wants to remove the cervix or the ovaries. So now we have subtotal also cervical which removes only the upper part of the uterus and keeps the cervix in place. So that's basically, it's called as partial hysterectomy in this diagram. Then we have total which removes the whole of the uterus and the cervix. So this area and then we have radical which removes the entire uterus and also the size of the uterus. So the connective tissues and the fat related than the cervix and the top part of the vagina. And this is generally done when the cancer is present. So we are talking about uh this form of radical hysterectomy or this. So this one includes the upper part of the vagina while this one doesn't. And we have classification for radical hysterectomy. Um So either you have the uh private classification or the moral classification. Um And so you can see that as type one, type two, type three and ABCD goes, you can see how extensive the procedures would be. So you start off from con colonization, which is basically biopsying or removing a very small amount of uh cervical tissue or any tissue uh for that matter. So, mainly cervical tissue, a wedge of a cervical tissue and then it goes all the way to pelvic insaturation and param uh parametrectomy is basically you're removing the um connective tissue and the fat that surrounds the uterus. Um And then you have leep as well, which is you use uh a core like tool, a wire loop to remove cancer as well as removing uh the fat and the tissue and the entire uterus that is connected to it all the way down to pelvic centration, which is basically removing all the organs that are connected to the pelvis, including if necessary colon and large Indust and so on. Then we have, when it comes to distinguishing different hysterectomy procedures, we have the abdominal hysterectomy, vaginal hysterectomy, the laparoscopic way and the robotic way. Um as you can appreciate in this uh picture. Abdominal hysterectomy has the longest length of stay in the hospital and also the longest recovery period about six to eight weeks. Whereas vaginal hysterectomy, the shortest operating time and the shortest recovery phase as well. But it has its own limitations. For example, abdominal hysterectomy, it has the highest rate of POSTOP complications, especially when it comes to incisional hernias, vaginal hysterectomy. It has uh, the highest blood loss. Unfortunately. And ideally you would have like a total laparoscopic hysterectomy. It has a low blood loss shot length of stay, um, disadvantages. I would say again when it comes to laparoscopic, it is about incisional hernias within the first three months of your surgery on that. I would go to the first question on the poll. Uh, rit, could you put up the pole, please? Which approach of hysterectomy is the most common? I've got up the goal. Now. Um I'm gonna give them about two minutes to answer the question. Yeah, no problem. Ok. So we have seven responses so far and 80 sorry, eight responses so far and 87% of them say laparoscopic funnily enough. That is what I thought when I was preparing the slides. But then it's actually vaginal hysterectomy. And the reason is, is because simply because of cosmesis because unless it is laparoscopy, laparoscopically assisted vaginal hysterectomy, um laparoscopic, just leave scars on the abdomen. So they much prefer to do a vaginal hysterectomy. Unless again, like I mentioned, it is much more. Uh the cancer is much more extensive and then you might need to do like an abdominal hysterectomy or laparoscopic abdominal hysterectomy. But the most common procedure that most gyne surgeons would do is a vaginal hysterectomy just because of cosmesis. They don't, you can't see those scars much at the end. So, on that note, we have the picture of vaginal hysterectomy this is a lithotomy position on how they're doing it. And then you have robotic assisted laparoscopic abdominal hysterectomy. And the difference between just using a laparoscope and just you and the robotic is you, uh you're not using uh what do you call um instruments through the, the, you're not using much uh of an incisional size when it comes to robotic surgery. So robotic surgery leaves extremely minimal scars as compared to um laparoscopic surgery. But then they have too many scars to deal with when it comes to robotic surgery. As compared to laparoscopic ways, then you have abdominal hysterectomy where they either do a midline or a vertical incision or a longitudinal or horizontal incision to do the procedure. And this is a total laparoscopic hysterectomy or supraclavicle, supra hysterectomy. And this is where I say that they use a little bit bigger scars because they want to insert the laparoscope instruments in. And you can see that uh there are bigger scars than um robotic surgeries. So now we have the reasons for hysterectomy and you can see the reasons are from abnormal bleeding for whatever the reason, all the way down to gender formation for males who are transgender and people who are non binary. Um So these are the kinds of reasons why people do hysterectomy and like I mentioned before, uh can for the first, the first line treatment of cancer in the cervix or any part of the female uh genitalia is usually Hysterectomy or Trachelectomy, which I'll be mentioning later. And for the rest of the other cases, there is um there are other ways or other medications to treat. And then the final case would be hysterectomy. Obviously, we have uh side effects and risks for the procedure if you are um under the age of menopause. So under the age of 55 and you still have periods, you will experience menopause. So you will not have periods. And because of the changes of that happens with early menopause, you might experience mood swings, you might experience uh post uh operative complications such as pain. You might experience like um long term effects. For example, congestive heart failure for women under 35 obesity, um high BP and so on. Again, with postoperative complications for specifically abdominal hysterectomy, you have shock, you have hemorrhage, you have infection and all the way down to incisional hernia. And I would like to mention about insertional hernia because the first three months after surgery, especially abdominal hysterectomy, the most common complication that you would get is an incisional hernia. And another very common complication you will get is a DVT as well because most of these patients, they would be on bed and they won't have the activity level like how they used to have before. So it's all about um the prevention would be giving them um drugs uh like um antiplatelets or anticoagulants for some uh for a couple of days in order to prevent DVT from happening and then you may have vomiting, you may have infection, like I said, um intestinal complications, pulmonary complications, pe especially and then this would be kind of like a timeline of how the operation would, I mean, how the recovery stages would be after the operation. So for one or two days, um you would be in the hospital during this time and then you might do basic stuff like get up, move about, go to the toilet, all that all the way down to 4 to 6 weeks and around one, around 2 to 4 weeks, you could possibly start building up strength and that would be the time that you'll be able to go to work. But about 4 to 6 weeks is the time that they say that you would be almost back to normal. But the timeline for hysterectomies is about three months to feel absolutely normal once again. And then now we are and now we are going to cervical and endometrial cancer learning objectives, sorry, uh learning. And now we're gonna start with endometrial cancer. So we have nonmodifiable and modifiable risk factors. So non modifiable risk factors include uh early start to your periods or late ending of your periods. So early menarche or late menopause. Another co another non modifiable risk factor is Li syndrome and Co uh Cowden syndrome and polymerase proof reading associated polyposis, which these conditions are basically familial conditions that uh that produce noncancerous tumors, especially along the intestinal tract and the genital tract. So, these conditions make you more predisposed to having cancer such as mentioned endometrial cancer or even colon cancer. And then you have modifiable risk factors which include uh metabolic syndrome, type two diabetes, uh sedentary lifestyle or unopposed estrogen replacement therapy or tamoxifen use in breast cancer. So, for endometrial cancer, we have two types. Type one has uh low grade cells, they are more common and more favorable when it comes to prognosis. And type two has high grade cells. And the incidence rate for having endometrial cancer is the sixth most commonly occurring female cancer worldwide. As you can mention in most cases are between 65 to 75 years of age and they have um usually type two. So their prognosis is unfortunately very poor. But as we can see that it also varies by ethnicity. And you can see that in the US, black women are found to have worse outcomes at every stage. And it may suggest additional factors such as uh phenotypic differences and also probably socioeconomic uh differences as well. Then tumor genomic differences can be of important factors. Like I mentioned about Lynn Syndrome Cowden syndrome. So TP 53 and P IK three are one mutations in type two. Endometrial cancer is very much common in black women along with high her two expression which is also found in, you know, women who have unfortunately, breast cancers or ovarian cancers, they might be more predisposed to having endometrial cancers. So this is the table that shows about um the differences between type one and type two endometrial carcinoma. And like I mentioned, the prognosis is really poor when it comes to type two endometrial carcinoma. And before I go to the next slide, risha, can you please put up the next poll? It says, what do you mean by grading and cancer diagnosis? We have seven responses so far and 71% say how closely related it is to the brain tissue. Yes, that is exactly correct. So grade is. So this is a histological slide of endometrioid carcinoma. So they call us endometrioid and this is clear cell, this is serous carcinoma. These two uh clear cell serous carcinoma and serous carcinoma. You can appreciate that. They don't look at all like endometrial tissue. Whereas an endometrioid adenocarcinoma, they look much more closely related to the endometrial tissue and hence, they have much more favorable prognosis as compared to the clear cells of the serous carcinoma types. So now we go on to the major symptoms of endometrial cancer. Um most common symptoms are spotting or vaginal bleeding between periods or postmenopausal vaginal bleeding. Uh for women who have type two endometrial cancer, the most common thing that would come up is the postmenopausal vaginal bleeding. And these are the ones and this is especially a red flag because they would have had menopause for, let's say, two or three years. Uh now and then if you have a vaginal bleeding, that's a sure hallmark of uh a cancer of some sort, additional symptoms may include uh painful sexual intercourse, unexpected weight loss or feeling a mass in the pelvic region. Then you have cervical cancer and the mod, you can see that they are modifiable and non modifiable risk factors. So, uh modifiable risk factors include early marriages. Like people who get married before the age of 20 apparently have a very high risk of cervical cancer or most common ones are multiple sexual partners, unprotected sex, uh, smoking, um, or having, uh, let's say decreased immunity because let's say aids and non modifiable risk factors include family history, socioeconomic status and uh other health conditions like diabetes or decreased immunity if it's congenital. All right. So the pathophysiology and etiology of cervical cancer, it is the fourth most common female related cancer worldwide and in the US and UK, most screening and diagnostic efforts efforts include HPV, testing and pap smear. So why? Because HPV is the most common cause for cervical cancer and it is done over here in the UK between the ages of 25 and 64 because if left undetected and untreated, it can develop into cervical cancer. And HPV is mostly, is found in mostly uh sexually active people at some point during their lifetime and there are 100 and 30 types, 20 of them are cancer related. Most common uh cancer related HPV types are 16 and 18 and they are pretty invasive and uh cervical cancer that peaks in middle aged women around 4050. Whereas if it, if you, if you observe younger females that are ages around 25 they even though they get cervical cancer, but it is largely self limiting as in it is much easier to get them diagnosed and to get them treated and cured as compared to middle aged women. And we, we are going to see why. So let's say a patient, a female patient gets infected at the age of 25 or 28 with an A uh with an HPV infection and it remains hidden for quite some time. And let's say it gets hidden for 2030 years and that is where the peak happens. That's where the deaths happen between 4050 years. So why does it erupt into cervical cancer where it has been hidden for so long? It could be because of stress, so physiological or psychological or they could be having uh conditions that they develop throughout this 20 year period or 30 year period, for example, diabetes uh or they could be having a comorbidity like an STD and E extra STD like HIV. And this enables HPV 16 and 18 to release vi viral oncogenes, which are E six and E seven, which increases, which helps it increase in reactive oxidative species. And this helps in having an a uh what do you call? This helps in having increased proliferation of cells and alter the apoptosis pathway. So it basically stops apoptosis from happening, which again is a hallmark of cancer cell thus causing DNA damage and thus causing cancer promotion. And that's how um HPV related cancers occur. Um Before I go on to the slide, risha, can we have the next pole on please? So the question is besides HPV, what is the another, what is another common cause for cervical cancer? So we have six responses so far and 50% 62% say all of the above. That is correct. It is actually all of the above because gonorrhea and syphilis, they are, they do cause pelvic inflammatory disease. But over the period of time, a coinfection with H I HPV can cause cervical cancer. You have a very high incidence of uh having cervical cancer. So now uh this is cancer in the cervix and this is a normal cervix. So, cancers in the cervix start at the transformation zone, which is this area right here. Then you have the external Os and then you have the squamal columnar junction and this is another squamous columnar junction. So this is a cancer in the cervix that happens at the transformation zone. Again, signs and symptoms very similar to endometrial cancer, which is uh again, vaginal bleeding. If you are postmenopausal, it's a red flag for cancers in the genitalia, especially because you're postmenopausal and you have pain and discomfort during sex, um, unpleasant odor from the vagina or leg pain, constant fatigue and weight loss. And you have differential diagnosis for both the cancers include um it starts with the most common urinary tract infection all the way up to va Willebrand disease and Vaughan Willie brand disease is um familial disorder whi which is uh like you have deficiency of Willie Brand factor, which is one of the components for blood clotting. And that is also a differential diagnosis for endometrial and cervical cancer. So, investigations include colposcopy D and C PAP test and MRI scan. So the difference between AD and C and A PAP test, if you can see, they look quite similar is the D and C, it goes all the way to the uterus. So if they are suspecting that that would be survived cancer, but they want to know whether it has spread to the uterus, they would do AD and C versus if it's a PAP test, they would just investigate only the cervix and investigations for endometrial cancer is one of them is again, di dilation and ridge which is D and C transvaginal ultrasound, endometrial biopsy. And also they would take the medical history and find out whether you actually are you suspect? Are you suspecting me uh endometrial cancer or not? Which brings on to the next question, Aisha, could you put up the next poll, please. Right. Which the next, yeah, which cancer spreads to the uterus. We have six responses so far. Sorry, seven responses so far. And 71% say breast and colon cancer. Actually, that is incorrect because stomach uh cancers can also spread to the uterus. And the way they spread to the uterus is through lymphatic drainage first to the ovary and then to the uterus. So it's kind of like an indirect way of how the cancer spreads from stomach all the way to the uterus rather than breast and colon being quite direct in the in lymphatic drainage. So now we have treatment options for uterine cancer or endometrial cancers. So, first off, like I said, in the hysterectomy portion that any cancer related to the uterus, it's the first thing is hysterectomy. So which may or may not include removal of other associated organs. So, depending on the stage of your, of the endometrial cancer, either fallopian tube involvement or ovary involvement or cervical or vaginal involvement. Hy hysterectomy is done. And then you may get chemotherapy radiation therapy, targeted therapy, hormonal therapy involved. So the same way for cervical cancer, the first option is surgery. Definitely. And these are the surgical options. So you have lets which is large loop, excision of transformation zone and also cone biopsy. So these two, they use a wire loop to excise uh the portion of cancer that has been involved in the cervix. So if it's a very small portion, they do a cone biopsy or conization, which is basically take it in the shape of a cone or a wedge. And large loop excision is again using the same loop. But then you remove all the cancer cells around the uh cervix. And then you may have trachelectomy, which is complete removal of the cervix and may involve upper part of the vagina nearby tissues. And then finally, if the cancer has spread a lot, it will be hysterectomy and then you may get radiotherapy chemotherapy and immunotherapy along it as along with it as well. All right guys. So these are the references you will see that there will be some videos re uh regarding how colposcopy or cone biopsy or let's procedure is done. Thank you so much for your time. I appreciate it. Thank you, bless you, Monica. I think you both did an a do a wonderful job and it was really good revision for us as well. So if you guys have any more questions that you'd like to ask that you just please put them in the chart and I think you'll address that now as well. And if no one has any other questions, then I think we can wrap up on the session. Thank you all for coming today. I will be putting this feedback home in the chart now should be up there. So now if you guys fill it up, you'll get your attendance certificate along with discount codes and uh follow us on the social media as well. We'll be putting out five more questions soon after and that'll be good practice for you guys. The sessions slides and all the recordings will be available. Just give us a little time to process all of that and we will put them out as soon as possible. And yeah, that's about it next week on Monday at 6 p.m. we have ophthalmology for anyone who's interested in that. So please join us if any of you would like to do that. Thank you guys.