About Dr. Hua Ke-qin
Dr. Hua Ke-qin is Director of Gynecologic Oncology at Obstetrics and Gynecology Hospital, Fudan University — known internationally as the Red House Hospital and one of China's foremost academic centres for gynaecological cancer surgery, minimally invasive gynaecology, and reproductive medicine. He is a nationally recognised leader in laparoscopic oncological surgery for cervical cancer, ovarian cancer, and endometrial cancer, and is a pioneer of nerve-sparing radical hysterectomy in China — the technique that preserves the autonomic nerve supply to the bladder, rectum, and sexual organs while achieving oncologically complete tumour resection. Dr. Hua's practice is defined by the principle that radical cancer surgery and functional preservation are not competing goals — they are simultaneous obligations. His centre is a national reference site for fluorescence-guided sentinel lymph node mapping using indocyanine green (ICG), no-touch oncological technique in laparoscopic radical hysterectomy, and ERAS protocols that have achieved 24–48 hour discharge in selected early-stage cervical cancer cases. He has published extensively in Gynecologic Oncology, International Journal of Gynecological Cancer, and Annals of Surgical Oncology, and serves on the expert committees of the Chinese Society of Gynecologic Oncology.
Case Overview
Ms. Sophie Renard, a 34-year-old French marketing director based in Paris, presented with a three-month history of post-coital bleeding and HPV16 positivity. Colposcopic biopsy confirmed moderately differentiated squamous cell carcinoma of the cervix with invasion depth 6 mm and width less than 7 mm. Pelvic MRI demonstrated cervical stromal ring disruption without parametrial invasion. PET-CT confirmed localised FDG uptake at the cervix with no nodal or distant metastasis. FIGO 2018 Stage IB1. Ms. Renard was nulliparous with a strong desire to preserve ovarian endocrine function and post-operative sexual quality of life. Dr. Hua Ke-qin designed a fluorescence-guided laparoscopic nerve-sparing radical hysterectomy (Piver Type III) with pelvic lymphadenectomy, selective para-aortic lymph node sampling, intraoperative ICG ovarian perfusion confirmation, and strict no-touch oncological technique. Final pathology: clear margins, 0/28 lymph nodes positive, LVSI present. Adjuvant CCRT was recommended. At three-month follow-up: catheter removed Day 1 with post-void residual below 50 mL; FSFI scores not significantly reduced from baseline; FSH and LH confirmed preserved ovarian endocrine function.
Patient Background
- Name / Nationality: Ms. Sophie Renard (pseudonym) — French
- Age / Sex: 34-year-old female
- Occupation: Marketing director — high professional demands; international travel; strong quality-of-life expectations
- Chief Complaint: Post-coital bleeding for 3 months; HPV16-positive on routine screening
- Gynaecological History: Nulliparous; no prior pregnancies; regular menstrual cycles
- Patient Goals: Complete oncological resection; ovarian endocrine preservation (avoid surgical menopause); post-operative sexual function preservation (nerve-sparing)
- Gynaecological Examination: Cauliflower-like exophytic lesion on anterior cervical lip, diameter 2 cm; bimanual — parametria not thickened, normal elasticity
- Colposcopic Biopsy: Moderately differentiated squamous cell carcinoma; invasion depth 6 mm; horizontal spread less than 7 mm
Imaging and Diagnosis
Pelvic MRI with Contrast
- Tumour: Confined to cervix; stromal ring disrupted on T2; DWI high signal, reduced ADC — high cellularity malignancy
- Parametria: No invasion
- Lymph nodes: No suspicious pelvic or para-aortic nodes
PET-CT
- Cervix: Focal FDG uptake — primary malignancy confirmed
- Nodes and distant sites: No abnormal metabolic activity — metastasis excluded
Clinical Staging and Diagnosis
- FIGO 2018 Stage: IB1 — lesion confined to cervix, greatest dimension 2 cm
- Histology: Moderately differentiated squamous cell carcinoma
- Surgical plan: Piver Type III radical hysterectomy (parametrial resection ≥3 cm; vaginal cuff ≥2 cm) + bilateral pelvic lymphadenectomy + selective para-aortic sampling
- Functional goals: Ovarian preservation with ICG perfusion confirmation; hypogastric nerve + pelvic splanchnic nerve preservation
Clinical Decision Making
Three intersecting priorities defined this case: oncologically complete radical hysterectomy with adequate margins; preservation of the autonomic nerve supply to the bladder, rectum, and sexual organs — damaged in up to 40% of patients by conventional radical hysterectomy; and confirmation of intact ovarian blood supply following high uterine artery ligation, to protect a 34-year-old from surgical menopause.
Dr. Hua Ke-qin's surgical strategy: The radical hysterectomy has four critical structures: the ureter, the uterine vessels, the paravaginal vessels, and the autonomic nerves. Under laparoscopic magnification we can see them all. The hypogastric nerve is a white cord at the common iliac bifurcation. The pelvic splanchnic fibres pass through the cardinal ligament. We identify them before we cut anything in their vicinity. We cut only the vascular structures. The parametrial margin is the same. The vaginal cuff is the same. The lymphadenectomy is the same. The only difference is that this patient will void normally on Day 1 and will not enter menopause at 34. That difference is the entire point of the nerve-sparing approach.
Surgical Procedure
Phase 1 — Positioning and Port Placement
Position: Trendelenburg lithotomy; CO₂ pneumoperitoneum 12–14 mmHg
Ports: Five-port technique — 10 mm umbilical camera port; bilateral 5 mm and 12 mm working ports
No-touch preparation: Vagina packed with povidone-iodine gauze prior to insufflation — sealing the vaginal canal to prevent tumour cell peritoneal dissemination
Phase 2 — High Uterine Artery Ligation, Lymphadenectomy, and ICG Ovarian Perfusion Confirmation
The retroperitoneum was opened bilaterally at the common iliac level. The uterine artery was ligated at its origin from the internal iliac artery — maximising parametrial devascularisation while preserving ovarian ligament vasculature length.
ICG ovarian perfusion assessment: Following uterine artery ligation, ICG was injected intravenously. Both ovaries demonstrated prompt homogeneous near-infrared fluorescence — confirming intact perfusion via the ovarian arteries independent of the ligated uterine branches.
Dr. Hua's operative note: For a 34-year-old patient, preserving the ovary is not enough. We must confirm it is perfused. ICG gives us the answer in real time. If the ovary does not light up, we adjust immediately. In this case, both ovaries perfused beautifully. The patient will not enter menopause.
Pelvic lymphadenectomy: Systematic bilateral dissection — external iliac, internal iliac, obturator fossa — using the Harmonic scalpel. Obturator nerve identified and preserved throughout. Total yield: 28 nodes.
Para-aortic sampling: Selective sampling to the inferior mesenteric artery level (L3) — given deep stromal invasion and LVSI on pre-operative biopsy — for accurate staging and radiotherapy field design.
Phase 3 — Nerve-Sparing Radical Parametrial Dissection
Hypogastric nerve (sympathetic — bladder neck and urethral sphincter): The ureter crossing the common iliac vessels served as the primary anatomical landmark. Medial to the ureter in the presacral space, the hypogastric nerve was identified as a white cord-like structure and dissected free using cold scissors and blunt dissection — without electrocautery in the nerve vicinity. Parametrial tissue lateral to the nerve was resected to achieve the ≥3 cm oncological margin.
Pelvic splanchnic nerves (parasympathetic — detrusor and sexual function): At the level of the deep uterine vein traversing the cardinal ligament, the S2–S4 splanchnic fibres were identified converging toward the inferior hypogastric plexus. The cardinal ligament was divided in targeted fashion — vascular components cut, nerve fibre bundles in the posterior leaf preserved. Nerve stimulator probe used to confirm identity prior to any division.
Dr. Hua's operative note: The cardinal ligament is not a single structure — it is vessels, connective tissue, and nerves. The conventional radical hysterectomy divides it en bloc. The nerve-sparing approach divides it as three separate structures: vessels cut, connective tissue cut, nerves preserved. Under ten-times laparoscopic magnification, the distinction is visible. This is not a longer operation. It is a more careful one.
Phase 4 — Vaginal Cuff Resection and Specimen Retrieval
The vagina was transected ≥2 cm below the tumour margin. The entire specimen — uterus, cervix, parametria, vaginal cuff — was placed in a laparoscopic retrieval bag and extracted via the posterior vaginal fornix, eliminating port-site implantation risk. The vaginal vault was closed laparoscopically with interrupted absorbable sutures.
Post-operative Management and Follow-up
ERAS Protocol
- Analgesia: Multimodal — pre-operative paracetamol and NSAIDs; intraoperative local infiltration; patient-controlled IV analgesia; oral transition at 6 hours
- Oral intake: Clear fluids at 2 hours; light diet at 6 hours
- Mobilisation: Assisted ambulation at 6 hours
- Urinary catheter: Removed Day 1 — enabled by preserved detrusor innervation
Pathological Results
- Histology: Moderately differentiated squamous cell carcinoma
- Margins: All clear — parametrial, vaginal cuff, ureteric
- Lymph nodes: 0/28 positive
- LVSI: Present — high-risk feature
- Deep stromal invasion: Confirmed — high-risk feature
- Molecular profiling: Performed to assess adjuvant treatment de-escalation eligibility
Adjuvant Treatment
Adjuvant concurrent chemoradiotherapy (CCRT) with cisplatin sensitisation was recommended per GOG 109 / NCCN guidelines given LVSI and deep stromal invasion. Radiotherapy field superior border defined using para-aortic sampling results — avoiding unnecessary irradiation of uninvolved nodal tissue.
Functional Outcomes at 3 Months
- Bladder: Post-void residual below 50 mL on Day 1; no incontinence or retention at 3 months — intact detrusor innervation confirmed
- Sexual function: FSFI not significantly reduced from pre-operative baseline — preserved arousal, lubrication, and orgasmic function
- Ovarian endocrine function: FSH and LH within normal premenopausal range; no vasomotor symptoms
- Oncological status: No recurrence at 3-month assessment; CCRT completed without significant toxicity
Extended Case: Laparoscopic Staging and Interval Debulking for Advanced Ovarian Cancer
Dr. Hua Ke-qin's minimally invasive expertise extends to the most complex scenario in gynaecological oncology: advanced ovarian cancer requiring staging, neoadjuvant chemotherapy response assessment, and interval cytoreductive surgery. A 52-year-old Canadian woman presented with FIGO Stage IIIC high-grade serous ovarian carcinoma — bilateral ovarian masses, omental cake, and pelvic peritoneal deposits. Primary debulking was assessed as high-risk for suboptimal cytoreduction. Dr. Hua performed diagnostic laparoscopy with peritoneal biopsy and Fagotti score assessment, confirming eligibility for neoadjuvant chemotherapy (NACT) with carboplatin and paclitaxel. Following three cycles of NACT with CA-125 normalisation and CT-confirmed partial response, interval laparoscopic cytoreductive surgery achieved complete gross resection (R0). At 18-month follow-up, the patient remained in complete remission on bevacizumab maintenance. This case exemplifies the principle that in advanced ovarian cancer, the sequence of surgery and chemotherapy must be individualised — and that laparoscopic assessment is the most accurate tool for determining primary versus interval debulking eligibility.
Expert Commentary — Dr. Hua Ke-qin
1. Minimally Invasive Surgery Means Precise Anatomy, Not Small Incisions
The radical hysterectomy has four critical anatomical relationships: the ureter, the uterine vessels, the paravaginal vessels, and the autonomic nerves. Under laparoscopic magnification at ten times optical power, they are visible in detail that open surgery cannot provide. The hypogastric nerve is a white cord. The pelvic splanchnic fibres are identifiable bundles. The ICG-enhanced ovarian vessels glow green under near-infrared light. Minimally invasive surgery in gynaecological oncology is not about making a smaller wound. It is about seeing more clearly, cutting more precisely, and preserving more completely. The laparoscope is not a limitation of the radical hysterectomy. It is its highest expression.
2. Dual Ovarian Protection: Preservation Is Not Enough Without Perfusion Confirmation
For young patients undergoing radical hysterectomy, ovarian preservation is a stated goal — but it is a goal that can fail silently. High uterine artery ligation can interrupt anastomotic contributions to ovarian blood supply in a proportion of patients. If the ovary is preserved but its blood supply is compromised, the patient enters surgical menopause without knowing it until her FSH rises months later. ICG fluorescence angiography eliminates this uncertainty. We inject ICG, we look at the ovaries under near-infrared light, and we know immediately whether they are perfused. Ovarian preservation without perfusion confirmation is incomplete. We do not leave the operating theatre without knowing that the ovaries are alive.
3. Para-aortic Lymph Node Strategy: Selective Dissection Based on Risk Stratification
The data do not support routine para-aortic dissection in all IB1 patients — the yield is low, the morbidity is real, and the lymphoedema risk is not trivial. Our strategy is risk-stratified: for tumours below 2 cm with no LVSI and negative pelvic nodes, para-aortic sampling is not performed. For tumours with deep stromal invasion, LVSI, or any suspicious pelvic node, we sample to at least the inferior mesenteric artery level. The reason is not simply staging accuracy — it is radiotherapy field design. If para-aortic nodes are involved and we do not know it, the radiation oncologist designs a pelvic field that misses the disease. That recurrence is preventable with a 20-minute sampling procedure.
4. The Future: Day-Case Radical Hysterectomy and Molecular De-escalation
Two developments are reshaping early-stage cervical cancer management. The first is ERAS-enabled hospitalisation reduction: with nerve-sparing laparoscopic technique and multimodal analgesia, we are achieving 24–48 hour discharge in selected IB1 patients. The second is molecular de-escalation of adjuvant treatment: molecular profiling — including PD-L1 expression, tumour mutational burden, and mismatch repair status — is identifying subgroups where chemotherapy can be safely omitted, sparing patients toxicity they do not need. These are the directions of our research collaboration with international gynaecological oncology groups.
How CMCS Shanghai Coordinated This Case
China Medical Concierge Shanghai (CMCS) supported Ms. Renard's care pathway from initial overseas inquiry through three-month post-operative follow-up and adjuvant treatment coordination. Our coordination included:
- Pre-arrival review of colposcopic biopsy pathology, pelvic MRI, PET-CT, and HPV genotyping results; specialist referral to Dr. Hua Ke-qin's gynaecological oncology team at Obstetrics and Gynecology Hospital, Fudan University
- Arrangement of comprehensive pre-operative assessment at the Red House Hospital: repeat pelvic MRI with DWI sequences, PET-CT review, gynaecological examination under anaesthesia, and multidisciplinary tumour board review — FIGO 2018 staging confirmed and surgical strategy finalised prior to arrival in Shanghai
- Bilingual interpretation during the pre-operative consultation — including detailed explanation of IB1 staging, Piver Type III rationale, nerve-sparing technique and functional implications, ICG ovarian perfusion protocol, no-touch oncological principle, and para-aortic sampling strategy
- Facilitation of informed surgical consent — ensuring Ms. Renard fully understood oncological goals, nerve-sparing objectives, anticipated Day 1 catheter removal, and possibility of adjuvant treatment based on final pathology
- Surgical admission logistics: laparoscopic theatre scheduling, anaesthesia pre-assessment, ICG fluorescence imaging equipment confirmation, and accommodation support for accompanying partner
- On-site medical interpretation throughout hospitalisation — including ICG findings explanation, ERAS protocol guidance, Day 1 voiding trial support, and discharge planning
- Pathology results coordination: bilingual translation of full pathological report including LVSI status, margin assessment, lymph node yield, and molecular profiling results; explanation of high-risk feature implications and adjuvant CCRT recommendation
- Adjuvant treatment coordination: radiation oncology referral for CCRT planning; radiotherapy field design communication incorporating para-aortic sampling results; cisplatin sensitisation scheduling and toxicity monitoring liaison
- Three-month follow-up coordination: FSFI assessment, FSH/LH endocrine panel, pelvic examination, and MRI scheduling; results translation and communication to Ms. Renard's gynaecologist in Paris; surveillance schedule established per NCCN guidelines
- Long-term surveillance planning: annual pelvic MRI protocol; direct communication channel between Dr. Hua's team and the Paris gynaecology-oncology team for recurrence monitoring and salvage treatment planning
For international patients facing cervical cancer, ovarian cancer, or other complex gynaecological malignancies — particularly those who are young, nulliparous, or have been told that radical surgery will compromise their bladder function, sexual function, or hormonal status — the combination of fluorescence-guided laparoscopic precision, nerve-sparing radical hysterectomy, ICG ovarian perfusion confirmation, and molecular-guided adjuvant de-escalation at the Red House Hospital represents a standard of gynaecological oncological care that is genuinely at the international frontier. CMCS exists to connect patients with that expertise: ensuring every functional preservation option is evaluated, every oncological decision is explained in their language, and every step from pre-operative staging to long-term surveillance is coordinated across borders with precision and care.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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