Hello. Hello mate. Hello Stephen. How are you? What's happening? Is my face on? Have I not got my actual video after? Er, no. No, not yet. Just got a very nice, solemn photo. You see me? That's how I'm looking. I can't see you guys. Yeah, can you see me now? There he is! There he is! None of us have a skill we do, there we go. It's all guesswork, mate. It's all guesswork. It looks the exact same as the last one. When Diggan gets on here, there's a problem. He'll just chat, and we'll have nothing to talk about. That's it. He's probably on his sunbed still. That's right. Here he is. There he is. See the sunbed still working. Come on, Diggan. Just rub the cream. There he is. I knew you were going to say that. I swear to God, I knew you were going to say that. Brilliant. How are you doing, son? How are you? I'm good, mate. If you have an ace, it's hard. What's the story? That Botox? No. I've just put a little bit of colour in it. I've just come out of the garden about half an hour ago. Guys, that's what I can say. How are you? Welcome to my dad's. I'm in the butchers, you know? I got my taxidermies. I was paying him taxidermies in the next few weeks. The shop's been short since my dad got sick. That's six weeks now, you know? I opened back up this week. I was paying over 35s last year, but the old body's not able for it, you know? Guys, you've been 35 for the last 15 years, guys, haven't you? No comment. You're right. You're right instead of free. Yeah. Love it. What age are you now, guys? 28. 31. 31. 31. Yeah. Yeah. I'm still in my 40s somewhere in there, yeah? You're right. You're so very similar. 40s. 48 in two months, yeah? Yeah, you look good. Yeah, I feel all right. The last 11 weeks now, it was March the 13th. Yeah. They've been all right. In some respects, it's flew past. It's been all right. I've actually... The kids have been very good. How many kids have you got? I've got two boys, yeah. So it's been... It's been great. I think we've just had time to spend together. I haven't had that time. You're getting a coach inside of stuff. You don't get time to actually spend that quality time. You're actually thinking about other stuff as you go along. So the actual main thing has been good, because we've had time together. So that's been good. Just being football, has it? Yeah, football school in here, you name it. Yeah. PE again today, guys, for seven hours. Yeah, exactly. We've done all right there. Sorry, big one. What's the actual date of this anniversary? I mean, I should know. Was it the 29th or the 26th? 26th of May, was it? I don't know. I ain't got a clue. It was definitely... It was the... It's 2003, that's as much as I've got. Yeah, definitely, yeah. 2003. Yeah, yeah. I should know. I scored one and set up four. LAUGHTER 17 years. Wow. My God. That doesn't seem like 17 years, does it? No. Incredible. It is incredible. Tough going down. I'd been in Bournemouth, what was that, 2002? I'd been in Bournemouth ten years, the first time we played in League Two, which obviously the bottom tier. And then we got off to a bad start. I mean, I was injured, I didn't come back till October, but I looked at the North tier, I'd been given and... Yeah. Didn't win in the first five games, did we? No, madster, yeah. We lost. I'll tell you how we got on. I remember that. We just couldn't win, we just kept drawing games. We drew the first three. Yeah. Await Boston, a home against Kidderminster, a home against Cambridge, then we lost Await Swansea. Then we drew at Ohm to Oxford, so we didn't get a win in the first five, and I think that's when... I think Peter Phillips, it's said to Drisk, Peter Phillips being the chairman, I think he'd give Drisk an ultimatum, because we were in bottom few of the League Two, down the bottom end. Yeah, it's under pressure. Yeah. I don't know if anything made you change, was it? I think we had a disruptive start pre-season, because I don't... Yeah, we did. I didn't play the first three, because I got sent off at the season before at Wrexham, I think, in the last game. Yeah. I don't remember us bringing any... Feel like we brought anyone in, did we? I don't... It felt like we got more lone players throughout the season that year. It was like... People came in, Lewis Buckston, didn't we have him for a while? He was on the bench. Yeah. Yeah. I don't remember how long he was with us. I can't remember how long he was with us. We had Browner came in, then he was one... Yeah. I mean, he gave us a bit of experience, didn't he? Yeah, he did that. He was a good sign for us, yeah. Obviously, you said we were so young, genuinely, I know we had, like, Fletch and Youngie and players like that, but, genuinely, we were the young group. Well, early 20s, yeah. Yeah. Like you said, we got up to... Wasn't Shona Driscoll given, like, ten games to serve as job by Peter Phillips? It was in the paper, wasn't it? Yeah. He said he's got to get us out of the situation at least, climb the league, and I think when we started picking up games, you beat Macclesfield away, then you beat Exeter away, eh, Drew Wilbrenford, then the next win was rushed in at home. I can't remember that 3-1. That was... looking now in the middle of September. Yeah, I scored in that, remember that? Yeah. Remember that one. Well, from my perspective... I remember that one as well, Peter. Yeah. That was miles out. 35 yards, I remember that. Yeah. Yeah, never forget that one, though. Wasn't across that one, Perch, was it? Yeah, weren't you in the back post, I think? It was one of those. I tried to put swerve in it until it. Yeah. Never crossed it for me. But, Perch, didn't that season, didn't you play in midfield? Yeah, I started... I started right back or left back, yeah, and then I went to centre mid. I mean, I played, I remember that, we were quite a settled team one way or another with the odd sort of lone player coming in or whatever. But, yeah, I ended up playing most of the games in there. Yeah, yeah. Because you obviously played in the back, didn't you? Yeah, I went in the back. It was me and Brody for a long period. Cole Broadhurst, and then... Kaz was pretty much settled where you were, weren't you? So, you were, right? Yeah. Wade would have been... Me and Brown are centre midfield. Yeah. Stopped you as well, obviously. That's hate. Feeney was there as well, wasn't he? Yeah, because Feeney got injured, didn't he? Feeney got injured. Because I was just talking to Shani Maradare just before this, and he says him and Feeney got drunk. I was telling him about the night before I did the game because they were... He was suspended or injured, you know? So, he went and involved. So, that's their memory of that, yeah? No, suspended or injured means drunk. Is that what he's saying again? He went and involved, and anyway... He went and involved. Well, I think we just looked at the fixtures there from the middle of September to the end of October. We went on an eight-game undefeated run, which accumulated with six wins and two draws. Like I said, we... We beat Rushton, and then we went away to Lincoln. Yeah, I remember that. I scored in that game as well. I scored in that game as well. I scored in that game as well. Yeah, you did, yeah. That was my comeback game. I've been out for 14 months. I remember I trained about a week, and I've been out for 14 months, and Rushton called me over and trained, and I think he said to me, he's going to ask you to travel on Saturday. I was like, yeah, good one. No chance. I've been injured for 14 months, and he was like, do you want to go on the bench? I was like, yeah. I'm not ready. Fletch, I remember that differently. I remember it as you going over, Rushton going, I'm fit. I'm ready to play. I'm really fit, and he went, no, you're not. No, you're not. We were like, no, he's not ready. No, he's not ready. All in the background going like that. 14 months to come back, like that. And you need to hold up. Yeah, amazing. Yeah, I was lucky. I should have had another month after all that time, but he asked me, he asked me, he said, do you want to go on the bench? I said, yeah, and I think the only reason is, looking back, because we were playing Lincoln, and they were a big physical team, they played a certain way, didn't they? They went direct. And I remember Rushton, Rushton, Rushton's tactics, because we were obviously renowned in that league, he was a bit of a footballer, but he wanted to go fire or fire, didn't he? Do you remember? And they won't be ready for it. I think I remember him saying, if we give them what as good as what they give us, and then our footballer will come through, and I remember that you scored an absolute worldly, from about 25 yards, wasn't it? As a corner, you stepped over it for the next, didn't you? The one where you stepped over it on the edge, yeah? Oh, yeah, another assist then, because he must have taken that corner. I'm going to read that one now. Did Alan get injured in that game? I think he did, yeah. I don't know. I came on in about the 75th minute or something, and it was someone got injured, I'm sure. But I remember the game, we won 2-1, and that was like... That was way from home, Fletcher, wasn't it? Yeah, sorry. Yeah, because Fletcher... That's the way from home. That's when Fletcher takes his hands off, leaves off. Bernie, the kitman, brought me a long-sleeved shirt. I haven't worn a long-sleeved shirt since I was four years old. So I cut it, and it was too high, and it went somewhere round there. That's why I cut it. But then we went on and won, and I think we beat York at home, Bristol Rovers at home, Hartlepool at home. I think Hartlepool was on Sky on the Sunday, wasn't it? Yeah, was that... I think it was very good, remember? Was it a really windy day or something? Yeah, that would be two... I think it would be even two-one, two now. Hartlepool... That was on the Sunday on the telly, yeah. So we'd gone like eight games then, and I think we ended up about fourth in the league, so that was basically... We cemented ourselves in the top view. I'm trying to look at the fixtures. Now, after that, we drew an orient, and we beat Oxford away, three-two in the cup. We beat York at home, talky, we go, do you remember talky away, four-nil? Got beat. You got beat, didn't you? No. I remember we beat them. I might have erased that one from your memory. I don't remember that one. Yeah. Wasn't that the one where... Richard O'Kelly was good. You must feel good because you look good, but Rich was four-nil down, mate. Can't look good. No, he wasn't there. He wasn't there. It was Peter Grant. Was it Peter Grant? Yeah, it would have been Grant, yeah. It was a different talky, we must have gone back in a few times, then. We battled at home before, as well. All the seasons rolled into one for you guys, didn't it? Yeah. If you do it by what... If you do the seasons by what different names the cage and the zoo went by, then it's got a better understanding of it. That's the title of the belt. I remember, I always felt going into every game. I always felt going into every game that we were going to win. I never felt that we went into any of the games sort of worried about the result. I don't know. I had that feeling in the changing before, and we had sort of... I don't know, you had Wally putting on certain songs. I don't know, it felt like we had a routine before the game that made us feel good before we went out. I remember that. I remember us all being very... On the pitch, we weren't afraid to let each other know that that weren't quite good enough. Yeah. I don't think we won. I think everyone was honest with each other. I suppose it's always easier when you win, but I always felt that we had each other one way or another, good or bad. Yeah. Yeah. I felt...  No, go on. Sorry, sorry, sorry. No, I felt that season, like I said, there wasn't loads of bad performances, and I like going through the results, there's some draws and some losses and stuff, and I think a lot of the games at that stadium, I felt like we were poor first half, because we were going to a... Had no stand, and then we turned around and we all seemed to kind of get a game. So I can imagine, I might be wrong, but I reckon there'd be a lot of goals in the second half for us in the games that we won and stuff, but I think we was all the... You know, apart from, obviously, Fletch and Youngie and Browner to a degree, but we was all very much similar ages, I think, which was quite a positive. So we was all kind of on the same wavelength and all kind of in the same period of our careers, which I think we all pushed one another, I think, which was, you know, such a good thing to have at the time. It was always good for a goal, weren't it? Yeah. Yeah. It did seem... Actually, yeah, you're right. It almost felt like we had to go 1-0 down to then come back 2-1. That was... Yeah, very much how it felt, yeah, you're right. There's loads of... There's loads of 2-1 victories, 2-1 victories. Yeah. 3-2s, yeah. We had loads of different goalkeepers that year as well, didn't we? Yeah. We had so many, Chris Tardiff. We had, obviously, Gai Stewart and Mossy then came on in loan, didn't he? Like, towards the end, we had so many goalkeepers that year. Jimmy Astone? Yeah. Yeah, I think he got taken back, didn't he? I think he was... Yeah. We got him, I think we didn't have him very long, but it was like, oh, yeah, we were happy with him and then I can't remember whether he got injured or he got recalled or something. Yeah, we had loads of keepers. Yeah, and then we were scraping the barrel and got Neil Moss in. February came back in my notes. Yeah, and I'm like, he was big, he was big for us. Yeah, he was. Another older player that we didn't have. Just a bit of experience, I think, that definitely helped just going through the scene when you had, like, Mossy, then you had Browner and then you had Fletch and Youngy as well. Just had a little bit more know-how than what the rest of us would have been. Like, Gaz says, what, 21, 22, 23 at the time. Yeah. I don't know. Then in my notes, it's got Gareth O'Connor scored in a 2-0 win against Darlington in March. Remember it, Gaz? No, I do not. It does, because you got 10 out of 10 in the echo. I said, Mr. Neil Perret give you a 10 out of 10. I remember 10 out of 10. Yeah, I remember that, that was in the echo. Yeah, are you only talking to Perret here or there? I was going to ask him to send me over that, a picture of that, you know, because I've lost it in the paper, you know. Good one. I don't remember the goal. There's probably a cracker now on me. I love you.  Yeah, that's it.  I must check them, probably one of those goals, you know. Remind me, send me the link or have a look later. Yeah, it's on YouTube, just type in Gaz O'Connor and it's a good clip. There we go. Yeah, that'll be one goal here, all right. So then it says Neil Young scored his first league goal for five years against a 1-1 draw with Torquay at home. Can't remember that. It says he scored, but it should have been an own goal from a Gareth O'Connor free kick in the dying seconds to equalise. So you must have put the ball in, guys. You only got a touch on it, but it must have been there. So that's another assist. Many assists this. You've been on fire. Yeah. I should have went the annoying, that poorly. And we got a certain Phil Gulliver in on loan. Yeah, from Middlesbrough. Big Phil. How did you find him as a partner? Who was your partner for most of the season then? It was Cole Broaddust. And then... It was injured, wasn't it? Yeah. He got injured at ankle again, I think. So it was out for quite a long period. But yeah, I think it was Broaddee for a long period, which, I mean, Broaddee had known each other since probably... Yeah, about under-12s, something like that. So we'd all come with the same age and kind of come through everything together through the youth team and stuff. So to both be playing at the back was quite good. But yeah, he got injured and then Phil come in. And again, another young one, but just seemed to work well, and he just kind of slotted in. He was a bit more robust and a bit more physical, which was quite good. Because, you know, I didn't really like to head it too much, if I'm going to be honest.   And obviously he ended up playing in the final, didn't he? Yeah. Was he ever present then from when he came in? I think so, yeah. Yeah, I think so, yeah. Do you remember the berry game, you know, to get into the actual final? Do you remember that? Yeah. Yeah. So, postcard in the home, the way one was ranked, wasn't it? Oh, that was horrific. Jesus Christ. That's the worst game I've played in. Bill Nill. Bill Nill. Two attempts on target. Me and you played. Two attempts on target. It was one of those games that it was just, we were just trying to get through it. They tried everything to get the players sent off. Yeah. It was one of the best games. Yeah, one of the best games. Yeah, I remember it was boiling hot. The pitch was horrendous, like, bobbly end of season. Yeah. I think I had a chance, I think I had early chance, early doors from a worked free kick. I think we'd done well. Spam round the back. And I should have scored, probably, to be fair, but the goalie made a good save. So, yeah, I've done that. Two attempts on target. Yeah. Yeah, but it was horrendous. To be fair, I think, I don't know about you guys, but I always felt confident going into the game, like Perk said earlier. So, even when it was, like, 0-0, I was fairly happy, I think, like, going back. I didn't feel like there'd be... Especially going back and the second leg was at night, obviously, being caught. I always felt we played well of an evening. I don't know why, but I remember, I almost probably remember that game, the second leg of the semi-final, almost probably a little bit more than the actual final. Yeah, I agree. I'm with you on that. I remember that day quite a lot of them. Again, there was a bit of a scuffle and stuff after that game, wasn't there? I remember in the tunnel, weren't there? Granted, I can't remember, it was quite heat. But I remember all the fans coming on the pitch and all that, it was a good night. Yeah. It was a manager, Fletch, you know. He plays, any Andy Priest, do you remember him? Big striker. When did he play? He played manager. Might have been. Might have been, yeah. He scored the goal when we were three and they loved one, we cruising, then he scored with about half an hour to go like, oh, no, don't say they're going to come back. Yeah, yeah. I was like, oh, look at that. It seemed such a long time then, didn't it, from that game until the final. Yeah. I think it was weird on fire that night, wasn't it? Might have been. Was it three-nil at half-time? Yeah, three-nil. Two or three. Was it two and then he scored straight away after? Did weird score a couple of goals as well? Might have done. Should we? Guys can't remember because he didn't score or assist him in that one. No. Yeah. We, um... Okay, yeah. Now, how do you set up the other two? Yeah, weird score a two. How do you set up the other two? Because we played, um, we played Lincoln, our last lead game, hadn't we? And then we got them in the... We got them obviously in the final, but we avoided them by getting beat. They beat us one-nil at home in our last home game. Last home game. Yeah. But the other results went for us, so we were cemented in our position and then beaten us, meant we didn't play them in the semi-final, and we played very instead. I can tell you, but I remember that game. I remember that game quite well, the one-nil we lost, and I think I thought we played really well that day. I think they got a scrappy goal, like... Yeah, they did. Yeah. I think, like, towards the death or something, but I think I feel like we dominated them in the game. And I think I knew from that game, if we beat them in the final, then I knew we were going to beat them. It was almost like... I don't know what it was, but it was almost like a fate kind of thing, knowing that we'd lose that day, but then go and beat them in the final. I was very confident going into it. Especially on the big pitch, you know what I mean? I knew we'd outplay them. Exactly what I was thinking. I think of all the teams, we knew the way they played, and we just thought, on a big pitch at the Millennium Stadium, we played anywhere near our capabilities, we could tell them apart. Because obviously when you're playing on smaller pitches like Lincoln, it's in Silbangia. You get sucked into the way they're playing, which is why we did them tactic. We beat them 2-1.  I mean, we played really well up there, but we knew, obviously, at the Millennium Stadium, it was going to be a totally different game, totally different atmosphere. And if we played anywhere near what we were, Cableville are playing with the players we had, we could tell them apart. And I know it was 5-2, and we probably had some scary moments in the game where they got back into it. But I think if you looked back at the game, and apparently it's going to be on AFC, BTV, this weekend coming, I think we absolutely murdered them. I don't think they were ever... We weren't great first after. No, but we... I remember that. But we dominated. I felt like we were always on top. I know when we scored the equaliser, and I thought for a moment, I thought, oh, no, no, it's going to go against us. But I just thought, we've got all players, ball players on it, especially guys and Wade, and we just had too much of them going forward. Yeah, I think what it was, I think as well, because we were young, it could have been... nerves and stuff could have got the better of us. But I think it was like a consistent thing throughout the season. We played the way we played, and everyone knew what they were doing. So you go into that game, whether how big or how small you think it is, everyone just knew what to do. So it was almost going into the game like it was no different. The atmosphere with the roof closed and everything was brilliant. We just played the way we played. I mean, just had the confidence to keep going with what we were doing. And I think it just helped us, I think, because I felt with them, they almost, especially second half, when we went up, there was almost like, didn't really know what to do kind of thing. And then we just obviously hit them second half with quick goals. I mean, your goals came out of that. Again, you talk about goals and stuff, but the actual goals came a massive, massive time, didn't they? Because of, you know, that whole flow of the game could have been so different if you two had scored your goals at that time. And obviously then, my one sort of killed it to a point, but then we still needed the next one. Just the goals we scored, you couldn't have picked better times for them. No, exactly right. Yeah, proud of the time in there. So we played on the side, didn't we? We played Saturday, the first one, the first final wasn't that person, because when we got there, we stayed at that hotel, and we'd never stayed in the hotel. We'd never stayed in hotels like that. We used to, like, teaming up in a room no bigger than about 15 foot. Like a tent. We had our own rooms, and it was like, wow, this is unbelievable. I can't believe where it was. Was it Fairlake and Morgan? Was it that one? Think it might have been. We're not worried, because it had a history of team Sting there. I was at the dressing room. I was at the dressing room. I think the hotel was a lucky one. Hotel was lucky, changing room one. That was lucky, but we got the away changing room, didn't we? And it was supposed to be unlucky, because I remember we went to the stadium on the Friday, and I think that's when we got told that the roof was going to be closed, because it was a choice. I don't know why they closed it, I'm not sure exactly why, but I think it was better in the end. It added to it, didn't it? It was so noisy. It wasn't until we were on the coach, we were actually on the coach going to the game. That was when he actually probably hit me a little bit, thinking, this is actually a big game. With the amount of fact, I've never seen, obviously, from my point of view, I've never really ever seen anything like that with the flags and the scarves. Wow, that was... That would always be a big game. Wow, that would always live with me that, because driving down that straight, and it was like, oh, my gosh, there's thousands and thousands here. It was amazing. Do you remember we trained on the indoor ashtow at the hotel, because it was the Vale of Morgan, I remember now. Yeah, yeah. Well, he got injured, hurt his ankle. Yeah, yeah. Who? Warren Cummins. Yeah, yeah. They took him to hospital, didn't they? Yeah, he had to go back down to Bournemouth, didn't he, to get, like, an injection in his ankle to then allow him to play, because I was then... Because if he was touching go, then there was a chance I might have actually gone to left back, and because Sean pulled me and just said, like, if worst case, Warren can't play, then I was going to play left back. So it's amazing how fate has it, doesn't it? Because if I had been at left back, then wouldn't have scored. Yeah, no. Yeah, yeah. You would have got two. Love it, yeah. So if we go, if we think about the game, I don't know how much recollection you've got of the actual day, but I remember, like, you just talked about going up to the... to the stadium and seeing all the fans, all the flags. I mean, I was fortunate enough to play at Wembley in the 98th Auto Winscreen Final, and we took, like, 30,000, 30,000 fans there. So I had sort of experienced that before, only once. I know, Carl, you obviously went on to play for big teams in the Premier League and, you know, played in massive games and for your country as well. But I just remember, because I'd been beat at Wembley, I know it was only a cup game. It was the auto-winscreens final, and obviously, yeah, it's disappointing, but your league status isn't affected.   I was, like, 20, you know, I was, I was more than 29, I think I was in 2003, so I was, like, 31 years of age and I was just sick of losing. And when we turned up at the stadium, I don't think I've ever, and probably never have been since, pumped up as much. Maybe the Grimsby game, obviously, six years back when we were just in the league, but apart from that, I've never been so pumped up to win a game. I was older than you boys, obviously, so I was feeling, I'm 31, I don't win this game, I'm never going to win anything in my career. I don't know how you boys felt, but it was a little bit different for me. I was the exact same. I normally got nervous at the start of every game, but at that game when I was warming up, I'd shivered up and down my body, just now I'm nervous, just saying, this is a bit of me, I was looking around the stadium, my family was there, I just remember that, the feeling of it, any game I played after that wasn't the same, obviously it's the biggest game that I've played in. Yeah, I'm with the same. Again, you hope there wasn't maybe the pinnacle of the games that you played, but obviously, ultimately, for me, it was. Yeah. I mean, I was lucky as well, my brother was part of the squad as well, and I shared a room with him, and then he went, and I'll never forget, we got in the changing room, him and Alan Connell, and Alan in the squad EVAR, so we literally sat down, those two had already got changed and gone on the pitch, because they wanted to go and score in the goal, I swear, they must have had the longest warm-up, because they were allowed to. I was never looking up when they got out there. Yeah, that was funny. Brilliant. Yeah, I think so, I took me a bit of time, because I think I was really disappointed that we didn't go up automatically, that was my first thing, because if we went down, that was the target, and then obviously not going up automatically, but when you look back now with everything that happened and with that actual game, you can't beat going up that way, if you can guarantee it. Yeah, I think, like you say, with you guys, how you felt about the game, you perched, you fledged, there was that kind of aura that we went into the game of like a, you know, it was a no-fair, it was almost like we went into the game not even thinking about losing, like learning any of us, learning. 90% of the expected to win. I was thinking, and I wish I had, I wish most of my career I'd went in thinking like that, because I thought there's no way we're getting beat, I'm not today, I'm not having it, I'm sick of losing, I wish I'd had that feeling throughout my career, I might have been a better player, but I remember all of us, when we were shaking hands at the beginning, whoever it was from the sponsors and the royalty who came and shook our hands, I remember us just being so focused and I just thought, this team's not getting beat today, there's no way this team, I just felt this was our day, I looked around and I think we all felt confident in the team we had around us, we knew what you were capable of, guys, what perch you can do, what defence might, our defence in your mind was, we had Mossy in goal, we have you, Fletcher, the back commander, you know, we had Browner experience, we had Wade on the wing, we had Hates up front who could get a goal, we had myself, you know, you could use me as a target man, so I just looked around and I had confidence in all my teammates and I just remember thinking there's no way we're getting beat today. And the squad as a whole, because the subs as well, because everyone in that season all played, didn't they, one way or another, and I think even that, the lads who came on, you always felt that whoever was going to come on could do something and make a sort of impact and just slot in nicely, so that's credit to obviously Sean for playing and bringing those lads in and the squad as a whole, I think, because it was one of those that everyone sort of had each other's back one way or another. Yeah, it was a great dressing room. It was, yeah. It was, we had good mix, like you said earlier, like Carl alluded to earlier, we had experience from me, Browner, Mossy and then obviously had some, in the middle with like, say, JT and Perti and then we had Kaz and then we had the younger ones. The younger ones, quite mature for their age. I'm not to say that you were here, Carl, because obviously you must have done some at right, because the air or the air after you obviously got a great move and you went on to play at the top level, so a lot of our younger lads had a good maturity on the pitch. Yeah, I think so, but I think that goes through probably come from Sean really, do you know what I mean? Just allowing us to take control.  If we felt like this ain't working and we needed to change things, then I think you would allow us to do it. And like you say, it's a good mix, you know, you had younger ones that were hungry and probably the older ones fed off that a little bit and you know what I mean, the older ones would give a bit of experience to the young ones as well, so it's just all a good mix at the right time and it's back at your career. You don't always get that I mean, you don't always get that teams and I think we probably didn't appreciate it as much as we did at the time, but when you're looking back, you obviously appreciate it now and realise what you know, good effect, you know, what a good group of lads we had at that time. And I think the disappointment thing as well, like, because it was one of those that we did have a good group that the next season we should have then gone up again, you know, you get greedy but you look at, you know, we started well and we were on a bit of a run and then we just faded and you just think we could have been, we could have ended up sort of going again, you know. Easily, yeah. Should have, yeah. Should have made their layoffs.  Come on, hit the free kick from probably Gas. Probably Gas again, never say so. No, no, no, that's the only one I didn't have an assistant, but I think it was Jungi, wasn't that Jungi? From in our own half, hit the good ball up, Browner flicked it on, I just gambled across the footch of the big six foot seven centre half and courted sweetly. It was a great feeling, ran off to my family and it was early, the only thing is it was really early in the game and I was thinking, you know, I was not a goal scorer, we know that, you know, I wish I was, but I wasn't, but I was thinking there's no way this is going to be the winning goal, there's no way this is going to be the winning goal, I wanted it to be, but there's no way it was going to be and then the equalised not long after, Fletcher got up for a header, but Mossy came to punch and he used his height, six foot seven and he got a header in, it went to one-one and I don't know how you felt but I feel my heart, I remember my heart sinking thinking, please, no, not again. Yeah, it's horrible, yeah. Yeah, no, I mean I didn't feel that Fletcher from not again, because I didn't think there was a lot in it early doors, yours was a good finish and then obviously the big guy that we knew about anyway, because he was so tall and fairly mobile, he'd been doing it all season, I think he was your man as well, Fletcher when he, so... I let Mossy punch and he missed it and I got the blitz, Mossy. One job for you, one job. One job, but yeah, no, I didn't think there was a lot in the game, so I didn't feel like no, they're massively on top now and I mean, it's going to be an avalanche and we're going to be struggling. I knew we hadn't, like Perch said earlier, I don't think we started that well to be fair, I think we, you know, which we hadn't done probably all that season. I don't think ever of our first half performances, wherever that remember them and think that they were amazing. So I wasn't too worried and I think obviously getting the goal just before half-time, I think that gives us a lot of time. Perch, you mentioned that, didn't you? Yeah, I just think for us that goal before, just to go in at half-time with where we were, it just allowed us to go, okay, we weren't amazing but we can go again for me and we did, we seem to, I don't know, that second half, we did definitely start better. I felt we did. I can't remember the game exactly, but I remember us feeling that we started a bit better and I don't know if then they ended up then just, I don't know, obviously the goal didn't come about from my point of view, which was a great feeling, but it was, again, that moment we needed that moment at that time just to calm us down and then enjoy it really. I think from that moment we could all just enjoy the rest of the game as in people gets his goal and from that point of view it just ended up sort of taking control, didn't it, and everyone could enjoy themselves. Go on, Gus. You could start to take, we knew we had won at that stage, you know what I mean, so we could enjoy that, I was taken out of that stage, you know, you could relax, you know, for you to whoop you're not getting beaten from there. It went by good second goal, Carl, the second goal came from, because you were in the box anyway, so it must have been a second from a corner or something. I think it's a wide free kick I think, so I think my role usually was, I used to be the first man I think to try and get across the front man, if I remember rightly, but I think it, like you said, it comes second phase, so I don't know whether they cleared it, but then I think Gus got it in. Yeah, and I checked on to me right and put it in. I remember it's a really poor cross and I had to make the most of it. It was the faintest of touches. First of all, I wasn't sure if he had actually got anything on it, but he did. It was the only way he was showing the scars. He ran away doing this, just to make sure if I know. He was running away touching me four. And then obviously the goal of the game after half time, I mean, it came from a long throw, I think from then Mossy punched out. Mossy made up for it. He just chopped us through it. I just remember Mossy punching it. Basically Mossy did what he should have done, should have done the first goal. I think the commentator says that. I think he actually just say that. He makes it up for the error in the first half. The ball went out wide and I was on the penalty spot and I just thought, wow, there's no one else out there. I just put my head down and just run and just thought if I get in the box there's a chance. You've got the pace of Wade and, you know, fortunately it was just one of those. When you are attacking rather than defending if you're running one way you've got more of a chance of getting there just because you always do. I think it's one of those things, fortunately. It went slightly behind because then that didn't allow the defender to get there and just got contact on it. It's unbelievable. Great counter-attack and like I said, Mossy punched. I don't know who picked up on the edge but they played it out. It was me. Wade and then the Reef. No, no. It's anyone. He played wide. It was James Hatter wanted. James Hatter picked it up. Wade made the run and then obviously you've just gone charging up in the edge of your box mate. I was thinking there's no chance of getting there. And I was looking I wouldn't even have gotten to the half-wheel I never would have tried. And I was like, who's that blonde lad running through the middle? Go on, Perchie. Go on, son. And then I was nowhere near you because I was in my own box. I was nowhere near you for the celebrations. I was captive. I thought you were just rude. Yeah, yeah. But I've let our members where we cleared it and I could see it from behind but you knew as soon as it broke we was going to have a chance at the end of it because I think we had the energy to get forward, we had the legs. I remember that goal because I remember them not being able to get back and I could just see our players just kind of running away from their defenders that were trying to get back. And I knew if it fell the right way that Perchie had a good strike all season that year. I mean, I think in training our member. Yeah. I think that goal really because obviously there were two one behind and we were probably on top but one goal in it but then all of a sudden two goals in it I think it really sucked them. It was a dagger to the heart really, you want it? Yeah, I think you could feel that because you could feel that not from just the players but their fans everything and then our fans obviously the noise I remember then from that moment again I think you remember certain things through the game much as a whole but those moments after say I think everyone relaxed after that a little bit more we ended up playing pretty well from that moment I think. Because we got the fourth goal I think the ball was played up to me guys you overlapped and I turned and hit it when I left foot and next thing you're running through I'm thinking he's definitely going to square it but somehow you took it early you took it early on me left put it on to me left foot to get it yeah then the bottom corner I think then 4-1 and maybe you're running over to the crowd and we all ran over to you we were celebrating the victory then. Now I know they went mid 4-2 and Carl obviously got the final goal you put the nail in the coffin but when we were celebrating we used guys at 4-1 with whatever 20 minutes to go I'm thinking we're celebrating the victory that's how I felt Fetch if you look at that goal again the way you actually celebrate me and you it's like we've won it now that's what you're thinking I thought the game was done then they go and get a glance and header in 4-2 and then you're looking up at the clock and you're thinking oh my god there's still 10-15 minutes left but then captain Marvel pops up with the winning not the winning goal but obviously the goal that was just converting another bad cross from Gazz which was but funny Fetch you say that you had that feeling at 4-1 I didn't have that feeling that I felt the game was over there was just too much time left and then when it went 4-2 I was not nervous but I was like they were very that season they were very good at putting bodies in the box anything could have fell to them and we were generally not a big side anyway so I didn't feel comfortable but as soon as the 5th one went in I knew that I had that feeling you had at 4-1 I had that at 5-2 I knew that as it came over this was a great cross from you guys Fetch I remember being right behind you because I actually when I look back at it I've joked as if I'm going to head it but you've got in front of your defender you've got a lovely little contact and the rest history really I think we knew all season what good quality he has on his right foot so you know if you're going to make a run that we generally done our runs in the box from free kicks and stuff so we cover all areas so you knew at some point it was going to come towards you then it's just trying to get a good contact I mean it wasn't miles in the corner or anything like that but I think just the speed of it that I got and I think like I said I felt that was game over then it was like a release I felt a relief that I felt like yeah we'd won that then 5-2 we'd done you know what I mean and that was the celebrations at the end we all have our own personal families we're looking up to and friends of the game but we got on that podium and obviously you lifted the cup Carl and I remember the elation and the feeling of me personally thank God in my career at 31 I've won something I can go back to my children get grandchildren and say you know I've actually achieved something on a big occasion and you lifting that trophy I remember the video of it and we're all jumping around like lunatics and we just felt as one I think that was the thing because we were all so close do you know what I mean you felt like you were doing it with all your mates we've all been in teams where people don't get on and they have their own clicks and they're doing it for their own agendas when you actually won things or winning games but I felt like everyone was pulling in the right direction with that and it was like a massive relief and it was just it's right out there one of the best days and I remember the Sunday the Sunday morning once we got back waking up that Sunday morning was like I never had that feeling at all just the happiness that comes over your body that you go out long because it seasons along and you go all the way through it and to have achieved something at the end of it I think it started it's I just want to remember go on guys I was just saying it doesn't happen often at the end of the season if you've achieved that really do you know what I mean it's the end of the season wherever I mean the coach on the way back obviously we obviously stopped straight away didn't we and whacked out a whole off licence literally we didn't have one flick on that bus yeah you didn't have one guys you said waking up on the Sunday oh he was still awake on the Sunday morning we we even dragged a certain Mr. Audrescal in the M&A club didn't we yeah we did yeah I mean that was the real one being clapped in to go into an element where it was straight off the coach weren't we straight off the coach straight in push it up and tie brilliant and I think even the next day I think Flex said that I remember because we weren't really ever in the papers for our performance obviously being in the league we were but we're actually on the back page of whatever it was the sun or the mirror of the game I think again something that not ever used to sort of see I mean obviously the guys nowadays have that every time they do anything but you know for us that was probably the first time we'd actually seen what it'd be like you win a big major thing and obviously it was for us massive yeah it was brilliant I remember going out and collecting all the newspapers because like you said we were on the back page of all the Nationals even had a double spread in one of them and it was amazing because obviously was four scoring the goals I think it was one of them and the four of us celebrating at the end and I was pulling a champion I heard Carl have the cartman amazing mate memories that we probably don't appreciate until maybe times like now when we're talking about it because supporters mention it but you don't really sit down and analyse it and think about it probably this was the first time in 10-15 years I've even thought about that game properly in its entirety I agree and then like you say the open top was amazing as well we didn't really have ever had many in the club's history I think obviously they got promotion in 87 apart from that I don't think the club had really celebrated you know winning anything or a promotion and having an open top bus ride around the town and that was a fantastic day I think guys you'd been awake for two and a half days solid no comment no comment oh he wasn't on the top of the bus he was down on the bottom driving it he only helped me oh he was thinking about not turning up for that I swear to God great times great times and like you say something we can talk about for many years to come and it goes down in I know obviously Bournemouth now in the Premier League but from the good old days as people like to speak about it's got to be one of the best times in all the supporters' lives that I have people come up to me now and talk about it and you think what we're achieving now in the Premier League and beaten Man United beaten Chelsea beaten Liverpool but they still talk about the Millennium as their best year ever as a Bournemouth supporter and I'm thinking why would you say that beaten Liverpool 4-3 or beaten Man United must be the best day ever and they go no flesh because we hadn't really achieved anything the club had not really done anything for many many years going to a big stadium like the Millennium Stadium and achieving what we did and yeah it was only League 2 but for supporters to still say that after everything they've been experiencing you know it holds it right up there and a huge achievement really I think like you say the fact that it was like almost it turns into a little cup competition and you obviously go away and you actually go in a different stadium and you have a final most of Bournemouth would have gone down that day as families to actually go and support and have a whole day out of it so in terms of memories it definitely stands out for people and like I said I've been lucky enough to have another promotion through the playoffs as well and it's just the same it's the best way to go up if you can guarantee it obviously if you can't obviously win the title outright but yeah I mean it's a great day I think like you say the whole thing the Millennium Stadium, the roof closed the way the game went I think it was a good ending to a season that had been up and down at times but something that we've just got better and better as the season went on just good to see everyone I think we've covered a lot of things we've talked about the season and certain games I mean obviously it is 17 years ago so it is hard to remember certain games unless you've maybe scored in them so I think we've covered a good multitude of the entertainment for that season and obviously accumulating in the final we've all spoke about how we felt our emotions and what it still means to the club because it's part of the history one thing Eddie does is when any player comes in a new player doesn't matter what club he's come from he always talks about days like Millennium where this club was where it's been, where we haven't just appeared in the Premier League we were basically a league one club who dropped down to lead two and worked our way up and the nice thing is we always talk about it with the players we bring in and Ed's always been like that he's always spoke about the history of the club and it is right up there with a huge achievement in the club's history and it's for me personally and I'm sure speaking of role for you, it's a fantastic thing to be part of going down in Bournemouth history is a mirror you only have to see how many of that squad come through and have continued their careers and staying in football whether it's coaching, managing or whatever it is I think we grew up a lot there and again a lot of credit to Sean and probably to Peter Phillips as well because it had been very easy after getting relegated, it had been very easy for him to kind of sack Sean and just like get someone else in or someone with a bit more experience or something like that completely different and to be honest, if they had maybe a lot of us wouldn't have played because they might have had some money and brought older players in more experienced ones than the ones we actually had and we might not have been allowed that time to develop and play games and get that experience I think a lot goes down to Peter and obviously to Sean to give us the platform to be able to go out and perform Well in the words of Sean Absolutely Glide Absolutely Glide Glide Where's he from, Fletch? Australian Brilliant Nice to see you guys Cheers guys See you guys


You can be a company with a product, but you'd have to be just as good as content at content at a certain point You basically have to be a media company and a product company in today's environment And if you're not your brand is gonna be worthless pretty quickly shout out to Gary V because he was just screaming about it And I was listening and I'm like we're gonna make three two to three ticktocks every single day for the next two years So let's see what happens And so then things got really exciting because this is when no one else was on there And so and and we're like do why is no holy?  I think we've got like five million likes 50 million organic impressions 180,000 70,000 followers. I've been a marketer trapped in an investment banker's body for four and a half years


So I'm going to talk a bit about the management of locally advanced disease So this basically this means that you know tumors that are more advanced more larger potentially involving the lymph nodes potentially involving the venous system That are associated with a worse prognosis as compared to those tumors that dr. Mateen was talking about So I'm going to touch a little bit on adjuvant therapy adjuvant therapy basically means Patients always ask is there something that I can do Some medicine I can take some radiation I can take that will decrease the risk of recurrence That's adjuvant therapy and then talk a bit about node dissection and then management of venous tumor thrombi So just a word about adjuvant therapy. There is none There is no role for chemotherapy or radiation or targeted therapy or any therapy after surgery In the absence of clinically detectable disease So if you do not have obvious evidence of metastatic disease on your CAT scan There is absolutely no role for systemic therapy or radiation after surgery That's not to say we haven't tried and actually md. Anderson and Other centers have done clinical trials that have examined a variety of different agents including vaccines immunotherapy with interleukin 2 and interferon A variety of different chemotherapy regimens and most recently The targeted agents seraphonib and synitinib which have shown so much promise in the setting of metastatic disease But what we were able to show with a very large Literally international clinical trial Is that they don't decrease the risk of recurrence So when patients have surgery it's not uncommon to have them asking you know in the recovery room Am I going to need chemo am I going to need radiation the answer is no None of those agents work So moving on to lymph node dissection What are the clinical questions that are relevant with regards to whether or not a lymph node dissection should be performed? First obviously who should have one or when can it be avoided should it be based on tumor size stage histology? Or on the size of the lymph nodes based on imaging or interoperative assessment There's debate about what is inadequate lymph node dissection should it be just the hyalum where the blood vessels go into the kidney should should it be Clearing off the ipsilateral grade vessel the vena cava or the aorta should it be a full bilateral dissection? There's no real agreement on what constitutes an adequate lymph node dissection And then the last question is can an adequate lymph node dissection be performed? minimally invasively More and more as dr. Mateen pointed out we're doing these surgeries minimally invasively and it becomes a question as to Whether or not you can adequately do a lymph node dissection using that technology So this is going to be a little bit of a case-based approach. Here's a patient. You can see he has a very tiny little tumor Sitting on the back of her right kidney And I think we can all agree that this patient probably is not going to benefit from a lymph node dissection Um arguably she may not even need her primary tumor treated as dr. Mateen had pointed out during his lecture Uh a biopsy may help us guide further therapy Although there are some exceptions where even these tiny tumors if they have these histologies can behave in aggressive manner And now here's another patient with a very large locally advanced tumor involving the right kidney And actually has evidence of clinically involved lymph nodes. You can see there's some large lymph nodes here and here This is the aorta. There's some nodes on the side of the aorta as well So Can we all agree that basically in this setting we're probably going to perform an aggressive lymph node dissection? Although the benefit really is unclear The knowledge of histology may play a role But arguably surgery for this patient with an aggressive resection is his best chance of cure If cure is possible and we can argue about whether that's uh the case But here are the here are some cases where the role of lymph node dissection is very unclear So here's a patient with a locally advanced tumor involving the right kidney. No evidence of any lymph node involvement at all Here's another patient with a very large tumor involving the right kidney With no evidence of any lymph node involvement at all and the question is whether or not this patient should undergo lymph node dissection And would they benefit from it? Well level one evidence which means You know based on clinical trial evidence that i'll show you There is no role for a lymph node dissection in these patients It's quite possible that just removing the kidney may remove lymph nodes as a sort of a collateral damage type technique People argue that we should remove lymph nodes to better stage patients And staging may be relevant in predicting prognosis and stratification for adjuvant trials But as I told you Knowing the stage doesn't mean that we have some magical treatment that we can give that patient to decrease the risk of recurrence We don't have any And really the clinically relevant question is are these patients likely to fail regionally meaning in the lymph nodes Or distantly meaning removal of the lymph nodes is not going to change their outcome Or both Well the data and literature would suggest that if we look hard enough we will find evidence of nodal disease This was a study that was published some years ago And what they noted was in patients who had locally advanced tumors If they removed more than 13 lymph nodes the rate of positivity was almost one third So nodal disease does exist and does occur And arguably you would believe that if we can remove it safely that patients would do better But there's actually no prospective evidence to suggest that that's the case These are data from the Mayo Clinic where they looked at where lymph node or where kidney tumors metastasize where the nodes are positive And that's this has helped better frame what actually constitutes an adequate lymph node dissection So they noted that in patients with right-sided tumors The overwhelming majority of lymph nodes are going to be in the right Or in between the aorta and the vena cava and very rarely will they metastasize over to the left hand side And the same is true on the left hand side where very rarely will they metastasize to the right so We know where the positive lymph nodes should be And we know what nodes have to be removed to adequately detect them The question is whether or not we're going to impact outcome by doing such a thing These are data looking at sentinel lymph node detection. Basically they inject Radioactive material into the primary tumor and then look where that radioactive material goes And again, it demonstrates basically the same findings as the Mayo Clinic study did That the nodes will end up on the ipsilateral side as well as in between the vena cava and the aorta Suggesting that we again know where the nodal disease should exist The question is whether or not removing it is going to change a patient's outcome The vast majority of the studies looking at lymph node dissection are retrospective. These are data from the University of California, Los Angeles Where they noted that patients who had no evidence of clinical node Involvement it didn't really matter whether or not you did a lymph node dissection their outcome was exactly the same But for the first time Their data suggested that in patients who had clinical evidence of nodal metastases meaning that they had in large lymph nodes If you remove those lymph nodes patients did better than if you left them in place We did a retrospective study looking at the role of aggressive surgical resection in patients who had positive nodes We identified out of a group of three more than 3000 patients 68 patients who had positive nodes in the absence of metastatic disease. So it's actually quite rare To have lymph node metastases and not have other sites of metastases again suggesting that lymph node dissection May not play a major role in in helping patients survive their disease What we noted was that those patients who had papillary histology had a better outcome Those patients who only had one node that was positive as opposed to multiple nodes had a better outcome Those patients who had sarcomatoid features had a worse outcome And their performance status meaning how functional they were at the time of surgery played an impact in terms of their outcome But what we noted was it almost half of the patients that we operated on were disease free at 12 months And you might say wow only half I would argue that these are patients who have obvious evidence of metastatic disease and that the fact that half of them Were disease free without any additional treatment at 12 months is pretty remarkable There is one Randomized trial that was done over in europe where they asked the question Does lymph node dissection play a role in the treatment of patients with kidney cancer? And so basically patients with kidney cancer were randomized to either get a lymph node dissection or not get a lymph node dissection It was a very large trial and unfortunately at the end of the day They were unable to demonstrate a benefit of lymph node dissection And patients with kidney cancer, but if you look a little closer at the trial You'll notice that the overwhelming majority of patients that were enrolled in this trial Were actually the least likely to harbor lymph known metastases and in fact the incidence of lymph known metastasis in this trial Was only three percent So while this trial was a negative trial suggested that there is no role for lymph node dissection Others would argue that this trial is underpowered to actually demonstrate a difference and actually should be redone Focusing on the more advanced stage tumors that are more likely to harbor nodal metastases The group from mayo clinic were able to demonstrate factors that predicted for nodal metastasis including nuclear grade The presence of sarcoma toy de differentiation tumor size tumor stage And the presence of histological tumor necrosis and in fact at the mayo clinic All kidney tumors are sent for frozen section at the time of surgery and if they have a variety of these different features It triggers a node dissection basically anybody that has more than two of the features that I outlined earlier Are scheduled to undergo a lymph node dissection with a higher incidence of nodal positivity detected These are data from over in europe where they tried to predict those patients most likely to harbor nodal metastases And what they noted in their study was that those that had an advanced t stage Evidence of clinically positive nodes meaning in large nodes on cascanner at the time of surgery The presence of metastases and tumor size all were predicted of patients having nodal metastases Last year We published our experience trying to predict patients who were likely to harbor positive nodes And we noted the performance status The presence of clinically enlarged nodes local symptoms related to the tumor and ldh We're all predictive of having positive nodes at the time of surgery And so moving forward we can use nomograms such as this To try and better identify patients who are likely to harbor nodal disease and benefit potentially from a node dissection So here's a patient with a locally advanced tumor involving their right kidney And this patient's likely to have a laparoscopic surgery And really the question is can an adequate lymph node dissection be performed laparoscopically and what exactly is adequate? I would argue that in the vast majority of cases This patient will not undergo a lymph node dissection and just have their kidney tumor removed with the kidney Here's another case of mine, uh that presents You know the potential problems would not performing a lymph node dissection This was an 81 year old gentleman who was undergoing evaluation for a pulmonary embolus none was found But he had an incidental finding of a right renal mass He had novencin metastatic disease and he had what I would classify as a Surgically hostile abdomen. He had multiple previous surgeries and you know, basically I was not looking forward to going through his abdomen to try and take out his tumor Here's the tumor involving the right kidney right here And so what we decided to do instead of going through the abdomen and potentially causing all sorts of problems with his Intestines and a stomach and his colon and so forth We went into a flank incision and just removed his kidney And there was the pathology was a type 2 papillary kidney cancer that was invasive into the renal pelvis and renal vein But we had negative margins Everyone high five the guy did well. He got out of the hospital and went home But then two years later Here is a positive note sitting in the middle of his Between his vena cava and his aorta and arguably if I had you know Bitten the bullet and taken the patient to the operating room and went through his abdomen and did an adequate node dissection This uh complication would not have occurred So we had to take the patient back. He was now older He had more medical problems and we identified the two of 28 lymph nodes were positive for metastatic disease So I would argue that the patient probably would have been saved from a second morbid surgery Now these older and more medical issues if I had done an initial lymph node dissection However, again, it's unclear what the impact of that would be Here's another patient this patient has a locally advanced tumor involving their right kidney With metastatic disease and the role of lymph node dissection in the setting of metastatic disease is completely uncharted waters But we performed a site reductive nephrectomy remove the kidney Remove multiple lymph nodes associated with the kidney and postoperatively the patient came back and If you can see all this sort of gray material surrounding the liver. This is the liver here. This is the stomach This is all fluid. It's called kyla societies And basically what it means is that when we did our lymph node dissection We tried to do a good job of clipping all the lymphatics that we cut But we didn't clip clip them all and so lymphatic fluid was leaking into the abdomen And this patient required a drain placement She had to go on a no-fat diet and had to get intravenous feeding to try and stop that lymphatic flow And as a consequence, she couldn't go on to get chemotherapy that she required for her metastatic disease So I would argue she definitely didn't benefit from a lymph node dissection and actually probably was harmed by it so Many urologists look to the guidelines and we all talk about guidelines as you know ways that we can sort of better Gage our behavior in the clinic. So these are the data from the european Urology association where basically they recommend that lymph node dissection should be performed on everybody Now I think that this is probably overkill. There clearly are patients who are not going to derive benefit from Lymph node dissection. I'm really not sure what the benefit is in the metastatic setting I think at patients who have clinically positive nodes aggressive resection is probably warranted I also think in the setting of locally advanced disease that doing a lymph node dissection to better enhance staging And potentially cure some patients who harbor micro metastatic disease. It's probably warranted However, I really don't see the benefit in lower stage disease such as t1 and t2 So the role of lymph node dissection and locally advanced disease remains undefined The evidence for improved curates with lymph node dissection is lacking We don't have any data to suggest that even if patients have positive lymph nodes That taking that disease out is going to make them live longer or do better People argue that improved staging and locally advanced disease is really the only argument to do a lymph node dissection But that somehow implies That if we know that the patient has a more advanced stage that we can do something to change their outcome And as I told you we have no therapies that we know of that will do that The benefit of lymph node dissection with clinically negative nodes in the setting of metastatic disease is completely uncharted waters And really needs to be evaluated in the context of a clinical trial I think the overall message is that we need to do a better clinical trial That specifically asked the question of what is the role of lymph node dissection in the setting of advanced disease And until that trial is done really there is no guidance with regards to whether or not we should be doing lymph node dissection And patients who present with locally advanced kidney cancer So I want to move on and talk a little bit about the management of venus tumor thrombi, which is something that Many people feel is unique to kidney cancer. It's actually not But it is a common finding happening in about 15 percent of patients who present with locally advanced kidney tumors So here's a classic example This is a patient of mine who has a locally advanced tumor involving the right kidney It seems to me I've shown you every single patient I've shown you today has had a tumor involving the right kidney It does actually occur on the left as well. I'm not sure why they're all right Uh, and here you can see there's a tumor thrombus extending up Into the venus cava and actually extends all the way up into the heart And here you can see tumors sitting in the right atrium of the heart without metastatic disease And this patient actually under one surgery And was cured after her surgery So venus tumor thrombi occur most often with patients who present with clear cell renal cell carcinoma But actually can occur with all different types of kidney cancer And actually can occur with a variety of other non renal retropartanial tumors such as urethial carcinoma adrenal tumors Wilms tumor, which is another tumor of the kidney as well as metastasis And actually this was a patient who presented with testicular cancer at a venus tumor thrombus So it happens as I said approximately 15 percent of cases of patients with kidney cancer actual Just renal vein involvement is fairly common It happens in about a third of patients but more extensive involvement involved with the venus cava or atrial extension is much more rare These are the different symptoms that patients can present with when they have venus tumor involvement And it's remarkable that almost 20 percent of patients actually have no symptoms Despite having extensive involvement of the venus system With regards to evaluation MRI is the gold standard However, with multi detector CTs the sensitivity has increased dramatically But most people still prefer an MRI for evaluating venus tumor thrombus involvement Because of the lots of additional information it can provide So here's a typical case Of a patient who has again a right-sided tumor with a venus tumor thrombus extending up to almost the retro patic venus cava But you can also see evidence of bland thrombus meaning just blood clot Involving the lower venus vena cava. You can see evidence of venus collaterals So MRI is actually very good for better staging IVC thrombi and looking for evidence of bland tumor thrombus and again allows for better surgical planning When you take these patients to the operating room It's important to get updated imaging I try to get imaging on patients within a week of surgery because the thrombus can progress rapidly You can take a patient who you believe has a level 2 thrombus to the operating room And then when you get in there find out that the tumor thrombus has grown dramatically And changes the complexity of the operation Most of these patients will start on anticoagulation to prevent them from having pulmonary emboli and improve blood flow There's such a thing as called an IVC filter Which is basically a screen that you can put into the vena cava To prevent blood clot migration Many people will put them in for these venus tumor thrombi However, it changes the complexity of the operation to remove the venus tumor thrombus Dramatically, so it encouraged no IVC filters should be placed preoperatively Again, these all relate to surgical planning If there's evidence of venus wall involvement Then we would want our cardiovascular surgeons to be available to help potentially reconstruct the vena cava And this is a retrospective study that demonstrated that the diameter of the vena cava and the renal vein Help to predict whether or not the vena cava wall is actually invaded by the tumor There are a variety of different staging systems out there And what this basically allows us to do is make sure that we're all speaking the same language When we're talking about venus tumor thrombi when we talk about a level zero versus a level one versus a two three or four That we're all speaking about the same Level of involvement of the vena cava and this one for the Mayo Clinic is the most common Staging system that's used out there So just step by step, how do we take these things out these this Probably is one of the most complex operations that urologists do First and foremost make sure that you have a very experienced team assembled that includes liver surgeons vascular surgeons as well as the urologist Um, this is primarily a vascular operation not a cancer operation And it's important that you operate on the vessels first To try and get the tumor thrombus out before removing the kidney So basically you ligate the renal artery to cut up blood flow to the kidney and to the uh Tumor thrombus isolate vena structures remove the thrombus remove any distal bland thrombus Fix the vena cava and then actually perform the nephrectomy to get out the the cancer and perform lymph node dissection So these are a variety of different scenarios I won't belabor this but basically for a free floating tumor thrombi the operation is very straightforward You just basically make an incision At the level of the renal vein extract the thrombus and then close it For patients who have evidence of blood clot distally in their in their lower extremities You can put in this vena cava filter here to prevent uh migration of this tumor thrombus and prevent pulmonary emboli And patients who have actually clotted off their vena cava because of a low flow state related to this tumor Thrombus plugging up the vena cava You can either staple or even transect The vena cava to prevent harm from this bland thrombus migrating and causing a pulmonary emboli But these are thankfully exceedingly rare So again, just highlighting this is primarily a vascular operation So this is a patient with a venous tumor thrombus and the first thing that we did was place ties on the renal artery To cut off blood flow to the tumor as well as to the tumor thrombus Uh, and then worked on the vena cava to extract the tumor thrombus So these are some cartoons that hopefully will show it more graphically for you So this is a patient with a level one or level two thrombus You can see the tumor thrombus here and basically it's you know like plumbing basically you get control above You get control below you control the contralateral renal vein And then you incise the os extract the thrombus and then just close the cave otomy It gets a little more complex with more advanced tumor thrombi Here we had to mobilize the liver to allow us to get higher on the vena cava to extract the tumor thrombus Oftentimes we'll use something called trans esophageal echocardiography So basically it's an ultrasound that passes down the throat into the esophagus To allow us to monitor the height of the thrombus and look for evidence of migration of the thrombus on real time In terms of level four, which means tumors that extend up into the heart They talk about veno-veno bypass something i've never used before but we have used Cardiopulmonary bypass where you open up the chest and put the patient on cardiopulmonary bypass and stop the heart To allow us to extract the tumor thrombus from the heart and then restart the heart after the tumor thrombus has been extracted And the vena cava repaired And even though this tumor thrombus is extending all the way up into the heart these patients still can be cured Approximately 50 to 60 percent of patients who present like that will be cured at five years out from surgery This slide just talks briefly about the devastating complication of pulmonary embolism So during the course of the surgery as we're moving things around to try and take out the kidney and take out the tumor thrombus A vast minority of patients will actually have migration of that tumor thrombus up into the lungs I've seen it happen twice. It's quite dramatic And the patient could actually die on the table as a consequence of this But in this particular series of patients, they reviewed nine cases where the patient had embolized their tumor thrombus They were put on cardiopulmonary bypass Hypothermic arrest was treated was used in for the patients and you could see the outcomes Uh, the overwhelming majority of patients did die of kidney cancer However, a significant number of patients were alive and had no evidence of disease So even though the tumor is involving the vena system, it doesn't mean that it's metastatic And it doesn't mean that the patient's destined to die from metastatic kidney cancer These are data from our institution where we again looked at the role of Surgery in patients who presented with pulmonary emboli and noted that those patients who had pulmonary emboli Had a very similar outcome to patients who presented without pulmonary emboli suggesting that the embolus was not necessarily tumor and possibly could be bland thrombus So what about the role of the robot? Dr. Mateen talked about the role of the robot in patients who presented with small renal masses What about in these patients who present with locally advanced disease? Well, there is literature out there although it's very a small amount of cases Here's a patient who has a locally advanced tumor involving the right kidney with an IVC thrombus You can see they put a vessel loop around the renal vein They opened up the vena cava here. So the tumor thrombus here you can see it better here And they extracted the tumor thrombus and then sewed up the vena cava So I think it highly select cases it is possible to use the robot to treat these patients But I would argue the vast majority of patients are ultimately destined to be treated with open surgery Here's another case Published by the same author where you had a locally advanced tumor involving the kidney with a venous tumor thrombus It extended down into one of the branches of the renal vein And this patient underwent a partial nephrectomy with the venous tumor thrombus extraction done robotically Again highly select should be done by pay by surgeons who have a lot of experience working with the robot But I would argue the vast majority of cases are likely going to be treated with open surgery And here this was a retrospective review of inferior vena cava tumor thrombus surgery done robotically You'll note that this was published in 2014. Only nine robotic cases had been published in the literature So this just looks at outcomes. We looked at our experience with patients who presented with IVC tumor thrombi. We had 605 patients over A number of years A median age was 60 follow-up was two years. You can see the vast majority had just renal vein involvement Although a significant percentage Did have evidence of involvement of the vena cava 45 percent of patients presented without evidence of metastatic disease The median blood loss was almost a leader. These are very bloody operations There was a 25 complication rate within the first 30 days And if you had no evidence of metastatic disease, your outcome was quite good The overall survival was more than five years However, patients who presented with nodal or distant metastases their outcome was significantly worse related to their metastatic disease 12 patients died as a consequence of surgery There was one intraoperative death and then 10 who died Within 30 days of surgery and one patient who had a mass of PE approximately three months out from surgery So the point is that the surgery despite being very complex and major Is safe So we looked at a variety of different variables to predict outcome. They're listed here The bottom line is we found that patients who had clear cell histology had a better outcome than those that did not Patients who had high grade disease or sarcomatoid de-differentiation Evidence of fat invasion nodal metastases or distant metastases all of those factors were associated with the worst outcome In patients who had IVC tumor thrombi We noted that patients who had tumor thrombi that extended up into the heart had a worse outcome than patients who just had involvement Of the vena cava below the level of the diaphragm And in comparing our series to other series that have been published in the literature in the past outcomes are very similar I'm going to pass through that This was looking at a finding that was really sort of surprising to me We looked at 270 patients who had venous tumor involvement And we noted that almost 20 percent of patients had cancer present at the margin And positive margins were more likely in patients who had a higher level tumor thrombus or those that had a higher grade tumor And so I looked at this data and I said wow, maybe we should do something to change our technique If more than almost 20 percent of patients had cancer present at the margin of resection And those patients were more likely to have a local recurrence and more likely to have metastatic progression So my thought was well, maybe we should change our Operative technique and check margins at the time of surgery and those patients that had positive margins Maybe we should you know resect more of the vena cava or maybe even resect the entire vena cava and reconstruct it But in fact if you actually look at how these patients recur The overwhelming majority of patients who had positive vein margins in the blue here Progress with metastatic disease And this would argue that changing the surgical technique or being more aggressive locally is not going to impact their outcome overall Because the vast majority are destined to progress with metastatic disease suggesting that this is a reflection of the biology of the tumor Not some inadequacies in the surgical technique Okay, I'm going to skip over this because it's not relevant So suppose we don't operate on these patients in in many cases Urologists out in the community are quite daunted by the prospect of taking one of these patients to the operating room Because of the complex nature of the surgery well This was a retrospective study looking at conservative management of patients who present With iBC tumor thrombin you can see the patients that are not operated on do poorly systemic therapy alone does not work in these patients This was a study out of the Mayo Clinic that showed this exact same thing So what about the role of systemic therapy in the treatment of these tumors many times patients out in the community Will be started on some form of targeted therapy And be and told that this this targeted therapy will make your tumor thrombus shrink and make your surgery easier And there are multiple anecdotes and literature Suggesting that starting patients on targeted therapy will dramatically reduce the size of their tumor thrombus Well, we published a retrospective study looking at the role of targeted therapy in shrinking tumor thrombi Long story short the bottom line is the vast majority of patients had little to no Impact on their tumor thrombus as a consequence of systemic therapy There were three patients that did have some decrease in the level of their tumor thrombus But the vast majority had little to no impact We did another study where we looked at patients with metastatic disease treated with targeted therapy We had 48 patients who had venous involvement And again the very similar story that the vast majority of cases Had little to no impact on their tumor thrombus as a consequence of being treated with targeted therapy You can see 75 percent at stable disease. And in fact 15 percent of patients actually grew while they were getting the targeted therapy So I would argue that there's little to no benefit from systemic therapy and treating patients Who present with venous tumor thrombi and that surgical therapy remains the gold standard Then lastly i'm going to talk about one of the devastating complications associated with The venous tumor thrombi and that's bud kiari syndrome. So basically if the tumor thrombus grows big enough It can grow past the hepatic veins and actually cut off blood flow draining from the liver and you can see this sort of Flow defect in the liver that's consistent with a bud kiari syndrome and patients will present with abdominal pain They'll have a cites, which means fluid in the abdomen. You can see there's fluid in the abdomen over here Uh, hepatomegaly meaning enlargement of the liver lower extremity edema and abnormalities in their liver function tests In our hands if patients present with this syndrome and we take them to the operating room the in-hospital mortality rate is in excess of 80 percent So basically the overwhelming majority of these patients if you try to operate on them will die So what we do now instead of taking them to the operating room is we will embolize the kidney Meaning to cut off blood flow to the kidney in the hopes that this vascular thrombus Will shrink as it did here and you can see that there's shrinkage of the tumor thrombus There's blood flow Occurring in the vena cava around the tumor thrombus. You no longer see that perfusion defect in the liver And after three months of allowing this tumor thrombus to shrink We were able to take this patient to the operating room and cure them of their kidney cancer So radical nephrectomy with ibc thrombectomy is a very demanding surgery that can be associated with significant side effects and mortality But in the absence of metastases or nodal disease or sarcomatoid de-differentiation or fat involvement Um, it does appear to be associated with an excellent prognosis Minimally invasive approaches are described But I would argue is not the the standard of care and patient selection appears to be critical In terms of better selecting patients for minimally invasive approaches And presurgical treatment with either embolization or targeted agents does not appear to be helpful And in fact may worsen a patient's prognosis So that's basically a sort of summary of how to treat patients who present with locally advanced disease again The take home points are adjuvant therapy does not exist in 2016 The role of lymph node dissection is unknown, but in locally advanced disease It's probably advocated and the management of ibc thrombi can be quite challenging But patients will still have excellent outcomes as long as they're treated at major centers by people who have experience