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Introduction The management of acetabulum fractures in osteoporotic elderly, as well as comminuted fractures in younger patients is likely to be difficult. These fractures need specific fixation techniques especially when the quadrilateral plate is involved. Standard implants may not be able to adequately support the fixation, so newer pre-shaped fixation plates have been proposed with some of these already in use. The concept of anatomic plates has come up for many fracture locations for providing a better buttress effect to the comminuted fragments. There has been a need to look for an anatomic buttress plates being developed for acetabulum fractures involving the quadrilateral surface. Materials and methods The literature has been reviewed to find the various newer designs that have been used for buttressing the quadrilateral surface in comminuted acetabular fractures. An attempt has been made to study their design characteristics and clinical outcomes. The review also includes the analysis of Anatomic Quadrilateral plate (AQP) used in fixation of acetabulum fracture involving quadrilateral surface in a series of 33 patients. Results There has been few anatomical plates developed for the stabilization of acetabular quadrilateral surface fractures. Some of these plates have been successfully used in management of acetabular fractures primarily in young patients. Issues however remain in their application and outcomes in osteoporotic fractures of the acetabulum, as these plates support the pelvic brim fragments either from superior or medial surface. The newer development i.e. ‘Anatomical Quadrilateral Plate’ is optimized to counter the displacement forces due to its positioning on the pelvic brim rather than its superior or medial surface. Other special features include the possibility of longer screws across bone due to oblique position of holes, the typical location of a locking hole on the plate beam which permits dual cortical compression fixation either by using a bigger screw or a specially designed screw in screw construct across the supra-acetabular corridor. The option of using hybrid fixation of both locking and unlocked screws in AQP allows proper stress distribution on the underlying bone, aiding both primary as well as secondary stability. The minimum of one year post surgery outcome of patients having acetabular fixation using this Anatomic quadrilateral plate has been analyzed in 33 patients. Twenty three of these were aged more than 50 years and 28 out of total 33 were males. Associated injuries included Ipsilateral lower limb injury in 2 patients and distal radius fracture in 5 patients. The fracture pattern included ‘Anterior column posterior hemi-transverse’ in 10 patients,’ Associated Both Column’ injury in 9 and ‘T type’ acetabular fractures in 8 patients. Isolated ‘Anterior column’ was fractured in 6 patients. The surgical approach was ‘Anterior Intra-pelvic’ (AIP) in 23 patients and ‘Modified Ileo-femoral’ in other 10 patients. One patient had additional K L approach. Among the implants, the AQP plate was used without its pubic arm in 6 patients. The post-operative x rays showed anatomical reduction in 28 patients, while other 5 had gaps and/or steps up to 2 mm size. In subsequent car, one of these patients needed hip arthroplasty for problem arising due to collapse in fixation within six months. EQ 5D 5L telephonic score was used to know the outcome at minimum of one year follow up in 33 patients. As per this score, only 3 patients had an issue with mobility, with only one having problem in self-care activity. Six patients complained of minor limitations in carrying out their usual activities and only one patient had anxiety affecting him. In their self-assessment of overall health status, 22 patients marked it 100, 7 made it 90, 3 as 80 and 1 had marked it as 70 in a score range of 0–100. Considering the predominant elderly profile in this series of patients, the acetabular reconstruction using ‘Anatomic quadrilateral plate’ has shown encouraging results. Conclusion For stabilization of acetabular fractures involving quadrilateral surface area and pelvic brim, various new implants have been used. The Anatomic quadrilateral plate due to its anatomical shape, the various options in fracture fixation is best optimized for management of comminuted acetabulum fractures especially in poor quality bones. It has been successful in achieving good outcome in elderly group of patients having these complex injuries.

Flank and lumbar hernias are challenging because of their rarity and anatomic location. Several challenges exist when approaching these specific abdominal wall defects, including location, innervation of the lateral abdominal wall musculature, and their proximity to bony landmarks. These hernias are confined by the costal margin, spine, and pelvic brim, which makes closure of the defect, including mesh placement, difficult. This article discusses the anatomy of lumbar and flank hernias, the various etiologies for these hernias, and the procedural steps for open and robotic preperitoneal approaches. The available clinical evidence regarding outcomes for various repair techniques is also reviewed.

This review article will focus on the classification and treatment options for pelvic ring fractures. The pelvic ring can be split into anterior and posterior supporting structures. Injury can result in mechanical pelvic instability, the significance of which is determined by the magnitude and direction of forces applied during injury. The typical fracture patterns of anteroposterior compression, lateral compression and vertical shear form the basis of the Young and Burgess classification. However, the logic of the Tile classification system is useful in determining the degree of pelvic instability and the optimal surgical stabilization options. Posterior pelvic ring stabilization is often performed percutaneous after closed fracture reduction with sacro-iliac screws. This avoids the soft tissue complications often associated with open posterior approaches. Alternative reduction techniques can be performed through an open anterior approach using the first ilio-inguinal window to approach sacro-iliac joint disruptions as well as crescent fractures of the posterior iliac wing. The anterior pelvic ring, traditionally stabilized with external fixation, can be well accessed with the open ‘STOPPA’ approach. This allows access to an area extending from the pubic symphysis around the pelvic brim to the anterior aspect of the sacro-iliac joint where plates can be applied. Other options for anterior ring stabilization include column screws and the use of the ‘In-fix’ (Internal Fixator).

This video shows the surgical excision of a 20-cm peritoneal inclusion cyst with laparoscopic repair of pelvic floor defects caused by the mass effect of the cyst. A 44-year-old woman presented with bulge symptoms and a reducible posterior prolapse extending 4 cm beyond the introitus inconsistent with an enterocele/rectocele. Dynamic MRI revealed a 20-cm cystic mass surrounding the uterine fundus extending down the posterior wall of the vagina, anterior to the rectum. Robotic-assisted laparoscopy revealed stage-IV endometriosis and a large peritoneal inclusion cyst extending from the pelvic brim to the rectovaginal septum. The cyst was mobilized through retroperitoneal dissection. Redundant peritoneum was excised down to the perineal body, and the distended posterior vaginal wall was plicated laparoscopically. The peritoneum was closed in a purse-string fashion, obliterating any potential space. Resolution of the prolapse was confirmed along with restoration of normal anatomy. We managed a unique case of a large peritoneal inclusion cyst presenting as vaginal prolapse. To correct defects after cystectomy, laparoscopic repair was performed similarly to closing an enterocele. Repair of a high posterior defect can be performed laparoscopically when working abdominally to avoid vaginal incisions, allowing for excellent visualization and access.

Introduction Quadrilateral plate fractures constitute one of the most challenging components of acetabular fractures. The objective of this study is to describe and evaluate the novel technique of buttress screw fixation of the quadrilateral plate component of the acetabular fractures. Patients & methods Forty cases of acetabular fracture with associated quadrilateral plate component were included in the study. Mean age was 35 years (range, 16 − 68 years), with a mean follow-up 16.4 months (range, 9 − 36 months). Fixation of the quadrilateral plate was achieved by one or more buttress screws. The screws were inserted through the reconstruction plate, and placed close to the edge of the pelvic brim. To effectively achieve the 3-point fixation principle, the screw was inserted through the plate hole then outside the bone rubbing on the pelvic surface of the quadrilateral plate. Results Anatomical reduction of the quadrilateral plate component of the fractures was achieved in all but one patient. The modified Merle D’Aubigne and Postel score was excellent in 13 cases, good in 23 cases, fair in three cases, and poor in one case. No screw displacement or failures were observed during follow-up evaluation. No major complications related to this technique were observed in this series. Conclusion Buttress screw fixation of the quadrilateral plate fracture component in associated acetabular fractures is a safe and effective technique for reduction and fixation of these challenging fractures with no major complications related to this novel technique.

Study Objective To demonstrate a surgical video wherein deep infiltrating endometriosis (DIE) was resected off the left pelvic sidewall. Design Step-by-step video demonstration of DIE resection from the external iliac vessels and the ureter. Setting Academic tertiary referral center. Patients or Participants 41-year-old female with history of endometriosis, presented with pelvic pain and left lower extremity swelling. Abdominal and pelvic imaging revealed extensive left pelvic sidewall fibrosis, resulting in compression of the external iliac vein, hydroureter and renal atrophy. Further urologic workup showed minimal to no residual function of the left kidney. Interventions Patient was taken to the operating room for resection of sidewall endometriosis and concomitant nephrectomy. Exploration of the peritoneal cavity showed that endometriosis was confined to the pelvis, heavily involving the left pelvic sidewall. The left retroperitoneum was entered and avascular spaces were elaborated. The left hydroureter and IP ligament were identified above the pelvic brim, as well as the common iliac vessels. Once proximal and distal access to the external iliac vessels were obtained, the majority of DIE was resected off the vessels. Complete resection of sidewall DIE would have led to vascular injury; therefore, the decision was made to proceed with debulking of fibrosis off the vessel surface and the remainder of the lesions inferior to the external iliac vessels. Given inability to salvage distal left ureter and non-functional kidney, concomitant left nephrectomy was performed. Measurements and Main Results The procedure and post-operative course were uncomplicated. There was significant improvement in patient's pelvic pain and lower extremity swelling. One month after surgery, she underwent balloon angioplasty and stenting of left external iliac vein to attain complete patency of the vein. Conclusion Long-standing DIE can lead to vascular compression and unsalvageable renal obstruction, which requires a multidisciplinary team approach in order to address this multisystem disease.

Objective To illustrate the surgical management of advanced endometriosis causing extrinsic ureteral compression. Design Video description of the case, demonstration of the surgical technique, reevaluation at 14-year follow-up, and review of urogenital endometriosis. Patient provided consent for the video recording and publication. This surgical report with no identifying patient data was exempt from Institutional Review Board approval. Setting Tertiary referral center. Patient(s) A 42-year-old nulligravida with a known history of endometriosis presented with persistent pelvic pain and no other specific symptoms. She had previously undergone a diagnostic laparoscopy demonstrating advanced endometriosis involving multiple organs, including the urinary tract. She was referred to us for further surgical management. Preoperative intravenous pyelogram showed partial obstruction and constriction of a long portion of the midpelvic and distal left ureter with proximal hydroureter, consistent with extrinsic ureteral compression. Intervention(s) The patient underwent operative video laparoscopy using a multipuncture technique, with enterolysis, extensive left ureterolysis, shaving of periureteral constrictive fibrosis and endometriosis, cystoscopy, and placement of left ureteral stent. Main Outcome Measure(s) There was extensive endometriosis and fibrotic adhesions involving the left pelvic sidewall. Proximal hydroureter was noted to the pelvic inlet secondary to severe periureteral fibrosis from the pelvic brim to the bladder meatus, with significant narrowing of the pelvic ureter. The endometriosis was resected using hydrodissection and shaving with a carbon dioxide laser. Histopathologic evaluation of the resection specimens confirmed endometriosis. Result(s) An intravenous pyelogram performed 4 weeks postoperatively revealed ureteral patency and resolving hydroureter, and her ureteral stent was removed. Annual renal ultrasounds for the subsequent 2 years were normal. Fourteen years later, she remained asymptomatic on no suppressive treatment. A follow-up intravenous pyelogram was performed and showed a normal urinary tract with bilateral ureteral patency and no recurrent strictures or hydroureter. Conclusion(s) In selected cases, conservative shaving of periureteral fibrotic endometriosis avoids ureteral resection and has acceptable outcomes.

Objective Excisional techniques used to surgically treat deep infiltrating endometriosis (DIE) can result in inadvertent damage to the autonomic nervous system of the pelvis, leading to urinary, anorectal, and sexual dysfunction 1 , 2 , 3 , 4 . This educational video illustrates the autonomic neuroanatomy of the pelvis, identifying the predictable location of the hypogastric nerve in relation to other pelvic landmarks, and demonstrates a surgical technique for sparing the hypogastric nerve and inferior hypogastric plexus. Design Using didactic schematics and medical drawings, we discuss and illustrate the autonomic neuroanatomy of the pelvis. With annotated laparoscopic footage, we demonstrate a stepwise approach for identifying, dissecting, and preserving the hypogastric nerve during pelvic surgery. Setting Tertiary care academic hospitals: Mount Sinai Hospital in Toronto, Ontario, Canada, and S. Orsola Hospital in Bologna, Italy. Interventions Radical excision of DIE with adequate identification and sparing of the hypogastric nerve and inferior hypogastric plexus bilaterally was performed, following an overview of pelvic neuroanatomy. The superior hypogastric plexus was described and the hypogastric nerve, the most superficial and readily identifiable component of the inferior hypogastric plexus, was identified and used as a landmark to preserve autonomic bundles in the pelvis. The following steps, illustrated with laparoscopic footage, describe a surgical technique developed to identify and preserve the hypogastric nerve and the deeper inferior hypogastric plexus without the need for more extensive pelvic dissection to the level of the sacral nerve roots: (1) transperitoneal identification of the hypogastric nerve, with a pulling maneuver for confirmation; (2) opening of the retroperitoneum at the level of the pelvic brim and retroperitoneal identification of the ureter; (3) medial dissection and identification of the hypogastric nerve; and (4) lateralization of the hypogastric nerve, allowing for safe resection of DIE. Conclusion The hypogastric nerve follows a predictable course and can be identified, dissected, and spared during pelvic surgery, making it an important landmark for the preservation of pelvic autonomic innervation.

Purpose The internal iliac artery displays variations that may predispose it to inadvertent injury during pelvic surgeries. This study aimed to describe variations of the internal iliac artery among Kenyans. Basic procedures Fifty-seven pairs of right and left-sided hemi-pelvises, 48 from males and 9 from females, were used in this study. We collected data on the internal iliac artery origin, relations, termination, branching, length and course of parietal branches. Data were then coded and entered into SPSS (version 21, Chicago, IL), where we performed descriptive statistics and analyses. Findings In all cases, the internal iliac artery originated singly from the common iliac artery. The IIA originated above the vertebral level of the L5/S1 disk (pelvic brim) in 30/57 (52.6%) cases, with the highest observed at L4. In most cases (32/57 [56.8%]), the IIA terminated at S1 vertebral level. The internal iliac artery lay medial, anterior and lateral to the sacroiliac joint in 37/57 (64.9%), 18/57 (30.6%) and 2/57 (5%) cases, respectively. Regarding parietal branching, 39/57 (64.8%) cases had a type 1 pattern as per the Adachi classification. The mean diameter and length of the internal iliac artery were 7.32 ± 1.69 mm and 36.97 ± 14.12 mm, respectively. The differences in dimensions of the IIA between the left and the right sides were not significant. Principal conclusions A considerable proportion of the Kenyan population demonstrates an origin of the internal iliac artery above the pelvic brim. Unique termination via trifurcation and ramification may also be observed in the Kenyan population. Surgeons and radiologists performing vascular interventions in the pelvis should be mindful of these variations.

Video Objective This video describes a systematic stepwise approach for complete dissection of ovarian remnant in the setting of a previous ureteral re-implantation. Setting A 40 year old patient presenting with a history of ureteral injury during hysterectomy, followed by re-implantation. She had another ureteral injury during oophorectomy which required a secondary re-implantation. The patient then developed pelvic pain, and she was found to have a large pelvic mass. Hormonal assays confirmed premenopausal status consistent with ovarian remnant syndrome. The patient decided on medical management for several years, including progestational agents and GnRH agonists, but ultimately the pain became excessive, and she decided on surgery. Interventions Laparoscopic resection of ovarian remnant was performed in a systematic stepwise approach, with sealing and cutting of the ovarian vessels at the pelvic brim, and removing of the entire ovarian vessels pedicle together with the adherent pelvic side wall. Conclusion This stepwise approach for ovarian remnant resection provides a roadmap for the effective and safe excision of the ovarian remnant, while minimizing the risk of injury to the bladder, the ureters and the rectum.

The number of acetabular fractures in the geriatric population requiring open reduction and internal fixation is increasing. Fractures with medial or anterior displacement are the most frequent types, and via the ilio-inguinal approach buttress plates have proved helpful to maintain the quadrilateral surface or medial acetabular wall. Seven to ten hole 3.5 mm reconstruction plates may be used as buttress plates, placed underneath the usual pelvic brim plate. This retrospective study presents our results with this technique in 13 patients at a minimum follow-up of 12 months (average, 31 months). 85% of the patients had a good result. The early onset of post-traumatic osteoarthritis necessitated total hip arthroplasty in two patients (15%) at 12 and 18 months follow-up, respectively. This treatment option should be considered in the surgeon's armamentarium when fixing these challenging cases.

Video Objective The objective of this video is to demonstrate the technique of performing an ovarian transposition using robotic assistance in order to preserve ovarian function in a patient who is planning to undergo pelvic radiation therapy. Setting The patient is a 29 y/o nulligravida with a history of stage 3B rectal adenocarcinoma. She is s/p neoadjuvant chemotherapy using Folfox and Capecitabine and is planning for pelvic radiation therapy. She elects to undergo a transposition procedure in order to reduce her risk of premature ovarian failure. Interventions The robotic trocars are placed in the standard gynecologic oncology robotic fashion in order to mobilize the ovaries above the pelvic brim and out of the radiation field. To avoid comprising the ovarian vasculature, retroperitoneal tunnels are created in the pelvic sidewalls bilaterally and the adnexa are pulled through. The ovaries are sutured in place superior to the anterior superior iliac spine and lateral to the psoas muscle. Surgical clips are placed at the border of each ovary for identification during radiation planning. Conclusion Pelvic radiation therapy is often required in the management of gynecologic and nongynecologic malignancies. The ovaries are extremely radiosensitive and very low doses can be associated with a high risk of ovarian failure. Premature menopause results in long-term deprivation of estrogen and can lead to increased risk of all-cause mortality, cardiovascular risk, and osteoporosis. Research indicates that many female patients diagnosed with cancer do not receive adequate information regarding ovarian preservation. One study reports that 50% of oncologists reported moderate to high confidence in knowledge of female fertility preservation. Laparoscopic ovarian transposition is a great surgical option for reproductive age women undergoing gonadotoxic radiation. Robotic assisted ovarian transposition has the advantage of improved visualization and articulation of wrist movements. Robotics can help to overcome the limitations of laparoscopy, especially in complicated procedures.

Video Objective To describe the anatomy of the ovarian vessels cephalad to the pelvic brim. Setting A 45 year old multiparous woman presents with chronic right pelvic pain following hysteroscopic tubal sterilization. Bilateral ovarian vein embolization was performed for suspected pelvic congestion syndrome. Her pain worsened post-embolization. After an extensive pelvic pain evaluation, the decision was made to remove her embolization and tubal occlusion coils. Interventions Laparoscopic dissection and removal of the right ovarian vessels above the pelvic brim is described. Multiple steps are required for a safe and complete resection: 1- Retroperitoneal access; 2- Maintaining hemostasis; 3- Traction/counter-traction; 4- sharp and blunt dissection; 5- judicious use of electrosurgical energy. Conclusion Successful dissection/resection of ovarian vessels is feasible and safe with in-depth knowledge of neighboring structures cephalad to the pelvic brim.

Aims The treatment of pelvic soft tissue sarcomas (STS) presents one of the most challenging problems in musculoskeletal oncology because of the complex anatomy of the pelvis, late diagnosis and large tumor size. Our study was designed to determine the outcome and prognostic factors for survival and local recurrence in patients with pelvic STS located deep to the fascia and deemed suitable for curative surgical treatment. Patients and methods Ninety consecutive pelvic STS patients with at least 5-year possible follow-up from diagnosis were studied. Mean age at diagnosis was 54 years. Mean follow-up and tumor size were 69 months and 13 cm, respectively. Histological grades were grade 3 in 51, grade 2 in 22 and grade 1 in 17 patients. Tumor locations were extra-pelvic or outside pelvic brim (n = 67), intra-pelvic or within pelvic brim (n = 10), and combined or involving both outside and within pelvic brim (n = 13). Result Surgical treatment was excision in 84 patients and hindquarter amputation in 6 patients. In 84 patients who underwent excision, surgical margin was wide in 21 patients, marginal in 33, and intralesional in 30. Radiotherapy was used for all high grade tumors. Disease-specific survival was 53.3% at 5 years. Local recurrence occurred in 23%. Development of local recurrence was related to surgical margin (p = 0.03). Local recurrence, tumor histological grade and metastasis at diagnosis independently influenced disease-specific survival (p = 0.0008, p Conclusion The patients with high grade tumors and positive surgical margins represent a particular group with high risk of local recurrence even with radiotherapy.

Background Recurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient. Case An 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim. Summary and Conclusion In the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.

The purpose of the study was to assess the stability provided by an ilio-iliac dorsal plate fixation technique using an AO narrow DCP on the pelvic brim in vertically and rotationally unstable type-C pelvic ring injuries.We examined 12 fresh cadaver pelvises in a single limb stance load. A type-C pelvic ring injury (a type I lateral sacral fracture in the classification of Denis with symphysis pubis rupture) was performed on the cadaver specimen and fixed with a four-hole narrow dynamic compression plate to stabilize the symphysis pubis rupture; the sacrum fracture was stabilized either anteriorly with two 3-hole reconstruction plates ("anterior plate osteosynthesis") or with a posterior fixation using a 12-hole narrow DCP. A cyclic load of between 100 and 250 N was applied to the fifth lumbar vertebra of the specimen. An extensometer was attached to both sides of the sacrum fracture to detect movements at the fracture site.We were able to achieve usable measurements in nine specimens. Three measurements were performed on each specimen, and the movements recorded at the fracture gap in trans-sacral plate fixation were higher than or similar to those observed for anterior plate synthesis in 23 out of 27 cases.Dorsal ilio-iliac bridge plate fixation provides somewhat reduced stability compared to anterior plate fixation, but the difference is not significant.

The retroperitoneum is the compartmentalized space bounded anteriorly by the posterior parietal peritoneum and posteriorly by the transversalis fascia. It extends from the diaphragm superiorly to the pelvic brim inferiorly. This article discusses clinically relevant anatomy of the abdominal retroperitoneal spaces, their cross-sectional imaging evaluation with computed tomography and magnetic resonance imaging, and the imaging features of common retroperitoneal pathologic processes.

Study Objective To present the feasibility of single-port laparoscopic surgery at patients with deep infiltrating endometriosis. Design Step by step explanation of the surgery using videos (Canadian Task Force classification III-c). Setting Single-port laparoscopic surgery is an emerging technique and an option for improving the benefits of laparoscopic surgery. The goals of single-port laparoscopic surgery is to further enhance the cosmetic benefits of minimally invasive surgery and minimize the potential risk and morbidity associated with multiport surgery [ 1 , 2 ]. This procedure is not without challenges, however, such as instrument crowding and clashing, ergonomic difficulties, loss of instrument triangulation, and the need for advanced laparoscopic skills [ 1 , 2 ]. Despite these challenges, technical advances in optics and instrumentation have led to the widespread use of single-port laparoscopic surgery to treat such gynecologic disorders as endometriosis, uterine myomas, and cancers [ 2 , 3 ]. Interventions A 42-year-old woman was admitted to our clinic with a complaint of chronic pelvic pain dysmenorrhea and deep dyspareunia. Her medical history revealed a cesarean section delivery and a diagnosis of endometriosis. Despite treatment of her endometriosis with dienogest, there has been no decline at her complaints. Ultrasound examination performed at admission revealed a 6 × 6 cm right adnexal mass compatible with endometrioma, with a normal left ovary and uterus. Rectovaginal examination detected no endometriotic nodules. Although all treatment options were explained and discussed and laparoscopic excision of right ovarian endometrioma was recommended, the patient strongly desired removal of the uterus and the ovaries to avoid recurrence of endometriosis and related complaints. Thus, laparoscopic hysterectomy and bilateral salpingo-oophorectomy were planned. Under general anesthesia and endotracheal intubation, the patient was placed in low lithotomy position with the arms tucked. An orogastric tube and a Foley catheter were placed. Abdominal access was performed following an open Hasson technique with a 2.0- to 2.5-cm vertical umbilical incision and a 4-channel (with two 10-mm and two 5-mm channels) access port was placed into the peritoneal cavity. On pelvic examination, a 6 × 6-cm right ovarian endometrioma adherent to the pelvic sidewall was detected, along with severe adhesions on the left side between the left adnex and the pelvic sidewall. The uterus was normal. The adhesion on the left side was released using a Harmonic scalpel (Ethicon Endosurgery, Cinncinnati, OH). The pelvic sidewall peritoneum was opened, and the ureters were identified and isolated at the pelvic brim and followed toward the true pelvis. The internal iliac artery, uterine and obliterated umbilical artery, and infundibulopelvic ligament were dissected and identified. The paravesical, pararectal, and rectouterine spaces were opened. Deep infiltrating endometriosis implants on the right side located in the uterosacral ligment and pararectal space were dissected and excised. After restoration of pelvic anatomy, hysterectomy and bilateral salpingo-oophorectomy were performed. The vaginal cuff was closed with intracorporeal knots. The patient was discharged on postoperative day 1, and reported no problems at follow-up. Conclusion Single-port laparoscopic hysterectomy appears to be a safe and feasible option in patients with deep infiltrating endometriosis, especially when performed by well-experienced surgeons.

Urinary tract calculi have plagued humans since the dawn of civilization. The obstruction of the urinary tract by calculi at the narrowest anatomic areas (ureteropelvic junction, near the pelvic brim, ureterovesical junction) leads to impaired drainage, which usually eventually causes the agonizing pain of renal colic. The primary objective of the therapeutic management of urolithiasis is to provide relief of pain during an event of acute renal colic. Current evidence suggests that nonsteroidal anti-inflammatory drugs and opioids are the "traditional" choices, and some specific agents also may be effective. Adverse events of the medication administered for the management of renal colic should be considered before using these agents. An additional aim of the urologist is to overcome the obstruction and to preserve renal function. Medical expulsion therapy for ureteral stones has been suggested as a method of conservative management of ureteral stones. The aim of this medication is to facilitate the passage of ureteral stones, an area that currently seems to be a field for continuous investigation. Current literature suggests the use of calcium-channel blockers and α-blockers for facilitating expulsion of stones, regardless of size. Nevertheless, patients with stones

Anaesthetists often stand in the front line to manage postpartum neurological deficits, although epidural analgesia is rarely responsible for these complications. An epidural analgesia was performed to relieve pain during spontaneous labor in a 34-year-old parturient. An emergency C-section was subsequently required due to fetal heart rate abnormalities. Twelve hours after catheter removal, the parturient developed a severe right leg motor and sensory neurological deficit, predominant on L5 and S1 roots and diagnosed by a neurologist as a central nerve root injury. Lumbar MRI identified a non-compressive epidural bleeding in front of the L5 vertebral body. Epidural bleeding after labor epidural analgesia is a rare complication that may jeopardize the functional prognosis. It may be difficult in some cases to differentiate an upper plexus injury due to labor and delivery from a central epidural analgesia-related nerve root lesion. Fetal head compression at the pelvic brim may induce neurological deficits in several well-differentiated nervous territories, thus mimicking an anaesthetic-induced perimedullar radiculopathy.

Purpose: To assess the adequacy of nodal coverage of "conventional" pelvic radiation fields for carcinoma of the cervix, with contoured pelvic vessels on simulation computed tomography (CT) as surrogates for lymph node location. Methods and Materials: Pelvic arteries were contoured on non–contrast-enhanced CT simulation images of 43 patients with cervix cancer, FIGO Stages I–III. Vessel contours were hidden, and conventional pelvic fields were outlined: ( 1 ) anterior/posterior fields (AP): superior border, L5–S1 interspace; inferior border, obturator foramina; lateral border, 2 centimeters lateral to pelvic brim. ( 2 ) Lateral fields (LAT): Anterior border, symphysis pubis; posterior border, S2–S3 interspace. Distances were measured between the following: ( 1 ) bifurcation of the common iliac artery and superior border, ( 2 ) external iliac artery and lateral border of the AP field, and ( 3 ) external iliac artery and anterior border of the LAT field. The distances were considered as "inadequate" if 20 mm. Results: Superiorly, 34 patients (79.1%) had inadequate coverage. On the AP, margins were generous in 19 (44.2%), but inadequate in 9 (20.9%). On the LAT, margins were inadequate in 30 (69.8%) patients. Overall, 41 (95.4%, CI, 84.2%–99.4%) patients had at least 1 inadequate margin, the majority located superiorly. Twenty-four (55.8%; CI, 39.9%–70.9%) patients had at least 1 generous margin, the majority located laterally on the AP field. Conclusion: Conventional pelvic fields based on bony landmarks do not provide optimal lymph node coverage in a substantial proportion of patients and may include excess normal tissue in some. CT simulation with vessel contouring as a surrogate for lymph node localization provides more precise and individualized field delineation.

Introduction Open reduction and internal fixation of sacroiliac (SI) joint is often performed through an anterior approach. However, there were no studies to our knowledge which described the “at risk area” for injury to the nutrient artery as it relates to open reduction and internal fixation of the SI joint. The purpose of this study was to determine the “at risk area” for the nutrient artery during anterior surgical approaches to the SI joint and to define the safe location of the plate for SI joint fixation. Materials and methods Six right and five left hemipelvises (three male and three female cadavers) were dissected with a mean age of 72 years (range, 51–90 years). Three bony landmarks including the pelvic brim, anterior SI joint line, and the anterior superior iliac spine (ASIS) were identified to quantify the measurements. Three different measurements were taken: from the nutrient foramen to the anterior SI joint line; from the nutrient foramen to the nearest point on the pelvic brim; from the nutrient foramen to ASIS using a flexible ruler with a 1 mm base. Results The nutrient artery courses across the SI joint to enter into the nutrient foramen. Whilst exposing the internal surface of the SI joint, the nutrient foramen was identified at a mean distance of 88.1 mm medial to ASIS, 20.1 mm above the pelvic brim, and 20.1 mm lateral to SI joint. The variability of the location of the nutrient foramen was identified and was located from 80 mm to 95 mm medial to the ASIS, 12 mm to 25 mm lateral to the SI joint, and 16 mm to 30 mm above the pelvic brim. Conclusion Familiarity of the vasculature of the internal pelvis is of utmost importance for the surgeon when considering operative fixation of the anterior SI joint. We were able to identify the relation of the nutrient artery to the anatomic landmarks of the internal pelvis and to define the “at risk area” for the nutrient artery. We believe increased understanding of the anatomy of the nutrient artery will aid in the avoidance of vascular complications during internal fixation of the anterior SI joint.

Objectives. To compare the safety and efficacy of ureteroscopy performed for proximal and distal ureteral calculi in a contemporary cohort. Ureteroscopy has been used most often for distal ureteral calculi. However, advances in endoscopic equipment have facilitated access to the proximal urinary tract and have broadened the indications for ureteroscopy. Methods. One hundred ninety-one patients underwent rigid and/or flexible ureteroscopy for ureteral calculi at the University of Michigan between January 1, 1997 and September 30, 1999. Only 7 patients with either bilateral calculi or steinstrasse were excluded. The final cohort consisted of 184 patients who underwent ureteroscopy for distal stones (n = 103) or middle/upper ureteral stones (n = 81). Results. Bivariate analyses of pretreatment and perioperative characteristics were used to assess the sample population. The initial success rate for the distal and proximal ureteral calculi was 96% and 78%, respectively ( P = 0.0008). After a “second-look” procedure in 4 and 7 patients with distal and proximal calculi, respectively, the success rate improved to 99% and 88%, respectively ( P = 0.004). No differences were noted between groups regarding the intraoperative ( P = 0.51) or postoperative ( P = 0.85) complication rates. Multivariate logistic regression analysis confirmed that larger stone size (odds ratio 1.2, P = 0.0006) and proximal ureteral location (odds ratio 4.8, P = 0.01) are independent predictors of treatment failure. Conclusions. Ureteroscopic management of proximal and distal ureteral calculi is highly successful, and the difference in success rates has narrowed substantially. Currently, no greater risk is conferred to the patient for endoscopy of more proximal ureteral calculi.

Objective : A retroperitoneal approach for laparoscopic treatment of ovarian remnant syndrome was developed. Design : Clinical study. Setting : Department of Gynecology, Friedrich-Schiller-University Jena. Patient(s) : During a 29-month period, seven consecutive patients with ovarian remnant syndrome were treated by laparoscopy. Patients were not preselected and preoperative, intraoperative, and postoperative data were registered prospectively. Intervention(s) : For removal of remnant ovaries we used a laparoscopic retroperitoneal approach that included complete dissection of the pelvic course of the ureter and coagulation and dissection of the infundibulopelvic ligament and of the uterine vessels. Result(s) : In the first patient's case, the right ureter was injured during dissection, which was initiated too far distally between ovary and externaliliac vessels. Thereafter, we changed our technique to start the dissection of the ureter at the pelvic brim. No subsequent patient had an intraoperative or postoperative complication. All patients reported fewer preoperative complaints and were free of recurrence by sonographic examination. Conclusion(s) : Using a retroperitoneal approach laparoscopic resection of a remnant ovary may be a safe and effective technique.

Magnetic resonance urographic (MRU) techniques possess image quality and diagnostic capability that are improving with increasingly sophisticated imaging sequences and shorter scanning times. We describe the application of a fast breath-hold MR sequence (HASTE) in the assessment of ureteric obstruction in pregnancy. In the patient presented, HASTE MRU was successful in depicting ureteral anatomy and demonstrated dilation of both ureters below the level of the pelvic brim. This observation suggested distal ureteral obstruction rather than simple hydronephrosis of pregnancy. As a result, bilateral nephrostomies were performed and neonatal prematurity was avoided. Interestingly, in this patient, HASTE MR imaging also showed evidence of concurrent fetal hydronephrosis.

Objective To determine if the new technique laparoscopic lateral transposition of the ovaries before pelvic radiotherapy for anal canal carcinoma prevents radiation-related ovarian failure. Design A case report. Setting The operating room of a Canadian teaching hospital. Patients A single patient with anal canal carcinoma, requiring pelvic radiotherapy, who desired preservation of ovarian function. Interventions Laparoscopic ovarian transposition to the level of the pelvic brim. Main Outcome Measures Follow-up clinical and laboratory evidence of ovarian failure. Results Initially ovarian failure was confirmed with the appearance of postmenopausal symptoms and the elevation of serum gonadotropins. These symptoms resolved by 8 months after radiotherapy, normal menstrual cycles resumed, and normal FSH levels were detected at that time. Conclusions The laparoscopic, lateral transposition of this patient’s ovaries was effective at preventing radiation-related ovarian failure.

A 57-year-old female was diagnosed with Stage IVA squamous cell carcinoma of the cervix. She underwent a primary concurrent chemoradiation therapy with high dose vaginal brachytherapy. She remained in clinical remission until 8 months after completion of her treatment she presented with a rectovaginal fistula. She was counseled regarding different surgical approaches and she elected to proceed with a robotic assisted TPE with an ileal loop urinary diversion and an omental J plasty for pelvic floor reconstruction. The patient was position in low lithotomy with her legs placed in padded Yellowfin stirrups (Allen Medical System) in a neutral position. The da Vinci S (Intuitive Surgical, Sunnyvale, CA) system was utilized. A 5 port technique was used for instrumentation. The Harmonic Scalpel was used for tissue dissection and coagulation of vessels. An articulating endoscopic-GIA stapler was used to divide the bowel. After appropriate port placement and intra-peritoneal assessment to rule out metastatic disease, the TPE procedure was undertaken. The round ligaments were divided using the Harmonic Scalpel. The anterior and posterior leaves of the broad ligaments were incised followed by the development of para-vesicle and para-rectal spaces. The space of Retzius was developed after incising the peritoneum along the pubic arch. The pubovesicial ligaments were then divided with the Harmonic Scalpel down to the level of the levator ani muscle. The division of urethra flush with the levator ani muscles was dissected utilizing the harmonic scalpel. The anterior division of the internal iliac vessels were isolated and controlled with a robotically applied hemolock (Intuitive Surgical, Sunnyvale, CA) clip. This was followed by transection of the parametrium, flush with the pelvic sidewalls down to the level of the levator hiatus. The ureters were ligated with hemolock clips at the level of the ureteric tunnel. The sigmoid colon was divided with the endo-GIA stapler at the level of the pelvic brim after creating a mesenteric window. The mesenteric blood supply of the sigmoid colon was divided using the Harmonic Scalpel. Finally, the retrorectal space was then developed followed by dissection of the mesorectum along anococcygeal ligament to the level of the posterior levator hiatus. The remainder of the procedure was complete with a perineal phase of the operation. An incision was made around the vagina, perineal body and around

Background: The association between unicornuate uterus and undescended ovaries has been reported in the past but is extremely rare. In many cases, the possibility is not considered or recognized and there is a significant delay in diagnosis. Of the mullerian duct anomalies, unicornuate uterus represent approximately 4% of these disorders of lateral fusion of the mullerian ducts. Case: The patient was a 12 year old premenstrual female who presented with onset of right upper quadrant pain and emesis. The patient was hospitalized for 3 days to rule out appendicitis and had resolution of her pain. The GI service after upper GI series with small bowel follow through, endoscopy and colonoscopy diagnosed possible Crohn's disease and patient was started on Pentasa and Zantac with no relief. The patient continued to have recurrent pain in the same location lasting from hours to days with a sporadic pattern of occurrence for the next 13 months. The patient was then rehospitalized for 5 days for severe pain which spontaneously resolved. Two months later the patient had a repeat hospitalization and was seen by pediatric surgery. Diagnostic laparoscopy was performed with the findings being absent right adnexa and otherwise normal pelvis. The patient was referred to pediatric gynecology. Ectopic right ovary was suspected as the cause of the pain and a right upper quadrant ultrasound revealed a 2.3 x 1.3 x 1.5 cm structure at the tip of the right liver lobe. Concomitant pelvic ultrasound revealed a normal left ovary and the right ovary was not visualized. The uterus appeared deviated to the left. A CT scan performed revealed a small multiloculated mixed density lesion at the inferior tip of the right liver lobe. Both kidneys were visualized in the normal position. The patient had a presumptive diagnosis of unicornuate uterus associated with a right ectopic ovary with the pain being intermittent torsion. The patient had a repeat laparoscopy with the right ovary noted just beneath the tip of the right liver lobe. Given the history of right upper quadrant pain likely being intermittent torsion, after consultation with the parents, the decision was made to excise the right ovary. The patient had an uneventful postoperative recovery and has remained pain free. Comments: The ovaries have an entirely separate origin from the mullerian system with primordial germ cells invading the primitive gonads on the gonadal ridge, eventually migrating from near the kidney to the true pelvis. If there are no mullerian duct derivatives or kidney on one side, i.e. failure of development of the entire urogenital ridge, including the genital ridge where the ovary forms, then the ovary may be malpositioned, located anywhere from the level of T4 to the pelvic brim. These ectopic locations for ovaries are associated with a 40% chance of associated unicornuate uterus. The failure to visualize either adnexa in a patient with unexplained pain should prompt a search for a potential ectopic location for the ovary.

Objective To report a case of unique anomalous pelvic vasculature in a woman with Mullerian agenesis. Design Case report. Setting University hospital. Patient(s) A 61-year-old woman with Mullerian agenesis and stage IIIc papillary serous ovarian cancer. Intervention(s) Surgery was performed, including bilateral salpingo-oophorectomy, omentectomy, right terminal ileum and right ascending colon resection, ileoascending/transverse colon reanastomosis, and debulking of pelvic plaques along bilateral ureters. The patient had subsequent chemotherapy with taxane and platinum agents and at the time of writing was in remission. Main Outcome Measure(s) None. Result(s) Absence of the uterus was confirmed; rudimentary uterine horns and associated fallopian tubes and ovaries were noted bilaterally. The right ureter coursed below and behind the right common iliac artery, which did not bifurcate into external and internal arteries at the pelvic brim. Instead there was only an external iliac artery that gave off a pelvic branch just before the inguinal ligament. On the left, there was only an internal iliac artery that gave off an external branch after diving into the pelvis. Conclusion(s) It is possible that the aberrant vasculature was partially responsible for the absence of the uterus. Preoperatively, it is important to recognize the possibility of abnormal pelvic vasculature in patients with Mullerian agenesis.

Background Iliac vein compression syndrome (IVCS) results from compression of the left iliac vein by the overlying right iliac artery against the pelvic brim. In many cases, patients are symptomatic. In symptomatic cases, management consists of angioplasty and stenting. Although therapy is often initially successful, factors associated with long-term outcome have been poorly defined. The purpose of this study was to identify factors associated with stent patency. Methods The medical records of all patients who underwent iliac vein percutaneous transluminal angioplasty and stenting from January 1996 to December 2006 for symptomatic IVCS were reviewed retrospectively. There were 50 women and 8 men, with a mean age of 42 years (median, 39 years; range, 17-71 years). Primary, assisted primary, and secondary patency rates were determined. Patient characteristics and clinical variables were evaluated by univariate and multivariate analysis to determine association with vein patency. Results Symptoms consisted of lower extremity swelling (81%) and lower extremity pain (67%). Iliac vein obstruction was treated with pharmacologic thrombolysis (31% of patients) and mechanical thrombus fragmentation (17% of patients). The primary, assisted primary, and secondary patency rates of angioplasty/stenting were 74.1%, 79.7%, and 85.8% at 1 year and 38.1%, 62.8%, and 73.8% at 5 years, respectively. Using a Cox proportional risk model, male sex (hazard ratio, 6.5; P = .001), recent trauma (hazard ratio, 5.3; P = .001), and age younger than 40 years (hazard ratio, 3.8; P = .015) were associated with decreased primary patency. In the absence of any risk factors, primary patency was 94.4% at 1 year and 63.0% at 5 years, decreasing to 28.6% and 0% for two or more risk factors. Conclusions Patency rates for iliac vein percutaneous transluminal angioplasty and stenting in patients with IVCS can potentially be predicted on the basis of a multivariate model. Assessing risk factors allows for patient stratification and appropriate clinical decision making. Prospective validation of these variables is necessary.

][] Endometriosis, long thought to be primarily a diagnosis of women in their twenties and thirties and often found on evaluation for infertility, is also found with regularity in adolescents with chronic pelvic pain or secondary dysmenorrhea. DESCRIPTION Endometriosis refers to the presence of ectopic endometrial tissue within or outside the pelvic cavity. The primary complaints are dysmenorrhea that is progressive and unresponsive to treatment or chronic pelvic pain, defined as pain within the pelvic brim, lasting more than 3 months, that is constant or intermittent, and has been evaluated at least three times without conclusive diagnosis. Abnormal or irregular pelvic bleeding is a third key complaint. Gastrointestinal or bladder disturbances, vaginal discharge, and dyspareunia in sexually active patients are other associated findings.

A 44-year-old woman presented with right lower quadrant abdominal pain of three months' duration and history of previous Cesarean section and abdominal hysterectomy. Pelvic examination and vaginal sonography revealed a large unilocular mass. Laparoscopy findings included a fixed, large endometrioma severely attached to the pelvic peritoneum and intestines in the pelvic cavity, and significant adhesions in the upper part of the prior midline abdominal hysterectomy incision. Two days after laparoscopic bilateral adnexectomy, she was readmitted with small-bowel obstruction and underwent prompt adhesiolysis via laparotomy. Thirty-nine days later, she presented with massive urinary ascites. Evaluation revealed right ureteral stricture at the uterine artery level and complete ligation and resection of the left ureter at the pelvic brim near the infundibulopelvic ligament stump. Left ureteral reimplantation with psoas hitch and right ureterolysis were performed. We conclude that, in cases of severe endometriosis with significant ureteral and intestinal involvement, laparotomy should be considered.

Since the initiation of the clinical trial utilizing a second-generation lithotripor (Lithostar, Siemens, Erlangen, FRG), 96 patients with distal ureteral calculi (i.e. calculi below the pelvic brim) underwent local shock-wave lithotripsy. Routine treatment was conducted under intravenous sedation and light analgesia only. Complete stone disintegration was achieved in 84 patients (87.5%), 11 requiring two sessions and 1 patient, three. In 7 patients ureteroscopy became necessary after unsuccessful local shock-wave treatment. In 2 of these patients a 9-french flexible ureteroscope and the Storz Q-switched neodymium-YAG laser was used for stone disintegration. In 3 cases loop extraction and in 2 cases open surgery had to be performed for definitive stone removal. All pre- and postoperative manipulations (except open surgery) were done on the Lithostar. Local shock-wave lithotripsy is a highly successful, noninvasive, time-saving and easily applicable technique. It has become our primary approach in the treatment of distal ureteral calculi.

Pressures were recorded monthly at two sites in the vaginas of nine horse mares with normal vulval conformation. The pressures were lowest when the mares' weights were minimal, and there was evidence of a descending pressure gradient from the vestibule to the cervix. Loss of body weight was also associated with shortening and angulation of the vulva, although it was not displaced above the pelvic brim.

1. 1. Dilatation of the upper urinary tract accompanies normal pregnancy as a result of mechanical pressure exerted by the pregnant uterus on the ureters as they cross the pelvic brim. 2. 2. The position of the fetus or the number of pregnancies does not influence the degree of dilatation. 3. 3. The period of gestation, due to the size and position of the uterus, influences the degree of dilatation to some extent, the greater degrees of dilatation occurring during the sixth, seventh and eighth months of pregnancy. 4. 4. Right-sided preponderance is due to the protection of the left ureter by the sigmoid, plus the added pressure on the right as a result of the forward thrust exerted by the sigmoid on the left side of the uterus. 5. 5. Uniform fibromas of the uterus and ovarian cysts produce the same phenomenon.

We have related the unfortunate history of an unrecognized case of gangrenous appendicitis in an individual whose appreciation of pain was remarkably dull. The pus from the appendiceal abscess perforated the parietal peritoneum and travelled upward to the liver. Extending along the right branch of the portal vein the infection produced an enormous liver abscess which later ruptured and drained through the appendiceal incision. Further extension of the infection proceeded by the retroperitoneal route toward the pelvic brim. The mesentery was involved and in one particular area an inflammatory tumor developed. This tumor was adjacent and adherent to the sigmoid. The wall of the sigmoid was edematous and congested at the area of contact. No open lesion of the sigmoid or in fact any portion of the intestinal tract could be demonstrated at autopsy and yet this patient expired as a result of a massive rectal hemorrhage. The remarkable feature of the case is the fact that such a large quantity of blood reached the lumen of the bowel through an intact but congested mucosa. Capillary oozing of this character is frequently noted in the stomach resulting in the so-called coffee-ground vomitus. In our experience such bleeding on an extensive scale is rarely seen in the lower end of the intestinal tract.

1. 1. The occipitoposterior position in the main is caused by the adaptation of the head to a pelvis having a narrow fore pelvis and an ample anteroposterior diameter and therefore may be considered “physiologic.” 2. 2. Degrees of the posterior position can be differentiated. A true posterior position is one in which the occiput is at or posterior to the sacroiliac synchondrosis. 3. 3. Occipitoposterior positions, although physiologic and in spite of the fact that 70 per cent deliver spontaneously, cause more dystocia than the other vertex positions. 4. 4. Dystocia in posterior positions originates with the abnormality of the pelvis in which they occur. 5. 5. Extension is a common feature of the posterior mechanism and is caused by the posterior axis of fetal drive. Extension not only results in larger presenting diameters but also causes a part of the uterine drive to be dissipated. 6. 6. Flexion greatly facilitates the mechanism and should be encouraged by posture. A forward excursion of the fetal axis must take place before flexion can occur. 7. 7. Internal rotation although receiving its impulse from the inclined planes of the pelvic floor receives its directional force from the variable resistances offered by the bony pelvis in all the pelvic planes through which the head is descending. 8. 8. Since the pelvic architecture shows marked variations in shape, it follows that the patterns of rotation show corresponding variations. 9. 9. Emphasis is placed on the importance of recognizing two fundamentally different pelvic forms frequently associated with posterior positions, viz., those forms in which the transverse diameters are contracted at the brim or midpelvis or at both levels with compensating ampleness in the anteroposterior diameters and the converse of this form in which the anteroposterior diameters are shortened by virtue of a flat posterior segment at the brim or a forward sacrum at the midpelvis level while the transverse diameters remain ample. It follows that operative techniques should be individualized for each type. 10. 10. The occipitoposterior mechanisms which have been reviewed may be translated into operative principles as follows: 10.1. a. When the posterior arrest is due to a narrow anthropoid pelvic brim preventing rotation, the head is pushed up and rotated above the brim. Version is also correct in principle. 10.2. b. When arrest is due to narrow spines in definite anthropoid types, the head is pushed up and rotated above the spines or above the brim. Version is also an alternative procedure. 10.3. c. When the posterior aspect of the inlet is flat or the sacrum is forward, rotation is carried to the transverse only and in this position the head is brought into the lower fore pelvis or the retropubic space thereby converting it into a deep transverse. Rotation is carried out at this low level. Upward displacement of head with rotation and version are incorrect procedures. 10.4. d. When the posterior aspect of the inlet is flat or the sacrum is forward and labor has progressed sufficiently to allow a deep transverse arrest to occur rotation is again carried out at a low level just behind the pubis. 10.5. e. When the head is arrested in a direct occipitoposterior, deliver without rotation only when the lower sacrum is not encroaching. In most cases the head should be rotated to the anterior. Such rotation is carried out at the level which is most suitable for the pelvis in which it occurs. 10.6. f. When the head is low, well-molded, and well-flexed manual rotation is the most desirable procedure. 10.7. g. Rotation at level of arrest is rarely a procedure of choice because in most instances there is some pelvic obstruction which is preventing rotation at that level. 10.8. h. The unmodified Scanzoni maneuver with simultaneous traction and rotation initiates the act of rotation at the level of arrest where there is obstruction. It is, therefore, an undesirable procedure in those cases which have a well-molded and flexed head. Even in this group of cases manual rotation is the operation of choice.

A distal ureteral calculus may induce premature labor as in our case report. Conservative management of calculi may be the best course in pregnant women without premature labor. However, if premature labor is present, the calculus may be a source of irritation for the gravid uterus. The exact mechanism is unknown. It is widefy accepted that acute pyelonephritis of pregnancy may precipitate premature delivery. Abramowicz and Kass* have convincing evidence showing that bacteriuria increases the risk of prematurity. Bacteriuria may have placed our patient at risk for premature labor. In addition, the obstruction of the kidney by the ureteral calculus may have created a situation ideal for subclinical pyelonephritis. This inflammatory process may have precipitated premature labor. I f a pregnant woman presents with premature labor and a ureteral calculus, a &-adrenergic drug (such as ritodrine) should be started to prevent premature delivery. If this attempt at conservative management proves unsuccessful, stone retrievai with a basket is then indicated if the calculus is below the pelvic brim. The use of spinal anesthesia is advocated. /?,-adrenergic drugs should be continued in the postoperative period until the uterine contractions subside. On the basis of our recent experience, stone retrieval with a basket has a place in the management of pregnant women with premature labor.