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Aims and objectives To assess the effects of flexible sacrum positions on mode of delivery, duration of the second stage of labour, perineal trauma, postpartum haemorrhage, maternal pain, abnormal foetal heart rate patterns and Apgar scores based on published literature. Background Maternal positions served as a nonmedical intervention may facilitate optimal maternal and neonatal outcomes during labour. Flexible sacrum positions are conducive to expanding pelvic outlet. Whether flexible sacrum positions have positive effects on maternal and neonatal well-being is a controversial issue under heated discussion. Design We performed a systematic review and meta-analysis based on PRISMA guidelines. Methods Randomised controlled trials (RCTs) comparing any flexible sacrum position with non-flexible sacrum position in the second stage of labour were included. PubMed, EMBASE, Cochrane Library, CINAHL, CNKI (China National Knowledge Infrastructure), SinoMed and Wanfang databases were searched from inception to 11 March 2019 for published RCTs. Risk of bias was assessed by the Cochrane criteria, and random-effects meta-analyses were conducted by RevMan 5.3. Results Sixteen studies (3,397 women) published in English were included. Flexible sacrum positions in the second stage of labour could reduce the incidence of operative delivery, instrumental vaginal delivery, caesarean section, episiotomy, severe perineal trauma, severe pain and shorten the duration of active pushing phase in the second stage of labour. However, flexible sacrum positions may increase the incidence of mild perineal trauma. There was no significant difference in the duration of the second stage of labour, maternal satisfaction and other outcomes. Conclusions Flexible sacrum positions are superior in promoting maternal well-being during childbirth. However, several results require careful interpretation. More rigorous original studies are needed to further explore their effects. Relevance to clinical practice The results support the use of flexible sacrum positions. Flexible sacrum positions are recommended to apply flexibly or tailor to individual woman's labour progress.

Objectives Obstetric demands have long been considered in the evolution of the pelvis, yet consideration of the interaction of pregnancy, the pelvis, and the gastrointestinal tract (gut) is lacking. Here, we explore sex differences in the relationship of gut volume with body size and pelvic dimensions. Materials and methods Computed tomography (CT) scans of living adult Homo sapiens (46 females and 42 males) were obtained to measure in vivo gut volume (GV) and to extract 3D models of the pelvis. We collected 19 3D landmarks from each pelvis model to acquire pelvic measurements. We used ordinary least squares regression to explore relationships between GV and body weight, stature, and linear pelvic dimensions. Results The gut-pelvis relationship differs between males and females. Females do not exhibit significant statistical correlations between GV and any variable tested. GV correlates with body size and pelvic outlet size in males. GV scales with negative allometry relative to body weight, stature, maximum bi-iliac breadth, inferior transverse outlet breadth, and bispinous distance in males. Discussion The lack of association between GV and body size in females may be due to limits imposed by the anticipation of accommodating a gravid uterus and/or the increased plasticity of the pelvis. The pattern of relationship between GV and the pelvic outlet suggests the role of the bony pelvis in supporting the adominal viscera in females may be small relative to its role in childbirth. We conclude that gut size inference in fossil hominins from skeletal proxies is limited and confounded by sexual dimorphism.

Background Technical difficulties in rectal surgery are often related to dissection in a limited surgical field. This study investigated the clinical value of MRI pelvimetry in the prediction of surgical difficulty associated with minimally invasive rectal surgery. Methods Patients with rectal cancer who underwent laparoscopic or robotic total mesorectal excision between 2005 and 2017 were reviewed retrospectively and categorized according to surgical difficulty on the basis of duration of surgery, conversion to an open procedure, use of the transanal approach, postoperative hospital stay, blood loss and postoperative complications. Preoperative clinical and MRI‐related parameters were examined to develop a prediction model to estimate the extent of surgical difficulty, and to compare anastomotic leakage rates in the low‐ and high‐grade surgical difficulty groups. Prognosis was investigated by calculating overall and relapse‐free survival, and cumulative local and distant recurrence rates. Results Of 121 patients analysed, 104 (86·0 per cent) were categorized into the low‐grade group and 17 (14·0 per cent) into the high‐grade group. Multivariable analysis indicated that high‐grade surgical difficulty was associated with a BMI above 25 kg/m2 (odds ratio (OR) 4·45, P = 0·033), tumour size 45 mm or more (OR 5·42, P = 0·042), anorectal angle 123° or more (OR 5·98, P = 0·028) and pelvic outlet less than 82·7 mm (OR 6·62, P = 0·048). All of these features were used to devise a four‐variable scoring model to predict surgical difficulty. In patients categorized as high grade for surgical difficulty, the anastomotic leakage rate was 53 per cent (9 of 17 patients), compared with 9·6 per cent (10 of 104) in the low‐grade group (P, This study highlights the impact of MRI pelvimetry in predicting surgical difficulty in laparoscopic rectal surgery. Multivariable analysis identified that surgical difficulty was significantly associated with four variables: BMI, tumour size, anorectal angle and pelvic outlet. A novel scoring model using these four variables to predict surgical difficulty is proposed. MRI pelvimetry and TME difficulty

Introduction: Maternal pelvic capacity plays a major role during childbirth because the passage of the fetus through the bony birth canal enables vaginal birth. Maternal birthing position may influence pelvic capacity because upright positions optimize capacity, possibly due to free movement of the pelvic joints. Herein, pelvic capacity was assessed by comparing changes in pelvic dimensions across pregnancy and in three birthing positions. Material and methods: This diagnostic imaging study of 50 pregnant women was conducted at Aarhus University Hospital, Denmark. Pelvic measurements were obtained with 1.5 T magnetic resonance pelvimetry during gestational weeks 20 and 32, in three birthing positions: kneeling squat, semi-lithotomy and supine. Pelvic capacity was compared between gestational weeks and positions. Results: In all three positions there is an overall increase in pelvic capacity from gestational week 20–32 at both the pelvic inlet and outlet. Comparing pelvic capacity at gestational week 32 between the semi-lithotomy and supine positions revealed that the pelvic inlet was larger in the supine position, whereas the mean pelvic outlet was 0.2 cm (p

Background Exact knowledge of the sacral anatomy is crucial for the percutaneous insertion of iliosacral screws. However, dysplastic anatomical patterns are common. In addition to a preoperative computed tomography (CT) analysis, conventional radiographic measures may help to identify upper sacral dysplasia and to avoid damage to surrounding structures. Aiming to further increase safety in percutaneous iliosacral screw placement in the presence of sacral dysmorphism, this study examined the prevalence of previously established radiographic signs and, in addition, defined the “critical SI angle” as a new radiographic criterion. Methods Pelvic CT scans of 98 consecutive trauma patients were analysed. Next to assessment of established signs indicating upper sacral dysplasia, the critical sacroiliac (SI) angle was defined in standardized pelvic outlet views. Results The critical SI angle significantly correlates with the presence of mammillary bodies and an intraarticular vacuum phenomenon. With a cut-off value of − 14.2°, the critical SI angle detects the feasibility of a safe iliosacral screw insertion in pelvic outlet views with a sensitivity of 85.9% and a specificity of 85.7%. Conclusions The critical SI angle can support the decision-making when planning iliosacral screw fixation. The clinical value of the established signs of upper sacral dysplasia remains uncertain.

Epidural anaesthesia is an effective form of pain relief during vaginal deliveries. However, neuraxial anaesthesia may slow the progression of labour. The assumption that epidurals lead to increased caesarean sections is also a topic of current debate. A holistic approach with the use of a birthing ball has been advocated as a potential modality to decrease labouring times and, therefore, reduce progression to caesarean section. Birthing balls aim to increase pelvic outlet opening, which facilitates labouring. Our aim is to review recent literature pertaining to birthing balls and their role in improving quality and outcomes of vaginal deliveries in patients with epidurals.IMPACT STATEMENTWhat is already known on the subject? Epidural anaesthesia may slow the progression of labour. It has been hypothesised that slowing progression of labour is associated with increased rates of vacuum and forceps delivery. Most common clinical indication for caesarean section is failure to progress during labour. Birthing Balls have been shown to quicken the progression of labour, theoretically reducing caesarean sections with those with epidurals.What do the results of the study add? Several studies have demonstrated a reduced duration of first and second stage of labour among women with epidural anaesthesia, but the existing literature is limited, and interpretation of results may be restricted by generalizability and inherent study biases. The objective of this article is to review existing literature and highlight the potential clinical utility of birthing balls in current obstetric practice.What are the implications of these findings for clinical practice and further research? Use of birthing balls has been advocated to decrease labouring time and therefore reduce progression to caesarean section. Larger studies or meta-analysis would be required to confirm potential benefits of birthing ball use.

The region anterior to the anal canal in women is composed of intertwined smooth and skeletal muscles. The present study aimed to clarify skeletal muscle morphology in the anterior region of the anal canal. The pelvic floor muscles of 28 pelvic halves from 16 female cadavers (mean age 79.75 years) were dissected from the inferior aspect to examine the perineal muscles, followed by midline transection and dissection from the inner surface to examine the pelvic outlet muscles. The bulbospongiosus muscle was found to be attached to the lateral surface of the external anal sphincter. The superficial transverse perineal muscle crossed superiorly to the bulbospongiosus and coursed medially toward its contralateral muscle bundle deep to the anterior portion of the external anal sphincter. The superficial transverse perineal muscle formed the middle sling. From the medial aspect, the anterior part of the levator ani was divided into anterior and posterior bundles to form the anterior and posterior slings, respectively. This study proposes that three muscular slings could be important in supporting the pelvic floor in women. In addition, this study shows that the anterior skeletal muscular wall of the anal canal is composed of the anterior muscle bundle of the levator ani, superficial transverse perineal, and proper external anal sphincter muscles.

Purpose Male sex, high BMI, narrow pelvis, and bulky mesorectum were acknowledged as clinical variables correlated with a difficult pelvic dissection in colorectal surgery. This paper aimed at comparing pelvic biometric measurements in female and male patients and at providing a perspective on how pelvimetry segmentation may help in visualizing mesorectal distribution. Methods A 3D software was used for segmentation of DICOM data of consecutive patients aged 60 years, who underwent elective abdominal CT scan. The following measurements were estimated: pelvic inlet, outlet, and depth; pubic tubercle height; distances from the promontory to the coccyx and to S3/S4; distance from S3/S4 to coccyx’s tip; ischial spines distance; pelvic tilt; offset angle; pelvic inlet angle; angle between the inlet/sacral promontory/coccyx; angle between the promontory/coccyx/pelvic outlet; S3 angle; and pelvic inlet to pelvic depth ratio. The measurements were compared in males and females using statistical analyses. Results Two-hundred patients (M/F 1:1) were analyzed. Out of 21 pelvimetry measurements, 19 of them documented a significant mean difference between groups. Specifically, female patients had a significantly wider pelvic inlet and outlet but a shorter pelvic depth, and promontory/sacral/coccyx distances, resulting in an augmented inlet/depth ratio when comparing with males (p p = 0.06) and S3 angle (p = 0.17). 3D segmentation provided a perspective of the mesorectum distribution according to the pelvic shape. Conclusion Significant differences in the structure of pelvis exist in males and females. Surgeons must be aware of the pelvic shape when approaching the rectum.

Yoga exercises undertaken during the maternity period may reduce unpleasant symptoms during pregnancy and reduce delivery pain. Flexibility of the hip joint improves the degree of pubic arch created in an open-leg posture and widens the pelvic outlet region, shortening the time required for delivery and facilitating easy delivery. The degree of pubic arch is related to the flexibility of the hip joint. Although many studies have shown the effect of yoga exercise during pregnancy, the effect on the degree of the pubic arch has not been elucidated. To elucidate whether the degree of the pubic arch is improved by yoga exercise during pregnancy, this study enrolled 177 pregnant subjects. The degree of pubic arch pre– and post–yoga exercise was measured using instruments in an open-leg posture (seated with femurs abducted). The mean pubic arch pre- and post-yoga was 122.61 and 127.93 degrees, respectively. The degree of pubic arch post–yoga sessions was significantly increased compared with pre–yoga sessions (p < 0.01). This study showed that yoga exercises during the pregnancy period appear to improve the degree of pubic arch.

Introduction The e physical anatomical characteristics of Vietnamese people are similar to those of other East Asian populations, with a deep and narrow pelvis but an average body mass index (BMI) among patients at the advanced stage of rectal cancer. Aim This study aimed to prospectively evaluate the short-term outcomes of transanal total mesorectal excision (TaTME) for rectal cancer treatment in a Vietnamese population. Methods A total of 64 patients who underwent TaTME were included in this study. The pelvic anatomical parameters, BMI, operative morbidities, macroscopic qualities of the mesorectal specimens, circumferential resection margins, and anal sphincter functional data were collected. The method popularized by Quirke and Kirwan's classification were used to assess to quality of the mesorectal specimens and the sphincter function, respectively. Statistical analysis was performed using SPSS 20.0. Results The mean age and BMI of the patients were 66.4 years and 20.5 kg/m2, respectively. Most patients had narrow pelvises, with mean transverse pelvic outlet diameters of 10.12 ±1.85 cm, for males, and 10.43 ± 1.32 cm, for females, and pelvic depths of 12.36 ±2.03 cm, for males, and 11.73 ±1.12 cm, for females. The mean tumor size was 5.17 ±1.62 cm. Among the mesorectal specimens, 82.8% were complete and 14.1% were nearly complete. Disease-free survival and overall survival rates were 98.2% and 100%, respectively. Sphincter functions at 12 months post-operation were rated as 30.8% Kirwan I, 42.3% Kirwan II, and 26.9% Kirwan III. Conclusion TaTME surgery represents a safe and suitable option among Vietnamese patients with narrow and deep pelvises and advanced rectal tumors in the middle third and lower third of the rectum.

PURPOSE To evaluate the reliability of pelvimetric measurements performed using stereoradiographic imaging (SRI), and to assess maternal and fetal radiation doses compared to low-dose computer tomography (CT) pelvimetry. MATERIALS AND METHODS Thirty-five pregnant women (mean age, 29.6±5.5 [SD] years; range: 20-41 years) were prospectively included. All women underwent simultaneous frontal and lateral low-dose SRI and low-dose CT examination of the pelvis. Pelvimetry measurements were obtained from both examinations and radiation doses obtained with the two techniques were compared. RESULTS SRI-CT correlation (Pearson coefficient correlation [r]; mean bias [mb]) was strong for transverse inlet diameter (r=0.92; mb=-0.09cm), anteroposterior diameter of the pelvic inlet (r=0.92; mb = 0.47cm), maximal transverse diameter (r=0.9; mb=0.21cm), sacrum length (r=0.9; mb=0.09cm). Correlation was good. Correlation was good for the sacrum depth (r=0.75; mb=0.06cm) and Magnin's index (r=0.7; mb=0.5cm). Correlation was moderate for anteroposterior diameter of pelvic outlet (r=0.6; mb=0.52cm). The fetal dose was 13.1 times lower using SRI (87±26μGy) than CT (1140±220μGy, P

Various predictors of the difficulty of total mesorectal excision for rectal cancer have been described. Although a bulky mesorectum was considered to pose technical difficulties in total mesorectal excision, no studies have evaluated the influence of mesorectum morphology on the difficulty of total mesorectal excision. Mesorectal fat area at the level of the tip of the ischial spines on magnetic resonance imaging was described as a parameter characterizing mesorectum morphology. This study aimed to evaluate the influence of clinical and anatomical factors, including mesorectal fat area, on the difficulty of total mesorectal excision for rectal cancer. This study enrolled 98 patients who underwent robotic-assisted laparoscopic low anterior resection with total mesorectal excision for primary rectal cancer, performed by a single expert surgeon, between 2010 and 2015. Magnetic resonance imaging-based pelvimetry data were collected. Linear regression was performed to determine clinical and anatomical factors significantly associated with operative time of the pelvic phase, which was defined as the time interval from the start of rectal mobilization to the division of the rectum. The median operative time of the pelvic phase was 68 min (range 33–178 min). On univariate analysis, the following variables were significantly associated with longer operative time of the pelvic phase: male sex, larger tumor size, larger visceral fat area, larger mesorectal fat area, shorter pelvic outlet length, longer sacral length, shorter interspinous distance, larger pelvic inlet angle, and smaller angle between the lines connecting the coccyx to S3 and to the inferior middle aspect of the pubic symphysis. On multiple linear regression analysis, only larger mesorectal fat area remained significantly associated with longer operative time of the pelvic phase (p = 0.009). Mesorectal fat area may serve as a useful predictor of the difficulty of total mesorectal excision for rectal cancer.

Cephalopelvic disproportion is common among Africans and is a major cause of maternal and perinatal mortality and morbidity. As the dimensions of the pelvis may vary between populations and according to stature and age, they need to be considered during childbirth and also in the planning and performance of pelvic and perineal procedures. The aim of this study was to assess the possible variations in the dimensions of the intact pelvic canal in South Africans and their implications. Eighty intact cadaver pelves, belonging to 40 white South Africans (20 males and 20 females) and 40 black South Africans (20 males and 20 females) were used for both metric and geometric morphometric analyses. Pelvic inlet shapes did not differ significantly between groups but pelvic inlet and midpelvic dimensions were the greatest in white South Africans and females. The pubic symphyseal length was the greatest in white males and the smallest in black females, resulting in a smaller pelvic cavity anteriorly than for white females. Pelvic outlet shapes varied significantly between sexes in white South Africans and between white and black males. Females presented with the greatest dimensions. Black South African females presented with an elongated anteroposterior outlet diameter. Certain transverse pelvic diameters correlated positively with age in white males and with height in females. In planning childbirth options, the smaller pelvic inlet of black females and stature-dependent diameters should be considered. Pelvic and perineal surgery may be technically more challenging because of smaller pelvic dimensions in black South Africans, especially in males.

English bulldogs have been reported to have a high incidence of dystocia and caesarean section is often performed electively in this breed. A narrow pelvic canal is the major maternal factor contributing to obstructive dystocia. The objective of this cross-sectional study was to assess the pelvic dimensions of 40 clinically healthy English bulldogs using computed tomography pelvimetry. A control group consisting of 30 non-brachycephalic dogs that underwent pelvic computed tomography was retrospectively collected from the patient archive system. Univariate analysis of variance was used to compare computed tomography pelvimetry of both groups and the effects of weight and gender on the measurements. In addition, ratios were obtained to address pelvic shape differences. A significantly (P = 0.00) smaller pelvic size was found in English bulldogs compared to the control group for all computed tomography measurements: width and length of the pelvis, pelvic inlet and caudal pelvic aperture. The pelvic conformation was significantly different between the groups, English bulldogs had an overall shorter pelvis and pelvic canal and a narrower pelvic outlet. Weight had a significant effect on all measurements whereas gender that only had a significant effect on some (4/11) pelvic dimensions. Our findings prove that English bulldogs have a generally reduced pelvic size as well as a shorter pelvis and narrower pelvic outlet when compared to non-brachycephalic breeds. We suggest that some of our measurements may serve as a baseline for pelvic dimensions in English bulldogs and may be useful for future studies on dystocia in this breed.

Biomechanical complications of childbirth, such as obstructed labor, are a major cause of maternal and newborn morbidity and mortality. The impact of birthing position and mobility on pelvic alignment during labor has not been adequately explored. Our objective was to use a previously developed computational model of the female pelvis to determine the effects of maternal positioning and pregnancy on pelvic alignment. We hypothesized that loading conditions during squatting and increased ligament laxity during pregnancy would expand the pelvis. We simulated dynamic joint moments experienced during a squat movement under pregnant and non-pregnant conditions while tracking relevant anatomical landmarks on the innominate bones, sacrum, and coccyx; anteroposterior and transverse diameters, pubic symphysis width and angle, pelvic areas at the inlet, mid-plane, and outlet, were calculated. Pregnant simulation conditions resulted in greater increases in most pelvic measurements – and predominantly at the outlet – than for the non-pregnant simulation. Pelvic outlet diameters in anterior-posterior and transverse directions in the final squat posture increased by 6.1 mm and 11.0 mm, respectively, for the pregnant simulation compared with only 4.1 mm and 2.6 mm for the non-pregnant; these differences were considered to be clinically meaningful. Peak increases in diameter were demonstrated during the dynamic portion of the movement, rather than the final resting position. Outcomes from our computational simulation suggest that maternal joint loading in an upright birthing position, such as squatting, could open the outlet of the birth canal and dynamic activities may generate greater pelvic mobility than the comparable static posture.

WOS: 000368075600009, PubMed ID: 26334957, Objectives: To determine the incidence of gynecoid pelvis by using classical criteria and measured parameters obtained from three-dimensional computed tomography (3D CT) pelvimetry in nonpregnant multiparous women who delivered vaginally. Subjects and Methods: Our hospital's picture archiving and communication system was reviewed retrospectively. All adult women who had undergone CT examination with routine abdominal protocols were identified. In the pelvic inlet, midpelvis, and pelvic outlet, classical criteria and measured parameters, both alone and in combination, were used to determine the presence of gynecoid pelvis. Results: 3D CT pelvimetry was performed on 226 women aged 23-65 years without any history of cephalopelvic disproportion and who had at least one delivery of an average fetal size (>2,500 g). The median parity was 4, and the mean (+/- SD) birth weight was 3,700 +/- 498 g. Compared to the classical criteria, measured parameters and their combined use with the classical criteria significantly reduced the frequency of gynecoid pelvis (51.3 and 47.8%, respectively, vs. 71.6%; p = 0.001); however, there was no significant difference between the measured parameters and their combined use with classical criteria with regard to the frequencies of gynecoid pelvis (p > 0.05). Conclusions: With the use of measured parameters of 3D CT pelvimetry, the incidence of gynecoid pelvis reduces to a more acceptable level (51.3%) in accordance with obstetric knowledge. Since there is no considerable decrease with the addition of classical criteria, 3D CT pelvimetry alone has merit for determining a woman's pelvic capacity for obstetric needs after the improvement and standardization of measured parameters. (C) 2015 S. Karger AG, Basel

Aim Unstable posterior pelvic ring injuries should be stabilised successfully by percutaneous iliosacral screwing. The intervention takes place under intraoperative fluoroscopic guidance. The inlet and outlet views are crucial and are performed by tilting the image intensifier. Safely interpreting fluoroscopic views can be challenging in certain clinical scenarios. We demonstrated on a series of patients howpreoperative CT scans can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views and positioning of the patient on the operating table, thereby avoiding possible operating table obstacles. Materials and methods We analysed at random 30 pelvic CT scans from patients of different ages and both sexes, utilising the sagittal reconstructions. Inlet and outlet angle measurements were calculated on the scans to determine the appropriate intraoperative inlet and outlet views. Results The analysed CT scans showed an average inlet view of 22.3° (range 10.4°–39.8°) and an average outlet view of 42.3° (range 31.5°–53.1°). Sex and age had no influence on results. The calculated required free space under the operating table for unobstructed tilting of the C-arm was a minimum of 145 cm. Conclusion The significant anatomic variations of the posterior pelvic ring have been well documented in the literature. The angles required to obtain appropriate intraoperative inlet and outlet views are not perpendicular and differ greatly from traditional settings, which directed the beam 45° caudally and 45° cranially. The fluoroscopic beam would need to be angled differently in each patient to obtain ideal cardinal views that ultimately assist in safe iliosacral screw placement. To avoid collision of the C-arm with the operating table, it is essential to provide secure free space under the operating table of at least 145 cm.

Background Ureteral herniations are a rare occurrence, generally found incidentally on cross sectional imaging or during surgical intervention for unrelated processes. Several locations of ureteral herniations can occur including the inguinal, femoral, sciatic, obturator, and thoracic regions. While few reports of ureteral hernias are reported in the literature overall, the vast majority of those reported are inguinoscrotal herniations found during evaluation and treatment of inguinal hernias. Pelvic outlet ureteral herniations intrinsically are more common secondary to their dependent locations. Intrathoracic ureteral herniations through diaphragmatic defects are an exceptionally rare subset of ureteral herniations and have only been described sparingly. Fewer than ten case reports of diaphramatic ureteral herniations have been reported and none have described both cystoscopic management and open reconstruction. Case presentation We report the case of a 81 year old female with flank pain who was found to have idiopathic diaphragmatic hernia with incarcerated proximal ureter. She had no prior injury or surgery that explained her clinical presentation. She was initially observed and then managed conservatively with ureteral stent exchanges. Ultimately she underwent open surgical repair of her diaphragmatic hernia, reduction, resection and anastomosis of redundant proximal incarcerated ureteral segment, and nephropexy for a hypermobile right renal unit. This case report illustrates the pre- and post-operative imaging studies of a very rare intrathoracic ureteral herniation as well as surgical approach to repair. Conclusion A herniated ureter is a potential source of serious renal and ureteral complications. The thoracic herniation of ureter is the rarest of the ureteral herniations. When discovered, they should be managed to preserve renal function and prevent strangulation of the affected segment of ureter. This case report documents the treatment of a thoracic ureteral herniation with observation, conservative endoscopic management, and finally open surgical reconstruction.

To evaluate long-term urologic outcomes of patients with pelvic neuroblastoma (NB) presenting with urinary retention.Five cases of pelvic NB presenting with urinary retention were identified between 1971 and 2011. Clinical presentation, treatment, survival and long-term voiding outcomes were analyzed.All five patients presented with acute urinary retention and pelvic outlet dysfunction including bladder perforation (20%), constipation (40%), or fecal incontinence (20%). The presenting age ranged from 7 days to 4 years with female to male ratio of 3:2. Two patients presented with bilateral hydronephrosis and three patients were stage 4 at presentation. All required debulking surgery, four patients required combined anterior and posterior approaches for tumor resection, with two patients requiring concurrent laminectomy. Adjuvant or neoadjuvant chemoradiation was used in four of five cases. Follow-up ranged from 2 to 41 years. Although the long-term oncological outcome is favorable, urologic outcomes of these patients ranged from normal bladder function to the need significant reconstructive procedures.Urologic outcomes are related to pelvic nerve and organ preservation during resection more than the severity of urinary symptoms at presentation.

Minimally invasive surgical techniques may decrease length of stay, operative duration and blood loss, and postoperative pain. Numerous technical challenges and concerns surround the placement of percutaneous pedicle screws at the lumbosacral level. Maximization of screw triangulation, bicortical purchase, and rostral bias toward the sacral promontory has been shown repeatedly to stabilize lumbosacral segment instrumentation and maximize pullout strength. Because of the unique anatomy, conventional anteroposterior (AP) and lateral radiographic views are relatively less reliable at determining screw depth and penetration of the sacral cortex. Percutaneous sacral pedicle fixation using AP and lateral 2-dimensional fluoroscopy is complicated by the variable contour of the sacral alae and promontory. The pelvic inlet view is ideal for visualization of the ventral screw extent and is obtained by directing 45-degree cephalad and 0-degree mediolateral, with adjustments aligning the patient's pelvic brim. The modified pelvic outlet view is obtained with the trajectory axis being directed 45-degree caudal from the AP plane. This aligns the pubic symphysis with the second sacral vertebrae providing visualization of the superior boundary of the S1-bony neural foramen and any inferior wall pedicle breaches. The authors describe this reliable fluoroscopic technique and their clinical experience with percutaneous S1-screw placement.

Objective To determine whether occult megarectum remains a commonly unrecognized cause of enuresis and whether treating it will cure enuresis in most children. A landmark study proved constipation was a commonly unrecognized cause of enuresis in 1986 in which constipation was defined as abnormal rectal distension. However, modern recommendations have focused on signs of functional constipation, such as hard or rare stools. Methods A retrospective review of 30 consecutive patients seen in our clinic with a chief complaint of nocturnal enuresis was performed, with an analysis of the results of their plain abdominal radiographs. The results of the studies were determined using a novel method termed the rectal/pelvic outlet ratio and Leech criteria. These results were compared with the reported constipation history according to the International Children's Continence Society guidelines, which recommends asking parents and children whether the child's bowel movements occur less often than every other day and whether the stool consistency is hard. Patients diagnosed with megarectum were treated with laxatives, with the goal of restoring normal rectal tone. Results All patients demonstrated rectal distension according to the rectal/pelvic outlet ratio, and 80% were constipated according to the Leech criteria. Only 10% of the patient or families reported clinical symptoms of constipation. All the adolescent patients in our study and 80% of the younger patients were cured of enuresis with laxative therapy. Conclusion Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis. Abdominal radiographs represent a simple, noninvasive method to diagnose megarectum and might improve the treatment of nocturnal enuresis.

The bony pelvis anatomy is highly variable. This study aims to examine the relationship between anthropometric measurements and the size of the adult female bony pelvis. Three-dimensional points of all pertinent landmarks of 96 adult female bony pelvises were obtained and the true conjugate, interspinous distance, intertuberous distance, and pelvic inlet and outlet areas were calculated. The relationship between these measurements and height and multiple anthropometric measurements were evaluated using Pearson’s correlation coefficient (r). Multiple anthropometric measurements were significantly correlated with the true conjugate and pelvic inlet and outlet areas, but not with the interspinous or intertuberous widths. Height had a greater correlation with pelvic areas than any other anthropometric measure considered, even after controlling for race. There were no significant differences in pelvic areas between races. Height and other anthropometric measurements were significantly correlated with the true conjugate and pelvic inlet and outlet areas.

Although the laparoscopic approach is accepted for the treatment of colon cancer, its value for low rectal cancer is unknown. The purpose of this study was to evaluate the influence of patient and tumor factors, particularly pelvic dimensions, on the difficulties in laparoscopic total mesorectal excision (TME) for low rectal cancer.Seventy-nine consecutive patients underwent laparoscopic TME with intracorporeal rectal transection and double stapling technique (DST) anastomosis for low rectal cancer. Gender, body mass index (BMI), tumor diameter, tumor depth, tumor distance from the anal verge, preoperative chemoradiotherapy, and 5 pelvic dimensions (pelvic inlet, pelvic outlet, length of sacrum, interspinous distance, and intertuberous distance) were analyzed as variables affecting the difficulties of laparoscopic TME. The dependent variables were pelvic operative time, which was defined as the time required for dissection of the rectum from the pelvis, intracorporeal transaction, and anastomosis. Other dependent variables were intraoperative blood loss, overall postoperative morbidity, and anastomotic leakage. Univariate and multivariate analyses were performed to determine the predictive significance of variables.Multivariate analysis showed that BMI (P.0001), tumor distance from the anal verge (P = .0003), tumor depth (P = .0021), and pelvic outlet (P = .0362) were independently predictive of pelvic operative time. Pelvic operative time was related to intraoperative blood loss (P.0001). The tumor distance from the anal verge (P = .0333, odds ratio [OR]: 1.06) was related to postoperative morbidity, and pelvic outlet was related to anastomotic leakage (P = .0305, OR: 1.13).BMI, tumor distance from the anal verge, tumor depth, and pelvic outlet were independent predictors for operative time and morbidity. These factors should be taken into account when planning laparoscopic TME.

Laparoscope-assisted restorative proctocolectomy is an alternative to conventional surgery for the treatment of ulcerative colitis. We present our approach of laparoscopic dissection and transection of rectum combined with transanal rectal mucosectomy. A total of 21 patients underwent laparoscopic total proctocolectomy with transanal rectal mucosectomy for ulcerative colitis. The rectum was mobilized and transected by using a combination of laparoscopic dissection and trans-anal mucosectomy without hand-assist or mini-laparotomy. The extent of laparoscopic dissection and the transection method varied according to the difficulty of pelvic dissection or the surgeon’s experience (early-phase method: laparoscopic transection of the muscular-cuff after transanal mucosectomy; intermediate-phase method: transection of the posterior side transanally and anteriolateral side laparoscopically; and recent-phase method: laparoscopic dissection down to the pelvic outlet and transanal circumferential transection of the rectum after mucosectomy). Using this approach, the median operative time was 404 minutes and the median operative blood loss was 120 g. There was no operative mortality, and no patients reported sexual or urinary complications during short-term follow-up. Laparoscopic total proctocolectomy for the treatment of ulcerative colitis is a feasible approach that demonstrates excellent views of the pelvis, which could be advantageous compared with conventional surgery. A step-by-step approach according to the surgeon’s experience and the difficulty of pelvic dissection may help minimize the risk of pelvic autonomic nerve injury.

The rate of cesarean section (CS) is increasing in Sweden as well as in most of the industrialized world. One of the most common indications for emergency CS is protracted labor. To what extent fetal pelvic disproportion is a cause of protracted labor is unclear. The value of pelvimetry has been questioned. The purpose of this study was to investigate whether women delivered with emergency CS because of protracted labor had a narrower pelvis than women delivered vaginally did.Thirty women delivered with CS because of protracted labor comprised the study group. Thirty women vaginally delivered served as controls. The two groups were matched for gestational age, birth weight, and parity. The study group and the control group underwent an X-ray pelvimetry within 1 month of delivery.The study group and the control group did not differ in maternal age or body mass index. The mean birth weight was 3914 g in the study group and 3884 g in the control group. The mean pelvic outlet was 328 mm in the study group and 346 mm in the control group (P=0.0024). The mean pelvic inlet was 245 mm in the study group and 255 mm in the control group (P=0.0038).A narrow pelvic outlet is associated with an increased risk of emergency CS because of protracted labor. A postpartum pelvimetry is recommended and should be used when to decide on route of delivery in forthcoming pregnancies.

Background: A difficult vaginal birth is known to be one of the causes of damage to the pelvic floor muscles. Prolonged second stage of labour is thought to be one of the implicating factors in this damage. If the muscles of the pelvic floor were hypertrophied in response to repetitive high impact training, then the ‘suspected phenomenon’ of a more difficult childbirth for very athletic women might be related to these muscles reducing pelvic floor compliance. Aim: To document the muscle morphology of the pelvic floor using magnetic resonance imaging (MRI) in a group of nulliparous female athletes and to compare this to the findings in a similar group of age-matched nulliparous nonathletic women. Methods: Static Magnetic Resonance (MR) imaging of the pelvic floor was performed with particular reference to the muscle morphology of levator ani and puborectalis. The cross-sectional area of the urogenital hiatus and the diameter of the bony pelvic outlet were also assessed. Results: Significant differences in the cross-sectional area and width of the pelvic floor muscles, measured in the line of the anal canal, were found between the athletic group and the controls. There were no differences found between the two groups in the cross-sectional area of the urogenital hiatus, and the adequacy of the pelvic outlet was established with reference to normative data. Conclusions: The differences shown in the pelvic floor muscles in the athletes and nonathletes provide a focus for further research into this area. This change might influence the function of the pelvic floor muscles in this subgroup of women.

The purpose of this study was to assess the impact of different positions on pelvic diameters by comparing pregnant and nonpregnant women who assumed a dorsal supine and kneeling squat position.In this cohort study from a tertiary referral center in Germany, we enrolled 50 pregnant women and 50 nonpregnant women. Pelvic measurements were obtained with obstetric magnetic resonance imaging pelvimetry with the use of a 1.5-T scanner. We compared measurements of the depth (anteroposterior (AP) and width (transverse diameters) of the pelvis between the 2 positions.The most striking finding was a significant 0.9-1.9 cm increase (7-15%) in the average transverse diameters in the kneeling squat position in both pregnant and nonpregnant groups. The average bispinous diameter in the pregnant group increased from 12.6 cm ± 0.65 cm in the supine dorsal to 14.5 cm ± 0.64 cm (P.0001) in the kneeling squat; in the nonpregnant group the increase was from 12 cm ± 0.76 cm to 13.9 cm ± 1.04 cm (P.0001). The average bituberous diameter in the pregnant group increased from 13.6 cm ± 0.93 cm in the supine dorsal to 14.5 cm ± 0.83 cm (P.0001) in the kneeling squat position; in the nonpregnant women the increase was from 12.6 cm ± 0.92 cm to 13.5 cm ± 0.88 cm (P.0001).A kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet. Because this indicates that pelvic diameters change when women change positions, the potential for facilitation of delivery of the fetal head suggests further research that will compare maternal delivery positions is warranted.

Three patients with complex perineal fistula after extensive pelvic surgery and radiotherapy underwent surgical treatment combining a biological mesh for pelvic floor reconstruction and a unilateral superior gluteal artery perforator (SGAP) flap for filling of the perineal defect. All patients had both fecal and urinary diversion. Two fistulas originated from the small bowel, necessitating parenteral feeding, and one from the bladder. Symptoms included severe sacral pain and skin maceration. After laparotomy with complete debridement of the pelvic cavity, the pelvic floor was reconstructed by stitching a biological mesh at the level of the pelvic outlet. Subsequently, patients were turned to prone position, and perineal reconstruction was completed by rotating a SGAP flap into the defect between the biomesh and the perineal skin. Operating time ranged from 10 to 12.5 h, and hospital stay lasted from 9 to 23 days. The postoperative course was uneventful in all three patients. Reconstruction of large pelvic defects with a combination of biological mesh and SGAP flap is a viable alternative to a rectus abdominis musculocutaneous flap and may be preferable after extensive pelvic surgery with ostomy.

Requisite to routine casework involving unidentified skeletal remains is the formulation of an accurate biological profile, including sex estimation. Choice of method(s) is invariably related to preservation and by association, available bones. It is vital that the method applied affords statistical quantification of accuracy rates and predictive confidence so that evidentiary requirements for legal submission are satisfied. Achieving the latter necessitates the application of contemporary population-specific standards. This study examines skeletal pelvic dimorphism in contemporary Western Australian individuals to quantify the accuracy of using pelvic measurements to estimate sex and to formulate a series of morphometric standards. The sample comprises pelvic multi-slice computer tomography (MSCT) scans from 200 male and 200 female adults. Following 3D rendering, the 3D coordinates of 24 landmarks are acquired using OsiriX® (v.4.1.1) with 12 inter-landmark linear measurements and two angles acquired using MorphDb. Measurements are analysed using basic descriptive statistics and discriminant functions analyses employing jackknife validation of classification results. All except two linear measurements are dimorphic with sex differences explaining up to 65 % of sample variance. Transverse pelvic outlet and subpubic angle contribute most significantly to sex discrimination with accuracy rates between 100 % (complete pelvis—10 variables) and 81.2 % (ischial length). This study represents the initial forensic research into pelvic sexual dimorphism in a Western Australian population. Given these methods, we conclude that this highly dimorphic bone can be used to classify sex with a high degree of expected accuracy.

We investigated the three-dimensional morphological characteristics of the pelvis in adult female patients with developmental dysplasia of the hip (DDH), using computerized tomography (CT) images. Forty-two subjects with normal hips and 40 DDH patients were recruited for the study. In the DDH group, the average transverse diameter of the pelvic inlet was significantly less and the average transverse diameter of the pelvic outlet was significantly greater than the measurements in the normal group. Further, the bony birth canal in DDH patients exhibited a higher incidence of anthropoid-type geometry, as defined by a longer sagittal diameter relative to the transverse diameter of the pelvic inlet. These findings indicate a characteristic pelvic geometry and suggest different development of the pelvis in the transverse direction in DDH patients. In addition, the obstetric conjugate length/transverse diameter of the pelvic inlet ratio was correlated to the degree of severity of acetabular dysplasia. This finding suggests that DDH is a manifestation of a developmental characteristic of the pelvis.

The projection point of the axis of the anterior column of the acetabulum on the outer table of the iliac wing was determined in 15 adult bony hemipelves. The optimal entry point for lag screw fixation in the anterior column was located 16 +/- 3.9 mm superior to the midpoint of the line connecting the apex of the sciatic notch with the notch between anterior superior iliac spine and anterior inferior iliac spine, and 46 +/- 5.9 mm superior to the acetabular rim. The mean inclination of the projected axis was 90.6 degrees +/- 5.0 degrees in the sagittal plane and 29.0 degrees +/- 4.4 degrees in the transverse plane. These data may facilitate insertion of a lag screw into the anterior acetabular column and minimize the risk of articular violation or cortical penetration because there is a narrow margin of safety. The lag screw placement also may be aided by palpating the anterior column with a finger and by intraoperative fluoroscopy for visualization of the hip joint and the anterior column in the obturator or pelvic outlet views.

INTRODUCTION AND HYPOTHESIS: The aim was to test the hypothesis that the pelvic outlet diameter (POD) is associated with pelvic organ prolapse (POP) in squirrel monkeys. METHODS: Magnetic resonance images (MRI) were obtained from 55 females with and without POP. Commercial software was used by two observers to measure the POD. POD, age, parity, and weight for the two groups were compared using Student’s t test. Associations of age, parity, and body weight with POD were evaluated with linear regression analysis. Multiple regression analysis examined the relationships of age, parity, and POD with POP. Receiver operating curve methods were used to set thresholds. RESULTS: Observers concurred on measurements (Cronbach’s alpha=0.96 with lower 95 % confidence limit of 0.94). POD was not related to parity (p=0.10) or weight (p=0.053), but was inversely related to age (p=0.011). Animals with POP did not differ from those without POP with regard to age (p=0.10), weight (p=0.17), or POD (p=0.99). The groups differed with regard to parity (p=0.007) and multiple regression methods demonstrated that only parity had a significant relationship with POP (p=0.002). Parity greater than 2 had 64 % specificity and 89 % sensitivity for POP. CONCLUSIONS: POD size does not contribute to POP in squirrel monkeys. This study confirms that among variables of age, body weight, POD, and parity, only parity appears as a risk factor for POP in squirrel monkeys.

Caring for patients with constipation and pelvic outlet obstruction can be challenging, requiring skill, patience, and empathy on the part of the medical professional. The mainstay of treatment is behavioral with surgery reserved for a select group of patients. The evaluation, diagnostic, and treatment modalities of both constipation and pelvic outlet with a focus on current advancements and technology are explored in depth.

PURPOSE: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14–92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16–78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1–8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5–64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test,P< 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

Chronic straining because of pelvic outlet obstruction is hypothesized to cause pudendal neuropathy (PN) by stretch injury. PURPOSE: The aim of this study was to determine any association between PN and pelvic outlet obstruction. METHODS: One hundred forty-seven constipated patients were evaluated by cinedefecography and pudendal nerve terminal motor latency assessment. PN was defined as a latency longer than 2.2 ms. Pelvic outlet obstructive patterns of evacuation included paradoxic contraction, nonrelaxation of the puborectalis muscle, or failure of opening of the anal canal. RESULTS: Median length of constipation including straining during evacuation was eight (range, 1–47) years. Ninety-one (62 percent) subjects had a normal pattern of evacuation, and 56 (38 percent) had an obstructed pattern. Both groups had a similar median age (68tvs.69 years, respectively;P>0.05) and same median length of symptoms. Overall incidence of PN was 23.8 percent (10.9 percent unilateral and 12.9 percent bilateral). There was no difference in the incidence of PN between patients with normal evacuation and patients with obstructed evacuation (24.2 percentvs.23.2 percent, respectively;P>0.05). Patients with PN had a similar incidence of physiologic pelvic outlet obstruction as did patients without PN. However, median age of patients with PN was higher than those without PN (73tvs.66 years, respectively;P>0.05). CONCLUSION: There was a difference in the incidence of PN between normal and obstructed patterns of evacuation. Therefore, the espoused theory that obstructed defecation causes PN appears flawed.

The study reports a reconstruction of the sacrum in STS 14 based on extrapolation from the measurements of the first two sacral vertebrae of STS 14 and of the angle formed by the anterior surfaces of their vertebral bodies. Reconstruction is based on comparisons of, and extrapolation from, sacra of Pan troglodytes, Homo sapiens, and Australopithecus afarensis. The reconstructed sacrum has an anterior sacral curvature of 39°. The two ossa coxae were also completed by mirror imaging of one side by the other. With the pelvis completely reconstructed, the pelvic dimensions for the antero-posterior (AP) diameters of the pelvic inlet, midpelvis, and pelvic outlet are 85, 68, and 69 mm and the corresponding transverse (TR) diameters are 109, 88, and 103 mm, respectively. The posterior sagittal diameters in the three pelvic planes are small compared to the anterior sagittal diameters. This analysis indicates that the STS 14 pelvis is platypelloid in the three pelvic planes; i.e., all the AP diameters are smaller than the corresponding TR diameters. This makes the STS 14 pelvis similar to that to Al 288-1, save for a less pronounced degree of platypelloidy at the inlet in the former. © 1995 Wiley-Liss, Inc.

Background Constipation in children is a commonly encountered problem with a broad variety of causes. Constipation caused by a narrow pelvis has, to our knowledge, not been reported in the human literature. Methods Retrospective review of patient chart, in depth follow-up appointment with the patient and review of literature. Results A 15year old girl with sacral agenesis and significant co-morbidities was referred for consideration of cecostomy tube placement to manage her constipation. Digital rectal exam revealed a very narrow pelvic outlet and CT scan confirmed abnormal configuration of the bony pelvis. Discussions with orthopaedic colleagues concluded that bilateral pelvic osteotomies to widen her pelvis may relieve her constipation. The procedure was uneventful and radiologic follow-up confirmed widening of the pelvic outlet and increased pelvic volume. Her stooling pattern improved postoperatively and she was satisfied with the result on follow up at one year. Conclusions Although previously described only in the veterinary literature, surgical widening of a narrow pelvis can be considered for the management of constipation in the rare patient with appropriate physical and radiologic findings.

Experience of 32 cases of symphysiotomy carried out in Mozambique and in Botswana is reviewed. Of all cases only 1 was lost to follow-up. The observation period varied from 7 days to 6 months. Among 31 cases examined at discharge or on return from check-up few complications occurred. Vaginal laceration occurred in 3 cases, haematuria in 1 case and wound infection in 1 case. In 2 cases there was significant postoperative pain causing gait problems, but in no case were there significant problems with pain at discharge or at follow-up. It is concluded that the intervention is seldom complicated by severe sequelae, provided strict adherence to given indications is respected. In rural areas in the third world symphysiotomy is a life-saving and simple surgical intervention, which should be regarded as an adjunct measure in some cases with a moderately contracted pelvic outlet incompatible with normal vaginal delivery.

Laparoscopic surgery for rectal cancer is thought to be a technically more difficult operation than laparoscopic colectomy. Data from the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial showed that circumferential resection margin positivity was greater in the laparoscopic group (12%) than in the open surgery group (6%) undergoing anterior resection, although this difference was not significant [1]. In contrast, many nonrandomized studies, including ours, have suggested that laparoscopic surgery for rectal cancer is safe and feasible with careful case selection and expertise [2, 3]. The recent randomized Comparison of Open versus laparoscopic surgery for mid and low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial showed that laparoscopic surgery after preoperative chemoradiotherapy for mid and low rectal cancer is safe and that the quality of oncologic resection is similar to that of open surgery [4]. Because the future may see increasing demand for laparoscopic surgery to treat rectal cancer, a better understanding of the factors associated with the difficulty of laparoscopic surgery is important for surgeons, especially those learning these operations for proper case selection. In the December issue of Surgical Endoscopy, Killeen et al. [5] examined the influence of pelvic dimensions measured by magnetic resonance imaging (MRI) on difficulties in laparoscopic surgery for rectal cancer. Operative time was used as a measurement of operative difficulty. Univariate analysis showed that a less acutely curved sacrum and a larger sagittal pelvic outlet were significantly correlated with longer operative time, especially for a pelvis with a narrow intertuberous distance. Although Killeen et al. [5] introduced our study as supportive of their findings, indeed, we came to different conclusions [6]. We showed by multivariate analysis that narrower pelvic outlet together with higher body mass index, shorter tumor distance from the anal verge, and advanced tumor depth was independently predictive of longer operative time in laparoscopic total mesorectal excision (TME) with intracorporeal rectal transection and double-stapling technique (DST) anastomosis. There may be some reasons for the different conclusions. First, the total number of patients analyzed in the study of Killeen et al. [5] was small (n = 25). Second, multivariate analysis including patientand tumor-related factors other than pelvic dimensions was not performed in their study. Third, they evaluated the total operative time as dependent variable, and patients who underwent either laparoscopic anterior resection or abdominoperineal resection were included. However, excluding the procedures outside the pelvis might be necessary for accurate analysis of the influence that pelvic dimensions has on difficulties in laparoscopic surgery for rectal cancer because pelvic dimensions influence the procedures more directly after the pelvic cavity is reached. We also have reported that narrow pelvic dimensions were not associated with overall postoperative morbidity and anastomotic leakage [6]. On the contrary, larger pelvic outlet was independently predictive of anastomotic leakage [6]. Considering these results, we concluded in our T. Akiyoshi (&) M. Ueno Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan e-mail: takashi.akiyoshi@jfcr.or.jp

Six pelvic osteotomies (Salter, Sutherland, Steel, Tönnis, Chiari, and periacetabular) were performed on the right hemipelvis of adult female pelvic plastic models. Each pelvis underwent conventional X-ray and computed tomographic digital pelvimetry before and after osteotomy. The change in the anteroposterior and transverse dimensions at the inlet, midpelvis, and outlet were calculated. None of the osteotomies significantly decreased the inlet. The Salter and Sutherland osteotomies decreased the midpelvis to borderline low. The Salter, Sutherland, and Steel osteotomies significantly decreased the pelvic outlet. These changes correlated closely with those in living patients. Much of this decrease is nullified when the osteotomy is performed prior to the pubertal growth spurt.

To investigate correlation between key diameters of pelvic inlet and outlet planes and female pelvic floor dysfunction (FPFD).Correlation with incidence of FPFD was analyzed by measuring the two diameters of pelvic inlet and outlet planes (i.e. anteroposterior diameter of pelvic inlet and transverse diameter of pelvic outlet) in 298 patients with FPFD and 508 patients in control group taking into account of other relevant factors.The transverse diameter of pelvic outlet was significantly larger in experimental group than in control group (9.55cm vs. 8.50cm, P0.01); while the difference in anteroposterior diameter of pelvic inlet between the two groups was not statistically significant (11.63cm vs. 11.26cm, P=0.2050.01); Binary logistic regression analysis indicated that the anteroposterior diameter of pelvic inlet was not correlated with incidence of FPFD, but the transverse diameter of pelvic outlet was one of the influencing factor for FPFD.The transverse diameter of pelvic outlet is closely correlated with incidence of FPFD and represents one of the risk factors for FPFD; a transverse diameter of pelvic outlet greater than 9.5cm is the threshold for onset of FPFD and can be used as an early predictive index for FPFD.

OBJECTIVE. The purpose of this article is to present the route of extension in nine soft-tissue tumors and tumorlike lesions of the pelvic wall.CONCLUSION. Soft-tissue tumors of the pelvis, particularly malignant ones, extend into other compartments through specific pathways that are bordered by bones, ligaments, and fasciae. Such pathways include the greater sciatic foramen, the obturator foramen, the femoral canal, the muscular lacuna, the pelvic outlet, and the inguinal canal.

Four pelvic halves from two Japanese giant salamanders (Cryptobranchidae Megalobatrachus japonicus, one male and one female) were dissected in order to obtain detailed morphological data on the lumbosacral plexus and the muscles of the pelvic outlet. According to the positions of the passage of the metazonal nerves, the nerves can be divided into three groups: 1) the nerves passing dorsal to the caudofemoralis muscle, 2) the nerves passing between the caudofemoralis and the caudoischiadicus, 3) the nerves passing ventral to the caudoischiadicus. In consideration of the sites of origin from the lumbosacral plexus, a three-way stratificational analysis can be made, group 1 arising craniodorsal to group 2, and group 3 caudoventral to group 2. It is suggested that the three pelvic outlet muscles, the caudofemoralis, caudocruralis, and caudoischiadicus, have derived from the ventral muscles of the posterior limb, and have extended ventrocaudalwards.

Laparoscopic surgery for rectal cancer is now well estab-lished. Recent studies have shown no difference in survivalor oncologic outcomes when laparoscopic surgery iscompared to open procedures [1, 2]. The laparoscopicapproach does, however, present the surgeon with inherentchallenges. Previous abdominal surgery, tumours closer tothe anal verge, high body mass index (BMI), and preop-erative radiotherapy have been shown to increase the dif-ficulty of laparoscopic procedures in the pelvis [3–6].It is often assumed that laparoscopic resections for rectalcancer are also complicated by a deep, narrow pelvis inwhich access and vision are both restricted by pelvicanatomy. Although a majority of patients undergo preop-erative pelvic magnetic resonance (MR) staging, radio-logical measurement of the bony pelvis––pelvimetry––hasnot been fully assessed as a predictor of difficult laparo-scopic operations.Male sex has been shown to correlate with surgeons’perceived difficulty of laparoscopic resections, althoughmore objective evidence of increased difficulty, in the formof longer operating times or more frequent involvement ofthe circumferential resection margin (CRM), is sparse [6].Indeed, while some authors have demonstrated significantdifferences in pelvic measurements between the sexes [7,8], others have shown considerable overlap [9], suggestingthat the measurements themselves may be a more usefulpredictor of difficulty than sex alone.MR pelvimetry has been evaluated for potential appli-cation in predicting the technical difficulty and outcomes ofopen rectal resection and prostatectomy [3, 4, 7, 10].Various dimensions of the bony pelvis thought to be ofimportance during surgery were studied; all studies used acombination of anteroposterior (AP) measurements in themid-sagittal plane and some form of transverse measure-ment to describe the breadth and depth of the pelvis. Someauthors measured angles and dimensions on the mid-sag-ittal slices to define the acuity of the sacral curve and theother boundaries of the pelvis [3, 7, 10]. One author wentfurther, developing a synthetic measurement designed tobetter describe the pelvic depth observed by the surgeonperforming open radical prostatectomy––the apical depthof the pelvis divided by the transverse interspinous distance[11]. None of these measurements were shown to signifi-cantly predict any objective or subjective measure ofoperative difficulty and pelvimetry seems to have beenabandoned as a predictor in open resections.It is reasonable to expect that pelvic anatomy may bemore important in laparoscopic resections. A prominentsacral promontory, an acutely curved sacrum, or a pelvisparticularly narrow in the transverse plane could conceiv-ably represent anatomical bottlenecks, impeding vision,access, and space in which instruments can be manipulated.Indeed, initial research has shown correlations betweenlonger operating times and a larger pelvic outlet [4] and asmaller lower pelvis diameter [5] and between CRMinvolvement and shorter transverse interspinous distances[12]. Further ascertainment of the influence of pelvic

Objectives: To radiographically demonstrate the upper sacral nerve root tunnel (USNRT) in both cadaveric specimens and a clinical cohort and to quantify its clinical relevance. Setting: Level 1 trauma center and anatomy laboratory. Patients and Participants: Eleven cadaveric pelves and 23 consecutive patients who underwent fluoroscopically assisted iliosacral screw insertions. Interventions: Cadaveric pelves were fluoroscopically imaged using standard pelvic inlet, outlet, and true lateral sacral views. The course of the USNRT pathway was identified. Then, these tunnels were filled completely with a semisolid radio-opaque agent. The specimens were reimaged after the contrast injection. Clinically, 23 consecutive patients with unstable posterior pelvic ring disruptions were treated using fluoroscopically assisted percutaneous iliosacral screws based on these predictable radiographic landmarks. A total of 44 iliosacral screws were inserted. Main Outcome Measurements: For the cadaveric portion, the images with contrast were used to identify the USNRTs. For the clinical study, tunnel visualization was determined on all views intraoperatively. Screw placement was documented by postoperative pelvic plain radiographs and computed tomography scan. Results: In the cadaveric specimens, the contrast agent consistently demonstrated the USNRTs on all 3 pelvic radiographic views. In the clinical series, the USNRTs were well visualized on the pelvic outlet image in all 23 patients (100%). Using the inlet image, the USNRTs were visualized in only 5 of 23 patients (21%). On the true lateral sacral views, the USNRTs were seen in 21 of 23 patients (91%). Using these USNRT radiographic landmarks, no iliosacral screw was extraosseous. Conclusions: The USNRTs have a consistent radiographic appearance that is best seen on the pelvic outlet and true lateral sacral views, but their course is best understood when seen on all 3 views. Awareness and understanding of the USNRT, its course, and its radiographic landmarks allow the surgeon to avoid tunnel intrusion by an iliosacral screw.

EDITORIAL COMMENT: This paper compares conventional X-ray pelvimetry with CT pelvimetry and the authors conclude that the latter is preferable due to the lower radiation dose, patient comfort and shorter time of examination; surprisingly they commented that the 2 procedures had no significant difference in cost. Ultrasonography has virtually replaced radiography in obstetric practice The exception is X-ray pelvimetry which is still performed in many centres in the management of breech delivery at term, and in patients in whom a trial of vaginal delivery is planned after previous Caesarean section although the latter indication is not accepted in many centres (e.g. Dublin). In our mixed Australian community, moderate to severe pelvic contraction, even predominantly of the pelvic outlet (and hence especially relevant to breech delivery) is a reasonably common finding. Not all radiologists will agree with the conclusions in this paper. Our reviewers pointed out that the actual radiation doses were not measured but were quoted from references, those for conventional pelvimetry being 1962 and 1963 references. It should be noted that with modern X-ray technique the radiation dose has been considerably reduced and ‘the radiation dose from CT pelvimetry including the 2 scout films and one axial slice using a reduced MAS is comparable to conventional pelvimetry including 2 films, the erect lateral film and the tube shift film for the transverse diameters but excluding the outlet view!’ Our reviewers believe that both methods of pelvimetry are comparable and require meticulous technique; they agreed that there was no significant interobserver variability reporting the pelvimetries in this study. The take away message seems to be that there is still a place for pelvimetry in obstetric practice and CT pelvimetry is likely to become more popular. We agree with the practice of postpartum pelvimetry to avoid fetal irradiation and provide information for management of subsequent pregnancies in nulliparas who were delivered by Caesarean section or difficult forceps delivery. Summary: In this study 24 patients who had conventional erect lateral X-ray pelvimetry had a CT pelvimetry done after delivery to complete the pelvimetry views. The erect lateral pelvimetry was read independently by a Consultant Radiologist, Consultant Obstetrician and a Medical Officer training in Obstetrics and Gynaecology. Using CT pelvimetry as the ‘gold standard’ (as the error of measurement was known with the machine used) the 3 readings were compared. There was no statistical difference in the values suggesting that X-ray pelvimetry is comparable to CT pelvimetry. However CT pelvimetry is preferred, if available, because of the lower dose of radiation involved, more comfort for the patient and shorter time in performing the procedure. Measurements done are easily read directly from the CT console.

Magnetic resonance imaging pelvimetry in 186 patients with rectal cancer confirms an overlap in pelvic size between males and females Introduction It has generally been considered that open pelvic surgery is almost always easier in female subjects because of anatomical differences facilitating surgical access. In contrast, the male pelvis has been considered to be narrower and deeper. The objective of this study was to assess magnetic resonance imaging (MRI) pelvimetry in patients with rectal cancer in whom any difference in pelvimetry may potentially affect operative management. Male and female pelvic bony dimensions were compared. Method A cohort of 186 patients (112 males and 74 females) with rectal cancer who had been recruited prospectively to the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study (MERCURY Study) were assessed. Complete digital images were available on these patients. A comparison of the pelvic dimensions was made between the sexes using 16 dimensions measured on the MRI workstation using the mid-sagittal and axial images. Results There was no significant difference and considerable overlap between the sexes with respect to each of the 14 parameters measured from the preoperative sagittal MRI scan. However, there was a highly significant difference between the interspinous and intertuberous transverse diameter of the pelvis (P < 0.0001). Conclusion Outcome after surgery may be influenced by the technical difficulty of the operation and this had been thought to be partly affected by the pelvic size. In this cohort of 186 patients, the only difference seen between the sexes, was in the transverse mid-inlet and pelvic outlet diameter.

Background: A number of parameters are used to assess the pelvis for clinical, physical and forensic anthropological reasons. When it is adequately assessed within any population group, the pelvis displays wide variations. Although the sub-pubic angle is one of the three forensically important angles of the pelvic outlet, literature is scanty or lacking on East and Central Africans, and no published report is available on indigenous Malawian subjects. Objectives: To determine the sub-pubic angle in indigenous Malawians and compare them with angles from other population groups previously reported. Design: A cross-sectional study. Setting: Queen Elizabeth Central and Blantyre Adventist hospitals in the city of Blantyre. Subjects: One hundred and nineteen antero-posterior radiographs of pelves of adults indegenous Malawians aged 20-84 years to determine their sub-pubic angle. Results: Women showed significantly wider sub-pubic angles than men (129.07 ± 14.19° SD women and 99.16 ± 15.73° SD men; P < 0.001), confirming similar results previously studied in other population groups. We have demonstrated that the sub-pubic angle alone could accurately assign sex to 67.12% of males and 63.04% of females, and race could be accurately assigned to 21.92% of men and 89.96% of females. Malawians showed significantly wider angles than Amerindians, Black and White Americans (P < 0.001). Conclusion: This study documents sexual and racial differences and for the first time (on comparison) the sub-pubic angles indicate geographical variations, underpinning the need to establish normal ranges of these angles in any given population. We recommend the establishment of local references of the sub-pubic angle to other countries in the sub-region.