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Objective To describe in detail the variability of the attachments of the iliopectineal fascia (IPF) and its relation to the external iliac vessels to inform surgical approaches and help prevent injury to the adjacent vascular structures. Methods A cadaveric study was performed on 16 specimens. The IPF was identified from the lateral and medial perspectives of the II and anterior intrapelvic approaches, respectively, and its anatomic characteristics were described. Results The IPF originates in the fascia of the psoas muscle, it has variable attachments in the pelvic brim, and it inserts in the medial surface of the iliac bone where it is continuous with the obturator internus fascia. Two variants were found in relation to the external iliac vessels. In one variant found in 4 cadavers, the IPF formed a sail-like structure that surrounds the external iliac vessels. In the other variant observed in 4 cadavers, the IPF overlaid the iliac fossa, under the external iliac vessels which laid free in the iliac fossa. Conclusions The anatomic variants of the attachment of the IPF to the pelvic brim and its variants in relation to the external iliac vessels must be accounted for when performing acetabular surgery to prevent vascular injury and attain adequate exposure.

While laparoscopic heminephrectomy is performed for poorly functioning moieties, laparoscopic reconstruction with renal preservation is feasible when the affected moiety is functioning. Laparoscopic pyelopyelostomy at the level of pelvic brim can offer an alternative solution. We retrospectively reviewed the records of patients treated between 2017 and 2019 with renal duplication anomalies, and a preserved function. Five patients were identified, who underwent laparoscopic high internal diversion after placing a retrograde double J stenting in the receiving moiety. Stents were removed 8 weeks after surgery. All patients had uneventful post-operative recovery and showed clinical and radiological improvement at 1-year follow-up with no further episodes of urinary tract infection (UTI). The mean operative time was 155 min (range 130–170) and mean time to discharge was 4 days (range 2–5). The management of the duplex renal systems should be individualized for every patient. In the presence of a functioning moiety, laparoscopic reconstruction can be accomplished by pyelopyelostomy. This approach gives wider anastomosis, is easier to perform and gives better drainage than laparoscopic uretero-ureterostomy where the receiving ureter is often narrow potentially risking the normal moiety.

This study presents our experience of internal fixation of the acetabular fractures and pelvic fractures using a newly modified Stoppa approach, which provides closer visualization to the entire anterior column, quadrilateral surface and the pelvic brim portion of the posterior column, and permits stable internal fixation for the acetabular fracture patterns with main anterior displacement and the anterior and lateral parts of the pelvis. The present study was a prospective clinical study including 10 patients with acetabular fractures who were treated operatively using modified Stoppa approach . The classification of acetabular fractures described by Letournel and Judet. All operative data was recorded Patients were followed-up for 12 months after the operation. The maximum displacement of the bony fragment was measured in the unit of mm by using PACS, Marosis mview ver. 5.4 Our result shows the incidence of perioperative complication. Two patients developed DVT and two patients developed obturator nerve palsy. Our result shows the radiological outcomes of the included patients. The mean CT gap was 1.685 ±0.27mm. Eighty percent of the patients had anatomical Matta class. Our result shows the Merle D‟Aubigne-Postel score of the included patients. Eighty percent of the patients had excellent score. The incidence of MVO after PPCI may be lowered by the addition of manual TA (6,24). The results of the present study show that the additional intracoronary administration of a high dose of adenosine may further improve STR up to 70%. Future larger studies with clinical endpoints are warranted to confirm the benefit of intracoronary administration of a high dose of adenosine in addition to glycoprotein IIb/ IIIa antagonist administration and TA in the setting of PPCI or rescue PCI.

Introduction/Background* Laparoscopic Ovarian Transposition (OT) has already been proven to be a safe and effective procedure to preserve ovarian function in patients receiving pelvic radiotherapy for a variety of gynaecological malignancies. Different techniques have been described. Aim This video demonstrates our PS technique for OT in a 32-year-old patient with stage 1B3 poorly differentiated squamous cell carcinoma of the cervix who subsequently underwent radical chemoradiation. Methodology/Technique Laparoscopy was performed as usual, using a 10mm umbilical optic port and four 5mm ports placed in both iliac fossae and high in both flanks. Thorough inspection of the peritoneal cavity revealed no evidence of disseminated disease. Approximately 100mls of free blood was seen in the pelvis. Both ovaries were slightly enlarged and the right ovary had a ruptured haemorrhagic cyst. She had previously developed OHSS after ovarian stimulation and egg retrieval. The uterus was bulky and retroverted. Both tubes were normal. All the upper abdominal organs looked normal and there was no evidence of disease on the ovaries or peritoneal surfaces therefore we decided to proceed to bilateral ovarian transposition. Result(s)* Bilateral retrograde salpingectomy was performed using a Harmonic scalpel and specimens were sent for histology. Both pelvic side walls were opened and both ureters were identified. Both utero-ovarian ligaments were transected along with 2cm of round ligament on both sides and ovarian flaps were created. The ovarian flaps were mobilised and the infundibulopelvic ligaments were skeletonised. The para-colic gutters were incised approximately 10cm above the pelvic brim and were tunnelled. Both ovarian flaps were pulled through and stapled outside the irradiation fields to prevent them from falling back into the pelvis following the procedure. Titanium staples were used for easy identification of ovaries on imaging. At the end of the procedure both ovarian pedicles were tension-free with good mobility and no risk of necrosis or torsion. There were no intraoperative complications and the patient experienced a good recovery. Conclusion* We consider that the ovarian flap allows the ovaries to have a degree of natural movement, while at the same time preventing torsion and minimising ovarian damage associated with the use of transfixed stitches.

To determine the optimal position of reduction clamps applied to reduce transtectal transverse acetabular fractures approached through the anterior intrapelvic route. Transtectal transverse fractures were created in sawbone hemipelvis models. Fractures were reduced and held with a large pointed reduction clamp with one tine centered on the quadrilateral plate and the other placed in one of nine various positions on the pelvic brim accessible from the anterior intrapelvic (AIP) approach. Reduction was assessed by measuring maximum gapping and step-off at the joint surface. The posterolateral pelvic brim clamp position provided the most accurate reduction with the smallest articular fracture gap (mean 1.09 ± 1.05 mm) and step-off (mean 0.87 ± 1.35 mm). This clamp position, compared with the other positions as a whole, also yielded the highest proportion of perfect reductions (0 mm maximum displacement) for both step-off (83% vs 34%; RR 2.4, 95% CI 1.7–3.2) and gap (88% vs 49%; RR 1.8, 95% CI 1.4 to 2.2). When clamping transtectal fractures through the AIP approach, positioning the clamp posterolaterally on the pelvic brim appears to provide the best reduction in this fracture model.

The aim of this study was to clarify the relationship between the length of the round ligament and the presence of a patent processus vaginalis (PV) based on the hypothesis that a short round ligament is the cause of ovarian inguinal hernia in female infants. Between April 2011 and March 2017, 132 girls underwent laparoscopic surgery for inguinal hernia. Before surgery, the presence of ovarian prolapse was diagnosed. We observed the internal inguinal ring laparoscopically and examined the diameter of the PV orifice as well as the round ligament length. Medical records and video records were reviewed to evaluate PV patency and round ligament length. Seventeen of the 132 cases had an ovarian inguinal hernia; all of them were infants. In all infants, with or without a prolapsed ovary, the round ligament was short, causing the ovary and fallopian tube to be close to the hernia orifice over the pelvic brim. In girls aged over 12 months, the round ligament lengths on the hernia side, contralateral open PV side, and contralateral closed PV side were 33.0 ± 9.3, 36.8 ± 7.5, and 41.4 ± 8.5 mm, respectively. The round ligament length in open PV was significantly shorter than in the closed PV, but the difference was smaller in older patients. The round ligament, which is the female gubernaculum in the fetus, was shorter in the open PV than in the closed PV in younger girls. The short round ligament results in the ovarian prolapsed hernia.

Introduction In fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone. Materials and methods We retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO. Results 48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO. Conclusion There is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.

A 31-year-old woman, who is a known case of polycystic ovary syndrome, underwent modified radical hysterectomy and right ovarian transposition to the anterior abdominal wall for endometrioid adenocarcinoma Grade II. She then visited our facility for in vitro fertilization (IVF) and surrogacy in the year 2016. Three cycles of IVF were performed using gonadotropin-releasing hormone (GnRH) antagonist in the first two attempts and GnRH agonist in the third attempt, with percutaneous technique of oocyte retrieval from the transpositioned right ovary. In the third attempt in July 2017, we were able to retrieve five oocytes and subsequently froze three embryos and one blastocyst. The surrogate underwent sequential transfer in June 2018 which resulted in a positive clinical singleton pregnancy. The outcome of IVF following percutaneous oocyte retrieval led to a successful pregnancy and subsequent delivery by emergency cesarean by a healthy female baby on February 16, 2019. This is the first reported case of ovarian hyperstimulation and percutaneous aspiration of oocytes from a transpositioned right ovary (subcutaneous plane) in our country. Global literature survey revealed publications only of transabdominal retrieval of ovaries moved above the pelvic brim.

The study objective is to compare the effectiveness and safety of using 4-and 6-arm mesh prostheses in transvaginal correction of urogenital prolapse. Materials and methods . From 2013 to 2018, 164female patients with grade II—IV prolapse of the pelvic muscles underwent surgery. Reconstruction of the pelvic floor using 4-arm prosthesis Prolift anterior was performed in 54 (33 %) patients (group 1), 6-arm prosthesis OPUR — in 110 (67 %) patients (group 2). The patients’ age varied between 45 and 76years (mean age 56.3 years). All women previously delivered children (69 % delivered 2 or more children). In 73 % patients, labor was complicated by raptured cervix and/or groin, episioto-my, fetal skull remaining stationary above the pelvic brim. In 25 % of women, grade IV cystocele was diagnosed at the time of examination, in 62 % — grade III, in 13 % — grade II; grade IVhysteroptosis was diagnosed in 12 % of women, grade III — in 54 %, grade II — in 34 %. Results. In the group 1, cystocele was corrected in 90 % of cases, hysteroptosis — in 75 %. Mean blood loss was 150.0 + 69.6 ml. Operative time varied between 60 and 169 min. In the group 2, cystocele was corrected in 100 % of cases, hysteroptosis — in 98 %. Mean blood loss was 125.0 + 59.6 ml. Operative time varied between 38 and 143 min. Women noted decreased emotional tension during sex. Conclusion. Disadvantages of 4-arm meshes include worse correction of hysteroptosis and significant complications, rate and grade of which lead to a decrease in manufacture of the prosthesis. Modern 6-arm mesh prosthesis OPUR is safer and more effective. Its construction and method of implantation were developed with the goal to eliminate the main disadvantages of 4-arm prostheses.

The incidence of secondary perineal hernia (SPH) has increased since the introduction of extralevator abdominoperineal resection and laparoscopic abdominoperineal resection. Currently, laparoscopic mesh repair is the usual procedure. Here, we demonstrate a repair of SPH without mesh that uses the mobilized cecum to cover the pelvic hernial orifice. An 83-year-old man complained of discomfort when sitting for long periods. He was status post laparoscopic abdominoperineal resection and was diagnosed with SPH. Hernia repair was performed. After transperitoneal adhesiolysis in the inferior pelvis, the right colon was laparoscopically mobilized, and the pelvic orifice was covered by suturing the cecum to the pelvic brim. The perineal skin was managed with negative pressure wound therapy. The postoperative course was uneventful. There has been no sign of recurrent herniation for 12 months. This method of SPH repair is simple to perform and avoids mesh-related complications.

Musculoskeletal injuries such as dislocation of the shoulder and hip joints and fractures of the femoral neck are known complications of seizures. Bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture is a rare entity and is prone to delayed diagnosis, even more so in patients who experience post-seizure disorientation. The authors report the case of a 74-year-old male patient with bilateral central subluxation of the hip joint with associated bilateral quadrilateral plate fracture due to seizure activity. Bilateral open reconstruction and fixation of the quadrilateral plate with a 3.5-mm pre-bent reconstruction plate reinforced with 3.5-mm pelvic brim reconstruction plate was performed. In conclusion, this case is an example of rare bilateral quadrilateral plate fracture caused due to seizure activity, a fracture for which a high level of suspicion should be kept in mind while evaluating the patient post-seizure episode.

Dislodgment of trial femoral heads and migration into the pelvis during total hip arthroplasty is a rarely reported complication with limited published cases. There are three primary mechanisms of femoral head separation: dislodgement during reduction attempt, disassociation from anterior dislocation while assessing anterior stability, and during dislocation after implant trialing. If the trial femoral migrates beyond the pelvic brim, it is safer to finish the total hip arthroplasty and address the retained object after repositioning or in a planned second procedure with a general surgeon. We recommend operative retrieval since long-term complications from retention or clinical results are lacking. Keywords: Total hip arthroplasty, THA, Complications, Femoral head dislodgement

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.

Acetabular fracture in older patients presents many challenges to even experienced pelvic surgeons. There remains a lack of clarity regarding many indications for nonoperative or operative management. Chronological age should not be considered in isolation when deciding upon a treatment plan; rather, the surgeon must individualize the plan to the patient’s activity level, physiological age, and risks for blood loss and general anesthesia. When an operative path is chosen, closed or limited open reduction techniques paired with percutaneous screw stabilization are an option for fracture patterns not associated with posterior instability of the hip joint. The goals of treatment should be restoration of the normal relationship of the cranial femoral head with the dome of the acetabulum and to provide fixation that is stable to allow for early mobilization. Fixation with screws alone provides less resistance to loss of reduction than do plates, but allows for implant placement without large open approaches. A secondary benefit of fixation with percutaneous screw is the ability to remove them at a later date with percutaneous incisions rather than open approaches. Common screw pathways used are familiar to pelvic surgeons and include anterior and posterior column screw and the LC-2 (pelvic brim) screw, but screw placement is only performed after an appropriate reduction has been achieved.

Deep infiltrating endometriosis of the urinary tract is rare but can result in ureteric obstruction, hydroureteronephrosis and renal failure. Ureteric endometriosis usually affects the distal third of the left ureter among women of reproductive age. Greater awareness of ureteric endometriosis and a multidisciplinary approach in the management is essential to achieve optimal outcomes. We present an atypical case of right ureteric obstruction due to endometriosis at the pelvic brim resulting in complete loss of renal function and necessitating nephroureterectomy.

Aim: Breech is the most common form of malpresentation. It is defined as when foetus occupies a longitudinal lie with the pelvic extremity at the pelvic brim and head at the fundus of the uterus. The present study was conducted on 100 cases of breech presentation to find out the labour outcome in breech deliveries and various factors affecting it. Materials and Methods: The present study was conducted in the Department of Obstetrics and Gynaecology, Umaid Hospital, attached to Dr. S.N. Medical College, Jodhpur. A total of 100 cases of breech presentation including single as well as plural pregnancies in which one or more foetuses were presenting as breech were taken. Both booked and unbooked cases in primigravidae and multigravidae were studied. The cases were selected at random among those who got admitted in labour room. Results: In the present series, incidence of breech deliveries came to be 4.1094%. Incidence of breech presentation was maximum (45%) in the age group of 21–25 years. In this study, out of 100 cases, 62 were multigravidae and 38 were primigravidae, and 43 cases (43%) were associated with factors which endanger of life of the foetus, among which twin pregnancy and pre-eclamptic toxaemia were the most commonly associated factors. In the present series, among 100 cases studied, 14 were breech babies and congenital malformation, of which hydrocephalus was the most common malformation found. Conclusion: The study concludes that prematurity is associated with high incidence of breech presentation. The most common variety of breech presentation is flexed breech, which is found more in multigravidae. Caesarean section is the mode of delivery of choice as it carries minimal foetal loss. Extended variety of breech is safest for the baby and carries minimal foetal loss.

Purpose The triradiate cartilage transiently projects medially within the pelvic brim around the time of triradiate closure, mimicking the ischial spine sign. The purpose of this study was to characterize this newly identified radiographic sign using a longitudinal radiographic study. Methods We identified 72 subjects from a longitudinal radiographic study of healthy adolescents, each with at least four consecutive, annual anterior−posterior radiographs of the left hip, including physeal closure. Images were reviewed to identify the presence of the triradiate bump, the year it was most prominent, and the number of years relative to triradiate closure after which it had completely remodeled. Results The transient medial projection of the triradiate cartilage (triradiate bump) was identified in 26/40 (65 %) females and 22/32 (69 %) males ( p = 0.74). The medial projection of the triradiate cartilage was most prominent at 10.8 ± 0.8 years of age in females and 12.6 ± 0.7 years of age in males ( p < 0.001). The triradiate cartilage projected medially a mean of 4.7 ± 0.8 or 5.1 ± 1.4 mm for females and males, respectively ( p = 0.29), but remodeled completely in all cases around triradiate closure. Conclusions The transient medial projection of the triradiate cartilage within the pelvic brim, the ‘triradiate bump sign’, is a common radiographic finding in healthy adolescents around the time of closure of the triradiate cartilage that may mimic the ischial spine sign. These two signs can be distinguished as the projection of the ischial spine is located more inferiorly within the pelvic brim and the triradiate bump has a horizontal limb of radiolucency extending to its medial border.

Infertility due to ovarian maldescent is extremely rare and diagnosis can be challenging in the absence of uterine anomalies. We present a case of infertility due to bilateral ovarian maldescent with normal uterine anatomy who conceived after in vitro fertilization and did not require removal of the ovaries. A 19-year-old woman presented with primary infertility. After three failed cycles of ovulation induction/intrauterine insemination and one failed cycle of fresh embryo transfer, the patient underwent laparoscopy, which showed bilateral ovaries above the pelvic brim. The patient conceived after second in vitro fertilization and delivered at 34 weeks. Accurate diagnosis of ovarian maldescent in a patient of unexplained infertility and normal uterus is crucial for successful follicular aspiration and infertility treatment. It is important to counsel patients about the benign nature of this rare entity and future fertility.

Renal migration anomalies are rare and often under-reported. Kidneys that fail to ascend to their normal location in the renal fossa are usually termed 'ectopic' kidneys, which can be unilateral or bilateral. Those that fail to ascend above the pelvic brim are commonly termed pelvic kidneys. We present a case of a 41-year-old male haemophiliac on routine investigation with a previous history of anaemia and bone pains, currently asymptomatic. He was found to have malrotated pelvic kidneys with vascular anomalies. Even though most patients with pelvic kidneys are asymptomatic, they are usually discovered in childhood or as young adults. This case is important because, in addition to the late discovery of the bilateral pelvic kidneys, there is coexistence of a bleeding disorder which may pose a challenge in patients' management. This is to also make the patient aware of his condition and avoid taken unnecessary risk which might make his condition worse.

Objectives The aim of this study was to describe a case of uterovaginal prolapse managed with robotic-assisted sacral colpopexy complicated by severe right-sided hydronephrosis despite normal intraoperative cystoscopy. Methods A 68-year-old woman presented with a worsening vaginal bulge over the past 2 years. Tricompartment stage 2 uterovaginal prolapse, with dominant cystocele and skin erosion at the posterior fourchette from prolapse friction, was identified on physical examination, and the patient underwent pelvic reconstructive surgery, including sacral colpopexy. Results The patient was discharged on postoperative day 4 after being treated for a urinary tract infection. At her 6-week postoperative visit, the patient demonstrated normal vaginal support. She presented 6 months postoperatively with right-sided hydronephrosis with an almost imperceptible stricture where the right iliac vessels cross the pelvic brim, demonstrating a delayed manifestation of ureteral injury. She underwent open ureteroscopy, ureteroneocystostomy with vesicopsoas hitch, and ureteral stent placement. Ureteroscopy demonstrated a very mild narrowed caliber of the ureter just above the sacroiliac joint without overt obstruction. Follow-up intravenous pyelogram demonstrated no evidence of damage or obstruction. At nearly 1-year follow-up, the patient remained asymptomatic and had normal renal function. Conclusion This case demonstrates the challenges of an uncommon, but highly morbid, complication of pelvic reconstructive surgery. Even when adequate visualization of the ureters and delicate ureteral dissection is achieved throughout surgery, occult injuries can still occur. Surgeons should maintain a high index of suspicion of ureteral injury when evaluating patients for late presentations of postoperative complications.

Shoulder dystocia can lead to death or brain damage for the baby. Traction on the head can damage the brachial plexus. The diagnosis should be made when the mother cannot push the shoulders out with her own efforts with the next contraction after delivery of the head. There should be no traction on the head to diagnose shoulder dystocia. McRoberts' position is acceptable but it should not be accompanied by any traction on the head. If the posterior shoulder is in the sacral hollow then the best approach is to use posterior axillary traction to deliver the posterior shoulder and arm. If both shoulders are above the pelvic brim, the posterior arm should be brought down with Jacquemier's maneuver. If that fails, cephalic replacement or symphysiotomy is the next step. After shoulder dystocia is resolved, one should wait 1 minute or so to allow placental blood to return to the baby before cutting the umbilical cord.

Overview Introduction The periacetabular osteotomy procedure reorients a retroverted acetabulum into a more anatomically appropriate position. Step 1: Evaluation of Acetabular Retroversion Evaluate acetabular retroversion on the basis of a combination of radiographic signs. Step 2: Patient Positioning and Skin Incision After draping and sterile preparation with the patient in a supine position, make an incision following the skin lines of the inguinal fold. Step 3: Exposure of the Deep Muscle Layers and the Pelvic Brim Detach the abdominal wall muscles from the anterior iliac crest and detach the sartorius muscle and the inguinal ligament to expose the iliac fossa and the pelvic brim. Step 4: Surgical Dissection for Preparation of the Ischial Osteotomy Detach the iliocapsularis muscle and mobilize it medially to allow access to the infra-articular space and palpation of the ischial bone. Step 5: Incomplete, Partial Ischial Osteotomy Introduce a curved chisel with a crescent-shaped tip into the infra-articular space in order to perform the osteotomy of the ischial bone. Step 6: Osteotomy of the Superior Pubic Ramus Place subperiosteal blunt retractors around the superior pubic ramus to ensure safe and complete pubic bone osteotomy. Step 7: Supra-Acetabular and Retroacetabular Osteotomy Start the supra-acetabular horizontal osteotomy at the anterior superior iliac spine and end it 2 cm lateral to the pelvic brim, where the osteotomy is angled 100° distally. Step 8: Mobilization of the Acetabular Fragment With the help of a spreader and a 4.5-mm threaded Schanz pin, free and mobilize the acetabular fragment. Step 9: Reorientation of the Acetabular Fragment Perform internal rotation of the acetabular fragment with the help of the threaded Schanz pin. Step 10: Improvement of Anterior Head-Neck Offset (Femoral Neck Osteoplasty) Anterior capsulotomy and improvement of anterior head-neck offset is recommended when internal rotation is Step 11: Anteroposterior Pelvic Radiograph Following Periacetabular Osteotomy Ideally, a postoperative radiograph should show negative crossover and posterior wall signs while the ischial spine sign typically remains positive. Results The long-term results of the periacetabular osteotomy in a series of twenty-two patients (twenty-nine hips) with symptomatic acetabular retroversion were evaluated after a mean duration of follow-up of eleven years (range, nine to twelve years). Indications Contraindications Pitfalls & Challenges

Study Objective To demonstrate techniques of ureterolysis during complex laparoscopic hysterectomy. Design Technical video demonstrating different approaches to ureterolysis for complex benign pathology during laparoscopic hysterectomy (Canadian Task Force classification III). Setting Benign gynecology department at a university hospital. Intervention Performance of ureterolysis during laparoscopic hysterectomy for benign pathology. Conclusion Ureteric injury has significant morbidity and is the most common reason for litigation following hysterectomy, with an estimated risk of 0.02% to 0.4%. 1 , 2 . Ureterolysis is infrequently practiced by benign gynecologists; however, it may be necessary during complex surgery. Benign pathology requiring hysterectomy, such as endometriosis, myomas, large uteri, and adnexal masses, are recognized risk factors for ureteric injury [3] . Most injuries occur during division of the uterine artery at the level of the internal cervical os. The average distance between the ureter and cervix is 2 cm, but it is only 0.5 cm in 3.2% of the population with a normal pelvis [4] . Preventive strategies, such as the use of a uterine manipulator, may increase this distance, although it still might not be sufficient to prevent injury in women with normal anatomic variants and complex pathology. Visualizing the ureter at the pelvic brim and side wall without retroperitoneal dissection may be inadequate because the segment of ureter between the intersection of the uterine artery and the bladder is not visible. The ureter can be safely dissected up to 15 cm without compromising its viability. In this educational video, we demonstrate various simple, quick, and reproducible techniques to perform ureterolysis for complex benign pathology. These techniques can be used by both expert and novice surgeons to perform and teach ureterolysis. Our method determines the course of the ureter throughout the pelvis and relation to the uterine artery to reduce intraoperative injury. We have performed more than 350 cases with no injuries.

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.

Aim: Ipsilateral ureteroureterostomy is an established method for the treatment of duplication anomalies in children. With the advent of pediatric laparoscopy, many urologic procedures in children are being performed using minimal access techniques. We present our experience with laparoscopic ipsilateral ureteroureterostomy (LIUU) for duplex anomalies. Patients and Methods: The data of children who underwent LIUU was reviewed for demographic parameters, clinical and operative details, follow-up and results. Results: Over 3 years period, LIUU was performed in eight children (age 6-60 months). Five children had complete ipsilateral duplication with ectopic upper moiety ureter, one child each had ipsilateral incomplete duplication and bilateral duplex systems (with ipsilateral ectopic upper moiety ureter). One child had ipsilateral complete duplex with Grade V vesicoureteric reflux into the lower moiety ureter. Four children had antenatal diagnosis of hydronephrosis; three children had a urinary infection and two children presented with urinary incontinence. The surgical procedure consisted of cystoscopy, retrograde studies and cannulation of the recipient ureter. Then, LIUU was performed using three ports. The ectopic (donor) ureter was divided at the pelvic brim; the recipient ureter was opened and end-to-side LIUU was performed with 5/0 vicryl stitches over a double J (DJ) stent placed in the recipient ureter. Bladder catheter was removed after 2 days, and DJ stent was removed after 4 weeks. At a mean follow-up of 19 months (3-36), all children are asymptomatic and continent, with a significant reduction in hydroureteronephrosis on ultrasound. The cosmetic results were excellent. Conclusion: LIUU is a safe and effective technique in the management of duplication anomalies in children. It could be performed with minimal blood loss, minimal postoperative pain, excellent cosmesis and good success.

Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [ Orthopedics. 2017; 40(6);e947–e951.]

The ilioinguinal approach for psoas recession over the pelvic brim allows for direct visualization and protection of the femoral nerve while preserving hip flexion strength. Hip flexion contracture is a common problem in patients with spastic paresis such as cerebral palsy and may also affect patients who have sustained trauma about the hip. These contractures may impair gait and the ability to carry out activities of daily living. The iliopsoas muscle is the main deforming force; however, contraction of the hip capsule and surrounding soft tissue may also contribute1. Iliopsoas tenotomy at the level of the lesser trochanter treats the contracture at the cost of hip flexor strength, making it difficult for ambulatory patients to climb stairs or even walk on a level surface2,3. Intramuscular psoas recession over the pelvic brim is an alternative that preserves hip flexor strength while correcting the flexion contracture4-8. In this procedure, the psoas tendon is lengthened as it traverses the pelvic brim while the iliacus is preserved (Video 1). Thus, the iliopsoas unit is fractionally lengthened, preserving its ability to flex the hip. Previous studies have shown that hip flexion strength against gravity and manual resistance is maintained while improving dynamic pelvic tilt and step length during gait after this procedure4,8. Video 1 Introduction to psoas recession over the pelvic brim. An image in the video is copyrighted by, and reproduced with permission of, the AO Foundation, Switzerland.

The abdominal seatbelt sign (ASBS) has an established association with abdominal injury, yet its definition remains ill-defined. We hypothesize specific imaging characteristics associated with the ASBS such as location above the pelvic brim and depth of abdominal wall contusion would better predict underlying injury and need for operative intervention.We performed a retrospective chart review of subjects suffering from restrained motor vehicle collisions (MVC) evaluated at a level one trauma facility from 2010 to 2015. CT imaging was reviewed for the presence of a transverse abdominal wall contusion consistent with lap belt use. Contusion location was determined in relation to the anterior superior iliac spine (ASIS). Abdominal wall thickness as well as contusion depth were measured at the contusion level and an abdominal seatbelt sign depth index (ASBSI) was calculated.Sample size for the cohort was 551 subjects. Operative need was 19.73% in those with ASBS on CT (CT ASBS) above the ASIS and 4.05% (p-value 0.01) in those with only clinical evidence of ASBS (CL ASBS). CT ASBS above the ASIS was associated with higher incidence of intra-abdominal injuries (31.97% vs 16.45%; p = 0.01) and a higher rate of abdominal operations (19.73% vs. 7.59%; p 0.01) compared to below the ASIS. In contrast, CT ASBS below the ASIS was associated with a higher incidence of pelvic fractures (17.72% vs. 8.16%; p = 0.01) with fractures being an independent risk factor for abdominal injury requiring intervention. Logistic regression analyses and receiver-operator characteristic curves demonstrated ASBSI was significantly associated with abdominal injury requiring operative intervention.Characteristics of abdominal wall injury on imaging such as location and contusion depth (ASBSI) are better predictors of abdominal operative need than standard clinical measures. This analysis substantiates a novel diagnostic tool which may have the potential to facilitate clinical diagnosis and management decisions in patients with abdominal seatbelt sign.

The management for ovarian dysgerminoma is different from those of other ovarian tumors, making accurate diagnosis crucial for patient care. We report a case of 9 year old girl who presented with abdominal distension. Examination revealed a huge palpable intra-abdominal mass. Plain X ray abdomen showed a large homogenous mass filling the mid part of the abdomen and causing displacement of bowel loops laterally. Abdominal sonography showed a large heterogenous lobulated abdominal mass reaching up to the pelvic brim. CECT abdomen showed a large well defined lobulated heterogeneously enhancing mass of 59-61 HU occupying most of the mid part of abdomen and reaching up to the pelvic brim. It showed multiple areas of necrosis with few small specks of calcification. The mass was removed after laparotomy under general anesthesia. Finally, after histopathological examination with raised β-human chorionic gonadotropin (β-hCG) levels, the diagnosis of ovarian germ cell tumor (Dysgerminoma) was made.

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.

Objective: To evaluate the safety and efficacy of semi-rigid ureteroscopy in proximal and distal ureteral stones, and to compare the operative and perioperative characteristics between the two stone groups. Materials and Methods: We retrospectively reviewed the medical records of patients who underwent semi-rigid ureteroscopy for management of ureteral stones at the International Medical Center between June 2007 and September 2012. All stones were fragmented using Holmium: yttrium-aluminum-garnet (YAG) laser lithotripter. Stones located above the pelvic brim are considered proximal and below it are distal. Results: One hundred and ninety-one patients were included. One hundred and three patients (54%) underwent ureteroscopy for proximal stones and 88 (46%) for distal stones. The stone size in the proximal group was 10 mm (±5.5) versus 8.6 mm (±5) in the distal group. The initial stone-free rate for proximal and distal calculi were 89–98.2%, respectively. The perioperative complication rate was higher in the proximal group 10% compared to the distal group which is 1.5% (P = 0.06). Both groups have the same average of hospital stay 1.2 days. Conclusion: Although there is a clinical difference between proximal and distal calculi groups in terms of complication and stone-free rates, this difference remained statistically insignificant (P = 0.06). Using a smaller caliber semi-rigid ureteroscopy combined with Holmium-YAG laser can be carried out as a day care procedure and showed a slightly higher risk in patients with proximal ureteral calculi which should be explained to the patient

Case Description—A 7-year-old 573-kg (1,261 -lb) Swiss Warmblood gelding was evaluated because of signs of acute abdominal pain. Clinical Findings—Physical examination revealed a markedly distended abdomen with subjectively reduced borborygmi in all abdominal quadrants. A large, gas-distended viscus was present at the pelvic brim preventing complete palpation of the abdomen per rectum. Ultrasonographic evaluation could not be safely performed in the initial evaluation because of severe signs of abdominal pain. Treatment and Outcome—Ventral midline celiotomy was performed, and right dorsal displacement of the ascending colon was corrected. Progressive signs of abdominal pain after surgery prompted repeat ventral midline celiotomy, and small intestinal incarceration in a large, radial mesojejunal rent was detected. The incarceration was reduced, but the defect was not fully accessible for repair via the celiotomy. Repair of the mesenteric defect was not attempted, and conservative management was planned after surgery; however, signs of colic returned. A standard laparoscopic approach was attempted from both flanks in the standing patient, but the small intestine could not be adequately mobilized for full evaluation of the rent. Hand-assisted laparoscopic surgery (HALS) allowed identification and reduction of jejunal incarceration and repair of the mesenteric rent. Although minor ventral midline incisional complications were encountered, the horse recovered fully. Clinical Relevance—HALS techniques should be considered for repair of mesenteric rents in horses. In the horse of this report, HALS facilitated identification, evaluation, and repair of a large radial mesenteric rent that was not accessible from a ventral median celiotomy.

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.

A 50-year-old man with intractable anal pain attributed to proctalgia fugax underwent insertion of a sacral nerve stimulator via the right S3 vertebral foramen for pain control with good symptomatic relief. Thirteen months later, he presented with signs of sepsis. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a large presacral abscess. MRI demonstrated increased enhancement along the pathway of the stimulator electrode, indicating that the abscess was caused by infection introduced at the time of sacral nerve stimulator placement. The patient was treated with broad spectrum antibiotics, and the sacral nerve stimulator and electrode were removed. Attempts were made to drain the abscess transrectally using minimally invasive techniques but these were unsuccessful and CT guided transperineal drainage was then performed. Despite this, the presacral abscess progressed, developing enlarging gas locules and extending to the pelvic brim to involve the aortic bifurcation, causing hydronephrosis and radiological signs of impending sacral osteomyelitis. MRI showed communication between the rectum and abscess resulting from transrectal drainage. In view of the progressive presacral sepsis, a laparotomy was performed with drainage of the abscess, closure of the upper rectum and formation of a defunctioning end sigmoid colostomy. Following this, the presacral infection resolved. Presacral abscess formation secondary to an infected sacral nerve stimulator electrode has not been reported previously. Our experience suggests that in a similar situation, the optimal management is to perform laparotomy with drainage of the presacral abscess together with simultaneous removal of the sacral nerve stimulator and electrode.

Radical cystectomy is the treatment of choice for muscle invasive carcinoma bladder [1]. Ileal conduit is the preferred type of urinary diversion, especially in patients with positive distal margins, prostatic urethral involvement and those not keen on self catheterization [2]. Completely intracorporeal ileal conduit urinary diversion avoids the need for larger incision as in laparoscopy assisted approach.

Background Chylous ascites is defined as the pathologic accumulation of lymphatic fluid within the peritoneal cavity and has been reported to complicate gynecologic surgeries, with an incidence of 0.17-2%. We report a case of chylous ascites after complex surgery for placenta percreta. Case A 26-year-old woman underwent cesarean delivery followed by bilateral uterine artery embolization and modified radical hysterectomy at 26 5/7 weeks of gestation for placenta percreta invading the urinary bladder. No surgical dissection was performed above the pelvic brim or deep into the pelvic sidewalls. On postoperative day 4, milky fluid consistent with chylous ascites was noted coming from a percutaneous drain. This completely resolved after 12 days of conservative management with intravenous nutritional support. Conclusion Chylous ascites is a potential complication of modified radical hysterectomy for placenta percreta that responds to conservative management.

The surgical goal for unstable pelvic injuries is to reduce and stabilize the anterior and posterior pelvic rings. Anatomical reduction and stable internal fixation of both the anterior and posterior rings can result in good radiologic and clinical outcomes. The surgical approach and fixation method used are based on the fracture classification, the amount of displacement, soft tissue condition, associated injuries, and overall hemodynamic status of the patient. Surgical fixation was focused on the posterior pelvic ring, which contributes about 60% of the overall pelvic ring stability, and then the anterior ring lesion is assessed for its need of fixation, if required. Matta and Tornetta1) have emphasized the importance of an accurate reduction and stable fixation for posterior ring injuries. Posterior pelvic ring fixation is traditionally associated with vertically unstable fractures. These injuries are associated with a substantial risk of retroperitoneal hemorrhage, presence of the Morel-Lavallee lesion, and 25% incidence of skin breakdown following internal fixation of these fractures. However, the visualization necessary for the reduction often requires significant soft tissue dissection and long operative times, which are problematic in unstable patients. There are various surgical options for anterior ring fixation, including external fixator, retrograde intrapubic screw, and plate. The most commonly used surgical approach is a Pfannenstiel-type incision for the symphyseal disruption and medial ramus fracture. For the plate fixation of a displaced lateral ramus fracture and anterior column, an ilioinguinal approach, described by Letournel,2) is widely used as the exposure of choice, which may require a long operation time, meticulous handling around the neurovascular bundle, and significant blood loss. Based on the current concept of minimally invasive surgery that emphasizes less tissue dissection, the modified Stoppa approach has gained in popularity. The Stoppa approach has been introduced for the treatment of pelvic-acetabular fractures, allowing the easy exposure of the pelvic brim, where bone quality is optimal for screw fixation.3,4,5,6) The purpose of our study was to investigate the surgical outcomes of unstable pelvic ring injuries treated using the Stoppa approach for stable anterior ring fixation.

One year and nine month old baby girl brought to the hospital with swelling in the left gluteal region noticed by the parents since three months of age. They consulted a local practitioner who suggested aspiration by needle, which was done multiple times. The size of the swelling used to decrease immediately after aspiration but returned to its usual size within 1-2 months. On examination, the child was alert, active with normal growth and development. Left gluteal region was more prominent with skin over the region showing multiple puncture marks (Fig. 1), palpation revealed an illdefined, immobile, and non-tender mass with variable consistency. Per rectal examination showed mass extending up to the presacral region. Bimanual palpation revealed extension of the mass up to the level of the pelvic brim. Ultrasound revealed a well-defined anechoic cystic lesion near coccyx. MRI of the left gluteal region showed two peripherally enhancing lesions near the anterior-inferior part of the coccyx confirming the diagnosis of SCT (Fig. 1). Serum alpha fetoprotein level was normal. At operation, a large dumb-bell shaped mass with both solid and cystic (mainly) components, arising from the coccyx, was completely excised along with coccygectomy. Postoperative recovery was uneventful. Biopsy report showed it to be mature teratoma (Fig. 1) with margins free of tumor. The parents were counseled for regular follow-up.

Aim Sigmoid volvulus is common in sub-Saharan Africa. The aim of the study was to document the clinicopathological patterns of sigmoid volvulus in KwaZulu-Natal. Method Analysis was performed of prospectively collected data of patients presenting with sigmoid volvulus at the KwaZulu-Natal Teaching Hospitals from 2000 to 2009. Data collected included demographics, clinical presentation, operative findings, management and outcome. Results There were 135 patients (122 male) of mean age 39.3 ± 17 years. Management was by emergency surgery (103), elective surgery (23), no surgery (9). The level of the twist was at the pelvic brim. Fifty-four patients had gangrenous bowel and 81 had viable bowel. Resection was accompanied by primary anastomosis (80) and Hartmann’s procedure (46). Complication and mortality rates were 47% and 17% respectively. Mortality rates for emergency and elective surgery were 19% and 9% (P = 0.330), and those for primary anastomosis and Hartmann’s procedure were 14% and 24% respectively (P = 0.305). Mortality rates for gangrenous and viable bowel were 21% and 15% respectively (P = 0.624). Twenty-eight (22%) patients required intensive care in the intensive care unit (ICU) with an ICU stay of 8.8 ± 8 days. Hospital stay was 10.5 ± 14.4 days. Conclusion The clinicopathological picture of sigmoid volvulus resembles that in the rest of Africa in that it affects predominantly young African males. The level of the twist is at the pelvic brim. The timing of surgery, the type of anastomosis and the viability of the bowel does not influence outcome.

This study describes and evaluated the effectiveness of occluding distal ureters in the clinical setting of urinary vaginal (vesicovaginal or enterovesicovaginal) fistulae utilizing a new technique which combines Amplatzer vascular plugs and N-butyl cyanoacrylate. This is a retrospective study (January 2007–December 2010) of patients with urinary-vaginal fistulae undergoing distal ureter embolization utilizing an Amplatzer- N-butyl cyanoacrylate-Amplatzer sandwich technique. An 8–12–mm type-I or type-II Amplatzer vascular plug was delivered using the sheath and deployed in the ureter distal to the pelvic brim. Instillation of 0.8–1.5 cc of N-butyl cyanoacrylate into ureter proximal to the Amplatzer plug was performed. This was followed by another set of 8–12-mm type-I or type-II Amplatzer vascular plugs in a technique referred to as the “sandwich technique.” Five ureters in three patients were occluded utilizing the above-described technique during the 4-year study period. Mean maximum size Amplatzer used per ureter was 10.8 mm (range, 8–12). One ureter required three Amplatzer plugs and the rest required two. Two patients (3 ureters) were clinically successful with complete resolution of symptoms in 36–48 h. The third patient (2 ureters) was partly successful and required a second Amplatzer- N-butyl cyanoacrylate sandwich technique embolization. The mean clinical follow-up was 11.3 months (range, 1.7–29.2). The Amplatzer- N-butyl cyanoacrylate-Amplatzer sandwich technique for occluding the distal ureter is safe and effective with a quick (probably due to the N-butyl cyanoacrylate) and durable (probably due to the Amplatzer plugs) clinical response.

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 objective of our study was to evaluate the incidence of ovarian mal-descent in patients with and in those without müllerian duct anomalies.Multiplanar MRI examinations of patients with (n = 65) and those without (n = 64) congenital uterine anomalies were evaluated for ovarian size, position, follicle count, and associated renal anomalies. Patients who were pregnant, had known prior pelvic surgery, or had large uterine leiomyomas were excluded. Two criteria were used to determine ovarian malposition: Was the upper pole of the ovary above the pelvic brim, as defined by the pubic symphysis-sacral promontory line, or was the upper pole of the ovary at or above the iliac artery bifurcation?The müllerian duct anomalies identified in the study group included hypoplasia, unicornuate, didelphys, bicornuate, and septate uterus. Ovarian maldescent was identified in 12 of 65 women with uterine anomalies (17%) as compared with two of 64 women with normal uterine anatomy (3%) using the criterion of the ovarian pole being above the iliac bifurcation. Among the women with müllerian duct anomalies, only three of 29 with septate uterus (10%) had ovarian maldescent compared with the remaining nine of 36 women with other anomalies (25%). Ovarian size did not vary significantly between the two groups. Follicle count was increased in women with müllerian duct anomalies. Renal anomalies were present in 16 of 65 patients, five of whom had concomitant ovarian maldescent.The incidence of ovarian maldescent is increased in patients with müllerian duct anomalies, with the highest association seen in those with didelphys, unicornuate, or bicornuate uterus.