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Retroperitoneal fibrosis typically affects the region extending from the second lumbar vertebra to the pelvic brim. Where it extends below the pelvic brim, encasement of individual pelvic organs can mimic malignant disease.1,2

Uterine incarceration is a rare complication of pregnancy, usually presenting between 12 and 20 weeks' gestation, when the gravid uterus normally ascends through the pelvic brim. Conditions such as pelvic inflammatory disease, endometriosis, postoperative adhesions, posterior wall leiomyomas, and pelvic contraction may lead to fixed retroflexion of the uterus, predisposing to this condition. A case of incarceration is presented. Clinical features, diagnosis, treatment, and potential complications are discussed.

Certain minimally displaced acetabular fracture patterns are amenable to treatment with computed tomography (CT) assisted percutaneous fixation using cannulated screws (Kahler DM, et al. Presented at AAOS Annual Meeting, Feb. 1996). Although the early results have shown promise in the treatment of transverse, anterior column, and anterior column/posterior hemitransverse fractures, there remain concerns regarding radiation exposure to the patient, operative time averaging 45 minutes per screw, and the questionable sterility of the CT suite. A feasibility study was therefore undertaken to evaluate a new technique of percutaneous acetabular fracture fixation utilizing a stored CT image of the pelvis in a computer integrated surgical system, consisting of an array of three CCD cameras and a computer workstation. Five human cadaver pelvis specimens with intact external soft tissues were obtained, and simulated transverse acetabular fractures with roof arcs of approximately 30 degrees were created bilaterally. An external fiducial array consisting of aluminum spheres affixed to carbon fiber rods was attached to the iliac wing of each specimen with two 4.5 mm Schanz pins. Computed tomography was performed to allow segmentation of the specimens and fiducial arrays. The digitized scans were then loaded onto a computer workstation, and ideal pin placement and length were planned. The fiducial arrays were registered using a probe to allow orientation of the pelvis, and the specimen and drill guide were then optically and dynamically tracked during the procedure. Internal fixation was simulated by the percutaneous placement of a 2.8 mm guide wire perpendicular to the fracture cephalad to the joint surface, and a second wire crossing the fracture into the anterior column. Plain radiographs and specimen dissection were performed after fixation for evaluation of the accuracy of pin placement. There was no sign of penetration of the hip joint or the cortical bone of the pelvic brim along the entire path of the wires. It was found that computer integrated percutaneous fixation of transverse acetabular fractures in vitro provides comparable accuracy to CT-guided procedures without the need for intraoperative CT or a formal surgical exposure. Additionally, operative time is greatly reduced in comparison with CT-guided technique, and the computer integrated surgical system allows greater variability in the angle of screw placement to compensate for variations in pelvic anatomy. Computer integrated surgery may allow accurate percutaneous placement of cannulated screws in acetabular fracture surgery, and may prove a useful adjunct to conventional internal fixation using standard surgical approaches.

A middle-aged man with a history of Hodgkin's disease presented with loin pain and microscopic hematuria. Radiologic studies demonstrated a urinoma secondary to ureteric obstruction at the pelvic brim. Percutaneous nephrostomy was performed to decompress the collection and a ureteric stent inserted to maintain drainage. Laparotomy revealed an unsuspected rectal adenocarcinoma. A metastatic deposit compressing the ureter had produced the urinoma. Metastatic colorectal carcinoma is a rare cause of urinoma.

A new approach, a pyramid template matching as guided by a snake, is developed for the extraction of pelvic features in both portal and simulation images. Initially, the treatment field edge was extracted using a Canny edge detector. A template modeled using a polynomial function for the typical pelvic structures was used as the initial approximation for the anteroposterior (AP) pelvic brim. Several energies were defined to search the actual bony structures as guided by the snake in a larger range. In this study, a double-snake model coupled with a spring was developed to define the external constraint force. The image force was calculated from various processed images using different edge detection algorithms. The criterion used for search termination was to find the locations where the overall energy was at its minimum. The result of the initial search was fit using a polynomial function as the second approximation for the pelvic bony structure. Snake searching technique was repeated in a smaller range around the initial identified features for fine search of pelvic bony structure. This technique has shown to be very promising for extracting pelvic features.© (1996) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Forty-three patients with single ureteral calculi located above the pelvic brim were treated by electrohydraulic lithotripsy (EHL) using a semirigid mini-ureteroscope. Of the 43 calculi, 36 (84%) were fragmented in one procedure. Six calculi (14%) were pushed back to the renal pelvis and treated successfully by complementary extracorporeal shockwave lithotripsy (SWL). The total success rate of ureteroscopic manipulation thus was 98%. The operation time (mean 26.4 minutes) and postoperative hospital stay (mean 2.53 days) were relatively short. Complications were limited to four (9%) minor perforations of the ureter managed by internal stenting. Among these patients with complications, there were no significant ureteral strictures noted on excretory urography or ureteroscopic examination 1 to 3 months after ureterolithotripsy. The costs of ureteroscopy with EHL are lower than that of SWL or ureteroscopic lasertripsy. The total fees for ureteroscopy with EHL are about two thirds those for SWL in Taiwan. Despite the longer learning curve required for ureteroscopy, ureteroscopy associated with EHL is a cost-effective alternative for the treatment of upper ureteral calculi, especially when SWL is not readily available.

We present a 36-year-old female patient who was injured in the pelvic region by a mortar shell fragment. The trauma comprised a complex lesion to both ureters, to the urinary bladder, and to the pelvic brim. The ruptured urinary bladder was sutured and a bilateral ureterocutaneostomy was performed in a hospital near the front line. Because of a large scar and the right ureter necrosis, a kidney autotransplant was performed 3 months later. A left ureterocystoneostomy was done. Five years later, because of urosepsis and hydronephrosis caused by a ureteral calculus, a nephrostomy was placed in the proximal right ureter, antibiotic treatment was prescribed, and the calculus was managed by crushing the stones using extracorporeal shock wave lithotripsy. Ten years after the initial trauma, the patient is well, has normal micturition, and both of her kidneys are functioning normally.

Burst fractures of the low lumbar spine (L3-5) represent a small percentage of all spinal fractures. Due to their rarity, most of the literature regarding the best treatment for burst fractures concerns the thoracolumbar junction, rather than the low lumbar region. Fractures of these vertebrae have biomechanical and anatomic characteristics that distinguish them from thoracolumbar burst fractures. In particular, the iliolumbar ligaments and a location below the pelvic brim with major muscle support are two stabilizing factors that are unique to these fractures. Furthermore the spinal canal is widest in the low lumbar region. As a results, neurologic deficits are rare in low lumbar burst fracture compared with thoracolumbar burst fracture. The relative and absolute indications for surgery or conservative treatment for the management of low lumbar burst fractures remain controversial, especially in neurologically intact patients with severe canal compromise. Conservative treatment, including prolonged bed rest with subsequent bracing, has proven to be an effective means of treating low lumbar burst fractures. On the other hand, surgical treatment provides immediate spinal stability and more reliably restores sagittal alignment and canal dimensions. However, despite the advantages of earlier ambulation and anatomic reduction, due to major muscle support and forceful retraction for lateral to medial direction to insert screws, long segment fusion should be avoided in patients with a low lumShort Segment Screw Fixation without Fusion for Low Lumbar Burst Fracture: Severe Canal Compromise but Neurologically Intact Cases

The overall frequency of ureteral injury during laparoscopic adnexectomy for endometriosis is unknown, and intestinal obstruction after laparoscopy is rare. Our patient had two postoperative complications: small bowel obstruction and bilateral ureteral injuries discovered 2 and 39 days, respectively, after outpatient laparoscopic adhesiolysis and bilateral salpingo-oophorectomy for severe endometriosis. Pelvic examination and vaginal sonography revealed a large unilocular cystic mass. Laparoscopy showed a fixed large endometrioma firmly attached to pelvic peritoneum and intestines in the pelvic cavity, and significant adhesions in the upper part of a midline incision from prior abdominal hysterectomy. These midabdominal adhesions were not released. The patient underwent laparoscopic bilateral adnexectomy as an outpatient. Two days later she was admitted with small bowel obstruction. Thirty-nine days later, diagnostic evaluation revealed urinary ascites with right ureteral stricture at the uterine artery level, and complete ligation and resection of the left ureter at the pelvic brim near the infundibulopelvic ligament stump. She underwent left ureteral implantation with psoas hitch and right ureterolysis. Follow-up cystogram and intravenous pyelography at 6 and 20 weeks revealed complete recovery. In cases of severe endometriosis with significant ureteral and intestinal involvement, laparotomy may have to be considered.

Objective Determine if laparotomy further destabilizes an unstable pelvic injury and increases pelvic volume, and if reduction and stabilization restores pelvic volume and prevents volume changes secondary to laparotomy. Design Cadaveric pelvic fracture model. Materials and Methods Unilateral open-book pelvic ring injuries were created in five fresh cadaveric specimens by directly disrupting the pubic symphysis, left sacroliac joint, and sacrospinous and sacrotuberous ligaments. Pelvic volume was determined using computerized axial tomography for the intact pelvis, disrupted pelvis with both a laparotomy incision opened and closed, and disrupted pelvis stabilized and reduced using an external fixator with the laparotomy incision opened. Measurements and Main Results The average volume increase in the entire pelvis (from the top of the iliac crests to the bottom of the ischial tuberosities) between a nonstabilized injury with the abdomen closed and then subsequently opened was 15 +/- 5% (423 cc). The average increase in entire pelvic volume between a stabilized and reduced pelvis and nonstabilized pelvis, both with the abdomen open, was 26 +/- 5% (692 cc). The pubic diastasis increased from 3.9 to 9.3 cm in a nonstabilized pelvis with the abdomen closed and then subsequently opened. Application of a single-pin anterior-frame external fixator reduced the pubic diastasis anatomically and reduced the average entire and true (from the pelvic brim to the ischeal tuberosities) pelvic volumes to within 3 +/- 4 and 8 +/- 6% of the initial volume, respectively. Conclusions We believe that the abdominal wall provides stability to an unstable pelvic ring injury via a tension band effect on the iliac wings. Our results demonstrate that a laparotomy further destabilized an open-book pelvic injury and subsequently increased pelvic volume and pubic diastasis. This could potentially increase blood loss from the pelvic injury and delay the tamponade effect of reduction and stabilization. A single-pin external fixator prevents the destabilizing effect of the laparotomy and effectively reduces pelvic volume. These data support reduction and temporary stabilization of unstable pelvic injuries before or concomitantly with laparotomy.

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

Purpose: The role of bipedal lymphangiogram in tailoring radiation portals in radical radiation therapy for Stages II or III cervix cancer is investigated. Methods and Materials: The records and simulation films of 87 patients with Stage II or III carcinoma of the cervix treated with radical radiation therapy alone have been retrospectively reviewed. Results: Sixty-two percent of patients who had a bipedal lymphangiogram, subsequently had their radiation fields altered from a "standard portal." The most frequently altered fields were the lateral margin of the postero anterior field and the anterior margin of the lateral fields. In order to cover the lymphatic channels in the pelvis in 90% of cases as outlined by the bipedal lymphangiogram, the lateral margins of the postero anterior fields would need to be 2.5 cm lateral to the pelvic brim and the anterior border of the lateral field, 0.5 cm anterior to the pubic symphysis. Conclusion: "Standard" fields adequately cover the median distribution of lymphatics, but may result in a geographic miss in some patients. Bipedal lymphangiograms allow a more accurate tailoring of pelvic lymphatic fields.

Since the first edition of this book, the use of CT scanning has become widespread and is now almost routine. At present only a few centres have access to 3-D CT reconstruction; when this is available everywhere, the understanding of acetabular fractures will be much easier. With good 3-D analysis, one just needs to know the classification to be able to link the case being treated to one of the fracture types described. It made us very happy to see that the 3-D images fully confirm the descriptions we gave of the different types of acetabular fracture.

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

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

We present a rare case of uterine rupture in a 16year-old primigravida who was admitted complaining of abdominal pain and mild vaginal bleeding. Findings on examination were: height of fundus 30 weeks,. absence of fetal heart sounds, cervix 4-5 cm dilated, intact membranes, and head O/5 above the pelvic brim. The patient was admitted to the labor ward with a diagnosis of intrauterine fetal death in labor. Six hours later, artificial rupture of the membranes was carried out and an infusion of 2.5 IU/l followed by 10 IU oxytocin synthetic was commenced. Ten hours later the cervix dilated to 9 cm accompanied by very mild contractions. Oxytocin synthetic 20 IU, sedation and antibiotics were added. Two hours later the cervix was still 9 cm and the head was 3 cm below the ischial spines. Vacuum extraction was carried out and the head came out without difficulty but with arrested shoulders and difficulty in rotating the body (only elongated neck felt on vaginal examination). The patient opted for fetal decapitation under general anesthesia and once the head was

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

Because the pulsed dye laser can be transmitted through a thin, flexible quartz fiber a small caliber ureteroscope and flexible ureterorenoscope are applicable. Therefore, the use of a rigid or flexible ureterorenoscope was combined with laser lithotripsy to treat upper urinary tract calculi. All 14 ureteral stones below the pelvic brim were removed successfully with a rigid 7.2F (outer diameter) ureteroscope and 14 of 16 stones above the pelvic brim were removed with a flexible ureterorenoscope. Laser monotherapy was effective in 24 cases and the complementary use of forceps or electrohydraulic lithotripsy was required in 4. Two stones were lost from the visual field during endoscopic manipulation. There was no complication requiring surgical correction. The combined use of these instruments is highly successful and safe for the treatment of upper urinary tract calculi. (J. Urol., 143: 273–274, 1990).

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

Skeletal evidence exists for life stresses of 120 Black individuals from 25 sites in Maryland, Virginia, and the Carolinas. Periods for statistical comparison are eighteenth century, 1690-1770; Catoctin Furnace, Maryland industrial slaves, 1790-ca.1820; 1800-ca.1860, nineteenth century; and a twentieth-century Black sample compiled from forensic (accidental deaths) cases. From these archaeological sources, skeletal age at death shifts from 36 years, female, and 30 years, male in eighteenth century (N = 29) to 34.8, female, and 36.3, male in nineteenth century (N = 56). Catoctin Furnace slaves' longevity may reflect special conditions for skilled males (34.6 years, female; 41.2 years, male (N = 16). Nutritional stresses are indicated by dental lesions, hypoplasias, stature, and skull base height and pelvic brim index. Occupational stress occurs in some adolescents and in many adults as exaggerated development of lifting muscles (deltoid and pectoral crests) and early vertebral and shoulder breakdown. Lead content of bone may reflect site of occupation. The most common pathology is anemia or sicklemia; parietal depressions and ulna fractures ("parry") indicate violence-related trauma.

The congregation of the Reverend Henry Simmons (First African Baptist Church at 8thVine, Philadelphia) from 1823 to 1841 used a cemetery rediscovered through subway expansion which was carefully excavated by M. Parrington and S. Pinter in 1983-1984; currently 75 adults were available for study. As an overall health indicator, longevity at 38.9 years (N = 39) female and 44.8 (N = 36) male indicates more stress on females. Probable causes of stress are inadequate nutrition for the performance of arduous labor, pregnancy, and childrearing, unsanitary living conditions, limited exposure to sun, and extensive exposure to infectious diseases. Nutritional indicators of stature, dental lesions, skull base height, and pelvic brim index scarcely advance over 1790-1820 Catoctin Furnace, Maryland, slaves' indicators. Disease evidence includes limb-distorting rickets in one child who died at age 8, anemia, and arthritis; but the incidence of arthritis was less than at Catoctin. Genetic traits are chiefly African. Family links show in details: os acromiale in about 30%. This plus less violence (fewer fractures) suggests community strength developing.

EDITORIAL COMMENT: This paper reviews the results of a large series of patients with urinary incontinence treated by the Burch colposuspension with a few minor alterations. The operation is performed entirely from above, the vagina being suspended on either side of the bladder neck and attached to the iliopectineal ligament at the pelvic brim. It is noteworthy that only 36 of the 174 patients had pure stress incontinence as a symptom and 59 were obese. Selection of the patient who requires surgery when stress incontinence is associated with urgency and other urinary symptoms is very difficult. All of the 30 patients who remained incontinent after the operaton had urodynamic investigaton and 16 were found to have detrusor instability. It would seem that the author's results justify their willingness to operate on patients with mixed urinary symptoms. The success rate and incidence of complications in this series is consistent with other studies — however, there was a high incidence of voiding difficulties postoperatively as revealed by a mean postoperative catheter drainage time of 10 days, 5 patients requiring to go home using self-catheterization with 2 needing this long-term, and a postoperative incidence of detrusor instability of 10%. One reviewer believes this is due to overelevation of the bladder neck at the time of colposuspension which may be avoided by leaving the suspending sutures long at the time of surgery. The takeaway message is that patients with mixed urinary symptoms who have stress incontinence confirmed urodynamically have a good chance of being cured by surgery. It would be prudent that such patients should have a trial of medical management and pelvic floor exercises before resorting to surgery. Summary: Between June 1, 1983 and June 30, 1988, 174 patients with stress incontinence were treated with a colposuspension operation; 144 patients were cured, 30 remained wet. Sixteen patients who remained wet had detrusor instability; 9 of these were cured by anticholinergic medications. Of 25 patients who had dual pathology 19 were cured. Seventy nine patients had urinary tract infections. Two patients had ureteric obstruction due to kinking; it is postulated that this can be an in-fequent and sometimes unavoidable complication.

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

In the case of surgically dressed necroses of the hip condyle and coxarthroses a condition was found after fracture of the pelvis or after dislocation of the hip joint in 7.2% of the cases. In 13.2% of the cases a trauma was found anamnestically. It was subdivided into fractures of the acetabulum, fractures of the pelvic girdle, dislocations, and fractures of the pelvic brim on the basis of the system of Judet and Engler as well as Feldkamp. Fractures of the pelvic brim through muscular traction, traction of the ligament, and direct trauma were discussed. The most frequent delayed consequences arising after dislocations of the hip joint and fractures of the acetabulum are: necroses of the head of the femur, coxarthroses, pseudarthroses, and myositis ossificans. The pathogenesis of the delayed injuries resulted from: capsular and vascular lesions, damage to cartilage with fractures in the spongiosa region, incongruence of the surface of the joint, insufficiency of the static structure of the pelvic ring, deposit of calcium salt outside the bone. In some cases the progress of the necrosis could be arrested by means of osteotomy and spongiosa filling. The rate of necrosis increases in proportion to the period between the time of occurrence of the accident and reposition (limit of 6 h). Even though about half the pelvic girdle fractures show good results with conservative treatment, in the case of fractures of the acetabulum a reconstruction as far as possible continuous and without stages is to be aimed at. In many cases the development of a myositis ossificans cannot be prevented.

A case of basosquamous or so-called transitional cloacogenic carcinoma of the sigmoid colon, which arose above the pelvic brim at the peritoneal reflection, is reported. We were not able to find a report of this histologic type of tumor arising this far from the pectinate line of the anus, which is the most common primary site of this neoplasm. Possibilities as to the histogenesis of this tumor at this site are stated. The neoplasm also produced parathyroid hormone (PTH) and also possibly adrenal corticotrophic hormone (ACTH), which had not been previously reported for this specific neoplasm.

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

This paper reports the only 6 cases of ureteric obstruction apparently caused by the gravid uterus diagnosed at the Mercy Maternity Hospital in the past 17 years, during which time there were 82,836 confinements. In 3 of the 6 cases there was clear radiographic evidence that the level of obstruction was at the pelvic brim. The rapid resolution of the ureteric obstruction shortly after delivery strongly suggested that the gravid uterus was the cause of the obstruction. Cases 1-3 were the only patients of 793 with polyhydramnios who developed bilateral ureteric obstruction and acute renal failure. In Cases 4 and 5 there was unilateral ureteric obstruction and pyelonephritis; in Case 4 a ureteric catheter was inserted from below, and in Case 5 a ureteric stent was inserted via a nephrostomy tube. In Case 6 a percutaneous nephrostomy tube was inserted.

Among 851 resected cases of colo-rectal carcinoma, there were 54 cases with deliberate resections and 29 cases with accidental injuries of. the urinary tract. We studied those 83 cases in respect of reconstructive procedures of the urinary. tract. In 54 cases postoperative coures were almost uneventful. Among 29 cases, thirteen cases occurred accidental injuries of the urinary tract during surgery, however sixteen occurred postoperatively. Three cases with ureteric injury occurred above pelvic brim, were treated by end to end anastomosis of injured ureter.Postoperative course-of these cases were uneventful. In cases with-ureteric injuries occurred below the pelvic brim, uretero-neocystestomy should be performed for reconstruction of the injured ureter. There were eight cases with vesicoperineal fistula among 320 cases of abdominoperineal exsion of the rectum. Among those eight cases four have irradiated bladder. In such a case with Irradiated bladder, urinary diversion should be performed.

The results of a prospective study of 34 Nigerian women with obstetric neuropraxia (puerperal paresis of the lower limbs) seen at the University College Hospital, Ibadan, are presented. The height of 29 (84%) was under 62 in (1.58 m). All were younger than 45, and 41% (14) were primiparous. Lumbosacral plexus injury with a foot-drop was the most frequent presenting feature (88%), bilateral involvement was observed in 13 patients (38%), femoral neuropathy was observed in nine (26%) and the ankle tendon jerks were absent in 35%. Spastic paraparesis was not uncommon (15%). Results of electromyographic examination and determinations of conduction velocities were consistent with proximal neuropraxia of the lumbasacral trunk in many of them (88%). The presentation of the fetus was cephalic in 97% of the women. The major predisposing factor was prolonged labor. Among the complications associated with the neuropraxia were hydroureters above the pelvic brim and vesico- and rectovaginal fistulae. Perinatal mortality was high particularly with labor of more than 18 hours. Recovery from the neuropraxia was complete for 76% of the patients. It is concluded that direct pressure on the lumbosacral plexus and nerve trunks by the presenting fetal part is the major factor in the pathogenesis of obstetric neuropraxia encountered in Nigerians.

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

The most important pelvic diameter from the point of view of the obstetrician is the true conjugate. It can be measured either from the outside or from the inside. The external measurements are seldom reliable, as from them the internal pelvic diameter can be calculated only indirectly. The internal measurement of the true conjugate, either by digital vaginal examination or by means of the Bilicki-Gauss internal pelvimeter, although quite reliable in experienced hands, is most disagreeable to the patients, is not always devoid of danger, and cannot be carried out when the head is engaged in the pelvic brim. The transverse diameter cannot be measured directly either externally or internally. The radiological examination of the pelvis has therefore become an extremely valuable factor in obstetric diagnosis, as it allows exact measurement of the pelvic canal at any time during pregnancy without the slightest risk or discomfort to the patient. The first radiography of the pelvis was performed by Varnier and C...

1. Partial duodenal obstruction can be demonstrated in a large proportion of oases with chronic dyspeptic symptoms. 2. The cause of the obstruction varies, but the most common is compression by the supr. mesenteric artery. 3. In our experience it is nearly always associated with an abnormal condition of the colon. 4. The possession of a mesentery,i.e., Mobility alone is not sufficient; some other factor is necessary, such as descent over the pelvic brim, chronic constipation or loss of tone in the abdominal muscles. 5. Treatment consists in regular emptying of the colon with support for the latter by an efficient abdominal belt. Failing improvement on these lines, colopexy is indicated, or possibly duodeno-jejunostomy.

These measurements should be taken as early in pregnancy as possible as it is then much easier to get a distinct and complete outline of the pelvic brim. In the later months it is much more difficult and throws a greater strain on the apparatus and tube. A. A “hatchet.” This is a piece of thin sheet lead, supported between layers of ply-wood, and shaped as shown. It is free to rotate at the end of a handle about eighteen inches long. Its concave portion is used to shade off the anterior portion of the patient's body during the radiographic exposure, as described later. B. A pair of obstetric callipers. C. A strip of lead, called a “rule,” about twelve inches long and two wide, supported by ply-wood. It has small holes drilled down the centre, exactly half-an-inch apart. From this “rule” the “pubic scales,” Fig. 2, are made in the following way. The “rule” is supported horizontally over the Potter-Bucky four and three-quarter inches above the surface, a film in a cassette being placed in the usual position...

During intravenous urography, iliac artery sign is an oblique filling defect in the ureter at the pelvic brim produced by the ureter crossing the iliac artery. It delineates the lower limit of pregnancy dilatation, thereby characterizing all changes associated with pregnancy. Asymmetry of the iliac arteries and ureters at the pelvic brim accounts for the characteristic distribution of pregnancy dilatation. There are permanent subtle functional and anatomical changes in the ureter after the first pregnancy. Upper urinary tract infection during pregnancy produces persistent ureteric dilatation which may be the only evidence of upper urinary tract involvement in the adult.

Summary: Forty patients with obstructed labour seen the General Hospital, Port Moresby, are described. The commonest cause of this complication was cephalopelvic disproportion at the pelvic brim. Other common causes were transverse lie and occipito-posterior positions and transverse arrest of the head. There was no maternal mortality and the possible reasons for this are discussed.

London, England. 14 ix 70 The form of the female pelvis in Uganda has long been a matter of interest to anthropologists. Reported as early as 1884 by the medical traveller R. W. Felkin, it has since been discussed by many authors (Cook 1938, Mitchell 1938, Rendle-Short 1958, Allbrook and Sibthorpe 1961, Allbrook 1962, Zivanovic 1968a,b). Most of these authors have focused upon the close relationship between the form of the female pelvis and the problem of childbirth known as dystocia, or difficult labour. This was and still is one of the main obstetrical and vital problems in many African women. Hospital records in Uganda show that operative delivery for obstructive dystocia averages more than 12% of all deliveries, and this must be considered a relatively large percentage because most women do not come to the hospital for delivery. To deal with the problem of dystocia, the people of Uganda (not only the Ganda tribe) evolved an original method of performing Caesarean sections, using their own instruments, antiseptics, and anaesthetics, centuries before the influence of Western medicine began to spread throughout tropical Africa. Research on the relationship between dystocia and the form of the pelvis has recently been reviewed by Allbrook (1962). Investigations reported by Allbrook and Sibthorpe (1961) have shown that the Ganda female pelvis is one of the smallest on record, but has the same configuration as female pelves in human populations everywhere. The pelvic brim configuration is usually brachypellic or mesatipellic; the pelvis is generally contracted. The main dimensions fall within the range of variation for other human populations. The differences noted are insufficient to explain the frequency of dystocia. Recent work, however, has brought to light a characteristic of some importance. Using a measure developed by Radojevic (1961) for the height of the pubic arch-the distance of the pubic tubercle from a line drawn between the innermost parts of the two anterior superior iliac spines (Fig. 1)-I found

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

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A method of pelvimetry is described which is recommended for standardisation. Two radiographic views are required, three if the pelvic outlet is to be measured. Only two measurements are recorded by the radiographer. No calculations are necessary. Procedure.—Metal calipers are applied to the pelvis in the manner suggested by Hederman (1940): (a) At the level of the pelvic brim in Thoms' position (a special manoeuvre ensures that the obstetric conjugate is horizontal). (b) In the sagittal plane. The anode-film distance is not critical. The caliper measurement is recorded in each instance. The “pelvimetry protractor” is constructed from a rectangular sheet of perspex. It bears a centimetre scale from each division of which lines are engraved which radiate uniformly. A cursor thread with sliding hooks may be moved up and down parallel to the scale. Mode of use.—Two radiating lines are chosen according to the recorded caliper measurement by reference to the basal centimetre scale. The protractor is placed ove...

Engagement of the Head does not depend only on the size and shape of the brim, but also on the angle of inclination of the brim. The methods of determining this inclination are considered and the angle between the plane of the brim and the front of the body of the 5th lumbar vertebra is found to furnish the best index of the inclination. Analysis of a series of cases shows that this angle varies considerably. Its postural range is demonstrated. When the inclination is high the head does not easily engage although the measurements may be normal, and a high inclination is one of the commonest causes of unexpected dystocia. Because these cases are usually selected for a “trial of labour”, criteria are necessary to select the cases suitable. Success or failure of trial labour in these cases depends on the amount of room in the upper pelvis. A part from the actual size of the true conjugate the amount of room is shown to depend both on the sacral inclination, a method of measuring which is described, and the shape of the upper sacrum, which shows considerable vriation. A common type of pelvis causing dystocia is one in which the inclination of the brim is high and the upper sacrum is relatively vertical and convex. Pelves of this type do not always fit into any of the standard classifications. The uses and limitations of postural treatment of these cases are discussed.

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

Scant attention has been paid to distant metastases from cancer of the cervix as it was considered generally not to spread above the pelvic brim. A review of the early literature reveals a wide variance in the reported incidence of metastases from cervical carcinoma, not only overall, but also in distribution (1, 3–5). Publications concerning unusual manifestations of metastases from cancer of the cervix have appeared sporadically, but a comprehensive evaluation of a large series of patients portraying the overall incidence of distant metastases as well as that of various organ involvements has not appeared. Modern radiotherapy achieves better control of cancer in the pelvis and allows more patients to survive longer, which, in turn, permits distant metastases to become clinically evident. The present study was undertaken to analyze the incidence and distribution of distant metastases in patients treated at The University of Texas M. D. Anderson Hospital and Tumor Institute, Houston, Texas, between Septem...

Some time ago I evolved the following technique for radiographic pelvimetry, because I found that each of the existing methods had certain disadvantages in practice. Chief of these are the following: 1. The majority of my cases are sent towards full term with a request for a report on the position, presentation, and full pelvic measurements. Now in order to estimate the position, two views are normally required: antero-posterior and true lateral, while the customary methods of X-ray pelvimetry require a semi-recumbent attitude of the patient. These are all of necessity exposures requiring a large intensity of radiation. It therefore became apparent that some method of obtaining pelvic measurements from the ordinary antero-posterior and lateral views was to be desired. 2. I had always used Thoms' method in preference to the others, but it seemed that one could never be sure that the perforated metal sheet was in the exact plane previously occupied by the pelvic brim, especially in obese patients. The metho...

Psoas muscle spasticity is hypothesised as a rare cause of low back pain in patients with infantile cerebral palsy. The authors describe a new manoeuvre for the study of psoas tenderness and ultrasound (US)-guided transabdominal botulinum toxin injection technique. A possible causal relationship between psoas tension and low back pain was found incidentally in two examined cases. In subsequent patients, botulinum toxin was injected and, in cases of disappearance of symptoms, the psoas tendon was sectioned at the pelvic brim with definitive disappearance of pain. The relationship between psoas tension and low back pain in patients with infantile cerebral palsy seems likely, given the result in the four patients.