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Measurements of bowel width and rectal area were used to define normal limits of size in 50 double-contrast barium enema films. Two types of patient with constipation were defined by comparison with these results. In 18 women with prolonged whole-gut transit time, the measurements were within the normal range. Of 11 men and 9 women with a previous radiologic diagnosis of idiopathic megacolon, all had an enlarged rectum and the abnormal width extended proximally to involve the colon for a variable distance. A width of 6.5 cm at the pelvic brim provides a convenient and discriminating separation of normal from abnormal.

Until recently, the indications for extracorporeal shock wave lithotripsy (ESWL) have been limited to renal calculi and ureteral calculi above the pelvic brim. However, the distal ureter can be made available for shock wave treatment as well, by modifying the position of the patient on the support of the Dornier lithotripter HM-3. Using this “sitting position” technique, 133 patients with stones or stone fragments in the lower ureter were treated from January through November 1986. Treatment was successful in 125 patients (94%), 14 of whom required 2 sessions. In 8 patients, treatment failed and stone removal was accomplished using ureteroscopy or open surgery. No complications or adverse side effects were encountered in the entire series. We consider ESWL the treatment of choice in the management of distal ureteral calculi and Steinstrassen.

The small bowel often partakes in complications seen after major colorectal and other pelvic operations. Trapped loops of small intestine within the pelvic basin may produce benign adhesive obstruction and are also exposed to recurrent malignancy. These problems may be compounded by the effects of radiotherapy. To reduce some of these complications, many methods have been devised to reconstruct the pelvic floor and thereby retain the small intestine within the abdominal cavity. Autogenous material such as omentum and peritoneal flaps have been employed as a substitute for the excised peritoneal pelvic lining. However, these methods may not be feasible in some reoperated patients, especially if prior irradiation has induced extensive peritoneal fibrosis, or if the omentum is absent or attenuated. We describe a technique in which the small-bowel mesentery is used as a hammock across the pelvic brim in order to support the small intestine out of the pelvic cavity. It has been used successfully in patients with complications after abdominoperineal resection for carcinoma of the rectum: one enterovaginal fistula associated with radiation injury and cancer, and three enteroperineal fistulas.

A total of 206 procedures was performed on 193 patients with ureteral calculi. The success rate was 62 per cent for stones proximal to the pelvic brim and 94 per cent for stones distal to the pelvic brim (87 per cent success over-all). Of the procedures 61 were done for fragments lodged in the ureter following extracorporeal shock wave lithotripsy. Ureteroscopy was done in 147 cases. Our current management concepts (including extracorporeal shock wave lithotripsy) for proximal and distal ureteral calculi are presented

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of 105 patients with ureteral stones. There were 77 stones in the upper part of the ureter, i.e. above the pelvic brim, and 28 in the lower part, i.e. below the sacroiliac joint. Successful fragmentation was attained in 101 (96%). In 93% of the patients with stones in the upper ureter and in 100% with stones in the lower ureter the fragments were eliminated completely. In 87% of the patients with stones in the upper ureter, a ureteral catheter was introduced under local anesthesia but without fluoroscopic control. It was thereby possible to remove 30% of the stones from the ureter to the kidney. For the remaining stones, saline was infused through the catheter during ESWL. For patients with stones in the lower part of the ureter, a ureteral catheter was passed in 79% and saline infused during treatment. Whereas some form of anesthesia was used for treatment of all upper ureteral stones, 89% of the treatments for lower ureteral stones were performed without anesthesia. Auxiliary procedures after ESWL were limited to four ureteral catheter manipulations for distal stones. Four proximal stones which remained unaffected by ESWL had to be treated by open surgery (3 stones) or percutaneous surgery (1 stone). Of 82 ureteric stones treated in situ the success fragmentation rate was 95%. The average number of ESWL sessions was 1.04 for both proximal and distal ureteral stones.

In this retrospective investigation of 51 female patients with Hodgkin's disease, the age of the patient at the time of primary treatment and the extent of radiation therapy were the two most important factors determining post-therapy ovarian function. Favourable indicators of ovarian preservation included young age, especially premenarchal , at the time of primary therapy, and irradiation confined to above the pelvic brim, whereas, age over 40 and irradiation below the pelvic brim predicted high probability of ovarian failure. Overall, 55 per cent of female patients under the age of 50 treated with chemotherapy alone or with radiation therapy above the pelvic brim retained normal ovarian function. The stage of disease at presentation and the post-therapy status of disease had no apparent effect on subsequent menstrual function.

The students are expected to develop competence in taking a history and performing a physical examination so that obstetric or gynaecological abnormalities can be recognized and appropriate management initiated.

A technique that provides a craniocaudal axial view of the sacroiliac joint is described. This technique gives information about the ventral aspect of the sacroiliac joint, particularly at the level of the pelvic brim. It can demonstrate extraarticular ventral ankylosis of the joint, which is not visible or only suspected on anteroposterior films. In osteitis condensans ilii, it shows the thickness of the involved iliac bone. It is very useful for the accurate localization of paraarticular changes.

From July 1985 to June 1987, 303 patients with ureteral stones were treated by either extracorporeal shock-wave lithotripsy (ESWL) or transurethral ureterolithotripsy (TUL). The ureteral stones were classified into two groups, upper and lower ureteral stones. The upper ureteral stone was defined as a stone located above the pelvic brim in radiological examinations. ESWL was performed using a Dornier lithotriptor HM-3. For TUL, following the insertion of a guide wire and dilatation of the intramural ureter by ureteral bougie, a ureteroscope was introduced into the ureter. The success rate included both patients who became stone free and patients whose stones were disintegrated into less than 4 mm. The success rate of ESWL for upper ureteral stones was 90%, and 8.5% were treated subsequently by TUL. The success rate of TUL for upper ureteral stones was 42%, and the remaining required another session of TUL or another procedure, mainly ESWL. On the other hand, the success rate of TUL for lower ureteral stones was 71%, and the remainder also required another session of TUL or another procedure, mainly ESWL. The efficacy of TUL for stone street was comparably low by the evaluation done at 5 days after the procedure. However, almost all patients with stone street, which had developed after ESWL treatment, became stone free several weeks after TUL and insertion of a stent catheter. Major complications or side effects for ESWL were fever of more than 37.5 degrees C (7.5%) and pain attacks (8.9%).(ABSTRACT TRUNCATED AT 250 WORDS)

SUMMARY Barium enema examination of 9 patients with pelvic abscess reveals characteristic findings: 1. Compression of the rectum and sigmoid colon, causing narrowing in the antero-posterior dimension. Severe compression occurs at the pelvic brim where the sigmoid lies over the promontory of sacrum and the left sacro-iliac wing. 2. No elevation of the sigmoid loop, but superior stretching of the distal sigmoid may be observed. 3. Presence of transverse mucosal folds and serrated margins. Longitudinal folds due to pleating and stretching may be seen at the maximum compression site over the promontory of sacrum. The involved segment is not less than 5 cm in length and shows limited collapsibility and distensibility. In most cases, after treatment, the colonic changes return to normal within 2 to 4 weeks. Barium enema has proved to be helpful for correct diagnosis and proper management in these patients.

Two cases of hydrocolpos are described presenting soon after birth. One infant who died on the first day had an intrauterine peritonitis caused by compression of the caecum on the pelvic brim. The other surviving infant developed a caecal perforation secondary to Hirschsprung's disease. Neither infant had rectal atresia, which is the commonest cause of intestinal obstruction in these infants. The association of hydrocolpos with polydactyly in one of these cases may represent an autosomal recessive trait.

An 1 1-year-old girl had intermittent right hip pain for 2 months. Five days before admission, she developed a limp and low grade fever. There was no history of trauma on recent illness, and no constitutional symptoms. On physical examination hen temperature was 38.3#{176}Cand she had bilateral cataracts. Examination of the chest was normal and there was no hepatosplenomegaly. Right lower quadrant tenderness was present with a mass palpable above the night inguinal ligament. Rebound tenderness and guarding were absent. The mass was tender to palpation on rectal examination. Examination of the night hip joint was normal, as was neurologic evaluation. There was no cervical on axillary lymphadenopathy. Serum hemoglobin was 1 1 .7 g/dl on admission, with a white blood cell count of 1 8,600. Serum electrolytes were normal. An antenopostenion radiograph of the pelvis demonstrated a large soft-tissue mass within the right hemipelvis, with adjacent lamellated peniosteal new bone formation involving the right pelvic brim extending from the right iliac bone into the superior pubic namus (fig. 1 A). There was no focal bone destruction beneath the area of peniosteal new bone formation. Excretory urography showed medial deviation of the distal right ureter by the soft-tissue mass, with displacement of the bladder to the left side of the pelvis (fig. 1 A). Pelvic sonognaphy revealed a 5 x 9 x 9 cm predominantly anechoic mass within the night lower quadrant, medial to iliopsoas muscle, consistent with an abscess (fig. 1 B). An exploratory laparotomy demonstrated a large netropenitoneal iliac fossa mass without involvement of adjacent pelvic viscera or bowel; the appendix was normal. The mass was incised and much purulent material was drained. Staphylococcus aureus was grown on culture. The patient was given antibiotic therapy and was postoperatively afebnile. She made an uneventful recovery. Discussion

Between July, 1986 and July, 1987, 128 patients with large impacted ureteral stones or persistent Steinstrasse required ureterolithotripsy at UCLA (Table 1). Indications were: failed stone manipulation with or without ESWL for stones located a) above the iliac crest, b) in the true pelvis, c) in the “stonecracker’s nomansland” between the iliac crest and pelvic brim, and d) in the management of ureteral Steinstrasse when the debris did not pass spontaneously within eight weeks after insertion of a percutaneous nephrostomy (PCN)-tube. Of the stones treated, 29% were located above the iliac crest, 24% in the stonecracker’s nomansland, and 47% in the lower third of the ureter (Table 2).

As with renal calculi, extracorporeal shock-wave lithotripsy (ESWL) has rapidly replaced surgical procedures for the treatment of ureteric calculi in recent years. In the beginning, indications for ESWL were confined to stones in the ureter above the pelvic brim (1–3), as the lower ureter was considered to be not accessible for shock waves because of the overlying bony pelvis. This problem has recently been overcome by a modification of the positioning of the patient on the lithotripter stretcher (4) and by the advent of tubless second-generation lithotripters (5, 6), thus adding lower ureteric calculi to the indications of non-invasive stone management.

A prospective study into causes of non-engagement of the fetal head at term in the negroid primigravida showed no correlation with fetal birth weight nor with the pelvic brim inclination. However, there was a significant difference (p less than 0.05) between the mean head circumference of babies with heads which had not engaged (34.1 cm) and with those which had (33.1 cm). Labour was generally prolonged with a high head at term, but there was no increase in the incidence of fetal or maternal mortality and morbidity nor was it associated with an increase in the rate of operative interference. In addition, retrospective studies on pelvic brim inclination between 31 Nigerian primiparae and matched Caucasians at the Queen Charlotte's Maternity Hospital showed no statistically significant differences. It is suggested that an unengaged fetal head in early labour should not by itself be an indication for early delivery by caesarean section.

Posterior position of the occiput occurs in 12.5 per cent of vertex presentations. It is usually associated with an attitude of incomplete flexion which is responsible for larger diameters of the foetal skull presenting at the pelvic brim and for abnormalities in uterine action.

To date, the use of extracorporeal shockwave lithotripsy (ESWL) has been limited to renal calculi and ureteral calculi above the pelvic brim. Modifying the position of the patient on the support of the Dornier lithotripter HM3, we were able to localize and treat distal ureteral calculi. Until April 1986, 43 patients with stones in the lower ureter underwent contact-free lithotripsy. Treatment was successful in 39 patients (90%), 2 of these requiring 2 sessions. In 4 patients treatment failed and stone removal was accomplished using ureteroscopy or open surgery. No complications or adverse side effects were encountered in the whole series. ESWL is now the method of choice for the treatment of distal ureteral calculi in our department.

Hughes and Gleadell (1962) reported their experiences in 106 cases of complete rectal prolapse and of these patients, 17 had been managed with a synchronous combined pelvic fasciai repair, together with extended perineorrhaphy, and the essential features of their procedure included: 1) dissection and excision of the cul-de-sac 2) identification of both ureters from the pelvic brim to the broad ligaments, and then clearing the pelvic surface of each levator muscle mass 3) identification of the levator hiatus from above and below, and its closure by sutures passed from below through the right and left muscle masses, to be tied on the pelvic aspect 4) obliteration of the denuded pelvic cavity with a series of purse-string sutures, followed by high peritoneal closure and finally 5) perineorrhaphy.

Extracorporeal shock-wave lithotripsy (ESWL) has become the therapy of first choice in the treatment of most ureteral stones. Parameters for the selection of the optimal procedure (ESWL in situ, stone manipulation and consecutive ESWL, ureteroscopic or open surgical stone removal) have been recently established and proven in a larger series of patients. Controversy as to whether ESWL should be done in an “in situ” fashion or whether it should be preceded by ureteral stone manipulation, however, has persisted. In this regard, we basically have noticed a continental shift reflecting the peculiarities of different health systems in Europe and the USA. In the United States, most centers prefer stone manipulation by ureteral stents in a retrograde fashion. This is done in order to dislodge the stone from its confinement in the edematous stone bed. Ideally, the stone is repositioned into the renal collecting system, the natural expansion chamber. If this can not be accomplished, creation of an artificial expansion chamber by passing ureteral stents alongside the stone is attempted. At UCLA, a differentiated approach is utilized which is as follows: based on the radiographic appearance of an existing natural expansion chamber (gross ureteral dilatation above the stone, no complete obstruction), approximately 10% of stones above the iliac crest, and 25% of stones located in the pelvic window (for example, in the true pelvis) below the pelvic brim are eligible for in situ ESWL treatment. All other stones which do not qualify for in situ treatment still undergo ureteral stone manipulation utilizing stents. This approach has advantages over our previously-described combined approach in that it does not change the success rate (97%) and overall hospital stay (1.2 days), but it does save ureteral manipulation for approximately 30% of patients (Tables 1 and 2).

Since its introduction for general use, the role of rigid ureteroscopy in the diagnosis and therapy of urological disease has been in evolution. We evaluated retrospectively the experience at our institution with rigid ureteroscopy from January 1983 to July 1986 in an attempt to identify clinical situations or techniques that tended to increase the incidence of either success or complications. We determined that ureteroscopic complications were rare in procedures performed for diagnosis compared to those performed for calculi (2 of 33 or 6 per cent versus 27 of 99 or 27 per cent, p less than 0.025). The likelihood of failure or complication was greater for stones above than for those below the pelvic brim (15 of 25 or 60 per cent versus 26 of 75 or 35 per cent, p less than 0.05). Major complications were more common early in our experience (9 of 63 or 14 per cent versus 2 of 69 or 3 per cent for the combined years 1983 and 1984 compared to 1985 and 1986, p less than 0.05). Our success rates in the treatment of calculous disease were similar to those reported previously, and they were somewhat better for stones located below (62 of 75 or 83 per cent) than for those above (17 of 25 or 68 per cent) the pelvic brim. Based on our findings we conclude that carefully performed diagnostic ureteroscopy has little potential for major complications, ureteroscopy for stones above the pelvic brim should be avoided when possible, and an increased rate of complications and failures is expected early in any series owing at least partly to the learning curve effect.

Portion of thoracoabdominal cavity inferior to respiratory diaphragm, traditionally divided into larger abdominal cavity and smaller pelvic cavity. Plane of division is pelvic brim, i.e., superior inlet of pelvis.

Dilatation of the upper urinary tract in pregnancy is caused by an obstruction at the pelvic brim, of varying degree. In some women this obstruction occurs acutely, resulting in renal colics. Our experience with this condition in 17 patients is reported. In 7 patients relief of the obstruction was necessary. The method of choice was drainage with pig-tail stents. The indications for such treatment are discussed.

Urinary tract infections are relatively common during pregnancy and the puerperium, and sometimes the upper urinary tract and kidney are involved. Quite often urinary infection is asymptomatic and only discovered on routine urine culture. Discovery of urinary infection, whether overt or covert, is important since treatment lessens the risk of pyelonephritis which in pregnancy is usually acute and generally occurs after the 20th week. The risk is probably related to the physiological dilatation and reduced peristalsis of the ureter and renal pelvis which occurs during pregnancy and often persists for some weeks after delivery1. The ureteric dilatation, formerly thought to be due to compression of the ureter at the pelvic brim by the gravid uterus, is probably an hormonal effect.

The ureters are muscular tubes that convey urine from the renal pelvis to the bladder. They vary in length from 25 to 30 cm, depending upon the height of the person and the position of the kidneys. The left ureter is usually 1 cm longer than the right, size varying with the position of the kidney. Both ureters tend to be longer in males. Jewett found in a study of 100 newborn infants that only 16 had visible ureteropelvic junctions; and of 200 adults only 14% showed a well marked junction [14]. The majority of individuals had a funnel-type renal pelvis and ureter with no clear line of demarcation. Ureteral stenosis was most commonly found at the ureteropelvic junction.

The occurrence of hydronephrosis and hydroureters during pregnancy has been termed physiological, inasmuch as it is seen in more than 80%, most frequently and most pronounced in primigravida. The dilatation develops during the second trimester, and becomes more prominent on the right side, is only seen above the linea terminalis and disappears within a few weeks after birth. The condition is not seen in women whose ureters do not cross the pelvic brim. The extent of the dilatation can be reduced by placing the woman on the side least affected or in the knee-elbow position. After a survey of the literature, the conclusion is reached that today there is every probability that hydronephrosis during pregnancy develops as a result of compression of the ureters between the pregnant uterus and the linea terminalis. It has not been demonstrated that the change in hormonal balance during pregnancy is of importance. The clinical significance of hydronephrosis lies in the association between ureteral obstruction and the high frequency of ascending urinary tract infection during pregnancy and in the understanding of the importance--in the treatment of infection--of improving drainage by means of a change in position. Isotope renographic studies seem to show a possible relationship between bilateral ureteral obstruction and the development of pre-eclampsia. Similarly, it appears that acute hydronephrosis or worsening of an existing hydronephrosis has been somewhat overlooked as a possible cause of uncertain abdominal pain during pregnancy. These conditions should be examined by means of ultrasonography, and an attempt at treatment by a change in position should be made. In cases of continued pain or affected renal function, treatment should consist of the insertion of a ureteral catheter.

Of 296 patients with pelvic malignancy and ileal urinary conduits, urinary tract calculi developed in 14. Calculi which ordinarily require surgical intervention because of their size may pass spontaneously in patients with ileoconduits bccausc of the presence of a chronically dilated collecting system and the surgical elimination. of three of the four sites of stone impaction (pelvic brim, ureterovesical junction., and ureteral orifice). In 1 patient multiple calculi developed around the surgical staples used to create the proximal end of the ileal conduit. We recommend that autosuture with stapling devices not be used to create the proximal end of an ileal urinary conduit.

A method was developed of measuring the interspinous diameter of the female pelvis with the ultrasound B-apparatus Vidoson 635. The method was used in a group of 30 patients, who simultaneously had X-ray pelvimetry. The difference between the results obtained by ultrasonic measurement and X-ray was δa = ± 0.13 cm. Other authors have achieved similar differences by ultrasonic measurement of the biparietal diameter of the fetal head and the sagittal diameter of the pelvic brim.

† Hormonal factors that control the course of pregnancy as well as the pressure of the gravid uterus on the ureters cause physiological changes in the kidneys and ureters of at least 90% of pregnant women. Mechanical pressure occurs only at the pelvic brim, but the hormonal influences producing dilatation, atony, and reduced irritability of smooth muscle involve the entire upper urinary tract. Previous diagnosis of urinary disease or congenital anomalies is important in anticipating these changes. Pyelonephritis is still frequent, but its management in pregnant women is no longer different from that in the non-pregnant. Preexisting surgical renal disease must be carefully evaluated before pregnancy is permitted; disease discovered during pregnancy may or may not necessitate therapeutic abortion. The decision in either case depends on the nature and extent of the renal disease, the general health of the patient, and, in borderline cases, the risks that the parents are prepared to take in order to obtain a child.

While the rectosigmoid is one of the most frequent sites of disease of the alimentary tract, it is the most difficult to examine roentgenographically. Newer technics (1) have been of considerable assistance in revealing the anatomy of the rectum as well as various pathological conditions not shown by routine methods. Any additional light that can be thrown on the presence or extent of disease in this region should be helpful to both the roentgenologist and the surgeon. It is unfortunate that lateral roentgenograms of the colon before and after evacuation of a barium enema are too infrequently employed, for in our experience they have often given more information than could be obtained from the postero-anterior films. The sigmoid colon begins at the pelvic brim as a continuation of the descending colon and ends at its junction with the rectum at the level of the third sacral vertebra. The rectum extends from the third sacral vertebra to the pelvic diaphragm, where it becomes continuous with the anal canal....

IN A RECENT series of 34 patients with deep venous thrombosis, Smith 1 found that 29 cases involved the left and 5 the right leg. Similarly, Hafner et al 2 noted that deep venous thrombosis occurred more commonly in the left lower extremity than in the right, with a ratio of 31:10 in his cases. He suggested that the anatomic cause for this finding may be that the left iliac vein is compressed between the right iliac artery and the pelvic brim. However, Brockman and Vasko, 3 in a collective review of the literature on phlegmasia cerulea dolens, observed that 115 cases were in the right leg, 110 in the left leg, and 32 bilateral. Comparison of blood flows in the legs is therefore of interest in its relationship to the distribution of deep venous thrombosis in the extremities. The present study represents the simultaneous determinations of bilateral femoral venous

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The etiology of hydronephrosis of pregnancy has not been completely elucidated. The rhesus monkey has been used as the test animal since hydronephrosis of pregnancy occurs naturally in the primate as opposed to other mammals (Roberts and Wolf, 1971). The fact that the pelvic ureter is usually normal suggests that hydronephrosis is due to obstruction at the pelvic brim by the gravid uterus.

Postpartum pelvic hematomas, collections of blood anywhere in the pelvis between the pelvic brim and the perineum, are much more common than is evident from reports in the literature. They vary in significance from minor local vulvar and perineal hematomas that are readily visible to massive hidden retroperitoneal hematomas that may be fatal. Pain is a frequent symptom. With the vulvovaginal or vaginal hematoma, the chief complaint may be rectal pain. The proctologist should be cognizant of the entity and the similarity of its presenting symptoms to those of rectal abscess. A case of a patient who had postpartum pelvic hematoma is described. The initial symptom was severe rectal pain. The hematoma was drained by an unusual route, with a very satisfactory result.

The rarity of this condition makes it interesting from an embryologic and surgical standpoint. The colon in its embryologic course from left to right brings the original right leaf of the mesocolon across the duodenojejunal angle, and in so doing leaves this portion as the inferior layer of the transverse mesocolon, covering this area of the small intestine with a crescent shaped part of the original right leaf of the mesocolon, and in turn forming the duodenojejunal fold. In the case to be reported, the inferior layer of the transverse mesocolon covered the first 6 inches of the jejunum, resulting in making the projection of the small intestine into the peritoneal cavity near the pelvic brim instead of at the inferior border of the transverse mesocolon (Fig. 1). W. J. N., man, aged 45, for six years had had epigastric pain coming three or four hours after meals, relieved by

In a study of occipitoposterior positions of the vertex, one should turn to the three fundamental branches of medicine—anatomy, physiology and pathology—in order to obtain the foundation for the understanding of this complicating obstetric problem. The anatomy should include the normal female pelvic measurements and the normal measurements of the fetal head. The physiology should give one the mechanism of the engagement of the fetal head in a maternal pelvis, and the pathology the abnormal factors present when the fetal head tries to engage in the posterior position. It should explain how this position differs from the normal engagement of the occiput anterior. The fetal head presents at the pelvic brim in a military attitude, sitting erect on the shoulders. The diameters opposing each other are the occipitofrontal of from 11 to 11.5 cm. and the suboccipitobregmatic of from 9 to 9.5 cm., while the normal pelvis presents at the

0 N RARE occasions, following an extensive pelvic operation, the question of ureteral obstruction will present itself while the abdomen is still open. This is especially true following a d:fficult hysterectomy for endometriosis, ruptured uterus, pelvic hematoma, or tuboovarian abscess. In such instances, where time is an important factor because of the patients’ tenuous state and where the tissues are so edematous and traumatized, making further dissection ill-advised, a simple method to determine ureteral patcnc) would be valuable. An extensive ureteral dissection or unroofing of the ureter as it passes through the cardinal ligament as done in the Wertheim operation is unfeasible in such instances. A 2 to 3 cm. incision is made in the pehic peritoneum adjacent to the ureter at the level of the pelvic brim. ‘The ureter is grasped with a Babcock clamp and eIevated so that the structure is under some tension. Then 0.5 c.c. i>f methylene blue is injected directly into the ureteral lumen. Within ‘2 to 5 minutes thl. clyr will appear in the bladder catheter tubing.

Purpose. Due to the anatomic structure of the pelvis, free-hand placement of screws in the acetabular fracture management can be difficult. Infra-acetabular screw fixation increases acetabular stability by distal fixation of the cup. Aim of this cadaveric study is to investigate if a plate-referenced drill guide can provide save placement of an infra-acetabular screw over a precontoured suprapectineal quadrilateral buttress plate (SQBP). Methods. We constructed a drill guide for an infra-acetabular screw based on the surface of an anatomically precontoured SQBP. A total of 12 adult cadaveric acetabular specimens were used for drill guide-assisted placement of the infra-acetabular screw. The drill guide contains a radiopaque spiral to allow longitudinal fine adjustment of the SQBP along the pelvic brim to assure correct position of the plate-drill-guide construct in relation to the Koehler’s teardrop. After screw placement, we conducted a computed tomography (CT) scan of all specimens to assess the actual position of the screw in relation of the infra-acetabular corridor and the acetabular joint surface. Results. The position of the screw was within the infra-acetabular corridor in all cases. We did not see any intra-articular or intrapelvic screw penetration. The mean distance of the centerline of the screw to the medial border of the infra-acetabular corridor was 3.35 mm. The secure distance to the virtual surface of the femoral head to was 7.3 mm. Conclusions. A plate-referenced drill guide can provide safe placement of an infra-acetabular screw for treatment of acetabular fractures. Radiographic fine adjustment is necessary to access the optimal entry point.

The first case of ureteral endometriosis above the pelvic brim location is reported.

We thank Dr. D.J.R. Hutchon for his interesting comments and comparisons but we think it is fair to emphasize that our study did not exclude patients with nonengagement of the fetal head at term in whom minor cephalopelvic disproportion at the pelvic brim was suspected. The mean birthweights and standard deviations for the estradiol and (PGE) prostaglandin E2 groups were 3.24 + or - 0.50 kg and 3.21 + or - 0.59 kg respectively. There was no significant difference. The cesarean section rate in patients in whom surgical induction of labor was feasible following treatment with estradiol or PGE2 was 18% and 15% respectively. There were 7 patients in whom induction of labor was not feasible despite 2 treatments. 2 of these were then delivered by elective cesarean section for a combination of reasons. In the other 5 patients labor was medically induced using an intravenous PGE2 infusion. 4 of these women were subsequently delivered by emergency cesarean section. The post-gel cervical scores for the 2 spontaneously laboring patients were 10 and 13. We believe that these high scores did not distort the statistical analysis because a nonparametric test was employed. The duration of labor in these 2 patients was 11 hours and 1 hour respectively. (Authors modified)

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

Uterine artery calcification presents a recognizable roentgen pattern. Since the finding is not well known, four examples are presented in this communication. The phenomenon is more common in the elderly but may be observed in younger women. In every patient in whom we detected this calcification, arteriosclerotic changes in other arteries were roentgenographically demonstrable. The uterine artery is a branch of the anterior division of the internal iliac artery (hypogastric). It originates near the pelvic brim and is divided roughly into three portions. In its first part it courses downward along the lateral pelvic wall for about 4 em. The second portion traverses the broad ligament medially and slightly anteriorly to the side of the uterine body where it divides into superior and inferior branches to form the third portion. The ascending portion rises to the level of the junction of the uterine tube and body, giving off arcuate branches around the body as it rises. It then runs laterally to join with th...

2 ) with no history of health problems presented with hypermenorrhea. Transvaginal ultrasonography revealed a submucous leiomyoma measuring 4 cm in size. We suggested two surgical options (hysteroscopic myomectomy or TLH) to the patient. After a lengthy discussion with the patient about the various implications, at the patient’s request we decided to perform TLH. The patient was hospitalized and underwent TLH. The operative time was 161 minutes and the intraoperative blood loss was 100 mL. The weight of the resected specimen was 220 g. During TLH, we routinely expose the avascular retroperitoneal space by the lateral approach at the beginning of the operation. By displacing the uterus to the contralateral side, a pelvic sidewall triangle formed by the round ligament, the external iliac artery, and the infundibulopelvic ligament is identified. The peritoneum in the middle of the triangle is then incised, and the broad ligament is opened by bluntly separating the areolar tissues. We next proceed to locate the umbilical ligament in the retroperitoneal space. After identifying the umbilical ligament, we search caudally for the uterine artery along its structure. The uterine artery is then ligated at its origin with 2e0 Vicryl to reduce the blood flow. The ureter, which adheres to the posterior leaf of the broad ligament, can thus be identified at the same time. In order to prevent ureteral injury, the course of the ureter is caudallyexposed until the entrance of the ureteral tunnel. Usually, the entire pelvic course of the ureter becomes visible during these procedures. However, in this case, the course of the ureter was not clearly visible. Therefore, we searched for the ureter distal (cranial) to the pelvic brim and then peeled the ureter from the posterior leaf of the broad ligament for its entire pelvic course in order to expose it. Surprisingly, incomplete duplication of the right ureter was observed during the procedure (Fig.1). Distally, both ureters were joined together and running as a single segment for approximately 5 cm in length prior to entering the bladder. The left ureter and the bladder were normal in appearance. The patient was uneventfully discharged on postoperative Day 4. Renal ultrasonography later confirmed no evidence of hydronephrosis. Intravenous pyelography was not performed during the postoperative period at the patient’s request. The patient was doing well during the postoperative follow-up.

In an excellent recent article (Dunster et al., 1976) comparison was made between the ultrasonic and isotopic methods of localizing the placenta. Although not disagreeing for one moment with the authors' eventual conclusion that the ultrasonic method was preferable, perhaps two other factors should be considered. Firstly, the lower segment cannot be regarded as “an area within 5 cm of the internal cervical os”. In a 20-week pregnancy, the lower uterine segment hardly exists at all and yet by the time labour commences at term it may include the whole area of the uterus between the internal os and the pelvic brim, rather, more than 5 cm.

To the Editor: —All instructors in the study of obstetrics should be urged to teach the necessity of examining every infant on delivery, for a possible congenital dislocation of the hip. It is not difficult to detect this abnormality with sufficient surety, to indicate the necessity of a radiographic demonstration to decide the diagnosis. Lay the infant on a table and hold the infant's pelvis secure with one hand placed over the front of the pelvic brim. Grasp the femur at the condyles and shove upward and then pull downward. If the head of the femur is not in the acetabulum, the head of the bone may be moved up and down on the dorsum of the ilium from 1½ to 2 inches without moving the pelvis. Next turn the infant on one side and over the gluteal muscles palpate the head of the femur with one hand, while gently