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Lateral pelvic lymph node dissection (LLND) combined with removal of the internal iliac vessels is a challenging surgical procedure in minimally invasive surgery. We herein report our dissection approach and short-term outcomes. We conducted a study on rectal cancer patients who underwent laparoscopuic LLND combined with removal of the internal iliac vessels at our institution in March 2017–December 2019. In performing the surgery, we identified and dissected along the three pelvic sidewall fasciae (ureterohypogastric, umbilical prevesical and parietal pelvic fascia), located the internal ilial vein at the level of the common iliac vessels and carried out our dissection along the medial anterior surface of the internal iliac before transecting the vein. The duration of LLND was recorded as was the blood loss. There were 16 patients (10 males, mean age 65.4 ± 10.8 years). Five patients had primary surgery, and 11 had surgery for recurrence. The median blood loss of LLND was 10 ml (range, 0–250 ml), the median operating time was 173 min (range, 65–358 min), and post-operative complications were relatively mild. Seven of 16 patients (43.8%) were diagnosed with positive lateral nodes. The 2-year local recurrence-free and disease-free survival rates were 87.5% and 58.0%. Recognizing the pelvic anatomical points illustrated in the present study contributes to the surgical safety of LLND combined with removal of the internal iliac vessels.

The widely held dogma of three physiological narrowings in the upper urinary tract has proven incorrect by recent several studies using computed tomography images. There are only two common obstruction sites: the upper ureter and the ureterovesical junction. The second narrowing, where the ureter crosses the iliac vessels, cannot be regarded anymore as a common obstruction site. The mechanism by which stones lodge in the upper ureter is explained anatomically by the change in ureteral mobility and compliance at the level where the ureter exits the perirenal space. This level can be identified radiologically as the point where the ureter crosses under the ipsilateral gonadal veins, termed the “crossing point”. Kinking of the upper ureter is another manifestation of this anatomical phenomenon, visible in radiological images. It is caused by loosening of the ureter at or above the crossing point (within the perirenal space), corresponding with renal descent such as during the inspiratory phase. This new anatomical discovery in the retroperitoneum will not only bring about a paradigm shift in terms of the physiological narrowings in the upper urinary tract, but may also lead to the development of new surgical concepts and approaches in the area.

Atherosclerosis is common in patients with end-stage renal disease. Severe calcification of the iliac vessels is expected in the growing pool of kidney transplant candidates. Thus, transplant surgeons must constantly develop alternative operative strategies to deal with the technical challenges that this condition confers. This case report aims to highlight a reconstructive vascular technique to salvage a completely calcified recipient external iliac artery using a deceased donor's arterial iliac allograft from the same donor as the renal allograft in a 59-year-old man, as an effective method to decrease vascular complications. Keywords: Kidney transplantation, Vascular complications, Surgical technique, Arterial allograft, Arterial reconstruction, Atherosclerosis

Standard upper gastrointestinal flexible radial EUS probes are well suited for imaging of anorectum and pelvic pathologies. They offer multiple advantages over conventional rigid rectal probes. The current transducers allow imaging at variable frequencies and are Doppler capable. The flexible shaft of the endoscope and optics allow easy probe insertion to upper sigmoid. Flexible radial EUS probes allow evaluation of anal sphincter complex, rectosigmoid mural pathologies, and paraluminal pelvic disorders. A thorough understanding of pelvic anatomy and image orientation is the key to appropriate image interpretation. In this review, we describe the principles and methodology for anorectal EUS imaging using a flexible radial EUS probe.

For the preperitoneal mesh hernioplasty of groin hernias through posterior approaches and other published anterior approaches, the mesh fixation is not done with the inguinal ligament inferiorly, rather, the mesh is overlapped behind the inguinal ligament and on the area which contains the external iliac vessels and important nerves. With the modified Lichtenstein technique, transinguinal preperitoneal placement of the mesh is achieved avoiding dissection or exposure of blood vessels behind the inguinal ligament, the mesh is fixed inferiorly to inguinal ligament as is standard for Lichtenstein technique. Superiorly, medially, and laterally, the mesh is placed preperitoneally behind the buttress of the inguinal muscles.

Background Recent reports have demonstrated uterus transplantation as a relevant solution to treat absolute uterine infertility. Training on animal models is a prerequisite to set up a uterine transplantation program in humans. Sheep have been used as an optimal model for training and research as they display similar vessels size to human. While the ovine model might seem easy there are many difficulties in performing this complex surgery. In this study we describe through our experience the critical initial steps toward building a learning curve toward an optimal ovine uterine transplantation model. Materials We performed nine orthotopic uterine autotransplantations using end-to-side anastomoses to the external iliac vessels in sheep. We recorded the duration of all surgical steps and pointed out specific difficulties and solution found. Results We were able to perform optimal uterine dissection after the first 5 cases and optimal bilateral arterial and venous anastomoses, after 7 and 9 cases respectively. The main factors associated to success rate were optimal exposure, appropriate equipment, careful vessel preparation and modification of the anastomosis technique. Conclusion As uterine transplantation research programs are expanding, setting up an ovine model to train and perform research is critical. Such model is complex and requires optimized multidisciplinary approach to build an efficient learning curve.

Objective The current article encompasses a literature review and recommendations for radiotherapy in nodal oligorecurrent prostate cancer. Materials and methods A literature review focused on studies comparing metastasis-directed stereotactic ablative radiotherapy (SABR) vs. external elective nodal radiotherapy (ENRT) and studies analyzing recurrence patterns after local nodal treatment was performed. The DEGRO Prostate Cancer Expert Panel discussed the results and developed treatment recommendations. Results Metastasis-directed radiotherapy results in high local control (often > 90% within a follow-up of 1–2 years) and can be used to improve progression-free survival or defer androgen deprivation therapy (ADT) according to prospective randomized phase II data. Distant progression after involved-node SABR only occurs within a few months in the majority of patients. ENRT improves metastases-free survival rates with increased toxicity in comparison to SABR according to retrospective comparative studies. The majority of nodal recurrences after initial local treatment of pelvic nodal metastasis are detected within the true pelvis and common iliac vessels. Conclusion ENRT with or without a boost should be preferred to SABR in pelvic nodal recurrences. In oligometastatic prostate cancer with distant (extrapelvic) nodal recurrences, SABR alone can be performed in selected cases. Application of additional systemic treatments should be based on current guidelines, with ADT as first-line treatment for hormone-sensitive prostate cancer. Only in carefully selected patients can radiotherapy be initially used without additional ADT outside of the current standard recommendations. Results of (randomized) prospective studies are needed for definitive recommendations.

In some cases of locally advanced ovarian cancer, iliac vessels are infiltrated or are tightly adhered. In particular, involvement of the external iliac vessels is a rare situation.[1][1] These cases are mostly accepted as being inoperable and are referred for neoadjuvant chemotherapy. However

Primary retroperitoneal melanoma is a very rare extracutaneous presentation of melanoma. In this case report, we present a 65-year-old female with unilateral lower extremity edema secondary to occlusion of iliac vessels by a primary retroperitoneal melanoma tumor. We also review the findings in other cases previously described in the literature.

Iatrogenic iliac arteriovenous fistula (IAVF) is an extremely rare complication after lumbar discectomy surgery (LDS), with potentially life-threatening consequences. An IAVF results from the close anatomic relation between the iliac vessels and the last lumbar vertebrae and the corresponding discs. We report the case of a 45-year-old woman who developed a large right IAVF 3 years after L4-L5-S1 laminectomy. The arteriovenous fistula (AVF) was successfully treated with an endovascular technique using a WALLSTENT self-expanding stent. The postoperative period was uneventful, and the patient was discharged from the hospital in good general condition on the third postoperative day.

Background The aim of this study was to assess whether the autologous internal iliac artery and vein could be used as an interpositional graft for vascular reconstruction in segmental intestinal allografts and autografts. Methods Thirty-four intestinal transplants (19 living-related allografts and 15 autografts) were conducted in our programs between January 2011 and January 2019. Patient characteristics, type of vascular reconstruction, and post-operative complications were reviewed. Results There were 20 males and 14 females with a median age of 35 years. Of 34 grafts, 22 (64.7%) (11 allografts and 11 autografts) were revascularized using the autologous internal iliac artery and vein for reconstruction. Vascular reconstruction on the back table took 21 ± 6 min to complete. Both total operative time and cold ischemia time tended to be longer in the vascular-reconstruction group than in the direct-anastomosis group (530 ± 226 vs 440 ± 116 and 159 ± 49 vs 125 ± 66 min, respectively), but these differences were not significant. The incidence of vascular thrombosis tended to be higher in the direct-anastomosis group than in the vascular-reconstruction group (16.7% vs 0%, P = 0.118). At a median follow-up of 36.9 months, no stenosis or pseudoaneurysms developed. In 19 allografts, acute rejection occurred in 4 (21.1%) and chronic rejection occurred in 1 (5.2%). Conclusions Our results indicate that the use of an autologous internal iliac interposition graft greatly facilitates intestinal graft implantation and minimizes the risk of vascular complications.

Background Internal herniation of small intestine in the lesser pelvis alongside iliac vasculature is a rare occurrence. Skeletonization of iliac vessels during pelvic lymph node dissection (LND), as part of surgical staging or treatment of patients with uterine, ovarian or urogenital cancer, is a strict prerequisite for orifice formation. Case presentation A 68-year-old woman presented at the emergency department with complaints of constipation for the last 3 days and acute-onset abdominal pain, nausea and vomiting since few hours. She had a history of laparoscopic hysterectomy, bilateral salpingo-oophorectomy and para-aortic and pelvic LND 7 years ago. A distended abdomen with diffuse tenderness on palpation was noted. A CT scan demonstrated bowel obstruction secondary to an incarcerated hernia underneath an elongated right external iliac artery. During an emergency exploratory laparotomy, the incarcerated bowel was reduced and the hernial orifice closed with a running suture. The patient had an uneventful postoperative period and was discharged on the fifth postoperative day. Discussion This rare internal hernia can manifest with non-specific symptoms of small bowel obstruction at any given point after index surgery, sometimes even after several years free of complaints. Contrast-enhanced computed tomography is the method of choice for fast and reliable diagnosis and helps in planning the necessary emergency laparotomy. Conclusion This life-threatening complication adds to the current controversy of pelvic and para-aortic lymphadenectomy in patients with endometrial cancer. Primary closure of peritoneal defects should be considered to potentially prevent internal hernias, especially when elongated iliac vessels are present.

Large indirect or scrotal hernias present several challenges for surgeons with both the open and minimally invasive approaches. Some argue that open surgery provides more benefits than laparoscopic repair in terms of ease of hernia manipulation, but increased wound morbidity and risk of adverse postoperative outcomes explain the choice of minimally invasive techniques for these repairs. One technique that carries over from the open and laparoscopic approaches into robotic repair is the preperitoneal method. As opposed to laparoscopic repair, the robotic platform may be favorable in terms of a superior visual field and more precise dissection in a region with surrounding delicate structures such as gonadal and iliac vessels, as well as nearby femoral nerve branches. Suturing of the peritoneal flap is also arguably facilitated with the robotic platform, and this advantage may carry over into the postoperative period, with lower rates of complications and pain.

The vascular techniques in uterus transplantation are largely adopted from early work by the Nobel laureate Alexis Carrel in the early 1900. The organ is placed in the pelvis to make it possible to complete the vaginal anastomoses, used for future embryo transfer. The choice of the external iliac vessels simplifies the implant, just like in a kidney transplantation.

IntroducciónEn las cirugías de la región retropúbica, la sección o ruptura de la anastomosis puede causar graves hemorragias de difícil control. Nuestro objetivo fue verificar la presencia o no de anastomosis arterial o venosa entre los vasos ilíacos y obturadores en la región retropúbica.Materiales y MétodosTreinta cadáveres (14 hombres/16 mujeres; 60% de raza blanca y 40%, no blanca). Después de la disección, se verificó si había anastomosis y su distancia de la sínfisis púbica.ResultadosEl 13,3% no tenía comunicación y el 86,6% tenía algún tipo de anastomosis (p 0,05). El 72% de los blancos y el 67% de raza no blanca tenían anastomosis (p >0,05).ConclusionesLa presencia de anastomosis es más frecuente que la ausencia y no existe diferencia significativa en cuanto al lado. Está localizada, en promedio, a 5,7 cm de la sínfisis púbica y la venosa es significativamente más frecuente. Es significativamente más frecuente en las mujeres. No hay diferencia estadística en cuanto a la presencia de anastomosis entre la raza blanca y no blanca.

The possibility of implementing active surgical tactics in patients with locally advanced tumoral process in the small pelvis is demonstrated, despite the invasion of the main iliac vessels. It has been established that the use of a personified approach to the planning of surgical treatment, along with the use of a wide range of reconstructive-plastic techniques, allows achieving good long-term results even in such complex clinical situations.

A 64-year-old woman with recurrent ovarian cancer isolated to the left pelvic sidewall underwent robotic resection of a tumor adherent to the external iliac vein and encasing the ureter and internal iliac vessels. A narrated video-clip of the case is included.

The involvement of large vessels in the tumor process is the cause of the refusal of the surgery. Resection of aorta, even in specialized cancer centers is carried out very rarely. We report the result of long-term treatment of the female patient with retroperitoneal liposarcoma with invasion of the iliac artery, and 22 months later - in aorta.

Internal iliac artery ligation is a life-saving and a uterus-saving procedure. Though one may not be practicing high-risk obstetrics or operating on complicated gynecological conditions, one must be well versed with internal iliac artery ligation. This is because the need for performing it can arise suddenly. There can be profuse hemorrhage even during routine deliveries and surgeries. The internal iliac artery ligation has to be accomplished very quickly and one must know how to gain access to this vessel without traumatizing any other vessels since this will only worsen the situation. After gaining access, one must know how to identify the structures—the iliac vessels and the ureter— and must correctly ligate the internal iliac artery without damaging the ureter or the thin-walled veins which are in the vicinity. This procedure can be done by two approaches: by dividing the round ligament or through the pouch of Douglas. The latter approach is preferred during obstetric situations, whereas the former is preferred in gynecological situations.

Involvement of major pelvic vessels is one of the traditional contraindications of surgical treatment for recurrent gynecologic cancers. In our experience, ligation of the external iliac vein is also feasible without replacement, though it does however cause transitory severe edema of the lower leg

Pelvic side wall recurrences represent a challenge for oncologic surgeons, especially in cases requiring major vascular resections. Until the description of the out-of-the-box lateral resection surgical technique, lateral pelvic wall involvement was considered a contraindication for surgery.[1 2][1

Kidney transplantation is a major surgical procedure, involving vascular and ureteric anastomoses, and it is usually performed by a dedicated transplant surgeon. Kidneys may be available from deceased or living donors, and a variety of techniques may be adopted depending on recipient characteristics, such as status of iliac vessels, or features of the kidney itself, such as multiple vessels. In this chapter we will describe the procedure in full, including all aspects of surgery, and incorporating a description of various challenges the transplant surgeon may face.

Conventional open lateral lymph node (LLN) dissection performed along the internal iliac vessels frequently results in increased bleeding and postoperative complications [1, 2]. However, laparoscopic LLN dissection is a feasible, oncologically acceptable alternative [3-6]. We have developed a laparoscopic autonomic nerve-preserving technique for LLN dissection based on the vesicohypogastric fascia (VF) and ureterohypogastric nerve fascia (UNF) [7].Surgical and oncological outcomes were compared between 12 patients undergoing laparoscopic hemi-LLN dissection and 13 patients undergoing conventional open hemi-LLN dissection. Our standardized procedure for LLN dissection is shown in the video.The number of harvested LLNs and the postoperative hospital stay was similar in both groups. In the open dissection (OD) and laparoscopic dissection (LD) groups, the median operation times were 373.3 and 443.1 min, respectively. However, the median (range) blood loss was 38.8 (20-75) ml in the LD group versus 836.9 (365-2060) ml in the OD group. One LD patient had anastomotic leakage and one had hydronephrosis. One OD patient had anastomotic leakage, four had small bowel obstruction, three had wound infection and one had lymphatic leakage. Postoperative recovery was faster in the LD group: The median time to resumption of oral intake was 3.3 (2-6) days, versus 8.7 (3-34) days in the OD group. There was one case of grade 2 urinary retention in the LD group, but there were five cases of grade 2 or 3 urinary retention in the OD group. Surgical curability was R0 in all LD patients, whereas 7 of 13 patients were R0 in the OD group. After a mean follow-up of 24.4 (16.2-45.3) months, all LD patients were alive without recurrence. After 31.5 (6-63) months, three OD patients had local recurrence and two had distant metastasis.Laparoscopic LLN dissection based on VF and UNF is feasible, with acceptable surgical and oncological outcomes.

Highlights • Retroperitoneal pelvic desmoid tumours are rare with limited publications. • A rare case of a retroperitoneal pelvic desmoid tumour is discussed. • Excision was challenging requiring the sacrifice of some of the iliac vessels. • No other case reports document a surgical excision requiring this. • To date our patient suffers minimal morbidity and has had no recurrences.

In hostile iliac vessels for which transfemoral transcatheter aortic valve replacement (TAVR) is not feasible, alternative access is required. The choice of access between peripheral (subclavian/axillary and carotid) and central (transapical and transaortic) alternative access TAVR has not been

Introducción: En las cirugías de la región retropúbica, la sección o ruptura de la anastomosis puede causar graves hemorragias de difícil control. Nuestro objetivo fue verificar la presencia o no de anastomosis arterial o venosa entre los vasos ilíacos y obturadores en la región retropúbica. Materiales y Métodos: Treinta cadáveres (14 hombres/16 mujeres; 60% de raza blanca y 40%, no blanca). Después de la disección, se verificó si había anastomosis y su distancia de la sínfisis púbica. Resultados: El 13,3% no tenía comunicación y el 86,6% tenía algún tipo de anastomosis (p 0,05). El 72% de los blancos y el 67% de raza no blanca tenían anastomosis (p >0,05). Conclusiones: La presencia de anastomosis es más frecuente que la ausencia y no existe diferencia significativa en cuanto al lado. Está localizada, en promedio, a 5,7 cm de la sínfisis púbica y la venosa es significativamente más frecuente. Es significativamente más frecuente en las mujeres. No hay diferencia estadística en cuanto a la presencia de anastomosis entre la raza blanca y no blanca. Introduction: During surgical interventions, section or rupture of the anastomosis may cause severe difficult-to-control bleeding. The aim of this study was to verify the presence or absence of arterial or venous anastomosis among iliac and obturator vessels in the retropubic region. Methods: Thirty cadavers (14 men/16 women; 60% white and 40% non-white). After dissection, the presence of anastomosis and its distance from the pubic symphysis were verified. Results: The 13.3% presented no communication and 86.6% presented some type of anastomosis (p0.05). Anastomosis was observed in 72% of whites and 67% of non-whites. Conclusions: Presence of anastomosis is more frequent than its absence, and there is no significant difference regarding side. It is located at 5.7 cm from the pubic symphysis and venous anastomosis is significantly more frequent. Anastomosis is significantly more frequent in females. There is no statistically significant difference between white and non-white races.

Transfemoral access remains a versatile and commonly used access location for a variety of cardiac and vascular procedures. Using anatomical landmarks, ultrasound, and fluoroscopy, an adequate access location can be secured. The use of the micropuncture technique allows for a nearly guaranteed adequate access location, and a femoral angiogram performed through the sheath defines the anatomy of the vessel and the location of the access. This is important for the success of the procedure and to minimize the occurrence of complications, namely bleeding and development of pseudoaneurysms. Retrograde access is the most commonly used access. Some patients require antegrade access in order to facilitate femoral and tibial interventions and to avoid the need for crossover in diseased, tortuous, or previously stented iliac vessels.