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Background: The management of hemodynamically unstable pelvic ring injuries necessitates surgical intervention, often involving procedures such as external fixation and percutaneous screw placement. Given the infrequent performance of these procedures, regular training is imperative to ensure readiness for emergencies. Our pre- post simulation study aimed to adapt and validate a realistic simulation model for stabilizing unstable pelvic ring injuries, facilitating participants' knowledge retention and procedural confidence enhancement. Methods: A standardized simulator of an unstable pelvic ring utilizing synthetic pelvic bones featuring complete disruption of the symphysis and sacroiliac joint was developed. Trauma surgeons of a level one academic hospital were invited to perform external fixation and emergency sacroiliac screw application under C-arm guidance. Prior to and following the simulation session, participants completed a subjective questionnaire assessing their confidence in emergency interventions on a 10-point Likert scale (10-LS). Objective parameters, such as intraoperative imaging quality, reduction accuracy, and the positioning of screws, wires, and external fixators, were also evaluated as secondary outcome measures. Results: Fifteen trauma surgeons (10 residents, 5 consultants) participated in the simulation over the course of one day. The mean total operation time was 20.34 ± 6.06 min, without significant differences between consultants and residents (p = 0.604). The confidence for emergency SI-Screw placement increased significantly after the simulator (10-LS: Before = 3.8 ± 3.08 vs. After = 5.67 ± 2.35; p = 0.002) as well as after external fixation (10-LS: Before = 3.93 ± 2.79 vs. After = 6.07 ± 2.52; p = 0.002). In addition, confidence in (intraoperative) pelvic imaging increased significantly (10-LS: Before = 4.60 ± 3.0 vs. After = 6.53 ± 2.39; p = 0.011). Overall, the model was rated as a realistic simulation of clinical practice (10-LS = 7.87 ± 1.13). Conclusions: Our unstable pelvis fracture model is a tool to practice emergency interventions such as external fixation and percutaneous techniques. Participants benefitted from this in terms of technical instrumentation as well as intraoperative imaging. Further studies are required to validate the objective benefits and improvements that participants undergo through frequent training. [ABSTRACT FROM AUTHOR]

Abstract Background The management of hemodynamically unstable pelvic ring injuries necessitates surgical intervention, often involving procedures such as external fixation and percutaneous screw placement. Given the infrequent performance of these procedures, regular training is imperative to ensure readiness for emergencies. Our pre- post simulation study aimed to adapt and validate a realistic simulation model for stabilizing unstable pelvic ring injuries, facilitating participants’ knowledge retention and procedural confidence enhancement. Methods A standardized simulator of an unstable pelvic ring utilizing synthetic pelvic bones featuring complete disruption of the symphysis and sacroiliac joint was developed. Trauma surgeons of a level one academic hospital were invited to perform external fixation and emergency sacroiliac screw application under C-arm guidance. Prior to and following the simulation session, participants completed a subjective questionnaire assessing their confidence in emergency interventions on a 10-point Likert scale (10-LS). Objective parameters, such as intraoperative imaging quality, reduction accuracy, and the positioning of screws, wires, and external fixators, were also evaluated as secondary outcome measures. Results Fifteen trauma surgeons (10 residents, 5 consultants) participated in the simulation over the course of one day. The mean total operation time was 20.34 ± 6.06 min, without significant differences between consultants and residents (p = 0.604). The confidence for emergency SI-Screw placement increased significantly after the simulator (10-LS: Before = 3.8 ± 3.08 vs. After = 5.67 ± 2.35; p = 0.002) as well as after external fixation (10-LS: Before = 3.93 ± 2.79 vs. After = 6.07 ± 2.52; p = 0.002). In addition, confidence in (intraoperative) pelvic imaging increased significantly (10-LS: Before = 4.60 ± 3.0 vs. After = 6.53 ± 2.39; p = 0.011). Overall, the model was rated as a realistic simulation of clinical practice (10-LS = 7.87 ± 1.13). Conclusions Our unstable pelvis fracture model is a tool to practice emergency interventions such as external fixation and percutaneous techniques. Participants benefitted from this in terms of technical instrumentation as well as intraoperative imaging. Further studies are required to validate the objective benefits and improvements that participants undergo through frequent training.

Objective: To explore the feasibility of using the entry point and screw path parameters of sacroiliac (S 2 AI) screws inserted under O-arm 3D computer navigation as a reference for freehand screw insertion in patients with degenerative spinal deformities. Methods: A retrospective analysis was conducted on the clinical data of 66 patients with degenerative spinal deformities who received S 2 AI screw fixation assisted by the O-arm 3D computer navigation system at Nanjing Drum Tower Hospital Affiliated with Nanjing University Medical School from January 2017 to April 2022. The patients included 6 males and 60 females, with a mean age of (64.3±5.9) years. Preoperatively, the entry point was set as the intersection of 1 mm from the outer and lower edges of the S 1 foramen, adjusted intraoperatively by navigation, and verified postoperatively by full spinal CT scans and 3D reconstructions. Using the S 1 screw entry point as the origin, the position of the bilateral S 2 AI screw entry points, tailward angulation (SA), outward angulation (TA), and vertical distance from the entry point to the skin (SD) were measured on postoperative CT 3D images. The accuracy of S 2 AI screw placement and any intraoperative and postoperative complications were recorded. Differences in entry point coordinates and screw path parameters between the left and right sides were compared. The intraclass correlation coefficient (ICC) was used to assess intra-observer and inter-observer agreement. Results: The coordinates and screw path parameters for the S 2 AI screws placed using the O-arm navigation demonstrated good intra-observer and inter-observer consistency (ICC>0.75). The left entry point was located (8.08±1.39) mm laterally and (24.47±2.20) mm caudally from the S 1 entry point, while the right entry point was (8.09±1.41) mm laterally and (24.40±2.54) mm caudally, with no significant difference between the left and right sides (both P >0.05). The left TA was 46.33°±3.44°, SA was 39.14°±6.12°, and SD was (60.38±13.37) mm; the right TA was 46.37°±3.41°, SA was 39.59°±5.89°, and SD was (60.30±12.24) mm, with no significant differences between the left and right parameters (all P >0.05). There was no significant neurovascular complications intraoperatively or two weeks postoperatively, with a screw insertion accuracy of 97.7% (129/132). Conclusions: In the fixation of the pelvis in degenerative spinal deformities, the use of O-arm navigation-assisted S 2 AI screw insertion has a high accuracy rate. It is recommended that for freehand screw insertion, the entry point should be located 24 mm caudally and 8 mm laterally from the outer and lower edges of the superior articular process of S 1 , with an TA of approximately 46° and a SA of approximately 39°.

Objectives: To quantify the occupational radiation exposure with a 3-dimensional (3D) fluoroscopic machine during routine use in pelvic and acetabular surgery and to determine whether the additional radiation exposure encountered with the 3D fluoroscopic spin is within previously accepted limits., Design: Prospective cohort study., Setting: Level I trauma center., Patient Selection Criteria: All patients undergoing 3D fluoroscopy intraoperatively during pelvis (OTA/AO 61B,C) or acetabular (OTA/AO 62A-C) surgery between April 2021 and July 2021., Outcome Measures and Comparisons: Radiation dose at standardized locations around the operating room during the spin portion of the 3D fluoroscopy., Results: Seventy-six 3D spins were performed on 69 patients during the study period. The average emitted radiation dose from the machine for the routine fluoroscopy portion of the case was 74.5 mGy. The average displayed radiation dose in the air for the spin portion of the case was 39.9 mGy, an average of 53.6% less radiation than the routine fluoroscopy portion. For the spin portion, the average radiation exposure seen by the patient was 3.42 mGy (centered on the patient) and the average maximal exposure in the room was 0.062 mGy. Minimal radiation was detected outside the operating room doors., Conclusions: The radiation exposure encountered by operating room personnel with 3D fluoroscopy appears to be within safe occupational limits. The marginal increase in radiation exposure during pelvic and acetabular surgery should not discourage the use of 3D imaging intraoperatively., Level of Evidence: Level IV, Case Series., Competing Interests: M. M. Gosselin: Board member for AAOS, Orthopaedic Trauma Association and Society of Military Orthopaedic Surgeons; A. E. Levack: Board member for Orthopaedic Trauma Association, Grant funding from NIH and DePuy Synthes, all unrelated this work; J. L. Gary: Stryker—consulting and royalties, Smith and Nephew—consulting, SMV Scientific—stockholder, Curvafix—consulting and stock options, AONA—Board Member, JOT and JBJS—Editorial Board Member, all unrelated to this work; S. J. Warner: AAOS, AONA, OTA Committee member, Globus, Smith and Nephew, Stryker: paid presenter/speaker; M. L. C. Routt: AONA Board member, Johnson and Johnson, Stryker and Zimmer: paid presenter/speaker. The remaining authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: Anastomotic leakage following rectal cancer surgery remains a challenging complication, with a nonhealing rate of approximately 50% at 1 year. Pelvic sepsis may require tertiary treatment that encompasses additional admissions, extensive surgery and other types of interventions. The aim of this study is to analyse the financial burden of pelvic sepsis in a tertiary hospital., Method: From 2010 until 2020, all patients referred to a tertiary centre for pelvic sepsis after low anterior resection for rectal cancer were prospectively registered and retrospectively reviewed. The cost analysis adhered to Dutch National Healthcare Institute guidelines and covered hospital-imposed medical costs from salvage surgery to the last registered intervention, adjusted for inflation and priced in euros., Results: This analysis included 126 patients, with an average total cost per patient of €31 131. Salvage surgery accounted for €21 326, with an additional €9805 for reinterventions and readmissions. Salvage surgery comprised nonrestorative surgery in 48% and restorative salvage surgery in the remaining cases. Length of hospital stay averaged 9.6 days on the general ward and 0.8 days in the intensive care unit. Common reinterventions included endoscopic vacuum sponge changes (n = 153), stoma closures (n = 59) and radiological abscess drainages (n = 51). Total costs did not differ significantly between nonrestorative surgery and restorative surgery (mean = €31 950 vs. €30 362, respectively; p = 0.893)., Conclusion: Treating pelvic sepsis after rectal cancer resection in a tertiary hospital carries a substantial economic burden, averaging €31 131 per patient, and this work helps to quantify the potential economic impact of innovative care to reduce anastomotic leakage., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: The triglyceride-glucose index, a reliable surrogate biomarker of insulin resistance, has been reported to be associated with cardiovascular events and atherosclerosis. However, few studies have investigated the association of the triglyceride-glucose index with postoperative infections. This study aimed to study the clinical risk values of the preoperative triglyceride-glucose index in postoperative infection complications in elderly patients undergoing gastrointestinal-related abdominal and pelvic surgery., Methods: This retrospective cohort study included 3,225 older patients who underwent gastrointestinal-related abdominal and pelvic surgery between 2014 and 2019. The patients were divided into groups of triglyceride-glucose index ≤8.268 and triglyceride-glucose index >8.268 according to the optimal triglyceride-glucose index cut-off value. The outcome of interest was postoperative infections within 30 days after surgery. Primary and subgroup analyses were performed to confirm that preoperative triglyceride-glucose index qualifies as a reliable, independent risk indicator. Propensity score matching analysis was further applied to address covariates' potential residual confounding effect and test the robustness of the results., Results: In this study, the median age was 71 years (interquartile range, 67, 75 years), the proportion of male patients was 66.3%, and 1,058 (32.8%) were infected within 30 days after surgery. A triglyceride-glucose index >8.268 was associated with an increased risk of postoperative infections in multivariate regression analysis (odds ratio, 1.37; 95% confidence interval, 1.15-1.64; P < .001). The correlation between the triglyceride-glucose index and postoperative infections remained significantly robust (odds ratio, 1.52; 95% confidence interval, 1.21-1.92; P < .001) in the propensity score matching analysis., Conclusions: The triglyceride-glucose index elevation determined by the optimal cutoff value of 8.268 was an independent risk factor for developing postoperative infections., Competing Interests: Conflicts of Interest/Disclosure All authors report no potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the effect of various pelvic fixation techniques and number of rods on biomechanics of the proximal junction of long thoracolumbar posterior instrumented fusions., Methods: A validated spinopelvic finite-element (FE) model was instrumented with L5-S1 ALIF and one of the following 9 posterior instrumentation configurations: (A) one traditional iliac screw bilaterally ("2 Iliac/2 Rods"); (B) T10 to S1 ("Sacral Only"); (C) unilateral traditional iliac screw ("1 Iliac/2 Rods"); (D) one traditional iliac screw bilaterally with one midline accessory rod ("2 Iliac/3 rods"); (E) S2AI screws connected directly to the midline rods ("2 S2AI/2 Rods"); and two traditional iliac screws bilaterally with two lateral accessory rods connected to the main rods at varying locations (F1: T10-11, F2: T11-12, F3: T12-L1, F4: L1-2) ("4 Iliac/4 Rods"). Range of motions (ROM) at T10-S1 and T9-T10 were recorded and compared between models. The T9-T10 intradiscal pressures and stresses of the T9-10 disc's annulus in addition to the von Mises stresses of the T9 and T10 vertebral bodies were recorded and compared., Results: For T10-S1 ROM, 4 iliac/4 rods had lowest ROM in flexion and extension, while 2 S2AI/2 rods showed lowest ROM in rotation. Constructs with 3 or 4 rods had lower stresses on the primary rods compared to 2-rod constructs. At the proximal adjacent disc (T9-10), 4 iliac/4 rods showed lowest ROM, lowest intradiscal pressures, and lowest annular stress in all directions (most pronounced in flexion-extension). Under flexion and extension, 4 iliac/4 rods also showed the lowest von Mises stresses on the T10 vertebral body but the highest stresses on the T9 vertebral body., Conclusions: Dual iliac screws with 4 rods across the lumbosacral junction and extending to the thoracolumbar junction demonstrated the lowest T10-S1 ROM, the lowest adjacent segment disc (T9-T10) ROM, intradiscal pressures, and annular stresses, and the lowest UIV stresses, albeit with the highest UIV + 1 stresses. Additional studies are needed to confirm whether these biomechanical findings dictate clinical outcomes and effect rates of proximal junctional kyphosis and failure., (© 2024. The Author(s).)

Background: The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. The authors aimed to evaluate outcomes of the VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction., Methods: The authors conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January of 2001 and March of 2021. Our primary outcome measure included recipient and donor surgical-site occurrences (SSOs)., Results: The authors identified a total of 546 patients (55% women) with a mean age of 58 years and mean body mass index of 27 kg/m 2 . Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient SSOs occurred in 38% of patients, and donor SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients, and bulge developed in 6.4% of patients. The Cox proportional hazards regression model for hernia occurrence identified age, body mass index, tobacco use (hazard ratio, 2.03; 95% CI, 1.02 to 4.04), and use as an extended VRAM flap (hazard ratio, 2.13; 95% CI, 1.04 to 4.36). The use of mesh or component separation were not independent protective factors for hernia occurrence., Conclusions: The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor-site hernia occurrence., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: This study is to investigate the safety and efficacy of ureteroscope-assisted laparoscopic ureteroplasty in treating ureteral stricture after pelvic surgery., Methods: A retrospective analysis of the clinical data of 95 patients treated for ureteral stricture at Ganzhou People's Hospital from June 2017 to March 2023 after pelvic surgery. In this group, 49 patients underwent ureteroscope and laparoscopic ureteroplasty under lithotomy position. The control group consisted of 46 patients who underwent simple laparoscopic ureteroplasty in a supine position. Postoperative data from both groups were collected and compared, including operation time, amount of blood loss during surgery, postoperative hospital stay, incidence of complications, success rate of ureteroplasty, and effectiveness of the operation., Results: The success rate of end-to-end ureteral anastomosis in the observation group was 93.88%, and the operation effectiveness rate was 100%. The success rate in the control group was 78.26% and the operation effectiveness rate was 89.1%.The average operation time and intraoperative blood loss in the observation group were (121.3 ± 44.6) min and (137.5 ± 34.2) ml, respectively, while in the control group they were (151.2 ± 52.3) min and (165.6 ± 45.8) ml, the difference were statistically significant (P < 0.05). The incidence of perioperative complications in the observation group was 2%, significantly lower than that in the control group (19.6%) (P < 0.05)., Conclusion: Ureteroscope-assisted laparoscopic ureteroplasty for ureteral stricture after pelvic surgery has the advantages of shortened operation time, increased success rate, and reduced incidence of complications, making it an optional surgical scheme in clinical practice., (© 2024. The Author(s).)

As the global surgical robotic ecosystem diversifies, multi-platform surgery is becoming increasingly common. The natural question is whether these robots differ in performance and cost. We address this question and report the first systematic review comparing platforms. A systematic search identified clinical studies comparing at least two platforms. Of 287 studies, 31 were included, with 5 RCTs and 26 cohort studies, including 3624 patients. All studies compared da Vinci with Hintori, Hugo, KangDuo, Micro-Hand, Revo-I, Senhance, and Versius robots. Comparisons were across specialties: urology (18 studies; upper and lower tract), general surgery (11 studies; inguinal and ventral hernia, cholecystectomy, colorectal, pancreatic, oesophagectomy, distal gastrectomy), gynaecology (3 studies; hysterectomy, sacrocolpopexy). There were no differences in conversion rate, estimated blood loss, complication rate, pathological parameters, oncological outcomes (6 months), and functional outcomes (12 months). Results were mixed on operative time and its components. Length of stay was largely similar. Surgeon task load was similar (2 studies). Operative cost was 45-60% lower on the newer platforms (3 studies). Operative, clinical, oncological, and functional outcomes were similar for da Vinci and the newer robots across a range of abdominopelvic procedures, with a signal of lower cost on newer types. Studies were heterogeneous. Data on non-technical skills, other human factors, and comparative learning curves was scant. The majority of evidence was low quality and retrospective. However, accumulating evidence on safety, efficacy, and non-inferiority of the newer platforms has implications for robotic training programmes and procurement., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: Total Hip Arthroplasty (THA) is the primary treatment for hip diseases today. Nevertheless, total hip arthroplasty has its challenges, and one of these challenges is the potential for incorrect execution of the preoperative planning process. Such errors can lead to complications such as loosening and instability of the prosthesis and leg length discrepancy. In this study, we used human phantoms to investigate the influence of pelvic and femoral factors on prosthesis size selection in the preoperative planning of total hip arthroplasty and to provide a reference standard for clinical imaging in preoperative planning of total hip arthroplasty., Methods: In this experiment, we utilised a custom-made experimental device that enabled us to manipulate the movement of the pelvis and femur in various directions. The device also incorporated sensors to control the angle of movement. By obtaining X-rays from different positions and angles, we were able to determine the size of the prosthesis based on the 2D preoperative planning generated by the mediCAD software., Results: When the pelvis was in a nonneutral position, the size of the acetabular cup varied within a range of three sizes. Similarly, when the femur was in a nonneutral position, the size of the femoral stem varied within a range of two sizes. The movement of the pelvis and femur in the coronal plane, relative to the neutral position, did not impact the selection of the prosthesis size. However, the motion of the pelvis and femur in the sagittal and transverse planes had a notable effect., Conclusion: The selection of the prosthesis size for preoperative planning can be significantly influenced by specific positions of the pelvis and femur. It is crucial for the radiographer to ensure that the pelvis and femur maintain a standard neutral position, particularly in the sagittal and transverse planes, during the image acquisition process., (© 2024. The Author(s).)

Anterior approaches to the acetabulum can be distinguished into extrapelvic, intrapelvic and combined extrapelvic and intrapelvic approaches. Historically, the extrapelvic ilioinguinal approach was introduced in the French, English and German literature during the late 60s and became gradually the Gold-standard in treating anterior acetabular fractures. In the meantime, the intrapelvic approach, introduced by the Helsinki group, is favored by many surgeons with ongoing interest allowing direct antero-medial access to the true pelvis below the linea terminalis, to the quadrilateral plate and medial side of the posterior column. More recently, more supero-medial approaches, allowing access to the large and true pelvis have been developed, e.g. the Pararectus approach. The historical development, the value and approach-related results of the ilioinguinal approach are analyzed and discussed., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: In June 2023, our institution adopted the Medtronic Hugo RAS system for colorectal procedures. This system's independent robotic arms enable personalized docking configurations. This study presents our refined multi-docking strategy for robotic low anterior resection (LAR) and deep pelvic procedures, designed to maximize the Hugo RAS system's potential in rectal surgery, and evaluates the associated learning curve., Methods: This retrospective analysis included 31 robotic LAR procedures performed with the Hugo RAS system using our novel multi-docking strategy. Docking times were the primary outcome. The Mann-Kendall test, Spearman's correlation, and cumulative sum (CUSUM) analysis were used to assess the learning curve and efficiency gains associated with the strategy., Results: Docking times showed a significant negative trend (p < 0.01), indicating improved efficiency with experience. CUSUM analysis confirmed a distinct learning curve, with proficiency achieved around the 15th procedure. The median docking time was 6 min, comparable to other robotic platforms after proficiency., Conclusion: This study demonstrates the feasibility and effectiveness of a multi-docking strategy in robotic LAR using the Hugo RAS system. Our personalized approach, capitalizing on the system's unique features, resulted in efficient docking times and streamlined surgical workflow. This approach may be particularly beneficial for surgeons transitioning from laparoscopic to robotic surgery, facilitating a smoother adoption of the new technology. Further research is needed to validate the generalizability of these findings across different surgical settings and experience levels., (© 2024. The Author(s).)

Learning Objectives: After studying this article, the participant should be able to: 1. Classify types of bony pelvic resections. 2. Outline reconstructive options for pelvic and perineal defects. 3. Identify advantages and drawbacks of various reconstructive techniques. 4. Recognize the functional benefits of bony and soft-tissue reconstruction., Summary: Defects of the pelvis and perineum arise from tumors, trauma, infection, congenital differences, and gender incongruence. Pelvic resections can result in bony instability and soft-tissue deficiency. The goals of reconstruction are maintenance of spinopelvic continuity, elimination of dead space, resurfacing of cutaneous defects, and prevention of hernias. Perineal reconstruction has important functional considerations. Abdominoperineal resection and pelvic exenteration defects benefit from flap reconstruction to decrease pelvic wound complications. Vulvovaginal reconstruction is performed with flaps from the perineum, thigh, or abdomen. Scrotal and superficial penile defects are most commonly reconstructed with scrotal flaps and skin grafts. Total penile reconstruction most commonly uses a radial forearm free flap., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Purpose: While existing adult spinal deformity (ASD) alignment schemas acknowledge the dynamic relationship between the pelvis and spine, consideration of vertebral pelvic angles (VPA) thresholds for PJK may provide further insight into the relationship of each individual vertebra to the pelvis, which may allow for greater individualization of operative targets. Herein, we examine VPA's utility in preventing mechanical complications and its possible unification with prevalent scoring systems., Methods: In a retrospective cohort study of a prospectively collected database, operative ASD patients ≥ 18 years with complete baseline (BL) and two-year (Y) operative, radiographic, and health-related quality of life data were included. Descriptive analyses, means comparison, and logistic regression tests were applied to explore demographic and surgical differences, as well as the impact of alignment goals on outcomes. Cohorts were grouped as patients who met VPA non-PJK thresholds, as defined by Duvvuri et al. 2023 alone versus traditional GAP/SAAS alignment matching versus combined VPA + SAAS + GAP. The Non-PJK VPA validated mean for L1PA was 10.4 ± 7.0 and T9PA 8.9 ± 7.5., Results: 398 patients met inclusion criteria (mean age 61 ± 14 years, 78% female, BL BMI 27 ± 6, BL CCI 2 ± 2). At baseline, mean vertebral pelvic angles were as follows: T1PA: 24 ± 14; T4PA 20 ± 13, T9PA 15 ± 12, L1PA 11 ± 10, L4PA 11 ± 6. Mean vertebral pelvic angles at 6 W postoperatively: T1PA 16 ± 10, T4PA 12 ± 10, T9PA 8 ± 9, L1PA 9 ± 8, L4PA 11 ± 5. 240 (60%) patients attained optimal L1PA, while 104 patients (26.1%) reached non-PJK mean for T9PA. 89 patients (22%) were optimal by both VPA standards. VPA-Optimal group demonstrated significantly lower rates of 1Y PJK (17% v 83%, p = 0.042) and PJF by 2Y (7% v. 93%, p = 0.038). When patients attained VPA goals in addition to GAP/SAAS goals at 6 W, they demonstrated significantly lower rates of Y1 PJK (p = 0.026) and Y1 and Y2 PJF. Those with optimal VPA registered greater SRS-22 scores across multiple domains (p < 0.02) as well as a greater rate of normal neurological examination at 6 W (p = 0.048)., Conclusions: Vertebral pelvic angles are a reliable measure of global alignment, and respecting certain targets may help prevent development of PJK/PJF. The value of VPA can be augmented through integration with GAP/SAAS frameworks to prevent complications and improve quality of life., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To identify the risk factors for distal junctional failure (DJF) in women treated for adult spine deformity with fusion to L5 and to highlight the significance of preoperative assessment, surgical decision-making, and postoperative care., Methods: This is a retrospective study of data collected prospectively on the local institutional spine surgery registry (2016-2021). All patients, women older than 18 years, with a diagnosis of adult spine deformity who underwent long posterior instrumentation to L5 and had a minimum of 2-years follow-up were included in the study (two groups: with or without DJF). Demographic and radiographic data, corrective strategy, preoperative level of degeneration at L5/S1 and GAP score were compared between the two groups., Results: Forty-eight patients (n = 48) satisfied eligibility criteria. At two-years follow-up, nine patients (18,7%) developed a DJF that required surgical revision. Thirty-nine patients did not present distal junctional complications. Patients with or without DJF showed significant differences in terms of preoperative spinopelvic parameters (PT: 28°± 6° vs. 23°± 9°, p-value 0.05; DJF group vs. not DJF) and degeneration of L5-S1 (Pfirmann grade L5-S1 disc 3.7 ± 1.0 vs. 2.6 ± 0.8, p-value 0.001; DJF group vs. not DJF) (L5-S1 Facet joint Osteoarthritis 3.1 ± 0.8 vs.2.4 ± 0.8, p-value 0.023; DJF group vs. not DJF)., Conclusion: DJF following spinal deformity correction surgery is influenced by a combination of patient-related, surgical and implant-related factors. Fusion construct length, preoperative and postoperative sagittal alignment and the grade of degeneration of the distal disc have been identified as significant risk factors. Surgeons should carefully evaluate these factors and employ appropriate strategies., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Indocyanine green (ICG) is a visible near-infrared fluorescent dye. Several studies have reported its benefit in identifying important anatomical structures, tissue vascularization, and sentinel lymph nodes in the case of tumors. Studies have shown that ICG is critical and safe in gynecologic surgeries. However, research on how ICG dye can help surgeons in laparoscopic surgeries correctly identify the course of the ureter has yet to be further investigated., Method: This cross-sectional study enrolled 62 gynecology attending and resident surgeons who were asked to identify the course of the ureter on images of laparoscopic surgeries. The results were then compared with images in which ICG dye highlighted the course of the ureter. The purpose of this study was to detect the ability of surgical assistants and residents to adequately identify the course of the ureter in laparoscopic pelvic surgeries., Results: No statistically significant differences were found in terms of year of residency, years of experience, number of laparoscopic procedures attended, and correct identification of ureter course. ICG proved useful in identifying the correct ureteral trajectory., Conclusions: ICG can be a valuable tool to improve the correct identification of ureters and improve surgical outcomes.

Objective: To investigate the improvement of spinopelvic parameters and therapeutic efficacy in the treatment of complex degenerative lumbar spondylolisthesis (CDLS) after oblique lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF)., Methods: From January 2018 to December 2020, 71 patients with CDLS underwent OLIF or TLIF at the same hospital: 31 in the OLIF group and 40 in the TLIF group. The spinopelvic parameters, perioperative data, and clinical outcomes were elected and compared between the 2 groups., Results: There were no statistic differences in demographic perioperative complication rates and preoperative spinopelvic parameters between the two groups. OLIF group showed lower serum C-reactive protein in the early postoperative stage, shorter length of stay, less estimated blood loss and larger slippage correction rate (88.05 vs. 62.37%) (all P ＜ 0.05). There was no significant difference in the visual analog scale and Oswestry disability index scores before operation and three and six months after surgery, but OLIF group was better in the long-term with visual analog scale and Oswestry disability index (1.7/13.2 vs. 2.3/16.5). And it was significantly different in the lumbar lordosis angle, segmental lordosis angle, pelvic tilt, sacral slope (46.0°/9.3°/18.2°/35.9° vs. 40.4°/7.2°/23.9°/31.1°), and sagittal vertical axis (21.6 vs. 31.7mm) after surgery between OLIF and TLIF groups (all P ＜ 0.05)., Conclusions: In the therapy of CDLS, OLIF can better reduce pelvic tilt, L1 axis S1 distance, and sagittal vertical axis, and increase lumbar lordosis angle and sacral slope, showing advantages over TLIF in improving and maintaining spinopelvic parameters. Although there was no difference in complication rates between OLIF and TLIF, OLIF was more minimally invasive, had less tissue damage, had faster recovery, and had better long-term outcomes., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To compare the 2-year reoperation rates for adjacent segment disease between patients with pelvic incidence-lumbar lordosis (PI-LL) mismatch postoperatively and patients with normal PI-LL measurements., Methods: Patients undergoing elective 1- to 2-level lumbar fusion for degenerative conditions between 2016 and 2018 were retrospectively reviewed. Spinopelvic radiographic parameters immediately postoperation were measured, and PI-LL mismatch was determined using the age-adjusted thresholds defined in Lafage et al. After propensity score matching, early reoperation rates were compared between the PI-LL mismatch and normal PI-LL cohorts. Early reoperation was defined as symptomatic adjacent segment disease (ASD) requiring reoperation within 2 years of the index surgery., Results: A total of 219 patients were identified. The average age was 59 years of age, with 59.8% female. The PI-LL mismatch cohort (n = 148) was younger (57.5 vs. 63.5 years, P < 0.001) and had a higher proportion of Black patients (31.8% vs. 11.3%, P = 0.001) than the normal PI-LL cohort, respectively. A total of 100 patients in the PI-LL mismatch cohort were propensity score matched to 66 patients in the normal PI-LL cohort, resulting in no difference in age (P = 0.177), sex (P = 0.302), race (P = 0.727), or body mass index (P = 0.892). Using these matched cohorts, the rate of early reoperation for ASD was 8.0% in the PI-LL mismatch cohort and 9.1% in the normal PI-LL cohort (P = 0.805), with a mean time to reoperation of 1.28 and 1.33 years, respectively., Conclusions: After propensity score matching, PI-LL mismatch was not associated with early reoperation for ASD in patients undergoing 1- to 2-level lumbar fusions for degenerative conditions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

A retrospective cohort study of patients undergoing laparoscopic inguinal hernia repair compared short- and long-term outcomes between individuals with or without history of previous abdominopelvic surgery, aiming to determine the feasibility of totally extraperitoneal (TEP) repair within this population. All patients who underwent elective TEP inguinal hernia repair by one consultant surgeon across three London hospitals from January 2017 to May 2023 were retrospectively analysed to assess perioperative outcomes. Two hundred sixty-two patients were identified, of whom two hundred forty-three (93%) underwent laparoscopic TEP repair. The most frequent complications were haematoma (6.2%) and seroma (4.1%). Recurrence occurred in four cases (1.6% of operations, 1.1% of hernias). One hundred eighty-four patients (76%) underwent day-case surgery. There were no mesh infections or explanations, vascular or visceral injuries, port-site hernias, damage to testicle, or persisting numbness. There were no requirements for blood transfusion, returns to theatre, or readmissions within 30 days. There was one conversion to open and one death within 60 days of surgery. Eighty-three (34%) had a history of previous AP surgery. There was no significant difference in perioperative outcomes between the AP and non-AP arms. This finding carried true for subgroup analysis of 44 patients whose AP surgical history did not include previous inguinal hernia repair and for those undergoing repair of recurrent hernia. In expert hands, laparoscopic TEP repair is associated with excellent outcomes and low rates of long-term complications, and thus should be considered as standard for patients regardless of a history of AP surgery., (© 2024. The Author(s).)

Objective: During radical pelvic surgeries fibers of the autonomic pelvic nervous network can be accidentally damaged leading to significant visceral sequelae, which dramatically affect women's quality of life because of urinary, anorectal, and sexual postoperative dysfunctions. 1 , 2 Direct visualization is one way to preserve hypogastric nerves (HNs), pelvic splanchnic nerves (PSNs), and the bladder branches from the inferior hypogastric plexus (IHP). However, the literature lacks critical photos and/or illustrations that are necessary to understand the precise anatomy needed to preserve the pelvic autonomic fibers., Design: Narrated laparoscopic video footage for identifying, dissecting, and preserving the autonomic nerve bundles during pelvic surgery., Setting: Tertiary level hospital-"IRCCS Istituto Nazionale dei Tumori", Milano, Italy., Interventions: Visceral pelvic innervation is established by the superior hypogastric plexus(SHP) located anteriorly to the aortic bifurcation and the median sacral vessels and carries mostly sympathetic fibers. SHP divides in front of the sacrum into the right and left HN. At the level of the paracervix, the HNs join the parasympathetic PSNs coming out from sacral root S2, S3, S4 to form the IHP. 2-5 Here, we performed laparoscopic surgery, before "Laparoscopic Approach to Cervical Cancer" trial (LACC) era, identifying key anatomic landmarks useful to highlight the path of the most commonly encountered autonomic pelvic nerves in gynecologic radical surgery: during the narration we describe and illustrate the procedure to identify all autonomic pelvic nerves, the sympathetic fibers, the PSNs, and the bladder branch emerging from the IHP in order to preserve their anatomic and functional integrity. This technique is anatomically and surgically indicated for adequate removal of the parametrical issues and vagina while preserving the total pelvic nervous system., Conclusion: Nerve-sparing surgery reduces bowel-, bladder- and sexual- dysfunction without decreasing surgical efficacy. 1 , 2 To accomplish safe and effective surgery, comprehension of the 3 dimensional structure of the vascular and nerve anatomy in the pelvis is essential. This video provides a great resource to educate surgeons, especially the youngest ones, about the retroperitoneal nervous networking: we identified the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacro-uterine, rectouterine/vaginal, and vesico-uterine ligaments., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Background Context: Returning to recreational sporting activities after adult spinal deformity (ASD) correction may significantly impact the patient's perceived quality of life., Purpose: This study sought to characterize participation in sporting activities before and after ASD surgery, and to identify factors associated with impaired return to sports., Study Design: Cross-sectional survey and retrospective review of prospectively collected data., Patient Sample: Patients who underwent posterior-only thoracolumbar ASD surgery between 2016 and 2021 with ≥1 year follow-up and ≥3 levels of fusion to the pelvis were included., Outcome Measures: Preoperative and postoperative participation in sports, timing of return to these activities, and reasons for limited sports participation postoperatively were assessed., Methods: A survey was used to evaluate outcome measures. Differences in demographic, surgical, and perioperative variables between patients who reported improved, unchanged, or worsened activity tolerance were evaluated., Results: Ninety-five patients were included (mean age: 64.3±10.1 years; BMI: 27.3±6.1 kg/m 2 ; median levels fused: 7). The survey was completed at an average of 43.5±15.9 months after surgery. Sixty-eight (72%) patients participated in sports preoperatively. The most common sports were swimming (n=33, 34.7%), yoga (n=23, 24.2%), weightlifting (n=20, 21.1%), elliptical (n=19, 20.0%), and golf (n=11, 11.6%). Fifty-seven (83.8%) returned to at least one sport postoperatively, most commonly 6-12 months after surgery (45%). Elliptical had the highest rate of equal or improved participation (53%). Patients generally returned below their preoperative level to all other sports. Reasons for reduced sporting activities included physical limitation (51.4%), fear (20.0%), pain (17.1%), and surgeon advice (8.6%). There were no differences in the demographic, surgical, or perioperative characteristics between those who returned to sports at the same or better level compared with those who returned at a lower level., Conclusions: About 84% of patients successfully resumed sporting activities after undergoing fusion to the sacrum/pelvis for ASD. However, this return is typically at a lower level of participation than their preoperative participation, particularly in higher demand sports. Understanding trends in sporting activity may be valuable for counseling patients and setting expectations., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Lateral pelvic lymph node dissection is performed for selected patients with rectal cancer with persistent lateral nodal disease after neoadjuvant therapy. This technique has been slow to be adopted in the West because of concerns regarding technical difficulty. This is the first report on the learning curve for lateral pelvic lymph node dissection in the United States or Europe., Objective: This study aimed to analyze the learning curve associated with robotic lateral pelvic lymph node dissection., Design: Retrospective observational cohort., Setting: Tertiary academic cancer center., Patients: Consecutive patients from 2012 to 2021., Intervention: All patients underwent robotic lateral pelvic lymph node dissection., Main Outcome Measures: The primary end points were the learning curves for the maximum number of nodes retrieved and urinary retention, which was evaluated with simple cumulative sum and 2-sided Bernoulli cumulative sum charts., Results: Fifty-four procedures were included. A single-surgeon learning curve (n = 35) and an institutional learning curve are presented in the analysis. In the single-surgeon learning curve, a turning point marking the end of a learning phase was detected at the 12th procedure for the number of retrieved nodes and at the 20th procedure for urinary retention. In the institutional learning curve analysis, 2 turning points were identified at the 13th procedure, indicating progressive improvements for the number of retrieved nodes, and at the 27th procedure for urinary retention. No sustained alarm signals were detected at any time point., Limitations: The retrospective nature, small sample size, and the referral center nature of the reporting institution may limit generalizability., Conclusions: In a setting of institutional experience with robotic colorectal surgery, including beyond total mesorectal excision resections, the learning curve for robotic lateral pelvic lymph node dissection is acceptably short. Our results demonstrate the feasibility of the acquisition of this technique in a controlled setting, with sufficient case volume and proctoring to optimize the learning curve. See Video Abstract., La Curva De Aprendizaje De La Diseccin Robtica De Los Ganglios Linfticos Plvicos Laterales En El Cncer De Recto Una Visin Desde Occidente: ANTECEDENTES:La disección lateral de los ganglios linfáticos pélvicos se realiza en pacientes seleccionados con cáncer de recto con enfermedad ganglionar lateral persistente tras el tratamiento neoadyuvante. La adopción de esta técnica en Occidente ha sido lenta debido a la preocupación por su dificultad técnica. Éste es el primer informe sobre la curva de aprendizaje de la disección de los ganglios linfáticos pélvicos laterales en EE.UU. o Europa.OBJETIVO:El objetivo de este estudio fue analizar la curva de aprendizaje asociada a la disección robótica de los ganglios linfáticos pélvicos laterales.DISEÑO:Cohorte observacional retrospectiva.LUGAR:Centro oncológico académico terciario.PACIENTES:Pacientes consecutivos desde 2012 al 2021.INTERVENCIÓN:Todos los pacientes fueron sometieron a disección robótica de ganglios linfáticos pélvicos laterales.PRINCIPALES MEDIDAS DE RESULTADO:Los criterios de valoración primarios fueron las curvas de aprendizaje tomando en cuenta el mayor número de ganglios recuperados y la retención urinaria que fueron evaluados con gráficos de suma acumulativa simple y de suma acumulativa de Bernoulli de dos caras.RESULTADOS:Fueron incluidos 54 procedimientos. En el análisis se presentan una curva de aprendizaje de un solo cirujano (n = 35) y una curva de aprendizaje institucional. En la curva de aprendizaje de un solo cirujano, se detectó un punto de inflexión que marcaba el final de una fase de aprendizaje en el duodécimo procedimiento para el número de ganglios extraídos y en el vigésimo para la retención urinaria. En el análisis de la curva de aprendizaje institucional, se identificaron dos puntos de inflexión en las intervenciones 13.ª y 26.ª, que indicaron mejoras progresivas en el número de ganglios extraídos, y en la 27.ª en la retención urinaria. No se detectaron señales de alarma sostenidas en ningún momento.LIMITACIONES:La naturaleza retrospectiva, el pequeño tamaño de la muestra y la naturaleza de centro de referencia de la institución informante que pueden limitar la capacidad de generalizarse.CONCLUSIONES:En un entorno de experiencia institucional con cirugía robótica colorrectal incluyendo más allá de las resecciones TME, la curva de aprendizaje para la disección robótica de ganglios linfáticos pélvicos laterales es aceptablemente corta. Nuestros resultados demuestran la viabilidad de la adquisición de esta técnica en un entorno controlado, con un volumen de casos suficiente y una supervisión que puede optimizar la curva de aprendizaje. (Traducción-Dr. Osvaldo Gauto )., (Copyright © The ASCRS 2024.)

Study Objective: To evaluate the effectiveness of using vascular clips to seal targeted lymphatics in gynecological malignancies for the prevention of postoperative pelvic lymphocele and symptomatic lymphocele after laparoscopic pelvic lymphadenectomy., Design: Retrospective analysis., Setting: Single-center academic hospital., Patients: In total, 217 patients with gynecological malignancies were included., Interventions: Patients were classified into two groups: group 1 (vascular clips were used to seal the targeted lymphatics) and group 2 (electrothermal instruments were used to seal the targeted lymphatics). The patients were followed up 4-6 weeks after surgery to evaluate the incidence of lymphoceles by ultrasound or CT. Symptomatic lymphoceles are defined as those that cause infection, deep vein thrombosis with or without swelling of the extremities, edema (swelling) of the extremities or perineum, hydronephrosis, and/or moderate to severe pain., Measurements and Main Results: One hundred and thirteen patients were enrolled in group 1, and 104 patients were enrolled in group 2. Lymphoceles were observed in 46 (21.2%) patients. Fewer lymphoceles occurred in group 1 than in group 2 (8 [7.1%] vs. 38 [36.5%], p <.001). The percentage of significantly sized lymphoceles was lower in group 1 than that in group 2 (4 [3.5%] vs. 30 [28.8%], p <.001]. Symptomatic lymphoceles occurred in 18 patients (8.3%), and only one (1.0%) occurred in group 1, while 17 (16.3%) occurred in group 2 (p <.001). A multivariate analysis revealed that vascular clips were the only independent factor for preventing lymphocele (OR = 7.65, 95% CI = [3.30-17.13], p <.001) and symptomatic lymphocele (OR = 22.03, 95% CI = [2.84-170.63], p = .003)., Conclusion: The results indicate that the use of vascular clips may be useful for the prevention of the development of lymphocele and symptomatic lymphocele secondary to pelvic lymphadenectomy performed via laparoscopy., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: This study sought to explore the efficiency of para-aortic and pelvic lymphadenectomy in the treatment of locally advanced cervical cancer (LACC) with pelvic lymph node (PLN) metastasis., Methods: A total of 171 LACC patients with imaging-confirmed pelvic lymph node metastasis were included in this study. These patients were divided into two groups: the surgical staging group, comprising 58 patients who had received para-aortic and pelvic lymphadenectomy (surgical staging) along with concurrent chemoradiation therapy (CCRT), and the imaging staging group, comprising 113 patients who had received only CCRT. The two groups' progression-free survival (PFS), overall survival (OS) and treatment-related complications were compared., Results: The surgical staging group started radiotherapy 10.2 days (range 9-12 days) later than the imaging staging group. The overall incidence of lymphatic cysts was 9.30%. In the surgical staging group, para-aortic lymph node metastasis was identified in 34.48% (20/58) of patients, while pathology-negative PLN was observed in 12.07% (7/58). Over a median follow-up period of 52 months, no significant differences in PFS and OS rates were found between the two groups (p > 0.05). Subgroup analysis of patients with lymph node diameters of ≥ 1.5 cm revealed a five-year PFS rate of 75.0% and an OS rate of 80.0% in the surgical staging group, compared to 41.5% and 50.1% in the imaging staging group, respectively, showing statistically significant differences (p = 0.022, HR:0.34 [0.13, 0.90] and p = 0.038, HR: 0.34 [0.12,0.94], respectively for PFS and OS). Additionally, in patients with two or more metastatic lymph nodes, the five-year PFS and OS rates were 69.2% and 73.1% in the surgical staging group, versus 41.0% and 48.4% in the imaging staging group, with these differences also being statistically significant (p = 0.025, HR: 0.41[0.19,0.93] and p = 0.046, HR: 0.42[0.18,0.98], respectively)., Conclusion: Performing surgical staging before CCRT is safe and delivers accurate lymph node details crucial for tailoring radiotherapy. This approach merits further investigation, particularly in women with pelvic lymph nodes measuring 1.5 cm or more in diameter or patients with two or more imaging-positive PLNs., (© 2024. The Author(s).)

The concept of membrane anatomy has been widely accepted and applied in clinical practice, but there are still many theoretical and practical conflicts. This article elucidates the fundamental concepts and manifestations of membrane anatomy, delineating its comprehensive integration of anatomical and surgical disciplines. Thereafter, this article specifically discusses its differences from the traditional anatomy and surgery, and then clarifies the important role of membrane anatomy as the third generation of surgical anatomy and the new surgical concept for the development of pelvic surgery.

Objective: The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery., Methods: Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups., Results: A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9)., Conclusions: There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.

Purpose: This study aimed to determine whether Cobb and pelvic obliquity corrections can be predicted using supine traction radiographs in patients with cerebral palsy (CP) who underwent posterior spinal fusion (PSF) from T2/3 to L5., Methods: From January 2010 to January 2020, 167 non-ambulatory patients with CP scoliosis underwent PSF using pedicle screws in two quaternary centers with a minimum of 2 years follow-up (FU). Radiological measurements and chart reviews were performed., Results: A total of 106 patients aged 15.6 ± 0.4 years were included. All patients had significant correction of the Cobb angle (MC), pelvic obliquity (PO), thoracic kyphosis (TK), and lumbar lordosis (LL) without loss of correction at the last FU (LFU). Curve flexibility was significantly correlated with Cobb correction (δMC) immediately postoperatively (p < 0.0001, r = 0.8950), followed by the amount of correction in pelvic obliquity under traction (δPOT) (p = 0.0252, r = 0.2174). For correction in PO (δPO), the most significant variable was δPOT (p < 0.0001, r = 0.7553), followed by curve flexibility (p = 0.0059, r = 0.26) and the amount of correction in Cobb under traction (p = 0.0252, r = 0.2174)., Conclusions: Cobb and PO corrections can be predicted using supine traction films for non-ambulatory CP patients treated with PSF from T2/3 to L5. The variables evaluated were interconnected, reinforcing preoperative planning for these patients. Comparative large-scale studies on patient-related clinical outcomes are required to determine whether this predicted correction is associated with improved surgical outcomes and reduced complication rates., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design: Retrospective cohort., Objective: Examine the relationship between compensatory pelvic retroversion, positive sagittal imbalance (measured by C2 tilt), and the C2 pelvic angle (C2PA) in patients before long spinal fusions; and to determine the association between changes in C2PA and pelvic tilt (PT) following long spinal fusions., Background: Adult spinal deformity surgical goals often include a PT target, yet patients frequently demonstrate persistent compensatory pelvic retroversion following surgery., Methods: Adults above 18 years old undergoing long spinal fusions (>4 levels) with standing preoperative and postoperative radiographs were included. To examine drivers of preoperative sagittal balance, regression models were fit to estimate the association between preoperative C2PA and pelvic incidence with preoperative PT and C2 tilt. To predict postoperative change in PT, multivariable regression was used to estimate change in PT, adjusting for change in C2PA and preoperative C2 tilt., Results: Among the 80 patients identified, the median age was 61 (IQR: 45-72) and 46 (58%) were female. The median number of levels fused was 10 (IQR: 8-13) and 55 (69%) were instrumented to the sacrum/pelvis. Preoperative C2PA had a significant nonlinear association with preoperative PT ( r2 =0.81, P <0.001) and preoperative C2 tilt ( r2 =0.41, P =0.002). Postoperative change in PT was strongly associated with change in C2PA (β=0.81; P <0.001) and preoperative C2 tilt (β=0.55; P <0.001)., Conclusions: Following long spinal fusions, change in PT (or lack thereof) can be reliably predicted based on change in C2PA and preoperative C2 tilt. In patients with normal preoperative C2 tilt, the change in C2PA is nearly equivalent to the change in PT, but in patients with more positive C2 tilt (sagittal imbalance), a greater change in C2PA will be required to achieve an equivalent change in PT., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Pelvic osteotomies are essential to approximate widened symphysis pubis in the exstrophy-epispadias complex, yet it is unknown which osteotomy type has the greatest effect on pelvic volume. We therefore used virtual surgery to study pelvic volume change with anterior, oblique, and posterior iliac osteotomies. Preoperative CT scans of two cloacal and one classic bladder exstrophy patients were used. Simulations were free-hand or constrained to keep minimal strain in the sacrospinous SSL and sacrotuberous STL ligaments. Changes in inter-pubic distance, pelvic volume, SSL and STL strains were measured. Mean pelvic volume decreased by 10% with free hand compared to 23% with constrained simulations ( P  = 0.171) and decreased by 7% with posterior, 17% with diagonal and 26% with horizontal osteotomies ( P  = 0.193). SSL and STL were strained by 20% and 26%, respectively, with free-hand simulations. A statistically significant moderate positive correlation was found between the decrease in inter-pubic distance and reduction in pelvic volume (r = 0.6, P  = 0.004). Mean pelvic volume decreased 0.05, 0.37 and 0.62% for each mm of pubic symphysis approximation with posterior, diagonal and horizontal osteotomies, respectively. Differences in effect on pelvic volume were identified between the osteotomies using virtual surgery which predicted residual diastasis in actual cloacal exstrophy surgical reconstructions. Oblique osteotomies are a compromise, avoiding difficulties with posterior osteotomies and excessive pelvic volume reduction with horizontal osteotomies. Understanding how osteotomy type affects pelvic morphology with virtual surgery may be an effective adjunct to pre-operative planning in exstrophy spectrum., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aimed to show the association between tumor location and laterality of positive lymph nodes by evaluating biopsy and magnetic resonance imaging (MRI) findings, and to optimize the extended pelvic lymph node dissection (ePLND) side for prostate cancer., Methods: The study enrolled patients who underwent robot-assisted radical prostatectomy with ePLND. Tumor locations were determined according to International Society of Urological Pathology grade group 4/5 in biopsies and Prostate Imaging-Reporting and Data System category 4/5 in MRI results. The concordance of tumor location lobe and positive lymph node side with the performance of tumor location-guided ePLND for positive lymph node detection was evaluated., Results: For 301 patients who underwent ePLND at Kyushu University Hospital, tumor locations determined by biopsy and MRI findings showed no lesion in 8 (2.7%) patients, unilateral lobe in 223 (74.1%) patients, and bilateral lobe in 70 (23.3%) patients. The accuracies for detection of any and all positive lymph nodes by tumor location-guided unilateral ePLND were 99.6% and 97.3%, respectively. Among the patients at St. Luke's International Hospital, the accuracies for detection of any and all positive lymph nodes by tumor location-guided unilateral ePLND were estimated to be 99.0% and 97.3%, respectively., Conclusions: This study proposed tumor location-guided ePLND according to biopsy and MRI findings. This novel strategy is expected to reduce the burden of bilateral ePLND at the cost of acceptable risk of failing to detect positive lymph nodes., (© 2024. Society of Surgical Oncology.)

Background: Different strategies have been proposed to prevent lymphocele (LC) formation after radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). According to several recently published randomized control trials (RCTs) on the topic, peritoneal reconfiguration appears to be associated with promising results. This systematic review aimed to assess the impact of peritoneal reconfiguration on LC formation in patients undergoing RARP and PLND., Methods: A comprehensive bibliographic search was conducted in August 2023. Studies assessing patients with prostate cancer undergoing RARP with PLND (P) and concomitant peritoneal reconfiguration (I) compared or not with other techniques (C) to prevent LC formation (O) were included. Original prospective and retrospective studies (S) were selected. LC and symptomatic LC rates were chosen as co-primary outcomes. Only RCTs were included in the meta-analysis., Results: Eleven studies investigating 2991 patients were included in the systematic review, and five RCTs evaluating 1712 subjects were deemed eligible for meta-analysis. Peritoneal flap (PF) was the most common surgical technique used for LC prevention (9 studies). A significantly lower likelihood of LC was observed after PF (OR 0.82, 95% CI 0.27-1.37, I 2  = 74.54%), with no significant difference in terms of symptomatic LC (OR 0.21, 95% CI -0.41-0.84, I 2  = 0%). Probability of LC-related complications (OR 0.36, 95% CI 0.04-0.67, I 2  = 0%), Clavien-Dindo ≥ 3 overall complications (OR 0.61, 95% CI 0.21-1.0, I 2  = 0%), and Clavien-Dindo ≥ 3 LC-related complications (OR 0.98, 95% CI 0.29-1.67, I 2  = 0%) were significantly lower after PF., Conclusions: PF after RARP with PLND reduces LC formation, LC-related complications, and severe postoperative adverse events., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Pelvic organ-preserving radical cystectomy (POPRC) has been reported to result in a better postoperative quality of life in female with bladder cancer compared to standard radical cystectomy (SRC). However, its oncological outcomes remain a concern., Patients and Methods: Female patients with bladder cancer who underwent POPRC or SRC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Logistic regression was used to identify predictors of POPRC usage. To avoid the potential impact of baseline differences between groups on survival, a 1:2 propensity score matching (PSM) was implemented. After that, Kaplan-Meier curves and Log-rank tests were used to determine the significance of overall survival (OS) differences between patients in the SRC group and POPRC group. Finally, subgroup analysis based on predetermined indicators was performed., Results: A total of 2193 patients were included with a median follow-up of 53 months, of whom 233 (10.6%) received POPRC and 1960 (89.4%) received SRC. No definitive predictors of POPRC were identified. Before PSM, POPRC resulted in comparable OS to SRC (HR = 1.09, p = 0.309), while after PSM, POPRC was associated with significantly worse OS (HR = 1.23, p = 0.038). In subgroup analyses, POPRC led to non-inferior OS (HR = 1.18, 95%CI 0.71-1.95, p = 0.531) in patients with non-muscle invasive bladder cancer (NMIBC) and T2 patients (HR = 1.07, p = 0.669), but significantly worse OS in T3 patients (HR = 1.41, p = 0.02)., Conclusion: Currently, patients undergoing POPRC have not undergone strict screening, and candidates for POPRC should have more stringent criteria in the future to achieve satisfactory oncological outcomes. However, flaws in the study make more evidence needed to support our findings., (© 2024. The Author(s).)

This study aimed to construct a novel pelvis-prostate model BPPP which consists of body mass index (BMI), prostate volume (PV), pelvic cavity index (PCI) and prostate-muscle index (PMI) to predict the immediate urinary continence after Retzius-sparing robot assisted laparoscopic radical prostatectomy (RS-RARP). The perioperative data of patients with prostate cancer who underwent RS-RARP in the department of urology of Nanjing Drum Tower Hospital from June 2018 to June 2022 were retrospectively analyzed. 280 patients were eligible for this study in total. Multivariate analysis showed that BMI, PV, PCI, PMI and NVB preservation were significantly associated with immediate urinary continence after RS-RARP. Subgroup analysis showed that patients with low BMI, low PV, high PCI and high PMI had a higher recovery rate of immediate urinary continence. The area under the curve of BPPP (BMI + PV + PCI + PMI) for predicting the immediate recovery of urinary continence after RS-RARP was 0.726. Delong test showed that the area under the curve of the combined test for predicting the immediate urinary continence after RS-RARP was better compared with single parameter (p < 0.05). In conclusion the novel pelvis-prostate model BPPP may predict the immediate urinary continence after RS-RARP, providing information for preoperative decision-making., (© 2024. The Author(s).)

Study Design: Retrospective analysis of prospectively collected data., Objective: To identify the best definition of primary anteverted pelvis in the setting of adult spine deformity (ASD), and to investigate whether this is a pathologic setting that requires surgical correction., Summary of Background Data: While pelvic retroversion has been thoroughly investigated, pelvic anteversion (AP) is a far lesser discussed topic. Four different AP definitions have been proposed, and AP has been described as a normal or pathologic entity by different authors., Materials and Methods: All patients consulting for ASD at the five participating sites were included. First, the four definitions of AP were compared with descriptive statistics (anatomic method-Pelvic Tilt <0°; Relative Pelvic Version method-RPV >5°; Roussouly method-Pelvic Incidence (PI)<50° and Sacral Slope (SS)>35°); low PT method-PT/PI <25th percentile). Second a subgroup analysis among operated AP patients with a two-year follow-up was performed. Complication rate, radiographic parameters, and clinical scores (ODI, SF-36) were compared in a multivariate analysis between patients who did and did not maintain an AP at the 2-year follow-up., Results: A total of 1163 patients were available for the first analysis. The RPV method seemed to be the most appropriate to define AP in ASD patient. For the second analysis, data on 410 subjects were available, and most of them were young adults with idiopathic scoliosis that did not require pelvic fixation. AP patients who maintained an AP after ASD surgery presented comparable radiographic and clinical outcomes to the patients who presented a normoverted/retroverted pelvis after surgery., Conclusions: According to the results of the presented study, the RPV method is the most appropriate to define primary AP, which is not a pathologic condition and is most often observed in young adults with idiopathic scoliosis. Anteverted pelvis does not require direct surgical correction in this patient group., Competing Interests: LB Consultant: Spineart, Spinevision; I.O.: Royalties : Spineart, alphatec, Clariance, Consultant : Medtronic, Depuy, spinevision Research support : Medtronic, Depuy; JP Consultant: Medtronic, Grants: Medtronic Depuy; F.P.: Research support: DePuySpine Synthes/Medtronic/Nuvasive/Orthofix/SpineArt Consultant: Medtronic/Nuvasive; A.A.: Consultancy: Globus, Zimvie, Research Grant: Depuy, Medtronic Royalty: Zimvie; F.K.: Depuy Spine Speakers Bureau and Research Grant; YPC: Consultant: Clariance, Stryker, Ceraver, Spinevision, Research Grants: Clariance, Stryker, Medtronic; C.Y.: Consultant, Medtronic. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The Briganti nomogram (cut-off value 5%) is commonly used to determine the indications for pelvic lymph node dissection (PLND) in patients with prostate cancer. We retrospectively analyzed the potential oncological benefit of PLND based on the 5% cut-off value on the Briganti nomogram. We obtained the data from the Medical Investigation Cancer Network (MICAN) Study, which included 3,463 patients who underwent a radical prostatectomy (RP) at nine institutions in Japan between 2010 and 2020. We included patients with Briganti scores ≥ 5% and a follow-up period ≥6 months and excluded patients categorized in the very high-risk group (based on NCCN categories); a final total of the cases of 1,068 patients were analyzed. The biochemical recurrence (BCR)-free survival was significantly worse in the patients who underwent PLND compared to those who did not (p=0.019). A multivariate analysis showed that high prostate-specific antigen (PSA) levels (p<0.001) and an advanced T-stage (p=0.018) were significant prognostic factors for BCR, whereas PLND had no effect on BCR (p=0.059). Thus, PLND in patients with prostate cancer whose Briganti score was 5% did not provide any oncological benefit. Further research is necessary to determine the indication criteria for conducting PLND., Competing Interests: No potential conflict of interest relevant to this article was reported.

Unstable trauma lesion of the spinopelvic junction, including U-shaped sacral fractures and Tile C pelvic ring disruptions, require surgical stabilization in order to realign the bone arches of the pelvis thus reducing the upcoming orthopaedic impairment during sitting, standing, and walking positions, decompress the nerves roots of the cauda equina in a view of reducing neurological impairment, and allow early weight bearing. Even though posterior open modified triangular spinopelvic fixation is particularly efficient for treating unstable trauma lesions of the spinopelvic junction, it may not be sufficient alone in order to prevent long-term counter-nutation, i.e. rotation and anteflexion deformity of the anterior pelvis under load bearing conditions. Such progressive deformation is caused by either the slight rotation of the iliac connectors within the head of iliac screws for spinopelvic constructs, or the slight rotation of sacral cancellous bone around transsacral screws in case of percutaneous procedure. Regardless of the posterior surgical technique that is used, complementary anterior pelvic fixation appears mandatory in order to prevent such deformation over time, which can lead to pelvic asymmetry and then gait imbalance., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary., Design: We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures., Results: 224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms., Conclusion: Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal., Competing Interests: Conflict of Interest NL: Advisory Board for Integra LifeSciences Inc.; Speaker honoraria for Pfizer Inc. and Medtronic Inc. MFB: National Institute of Neurological Disorders and Stroke (NINDS) of the National Institutes of Health (NIH) under Award Number NS123206-01., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Aim: To identify factors influencing the Trendelenburg angle required during laparoscopic gynecological surgery., Methods: Patients who underwent laparoscopic surgery at a single university hospital between May 1, 2019, and March 31, 2021 were enrolled. Data were extracted from the medical records, while magnetic resonance imaging scans and all laparoscopic surgery videos were retrospectively reviewed to assess the presence of the small intestine in the pelvic cavity as well as the adhesions at each site. Groups with and without the small intestine in the pelvic cavity, and those requiring a Trendelenburg angle above or below 13° were compared., Results: In total, 219 patients were examined. The Trendelenburg angle was significantly higher (p = 0.004), while a significant increase in ovarian adhesions was observed (p = 0.033; odds ratio [OR], 2.30; 95% confidence interval [CI], 1.05-5.01) in the group without the presence of the small intestine in the pelvic cavity. Furthermore, the group requiring a Trendelenburg angle of ≥13° had significantly thicker subcutaneous fat (p = 0.044) and more ileal adhesions (p = 0.040, OR, 1.82; 95% CI, 1.03-3.23) than the group with an angle of <13°., Conclusion: Cases of ileal adhesions or thick subcutaneous fat are more likely to require a Trendelenburg angle of ≥13°. Therefore, Trendelenburg complications should be considered in this group. In addition, ovarian adhesions make it more difficult to exclude the small intestine from the small pelvic cavity, and may be associated with endometriosis., (© 2024 Japan Society of Obstetrics and Gynecology.)

To compare the difference in perioperative outcomes between standard pelvic lymph node dissection (sPLND) and extended pelvic lymph node dissection (ePLND) in robot-assisted radical cystectomy (RARC) and evaluate the survival outcomes. The clinical data were retrospectively collected from patients who underwent RARC between January 2016 and December 2020 in Nanjing Drum Hospital. The patients were divided into sPLND and ePLND group according to the extent of pelvic lymph node dissection. Finally, 80 pairs of patients obtained for two groups by propensity score matching (PSM) and their perioperative and survival outcomes were analyzed. The median number of dissected lymph nodes (LN) after PSM was 13 in sPLND group and 16 in ePLND group (P = 0.004). Perioperative complications were similar between 2 groups. After PSM, ePLND improved 5-year RFS and OS in all patients (85.74 vs. 61.94%, P = 0.004; 82.80 vs. 67.50%, P = 0.033), patients with ≥ T3 disease (73.66 vs. 23.86%; P = 0.007; 68.20 vs. 36.20%; P = 0.032) and patients with LN metastasis (67.70 vs. 7.33%; P = 0.004; 60.60 vs. 16.67%; P = 0.045) compared to sPLND. Extended PLND significantly increased lymph node yield without increasing complication and improved RFS and OS compared to sPLND., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Fundamental morphologic differences between male and female pelvises are historically recognised. Despite this, little consideration has been given as to whether or not conventional positioning supports used for primary total hip arthroplasties (THAs) performed in the lateral position do an equally effective job of maintaining the intended set up position when comparing genders. Given that recent research has highlighted that unintended pelvic roll occurs commonly during hip surgery, and that such movement may have a mechanically-deleterious consequence upon final construct performance and complication rates, this study was undertaken to explore the differences in pelvic roll between genders., Methods: The output of a high-precision, commercially-available, imageless intra-operative navigation system was prospectively-collected for 85 consecutive patients undergoing unilateral, primary THAs. These data were separated by gender and were utilised to determine differences in pelvic movement around a central sagittal axis., Results: Demographic data were similar between genders, with no between-group differences in mean BMI (p = 0.09) or indication for surgery (p = 0.66), however participating males (mean 68.04) were slightly younger than females (mean 73.31). The mean anterior pelvic roll for females was 9.50°, and for males 8.68°. There were no statistically significant independent correlations observed between gender (p = 0.21) and pelvic roll., Conclusion: The findings of this novel study do not suggest gender differences in the magnitude of unintended, intra-operative, anterior roll, even when corrected for BMI and surgical indication. Average roll of ~ 9° was demonstrated across both groups. An awareness of such positional change during THA surgery may reduce potentially-avoidable post-operative complications., (© 2024. The Author(s).)

Purpose: To assess, in a large population of Adult Spinal Deformity (ASD) patients, the true interest of varying the upper anchors as a protective measure against Proximal Junctional Kyphosis (PJK), by analyzing and comparing 2 groups of patients defined according to their proximal construct. Another objective of the study is to look for any other factors, radiological or clinical, that would affect the occurrence of the proximal failure., Methods: Retrospective review of a prospective ASD database collected from 5 centers. Inclusion criteria were age of at least 18 years, presence of a spinal deformity with instrumentation from T12 or above to the pelvis, with minimum 2 years of follow-up. Demographic data, spinopelvic parameters, functional outcomes and complications were collected. Multiple logistic regression analysis was performed to identify the risk factors that would affect the occurrence of PJK., Results: 254 patients were included. 166 in the group "screws proximally" (SP) and 88 in the group "hooks proximally" (HP). There was no difference between both groups for PJK (p = 0.967). The occurrence of PJK was rather associated with greater age and BMI, higher preoperative kyphosis, worst preoperative SRS22 and SF36 scores, greater postoperative Sagittal Vertical Axis (SVA), coronal malalignment and kyphosis., Conclusion: The use of proximal hooks was not effective to prevent PJK after ASD surgery, when compared to proximal screws. Worse preoperative functional outcomes and worse postoperative sagittal and also coronal malalignment were the main drivers for the occurrence of PJK regardless the type of proximal implant., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Poor restoration of pelvic version after adult spinal deformity (ASD) surgery is associated with an increased risk of mechanical complications and worse quality of life. We studied the factors linked to the improvement of postoperative pelvic version., Materials and Methods: This is a retrospective analysis of a prospective multicenter ASD database. Selection criteria were: operated patients having preoperative severe pelvic retroversion as per GAP score (Relative Pelvic Version-RPV < - 15°); panlumbar fusions to the pelvis; 2-year follow-up. Group A comprised patients with any postoperative improvement of RPV score, and group B had no improvement. Groups were compared regarding baseline characteristics, surgical factors, and postoperative sagittal parameters. Parametric and non-parametric analyses were employed., Results: 177 patients were studied, median age 67 years (61; 72.5), 83.6% female. Groups were homogeneous in baseline demographics, comorbidities, and preoperative sagittal parameters (p > 0.05). The difference in RPV improvement was 11.56º. Group A (137 patients) underwent a higher percentage of ALIF procedures (OR = 6.66; p = 0.049), and posterior osteotomies (OR = 4.96; p < 0.001) especially tricolumnar (OR = 2.31; p = 0.041). It also showed a lower percentage of TLIF procedures (OR = 0.45; p = 0.028), and posterior decompression (OR = 0.44; p = 0.024). Group A displayed better postoperative L4-S1 angle and relative lumbar lordosis (RLL), leading to improved sacral slope (and RPV), and global alignment (RSA). Group A patients had longer instrumentations (11.45 vs 10; p = 0.047) and hospitalization time (13 vs 11; p = 0.045). All postoperative sagittal parameters remained significantly better in group A through follow-up. However, differences between the groups narrowed over time., Conclusions: ALIF procedures and posterior column osteotomies improved pelvic version postoperatively, and associated better L4-S1 and lumbar lordosis restoration, indirectly improving all other sagittal parameters. However, these improvements seemed to fade during the 2-year follow-up., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Locally recurrent rectal cancer (LRRC) involving the lateral pelvic sidewall requires a complex approach to maximize the likelihood of R0 resection, which is the only predictor of survival. The purpose of this report is to describe a novel technique to resect a localized lateral pelvic sidewall LRRC. A 63-year-old male patient was referred for a 15-mm LRRC near the right internal iliac vessels. Endoscopic ultrasound and magnetic resonance imaging excluded any involvement of the pelvic colon or residual rectum. A combined extraperitoneal antero-lateral approach and gluteal access were used to optimize vascular control on the internal iliac vessels, to promptly identify the ureter and to achieve a better posterior exposition of the sciatic notch. This technique allowed a controlled and tailored resection of pelvic sidewall without entering into the abdominal cavity. The postoperative course was uneventful. The pathologic report confirmed clear margins (R0), with one involving obturator lymph node. At 3 months, the patient is alive and free from local re-relapse. A right lung metastasis has occurred, and it was treated by stereotactic radiotherapy. The present report proposes a novel extraperitoneal pelvic sidewall excision to resect lateral LRRC with a colorectal-sparing approach, thus minimizing the risk of exenterative surgery-related complications. A proper selection of patients is mandatory, as the proposed technique could not be generalized as the standard of care in all lateral LRRCs., (© 2024. Italian Society of Surgery (SIC).)