Vesico-obturator venous plexus - a rare termination of obturator vein.

Obturator vein usually terminates into the internal iliac vein. Its variations are the cause major bleeding problems in pelvic surgeries. We observed a rare variation in the termination of the right obturator vein. There was a duplication of right obturator vein. Both obturator veins entered the pelvic cavity through the obturator foramen and joined with two vesical veins to form a vesico-obturator plexus. This plexus surrounded the internal iliac artery and terminated into the internal iliac vein. Awareness of this rare variation could be of importance to anatomists, radiologists, gynaecologists, urologists, and orthopaedic surgeons. The plexus might lead to hazardous bleeding in pelvic lymph node clearance procedures, hernia surgeries, gynaecological and orthopaedic procedures in this region. The pelvic fractures too can provoke dramatic retroperitoneal hematomas related to these veins injuries.

Relationship between the shoulder, trunk, and pelvis kinematics during the deceleration phase of throwing.

Background: The shoulder motion during pitching is influenced by the trunk and pelvis motions, but their relationship during the deceleration phase of throwing on flat ground has not yet been clarified. This study aimed to investigate the relationship between shoulder, trunk, and pelvis kinematics at the maximum internal rotation (MIR) of the shoulder during the deceleration phase of throwing on flat ground. Methods: The study participants included 17 male baseball players over 20 years old and at the recreational playing level. The recreational level was illustrated by players who did not practice at high intensity and had played only 1-2 competitions per week. Reflective markers were applied to the subject, and throwing motion was assessed using a three-dimensional motion capture system. Data were captured at 1000 Hz. We assessed the angle of the shoulder, spine, and pelvis at the MIR on flat ground. Internal shoulder rotation velocity and spinal and pelvic angular velocities were also assessed. The relationship between the shoulder, spine, and pelvis kinematics at the MIR was examined using simple linear regression analysis. Results: The internal shoulder rotation angle at the MIR was negatively associated with only the spinal flexion and rotation angle at the MIR (P = .006 and P = .010, respectively). No other significant associations between shoulder, spine, and pelvis kinematics were detected at the MIR. Conclusion: For throwing on flat ground, the internal shoulder rotation motion may be suppressed by producing trunk flexion and rotation motion at the MIR.

Primary Mucinous Adenocarcinoma of the Renal Pelvis: A Case Report.

Mucinous adenocarcinomas of the upper urinary tract are extremely rare, and the majority of information available comes from case reports or short case series. Intestinal metaplasia is considered a premalignant condition in carcinogenesis. Here we present a case of a 55-year-old male who presented with a left flank mass extending to the left hemiabdomen and macroscopic hematuria. Pathologic findings revealed that the kidney was transformed into a multiloculated cystic mass measuring 18 × 12 × 11 cm, with a dilated pelvicalyceal system obstructed by a stone at the renal hilus and filled with a gray, soft, gelatinous material. Histopathologic sections showed glandular metaplasia of the proximal ureter ascending to the renal pelvis, lined by intestinal-type columnar epithelium containing goblet cells admixed with malignant glands floating in abundant extracellular mucin, along with poorly differentiated areas composed of signet ring cells. Immunohistochemistry studies showed positive periodic acid Schiff (PAS)/periodic acid Schiff-diastase (PAS-D), consistent with the mucinous nature of the intracellular and extracellular materials. Positive immunohistochemical staining for CK7, CK20, and CDX2 (CK7+/CK20+/CDX2+) highlighted the intestinal differentiation of this neoplasm. This offers evidence for the intestinal metaplasia-dysplasia-carcinoma sequence rather than a teratomatous or coelomic epithelial origin in mucinous ovarian-like cystadenocarcinoma involving the renal pelvis.

Posttraumatic Renal Artery-Inferior Vena Cava Fistula-Induced High-Output Cardiac Failure: A Case Study.

High-output cardiac failure is a less prevalent form of heart failure. Most patients with heart failure are typically categorized as having either systolic or diastolic dysfunction with elevated systemic vascular resistance. Individuals with high-output cardiac failure exhibit normal cardiac function and decreased systemic vascular resistance. This reduction may stem from diffuse arteriolar dilation or potential bypass of arterioles and capillary beds, prompting the activation of neurohormones. This case report details the diagnosis and treatment of an unusual etiology of high-output cardiac failure involving an arteriovenous fistula connecting the renal artery to the inferior vena cava and right common iliac vessels, resulting in a left-to-right shunt in a 50-year-old male patient. The report explores the etiology, pathophysiology, and clinical presentation of high-output heart failure, emphasizing the crucial role of radiology in interprofessional teams.

Uncharted Territories: Dynamic Hip Screw Migration Into the Pelvis Requiring Laparotomy.

Hip fractures are common in patients with poor bone quality and are seen to affect the elderly and frail population. We report a case of implant failure after fixing an unstable intertrochanteric fracture with a dynamic hip screw (DHS). The patient presented with a DHS that had migrated into the pelvis approximately six months after surgery. Plain radiographs showed migration of the DHS through the acetabulum and into the pelvis. Migration of DHS into the pelvis is an extremely rare complication and has only been reported a few times. A 71-year-old man presented with a fall and confusion. The patient reported having a fall but could not recall the exact events. Past medical history included Alzheimer's dementia, osteoporosis, left total hip replacement, right DHS, peripheral neuropathy, and recurrent falls. He had undergone reduction and fixation of a right intertrochanteric fracture with DHS implant via direct lateral approach six months before hospital admission. On examination, he had right-sided hip pain and was unable to straighten leg raise. His abdomen was soft and non-tender, with no distension or palpable masses. Neurovascular status was normal, and no signs of infection were detected. On the anteroposterior radiograph, the implant seemed to have migrated through the acetabulum and into the abdomen. A CT of the abdomen and pelvis was performed to identify any visceral injuries (negative) and for surgical planning. The patient underwent a midline laparotomy to remove the implant. Although the exact reason for the implant failure is unknown, the migration of an unbroken hip screw into the abdomen and pelvis requiring laparotomy has not been reported in literature.

Rectus sheath patch. A novel surgical technique in the repair of isolated renal pelvis necrosis in a transplanted kidney. A case report.

INTRODUCTION: Focal necrosis of the renal pelvis in a transplanted kidney is a rare but often morbid complication that may lead to graft loss. Given the scarcity of donor organs, all attempts are made to preserve the graft. Currently there is no standard surgical technique for reconstruction or repair of isolated renal pelvic necrosis. PRESENTATION OF CASE: A 70-year-old male with end stage kidney disease underwent renal transplantation. The patient developed a day-three post-operative urine leak. During surgical exploration, a focal area of pelvic necrosis was observed without evidence of proximal or distal ureteric involvement. Given the excellent function of the renal allograft, a novel surgical technique was successfully used to repair the necrotic defect. Reconstruction of the renal pelvis was performed using an avascular rectus sheath patch. The patch was secured over the open pelvis following necrotic tissue debridement. The patient made a successful recovery with complete resolution of urine leak. A 6-week post-operative retrograde pyelogram confirmed no ongoing urine leak. DISCUSSION: To restore anatomy, the pelvic defect was patched with avascular rectus sheath fascia. Advantages of this reconstructive method were technique simplicity and low donor site morbidity. Potential complications included patch failure with ongoing urine leak, ventral wall hernia through the fascial donor site and stenosis of the ureteropelvic junction. CONCLUSION: This case highlights the successful surgical management of a renal pelvis urine leak patched with rectus sheath fascia. This technique could be considered as a graft saving procedure in similar cases where the alternative is transplant nephrectomy.

Pelvic Fixation for Non-Ambulatory Patients with Neuromuscular Scoliosis Treated with Magnetically Controlled Growing Rods-A 4-Year Comparison of Two Different Fixation Methods.

Background/Objectives: This study aims to analyze the efficacy and safety of the two pelvic fixation systems, S-hooks (SH) and lumbar-sacral-alar-iliac (SAI) screws, when used in association with magnetically controlled growing rods (MCGRs) in non-ambulatory children with severe neuromuscular scoliosis (NMS). Methods: Forty-one patients were retrospectively examined and subdivided corresponding to ilium hook fixation or SAI screws. The major curve correction (%) and pelvic obliquity (PO) correction (%) were assessed utilizing scoliosis plain film radiographs over time. Complications and unplanned return to the operating room (UPROR) were recorded. Patient-specific pre- and postoperative values were included in a backward stepwise regression model to assess UPROR. Results: Mean age at index intervention was 9.4 years. Preoperative main curve was 81° and PO was 22°. 21 and 20 patients were categorized into the SH and SAI subgroups, respectively. Initial curve correction was significantly better in the SAI subgroup (63 vs. 42% in the SH, p = 0.045), while PO correction was equally good. Curve and PO correction were maintained throughout the follow-up period of 55 months. UPROR rate was 38% in the SH subgroup, and 5% in the SAI subgroup (p = 0.010). Regression analysis identified postoperative curve correction as predictive value for UPROR (p = 0.006). Conclusions: SAI screw fixation has a low UPROR rate and achieves superior curve correction. S-hooks are a viable option to correct PO and NMS in children with high operative risk to reduce operative time, but revision surgery is not uncommon.

Impact of introducing 3D printing-assisted surgery into clinical practice for traumatic pelvic and acetabular fractures.

Background: Given the novelty of three-dimensional (3D) printing-assisted fracture surgery in orthopaedics, surgeon familiarity is limited and learning curve is high. As such, it is unclear how the introduction of 3D printing into clinical practice for pelvic and acetabular fracture surgery would impact perioperative outcomes. The aim of this study was to determine the impact of introducing 3D printing-assisted surgery on perioperative outcomes for traumatic pelvic and acetabular fractures. Methods: We retrospectively identified consecutive patients who underwent surgical fixation of traumatic pelvic and acetabular fractures from 2018 to 2022 at a single tertiary hospital. The patients included in the study were divided into two groups: (1) 3D printing-assisted surgery and (2) conventional surgery. Baseline demographics and perioperative outcomes of total surgical duration, estimated blood loss, blood transfusion, number fluoroscopy images, fluoroscopy duration and postoperative disposition were recorded and compared between the two groups. Results: In total, 26 patients were included in the present study, with 3D printing-assisted surgery being used in 34.6 % (n = 9) of cases. There were no significant differences in baseline demographics or fracture type between the 3D printing group and conventional group. As compared to patients who underwent conventional surgery, those that underwent 3D printing-assisted surgery had, on average, shorter surgical duration (299.8 ± 88.2 vs 309.1 ± 143.1 min), lesser estimated blood loss (706.3 ± 330.0 vs 800.0 ± 584.2 ml), lower transfusion rates (50.0 % vs 52.9 %), lower number of intraoperative fluoroscopy images (62.8 ± 74.5 vs 71.6 ± 47.9 images) and shorter fluoroscopy duration (235.0 ± 79.2 vs 242.3 ± 83.5 min), although statistical significance was not achieved. None of the patients in the present study developed surgical complications postoperatively. Conclusion: The introduction of 3D printing-assisted surgery in clinical practice for pelvic and acetabular fractures is a safe and viable adjunct in pelvic and acetabular surgery, achieving comparable perioperative outcomes in the initial phase.

Shape variations of pelvis in different classes of dogs using geometric morphometry.

The ossa coxae are the bones that connect the hindlimbs to the axial skeleton. The right and left os coxae join at the median plane to form the pelvis. In this study, variations in pelvis shape and the asymmetric structure of the pelvis were investigated across different classes of dogs. To achieve this, computed tomography images of the pelvis were obtained from 35 dogs, and 3D modelling of the pelvis was created. Subsequently, 45 landmarks were identified on these models. As a result of the Principal Component Analysis, the shape variation was observed in the pelvic canal and crista iliaca. Directional asymmetry between Principal Component 1 and Principal Component 2 accounted for 33.84% of the total variation, while fluctuating asymmetry contributed 23.66%. Canonical variate analysis revealed that canonical variate (CV) 1 explained 56.56% of the total variation between groups, with CV 2 explained 28.98%. Male dogs exhibited greater pelvic variation than females. Procrustes ANOVA indicated that the greatest proportion of shape variation corresponds to the effect of differences among individuals. While directional asymmetry was statistically significant, fluctuating asymmetry was not. Male dogs displayed more pronounced pelvic shape asymmetry, typically towards the right. Gundogs had a narrower pelvic canal and a wide crista iliaca, whereas terriers had a wider pelvic canal and smaller crista iliaca in shape. Geometric morphometry enables statistical analysis and the derivation of average shapes from samples, making it a vital tool in veterinary anatomy. This study provides insights into pelvic geometric morphometry across different classes of dogs.

The impact of siphoning effect on renal pelvis pressure during ureteroscopy using an in vitro kidney and ureter model.

PURPOSE: To experimentally measure renal pelvis pressure (PRP) in an ureteroscopic model when applying a simple hydrodynamic principle, the siphoning effect. METHODS: A 9.5Fr disposable ureteroscope was inserted into a silicone kidney-ureter model with its tip positioned at the renal pelvis. Irrigation was delivered through the ureteroscope at 100 cm above the renal pelvis. A Y-shaped adapter was fitted onto the model's renal pelvis port, accommodating a pressure sensor and a 4 Fr ureteral access catheter (UAC) through each limb. The drainage flowrate through the UAC tip was measured for 60 s each run. The distal tip of the UAC was placed at various heights below or above the center of the renal pelvis to create a siphoning effect. All trials were performed in triplicate for two lengths of 4Fr UACs: 100 cm and 70 cm (modified from 100 cm). RESULTS: PRP was linearly dependent on the height difference from the center of the renal pelvis to the UAC tip for both tested UAC lengths. In our experimental setting, PRP can be reduced by 10 cmH20 simply by lowering the distal tip of a 4 Fr 70 cm UAC positioned alongside the ureteroscope by 19.7 cm. When using a 4 Fr 100 cm UAC, PRP can drop 10 cmH20 by lowering the distal tip of the UAC 23.3 cm below the level of the renal pelvis. CONCLUSION: Implementing the siphoning effect for managing PRP during ureteroscopy could potentially enhance safety and effectiveness.

Adjustments of iodinated contrast media using lean body weight for abdominopelvic computed tomography: A systematic review and meta-analysis.

PURPOSE: This systematic review aimed to compare the effect of contrast media (CM) dose adjustment based on lean body weight (LBW) method versus other calculation protocols for abdominopelvic CT examinations. METHOD: Studies published from 2002 onwards were systematically searched in June 2024 across Medline, Embase, CINAHL, Cochrane CENTRAL, Web of Science, Google Scholar and four other grey literature sources, with no language limit. Randomised controlled trials (RCT) and quasi-RCT of abdominopelvic or abdominal CT examinations in adults with contrast media injection for oncological and acute diseases were included. The comparators were other contrast dose calculation methods such as total body weight (TBW), fixed volume (FV), body surface area (BSA), and blood volume. The main outcomes considered were liver and aortic enhancement. Titles, abstracts and full texts were independently screened by two reviewers. RESULTS: Eight studies were included from a total of 2029 articles identified. Liver parenchyma and aorta contrast enhancement did not significantly differ between LBW and TBW protocols (p = 0.07, p = 0.06, respectively). However, the meta-analysis revealed significantly lower contrast volume injected with LBW protocol when compared to TBW protocol (p = 0.003). No statistical differences were found for contrast enhancement and contrast volume between LBW and the other strategies. CONCLUSION: Calculation of the CM dosage based on LBW allows a reduction in the injected volume for abdominopelvic CT examination, ensuring the same image quality in terms of contrast enhancement.

Prevalence of fracture progression in fragility fractures of the pelvis: Systematic review and meta-analysis.

BACKGROUND: Fragility fractures of the pelvis (FFP) are a growing problem in aging populations. Fracture progression (FP) occasionally occurs during FFP treatment; however, its prevalence remains unclear. This systematic review and meta-analysis aimed to assess the prevalence of FP among patients with FFP. METHODS: We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. All cohort studies that reported the prevalence of FP in patients with FFP were included. FP was defined as the appearance of additional pelvic fractures after the initial FFP. We searched the CENTRAL, MEDLINE, and EMBASE databases until April 2024. The pooled prevalence was generated using a random-effects model and presented as a 95 % confidence interval (CI) and prediction interval (PI). We assessed the risk of bias in each study using the Joanna Briggs Institute's Prevalence Critical Appraisal Tool. RESULTS: This review included eight studies (925 patients). The pooled prevalence of FP in patients with FFP was 11 % (95 % CI, 5-19 %; 95 % PI, 0-44 %). Subgroup analysis showed that the pooled prevalence of FP in patients with FFP (conservative treatment vs. surgery for initial FFP) was 16 % (95 % CI, 9-24 %) and 2 % (95 % CI, 0-11 %), respectively (test for subgroup difference, P = 0.03). Additional analysis showed that in patients with FP, the pooled prevalence of the fractured site (ipsilateral site, contralateral site, and both sites) was 66 %, 12 %, and 19 %, respectively. The pooled prevalence of fractured bone (pubis, ischium, ilium, and sacrum) was 25 %, 0 %, 15 %, and 68 %, respectively. The risk of bias in the patient sampling method and sufficient data analysis in all included studies was high. CONCLUSION: This review suggests that the prevalence of FP in patients with FFP is relatively high. Clinicians should recognize FP as a possible diagnosis in patients experiencing additional pain after FFP. However, further prospective studies with adequate patient sampling are required to confirm the true prevalence.

Technical note: Prediction of body mass from stature and pelvic breadth.

Equations for predicting body mass from stature and bi-iliac (maximum pelvic) breadth have been developed, but have had variable success when applied to living or recently deceased individuals, calling into question their general applicability. Here we test these equations on a large, ethnically diverse sample. Skeletal and anthropometric data for 507 recently deceased Indigenous, Hispanic, and non-Hispanic White adults were obtained from the New Mexico Decedent Image Database. The body mass of individuals with a "normal" body mass index (BMI = 18.5-24.9) is very accurately predicted, with an average directional bias of about 1% and an average random error of less than 8%. Underweight individuals (BMI < 18.5) are overpredicted, while overweight (BMI = 25-29.9) and especially obese (BMI≥30) individuals are underpredicted. Within BMI categories, there is a strong and isometric relationship between predicted and true body mass. Individual body mass prediction errors using the stature/bi-iliac method are mainly dependent on variation in BMI. Because earlier humans were more likely to fall within or close to the normal BMI range, the equations should be applicable, on an individual basis, in archeological and paleontological contexts. Because of the prevalence of obesity in many modern populations, these equations are not applicable in a general forensic context. We derive new equations from nonobese individuals in our sample (n = 338), which produce reasonable average prediction errors. If obese individuals can be identified using other skeletal parameters, these equations may be useful in estimating body mass in nonobese forensic cases.

Evaluation of the performance of digital x-ray systems in pelvis radiography.

The aim of this study was to investigate the performance of eight digital radiography systems and to optimise the dose-image quality relationship for digital pelvis radiography. The study involved eight digital radiography systems used for general examinations at Vilnius University Hospital Santaros Klinikos. An anthropomorphic pelvic phantom (CIRS, US) was used to simulate a patient undergoing clinical pelvis radiography. Dose quantities entrance surface dose, dose area product (DAP) and exposure parameters (kVp, mA, mAs) were measured and the effects on the images were evaluated, considering physical contrast to noise ratio (CNR) and observer-based evaluations as image quality metrics. Increasing the tube voltage by 5 kVp from standard protocol led to a reduction in radiation dose (DAP) by 12%-20% with a slight impact on image quality (CNR decreases by 2%-10%). There was an inter-observer variability in image rating across different equipment (kappa value between 0 and 0.3); however, both observers agreed that increasing kVp up to 85-90 kV had no effect on perceived image quality. The results indicate that optimisation strategies should be tailored specifically for each x-ray system since significant performance differences and wide variations in radiation dose exist across various digital radiography systems used in clinical settings. The use of high kVp can be used for dose optimisation in digital pelvis radiography without compromising image diagnostic accuracy.

Epidemiology and patient-reported measurement outcome of pelvic fractures in children and adolescents - A population-based cohort study from the Swedish fracture register.

BACKGROUND AND PURPOSE: Pediatric pelvic fractures are uncommon, representing 0.2-3% of total pediatric fractures. The long-term patient-reported outcome in the pediatric population has not been evaluated yet. The purpose of the study was to describe the epidemiology of pelvic and acetabular fractures in pediatric patients including long-term patient-reported outcomes. PATIENTS AND METHODS: The Swedish Fracture Register (SFR) was used to identify all patients aged 6-17 years at injury with a pelvic fracture between 2015 and 2021. All patients were invited to answer Patient-Reported measurement instruments in 2021. RESULTS: The study cohort consisted of 223 patients with a median age at fracture of 15 years and with 62 % boys. 201 sustained a pelvic and 22 acetabular fractures. Falls were the leading cause of fracture, followed by transport accidents. Most fractures (both pelvis and acetabulum) were type A (73 %), and 21 fractures (9 %) could not be classified according to AO. 85 % of fractures were treated non-surgically. All Type C fractures were treated surgically. Seven PROMIS® profile domains were completed by 31 % of the sample at a mean follow-up time of 3.5 years after pelvic/acetabular fracture. Most patients had "no concern" or "mild concern" but those who had surgery had an inferior t-score in most domains. CONCLUSION: Most fractures occurred in older individuals, with falls during sports activities being the most common cause. This raises important questions about prevention strategies. The PROMIS-Pain-Interference scale indicated that the younger the age at fracture, the more pain was reported at follow-up.

Acute Coronary Syndrome and Acute Abdomen Suspected for Type B Aortic Dissection in an Elderly Woman.

Being an uncommon and challenging disorder, acute aortic dissection (AAD) can have fatal outcomes in the event of missed diagnosis or treatment delay. AAD could easily be misdiagnosed, as symptoms usually mimic other common clinical syndromes showing up in Accident and Emergency (A&E), including acute coronary syndrome (ACS), pericarditis, pulmonary embolism, acute abdomen, musculoskeletal pain, as well as presenting as heart failure, stroke, syncope, and absent peripheral pulses. We present a case of a 77-year-old female who presented to the medical decision unit with acute-onset chest, back, and abdominal pain that occurred on standing for six hours She was thought initially to have acute coronary syndrome based on electrocardiography (ECG) changes, troponin, a normal chest X-ray, and no blood pressure discrepancies in upper extremities. Due to worsening abdominal pain and a previous history of a perforated diverticulum, contrast computed tomography (CT) of the abdomen was arranged and this showed acute type B aortic dissection. By the time the CT was performed, the patient had been in hospital for 16 hours, almost 22 hours from the onset of pain.

Pre- and Post-Operative Pain Intensity and Physical Activity Levels in Individuals with Acetabular Dysplasia Undergoing Periacetabular Osteotomy: A Prospective Cohort Study.

Background: Acetabular dysplasia (AD) causes pain, limited function, and development of early hip osteoarthritis. Periacetabular osteotomy (PAO) is a surgical treatment for AD that aims to reposition the acetabulum to reduce pain and improve function. Purpose: To examine pain recovery and physical activity (PA) before and during the six months after PAO. Study Design: Case series, prospective. Methods: Individuals with AD scheduled for PAO were enrolled. Pain intensity was evaluated before PAO and at one week and one, three, and six months following PAO. PA levels was evaluated before and six months following PAO using accelerometers (time spent in sedentary behavior, light PA, moderate-to-vigorous PA [MVPA], and daily steps) and the International Physical Activity Questionnaire (IPAQ; time spent in walking and in MVPA). Pain improvements was examined over time following PAO using a repeated-measures one-way ANOVA as well as improvements in PA levels before and six months after PAO using paired-sample t tests. In addition, time spent in MVPA was qualitatively summarized at each time point (before and six months after PAO) measured by both the accelerometers and IPAQ. Results: Out of 49 screened participants, 28 were enrolled, and 23 individuals (22 females; age=23.1±7.9 years) completed both study visits. Compared to pre-PAO pain, participants reported significant improvements in pain at one month and onward following PAO (p\<0.011). However, PA levels at six months following PAO did not differ from pre-PAO PA levels (p>0.05). Qualitatively, participants reported spending more time in MVPA recorded by the IPAQ (pre-PAO=73.3±150.2 mins/day; six-months after PAO=121.2±192.2 mins/day), compared with MVPA recorded by accelerometers (pre-PAO=22.6±25.2 mins/day; six-months after PAO=25.0±21.4 mins/day). Conclusions: Individuals with AD reported significant pain reduction at one month and up to six months after PAO, but PA levels did not change six months after PAO compared to baseline testing. Future studies should consider examining longitudinal pain recovery and PA improvements over longer periods of time with larger samples of individuals with AD undergoing PAO and identifying modifiable factors to minimize pain and increase PA participation. Level of Evidence: III.

Eureka: objective assessment of the empty pelvis syndrome to measure volumetric changes in pelvic dead space following pelvic exenteration.

BACKGROUND: Large tissue defects following pelvic exenteration (PE) fill with fluid and small bowel, leading to the empty pelvis syndrome (EPS). EPS causes a constellation of complications including pelvic sepsis and reduced quality of life. EPS remains poorly defined and cannot be objectively measured. Pathophysiology of EPS is multifactorial, with increased pelvic dead space potentially important. This study aims to describe methodology to objectively measure volumetric changes relating to EPS. METHODS: The true pelvis is defined by the pelvic inlet and outlet. Within the true pelvis there is physiological pelvic dead space (PDS) between the peritoneal reflection and the inlet. This dead space is increased following PE and is defined as the exenteration pelvic dead space (EPD). EPD may be reduced with pelvic filling and the volume of filling is defined as the pelvic filling volume (PFV). PDS, EPD, and PFV were measured intraoperatively using a bladder syringe, and Archimedes' water displacement principle. RESULTS: A patient undergoing total infralevator PE had a PDS of 50 ml. A rectus flap rendered the pelvic outlet watertight. EPD was then measured as 540 ml. Therefore there was a 10.8-fold increase in true pelvis dead space. An omentoplasty was placed into the EPD, displacing 130 ml; therefore, PFV as a percentage of EPD was 24.1%. CONCLUSIONS: This is the first reported quantitative assessment of pathophysiological volumetric changes of pelvic dead space; these measurements may correlate to severity of EPS. PDS, EPD, and PFV should be amendable to assessment based on perioperative cross-sectional imaging, allowing for potential prediction of EPS-related outcomes.

Elastography of the Male Pelvic Region-Perspectives on Malignant Lesions.

Ultrasound elastography is widely used to assess tissue stiffness for lesion characterization, including differentiation between benign and malignant lesions. This study focuses on the use of elastography in the male pelvis, including the prostate, testicles, and rectum, by comparing elastography types (shear wave and strain). This article provides a summary of the existing literature on the use of elastography in the male pelvic region and outlines the clinical perspective. Ultrasound elastography is a good technique for evaluating and monitoring lesions in the male pelvic region.

Whole pelvis vs. hemi pelvis elective nodal radiotherapy in patients with PSMA-positive nodal recurrence after radical prostatectomy - a retrospective multi-institutional propensity score analysis.

PURPOSE: Despite growing evidence for bilateral pelvic radiotherapy (whole pelvis RT, WPRT) there is almost no data on unilateral RT (hemi pelvis RT, HPRT) in patients with nodal recurrent prostate cancer after prostatectomy. Nevertheless, in clinical practice HPRT is sometimes used with the intention to reduce side effects compared to WPRT. Prostate-specific membrane antigen positron emission tomography / computed tomography (PSMA-PET/CT) is currently the best imaging modality in this clinical situation. This analysis compares PSMA-PET/CT based WPRT and HPRT. METHODS: A propensity score matching was performed in a multi-institutional retrospective dataset of 273 patients treated with pelvic RT due to nodal recurrence (214 WPRT, 59 HPRT). In total, 102 patients (51 in each group) were included in the final analysis. Biochemical recurrence-free survival (BRFS) defined as prostate specific antigen (PSA) < post-RT nadir + 0.2ng/ml, metastasis-free survival (MFS) and nodal recurrence-free survival (NRFS) were calculated using the Kaplan-Meier method and compared using the log rank test. RESULTS: Median follow-up was 29 months. After propensity matching, both groups were mostly well balanced. However, in the WPRT group there were still significantly more patients with additional local recurrences and biochemical persistence after prostatectomy. There were no significant differences between both groups in BRFS (p = .97), MFS (p = .43) and NRFS (p = .43). After two years, BRFS, MFS and NRFS were 61%, 86% and 88% in the WPRT group and 57%, 90% and 82% in the HPRT group, respectively. Application of a boost to lymph node metastases, a higher RT dose to the lymphatic pathways (> 50 Gy EQD2α/ß=1.5 Gy) and concomitant androgen deprivation therapy (ADT) were significantly associated with longer BRFS in uni- and multivariate analysis. CONCLUSIONS: Overall, this analysis presents the outcome of HPRT in nodal recurrent prostate cancer patients and shows that it can result in a similar oncologic outcome compared to WPRT. Nevertheless, patients in the WPRT may have been at a higher risk for progression due to some persistent imbalances between the groups. Therefore, further research should prospectively evaluate which subgroups of patients are suitable for HPRT and if HPRT leads to a clinically significant reduction in toxicity.