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The minor aries to us an interesting case--woman, 30 years with two deliveries-at gynaecological examination in the polyclinic it is found a formation in the region of the left ovary. The laparotomy in this connection finds ectopic situated left kidney in the minor pelvis. The author calls attention to the differential diagnostic difficulties, which poses this casus to the practising gynaecologists and that it always must be thinking about this also on a large aspect.
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It is known that presently the diagnostic process is enriched by the application of endoscopic methods like laparoscopy and hysteroscopy. The aim of our work is to point out the importance of laparoscopy in differential diagnostical processes. 358 laparoscopies were carried out for the period 1988-92. After laparoscopy the authors correct clinical diagnoses of the different patients' groups. The results of our experience in application of laparoscopy to cases of pathologic changes in the pelvis enable us to recommend this additional method, having in mind ist considerable value for the differential diagnosis in the gynaecological practice.
The paper presents the technique and results of electromyography of the penis (EMP) for 68 males divided into 3 groups: 21 volunteers with erectile disorders, 20 patients with nonvasculogenic erectile dysfunction and no history of pelvic operations, 27 patients with erectile abnormalities as a result of pelvic operations (after cystectomy -11, cystoprostatectomy -1, rectal resection -7, rectal extirpation -8 patients, groups 1, 2, 3 and 4, respectively). Autonomic innervation of the penis is primarily characterized by such EMP parameters as amplitude, synchronism and frequency of potentials. Neurogenic penile disorder was identified in 3 patients of group 2 (1 patient with intervertebral disk hernia, 2 patients with lumbosacral osteochondrosis), in all patients of group 3 (electric silence was recorded in 22 patients). EMP should be included in the algorithm of examination of patients with erectile dysfunction as providing a reliable assessment of autonomic penile innervation.
The lesser pelvis parameters measured by ultrasonic pelvimetry are characterized by different prognostic value for the functional assessment of various anatomic forms of contracted pelvis. Direct dimensions of the lesser pelvis, a difference of direct size of the orifice and fetal head biparietal size, and the pelviocranial index are prognostically the most valuable for patients with generally contracted pelvis. The same parameters are valuable for cases with Deventer's pelvis, and the sacrum flattening index value is also significant here. This latter characteristic is the only one prognostically valuable for cases with mesatipellic pelvis, permitting the prediction of possible labor complications.
AIMS: A retrospective audit was carried out to determine the rate of local recurrence (recurrent tumour within the lesser pelvis or the perineal wound) in 88 rectal cancer patients treated with 20 Gy/four fractions of adjuvant preoperative radiotherapy and curative surgery. MATERIALS AND METHODS: All patients were followed-up by clinical examination with rigid sigmoidoscopy at 6 monthly intervals if the rectum was intact, and computed tomography of the pelvis at 1, 2 and 5 years after surgery. In total, 171 patients with rectal cancer were identified under the care of one surgeon over a period of 11 years from May 1992 to April 2003. We excluded patients with rectal cancer from preoperative adjuvant radiotherapy if they had evidence at presentation of distant metastases, if they had fixed rectal tumours, were treated by local excision and had previous radiotherapy to the pelvis. On this basis, only 88 were considered for preoperative radiotherapy and curative resection with a median follow-up of 5.16 years. RESULTS: The 5-year survival by stage was Dukes A 96%, Dukes B 65% and Dukes C 36%. Overall, four patients (of 88) developed a recurrence within the lesser pelvis or the perineal wound, giving a local recurrence of 4.2% at 3 years (from a Kaplan-Meier graph). CONCLUSIONS: This single-centre audit suggests that a lower dose of radiotherapy to a smaller volume provides an acceptable local recurrence rate that compares very favourably with the well-publicised Swedish and Dutch trials of 25 Gy/five fractions. It was not the intention of this audit to suggest that this dose should be widely adopted. However, given the long-term gastrointestinal morbidity and risk of second malignancies, we advise caution when formulating even more intensive radiotherapy and chemoradiotherapy regimens for rectal cancer.
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The importance of the long pelvis with lumbo-sacral assimilation in obstetrics is evaluated. 111 x-rays of the pelvis in cases with abnormal deliveries were evaluated and compared to the clinical data. The incidence of the long pelvis was not increased in the total group, nor in the 100 cases with abnormal deliveries. A long pelvis was present in 30.2% of the 43 breech presentations. In 4 cases with a funnel pelvis vaginal delivery occurred without difficulty. In 42 posterior vertex presentation the long pelvis appears to have a pathogenetic importance regarding the primary posterior position. The further course of the delivery was not influenced by the long pelvis. In 7 cases of low transverse arrest, 4 had a long pelvis but only 1 had a funnel pelvis to explain this abnormal position. In summary, the long pelvis even in its most severe form, the funnel pelvis, does not block the adaptation processes in the lesser pelvis. The changes in the pelvic inlet due to the lumbo-sacral assimilation have an etiologic importance on the initial presentation at the inlet such as breech presentation, military vertex presentation, brow presentation, or Roederers anomaly. However, no prognostic value for the mechanism of the delivery can be derived from the initial presentation. The delivery dose not depend on the long pelvis but on the malpresentation when delivery becomes necessary.
Restorative proctocolectomy with an ileal pouch-anal anastomosis preserves anal sphincters, the normal route of defaecation and the normal body image and it has been suggested that the procedure might be associated with less gynaecological and sexual problems than conventional proctocolectomy. To shed further light on this subject 60 female patients were invited to participate in a study comprising a detailed interview, examination by a gynaecologist and investigation with hysterosalpingography and vaginography. Twenty-one women with a mean follow-up of 38 months after surgery agreed to participate. Their gynaecological state was considered normal although one woman complained of vaginal discharge. Five women experienced occasional dyspareunia and 2 patients had to take special precautions to avoid bowel leaks at intercourse. While the position of the vagina and uterus in the pelvis appeared normal, hysterosalpingography disclosed bilateral occlusion of the fallopian tubes in 2 and unilateral occlusion in another 9 patients with tubes adhering to the bottom of the lesser pelvis in 10 of the patients. Only one out of 14 patients succeeded in trying to conceive during the follow-up period. Among the remaining 39 women not specially studied 5 out of 14 had conceived after the operation.
There are no detailed descriptions of the neural structures that may be seen during surgical interventions of the pelvis. Anatomic dissections were performed to see which nerves are endangered in approaches to the anterior sacroiliac joint for plate fixations. Sixty cadavers were dissected bilaterally. Fifty-one were male and nine were female. L4 and L5 nerve roots were followed along the sacroiliac joint from the intervertebral foramen to the entrance into the lesser pelvis. Measurements were made between the nerves and sacroiliac joint from the proximal end of the joint to the pelvic brim. The L4 nerve root and the lumbosacral trunk (and not the L5 nerve root) were the nerves most susceptible to injury because of their course and proximity to the sacroiliac joint. As a result, during the anterior approach and fixation of the sacroiliac joint with plates, extreme care should be taken to identify the L4 nerve root or lumbosacral trunk or both at the anteroinferior third of the joint because the distance between the nerve and the joint is less than 1 cm.
OBJECTIVES: To demonstrate the therapeutic potential of the laterally extended endopelvic resection (LEER) especially for patients with recurrent cervical carcinomas involving the side wall of an irradiated pelvis. These patients, suffering from the most common situation of local failure, have so far no longer been considered for curative therapy. METHODS: Extending the lateral resection plane of pelvic exenteration to the medial aspects of the lumbosacral plexus, sacrospinous ligament, acetabulum, and obturator membrane enables the complete removal of a subset of locally advanced and recurrent tumors of the lower female genital tract fixed to the pelvic wall with free margins (R0). Patients selected for LEER were accrued to a prospective outcome trial. RESULTS: Thirty-six patients with recurrent (n = 29) or primary advanced (n = 7) gynecologic malignancies involving the side wall of the lesser pelvis underwent LEER from July 1996 until October 2002. The majority of the patients suffered from cervical carcinoma (n = 29) and had received previous pelvic irradiation (n = 24). Tumor-free (R0) lateral margins were obtained in 34 patients. Severe postoperative complications occurred in 14 patients with one treatment-related death. Five-year survival probability is 49% for the whole group and 46% for those patients considered only for palliation with current treatment options. Most patients without evidence of disease at least 1 year after LEER achieved good quality of life. CONCLUSIONS: LEER can be offered as novel surgical salvage therapy to a selected subset of patients with locally advanced and recurrent cervical carcinoma involving the pelvic wall.
The main problem with clinical introduction of laparoscopic techniques in urology is that despite experience with endoscopy no significant endoscopic training is given. Laparoscopic nephrectomy, in particular, is a rather complicated procedure and needs an adequate training concept: The beginner should have the possibility of practising in vitro in a closed "pelvi-trainer" to learn video-optical coordination and orientation; then it is necessary to get used to handling the instruments and practise the different steps of the procedure (i.e. clipping of vessels, sacking of the kidney) either in phantom models or in explanted animal organs. On this basis, we performed laparoscopic nephrectomy in an animal model (n = 18 porcine kidneys). We were able to standardize the technique of creating a pneumoperitoneum, the positioning of the animal, the site and size of the trocars, and preparation and clipping techniques (i.e. Endo-GIA) and entrapment of the kidney (testing different organ bags). A step-by-step approach was used for the introduction to clinical application. For simulation and training of video-assisted preparation techniques in patients and step-wise introduction to laparoscopy (instruments, endocoagulation, trocars), we created a "lap-tent", which was placed over the wound after exposition of Gerota's fascia. Further preparation was performed under laparoscopic conditions (without pneumoperitoneum) with a limited time allowed (1 h). Thereafter, we started with time-limited laparoscopy and laparoscopic lymphadenectomy prior to pelvic surgery (prostatectomy, cystectomy) to introduce the staff to the technique of pneumoperitoneum and placement of the trocars and to the use of the instruments in general. Based on this step-by-step training concept, after a 6-months period we were successful in introducing transperitoneal laparoscopic nephrectomy (TLN) to our clinical routine. So far, we have performed 20 laparoscopic nephrectomies, 1 nephro-ureterectomy, 4 tumour nephrectomies (inducing adrenalectomy), 2 adrenalectomies, and 6 modified retroperitoneal lymphadenectomies. In the lesser pelvis we have experience with 20 laparoscopic varicocelectomies, 23 pelvic lymphadenectomies, and 5 diagnostic laparoscopies for cryptorchidism (February 1993).
In the past, tumors of the iliac fossa, those of the area of the external iliac vessels, and those fixed to the wall of the lesser pelvis with extension into and involvement of the pubic bone were often considered unresectable through the conventional surgical incisions or were treated with hemipelvectomy. For such tumors, although there was exposure of the cephalad aspect through routine incisions, there was lack of exposure on the caudal or lateral aspects, which often extended anteriorly to involve the lower abdominal wall or continued behind the inguinal ligament or through the obturator foramen into the thigh. The abdominoinguinal incision provides exposure for resection of the majority of these tumors with preservation of the extremity. It involves a lower midline incision, which is extended from the pubic symphysis transversely to the midinguinal point on the affected side and then vertically for a few centimeters in the femoral triangle. The femoral vessels are exposed, the ipsilateral rectus abdominis and anterior sheath are divided off the pubic crest, the inguinal ligament is divided off the pubic tubercle, the inferior epigastric vessels are ligated and divided near their origin from the vessels, and the lateral third of the inguinal ligament is detached from the iliac fascia. This incision provides full exposure of the lower abdominal aorta, inferior vena cava, and iliac vessels on the side of involvement in their continuity with the femoral vessels. With improved exposure and vascular control, the majority of tumors with lateral pelvic fixation become resectable.