Self-expanding foam versus preperitoneal packing for exsanguinating pelvic hemorrhage

BACKGROUND

Mortality for pelvic fracture patients presenting with hemorrhagic shock ranges from 21% to 57%. The objective of this study was to develop a lethal and clinically relevant pelvic hemorrhage animal model with and without bony fracture for evaluating therapeutic interventions. ResQFoam is a self-expanding foam that has previously been described to significantly decrease mortality in large-animal models of abdominal exsanguination. We hypothesized that administration of ResQFoam into the preperitoneal space could decrease mortality in exsanguinating pelvic hemorrhage.

METHODS

Two pelvic hemorrhage models were developed using noncoagulopathic swine. Pelvic hemorrhage model 1: bilateral, closed-cavity, major vascular retroperitoneal hemorrhage without bony pelvic fracture. After injury, animals received no treatment (control, n = 10), underwent preperitoneal packing using laparotomy pads (n = 11), or received ResQFoam (n = 10) injected into the preperitoneal space. Pelvic hemorrhage model 2: unilateral, closed-cavity, retroperitoneal hemorrhage injury (with intraperitoneal communication) combined with complex pelvic fracture. After injury, animals received resuscitation (control, n = 12), resuscitation with preperitoneal packing (n = 10) or with ResQFoam injection (n = 10) into the preperitoneal space.

RESULTS

For model 1, only ResQFoam provided a significant survival benefit. The median survival times were 50 minutes and 67 minutes for preperitoneal packing and ResQFoam, compared with 6 minutes with controls ( p = 0.002 and 0.057, respectively). Foam treatment facilitated hemodynamic stabilization and resulted in significantly less hemorrhage (21.5 ± 5.3 g/kg) relative to controls (31.6 ± 5.0 g/kg, p < 0.001) and preperitoneal packing (32.7 ± 5.4 g/kg, p < 0.001). For model 2, both ResQFoam and preperitoneal packing resulted in significant survival benefit compared with controls. The median survival times were 119 minutes and 124 minutes for the preperitoneal packing and ResQFoam groups, compared with 4 minutes with controls ( p = 0.004 and 0.013, respectively).

CONCLUSION

Percutaneous injection of ResQFoam into the preperitoneal space improved survival relative to controls, and similar survival benefit was achieved compared with standard preperitoneal pelvic packing. The technology has potential to augment the armamentarium of tools to treat pelvic hemorrhage.

Sex differences in zymosan-induced behavioral visceral hypersensitivity and colorectal afferent sensitization

Sex differences in visceral nociception have been reported in clinical and preclinical studies, but the potential differences in sensory neural encoding of the colorectum between males and females are not well understood. In this study, we systematically assessed sex differences in colorectal neural encoding by conducting high-throughput optical recordings in intact dorsal root ganglia (DRGs) from control and visceral hypersensitive mice. We found an apparent sex difference in zymosan-induced behavioral visceral hypersensitivity: enhanced visceromotor responses to colorectal distension were observed only in male mice, not in female mice. In addition, a higher number of mechanosensitive colorectal afferents were identified per mouse in the zymosan-treated male group than in the saline-treated male group, whereas the mechanosensitive afferents identified per mouse were comparable between the zymosan- and saline-treated female groups. The increased number of identified afferents in zymosan-treated male mice was predominantly from thoracolumbar (TL) innervation, which agrees with the significant increase in the TL afferent proportion in the zymosan group as compared with the control group in male mice. In contrast, female mice showed no difference in the proportion of colorectal neurons between saline- and zymosan-treated groups. Our results revealed a significant sex difference in colorectal afferent innervation and sensitization in the context of behavioral visceral hypersensitivity, which could drive differential clinical symptoms in male and female patients.NEW & NOTEWORTHY We used high-throughput GCaMP6f recordings to study 2,275 mechanosensitive colorectal afferents in mice. Our results revealed significant sex differences in the zymosan-induced behavioral visceral hypersensitivity, which were present in male but not female mice. Male mice also showed sensitization of colorectal afferents in the thoracolumbar pathway, whereas female mice did not. These findings highlight sex differences in sensory neural anatomy and function of the colorectum, with implications for sex-specific therapies for treating visceral pain.

A retrospective observational study assessing mortality after pelvic trauma embolisation

INTRODUCTION

Trauma to the pelvic ring and associated haemorrhage represent a management challenge for the multidisciplinary trauma team. In up to 10% of patients, bleeding can be the result of an arterial injury and mortality is reported as high as 89% in this cohort. We aimed to assess the mortality rate after pelvic trauma embolisation and whether earlier embolisation improved mortality.

METHODS

Retrospective study at single tertiary trauma and referral centre, between 1 January 2009 and 30 June 2022. All adult patients who received embolisation following pelvic trauma were included. Patients were excluded if angiography was performed but no embolisation performed.

RESULTS

During the 13.5-year time period, 175 patients underwent angiography and 28 were excluded, leaving 147 patients in the study. The all-cause mortality rate at 30-days was 11.6% (17 patients). The median time from injury to embolisation was 6.3 h (range 2.8-418.4). On regression analysis, time from injury to embolisation was not associated with mortality (OR 1.01, 95% CI 0.952-1.061). Increasing age (OR 1.20, 95% CI 1.084-1.333) and increasing injury severity score (OR 1.14, 95% CI 1.049-1.247) were positively associated with all-cause 30-day mortality, while non-selective embolisation (OR 0.11, 95% CI 0.013-0.893) was negatively associated.

CONCLUSION

The all-cause mortality rate at 30-days in or cohort was very low. In addition, earlier time from injury to embolisation was not positively associated with all-cause 30-day mortality. Nevertheless, minimising this remains a fundamental principle of the management of bleeding in pelvic trauma.

Pelvic AVM Embolization: A Tricky Affair-Multicenter Retrospective Experience

PURPOSE

Pelvic arteriovenous malformations (pAVMs) are congenital or acquired vascular anomalies, presenting with hematuria, menometrorrhagia, pelvic pain, and varices; they can be life-threatening in case of rupture. Surgical therapies have been proposed but endovascular embolization has been recognized as the primary modality. The aim of this article was to report a retrospective multicenter experience concerning embolization of pelvic AVMs and provide literature overview.

MATERIALS AND METHODS

We describe 18 patients (14 female and 4 male) diagnosed with pAVM and treated with minimally invasive methods. The pre-procedural imaging evaluation was based on transpelvic and/or transvaginal color Doppler ultrasound, contrast-enhanced computed tomography, and/or magnetic resonance. In 3 cases, the malformation was congenital and in other 15, acquired. Most common symptoms were menometrorrhagia, hematuria, pelvic pain and pressure, and heaviness in the lower abdominal region. In 10 cases (56%), only 1 procedure was required. Eight patients underwent multistage treatment.

RESULTS

Complete occlusion of the lesion in post-procedural angiography was observed in 12 patients (67%). No major periprocedural complications were observed. In 14 cases (78%), both satisfactory embolization and significant clinical improvement was achieved in long-term follow-up. Sixteen patients (88%) were at least satisfied with the clinical outcome. One patient reported subsequent successful pregnancy 5 years after the treatment.

CONCLUSION

Hemodynamics of pAVM are variable and thorough understanding of the vessel anatomy is crucial in planning and choosing proper treatment. Both transarterial and percutaneous direct puncture embolization strategies appear safe, technically feasible, and clinically effective.

CLINICAL IMPACT

In this manuscript, we discuss the role of interventional radiology methods in the treatment of pelvic arteriovenous malformations along with its advantages, limitations and possible complications. In addition to this, we review the current literature and confront our findings with those made by other authors. We believe that modern endovascular methods offer safe and reliable alternative for traditional surgical therapy and should be therefore considered during multidisciplinary treatment of these patients.

Cakirgil method in the surgical treatment of older children with developmental dysplasia of the hip: Mid-term follow-up results of 17 hips and literature review

OBJECTIVES

This study aimed to evaluate the results of the Cakırgil method in patients with advanced developmental dysplasia of the hip (DDH).

PATIENTS AND METHODS

Patients who underwent surgical treatment with the Cakırgil method between January 2011 and December 2022 with a diagnosis of DDH were retrospectively scanned. Thirteen patients (7 females, 6 males; 8.0±2.7 years; range, 5 to 12 years) with severe DDH were included in the study. The results of the Cakirgil method, including adductor tenotomy, open reduction, femoral shortening, varus and derotation osteotomy, and Dega acetabuloplasty, were retrospectively evaluated in 17 hips of these 13 patients. Clinical and radiological evaluation was performed according to the acetabular index, center edge angle, Severin score, and McKay criteria.

RESULTS

Five patients had comorbidities. The mean follow-up period was 78.3±28.9 (range, 12 to 135) months. The acetabular index decreased from 35.24° to 22.06° and center edge angle improved from -34.71° to 26.59°. The Severin score decreased from 4.82 to 2.29 and the McKay criteria from 3.47 to 1.88. All changes were statistically significant (p<0.001). Redislocation was observed in only one hip.

CONCLUSION

Surgical treatment of the older patients with neglected DDH is technically difficult, and the results are prone to complications. The technique outlined by Prof. Dr. Güngör Sami Cakırgil, a renowned specialist in DDH surgeries in Türkiye who has made notable contributions to the relevant research, yields satisfactory outcomes when employed under suitable circumstances.

Previous external beam radiation therapy for pelvic malignancy increases complications of total hip arthroplasty

INTRODUCTION

External beam radiation therapy (EBRT) has known effects on bone health. No large database studies have looked at the effects of pelvic EBRT on total hip arthroplasty (THA) outcomes. The purpose of this study was to evaluate 90-day and long-term (>2 years) complication rates following THA in patients with a history of pelvic malignancy and EBRT.

METHODS

Patients were retrospectively identified using a national insurance claims database. Subjects who underwent THA for osteoarthritis or avascular necrosis were included if they had at least 2-year follow-up and were stratified into 3 cohorts: (1) prior pelvic malignancy diagnosis (prostate, cervical, uterine, ovarian, or rectal) and EBRT (Group A); (2) prior malignancy diagnosis but no EBRT (Group B); and (3) neither prior malignancy diagnosis nor EBRT (Group C). Univariate and multivariate analyses were conducted to evaluate for an association between prior EBRT and the incidence of 90-day and 2-year complication rates using chi-square, student t-tests, and logistic regression analyses where appropriate.

RESULTS

671,554 patients met the inclusion criteria. Group A had higher odds of all-cause revision, septic revision, and loosening with revision after 2 years when compared to Group C and Group B (p < 0.001). Group A subjects had higher rates of 90-day deep vein thrombosis, sepsis, and stroke (p < 0.001) than groups B and C.

CONCLUSIONS

Prior EBRT for pelvic malignancy was associated with significantly increased rates of all-cause revision, septic revision, and loosening as well as 90-day medical complications.

The Dosimetric Analysis of Duodenal and Intestinal Toxicity After a Curative Dose Re-irradiation Using the Intensity-Modulated Radiotherapy for Abdominopelvic Lymph Node Lesions

INTRODUCTION

This study aimed to examine the influence of dosimetric factors on gastrointestinal toxicity after radical re-irradiation for lymph node recurrence in the abdominopelvic region using a composite plan.

METHODS

Between January 2008 and March 2017, 33 patients underwent radical re-irradiation for lymph node recurrence in the abdominopelvic region with a complete overlap with previous radiation therapy (RT) with the median prescription dose of the second RT of 71.7 Gy10. Re-irradiation planning protocol for target volume and organs at risk (OARs) (duodenum, small and large intestines) was decided as follows: more than equal to 97% of the prescription dose was administered to the D95 (percentage of the minimum dose that covered 95% of the target volume) of planning target volume (PTV); minimal dose to the maximally irradiated doses delivered to 1cc [D1 cc] and 5cc [D5 cc] of OARs was set below 70 Gy3 and 50 Gy3, respectively; and D1 cc and D5 cc in the cumulative plans to OARs were 120 Gy3 and 100 Gy3. Kaplan-Meier analyses were performed to evaluate overall survival (OS) and univariate log-rank and multivariate Cox proportional hazards model analyses were performed to explore predictive factors. Using dose summation of the first and re-irradiation plans, we conducted a dosimetric analysis for grade ≥ 3 toxicities of the duodenum and intestine.

RESULTS

With a median follow-up of 18 months, the two-year OS rate was 45.5%. The number of RT fields (localized or multiple) was a significant predisposing factor for OS rate with a hazard ratio of 0.23 (95% confidence interval 0.07-0.73). The two-year OS of the patients with a localized RT field was 63.6% and 9.1% for multiple RT fields (p= 0.00007). Four patients experienced grade ≥3 gastrointestinal toxicity related to re-irradiation (4/33=12.1%). We could not find any predisposing dosimetric value in the comparisons with and without toxicity.

CONCLUSIONS

The dose constraints presented in this study are relatively low rates of toxicity, which may be useful when planning re-irradiation. Especially, for the patients who could be treated with localized RT field, radical re-irradiation with a high curative dose is a good option. No dosimetric predisposing factor was found for radical re-irradiation of abdominopelvic lesions in the composite plan.

Physiotherapy Management Focusing on Early Mobilisation in Complex Pelvic and Pott's Fracture

Pelvic fractures (PFs), involving the disruption of the bony structures in the pelvic region, are complex injuries often associated with high-energy trauma. Such fractures can significantly impact a patient's mobility and overall quality of life. Concurrently, fractures of the malleoli, specifically the lateral and medial aspects of the ankle, are common lower extremity injuries that can result from various mechanisms, including twisting or direct trauma. This case report presents the multidisciplinary approach employed in the successful treatment of a 26-year-old male patient with a rare combination of PFs involving both anterior and posterior columns, along with lateral and medial malleolus fractures. The patient underwent a series of surgical interventions to stabilise the fractures, followed by a tailored physiotherapy management plan. The report discusses the postoperative care strategies and the crucial role of physiotherapy in the rehabilitation process.

Predicting the Risk of Total Hip Replacement by Using A Deep Learning Algorithm on Plain Pelvic Radiographs: Diagnostic Study

BACKGROUND

Total hip replacement (THR) is considered the gold standard of treatment for refractory degenerative hip disorders. Identifying patients who should receive THR in the short term is important. Some conservative treatments, such as intra-articular injection administered a few months before THR, may result in higher odds of arthroplasty infection. Delayed THR after functional deterioration may result in poorer outcomes and longer waiting times for those who have been flagged as needing THR. Deep learning (DL) in medical imaging applications has recently obtained significant breakthroughs. However, the use of DL in practical wayfinding, such as short-term THR prediction, is still lacking.

OBJECTIVE

In this study, we will propose a DL-based assistant system for patients with pelvic radiographs to identify the need for THR within 3 months.

METHODS

We developed a convolutional neural network-based DL algorithm to analyze pelvic radiographs, predict the hip region of interest (ROI), and determine whether or not THR is required. The data set was collected from August 2008 to December 2017. The images included 3013 surgical hip ROIs that had undergone THR and 1630 nonsurgical hip ROIs. The images were split, using split-sample validation, into training (n=3903, 80%), validation (n=476, 10%), and testing (n=475, 10%) sets to evaluate the algorithm performance.

RESULTS

The algorithm, called SurgHipNet, yielded an area under the receiver operating characteristic curve of 0.994 (95% CI 0.990-0.998). The accuracy, sensitivity, specificity, and F1-score of the model were 0.977, 0.920, 0932, and 0.944, respectively.

CONCLUSIONS

The proposed approach has demonstrated that SurgHipNet shows the ability and potential to provide efficient support in clinical decision-making; it can assist physicians in promptly determining the optimal timing for THR.

Improved Outcomes with Concurrent Instrumentation and Fusion of the Sacroiliac Joint in Patients with Long Lumbosacral Constructs

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Spinal fusion, specifically constructs connected to pelvic bones, has been consistently reported as a predisposing factor to sacroiliac joint (SIJ) pain. The aim of this study is to compare SIJ outcomes in patients with constructs to the pelvis following instrumentation vs instrumentation plus fusion of the SIJ.

METHODS

Data of study subjects was extracted from a prospectively maintained database as well as retrospectively collected from records at a tertiary academic medical center in the United States between 2018 and 2020.

RESULTS

A cohort of 103 patients was divided into 2 groups: 65 in Group 1 [S2AI screw without fusion device] and 38 in Group 2 [S2AI screw with fusion device]. None of the patients in Group 2 developed postoperative SIJ pain compared to 44.6% in Group 1. Sacroiliac joint fusion occurred in all Group 2 but none of Group 1 patients. The postoperative Visual Analogue Scale (VAS) for lower extremity (LE) pain (.8 vs .5; P = .03) and postoperative Oswestry Disability Index (ODI) (18.7 vs 14.2; P < .01) were significantly higher in Group 1. The rate of distal junctional break, failure, and/or kyphosis (DJBFK) and time to DJBFK were not significantly different between the two groups, and the rate of DJBFK did not change in the presence of multiple covariates.

CONCLUSION

The SIJs carry the heavy load of long lumbosacral fusion constructs extending to the pelvis. Simultaneous SIJ instrumentation and fusion decreases the risk of disability, prevents the development of postoperative SIJ pain, and may also protect the S2AI screw from loosening and failure.

Perianal Endometriosis: An Uncommon Site for a Common Problem

Endometriosis is the presence of uterine glands and stroma outside of the uterus. It is highly prevalent in women of reproductive age. It is usually found in the pelvis, with most cases being found on the peritoneum, ovaries, or deep in the pelvis. Extraperitoneal endometriosis is uncommon. Perianal endometriosis has an incidence of only 0.2%. We present the case of a 37-year-old woman with recurrent pain and swelling in the perineum at the site of a previous episiotomy scar. Initial imaging and assessment determined this to be scar tissue. Following re-presentation, it was mistakenly diagnosed as a perianal abscess, and the patient underwent incision and drainage. The wound failed to heal with significant induration. Further assessment of the wound was undertaken under general anesthesia. An excision of the affected area was performed, with histological analysis confirming endometriosis. This case highlights that extra-peritoneal endometriosis is a rare but treatable cause of recurrent, cyclical pelvic pain and swelling in the perineum. A high index of clinical suspicion is required due to its ability to mimic other pathologies, including abscesses and cysts. The primary management of perianal endometriosis is surgical excision. Where complete excision is not possible, medical management with hormone therapy should be considered.

Performance Evaluation for Clinical Stroke Rehabilitation via an Automatic Mobile Gait Trainer

This paper investigates the clinical efficacy of an automatic mobile trainer for gait training in stroke patients. Neuro-Developmental Treatment (NDT) is a rehabilitation method for stroke patients that enhances motor learning through repeated practice. Despite the proven effectiveness of therapist-assisted NDT, it is labor-intensive and demands health resources. Therefore, we developed automatic trainers based on NDT principles to perform gait training. This paper modifies the mobile trainer's intervention patterns to improve the subject's longitudinal gait symmetry, lateral pelvic displacement symmetry, and pelvic rotation. We first invited ten healthy subjects to test the modified trainer and then recruited 26 stroke patients to undergo the same gait training. Longitudinal symmetry, lateral symmetry, and pelvic rotation were assessed before, during, and after the intervention. Most subjects show improvements in longitudinal symmetry, lateral symmetry, and pelvic rotation after using the trainer. These results confirm the trainer's effectiveness of the modified intervention schemes in helping clinical gait rehabilitation for stroke patients.

Dietary Intervention Improves Gastrointestinal Symptoms after Treatment of Cancer in the Pelvic Organs

Gastrointestinal (GI) symptoms are common in patients receiving radiotherapy, chemotherapy, and/or surgery for cancer in the pelvic organs. The aim of the present prospective cohort study was to report the efficacy of dietary intervention in patients with chronic GI sequelae to treatment of cancer in pelvic organs and insufficient symptomatic effect of medical treatment. Eighty-eight patients were offered specialist dietitian guidance. Gastrointestinal symptoms and quality of life were assessed before and after intervention by validated questionnaires. The main dietary interventions were low-fat diet (n = 44; 50%), modification of dietary fiber content (n = 19; 33%), dietary restrictions with a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet (n = 18; 20%), gluten-free diet (n = 1; 1%), and other dietary advice (n = 6; 7%). Compared to baseline, dietary intervention improved quality of life (EQ5D scale) (p < 0.01), bowel function for the last four weeks (p < 0.02), stool frequency (p < 0.03), constipation (p < 0.05), incomplete rectal emptying at defecation (p < 0.02), and performing usual activities (p < 0.0). In conclusion, this observational study using tailored dietary intervention showed that symptoms can be reduced and quality of life can be improved in patients with chronic GI sequelae following treatment of cancer in the pelvic organs not responding sufficiently to medical treatment.

Application of a three-dimensional printed pelvic model in laparoscopic radical resection of rectal cancer

Introduction

To investigate the application value of a three-dimensional (3D) printed pelvic model in laparoscopic radical resection of rectal cancer.

Methods

Clinical data of patients undergoing laparoscopic radical rectal cancer surgery in The Second People's Hospital of Lianyungang City from May 2020 to April 2022 were selected. Patients were randomly divided into general imaging examination group (control group, n=25) and 3D printing group (observation group, n=25) by random number table method, and the perioperative situation of patients in the two groups was compared.

Results

There was no significant difference in general data between the two groups (p>0.05). Operation time, intraoperative blood loss, intraoperative time to locate inferior mesenteric artery, intraoperative time to locate left colic artery, first postoperative exhaust time and length of hospital stay in the observation group were all lower than those in the control group (P < 0.05); There were no significant differences in the total number of lymph nodes and complications between the two groups (P > 0.05).

Discussion

The application of 3D printed pelvic model in laparoscopic radical resection of rectal cancer is conducive to understanding pelvic structure and mesenteric vascular anatomy, reducing intraoperative bleeding and shortening operation time, which is worthy of further clinical application.

Light and energy-based therapeutics for genitourinary applications: Consensus on protocols and best practices

BACKGROUND

Lasers and energy-based technologies have been developed for genitourinary applications over the past several decades.

AIMS

This consensus article aims to categorize the published articles and clinical trial data that culminated in protocol development of technology for genitourinary applications, and to develop consistent parameters in future clinical trials.

MATERIALS AND METHODS

The published articles and clinical trials data on lasers and energy-based devices applied to genitourinary conditions were categorized according to device and condition and consensus developed on protocols and parameters.

RESULTS

The devices in genitourinary applications were classified as fractional lasers, radiofrequency and high-intensity focused electromagnetic field therapy. The consensus of the protocols and parameters based upon the published clinical trials of their application to the vaginal and urologic conditions associated with genitourinary syndrome of menopause was developed and organized according to device and condition.

DISCUSSION

The status of FDA clearances and future pathways are discussed.

CONCLUSIONS

This consensus article categorizes and presents the protocols and practices for the main classes of lasers and energy-based devices for genitourinary applications in future clinical trials.

Effects of cycling on the morphology and spinal posture in professional and recreational cyclists: a systematic review

The aim was to know if cycling affects spinal morphology in postures off the bicycle, such as adapting the spinal curvatures on the bicycle depending on the handlebar type and position on the handlebars. A systematic review was conducted following the PRISMA guidelines. The studies selected met the following criteria: a) the study design was cross-sectional or longitudinal (experimental or cohorts); b) the study evaluated the sagittal morphology of the spine on the bicycle; c) the study included healthy and trained participants without injuries or cyclists reporting low back pain. Fifteen studies reported that a greater pelvic tilt was observed that when the handlebar was in a lower position. Sixteen studies found that lumbar kyphosis was greater when the handlebar grip was lower and farther from the saddle. Twelve studies reported that a tendency towards greater thoracic flexion as the time spent pedalling on the bicycle increased. In conclusion, the practice of cycling produces adaptations in the morphology of the spine of the cyclist compared to non-cyclists, such as an increase in pelvic tilt and a greater capacity for lumbar flexion in trunk flexion positions, and a greater thoracic kyphosis in the standing position.

Erratum: A comparison study between CNN-based deformed planning CT and CycleGAN-based synthetic CT methods for improving iCBCT image quality

[This corrects the article DOI: 10.3389/fonc.2022.896795.].

Assessment of the acetabular version in relation to sagittal sacropelvic parameters

The relationship between acetabular orientation and the sacropelvic parameters is of interest to both hip and spine surgeons as it is increasingly clear disease in one area can affect the other, including the outcome of surgical procedures. The aim of this study was to further clarify the relationship between measures of acetabular orientation and sacropelvic parameters. This study utilized a trauma CT database. A total of 100 scans on adult patients without overt hip or spinal disease were included. Measures of acetabular orientation included the acetabular sagittal angle (ASA) which uses the anterior pelvic plane as a reference and sacroacetabular angle which uses the sacral endplate as a reference (SA); spinopelvic parameters include the pelvic incidence (PI), sacral anatomic orientation (SAO) and pelvic thickness (PTH). Mean age 48.2 years (SD 18.0), 62% male. Mean values were: PI 50.5, SAO 50.7, PTH 106.4 mm, ASA-right 62.1, ASA-left 64.0, SA-right 67.2, and SA-left 65.4. There was substantial correlation between PI and SA (r = 0.628-0.630) and also between SAO and SA (-0.657 to -0.692). Liner regression determined SA was best predicted by the model: SA = 81 × SAO + 0.36 × PI. When using the anterior pelvic plane as a reference to define acetabular orientation, there does not appear to be any significant relationship between the sagittal orientation of the acetabulum and sacropelvic parameters. Using the sacrum as a common point of reference allows some further understanding of the interplay between pelvic parameters and the orientation of the acetabulum.

Application of a Deep Learning Algorithm for Combined Super-Resolution and Partial Fourier Reconstruction Including Time Reduction in T1-Weighted Precontrast and Postcontrast Gradient Echo Imaging of Abdominopelvic MR Imaging

Purpose: The purpose of this study was to test the technical feasibility and the impact on the image quality of a deep learning-based super-resolution reconstruction algorithm in 1.5 T abdominopelvic MR imaging. Methods: 44 patients who underwent abdominopelvic MRI were retrospectively included, of which 4 had to be subsequently excluded. After the acquisition of the conventional volume interpolated breath-hold examination (VIBEStd), images underwent postprocessing, using a deep learning-based iterative denoising super-resolution reconstruction algorithm for partial Fourier acquisitions (VIBESR). Image analysis of 40 patients with a mean age of 56 years (range 18−84 years) was performed qualitatively by two radiologists independently using a Likert scale ranging from 1 to 5, where 5 was considered the best rating. Results: Image analysis showed an improvement of image quality, noise, sharpness of the organs and lymph nodes, and sharpness of the intestine for pre- and postcontrast images in VIBESR compared to VIBEStd (each p < 0.001). Lesion detectability was better for VIBESR (p < 0.001), while there were no differences concerning the number of lesions. Average acquisition time was 16 s (±1) for the upper abdomen and 15 s (±1) for the pelvis for VIBEStd, and 15 s (±1) for the upper abdomen and 14 s (±1) for the pelvis for VIBESR. Conclusion: This study demonstrated the technical feasibility of a deep learning-based super-resolution algorithm including partial Fourier technique in abdominopelvic MR images and illustrated a significant improvement of image quality, noise, and sharpness while reducing TA.

Numerical Analyses of Fracture Mechanism of the Pelvic Ring during Side-Impact Load

The aim of this study is the analysis of the multiple pelvis fracture mechanism in side-impact dynamic load cases. The elaborated numerical model of a pelvis complex includes pelvic and sacral bones as well as soft tissues such as ligaments and cartilages. The bone has been modelled as a viscoelasticity material based on the Johnson-Cook model. The model parameters have been chosen based on the experimental data. The uniqueness of a presented approach refers to the selection of crack criteria for the bone. Thus, it was allowed to analyse the process of multiple fractures inside the pelvic bones. The analysis was evaluated for the model in which the deformation rate influences the bone material properties. As a result, the stress distributions inside particular bones were changed. It has been estimated that the results can vary by 50% or even more depending on the type of boundary conditions adopted. The second step of work was a numerical analysis of military vehicle subjected to an IED. An analysis of the impactor's impact on the pelvis of the Hybrid ES-2RE mannequin was conducted. It was shown that the force in the pelvis exceeds the critical value by a factor of 10. The results of the numerical analysis were then used to validate the model of a military vehicle with a soldier. It was shown that for the adopted loading conditions, the critical value of the force in the pelvis was not exceeded.

Central sensitisation in pelvic pain: A cohort study

BACKGROUND

Central sensitisation (CS) leads to pain amplification and impacts on the management of pelvic pain (PP). Identification of CS in patients with PP may provide additional treatment pathways and improve patient outcomes.

AIMS

The aims are to quantify the prevalence of questionnaire-predicted CS (QPCS) in patients presenting with PP and investigate associations between QPCS and clinical variables.

MATERIALS AND METHODS

This was an observational, cross-sectional study. Subjects with PP completed a questionnaire comprising four validated tools: the Central Sensitisation Inventory (CSI) for QPCS, Pain Catastrophising Scale for Catastrophising Trait, Bladder Pain/Interstitial Cystitis Symptom Score for bladder pain syndrome (BPS) and the Rome IV criteria for irritable bowel syndrome (IBS).

RESULTS

One hundred and eleven women were enrolled in the study; 74.8% (n = 83) had a CSI score of >40, indicating the presence of QPCS. Subjects with QPCS were more likely to screen positive for catastrophising trait (odds ratio (OR) 3.57, 95% CI 1.19-10.76, P = 0.02), BPS (OR 11.77, 95% CI 2.13-64.89, P = 0.005) and IBS (OR 2.6, 95% CI 1.05-6.43, P = 0.04). They were more likely to experience pain for more than two years (OR 4.98, 95% CI 1.94-12.82, P = 0.001) and other pain symptoms involving bladder (OR 9.87, 95% CI 2.52-38.67, P = 0.001), bowel (OR 3.13, 95% CI 1.31-7.48, P = 0.01), back (OR 4.17, 95% CI 1.66-10.51, P = 0.002) and vulva (OR 3.61, 95% CI 1.21-10.82, P = 0.02). They also had higher previous diagnoses of mental health disorder (OR 3.5, 95% CI 1.5-8.4, P = 0.005) or IBS (OR 8.9, 95% CI 1.6-49.1, P = 0.01).

CONCLUSIONS

QPCS occurs frequently in patients with PP, and subjects with QPCS experience more prolonged and complex pain.

Potential Feasibility of an Online Hypnosis Intervention for Women with Persistent Pelvic Pain

This study aimed to examine the potential feasibility of an online hypnotic intervention for women with persistent pelvic pain. The secondary aim was to explore the effect of the hypnosis intervention on anxiety, depression, pain severity, coping, pain catastrophizing, and pain disability in comparison to a no-intervention control. Twenty women with persistent pelvic pain completed assessment questionnaires and were recruited from a variety of social media sites related to persistent pelvic pain and randomized to either control or hypnotic intervention groups. The intervention group completed a 7-week online hypnotic intervention. Results found a 30% dropout rate and modest compliance (90%-40%) with practice of audio recordings. Comments from the 7 participants who completed the hypnosis intervention indicated it was acceptable. Significant reductions in screening measures of anxiety and depression were found; however, there were no significant effects shown for pain severity, avoidant coping, pain catastrophizing, or pain disability. The intervention is potentially feasible, but further refinement and optimization is needed to increase retention, compliance, and potential effects.

Challenges and Complications in Freehand S2-Alar-Iliac Spinopelvic Fixation and the Potential for Robotics to Enhance Patient Safety

STUDY DESIGN

Narrative Summary Review for Navigation & Robotics Focus Issue.

OBJECTIVE

To discuss the challenges and complications of S2-Alar-Iliac (S2AI) spinopelvic fixation using freehand techniques, and to introduce the utility of navigation & robotics to enhance patient safety.

METHODS

This study involved search of literature using the PubMed database, including retrospective clinical studies, anatomic reports, and surgical reports. The intention was to find literature that discussed complications regarding screw malfunction from manual S2AI placement, anatomical complexity of the sacroiliac joint, and outcomes of S2AI procedures conducted with robotic guidance systems.

RESULTS

The sacroiliac joint presents numerous complexities that can lead to challenges in free-hand placement of the S2-alar-iliac screw. Anatomic considerations of the S2AI screw involve close proximity to vital neurovascular structures, including: superior gluteal vessels, external iliac vessels, pudendal vessels, superior gluteal nerves, sciatic nerve, sympathetic chain ganglia, and pudendal nerves. The complications associated with manual S2AI screw installation include screw misplacement, breach of cortical bone, and injury to neurovascular structures. Robotic techniques for establishing S2AI screws involve greater accuracy of screw placement and reduced complications.

CONCLUSIONS

Accurate placement of S2AI screws is compromised by variation in pelvic anatomy and by a pathway that traverses dense cortical bone of the sacroiliac joint. Accurate placement of S2AI screws is important for patient safety regarding neurovascular structures, and for effective, stable fixation across the SI joint. Robotic navigation of S2AI fixation offers significant utility in improving the accuracy of screw placement and patient safety.

Proton Therapy for Primary Bone Malignancy of the Pelvic and Lumbar Region - Data From the Prospective Registries ProReg and KiProReg

Purpose/Objective(s)

Multimodality treatments together with local proton therapy (PT) are commonly used in unresectable primary bone malignancies in order to provide better tumor control rate while maintaining good feasibility. The aim of this study is to provide data on outcome of PT for the challenging cohort of pelvic and lumbar bone tumors.

Methods and Materials

This retrospective study includes all patients with primary bone malignancy of the pelvis and lumbar spine receiving PT in our institution between May 2013 and December 2019 enrolled in the prospective registries KiProReg and ProReg collecting information on demographics, treatment, tumor characteristics, toxicities, and outcome.

Results

Eighty-one patients were enrolled with a median age of 19.7 years (1.3–85.8). The median follow-up time was 27.5 months (1.2–83.2). The majority of patients was male (64.2%), ECOG status of 0–1 (75.2%), underwent only biopsy (50.6%), received chemotherapy (69.1%) and was assigned for definite PT (70.4%). The predominant tumor characteristics were as follows: Ewing’s sarcoma histology (58%), negative nodal involvement (97.5%) and no metastasis at diagnosis (81.5%). Median maximal diameter of tumor was 8 cm (1.4–20). LC, EFS and OS rate were 76.5, 60, and 88.1% at two years and 72.9, 45.7, and 68.9% at three years, respectively. Age over 20 years was a significant negative factor for LC, EFS, and OS. Metastatic disease at initial diagnosis affected OS and ECOG status of 2–4 affected EFS only. Regarding 17 relapsed cases (21%), isolated distant relapse was the most common failure (46.9%) followed by local failure (40.6%). Eleven out of 14 evaluable patients relapsed within high-dose region of radiotherapy. Acute grade 3–4 toxicity was found in 41 patients (50.6%) and all toxicities were manageable. Late grade 3 toxicity was reported in 7 patients (10.4%) without any of grade 4. Most common higher grade acute and late side effects concerned hematologic and musculoskeletal toxicity.

Conclusion

Proton therapy resulted in good oncological outcomes when being part of the multimodality treatment for pelvic and lumbar primary bone malignancies. However, distant metastases and local failures within the high-dose region of radiotherapy are still a common issue. Acute and late toxicities of combined therapy were acceptable.

Outcomes in Blunt vs Penetrating Pelvic Vascular Injuries

OBJECTIVES

The purpose of this study is to determine if there is a difference in outcomes for patients with blunt and penetrating vascular injuries of the pelvis.

METHODS

Data were abstracted from the Trauma Quality Improvement Program database from 2011 to 2015. Patients >18 years with hypogastric, iliac, uterine, or ovarian arterial or venous injuries were included. Individuals with an AIS head or chest score >3 were excluded.

RESULTS

Of the 2559 patients included, the mean age was 43 years (±19), 75.25% were male, and 32.6% had a comorbidity. 64.9% presented with blunt injury (mean ISS of 23 (±12)). 74.9% experienced a complication. The median hospital length of stay (LOS) and ICU LOS were 10 days and 4 days, respectively. 6.7% had an adverse discharge. Mortality occurred in 8.3%. On bivariate analysis, patients who sustained blunt trauma were older (51 vs 31 years), female (32.7% vs 10.1%), had a higher ISS (25.71 vs 17.65), and had a longer hospital LOS (16.65 vs 13.88). Patients with penetrating trauma had an increased chance of complications (78.4% vs 73.0%) and mortality (10.7% vs 7.0%). Multivariate analysis revealed in patients with blunt injuries have more complications (OR: 1.950 CI: 0.886-4.291 P = .097), a lower ISS (OR: 0.919, CI: 0.908-0.930, P < .001, were more likely to have an adverse discharge (OR: 2.05, CI: 1.62-2.60, P = .000), and had a higher risk of mortality (OR: 4.08 CI: 2.78-6.41 P < .000).

CONCLUSION

Patients with blunt pelvic vessel injuries are at risk for an increased number of complications and have a higher risk of mortality. Those who survive are more likely to have an adverse discharge.

Radiological and Functional Assessment of Treatment Outcomes in Patients after Open Reduction with Internal Fixation (ORIF) of Acetabular Fractures

(1) Fracture of the pelvis usually happens in young men and results from high-energy trauma. It generates high social and economic costs and results in further health problems. It is therefore important to assess long-term treatment results. (2) The study (NCT04902209) involved 31 patients (mean age 43.6 ± 14.8 years). We conducted fixation assessment on the basis of radiographs and CT scans and functional assessment based on functional scales. (3) We observed more degenerative changes in the less precise reconstruction of the acetabulum (p = 0.075). We did not find statistically significant relationships between the area of surgical approach, the gravity of fracture, and the development of degenerative changes. We did not find statistically significant relationships between patients' functional states and the type of surgical approach or the complexity of the fracture. We found a positive correlation between the time of surgical treatment and patients' functional state (p = 0.04). Patients whose joint surfaces were reconstructed anatomically had significantly higher scores in functional scales (HHS p = 0.05, Merle p = 0.03). (4) Patients after surgical fixation of the acetabulum have low functional abilities. The quality of reconstruction of the loaded surface as well as the length of time post-surgery seems to be essential for the patients' functional state.

A Comparison Study Between CNN-Based Deformed Planning CT and CycleGAN-Based Synthetic CT Methods for Improving iCBCT Image Quality

Purpose

The aim of this study is to compare two methods for improving the image quality of the Varian Halcyon cone-beam CT (iCBCT) system through the deformed planning CT (dpCT) based on the convolutional neural network (CNN) and the synthetic CT (sCT) generation based on the cycle-consistent generative adversarial network (CycleGAN).

Methods

A total of 190 paired pelvic CT and iCBCT image datasets were included in the study, out of which 150 were used for model training and the remaining 40 were used for model testing. For the registration network, we proposed a 3D multi-stage registration network (MSnet) to deform planning CT images to agree with iCBCT images, and the contours from CT images were propagated to the corresponding iCBCT images through a deformation matrix. The overlap between the deformed contours (dpCT) and the fixed contours (iCBCT) was calculated for purposes of evaluating the registration accuracy. For the sCT generation, we trained the 2D CycleGAN using the deformation-registered CT-iCBCT slicers and generated the sCT with corresponding iCBCT image data. Then, on sCT images, physicians re-delineated the contours that were compared with contours of manually delineated iCBCT images. The organs for contour comparison included the bladder, spinal cord, femoral head left, femoral head right, and bone marrow. The dice similarity coefficient (DSC) was used to evaluate the accuracy of registration and the accuracy of sCT generation.

Results

The DSC values of the registration and sCT generation were found to be 0.769 and 0.884 for the bladder (p < 0.05), 0.765 and 0.850 for the spinal cord (p < 0.05), 0.918 and 0.923 for the femoral head left (p > 0.05), 0.916 and 0.921 for the femoral head right (p > 0.05), and 0.878 and 0.916 for the bone marrow (p < 0.05), respectively. When the bladder volume difference in planning CT and iCBCT scans was more than double, the accuracy of sCT generation was significantly better than that of registration (DSC of bladder: 0.859 vs. 0.596, p < 0.05).

Conclusion

The registration and sCT generation could both improve the iCBCT image quality effectively, and the sCT generation could achieve higher accuracy when the difference in planning CT and iCBCT was large.

Prognosis of Early Stage Cervical Cancer According to Patterns of Recurrence

Purpose

Patterns of recurrence in cervical cancer may be useful as prognostic indicators. The aim of the present study was to determine the value of patterns of recurrence for predicting prognosis of early-stage cervical cancer.

Patients and Methods

Of the 1934 patients diagnosed with primary cervical cancer between August 2008 and July 2013, 167 experienced recurrence after radical hysterectomy, including pelvic lymphadenectomy, and adjuvant postoperative treatment. The patterns of recurrence were classified into four groups: central, pelvic, distant only, and combined metastases, and the relationship between patterns of recurrence and prognosis was evaluated.

Results

The patterns of lung only (21.6%), central (21.0%), and pelvic recurrence (17.4%) were the most common sites, followed by distant lymph nodes and lung with other sites. The longest 5-year survival period occurred in patients with central recurrence (70.5%), followed by distant lymph nodes (58.4%), peritoneum (58.3%), and lung only (36.8%). Late recurrence was detected in 28 patients (1.4%), who showed a better prognosis than those with early recurrence (p = 0.003).

Conclusion

The patterns of recurrence help to predict prognosis. A central pattern of recurrence, distant lymph node recurrence, and peritoneal recurrence were associated with favorable outcomes after salvage therapy; however, patients who suffered other recurrent patterns, along with early recurrence, require more effective therapeutic strategies to improve survival.

Computed tomography (CT) features of pelvic rhabdomyosarcoma (RMS) in children

BACKGROUND

Currently, there are few literature reports on the CT features of pelvic rhabdomyosarcoma, most of which exist in the form of case reports, and some literature reports have suggested that CT features of pelvic rhabdomyosarcoma lack specificity. This study was designed to investigate the CT features of pelvic RMS in children to provide imaging evidence for clinical diagnosis.

METHODS

We retrospectively reviewed radiographic and clinical data of all paediatric patients with pelvic neoplastic lesions pathologically proven to be malignant in our hospitals from January 2012 through March 2021. The data of the included paediatric patients were divided into two groups according to whether the pathology results indicated RMS. CT features of RMS (n= 37) and non-RMS (n= 91) were compared by two abdominal radiologists.

RESULTS

A total of 9 CT features were statistically significant for the diagnosis of pelvic RMS in children (p＜0.05). The sensitivity (range, 0.64-0.74) and specificity (range, 0.86-0.93) of the CT features showing multinodular fusion, surrounding blood vessels, and heterogeneous progressive centripetal enhancement were both relatively high. The CT features indicating lower than muscle density, necrosis, non-calcification and non-haemorrhage exhibited high specificity (range, 0.86-0.97), but the sensitivity (range, 0.32-0.40) was relatively low, while the sensitivity (range, 0.37-0.46) and specificity (range, 0.75-0.83) of other CT features used for diagnosing pelvic RMS, namely, lobulated and lymphatic metastasis, were both relatively low.

CONCLUSION

Pelvic rhabdomyosarcoma in children has its own specific CT features.

Prophylactic ureteral catheterization in the intraoperative diagnosis of iatrogenic ureteral injury

BACKGROUND

Iatrogenic ureteral injury (IUI) is a rare but feared complication in pelvic surgery. Prophylactic ureteral catheterization (PUC) is inconsistently used to reduce this risk, however no strong evidence exists for this practice. The objective is to investigate whether prophylactic ureteral catheterization can enhance intraoperative detection of IUI and reduce associated patient morbidity.

METHODS

The database of our tertiary referral hospital was retrospectively queried for ureter repairs due to iatrogenic injuries. The search yielded 845 unique patient files. After application of exclusion criteria and manual review of files, 155 individual cases remained. Statistical analysis was performed on the following parameters: timing of ureteral injury discovery, duration until catheter removal and postoperative complications.

RESULTS

Prophylactic ureteral catheterization was able to significantly enhance intraoperative diagnosis of IUI (OR = 5.09; 95%CI = 2.26-11.48). The number needed to treat is 2.6 patients. Furthermore, when the IUI was diagnosed during surgery, a significant reduction in postoperative complications was observed (RR = 0.64; 95%CI = 0.42-0.98).

CONCLUSION

Although the beneficial effects of PUC on IUI incidence remain controversial, when a ureteral injury occurs during pelvic surgery, the presence of prophylactic ureteral catheters can significantly reduce both diagnostic delay and postoperative morbidity. By promoting an immediate repair, ureteral catheterization reduces need for further diagnostics and secondary interventions.

Psychological Interventions for Women with Persistent Pelvic Pain: A Survey of Mental Health Clinicians

Objective

To establish which psychological therapies mental health professionals use with reference to the treatment of women with persistent pelvic pain conditions. This research investigates overall therapies and specific techniques that clinicians believe are the most effective with this patient group, and the challenges mental health clinicians face in administering interventions. The study aims to suggest improvements to clinical practice and establish directions for targeted future research.

Design

Cross-sectional survey design.

Methods

An online survey was developed to ask mental health clinicians questions regarding the therapies and techniques they use with women experiencing persistent pelvic pain, their perspective on their practice in this area. The survey was advertised on relevant social media and professional websites. Survey results were tabled, and chi-square statistical analyses were undertaken to examine differences in therapy use according to country and profession.

Results

Mental health clinicians predominantly utilized cognitive behavioral therapy, acceptance and commitment therapy and associated techniques for women with persistent pelvic pain conditions. The results of the chi-square analyses showed that psychologists were more likely to use cognitive behavioral therapy or acceptance and commitment therapy, than counsellors who preferred counselling interventions. Chi-square analyses showed that Australian clinicians used acceptance and commitment therapy with a higher frequency than mental health clinicians in other countries. Clinicians provided multiple insights into their experiences working with women affected by persistent pelvic pain and their opinions as to valuable future research directions.

Conclusion

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness therapies were most commonly used by mental health clinicians working with women with persistent pelvic pain conditions, despite severely limited evidence for the use of these psychological interventions in this client group.

A case of pelvic actinomycosis affecting genital, urinary and digestive tracts: a rare misleading diagnosis

Pelvic actinomycosis is an uncommon chronic invasive disease caused by a bacteria of the Actinomyces spp. Its diagnosis constitutes a clinical challenge and is usually reached in the postoperative period after resecting a pelvic mass that usually mimics advanced ovarian cancer. Although pelvic actinomyocosis involving the digestive and genital tract has been commonly described, very few reports have described cases involving both ovaries and requiring partial cystectomy for bladder involvement. Herein, we illustrate a case of pelvic actinomycosis with extensive involvement of multiple pelvic organs, misleading the surgeon into undergoing a complete clearance of the wrongfully thought adnexal malignancy.

Actinomycosis is an infection that affects the genital tract and is usually related to the presence of a foreign body on which the bacteria develops and then spreads to organs of the genital, urinary and digestive system. The infection can spread through organs by destroying and infiltrating the anatomical limits between them. Physicians are prone to performing a resection of these infiltrative lesions for fear of cancer. However, the disease can be simply cured by prescribing antibiotics for a prolonged period of time. New techniques can be used to identify the germ and prevent physicians from performing unnecessary resections.

Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center

Background

Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center.

Methods

We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry.

Results

A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%.

Conclusion

Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.

Endovascular Management of Pelvic Trauma

Major pelvic fractures result from high-energy trauma including traffic accidents and falls, which usually leads to multiple injuries complicating the patient's management. Management of these patients requires a coordinated multidisciplinary approach. Transcatheter embolization is a minimally invasive and effective technique to control massive hemorrhage and can be performed using a variety of embolic agents. It has become an accepted first-line management option for retroperitoneal bleeds in many centers. In this article, the indications for endovascular management of hemorrhage from pelvic trauma, the various embolization techniques, and potential complications will be discussed.

High-Throughput Functional Characterization of Visceral Afferents by Optical Recordings From Thoracolumbar and Lumbosacral Dorsal Root Ganglia

Functional understanding of visceral afferents is important for developing the new treatment to visceral hypersensitivity and pain. The sparse distribution of visceral afferents in dorsal root ganglia (DRGs) has challenged conventional electrophysiological recordings. Alternatively, Ca²⁺ indicators like GCaMP6f allow functional characterization by optical recordings. Here we report a turnkey microscopy system that enables simultaneous Ca²⁺ imaging at two parallel focal planes from intact DRG. By using consumer-grade optical components, the microscopy system is cost-effective and can be made broadly available without loss of capacity. It records low-intensity fluorescent signals at a wide field of view (1.9 × 1.3 mm) to cover a whole mouse DRG, with a high pixel resolution of 0.7 micron/pixel, a fast frame rate of 50 frames/sec, and the capability of remote focusing without perturbing the sample. The wide scanning range (100 mm) of the motorized sample stage allows convenient recordings of multiple DRGs in thoracic, lumbar, and sacral vertebrae. As a demonstration, we characterized mechanical neural encoding of visceral afferents innervating distal colon and rectum (colorectum) in GCaMP6f mice driven by VGLUT2 promotor. A post-processing routine is developed for conducting unsupervised detection of visceral afferent responses from GCaMP6f recordings, which also compensates the motion artifacts caused by mechanical stimulation of the colorectum. The reported system offers a cost-effective solution for high-throughput recordings of visceral afferent activities from a large volume of DRG tissues. We anticipate a wide application of this microscopy system to expedite our functional understanding of visceral innervations.

Updated reference values in pelvic ultrasonography for a Spanish population of healthy girls between 6 and 12 years old

Background

Pelvic ultrasonography (PUS) of the uterus and ovaries allows the diagnosis of changes in sexual development. However, the reference values used in Spain originate from old studies conducted in other countries.

Objective

To determine reference uterine and ovarian measurements by PUS and according to pubertal status and bone age in a Spanish population of healthy girls aged between 6 and 12 years.

Materials and methods

Descriptive cross-sectional study performed on 221 healthy girls from 2017 to 2019. Ovarian and uterine measurements were described and associated with chronological age, bone age, and Tanner stage. ROC curves were used to assess the predictive value of tests for Tanner stage II.

Results

We described reference values for all PUS uterine and ovarian measurements assessed. Subjects in Tanner II (thelarche) had a mean age of 9.7 years (SD = 1.1) and mean BMI of 19.2 kg/m². Fundal-cervical ratio changed from 1:1 to 2:1 at 12 years of chronological age (62.5% with 1:1 ratio; p < 0.0001) and 13 years of bone age (2:1 in 85.71%, p < 0.0001). Mean uterine length for Tanner II was 4.065 cm (SD = 0.736); mean ovarian volume was 2.466 cm³ (SD = 1.719). Bone age, ovarian volume, and uterine length were good predictors of Tanner stage II.

Conclusion

This is the first study providing reference uterine and ovarian PUS values in a Spanish population of healthy girls aged 6 to 12 years. Use of updated data characteristic of a specific population increases the diagnostic accuracy.

Surgical resection for pelvic retroperitoneal Castleman's disease: A case report and review literature

Castleman's disease (CD) is a rare atypical lymphoproliferation disorder first reported in 1954. Clinically, CD is classified as unicentric or multicentric CD based on anatomical distribution. Unicentric CD primarily affects the mediastinum, and rarely affects the retroperitoneal location. The standard treatment for unicentric CD is complete surgical resection; however, this can be complicated by a high degree of attachment with other organs or hypervascularity. Preoperative angiography and embolization of the arteries that feed the problematic mass can reduce intraoperative bleeding in cases of CD with hypervascularity. In the present case report, a 44-year-old man who was found to have a pelvic retroperitoneal mass with calcification based on abdominal imaging results is discussed. Due to the hypervascularity of the mass, preoperative embolization was performed. The mass was completely resected without any complications. Additionally, a review of the literature on pelvic CD and preoperative embolization of CD was performed to provide an up-to-date reference on the management and outcomes of patients with CD.

Laparoscopic Nephroureterectomy for Nonfunctioning Ectopic Pelvic Kidney with Ectopic Ureter and Lower Ureteral Stricture Opening in the Vestibule of the Vagina But No Incontinence: Challenges in Diagnosis and Surgical Dissection

Failure of mature kidney to reach its natural location in renal fossa is termed as renal ectopia. Ectopic kidney can be found in pelvic, iliac, abdominal, and thoracic location. Pelvic ectopia has been estimated to occur in 1 of 2100 to 3000 autopsies. In contrast, ectopic ureters are commonly associated with complete renal duplication. Commonest presentation in females in continuous urinary incontinence with normal voiding habits as ectopic ureter open below the bladder neck in urethra or vagina. An ectopic kidney with ectopic ureter is extremely rare congenital anomaly. We report a 36-year-old woman presenting with left lower abdomen pain with no history of fever, dysuria, or urinary incontinence. On evaluation, she was found to have left nonfunctioning ectopic pelvic kidney with ectopic ureter opening in the vestibule of the vagina, which was managed with laparoscopic nephroureterectomy. One should suspect an ectopic ureter in a female presenting with continuous urinary incontinence since birth. However, diagnosis is challenging when clinical presentation is unusual with no urinary incontinence as seen in the index case. Detailed local examination in correlation with imaging is key for diagnosis and rule out other congenital anomalies. Laparoscopic approach in such clinical scenario is a safe and feasible option.

EUS-guided pelvic drainage: A systematic review and meta-analysis

Background and Objectives:

EUS-guided pelvic abscess drainage (EUS-PAD) is a procedure that utilizes an echoendoscope to visualize an area of interest for needle insertion and placement of a stent, catheter, or both for drainage of the target abscess. The aim of this study was to perform a systematic review and meta-analysis for the safety and efficacy of EUS-PAD.

Materials and Methods:

We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to February 2020). The primary outcomes for this study were the technical and clinical success of EUS-PAD. The secondary outcomes assessed for this study were adverse events of the procedure and subgroup analysis of individual adverse events.

Results:

Eight studies with a total of 135 patients combined were included in our analysis. The rate of technical success was 100% and the calculated pooled rate of clinical success was 92% (95% confidence interval [CI]: 87%, 98%; P = 0.31; I² = 15%). The calculated pooled rate of adverse events was 9.4% (±17.9%), with stent migration (5.5 ± 18.06%) being the most common adverse event.

Conclusion:

EUS-PAD offers a viable alternative that can minimize the need for surgical intervention in the drainage of pelvic abscesses. EUS-PAD has also demonstrated long-term clinical success with an acceptable rate of complications.

Phosphodiesterases 5 Inhibitors and Erectile Dysfunction Recovery after Pelvic Surgery: Future Perspectives for New Drugs and New Formulations

BACKGROUND

Phosphodiesterase 5 inhibitors (PDE5I) represent the first-line treatment in the management of post-operative erectile dysfunction (ED) after pelvic oncological surgery. The aim of our study is to evaluate the available evidence on the efficacy of PDE5Is, including new formulations and penile rehabilitation post-pelvic surgery.

EVIDENCE ACQUISITION

A systematic review of the literature was performed until May 2020. The following databases were searched: Scopus, Medline and Web of Science. The MeSH search was conducted by combining the following terms: 'erectile dysfunction', 'radical prostatectomy' 'pelvic' 'bladder' 'phosphodiesterase' inhibitors' 'avanafil' 'sildenafil' 'tadalafil' 'lodenafil' 'mirodenafil' 'udenafil' 'vardenafil' 'sublingual' 'orodispersible' 'penile' 'rehabilitation'.

EVIDENCE SYNTHESIS

Sildenafil, Tadalafil, vardenafil and Avanafil improve EF compared with placebo in men with all levels of ED severity after radical prostatectomy with good tolerability. No specific recommendations can be suggested regarding the superiority of a drug over the other. The optimal dose, continuous vs. on-demand and duration of treatment, is still under investigation. In vitro and preclinical studies suggest the possible role for lodenafil, mirodenafil and oro-dispersible formulations in patients undergoing oncological pelvic surgery. Few studies demonstrated the efficacy of udenafil in improving ED after rectal surgery or radical prostatectomy. Complete recovery of EF after surgery is still an unmet need in the field of penile rehabilitation after pelvic surgery.

CONCLUSION

PDE5Is have a crucial role in the management of post pelvic surgery of ED. New drugs and new formulations have shown excellent results in patients with ED; however, data in patients after surgery is still scarce. Further well designed RCT should clarify the role of these new compounds and oro-dispersible formulations in the management of ED in patients undergoing pelvic surgery.

Age-adjusted charlson comorbidity index and 30-day morbidity in pelvic surgeries

Introduction:

Charlson comorbidity index (CCI) is a validated tool enabling clinicians for prediction of adverse events posttherapy. In this study, we planned to estimate the predictive value of age-adjusted CCI (ACCI) in assessing the perioperative complication in oncological patients undergoing major pelvic surgeries.

Methods:

This was a single arm, prospective, observational study, in which adult patients with pelvic malignancies undergoing pelvic surgeries were selected. The relationship between the ACCI and Grade 3–5 adverse events were tested using Fisher's test.

Results:

The rate of Grade 3–5 adverse event rate was 16.7% (11 patients, n = 66). Among the whole cohort, 11 patients (16.7%) had high score on ACCI. The rate of Grade 3–5 adverse events was higher in the cohort of patients with high ACCI score (45.5% vs. 10.9%, P = 0.014). The sensitivity, specificity and negative and positive predictive values were 45.5%, 89.1%, 89.1%, and 45.5%, respectively.

Conclusion:

ACCI can predict for postsurgical adverse events. It has a high negative predictive value for nonoccurrence of adverse events.

Treatment of pelvic fractures in cats with patellar fracture and dental anomaly syndrome

Objectives

The aim of this study was to describe the treatment and outcome of acetabular and other pelvic fractures in cats with patellar fracture and dental anomaly syndrome (PADS) and to provide advice on how to manage these cases in practice.

Methods

Data were collated on cats with PADS that were reported to have sustained pelvic fractures or had fractures or fissures of the pelvis identified on submitted radiographs. The details of the fractures were recorded, in addition to any treatment and outcome information.

Results

Of the 215 cases reported with PADS, 58 cats (27%) were found to have pelvic fractures, none of which were known to have resulted from significant trauma. There were 101 fractures in total and of these 15 were treated with surgery, including 10 acetabular fractures, two ilial, two pubic and one ischial fracture. Screw loosening and loss of fracture reduction was seen in four of the surgically treated fractures (two pubic fractures, one ilial and one acetabular fracture). Fourteen cats were euthanased as a direct result of a fracture occurring. While most pelvic fractures healed uneventfully, some cats remained intermittently lame, but it was not always possible to determine the cause of the lameness from the information available and because all cats had concurrent patellar fractures.

Conclusions and relevance

Many of the pelvic fractures healed with conservative management. Fractures involving articular surfaces such as acetabular fractures may benefit from surgical stabilisation as surgery may offer the benefits of articular fracture repair with improved joint congruency and a faster return to normal activity.

Imaging Strategies for Rectal Cancer Initial Staging: Does Pelvic Computed Tomography Provide Significantly Additional Findings when High-resolution Magnetic Resonance Imaging has Been Performed?

BACKGROUND

Initial staging of rectal cancer is done by high-resolution magnetic resonance imaging (MRI), however, pelvic computed tomography (CT) is also frequently used. The aim of this study was to evaluate the added clinical benefit of pelvic CT or whether it can alter the initial staging or not.

METHODS

The study was composed of 187 patients with rectal cancer. Firstly, imaging except pelvic CT was evaluated. Secondly, the pelvic CT was evaluated and the staging was adjusted according to the new findings. Subsequently, the two staging results were compared to investigate the added clinical benefit of pelvic CT.

RESULTS

Compared with the imaging data except pelvic CT, new findings revealed by the pelvic CT included metastases of the pelvic bone (n = 1) and pelvic peritoneum (n = 3). However, the new findings did not change the primary staging. Of the three patients with pelvic peritoneal metastasis, two were already determined with peritoneal involvement and ascites by abdominal CT, and the third patient was observed with liver and distant lymph node metastasis. Thus, none of their initial stagings needed to be changed.

CONCLUSION

The addition of pelvic CT to the pre-treatment imaging strategy cannot provide added clinical benefit for the primary evaluation of rectal cancer.

Pelvic kidney as a cause of May-Thurner syndrome

Deep venous thrombosis is a common clinical problem with significant morbidity and mortality. Since the iconic publication by Virchow in 1856, which placed all known causes of deep venous thrombosis into three groups, namely venous stasis, vascular injury and hypercoagulability, numerous causes have been added to each category. This case report highlights the importance of an anatomical imaging study of the pelvis in cases of recurring, proximal deep venous thrombosis of the lower limb.

Primary pelvic hydatid cyst in an infertile female, A case report

It is important to consider hydatidosis as a differential diagnosis in all suspected cysts in endemic regions. The wide range of hydatidosis presentations makes it difficult to differentiate from similar symptoms.

Outcomes of comprehensive treatment for primary osteosarcoma

Purpose:

This study aimed to evaluate the clinical features and outcomes of osteosarcoma to identify prognostic factors and determine new strategies to improve overall survival.

Patients and Methods:

We retrospectively analyzed 12 cases of osteosarcoma treated at our hospital from 2012 to 2017. Tumor site, tissue type, stage, treatments, adverse effects, postoperative limb function, surgical margin, and final outcomes were evaluated.

Results:

All patients received chemotherapy, and 10 underwent wide resection. The Musculoskeletal Tumor Society scores were more than good in all cases, and the 3-year survival rate was 73.3%. Two patients are alive with disease, eight have remained disease-free, and two died of the disease. Three of the four recurrent cases involved the pelvis.

Conclusion:

The treatment of primary osteosarcoma with wide resection in our department, therefore, yielded favorable outcomes. However, improved treatment strategies are needed for pelvic and advanced cases.

Predictors of Psychological Outcomes and the Effectiveness and Experience of Psychological Interventions for Adult Women with Chronic Pelvic Pain: A Scoping Review

Objective

CPP affects approximately 15% of women worldwide and has significant psychological, physical and financial impact on the lives of sufferers. Psychological interventions are often recommended as adjuncts to medical treatment for women with chronic pelvic pain (CPP). This is as women with CPP experience higher rates of mental health concerns and difficulties coping with their pain.. However, recent systematic reviews have highlighted that the efficacy of psychological interventions is not conclusive in this population. This review aimed to identify predictors of mental health outcomes and effective psychological techniques and interventions in women with CPP to inform the development of future psychological therapies.

Methods

Scoping review using the method outlined by Arskey & O'Malley (2005). Relevant databases, reference lists and grey literature were searched to identify effective mental health interventions and predictors of psychological outcomes for women with CPP.

Results

Methodological concerns made identifying predictors of mental health outcomes and effective psychological interventions difficult. However, cognitive behavioural therapy and Mensendieck therapy emerged as therapeutic interventions with the best evidence for women with CPP. A number of useful predictors of mental health outcomes and techniques included in effective interventions were identified.

Conclusion

The evidence provided in this review has the potential to inform future research directions and the development of targeted psychological interventions for women with CPP.

Pneumatosis cystoides intestinalis in an elderly patient, better to be safe than sorry

Pneumatosis cystoides intestinalis is a rare pathology with nonspecific symptoms that can be easily misdiagnosed. Clinical awareness along with close surveillance is critical to effectively diagnose and treat this condition. Current treatment is based on conservative therapy including antibiotics and oxygen. Surgery is only recommended when complications are suspected. Here, we present the case of a 72-year-old female admitted to the emergency department with abdominal pain and vomits. Pneumatosis cystoides intestinalis was diagnosed and was successfully treated. On follow-up visits, patient is recovering and doing well.