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The today well accepted intrapelvic approach for acetabular and pelvic ring injury fixation was first described by Hirvensalo and Lindahl in 1993 followed by a more detailed description by Cole and Bolhofner in 1994. Compared to the well-known ilioinguinal approach, described by Letournel, this approach allows an intrapelvic view to the medial acetabulum, while using the ilioinguinal approach a more superior, extrapelvic view, is dissected to the area of the acetabulum. Several names have been used to describe the new intrapelvic approach with increasing usage, mainly ilio-anterior approach, extended Pfannenstiel approach, Stoppa-approach, Rives-Stoppa approach, modified Stoppa approach and recently anterior intrapelvic approach. Especially names including “Stoppa”, based on the French surgeon Rene Stoppa, an inguinal hernia surgeon, have been discussed. In contrast to the presently used intrapelvic approach, the original the Rives-Stoppa approach refers to a sublay-retromuscular technique, which places a mesh posterior to the rectus muscle and anterior to the posterior rectus sheath without dissecting along the upper pubic ramus. Thus, intrapelvic approach is not a Rives-Stoppa approach. The Cheatle-Henry approach, another inguinal hernia approach, refers best to the presently used intrapelvic approach. Discussing the anatomy and the different dissections, this approach allows anteromedial access to the anterior column and a direct view from inside the true pelvis to the quadrilateral plate and medial side of the posterior column. Thus, we favor to use the term “Intrapelvic Approach”.

PurposeTo evaluate the feasibility of measuring the intrapelvic pressure (IPP) during f-URS with a wire including a pressure sensor and to assess IPP profiles during the procedure.MethodsPatients undergoing f-URS for stone disease were recruited. A wire with pressure sensor was placed in the renal cavities to measure IPP. For these cases, either no ureteral access sheath (UAS) or 10/12 or 12/14-Fr UASs were used according to surgeon discretion. Irrigation was ensured by a combination of a continuous pressure generator set at 80 cmH2O and a hand-assisted irrigation system providing on-demand forced irrigation to provide proper visibility. Pressures were monitored in real time and recorded for analysis.ResultsFour patients undergoing five f-URS were included. IPP monitoring was successful in all patients. Mean baseline IPP was 6 cmH2O. During f-URS with only the endoscope in the renal cavities and irrigation pressure set at 80 cmH2O without any forced irrigation, the mean IPP was 63 cmH2O. Mean IPP during laser lithotripsy with the use of on-demand forced irrigation was 115.3 cmH2O. The maximum pressure peaks recorded during this therapeutic period using forced irrigation ranged from 289.3 to 436.9 cmH2O.ConclusionHigh IPP levels may be achieved during f-URS with on-demand irrigation systems. The impact of these high pressures on the risk of complications and long-term consequences still need to be evaluated adequately. But, in this preliminary pilot study, IPP could be reliably and conveniently monitored and recorded using a wire with a digital pressure sensor.

PurposeTo perform a review on the latest evidence related to intrarenal pressures (IRPs) generated during upper-tract endourology, and present different tools to maintain decreased values, to decrease complication rates.MethodsA literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model and human studies. Different keywords were: percutaneous nephrolithotomy, PCNL, ureteroscopy, URS, RIRS, irrigation flow, irrigation pressure, intrarenal pressure, intrapelvic pressure and renal-pelvic pressure.ResultsIRPs reported during retrograde intrarenal surgery (RIRS), PCNL, miniPCNL, and microPCNL range 40.8–199.35, 3–40.8, 10–45 and 15.37–41.21 cm H2O, respectively. By utilizing ureteral access sheaths (UASs) IRPs usually remain lower than 30 cm H2O at an irrigation pressure (IP) of ≤ 100 cm H2O but could increase to > 40 cm H2O at an IP of 200 cm H2O. By utilizing the minimally invasive PCNL system, IRPs remain low at 20 cm H2O even at high IPs. Utilizing endoluminal isoproterenol during RIRS, could reduce IRP increases with a rate of 27–107%, and maintain low IRPs values, usually below 50 cm H2O.ConclusionsIncreased IRP values have been reported during RIRS and UASs constitute the most efficient tool for decreasing them. IRPs during mini-PCNL can be decreased utilizing the vacuum-cleaner and purging effects but might remain uncontrolled during micro- and ultra-mini PCNL. Intraluminal pharmacological treatment could play a role in IRP decrease, with isoproterenol being the most studied agent.

PurposeTo compare intrapelvic pressure (IPP) levels achieved during f-URS, mini-PCNL, standard PCNL, and endoscopic combined intrarenal surgery in a kidney model.MethodsA silicone model simulating the complete urinary tract was used for all the experiments. We compared: a 9.5Fr f-URS, a 12Fr mini-nephroscope and a 26Fr nephroscope. The irrigation pressure was set at 40 and 193 cmH2O. We compared: f-URS-S ± ureteral access sheath (UAS, 10/12Fr, 11/13Fr, 12/14Fr) ± 273 μm laser fiber, Mini-PCNL with different sizes of operating sheath (15/16Fr, 16.5/17.5Fr, 21/22Fr) ± 365 μm laser fiber, Standard PCNL with an operating sheath of 30Fr ± Lithotripter LithoClast Master 11.4Fr.Resultsf-URS: IPP values ranged between 1.4 and 46.2 cmH2O. Factors reducing IPP were an irrigation pressure at 40 cmH2O, an occupied working channel, and the use of a UAS except with the 10/12Fr at 193 cmH2O. Mini-PCNL: IPP values ranged between 2.4 and 39.7 cmH2O. Factors reducing IPP were irrigation pressure at 40 cmH2O, a large operating sheath (> 15/16Fr). The occupation of the working channel did not affect the IPP at 40 cmH2O, while it decreased at 193 cmH2O.Standard PCNL: IPP values ranged between 1.4 and 7.3 cmH2O. Occupancy of the working channel did not affect IPP at 40 cmH2O, while it increased at 193 cmH2O.ConclusionWe recorded for the first time IPP values according to different endourological techniques and configurations. IPP never exceed 50 cmH2O irrespectively of the assessed technique/setup. The factors reducing IPP were a low irrigation pressure (40 cmH2O), the use of a UAS or a working sheath appropriate to the diameter of the endoscope, as well as the occupation of the working channel in the case of f-URS.

(1) Introduction: To evaluate the feasibility of measuring the intrapelvic pressure (IPP) during flexible ureterorenoscopy (f-URS) with a PressureWire and to optimize safety by assessing IPP during surgery. (2) Methods: Patients undergoing f-URS for different treatments were recruited. A PressureWire (0.014”, St. Jude Medical, Little Canada, MN, USA) was placed into the renal cavities to measure IPP. Gravity irrigation at 40 cmH2O over the patient and a hand-assisted irrigation system were used. Pressures were monitored in real time and recorded for analysis. Fluid balance and postoperative urinary tract infection (UTI) were documented. (3) Results: Twenty patients undergoing f-URS were included with successful IPP monitoring. The median baseline IPP was 13.6 (6.8–47.6) cmH2O. After the placement of the UAS, the median IPP was 17 (8–44.6) cmH2O. With irrigation pressure set at 40 cmH2O without forced irrigation, the median IPP was 34 (19–81.6) cmH2O. Median IPP during laser lithotripsy, with and without the use of on-demand forced irrigation, was 61.2 (27.2–149.5) cmH2O. The maximum pressure peaks recorded during forced irrigation ranged from 54.4 to 236.6 cmH2O. After the surgery, 3 patients (15%) presented UTI; 2 of them had a positive preoperative urine culture, previously treated, and a positive fluid balance observed after the surgery. (4) Conclusion: Based on our experience, continuous monitoring of IPP with a wire is easy to reproduce, effective, and safe. In addition, it allows us to identify and avoid high IPPs, which may affect surgery-related complications.

Case summary Dynamic intrapelvic urinary bladder displacement (DIUBD) is an uncommon condition where the urinary bladder intermittently displaces caudally into the pelvic canal, resulting in episodic lower urinary tract obstruction. Although this phenomenon is recognized more commonly in canine patients with perineal hernias, documented feline cases remain rare. Trauma or pelvic fractures can compromise the strength and conformation of local musculature and fascia, permitting the bladder to slip caudally under changing pressure gradients. In this case, an 8-year-old spayed female domestic shorthair cat, previously affected by multiple healed pelvic fractures, developed progressive urinary and defecatory straining. Initial imaging, including abdominal radiographs and ultrasonography, confirmed a caudally displaced bladder occasionally reverting to a more cranial position. Blood work and repeated urinalyses indicated post-renal azotemia on re-presentation. Surgical exploration revealed a mobile bladder without a distinct muscular defect, prompting cystopexy to anchor the bladder in a stable cranial position. Postoperative monitoring showed rapid improvement in clinical signs and renal values, and follow-up imaging confirmed that the bladder retained its corrected orientation. This case supports the importance of thorough imaging and an early corrective procedure for cats with recurrent lower urinary obstruction and a history of pelvic fractures. Relevance and novel information Although DIUBD is more often recognized in dogs, this case indicates that it can similarly arise in cats with a history of pelvic trauma. Targeted imaging coupled with cystopexy can successfully address the intermittent obstruction.

This report describes a 32-year-old primigravida diagnosed with bilateral anterior sacral meningoceles without bony defect of the sacrum during pregnancy. The patient remained asymptomatic throughout the pregnancy, with regular monitoring via transvaginal ultrasound and MRI. An elective cesarean section was planned at 38 weeks. However, the patient presented in obstructed labor at 42 weeks and underwent an emergency cesarean section, resulting in the birth of a healthy infant. This case is unique as it involves bilateral anterior meningoceles without sacral anomalies. Anterior sacral meningoceles are rare findings in pregnancy. Anterior sacral meningoceles are either congenital with bony defect of the sacrum or acquired lesions due to connective tissue disorders characterized by the herniation of the meninges through the sacral foramina. In pregnancy, these lesions pose unique challenges due to potential complications such as rupture, infection, or obstructed labor. Management strategies vary, and individualized approaches with close monitoring and patient counseling are crucial in determining the appropriate mode and timing of delivery.

Purpose This study aims to assess the effect of pre‐stenting and bladder drainage on intrapelvic pressure (IP) during Retrograde Intrarenal Surgery (RIRS). Methods Eighty‐five consecutive patients were prospectively enrolled and meticulously recorded in a data form. Forty‐two patients meeting the inclusion criteria after applying exclusion factors. The patients were divided into two groups: Group 1 (21 patients with preoperative JJ stents) and Group 2 (21 patients without preoperative JJ stents). IP was measured during RIRS, and the impact of various factors, including pre‐stenting, bladder drainage and hydronephrosis (HN) grade, on IP was analysed through univariate and multiple linear regression. Results The perioperative mean highest IP (78 ± 18.2 mmHg vs. 110 ± 23.9 mmHg), median lowest IP (29 mmHg vs. 42 mmHg) and median overall IP (41 mmHg vs. 69 mmHg) were significantly lower in Group 1 compared to Group 2 (all p < 0.001). Multivariate analysis showed that pre‐stenting and mild HN (Grade 0–1) were independent predictors of reduced IP. Conclusion Pre‐stenting led to a significant reduction in IP during RIRS, likely due to passive ureteral dilation. Additionally, bladder drainage with urethral catheter further decreased IP. These findings suggest that pre‐stenting and bladder drainage should be considered as strategies to reduce IP during RIRS, potentially improving surgical outcomes.

Background The purpose of the study is to evaluate the use of the suprapectineal quadrilateral surface (QLS) plates associated with the anterior intrapelvic approach (AIP) to the acetabulum in the surgical treatment of acetabular fractures with anterior involvement. Methods We did a retrospective study of patients surgically treated with QLS plates and AIP for acetabular fractures with the involvement of the anterior column, between February 2018 and February 2020, in our Hospital. The following data were recorded: mechanism of injury, the pattern of fracture, presence of other associated injuries, the time before performing the surgery, surgical approach, position on operating table, time of surgery, intraoperative bleeding, hospitalization time, intraoperative and postoperative complications. Follow-ups were performed at 1, 3, 6, 12 months, then annually. The clinical-functional outcome was assessed with the Merle d’Aubigne Postel score (MAP) modified by Matta; while the radiological outcome with the Matta Radiological Scoring System (MRSS). A Chi-square test was utilized to examine associations between parametric variables. Results We included 34 patients, mean age 62.1, with an average follow-up of 20.7 months. The most frequent traumatic mechanism was road trauma. There were 15 isolated anterior columns and 19 associated patterns. There were 5 cases of associated visceral injuries, and 10 cases of other associated skeletal fractures. All patients were in the supine position. The surgical approach used was the AIP in all cases, with the addition of the first window of the ilioinguinal approach in 16 cases and of the Kocher-Langenbeck approach in 2 cases. The average time before performing the surgery was 8.5 days. The mean time of the surgery and the mean length of stay after surgery were 227.9 min and 8.2 days, respectively. There weren’t cases of intra-operative complications, while there were postoperative complications in 5 patients. The MRSS was judged anatomical in 26 cases, imperfect in 7 cases and poor in 1 case. The average MAP value was 15.2. We observed a significant relationship between the radiological outcome and the clinical outcome ( p  < 0.05). Conclusions The QLS plates in association with the AIP approach represent an effective treatment strategy for the treatment of acetabular fractures with anterior involvement.

Thermal injury to kidney tissue during holmium laser lithotripsy represents a significant complication. This issue is often unavoidable due to the variability of renal conditions and the absence of techniques for real-time intrarenal temperature monitoring. The objective of this research was to evaluate influence of manual hand pump irrigation on temperature of the fluid within a pelvicalyceal model during holmium laser lithotripsy. Laser lithotripsy of artificial stones was carried out in a 3D-printed model of the renal pelvicalyceal system. The irrigation system employed a continuous gravity approach (P = 60 cmH O), augmented by manual pumping as required. A 9.2 Fr ureteroscope was inserted into the model via a ureteral access sheath (UAS), with sizes of either 10/12 Fr or 12/14 Fr.The power settings for the lithotripsy varied between 12 and 25 W. Temperature monitoring during the procedure was conducted using thermographic methods. For all laser power settings, the temperatures recorded under gravity irrigation alone were significantly higher compared to those achieved when gravity was combined with a manual hand pump, regardless of the ureteral access sheath size. When using the hand pump system and a 12/14Fr UAS, the median temperatures in none of the laser settings exceeded 30°C. However, using a 10/12Fr UAS, the median temperatures did not exceed 35°C in any of the settings and were significantly lower compared to the use of the gravity flow system alone. The employment of gravity irrigation supplemented by a manually on-demand pump in retrograde intrarenal surgery is a critical component in mitigating the risk of significant temperature elevations, leading to thermal injury to the adjacent kidney tissues. Moreover, the interquartile ranges of temperatures indicating that gravity system enhanced by an on-demand pump irrigation not only reduce the median temperature but also promote a more consistent thermal environment.