Risks, symptoms, and management of pelvic nerve damage secondary to surgery for pelvic organ prolapse: a report of 95 cases. Int Urogynecol J. 2011;22:1485-1490. [PMID: 21979388 DOI: 10.1007/s00192-011-1539-4]

The anatomy of the pelvic plexus in female cadavers: implications for retroperitoneal nerve-sparing surgery

Background

The inferior hypogastric plexus (IHP) is a crucial structure for female continence and sexual function. A nerve-sparing approach should be pursued to reduce the risk of pelvic plexus damage during retroperitoneal pelvic surgery.

Objectives

To analyse the relationship between the female IHP and several pelvic anatomical landmarks.

Materials and Methods

Standardised cadaveric dissection was performed on 5 nulliparous female cadavers. The relationships of the IHP and the mid-cervical plane (MCP), the mid-sagittal plane (MSP), and the uterosacral ligament (USL) were investigated.

Main outcome measures

Distance between IHP and MCP, MSP, and USL.

Results

Distances between the right IHP and the right MSP (mean distance: 16.3 mm; range: 10.0-22.5 mm) and the right USL (mean distance: 4.8 mm; range: 0-15.0 mm) were shorter than those between the left IHP and ipsilateral landmarks (left MSP distance: 23.5 mm; range 18.0-30.0 mm; left USL distance: 5.0 mm; range: 0-20.0 mm). Although the MCP was 3.3 mm (range: 2.5-4.0 mm) left and lateral to the midsagittal line, the right IHP was closer to the MCP (mean distance: 19.6 mm; range: 13.0-25.0 mm) than the left one (mean distance: 20.2 mm; range: 15.0-26.0 mm).

Conclusions

Distances between the right IHP and the MSP, MCP, and ipsilateral USL, are shorter compared to these associated to the left IHP.

What is new?

Right autonomic pelvic plexus is closer to the midline planes and the ipsilateral USL. These anatomical relationships may be greatly helpful for pelvic surgeon while facing retroperitoneal pelvic surgery and looking for a nerve-sparing approach.

Pudendal Neuralgia: Two case reports with laparoscopic nerve decompression

Pudendal neuralgia (PN) is a rare and underestimated condition. The reported incidence by the International Pudendal Neuropathy Association is 1/100000. However, the actual rate may be significantly higher, with a propensity for women. It is most frequently caused by an entrapment of the nerve at the level of the sacrospinous and sacrotuberous ligament, also known as pudendal nerve entrapment syndrome. Due to the late diagnosis and inadequate management, pudendal nerve entrapment syndrome often leads to considerable reduction in the quality of life and high health care costs. The diagnosis is made using Nantes Criteria, in conjunction with the patient's clinical history and physical findings. Clinical examination with an accurate assessment of the territory of the neuropathic pain is mandatory to set the therapeutic strategy. The aim of the treatment is to control the symptoms and it usually starts with conservative approaches which include analgesics, anticonvulsants, and muscle relaxants. Surgical nerve decompression can be proposed after failure of conservative management. The laparoscopic approach is a feasible and appropriate technique to explore and decompress the pudendal nerve, and to rule out other pelvic conditions that can cause similar symptomatology. In this paper, the clinical history of two patients affected by compressive PN is reported. Both patients underwent laparoscopic pudendal neurolysis suggesting that the treatment for PN should be individualised and carried out by a multidisciplinary team. When conservative treatment fails, laparoscopic nerve exploration and decompression is an adequate option to propose and should be performed by a trained surgeon.

Case report: Transvaginal single-port extraperitoneal laparoscopic sacrospinous ligament fixation for apical prolapse: A single-center case series

Background

Sacrospinous ligament fixation (SSLF) is a minimally invasive and effective procedure for the treatment of apical prolapse. Because intraoperative exposure of the sacrospinous ligament is difficult, SSLF is difficult. The aim of our article is to determine the safety and feasibility of single-port extraperitoneal laparoscopic SSLF for apical prolapse.

Methods

This single-center, single-surgeon case series study included 9 patients with pelvic organ prolapse quantification (POP-Q) III or IV apical prolapse who underwent single-port laparoscopic SSLF. Additionally, transobturator tension-free vaginal tap (TVT-O) was performed in 2 patients, and anterior pelvic mesh reconstruction was performed in 1 patient.

Results

The operative time ranged from 75 to 105 (mean, 88.9 ± 10.2) min, and blood loss ranged from 25 to 100 (mean, 43.3 ± 22.6) ml. No serious operative complications, blood transfusions, visceral injuries, or postoperative gluteal pain were reported for these patients. After 2–4 months of follow-up, no recurrence of POP, gluteal pain, urinary retention/incontinence, or other complications was observed.

Conclusion

Transvaginal single-port SSLF is a safe, effective, and easy-to-master operation for apical prolapse.

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence

AIMS

To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data.

METHODS

Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value.

RESULTS

The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery.

CONCLUSION

Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

Laparoscopic High Uterosacral Ligament Suspension vs. Laparoscopic Sacral Colpopexy for Pelvic Organ Prolapse: A Case-Control Study

Introduction

Laparoscopic sacral colpopexy is the gold standard technique for apical prolapse correction but it is a technically challenging procedure with rare but severe morbidity. Laparoscopic high uterosacral ligament suspension could be a valid technically easier alternative using native tissue.

Material and Methods

In the period from 2015 to 2018, 600 women were submitted to laparoscopic sacral colpopexy while 150 to laparoscopic high uterosacral ligament suspension in three Italian urogynecology referral centers. We enrolled women with apical prolapse stage ≥2 alone or multicompartment descensus. To reduce allocation bias, we performed a propensity matched analysis. Women undergoing laparoscopic high uterosacral ligament suspension surgery were matched 1:2 to women undergoing laparoscopic sacral colpopexy. The cumulative proportion of relapse-free women in time was analyzed by the Kaplan–Meier method. The primary objective of this multicenter case-control retrospective study was to compare the recurrence rate while the secondary objectives were to compare feasibility, safety, and efficacy of laparoscopic sacral colpopexy and laparoscopic high uterosacral ligament suspension in surgical treatment of pelvic organ prolapse.

Results

Three hundred and nine women were enrolled (103 laparoscopic high uterosacral ligament suspension; 206 laparoscopic sacral colpopexy). Median operatory time was significantly shorter in the laparoscopic high uterosacral ligament suspension group (P = 0.0001). No statistically significative difference was found in terms of estimated blood loss, admission time, intraoperative, and major early postoperative complications, postoperative pelvic pain, dyspareunia and de novo stress urinary incontinence. Surgical approach was the only independent risk factor for prolapse recurrence (RR = 6.013 [2.965–12.193], P = 0.0001). The objective cure rate was higher in the laparoscopic sacral colpopexy group (93.7 vs. 68%, 193/206 vs. 70/103, P = 0.0001) with a highly reduced risk of recurrence (RR = 5.430 [1.660–17.765]). Median follow up was 22 months.

Conclusion

Both techniques are safe, feasible, and effective. Laparoscopic sacral colpopexy remains the best choice in treatment of multicompartment and advanced pelvic organ prolapse while laparoscopic high uterosacral ligament suspension could be appropriate for moderate and isolated apical prolapse when laparoscopic sacral colpopexy is not suitable for the patient or to prevent prolapse in women at high risk at the time of the hysterectomy.

Lumbosacral plexus MR tractography: A novel diagnostic tool for extraspinal sciatica and pudendal neuralgia?

BACKGROUND

Diagnosing extraspinal sciatica and pudendal neuralgia remains a clinical challenge. MRI and MR Neurography (MRN) are currently the standard techniques used to support the diagnosis of extraspinal lumbosacral plexus entrapments; however, for the intrapelvic portions of the lumbosacral plexus their accuracy is still limited. MR Tractography (MRT) feasibility to image the lumbosacral plexus has been demosntrated, but its clinical applications have yet to be determined.

PURPOSE

To correlate MRT with intraoperative findings in patients undergoing laparoscopic treatment of intrapelvic entrapments of the lumbosacral plexus and compare its accuracy with Neuropelveological clinical assessment and MRN.

MATERIALS AND METHODS

This is a retrospective analysis of MRT reconstructions of diffusion tensor imaging (DTI) sequences acquired for the MRN collected from a cohort of 13 patients undergoing laparoscopic detrapment of the lumbosacral plexus. The primary outcome of this study was the correlation of MRT reconstruction with intraoperative findings. Secondary outcomes included the correlation of MRN, preoperative Neuropelveological clinical diagnoses and the diffusion-weighted imaging (DWI) fractional anisotropy (FA) and Apparent Diffusion Coefficient (ADC) in patients undergoing pelvic MRI and MRN for the investigation of intrapelvic nerve entrapments.

RESULTS

MRT correlated with intraoperative findings in 11 of 13 patients (85%). Neuropelveological clinical assessment was able to accurately diagnose a pelvic nerve entrapment in 12/13 patients (92%) and MRN agreed with surgical findings in only 2/13 (15%) patients. MRT was significantly superior to MRN (p < 0.001). FA and ADC did not correlate with the identification of a nerve entrapment, likely due to limitations regarding the placement of the seedpoints.

CONCLUSIONS

This initial, retrospective analysis, suggests that MRT is superior to MRN at diagnosing intrapelvic entrapments of the lumbosacral plexus. A prospective, double-blinded study is underway to validate this data, but these initial findings show great potential for MRT as a diagnostic tool for extraspinal sciatica and pudendal neuralgia. Clinical Trials Registry: U1111-1261-4910 (REBEC - Brazilian Registry for Clinical Trials).

Laparoscopic lateral suspension for pelvic organ prolapse: A systematic literature review

BACKGROUND

Abdominal lateral suspension with mesh represents an alternative treatment to suspend the vaginal apex.

OBJECTIVES

The aim of this study was to summarize literature data regarding the anatomical and functional outcomes, and intra- and postoperative complications of this technique with minimally invasive approach (laparoscopic/robotic).

SEARCH STRATEGY

Systematic literature search using MEDLINE/PubMed, SCOPUS, Web of Science.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on baseline characteristics (age, BMI, prior pelvic reconstructive surgery, preoperative POP stage), perioperative outcomes (operative time, estimated blood loss, intraoperative and postoperative complications, admission time), objective and subjective success rate, surgical failure, time of follow-up. Data were presented descriptively.

MAIN RESULTS

Thirteen studies were included in the review. The overall number of patients for our analysis was 1066. Patients referred for laparoscopic/robotic lateral suspension were most frequently postmenopausal, aged 50 to 65 years, BMI ≥ 25 kg/m2; 22.2% were already hysterectomized, while 17% had already a previous POP surgery. Operative time ranged from 78.4 ± 29.7 to 254 ± 45 min. The overall anatomic success was more than 90% in the apical compartment and more than 88% in the anterior compartment. Subjective cure rate varies from 78.4% to 100% in medium-term follow-up. Post-operative complication grade >= 3 according to Claiven-Dindo Scale was 1.03%. Mesh erosion rate varied between 0% and 13%.

CONCLUSIONS

Results coming from our systematic review suggest safety, efficacy and feasibility of minimally invasive lateral suspension with optimal anatomical and functional outcomes. Well-designed, randomized, controlled trials are required to confirm this data.

Laparoscopic approach to refractory extraspinal sciatica and pudendal pain caused by intrapelvic nerve entrapment

Entrapments of the intrapelvic portions of the lumbosacral plexus are an important extraspinal cause of sciatica and pudendal neuralgia. They can be treated using Laparoscopic Neuronavigation (LANN), a minimally invasive technique that has set the foundations of an emerging field in Medicine—Neuropelveology. This retrospective-prospective study analyzes the outcomes of 63 patients treated with the LANN technique over a 10 year time period. One year after surgery, 78.3% of patients reported clinically relevant pain reduction, defined as ≥ 50% reduction in Numeric Rating Scale (NRS) score; these results were maintained for a mean follow up of 3.2 years. Preoperative chronic opioid use (≥ 4 months of ≥ 10 mg morphine equivalents/day) was a predictor of poor surgical outcome—clinically relevant pain reduction was observed in only 30.8% in this group of patients, compared to 91.5% in patients not regularly taking opioids preoperatively (p < 0.01). Perioperative complication rate was 20%. Our results indicate that the LANN technique is an effective and reproducible approach to relieve pain secondary to intrapelvic nerve entrapments and that preoperative chronic opioid therapy significantly reduces the likelihood of a successful surgical outcome. This study provides detailed information on perioperative complication and postoperative course, which is essential for patient consenting.

Review: Pelvic nerves - from anatomy and physiology to clinical applications

A prerequisite for nerve-sparing pelvic surgery is a thorough understanding of the topographic anatomy of the fine and intricate pelvic nerve networks, and their connections to the central nervous system. Insights into the functions of pelvic nerves will help to interpret disease symptoms correctly and improve treatment. In this article, we review the anatomy and physiology of autonomic pelvic nerves, including their topography and putative functions. The aim is to achieve a better understanding of the mechanisms of pelvic pain and functional disorders, as well as improve their diagnosis and treatment. The information will also serve as a basis for counseling patients with chronic illnesses. A profound understanding of pelvic neuroanatomy will permit complex surgery in the pelvis without relevant nerve injury.

Neuropelveology: An Emerging Discipline for the Management of Pelvic Neuropathies and Bladder Dysfunctions through to Spinal Cord Injury, Anti-Ageing and the Mars Mission

Neuropelveology is a new specialty in medicine that has yet to prove itself but the need for it is obvious. This specialty includes the diagnosis and treatment of pathologies and dysfunctions of the pelvic nerves. It encompasses knowledge that is for the most part already known but scattered throughout various other specialties; neuropelveology gathers all this knowledge together. Since the establishment of the International Society of Neuropelveology, this discipline is experiencing an ever-growing interest. In this manuscript, the author gives an overview of the different aspects of neuropelveology from the management of pelvic neuropathic pain to pelvic nerves stimulation for the control of pelvic organ dysfunctions and loss of functions in people with spinal cord injuries. The latter therapeutic option opens up new treatments but also widens preventive horizons not only in the field of curative medicine (osteoporosis and cardio-vascular diseases) but also in preventive medicine and anti-ageing, all the way to future applications in the "Mars mission" project.

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.

RESULTS

Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

Neuropatía del pudendo como causa de dolor pélvico

El síndrome de atrapamiento del nervio pudendo es una de múltiples causas de dolor pélvico crónico. Hemos realizado una revisión de la literatura sobre su presentación clínica, diagnóstico y tratamiento, con el propósito de conocer los detalles más relevantes de una enfermedad que cada vez está siendo más diagnosticada, con el fin de realizar un abordaje precoz desde un punto de vista integral.

[POSTOPERATIVE CHRONIC PAIN FOLLOWING MESH AND NON-MESH REPAIR OF PELPIC ORGAN PROLAPSE]

(Objective) A FDA alert in 2011 warned about postoperative chronic pain following transvaginal mesh (TVM) for pelvic organ prolapse (POP). We studied cases with chronic pain after TVM, natural tissue repair (NTR) and laparoscopic salcocopopexy (LSC). (Methods) We retrospectively reviewed medical charts of patients who underwent POP operations in our hospital or were referred to us after POP operations in other hospitals between 2006 and 2016. Postoperative chronic pain was defined as persistent pain for more than three months following the first three months from the time of POP operations.Patients' characteristics and treatments were analyzed. (Results) In patients who underwent POP operations in our hospital, the rates of chronic postoperative pain after TVM, NTR and LSC were 12/2,457 (0.49%), 1/402 (0.26%) and 0/29 (0%), respectively. Another 8 patients were referred to us after POP operations in other hospitals. Thus, a total of 21 patients (15: TVM, 6: NTR) had either medications, surgical treatment or were referred to other doctors due to postoperative chronic pain. All of them were parous women aged 53 to 81 years old. Preoperative chronic pelvic pain was found in seven patients (33%), and another four patients (19%) had orthopedic diseases with chronic pain. The main locations of pain were; vagina 11, vulva 2, urinary bladder 2, urethra 1, coccyx 1, buttocks 1, anus 1, perineum 1 and groin 1. Nineteen patients had pharmacological treatment using tricyclic antidepressants, Ca²⁺ channel α₂δ ligand and/or serotonin-noradrenalin reuptake inhibitor (SNRI); 9 (47%) of the patients showed a notable improvement. Three patients following TVM had surgical treatment; one with bladder mesh exposure was resolved with TURis, one with vaginal mesh exposure was resolved with mesh trimming, but one with tenderness on the mesh arm did not improve after a partial mesh removal. Four patients were referred to pain clinics. (Conclusions) Postoperative chronic pain can occur following both TVM and NTR therefore, attentive listening and proper medication are important as initial therapies. It is mandatory to examine the presence of mesh exposure in patients after using mesh. We should be careful about preoperative chronic pain, pelvic or elsewhere, as a risk factor for postoperative chronic pain.

First sacral nerve and anterior longitudinal ligament anatomy: clinical applications during sacrocolpopexy

BACKGROUND

The recommended location of graft attachment during sacrocolpopexy is at or below the sacral promontory on the anterior surface of the first sacral vertebra. Graft fixation below the sacral promontory may potentially involve the first sacral nerve.

OBJECTIVE

The objectives of this study were to examine the anatomy of the right first sacral nerve relative to the midpoint of the sacral promontory and to evaluate the thickness and ultrastructural composition of the anterior longitudinal ligament at the sacral promontory level.

STUDY DESIGN

Anatomic relationships were examined in 18 female cadavers (8 unembalmed and 10 embalmed). The midpoint of the sacral promontory was used as reference for all measurements. The most medial and superior point on the ventral surface of the first sacral foramen was used as a marker for the closest point at which the first sacral nerve could emerge. Distances from midpoint of sacral promontory and the midsacrum to the most medial and superior point of the first sacral foramen were recorded. The right first sacral nerve was dissected and its relationship to the presacral space was noted. The anterior longitudinal ligament thickness was examined at the sacral promontory level in the midsagittal plane. The ultrastructural composition of the ligament was evaluated using transmission electron microscopy. Height of fifth lumbar to first sacral disc was also recorded. Descriptive statistics were used for data analyses.

RESULTS

Median age of specimens was 78 years and median body mass index was 20.1 kg/m². Median vertical distance from midpoint of sacral promontory to the level of the most medial and superior point of the first sacral foramen was 26 (range 22-37) mm. Median horizontal distance from the midsacrum to the first sacral foramen was 19 (range 13-23) mm. In all specimens, the first sacral nerve was located just behind the layer of parietal fascia covering the piriformis muscle, and thus, outside the presacral space. Median anterior longitudinal ligament thickness at the sacral promontory level was 1.9 (range 1.2-2.5) mm. Median fifth lumbar to first sacral disc height was 16 (8.3-17) mm.

CONCLUSION

Awareness of the first sacral nerve position, approximately 2.5 cm below the midpoint of the sacral promontory and 2 cm to the right of midline, should help anticipate and avoid somatic nerve injury during sacrocolpopexy. Knowledge of the approximate 2-mm thickness of the anterior longitudinal ligament should help reduce risk of discitis and osteomyelitis, especially when graft is affixed above the level of the sacral promontory.

Nerve preserving vs standard laparoscopic sacropexy: Postoperative bowel function

AIM

To compare our developed nerve preserving technique with the non-nerve preserving one in terms of de novo bowel symptoms.

METHODS

Patients affected by symptomatic apical prolapse, admitted to our department and treated by nerve preserving laparoscopic sacropexy (LSP) between October, 2010 and April, 2013 (Group A or “interventional group”) were compared to those treated with the standard LSP, between September, 2007 and December, 2009 (Group B or “control group”). Functional and anatomical data were recorded prospectively at the first clinical review, at 1, 6 mo, and every postsurgical year. Questionnaires were filled in by the patients at each follow-up clinical evaluation.

RESULTS

Forty-three women were enrolled, 25/43 were treated by our nerve preserving technique and 18/43 by the standard one. The data from the interventional group were collected at a similar follow-up (> 18 mo) as those collected for the control group. No cases of de novo bowel dysfunction were observed in group A against 4 cases in group B (P = 0.02). Obstructed defecation syndrome (ODS) was highlighted by an increase in specific questionnaires scores and documented by the anorectal manometry. There were no cases of de novo constipation in the two groups. No major intraoperative complications were reported for our technique and it took no longer than the standard procedure. Apical recurrence and late complications were comparable in the two groups.

CONCLUSION

Our nerve preserving technique seems superior in terms of prevention of de novo bowel dysfunction compared to the standard one and had no major intraoperative complications.

Pudendal neuralgia after pelvic surgery using mesh: Case reports and laparoscopic pudendal nerve decompression

Persistent pain after vaginal mesh surgery is a rare and agonizing entity that has devastating consequences for the patient's quality of life. Many etiologies have been blamed including nerve injuries and entrapments. Pudendal neuralgia is a rare chronic neuropathic pain syndrome in the anatomical territory of the pudendal nerve. Various treatment options, such as medication management, physiotherapy, nerve blocks, decompression surgery and neuromodulation, have been used, but the most appropriate treatment for pudendal neuralgia has not yet been determined. In this article, we present two cases of postoperative pelvic pain thought to be secondary to injury or mechanical distortion of the pudendal nerve after rectocele repair using mesh and tension-free vaginal tape sling. In cases of failed conservative treatment and of mesh removal surgery, laparoscopic pudendal nerve decompression and omental flap wrapping operation can be a treatment option for pudendal neuralgia.

Vascular entrapment of the sciatic plexus causing catamenial sciatica and urinary symptoms

AIM OF THE VIDEO / INTRODUCTION

Pelvic congestion syndrome is a well-known cause of cyclic pelvic pain (Ganeshan et al., Cardiovasc Intervent Radiol 30(6):1105-11, 2007). What is much less well known is that dilated or malformed branches of the internal or external iliac vessels can entrap the nerves of the sacral plexus against the pelvic sidewalls, producing symptoms that are not commonly seen in gynecological practice, such as sciatica, or refractory urinary and anorectal dysfunction (Possover et al., Fertil Steril 95(2):756-8. 2011). The objective of this video is to explain and describe the symptoms suggestive of vascular entrapment of the sacral plexus, as well as the technique for the laparoscopic decompression of these nerves.

METHOD

Two anecdotal cases of intrapelvic vascular entrapment are used to review the anatomy of the lumbosacral plexus and demonstrate the laparoscopic surgical technique for decompression at two different sites, one on the sciatic nerve and one on the sacral nerve roots.

RESULT

After surgery, the patient with the sciatic entrapment showed full recovery of the sciatica and partial recovery of the myofascial pain. The patient with sacral nerve root entrapment showed full recovery with resolution of symptoms.

CONCLUSION

The symptoms suggestive of intrapelvic nerve entrapment are: perineal pain or pain irradiating to the lower limbs in the absence of a spinal disorder, and lower urinary tract symptoms in the absence of prolapse of a bladder lesion. In the presence of such symptoms, the radiologist should provide specific MRI sequences of the intrapelvic portion of the sacral plexus and a team and equipment to expose and decompress the sacral nerves should be prepared.

Laparoscopic approach to intrapelvic nerve entrapments

It is long known that a large portion of the lumbosacral plexus is located intra-abdominally, in the retroperitoneal space. However, most of literature descriptions of lesions on this plexus refer to its extra-abdominal parts whereas its intra-abdominal portions are often neglected. The objective of this review article is to describe the laparoscopic anatomy of intrapelvic nerve bundles, as well as the findings and advances already achieved by Neuropelveology practitioners.

Axotomy of tributaries of the pelvic and pudendal nerves induces changes in the neurochemistry of mouse dorsal root ganglion neurons and the spinal cord

Using immunohistochemical techniques, we characterized changes in the expression of several neurochemical markers in lumbar 4-sacral 2 (L4-S2) dorsal root ganglion (DRG) neuron profiles (NPs) and the spinal cord of BALB/c mice after axotomy of the L6 and S1 spinal nerves, major tributaries of the pelvic (targeting pelvic visceral organs) and pudendal (targeting perineum and genitalia) nerves. Sham animals were included. Expression of cyclic AMP-dependent transcription factor 3 (ATF3), calcitonin gene-related peptide (CGRP), transient receptor potential cation channel subfamily V, member 1 (TRPV1), tyrosine hydroxylase (TH) and vesicular glutamate transporters (VGLUT) types 1 and -2 was analysed seven days after injury. L6-S1 axotomy induced dramatic de novo expression of ATF3 in many L6-S1 DRG NPs, and parallel significant downregulations in the percentage of CGRP-, TRPV1-, TH- and VGLUT2-immunoreactive (IR) DRG NPs, as compared to their expression in uninjured DRGs (contralateral L6-S1-AXO; sham mice); VGLUT1 expression remained unaltered. Sham L6-S1 DRGs only showed a small ipsilateral increase in ATF3-IR NPs (other markers were unchanged). L6-S1-AXO induced de novo expression of ATF3 in several lumbosacral spinal cord motoneurons and parasympathetic preganglionic neurons; in sham mice the effect was limited to a few motoneurons. Finally, a moderate decrease in CGRP- and TRPV1-like-immunoreactivities was observed in the ipsilateral superficial dorsal horn neuropil. In conclusion, injury of a mixed visceral/non-visceral nerve leads to considerable neurochemical alterations in DRGs matched, to some extent, in the spinal cord. Changes in these and potentially other nociception-related molecules could contribute to pain due to injury of nerves in the abdominopelvic cavity.

Bilateral obturator neuropathy after transobturator vaginal sling: a case report

Transobturator tape procedure is a popular and effective minimally invasive technique to treat stress urinary incontinence. We report a case of transient obturator neuropathy caused by transobturator tape placement for stress urinary incontinence. Findings on physical examination were significant for bilateral obturator neuropathy resulting in significant motor deficit, prompting removal of the sling to avoid the potential of prolonged or permanent morbidity. There was immediate complete resolution of neuropathy with the return of motor function after surgical removal of the sling.

Voiding Dysfunction Associated with Pudendal Nerve Entrapment

Pudendal nerve entrapment (Alcock canal syndrome) is an uncommon source of chronic pelvic pain, in which the pudendal nerve is entrapped or compressed. Pain is located in the perineal, genital and perianal areas and is worsened by sitting. By simple entrapment of the PN without neurogenic damages, pain is usually isolated. In neurogenic damages to the PN, genito-anal numbness, fecal and/or urinary incontinence can occurred. PNE can be caused by obstetric traumas, scarring due to genitoanal surgeries (prolaps procedures!), accidents and surgical mishaps. Diagnosis is based on anamnesis, clinical examination including vaginal or rectal palpation of the pelvic nerves with selective nerve blockade. Pudendal pain non systematic mean PNE since other neuropathies may induce pudendal pain. So sacral radiculopathies (sacral nerves roots S#2-4) are underestimated etiologies frequently responsible for pudendal pain with irradiation in sacral dermatomes, bladder hypersensitivity or in neurogenic lesions, bladder retention.