Laparoscopic pudendal nerve decompression and transposition combined with omental flap protection of the nerve (Istanbul technique): technical description and feasibility analysis

The pudendal syndrome: A photo essay of nerve compression damage visualized at neurolysis in patients with chronic neuropathic pelvic pain

AIMS

(1) To use intraoperative photographs to visualize and explain pudendal nerve compressions and anatomical variations of compression sites in patients with chronic pelvic pain. (2) To emphasize the diagnostic importance of sensory examination with a safety pin at the six pudendal nerve branches in all patients with chronic pelvic pain; the dorsal nerves (penis or clitoris; the perineal nerves; and the inferior rectal nerves).

METHODS

Between 2003 and 2014, "definite" pudendal neuropathy was diagnosed by examination and with two neurophysiologic tests. Neurolysis, via a transgluteal approach, was recommended only after 14 weeks of conservative care failed to adequately improve symptoms and validated symptom scores. Photographs of surgical findings were culled for their educational impact. An illustration of each photo clarifies the surgical anatomy.

RESULTS

The transgluteal incision permits access to pudendal anatomy and compression sites from the subpiriformis area through the interligamentary space and the pudendal canal (Alcock canal). Compressions were acquired or congenital and severity varied significantly. Pinprick sensory testing diagnoses pudendal neuropathy in 92% of both genders. Mid-nerve compression occurred commonly between the sacrotuberous and sacrospinous ligaments less frequently in the Alcock canal, but also at aberrant pathways, for example, between layers of the sacrotuberous ligament; a separate inferior rectal nerve passing through the sacrospinous ligament; at an anomalous lateral pathway posterior to the ischial spine. The results of international surgeons are discussed.

CONCLUSIONS

Decompression surgery was recommended in approximately 35% of patients in this practice, when pudendal neuropathy (pudendal syndrome), did not respond to two conservative levels of treatment: (1) nerve protection and medications and, (2) a series of three pudendal nerve perineural injections given at 4-week intervals. Significant nerve compression is consistently observed. Pathophysiology includes axonopathy from ischemia and demyelination. Neuropathy is readily diagnosed using a pinprick sensory examination of six pudendal nerve branches. Monitoring with the National Institutes of Health Chronic Prostatitis Symptom Index records cures >13 years.

Surgical approaches for pudendal nerve entrapment: insights from a systematic review and meta-analysis

BACKGROUND

Pudendal nerve entrapment (PNE) is an underdiagnosed condition affecting a spectrum of pelvic functions, primarily pain, as outlined by Nantes diagnostic criteria. Although numerous surgical decompression techniques are available for its management, consensus on efficacy and safety is lacking. This study conducts a systematic review and meta-analysis to assess the efficacy and complication rates of the main surgical decompression techniques.

METHODS

A comprehensive literature search was conducted in PubMed®, Embase®, Web of Science®, and ClinicalTrails.gov® on 19th of April 2023. Initial screening involved title and abstract evaluation, with subsequent retrieval and assessment of abstracts and full-text articles. Studies assessing pain outcomes before and after surgical release of the pudendal nerve were included. Studies without full-text, focusing on diagnostic methods or with outcomes relating solely to LUTS, digestive symptoms, or sexual dysfunction, were excluded. Risk of bias assessement was conducted using the National Institute of Health (NIH) Study Quality Assessment tool. Studies were categorized based on three surgical techniques: perineal, transgluteal, and laparoscopic transperitoneal. Random-effects meta-analysis with subgroup analysis were used. Meta-regression analyses were conducted to investigate the influence of covariates on the observed outcomes.

RESULTS

Nineteen studies, comprising 810 patients, were included. The overall significant pain relief rate across all techniques was estimated at 0.67 (95% CI 0.54 to 0.78) with considerable heterogeneity (I2 = 80.4%). Subgroup analysis revealed success rate for different techniques: laparoscopic (0.91, 95% CI 0.64 to 0.98), perineal (0.69, 95% CI 0.52 to 0.82), and transgluteal (0.50, 95% CI 0.37 to 0.63). The laparoscopic technique exhibited a complication rate of 16.0%. Meta-regression indicated that patient age and median follow-up significantly influenced outcomes.

CONCLUSION

While comparing surgical techniques is challenging, this meta-analysis highlights important outcome differences. The laparoscopic technique appears most promising for pain improvement. However, the study also emphasizes the need for further robust, long-term research due to significant heterogeneity across studies and prevelent risk of bias. PROSPERO database: CRD42023496564.

Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy

To assess the effectiveness and safety of various techniques of pudendal nerve neurolysis (PNN) in patients with pudendal nerve entrapment (PNE). A comprehensive literature search was conducted on May 20th, 2023, using Scopus, PubMed, and Embase databases. Only studies in English involving adults were accepted, while meeting abstracts and preclinical studies were excluded. A total of 34 papers were included. Transperineal PNN emerged as a promising technique, demonstrating significant potential in alleviating pain, restoring erectile function in males, and improving the resolution of urinary stress incontinence in females. Furthermore, the bilateral approach consistently yielded positive outcomes in addressing urinary symptoms. The transgluteal technique appeared particularly suitable for cases of posterior PNE, situated between the sacrospinous ligament and the lesser sciatic foramen. A progressive amelioration of painful symptoms was observed during follow-up. Minimally invasive PNN is evolving and enables decompression along the entire proximal tract up to the Alcock canal, minimizing the risk of comorbidities. In addition to reducing pudendal neuralgia, robot-assisted and laparoscopic approaches determined a reduction in lower urinary tract symptoms and an improvement in erectile function, though further studies are required to corroborate these findings. PNN emerges as an effective treatment for PNE with minimal morbidity. Therefore, PNN should be tailored according to the site of PNE to enhance functional outcomes and improve patient quality of life.

First case-series of robot-assisted pudendal nerve release: technique and outcomes

OBJECTIVE

Pudendal Nerve Entrapment (PNE) may determine chronic pelvic pain associated with symptoms related to its innervation area. This study aimed to present the technique and report the outcomes of the first series of robot-assisted pudendal nerve release (RPNR).

PATIENTS AND METHODS

32 patients, who were treated with RPNR in our centre between January 2016 and July 2021, were recruited. Following the medial umbilical ligament identification, the space between this ligament and the ipsilateral external iliac pedicle is progressively dissected to identify the obturator nerve. The dissection medial to this nerve identifies the obturator vein and the arcus tendinous of the levator ani, which is cranially inserted into the ischial spine. Following the cold incision of the coccygeous muscle at the level of the spine, the sacrospinous ligament is identified and incised. The pudendal trunk (vessels and nerve) is visualized, freed from the ischial spine and medially transposed.

RESULTS

The Median duration of symptoms was 7 (5, 5-9) years. The median operative time was 74 (65-83) minutes. The median length of stay was 1 (1-2) days. There was only a minor complication. At 3 and 6 months after surgery, a statistically significant pain reduction has been encountered. Furthermore, the Pearson correlation coefficient reported a negative relationship between the duration of pain and the improvement in NPRS score, - 0.81 (p = 0.01).

CONCLUSIONS

RPNR is a safe and effective approach for the pain resolution caused by PNE. Timely nerve decompression is suggested to enhance outcomes.

Clinical usefulness of quantitative thermal sensory testing in the diagnosis and surgical treatment of women with pudendal neuropathy

BACKGROUND

The aim of this study, conducted on women with pudendal neuropathy, was to evaluate the usefulness of quantitative thermal sensory testing (QTST) in the diagnosis, surgical management, and prognosis of the disease.

METHODS

The study was conducted on 90 women with pudendal neuropathy. QTST in pudendal nerve sensory innervation territory was realized before and more than 24 months after operative pudendoscopy on most patients. Cold and warm thresholds were evaluated together with a search for qualitative anomalies. The diagnostic value of QTST was assessed by comparing baseline data with normative values previously derived from 41 presumably healthy women. The effect of operative pudendoscopy on thermal sensitivity was tested by comparing preoperative and postoperative measurements. Assessment of the long-term prognostic value of QTST was based on "surgical success" defined as a VAS pain level less than 4 at least 2 years after surgery.

RESULTS

The existence of qualitative anomalies, like anesthesia, allodynia, dysesthesia, radiation, and dyslocalization, was clearly indicative of pudendal neuropathy. The presence of after sensation and "out of limit" values of skin temperature and cold detection threshold were also helpful for diagnosing the disease. Surgery reduced qualitative anomalies but had no positive effect on QTST thresholds. QTST measurements had no real prognostic value but other factors like constipation and abnormal perineal descent were predictive of surgical success.

CONCLUSION

For women with pudendal neuropathy, QTST can be considered a useful, non-invasive tool in the diagnosis, and management of the disease, but it cannot predict satisfactorily long-term outcome of operative pudendoscopy.

Dorsal Root Ganglion Stimulation Therapy for Refractory Idiopathic Pudendal Neuralgia

Dorsal root ganglion stimulation is a relatively new treatment option for chronic pain conditions such as pudendal neuralgia, which is a chronic pain condition affecting the pudendal nerve in the pelvic region. Pudendal neuralgia is a debilitating condition that can significantly affect the patient's quality of life. In dorsal root ganglion stimulation, a small device is implanted that delivers electrical impulses to the dorsal root ganglion to modulate pain signals coming from the pudendal nerve. The procedure is considered investigational and has been investigated in case series and case reports with promising results. However, more research is needed to fully understand its safety and effectiveness. This case report highlights the potential of dorsal root ganglion stimulation as a treatment option for pudendal neuralgia and the need for further research to establish it as a standard treatment option.

Right laparoscopic pudendal release + neurostimulator prosthesis (LION procedure) in pudendal neuralgia

AIM

Pudendal neuralgia is a highly disabling entity with complex diagnostic and controversial treatment results. Surgical neurolysis has been shown to be the most effective treatment. Sacral root neurostimulation or posterior tibial nerve stimulation are used to rescue patients who either have not responded to surgery or have worsened after an initial improvement.

METHODS

Given the excellent visualization of the pudendal nerve during laparoscopic pudendal release, we propose to combine this procedure with neurostimulation, taking advantage of the possibility of in situ placement of the electrode. The abdominal cavity is accessed laparoscopically through four ports, and after identifying and releasing the pudendal nerve a neurostimulation electrode is placed next to the nerve and is connected to a generator located in a subcutaneous pocket.

RESULTS

This procedure has been performed in one patient with a satisfactory result.

CONCLUSIONS

Laparoscopic pudendal release with neurostimulator prosthesis is an experimental technique that can be promising for the treatment of pudendal neuralgia.

Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review

AIM

Pudendal and inferior cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Diagnosis is challenging and patients often suffer several years before diagnosis is made. The purpose of the review was to inform healthcare workers about this disease and to provide a basis of anatomy and physiopathology, to inform about diagnostic tools and invasive or non-invasive treatment modalities and outcome.

METHODS

A description of pudendal and inferior cluneal nerve anatomy is given. Physiopathology for entrapment is explained. Diagnostic criteria are described, and all non-invasive and invasive treatment options are discussed.

RESULTS

The Nantes criteria offer a solid basis for diagnosing this rare condition. Treatment should be offered in a pluri-disciplinary setting and consists of avoidance of painful stimuli, physiotherapy, psychotherapy, pharmacological treatment led by tricyclic antidepressants and anticonvulsants. Nerve blocks are efficient at short term and serve mainly as a diagnostic tool. Pulsed radiofrequency (PRF) is described as a successful treatment option for pudendal neuralgia in patients non-responding to non-invasive treatment. If all other treatments fail, surgery can be offered. Different surgical procedures exist but only the open transgluteal approach has proven its efficacy compared to medical treatment. The minimal-invasive ENTRAMI technique offers the possibility to combine nerve release with pudendal neuromodulation.

CONCLUSIONS

Pudendal and inferior cluneal nerve entrapment syndrome are a challenge not only for diagnosis but also for treatment. Different non-invasive and invasive treatment options exist and should be offered in a pluri-disciplinary setting.

Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus

BACKGROUND

Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE.

METHODS

The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid.

RESULTS

The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri-tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow-up to be currently proposed in this indication.

CONCLUSION

These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care.

SIGNIFICANCE

Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.

Can anatomical feasibility studies drive neurosurgical procedures and reach patients faster than traditional translational research?

Often, surgical techniques are practiced and studied in the anatomy laboratory. Occasionally, new surgical methods are developed with cadaveric anatomical studies. Some cadaveric feasibility studies, if published, might go on to be used by surgeons from around the world for improved patient care. Herein, we review our experience with 37 published anatomical feasibility studies over an 18-year period (2002-2020) and analyze the literature for published examples of surgical application of these same anatomical studies. We found that, for cadaveric anatomical feasibility studies within 7 years of their publication date, approximately 22% will be used in neurosurgery with the clinical applications published. Of these studies awarded clinical citation within 7 years of publication, the median time to that citation was approximately 3.4 years. As the average time for translational research to reach patient care is 17 years, cadaveric anatomical studies in this series reached patient care much sooner than traditional translational research. Cadaveric anatomical studies, based on our experience, can drive neurosurgical procedures.

Sexual dysfunction due to pudendal neuralgia: a systematic review

Background

The pudendal nerve is considered as the main nerve of sexuality. Pudendal neuralgia is an underdiagnosed disease in clinical practice. The aim of this systematic review is to highlight the role of pudendal neuralgia on sexual dysfunction in both sexes.

Methods

A PubMed search was performed using the following keywords: “Pudendal” AND “Sexual dysfunction” or “Erectile dysfunction” or “Ejaculation” or “Persistent sexual arousal” or “Dyspareunia” or “Vulvodynia”. The search involved patients having sexual dysfunction due to pudendal neuralgia. Treatment received was also reported.

Results

Five case series, seven cohort studies, two pilot studies, and three randomized clinical trials were included in this systematic review. Pudendal nerve and/or artery entrapment, or pudendal neuralgia, is a reversible cause of multiple sexual dysfunctions. Interventions such as anesthetic injections, neurolysis, and decompression are reported as potential treatment modalities. There are no studies describing the role of pudendal canal syndrome in the pathophysiology or treatment of delayed ejaculation or penile shortening.

Discussion

Pudendal neuralgia is an underestimated yet important cause of persistent genital arousal, erectile dysfunction (ED), premature ejaculation (PE), ejaculation pain, and vulvodynia. Physicians should be aware of this entity and examine the pudendal canal in such patients before concluding an idiopathic cause of sexual dysfunction.

Erectile function recovery after laparoscopic decompression of pudendal artery and nerve: a documented case report

The aim of this article is to report the effectiveness of laparoscopic decompression of pudendal artery (PA) and nerve for erectile dysfunction (ED) restoration. A 32-year-old man presented with a long-term complaint of ED not responsive to medical therapy. Endocrine screening and neurological evaluation did not show any abnormalities. Color Doppler ultrasound revealed the absence of blood flow in the right PA. After failure of conservative treatments and in accordance to the patient's desire, laparoscopic pudendal artery decompression was performed. The patient reported significant amelioration of ED one month after surgery. At 8-months follow-up, Doppler ultrasound showed complete revascularization of the right PA.

Pilot study: pudendal neuromodulation combined with pudendal nerve release in case of chronic perineal pain syndrome. The ENTRAMI technique: early results

INTRODUCTION AND HYPOTHESIS

Chronic perineal pain syndrome due to pudendal nerve impingement is difficult to diagnose and to treat. All the known treatment options leave room for improvement considering the outcome. Early neuromodulation of the pudendal nerve after its surgical release could improve outcomes.

OBJECTIVES

The aim of the study was to evaluate the potential beneficial effect of pudendal neuromodulation combined with release surgery using the ENTRAMI technique (endoscopic transgluteal minimally invasive technique).

STUDY DESIGN

This is a single-center prospective descriptive study. Between March 2019 and March 2020, 16 patients (2 males, 14 females) were included. Data were collected at baseline and 1 month after surgery.

METHODS

Patients eligible for inclusion had chronic perineal pain for at least 3 months in the area served by the pudendal nerve. We combined pudendal nerve release with neuromodulation.

RESULTS

At 1 month, the numeric pain rating scale (NPRS) dropped from 9.5 at baseline to 3.5 (p = 0.003). Seventy-six percent of patients showed a global impression of change (PGIC) of > 50% at 1 month, and optimal treatment response (PGIC ≥ 90%) was found in 41% of patients.

LIMITATIONS

The drawback of our study was that it was not randomized or blinded. The peripheral nerve evaluation lead (PNE) used could only be implanted for 1 month because of infection risk and is also prone to dislocations and technical failures.

CONCLUSION

Pudendal nerve liberation by the ENTRAMI technique combined with short-term pudendal neuromodulation seems feasible and promising in treating patients with chronic perineal pain. Clinical trial number: NCT03880786.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome

INTRODUCTION

Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported.

METHODS

A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval.

RESULTS

The mean operating time per side was 33.9 ± 6.8 min and the average hospital stay was 1.9 ± 0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600 ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001).

CONCLUSION

A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.

Pudendal Neurolysis: 6-Step Laparoscopic Approach

OBJECTIVE

To demonstrate the safety and feasibility of the laparoscopic approach to perform pudendal neurolysis in a case of pudendal nerve entrapment syndrome [1-3].

DESIGN

A video tutorial that highlights the laparoscopic steps to performing pudendal neurolysis, with a focus on the main anatomic landmarks [4,5].

SETTING

A tertiary care regional hospital.

INTERVENTIONS

This video shows a 6-step approach to laparoscopic pudendal neurolysis for the treatment of pudendal nerve entrapment between the sacrospinous and sacrotuberous ligaments [2,6-8]. Step 1: Identification of the umbilical artery. Step 2: Dissection and development of the lateral paravesical space until the pelvic floor. Step 3: Identification of the arcus tendineus of the endopelvic fascia. Step 4: Identification of the ischial spine and the sacrospinous ligament covered by the coccygeus muscle. Step 5: Coagulation and section of the coccygeus muscle and the sacrospinous ligament. Step 6: Medialization of the pudendal nerve until its entrance into the Alcock canal.

CONCLUSION

This video demonstrates the safety, feasibility, and reproducibility of laparoscopic pudendal neurolysis in 6 steps. A minimally invasive approach is adequate to treat the pudendal compression until the Alcock canal [2].

Endoscopic trans gluteal minimal-invasive approach for nerve liberation (ENTRAMI technique) in case of pudendal and/or cluneal neuralgia by entrapment: One-year follow-up

BACKGROUND

Chronic neuropathic perineal pain syndrome is a collective term that encompasses several diagnoses. In patients where the neuropathic pain syndrome is caused by pudendal or cluneal nerve entrapment, surgical release can be proposed if other measures have failed. The aim of this study is to evaluate the clinical outcome of patients suffering from pudendal and/or cluneal nerve entrapment at 1 year after this minimal invasive surgery, which is based on the open trans gluteal approach who has proven its efficacy compared to medical treatment in a randomized control trial.

METHODS

Patients eligible for inclusion had chronic perineal neuropathic pain for at least 3 months in the area served by the pudendal and/or cluneal nerve, refractory to conservative measurements. Patients met all five of the Nantes criteria.

RESULTS

Fifteen patients underwent the ENTRAMI technique. At 1 year after surgery, overall reduction of the average maximal Numeric Pain rating Scale (NPRS-score) was from 9 (range, 7-10) at baseline to 5 (range, 0-10; P-value <.05). At 1 year 73% of patients declared to have a "good treatment response" (patient global impression of change [PGIC] >30%) and optimal treatment response (PGIC ≥90%) was found in 40% (P-value <.05). No complications were recorded.

CONCLUSION

This study clearly shows that the technique is feasible with promising long-term results in a difficult to manage patient group.

Urethral leak: an unusual symptom of pudendal nerve entrapment

Pudendal nerve (PN) entrapment is one of the most misunderstood and underdiagnosed medical conditions. It is recognized as a cause of chronic pelvic pain syndrome. However, due to the pudendal nerve’s mixed composition and complex anatomy, the presenting symptoms are varied and go beyond pain, depending on the entrapment’s nature, location and duration. We report a unique case of a young patient presenting with a urethral leak refractory to antibiotics. Patient evaluation highlighted findings suspicious of pudendal nerve entrapment. The patient was submitted to a laparoscopic transperitoneal PN neurolysis, resulting in major symptoms improvement.

Laparoscopic treatment of pudendal nerve and artery entrapment improves erectile dysfunction in healthy young males

Erectile dysfunction (ED) is increasingly becoming more common in young healthy males and is attributed mainly to psychogenic causes in these patients. Recent studies have reported that ED could be secondary to pudendal nerve or artery entrapment. This perspective assessed the efficacy of laparoscopic pudendal nerve and artery decompression in young patients suffering from refractory ED, associated to a pudendal nerve entrapment syndrome. After excluding patients with psychological ED and venous leakage, five young male patients with a history of both ED and pudendal nerve entrapment syndrome diagnosed based on the Nantes criteria were recruited. Pudendal nerve and artery release was performed using a laparoscopic transperitoneal approach. International Index for Erectile Function (IIEF-5) and erectile hardness score (EHS) improved significantly in all patients, 3 months after surgery. Pudendal nerve and artery entrapment could be therefore a reversible cause of ED in young healthy males, and its treatment by laparoscopic pudendal nerve and artery decompression seems to be safe and effective.

Laparoscopic selective pudendal neuromodulation for neurogenic bladder: a review of literature

This study presents an alternative technique for neuromodulation in cases where percutaneous sacral implantation is difficult or has previously failed. We aimed to describe a novel technique of selective placement of an electrode over the pudendal nerve (PN), via laparoscopic approach in a patient with urinary retention who previously failed sacral neuromodulation (SNM) treatment.

A minimally invasive, endoscopic transgluteal procedure for pudendal nerve and inferior cluneal nerve neurolysis in case of entrapment: 3- and 6-month results. The ENTRAMI technique for neurolysis

BACKGROUND

Pudendal and cluneal nerve entrapment can cause a neuropathic pain syndrome in the sensitive areas innervated by these nerves. Recently, a new endoscopic minimal invasive approach for pudendal and inferior cluneal nerve neurolysis has been published in a cadaver study. The aim of our study was to describe the feasibility of this new approach and to evaluate the clinical outcome.

METHODS

Fifteen patients underwent the ENTRAMI technique. The Numeric Pain Rating Scale (NPRS) and Patient Global Impression of Change (PGIC) were recorded at baseline and at 3 and 6 months after surgery.

RESULT

The average duration of intervention (skin to skin) was 139 min (range 50-270 min) for bilateral pudendal neurolysis and/or cluneal neurolysis and 113 min (range 100-130 min) for unilateral pudendal and/or cluneal neurolysis. No perioperative blood loss occurred. At 3 months, 50% of patients declared a more than 30% improvement of their PGIC, increasing to 57% at 6 months; 31% reported more than 90% improvement of PGIC at 6 months. Overall reduction of the average maximal NPRS score was from 9 (range 7-10) to 6 at 3 months (range 0-10; p value < 0.05) and to 5 at 6 months (range 0-10; p value < 0.05). There were no postoperative complications.

CONCLUSIONS

The ENTRAMI technique is feasibly in patients suffering from pudendal and/or cluneal neuralgia and preliminary results are promising.

CLINICAL TRIAL NUMBER

NCT03883178.

Successful Treatment of Penile Numbness and Erectile Dysfunction Resulting From Pudendal Nerve Entrapment

Pudendal nerve decompression surgery has not been studied or reported for the treatment of penile numbness in the absence of pain. Herein, we report a case of a male patient with chronic numbness of the penis and erectile dysfunction in the absence of pelvic pain who was found to have pudendal nerve entrapment. This patient was treated with surgical decompression of the pudendal nerves that resulted in the return of genital sensation and erections. Thus, we propose that pudendal nerve entrapment may be considered as a cause of penile numbness and that pudendal nerve decompression surgery in these patients may be effective.

Chronic prostatitis: current treatment options

Male chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is represented by a heterogeneous group of symptoms that can cause an important impairment of daily quality of life for patients. Diagnosis of CP/CPPS is often not clear and treatment can be challenging, as it varies according to the different causative factors and derived symptoms. Differently from approaches used in the past, the diagnosis and subsequent treatment rely on separating this entity from chronic bacterial prostatitis and considering it as a multifactorial disease. Autoimmunity and inflammation, myofascial tenderness, neuroinflammation, and psychological causes have been clearly related to this disease, and therefore CPPS should not only be considered as related to benign prostatic enlargement. A multitude of different symptoms related to urinary, genital, rectal, and perineal areas can be attributed to this condition and therefore should be routinely investigated in patients, as well as possible differential diagnoses which can cause the same symptoms, such as pudendal nerve entrapment syndrome. The aim of this narrative review is to focus on CPPS after an infectious cause has been excluded.

The ENTRAMI technique: Endoscopic transgluteal minimal invasive technique for implantation of a pudendal electrode under full visual control: A cadaver study

AIM

The aim of this article is to describe a minimal invasive trans gluteal endoscopic approach to implant a pudendal electrode for neuromodulation under full visual control.

METHODS

Eight trans gluteal approaches were performed on four cadavers. The sacral transforaminal percutaneous technique was performed to implant the electrode. The electrode was then picked up and placed under visual control next to the pudendal nerve.

RESULTS

The first trocar was placed in the upper lateral quadrant of the gluteal region. The 0° optical system was used to help with the pneumodissection to identify the sciatic nerve. At that point a second 3 mm trocar was placed to insert a dissecting grasping forceps. In some cases, a second 3 mm trocar was placed. A step by step dissection, based on anatomical findings, was necessary to be able to locate the pudendal nerve. The electrode, which was placed percutaneously and transforaminal through S3 or S4, was picked up and placed under full visual control next to the pudendal nerve, slightly entering the Alcock's canal. The electrode was placed in an ideal manner, meaning that all 4-contact points of the electrode are in parallel and in contact with the targeted nerve. The electrode was fixed in that ideal position at the level of the sacrospinous ligament. After placement of that electrode, an X-ray of the pelvic area was done.

CONCLUSIONS

The ENTRAMI technique allows optimal pudendal electrode placement under full visual control and should now be tested in a clinical setting.

Robot-assisted pudendal neurolysis in the treatment of pudendal nerve entrapment syndrome

INTRODUCTION

Pudendal nerve entrapment syndrome (PNE) is characterised by the presence of neuropathic pain in the pudendal nerve (PN) territory, associated or not with urinary, defecatory and sexual disorders. Surgical PN decompression is an effective and safe alternative for cases when conservative treatment fails. The aim of this study is to describe the first robot-assisted pudendal neurolysis procedure performed in our country.

MATERIAL AND METHODS

We describe step by step the technique of robot-assisted laparoscopic neurolysis of the left PN performed with intraoperative neurophysiological monitoring on a 60-year-old patient diagnosed with left PNE.

RESULTS

The procedure was performed satisfactorily without complications. After 24h, the patient was discharged from the hospital. We observed a 50% reduction in pain measured using the visual analogue scale 2 weeks after the procedure, which remained after 10 weeks of the neurolysis.

CONCLUSIONS

Robot-assisted neurolysis of the PN constitutes a feasible and safe approach, enabling better visualisation and accuracy in the dissection of the PN. Intraoperative neurophysiological monitoring is useful for locating the PN and for detecting intraoperative changes after the release of the nerve.

A new endoscopic minimal invasive approach for pudendal nerve and inferior cluneal nerve neurolysis: An anatomical study

AIM

To describe a new minimal invasive approach of the gluteal region which will permit to perform neurolysis of the pudendal and cluneal nerves in case of perineal neuralgia due to an entrapment of these nerve trunks.

METHOD

Ten transgluteal approaches were performed on five cadavers. Relevant anatomic structures were dissected and further described. Neurolysis of the pudendal nerve or cluneal nerves were performed. Landmarks for secure intraoperative navigation were indicated.

RESULTS

The first operative trocar for the camera was inserted with regards to the iliac crest in the deep gluteal space. With the aid of pneumodissection, the infragluteal plane was dissected. The piriformis muscle was identified as well as the sciatic and the posterior femoral cutaneous nerve. Consequently, the sciatic tuberosity was visualized together with the cluneal nerves. Hereafter, the second trocar was introduced caudal to the first one and placed on an horizontal line passing at the level of the coccyx, allowing access to the ischial spine and the visualization of the pudendal nerve and vessels. A third 5 mm trocar was then inserted medial from the first one, permitting to dissect and transsect the sacrospinous ligament. The pudendal nerve was subsequently transposed and followed on its course in the pudendal channel.

CONCLUSIONS

A reliable exploration of the gluteal region including identification of the sciatic, pudendal, and posterior femoral cutaneous nerves is feasible using a minimal invasive transgluteal procedure. Consequently, the transposition of the pudendal nerve and the liberation of the cluneal nerves can be performed.

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.