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Mylle T, De Corte R, Hervé F, Everaert K, Bou Kheir G. Surgical approaches for pudendal nerve entrapment: insights from a systematic review and meta-analysis. Surg Endosc 2024:10.1007/s00464-024-10990-w. [PMID: 38942945 DOI: 10.1007/s00464-024-10990-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/08/2024] [Indexed: 06/30/2024]
Abstract
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.
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Affiliation(s)
- Toon Mylle
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - René De Corte
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - François Hervé
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Karel Everaert
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - George Bou Kheir
- Department of Urology, ERN Accredited Centre, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Giulioni C, Pirola GM, Maggi M, Pitoni L, Fuligni D, Beltrami M, Palantrani V, De Stefano V, Maurizi V, Castellani D, Galosi AB. Pudendal Nerve Neurolysis in Patients Afflicted With Pudendal Nerve Entrapment: A Systematic Review of Surgical Techniques and Their Efficacy. Int Neurourol J 2024; 28:11-21. [PMID: 38569616 PMCID: PMC10990758 DOI: 10.5213/inj.2448010.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/04/2024] [Indexed: 04/05/2024] Open
Abstract
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.
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Affiliation(s)
- Carlo Giulioni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | | | - Martina Maggi
- Department of Maternal-Infant and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Lucia Pitoni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Demetra Fuligni
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Mattia Beltrami
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Vanessa Palantrani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Virgilio De Stefano
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Valentina Maurizi
- Department of Clinical and Molecular Sciences, Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Polytechnic University of Marche, Ancona, Italy
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Clinical usefulness of quantitative thermal sensory testing in the diagnosis and surgical treatment of women with pudendal neuropathy. Neurol Sci 2023:10.1007/s10072-023-06663-6. [PMID: 36781566 DOI: 10.1007/s10072-023-06663-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/03/2023] [Indexed: 02/15/2023]
Abstract
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.
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Jottard K, Bonnet P, Thill V, Ploteau S, de Wachter S. Diagnosis and treatment of pudendal and inferior cluneal nerve entrapment syndrome: a narrative review. Acta Chir Belg 2022; 122:379-389. [PMID: 36074049 DOI: 10.1080/00015458.2022.2123138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Katleen Jottard
- Department of Surgery, CHU Brugmann, Arthur Van Gehuchtenplaats 4, 1020 Brussels, Belgium
| | - Pierre Bonnet
- Department of Urology and Department of Anatomy, CHU Sart-Tilman, Liège, Belgium
| | - Viviane Thill
- Department of Surgery, CHU Brugmann, Arthur Van Gehuchtenplaats 4, 1020 Brussels, Belgium
| | - Stephane Ploteau
- Department of Gynecology and Obstetrics, Center Hospitalier Universitaire, Nantes, France
| | - Stefan de Wachter
- Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium
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Levesque A, Bautrant E, Quistrebert V, Valancogne G, Riant T, Beer Gabel M, Leroi AM, Jottard K, Bruyninx L, Amarenco G, Quintas L, Picard P, Vancaillie T, Leveque C, Mohy F, Rioult B, Ploteau S, Labat JJ, Guinet-Lacoste A, Quinio B, Cosson M, Haddad R, Deffieux X, Perrouin-Verbe MA, Garreau C, Robert R. Recommendations on the management of pudendal nerve entrapment syndrome: A formalised expert consensus. Eur J Pain 2021; 26:7-17. [PMID: 34643963 DOI: 10.1002/ejp.1861] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/09/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Amélie Levesque
- Urology Department, Nantes University Hospital, Nantes, France
| | - Eric Bautrant
- Pelvi-Perineal Surgery and Rehabilitation Department, Private Medical Centre "l'Avancée-Clinique Axium", Aix en Provence, France
| | | | | | - Thibault Riant
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Marc Beer Gabel
- Neurogastroenterology and Pelvic Floor Unit, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | - Luc Bruyninx
- Department of Surgery, Brugmann Hospital, Brussels, Belgium
| | - Gerard Amarenco
- GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Lara Quintas
- Department of Gynecology, Clinical Institute of Gynecology, Obstetrics, and Neonatology, Faculty of Medicine, Barcelona, Spain
| | - Pascale Picard
- Neurology Department, Clermont-Ferrand University Hospital, Inserm, Clermont-Ferrand, France
| | - Thierry Vancaillie
- School of Women and Children, University of New South Wales, Sydney, New South Wales, Australia
| | - Christine Leveque
- Pelvi-Perineal Surgery and Rehabilitation Department, Private Medical Centre "l'Avancée-Clinique Axium", Aix en Provence, France
| | - Frédérique Mohy
- Pain Management Center, University Hospital Felix Guyon, SAINT DENIS, La Reunion, France
| | - Bruno Rioult
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
| | - Stéphane Ploteau
- Department of Gynecology-Obstetrics and Reproductive Medicine, Nantes University Hospital, Nantes, France
| | | | - Amandine Guinet-Lacoste
- Hospices Civils de Lyon, Hôpital Henry Gabrielle, Plate-forme Mouvement et Handicap, Lyon, France
| | - Bertrand Quinio
- Pain Center, Regional University Hospital la Cavale Blanche, Brest, France
| | - Michel Cosson
- Departement of Gynecology, University Hopsital Jeanne De Flandre, Lille, France
| | - Rebecca Haddad
- GRC 001, GREEN Groupe de Recherche Clinique en Neuro-Urologie, AP-HP, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Xavier Deffieux
- Department of Obstetrics and Gynecology, Antoine Beclere Hospital, Assistance Publique Hopitaux de Paris, Clamart University Paris-Saclay, Clamart, France
| | | | | | - Roger Robert
- Maurice Bensignor Multidisciplinary Pain Center, Centre Catherine de Sienne, Nantes, France
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Aoun F, Mjaess G, Akl B, Nassar D, Kallas Chemaly A, Haydar A, Raad R, Absil F, Nemr E, Bollens R. Pudendal nerve release for lower urinary tract symptoms in young males. Low Urin Tract Symptoms 2020; 13:286-290. [DOI: 10.1111/luts.12368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/05/2020] [Accepted: 11/15/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Fouad Aoun
- Urology Department Institut Jules Bordet Brussels Belgium
- Urology Department Hotel‐Dieu de France, University of Saint Joseph Beirut Lebanon
| | - Georges Mjaess
- Urology Department Hotel‐Dieu de France, University of Saint Joseph Beirut Lebanon
| | - Bernard Akl
- Faculty of Medicine and Medical Sciences University of Balamand Beirut Lebanon
| | - Dany Nassar
- Urology Department Hotel‐Dieu de France, University of Saint Joseph Beirut Lebanon
| | | | - Asad Haydar
- Faculty of Medicine and Medical Sciences University of Balamand Beirut Lebanon
| | - Rami Raad
- Urology Department Rizk Hospital (Lebanese American University Medical Center) Beirut Lebanon
| | | | - Elie Nemr
- Urology Department Hotel‐Dieu de France, University of Saint Joseph Beirut Lebanon
| | - Renaud Bollens
- Urology Department Wallonie Picarde Hospital Tournai Belgium
- Department of Urology Université Nord de France, St Phillibert Hospital Lille France
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Beco J, Mouchel J. Perineural dextrose injections in the treatment of lower urinary tract symptoms and dyspareunia induced by obturator neuralgia. Med Hypotheses 2020; 144:109991. [DOI: 10.1016/j.mehy.2020.109991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 12/18/2022]
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Jottard K, Bruyninx L, Bonnet P, Mathieu N, De Wachter S. Pilot study: pudendal neuromodulation combined with pudendal nerve release in case of chronic perineal pain syndrome. The ENTRAMI technique: early results. Int Urogynecol J 2020; 32:2765-2770. [PMID: 33048179 DOI: 10.1007/s00192-020-04565-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/02/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Katleen Jottard
- Department of Surgery, CHU Brugmann, Arthur Van Gehuchtenplaats 4, 1020, Brussels, Belgium.
| | - Luc Bruyninx
- Department of Surgery, CHU Brugmann, Arthur Van Gehuchtenplaats 4, 1020, Brussels, Belgium
| | - Pierre Bonnet
- Department of Urology and Department of Anatomy, CHU Sart-Tilman, Liège, Belgium
| | - Nathalie Mathieu
- Department of Anesthesiology, Pain Clinic, Brugmann Hospital, Brussels, Belgium
| | - Stefan De Wachter
- Department of Urology, Antwerp University Hospital, Edegem, Belgium.,Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wilrijk, Belgium
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Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome. Surg Endosc 2020; 35:6031-6038. [PMID: 33048235 DOI: 10.1007/s00464-020-08092-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/03/2020] [Indexed: 12/27/2022]
Abstract
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.
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Habib N, Labanca L, Fernandes R, Afors K, Solima E, Moawad G, Centini G. Pudendal Neurolysis: 6-Step Laparoscopic Approach. J Minim Invasive Gynecol 2020; 28:1280-1281. [PMID: 32730993 DOI: 10.1016/j.jmig.2020.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/30/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
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].
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Affiliation(s)
- Nassir Habib
- Department of Obstetrics and Gynecology, Francois Quesnay Hospital, Mantes-la-Jolie, France (Dr. Habib).
| | - Luca Labanca
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy (Drs. Labanca and Centini)
| | - Rodrigo Fernandes
- Discipline of Gynecology, Department of Obstetrics and Gynecology, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (Dr. Fernandes)
| | - Karolina Afors
- Department of Obstetrics and Gynecology, Whittington Hospital, London, United Kingdom (Dr. Afors)
| | - Eugenio Solima
- Department of Obstetrics and Gynecology, Macedonio Melloni Hospital, University of Milan, Milan, Italy (Dr. Solima)
| | - Gaby Moawad
- Gynecology Department, The George Washington University School of Medicine and Health Science, Washington, District of Columbia (Dr. Moawad)
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy (Drs. Labanca and Centini)
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Jottard K, Bruyninx L, Bonnet P, De Wachter S. 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. Neurourol Urodyn 2020; 39:2003-2007. [PMID: 32678485 DOI: 10.1002/nau.24462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | - Luc Bruyninx
- Department of Surgery, Brugmann Hospital, Brussels, Belgium
| | - Pierre Bonnet
- Department of Urology and Department of Anatomy, CHU Sart-Tilman, Liège, Belgium
| | - Stefan De Wachter
- Department of Urology, Antwerp University Hospital, Edegem, Belgium.,Department of Urology, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Antwerp University, Antwerp, Belgium
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