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Ruffolo AF, Dolci C, Rubod C, Candiani M, Salvatore S, Lallemant M, Cosson M. Urodynamic Profile and Impact of Surgery in Women Affected by Deep Infiltrating Endometriosis: a Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2024:S1553-4650(24)00428-X. [PMID: 39326841 DOI: 10.1016/j.jmig.2024.09.020] [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: 06/26/2024] [Revised: 09/18/2024] [Accepted: 09/19/2024] [Indexed: 09/28/2024]
Abstract
OBJECTIVE to evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection. DATA SOURCES A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: 30 April 2024). METHODS OF STUDY SELECTION we included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials (RCTs), observational prospective or retrospective studies and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included. TABULATION, INTEGRATION, AND RESULTS Nine studies including 574 women affected by DIE and submitted to urodynamic assessment were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% CI 3, 26; I2=93.9%, p<0.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2=78.1%, p<0.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2=97.2%, p<0.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2=86%, p<0.001), low preoperative bladder compliance was reported in 35% of patient (95% CI 30, 40; I2=0%, p=0.66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2=0%, p=0.58). No difference between preoperative and postoperative UDS DO was reported (OR 0.45; 95% CI -0.10, 1.0, I2=0%; p=0.66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2=49.6%; p=0.12). CONCLUSION Abnormal urodynamic findings before surgery are prevalent in women with deep infiltrating endometriosis. Surgery seems not affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings.
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Affiliation(s)
| | - Carolina Dolci
- Unit of Gynecology and Obstetrics, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Chrystele Rubod
- Department of Gynecology, Jeanne de Flandre University Hospital, 59000 Lille, France
| | - Massimo Candiani
- Unit of Gynecology and Obstetrics, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Stefano Salvatore
- Unit of Gynecology and Obstetrics, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Marine Lallemant
- Department of Gynecology, Jeanne de Flandre University Hospital, 59000 Lille, France
| | - Michel Cosson
- Department of Gynecology, Jeanne de Flandre University Hospital, 59000 Lille, France
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Choi S, Roviglione G, Chou D, D'Ancona G, Ceccaroni M. Nerve-sparing surgery in deep endometriosis: Has its time come? Best Pract Res Clin Obstet Gynaecol 2024; 96:102506. [PMID: 38981835 DOI: 10.1016/j.bpobgyn.2024.102506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/05/2024] [Accepted: 05/19/2024] [Indexed: 07/11/2024]
Abstract
Nerve-sparing (NS) surgery was first introduced for the treatment of deep endometriosis (DE) 20 years ago, drawing on established neuroanatomy and success from oncological applications. It aims to identify and preserve autonomic nerve fibres, reduce iatrogenic nerve injury, and minimize postoperative visceral dysfunction, without compromising the therapeutic effectiveness against endometriosis. The evolution of NS surgical techniques over the past two decades has been supported by an expanding body of literature on anatomical details, dissection techniques, and functional outcomes. Recent evidence suggests that NS surgery results in reduced postoperative voiding dysfunction (POVD). Transient POVD may be influenced by preoperative dysfunction, with parametrial infiltration being a strong predictive factor for POVD. While the benefits in bowel and sexual functions are less pronounced and consistent, NS surgery potentially prevents de novo dysfunctions in these areas. Furthermore, perioperative complication rates, effectiveness in pain relief, and fertility outcomes are reportedly on par with conventional surgery.
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Affiliation(s)
- Sarah Choi
- Sydney Women's Endosurgery Centre, Women's & Children's Health, St. George Hospital, South Eastern Sydney Local Health District, New South Wales, 2217, Australia.
| | - Giovanni Roviglione
- Department of Obstetrics and Gynaecology, Gynaecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacro-Cuore - Don Calabria Hospital, Via Don A. Sempreboni 5, Negrar, Verona, Italy.
| | - Danny Chou
- Sydney Women's Endosurgery Centre, Women's & Children's Health, St. George Hospital, South Eastern Sydney Local Health District, New South Wales, 2217, Australia; Division of Obstetrics and Gynaecology, School of Clinical Medicine, Health and Medicine, University of New South Wales, Sydney, New South Wales, 2052, Australia.
| | - Gianmarco D'Ancona
- Department of Obstetrics and Gynaecology, Gynaecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacro-Cuore - Don Calabria Hospital, Via Don A. Sempreboni 5, Negrar, Verona, Italy.
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynaecology, Gynaecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacro-Cuore - Don Calabria Hospital, Via Don A. Sempreboni 5, Negrar, Verona, Italy.
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3
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Thiel P, Kobylianskii A, McGrattan M, Lemos N. Entrapped by pain: The diagnosis and management of endometriosis affecting somatic nerves. Best Pract Res Clin Obstet Gynaecol 2024; 95:102502. [PMID: 38735767 DOI: 10.1016/j.bpobgyn.2024.102502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/22/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
Somatic nerve entrapment caused by endometriosis is an underrecognized and often misdiagnosed issue that leads to many women suffering unnecessarily. While the classic symptoms of endometriosis are well-known to the gynaecologic surgeon, the dermatomal-type pain caused by endometriosis impacting neural structures is not within gynecologic day-to-day practice, which often complicates diagnosis and delays treatment. A thorough understanding of pelvic neuroanatomy and a neuropelveologic approach is required for accurate assessments of patients with endometriosis and nerve entrapment. Magnetic resonance imaging is the preferred imaging modality for this presentation of endometriosis. Surgical management with laparoscopic or robotic-assisted techniques is the preferred approach to treatment, with excellent long-term results reported after nerve detrapment and endometriosis excision. The review calls for increased awareness and education on the links between endometriosis and the nervous system, advocating for patient-centered care and further research to refine the diagnosis and treatment of this challenging condition.
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Affiliation(s)
- Peter Thiel
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada
| | - Anna Kobylianskii
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada
| | - Meghan McGrattan
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada
| | - Nucelio Lemos
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Gynecology, Women's College Hospital, Toronto, Ontario, Canada; Department of Gynecology, University of Sao Paolo, Sao Paolo, Brazil; Department of Neuropelveology and Advanced Pelvic Surgery, Institute for Care and Rehabilitation in Neuropelveology and Gynecology (INCREASING), Sao Paolo, Brazil.
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4
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Sermer C, Li ALK, Fernandes GL, Ribeiro AM, Polesello G, Tokechi D, Cancelliere L, Lemos N. Intrapelvic entrapment of sacral nerve roots by abnormal bundles of the piriformis muscle: description of an extra-spinal cause of sciatica and pudendal neuralgia. J Hip Preserv Surg 2021; 8:132-138. [PMID: 34567608 PMCID: PMC8460165 DOI: 10.1093/jhps/hnab041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 03/21/2021] [Indexed: 11/13/2022] Open
Abstract
Piriformis syndrome is a well-known extra-spinal cause of sciatica characterized by the entrapment of the sciatic nerve by variant bundles of the piriformis muscles in the deep gluteal space. In this case series, we describe the entrapment of intrapelvic portions of the sacral nerve roots by a variant bundle of the piriformis muscle originating medially to the sacral foramina, the surgical technique for the laparoscopic treatment of this condition, and the outcomes of the first eight cases treated with this technique. Five female and three male patients presenting with sciatica, pudendal pain and lower urinary tract symptoms underwent a laparoscopic exploration of the intrapelvic portion of the sacral nerve roots and transection of the abnormal piriformis bundle. Surgical technique is demonstrated in the Supplementary Video. Clinical success was achieved in seven of the eight patients, with a reduction of pain numeric rating scale from 8.5 (±1.2; 7-10) pre-operatively to 2.1 (±2.6; 0-7), 1-year following surgery. In conclusion, entrapment of intrapelvic portions of the sacral nerve roots by variant bundles of the piriformis originating medially to the sacral foramina are an extraspinal cause of sciatica, which can be treated though a laparoscopic approach.
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Affiliation(s)
- Corey Sermer
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada
| | - Adrienne L K Li
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada
| | - Gustavo L Fernandes
- Department of Gynecology, Federal University of São Paulo. Rua Napoleão de Barros, 608, São Paulo, SP, Brazil.,Department of Gynecology, Faculdade de Ciências Médicas da Santa Casa de São Paulo. Rua Doutor Cesário Mota Júnior, 42, São Paulo, SP, Brazil
| | - Augusta M Ribeiro
- Department of Gynecology, Federal University of São Paulo. Rua Napoleão de Barros, 608, São Paulo, SP, Brazil
| | - Giancarlo Polesello
- Department of Gynecology, Faculdade de Ciências Médicas da Santa Casa de São Paulo. Rua Doutor Cesário Mota Júnior, 42, São Paulo, SP, Brazil
| | - Denise Tokechi
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91, São Paulo, SP, Brazil
| | - Laura Cancelliere
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada
| | - Nucelio Lemos
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada.,Department of Gynecology, Federal University of São Paulo. Rua Napoleão de Barros, 608, São Paulo, SP, Brazil
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5
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Lemos N, Melo HJF, Sermer C, Fernandes G, Ribeiro A, Nascimento G, Luo ZC, Girão MJBC, Goldman SM. Lumbosacral plexus MR tractography: A novel diagnostic tool for extraspinal sciatica and pudendal neuralgia? Magn Reson Imaging 2021; 83:107-113. [PMID: 34400289 DOI: 10.1016/j.mri.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/10/2021] [Accepted: 08/11/2021] [Indexed: 11/30/2022]
Abstract
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).
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Affiliation(s)
- Nucelio Lemos
- Department of Obstetrics and Gynecology of Women's College Hospital and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada; Department of Gynecology, Escola Paulista de Medicina, Federal University of São Paulo, Brazil; Department of Neuropelveology and Advanced Pelvic Surgery, Increasing - Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil.
| | - Homero J F Melo
- Instituto de Educação Superior IMEB (IMEB-IES), Brasilia, Brazil
| | - Corey Sermer
- Department of Obstetrics and Gynecology of Women's College Hospital and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Gustavo Fernandes
- Department of Gynecology, Escola Paulista de Medicina, Federal University of São Paulo, Brazil; Department of Neuropelveology and Advanced Pelvic Surgery, Increasing - Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil; Department of Obstetrics and Gynecology, Santa Casa School of Medical Sciences, São Paulo, Brazil
| | - Augusta Ribeiro
- Department of Gynecology, Escola Paulista de Medicina, Federal University of São Paulo, Brazil; Department of Neuropelveology and Advanced Pelvic Surgery, Increasing - Institute of Care and Rehabilitation in Neuropelveology and Gynecology, São Paulo, Brazil
| | - Geovanne Nascimento
- Department of Magnetic Resonance Imaging, CURA- Centro de Ultrassonografia e Radiologia Aplicada, São Paulo, SP, Brazil
| | - Zhong Cheng Luo
- Lunenfeld-Tanenbaum Research Institute, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Manoel J B C Girão
- Department of Gynecology, Escola Paulista de Medicina, Federal University of São Paulo, Brazil
| | - Suzan Menasce Goldman
- Department of Magnetic Resonance Imaging, CURA- Centro de Ultrassonografia e Radiologia Aplicada, São Paulo, SP, Brazil; Department of Radiology, Escola Paulista de Medicina, Federal University of São Paulo, Brazil
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6
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Lemos N, Sermer C, Fernandes G, Morgado-Ribeiro A, Rossos A, Zhao ZY, Girão MJBC, Peng P. Laparoscopic approach to refractory extraspinal sciatica and pudendal pain caused by intrapelvic nerve entrapment. Sci Rep 2021; 11:10820. [PMID: 34031480 PMCID: PMC8144185 DOI: 10.1038/s41598-021-90319-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Nucelio Lemos
- Department of Obstetrics and Gynecology, Mount Sinai and Women's College Hospital, University of Toronto, Toronto, ON, Canada. .,Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil. .,Department of Obstetrics and Gynecology, Mount Sinai and Women's College Hospital, University of Toronto, 700 University Avenue
- Room 8-917, Toronto, ON, M5S 1Z5, Canada.
| | - Corey Sermer
- Department of Obstetrics and Gynecology, Mount Sinai and Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Gustavo Fernandes
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | | | - Andrea Rossos
- Department of Obstetrics and Gynecology, Mount Sinai and Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Zi Ying Zhao
- Department of Obstetrics and Gynecology, Mount Sinai and Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Manuel J B C Girão
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Philip Peng
- Department of Anesthesiology and Pain Management, Mount Sinai and Women's College Hospital, University of Toronto, Toronto, ON, Canada
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Intrapelvic Nerve Entrapment Syndrome Caused by a Variation of the Intrapelvic Piriformis Muscle and Abnormal Varicose Vessels: A Case Report. Int Neurourol J 2021; 25:177-180. [PMID: 33504131 PMCID: PMC8255827 DOI: 10.5213/inj.2040232.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/16/2020] [Indexed: 11/08/2022] Open
Abstract
Entrapment neuropathy of the sciatic nerve and pudendal nerve are painful syndromes that are often overlooked by physicians. Laparoscopic surgical interventions for nerve entrapment syndromes of the posterior pelvis focus on removing the compression lesion with the purpose of eliminating the suspected cause of sciatica, as well as pudendal neuralgia. Herein, the authors report the rare event of sciatic and pudendal nerve entrapment, which was caused by aberrant vessels and a variant piriformis muscle bundle, as a seldom-diagnosed cause of sciatica and pelvic pain, for both neurosurgeons and neuropelveologists. The authors present the laparoscopic decompression technique for the pudendal and sciatic nerves by giving our technical “tips and tricks” enriched by a surgical video.
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Marcu I, Balica A, Gavard JA, Campian EC, Fernandes GL, Solnik MJ, Morozov V, Lemos N. Closing the knowledge gap in pelvic neuroanatomy: assessment of a cadaveric training program. BMC MEDICAL EDUCATION 2021; 21:26. [PMID: 33413351 PMCID: PMC7792346 DOI: 10.1186/s12909-020-02443-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/10/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The objective of this study is to characterize participants in a laparoscopic cadaveric neuroanatomy course and assess knowledge of pelvic neuroanatomy before and after this course. METHODS This is a survey-based cohort study with a setting in a university educational facility. The participants are surgeons in a multiday laparoscopic cadaveric pelvic neuroanatomy course. Participants completed a precourse survey, including demographics and comfort with laparoscopic surgery. They then completed an identical precourse and postcourse anatomic knowledge test. Main outcomes are scores on the anatomic knowledge test precourse and postcourse. RESULTS 44 respondents were included: 25 completed fellowship, 15 completed residency, 2 were residents, and 2 were fellows. Participants were on average 11.09 years post training, with an average of 8.67 years from training if they completed fellowship and 18.62 years if they completed residency only. 22 of 42 respondents strongly agreed or agreed they are comfortable performing complex laparoscopic hysterectomies. The average precourse score was 32.18/50 points and the mean difference score (MDS, defined as mean of Postcourse scores minus Precourse scores) was 9.80, showing significant improvement (p < 0.001). Precourse and MDS scores were not significantly different when comparing country of practice, level of training, or time since training. CONCLUSION Baseline knowledge of pelvic neuroanatomy was similar among groups when comparing fellowship status, place of training, or time since training. There was significant improvement in knowledge after training in this dissection method. This course garnered interest from surgeons with broad training backgrounds.
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Affiliation(s)
- Ioana Marcu
- Department of Obstetrics and Gynecology, Saint Louis University School of Medicine, Saint Louis, MO, USA.
| | - Adrian Balica
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jeffrey A Gavard
- Department of Obstetrics and Gynecology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Eugen C Campian
- Department of Obstetrics and Gynecology, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Gustavo Leme Fernandes
- Department of Obstetrics and Gynecology, Faculdade de Medicina do ABC, Santo André, São Paulo, Brazil
| | - M Jonathon Solnik
- Department of Obstetrics and Gynecology, Division of Gynecology and Minimally Invasive Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Vadim Morozov
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, University of Maryland, Baltimore, MD, USA
| | - Nucelio Lemos
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
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Soares M, Mimouni M, Oppenheimer A, Nyangoh Timoh K, du Cheyron J, Fauconnier A. Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes. J Minim Invasive Gynecol 2020; 28:1194-1202. [PMID: 33130225 DOI: 10.1016/j.jmig.2020.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity. DESIGN Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. SETTING Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. PATIENTS This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions. INTERVENTIONS For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves. MEASUREMENTS AND MAIN RESULTS Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031). CONCLUSION Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.
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Affiliation(s)
- Michelle Soares
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye (Drs. Soares, Mimouni, Fauconnier, and Mr. du Cheyron), Poissy.
| | - Myriam Mimouni
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye (Drs. Soares, Mimouni, Fauconnier, and Mr. du Cheyron), Poissy
| | - Anne Oppenheimer
- EA 7285 Research Unit: Risk and Safety in Clinical Medicine for Women and Perinatal Health, Versailles-Saint-Quentin University (Drs. Oppenheimer and Fauconnier), Montigny-le-Bretonneux
| | - Krystel Nyangoh Timoh
- Department of Gynecology and Obstetrics, Centre Hospitalier Universitaire de Rennes Cedes (Dr. Nyangoh-Timoh), Rennes, France
| | - Joseph du Cheyron
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye (Drs. Soares, Mimouni, Fauconnier, and Mr. du Cheyron), Poissy
| | - Arnaud Fauconnier
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye (Drs. Soares, Mimouni, Fauconnier, and Mr. du Cheyron), Poissy; EA 7285 Research Unit: Risk and Safety in Clinical Medicine for Women and Perinatal Health, Versailles-Saint-Quentin University (Drs. Oppenheimer and Fauconnier), Montigny-le-Bretonneux
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Raimondo D, Mattioli G, Casadio P, Borghese G, Ambrosio M, Arena A, Paradisi R, Del Forno S, Coppola F, Valerio D, Garattoni M, Golfieri R, Seracchioli R. Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis. J Gynecol Obstet Hum Reprod 2020; 49:101697. [PMID: 32018043 DOI: 10.1016/j.jogoh.2020.101697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/25/2019] [Accepted: 01/24/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms. MATERIAL AND METHODS We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea. RESULTS Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group. CONCLUSIONS Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.
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Affiliation(s)
- Diego Raimondo
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Giulia Mattioli
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy.
| | - Paolo Casadio
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Giulia Borghese
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Marco Ambrosio
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Alessandro Arena
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Roberto Paradisi
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Simona Del Forno
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
| | - Francesca Coppola
- Radiology Unit, Department of Digestive Disease and Internal Medicine, DIMES, S. Orsola Hospital, University of Bologna, Italy
| | - Domenico Valerio
- Radiology Unit, Department of Digestive Disease and Internal Medicine, DIMES, S. Orsola Hospital, University of Bologna, Italy
| | - Monica Garattoni
- Radiology Unit, Department of Digestive Disease and Internal Medicine, DIMES, S. Orsola Hospital, University of Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Digestive Disease and Internal Medicine, DIMES, S. Orsola Hospital, University of Bologna, Italy
| | - Renato Seracchioli
- Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy
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Lemos N, Cancelliere L, Li ALK, Moretti Marques R, Fernandes GL, Sermer C, Kumar K, Sebastião Afonso J, Girão MJBC. Superior gluteal vein syndrome: an intrapelvic cause of sciatica. J Hip Preserv Surg 2019; 6:104-108. [PMID: 31660194 PMCID: PMC6662955 DOI: 10.1093/jhps/hnz012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/20/2019] [Indexed: 11/17/2022] Open
Abstract
The role of malformed or dilated branches of iliac vessels in causing pelvic pain is not well understood. Such vessels may entrap nerves of the lumbosacral (LS) plexus against the pelvic sidewalls, producing symptoms not typically encountered in gynecological practice, including sciatica and refractory urinary and/or anorectal dysfunction. We describe cases of sciatica in which laparoscopy revealed compression of the LS plexus by variant superior gluteal veins (SGVs). In demonstrating an improvement in patient symptoms after decompression, we identify this neurovascular conflict as a potential intrapelvic cause of sciatica. This study is a retrospective case series (Canadian Task Force Classification II-3). Nerve decompression laparoscopies were performed in São Paulo, Brazil. Thirteen female patients undergoing laparoscopy for sciatica with no clear spinal or musculoskeletal causes were included in this study. In all cases, we identified LS entrapment by aberrant SGVs, and performed decompression by vessel ligation. The average preoperative visual analog scale score of 9.62 ± 0.77 decreased significantly to 2.54 ± 2.88 post-operatively (P < 0.001). The success rate (defined as ≥ 50% improvement in visual analog scale score) was 92.3%, over a follow-up of 13.2 ± 10.6 months. Our case series demonstrates a high success rate and significant decrease in pain scores after laparoscopic intrapelvic decompression, thereby identifying pelvic nerve entrapment by aberrant SGVs as a potential yet previously unrecognized cause of sciatica. This intrapelvic neurovascular conflict—the SGV syndrome—should be considered in cases of sciatica with no identifiable spinal or musculoskeletal etiology.
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Affiliation(s)
- Nucelio Lemos
- Pelvic Functional Surgery and Neuropelveology Clinic, Neuropelveology and Pelvic Functional Surgery Special Interest Group (NPFSSIG), Department of Obstetrics and Gynecology of Women's College and Mount Sinai Hospitals, University of Toronto, 700 University Avenue, Room 8-917, Toronto, ON, Canada.,Pelvic Neurodysfunction Clinic, Department of Obstetrics and Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Laura Cancelliere
- Pelvic Functional Surgery and Neuropelveology Clinic, Neuropelveology and Pelvic Functional Surgery Special Interest Group (NPFSSIG), Department of Obstetrics and Gynecology of Women's College and Mount Sinai Hospitals, University of Toronto, 700 University Avenue, Room 8-917, Toronto, ON, Canada
| | - Adrienne L K Li
- Pelvic Functional Surgery and Neuropelveology Clinic, Neuropelveology and Pelvic Functional Surgery Special Interest Group (NPFSSIG), Department of Obstetrics and Gynecology of Women's College and Mount Sinai Hospitals, University of Toronto, 700 University Avenue, Room 8-917, Toronto, ON, Canada
| | - Renato Moretti Marques
- Pelvic Neurodysfunction Clinic, Department of Obstetrics and Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Gustavo L Fernandes
- Pelvic Neurodysfunction Clinic, Department of Obstetrics and Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Corey Sermer
- Pelvic Functional Surgery and Neuropelveology Clinic, Neuropelveology and Pelvic Functional Surgery Special Interest Group (NPFSSIG), Department of Obstetrics and Gynecology of Women's College and Mount Sinai Hospitals, University of Toronto, 700 University Avenue, Room 8-917, Toronto, ON, Canada
| | - Kinshuk Kumar
- Pelvic Functional Surgery and Neuropelveology Clinic, Neuropelveology and Pelvic Functional Surgery Special Interest Group (NPFSSIG), Department of Obstetrics and Gynecology of Women's College and Mount Sinai Hospitals, University of Toronto, 700 University Avenue, Room 8-917, Toronto, ON, Canada
| | - Jose Sebastião Afonso
- Department of Obstetrics and Gynecology, Amazonas State University, Manaus, AM, Brazil
| | - Manoel J B C Girão
- Pelvic Neurodysfunction Clinic, Department of Obstetrics and Gynecology, Federal University of São Paulo, São Paulo, Brazil
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Kale A, Basol G, Usta T, Aytuluk HG. Laparoscopic evaluation of female pelvic neuroanatomy and autonomic plexuses in terms of gynecologic perspective. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2018. [DOI: 10.1177/2284026518798331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The nerves located in the deepest areas can be exposed and dissected via laparoscopic magnification. This technological innovation does not only help us to avoid surgery-related complications but also allows us to diagnose the vascular entrapment syndromes. The aim of this article is to demonstrate female neuroanatomy and autonomic plexus via enriched photos and videos to reveal the relationship of the pelvic nervous system with gynecological operations.
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Affiliation(s)
- Ahmet Kale
- Department of Obstetrics and Gynecology, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Gulfem Basol
- Department of Obstetrics and Gynecology, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Taner Usta
- Department of Obstetrics and Gynecology, Acibadem University, Altunizade Hospital, İstanbul, Turkey
| | - Hande G Aytuluk
- Department of Anesthesiology and Reanimation, Derince Education and Research Hospital, Kocaeli, Turkey
- Department of Anatomy, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
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Abstract
Understanding the etiology of and evolving research on intra- and extra-articular hip complaints requires comprehensive diagnosis and management of the spectrum of posterior hip diseases. Interest in posterior hip disorders has increased in recent years as new studies and theories have emerged regarding the disease process. Although most of the differential diagnoses around the posterior hip have traditionally been considered uncommon, recent reports suggest that these complaints have instead been commonly overlooked. Failure to identify the cause of posterior hip pain in a timely manner can increase pain perception, deteriorate the patient's hope, and consequently affect quality of life. Posterior hip pain could be differentiated as intrapelvic and extrapelvic, and differential diagnosis is made based on a comprehensive history, physical examination, and imaging studies. Plain radiography, CT, MRI, 3T MRI, and imaging-guided injection tests are usually necessary for accurate diagnosis. Surgical intervention, whether endoscopic or open, is required for patients with long-standing symptoms for whom nonsurgical treatment has been unsuccessful and who have experienced temporary relief of their symptoms after injection. Orthopedic surgeons are uniquely trained in understanding the anatomy, biomechanics, clinical evaluation and treatment of all five layers of the hip.
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Tobar Roa V, Gómez M, González A, Zableh A. Neuropatía del pudendo como causa de dolor pélvico. UROLOGÍA COLOMBIANA 2018. [DOI: 10.1016/j.uroco.2017.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ResumenEl 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.
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Affiliation(s)
- Verónica Tobar Roa
- Universidad Autónoma de Bucaramanga; Uróloga Pontificia Universidad Javeriana; Máster Universitario de Investigación Clínica en Donación y Trasplante de Órganos, Tejidos y Células, Universidad de Barcelona; Uróloga, Centro Urológico Foscal, Floridablanca, Santander, Colombia
| | - María Gómez
- Universidad Industrial de Santander; Anestesióloga, Universidad Militar Nueva Granada; Fellow Anestesia Regional guiada por Ultrasonido programa CLASA-WFSA-SBA; Anestesióloga Sociedad Especializada de Anestesiología SEA S.A., Clínica Carlos Ardila Lulle, Floridablanca, Santander, Colombia
| | - Ana González
- Universidad Autónoma de Bucaramanga; Residente de Segundo año de Urología, Universidad Autónoma de Bucaramanga, Floridablanca, Santander, Colombia
| | - Ana Zableh
- Interna, Pontificia Universidad Javeriana, Bogotá, Colombia
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Urodynamic observations and lower urinary tract symptoms associated with endometriosis: a prospective cross-sectional observational study assessing women with deep infiltrating disease. Int Urogynecol J 2018; 29:1349-1358. [DOI: 10.1007/s00192-017-3531-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
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Neuropelveology: An Emerging Discipline for the Management of Chronic Pelvic Pain. Int Neurourol J 2017; 21:243-246. [PMID: 29298475 PMCID: PMC5756824 DOI: 10.5213/inj.1735036.518] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 12/06/2017] [Indexed: 02/06/2023] Open
Abstract
Chronic pelvic pain (CPP) is a common condition involving multiple, organ-specific medical specialties, each with its own approach to diagnosis and treatment. Management requires knowledge of the interplay between pelvic organ function and neuro-functional anatomy, and of the neurologic and psychological aspects of CPP, but no current specialty fully encompasses this approach. Neuropelveology is an emerging discipline focusing on pathologies of the pelvic nervous system on a cross-disciplinary basis. It involves a neurological/neurosurgical approach, combining the knowledge required for a proper neurologic diagnosis, confirmation by transvaginal/transrectal examination of the pelvic nerves, and advanced laparoscopic surgery in selected cases of CPP. The management of CPP requires multidisciplinary contributions, and neuropelveology may offer an educational framework for the interdisciplinary exchange of knowledge between clinical physicians and basic researchers.
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Lemos N, Marques RM, Kamergorodsky G, Ploger C, Schor E, Girão MJBC. Vascular entrapment of the sciatic plexus causing catamenial sciatica and urinary symptoms. Int Urogynecol J 2015. [PMID: 26209951 DOI: 10.1007/s00192-015-2777-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Nucelio Lemos
- Pelvic Neurodysfunction Clinic of the Department of Obstetrics and Gynecology, Federal University of São Paulo, Rua Jose de Magalhaes, 373 ap904., São Paulo, SP, CEP: 04026-090, Brazil.
| | - Renato Moretti Marques
- Pelvic Neurodysfunction Clinic of the Department of Obstetrics and Gynecology, Federal University of São Paulo, Rua Jose de Magalhaes, 373 ap904., São Paulo, SP, CEP: 04026-090, Brazil
| | - Gil Kamergorodsky
- Pelvic Neurodysfunction Clinic of the Department of Obstetrics and Gynecology, Federal University of São Paulo, Rua Jose de Magalhaes, 373 ap904., São Paulo, SP, CEP: 04026-090, Brazil
| | - Christine Ploger
- Pelvic Neurodysfunction Clinic of the Department of Obstetrics and Gynecology, Federal University of São Paulo, Rua Jose de Magalhaes, 373 ap904., São Paulo, SP, CEP: 04026-090, Brazil
| | - Eduardo Schor
- Pelvic Neurodysfunction Clinic of the Department of Obstetrics and Gynecology, Federal University of São Paulo, Rua Jose de Magalhaes, 373 ap904., São Paulo, SP, CEP: 04026-090, Brazil
| | - Manoel J B C Girão
- Pelvic Neurodysfunction Clinic of the Department of Obstetrics and Gynecology, Federal University of São Paulo, Rua Jose de Magalhaes, 373 ap904., São Paulo, SP, CEP: 04026-090, Brazil
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