REFRACTORY PUDENDAL PAIN AND PELVICFLOOR DYSFUNCTION CAUSED BY INTRAPELVIC NERVE ENTRAPMENTS - A REVIEWOF 50 CONSECUTIVE CASES
N. L. LEMOS1, J.PAPILLON-SMITH 1, R. MORETTI-MARQUES 2, G. L.FERNANDES 2, M. J. GIRÃO 3, J. M. SOLNIK 4;
1Dept. Obstetrics and Gynecology, Division of PelvicFunctional Surgery and Neuropelveology, Univ. of Toronto, Toronto,Canada, 2Dept. of Gynecology, Division of Pelvic PelvicNeurodysfunctions, Federal Univ. of São Paulo, São Paulo, Brazil,3Dept. Gynecology, Federal Univ. of São Paulo, SãoPaulo, Brazil, 4Dept. Obstetrics and Gynecology, Divisionof Minimally Invasive Surgery, Univ. of Toronto, Toronto, Canada.
Introduction: The intrapelvicportions of the lumbosacral nerves have been well described fordecades. However, capable laparoscopic surgeons in the fields ofgynecology, urology and colorectal surgery are not accustomed todiagnosing and treating peripheral nerve entrapments, whilespecialists who are (neurosurgeons, spine, hip and hand surgeons),rarely have the skills required to navigate the pelvislaparoscopically, the best route to approach these nerves. Forthis reason, intrapelvic nerve entrapment remains a significant,neglected cause of perineal and sciatic pain, as well as refractorypelvic floor dysfunction.
Objective: To report theoutcomes of the first 50 patients undergoing laparoscopic nerve rootdecompression for refractory pudendal nerve pain and pelvic floordysfunction at our center.
Methods: A retrospective cohortstudy of 50 consecutive patients undergoing laparoscopic nerve rootdecompression from December 2009 to December 2017 was conducted atour center. A diagnosis of nerve entrapment was made based onsymptomatology, clinical and neurological examinations. The onset ofsymptoms was recorded at the initial consultation. The number ofprevious surgeries documented included only those aimed at treatinglumbosacral nerve entrapment. Visual analogue scale (VAS) scores wereused to assess pain severity at each patient visit. A paired t-testwas used to compare preoperative VAS-scores to VAS-scores at the lastpost-operative visit. A 50% reduction on VAS score and/or asignificant reduction in the use of analgesics was considered asuccessful outcome.
Results: Etiologies of the intrapelvicnerve entrapments, the nerves involved, and the clinical and surgicaldata are displayed in tables 1 & 2. Success was 86%. Theseresults are in keeping with those reported in the literature using the same technique. The average interval between symptom onsetand correct diagnosis was 4.5 years, with patients undergoing anaverage 1.2 previous ineffective surgery for treatment of theirsymptoms. Following nerve decompression, 52.9% of patientsexperienced neuropathic pain, lasting on average 4.1 months and 19.6%experienced a post-decompression motor deficit, lasting on average2.6 months. Perioperative complications: one pudendal nervetransection, one obturator nerve tear, one ureteral injury, 2 casesof genitofemoral neuropathy, 2 cases of urinary retention, oneincisional hernia, one rectovaginal fistula and one case ofpyriformis muscle adhesions requiring a transgluteal endoscopicprocedure.
Conclusions: Laparosocpic detrapment ofintrapelvic portions lumbosacral plexus laparoscopically yieldssatisfactory and reproducible results. Awareness must be raised inorder to provide patients with a more timely diagnosis and treatment,and to avoid unnecessary or ineffective surgicalprocedures.
References: 1.Possover M, Chiantera V,Baekelandt J. Anatomy of the Sacral Roots and the Pelvic SplanchnicNerves in Women Using the LANN Technique. Surg Laparosc EndoscPercutan Tech. 2007 Dec;17(6):508-10.2.Lemos N, Possover M.Laparoscopic approach to intrapelvic nerve entrapments. Journal ofHip Preservation Surgery. , 2015. doi: 10.1093/jhps/hnv030.3.PossoverM. Laparoscopic management of endopelvic etiologies of pudendal painin 134 consecutive patients. J Urol. 2009 Apr;181(4):1732-6.doi:10.1016/j.juro.2008.11.096.
Table1. Etiology and localization of nerve entrapments
S2,S3, or S4 nerve roots R
S2,S3, or S4 L
S2,S3, or S4 (bilat.)
Sciatic& pudendal R
Sciatic& pudental L
Table2. Clinical Variables (p value is for paired t test