ENDOUROLOGY & LAPAROSCOPY

Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients
Possover M
Department and Gynecology and Neuropelviology, Hirslanden Clinic, Zürich, Switzerland
J Urol. 2009; 181: 1732-6

• Purpose: The feasibility of the laparoscopic transperitoneal approach to the pelvic somatic nerves was determined for the diagnosis and treatment of anogenital pain caused by pudendal and/or sacral nerve root lesions.
• Materials and Methods: The records of 134 consecutive patients who underwent laparoscopy for refractory anogenital pain were retrospectively reviewed. All neurosurgical procedures, such as neurolysis/decompression of the pudendal nerve and the sacral nerve roots or neuroelectrode implantation to the sacral plexus for postoperative neuromodulation, were done via the laparoscopic transperitoneal approach to the pelvic nerves.
• Results: A total of 18 patients had Alcock’s canal syndrome and decompression was successful in 15. Due to failed decompression 3 patients underwent secondary sacral laparoscopic neuroprosthesis implantation with a decrease of at least 50% on the pain visual analog scale. Sacral plexus lesions or radiculopathies, most commonly postoperative lesions and retroperitoneal endometriosis, were found in 109 patients who underwent laparoscopic neurolysis of the sacral plexus. The final outcome depended on the etiology. Of patients with postoperative nerve damage 62% had a decrease in the mean +/- SD preoperative visual analog scale score of from 8.9 +/- 2.9 (range 7 to 10) to 2.4 +/- 2.3 points (range 0 to 4) at the time of article submission at a mean followup of 17 months (range 3 to 39). Because of failed decompression, 8 patients underwent secondary sacral laparoscopic neuroprosthesis implantation and a decrease in the pain visual analog scale score was achieved in 5. Of patients with an endometriosis lesion of the sacral plexus 78% had a decrease in the mean preoperative visual analog scale score of 8.7 +/- 1.9 (range 8 to 10) to 1.1 +/- 0.7 points (range 0 to 2) at the time of article submission at a mean followup of 21 months (range 2 to 42). All 6 patients with vascular entrapment of pelvic nerves achieved complete relief. The last 7 patients underwent primary sacral laparoscopic neuroprosthesis implantation with at least a 50% decrease in the pain visual analog scale score in 4.
• Conclusions: Our findings emphasize that in patients with seemingly inexplicable anogenital pain, especially after failed treatment for Alcock’s canal syndrome, laparoscopic exploration of the pelvic nerves must be done for further diagnosis and therapy before prematurely labeling the patients as refractory to treatment.
  
  
• Editorial Comment
  Laparoscopic minimally invasive approach has been applied in Urology for benign, oncological diseases, reconstructive surgery; but this novel approach to manage endopelvic etiologies of pudendal pain is a pioneer approach to a complex urogynecological problem.
  The author describe a protocol that when followed seemed to successfully deal with the complex pelvic pain disease.

Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Associate Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu