Pudendal nerve decompression surgery is an option that is usually considered after more conservative therapies such as lifestyle changes, pelvic floor physical therapy, and nerve blocks have not proved to be successful. In the published literature PNE surgery can achieve a success rate of anywhere from 60% to 85% but success does not necessarily mean a cure. Surgery is generally considered successful if there is at least a 50% reduction in pain and symptoms. Occasionally pain and symptoms are permanently worse after surgery therefore the decision should be made carefully.
The Pudendal Nerve is located between two ligaments in the pelvic floor. The top ligament is called the sacrotuberous ligament (ST) and the bottom ligament is called thesacrospinous ligament (SS). The cause of Pudendal Nerve Entrapment is sometimes unknown and other times some patients can pinpoint the exact activity that occurred when the pain struck for the first time. It can be caused by prolonged sitting, a trauma, heavy lifting or surgery. One hypothesis is that the patient is predisposed to PNE and something happens to trigger it.
The entrapment of the nerve can be caused by tight muscles, ligaments or an unaligned pelvis causing undue pressure on the nerve. These conditions cause the nerve to rub on one of the ligaments that encase it. This irritation is what causes the pain and what needs to be repaired.
There are four approaches to pudendal nerve decompression surgery but only three of them have been described in the peer-reviewed literature. The four approaches are
- the transgluteal approach
- the trans-ischiorectal fossa approach
- the perineal approach
- the laparoscopic approach.
There are several different approaches to the release, but the method performed at our department by Prof. Dr. Tibet Erdogru (Urology) is the laparoscopic or robotic approach. It is probably the most helpful method to reach the ligaments because it allows the beter and magnified (10-12x) high definition visualization of the nerve during surgery.
Laparoscopy is a technique that is performed by a camera placed from 4 or 5 tiny holes (0.5-1 cm) and long-thin surgery equipments instead of large surgery cuts (about 20 cm) in surgical treatment of intraabdominal or intra pelvic organs (Figure 1) Also, a high definition digital telescopic camera system with 1.5 cm placed in one of tubes that provides to view organs to be operated such as kidney, prostate, pelvic structures (such as pudendal nerves) is used. The image in the body is reflected to a screen by this telescope-camera system and the operation is performed with this 10-20 times enlarged view of normal. Because of these tiny holes used in laparoscopic surgery provides less discomfort and more aesthetic appearance after the laparoscopic surgery according to large surgery cuts in open surgery. Operation pain and use of pain killers, hospitalization and recovery period decreases ver much after the surgery with laparoscopy. Laparoscopic surgery is performed under general anhestesia like open surgery. Although laparoscopic surgery is a technique that provides great convenience according to open surgery in terms of patients, application requires large experience.
Prof. Dr. Tibet Erdogru has a great experience about laparoscopic surgery with surgeries over 1000 and laparoscopic radical pelvic surgery over 400 consisting of laparoscopic pudendal nerve decompression and transposion.
In my laparoscopy practice, I always perform obturator and internal iliak lymph disseciton to easily reach pelvic floor between internal iliac vessels and obturator nerve.
After opening the arcus tendineous fascia, pudendal nerve with its vessels (pudendal artery and vein) are identified and dissected. I always open the sacrospinous ligaments with sharply insicion and pudendal nerve is completely freed. During laparoscopic surgery the sacrospinous ligament is severed allowing visual access of the nerve at the ischial spine and Alcock’s canal. The nerve is freed from scarring, fibrotic tissue, and swollen varicose veins. A solution of heparin may be infused into the area to prevent scar tissue from forming. Manipulation is minimal and usually patients can go home within 24 hours.
What kind of benefits will be gained by laparoscopic surgery?
Many determined benefits are provided in researches in terms of patients when compared with open surgery.
The clinical conditions treated by pudendal nerve release,
* Less post operational pain
* Less bleeding
* Less hospitalization period
* Acceptable aesthetic apperance/small scar
* Rapid return to daily activity
Laparoscopic surgery indications (applicable status)
Laparoscopy is a technique that is applied in many surgical interventions. Actually, surgical removal of urological organs (kidney, surrenal gland, urehtra, prostate, lymph gland of main artery) which are out of abdominal membrane is accepted increasing gradually, they are performed laparoscipally with less damage and pain advantages. Laparoscopic surgery which is accepted as minimal invasive surgery (less injurious) has become frequently applicable in developed centres all over the world.
Pudendal Nerve Entrapment
- Chronic Prosatitis (CP) (Type IIIB)
- Non-bacterial Prostatitis
- Interstitial Cystitis (IC)
- Chronic Pelvic Pain Syndrome (CPPS)
- Pudendal Neuralgia / Pudendal Nerve Entrapment (PNE)
- Urethral Syndrome
- Pelvic Floor Muscular Dysfunction
- Levator Ani Syndrome