Marc Possover

Voiding Dysfunction Associated with Pudendal Nerve Entrapment.

Pudendal nerve entrapmentu2009(Alcock canal syndrome)u2009is an uncommonu2009source ofu2009chronic pelvic pain, in which theu2009pudendal nerveu2009is entrapped or compressed.u2009Pain is located in the perineal, genital and perianal areas and is worsened by sitting. By simple entrapment of the PN without neurogenic damages, pain is usually isolated. In neurogenic damages to the PN, genito-anal numbness, fecal and/or urinary incontinence can occurred. PNE can be caused byu2009obstetric traumas, scarring due to genitoanal surgeries (prolaps procedures!), accidents and surgical mishaps. Diagnosis is based on anamnesis, clinical examination including vaginal or rectal palpation of the pelvic nerves with selective nerve blockade. Pudendal pain non systematic mean PNE since other neuropathies may induce pudendal pain. So sacral radiculopathies (sacral nerves roots S#2-4) are underestimated etiologies frequently responsible for pudendal pain with irradiation in sacral dermatomes, bladder hypersensitivity or in neurogenic lesions, bladder retention.

The Sacral LION Procedure for Recovery of Bladder/Rectum/Sexual Functions in Paraplegic Patients after Explantation of a Previous Finetech-Brindley Controller

STUDY OBJECTIVEnTo report on our technique of sacral laparoscopic implantation of aneuroprosthesis-LION procedure-for recovery of bladder/intestinal/sexual function in paralyzed patients after spinal cord injury.nnnDESIGNnProspective case series report.nnnSETTINGnAcademic community teaching hospital.nnnPATIENTSnEight consecutive complete T-paralyzed patients after explantation of a previous dorsal implanted Brindley-Finetech controller with a sacral deafferentation.nnnINTERVENTIONSnLaparoscopic transperitoneal exposure of the sacral plexuse and bilateral implantation of Brindley-Finetech electrodes to the sacral nerve roots S2 to S4.nnnMEASUREMENTS AND MAIN RESULTSnFeasibility, complications, and outcome of the procedures. In 6 patients, recovery of electrically induced micturition and defecation could be obtained and in 2 men recovery of electrically induced erection. In 2 other patients, exposure and intraoperative stimulation of the sacral nerve roots showed irreversible destruction of the motoric vesical and rectal nerves. In one, the bilateral implantation of neuromodulation electrodes permitted complete control of the spasticity of the lower limbs and to the autonomic dysreflexia.nnnCONCLUSIONnThe laparoscopic transperitoneal approach offers minimally invasive access for implantation of electrodes to the sacral nerve roots in paralyzed patients for recovery of pelvic visceral functions after failure of a previous implanted dorsal Brindley-Finetech controller with sacral deafferentation.

A Novel Implantation Technique for Pudendal Nerve Stimulation for Treatment of Overactive Bladder and Urgency Incontinence

Herein is described laparoscopic implantation of a neuroprosthesis to the pudendal nerve for treatment of non-neurogenic bladder overactivity. This case series study was performed at a tertiary referral unit that specializes in advanced gynecologic surgery and neuropelveology. Fourteen consecutive male and female patients underwent laparoscopic implantation of an electrode to the endopelvic portion of the pudendal nerve for pudendal neuromodulation. All procedures were performed successfully via laparoscopy, without any complications. The mean operative time for the entire procedure was 18 minutes. After a successful test phase of external stimulation, 11 patients (78.57%) underwent implantation of a permanent generator. These patients demonstrated a mean (SD) decreased micturition frequency, from 25 (11.7; range, 13-50) per day on average to 10.18 (2.7; range, 7-15) at final evaluation (mean follow-up, 18 months; range 9-49 months). Nocturia decreased from 5.82 (4.2; range, 3-18) to 2.18 (1.08; range, 1-5) micturitions per night. Cystometric bladder capacities increased from 159 mL (53; range, 80-230 mL) to 312 mL (104.9;160-500 mL). Mean incontinence episodes at the initial evaluation, based on a 3-day voiding diary, were 8.1. At final evaluation, 6 patients were completely dry. Number of pads used per day decreased from 7.3 (4.2) to 1.6 (2.3). No lead dislocation or migration occurred. It was concluded that laparoscopic implantation of a neuroprosthesis to the pudendal nerve is an effective, safe, and reproducible day procedure for treatment of intractable non-neurogenic overactive bladder with urinary urgency incontinence.

A New Technique of Laparoscopic Implantation of Stimulation Electrode to the Pudendal Nerve for Treatment of Refractory Fecal Incontinence and/or Overactive Bladder With Urinary Incontinence

STUDY OBJECTIVEnTo show a new technique of laparoscopic implantation of electrodes for stimulation of the pudendal nerve for treatment of fecal incontinence and/or overactive bladder with urinary incontinence.nnnDESIGNnStep-by-step explanation of the technique using videos and pictures (educative video).nnnSETTINGnHyperactivity of the bladder with urinary incontinence, in particular the non-neurogenic form of the condition, but also fecal incontinence may affect millions of women worldwide without any comorbidities and in particular without any neurologic disorders or prolapsed organs. First-line conservative treatments do not always result in sufficient improvement of symptoms and are often associated with disabling adverse effects leading to treatment failure. Electrical stimulation of the pelvic nerves has emerged as an alternative and attractive treatment in refractory cases. A novel technique of implantation of an electrode to the pudendal nerve has been developed for treatment of fecal incontinence and of hyperactivity of the bladder with urinary incontinence. The laparoscopic approach is the only technique that enables placement of an electrode in direct contact with the endopelvic portion of the pudendal nerve within the protection of the pelvis.nnnINTERVENTIONnLaparoscopic transperitoneal implantation of a stimulation electrode to the endopelvic portion of the pudendal nerve.nnnCONCLUSIONnThis technique of transperitoneal placement of an electrode to the endopelvic portion of the pudendal nerve is an effective, safe, and reproducible day procedure for treatment of intractable hyperactive bladder, urinary incontinence, fecal incontinence, and a combination of both forms of incontinence.

Laparoscopic management of sacral nerve root schwannoma with intractable vulvococcygodynia: report of three cases and review of literature.

Herein we report the feasibility of laparoscopic resection of schwannomas of the sacral nerves roots in 3 women with intractable vulvodynia and coccygodynia. Laparoscopic en bloc resection of the sacral schwannomas was performed, with primary control of the tumor blood supply and with exposure and sparing of the sacral nerve roots. In all 3 patients, laparoscopy was successful, with minimal blood loss and without complications. Histologic examination confirmed the diagnosis of schwannoma without malignant transformation in all 3 women. At mean follow-up of 27.66 months, no patient reported recurrence or worsening of symptoms. All patients are able to walk normally without gait aids. Primary control of the tumor blood supply during laparoscopic surgery to resect deep sacral masses reduces considerably the risk of operative hemorrhage. Compared with classic neurosurgical approaches, laparoscopic exposure of the rectum, ureters, and sacral nerve roots renders the procedure safer and easier, with less risk of postoperative functional morbidity.

Laparoscopic assisted resection of a ilio-sacral chondrosarcoma: A single case report

INTRODUCTION Sacral tumor often involves en bloc surgical resection with tumor-free margins and functional reconstruction challenges. Such a management is challenging because of difficulties in accessing the lesion, risks for damages of neighboring organs, and risks for massive blood loss. In posterior approach, because first elevation of the sacrum allows dissection of presacral structures, such risks for damages intrapelvic structures and hemorrhage are especially high. PRESENTATION OF CASE We report here about a laparoscopic assisted posterior resection of a ilio-sacral chondrosarcoma in a women, 6 weeks after vaginal delivery. Primary laparoscopic approach consisted in dissection of the ureter and of the colon with control to the pelvic vessels and nerves and determination of limits of the resection. The iliac osteotomy was performed from posterior approach with saw and osteotomes at the predetermined extralesional level. The defect was replaced with a structural fresh frozen femoral allograft and stabilization performed by lumbo-ischial screw/rod fixation. DISCUSSION Surgical time was about 360 min. No intra-postoperative complications occurred. Blood loss was estimated to about 1000 cm3. Histologic examination of the specimen showed tumor-free margins. At 8 months follow-up, the patient appears to be without recurrence. Because of the denervation of the nerve root L5 and below, she mostly uses two canes, but she has a functioning quadriceps. Continence and voiding functions for urine and stool have fully recovered. CONCLUSION Primary laparoscopic approach appeared to be a good way for preparation orthopedics sacroiliac resection to reduce postoperative morbidity, intraoperative blood loss and better assure macroscopic tumor-free margins.

Comparative Study of the Neuropeptide-Y Sympathetic Nerves in Endometriotic Involved and Noninvolved Sacrouterine Ligaments in Women with Pelvic Endometriosis

STUDY OBJECTIVEnTo show the relationship between the neuropeptide-Y pelvic sympathetic nerves and neoangiogenesis in the development of endometriosisnnnDESIGNnProspective study.nnnSETTINGnAcademic community teaching hospital.nnnPATIENTSnFifteen consecutive women with unilateral endometriotic infiltration of the sacrouterine ligaments.nnnINTERVENTIONSnA laparoscopic excision/biopsy of involved and noninvolved parts of the sacrouterine ligaments were taken. The sections were incubated with the neuronal marker rabbit polyclonal anti-protein gene product 9.5 and rabbit polyclonal anti-neuropeptide-Y. We made a comparative study on the distribution of nerve fibers and their relationship to the vessels on intact and endometriotic involved tissue.nnnMEASUREMENTS AND MAIN RESULTSnThe results show that a large amount of nerves are present around the blood vessels in the endometriosis samples, and a large number of these nerves are neuropeptide-Y sympathetic nerves. Adrenergic fibers are also present in the intact control subjects, however, in significantly smaller amounts.nnnCONCLUSIONnThis finding shows a strong relationship between the neuropeptide-Y sympathetic pelvic nerves and the neoangiogenesis required for the development of endometriosis.

Laparoscopic dissection and anatomy of sacral nerve roots and pelvic splanchnic nerves.

STUDY OBJECTIVEnTo demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves.nnnDESIGNnCase report (Canadian Task Force classification III).nnnSETTINGnPrivate practice hospital in São Paulo, Brazil.nnnPATIENTnA 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0-10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm.nnnINTERVENTIONSnStandard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4.nnnMEASUREMENTS AND MAIN RESULTSnThe surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0-10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves.nnnCONCLUSIONnLaparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

Recovery of supraspinal control of leg movement in a chronic complete flaccid paraplegic man after continuous low-frequency pelvic nerve stimulation and FES-assisted training

Introduction:More than 30 years ago, functional electrical stimulation (FES) was developed as an orthotic system to be used for rehabilitation for SCI patients. In the present case report, FES-assisted training was combined with continuous low-frequency stimulation of the pelvic somatic nerves in a SCI patient.Case Presentation:We report on unexpected findings in a 41-year-old man with chronic complete flaccid paraplegia, since he was 18 years old, who underwent spinal stem cell therapy and a laparoscopic implantation of neuroprosthesis (LION procedure) in the pelvic lumbosacral nerves. The patient had complete flaccid sensomotoric paraplegia T12 as a result of a motor vehicle accident in 1998. In June 2011, he underwent a laparoscopic implantation of stimulation electrodes to the sciatic and femoral nerves for continuous low-frequency electrical stimulation and functional electrical stimulation of the pelvic nerves. Neither intraoperative direct stimulation of the pelvic nerves nor postoperative stimulation induced any sensation or muscle reactions. After 2 years of passive continuous low-frequency stimulation, the patient developed progressive recovery of electrically assisted voluntary motor functions below the lesions: he was first able to extend the right knee and 6 months later, the left. He is currently capable of voluntary weight-bearing standing and walking (with voluntary knee movements) about 50u2009m with open cuff crutches and drop foot braces.Discussion:Our findings suggest that continuous low-frequency pelvic nerve stimulation in combination with FES-assisted training might induce changes that affect both the upper and the lower motor neuron and allow supra- and infra-spinal inputs to engage residual spinal and peripheral pathways.

Five-Year Follow-Up After Laparoscopic Large Nerve Resection for Deep Infiltrating Sciatic Nerve Endometriosis

OBJECTIVEnTo report neurologic follow-up of patients after laparoscopic large resection of deep infiltrating endometriosis of the sciatic nerve.nnnDESIGNnProspective clinical case series.nnnSETTINGnTertiary referral unit specializing in advanced gynecologic surgery and neuropelveology.nnnPATIENTSnAll data for patients who underwent laparoscopic surgery for endometriosis of the sciatic nerve between 2004 and 2016 (nxa0=xa0259) were documented prospectively. In this study, patients who underwent a large resection of the sciatic nerve (>30% of the nerve) and were followed for at least 5xa0years were evaluated (nxa0=xa046). All patients presented preoperatively with incapacity for normal gait and foot drop. All were suffering from intractable and constant neuropathic sciatic pain (visual analog scale [VAS] score of 9 to 10 despite strong pain medicine), with sensorimotor disorders of the affected leg.nnnINTERVENTIONSnLaparoscopic large resection of endometriosis of the sciatic nerve.nnnMEASUREMENTS AND MAIN RESULTSnAll procedures were performed by laparoscopy. Postoperative management included medical treatment with neuroleptic agents and intensive physiotherapy. At the 5-year follow-up, all patients reported significant pain reduction, with a median VAS score of 2.1 (range, 0 to 3) and recovery of normal gait, including the ability to climb stairs.nnnCONCLUSIONnIn deep infiltrating intraneural endometriosis of the sciatic nerve, patients present with motor disorders before and after surgical resection. The average VAS score was reduced from 9.33 preoperatively to 1.25 at a 3-year follow-up. When full resection of endometriosis including nerve resection is completed, sciatic nerve function recover, but recovery of a normal gait may take at least 3xa0years and intensive physiotherapy.