Nucelio Lemos

Tela de polipropileno versus correção sítio-especifica no tratamento do prolapso de parede vaginal anterior: resultados preliminares de ensaio clínico randômico

OBJECTIVE Pelvic organ prolapse is a disorder caused by the imbalance between the forces responsible for supporting the pelvic organs in their normal position and those that tend to expel them from the pelvis. Anterior vaginal wall prolapse, known as cystocele, is the most common form of prolapse and can result from lesions in different topographies of the endopelvic fascia. Currently, a woman has an 11% risk of being submitted to a surgical procedure to correct pelvic floor disorder, and a 29% chance of being reoperated due to failure in the first surgery. METHODS A prospective randomized study was conducted to compare the use of polypropylene mesh with site-specific repair in the surgical treatment of anterior vaginal prolapse. Thirty-two patients aged between 50 and 75 years, who had previous vaginal prolapse at stage III or IV, or prolapse recurrence, were operated. Mean follow-up was 8.5 months. RESULTS The results demonstrate the superiority of the anatomical outcomes with the use of polypropylene mesh over site-specific repair. Regarding surgical morbidity, shorter operative time was observed for the mesh group. CONCLUSION The results observed in this study indicate the superiority of anatomical results obtained with the use of polypropylene mesh over site-specific repair.

Risks, symptoms, and management of pelvic nerve damage secondary to surgery for pelvic organ prolapse: a report of 95 cases

Introduction and hypothesisThis study aims to report pelvic nerve damage secondary to surgical treatment of pelvic organ prolapse and the role of laparoscopy in the diagnosis and treatment of such nerve damage.MethodsNinety-five consecutive patients complaining of pain and/or bladder or bowel dysfunction following surgery for pelvic prolapse underwent laparoscopic exploration for pelvic neuropathy.ResultsA mean reduction in visual analog score (VAS) from 8.9 (±0.96; 6–10) preoperatively to 2.9 (±2.77; 0–6) at 1-year follow-up was obtained in patients after laparoscopic nerve decompression (n = 90; p < 0.001). Success, defined as a reduction in VAS score of greater than 50%, was obtained in 84% of patients. Sixty-five patients (68%) discontinued the regular use of analgesics.ConclusionsBecause secondary nerve damage can appear months or years after the primary procedure, long-term follow-up is mandatory and should focus on nerve damage as well as anatomical and functional outcomes. Laparoscopy is a unique method for etiologic diagnosis and neurosurgical treatment of such nerve lesions through decompression or implantation of an electrode for neuromodulation.

Histologic classification of specimens from women affected by superficial endometriosis, deeply infiltrating endometriosis, and ovarian endometriomas

In this retrospective observational study involving 176 patients and 271 biopsies, the histologic differentiation in superficial endometriosis, deeply infiltrating endometriosis, and ovarian endometriomas was evaluated according to a previously proposed classification system. Results showed a predominance of the undifferentiated glandular pattern (33.5%) and mixed glandular pattern (46.9%) in deeply infiltrating endometriosis lesions, whereas the well-differentiated glandular pattern (41.8%) was most frequently seen in superficial endometriosis lesions, and in ovarian endometriomas a predominance of both the undifferentiated (40.5%) and mixed patterns (37.8%) was observed.

Multicenter inter-examiner agreement trial for the validation of simplified POPQ system

Introduction and hypothesisThe primary aim of this study was to evaluate the inter-examiner agreement of a previously described simplified pelvic organ prolapse quantification (S-POP) system in a multicenter, prospective, randomized, blinded fashion. Pelvic organ prolapse quantification (POPQ) system’s use in daily practice is hampered due to perceived complexity and difficulty of use. The S-POP was introduced in order to make the POPQ user-friendly and increase its usage (Swift et al. in Int Urogynecol J 17(6):615–620, 2006).MethodsFive hundred eleven subjects underwent two separate pelvic exams in random order by two blinded examiners employing the S-POP at 12 centers around the world. Data were compared using weighted kappa statistics.ResultsThe weighted kappa statistics for the inter-examiner reliability of the S-POP were 0.87 for the overall stage, 0.89 and 0.81 for the anterior and posterior vaginal walls, 0.82 for the apex/cuff 0.89, and 0.84 for the cervix and vaginal fornix, respectively.ConclusionThere is an almost perfect inter-examiner agreement of the S-POP system for the overall stage and each point within the system.

Optimizing pelvic organ prolapse research

For many years, researchers on this field have suffered from the lack of an efficient method for describing pelvic organ prolapse. Struggling to solve this problem, the International Continence Society has proposed a pelvic organ prolapse quantification (POP-Q) system [Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, Shull B, Smith ARB, Am J Obstet Gynecol, 175(1):1956–1962, 1996], which was validated as a precise and reproducible technique for describing pelvic organ position. However, even though very precise at describing pelvic organ position, our critic to this system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four grades, almost the same way as Baden and Walker did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this paper is to propose a method that makes POP research more efficient by directly measuring prolapse as a continuous variable that requires lesser number of subjects in order to achieve statistical significance.

Sacral nerve infiltrative endometriosis presenting as perimenstrual right-sided sciatica and bladder atonia: case report and description of surgical technique.

Endometriosis infiltrating the sacral nerve roots is a rarely reported manifestation of the disease. The objectives of this article are to report such a case and to describe the surgical technique for laparoscopic decompression of sacral nerve roots and treatment of endometriosis at this site. The patient as a 38-year-old woman who had undergone 2 previous laparoscopic procedures for electrocoagulation of peritoneal endometriosis and self-reported perimenstrual right-sided sciatica and urinary retention. Clinical examination revealed allodynia (pain from a stimulus that does not normally cause pain) on the S2 to S4 dermatomes and hypoesthesia on part of the S3 dermatome. Magnetic resonance imaging showed an endometriotic nodule infiltrating the anterior rectal wall. Laparoscopic exploration of the sacral nerve roots demonstrated vascular compression of the lumbosacral trunk and endometriosis entrapping the S2 to S4 sacral nerve roots, with an endometrioma inside S3. The endometriosis was removed from the sacral nerve roots and detached from the sacral bone, and a nodulectomy of the anterior rectal wall was performed. Normal urinary function was restored on postoperative day 2, and pain resolved after a period of post-decompression. Intrapelvic causes of entrapment of sacral nerve roots are rarely described in the current literature, either because of misdiagnosis or actual rareness of the condition. Recognition of the clinical markers for these lesions may lead to an increase in diagnosis and specific treatment.

Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of autonomic nerve bundles

OBJECTIVE To demonstrate the laparoscopic neuroanatomy of the autonomic nerves of the pelvis using the laparoscopic neuronavigation technique, as well as the technique for a nerve-sparing radical endometriosis surgery. DESIGN Step-by-step explanation of the technique using videos and pictures (educational video) to demonstrate the anatomy of the intrapelvic bundles of the autonomic nerve system innervating the bladder, rectum, and pelvic floor. SETTING Tertiary referral center. PATIENT(S) One 37-year-old woman with an infiltrative endometriotic nodule on the anterior third of the left uterosacral ligament and one 34-year-old woman with rectovaginal endometriosis. INTERVENTION(S) Exposure and preservation by direct visualization of the hypogastric nerve and the inferior hypogastric plexus. MAIN OUTCOME MEASURE(S) Visual control and identification of the autonomic nerve branches of the posterior pelvis. RESULT(S) Exposure and preservation of the hypogastric nerve and the superficial part of the left hypogastric nerve were achieved on the first patient. Nerve roots S2, S3, and S4 were identified on the second patient, allowing for the exposure and preservation of the pelvic splanchnic nerves and the deep portion inferior hypogastric plexus. DISCUSSION(S) Radical surgery for endometriosis can induce urinary dysfunction in 2.4%-17.5% of patients owing to lesion of the autonomic nerves. The surgeons knowledge of the anatomy of these nerves is the main factor for preserving postoperative urinary function. The following nerves are the intrapelvic part of the autonomic nervous system: the hypogastric nerves, which derive from the superior hypogastric plexus and carry the sympathetic signals to the internal urethral and anal sphincters as well as to the pelvic visceral proprioception; and the pelvic splanchnic nerves, which arise from S2 to S4 and carry nociceptive and parasympathetic signals to the bladder, rectum, and the sigmoid and left colons. The hypogastric and pelvic splanchnic nerves merge into the pararectal fossae to form the inferior hypogastric plexus. Most of the nerve-sparing techniques involve the dissection and exposure of the pelvic splanchnic nerves and the inferior hypogastric plexus. However, knowledge of the topographic anatomy and awareness of the landmarks for avoiding intraoperative nerve injuries seem to be the most important factors in avoiding postoperative bladder and bowel dysfunction, although this latter nerve-sparing technique seems to be associated with reduced radicality and symptom persistence. CONCLUSION(S) This video demonstrates a technique to expose the sympathetic and parasympathetic nerves of the pelvis to preserve them in radical pelvic surgery, by means of direct visualization, in a similar fashion to the technique used to preserve the ureters. An alternative to this technique is to use landmarks for limiting dissection and avoiding intraoperative nerve injury. Despite being safe and more easily reproducible, this latter technique is associated with a higher rate of symptom persistence.

Laparoscopic approach to intrapelvic nerve entrapments

It is long known that a large portion of the lumbosacral plexus is located intra-abdominally, in the retroperitoneal space. However, most of literature descriptions of lesions on this plexus refer to its extra-abdominal parts whereas its intra-abdominal portions are often neglected. The objective of this review article is to describe the laparoscopic anatomy of intrapelvic nerve bundles, as well as the findings and advances already achieved by Neuropelveology practitioners.

Vascular entrapment of the sciatic plexus causing catamenial sciatica and urinary symptoms

Aim of the video / IntroductionPelvic 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.MethodTwo 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.ResultAfter 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.ConclusionThe 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.

Neuropelveology: New Groundbreaking Discipline in Medicine

Intractable chronic pelvic, genital, and low lumbar pain, oftenwith distal radiation, are frequent complaints in the general population. Inmany cases no etiology is found, and these patients are treated with analgesics, often in combination with antipsychotics or anticonvulsants. Pathologies of the pelvic nervesmight explain some of these cases, but this possibility is seldom explored clinically. Reasons are various: difficult access to the pelvic nerves make visualization, clinical assessment, and microneurosurgical procedures complicated and invasive; electrophysiologic explorations are unreliable because they can be abnormal after delivery or pelvic surgeries and fail to define the neurologic level of the pathology; or medical imaging might be useful but only when data interpretation is done by a radiologist trained in pelvic neuroradiology. A more stringent approach to pelvic pain and neuronal dysfunction is therefore needed. Neuropelveology represents the first medical practice with specific focus on pathologies of the pelvic neuronal structures [1] and combines knowledge and diagnostic methods from different areas. Clinically, neuropelveologic assessment includes an adaptation of clinical neurology to the pelvic nerves combined with investigation of the pelvic nerves by vaginal or rectal examination, sonography, and other imaging techniques [2]. The major challenge is to adopt a ‘‘neurologic way of thinking’’: whereas in gynecology etiologies and pain are usually located in the same area, the neuropelveologic approach perceives pain location and irradiations as information about the pathways used by pain signals to reach the brain, not necessarily the etiologies and their locations. Because the pelvic neuronal structures are involved in multiple sensory and motor functions, neuropelveology deals with the diagnosis and treatments of several conditions: Pelvic neuropathic pain syndromes, such as pudendal pain, gluteal pain, lower abdominal pain, sciatic pain, vulvar or coccygeal pain, and other pelvic pain conditions from neurogenic and non-neurogenic etiologies [3]. Specific attention is paid to pathologies that might affect the pelvic nerves, including neurologic, vascular, and orthopedic etiologies. When needed, minimally invasive techniques are applied for exploration and treatment [3]. Pelvic organ dysfunctions such as overactive bladder, urinary and fecal incontinence, urinary retention and chronic constipation, and aspects of sexual dysfunction function [4]. These aspects of neuropelveology concern what might be termed ‘‘neurogynecology.’’ Some pathologies of the central nervous system responsible for pelvic organs and lower extremities dysfunctions. This field focuses on the application of new, minimally invasive surgical techniques, including the lapoaroscopic implantation of neuroprothesis procedure. This intervention comprises application of stimulation electrodes to the pelvic nerves and plexuses for treatment of pelvic organ dysfunction/pain in neurogenic conditions such as polyneuropathies, Parkinson syndrome, or multiple sclerosis. One special aspect is stimulation of the somatic pelvic nerves in patients with spinal cord injuries and in spina bifida patients. This approach aims not only at electrically induced recovery of function but also at the potential recovery of supraspinal control of leg and pelvic organ through neuronal growth and reconnection [5]. Because of growing interest from the medical community for these new promising therapeutic modalities, the International Society of Neuropelveology (see www.theison.org) was set up in 2014 with three major objectives: to stimulate basic and applied research in neuropelveology, to contribute to the standardization and evaluation of diagnostic and therapeutic procedures in neuropelveology, and to develop an international system of continuous medical education in neuropelveology.