Neuropelveology

PROGRESS IN PELVIC RESEARCH
Latest Developments in Pelvic Neurofunctional Surgery

NEUROPELVEOLOGY
The International Society of Neuropelveology ... I‘l re a comeerry, betch he he cany thence shown ortent
st, ats throut liences! I why, beell re he miley raboad, was innat of me, alley naph. Thickler Smill yout ther Marc Possover
ater, a filey a so by – the‘d could his alon he an‘t – I‘d lers to pup, st wou‘d if ther and dog. I‘l, anakepliab-
leraboys: Thimor yar says age; and tunte way ke ring. Any frog tany welse dog this
Prof. Marc Possover has developed as pioneer the field of the Neuropelveology that deal with neuro
pathic pelvic pain, endometriosis of the pelvic nerves, dysfunctions of the pelvic nerves and the worldwide Marc Possover
NEUROPELVEOLOGY
pioneering leader in applying laparoscopy for nerves sparing techniques in pelvic surgeries and for
implantation neuroprothesis to the pelvic nerves for recovery pelvic functions and locomotion in spinal
cord injured peoples. Latest Developments in Pelvic Neurofunctional Surgery

NEUROPELVEOLOGY
The International Society of Neuropelveology ... I‘l re a comeerry, betch he he cany thence shown ortent
st, ats throut liences! I why, beell re he miley raboad, was innat of me, alley naph. Thickler Smill yout ther Marc Possover
ater, a filey a so by – the‘d could his alon he an‘t – I‘d lers to pup, st wou‘d if ther and dog. I‘l, anakepliab-
leraboys: Thimor yar says age; and tunte way ke ring. Any frog tany welse dog this
Prof. Marc Possover has developed as pioneer the field of the Neuropelveology that deal with neuro
pathic pelvic pain, endometriosis of the pelvic nerves, dysfunctions of the pelvic nerves and the worldwide Marc Possover
NEUROPELVEOLOGY
pioneering leader in applying laparoscopy for nerves sparing techniques in pelvic surgeries and for
implantation neuroprothesis to the pelvic nerves for recovery pelvic functions and locomotion in spinal
cord injured peoples. Latest Developments in Pelvic Neurofunctional Surgery
UMSCHLAG 2 = VORSATZSEITE 1 VORSATZSEITE 2
Univ.-Prof. Prof. Dr. med. Marc Possover
NEUROPELVEOLOGY
VORSATZSEITE 3 TEXTSEITE 1
Univ.-Prof. Prof. Dr. med. Marc Possover
NEUROPELVEOLOGY
DEDICATION
Silke, mon Amour, pour ton soutien quotidien, la motivation que tu me procures,
et le temps que tu m'accordes à écouter mes idées folles. Je t'aime plus que tout.
Jean-Matthieu et Louis-Charles, vous avez été si souvent privés de votre père.

Je m'en excuse et vous offre tout mon Amour.
Axel, notre Amitié n'a pas de précèdent. Merci de m'avoir permis de devenir ton
Ami et Confrère à lÚniversité de Aarhus.
Mon cher Ralf, j'espère que nos chemins resteront croisés encore très longtemps.
Ton intelligence et ta professionnalité m´éblouissent chaque jour.
Vito, merci pour la correction de ce livre, tes conseils si riches en expérience, et un

grand Merci pour ton Amitié.
Nucelio, ton énergie mínfecte chaque fois que nous nous rencontrons. Continue to
chemin, tu es l’avenir.
A toi, Benoit, le premier à avoir cru a la neuropelveologie. Merci a toi et a ton pere.
A vous, Messieurs Daniel Dargent et Maurice-Antoine Bruhat, vous qui nous avez
quittés trop tôt, vous qui nous avez appris que l’imagination et l’enthousiasme
n’ont ni âge ni barrières.
A tous ceux qui lirons ce manuel. Merci de prendre soin de mon enfant, l’ ISON,
et de l’aider a grandir.
Avec toute mon Amitié

7
The International School for Neuropelveology

Ringstrasse 17
CH- 6332 Hagendorn
CONTENTS
© 2015 Possover M. All rights reserved Electronic Storage, Videos, or Usage
Permission of Prof. Possover is required to store or
This work is protected under copyright by Prof. use electronically any material contained in this CHAPTER I
Possover M ®, and the following terms and con- work, including any chapter or part of a chapter. PELVIC NEUROFUNCTIONAL ANATOMY
ditions apply to its use:
Except as outlined above, no part of this work 1. Introduction............................................................................................ 12
Photocopying may be reproduced, stored in a retrieval system, 2. The sacral plexus ..................................................................................... 12
Single photocopies of single chapters may be or transmitted in any form or by any form or by 3. The pelvic splanchnic nerves .................................................................. 17
made for personal use as allowed by national any means, electronic, mechanical, photocopy- 4. Sympathic innervation of the pelvis ........................................................ 17
copyright laws. Permission of Prof. Possover and ing, recording, or otherwise, without prior writ- 5. The lumbar plexus .................................................................................. 21
payment of a fee is required for all other pho- ten permission of Prof. Possover. 6. Innervation of the vulva and vagina ........................................................ 23
tocopying, including multiple or systematic co- Address permissions requests to: International
pying, copying for advertising or promotional School for Neuropelveology GmbH, at the fax
purposes, resale, and all forms of document de- and e-mail addresses noted above. HAPTER II
C
livery. Special rates are available for educational DIAGNOSIS IN NEUROPELVEOLOGY
institutions that wish to make photocopies for Notice
nonprofit educational classroom use. No responsibility is assumed by Prof. Possover 1. Introduction ........................................................................................... 26
for any injury and/or damage to persons or pro- 2. Neuropelveological algorithm ................................................................ 28
Permissions may be sought directly from Prof. perty as a matter of products liability, negligen- 3. Patient history ......................................................................................... 33
Possover, e-mail: m.possover@possover.com, ce, or otherwise, or from any use or operation 4. Pelvic examination ................................................................................. 36
phone: (+41) 44 387 2830, fax: (+41) 44 387 of any methods, products, instructions, or ideas 5. Neurological examination ...................................................................... 36
2831, address: International School for Neuro- contained in the material herein. Because of ra- 6. Pelvic ultrasound ................................................................................... 38
pelveology GmbH, Ringstrasse 17, 6332 Hagen- pid advances in the medical sciences, in particu- 7. Renal ultrasound .................................................................................... 38
dorn, CH. lar, independent verification of diagnoses, drug 8. Cystometry and urodynamic testing ........................................................ 40
dosages, and use of pelvic nerve neuromodulati- 9. Neurophysiological testing ..................................................................... 40
Derivate Works on should be made.
Tables of contents may be reproduced for inter-
nal circulation, but permission of Prof. Possover First edition 2015 HAPTER III
C
is required for external resale or distribution of LAPAROSCOPIC EXPOSURE OF THE
such material. Permission of Prof. Possover is re- ISBN: 978-3-9524533-0-8 PELVIC NERVES—METHODOLOGY
quired for all derivate works, including compila-
tions and translation. ∞ The paper used in this publication meets the 1. Introduction ........................................................................................... 44
requirements of ANSI/NISO Z39.48-1992 (Per- 2. Exposure of the femoral nerve ................................................................ 44
manence of Paper) 3. Exposure of the sciatic and pudendal nerves .......................................... 44
Printed in Germany 4. Exposure of the sacral nerves and the pelvic splanchnic nerves .............. 53
CONTENTS 9
HAPTER IV
C
PELVIC NEUROPATHIC PAIN SYNDROMES AND ETIOLOGIES
1. Introduction ........................................................................................... 62
2. Somatic versus visceral pelvic pain ........................................................ 63
3. Vulvodynia ............................................................................................. 65
4. Pudendal neuralgia ................................................................................ 69
5. Endometriosis of the pelvic nerves .......................................................... 72
6. Sacral radiculopathy by neurovascular conflict ....................................... 73
7. Piriformis syndrome ............................................................................... 76
8. Postsurgical pelvic neuropathies ............................................................. 76
9. Sacrococcygeal teratoma ........................................................................ 86
10. Pelvic schwannoma ................................................................................ 88
11. Pelvic osteochondrosarcoma .................................................................. 92
12. The sciatic LION procedure in leg amputee patients ............................. 100
CHAPTER V
THE LION PROCEDURE IN PELVIC DYSFUNCTIONS
1. Indications ........................................................................................... 110

2. Therapeutic options for OAB and incontinence .................................... 112
3. Neurophysiology of the PN .................................................................. 113
4. The pudendal LION procedure – implantation methodology ................. 115
5. PN stimulation for treatment of OAB and incontinence ........................ 121
6. Sacral stimulation in urinary retention and chronic constipation .......... 123
CHAPTER VI
THE LION PROCEDURE IN SPINAL CORD PATHOLOGIES AND INJURIES
1. Introduction .......................................................................................... 130

2. The LION procedure in SCI patients ..................................................... 131
3. The LION procedure in children with spina bifida ................................ 138
THE AUTHOR
Marc Possover........................................................................................ 143

10 NEUROPELVEOLOGY 11
CHAPTER I PELVIC NEUROFUNCTIONAL ANATOMY

12 NEUROPELVEOLOGY CHAPTER I | PELVIC NEUROFUNCTIONAL ANATOMY 13
1. INTRODUCTION 2. THE SACRAL PLEXUS
The innervation of the pelvis is very complex. Sen- The sacral plexus is part of the somatic nervous
sory and motoric nerves are found in the pelvis; system. The sacral plexus is formed from the
the sensory nerve fibers give information to the lumbosacral trunk and the ventral rami of sacral
periphery of the brain (afferent), or vice versa nerve roots S1–S4/S5.
(efferent), and the motoric nerves divide into the
following nerves: The sacral nerves have both afferent and efferent
fibers; thus, they play a role in both sensory
he somatic nerves, which innervate
T perception and the movements of the lower
the skeletal muscles (voluntary, or red, extremities (red skeletal muscles).
muscles). These nerves originate in the
ventral roots of the spinal nerves. The pudendal and gluteal nerves arise at diffe-
rent levels from the sacral plexus, as does the
he autonomous nerves, which innervate
T nerve of the levator ani muscle (Fig. 1.1).
the glands and the smooth muscles
(involuntary, or white, muscles). These The pelvic splanchnic nerves (parasympathetic
nerves divide into sympathetic nerves fibers) arise from S2, S3, and S4; these nerves
(ventral roots of spinal nerves T1–L2) and supply the descending colon and rectum,
the parasympathetic nerves (ventral roots urinary bladder, and genital organs.
of spinal nerves S2–S4/S5).
A B
This division is of great importance in understan- 2.1. THE LUMBOSACRAL TRUNK

ding neural anatomy. Innervation of the pelvis
G
is complex because all autonomous neural The lumbosacral trunk comprises the whole of
systems anastomose together in the inferior the anterior division of the 5th and a part of
hypogastric plexus. However, a relative anato- that of the 4th lumbal nerve roots. It appears at
mical division of the different plexuses can be the medial margin of the psoas major and runs
F
described so that the surgeon can, with under- downward over the pelvic brim to join the first
standing of these neural structures, reduce the sacral nerve, S1. Laparoscopic exposure of the
morbidity resulting from radical operations. lumbosacral trunk is best obtained by dissection E
of the lumbosacral space lateral to the external

The most important nerve groups are the sacral iliac vessels, by following strictly the caudal C
and the lumbar plexuses for the somatic nervous border of the psoas muscle. The trunk reveals D
system, and the hypogastric plexus and the itself as a white band that runs along the linea ter-
sympathetic trunk for the autonomous nervous minalis, about 1 cm below the obturator nerve.
system. Fig. 1.1: Sacral plexus, sciatic nerve, superior and inferior gluteal nerves on the right side
A: obturator nerve – B: sciatic nerve – C: sacral nerve S2 – D: lumbosacral trunk –
E: superior gluteal nerve – F: piriform muscle – G: inferior gluteal nerve
2.2. THE GLUTEAL NERVES and the inferior gluteal artery and vein run bet-
ween the second and third sacral nerves.
The superior gluteal nerve emerges from the
lumbosacral trunk about 2 cm above the great Sacral nerve S1 mediates the Achilles reflex.
sciatic notch, and leaves the pelvis through the
greater sciatic foramen above the piriformis, S4 electrical stimulation does not produce any
accompanied by the superior gluteal artery and motoric reaction in the lower extremities, whe-
the superior gluteal vein. This small nerve is reas stimulation of S3 nerves is confirmed visual-
extremely important for the stability of the ly by a deepening and flattening of the buttock
pelvis because it supplies the gluteus medius, groove as well as a plantar flexion of the large
the gluteus minimus, and the tensor fasciae latae toe and, to a lesser extent, of the smaller toes.
muscles. Stimulation of S2 produces an outward rotation
of the leg and plantar flexion of the foot, as well
as a clamp-like squeeze of the anal sphincter
2.3. SACRAL NERVES S1–S4/S5 from the anterior to the posterior.
The four (or sometimes five) sacral nerve roots

emerge from the sacral foramens directly lateral 2.4. THE PUDENDAL NERVE
to the sacral bone. From their emergence out of
the sacral foramens, sacral nerve roots S1–S4/5S The pudendal nerve is a sensory and somatic
lie on the back of the pelvis and build the in- nerve that originates from the ventral rami of the
fracardinal portion of the plexus limiter laterally 2nd to 4th (and occasionally 5th) sacral nerve
by the piriformis muscle, laterally by the sacral roots. After branching from the sacral plexus just
hypogastric fascia and the rectum, and ventrally proximal to the sacrospinous ligament, the nerve
by the cardinal ligament. leaves the pelvis through the great sciatic notch
(Fig. 1.2), re-enters the pelvic cavity through the
After crossing the cardinal ligament from the la- lesser sciatic notch, and finally travels to three
teral, the sacral nerves building the supracardi- main regions: the gluteal region, the pudendal
nal portion of the sacral plexus pass through the canal, and the perineum. It accompanies the
suprapiriformis space, cross the piriformis musc- internal pudendal vessels upward and forward B
C
le, converge toward the lower part of the grea- along the lateral wall of the ischiorectal fossa,
ter sciatic foramen, and unite to form the sciatic being contained in a sheath of the obturator fas-
nerve at the infrapiriformis space. cia termed the pudendal canal (Alcock's canal).
A
The pudendal nerve gives off three distal bran-
The sciatic nerve and the inferior gluteal nerve ches: the inferior rectal nerve, the perineal ner-
leave the pelvis through the greater sciatic notch, ve, and the dorsal nerve of the penis (in males) or
caudal to the piriformis muscle. the dorsal nerve of the clitoris (in females).
The superior gluteal artery and vein run between Fig. 1.2: Left intrapelvic pudendal nerve
the lumbosacral trunk and the first sacral nerve, A: sciatic nerve – B: pudendal nerve – C: obturator nerve
This runs to the ischiococcygeal muscle and di- neck and modulate their function. This neuro- 3. THE PELVIC SPLANCHNIC 4. SYMPATHETIC INNERVATION
vides into three major branches: modulation effect works exclusively at the spinal NERVES OF THE PELVIS
level and appears to be at least partly respon-
he anal nerve, which supplies the exter-
T sible for bladder neck competence and urinary
nal anal sphincter and is responsible for continence. Pudendal supply is not significant The vagus nerve, or pneumogastric nerve, is Sympathetic innervation of the pelvis is per-
sensation in the anal canal in the vaginal wall because there is no striated generally called the bowel nerve. The right vagus formed by two different sympathetic systems
muscle, but efferent supply largely from the pu- nerve mainly innervates the bowel channel up to (Fig. 1.4):

The visceral branches for the external dendal nerve controls the levator muscle that the colon flexure, whereas the left vagus nerve
urethral sphincter (responsible for volun- provides support for and influences the function mainly innervates the epigastric region and the The hypogastric plexus and nerves
tary control of the bladder) of the lower third of the vagina. liver.
The sympathetic trunks

The visceral branches for the vagina, Pelvic parasympathetic innervation is carried out
clitoris, and perineum by the pelvic splanchnic nerves (PSN), the pre-
ganglion fibers that lead out of sacral nerve roots
The pudendal nerve is the main nerve of the S2–S4/S5. The pelvic splanchnic nerves transfix 4.1. THE HYPOGASTRIC PLEXUS AND
perineum. It carries sensation from the exter- the sacral hypogastric fascia, where they form NERVES
nal genitalia of both sexes and the skin around a meshwork of five to seven smaller nerves
the anus and perineum, as well the motor sup- after sprouting out from different orientations Different plexuses originate from the vegetati-
ply to various pelvic muscles, including the ex- (Fig. 1.3). A medial group of fibers crosses the ve solar plexus, orientate themselves along the
ternal urethral sphincter and the external anal pararectal space tangentially and anastomoses various collaterals of the aorta, and innervate all
sphincter. to the pelvic plexus at the postero-lateral aspect the abdominal organs. One of these plexuses is
of the rectum. The more lateral fibers are more the intermesenteric plexus, which runs ventro-
As the bladder fills, the pudendal nerve becomes vertical and anastomose to the pelvic plexus laterally to the aorta between both mesenteric
excited. Contraction of the external sphincter, ventrally at the level of the bladder pillar laterally arteries and forms the inferior mesenteric plexus.
coupled with that of the internal sphincter, and caudally to the ureterovesical junction. This plexus dispatches branches that partly
maintains urethral pressure (resistance) higher accompany the mesenteric arteries, and bran-
than normal bladder pressure. The storage phase From a surgical point of view, the best way to ches that run between the inferior mesenteric
of the urinary bladder can be switched to the expose the pelvic splanchnic nerves consists of artery and the aorta and form the roots of the
voiding phase either involuntarily (reflexively) first exposing sacral nerves S3–S4 laterally to the inferior hypogastric nerves.
or voluntarily. The pudendal nerve causes then sacral hypogastric fascia, and then following
relaxation of the levator ani so that the pelvic them ventrally until the nerves emerge from the In order to avoid injury to these nerves during
floor muscle relaxes. The pudendal nerve also roots. a left-sided paraaortic lymphadenectomy, it
signals the external sphincter to open. The sym- is recommended to prepare the mesosigmoid
pathetic nerves send a message to the internal The pelvic splanchnic nerves regulate the dorsal of the inferior mesenteric artery along the
sphincter to relax and open, resulting in a lower emptying of the urinary bladder, control opening left common iliac artery. This way, one can reach
urethral resistance. The pudendal nerve is also and closing of the internal urethral sphincter, an anatomical level dorsal of the superior hypo-
known to have a potential modulatory effect on influence motility in the rectum, and influence gastric plexus.
bladder function. Somatic afferent fibers of the sexual functions such as erection.
pudendal nerve are thought to project on sym-
pathetic thoracolumbar neurons to the bladder
Uterus Bladder
Ureter
Pelvis
Rectum
Fig. 1.4: Sympathic and parasympathetic innervation of the pelvic organs

A: inferior hypogastric plexus – B: inferior hypogastric nerve – C: sympathetic trunk – D: pelvic splanchnic nerves
T12
L1
A Subcostal n.
B
L2
Illiohypogastric n.
Illioinguinal n.
L3
L4
Lateral cutaneous n. of thigh
L5
Fomoral n.
Lumbosacral trunk
Genitofemorol n.
Accessory obturator n. Obturator n.
Fig. 1.3: Pelvic splanchnic nerves on the right side Fig. 1.5: Lumbar plexus
A: sacral nerve S4 – B: pelvic splanchnic nerves
At the level of the 5th lumbar vertebrae or ventral The vesical plexus, which is sympathetic trunk remains hidden behind the
of the promontorium, the superior hypogastric anastomosed with the ureteral inferior vena cava and can only be damaged 5. THE LUMBAR PLEXUS
plexus divides into two inferior hypogastric plexus and lies on the crossing by a retrocaval lymphonodectomy. Damage to
nerves that run downward into the mesorectum, of the lateral to the dorsocaudal the lumbalis of the sympathetic trunk typically
ventral to the Waldeyer fascia. At the level of the part of the bladder. leads to homolateral peripheral vasodilation and The lumbar plexus is formed by the divisions of the
pelvis, the sympathic fibers build on both the a warming up of the homolateral foot. first four lumbar nerves (L1–L4) and from contribu-
rectum and the inferior hypogastric plexus. A perineal pelvic group, which also in- tions of the subcostal nerve (T12), which is the last
nervates the ureter, the bladder, the rec- The sacral part of the sympathetic trunk runs thoracic nerve. Additionally, the ventral rami of the
The inferior hypogastric plexus (also known as tal plexus, and the medial hemorrhoidal along the sacrum medial to the sacral foramens. 4th lumbar nerve pass communicating branches,
the knot from Lee, hypogastric knot, or plexus plexus It normally consists of three sacral ganglia that the lumbosacral trunk, to the sacral plexus. Several
pelvicus) lies deep in the pelvis in the superior form fibers ventral to the os sacrum of the oppo- branches of the lumbar plexus run into the pelvis
pelvirectal space, lateral to the rectum and The hypogastric plexus joins dorsally with the site ganglia and show anastomosis to the inferior and can be exposed by laparoscopy (Fig. 1.5).
the craniodorsal part of the vagina. The plexus sympathetic trunk, and caudally with the pelvic hypogastric plexus.
shows itself as a net of fibers that form a sacrou- splanchnic nerves.
terine ligament, also called a rectovaginal pillar. 5.1. THE ILIOHYPOGASTRIC NERVE
Stimulation of the inferior hypogastric nerve has
Two groups of terminal fibers emerge from the sympathetic effects: The iliohypogastric nerve runs anterior to the
inferior hypogastric plexus: psoas major on its proximal lateral border,
Relaxation of the flat musculature of the laterally and obliquely on the anterior side of
rectum quadratus lumborum. Lateral to this muscle, it
A craniomedial pelvic group that forms pierces the transversus abdominis to run above
four further plexuses: Contraction of the internal anal sphincter the iliac crest between that muscle and abdo-
minal internal oblique. It gives off several motor

The uterine plexus, which originates Sexual arousal branches to these muscles and a sensory branch
from the front part of the inferior hypog- to the skin of the lateral hip. Its terminal branch
astric plexus and runs along the uterine then runs parallel to the inguinal ligament to
plexus in the ventral and cranial part of exit the aponeurosis of the abdominal external
the sacrouterine ligament and reaches 4.2. THE SYMPATHIC TRUNK oblique above the external inguinal ring, where
the uterus in the area of the isthmus it supplies the skin above the inguinal ligament
The sympathetic trunk stretches on both sides of (i.e., the hypogastric region) with the anterior

The vaginal plexus the spine as a uniform nerve fiber–ganglion cord. cutaneous branch.
The trunk part of the sympathetic trunk joins up

The ureteral plexus along the terminal with the lumbal and sacral parts. Both lumbar
ureters, about 1 cm from the vesicou- trunks run directly along the medial insertion of 5.2. THE ILIOINGUINAL NERVE
reteral mouth. The periureteral tissue the iliopsoas muscle, ventral to the lumbar veins,
at this point should be preserved to and have approximately four associated neural The ilioinguinal nerve also runs on the quadratus
prevent ureter stenosis. ganglia. lumborum caudally to the iliohypogastric nerve.
At the level of the iliac crest, it pierces the lateral
Anatomically, the left sympathetic trunk can abdominal wall and runs medially at the level of
be revealed beside the aorta, whereas the right the inguinal ligament, where it supplies motor-
branches to both the transversus abdominis and 5.5. THE OBTURATOR NERVE 6. INNERVATION OF THE The genitofemoral nerve originates from
sensory branches through the external inguinal VULVA AND VAGINA the upper part of the lumbar plexus of
ring to the skin over the pubic symphysis and the The obturator nerve descends behind the psoas spinal nerves. In females, the genital
lateral aspect of the labia majora in females or major, then follows the linea terminalis into The female genital organs have several parallel branch of the genitofemoral nerve ends
the scrotum in males. the lesser pelvis lateral to the external vessels, nerve systems. The most important nerve groups in the skin of the mons pubis and labia
and finally leaves the pelvic area through the are the pudendal nerve, which has chiefly S2–S4 majora.
obturator canal. derivation; the inferior hypogastric plexus; and
5.3. THE GENITOFEMORAL NERVE the genital branches of the genitofemoral nerve. In absence of concomitant spinal cord patho
In the thigh, it sends motor branches mainly logies, vulvodynia corresponds with pathologies
The genitofemoral nerve originates from the to the adductor muscles. The anterior branch Sensory supply to the vulvar, perineal, of the genitofemoral nerve and/or of the
upper part of the lumbar plexus, pierces the contributes a terminal sensory branch, which and perianal skin and subcutaneous tissue pudendal nerve and/or of the sacral nerves roots;
psoas major anteriorly below the iliohypogastric supplies the skin on the medial, distal part of the of the lower two-thirds of the vagina is "middle vaginodynia" corresponds with disrupti-
and ilioinguinal nerves, then immediately splits thigh. assured by the pudendal nerve. Efferent on of the pelvic floor; and "high vaginodynia"
into two branches that run downward on the somatic supply is not significant in the corresponds with pathologies of the hypogastric
anterior side of the muscle, lateral to the vaginal wall because there is no striated nerves and plexus.
external iliac artery. The lateral femoral branch is 5.6. THE FEMORAL NERVE muscle, but efferent supply, largely from
purely sensory, and supplies the skin below the pudendal nerve, controls the levator
the in guinal ligament and the internal aspect The femoral nerve is the largest branch of the muscles that provide support for and
(i. e., the proximal lateral aspect of the femoral lumbar plexus. It provides considerable sensory influence the function of the lower third
triangle). The genital branch differs in males and innervation to the anterior aspect of the thigh of the vagina.
females. In males it runs in the spermatic cord, and knee, and motor innervation to the quadri
and in females in the inguinal canal together with ceps muscles. The femoral nerve runs in a Visceral nerve supply, which has chiefly
the round ligament of the uterus. It then sends groove between the psoas major and iliacus, hypogastric plexus derivation from T1–L2,
sensory branches to the skin of the mons pubis giving off branches to both muscles, and exits is significant for the upper vagina, muscu-
and the labia majora in females, and the scrotal the pelvis through the medial aspect of muscular lature, and glands. These nerves arise from
skin in males. In males it supplies motor inner- lacuna. In the thigh it divides into numerous the inferior hypogastric plexus, which gi- REFERENCES
vation to the cremaster (i. e., cremasteric reflex). sensory and muscular branches and the ves rise to three other divisions. One divisi-
saphenous nerve, its long sensory terminal on is the uterovaginal plexus (Frankenhäu- Possover M. Laparoscopic exposure and electrostimulation
branch, which continues down to the foot. ser's plexus) around the ureter and uterine of the somatic and autonomous pelvic nerves: a new
5.4. THE LATERAL CUTANEOUS artery. Fibers from the uterovaginal plexus method for implantation of neuroprosthesis in paralysed
FEMORAL NERVE It gives motor innervation to the iliopsoas, accompany the vaginal artery and vein to patients? J Gynecol Surg 2004;1:87-90.
pectineus, sartorius, and quadriceps femoris (the the vagina. The visceral afferent nerves of Possover M, Baekelandt J, Chiantera V: Anatomy of the
The fourth sensitive branch of the lumbar plexus patellar reflex is mediated by lumbar nerve L4), the uterovaginal plexus supply the parietal sacral roots and the pelvic splanchnic nerves in women
pierces the psoas major on its lateral side and runs and sensory innervation to the anterior thigh, peritoneum in the pouch of Douglas. No using the LANN technique. Surg Lap Endosc Percutan Tech
obliquely downward below the iliac fascia. Me posterior lower leg, and hind foot. Electrical parasympathetic fibers have been des 2007;17(6):508-10.
dial to the anterior superior iliac spine, it leaves stimulation of the femoral nerve induces an ex- cribed in association with this hypogastric Possover M, Rhiem K, Chiantera V. The "laparoscopic
the pelvic area through the lateral muscular lacu- tension of the knee. innervation of the vagina. The chief import- neuro-navigation"—LANN: from a functional cartography
na. In the thigh it briefly passes under the fascia ance of vaginal parasympathetic efferent of the pelvic autonomous neurosystem to a new field of
lata before it breaches the fascia and supplies the fibers (S2–S4) is to mediate sexual respon- laparoscopic surgery. Min Invas Ther & Allied Technol 2004;
skin of the anterior and lateral aspects of the thigh. se in the lower portion of the vagina. 13:362-7.
CHAPTER II DIAGNOSIS IN NEUROPELVEOLOGY

26 NEUROPELVEOLOGY CHAPTER II | DIAGNOSIS IN NEUROPELVEOLOGY 27
1. INTRODUCTION Vulvodynia, coccygodynia, inguinodynia
Because pain is transmitted by peripheral nerves Dysuria and/or painful ejaculation

that convey sensory signals throughout the body
to the central nervous system, the location of pain Refractory urinary symptoms
mainly does not correspond with the origin of
pain but instead indicates through which nerves Refractory pelvic and perineal pain
the pain signal is transmitted to the brain. There
fore, knowledge of patient history regarding the The vulva and the vagina are the key organs
location and radiation of the pain, along with involved in a proper neuropelveological diag
knowledge of the corresponding peripheral nosis. Deep vaginal pain corresponds to irritation
innervation, is essential (Fig. 2.1). of the inferior hypogastric plexus and is cha-
racterized by visceral pain accompanied by
Pelvic pain can be categorized as visceral pain vegetative symptoms. Anterior vulvodynia com-
(the sympathetic plexus is affected) and somatic bined with groin pain (which may or not

pain (the somatic nerves and plexus are affected). radiate to the medial aspect of the thigh) suggests
pathology of the genitofemoral nerve (or lumbar
Autonomic nerve irritation will produce com- plexus). Pudendal nerve pathology (Alcock's
bined visceral pain and vegetative symptoms, canal syndrome) combines vulvar pain, perine-
such as urinary frequency or urgency, dysuria, al pain, and perianal pain without any further
rectal pain, suprapubic pain, and/or abdominal radiation. The combination of pudendal pain
cramps and chills. with nongynecological pain, such as sciatica,
gluteal pain, or low-back pain, suggests patho-
Pathologies of the sacral plexus or other somatic logy of the sacral plexus (sacral radiculopathy
nerves will produce pain on the affected nerve's S2–S4). Further pain that radiates to the anterior
dermatomes, with symptoms such as burning part of the thigh (lumbar dermatomes) generally
pain (allodynia), tingling, electric shock–like corresponds to a spinal cord and/or spinal column
pain, numbness, and muscle weakness, along disorder.
with urinary and bowel dysfunctions. The main
symptoms of pelvic somatic nerve irritation are
as follows:
S ciatica associated with urinary symptoms

(urgency, frequency, dysuria) without any
clear orthopedic cause
luteal pain associated with perineal,

G
vaginal, or penile pain
Pudendal pain, partial or complete Fig. 2.1: Lumbosacral Dermatomes

2. NEUROPELVEOLOGICAL In somatic pain, the location of the pain can 2.2. STEP 2: DETERMINE THE NERVE cable or not, it makes no sense to observe the
ALGORITHM described very specifically. For example, patients PATHWAYS INVOLVED IN THE electrical cable; what is needed is to watch the
may report feeling "burning pain" with distal RELAY OF PAIN INFORMATION bulb at the end of the cable. In pain situations,
A neuropelveological workup always follows four radiation to the corresponding dermatome(s). TO THE BRAIN the electrical cable is the nerves, and the bulb
steps, as described in the following subsections. Because somatic nerves are mixed nerves, is the dermatomes. Pain location and radiati-
somatic pain is usually associated with functional In somatic neuropathic pain, because all on thus reveal the peripheral nerve pathways
problems in the pelvic organs, and sometimes in somatic nerve fibers end in dermatomes, the involved in the pain process (Tab. 2.2).
the legs. Vegetative symptoms are absent, except location of superficial pain on the skin gives
2.1. STEP 1: DETERMINE WHETHER THE as side effects of painkillers. information on which peripheral nerve pathways In situations of confusing pain locations, neuro
PAIN IS VISCERAL OR SOMATIC PAIN are involved. It is essential that medical doctors genic pathologies such as multiple sclerosis,
adopt a "neurological way of thinking." Standard Lyme disease, and other pathologies of the
Some types of pain are induced by organic medical training imparts the concept that the nervous system must be excluded, but also the
pelvic conditions (visceral pain > classical lower location of the pain and its etiology correspond statement of the patient regarding the pain's
abdominal pain), whereas other types result to the same area. For neuropelveological assess- location must questioned further.
from pathologies of the somatic nerves (somatic ment, however, it is important to understand
pains). Each type of pain is accompanied by that the location of the patient's pain mainly
different symptoms. Table 2.1 shows the main corresponds to the area innervated at the end 2.3. STEP 3: EVALUATE THE LEVEL OF PAIN
characteristics of both types of pain. of the nerve fibers (dermatomes), whereas the
etiology is mostly located more cranially, some- Again considering the example of the lamp, now
where on the way from that point to the cen- we need to imagine and understand the level of
VISCERAL PAIN SOMATIC PAIN tral nervous system, or on the path from the the problem's location: whether the switch is
dermatome to the brain. This situation can be defective, the cable is broken, or the bulb is
Pain quality: Pain quality: schematized as a lamp that will not light. To see destroyed.
Vague; poorly localized in the entire lower Allodynia; similar to an electrical shock; if electricity is running through the electrical
abdomen with radiation to the lower back; very specific location; precise and clear pain
dull in nature description; lack of vegetative symptoms
PRIMARY LOCATION OF PAIN CORRESPONDING NERVES
+ Vegetative symptoms: + Caudal radiation to the corresponding Genital pain (scrotum/penis/vulva) Genitofemoral nerve /pudendal nerve / S3–S4
Malaise/oppression/syncope dermatome(s)
Fatigue Anal pain Pudendal nerve / S2–S3
Irritability + Pelvic motor dysfunction: Perineal pain Pudendal nerve /S2–S3/S4
Pupil dilation Pelvic organ dysfunctions
Coccygeal pain) S2—S3/S4
Salivation inhibition Sexual dysfunction
Tachycardia Locomotion dysfunction Low-back pain L5—S1/S2
Nausea/vomiting
Gluteal pain S1—S2
Pallor
Diaphoresis Dorsal sciatica S1—S2
Anxiety Ventral sciatic below the kni L5
Tab. 2.1: Visceral Versus Somatic Pain: Symptoms Tab. 2.2: Primary Location of Pain and Corresponding Nerve Pathway
The irritation of single nerves always induces a and lumbar dermatomes. Bilateral neu-
feeling of pain at the end of the nerves, inde- ropathic pain is a normal orientation for Leg
pendent of the location of the pain's origin. In a spinal or central condition. Magnetic
order to understand the precise localization of a resonance imaging (MRI) of the rachis SN
nerve lesion, it is mandatory to imagine the nerve along with neuro-MRI of the spinal cord
pathways as a highway with multiple road inter- is suggested. PN Pudendal areas
sections: The more dermatomes that are painful,
the more nerves are affected, or the more cranial In pathologies of the sacral plexus and it
the lesion will be. branches, neuroanatomical considerations are
essential for understanding the combination of
US
The two most important factors for deter- symptoms (Fig. 2.2):
mination of the level of pain are the patient
history and digital palpation of the pelvic nerves. S 1 and L5 radiculopathy induces pain in Bladder
Whereas the distal branches of the lumbar the lower back, the buttock, and the dorsal/
plexus are accessible for external percutaneous external aspect of the leg (dermatomes
palpation (inguinal palpation of the ilioinguinal L5 and S1), without any genito-anal/ PSN
and genitofemoral branches), the pudendal pudendal pain. With a neurogenic lesion,
nerve and the sacral nerves (S2–S4) are accessible problems with extension of the foot and
by vaginal or rectal palpation. The reproduction motion of the leg can occur, as well as
of the pain (trigger point) in combination with a gluteal muscle hypotrophy.
positive Tinel sign (Tinel, 1905) and an improve L5 S1 S2 S3 S4
ment of pain of at least 50% after administration S2 radiculopathy induces pain in the
of local anesthesia at the trigger point confirm buttock and the dorsal/medial aspect of
which nerve is involved. the leg, as well as in the pudendal area Fig. 2.2: Neurofunctional anatomy of the sacral plexus
(mostly the perianal area). Damage to S2 SN: sciatic nerve; PN: pudendal nerve; US: urethral sphincter; PSN: pelvic splanchnic nerves
In addition, the combination of pain locations also induces difficulties with motion in
and dysfunctions will inform determination of the toes.
the level of the lesion.Patient anamnesis is extre-
mely important. A history of previous surgeries, S3 and S4 radiculopathy induces only
accidents, or varicose veins in the lower extre- pudendal pain (mostly in the perineal and
mities will orient the diagnosis: vulvar areas, vulvodynia), without radia-
tion to the buttock or the leg; problems
elvic origin versus spinal origin: A pelvic
P with bladder function (retention in neuro-
irritation of the sciatic nerve will induce genic lesion, hyperactivity or hypersensi-
allodynia in the sacral dermatomes only, tivity in nonneurogenic lesions).
in the bottom and the dorsal face of the
leg. In a lumbar discus hernia, because udendal neuralgia induces pain in the
P
not only the sacral nerves are irritated, ventral, middle, and dorsal pudendal
sciatica will combine dorsal and ventral areas combined, without any radiation to
leg pain according to the involved sacral the buttock or the leg. Bladder and rectal
dysfunction (bladder retention, chro- Simple neurologic examination permits differen- 2.5. STEP 4: CONFIRMATION OF 3. PATIENT HISTORY
nic constipation, and rectal deviation in tiation between a neurogenic lesion (with axo- AND THERAPY FOR A POTENTIAL
neurogenic lesions; bladder overactivity nal damage) and nonneurogenic lesion (without ETIOLOGY
or hypersensitivity and irritable colon in axonal damage): Patients are asked a set of questions regarding
nonneurogenic lesions). In situations where the affected nerve is easily potential causes (e.g., previous surgery, opera-

Neurogenic condition: Nerve functions are accessible by injection, local anesthesia might tive vaginal delivery, episiotomy, endometriosis,
reduced. Symptoms combine problems be extremely helpful for confirmation of the dia- etc.), time of onset, duration, and severity of pain
2.4. STEP 3: ESTABLISH A POTENTIAL with locomotion, hypo- or anesthesia, gnosis and for treatment (nerve block with botu- using a pain intensity scale (visual analog scale
ETIOLOGY bladder retention, sexual dysfunction, linum toxin A). [VAS]) of 0 (no pain) to 10 (worst imaginable
and chronic constipation. pain).
Patient history, neuropelveological examination, When the affected nerves are deeply placed wit-
and pelvic neuro-MRI (with particular attention
Nonneurogenic condition: Nerve func- hin the pelvic cavity, laparoscopic exploration is
to pelvic tumors, pelvic varicosities, and pelvic tions are increased. Symptoms combine the key for a proper diagnosis and a potential neu- 3.1. RISK FACTORS FOR NERVE DAMAGE
sidewall endometriosis) orient the diagnosis to a superficial hypersensitivity, paresthesia, rofunctional treatment (nerve release, neuroly-
potential etiology. bladder hypersensitivity or even over sis, laparoscopic implantation of neuroprosthe- Previous pelvic/abdominal surgeries or obste-
activity, irritable colon, phantom pain. sis for neuromodulation [LION] procedure, etc.). tric events are very important risk factors. All
The neuropelveologist requires thorough know inguinal procedures, such as surgical repair for
ledge of pelvic surgeries and must understand inguinal hernia, low abdominal trocar or drai-
which procedures can cause damage to which nage incision, and Pfannenstiel incisions, are
nerves (Tab. 2.3). associated with a risk of damage to the genito-
femoral and/or ilioinguinal nerves. Laparoscopic
and laparotomic approaches to the pelvic side-
wall or parametric tissues place patients at risk
PROCEDURES CORRESPONDING NERVE DAMAGE
of damage to the somatic pelvic nerves. Central
Pelvic sidewall procedures Sacral plexus – obturator nerve pelvic surgeries (hysterectomy and laparoscopic
uterosacral nerve ablation [LUNA]) are associa-
McCall fixation Sacral nerves S2–S3 ted with risk of injury of the inferior hypogastric
Amreich-Richter fixation Pudendal nerve, right plexus. Presacral neurectomy is associated with
risk of injury to the superior hypogastric plexus.
Trans-obturator sling (OT)/
Both situations expose patients to a risk of vi-
Prolift/episiotomy Pudendal nerve
sceral pelvic pain. Perineal, proctological, and
Hip surgeries (prosthesis) Pudendal nerve; inferior gluteal nerve obstetrical interventions are associated with risk
Rectopexy/sacropexy Sacral nerves S2–S3, right of pudendal nerve injury.
Vaginal delivery (forceps, vacuum) Pudendal nerve

Pelvic interventions and thrombosis may also
Herniorrhaphy/lateral trocar by promote changes in pelvic vein circulation that
laparoscopy Ilioinguinal/genitofemoral nerves may trigger the development of pelvic varicose
Renal procedures/lithotripsy Lumbar plexus veins, with potential risk for neurovascular con-
flict or sacral compartment syndrome. Because
Tab. 2.3: Pelvic Surgical Procedures with Corresponding Potential Nerve Injuries the anatomy of the pelvic and lower limb veins
is similar, patients with varicose veins in the legs damage (axonal nerve damage). Somatic pain
may also have a higher risk of pelvic varicose is well described as localized pain with distal
veins. radiation in the corresponding dermatome(s)
(Fig. 2.3). Generally, there is a trigger point at
GFN
History taking should also focus on pathologies the level of irritation. Further symptoms may
of the spinal cord, vertebral column, central ner- include increased sensitivity; electric shock-like
vous system (e.g., multiple sclerosis, Parkinson's sensations and/or stabbing, knife-like, or aching
disease, etc.), and peripheral nervous system pain; lump or foreign body sensations; twisting L5 S1 S2
(polyneuropathy). or pinching sensations; abnormal temperature
sensations; constipation; pain and straining
Finally, the use of painkillers should be thorough with bowel movements; straining or burning on S3
ly documented. urination; painful intercourse; and sexual dys-
S4 PN
function, including hyperarousal or decreased
SN
sensitivity.
3.2. CHARACTERISTICS OF PAIN –
QUALITY, LOCATION, AND
RADIATION 3.3. AGGRAVATING OR RELIEVING
FACTORS
Because visceral nerves extend throughout the Fig. 2.3: Sacral dermatomes
pelvic organs like a spider web, visceral pelvic Pudendal neuralgia caused by compression of SN: sciatic nerve; PN: pudendal nerve; GFN: genitofemoral nerve
pain is usually described as vague, poorly loca- the pudendal nerve in Alcock‘s canal (Alcock's
lized, and dull, or as general malaise rather than canal syndrome) typically induces severe pu-
specific pain, which generally radiates to the dendal nerve pain on sitting, which is relieved
lower back. Visceral pain is often associated with by standing and absent when recumbent or
vegetative symptoms such as nausea, vomiting, when sitting on a toilet seat. Neuropathic pain
pallor, diaphoresis, and tachycardia. induced by endometriosis of the pelvic nerves Immediate genito-anal pain after sitting Alcock's canal syndrome
increases during menstruation and may decrease
Secondary pain after sitting/standing
Somatic pelvic pain occurs due to damage of in response to gonadotropin-releasing hormone
Aggravation by Valsalva maneuver
the somatic pelvic nerves and is classified as (GnRH) analogues. In neurovascular conflict,
Amelioration of pain while lying/at night
truncular (damage to the sciatic, obturator, pain is aggravated by all situations that induce an Sacral radiculopathy by vascular entrapment
Varicosis veins/thrombosis of the legs
femoral, or pudendal nerves) or radicular (damage increase in pelvic venous pressure (e.g., prolon-
Tricuspid insufficiency
to the lumbar or sacral plexus). Neuropathic ged standing or sitting, the Valsalva maneuver,
Secondary to pelvic surgeries
pain causes numerous symptoms, ranging from etc.) or marked pulsation of the pelvic veins
Cyclical sciatic L5–S1 Endometriosis of the sciatic nerve (isolated form)
allodynia, paresthesias, and sensations of elec (e.g., tricuspid insufficiency, close anatomic
trical discharges to phantom sensations, which relationship with arteries, etc.) (Tab. 2.4). Cyclical radiculopathy S2–S4 Endometriosis of the infralevator part of the
are even more confusing when no morphologic sacral plexus
correlates are found. Hyperesthesia is usually Onset of pain directly after surgery Surgical nerve damage
the result of lesions causing nerve irritation,
Onset of pain > 6 months after surgery Nerve fibrotic/vascular entrapment
whereas hypoesthesia, anesthesia, and phantom
pain generally develop after neurogenic nerve Tab. 2.4: Risk and Aggravating Factors for Somatic Pelvic Neuropathy
4. PELVIC EXAMINATION 5. NEUROLOGICAL

EXAMINATION
The pelvic clinical examination focuses on

inspection of the genital organs (colposcopy), A full neurological examination includes assess-
supported by vaginal culture, urinalysis, vaginal ment of both the motor and sensory systems.
pH testing, Pap smear, and biopsy of abnormal
vulvar areas. Recto-vaginal palpation not only
focuses on the parametrium and rectovaginal 5.1. MUSCLE TONE AND POWER
space, but also on the pudendal nerves and the
lower sacral nerve roots (sacral nerve roots L5 Ankle clonus is checked by placing the patient's
and S1 are not accessible by vaginal or rectal leg turned outward on the bed, moving the ank-
palpation). Direct digital palpation of the pelvic le joint a few times to relax it, and then sharply
nerves is the key to diagnosis. Affected patients dorsiflexing it. Any further movement of the joint
have exquisite tenderness when digital pressure may suggest clonus. The patient is also assessed
is applied to the damaged nerve, typically pro- for possible motor deficits in hip adduction (L3/
ducing Tinel's sign (a sensation of tingling or obturator nerve), knee extension (L1–L4/femoral
"pins and needles") in the distal distribution of nerve), ankle dorsiflexion (foot drop–L5) and an- Fig. 2.4: Left gluteal hypotonia secondary to neurogenic damage of sacral roots S1–S2 or the gluteal nerves
the nerve. The pudendal nerve is accessible to kle plantar flexion (S1), and contraction of the
palpation a few millimeters dorsomedial to the gluteal muscles (Fig. 2.4).
sciatic spine, and the lower sacral nerve roots
are accessible at the sacral bone, a few centi-
meters to the left and right of midline (Fig. 2.3). 5.2. REFLEXES
A selective nerve block is crucial for confirma-
tion of the diagnosis. A pudendal nerve block The patellar reflex corresponds to the L4 nerve,
can be performed via a perineal approach with whereas ankle jerk corresponds to the S1 root.
concomitant vaginal/rectal palpation, and sacral The cremasteric reflex corresponds to the genital
nerve root block can be achieved by epidural or branch of the genitofemoral nerve in men.
dorsal transforaminal epidural injection.
5.3. PATIENT WALKING AND

ROMBERG'S TEST
When the patient is standing with the feet

apart and the eyes closed, any swaying may be
suggestive of posterior column pathology.
5.4. SENSATION 6. PELVIC ULTRASOUND
The patient is assessed for light touch and pin-

prick sensation in all lumbosacral dermatomes. Vaginal ultrasound is not only used for assess-
Extrinsic lesions (> nerve irritation) do not cause ment of organs and structures within the female
any loss of sensation or feeling of numbness, pelvis, but also for evaluation of postvoid residual
whereas neurogenic nerve damage is accompa- urine volume and bladder wall thickness. Pelvic
nied by a loss of sensation or numbness in the varicose veins can also be identified directly via
corresponding nerve distribution. transvaginal/rectal Doppler ultrasound. Pelvic
varicose veins are defined as the presence of
dilated (diameter ≥ 7 mm), tortuous vessels with
5.5. VIBRATION reflux (presence of bidirectional flow during the
Valsalva maneuver) (Fig. 2.5).
Vibration is assessed using a sounding tuning
fork placed on the medial malleolus.
5.6. PROPRIOCEPTION Fig. 2.5: Pelvic varicose veins with reverse flow
Proprioception is assessed by up-and-down

movement of the joint of the great toe (> joint
position sense).
7. RENAL ULTRASOUND
Routine renal ultrasound may be recommended

in all patients with pelvic endometriosis for pre-
vention of silent ureteral stenosis, especially when
deeply infiltrating endometriosis is suspected.
8. CYSTOMETRY AND 9. NEUROPHYSIOLOGICAL REFERENCES

URODYNAMIC TESTING TESTING
Debodinance P, Amblard J, Fatton B, Cosson M, Jacquetin
B. The prosthetic kits in the prolapsed surgery: is it a gad-
Pathologies of sacral nerve roots S2–S4 and/or of Some of the more commonly used tests include get? J Gynecol Obstet Biol Reprod 2007;36(3):267-75.
the pelvic splanchnic nerves induce neuropathic the pudendal nerve terminal motor latency test Possover M. Laparoscopic management of endopelvic
pain as well as lower urinary tract and intestinal (PNTML), EMG, and magnetic resonance neu- etiologies of pudendal pain in 134 consecutive patients.
dysfunctions. Such disorders may be evaluated rography (MRN). EMG studies of the pudendal J Urol 2009;181:1732-6.
by urodynamic testing (cystometry, uroflowmet- nerve, often touted as a diagnostic tool, are unre- Possover M. New surgical evolutions in management of
ry, and pressure flow studies), pelvic electromyo- liable because they can be abnormal after vagi- sacral radiculopathies. Surg Technol Int 2010;19:123-8.
graphy (EMG) recording, and video-urodynamic nal delivery or vaginal hysterectomy. Moreover, Possover M, Schneider T, Henle KP. Laparoscopic therapy
studies. When assessing bladder function, it is they do not define the neurologic level of the of endometriosis and vascular entrapment of sacral plexus.
very important to differentiate between detrusor pathology. Fertility & Sterility 2011;95:756-8.
hypotonia, which indicates neurogenic damage Reitz A, Schmid DM, Curt A, Knapp PA, Schurch B. Affe-
to the pelvic nerves, and irritation of the pelvic rent fibers of the pudendal nerve modulate sympathetic
nerves, which is associated with bladder hyper- neurons controlling the bladder neck. Neurourol Urodyn
sensitivity or overactive bladder (OAB). Urgency, 2003;22(6):597-601.
the cardinal symptom of OAB, is defined as a Tinel J. Le signe du fourmillemnt dans les lesions des nerfs
sudden and compelling desire to pass urine that peripheriques. Presse medicale 1915; 47:388-389.
is difficult to defer, whereas bladder hypersensi- Verdeja AM, Elkins TE, Odoi A, Gasser R, Lamoutte C. Trans-
tivity is a urodynamic diagnosis characterized by vaginal sacrospinous colpopexy: anatomic landmarks to be
an early desire to void without fear of leakage aware of to minimize complications. Am J Obstet Gynecol
or pain that persists and becomes annoying to 1995;173:1468-9.
the patient. Bladder hypersensitivity may resem- Virseda Chamorro M., Salinas-Casdo J, Zarza-Lucianez D,
ble irritation of the pelvic nerves in terms of an Mendez-Rubio S, Pelaquim H, Esteban-Fuertes M. Participa-
incontrollable desire to pass urine without leaka- tion of the pudendal innervation in the detrusor overactivity
ge and without a rise in detrusor pressure during of the detrusor and in the overactive bladder syndrome.
filling cystometry, but less so with pathologies of Actas Urol Esp 2012;36(1):37-41.
the bladder itself.
CHAPTER III LAPAROSCOPIC EXPOSURE OF

THE PELVIC NERVES – METHODOLOGY
44 NEUROPELVEOLOGY CHAPTER III | LAPAROSCOPIC EXPOSURE OF THE PELVIC NERVES – METHODOLOGY 45
1. INTRODUCTION 2. EXPOSURE OF THE

FEMORAL NERVE
Since the introduction of laparoscopy in pelvic Regarding the femoral nerve, the area of interest
surgery, with its view magnification that allows is located at the pelvic sidewall above the cranial
an optimal dissection even in the deepness of border of the psoas muscle. After opening of
the pelvic retroperitoneum, it has become one the retroperitoneal space, the iliac fascia must
of the most useful and powerful instruments for be incised parallel to the border of the psoas
learning pelvic anatomy. Laparoscopic exposure muscle. At the middle distance between the
of pelvic nerves thus became feasible in routi- anterior abdominal wall and the common iliac
ne laparoscopic surgery (Possover, 2004), and artery, the muscle is retracted caudally, per-
use of the laparoscopic neuronavigation (LANN) mitting the exposure of the femoral nerve as a
technique now permits intraoperative assess- white band of a half centimeter in diameter loca-
ment of the motoric functionality of the exposed ted in the gutter formed by the psoas and the iliac
somatic and autonomous nerves in the pelvis muscle (Fig. 3.1).
(Possover et al., 2004).
Not only did such advances lead to new

knowledge of neurofunctional pelvic anatomy in
women, they also made possible detailed neuro-
functional cartography, allowing the possibility
to expose, spare, and treat each single nerve and 3. EXPOSURE OF SCIATIC AND
plexus. PUDENDAL NERVES
The parasympathetic nerve sparing technique The transperitoneal lumbosacral way is used
for reduction of postoperative functional morbi- for exposure of the endopelvic portion of the
dity of the bladder, the rectum, and the sexual sciatic nerve and the pudendal nerve. After wide
organs in radical pelvic surgery is based on this opening of the retroperitoneal space laterally to A
concept of electively exposing and sparing the the external iliac artery, the lumbosacral space
pelvic splanchnic nerves during transection of is expanded downward up to the lumbosacral
the parametrium. trunk. By following the trunk distally, the sciatic B
nerve is identified just before its entry through
All procedures reported in this book are mainly the greater sciatic notch (Figs. 3.2–3.8).
based on the ability of laparoscopy to expose all
pelvic plexuses and somatic nerves. By further gentle detachment of the pelvic fat
and lymph tissue covering the nerve, the sacro-
spinous ligament and the caudal border of the
sciatic nerve are also exposed. At the lesser
sciatic foramen, the pudendal nerve is identified Fig. 3.1: Exposure of the femoral nerve
just before it leaves the pelvis. A: femoral nerve – B: spoas muscle
B
A
Fig. 3.2: Opening of the peritoneum along the external iliac artery Fig. 3.3: Exposure of the external iliac artery
A: psoas muscle – B: rectum A: external iliac artery – B: psoas muscle
A
D C
B C
A B
Fig. 3.4: Opening of the lumbosacral space Fig. 3.5: Identification of the obturator nerve
A: external iliac aretry – B: lumbosacral space – C: psoas muscle A: external iliac artery – B: obturator nerve – C: psoas muscle – D: lumbosacral space
A B A
Fig. 3.6: Exposure of the lumbosacral trunk Fig. 3.7: Exposure of the sciatic nerve
A: lumbosacral trunk – B: linea terminalis A: sciatic nerve – B: pudendal nerve – C: greater sciatic notch
4. EXPOSURE OF THE SACRAL REFERENCES

NERVES AND THE PELVIC
SPLANCHNIC NERVES Brindley GS, Polkey CE, Rushton DN, Crdozo L. Sacral an-
terior root stimulators for bladder control in paraplegia: the
first 50 cases. J Neurol Neurosur Ps 1986;49:1104-14.
In order to expose the sacral nerve roots, the dis- Possover M. Laparoscopic exposure and electrostimulati-
section is started with the incision of the pararec- on of the somatic and autonomous pelvic nerves: a new
tal peritoneum medial to the ureter, followed by method for implantation of neuroprosthesis in paralysed
the dissection of the avascular pararectal space patients? J Gynecol Surg 2004;1:87-90.
downward to the coccygeal bone. The dissecti- Possover M, Rhiem K., Chiantera V. The "laparoscopic neu-
on is further carried out laterally by the transec ro-navigation —LANN: from a functional cartography of the
tion of the sacral hypogastric fascia. Sacral roots pelvic autonomous neurosystem to a new field of laparosco-
S1 to S4 are selectively exposed by very gentle pic surgery. Min Invas Ther & Allied Technol 2004;13:362-7.
dissection (Figs. 3.9–3.13). Confirmation of the Possover M, Stöber S, Plaul K, Schneider A. 2000. Identi-
origin of the different sacral roots can be gained fication and preservation of the motoric innervation of the
by using the LANN technique. bladder in radical hysterectomy type III or IV. Gyneco Onco
2000;79:154-7.
With a bipolar laparoscopic forceps designed
for intraoperative electrostimulation and a cur-
rent with a square-wave pulse duration of 250
μs, a pulse frequency of 35 Hz, and an electric
C potential of 3–6 V, stimulation of the S3 nerve
is confirmed visually by a deepening and flat-
tening of the buttock groove as well as a plantar
flexion of the large toe and to a lesser extent of
B
the smaller toes. Stimulation of S2 produces an
outward rotation of the leg and plantar flexion of
the foot, as well as a clamp-like squeeze of the
anal sphincter from the anterior to the posterior.
Because in humans most of the parasympathetic

and pudendal nerves originate from S2 and S3
A
(Brindley et al., 1986), gentle dissection of both
roots is extended ventrally in order to expose
the pelvic splanchnic nerves sprouting out from
both roots (Fig. 3.14).
Fig. 3.8: Exposure of the pudendal nerve General anesthesia without myorelaxation
A: sciatic nerve – B: pudendal nerve (1st segment) – during the neurostimulation period is used for all
C: lesser sciatic foramen procedures.
A
B A
Fig. 3.9: Opening of the peritoneum at the promontory Fig. 3.10: Dissection of the pararectal space
A: external iliac artery – B: ureter – C: sigmoide – D: promontorium A: pararectal space
C
A
B
A
Fig. 3.11: Dissection of the retrorectal space Fig. 3.12: Exposure of the sacral hypogastric fascia and transection
A: paracetal space A: pararectal space –B: sacral hypogastric fascia – C: lateral sacral vein – D: sacrum
C
D
A D
C
B
B
Fig. 3.13: Exposure of sacral nerves S1–S4 Fig. 3.14: Exposure of the pelvic splanchnic nerves (S3)
A: sacral nerve S 2 – B: sacral nerve S3 – C: sacral nerve S4 – A: sacral nerve S4 – B: pelvic splanchnic nerves rectale –
D: pelvic splanchnic nerves – E: sacrum C: inferior hypogastric plexus – D: pelvic pslanchnic nerves vesicale
CHAPTER IV PELVIC NEUROPATHIC

PAIN SYNDROMES AND ETIOLOGIES
62 NEUROPELVEOLOGY CHAPTER IV | PELVIC NEUROPATHIC PAIN SYNDROMES AND ETIOLOGIES 63
1. INTRODUCTION nerves may be responsible for many intractable 2. SOMATIC VERSUS VISCERAL Irritation of S2 can induce sexual dys-
chronic pelvic pain conditions. PELVIC PAIN functions, whereas lesions on S3 and S4
will induce hyperactivity or hypersensi-
Low-lumbar pain radiating into the buttock and This chapter covers the most frequent etiologies tivity of bladder and/or rectum.
the leg without focal neurologic deficit has a high for pelvic neuropathic pain, highlighting also the Pelvic pain, acute or chronic, is a common
prevalence in the general population. The classic difference between the sacral and the lumbal condition in daily medical practice. Numerous When true axonal damage occurs (neu-
diagnostic workup focuses on pathologies of the plexus, which are often referred to in the lite- pelvic pathologies responsible for pelvic pain rogenic lesions), patients might suffer
spinal cord and of the vertebral column. When rature as the "lumbosacral plexus", even though have been reported in the literature. from bladder retention, chronic consti-
no causes are discovered, treatment is all too they are totally different both anatomically and pation, and loss of sensation in some
often limited to medical treatments, infiltrations, functionally. In order to understand the possible differential dermatomes, as well as loss of erection
and physiotherapy for pain control. diagnosis of pelvic pain, it is important to diffe- in men.
rentiate between visceral and somatic pain:
Pathologies of the pelvic nerves, especially
Visceral pelvic pain is usually descri-
of the sacral plexus, are quite always omitted.
Somatic pain is mostly caused by patho- bed as vague, poorly localized, and
Moreover, when the pelvic pain presents in form logies involving the sacral plexus and dull in nature, with malaise or oppres-
of vulvodynia, coccygodynia, or incomplete its branches. Neuropathic pain resul- sion rather than specific pain. Thus it is
pudendal pain, and no morphologic correlate ting from lesions of the pelvic somatic often associated with vegetative symp-
is found, omission of pelvic nerve diagnostic nerves is reported as "burning pain" toms such as nausea, vomiting, pallor,
flowchart and prescriptions of painkillers, local (allodynia) or "electrical pain" loca- diaphoresis, and tachycardia.
topical medications, or psychiatric medications ted in the dorsal face of the thigh (S1,
build the classic form of treatment. S2); the perianal, genital, and perineal When secondary to pelvic radical
dermatomes (S3, S4—pudendal nerve); surgery such radical hysterectomy
The only exception to this habit is in the case the buttock (S1, S2, S3); the dermatomes or excisional surgery of the parame-
of compression of the pudendal nerve at the of the lower back (L5, S1); the internal der- tric tissues, the pain occurs due to
Alcock's canal, or Alcock's canal syndrome. The matomes of the thigh (obturator nerve); lesions on the inferior hypogastric
popularity of the diagnosis of this condition is or the anterior dermatomes of the thigh plexus (IHP) and could be consi-
obviously due to the highly accessible nature (femoral nerve). dered as a kind of pelvic phantom
of the pudendal nerve for neurophysiological pain. In this case the pain may be
exploration, infiltration, and surgical decom- A lesion of a pudendal nerve induces caused by the formation of neuromas in
pression through the perineal or gluteal areas. an isolated ipsilateral pudendal pain the IHP comparable with the phantom
On the contrary, any pathology of supralevator (usually without any incontinence as stump pain after lower extremity am-
pelvic nerves is normally not investigated due long as pudendal destruction is not bi- putation.
to the difficulties of manual exploration and of lateral).
surgical access. However, trying to find a pelvic neu-
Different sacral radiculopathies might roma in the IHP even with the mag-
The feasibility of a surgical approach and a also induce pudendal pain (S3, S4), but nification of laparoscopy is quite im-
functional exploration of the endopelvic nerves in combination with sciatica (L5, S1, possible, and removal of this plexus
by laparoscopy has significantly increased the S2), pain in the buttock (S1, S2, S3), or is not viable because it is involved in
attention on pelvic nerve pathologies, resulting low-back pain (L5, S1, S2). the pelvic visceral reflexes (Cervero,
in the knowledge that any alteration of those 1994). In addition, a blockade of all
involved afferent pathways is very ted with an alteration of sensa- ration of the entire sacral plexus is then essen- 3. VULVODYNIA
difficult, with five major autonomic tion regarding rectum fullness tial to diagnose the presence of local etiologies.
pathways that could transmit no- or bladder fullness. Through intraoperative confirmation, laparo
ciceptive information from the pelvis scopic decompression is the treatment of choice, The term vulvodynia is reserved for those
(Bosscher, 2001). based on the separation of offending tissue or patients suffering from chronic pain in the vulvar
A lesion of the lower third of vessels from the nerves. Moreover, such proce- area that occurs in the absence of physical

Moreover, information may also the IHP, as in a radical hyste dures are safe and have a high rate of success. findings (Harefner, 2007). Conditions of infec
not necessarily follow just one pa- rectomy or in deep anterior The laparoscopic approach gives the possibility tious, inflammatory, neoplastic, and immunolo-
thway, and high stimuli may result rectum resection, will affect the to reduce morbidity and improve results by pro- gic origin, as well as evidence for any systemic
in the activation of the neighboring pelvic splanchnic nerves. viding wider insight into the operating field with illness, physical trauma to the vulva, dermato-
unmyelinated fiber originating from a lessened risk of intraoperative injury. logic conditions, and urinary tract syndromes,
different site; thus, a blockade of one Thus, in patients with suspected elective lesions should be ruled out prior to making a diagnosis.
particular pathway is unlikely to provide of the first and/or the second segments of the Nevertheless, the quality and success rate of all
complete pain relief. plexus, as in a simple hysterectomy or plastic neuropelveological treatments will depend di- The diagnostic flowchart is then based on the
resection of the sacrouterine ligaments, the supe- rectly on the quality and accuracy of the diag- typical complaints of the patients, normal gyne-
Theoretically, the aim of a blockade is rior hypogastric plexus (SHP) is therapeutically nosis. cological and dermatological examination, and
to stop the greatest possible amount of blocked. Different surgical (Soysal et al., 2003) the absence of identifiable causes. The patient
pathways involved in pain transmission. and chemical (Gamal et al., 2006) techniques history should focus on all symptoms, including
Because the IHP is composed of three for a blockade of the SHP have been reported allodynia, numbness, hypersensitivity, electric
different functional levels, the type of in the literature, but all of these techniques are shock–like pain, stabbing pain, knife-like or
injured afferent sympathetic fibers and destructive and irreversible. In case an inferior aching pain, feeling of a lump or foreign body,
consequently the site of the blockade of block is necessary, a nondestructive method is twisting or pinching, abnormal temperature sen-
afferent pathways could depend on the preferred: infiltration of the IHP with botulinum sations, constipation, pain and straining with
level of the lesion in the plexus: toxin A. bowel movements, straining or burning when
urinating, painful intercourse, and sexual dys-
In case of lesions of the first seg- In consideration of the dramatic situation of function, including hyperarousal and hyposen-
ment (upper third), as in simple patients suffering from neuropathic pelvic pain sitivity.
hysterectomy, the injury will be and the amount of inadequate, ineffective, and
at the level of the afferent fibers invasive treatments that are still proposed to An accurate diagnosis focused on genital and
passing through both inferior these patients, it is highly important to consider extragenital (lumbosacral areas) symptoms re-
hypogastric nerves. all mentioned etiologies in the diagnostic and quires a comprehensive anamnesis on previous
therapeutic flowchart of intractable neuropathic surgical/obstetrical procedures and concomit-
In lesions affecting the second pelvic pain. ant pelvic pathologies. Information on possible
segment of the IHP, injuries pathologies of the central nervous system (e.g.,
of the sympathetic fibers con As a first step for such patients, it is mandatory spinal cord lesions, multiple sclerosis, Lyme di-
tained in the first segment will to recognize the characteristics of "neuropathic sease, etc.) and dysfunctions of the peripheral
be associated with lesions of nonneurogenic" and "pelvic origin" of the nervous system, such as motor deficits of hip
the sympathetic fibers joining symptoms. In such cases a neuropelveologi- adduction (L3/obturator nerve), knee extensors
the sympathetic trunks, and cal approach is absolutely essential to obtain a (L1–L4/femoral nerve), ankle dorsiflexion (foot
pain will be generally associa- complete treatment result. Laparoscopic explo- drop—L5), and ankle plantar flexion (S1), are
of major importance. Sphincters dysfunctions, 3.1 DIFFERENTIAL DIAGNOSIS Infections such as candidiasis (caused by syndrome, back pain, and temporomandibular
motor/sensitive urinary urgency or voiding diffi- Candida albicans) and bacterial vaginitis are joint disorder. Several studies have noted an in-
culties are explored by urodynamic testing. There are many possible causes for vulvodynia, usually the first conditions considered, but are crease in anxiety, stress, and depression among
with the most frequent being of dermatologic rarely cause of vulvar pain and never cause women who have vulvodynia (Red et al., 2000;
Clinical examination focuses on inspection of origin (Tab. 4.1). chronic vulvar pain. Very rarely they may cause Sadownik, 2000).
the genital organs, supported by vaginal culture, recurrent pain that clears, at least briefly, with
urinalysis, control of vaginal pH, Pap smear, In postmenopausal women, atrophic vaginitis treatment. Herpes simplex virus is very frequent- The following comorbidities are particularly hel-
biopsy of abnormal vulvar areas, and psychoso- can also cause burning pain. Yeast and lichen ly suggested as a potential cause for vulvodynia, pful in establishing the diagnosis of a neurologi-
cial assessment. simplex chronicus typically produce itching, but is usually a cause of recurrent rather than cal etiology.
although sometimes can present with irritation chronic pain. Generally, chronic pain is more
Neurologic examination should include explora- and pain. Lichen sclerosus manifests with white likely to be caused by skin disease than by infec- Distal lesions of the pudendal branches
tion of all lumbosacral nerves, with vaginal and/ epithelium that has a crinkling, shiny, or waxy tion. Lichen simplex chronicus (also known as
or rectal palpation of the pudendal nerves and texture. It can produce pain, especially dyspa- eczema) causes itching, with pain due to erosion Vulvodynia mostly located in the dorsal
sacral nerve roots S3–S5. Onset of an exquisite reunia. In this case pain is caused by erosion that from patients' scratching; any other pain that portion of the vulva is often secondary to obste-
tenderness and Tinel´s sign (sensation of tingling arises from introital narrowing, fragility, and in- arises is produced by visible excoriations. Skin trical or proctological procedures with damage
or "pins and needles" in the distribution of the elasticity. Vulvovaginal lichen planus is usually diseases that affect the vulva are usually pruritic, to the middle or the dorsal branch of the
damaged nerve) when digital pressure is applied erosive and preferentially affects mucous mem- and pain is a later sign. It is always important to pudendal nerve. A superficial vulvar positive
over a pelvic nerve and pain improvement of branes, especially the vestibule; it sometimes consider cancer when a patient has an abnormal trigger point is found, whereas palpation of the
more than 50% of the VAS score when a selec- affects the vagina and mouth as well. vulvar appearance and pain that persists despite pelvic nerves is normal. Pelvic organ dysfunc-
tive block of the nerve is obtained will confirm treatment. tions are lacking. Improvement in pain resulting
unequivocally the diagnosis. from lidocaine infiltration in the trigger point
confirms the diagnosis. Treatment then consists
3.2 NEUROPATHIC ETIOLOGIES AND of local infiltration of the same area with botu-
CORRESPONDING TREATMENTS linum toxin A.
Acute irritant contact dermatitis (e.g., erosion Immunobullous diseases (including cicatricial
due to podofilox, imiquimod, cantharidin, pemphigoid, pemphigus vulgaris, linear im- Pudendal neuralgia (PN), diabetic neuropathy, Genitofemoral neuropathy
fluorouracil, or podophyllin toxin) munoglobulin A disease, etc.) and post-herpetic neuralgia are the most com-
Aphthous ulcer Lichen planus mon specific neurologic causes of vulvar pain When the genitofemoral nerve is affected, pain
reported in the literature. Some possible causes may be felt in the inguinal area, with radiation
Atrophy Lichen sclerosus
are inflammatory or autoimmune illness or even to the internal aspect of the thigh and also to the
Bartholin's abscess Podophyllin overdose (see above) frequent infections. Multiple sclerosis can also genital area. Distal lesions of the genital branch
produce such pain. of the nerve induce anterior vulvodynia. Be
Candidiasis Prolapsed urethra
cause the genitofemoral nerve is a sensory nerve
Carcinoma Sjogren's syndrome An involvement of the nervous system in any only, symptoms are restricted to sensory chan-
Chronic irritant contact dermatitis Trauma form should be suspected when women suffering ges, except in males, where loss of the cremaste-
from vulvodynia or vaginodynia report a history ric reflex can be observed.
Endometriosis Trichomoniasis
of headache, irritable bowel syndrome (Arnold
Herpes (simplex and zoster) Vulvar intraepithelial neoplasia et al., 2006), interstitial cystitis (Clemens et al., Surgical access to the inguinal region (e.g., ap-
2005; Kahn et al., 2010; Parsons et al., 2002), pendectomy, herniorrhaphy, introduction of late-
Tab. 4.1: Gynecologic/Dermatologic Conditions for Vulvovaginal Pain fibromyalgia (Yunas, 2007), chronic fatigue ral trocar for laparoscopy, etc.) exposes patients
4. PUDENDAL NEURALGIA 4.1. ALCOCK'S CANAL SYNDROME

to such groin pain. Treatment in those cases has In all cases of nerve damages secondary to
proven to be extremely difficult. pelvic procedures, laparoscopic exploration of Amarenco (Amarenco et al., 1989) first de
the injured nerves for possible decompression is Pudendal neuralgia presents with neuropathic scribed Alcock's canal syndrome in 1987. The
Sacral radiculopathies (SRs) indicated as soon as possible, before the damage pain in the entire nerve distribution area – vulvar, pudendal nerve is irritated but not destroyed, so
becomes irreversible and the process of beco- perineal, and perianal – which is typically that pain is the main concern, and no or few mo-
Very often, pudendal neuralgia with pain radia ming chronic or memorized pain begins. worsened by sitting, is relieved by standing, and toric failures can be expected.
tion to the buttock or the legs is not a true puden- disappears when recumbent or on a toilet seat.
dal problem but rather a sacral radiculopathy. In endometriosis of the SR, pain is cyclical, The classic etiology is a chronic compression of
progressive over time, and triggered by men Various further symptoms can be observed, such the nerves in the Alcock's canal, often caused
The semiology is very subtle, combining pelvic struation. In massive involvement, problems as urinary hesitancy, frequency, or urgency; by a bicycle saddle for cyclists or by a continual
pain such dyspareunia, troubles with or loss of with locomotion and pelvic organ dysfunctions constipation or painful bowel movements; sitting position in certain occupational groups.
vesical and/or rectal sensation, pudendal pain may occur. Laparoscopic exploration enables reduced awareness of defecation; and sexual
(S2–S4), vulvo- or vaginodynia, coccygodynia confirmation of the diagnosis, with the possibi- dysfunction, including loss of libido. This syndrome should also be of gynecological
(S3–S4), and sciatica (L5–S2) with nonpelvic lity of direct treatment based on decompression interest, as 70% of the patients affected are female
symptoms such as low-back pain (lumbosacral of the nerves and resection of the endometriosis. Perianal and perineal pain is a frequent com and obstetric etiologies are often also present:
trunk, L5) and pain or abnormal sensations in the plaint but usually as a result of easily recogni-
legs or in the buttock. SR by "pelvic compartment syndrome" must also zable organic disorders such as anal fistula,
Compression of the nerves through a
always be considered as a potential etiology. thrombosed hemorrhoids, or anorectal cancer. postpartum hematoma of the ischio
Surgical damage, endometriosis, and compres The pain worsens in every situation where an Perianal and perineal pain can also occur under rectal fossa
sion of the sacral nerve roots (sacral compart- increase in pelvic venous pressure occurs (e.g., circumstances in which no organic cause can
ment syndrome) are the most frequent etiologies prolonged standing or sitting position), or with be found: levator ani syndrome, coccygodynia,
Idiopathic fibrosis of the pudendal
for SRs. any marked pulsation of the pelvic veins (e.g., proctalgia fugax (Mazza et al., 2004), and canal, secondary to a local hematoma
tricuspid insufficiency, close anatomic relations- Alcock's canal syndrome. or infection
In SR secondary to surgical interventions, hip with arteries, etc.).
damage to multiple nerves often occurs, most- However, pudendal neuropathy (e.g., Alcock's
Stretching of the nerve against the pel-
ly due to a lack of knowledge of pelvic neuro Because the pelvic and lower limb veins are canal syndrome), although well known by physi- vic wall by the head of the child during
anatomy: section of the nerves, ligature close similarly anatomically, patients with varicose cians and patients and curable not only by sym- birth
to a pelvic nerve, traction and clamping in the veins in the legs should be carefully examined ptomatic but also by surgical treatment (Robert
area of the sacral roots, suction by continuous for pelvic varicose veins. Also, pelvic surgery or et al., 2005), is not the only etiology for perineal A fetal weight at partum of over 4 kg, duration
blood aspiration near the nerves, pressure and pelvic vein thrombosis may promote changes and perianal pain. Irritation or damage in the end- of the expulsive stage of over 30 minutes, and
ischemia by excessive dissection, electrical or in the circulation of local veins. Further, rare opelvic portion of the pudendal nerve or in sacral especially forceps delivery are class risk factors
thermal injury, and even direct cutting. diagnoses such as sacral tumors or pelvic nerve nerve roots S2–S4 can also induce similar perine- for this pathology.
tumors can also be potential etiologies. al or perianal pain. Unfortunately, such endopel-
In such cases, neuropathic pain with neurologic vic lesions are less well known, their diagnosis A further frequent cause for Alcock's canal
problems begins immediately after the proce- In all of these cases, laparoscopy enables a clear is difficult, and the surgical approach both to the syndrome is a direct suture of the pudendal ner-
dure. In contrast, nerve entrapment resulting etiological diagnosis and direct treatment by sacral nerves and the endopelvic portion of the ve, a postoperative hematoma, or a local infec
from postoperative fibrosis or pelvic varicose decompression of the SR. pudendal nerve remains difficult for most pelvic tion of the Alcock's canal and/or ischiorectal
vein compression requires months or years to surgeons. Often, endopelvic etiologies are inclu- fossa after a sacrospinal fixation of the vaginal
develop. ded in the category of nonorganic etiologies and stump (Amreich-Richter procedure).
managed with long-term symptomatic treatments.
In this case the classic pain in the right gluteal logy of the pain. In this manner, the author and Such pathologies should be suspected when:
A possible etiologic treatment by re-
region described by patients after this operation colleagues have obtained an improvement in the moval of enlarged or atypical vessels,
can be traced back to tension on the sacrospi- control of pain, with up to 70% of patients free
Vaginal/rectal palpation of the pudendal releasing the nerve by transection of the
nal ligament. When pain does not lessen after a from their pain. nerve at the sciatic spine does not in- sacrospinous ligament, or removal the
couple of weeks or even increases and worsens duce any trigger pain. ligament in extended pelvic sidewall en-
while sitting, Alcock's canal syndrome should To treat pudendal neuralgia, Robert et al. (1993) dometriosis (Possover et al., 2007a). As
be considered. Pelvic radiotherapy – especially have described a transgluteal approach for neu-
Local infiltration of the pudendal nerve demonstrated in the patient series of the
brachytherapy – can lead to Alcock's canal syn- rolysis of the pudendal nerve at the infrapiriform at the Alcock's canal does not induce author and colleagues, the laparoscopic
drome, even after a long time, and is normally canal combined with transection of the sacrospi- any pain relief. approach to the pelvis offers the conco-
accompanied by neurogenic fecal or urinary in- nal ligament in order to free the nerve from the mitant treatment of possible associated
continence. tension of the ligament. Robert et al. consider
The patient reports associated pain ra- painful pathologies such as pelveo-ab-
the fascia in the posterior half of the Alcock's diation in the sciatic nerve distribution dominal adhesions (Possover, 2009a).
Therapy for Alcock's canal syndrome depends canal and the fascia around the inferior rectal (sciatica or neuralgia of the inferior glu-
on its etiology. The therapy of choice following nerve as an important even if secondary source teal nerve). Another therapeutic option to control perianal/pe-
a sacrospinal fixation of the vaginal stump is the of pain. Shafik (1992) has attempted to decom- rineal pain is sacral neuromodulation. Until recent-
removal of the suture combined with a neuroly- press the pudendal nerve by following a perineal
A slight sensory disturbance in the sac- ly, neuromodulation had not been considered as a
sis of the pudendal nerve. When a hematoma para-anal pathway. His dissection follows the in- ral dermatomes is present, suggesting real therapeutic option for pudendal neuralgia or
has caused the syndrome or in cases of abscess ferior rectal nerve to the Alcock's canal (Shafik, that the disorder is related to a radiculo- treatment of perianal/perineal pain (Alo and Hols-
formation in the ischiorectal fossa, the fossa is 1992) and focuses on the Alcock's canal itself. pathy of S2 (Boisson et al., 1966). heimer, 2002; Bosch, 2005; Peeren et al., 2005).
surgically dissected and the pudendal nerve is
released. In all other cases local infiltration with In the approach of the author and colleagues, For pathologies of the first (endopelvic) and Nevertheless, with laparoscopic implantation of
cortisone could be the first possible therapeutic the laparoscopic transperitoneal route to the pu- second portion of the pudendal nerve, laparos- neuroprosthesis for neuromodulation (the LION
option. dendal nerve focuses mainly on its proximal and copy offers a unique and reproducible surgical procedure), it is possible to obtain the stimulati-
medial portions and requires a more invasive dis- approach to the pelvic nerve that could never on of the pudendal nerve with just one electro-
In the experience of the author and colleagues, section. Thus, for surgical treatment of Alcock's be reached by the classic open perineal or trans de, a situation never achieved before. The endo-
transperineal infiltration of the pudendal nerve canal syndrome, the perineal and transgluteal gluteal approach, permitting the following: pelvic location of the lead electrode protects the
at the trigger point (by vaginal or rectal palpati- approaches should be preferred even if neither neuroprosthesis from dislocation, migration, or
on) with lidocaine is useful to confirm the diag- approach can offer an appropriate exposure of
The diagnosis of all endopelvic situations cable breakage.
nosis when a minimum pain reduction of grea- the endopelvic portion of the nerve. or pathologies responsible for the pelvic
ter than 50% is obtained. Then, in the same area, neuralgia. In the patient series of the au- Thus for the management of "prematurely
a second infiltration with botulinum toxin A 50 thor and colleagues, laparoscopic explo- labeled" refractory perineal/perianal pain,
IU can be given. This second injection might in- 4.2. PUDENDAL PAIN WITH ENDOPELVIC ration of the pelvic nerves permitted con- two laparoscopic therapeutic procedures are
duce significant pain improvement in most pati- ETIOLOGIES firmation of suspected diagnoses such as available: decompression and neuromodulation.
ents for a period of several months up to 1 year. extensive endometriosis or a postsurgical In nonneurogenic conditions (and after failure of
Multiple infiltrations over a lifetime are often not The most frequent etiologies for perineal and fibrosis of the retroperitoneal space, but medical treatments), laparoscopic exploration
necessary because after two to three treatments, perianal pain are not those described in the pre- also led to discovery of anatomical si- with decompression of the nerve is the procedure
durable pain relief can be achieved on long-term vious section, but pathologies/irritation of the tuations not previously suspected, such of choice, whereas in neurogenic lesions (puden-
basis. When no improvement is obtained with endopelvic portion of the pudendal nerve or of as the compression or entrapment of the dal hypo-anesthesia, neurogenic incontinence),
local infiltration, neurolysis of the pudendal ner- sacral nerves S2–S4. pudendal nerve by atypical pudendal the pudendal LION procedure enables treatment
ve is then indicated independently from the etio- vessels or a narrow lesser sciatic notch. of pain and dysfunctions at the same time.
5. ENDOMETRIOSIS OF dal and gluteal pains (involvement of traoperative hemorrhage or surgical nerve dama- 6. SACRAL RADICULOPATHY
THE PELVIC NERVES S3 and S4), sciatica (involvement of ge. Primary coagulation and transection of the BY NEUROVASCULAR
S2), problems with sensory and motor internal iliac vessels and their branches is often CONFLICT
functions of the pelvic organs (bladder required. Once the procedure is started, resecti-
Endometriosis, one of the most prevalent gyne- hyperactivity/sensitivity, incontinence, on of the lesions must be fully completed in or-
cological disorders, affecting millions of women detrusor hypocontractility, etc.). Prob- der to avoid further surgical intervention; every Some etiologies seldom considered in the past
around the world, has rarely been reported in lems with locomotion are never present. incomplete procedure makes a new surgery gained credibility after laparoscopic topographic
the literature as a possible etiology for sacral even more difficult and more dangerous, with and functional exploration of the pelvic nerves
radiculopathy (Mannan et al., 2008; Possover et
Sciatic nerve endometriosis and ISE increasing morbidities. The key of such a proce- proved some connection to the condition, well
al., 2007; Zager et al., 1998). are always located at the suprapiri- dure is the en-block dissection of the lesion after known by neurosurgeons, called neurovascular
form portion of the sciatic nerve (L5, primary exposure of all retroperitoneal structures conflict (Fig. 4.1).
Denton and Sherill, who reported a case of S1, ±S2) and are seldom seen in para- (ureter, iliac vessels, sacral plexus, etc.)
cyclic sciatica due to endometriosis in 1955, metric DIE. Symptoms include sciatica This condition corresponds to a nerve irritation
made the first report of intrapelvic nerve entrap- (involvement of L5 and S1), gluteal (nonneurogenic lesion) as a result of the vulner-
ment. After that, other case reports and small pain, and, sometimes, problems with ability of the nerve as it comes in close relation
series were published; Possover et al. (2011) locomotion (foot drop), without bladder ship with vessels.
described the largest series of patients, with all dysfunction. Pudendal pain is also ab-
cases treated laparoscopically. sent. Supralevator endometriosis seems Dilated veins alone, even when close to nerves,
to develop and grow inside the sciatic do not induce neuropathic pain; it occurs only
In cases of endometriosis entrapment, the sym- nerve itself and to expand caudally if the nerves are truly entrapped between two
ptoms tend to be cyclic, worsening on the pre- through the greater sciatic foramen. or several vessels, or between fixed anatomical
menstrual and menstrual days and ameliorating Therefore, the transgluteal approach for structures (ligament, bone, fascia, muscle) and
or even disappearing in the postmenstrual period. sciatic nerve decompression exposes vessels.
these patients to the risk for incomplete
There are two different types of pelvic nerve en- surgery by missing the endopelvic part In a series of 57 consecutive patients, Possover
dometriosis entrapment: sciatic nerve endomet- of the lesion. Intrafascicular neurolysis et al. (2015) found three anatomical levels for a
riosis, sometimes strictly isolated (ISE; Possover of the sciatic nerve with resection of the pelvic neurovascular conflict:
et al., 2007), and sacral nerve root endometrio- destroyed/involved parts of the nerve is
sis (SNRE). Each type has distinguishable clinical required, whereas in SNRE exposure/ L ocation 1:
and surgical findings: decompression of the sacral nerve roots compression of the lumbosacral trunk
is usually sufficient. and/or the sciatic nerve between enlar-

SNRE systematically is part of paramet- ged veins and the iliac bone (linea ter-
ric deep infiltrating endometriosis (DIE). In cases of deep endometriosis involving the pel- minalis).
Because of close anatomical relations- vic nerves, hormonal therapies may be indicated
hips with the sacrouterine ligament, DIE for some diagnostic targets, but not for therapy.
Location 2:
in this area is a risky for S3 and S4 invol- Laparoscopic radical removal of all endometrio- compression of the pudendal nerve (first
vement, whereas infiltrations of cardinal sis foci and fibrosis resection, eventually with segment) by enlarged vessels into the
ligaments and ovarian fossa correlate partial resection of the nerves, is mandatory. lesser sciatic notch.
with S2 and S3 involvements. Typical An absolute knowledge of pelvic vascular and
neurologic symptoms include puden- neuroanatomy is therefore required to avoid in-

Location 3: collateral veins responsible for recurrence, lapa-
compression of sacral nerves S1–S4 by roscopic resection of sacral varicose veins might
enlarged veins in the confined space show less risk for recurrence, as postoperative
built laterally by the piriformis muscle fibrosis reduces the risk for collateral develop-
and medially by the sacral hypogastric ment in proximity of the nerves. At the same
fascia. time, laparoscopy enables an etiologic diagnosis
and treatment with decompression of the nerves
All situations that increase venous blood flow by wide transection of the sacral hypogastric fas-
(sitting, long standing, tricuspid insufficiency, cia, with corresponding nerve decompression
etc.) result in an increased irritation of the ner- (Possover et al., 2011, Possover et al. 2014, Pos-
ve, with exacerbation of the pain. Conversely, all sover et al., 2015).
situations that decrease venous blood pressure
(lying, sleeping, hypotonic treatments, etc.) im-
prove the pain.
Because pelvic and leg veins are both exposed

to risk for venous insufficiency from damaged
valves, patients with varicose veins in the legs
are also at risk for pelvic varicose veins. Addi-
tionally, pelvic interventions and thromboses
may promote changes in pelvic vein circulation.
Because simple tubal sterilization may induce
uterine congestion and pelvic venous stasis, the-
re is no doubt that interventions such as hyste-
rectomies and prostatectomies may also induce
development of pelvic varicose veins (El-Minawi
et al., 1983).
B Different treatments for pelvic varicose have

A
been reported in the literature (e.g., transvenous
catheter embolization, surgical ligation, etc.),
with current treatment studies reporting impro-
vement from 24% to 100% (Tu et al., 2010).
Surgical treatments based on ligature of ovarian
veins have not shown significant long-term
efficacy (Gargiulo et al., 2003), and available
evidence is also not sufficient to determine
whether embolization is effective (Maleux,
Fig. 4.1: Entrapment of S2 by varicose veins 2000). Because a venous stasis upstream af-
A: sacral nerve S2 – B: sacral varicose veins ter embolization might induce formation of
7. PIRIFORMIS SYNDROME 8. POSTSURGICAL PELVIC

NEUROPATHIES
Piriformis syndrome is a neuromuscular disorder

that occurs when the sacral nerves or the sciatic All pelvic, perineal, and obstetrical procedu-
nerve is compressed or otherwise irritated by the res potentially expose patients to pelvic nerve
piriformis muscle, causing neuropathic pain, injuries. Damage that occurs during interven-
tingling, and numbness in the buttocks and/or tions (primary nerve injury [PNI]) can result from
the pudendal area and/or along the path of the coagulation, suturing, and ischemia, or from
sciatic nerve descending down the lower thigh cutting directly to the nerve, inducing problems
and into the leg. Numerous malformations of with sensation, pain, and dysfunctions that begin
the piriformis muscle have been described in the immediately after the procedure or after a short
deep gluteal space that can entrap sacral nerves. interval of several days. In contrast, nerve lesions
Hypertrophy of the muscle itself can be easily di- resulting from fibrotic tissue or vascular com-
agnosed by pelvic magnetic resonance imaging pression/entrapment (secondary nerve entrap-
(MRI) and treated as well by scan-guided infiltra- ment [SNE]) usually require several months or
tion of the muscle by botulinum toxin A. even years to develop. Implantation of sutures or
mesh material and hematoma/abscess formation
Laparoscopic exploration of this area in several in proximity to nerves constitutes a risky situation
patients has revealed that the intrapelvic fibers of for both PNI and SNE.
the piriformis muscle can also entrap the sacral
nerve roots. Transvaginal sacrospinous colpopexy is the
classic high-risk procedure that causes pudendal
In normal anatomy, muscle fibers originate from nerve injury, which results from a direct lesion
the sacral bone, laterally to the sacral foramina, while suturing the sacrospinous ligament (Ver-
but in some persons the piriformis fibers origina- deja et al., 1995), but also by entrapment when
te medially to the sacral foramina, tying the sac- a hematoma or an abscess of the ischiorectal
ral nerve roots (Fig. 4.2). Laparoscopic resection space develops. More recent interventions using A
of these atypical fibers could be the treatment of mesh material for sacrospinal fixation (Debo-
choice, removing completely the etiology of the dinance et al., 2007), sacrocolpopexy, or rec-
pain in such conditions. topexy may also expose patients to risk of nerve
damage.
However, reports of iatrogenic pudendal neu- B
ralgia are rare in current literature (Possover,

2009a, Possover et al., 2011). Only few case re-
ports are available on acute pelvic nerve damage
secondary to pelvic surgeries. This is in contrast
with the high numbers of patients suffering from Fig. 4.2: Entrapment of S2 by atopic piriform fibers on the right side
neurogenic dysfunctions of the lower urinary/ A: sacral nerve S2 – B: piriform muscle (atopic fibers)
intestinal tract and chronic neural pelvic pain Diagnosis is even more difficult because neu-
secondary to pelvic surgery. Difficulty in dia- ropathic pain is not located in the pelvis, but
gnosis and lack of awareness that such lesions at distance in the lower back, the buttock, the
may exist can contribute to this contradiction. A pudendal areas, or the lower extremities; all of
further dilemma for patients affected by pelvic these pain locations are usually correlated with
nerve pathologies is that etiologies, diagnoses, orthopedic or neurosurgical conditions.
and treatments are spread among different spe-
cialties, which often do not share the required Few reports are found in current literature. For
scientific knowledge. example, there are a few reports of neurologic
complications after implantation of trans-obtura-
tor tape systems, but these do not provide pro-
8.1. POSTSURGICAL SACRAL per neurologic diagnosis and only list unsuitable
RADICULOPATHIES symptoms such as "neuropathies", "difficulties
ambulating", "numbness in the lateral calf foot
Real rates of pelvic nerve injuries secondary to and posterior thigh", and "unspecified neuropa-
pelvic surgeries are unknown due to database thy" (Hamilton Boyles et al., 2007). Flynn et al.
limitations, under-diagnosing, and underrepor- (2006) also reported nerve damage after utero-
ting (Possover, 2009b, Possover et al., 2010). sacral ligament suspension. Because patients
had presented only with problems of sensation,
Although sacral nerve root damage secondary Flynn et al. suspected lesions of the posterior
to laparoscopic rectopexies (Fig. 4.3) has been cutaneous nerve of the thigh and proposed re-
the most frequent injury in the patient series of moval of the suture as the treatment of choice.
the author and colleagues, this kind of compli- The author and colleagues have found the same
cations has, to the knowledge of the author and neurologic complication after uterosacral liga-
colleagues, never been reported in the literature, ment suspension, but laparoscopic exploration
which mainly reports damage to the superior of pelvic nerves showed, in all patients, lesions
A
hypogastric plexus (Shiozawa et al., 2010). of sacral nerve root S2 (Fig. 4.4).
In PNI, because pain and dysfunction develop An isolated lesion of the posterior femoral cuta- B
right after the procedure, a possible surgical neous nerve during vaginal surgery is, in the
complication will be recognized early on by opinion of the author and colleagues, anatomi-
both the surgeon and the patient. This usually cally impossible because this nerve is a distal,
leads to re-intervention that can possibly extrapelvic branch of the inferior gluteal nerve.
result in etiologic treatment. In SNE, the situation Moreover, this last nerve arises from the lateral
is much more complex, because pain appears aspect of sacral nerve roots L5–S2, which makes
after an interval of several months or even years its isolation – without any damage to the sacral
and relationship between the intervention and nerve roots – by vaginal approach quite impos-
the pain is not evident. sible.
Fig. 4.3: Suture to S2 right
A: sacral nerve S2 – B: sacrum
Flynn et al. (2006) rejected the etiology of on was the second most frequent lesion in the
lesions of the sacral nerve roots because of lack patient series of the author and colleagues, and
of motor dysfunction in the patient; this is not seems to be correlated with exaggerated deep-
in contradiction to our findings because only ness at the placement of the sutures on the left
axonal lesions induce motor dysfunctions, whe- sacrouterine ligament reaching the left pelvic
reas extrinsic nerve irritations mainly induce sidewall; this is especially likely to occur when
problems with hypersensitivity or hyperactivity the surgeon is right-handed.
of the pelvic visceral organs, but no hypotony
or atony. Moreover, axonal lesions of the second The logical treatment of such nerve damage
sacral nerve root induce difficulties for motion of would be the removal of sutures and/or mesh,
the big toe, not for walking. but unfortunately research of the author and
colleagues has showed that the results of this
Although these interventions exposed patients re-intervention depend on the timing. When
to both primary and secondary nerve damage, diagnosis is made early after the procedure, the
interventions with mesh implantation by vaginal chances are high of completely curing the patient
approach for vaginal prolapses seem to expose of pain. Otherwise, if surgical indication is made
patients more to SNE. Especially when these after a long period of several months or years,
interventions involve new devices developed because dense fibrosis and/or atypical vessels
for vaginal implantation by technique of blind have had time to develop, simple removal of
needle driving and minimal dissection, bleeding the suture or mesh usually does not solve the
often occurs; the hematomas cannot drain and problem. In those cases, the approach of the
tend to dissect in retroperitoneal spaces, even at author and colleagues is therefore not based on
supralevatoric compartments. primary removal of sutures or mesh but on the
primary exposure and decompression of injured
The most common surgical cause observed in nerves, with partial removal of sutures or mesh
the patient series of the author and colleagues when these are in direct contact with the nerves.
was laparoscopic rectopexy – more than lapa- Even in these cases, the LION procedure is only
roscopic sacrocolpopexy – which produced PNI indicated when concomitant axonal damage is
caused by suturing of the mesh to the sacral present.
A B
bone, as well as SNE due to fibrosis and vascular
entrapment. All of these neurological considerations should
motivate pelvic surgeons to acquire proper know
The second sacral nerve root on the right side is ledge about neuropelveology. Early diagnosis
at risk: The left-sided position of the surgeon and offers patients the best chances for pain impro-
the middle position of the rectosigmoid make vement and protects surgeons against medico-le-
the fixation on the right side more lateral and gal troubles. This is even more important in cases
expose the patient to risk for nerve injury. when pain becomes chronic, where it is more
probable that the patients will consider nerve da-
Fig. 4.4: Suture to S2 left secondary to a McCall procedure for vaginal cuff fixation A lesion on S2 – especially on the left side – mage as a true surgical complication and will de-
A: sacral nerve S2 – B: rectum after vaginal uterosacral ligament suspensi- velop strong aversion to the medical community.
To avoid such dramatic situations, major symp- nerve in males, which can also induce problems inguinodynia caused by "meshoma", but did not However, the underlying cause, location, and
toms of somatic pelvic nerve damage should be with or loss of the cremasteric reflex. Direct ner- recommend neurolysis. On the contrary, Naha- type of pain, as well as attempts at conservative
recognized early on. ve damage that occurs during the intervention bedian and Dellon (1995) reported interesting procedures, should almost always be considered
usually results from direct coagulation, suturing, results in 23 patients who had neurolysis for late- before moving to destructive procedures
When a diagnosis of a pelvic nerve injury is sugge- ischemia, or cutting the nerve. The symptoms ral femoral cutaneous nerve entrapments: excel- (Richard, 2011). Neurectomies induce syste-
sted, meticulous clinical evaluation and precise then appear directly after the intervention, or af- lent – 78.3%, good – 17.4%, poor – 4.3%). matic numbness in the corresponding nerve
preoperative topographic diagnosis are man- ter a short interval of several days, and combine distribution and expose the patient to risk for
datory. When the exact injured nerve(s) is/are allodynia with hypesthesia or even numbness Nerve destruction is actually the most discus- development of neuromas, duplicating the pre-
clinically and urodynamically determined, lapa- (axonal destruction) in the corresponding nerve sed and proposed treatment option for care- existing pain level. This phenomenon has been
roscopic exploration must be considered as the distributions. fully selected patients. Cryoanalgesic ablation historically well described with detailed obser-
first step in management of patients, because it has been reported to successfully eliminate vations of Civil War amputees. In a survey of
results not only in a proper etiological diagnosis In contrast, nerve irritation or compression by ilioinguinal and genitofemoral neuralgia (Fanelli 590 veteran amputees, 55% reported phantom
but also allows for decompression of the nerves fibrotic tissue or vascular entrapment first in- et al., 2003). Zacest et al. (2010) proposed the ili- pain and 56% reported stump pain (Wartan et
and, in cases of axonal damage, for implanta- duces symptoms after a free interval of several oinguinal neurectomy as an effective treatment, al., 1997), and the higher the level of the lower
tion of electrodes for neuromodulation. Accor- months or even years; symptoms usually reflect but also highlighted that a high proportion of extremity amputation, the greater the incidence
ding to the findings of the author nad colleagues, a combination of neuropathic pain and normal patients reported some long-term recurrence of moderate to severe pain (up to 88%; Posto-
the riskiest procedures for pelvic nerve damages aesthesia or hyperesthesia. Implantation of mesh of pain, whereas complete or partial pain re- ne, 1987). One solution may involve implanting
are rectopexy (PNI S2 on the right side), vaginal material and hematoma or abscess formation in lief was achieved in 66% of the patients. The the proximal end of the cut nerve into an adja-
uterosacral ligament suspension (PNI S2 on the proximity to nerves can create situations of high most-used ablative technique actually is the cent bone or a nearby site, as proposed in the
left side), and dorsal mesh implantation (SNE of risk for such damage. Independent from etiolo- triple neurectomy, developed by Amid (2002): triple neurectomy technique (Ducic et al., 2008;
pelvic nerves). gies, management of postherniorrhaphy neuro- Because central and peripheral communication MacFarlane et al., 1997); this modification may
pathic groin pain is still controversial. of nerve involvement make it extremely difficult, decrease risks for stump pain but does not per-
The findings of the author and colleagues over if not impossible, to discern which nerve has manently relieve phantom pain (Wesolowski
the last decade (see References) highlight the Postsurgical groin pain has proven to be an to be treated, he proposed not only a neurec- and Lema, 1993) and super-added phantom sen-
importance of long-term follow-up of patients extremely difficult problem to treat (Callesen tomy of the grossly involved nerve but also of sations (Mitchell, 1872).
after surgeries for pelvic organ prolapse, focused and Kehlet, 1997; Lichtenstein et al., 1988; all three inguinal nerves (ilioinguinal, iliohypo-
not only on anatomical and functional outco- Rutkow and Robbins, 1993). In addition to me- gastric, and genitofemoral). This technique also Regarding neurolysis with or without removal
mes, but also on nerve damage that can appear dical treatments, several surgical procedures are includes the insertion of the proximal cut ends of the mesh, recognition and dissection of such
months or even years after the primary proce- interventions for this condition, which divided under the internal oblique muscle fibers to avoid small nerves among such dense fibrotic tissues is
dure. in two main categories: conservative (neurolysis, recurrent neuralgia caused by adherence of the very difficult and exposes the patient to risk for
removal of the mesh) and ablative (neurectomy). resected nerves into the aponeurotic elements of destruction or cutting of the nerve, with the same
Heise and Starling (1998) reported on remedial the groin. In a series of 49 consecutive patients, consequences as in neurectomies. Furthermore,
8.2. POSTSURGICAL INGUINODYNIA inguinal exploration and mesh removal (with or 80% percent of patients recovered completely, the dissection of a nerve at the damaged site
without neurectomy), with favorable outcomes and 16% had transient insignificant pain with almost always induces additional central ner-
Surgical access to the inguinal region always ex- noted for 60% of patients. In addition, Koop- no functional impairment (Amid, 2002). The vous plasticity, with the accompanying danger
poses patients to risk for injuries to the different mann et al. (2011) reported that meshectomy technique of triple neurectomy by laparoscopic of duplicating the pain level. Another option to
distal branches of the lumbar plexus responsible (with or without neurectomy) led to significant approach has also been reported, and offers a consider is the possibility of neuromodulation,
for chronic groin pain. Neurologic symptoms symptom improvement and patient satisfaction, minimally invasive way to expose the different which is particularly attractive because it is non-
are then restricted to sensory changes, with with acceptable morbidity and recurrence ra- nerves for transection (Song et al., 2011). destructive and reversible. The idea of achieving
the exception of injuries of the genitofemoral tes. Amid (2004) reported treatment of chronic pain relief by electrically stimulating the dorsal
columns of the spinal cord (spinal cord stimulati- of the triple neurectomy occurs, this technique
on [SCS]) was derived from the gate control the- represents the last option for pain control. There
ory of Melzack and Wall (1965). Implantation of fore, it is important that when a triple neurec-
two epidural eight-electrode leads to level T7– tomy is performed, the transection of the nerves
T9 has been reported to sustain pain relief for is not performed too cranially in order to enable
12 months following implantation, presenting electrode implantation.
an alternative treatment option for patients when
all others have failed (Yakovlev et al., 2010). The Treatment of postherniorrhaphy pain should be
technique of neuromodulation also has been aimed at residual nerve stump pain and phantom
applied to the peripheral nerves (Campbell and pain. Residual nerve stump pain is a nociceptor
Long, 1976). One technique consists of the sub- pain described as located directly in the affected
cutaneous implantation of an octipolar electrode area and is sent to the brain via the skin and the
in proximity to the injured nerve in the area of soft tissue through the spinal cord. Treatments
the herniorrhaphy scar (Lawrence et al., 2001). described previously, including electrical stimu-
lation of peripheral nerves, are predominantly
All of these techniques have the advantage of used for this type of pain.
being minimally invasive but are unspecific and
based on a blind technique of implantation. Con- Phantom pain is rarely improved through me-
versely, the laparoscopic technique of implanta- dical treatments. Recently, some potentially
tion into the endoabdominal portions of the peri- valuable treatments have arisen, based on new
pheral nerves requires a surgical approach under ways of perceiving the origin of the pain itself.
general anesthesia, but is the only method that Evidence suggests that stimulation of the mo-
permits the selective placement of an electrode tor cortex can reduce phantom pain: Mirror
in direct contact with the injured nerves. This therapy has been used with some success in
approach offers a safe dissection of the nerves in patients who have had a hand or arm amputated
normal anatomic conditions at a distance from (Ramachandran and Rogers-Ramachandran,
the herniorrhaphy scar tissue and placement 1996). In a more recent publication, mirror the-
A
of the electrode systematically proximal to the rapy reduced phantom limb pain in patients who
level of the nerve damages, a condition neces- had undergone amputation of lower limbs (Chan
sary for successful neuromodulation in painful et al., 2007), suggesting that these attempts to
neuralgia. Even when anatomic variations oc- link the visual and motor systems might be hel-
cur (Töns and Schumpelik, 1990) and diagnosis ping in re-creating a coherent body image and
presents difficulties, the use of an eight-channel reducing pain. However, long-term outcomes
electrode permits neuromodulation of all nerves are still unknown.
together or in different combinations (Fig. 4.5).
Actually, there is no single form of treatment
The LION procedure on the retroperitoneal that has been shown to consistently reduce both
branches of the lumbar plexus is a true option phantom and residual nerve stump pain. Phan-
for treatment of intractable postherniorrhaphy tom pain generally does not respond to surgical Fig. 4.5: LION procedure on the genitofemoral nerve
inguinodynia (Possover, 2013b). When a failure intervention, but intracranial neurostimulation A: genitofemoral nerve
has been used for phantom limb pain, with some 9. SACROCOCCYGEAL findings such as locoregional lymph node and
Solid teratomas may be strongly vascu-
success. As reported by Tasker and Kizz (1995), TERATOMA distal metastases, are clearly indicative of malig- larized, with subsequent high risk for in-
stimulation of the parvocellular part of the nancy (Keslar et al., 1994). traoperative hemorrhage (Localio et al.,
nucleus ventralis posterolateralis of the thala- 1980). Primary laparoscopic control of
mus led to a decrease in phantom limb pain, The sacrococcygeal area is the most frequent SCTs are classified into three histopathologic hemostasis with resection of the internal
but in most cases pain control was not perma- site of teratoma in infancy (Ahmed and Pollock, categories: mature, immature, and malignant. iliac vessels at least on one side helps in
nent. Katz and Melzack (1991) reported that the 1985). This tumor rarely presents in adulthood, Patients with either a malignant teratoma or a reducing intraoperative bleeding.
painful throbbing and pressure of phantom limb with a female predominance (Valdiserri and Yu- benign teratoma with malignant transformation
pain could be reduced by low-frequency (4- nis, 1981). Unlike teratomas in infants, which have a considerably poor prognosis, with a life Only patients with malignant teratomas should
Hz), high-intensity (10- to 30-V) auricular tran- are externally visible in 90% of cases, sacrococ- expectancy of 2 to 24 months following diag- receive additional treatment with chemotherapy
scutaneous electrical nerve stimulation (TENS). cygeal teratomas (SCTs) in adults mostly are con- nosis, whereas patients with benign disease can and/or radiotherapy.
The mechanism proposed for pain reduction is fined in the intrapelvic space. They are normally live free of disease for more than 4 years after
secondary to activation of brainstem structures benign and are referred to as mature teratomas. treatment (Miles and Stewart, 1974). In conclusion, although rare in adults, sacrococ-
that exert an inhibitory control over nociceptive Little is known about the embryogenesis of SCT, cygeal teratomas should be considered in the
neuromas in the spinal cord dorsal horn (Jensen but it has been hypothesized that the anomaly Complete surgical excision is the treatment of differential diagnosis of patients with a pelvic
and Rasmussen, 1989). However long-term fol- is derived from a primitive knot, also referred choice, and the primary laparoscopic approach mass presenting with obstructive symptoms. Sur-
low-up was not carried out. as Henson's node (Audet et al., 2000). Patients offers major advantages as compared with the gical removal is generally indicated at the time
with SCT may be initially asymptomatic, with classic approach: of detection, as these lesions carry a significant
Spinal cord stimulation has also been used for the tumor discovered on rectal exploration du- malignant potential, and the laparoscopic appro-
phantom limb pain. Seigfried and Zimmerman ring routine physical examination; otherwise,
Primary dissection of the rectum and of ach is preferred because of its ability to facilitate
(1981) reported that 51% of patients with im- they may present with a variety of symptoms the ureter is facilitated. precise surgical dissection and bleeding control.
planted spinal cord stimulators had a decrease in that are not indicative of SCT's malignant po-
pain of 50% or more, and 18% obtained a 25% tential. Especially if the mass is large enough,
Clear identification of the endopelvic
to 50% reduction in pain. However, Katayama patients may complain of constipation due to margins of the tumor is possible, which
et al. (2001) reported no evidence on the ad- rectal obstruction or recurrent urinary tract in- enables a resection within the free
vantage of motor cortex stimulation over spinal fections due to obstruction of the bladder neck. margins.
cord stimulation and deep brain stimulation of If an SCT has directly invaded the nerve roots of
the thalamic nucleus ventralis caudalis to con- the cauda equina or metastasized to the spinal
Because it is highly recommended also
trol phantom limb pain. Thus, in regard to the cord, the patient may complain of neurologic to remove coccyx to avoid a higher risk
evolution of the use of electrostimulation for tre- symptoms such as lower extremity numbness or of recurrence (Mahour, 1988), the lapa-
atment of phantom limb pain, the trend over the weakness. Sacrococcygeal teratomas and simple roscopic approach with passage of the
last decade was to apply the stimulation more cysts account for the majority of cystic lesions Gigli saw through the sacral foramens
and more proximally up the central nervous sys- in the presacral space. Serum tumor markers, easily enables an en block resection
tem. However, an interdisciplinary approach is such as alpha-fetoprotein and human chorio- together with the bone.
necessary to better understand the role of neuro- nic gonadotropin, are not helpful in differentia-
surgical procedures for control of phantom pain. ting between benign and malignant lesions, but
could be used in selected cases for postoperative
detection of recurrences (Ng et al., 1999). In-
vasion of adjacent structures, rather than simple
displacement, sacral destruction, and secondary
10. PELVIC SCHWANNOMA Laparoscopic exploration not only permits an

endopelvic resection within tumor-free margins,
but also primary exposure of the rectum, the ure-
A schwannoma is a benign nerve sheath ter, and the SNR, with control of the pelvic blood
tumor composed of Schwann cells, and can vessels. This makes the procedure safer and ea-
arise anywhere in the body. These rare tumors sier than classic neurosurgical approaches, with
normally arise within bone; the mandible and less risk for postoperative functional morbidi-
sacrum are the most common sites. Schwanno- ties and hemorrhage (Dawley, 2008; Possover,
mas may occur nearly anywhere in the body and 2013a; Sinha et al., 2008).
are the cause of 6% of primary retroperitoneal
neoplasms (Getachew, 1994). Less than 100
cases of retroperitoneal schwannomas have been
reported in literature, with slightly fewer than 20
of these situated in the pelvis (Figs. 4.6–4.9).
Presacral and/or retroperitoneal schwannomas

are rare, and they can be difficult to diagnose
(Ogose, 2001). The etiology of schwannomas is
unknown, but they sometimes occur in indivi- Fig. 4.6: Sacral schwannoma on the right side – MRI
duals with certain disorders, such as some types
of neurofibromatosis (Muir, 2003). Because they
arise within the nerve sheath, schwannomas
may theoretically not induce major disturbances
in nerve function other than neuropathic pain
caused by distortion or compression of nerve
fascicles. Sacral schwannomas require gyneco-
logical differential diagnosis because they may
induce gynecological symptoms such as vulvo-
dynia, coccygodynia, or pudendal pain caused
by the irritation of the sacral nerve roots. Any
assessment of intractable neuropathic chronic
pelvic pain may include also MRI of the pelvis. If
a schwannoma is suspected, surgical exploration
is then mandatory for histological confirmation
because malignant transformation has been iden-
tified. Surgical management of sacral schwanno-
mas is challenging because of the particular ana-
tomical site, difficult direct access to the lesion,
risk for massive intra- and postoperative blood Fig. 4.7: Sacral schwannoma on the left side with compression of the
loss, and high risk of surgical nerve damage. gluteal nerves – MRI
Fig. 4.8: Sacral schwannoma on the right side –

laparoscopic view after resection
Fig. 4.9: Sacral schwannoma on the left side – laparoscopic view

A: lumbosacral trunk – B: sacral nerve S2 – C: schwannoma
11. PELVIC OSTEO tumors, and the abdominal-inguinal approach

CHONDROSARCOMA is preferred for large retroperitoneal tumors
(Osaka and Toriyama, 1988, Varga et al., 2009).
In tumors of the sacral bone exposition is mostly
Primary therapy for sacral tumors often involves obtained by a posterior midline incision; lateral
en bloc surgical resection with tumor-free osteotomies are usually performed through the
margins, and in some case concomitant bone sacral foramina using a thread wire saw and Ker-
resection with challenging functional recon rison rongeurs. Although various reports have
struction of the sacrum (Fig. 4.10). Surgery in analyzed en bloc excision of sacral tumors, there
this area brings many difficulties, such as risk are still technical issues in improving protection
of injury to neighboring organs and massive of nerve roots, preserving surrounding structu-
blood loss due to the extensive vascularization. res, and reducing intraoperative bleeding, main-
Preoperative angiography should be routinely taining at the same time the oncological result.
performed in order to map the vascular anatomy This is especially true of the posterior approach
of the area and to determine if the lesion would because elevation of the sacrum allows dissecti-
be amenable to embolization (Rossi et al., on of presacral structures, and risk for injuries to
2001). Percutaneous intralesional embolization intrapelvic structures is high.
with injections of alcoholic emulsions has been
proposed; however, this procedure exposes the Wound infections, neurologic deficits, pelvic in-
patient to risk for ischemic neuropathy, with mo- stability, and cerebrospinal fluid leakage are the Fig. 4.10: Sacroiliac osteochondrosarcoma – MRI
tor and sensory deficits in the pelvis and lower main postoperative complications of sacrectomy
extremities (Donati et al., 2011). The author and (Raque et al., 2001; Sar and Eralp, 2002). Among
colleagues have recently proposed a new surgi- these complications, extensive intra operative
cal concept for management of iliosacral tumors hemorrhage is the most challenging complica-
based on a combination of anterior laparoscopic tion because it may threaten the patient's life
approach and posterior open resection of the in- and jeopardize the outcome of surgery. Angeli-
tact en bloc tumor (Fig. 4.11–4.15). ni and Ruggieri (2013) reported a sacral resec-
tion by posterior approach with a mean blood
Operative treatment of tumors in the sacroiliac loss of 2961 ml (range = 1000–8000 ml). In a
area is one of the most challenging muscle skele- further retrospective study on 173 patients who
tal tumor surgeries. Because almost all deaths underwent sacral tumor resection, 69 (39.88%)
from chondromas result from local recurrence, patients had blood loss greater than 3000 ml (Xi-
greater effort to obtain adequate surgical excision aodong et al., 2009). It is obvious that primary
has been made over the last decades. control of blood supply to the sacrum and to the
parametrium may reduce such intraoperative
Normally, a single or combined surgical ap blood loss and is therefore necessary.
proach is used, such as the posterior, postero-
lateral, anterior with posterior, or anterior and The results of several studies suggest preope-
lateral. The anterior and lateral combined appro- rative arterial embolization and aortic balloon
ach is preferred in the resection of large iliac occlusion (De Cristofaro et al., 1992; Zhang et
al., 2007). However, indications for performing bilization performed by lumbo-ischial screw/rod
embolization still remain uncertain. Moreover, fixation (Fig. 4.14).
because of numerous anastomoses between the
sacral (medial and lateral), gluteal (inferior and Pelvic bone amputation may also result in pelvic
superior), and pudendal vessels, single closure nerve damage. High amputation of the sacrum
of the internal iliac artery does not protect from inevitably results in damage to the sacral nerve
hemorrhage. Laparoscopic primary closure of all roots, the pudendal nerve, and the coccygeal
parametric vessels, including the internal iliac plexus (Gennari et al., 1987). Thus, simultaneous
artery, the gluteal vessels, and the sacral vessels, abdominosacral resection circumvents many of
before starting the bone resection is mandatory. these problems, providing good exposure of the
Open surgery exposes the patient to greater and intraabdominal structures and avoiding damage
unnecessary risk of morbidity, whereas control to the sacral nerve roots (Huth et al., 1984).
of the pelvic blood supply by laparoscopy does
not present major difficulties for pelvic surgeons Laparoscopic exposure of the sacral plexus and
trained in laparoscopic retroperitoneal surgery. other pelvic somatic nerves enables the explo-
ration of their relation to the tumor, which has
Primary laparoscopic dissection of the ureter a direct impact on the radical nature of the pro-
and of the bowel not only protects patients from cedure. Moreover, laparoscopic dissection of
severe visceral complications, but also permits the femoral nerve before psoas muscle resection
an adequate exploration of the pelvis for possible permits preservation of locomotion, and preser-
retroperitoneal, intraabdominal, and even visce- vation of sacral nerve roots S3 and S4 reduces
ral tumor infiltration. Laparoscopic dissection of the risk for bladder and rectum dysfunctions.
the tissue surrounding the tumor permits a precise
selection of the level of sacral resection with
macroscopic tumor-free margins (Fig. 4.11). B
The introduction of the Gigli saw through the

different sacral foramens contributes to a precise
transection of the bone under laparoscopic con-
trol (Fig. 4.12).
A
For posterior resection, the incision for the open
posterior approach might include the exit points
of the two for insertion of the Gigli saw (as in the C
Juder approach). A soft tissue margin must be left
on the specimen to be resected. The posterior os-
teotomy can be performed with saw and osteo-
tomes at the predetermined extra-lesional level
(Fig. 4.13). The defect might be replaced with a Fig. 4.11: Laparoscopic exposure of the limits of the tumor
structural fresh frozen femoral allograft and sta- A: tumor – B: rectum – C: sacrum
Fig. 4.13: Resection of the specimen by posterior approach
Fig. 4.12: Introduction of Gigli saw through sacral foramen

A: ureter – B: external iliac artery – C: external iliac vein – D: obturator nerve –
E: tumor
Fig. 4.15: Postoperative site – X-ray
B
A
Fig. 4.14: Stabilization of the pelvis using fresh frozen femoral allograft
A: lateral umbilical ligament – B: obturator nerve – C: allograft – D: screw
12. THE SCIATIC LION as well as increased side effects during long- Anatomically, the sciatic nerve begins in the pel- in patients who have had a hand or arm amputa-
PROCEDURE IN term therapy for chronic pain (Sherman, 1994). vis with the fusion of the sacral and lumbar nerve ted (Ramachandran and Rogers-Ramchandran,
LEG AMPUTEE PATIENTS Debilitating pain following amputation surgery roots and runs through the buttock and down the 1996). In a more recent publication, mirror the-
can seriously affect the long-term success of the lower limb. Before the sciatic nerve enters the rapy was shown to reduce phantom limb pain in
operation and the patient's quality of life. Often, great sciatic foramen, the gluteal and the puden- patients who had undergone amputation of lo-
It has been more than a century since Mitchell such patients are unable to ambulate because of dal nerves emerge, so that the only place in the wer limbs (Chan et al., 2007). This suggests that
(1872) described detailed observations about the pain when using a prosthesis and are treated entire body where all the afferent sciatic fibers any attempts to create a link between the visual
Civil War amputees; he classified the painful with high-dose narcotics, as well as antidepres- are located together is at this level on the sciatic and the motor systems might help patients to
phenomena as phantom limb pain, stump pain, sants, but still with little or no relief. Neuroab- nerve, situated deep inside in the pelvis. Percuta- re-create a coherent body image while reducing
and super-added phantom sensations. Since this lative neurosurgical procedures are now rarely neous implantation of an electrode in this area pain as a result of reduced and disordered input.
time, amputation, especially of the lower extre- performed, as they are effective only for a few exposes the patient to the risk for severe hemorr- However, in this study the long-term outcome is
mities, has induced real economic problems, as months, after which the pain always returns, and hage from the presence of the pudendal and glu- still unknown, and the therapy was aimed only
the incidence of amputation is increasing con- is frequently worsen. One neurosurgical opti- teal vessels. The perineal, the transgluteal, and at phantom limb pain and not residual stump
siderably not only due to traffic accidents but on involves implanting the proximal end of the the laparotomic approaches cannot offer a safe, pain.
also due to war: 80% of the injuries seen in the cut nerve into an adjacent bone or a nearby site easy, and minimally invasive way to access this
wars in Iraq and Afghanistan were to the extre- (Ducic et al., 2008; MacFarlane et al., 1997). part of the sciatic trunk. However, laparoscopy Therefore, because no single form of treatment
mities, and the numbers of amputations perfor- Unfortunately, this technique may decrease permits an easy and reproducible exposure of all has been shown to consistently reduce both
med by military surgeons on U.S. troops in Iraq stump pain but usually does not permanently re- pelvic nerves, including the sciatic, immediately phantom limb pain and residual stump pain to-
were twice as high as those recorded in previous lieve phantom pain (Wesolowski et al., 1993). before the entrance in the great sciatic foramen gether, the use of electrostimulation should be
wars. In a survey of 590 veteran amputees, 55% Because the state-of-the-art intervention for (Possover, 2004). Thus, the surgical approach taken into consideration. However, no surgical
reported phantom pain and 56% reported stump neurosurgical treatment of peripheral neuropa- is minimally invasive and offers an elective im- approach previously permitted a selective im-
pain (Wartan et al., 1997); the higher the level of thic pain is neuromodulation, spinal cord stimu- plantation of the electrode in direct contact with plantation of the electrode to the stump of the
lower extremity amputation, the greater was the lation has also been used for these patients. Ho- the trunk of the sciatic nerve under visual control sciatic nerve, and for this reason most applica-
incidence of pain, up to 88% (Postone, 1987). wever, the technique of spinal cord stimulation (Fig. 4.16), while also respecting the neurosurgi- tions were performed at the level of the spinal
No single method is able to treat both residu- permits only an unselective implantation of the cal standard for the peripheral nerve. Moreover, cord (Van Dongen and Liem, 1995) or above at
al stump pain and phantom pain in all patients. electrode to the spinal nerves, and thus can pre- if the patient also suffers from femoral neuropa- the level of the central nervous system (Owen
Multiple-discipline treatments are mandatory, sent some complications. Sacral nerve stimulati- thic pain, implantation of a second electrode at et al., 2007). The laparoscopic transperitoneal
and all alternatives must be considered. Treat- on by transforaminal implantation also appears the trunk of the femoral nerve is possible. approach to the pelvis, however, permits a mini-
ment of pain after lower limb amputation focu- to be ineffective, as it permits neuromodulation mally invasive, safe, and reproducible technique
ses on both types of pain, residual stump pain of only one or two (if a two-channel generator is Phantom limb pain is also generally intractable of implantation to the endopelvic stump of the
and phantom limb pain. used) sacral nerve roots, which is not enough to and chronic. Once it develops, it persists and is sciatic nerve, with the possibility of neuromodu-
control all sciatic afferent fibers. Optimal condi- rarely improved by medical treatments. Recent- lation for all sciatic afferent fibers, and should
Residual stump pain is a nociceptor pain descri- tions for neuromodulation should be the place- ly, some potentially valuable treatments have be considered for patients with pain symptoms
bed as located directly in the affected area and ment of the electrodes as distal as possible and arisen, based on new ways of perceiving the following lower limb amputation.
is sent to the brain via the skin and the soft tis- as close as possible to the neural lesion, in such origin of the pain itself. For example, use of an
sue and then via the spinal cord. Therefore, this a matter that all afferent fibers transporting the electrical prosthetic limb moved by signals from
kind of neural pain can be treated according to electrical information of pain are included in the the patient´s muscle can reduce the pain if used
the actual standard on peripheral neuropathic electrical field of the electrode. for several hours per day. Also, stimulation of the
pain. Although numerous medical treatments motor cortex can reduce phantom limb pain.
exist, many have shown only limited success, Mirror therapy has been used with some success
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CHAPTER V THE LION PROCEDURE

IN PELVIC DYSFUNCTIONS
110 NEUROPELVEOLOGY CHAPTER V | THE LION PROCEDURE IN PELVIC DYSFUNCTIONS 111
1. INDICATIONS
Overactive bladder (OAB) is a medi-
Prostatitis and prostadynia are lower is located in the perineal, genital, and
cal condition estimated to affect 17 to urinary tract disorders that have been perianal areas and is worsened by sit-
20 million people in the United States. suggested to affect approximately 2% ting. In cases of simple entrapment of
Pelvic floor disorders adversely affect the health Symptoms of OAB can include urinary of the adult male population (Collins et the PN without neurogenic damage,
and quality of life of millions of people. Pelvic frequency, urinary urgency, urinary urge al., 1998). Prostatitis is an inflammation pain is usually isolated and can be asso-
floor disorders include urinary control disorders incontinence due to a sudden and un- of the prostate, and includes bacterial ciated with OAB. In neurogenic damage
such as urge incontinency, urge frequency, voi- stoppable need to urinate, and nocturia prostatitis and nonbacterial etiologies. to the PN, genito-anal numbness and
ding efficiency, fecal control disorders, sexual or enuresis resulting from overactivity Chronic nonbacterial prostatitis is dis- fecal and/or urinary incontinence can
dysfunctions, and pelvic pain. Lower urinary of the detrusor muscle. Neurogenic tinguished from acute bacterial prosta- occur. PN entrapment can be caused by
tract disorders affect the quality of life of millions OAB occurs as a result of detrusor mu- titis based on the recurrent nature of the obstetric trauma, scarring due to geni-
of men and women worldwide every year. Thir- scle overactivity, referred to as detrusor disorder. to-anal surgeries (prolapse procedures),
teen million Americans suffer from various types hyperreflexia, secondary to known neu- accidents, and surgical mishaps. Sacral
of urinary incontinence (UI). rologic disorders, such as stroke, Parkin- Most patients affected by pelvic floor radiculopathies (sacral nerve roots S2–
son's disease, diabetes, multiple sclero- disorders not only suffer from urinary S4) are underestimated etiologies also
The most prevalent type of UI (22% of the total) sis, peripheral neuropathies, or spinal but also from intestinal disorders, and frequently responsible for pudendal
is stress urinary incontinence (SUI). SUI is cha- cord injuries. In contrast, nonneuroge- mostly from a combination of both. pain with radiation to sacral dermato-
racterized by the unintended emission of urine nic OAB occurs as a result of detrusor Fecal incontinence and constipation mes, bladder hypersensitivity, and, in
during everyday activities and events, such as muscle overactivity, referred to as detru- are the most frequent. Fecal inconti- neurogenic lesions, bladder retention.
laughing, coughing, sneezing, exercising, or lif- sor muscle instability, that arises from nence is the inability to control bowel
ting. These activities and events cause an increa- nonneurological abnormalities, such as movements, causing stool (feces) to
Erectile dysfunction is an additional field
se in bladder pressure, resulting in loss of urine bladder stones, muscle disease, urinary leak unexpectedly from the rectum. of indication for PN stimulation. Erectile
due to inadequate contraction of the sphincter tract infection, or drug side effects, or Also called bowel incontinence, fecal dysfunction is often a result of a com-
muscle around the outlet of the bladder. can be idiopathic (the most frequent si- incontinence ranges from an occasio- bination of psychological and organic
tuation). nal leakage of stool while passing gas factors, but it is thought to be purely psy-
Another prevalent type of urinary disorder is uri- to a complete loss of bowel control in chological in origin in less than 30% of
nary urge incontinence (18% of the total), which
Interstitial cystitis (IC) is another lower someone who is older than 4 years old. cases. Organic factors can include com-
is characterized by a strong desire to urinate, fol- urinary tract disorder of unknown etio- Common causes of fecal incontinen- plications from neurologic diseases (stro-
lowed by involuntary contractions of the bladder. logy that predominantly affects young ce include constipation, diarrhea, and ke, multiple sclerosis, Alzheimer's disea-
Such disorders of the lower urinary tract include and middle-aged females, although muscle or nerve damage. Fecal incont- se, brain or spinal pathologies), chronic
overactive bladder, interstitial cystitis, prostatitis, men and children can also be affected. inence may be due to a weakened anal renal failure, prostate pathologies, and
prostadynia, and benign prostatic hyperplasia. Symptoms of IC can include irritative sphincter associated with aging or to da- diabetes; pelvic surgeries and medica-
voiding symptoms, urinary frequency, mage to the nerves and muscles of the tions also play a major role. However,
Many people (47% of the total) have a combina- urinary urgency, nocturia, and suprapu- rectum and anus from giving birth. most cases of erectile dysfunction are
tion of bladder control disorders. bic or pelvic pain related to and relie- associated with vascular diseases. An er-
ved by voiding. Many IC patients also
Pudendal nerve (PN) entrapment is a ection cannot be sustained without suf-
Other pelvic floor disorders include the following: experience headaches as well as gast- further pathologic situation responsible ficient blood flow into and entrapment
rointestinal and skin problems. In some for bladder disorders. Pudendal neu- within the erectile bodies of the penis,
cases, IC can also be associated with ralgia is an uncommon source of chro- and vascular-related erectile dysfunction
ulcers or scars of the bladder. nic pelvic pain, in which the pudendal can be due to a malfunction of either the
nerve is entrapped or compressed. Pain arterial or the venous system.

Acute urinary retention is treated with 2. THERAPEUTIC OPTIONS voids by more than 50%, and less than 69% 3. NEUROPHYSIOLOGY
the insertion of a catheter through the FOR OAB AND reduced the number of voids to normal levels OF THE PN
urethra to void the bladder. This ini- INCONTINENCE (4 to 7 per day). This modality has also demons-
tial treatment relieves the immediate trated limited reliability. Of those who under-
distress of a full bladder and prevents went this procedure, 52% experienced thera- The pudendal nerve is a sensory and somatic
permanent bladder damage. Long-term Various treatment modalities for urinary function py-related adverse events, and of these, 54% nerve that originates from the ventral rami of
treatment for any case of urinary reten- disorders have been developed. The modalities required hospitalization or surgery to resolve the the 2nd, 3rd, and 4th (and occasionally the 5th)
tion (acute and chronic) depends on typically involve drugs, surgery, bladder infiltra- issue; in addition, 33% required surgical revisi- sacral nerve roots. The PN innervates the exter-
the cause. Therefore, the most common tion, or combinations of these. Pharmacotherapy ons. It has also been reported that 64% of peop- nal genitalia of both sexes, as well as sphincters
treatments are treatments to relieve pro- appears to moderate the incidence of UI episo- le undergoing sacral nerve neuromodulation for for the bladder and the rectum. As the bladder
state enlargement in men, and genital des, but not eliminate them. Current treatments urinary incontinence are not satisfied with their fills, the PN becomes excited. PN stimulation
prolapse in women. When no cause can for OAB include medication (anticholinergics), current treatment modality (National Associati- results in contraction of the external urethral
be found and treatment is unsuccessful, diet modification, programs in bladder training, on for Incontinence, 1988). sphincter. Contraction of the external sphinc-
stimulation of the pelvic splanchnic ner- detrusor infiltration with botulinum toxin A, sur- ter, coupled with that of the internal sphincter,
ves through sacral nerves S2–S4 might gery, and electrical stimulation. Limitations of In addition, sacral nerve stimulation does not maintains urethral pressure (resistance) higher
be the last therapeutic option. medical treatment include reduced efficacy over permit stimulation and/or neuromodulation of than normal bladder pressure. The storage phase
time, as well as side effects such as dry mouth, all pudendal fibers and is not effective in cases of the urinary bladder can be switched to the
dry eyes, dry vagina, blurred vision, cardiac of combined urinary and fecal disorders. voiding phase either involuntarily (reflexively) or
side effects (e.g., palpitations and arrhythmia), voluntarily. The PN then causes relaxation of the
drowsiness, urinary retention, weight gain, hy- An alternative surgical modality consists of the levator ani so that the pelvic floor muscle rela-
pertension, and constipation, which have pro- bilateral stimulation of both branches of the dor- xes. The PN also signals the external sphincter to
ven difficult for some individuals to tolerate. sal genital nerves using a single lead implanted open. The sympathetic nerves send a message to
One present surgical modality for treatment of in adipose or other tissue in the region at or near the internal sphincter to relax and open, resul-
incontinence as well as urgency involves the the pubic symphysis. This technique of implanting in a lower urethral resistance. The PN is also
posterior installation by a percutaneous needle tation below the pelvis without any protection known to have a potential modulating effect on
of electrodes through the muscles and ligaments of the electrode by anatomical structures expo- bladder function. Somatic afferent fibers of the
over the S3 spinal foramen near the right or left ses the patient to migration (dislocation), dis- pudendal nerve are thought to project on sym-
sacral nerve roots (Interstim® Treatment, Med- connection, or breakage of the electrode and/ pathetic thoracolumbar neurons of the bladder
tronic). The electrodes are connected to a remote or the lead. Furthermore, this technique is too neck and modulate their function. This neuro-
neurostimulator pulse generator implanted in a restrictive because it enables only treatment of modulation effect works exclusively at the spinal
subcutaneous pocket on the right hip to provide urinary dysfunctions but not fecal dysfunctions level and appears to be at least partly responsib-
unilateral spinal nerve stimulation. This surgical or situations involving pelvic pain (e.g., vulvo- le for bladder neck competence and continence.
procedure near the spine is complex and requi- dynia, pudendal neuralgia).
res the skills of specialized medical personnel. Electrical stimulation of the PN simultaneously
In terms of outcomes, the modality has demons- provides the following:
trated limited effectiveness. For people suffering
from urinary urge incontinence, less than 50%
Direct and selective activation of the
remained dry following the surgical procedure. sensory fibers that lead to inhibition of
In terms of the frequency of incontinence epi- the bladder and rectum, without activa-
sodes, less than 67% reduced the number of tion of other nerve fibers that are present
in the sacral nerves roots (> therapy for Laparoscopic placement of the electrode in 4. THE PUDENDAL LION (which exposes patients to risk for lymphocele)
OAB). direct contact with the nerve reduces the risk of PROCEDURE – is not required because all of the fat and lymph
fibrotic tissue creation between the electrode IMPLANTATION tissue of the obturator space can simply be deta-

Direct and selective activation of the and the nerves, which reduces the effectiveness METHODOLOGY ched by blunt dissection from the internal obtu-
motoric fibers that lead to contraction of stimulation. Laparoscopic implantation can rator muscle (laterally to the obturator nerve and
of the anal and urethral sphincters to be done at the same surgical time and by the vessels) and retracted medially. Through further
improve urinary and fecal incontinence, same surgical approach, uni- or bilaterally. The LION procedure can entail a two-stage sur- exposure of the caudal border of the SN, the en-
without activation of other nerve fibers gical procedure, which includes a test screening dopelvic portion of the PN is identified. A dis-
that are present in the sacral nerves The endoscopic transperitoneal or retroperito- phase, or a single-stage surgical procedure in section of the PN specifically through the sciatic
roots (> therapy for urinary and fecal in- neal approach for implantation of the electrode which the pulse generator is implanted without foramen is not necessary.
continence). avoids the risk of injury to the spine associated a screening phase.
with sacral nerve stimulation, and the risk of Confirmation of the functional integrity of the

Activation of spinal circuitry that coor- postoperative hemorrhage or hematoma asso- The first stage of implantation consists of lapa- nerves is obtained by intraoperative laparosco-
dinates efferent activity in the cavernous ciated with blind techniques of implantation. It roscopic exposure of the nerves that are to be pic stimulation of the nerves. PN stimulation in-
nerve, increasing filling via dilatation of does not require urodynamics, as simultaneous implanted. The laparoscopic step is performed duces a strong contraction of the external anal
penile arteries, and efferent activity in rectal palpation during intraoperative stimulation under general anesthesia, avoiding any myore- sphincter, which can be noticed by simple con-
the PN, preventing leakage via occlu- of the PN confirms structural integrity by an evi- laxation. For trans- or retroperitoneal laparosco- comitant digital rectal examination.
sion of penile veins, producing a sus- dent contraction of the external anal sphincter. py, one 10-mm (or 5-mm) trocar is placed in the
tained reflex erection. umbilicus to introduce a 10/5-mm/0° optic, and Once the PN is found, dissection is stopped,
Laparoscopy reduces the main problem of lead three further 5-mm trocars are placed in the lo- and the tunneling/applicator tool with a stump
In a blinded study of sacral versus pudendal anchoring that is present with all implantation wer abdomen, one on the middle line and two tip and sleeve is introduced (a small 2- to 3-mm
stimulation for voiding dysfunctions, the ma- techniques in which leads are placed outside lateral beyond the epigastric arteries, to intro- incision is required) just above the anterior iliac
jority of the patients rated the PN stimulation the pelvic area, with high risk for lead migrati- duce an atraumatic forceps, scissors, and bipolar crest through the lateral abdominal wall until the
as being superior to sacral nerve stimulation on, dislocation, and cable breakage. Endoscopic forceps to control hemostasis. A single-port or top is identified intraabdominally just below the
(Peters et al., 2005). Stimulation of the PN as an implantation of the electrode to the PN within natural orifice approach can also be used for this peritoneum (Fig. 5.1).
alternative to sacral nerve stimulation has been the protection of the pelvic bone and above the surgery. For stimulation of the PN, a neuropro-
proposed in the past, although the invasiveness pelvic floor protects against dislocation, dis- sthesis with a tunneling applicator tool designed By following the peritoneum and rotating the
of the surgical procedure for implanting leads connection, and/or external trauma. In the deep- for laparoscopic implantation is used (e.g., PN- tunneling/applicator tool downward, because of
made stimulation of the PN impractical. Howe- ness of the pelvis, above the pelvic floor, no mo- Stim, NeuroGyn AG). the curve of this tool, it passes laterally from the
ver, because the PN directly innervates much of vement occurs; the electrode is secured by distal external iliac artery into the previously dissected
the pelvic floor, it is believed to be a more op- and proximal tines, within the protection of the For the exposure of the endopelvic portion of space. This step is absolutely safe because the
timal stimulation site, with few undesired side pelvic bone, and thus there is practically no risk of the sciatic nerve (SN) and of the PN, the "lum- top of the tunneling/applicator tool is perma-
effects. Implantation of the electrode to the PN electrode migration. The technique of laparosco- bosacral way" is used. After transsection of the nently under visual control. The top of the tun-
by laparoscopic approach can be done safely pic transpelveo-abdominal access for implanting peritoneum laterally to the external iliac artery, neling/applicator tool is finally pushed under the
under the control of endoscopic vision, and it the lead electrode is to date the only technique exposure of the sciatic nerve is obtained by bl- sacrospinous ligament along the PN through the
is easily reproducible because it is performed in that enables location of a lead electrode to the en- unt dissection of the lumbosacral space along lesser sciatic foramen to about 1 cm (Fig. 5.2).
anatomic area where pelvic health care specia- dopelvic portion of the PN under visual control. the psoas major and separation of the inter-iliac
lists have expertise. fat and lymph tissue from the obturator muscle The risk for pudendal vessel lesions is extremely
laterally to the obturator nerve and vessels. Dis- minimal because the vessels run on the opposite
section or excision of the pelvic lymph nodes side of the PN.
Removal of the tunneling/applicator tool le- the region where the percutaneous extension
aves the sleeve in place in direct contact cable extends from the skin, the infection occurs
with the nerve being implanted, allowing the away from the region where the pocket for the
physician to pass the electrode from outside implanted pulse generator is to be formed. The
through the sleeve to the nerve. The removal of pocket incision site and the lead tunnel all the
the sleeve completely out of the body, and to- way to the electrode are thereby shielded from
ward the proximal end of the lead, leaves the channel infection during the first stage, in antici-
electrode in place and in direct contact with the pation of forming a sterile pocket for the implan-
nerve itself (Fig. 5.3). The removal of the sleeve table generator in the second stage.
also permits the distal and the proximal tines of
the lead to deploy and to secure the location of If a one-stage procedure is planned, the lead can
the electrode twice, at the nerve (through the les- be connected directly to the generator that is
ser sciatic foramen for the PN) and retroperitone- placed in a subcutaneous prepared pocket.
al in the adipose tissue from the abdominal wall
below the abdominal fascia (Fig. 5.4).
This technique of selective placement of the

electrode without dissection of the nerves and
the necessity for extended dissection with tran-
section of anatomic structures such as the sacro-
spinous ligament for PN implantation makes the
procedure safe, the operative time considerably
shorter, and the risk for migration of the electro-
de close to zero.
A
Optionally, the test stimulator may be coupled

to a lead electrode via a sterile cable to apply
stimulation pulses through the electrode, to con-
firm that the electrode resides in the location
previously found.
Having implanted the lead electrode, a subcuta-

neous tunnel is formed for connecting the lead
electrode to an extension cable. The same tun- A
neling/applicator tool with a sharp tip and sleeve B
is introduced through the incision site where the

lead electrode was passed transcutaneously, and
is pushed away from the primary incision to the
contralateral side of the pelveo-abdominal wall. Fig. 5.1: Retroperitoneal introduction of the tunneling tool
In this configuration, should infection occur in A: external iliac artery – B: psoas muscle – C: tunneling tool
B
C
B
D A
A
Fig. 5.2: Placement of the tunneling tool through the lesser Fig. 5.3: Electrode lead in place on the pudendal nerve
sciatic notch A: sciatic nerve – B: pudendal nerve – C: lesser sciatic foramen –
A: sciatic nerve – B: pudendal nerve – C: tunneling tool D: electrode lead
pudendal nerve stimulation (PNS). Because PNS

5. PN STIMULATION FOR reaches more "sphincter-vesico-anal" fibers than
TREATMENT OF OAB AND SNM, PNS has been proposed for patients who
INCONTINENCE have failed to respond to sacral neuromodulati-
(POSSOVER, 2014B) on (Rijkhoff and Wijkstra, 2003; Tai et al., 2007).
The positive effects of PNS in neurogenic (Spi-
nelli et al., 2005) and in some nonneurogenic
Overactive bladder treatment has many appro- disorders (Peters et al., 2007) may be explained
aches, from behavioral changes to medications by the more selective stimulation of nerve fibers
(antimuscarinics), botulinum toxin A injection, innervating the external urethral and external
and neuromodulation of the pelvic nerves. Des- anal sphincter muscles. In a blinded study of
pite the fact that pharmacological treatment is sacral versus pudendal stimulation for voiding
currently the first option for the treatment of wo- dysfunctions, the majority of the patients rated
men with clinical symptoms of overactive blad- PN stimulation as superior to sacral nerve sti-
der, adherence to treatment is low, especially due mulation (Peters et al., 2005). In this study, pu-
to side effects, leading to discontinuation in 60% dendal response (≥ 50% improvement) occurred
of cases (Abrams et al., 2000). According to the in 71.4% of the patients, and almost all patients
American Urological Association (AUA) Guide- (93.2%) who had previously failed to respond to
Fig. 5.4: Passage of the tunneling tool laterally to the external iliac vessels down to line from May 2012, clinicians may offer sacral sacral neuromodulation responded to pudendal
the sciatic spine neuromodulation as third-line treatment in a ca- stimulation. Neuromodulation of the PN shows
refully selected patient population characterized better results that SNM because it improves ur-
by severe refractory OAB symptoms or patients inary and fecal incontinence by two methods:
who are not candidates for second-line therapy
and are willing to undergo a surgical procedu-
Direct and selective activation of the
re. Intradetrusor injections of botulinum toxin A sensory fibers that lead to inhibition of
have also been proposed as third-line treatment the bladder and rectum
in the carefully selected and thoroughly coun-
seled patient who has been refractory to first-
Selective activation of the motoric fibres
and second-line OAB treatments. However, the that lead to contraction of the anal and
patient must be able and willing to return for fre- urethral sphincters, without activation
quent postvoid residual evaluation and able and of other nerve fibers that are present in
willing to perform self-catheterization if neces- the sacral nerve roots
sary (elevated postvoid residuals) (Kantartzis and
Shepherd, 2012). As mentioned, PN is also known to have a
potential modulating effect on bladder function.
Electrical stimulation has emerged as an alterna- Somatic afferent fibers of the pudendal nerve
tive and attractive treatment for refractory cases are thought to project on sympathetic thoraco-
of bladder overactivity. It involves percutaneous lumbar neurons of the bladder neck and modu-
posterior tibial nerve stimulation (PTNS), sacral late their function. This neuromodulation effect
neuromodulation (SNM), and, more recently, works exclusively at the spinal level and appears
to be at least partly responsible for bladder neck tion, and migration. The PN LION procedure
competence and continence. Because the PN The first, and probably the most important, ad- using the applicator tool permits such a reduc- 6. SACRAL STIMULATION IN
directly innervates much of the pelvic floor, it is vantage of the laparoscopic approach for OAB is tion of operative time that the procedure is sui- URINARY RETENTION AND
believed to be a more optimal stimulation site not to permit implantation of electrodes in direct table for day surgery. No special instrumentation CHRONIC CONSTIPATION
with few undesired side effects, as compared connection to pelvic nerves, but to enable a mor- and equipment (e.g., X-rays, electrophysiological
with SNM. phologic exploration of the pelvis for possible al- guidance) are required, just the classic operating
ternative etiologies of secondary nonneurogenic room (OR) instrument setup for laparoscopy. 6.1 INTRODUCTION
The main problem of PNS is the anatomical OAB. SNM and botulinum injections are purely
location of the nerve, which makes implantation symptomatic therapeutic options that omit such Infiltrating genital tumors and deeply infiltrating
of the electrodes difficult or even dangerous: In potential etiologies. Deeply infiltrating endomet- endometriosis (DIE) are pathologic conditions
its endopelvic portion, the PN is quite difficult riosis of the bladder, vesico-intestinal adhesions, than can affect not only the pelvic organs but
and dangerous to reach by percutaneous punc- and endometriosis/fibrosis/vascular entrapment also the pelvic nerves responsible for intestinal
ture techniques because it is located extremely of the sacral nerve roots or of the pudendal ner- and urinary disorders (de Lapasse et al., 2008;
deep within the pelvis and in proximity to the ve are all etiologies that can only be diagnosed Possover and Mallmann, 2002), but surgical
sciatic nerve and major pelvic veins. "Open- by laparoscopy, and can be treated this way as damage to the pelvic nerves is by far the most
access" neurosurgical procedures for implanting well (Possover and Forman, 2012). Etiologic common etiology for such functional morbidity.
leads are thus impractical for stimulation of the treatment is then the treatment of choice, thus Proper functioning of the sympathetic and
PN because of invasiveness. The PN is accessible avoiding unnecessary, protracted, and expensive parasympathetic nervous systems in the pelvis is
by puncture techniques below the pelvic floor, symptomatic therapies. Neuromodulation treat- essential for successful micturition. Radical
close to the Alcock's canal (Bion device), but ment is indicated when no etiology is found. pelvic surgery can injure the autonomic nerves,
because it is surrounded only by soft tissue and which is the main cause of surgical complica-
is exposed to external "trauma" (e.g., intercourse, Although neuro-urologists and coloproctologists tions related to bladder dysfunctions. The classic
sitting, walking), risks for technical failure, are familiar with SNM, gynecologists are less belief is that damage to the pelvic parasympa-
dislocation, and migration are very high. trained in this technique. Nevertheless, because thetic nerves (pelvic splanchnic nerves) is main-
of importance of OAB in gynecology, gyneco- ly responsible for bladder retention.
Spinelli et al. (2005) performed a staged pro- logists must have access to such neuromodula-
cedure similar to that of SNM to place a tined tion treatments (Stewart et al., 2003). Because However, damage to the parasympathetic pelvic
lead near the PN by transgluteal approach, gynecologists are well trained in laparoscopic nerves is not the only cause of functional mor-
using neurophysiological guidance. However, surgery, the laparoscopic technique of implanta- bidities; injuries of the sympathetic nerves may
this technique has not found much acceptance tion may become a true option that can be done also induce pelvic sensory disorders (Possover,
because implantation of the lead is difficult and in same surgical time as that required for pelvic 2014d). In studies of rectal cancer, neurogenic
not always feasible. exploration. bladder was encountered in 10% to 17% of
patients for whom conventional rectal surgery
All of these limitations were overcome with the Thus, the LION procedure is an easy, safe, and re- was performed (Havenga et al., 1996). To avoid
introduction of laparoscopy into the field of pel- producible technique for gynecologists trained in such morbidity, the technique of total mesorec-
vic retroperitoneal surgery. Developments in laparoscopic retroperitoneal surgery (Possover, tal excision (TME), which is based on preserva-
video-endoscopy and appropriate instruments 2012). The deep location of the neuroprosthesis tion of the layer that contains the pelvic plexus
now permit good access to and visibility of all within the pelvis and above the pelvic floor pro- and both inferior hypogastric nerves, has been
pelvic nerves and plexuses. tects the device from external trauma and thus developed. In rectovaginal or parametric DIE,
reduces risks for cable breakage, lead disloca- preservation of the inferior hypogastric nerves
can be obtained as in the TME procedure, but use of the Valsalva or Crede maneuvers. In cases gentle dissection, and confirmation of the origin Because the current varies with the inverse of the
distal transection of the pelvic plexus at the level of neurogenic bladder, intermittent self-cathe- of the different sacral roots is gained by using la- square of the distance, a much larger stimulating
of the uterosacral ligaments is mostly required terization must be started early so that bladder paroscopic electrostimulation, known as the la- current will be required as one moves away from
for full resection of the nodule. This explains the myogenic damage does not become irreversible. paroscopic neuronavigation (LANN) technique the nerve (creating electricity-induced pain). La-
high prevalence of neurogenic bladder atony as (Possover et al., 2004). Stimulation of S3 nerves paroscopy is the only implantation technique
compared with motor paralytic atony found in is confirmed visually by a deepening and flat- that enables placement of one wire in direct
Possover's (2014c) study. 6.2 THE SACRAL LION PROCEDURE tening of the buttock groove as well as a plantar contact with all sacral nerve roots together, un-
flexion of the large toe and, to a lesser extent, of der visual control, within the pelvic cavity and
In motor paralytic atony, bladder retention Sacral nerve stimulation is the "last-chance" the- the smaller toes. Stimulation of S2 produces an above the pelvic floor (reducing the risk of lead
occurs directly after the procedure and is rapeutic option to treat urinary retention and outward rotation of the leg and plantar flexion of migration and breakage).
dramatic, whereas in sensory disorders, patients chronic constipation (of neurogenic origin), as the foot, as well as a clamp-like squeeze of the
are capable of urination after the surgery. long as the patient has some functional pelvic anal sphincter from the anterior to the posterior. After laparoscopic implantation of the wire to
However, loss of sensation regarding bladder nerves (unfortunately, some pelvic surgeries can The quadripolar-lead electrode (NeuroGyn AG) the nerves, patients undergo a test phase of seve-
fullness results, inadvertently and insidiously, induce full destruction of the pelvic nerves in- can then be placed easily by using a tool appli- ral weeks' duration with an external stimulator.
over the time in reduced urinary frequency. This volved in bowel and bladder emptying). Reliable cator, while the lead is placed in between the After the test phase, the decision of whether to
in turn gradually augments bladder capacity, data show that neurostimulation can be benefi- sacral nerve roots and the piriformis muscle. This implant a permanent pacemaker under local an-
with secondary impairment of bladder elasticity cial for idiopathic nonobstructive retention. This location protects the lead from dislocation and esthesia is made. The stimulation from the pace-
and contractility (myogenic damages). Resulting is quality-of-life-driven treatment – if a patient keeps the electrodes in direct contact with the maker modulates the nerves with mild electrical
postvoid residual volumes increase over time, wants to forgo use of the catheter and no medi- nerves (Fig. 5.5). The thin wire (less than 1 mm pulses. This treatment is reversible and can be
and secondarily deteriorate bladder contractility cations have proven effective, neurostimulation in diameter) emits a harmless and painless elec- discontinued at any time by turning off or remo-
even further. For a while, patients do not feel any is the next step. trical pulse that stimulates the nerves, resulting ving the device.
deterioration of bladder functions. However, up in a better detrusor and colorectal contraction.
to 6 to 7 years after the procedure, problems ap- Sacral LION stimulation therapy focuses on the
pear, and the situation takes a drastic turn for the stimulation of all bladder and rectum splanchnic As noted, the sacral LION-Stim procedure is
worse; the bladder itself may become so large nerves together by stimulating sacral nerves S2, the "last-chance" therapy; if this therapy fails,
that it blocks off the urethra, rendering the pati- S3, and S4. One electrode wire is placed by lapa- self-catheterization must be used throughout the
ent unable to urinate. roscopy tangential to all of these nerves together patient's lifetime for emptying the bladder. For
within the pelvic cavity (which protects the chronic constipation, a laparoscopic left hemi-
To avoid such neurogenic disorders, a proper electrode from migration and cable breakage); colectomy can be proposed as the absolutely last
follow-up that focuses not only on recurrence the implantation can be done bilaterally. option. A simple rectopexy with resection of the
of endometriosis and bladder-voiding functions, rectum, a therapeutic option often proposed by
but also on bladder sensory function, is essential. For exposure of the sacral nerve roots, the dis- general surgeons, will not achieve improvement
Patient history must focus on symptoms of sen- section is started by incision of the pararectal pe- of constipation because the pelvic splanchnic
sory bladder disorders, such as relapsing cystitis, ritoneum medial to the ureter, and expansion of nerves innervate not only the rectosigmoid, but
urinary leakage, increasing back pain, reduced the anatomic pararectal space is carried out by the entire left colon to the left flexure.
urinary frequency, and weak urinary stream. absolute blunt dissection downward to the level
Postvoid residuals must be regularly controlled of the coccygeal bone. The dissection is expan- All other techniques of "blind" implantation to
and documented. Patients must be also informed ded laterally to the hypogastric fascia, which is the sacral nerve roots enable placement of a
of the risks for bladder atony and renal damage transected in order to open the view. Sacral roots wire to only one sacral nerve root, which can
due to increasing postvoid residual volumes and S2–S4 are selectively exposed by extremely be in greater or lesser proximity to the nerve.
Sep-Oct;21(5):888-92.
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nerve stimulation for treatment of overactive bladder and
Fig. 5.5: Sacral LION procedure urgency incontinence. J Minim Invasive Gynecol 2014b
A: sacral nerve S2 – B: sacral nerve S3 – C: sacral nerve S4 – D: electrode lead
CHAPTER VI THE LION PROCEDURE IN SPINAL

CORD PATHOLOGIES AND INJURIES
130 NEUROPELVEOLOGY CHAPTER VI | THE LION PROCEDURE IN SPINAL CORD PATHOLOGIES AND INJURIES 131
1. INTRODUCTION incidence of complications associated with the 2. THE LION PROCEDURE IN trodes are used. The electrode leads are placed
use of catheters and the cost and undesirable SCI PATIENTS in direct contact with the nerves, using anatomic
side effects of medical treatments (e.g., botu- planes to avoid extensive dissection. The genera-
Spinal cord injury (SCI), in a moment, dramati- linum, anticholinergics, antibiotics) continue tor is implanted in the anterior abdominal wall
cally changes the life of the affected person. The to motivate research into devices that could In view of trends in the epidemiology of SCI, it (Fig. 6.4). Neurectomy is not required. Because
loss of locomotion together with the impairment harness the nervous system to provide greater is becoming increasingly important to develop the leads are not fixed to the nerves, the proce-
of urinary bladder and bowel function causes control over lower urinary tract function. Many treatment strategies that can enhance recovery dure is reversible. The procedure can be done in
a profound deterioration in the quality of life. devices that attempt to restore control of the lo- of motor function, walking in particular, follo- a two-day hospital stay. The patient can carry out
Whereas non-paraplegic patients often rank the wer urinary tract with electrical stimulation have wing SCI. In conjunction with providing treat- the postoperative training program at home, and
recovery of locomotion as the highest priority, been developed. The Finetech-Brindley sacral ment to enhance recovery of walking, rehabili- stay in a rehabilitation center is not required.
patients affected by SCI are likely to consider the anterior root stimulator, which is implanted by tation specialists must consider the factors that
disturbances in autonomic nervous system fun- dorsal approach (laminectomy), has proven to may influence such recovery. Multiple modali-
ction to be even more devastating than the loss be the only commercially successful electrical ties have been tried to improve walking in SCI 2.1. POSTOPERATIVE TRAINING PROGRAM
of motor and sensory function. In Anderson's stimulation device to restore voiding in SCI pa- patients. Those modalities range from changes
(2004) study, paraplegic subjects rated normal tients (Brindley, 1977). However, in patients for in the internal constraints, such as pharmacolo- Continuous bilateral sciatic and femoral stimula-
sexual function as the highest priority; when the whom such a dorsal implantation is not feasible – gical or surgical modalities (Barolat, 1988), to tion is started on the first postoperative day, with
first and second choices were combined, reco- such as patients who have had a dorsal fixati- the use of modalities that modify the constraints, a current frequency of 5 to 10 Hz and a pulse
very of normal bladder and bowel function was on/osteosynthesis of the lumbosacral rachis, such as ambulatory assistive devices (Melis et width of 60 µs. The intensity of the stimulation is
given the highest priority. some patients with spina bifida, and patients al., 1999) and mechanical orthoses. Another modified from 0.1 to 3 V to determine the lowest
who have undergone explantation of a previous treatment modality is the use of active orthoses, value for the first visible minimal skeletal mu-
The recovery of a normal bladder not only im- Finetech-Brindley device – no options exist. In which assist walking through functional electri- scle contraction and then continued nonstop at
proves the quality of life of paralyzed patients, this special situation, a promising (r)evolution cal stimulation (FES). this calibration. This low-frequency/low-voltage
but is also crucial for their health. Detrusor hy- comes from a completely different field of me- stimulation has been used for muscle training,
perreflexia that occurs as a consequence of SCI dicine: neuropelveology. As demonstrated in The therapeutic use of electrical stimulation has control of spasticity of the lower extremities, and
may cause incontinence, and when it occurs earlier chapters, laparoscopy is the only surgical a long history. More than 30 years ago, FES was induction of peripheral vasodilatation for decu-
with detrusor sphincter dyssynergia (DSD), high approach that permits an easy and reproducible developed as an orthotic system to be used for bitus prophylaxis.
bladder pressures and vesico-ureteric reflux lead exposure of all pelvic motoric and autonomic SCI patients (Liberson et al., 1961). The goal of
to renal impairment and eventually failure. Befo- nerves and plexuses (Possover, 2004), allowing FES is to obtain an immediate contraction of the In parallel, three further programs are installed
re the introduction of modern treatments, renal for laparoscopic implantation of neural electro- skeletal muscles that will lead to a functional to train the quadriceps muscles, one for each
failure was a common cause of death following des in direct connection to pelvic nerves and movement. Even though FES-assisted walking leg, and one for both legs together. Stimulation
SCI. Thus, preventing upper renal tract damage is plexuses. Thus, laparoscopy presents new ap- has been available for more than three decades, parameters are fixed by a pulse width of 60 µs,
the primary aim of bladder management in pati- plications for patients with SCI (Possover et al., it has not been widely used in rehabilitation a frequency of 300 Hz, and variable intensi-
ents with SCI. 2008, Possover et al., 2010). because the stimulators are bulky, unreliable, ties for harmonious and stable extension of the
prone to breakage, and expensive. knees. After familiarization with the use of the
Because a complete biological cure for spinal electric stimulation unit, training is started with
cord injury is unlikely to be developed in the The LION procedure in SCI patients focuses on concomitant sciatic (contraction of the gluteal
near future (Fawcett, 2002), medical treatment the implantation of stimulatory electrodes to muscles) and femoral stimulation at 60 µs/300
and devices, specifically catheters, still play an the sciatic (Fig. 6.1), pudendal (Fig. 6.2), and Hz, performed three to five times per week at
important role in the daily regime of bladder femoral nerves (Fig. 6.3). A stimulation unit the patient's home, which consists of four sets
management for most people with SCI. The high (NeuroGyn AG) and four 4-array fine-wire elec- of 10 electrical-induced knee extensions at a
A
B
B C
A
Fig. 6.1: Introduction of the tunneling tool to the sciatic and pudendal nerves Fig. 6.2: Introduction of the tunneling tool below the femoral nerve
A: tunneling tool – B: sciatic nerve A: posas muscle – B: femoral nerve – C: tunneling tool
Fig. 6.4: Subcutaneous implantation of the generator
Fig. 6.3: Placement of the electrode lead on the femoral nerve

A: femoral nerve – B: electrode lead to the femoral nerve –
C: 2nd electrode lead (sciatic nerve)
5-second/5-second work/rest ratio, with a 3-mi- re-education with electrical-controlled eccentric sensory function, and enough supraspinal control including epidural (Ichiyama et al., 2008) and
nute interval of recovery between sets. Knee muscle actions and FES-assisted locomotor trai- of the lower limbs for some voluntary move intraspinal (Barthelemy et al., 2007) electrical
extension is performed as patients sit in a chair. ning can be started a few weeks after implan- ments. Two patients even recovered enough stimulation (Kubasak et al., 2008). Epidural elec-
Current from the stimulator is manually increa- tation. Nerve stimulation has major advantages, control for standing and stepping for few meters trical stimulation applied dorsally at the lumbar
sed in 2- to 3-second intervals to evoke full knee as compared with electrical muscle stimulation, without electrical stimulation. L2 or sacral S1 (Lavrov et al., 2008) spinal seg-
extension, followed by the eccentric action. in inducing a more harmonious movement with ments induces rhythmic limb movements. More
less fatigue. Because the electrodes are connec- Spontaneous extensive remodeling occurs ba- recently, Harkema et al. (2011) reported the ef-
After a period of 12 weeks, assisted training pro- ted to a rechargeable pacemaker, FES training sed on axonal sprout formation and removal fects of epidural stimulation of the lumbosacral
gresses from standing to stepping, first with the and continuous neuromodulation of the pelvic (Courtine, 2009). In addition, locomotor trai- spinal cord in a man with clinically complete
use of a bar table, and then with the use of a nerves are both feasible for the long term. ning alone (Manella et al., 2010; Murillo et al., SCI. Epidural stimulation enabled the patient
walker. The pacemaker is configured so that pa- 2012; Spiess et al., 2012) or in conjunction to achieve full weight-bearing standing with as-
tients can modify the current of stimulation to Both types of stimulation may induce a building with pharmacologic treatment can promote use- sistance and locomotor-like patterns under cont-
obtain optimum efferent patterns for standing of muscle mass that acts as a preventative factor dependent plasticity changes in the sensorimotor inuous spinal cord stimulation. This technique of
and stepping at home. To eventually improve against formation of decubitus lesions (Scremin circuits below the injury that lead to specific im- stimulation is similar to the technique described
control and harmony of neural connections, the et al., 1999). A clinical observation of the author provements of stepping patterns. The progressive here, as both activate the lower motor neurons,
author and colleagues advise patients to mental- and colleagues – confirmed by measurements caudalward recovery of sensory function might but pelvic nerve stimulation enables muscle
ly concentrate on performing the body function with a thermo-camera – is an increase of cuta- be a strong clinical sign for a process of rege- building and locomotor training before any ner-
and to think about the movements during trai- neous temperature in the stimulated areas, espe- neration or reconnection. Also, the fact that pa- ve recovery occurs and enables stimulation of
ning, rather than simply using the stimulation for cially the gluteal regions. This effect is probably tients initiate voluntary movements in the same the sympathic trunks (decubitus and osteoporo-
training while concentrating on something else. attributable to neuromodulation of the pelvic way of thinking as before the injury of the spinal sis prevention/treatment).
Over a period of months, the frequencies of the sympathetic nerves, which increases cutaneous cord is a clinical argument for such a process of
stimulation can be reduced progressively to 15 oxygen pressures and enhances angiogenesis spinal cure. Previous researchers have suggested This sympathic nerve stimulation may be the
to 20 Hz, with the advantage of considerably (Junger et al., 1997). The combination of the that exogenously applied weak electric fields reason for the previously mentioned cutaneous
reduced muscle fatigue. The pacemaker is con- thermal effect, the locomotor training (discharge near damaged axons play a role in facilitating peripheral vasodilation. Because of evidence of
figured so that patient use of the remote control of the bottom), and the stimulation-induced axonal regeneration, possibly by providing neu- the role of the sympathetic innervation of bone
is required only at the beginning and the end of building of gluteal muscle mass ("gluteal pads rotropic guidance to the growing axons (McCaig tissue and its role in the regulation of bone re-
the stepping phase, offering patients maximal effect") better protects patients from decubitus et al., 2000). Borgens et al. (1990) demonstra- modeling in humans (Takeda et al., 2002), lo-
autonomy. lesions, deep venous thrombosis, and edema ted in animal studies that regenerated axons with comotor training and sympathetic neuromodu-
(Mawson et al., 1993). applied electric fields were also able to make lation could also open new ways for treatment
functional synaptic connections with the caudal or prophylaxis of osteoporosis in SCI (Levasseur
2.2. FROM FES TO SCI CURE? In addition, when the primary aim of the LION end of the injured spinal cord when the cathode et al., 2003).
procedure is FES of the somatic pelvic nerves for electrode was placed caudal to the SCI. Other
Laparoscopic implantation of neuroprosthesis induction of involuntary movements of the legs experimental studies also indicate that electrical A further major difference from the findings of
for neuromodulation (the LION procedure) is the (Possover, 2014), a major unexpected effect ap- stimulation could lead to significant functional Harkema et al. (2011) is that some patients who
only minimally invasive technique of electrode pears to be the possibility of nerve reconnection recovery due to the formation of alternate syn- have undergone the LION procedure are capable
implantation that enables selective placement or even nerve growth (Possover, 2014): After a aptic pathways (Shapiro et al., 2005). of lower extremity motion even without stimu-
of electrodes under view control and in direct period of 2 to 3 years of training and continuous lation, whereas in spinal cord stimulation, leg
contact with the endopelvic portion of the lum- low-frequency pelvic nerve stimulation, some Several experimental strategies have also been movements occur only during epidural stimula-
bosacral nerves. Because separate electrodes patients – even some with complete SCI – pre- tested to activate locomotor circuits in mam- tion. In the study of the author and colleagues
are placed on the sciatic and femoral nerves, sented a progressive and caudalward recovery of mals after a complete spinal cord transection, (Possover et al., 2010), we applied continuous
low-frequency stimulation to the pelvic nerves 3. THE LION PROCEDURE implantation, and artificial urinary sphincter improvement concerning bladder compliance,
between the phases of training because frequency IN CHILDREN WITH implantation, do exist, but indications and effi- but no improvement for bladder voiding or in-
is well known to be an important factor for suc- SPINA BIFIDA cacies depend largely on the urodynamic pat- continence.
cess in both the quality and quantity of axon terns, age, and sex of the patient. Achieving and
regeneration, and in the growth of the surroun- maintaining bowel continence is probably the It is evident that the success of neuromodulation
ding myelin and blood vessels that support the Neurogenic bladder functional abnormalities most difficult challenge for people with spina depends largely on the urodynamic patterns and
axon. Histological analysis and measurement of occur in approximately 50% of children with bifida. As for urinary incontinence, conservati- neurologic damage of the patient, but the type of
regeneration showed that low-frequency stimu- spina bifida aperta. Additionally, 25% of child- ve methods and control of toileting are of major stimulation is also important: The more functio-
lation had a more successful outcome than did ren with occult spinal dysraphism have hyper- importance. When bowel emptying and fecal nal fibers that are reached by the stimulation, the
high-frequency stimulation for regeneration of activity of the bladder, which, in combination incontinence are not successfully controlled by higher the chance of success, especially for con-
damaged nerves (Lu et al., 2008). with detrusor-sphincter dyssynergia, carries a se- conservative methods, surgical procedures may trol incontinence. Whereas the transforaminal
rious risk of urinary tract damage. The incidence be indicated. The Malone procedure is used for technique of implantation enables stimulation
Because it is doubtful that a single researched of renal damage approaches 100% in patients the management of fecal incontinence and in- of only one sacral nerve root per electrode, the
element will provide the ultimate cure for spinal who are not adequately treated. To prevent such volves bringing the appendix to the surface of LION procedure presents the decisive advantage
cord regeneration, shared evidence from many irreversible damage, urologic and nephrologic the skin and creating a stoma (Hensle et al., of permitting stimulation of all fibers designated
research trials will point the way toward deter- treatments should start immediately after birth, 1998). Caecostomy catheter is also a feasible to the sphincter and to the sacral areas with only
mining the path of future research. There is no and life-long suppression of detrusor overacti- procedure that provides a regular, predictable one multiple-channel electrode. In children with
doubt that nerves can accomplish functions such vity is required (Ab et al., 2004; Riccabona et method for defecation, but it is difficult to use on spina bifida, the LION procedure permits bypass
as regeneration, reconnection, and reactivation, al., 2004). In the case of failure of such medical a long-term basis (Kalidasan et al., 1997). of the dorsal anatomic abnormalities and scar tis-
but there must be a strong necessity to do so. treatments, patients can be treated with surgical sue secondary to previous dorsal surgeries. The
This is directly correlated with the willpower of interventions. Vesicostomy is indicated in the Despite the functional success of all of these implantation is done ventrally to the sacral bone,
the patient. The author and colleagues strongly presence of persistent hydronephrosis and re- procedures, acceptance by parents and patients under normal anatomic and surgical conditions.
believe that will, hope, motivation, focus on a current urinary tract infection when the bladder is not always a matter of course because these The laparoscopic neuronavigation (LANN) pro-
possible cure, and re-education are essential continually fails to empty. Rhizotomies are not surgeries are invasive, irreversible, hide potential cedure enables the surgeon, directly during the
for potential nerve regeneration/reconnection. yet being used routinely. Augmentation proce- severe complications, and do not permit voliti- procedure, to establish a functional analysis of
All descending voluntary activations are sent to dures and urinary diversion are further possible onal voiding of the bladder. For these reasons, all pelvic somatic nerves, which in turn enables
the level of the spinal cord injury, whereas all procedures to manage bladder hyperactivity and alternative treatments have been sought. a placement of the electrodes that is adapted to
peripheral sensory information created by ner- urinary incontinence, but these procedures are the unique neural situation of each patient.
ve stimulation, re-education, and physiothera- invasive and permanent. Sacral neuromodulation is one promising the-
py sends afferent inputs upward to the level of rapeutic modality for spina bifida, but only few Spinal bifida is often neurophysiologically in-
injury. Low-frequency neuromodulation of the Urinary and fecal incontinence is the major series have been reported in the literature (Guys, complete; in such cases patients will benefit
pelvic nerves has the advantage of continuously source of poor quality of life and interferes with 2006). Despite percutaneous implantation being from training and neuromodulation of the ope-
providing such afferent inputs without the need educational opportunities, self-esteem, and so- minimally invasive and nondestructive, anato- rational neural pathways. For such patients, the
for the active participation of the patient. All of cial development. Management and control of mic abnormalities and scar tissue can make im- combined effects of continuous neuromodulati-
this information creates a "need" for reconnec incontinence is difficult, and urological surgery plantation difficult, whereas partial or complete on of the pelvic nerves may provide sufficient
tion and/or regeneration, resulting in the poten- is an important option for patients when other destruction of sacral nerve roots can compromi- afferent input and descending voluntary activa-
tial for neural plasticity and secondary impro- procedures, such as intermittent catheterization, se the effectiveness of the stimulation. In a pros- tion to promote neural plasticity and/or nerve
ved functional abilities. Therefore, motivation, are insufficient or not feasible. Minimally inva- pective randomized controlled study to evaluate regeneration and/or reconnection, resulting in
re-education, and peripheral nerve stimulation sive procedures, such as transurethral injection the possible benefits of sacral nerve stimula- improved functional abilities. Further research is
are essential in rehabilitation of people with SCI. therapy (Silveri et al., 1998), pubovaginal sling tion, Guys et al. (2004) reported some patient required to elucidate the extent to which other
people with spina bifida may benefit from a Guys JM, Haddad M, Planche D, Torre M, Louis-Borrione C, Mawson A, Siddiqui F, Connolly B, Sharp C, Summer W, Silveri M, Capitanucci MI, Mosiella G, et al. Endoscopic
similar intervention program. Breaud J. Sacral neuromodulation for neurogenic bladder Binndo J Jr. Effect of high voltage pulsed galvanic stimulation treatment for urinary incontinence in children with a conge-
dysfunction in children. J Urol 2004;172(4):1673-6. on sacral transcutaneous oxygen tension levels in the spinal nital neuropathic bladder. Britsh Journal of Urology, 1998;
Harkema S, Gerasimenko Y, Hodes J, et al. Effect of epidural cord injured. Paraplegia 1993;31:311-9. 82:694-7.
stimulation of the lumbosacral spinal cord on voluntary McCaig CD, Sangster L, Stewart R. Neurotrophins enhance Spiess MR, Jaramillo JP, Behrman AL, Teraoka JK, Patten C.
movement, standing, and assisted stepping after motor com- electric field-directed growth cone guidance and directed Unexpected recovery after robotic locomotor training at
plete paraplegia: a case study. Lancet 2011;377:1938-47. nerve branching. Dev Dyn. 2000;217:299-308. physiologic steeping speed: a single-case design. Arch Phys
Hensle TW, Reiley EA, Chang T. The Malone antegrade con- Melis EH, Torres-Moreno R, Barbeau H, Lemaire ED. Analy- Med Rehabil 2012;93:1476-85.
tinence enema procedure in the management of patients sis of assisted-gait characteristics in persons with incomplete Takeda S, Elefteriou F, Levasseur R, et al. Leptin regulates
with spina bifida. J Am Coll Surg 1998;186:669-74. spinal cord injury. Spinal Cord 1999;37:430-9. bone formation via the sympathetic nervous system. Cell
Ichiyama RM, Courtine G, Gerasimenko YP, et al. Step trai- Murillo N, Kumru H, Opisso E, et al. Recovery of assis- 2002;111:305-17.
ning reinforces specific spinal locomotor circuitry in adult ted overground stepping in a patient with chronic motor Wood MR, Cohen MJ. Synaptic regeneration and glial
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Junger M, Zuder D, Steins A, Hahn M, Klyscz T. Treatment 2012;31:401-7. Neurocytol 1981;10:57-79.
Ab E, Dik P, Klijn AJ, van Gool JD, de Jong TP. Detrusor of venous ulcers with low frequency pulsed current (Derma- Possover M. Laparoscopic exposure and electrostimulati-
overactivity in spina bifida: how long does it need to be pulse) effects on cutaneous microcirculation. Der Hautartzt on of the somatic and autonomous pelvic nerves: a new
treated? Neurourol Urodyn 2004;23(7):685-8. 1997;18:879-903. method for implantation of neuroprosthesis in paralysed
Anderson KD. Targeting recovery: priorities of the spinal Kalidasan A, Elgabroun MA, Guiney EJ. Button caecostomy patients? J Gynecol Surg 2004;1:87-90.
cord-injured population. J Neurotrauma, 2004;21:1371-83. in the management of faecal incontinence. 1997;84:694. Possover M. Recovery of sensory and supraspinal control
Barolat G. Surgical management of spasticity and spasms Kubasak MD, Jindrich DL, Zhong H, et al. OEG implanta- of leg movement in people with chronic paraplegia: a case
in spinal cord injury: an overview. J Am Paraplegia Soc tion and step training enhance hindlimb-stepping ability in series. Arch Phys Med Rehabil. 2014 Apr;95(4):610-4.
1988;11:9-13. adult spinal transected rats. Brain 2008;131:264-76. Possover M, Baekelandt J, Kaufmann A, Chianteras V.
Barthelemy D, Leblond H, Rossignol S. Characteristics Lavrov I, Dy CJ, Fong AJ, et al. Epidural stimulation induced Laparoscopic endopelvic sacral Implantation of a Brindley
and mechanisms of locomotion induced by intraspinal modulation of spinal locomotor networks in adult spinal Controller for recovery of bladder function in a paralyzed
microstimulation and dorsal root stimulation in spinal cats. J rats. J Neurosci 2008;28:6022-9. patient. Spinal Cord 2008;46(1):70-3.
Neurophysiol 2007;97:1986-2000. Levasseur R, Sabatier JP, Potrel-Burgot C, Lecoq B, Creveuil Possover M, et al. New strategies of pelvic nerves stimulati-
Borgens RB, Blight AR, McGinnis ME. Functional recovery C, Marcelli C. Sympathetic nervous system as transmitter of on for recovery of pelvic visceral functions and locomotion
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Brindley GS. An implant to empty the bladder or close the Liberson WT, Holmquest HJ, Scott D, Dow A. Functional A, Lusuardi L, Bauer SB. Botulinum-A toxin injection into
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Courtine G, Gerasimenko Y, van den Brand R, et al. zed with the swing phase of the gait in hemiplegic patients. with myelomeningocele with detrusor hyperreflexia. J Urol
Transformation of nonfunctional spinal circuits into fun- Arch Phys Med Rehabil 1961;42:101-5. 2004;171:845-8.
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THE AUTHOR 143
UNIV.-PROF. PROF. DR. MED. MARC POSSOVER, MD, PHD
THE AUTHOR Univ.- Prof. Prof. Dr. med. Marc Possover has absolved is medical study at the Uni-
versity of Nancy in France and is Swiss and German Board Certified in Obstetrics
and Gynecology, Surgical Gynecology and Gynecology Oncology.
He is currently the Chief of the Possover International Medical Center in Zürich,

associated Professor for Neuropelveology at the University of Aarhus in Denmark,
and Academic Affiliates of the University of Cologne in Germany.
Prof. Possover is the president of the International Society Of Neuropelveology

(www.theison.org) and the pioneering leader in applying minimal access surgery
to malignant pelvic gynecologic pathologies, treatment of severe pelvic multi-or-
gans endometriosis and the worldwide leader for treatments pathologies of the pel-
vic nerves. He has developed as pioneer the field of the Neuropelveology that deal
with neuropathic pelvic pain, endometriosis of the pelvic nerves, dysfunctions of
the pelvic nerves and the worldwide pioneering leader in applying laparoscopy for
nerves sparing techniques in pelvic surgeries and for implantation neuroprothesis
to the pelvic nerves for recovery pelvic functions and locomotion in spinal cord
injured peoples.
He is nationally and internationally known for his research, teaching, and clini-
cal contributions to the field gynecological oncology, endometriosis surgery and
neuropelveology. In addition to many book chapters and scientific articles, Prof.
Possover has received numerous awards from the most significant and leading me-
dical societies. He is a member of several distinguished medical societies, serves
as an advisor and reviewer to a number of scientific medical journals and is Board
member of the European Society for Gynecological Endoscopy, the German and
the Swiss Society for Gynecological Endoscopy and Oncology. He is consistently
listed among the top specialists in their field in various magazines. He is ambassa-
dor of the World Endometriosis Society and member of the Leading Surgeons of the
World. Prof. Possover travels worldwide sharing the knowledge of his techniques
and participates in a multitude of international events and seminars.
NACHSATZSEITE 1 UMSCHLAG 3 = NACHSATZSEITE 1

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PROGRESS IN PELVIC RESEARCH

Latest Developments in Pelvic Neurofunctional Surgery

Latest Developments in Pelvic Neurofunctional Surgery

Univ.-Prof. Prof. Dr. med. Marc Possover

Jean-Matthieu et Louis-Charles, vous avez été si souvent privés de votre père.

Vito, merci pour la correction de ce livre, tes conseils si riches en expérience, et un

Avec toute mon Amitié

The International School for Neuropelveology

1. Indications ........................................................................................... 110

1. Introduction .......................................................................................... 130

Marc Possover........................................................................................ 143

CHAPTER I PELVIC NEUROFUNCTIONAL ANATOMY

1. INTRODUCTION 2. THE SACRAL PLEXUS

This division is of great importance in understan- 2.1. THE LUMBOSACRAL TRUNK

of the lumbosacral space lateral to the external

The four (or sometimes five) sacral nerve roots

Fig. 1.4: Sympathic and parasympathetic innervation of the pelvic organs

CHAPTER II DIAGNOSIS IN NEUROPELVEOLOGY

1. INTRODUCTION Vulvodynia, coccygodynia, inguinodynia

Because pain is transmitted by peripheral nerves Dysuria and/or painful ejaculation

S ciatica associated with urinary symptoms

 luteal pain associated with perineal,

Pudendal pain, partial or complete Fig. 2.1: Lumbosacral Dermatomes

Vaginal delivery (forceps, vacuum) Pudendal nerve

4. PELVIC EXAMINATION 5. NEUROLOGICAL

The pelvic clinical examination focuses on

5.3. PATIENT WALKING AND

When the patient is standing with the feet

5.4. SENSATION 6. PELVIC ULTRASOUND

The patient is assessed for light touch and pin-

Proprioception is assessed by up-and-down

Routine renal ultrasound may be recommended

8. CYSTOMETRY AND 9. NEUROPHYSIOLOGICAL REFERENCES

CHAPTER III LAPAROSCOPIC EXPOSURE OF

1. INTRODUCTION 2. EXPOSURE OF THE

Not only did such advances lead to new

4. EXPOSURE OF THE SACRAL REFERENCES

Because in humans most of the parasympathetic

CHAPTER IV PELVIC NEUROPATHIC

4. PUDENDAL NEURALGIA 4.1. ALCOCK'S CANAL SYNDROME

Because pelvic and leg veins are both exposed

B Different treatments for pelvic varicose have

7. PIRIFORMIS SYNDROME 8. POSTSURGICAL PELVIC

Piriformis syndrome is a neuromuscular disorder

However, reports of iatrogenic pudendal neu- B

ralgia are rare in current literature (Possover,

10. PELVIC SCHWANNOMA Laparoscopic exploration not only permits an

Presacral and/or retroperitoneal schwannomas

Fig. 4.8: Sacral schwannoma on the right side –

Fig. 4.9: Sacral schwannoma on the left side – laparoscopic view

11. PELVIC OSTEO­ tumors, and the abdominal-inguinal approach

The introduction of the Gigli saw through the

Fig. 4.13: Resection of the specimen by posterior approach

Fig. 4.12: Introduction of Gigli saw through sacral foramen

Fig. 4.15: Postoperative site – X-ray

CHAPTER V THE LION PROCEDURE

This technique of selective placement of the

Optionally, the test stimulator may be coupled

Having implanted the lead electrode, a subcuta-

is introduced through the incision site where the

pudendal nerve stimulation (PNS). Because PNS

CHAPTER VI THE LION PROCEDURE IN SPINAL

Fig. 6.4: Subcutaneous implantation of the generator

1. INTRODUCTION Vulvodynia, coccygodynia, inguinodynia

Because pain is transmitted by peripheral nerves Dysuria and/or painful ejaculation

S ciatica associated with urinary symptoms

luteal pain associated with perineal,

Pudendal pain, partial or complete Fig. 2.1: Lumbosacral Dermatomes

4. PELVIC EXAMINATION 5. NEUROLOGICAL

5.3. PATIENT WALKING AND

8. CYSTOMETRY AND 9. NEUROPHYSIOLOGICAL REFERENCES

1. INTRODUCTION 2. EXPOSURE OF THE

4. EXPOSURE OF THE SACRAL REFERENCES

7. PIRIFORMIS SYNDROME 8. POSTSURGICAL PELVIC

11. PELVIC OSTEO tumors, and the abdominal-inguinal approach