Decompression Surgery

The Four Approaches

Surgery should, as always, be considered as a last resort, in the event of

failure of conservative treatments tried for at least six months to a year.

One absolute prerequisite is clear: You must be diagnosed positively for

pudendal neuralgia by an experienced pain management doctor using

the five Nantes Criteria. See main menu -> DIAGNOSIS.

The other is you must have tried the medical approved conservative or non-invasive

treatments. See Main Menu -> CONSERVATIVE TREATMENTS.

The surgery for the cause of pudendal neuralgia called Pudendal Neuralgia Entrapment (PNE) is called Decompression Surgery. It frees the pudendal nerve in Alcock's canal is considered the most effective long-term treatment and potential cure for pudendal nerve entrapment if there is actual nerve damage; that the pain is just not caused by muscular issues.

There are 4 Types (some say 5, see IIIa, IIIb) of Pudendal Nerve Entrapment (PNE) that would require Depcompression Surgery:

Type I, in the sciatic notch (is a notch in the ilium)
Type II, the Ischial spine and Sacrosciatic ligament
Type IIIa, the obturator internus muscle
Type IIIb, the obturator internus and piriformis muscles
Type IV, the distal (farthest two) branches, perineal & dorsal

The minimum limit of 6 months or more is retained because pudendal neuralgia pain

sometimes resolves with conservative treatments and you want to give your body the time it needs if this might be the case, and excellent news, for you.

The Four Approaches:

Pudendal Nerve Decompression Surgery

Each directly frees the pudendal nerve in Alcock's canal is considered the most effective long-term treatment and potential cure for pudendal nerve entrapment if there is actual nerve damage; that the pain is just not caused by muscular issues. (in no particular order):

1. Transischiorectal Fossa (TIR)

2. Transperineal (TP)

3. Transgluteal (TG)

4. Laparoscopic (LaPNDT)

1. TRANSISCHIORECTAL FOSSA (TIR)
Dr. Eric Bautrant – France 2003
- Women - Vaginal incision
- Men - Pararectal incision

WOMEN: The transischiorectal approach is a surgical approach via vertical vaginal incision in the lateral wall into the pararectal space.

MEN: The transischiorectal approach is via a paramedian transverse perineal incision, with entrance into the pararectal space.

Advantages of the TIR approach
Smaller incision
Spares the STL
Disadvantages of the TIR approach
Less visualization of the surgical area
No access to the STL if the nerve is entangled in that ligament.

Dr. Bautrant developed the transsischiorectal approach in order to avoid the need for transection (cutting) of the sacrotuberous ligament (STL) the large of the two and pelvis stabilizer. The approach cuts only the sacrospinal ligament (SSL).

Dissection is then directed to the ischiorectal fossa on the affected side. Electromyogram is used to direct the surgeon to the area of compression to limit the need for extensive dissection. Similarly, to the transperinal approach, access to the pudendal nerve is limited.
Transsischiorectal: Recovery is difficult in men (and can be with women) with painful incisions between the scrotum and rectum that are prone to infection.

Dr. Bautrant and his team keep patients for several days to manage pain and watch for complications. Reviews of his team are excellent. Bautrant initially reported 86% improvement in pain 12 months after surgery. Unfortunately, experience in the United States has not been able to reproduce successful outcomes and thus this approach.

Publication: Modern algorithm for trea􀆟ng pudendal neuralgia: 212 cases and 104 decompressions – Na􀆟tional Library of Medicine 2003. Link below.
htps://pubmed.ncbi.nlm.nih.gov/15067894/

Anecdote: I have spoken a woman who had this approach done in 2003 by Dr. Bautrant. He explained that it was a one-year healing period and provided progression details. She healed from pudendal neuralgia after the two years. She is roughly 67 years old today and continues to live a normal life.

2. TRANSPERIANAL (TP)

Dr. Ahmed Shafik, MD - Egypt (b 1933 – d 2007)

Dr. Shafik developed the transperineal approach to open the Alcock’s Canal in 1992.

This approach was originally developed to treat fecal incontinence. Patients are positioned in dorsal lithotomy position.

Advantages of TP approach

Least invasive

Spares all ligaments.

Disadvantages of TP approach

Least visualization for the surgeon

Unless modified, does not deal with entrapments at the ischial spine.

Difficult or impossible to free nerve from entanglement with ligaments.

A semicircular incision is made on the side of the anus on which the nerve is affected. The surgeon then identifies the inferior rectal nerve and follows it blindly with a finger until the pudendal nerve is reached.

Adhesions around the pudendal nerve are then bluntly reduced.

This approach allows access to the rectal branch and should be limited to patients with only rectal involvement of pudendal neuralgia.

Although one of the least invasive approaches, it’s a blind procedure that does not allow for extensive dissection of the nerve beyond the distal Alcock’s canal.

3. TRANSGLUTEAL (TG)

Dr. Roger Robert - France

Dr. Robert developed transgluteal decompression. This procedure was originally described by Robert from Centre Hospitalier Universitare in Nantes, France. This approach severs both the sacrotuberous ligament STL and the Sacrospinous Ligament SSL. A ligament attaches bone to bone.

Advantages of TG approach

Best visualization of the nerve

If the nerve is entangled in the ST ligament there is access to release it from the ligament

Disadvantages of TG approach

Relatively large incision

Possible post-operative pelvic instability from severed ligaments

Cuts the Sacrotuberous Ligament (STB) which is large and the stabilizes the Pelvis and the SSL

Ligaments have a very poor blood supply meaning that they do not have any blood vessels

that travel through them, which is what makes them very strong and resistant to stretch. This is also why the do not heal quickly, because they lack a direct blood supply. They do not have a direct blood supply within them as muscles do. This is why they take longer to heal than muscle.

The Sacrotuberous Ligament (STB) Stabilizes the Pelvis. Some doctors say that they can reattach to it. However, ligaments attach bones to other bones. They have a more limited blood supply than either muscle or tendon and often don’t heal well.

The patient is positioned in a prone jackknife position (facing down). A transgluteal incision is made in the location overlying the sacrotuberous ligament STL.

When the ligament is reached, it is transected at its narrowest portion and edges of the
ligament are reflected open. The pudendal nerve is found immediately below the ligament together with the pudendal vein and artery. Through this approach, the nerve can be

visualized from the subpiriformis fossa to the distal Alcock’s canal.

Studies show that TG surgery performed by an extremely experienced, knowledgeable,

ethical surgeon allows an improvement of symptoms in 70% of cases, a lack of improvement

in 30% of cases, 2% of which continue to worsen: this is not a question of worsening in the neurological sense but probably the disease which continues to evolve on its own account.

Beyond the age of 70, the improvement rate decreases to 50%. It is important to note that

there may be no improvement for 6 months and this may continue for 2 years. Results are improved by comprehensive care.

PNA encourages that you interview in person or via Zoom at least two surgeons after doing

in-depth research. The surgeon who select should require a positive diagnostic puendal nerve block ad do a complete physical exam.

We believe a positive outcome has the most to do with going to a highly experienced, knowledgeable, expert, ethical surgeon.
Effects of Cutting the Sacrospinous and Sacrotuberous Ligaments 2018. Link below
https://onlinelibrary.wiley.com/doi/10.1002/ca.23291

Conclusion: "The experiments presented here provide strong evidence for the stabilizing role of the SS and ST. A fortiori, the instability resulting from partial or complete SS and ST injury merits consideration in treatment strategies involving these ligaments as

important stabilizers."

Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia 2017
Publication does not list “No Conflict of Interests” nor does it follow the healing and stability of the pelvic after cutting the sacrotuberous ligament. Link below.
https://pubmed.ncbi.nlm.nih.gov/28072805/

Anecdote: I have spoken to a woman who had the TG approach and her STB never healed properly.

The highly experienced surgeon who now charges cash only cut the STL in a “Z” formation. Since the ligament failed to heal she was no longer able to walk with no pelvic stability. It is commend knowledge that ligaments and tendons do not heal as well as muscles because they don't have good blood supply.

Note: The patient paid cash, there was no hospital or insurance company to conduct oversight or for her to reach out to for help. She had to seek out help to walk on her own

She found an orthopedic doctor in another state to had corrected this problem before. The surgeon implanted two sacroiliac screws (SISs) to stabilize her pelvis (x-ray above) which after time for healing enabled her to walk again with a walker. The surgeon said the screws can be removed after two years and she should be able to walk normally..

There are studies published about this issue. I read one where two patients had the “repair.” However, the author uses the verb “divide” the STL. I don’t know if that means cut.

I need to do more research. Please do the same. I would contact at least one surgeon in Europe via Zoom since they have done one of the four approaches hundreds of not thousands of times.

PNA is not against the Transgluteal Approach (TG) and it is the most commonly done approach in the U.S. We haven't read posts or publications from the doctors who use it speak to the risks regarding the STL. Ask the surgeons to speak to patients who have undergone the surgery by them. Also consider the risks of using a surgeon who works on a cash only basis. There is no oversight and no regulation as to how much they can charge you. It's their whim and your money and body.

The fact that doctors in Europe and the U.S. cannot agree on the best approach, and at least half of the handful of component doctors in the U.S. accept cash only, informs us that we must be diligent protecting our bodies to the best of our ability.

4. LAPAROSCOPIC (robotic) LaPNDT

Dr. Tibet Erdogru – Turkey 2014

The approach cuts only the sacrospinous ligament SSL (smaller), not the sacrotuberous ligament STL (larger stabilizer).

It provides good visualization of the nerve’s course.

Erdogru described a new modification (the Istanbul technique) of laparoscopy using an omental flap (for protection) in 27 patients.

The outcome measurement was defined in terms of pain scores and quality of life. Approximately 80% of patients reported more than an 80% reduction in pain after six months.

Laparoscopic/robotic procedure is less invasive than other approaches.

Laparoscopy has the advantage of a better visual surgical field with built-in magnification.

Laparoscopic (LaPNDT) seems a feasible surgical modality for cautiously selected patients

with PNE. In addition, using an omental flap for protection of the nerve is one of the most important technical advantages of laparoscopy. The laparoscopic approach can be

technically feasible, with its promising preliminary results in the treatment of PNE. It is slightly less invasive than the others. It also allows for the option of leaving a neuromodulation

electrode in place as a backup, but it has a steep learning curve.

Placing a neuromodulation electrode at the time of decompression surgery seems reasonable in selected complicated or severe cases, as the electrode can always be removed later if it's not needed.I’ve read that there need to be more clinical studies.

REMINDERS:

PNA encourages that you have a consultation with at least two surgeons in person or via Zoom after doing in-depth research. This is especially true for decompression surgery as opposed to common surgeries because there are so few doctors worldwide who have extensive experience.

As non-doctors, we are unable to determine which approach is best. We only have one body. However, it will be difficult to determine as each surgeon believes the approach they use is the superior one so they can't agree. We must all continue to research and report through the Facebook Groups if an approach has succeeded or failed to stop our pain.

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Pudendal Neuralgia Alliance

contact@pudendalneuralgiaalliance.org

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