Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported.

A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data was recorded prospectively for all patients. Surgery steps were in brief as follows: (1) Placement of four trocars; (2) Peritoneal incision and development of the space below the obturator vein; (3) Identification of the internal obturator muscle and arcus tendineus fascia; (4) Pudendal nerve and artery decompression between sacrospinous ligament and the piriformis muscle by cutting the sacrospinous ligament and transposing the vessels and the nerve, at the level of the sciatic spine. Main surgery steps are presented in Figure 1. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (Urinary Symptom Profile USP, International Index for Erectile Function IIEF-5, and Patient Assessment of Constipation Symptoms  PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval. All patients have signed a written informed consent form.

The mean operating time per side was 33.9±6.8 min and the average hospital stay was 1.9±0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Safety outcomes are reported in Table 1. Perineodynia VAS dropped from 6.8±0.9 to 2.2±1.8 after surgery (p<0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs. 19.3, p=0.036). Mean USP scores significantly improved for the dysuria domain (4.2vs1.6, p=0.021) but not for stress urinary incontinence (3.9vs4.1, p=0.082) or overactive bladder symptoms (14.1vs13.8, p=0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8vs1.1, p<0.001).

Laparoscopic transperitoneal pudendal canal decompression is a quick, safe, and well-tolerated procedure with no major postoperative complications. It is also effective on most of the symptoms of pudendal canal entrapment. Pain in the territory of the pudendal nerve was significantly improved in all patients at 3 months. The pain disappeared immediately after the intervention for several days then some patients experienced worsening pain for a period of up to 3 months. The immediate improvement after the procedure could be related to the anesthetic effect and worsening afterward could be a sign of neurologic reinnervations. Of note, patients who experienced worsening for this short period of time had better outcomes afterwards. Terminal constipation was the most frequent symptom and the symptom that improved the most after the intervention. For urinary symptoms, improvement was less evident and only young males suffering from LUTS improved. No improvement was demonstrated in women with stress urinary incontinence or overactive bladder. Men suffering from mild to moderate erectile dysfunction (with no venous leak) improved rapidly (within 1 month) after the intervention. This quick response is mainly due to pudendal artery release. Pulsation of the pudendal artery at the end of the intervention was noted in all patients after cutting the sacrospinous ligament.

A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock’s canal, is a fast and safe surgery with promising functional results on pudendal neuralgia, as well as on erectile function, lower urinary tract symptoms and constipation.