Pudendal nerve entrapment following posterior transvaginal mesh procedure. Cataveric demonstration of pudendal nerve dissection. Objectives. We will briefly review pudendal neuralgia. We then demonstrate a cataveric dissection of the pudendal nerve through a transgluteal approach. Finally, we will share our data from a cataveric dissection showing the distance from the posterior prolift to the pudendal nerve and its branches. Pudendal neuralgia can be a severe and disabling pain syndrome which affects both men and women in the distribution of the pudendal nerve. In women, severe neuropathic pain is described in the clitoris, vulva, perineum, and rectum that is exacerbated by sitting and relieved by standing. Pudendal neuralgia is described in the literature following pelvic floor surgery, especially with surgery involving the sacrospinous ligament. In our practice, we have seen patients with pudendal nerve entrapment due to transvaginal mesh kits. This cataveric dissection describes a technique to expose and release pudendal nerve entrapment. We also demonstrate a cataveric dissection study which shows the distance from posterior mesh arms to the pudendal nerve and inferior rectal branch of the pudendal nerve. The pudendal nerve is derived from S2 to S4 and travels through the lesser sciatic foramen between the sacrotuberous and sacrospinous ligaments. It then travels into Alcox canal which is formed by the obturator internus fascia. The nerve then branches into the inferior rectal nerves, dorsal clitoral nerves, and perineal nerves supplying sensation to the external genitalia. Pudendal nerve block has been used for pain relief during the second stage of labor. Dissection for pudendal nerve release is approached via transgluteal incision. The ischial tuberosity and sacrum are palpated and labeled for the purposes of this video. The sacrotuberous ligament joins these two landmarks and is easily palpable. An incision is made between the sacrum and ischial tuberosity above the ligament. The subcutaneous layer is dissected and the gluteus muscle is split between its fibers. For dissection purposes, sharp dissection is performed. The muscle is taken down to the level of the sacrotuberous ligament. A Z incision is made in the sacrotuberous ligament to facilitate reapproximation following surgery. The lesser sciatic foramen is entered. Care is taken to avoid injuring the pudendal nerve, which may be directly under the sacrotuberous ligament. The two ends of the ligament are retracted for exposure using Kelly clamps. Using a surgical microscope, the nerve is isolated away from the adjacent vessels and is labeled with a vessel loop. Once exposed, any evidence of nerve entrapment is taken down, which may include scar tissue or aberrant synthetic mesh. The dissection is carried superiorly to the piriformis muscle. The inferior dissection is taken down into Alcox canal and is facilitated by inserting a nasal spectrum for exposure. Any encountered branches of the nerve are marked with vessel loops. This intraoperative footage shows a patient who had a transvaginal mesh kit for prolapse. She developed pain immediately after surgery. After locating the pudendal nerve with a neural integrity monitor, it is labeled with a blue vessel loop and is easily seen. The synthetic mesh is seen directly injuring the pudendal nerve. After carefully distinguishing the nerve from the mesh, sharp dissection is completed to dissect the mesh off of the nerve. Following release, the nerve is enveloped with a neuro-wrap nerve protector, which promotes healing. The sacrotuberous ligament is re-approximated with cadaveric gracilis or Achilles tendon if needed. The subcutaneous fat layers and skin are then closed. In a cadaveric experiment, our group applied the posterior trocars for the ProLift mesh kit and dissected the pudendal nerve to measure its proximity to a properly placed trocar. According to the manufacturer's instructions, the posterior trocar was placed through the gluteus, 3 cm lateral to the anus and 3-4 cm medial to the ischial spine through the sacrospinous ligament and brought out of the posterior wall of the vagina. Once trocar was placed, the cadaver was placed in the prone position and transgluteal dissection was performed. Trocar placement was verified to be in the correct location through the sacrospinous ligament and shortest distance to the pudendal nerve and the inferior rectal branch of the pudendal nerve was measured by two separate observers. Our data is presented here. The mean distance from the posterior trocar with proper placement from the pudendal nerve was 18 mm on the left and 15.67 mm on the right. The mean distance from the inferior rectal branch was 8.3 mm on the left and 11 mm on the right. Despite correct placement of the posterior trocar in the ProLift system, the distance from the pudendal nerve and its branches can be less than 1 cm. Injury to the pudendal nerve or its branches should be suspected if patient suffers intractable neuropathic pain starting immediately after surgery. Removal of the mesh may be required if conservative measures fail. Pudendal neuralgia is reported after placement of transvaginal mesh kits. This debilitating condition can occur from incorrect placement of the posterior trocars at the level of the ischial spine. Even with proper placement, the distance to the inferior rectal branch of the pudendal nerve is approximately 1 cm. This may lead to inadvertent injury despite proper placement. Pudendal nerve release can be performed through a transgluteal approach.

pudendal nerve entrapment

posterior transvaginal mesh procedure

pudendal neuralgia

cataveric dissection technique

pudendal nerve injury