Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation

Abstract

To analyse the efficacy of sacrospinous ligament (SSL) suture removal on the reduction of pain symptoms in the case of suspected pudendal nerve entrapment after sacrospinous ligament fixation (SSLF). Design: Retrospective cohort study.Setting: Tertiary referral centre, the Netherlands.Population: A cohort of 21 women having their SSLF sutures removed because of SSLF-related pain symptoms.Methods: Clinical record review. Main outcome measures:The primary outcome was reduction of pain after SSL suture removal. Secondary outcome measures were time interval between suture placement and suture removal, complete suture removal, adverse events and recurrence of pelvic organ prolapse (POP).Results: A total of 21 women underwent SSL suture removal for severe and/or persistent pain, which was confirmed on clinical examination: 95% of the women (20/21) reported pain reduction after suture removal, and 57% reported complete pain relief.The time interval between suture placement and suture removal was at a median of 414 days (range 8-1855 days). Sutures could be completely removed in 86% of cases (18/21). One woman had excessive blood loss (520 ml) without blood transfusion. At 6-8 weeks after surgery, 10% of the women (2/21) had renewed symptomatic POP, stage ≥ 2, for which additional POP surgery was indicated.Conclusions: When performed by an experienced clinician, SSL suture removal is feasible and efficacious, with low morbidity. In addition, the risk of recurrent POP in the short term appeared to be low.

Case report: Transvaginal single-port extraperitoneal laparoscopic sacrospinous ligament fixation for apical prolapse: A single-center case series

“…SSLF, a traditional surgery for apical prolapse, has good subjective and objective cure rates (5); however, by many patients experience postoperative complications. Gluteal pain is the most common complication of SSLF (7)(8)(9)(10)(11)(12). In Mowat's study of POP patients who underwent SSLF with the Capio device, 86% reported buttock pain at 1 week, and the incidence had dropped to 16% by the sixth week (9).…”

“…In Mowat's study of POP patients who underwent SSLF with the Capio device, 86% reported buttock pain at 1 week, and the incidence had dropped to 16% by the sixth week (9). Nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthesia, or surgical management are used to treat gluteal pain in some patients after SSLF (11)(12)(13)(14). In Katrikh's study, the S4 nerve root was found in the medial third of the SSL in 96% (43/45) of cadaveric specimens.…”

“…Gluteal pain is a common complication of SSLF surgery, with a reported postoperative incidence ranging from 6.1% to 84%. It is usually caused by a neurologic injury sustained when the SSL is sutured (7)(8)(9)(10)(11), and some patients require medication or local anesthesia to treat the pain (11)(12)(13)(14). According to a previous study, blood transfusion was required during this operation in 4.3% of patients due to intraoperative vascular injury (15).…”

More answers are needed before proposing surgical management of pudendal nerve entrapment after sacrospinous ligament fixation

“…Dear Dr. Papageorghiou, We read with interest 'Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation' by Vodegel et al in your journal. 1 We commend the authors on reviewing this poorly understood but debilitating complication. However, we would appreciate further clarification.…”

Authors’ reply: Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation

“…Dear Dr. Papageorghiou, We would like to thank Dr Okeahialam and colleagues for their kind words and valuable comments on our article 'Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation'. 1,2 Dr Okeahialam and colleagues wonder how the 'complete removal' of absorbable sutures is possible. For clarification, in the Netherlands it is common practice to use Prolene® sutures, which are non-absorbable.…”