Pudendal nerve is originated from the sacral roots S2-S4, sometimes gaining contributions from the roots S1 and S5. It supplies the somatic anal, urehtral and penile or clitoris musculature. The bulk of afferent fibres are contribute to S2 (60%) and S3 (%35). Moreover, the pudendal nerve is a major contributor oto both bladder regulation and bladder function. Due to the large percentage of afferent fibers, the pudendal nerve is attractive for neuromodulation therapy.
Pudenal nerve modulation is growing in some cases of sacral nerve modulation failure or as a primary treatment option. Use of the pudendal nerve in modulating pelvic floor function has drawn great interest in those who regularly perform sacral neuromodulation for intractable overactive bladder, or primarily in non-obstructive urinary retention, pelvic-perineal pain due to pudendal neuralgia, painful bladder syndrome and fecal incontinence and also chronic genital arousal syndrome.
Based on huge experience on Pudendal Neuralgia and Pudendal Nerve laparoscopic surgeries since 2011, Prof. Dr. Tibet Erdogru presented the impressive functional results of laparoscopic selective pudendal nerve modulation (LASE/PN) in International Continence Society 2019 in Gothenburg.
A 34 yrs-old woman with tethered cord presented with urinary retention (as neurogenic bladder). She was on clean intermittent self catheterization (CIC) for the last 18 years. Her previous history revealed chronic urinary tract infections before the start of CIC. The patient received a SNM therapy in 2017 by implanting a permanent electrode (tined lead; Medtronic, Minneapolis, Minnesota, USA) through S3 by Prof. Dr. Rahmi Onur.
Since filling sensation improved and patient was able to empty more than 1-2 / 3rd of her bladder during test period, permanent pulse generator (IPG, InterStim I or II; Medtronic) was implanted. SNM therapy continued to be successful for 5 months but patient reported resuming of urinary retention symptoms and need for CIC again. Since percutaneous sacral implantation was impossible to repeat on contralateral site, after detailed evaluation and discussion by Prof. Dr. Tibet Erdogru and Prof. Dr. Rahmi Onur, the patient was hospitalized for an alternative technique of selective PN neuromodulation with all detailed medical information.
As the first time in the world, Prof. Dr. Tibet Erdogru, using 4 small trocars, after visual identification of pudendal nerve, artery and vein beneath sacrospinous ligmanet (SSL) with laparoscopy, selectively and directly placed the electrode over the PN, as between pudendal nerve and SSL and fixed the electrode for preventing dislocation. Proximal side of the electrode has been taken out from the body with left inguinal puncture for connecting the battery. Selective PN implantation of electrode yielded a high sensation by stimulation of only 0.3 V. The patient tolerated the procedure well, and after anesthesia recovery at post-operative 8th hours, patient voided 680 ml without abdominal straining.
Her frequency volume chart revealed minimum 300 ml and maximum 740 ml voided volumes with 30 and 110 ml residual volumes measured by CIC.Two and six months after the procedure, she reported very well desire to urinate and voiding without abdominal straining. Her mean voided volume was between 400 and 600 ml. with less than 200 ml residual urine, measured with before sleeping CIC. Impulse generator settings were the same with 0.3 V, not need adjustment. She has no incontinence and recurrent urinary tract infection on follow-up. She reported high quality sexual pleasure after pudendal neuromodulation. Left pudendal neuromodulation was an incredibly effective treatment for her.
As a result, pudendal neuromodulation is perhaps settling into the unique role as an alternative approach to those who have failed sacral neuromodulation, or for managing some forms of chronic pelvic pain pudendal neuralgia, painful bladder syndrome and overactive bladder, non-obstructive urinary retention due to incomplete spinal cord injury, and chronic genital arousal syndrome.
LAparoscopic SElective Pudendal Neuromodulation (LASE/PN) with “Istanbul Technique” in a patient has been firstly described by Prof. Dr. Tibet Erdogru, with its impressive functional results not only in bladder function but also in her sexual function, was shared with scientists in ICS 2019 annual meeting in Gotheburg.