Dr. Tibet's & Dr. Hal Martins Laparoscopic PNE Surgery Info.

[shawnmellis]

Hi,I have not seen any posts, threads, comments, or any other more information on PudendalHope.org about this Dr. Tibet in Turkey who does Laproscopic on PudendalHope.org? Sorry, if I missed it somewhere.I think this Laparoscopic surgery sounds promising. I believe that Dr. Hal Martin in Oklahoma is also doing it Laparoscopic if I'm correct, and that this seems like a promising new, less invasive way of doing surgery, with hopefully less scar tissue resulting. The less scar tissue from surgery, the less chance of re-entrapment.
Here is the link and info about this which Violet posted:
New Publication by Dr. Tibet Erdogru - Turkey Laparoscopic Pudendal Nerve Decompression
"Pudendal nerve decompression, implied by a limited access to the pelvic nerves and plexuses, can now be overcome with the availability of laparoscopy: the development of video endoscopy and mircrosurgical instruments enables a unique access to all pelvic nerves and plexuses, providing the necessary visibility with high definition and magnification (15X) of the structures and the possibility to work with appropriate instruments...." Read the full article at http://www.pudendalhope.com/sites/defau ... rdogru.pdf

What is everybody's thoughts about Laparoscopic surgery in general for PNE, Dr. Tibet, and Dr. Hal Martin? I love innovation, and new advances in surgical approaches for PNE that may be able to give better results for everyone with PNE. If the Laparascopic approach is less invasive, can reach all or more areas of the Pudendal Nerve, and can do the same things as non-Laparoscopic PNE surgery or possibly more, then I would hope there will be more surgeons starting to do this Laparoscopically. It would make sense that if they do it Laparoscopically they could be less invasive and see where the source of entrapment is during surgery. I know that Possover and Beco have done Laparoscopic PNE decompression surgeries in the past, but I think that each doctor who has done Laparoscopic PNE decompression surgery, Possover, Beco, Hal Martin, and Dr. Tibet in Turkey may have their own unique approach in doing it. Does anybody know what the differences are in all of their Laparoscopic PNE decompression surgeries? Appreciate all feedback and help on this thread, as the Laparoscopic approach may possibly some day be a huge improvement in PNE surgery results. Dr. Tibet, is claiming so far pretty good success rates so far. I think Dr. Hal Martin is waiting to see the full outcomes of his surgeries and is also working on ways to improve and perfect the approach for Laparoscopic PNE decompression surgery, which I am thankful for.

I also found a publication from 2008 regarding Laparascopic PNE surgery at http://www.ncbi.nlm.nih.gov/pubmed/1803 ... d_RVDocSum The publication is listed below:
Intra-abdominal laparoscopic pudendal canal decompression - a feasibility study.
Loukas M, Louis RG Jr, Tubbs RS, Wartmann C, Colborn GL.
Source

Department of Anatomical Sciences, School of Medicine, St. George's University, Grenada, West Indies. edsg2000@yahoo.com
Abstract
BACKGROUND:

Pudendal canal syndrome (PCS) is induced by the compression or the stretching of the pudendal nerve within Alcock's canal.
METHODS:

Considering the difficulty and possible complications involved in exposing the pudendal canal and nerve by either transperineal, transgluteal or transischiorectal approaches, an intra-abdominal laparoscopic pudendal canal decompression (ILPCD) was employed. For this technique, 30 male adult human cadavers were examined.
RESULTS:

Measurements revealed an adequate working space in 16 (80%) of the 20 cadavers, while in four specimens the ischiococcygeus muscle was too large to be mobilized sufficiently. The mean working space was 24 mm with a range of 18 to 31 mm. It was considered that a working space of less than 20 mm would not be sufficient for manipulation of the instruments. With regards to pudendal nerve compression, it was observed that 7 (35%) of the 20 cadavers exhibited anatomic signs of PCS. In five (25%) specimens, the compression was observed between the sacrospinous and sacrotuberous ligaments, while the other two (10%) exhibited a broader compression, by the falciform portion of the sacrotuberous ligament. Under the guidance of a laparoscope, the peritoneum was cut laterally to the bladder, and fascia pelvis was identified. The latter was split and the internal iliac vein was traced to the opening of the pudendal canal allowing clear visualization of its contents. Subsequently, either the sacrospinous or sacrotuberous ligament was cut.
CONCLUSIONS:

Considering that none of the surgical procedures currently used are known to completely improve all the symptoms of PCS, ILPCD could theoretically reduce stretching of the pudendal nerve.

Here is some more information regarding Dr. Tibets Surgery and Questions asked.

For further information , feel free to contact DR. TIBET at dr@tibeterdogru.com

His website also explains his laparoscopic surgery method : http://www.pudendal.eu


Adresss: Prof. Tibet Erdogru, M.D.

Head

Memorial Istanbul Atasehir Hospital

Department of Urology Minimally Invasive & Robotic Surgery Center


Vedat Gunyol Cad. No:30,

Atasehir - Istanbul / TURKEY Phone:+ 90 570 66 66 (74 76) E-mail:dr@tibeterdogru.com


Pudendal Nerve Decompression Surgery

Pudendal nerve decompression surgery is an option that is usually considered after more conservative therapies such as lifestyle changes, pelvic floor physical therapy, and nerve blocks have not proved to be successful. In the published literature PNE surgery can achieve a success rate of anywhere from 60% to 85% but success does not necessarily mean a cure. Surgery is generally considered successful if there is at least a 50% reduction in pain and symptoms. Occasionally pain and symptoms are permanently worse after surgery therefore the decision should be made carefully.

The Pudendal Nerve is located between two ligaments in the pelvic floor. The top ligament is called the sacrotuberous ligament (ST) and the bottom ligament is called thesacrospinous ligament (SS). The cause of Pudendal Nerve Entrapment is sometimes unknown and other times some patients can pinpoint the exact activity that occurred when the pain struck for the first time. It can be caused by prolonged sitting, a trauma, heavy lifting or surgery. One hypothesis is that the patient is predisposed to PNE and something happens to trigger it.

The entrapment of the nerve can be caused by tight muscles, ligaments or an unaligned pelvis causing undue pressure on the nerve. These conditions cause the nerve to rub on one of the ligaments that encase it. This irritation is what causes the pain and what needs to be repaired.

There are four approaches to pudendal nerve decompression surgery but only three of them have been described in the peer-reviewed literature. The four approaches are

* the transgluteal approach
* the trans-ischiorectal fossa approach
* the perineal approach
* the laparoscopic approach.

There are several different approaches to the release, but the method performed at our department by Prof. Dr. Tibet Erdogru (Urology) is the laparoscopic or robotic approach. It is probably the most helpful method to reach the ligaments because it allows the beter and magnified (10-12x) high definition visualization of the nerve during surgery.

Laparoscopy is a technique that is performed by a camera placed from 4 or 5 tiny holes (0.5-1 cm) and long-thin surgery equipments instead of large surgery cuts (about 20 cm) in surgical treatment of intraabdominal or intra pelvic organs (Figure 1) Also, a high definition digital telescopic camera system with 1.5 cm placed in one of tubes that provides to view organs to be operated such as kidney, prostate, pelvic structures (such as pudendal nerves) is used. The image in the body is reflected to a screen by this telescope-camera system and the operation is performed with this 10-20 times enlarged view of normal. Because of these tiny holes used in laparoscopic surgery provides less discomfort and more aesthetic appearance after the laparoscopic surgery according to large surgery cuts in open surgery. Operation pain and use of pain killers, hospitalization and recovery period decreases ver much after the surgery with laparoscopy. Laparoscopic surgery is performed under general anhestesia like open surgery. Although laparoscopic surgery is a technique that provides great convenience according to open surgery in terms of patients, application requires large experience.

Prof. Dr. Tibet Erdogru has a great experience about laparoscopic surgery with surgeries over 1000 and laparoscopic radical pelvic surgery over 400 consisting of laparoscopic pudendal nerve decompression and transposion. In my laparoscopy practice, I always perform obturator and internal iliak lymph disseciton to easily reach pelvic floor between internal iliac vessels and obturator nerve.

After opening the arcus tendineous fascia, pudendal nerve with its vessels (pudendal artery and vein) are identified and dissected. I always open the sacrospinous ligaments with sharply insicion and pudendal nerve is completely freed. During laparoscopic surgery the sacrospinous ligament is severed allowing visual access of the nerve at the ischial spine and Alcock’s canal. The nerve is freed from scarring, fibrotic tissue, and swollen varicose veins. A solution of heparin may be infused into the area to prevent scar tissue from forming. Manipulation is minimal and usually patients can go home within 24 hours. What kind of benefits will be gained by laparoscopic surgery? Many determined benefits are provided in researches in terms of patients when compared with open surgery.


* Less post operational pain

* Less bleeding

* Less hospitalization period

* Acceptable aesthetic apperance/small scar

* Rapid return to daily activity


Laparoscopic surgery indications (applicable status) Laparoscopy is a technique that is applied in many surgical interventions. Actually, surgical removal of urological organs (kidney, surrenal gland, urehtra, prostate, lymph gland of main artery) which are out of abdominal membrane is accepted increasing gradually, they are performed laparoscipally with less damage and pain advantages. Laparoscopic surgery which is accepted as minimal invasive surgery (less injurious) has become frequently applicable in developed centres all over the world. The clinical conditions treated by pudendal nerve release,

* Pudendal Nerve Entrapment
* Chronic Prosatitis (CP) (Type IIIB)
* Non-bacterial Prostatitis
* Interstitial Cystitis (IC)
* Chronic Pelvic Pain Syndrome (CPPS)
* Pudendal Neuralgia / Pudendal Nerve Entrapment (PNE)
* Urethral Syndrome
* Pelvic Floor Muscular Dysfunction
* Levator Ani Syndrome



Laparoscopic and Robotic surgeries, also called minimally invasive surgery (MIS), keyhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5-1.0 cm) as compared to the larger incisions needed in laparotomy.

Laparoscopic and Robotic surgeries includes operations within the abdominal or pelvic cavities in Urology.

There are a number of advantages to the patient with laparoscopic and robotic surgeries versus an open procedure. These include reduced pain due to smaller incisions and hemorrhaging, and shorter recovery time.

Minimal invasive surgical procedures specially developed for Urologic Surgery employ video cameras and lens systems to provide the surgeon with anatomic visualization within the pelvis and the entire abdominal cavity during the procedure. The abdomen is usually insufflated, or essentially blown up like a balloon, with carbon dioxide gas. This elevates the abdominal wall above the internal organs like a dome to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures. One 1 cm incision in the navel is used for introduction of the laparoscope which allows optimal vision with magnification (up to x 15); Two to three further 5mm incisions in the lower abdomen permit insertion of narrow tubes for introduction small instruments to perform the surgery. The surgeon is able to view the surgical field on a video monitor which receives its pictures from a video camera attached to the laparoscope.

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure.

These include:

* Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.
* Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.
* Less pain, leading to less pain medication needed.
* Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
* Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
* Recovery time for this kind of surgery is usually based on how you feel, but the patient should consult their doctor after 2 weeks, so they can verify when they can get back to their active lifestyle.

We routinely perform the following procedures by laparoscopy:

Laparoscopic management of painful pathologies of the pelvic nerves

* Laparoscopic decompression/neurolysis of the sciatic nerves/ sacral nerve roots (endometriosis, post-surgery and trauma, Multiple sclerosis, others neuropathies..)
* Laparoscopic decompression/neurolysis of the pudendal nerve / Alock´s canal syndrom
* LION procedure to control refractary pudendal neuralgia
* LION procedure to control sacral roots neuralgia

LION procedures to control and recover pelvic functions


* LION procedure to recovery bladder/rectum function, erection and ejaculation in paralyzed patients
* LION procedure to control bladder/rectum neural incontinence
* LION procedure to control bladder hyperactivity in paralyzed (incomplete and complete)/ spina bifida / MS patients


Robotic management of painful pathologies of the pelvic nerves

* Laparoscopic decompression/neurolysis of the sciatic nerves/ sacral nerve roots (endometriosis, post-surgery and trauma, Multiple sclerosis, others neuropathies..)
* Laparoscopic decompression/neurolysis of the pudendal nerve / Alock´s canal syndrom

Laparoscopic & Robotic Managements of Pathologies of the Pelvic Nerves and Plexuses


Prof. Dr. Tibet Erdogru

Director of the Department of Urology,

Advanced Laparoscopic & Robotic Surgery Center in Urology,

Memorial Istanbul Atasehir Hospital, Istanbul, TR


Introduction

The pelvis not only contains different organs such as the rectum and urogenital organs, but also pelvic nerves, involved in sexuality and the control (voiding and storage) of the pelvic organs as well as locomotion. They are also involved in the transport of all sensitive information generated in the lower limbs and pelvis to the central nervous system. Damages to the pelvic nerves therefore lead to pelvic visceral dysfunctions, problems with locomotion and different kinds of pain.


Unfortunately, no specialist area deals exclusively with the pathologies of the pelvic nerves and plexuses related with Urology. That's why it became more than necessary to develop a specialist area that focuses on the pathologies of the pelvic nerves: the NeuroUroPelviology. This new branch of medicine, developed by Erdogru, in Turkey, focuses on the prevention and treatment of disorders of the pelvic nerves and involves different aspects for urologica problems.

* Sparing the pelvic visceral nerves during extended pelvic surgeries (prostate cancer -radical prostatectomy-, bladder cancer - radical cystoprostatectomy-, vault uterine prolapsus) to preserve the integrity of sexual, bladder and intestinal functions.
* Laparoscopic neurourologic surgery for the treatment of injuries to the pelvic nerves and plexuses (responsible for neuropathic pain and pelvic dysfunctions), secondary to pelvic pathologies (trauma, vascular or scar tissue entrapment…) or to pelvic surgeries (nerves injuries).

Laparoscopy Enables Surgery To The Pelvic Nerves. All the shortcomings mentioned above, implied by a limited access to the pelvic nerves and plexuses, can now be overcome with the availability of laparoscopy: the development of video endoscopy and microsurgical instruments enables a unique access to all pelvic nerves and plexuses, providing the necessary visibility with magnification (15x) of the structures and the possibility to work with appropriate instruments.


* Nerve fibers are present everywhere in the body; Some of them are transmitting information from the periphery to the central nervous system (afferent nerves), others transmit information from the brain to the periphery (efferent nerves). The "somatic nerves" are large nerves which contain both afferents and efferent fibers designated to the red muscles (lower limb, sphincters...). They are running freely into the pelvis, directly along the pelvic sidewall. These "somatic nerves" are the femoral nerve (quadriceps muscle / pain in the anterior area of the tight), the obturator nerve (adduction / pain in the interior face of the tight), the sciatic nerve (pain in the dorsal face of the entire lower limb; "sciatica"), as well as the gluteal nerves (buttock, standing up) and the pudendal nerves (continence, genitoanal pain).
* Damages to the pelvic nerves caused by compression, irritation or entrapment lead to neuropathic pain in the first place, but can also lead to other dysfunctions, such as difficulties to void the bladder, urinary or faecal incontinence, troubles of erection, or locomotion. When damages to the nerves also include any destructions of fibers of the nerve itself (=axonal lesions), pain and dysfunctions are worsened and usually accompanied by reduced skin sensibility (partial or complete loss of sensation) in the corresponding dermatome (=the skin area innervated by the affected nerve).
* While the identification and diagnosis of the affected nerve(s) is usually not a serious problem, the evaluation of the actual location of the lesion (periphery vs pelvis vs spinal cord vs head) is much more difficult: the lesion that induces the pain and dysfunction is usually not located where the patient actually feel the pain, but higher above. The best example for this phenomenon is the so-called "phantom pain" , secondary to leg amputation. Because the nerves, which are normally designated to transmitting information from the foot to the nervous system, are still working and still transmit pain information, the patient actually feel pain in the foot, although the leg has been amputated.
* The most frequent somatic pelvic pain is sciatica, with pain in the different sacral dermatomes, such as in the lower back, pelvis, pudendal area, buttock, including irradiations in the dorsal aspect of the thigh, the calf, and sometimes even in the foot (figure 2). The second most frequent somatic pelvic pain is the pudendal pain (by lesion of the sacral nerves roots, or by lesions of the pudendal nerve itself = Alcok's canal syndrom). This pain is typically located in the genito-anal regions and buttock, and increases when sitting or riding a bicycle.
* In practically all patients suffering from sciatica and/or pudendal neuralgia, or any other pelvic neuralgia, endopelvic pathologies have to bee evocated as a potential reason, as long as no other orthopedic or neurosurgical reasons can be found.
* Laparoscopy is the only method which enables us to confirm diagnosis and to treat the patient at the same time. The most frequent etiologies consist of lesions to the nerves, secondary to surgeries by cutting, suturing or coagulation of nerves, compression/irritation of nerves by scar tissue or enlarged vessels (=vascular entrapment), compression/infiltration of the nerves by pelvic organs (enlarged uterus) or pathologies (cancers, endometriosis…).
* When injuries to the nerves have occurred, laparoscopic exploration not only offers an anatomic and functional exploration of the nerves, but can also results in an effective neurosurgical treatment, using laparoscopic techniques of nerve decompression or reconstruction Laparoscopic management of neural pelvic pain in women secondary to pelvic surgery.
* In non-postsurgical damages, systematic laparoscopic exploration has shown that not only pelvic cancers can induce nerves damages, but also frequent pathologies, such as deeply infiltrating endometriosis, uterine myomas or ovarian processes, or even retroperitoneal vascular abnormalities (vascular entrapment) and retroperitoneal fibrosis. They also can induce pelvic neuropathies which can be treated by laparoscopic nerves decompression/neurolysis. Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall.
* Laparoscopy is therefore the essential and logical step in the management of pelvic nerve pathologies that must be indicated as soon as possible, before the nerve damage becomes irreversible and before the process of "pain chronification" begins.

Adress: Prof. Tibet Erdogru, M.D.

Head

Memorial Istanbul Atasehir Hospital

Department of Urology Minimally Invasive & Robotic Surgery Center


Vedat Gunyol Cad. No:30,

Atasehir - Istanbul / TURKEY Phone:+ 90 570 66 66 (74 76) E-mail:dr@tibeterdogru.com



Message I (20-Dec-2011 )

Dr. Tibet:

Chronic pelvic pain is a big problem for both men and women. besides the pain suffering, it becomes a huge problem with the social and psychological problems. this pain is usually attempted to be treated as chronic bladder or pordtst (#I think doctor means to say prostate#) infection. no improvement can be achieved ( #Here Dr.T is describing the common approaches done by other doctors #). however, the cause of some chronic pelvic pain cases is some effects such as the constriction and the compression of the nerves going towards the organs from the sacrum. The most critical of those is Pudendal Nerve Entrapment.

So far I treated the problems with 25 pudendal nerves with laparoscopy. The most important benefit of laparoscopic surgery is that all details in the pelvis can be viewed via entering the body from a tiny hole opened in abdomen. the nerves lying in deep areas can be reached. moreover, all nerves between sacrum and pelvis can be reached - not only one single nerve. laparoscopic surgery applies 15 times higher resolution display compared to open surgery. this is very important for the surgery of the nerves in this area. On the other hand, the complication risk is very low if you are experienced, there is no bleeding, recovery is fast and there are cosmetic benefits...

I have been applying this treatment for more than 1.5 years along with my advanced experience in prostate & bladder cancer surgeries. I will operate my 4 patients on 13-14 January 2012 and two well-known european professors will join this surgery to learn this surgery method. i will also have a meeting with them... my email address is available at http://www.pudendal.eu.


Message II (21-Dec-2011 )

Dr. Tibet:

I did my best to answer your questions (# here Dr. T refers to the file including the answers to the questions gathered from Facebook PNE support groups #) . It would be better for these patients to come here and visit me.

Firstly, i would evaluate them. Secondly, our gynecologist have to evaluate the women - I will evaluate the men (Gynecologist cannot evaluate sexual functions of men) (#I think Dr.T means evaluating the sexual functions for both men and women#). If I see it necessary, I would ask for consultation from Pain Department. I would require a pelvic MRI definitely.

I would apply the laparoscopic treatment at the maximum level and would hope that it helps them. they would need to stay at the hospital 2 days. and then they would need to rest for 4-5 days here. and then i would allow them to make their plane trip and go back home.

Thank you for your interest.

Dr. Tibet

First Email
Dr. Tibet's Response


1. Are you able to decompress the Dorsal Branch of the Pudendal Nerve, Distal Alcocks Canal, and Deep and Superficial Perineal Branch (Bulbosponsious Muscle) of the Pudendal Nerve or plan to in the future?

I can reach only İnferior rectal nerve and deep perineal branch yet. Reaching to distal end of canal and dorsal nerve is impossible for this approach now. patient by patient I will expanding my dissection.

However, my patients were very happy becasue they had no more pain with this releasing because about %90 entrapment are located at the level of SSL and enterance of Alcock canal.



2. Can you talk to Dr. Hal Martin in Oklahoma in the U.S. who is the only other surgeon doing Laparoscopic PNE decpression surgeries some time? If so, I would be happy to give him your phone number. We need more surgeons in the world who can do Laparoscopic PNE surgeries.

Of course I can talk with him. He can send me e-mails. I prefer to contact with mails than phone.



2nd Email to Dr. Tibet:

Dr. Tibet's Response:
I have performed 25 cases with PNE (5 of them PN decompression

combiend with sacral neurolysis depend on the preoperative findings)

I am organizing a workshop on 14th of January 2011 for national

gynecolgists and urologists including live transmission of my

laparoscopic technique from OR to the audience. Very importanat

urologists from Italy and Greece will come and observe my technique.

Becasue they would like to pefrom this technique in their countries.

With the experience, now I can open whole Alcock canal and SSL and

decompress the pudendal nerve inferior rectal nerve. At the same time

I check the internal obturator nerve, sciatic nerve and sacral roots

(S2-3-4) depend on the preoperative findings.

I basically use Nantes Criteria for diagnosis. Additionally, I am

working with together Dr. Gul Talu (Prof. in Pain& Anesthesiology) and

Dr. Dilek Uslu (Gynecoloists and special interest in Female Sexual

Function, Vulvadynia)..My advantage is I can manage both female and

male patients and handle male sexual dysfunction. This TEAM bring huge

advantages to our patients with different approach and perspective

from urology, gynecology and pain experience.

Laparoscopic approach with my experience in pelvic cancer surgery

(nerve sparing for erectile function prostate cancer and baldder

cancer and pelvic reconstructive surgeries more than 700 patients)

pelvic nerve anatomy and laparoscopic experience meet on pelvic

neuropelviology. With laparoscopy I can observe the pelvic pathology

and I can treat them at the same stage without postoperative pain and

discomfort and very good cosmesis. There was no complication in my 25

patients with laparoscopci pudendal decompression and the mean

hospital stay was about 1.5 days.



With my best wishes

Tibet

Other Recent Questions to Dr. Tibet from PNE patients
Q:

1)Can he visualize the Pudendal artery and address any pathology if there is one.

2)Can he trace the Rectal and Perineal branch in the Alcock's Cnal and how good is his visualization in the anterior and posterior Alcock's Canal..

3)How many men has he cured with ED,Urinary burning,Urinary frequency,Urgency.



A:

Yes, I can identified pudendal artery and vein together with pudendal nerve just beneath the sacrospinous ligament after passing under the ligament pudendal nerve artery and vein continue in the Alcock canal (the upper wall of the canal is aponeurosis of the internal obturator muscle). Therefore I cut this aponeurosis for opening the Alcock canal.

I can identified especially inferior rectal nerve during the incision on the Alcock canal as the first branch of the PN.

As I mentioned before with the laparoscopic advantages, as 15 x magnification, high definition vision at the deep pelvis, we can identified SSLve superior wall of Alcock canal and sacral roots. After incision of the superior wall of the canal, I can identified the other side of the canal with dissection or nerve.

5 males I have operated pain were completely disappeared after the surgery. Jowever, in one male Lower urinary tract symptoms continue because of chronification of the entrapment.

Total price of the surgery is 10.000 USD with the mean hospitalization 1.5 days in my previous 25 patients with no complication. I had temorarily urinary retention in young female due to sacral roots neurolysis.

I always perform bilateral PN decompression. Only very exceptional cases, with history and physical examination exactly show the one side, I perform unilateral. I did unilateral in 2 patients.



Q:

Can he reach the dorsal netve?



A:

No I can not reach the dorsal nerve with laparoscopically. Because it is very peripheral and for reaching to this

nerve I can not cut functional muscles as levator ani muscle.



Q:

I'm interested to know if the Pudendal Nerve can be PERMENETLY damaged as the RESULT of a Pudendal

Nerve Block. As you know, I NEVER had any problem with my Pudendal Nerve until AFTER I had a Pudendal Nerve Block that my urologist THOUGHT would help my Interstitial Cystitis. I had a series of 3 blocks within a one month period, and since the last block on 9/13/10, I have NO FEELING at all from the clitoris to the rectum, I have developed a Neurorgenic Bladder, and I now have SOMETHING wrong with my rectum...trouble pushing stool out (OH, SO SORRY SO GRAPHIC!) NO DOCTORS in my city have a CLUE about this. I also developed EXCRUCIATING pain in BOTH buttocks (he went in through the buttocks to do the Pudenadl block) that radiates down the BACKof my legs. Sitting is a luxuary that I don't have anymore.



A:

The entrapment or whatever should be treated ASAP before chronification.

In some patients pudendal block might cause severe pain. I need to know the side of the injections. Secondly, after evaluation, I need to go laparoscopic observation and treat the identified problem's as one stage (this is another advantage of the laparoscopic approach). Not only at the PN side, but also at the sacral roots and other nerves.

At this point, I strongly recommend to her laparoscopic assessment and treatment. I believe that it will help it for her situations.



Q:

I like the idea of him coming here to do us all at once and I like the idea of there possibly being someway to have

some of the costs defrayed; if those of us who are willing make it some sort of study and be tracked for results, etc.



A:

I believe that laparoscopic approach has huge advantages against the open surgeries.

In my personal experience in laparoscopy I can perform nerve sparing radical cystectomy and prostatectomy for

cancer diseases. As you know bladder and prostate is very deep in the pelvis. Nerves fort he erection are very close to the baldder and prostate. These nerves are not a single nerve, tehy are like a nerve bundle and network. Therefore deep pelvic area is very similar for me. When I saw an article 2005, I told by myself that I would perform the pudendal nerve surgery-decompression- with laparoscopically. Prospective placebo control study showed PN decompression is very attractive and effective alternative in the treatment of chronic pelvic pain. So, it is a very important treatment modality fort he patients with CPPS it is not study.



Q:

This may be a stupid question, but ask him if they are doing any research studies where they would pay travel costs.



A:

I believe that this treatment alternative is not a research. This is real treatment for PNE.



Q:

Can you ask him him thoughts on vestibulitis and PN? If PN causes it?



A:

The main reason of vestibulitis is unknown. PN might be the reason. After the PN decompression some of vestibulitis could be improved.

I would like to know the same as Ali but #3 concerning women. Did he help with urinary issue, vaginal pain... What is his success rate?



Q:

Did he help any women with urinary issues, vaginal pain, etc..? What is his success rate?



A:

While some female patients completely improve, the remaining (3 female about 3 months, 2 females about 1 month) had LUTS despite the sharp, dull pain totally gone. In one patient, there was no pain and symptoms for 6 months, however after 6 months she had vaginal discomfort without pain. The nerve should be decompressed ASAP before the chronification for preventing irreversible changes.



Q:

1) Is he able to help those with pudendal damage caused by surgery?



A:

Completely YES!!! I can treat not only the PN but also the other nerves such as sacral roots, sciatica...etc. in which

the previous surgery could be the main etiologic parameter. Such as sacrospinous fixation of the vagina.



Q:



Is he teaching American doctors how to do this? If not, why? I would think American doctors would want to

learn this procedure since it is possible less evassive than trans-glut. Does anyone know of anyone who has

had surgery by Dr Tibet? When did the patient have surgery? And how is that patient doing now? Patient female or male? I'm all eyes.



A:

If the US doctors would like to come here, I can show and teach my laparoscopic technique. I have to tell you the one Prof. from Italy (Prof. Vito Pansadoro) and Assoc. Prof. from Greece (Dr. Liatsikos) will come on 14th of January 2012 for joining my surgeries (I have fixed 4 patients) to show all details. They just call m efor joining the operation. That is it. US doctors can call me and they can come to here. If you want, you can find some patients from facebook, Ozlem Fanning from London, Gulsum Metin from a city of Turkey (she is engineer and can talk English).

I really do not know the US health insurance cover this very specific surgery. The cost of the surgery including hospital and doctors fee is 10.000 USD.

Lisa,l have read Dr. Tibet's paper in detaiLlt seems that he has some difficulty in reaching the Alcock's Canal.' would appreciate if Ahmet can emphasize on the Alock's Canal and the rectal and perineal branches.Can the endoscope decompress the nerve in the Alcock's and does he put the Endoscope in the Alock's Canal to liberate it froms car tissue. Thanks.



A:

Not endoscope decompress the nerve. Using the laparoscopic telescope and miniature surgical equipment, I am cutting the scar tissue or hypertrophis SSL and alock canal superior wall.. After the incision, I completely decompressed and freed the nerve. If it is required I transpose the nerve.



Q:

1. What approach does he use specifically (exact location) to do it Laparoscopically (TG, TIR, Anterior Pubic Ramus) etc?.

2. Is it different location for each person depending on where he feels they are entrapped?

3. How does he diagnose somebody's entrapment location prior to surgery? MRI, nerve block, EMG, physical exam

4. Can he decompress the dorsal branch and perineal branches and distal alcocks canal?

5. How is his Laparoscopic approach different from Beco's Laparoscopic approach?.

6. Can he break down his success rates of 80 percent improved in terms of how long it took to improve after surgery, how much they have improved

7. Can he come to the U.S. to help train Dr. Martin Hal, who is also doing surgery Laparoscopically for PNE surgery, and has done at least 10 or 15 so far, or can he come here to do all of us at one time?

Sorry for the long list of questions, but I just read his publication and now I understand more about him and this procedure and I am very interested in it now

II perform laparoscopic surgery.

II have huge experience from the laparoscopic pelvic oncologic surgeries. Especially 'laparoscopic radical cystectomy (removing of the bladder for cancer treatment) and radical prostatectomy. I perform these surgeries as nerve spaing for preservation of the erection.

After this experience, I perform PN decompression about 2 years in the deep pelvis. Depend on the physical findings and pain type I can evalaute during laparoscopy the sacral roots. I am cutting all potential obstructive structures such as SSL...

I can pudendal nerve at the level on SSL and proksimal part of the Alcock canal. Just after the surgery many patients feel pain free. I can come if he invite me. However I can come with my surgical

iasistence. However, I believe that Dr. Martin Hal can come to Istanbul. 14th of January I have fixed 4 cases for a meeting. I perform laparoscopic PN decompression with live transmission and very good 2 uro;ogists would like to come and observe and learn my technique. They are from Italy and Greece. So, Dr. Martin can join us if he wants.

[Violet M]

Shawn, there's a short thread about Dr. Erdogru's surgery in the Turkey section: http://www.pudendalhope.info/forum/viewforum.php?f=86.

Dr. Marc Possover has also published on the laparoscopic approach.

http://www.ncbi.nlm.nih.gov/pubmed/19233408

J Urol. 2009 Apr;181(4):1732-6. Epub 2009 Feb 23.
Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients.
Possover M.


Department and Gynecology and Neuropelviology, Hirslanden Clinic, Zürich, Switzerland.
Abstract
PURPOSE:

The feasibility of the laparoscopic transperitoneal approach to the pelvic somatic nerves was determined for the diagnosis and treatment of anogenital pain caused by pudendal and/or sacral nerve root lesions.
MATERIALS AND METHODS:

The records of 134 consecutive patients who underwent laparoscopy for refractory anogenital pain were retrospectively reviewed. All neurosurgical procedures, such as neurolysis/decompression of the pudendal nerve and the sacral nerve roots or neuroelectrode implantation to the sacral plexus for postoperative neuromodulation, were done via the laparoscopic transperitoneal approach to the pelvic nerves.
RESULTS:

A total of 18 patients had Alcock's canal syndrome and decompression was successful in 15. Due to failed decompression 3 patients underwent secondary sacral laparoscopic neuroprosthesis implantation with a decrease of at least 50% on the pain visual analog scale. Sacral plexus lesions or radiculopathies, most commonly postoperative lesions and retroperitoneal endometriosis, were found in 109 patients who underwent laparoscopic neurolysis of the sacral plexus. The final outcome depended on the etiology. Of patients with postoperative nerve damage 62% had a decrease in the mean +/- SD preoperative visual analog scale score of from 8.9 +/- 2.9 (range 7 to 10) to 2.4 +/- 2.3 points (range 0 to 4) at the time of article submission at a mean followup of 17 months (range 3 to 39). Because of failed decompression, 8 patients underwent secondary sacral laparoscopic neuroprosthesis implantation and a decrease in the pain visual analog scale score was achieved in 5. Of patients with an endometriosis lesion of the sacral plexus 78% had a decrease in the mean preoperative visual analog scale score of 8.7 +/- 1.9 (range 8 to 10) to 1.1 +/- 0.7 points (range 0 to 2) at the time of article submission at a mean followup of 21 months (range 2 to 42). All 6 patients with vascular entrapment of pelvic nerves achieved complete relief. The last 7 patients underwent primary sacral laparoscopic neuroprosthesis implantation with at least a 50% decrease in the pain visual analog scale score in 4.
CONCLUSIONS:

Our findings emphasize that in patients with seemingly inexplicable anogenital pain, especially after failed treatment for Alcock's canal syndrome, laparoscopic exploration of the pelvic nerves must be done for further diagnosis and therapy before prematurely labeling the patients as refractory to treatment.

PMID:
19233408
[PubMed - indexed for MEDLINE]

[Karyn]

Very interesting articles. This statement really stood out:

Our findings emphasize that in patients with seemingly inexplicable anogenital pain, especially after failed treatment for Alcock's canal syndrome, laparoscopic exploration of the pelvic nerves must be done for further diagnosis and therapy before prematurely labeling the patients as refractory to treatment.

[ezer]

Shawn,
As you know Dr.Filler has a laparoscopic approach to PNE. The biggest problem is that he can only decompress a section of the nerve where he feels your compression is the most likely located (based on his MRN and nerve blocks). He can only decompress in the vicinity of his entry point. If it is not the right location, you need to go for a second, third etc... surgery. I heard of somebody that had 5 surgeries to try to find the correct entrapment location.
The traditional TG and TIR surgeries are much more invasive but you at least get most of the potential entrapment locations addressed.
I had laparoscopic surgery with Dr.Filler and visibly the entrapment was not found. My first surgery addressed the segment from the spine to the piriformis. The ligaments and alcock's canal were not looked at however. When that surgery did not work I was offered another surgery to decompress the alcock's canal.

[Karyn]

Does anyone know what the difference between Laproscopic and Endoscopic is?

[Violet M]

According to WebMD:
http://www.webmd.com/digestive-disorder ... copy-16156

Laparoscopy

Laparoscopy is a surgery that uses a thin, lighted tube put through a cut (incision) in the belly to look at the abdominal organs or the female pelvic organs. Laparoscopy is used to find problems such as cysts, adhesions, fibroids camera, and infection. Tissue samples can be taken for biopsy through the tube (laparoscope).

According to Medlineplus:

http://www.nlm.nih.gov/medlineplus/endoscopy.html

Endoscopy

Endoscopy is a procedure that lets your doctor look inside your body. It uses an instrument called an endoscope, or scope for short. Scopes have a tiny camera attached to a long, thin tube. The doctor moves it through a body passageway or opening to see inside an organ. Sometimes scopes are used for surgery, such as for removing polyps from the colon.

There are many different kinds of endoscopy. Here are the names of some of them and where they look.

Arthroscopy: joints
Bronchoscopy: lungs
Colonoscopy and sigmoidoscopy: large intestine
Cystoscopy and ureteroscopy: urinary system
Laparoscopy: abdomen or pelvis
Upper gastrointestinal endoscopy: esophagus and stomach

[Anne]

Hi,
I had my decompression surgery with Prof. Possover by laparoscopic approach, and he is able to check the pudendal nerve from the sacral plexus to the ligaments and to the alcock's canal. He told me, that it is difficult to decompress the alcock's canal by the laparoscopic approach, but not impossible. Just wondering that Dr. Filler is not able to look at the pudendal nerve from the spine to the alcock's canal in one surgery. How about the other surgeons who are performing the laparoscopic approach?

[mikette]

Hi,
I had my decompression surgery with Prof. Possover by laparoscopic approach, and he is able to check the pudendal nerve from the sacral plexus to the ligaments and to the alcock's canal. He told me, that it is difficult to decompress the alcock's canal by the laparoscopic approach, but not impossible. Just wondering that Dr. Filler is not able to look at the pudendal nerve from the spine to the alcock's canal in one surgery. How about the other surgeons who are performing the laparoscopic approach?

Hi Anne, may I ask you if your surgery with Dr. Possover was successfull? I'm from Italy and I've been diagnosed with pudendal entrapment by a fellow of Possover but I'm not considering surgery yet.

[calluna]

My PN surgery was laparascopic - I don't have any opinion about Drs Martin or Erdogru, though, as I don't know really know anything about them.

In my own case I've had considerable improvement. My surgeon Mr Dixon told me that he was not able to actually get at the nerve as it was completely embedded in scar tissue; he took away as much of the scar tissue as he deemed safe. My pain level is definitely down - at the moment it is about the same level as it was before surgery, when I was on Lyrica/pregabalin - and I'm not taking any meds apart from to manage flares. I am still maintaining all the lifestyle changes, though.

One comment I would make is that the nasty abdominal pain I've had since the surgery seems to be because of the surgery - Mr Dixon told me today that in some patients it can be extremely painful post-op, near where the ports were - and in my case, with a pre-existing pain condition, things have been worse than usual. It does seem to be settling down gradually, though.

[ezer]

Hi,
I had my decompression surgery with Prof. Possover by laparoscopic approach, and he is able to check the pudendal nerve from the sacral plexus to the ligaments and to the alcock's canal. He told me, that it is difficult to decompress the alcock's canal by the laparoscopic approach, but not impossible. Just wondering that Dr. Filler is not able to look at the pudendal nerve from the spine to the alcock's canal in one surgery. How about the other surgeons who are performing the laparoscopic approach?

Anne,
If you read Dr.Filler's papers, he has 3 points of entry depending on where he is going to decompress. The higher point for the piriformis then the other points for the ligaments and the alcock's canal.
My surgery report makes no mention of a decompression in the alcock's canal and makes no mention of the ligaments. I subsequently asked him directly and indeed there was no decompression performed at the other entrapment locations.
If you look at his entry point for the piriformis for example, it clearly is the wrong angle to go access the alcock's canal and is therefore impossible.