Humans at the dawn of the in-body electrical nerve stimulation era.

Background: The neuroprosthesis laparoscopic implantation technique for electric pelvic nerve stimulation was introduced to gynaecology over 15 years ago to treat intractable pelvic neuropathic pain. Following this first indication, other applications were developed, particularly in parapleology. The LION procedure developed to assist patients with paraplegia and common problems associated with inertia when confined to a wheelchair could find revolutionary applications in aging medicine and prevention. Materials and Methods: Spinal cord injured patients who have undergone the Possover's LION procedure. Main outcome measure: PubMed was systematically searched to identify peer-reviewed articles published in English that reported on LION procedure. Results: Three independent studies published recently (100 patients worldwide) have shown revolutionary recovery of supra-spinal control in patients with chronic spinal cord injury following pelvic nerves stimulation, with 70% of them establishing a walker/crutches-assisted gait. The same studies have also shown significant whole-body muscle-mass building, peripheral vasodilatation, and an unexpected improvement in bone mineral density. Conclusion: These ground-breaking findings could find revolutionary applications in aging medicine and the prevention of osteoporosis, with a huge impact on global public health. Humanity is on the cusp of an exciting new era following the introduction of the in-body electrical nerve stimulation technique. What is new?: In-body electrical nerve stimulation for recovery and/or control of human peripheral somatic and autonomic nervous systems.

Pelvic congestion syndrome and May-Thurner syndrome as causes for chronic pelvic pain syndrome: neuropelveological diagnosis and corresponding therapeutic options.

OBJECTIVE: To report on diagnosis and management of pelvic congestion including the May-Thurner syndrome (MTS) as potential etiologies for intractable pelvic neuropathic pain. DESIGN: Retrospective study of women presented with intractable pelvic neuropathic pain, who had left sided venous uterine plexus above 6mm with reversed and slow flow on Doppler, with dilated arcuate veins passing through the uterine muscle. Those with suspicion of MTS underwent further radiological investigations and if applicable, endovascular interventions. SETTING: Tertiary referral unit specialized in advanced gynaecological surgery and neuropelveology. INTERVENTION: 61 consecutive patients were included. 14 with visceral pain presumed to be caused by Pelvic Congestion Syndrome were treated by ovarian vein embolization. An improvement of pain was observed in all patients - mean pain reduction of 3.93 points, from 7.21 (±1.42; 4-10) to 3.28 pts (±1.54; 1-6) over 6 months (p<0.01). 47 presented with pelvic somatic neuropathic pain; 19 underwent endovascular intervention (angioplasty, stenting) and finally all of them a laparoscopic exploration/decompression of the sacral plexus and the endopelvic portion of the pudendal nerves, with an overall VAS reduction from 8.56 (±1.1712;7-10) to 2.63 (±1.53; 0-6) at one-year-follow-up (p<0.01). CONCLUSION: Laparoscopic exploration/decompression of the nerves seems to be effective in a carefully selected group of patients. Endovascular interventions for pelvic somatic neuropathies may not be an effective treatment. We recommend that Doppler studies of the uterine vessels are performed as an extension to gynaecological examination in women with intractable pelvic pain.

Laparoscopic morphological aspects and tentative explanation of the aetiopathogenesis of isolated endometriosis of the sciatic nerve: a review based on 267 patients.

BACKGROUND: Endometriosis of the sciatic nerve (ESN) is considered a rare disease. How can endometriosis develop within the sciatic nerve; a structure which has nothing in common with the uterus either anatomically or functionally, and why it occurs in the absence of any retroperitoneal/parametric endometriosis, is unknown. A better understanding of the pathophysiology of this enigmatic disease may improve its diagnosis and therapy. MATERIALS AND METHODS: From a pool of 452 patients operated for ESN, only patients with "isolated" endometriosis of the sciatic nerve" confirmed at laparoscopy were included in this study. Patients with suspicion of ESN by extension from a parametric, ovarian or other intraperitoneal deeply infiltrating endometriosis were excluded from this study. MAIN OUTCOME MEASURE: All information acquired during the preoperative patient's medical history and clinical examination were collected and compared with the morphological aspects of the disease observed by the laparoscopic treatment. Patients were classified into three groups according to the time interval between the onset of sciatic pain and the time of surgery: less than 1 year (Group 1), between 1 and 3 years (Group 2), and more than 3 years (Group 3). RESULTS: Two hundred sixty-seven consecutive patients were included in this study. In Group 1 (n=67), 76% of the patients presented with cyclical sciatica, without sensory or motor disorders of the lower limbs. Laparoscopic exploration found in the great majority of these patients only the presence of an isolated endometrioma in the nerve itself, the size of which was proportional to the time elapsed since the onset of pain. In Group 2 (n=83), pain had become constant in 91% of the patients with neurological disorders of the lower limb (foot drop, Trendelenburg gait, atrophied muscles) in about 30% of patients. Laparoscopic examination revealed, in addition to intraneural cystic lesions, a retroperitoneal fibrosis in more than 80% of the patients. In the third group (N=117), more than 80% of the patients presented with neurological disorders of the lower limb, with, on laparoscopic examination, massive retroperitoneal fibrosis with endometriomas in the nerve and adjacent pelvic wall muscles in all patients and an infiltration of the obturator nerve in 41% of patients. CONCLUSIONS: The different morphologic aspects of ESN do not correspond to different forms of the disease, but obviously to one single disease at different stages of its evolution. ENS starts first with the development of an endometrioma within the sciatic nerve, then develops in a second step a perineural fibrosis that expands into the whole retroperitoneal space and finally involves surrounding anatomical structures. The ESN is a very particular pathology because it induces a completely new aspect on the pathogenesis of endometriosis: all hypothesis of implanted endometrial cells following retrograde menstruation, angiogenic spread, lymphogenic spread or the metaplasia theory cannot explain the pathogenesis of this disease. ESN obviously does not develop from "genital metastatic cells". A possible hypothesis for explanation the pathogenesis of ESN, could consist in the development of endometriosis of the nerve from progenitor stem cells present within the nerve, pluripotent cells which, for an as yet unknown reason (possibly in connection with iterative inflammations and micro-damages of the nerve itself), mutate and proliferate to form endometriosis.

Use of the LION procedure on the sensitive branches of the lumbar plexus for the treatment of intractable postherniorrhaphy neuropathic inguinodynia.

PURPOSE: To report on the use of the laparoscopic implantation of neuroprosthesis (LION) procedure on the sensitive branches of the lumbar plexus for the treatment of refractory postherniorrhaphy neuropathic inguinodynia. METHODS: Laparoscopic exposure and implantation of an electrode to the different nerves is undertaken by the transumbilical transperitoneal approach. The genitofemoral nerve is identified on the anterior surface of the psoas major muscle, the ilioinguinal, iliohypogastric, and of the lateral femoral cutaneous nerves on the anterior surface of the quadratus lumborum muscle behind the kidney and colon. A quadripolar electrode is placed laparoscopically in direct contact with the injured nerve(s). RESULTS: All patients included in this series had reported failure of all previous treatments. Twenty-three consecutive patients were included in this series. Success, defined as visual analog scale (VAS) reduction >50%, was obtained in 19 patients. To date (mean follow-up 28.61 months [± 16.2; min. 6 months to max. 68 months]), 11 patients report a reduction of the mean VAS of more than 80% and eight report a reduction of between 50 and 80%; the mean VAS score could be reduced, so far, from 8.1 (± 8.1; range 6-10) preoperatively to 3.1 (± 2.8; range 0-5) postoperatively (P < 0.001). CONCLUSIONS: The presented technique of laparoscopic implantation permits a selective implantation and neuromodulation of all sensitive branches of the lumbar plexus. These preliminary results suggest that the technique described is effective, safe, minimally invasive, and must be indicated in patients after failure of all other treatments.

Laparoscopic endopelvic sacral implantation of a Brindley controller for recovery of bladder function in a paralyzed patient.

BACKGROUND: A number of techniques are being investigated to accomplish bladder control recovery in paralyzed patients using the neurostimulation, but currently, all techniques are based on the dorsal implantation of the electrodes using a laminectomy. METHODS: On 27 April 2006 we performed a laparoscopic implantation of a Finetech-Brindley bladder controller on the endopelvic sacral roots in a Th8 completely paralyzed woman who had previously undergone the removal of a Brindley controller due to an arachnoiditis after extrathecal implantation with intradural sacral deafferentation. RESULTS: We required about 3.5 h for the entire surgical procedure; no complications occurred and the patients went home on 5th postoperative day. The patient is now able to void empty her bladder and her rectum using the controller without further need for self-catheterisation. CONCLUSIONS: The presented new technique of laparoscopic implantation of electrodes on the endopelvic portion of the sacral nerve roots is an option to be considered in all paralyzed patients with further wish for electrical induced miction/defecation after previous deafferentation.

Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall.

BACKGROUND: The aim of this study is to report on the feasibility of laparoscopic neurolysis of the plexus sacralis and the sciatic nerve in deep endometriotic infiltration of the lateral pelvic wall. METHODS: A transperitoneal approach to the pelvic nerves combined with the LANN technique for intraoperative assessment of the function of the exposed nerves permit exposure and sparing of all somatic nerves during resection of the endometriotic lesion. RESULTS: We report on our short experience with 21 patients who underwent this technique for the treatment of endometriotic infiltration of the sacral plexus at different levels. CONCLUSION: In young patients with chronic unilateral sciatica or unilateral pudendal neuralgia - Alcock's canal syndrome - where no neurological/orthopedic etiologies have been found, endometriotic infiltration of the lateral pelvic wall has to be implicated as a potential etiology and an indication for laparoscopy must be discussed. Laparoscopic neurolysis of the pelvic somatic nerves is a feasible procedure for trained laparoscopic surgeons who have a good knowledge of the retroperitoneal pelvic (neuro)anatomy.

"Occult" neuroendocrine component and rare metastatic pattern in cervical cancer: report of a case and brief review of the literature.

Distant metastases in small cell carcinomas of the uterine cervix are rare, and a disseminated manifestation of the disease is uncommon. This is a case report of a 40-year-old woman treated with platin-based radio-chemotherapy for a moderately differentiated squamous cell cervical cancer FIGO Stage IB 1 (with positive paraaortic lymph nodes). One year later she presented with remarkably unusual cutaneous metastases of the left thumb and scalp as the first signs of spread of disease, including kidney, lung and brain metastases. An advanced retrospective immunohistochemical staining of the cervical biopsy discovered a small neuroendocrine component of the carcinoma as the presumably causative factor for the rare metastastic pattern and poor prognosis.

[ENZIAN-score, a classification of deep infiltrating endometriosis]. / ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose.

The ENZIAN-Score is presented as a new instrument to classify the deep infiltrating endometriosis. Especially the retroperitoneal part of the severe endometriosis is focussed on. In analogy to an oncological staging four different stages are pronounced. The localisation and the expansion of the endometriosis nodule was indicated to different subgroups. The still used rAFS-score is of no clinical evidence, as we pointed out in a retrospective study of our patients with severe intestinal endometriosis.

Options for laparoscopic surgery in cervical carcinomas.

The laparoscopy in vaginal surgical technique in the therapy of cervical cancer causes some scepticism. However the results, particularly for lymphadenectomy, are very interesting. Moreover laparoscopic staging of cervical cancer can also be recommended when preoperative chemotherapy is planned. Using the laparoscopic staging method the treatment of the patient may be more individualized.

[Endometriosis and malignoma]. / Endometriose und Malignom.

Malignant tumors arising from endometriosis are rare. A frequency of about 1% has been reported with in 80% the ovary, and in 20% extragonadal sites being affected. The most common extragonadal manifestations are the rectosigmoid and the rectovaginal septum. For extragonadal malignant tumors arising from endometriosis, complete resection followed by post-operative radiotherapy, possibly plus adjuvant progestin therapy, is the treatment of choice. Endometriosis-associated ovarian carcinomas are likely to present with lower stage disease and predominantly lower grade tumors. While their treatment follows that of common ovarian cancer, a poorer response to chemotherapy must be considered. As unopposed estrogen replacement therapy has been identified as a risk factor for the development of endometriosis-associated cancer, it is not recommended for hormone replacement therapy in women with a history of endometriosis. Loss of heterozygosity and mutations of the PTEN tumor suppressor gene may be early events of tumorigenesis. Endometriosis and its malignant transformation, perhaps, may serve as a suitable model in this regard. According to recent studies, endometriosis is associated with an increased relative risk of non-Hodgkin lymphoma.

Slow-transit constipation after radical hysterectomy type III.

BACKGROUND: This study investigated ways to reduce the rate of slow-transit constipation after radical hysterectomy type III. METHODS: A prospective study was conducted involving 59 consecutive patients with cervical cancer stage IB1-IIIA at high risk for parametrial or lymph node involvement who were treated between May 1996 and March 1999 by laparoscopically assisted radical vaginal hysterectomy type III. RESULTS: During laparoscopic transection of the cardinal ligament, particular attention was focused on conservation of the pelvic splanchnic nerves. After vaginal removal of the uterus, a vaginal sacrocolporectopexy was performed transvaginally. Nerve preservation and pexy of the rectum allowed a significant reduction of postoperative constipation, as compared with classic radical hysterectomy without conservation of the splanchnic pelvic nerves and without sacrocolporectopexy. CONCLUSION: Refinements in the preparation of the parasympathetic nerves during radical pelvic surgery and refixation of the terminal rectum helps to prevent postoperative constipation.

Prospective randomized comparison of laparoscopic-assisted vaginal hysterectomy (LAVH) with abdominal hysterectomy (AH) for the treatment of the uterus weighing >200 g.

BACKGROUND: Laparoscopic-assisted vaginal hysterectomy (LAVH) can be used for the vaginal removal of large uteri (200 g), which are conventionally treated with an abdominal approach (AH). METHODS: Forty-eight women with a sonographically estimated uterine weight of >200 g were prospectively randomized to undergo either LAVH (n = 28) or AH (n = 20). RESULTS: The median uterus weight was 334 g for LAVH vs 428 g for AH (not significant). The median operative time (133 vs 132 min) and duration of recuperation (42 vs 42 days) were similar. LAVH was associated with significantly less intraoperative blood loss (median, 200 vs 600 ml; p < 0.05), a lower pain index at postoperative day 4 (median [who scale], 0 VS 5; P < 0.05), a lower decrease in hemoglobin (median,-0.6 VS -1.55 MG/DL; P < 0.05), and a lower decrease in hematocrit (median, -0.03% VS -0.07%; P < 0.05). There were no significant differences in the frequency of postoperative complications (14.3% for LAVH VS 30% for AH). Although all LAVH patients who answered the questionnaire said they would undergo the same procedure again, only 45% of the AH group were satisfied (P < 0.05). CONCLUSION: For the treatment of uteri >200 g, LAVH has several advantages over AH: lower postoperative morbidity, quicker short-term recuperation, and better patient acceptance.

Is the decision for colorectal resection justified by histopathologic findings: a prospective study of 100 patients with advanced ovarian cancer.

OBJECTIVE: We compare the indication for colorectal resection in patients with advanced ovarian cancer with histopathologic findings. We describe the effect on pelvic control and morbidity associated with surgery. METHODS: Between February 1995 and March 2001, 100 patients with FIGO stage IIIc ovarian cancer underwent pelvic en bloc resection with excision of the rectosigmoid colon as part of primary or secondary cytoreductive surgery. Decision for resection was made by the surgeon when tumor involvement of the cul-de-sac was suspected. Rectosigmoid infiltration was histopathologically defined as infiltration of the serosa or deeper. RESULTS: In 73 of 100 patients (73%) tumor involvement of the rectum was confirmed histopathologically: infiltration of the serosa in 28 (28%) patients, infiltration of the muscularis in 31 (31%) patients, and infiltration of the mucosa in 14 (14%) patients; in 27 (27%) patients no infiltration was found. Histopathologically confirmed pelvic R0 resection was achieved in 85 (85%) patients. In 11 (11%) patients the pelvic resection margins were tumor-involved and in four (4%) patients visible parametric tumor remained in situ. Pelvic recurrence occurred in 4 (4.7%) of 85 optimally debulked patients compared with 9 (60%) of 15 patients with suboptimal pelvic resection status (P < 0.05). End colostomy could be prevented in 94 (94%) of 100 patients. CONCLUSION: Pelvic en bloc surgery with rectosigmoid resection was justified by histopathologic outcome since deperitonealization with preservation of the rectosigmoid would have left tumor in situ in 73% of patients with suspected cul-de-sac involvement.

Laparoscopic-assisted formation of a colon neovagina.

We report the laparoscopic formation of a colon neovagina following radical hysterectomy with subtotal colpectomy and radiotherapy in a 43-year-old woman who wished to resume normal vaginal sexual intercourse. The rectum was transected by a laparoscopic stapling device, preserving the inferior mesenteric and the superior rectal artery. By suprapubic mini-laparotomy, the rectosigmoid colon was eventerated and transected 8 cm above the staple line. Following colorectal anastomosis, the isolated bowel segment was rotated 180 degrees and placed on the right side of the anastomosis. A 12-mm trocar was introduced, transvaginally, and the isolated bowel segment was sutured to the vaginal resection margin. There were no peri- or postoperative complications. Six months after surgery, a stenotic area at the entrance to the neovagina was incised. At 12 months after primary surgery, the neovagina allowed normal sexual activity. Laparoscopically assisted formation of a colon neovagina is a surgical alternative for vaginal reconstruction that can be performed successfully even in irradiated patients.

[New concepts for staging and therapy of cervix cancer by endoscopic surgery]. / Neue Konzepte für Staging und Therapie des Gebärmutterhalskrebses durch endoskopische Operationsverfahren.

Non-invasive staging of cervical cancer according to FIGO is out-dated. In contrast to clinical staging exact histopathologic evaluation of tumor extension and tumor biology can be achieved via laparoscopic evaluation. Invasive endoscopic staging is advantageous and should be integrated into the diagnostic armamentarium of gynecologic oncologists and radiotherapists. Through magnification and blood-less surgery minute anatomical structures can be identified laparoscopically. Thus, fibers of autonomic nerves can be visualized and parasympathetic fibres can be preserved. Conservation of these neural structures leads to significant reduction of postoperative morbidity of bladder and rectum. The concept of the sentinel lymph node is also valid for the uterine cervix. Selected biopsy of the sentinel node and identification of single tumor cells leads potentially to higher oncologic safety and may reduce morbidity associated with radical lymphadenectomy. In early stage cervical cancer fertility may be preserved by radical trachelectomy which is combined with laparoscopic parametric and pelvic lymphadenectomy. Following radical trachelectomy a pregnancy rate of 40% is achieved, the recurrence rate following conventional radical hysterectomy is identical.

Laparoscopically assisted radical vaginal versus radical abdominal hysterectomy type II in patients with cervical cancer.

BACKGROUND: In a retrospective study, we compared a laparoscopic radical vaginal approach with abdominal radical hysterectomy type II for treatment of patients with cervical cancer at International Federation of Gynecology and Obstetrics (FIGO) stages I to III. METHODS: Between January 1991 and March 1994, 70 patients with cervical cancer were treated by radical abdominal hysterectomy, and between August 1994 and May 1999, 70 patients with cervical cancer were treated by laparoscopically assisted radical vaginal hysterectomy. Data from both the abdominal group and the laparoscopic-vaginal group were obtained retrospectively. RESULTS: The mean duration of surgery was significantly longer for the laparoscopic-vaginal approach than for the abdominal approach (292.9 vs 209.9 min). Significantly more pelvic lymph nodes were removed by laparoscopy (27 vs 10.7). Blood loss and transfusion rates were significantly lower in the laparoscopic-vaginal group. Intraoperative complications were seen more often during laparoscopic-vaginal surgery (p < 0.05). Early postoperative complications occurred significantly more frequently after the abdominal approach. The mean duration of hospital stay was significantly shorter for patients treated by laparoscopic-vaginal surgery (11.4 vs 22.8 days). CONCLUSION: Compared with laparotomy, the laparoscopic-vaginal approach for treatment of cervical cancer is associated with lower rates of transfusion and early postoperative morbidity.

Laparoscopic lymph node staging of cervical cancer in the 19th week of pregnancy. A case report.

We present the case of a 39-year-old gravida I para 0 woman who underwent laparoscopic staging of lymph node involvement in cervical cancer in the 19th week of pregnancy. She had been diagnosed with adenosquamous carcinoma of the cervix, stage 1B1, grade 2, with tumor involvement of the lymphovascular space and tumor involved resection margins via a cone biopsy in the 16th week of pregnancy. In order to decide whether it would be safe to proceed with the pregnancy, she was submitted to the laparoscopic exposure and removal of 18 parametric and pelvic lymph nodes. One positive lymph node was detected at the right internal iliac artery; therefore, an open radical hysterectomy with paraaortic lymphadenectomy was performed. This case shows that lymph node staging for cervical cancer can be done laparoscopically in the 2nd trimester. Information yielded during the course of this procedure can be crucial in deciding whether it is possible to preserve the pregnancy.

Laparoscopic-assisted vaginal versus abdominal surgery in patients with endometrial cancer--a prospective randomized trial.

OBJECTIVE: We compared a laparoscopic-vaginal approach with the conventional abdominal approach for treatment of patients with endometrial cancer. METHOD: Between July 1995 and August 1999, 70 patients with endometrial cancer FIGO stage I-III were randomized to laparoscopic-assisted simple or radical vaginal hysterectomy or simple or radical abdominal hysterectomy with or without lymph node dissection. RESULTS: Thirty-seven patients were treated in the laparoscopic versus 33 patients in the laparotomy group. Lymph node dissection was performed in 25 patients by laparoscopy and in 24 patients by laparotomy. Blood loss and transfusion rates were significantly lower in the laparoscopic group. Yield of pelvic and para-aortic lymph nodes, duration of surgery, and incidence of postoperative complications were similar for both groups. Overall and recurrence-free survival did not differ significantly for both groups. CONCLUSION: The laparoscopic-vaginal approach for treatment of endometrial cancer is associated with lower perioperative morbidity compared with the conventional abdominal approach.

Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III.

OBJECTIVE: To decrease postoperative morbidity associated with radical hysterectomy Rutledge type III, we identified the parasympathetic innervation of the bladder in the cardinal ligament. METHODS: During laparoscopic dissection of the cardinal ligament, we used 7x magnification on 38 consecutive patients with cervical cancer stages IB1 to IIIA with high risk for parametrial involvement when we performed laparoscopy-assisted radical vaginal hysterectomy type III between August 1997 and January 1999. RESULTS: The middle rectal artery was identified as a landmark separating the vascular from the neural part of the cardinal ligament. The neural part was shown to contain the splanchnic pelvic nerves which anastomose with the pelvic plexus. Following preservation of these neural structures all patients were able to void their bladder spontaneously. Following nerve-sparing technique, patients regained bladder function significantly quicker compared with a control group (n = 28) in which the neural part of the cardinal ligament had not been preserved: suprapubic drainage 11.2 days versus 21.4 days (P = 0.0007). CONCLUSION: Using the middle rectal artery as a landmark the neural part of the cardinal ligament can be preserved, resulting in preservation of the motor function of the bladder.

Laparascopically assisted vaginal resection of rectovaginal endometriosis.

BACKGROUND: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. TECHNIQUE: The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. EXPERIENCE: Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. CONCLUSION: The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.