Pudendal Research Articles

Current role of neuromodulation in bladder pain syndrome/interstitial cystitis.

Neuromodulation is recommended by major international guidelines as a fourth-line treatment in bladder pain syndrome/interstitial cystitis (BPS/IC) patients after failure of behavioural, oral and intravesical pharmacological treatments, including hydrodistension. A non-systematic review of studies identified by electronic search of MEDLINE was performed with no time limitation. A narrative synthesis of the existing evidence regarding the results of sacral, tibial and pudendal nerve stimulation in the management of BPS/IC was developed. Neuromodulation in pelvic chronic pain disorders, including BPS/IC, is a useful tool for refractory patients to conventional treatments. Sacral neuromodulation may be effective in patients with BPS without Hunner's lesions, and the effect seems to be maintained in the mid- and long-term. Posterior tibial nerve stimulation can be offered to patients with BPS/IC in the context of a multidisciplinary approach. When pudendal neuralgia is suspected, selective pudendal nerve stimulation has a high response rate. The aetiology of the pain can influence the outcomes in the mid- and long-term of the different neuromodulation approaches, thus careful diagnosis is recommended.

Decompression of Inferior Rectal Nerve in Refractory Perianal Pain Caused by Pudendal Nerve Entrapment: A Case Report

Decompression of Inferior Rectal Nerve in Refractory Perianal Pain Caused by Pudendal Nerve Entrapment: A Case Report

The “Possover-LION Procedure” to the Pelvic Somatic Nerves in People With a Spinal Cord Injury

To demonstrate the technique of laparoscopic implantation of neuroprosthesis to the pelvic somatic nerves for recovery of voluntary walking motion in some patients with chronic spinal cord injuries. Video. Tertiary referral unit specialized in advanced gynecologic surgery and neuropelveology. The technique of laparoscopic implantation of electrodes on the pelvic nerves-the LION (Laparoscopic Implantation of Neuroprothesis) procedure-was introduced by Possover in gynecology more than 15 years ago for the treatment of refractory pelvic neuropathic pain and bladder dysfunctions. From this first indication, further applications were developed, especially in the field of parapleology. The "Possover-LION" procedure consists of a laparoscopic implantation by transperitoneal approach of 4 stimulation lead electrodes to the sciatic, pudendal, and femoral nerves on both sides in those with a spinal cord injury. The femoral nerves are identified laterally to the psoas muscles, whereas exposure of the sciatic and pudendal nerves is obtained by blunt dissection of the lumbosacral space, laterally to the external iliac vessels. The lead electrodes are simply placed in direct contact to the nerves, while the retroperitoneal loop of cables prevents from dislocation. Finally, all cables are connected to a multichannel generator implanted in paraumbilical position, fixed to the abdominal fascia. The LION procedure allows the stimulation of the pelvic somatic nerves for recovery of a voluntary electrically assisted walking motion in approximately 70% of patients with chronic complete or incomplete spinal cord injury.

Clinical Observation of Bilateral Pudendal Nerve Block Anesthesia Combined with Unprotected Perineal Delivery

Clinical Observation of Bilateral Pudendal Nerve Block Anesthesia Combined with Unprotected Perineal Delivery

Overview of the anatomical basis of the piriformis syndrome-dissection with magnetic resonance correlation.

The piriformis syndrome is one of the most commonly misdiagnosed causes of lower back and gluteal pain caused by the compression of the sciatic nerve and the internal pudendal neurovascular bundle by the piriformis muscle. Although this syndrome was first suggested over 90 years ago, its diagnosis still represents a challenge for clinicians. In the present study, dissection was used to determine the intra- and extrapelvic anatomical course of the internal pudendal nerve and the data were compared with the information obtainable through MRI examination, in order to identify the piriformis syndrome and to differentiate it from other causes of internal pudendal neuralgia. Thorough dissections of the pelvis and deep gluteal region were conducted on female cadavers, which were correlated with MRI scans, in order to describe the course of the internal pudendal nerve in contact with the piriformis muscle. The dissection findings and MRI scans obtained allowed us to describe and demonstrate the compression points along the course of the sciatic nerve and the internal pudendal bundle, the anatomical correlations between the piriformis muscle and the nervous structures around it, emphasizing the areas most susceptible to possible nerve impingement syndromes. In the anatomic trajectory of the sciatic nerve and the internal pudendal bundle there are multiple contact points with anatomical structures that may lead to compression of the nerve structures, generating symptoms that comprise the piriformis syndrome. The present study sought to establish clear osseous landmarks that may help evaluate these associations and possible nerve compressions on pelvic MRI examination.

Tinel's four signs for functional diagnosis of pudendal nerve compressive syndromes

Background: Pudendal nerve entrapment is a prevalent condition, physically and emotionally limiting. Due to myofascial origins, there is an important role for pelvic physiotherapy, but kinesiological-functional tests are still needed. Aims: To propose palpatory tests for the location, differentiation and qualification of the severity of different pudendal nerve entrapments. Method: Integrative review on Pubmed, LILACS, PEDro and Scielo databases, seeking the anatomical and functional bases of pudendal compression syndromes. Results: More than a thousand papers returned from the searches, of which 106 survived the inclusion and exclusion criteria. Precise anatomical descriptions of the pudendal nerve pathways and the main sites of possible entrapment were found. From there, four specific irritative tests could be proposed. Conclusion: There are anatomical and functional bases for four pudendal irritative nerve compression tests at four levels to provide functional tools for the assessment and treatment of compressive neuralgias of this nerve. For historical and technical reasons these should be known as The Tinel signs for the Pudendal Nerve.

Development of an ultrasound-guided transgluteal injection of the pudendal nerve in cats: a cadaveric study

ObjectiveTo develop an ultrasound-guided interfascial plane technique for injection of the pudendal nerve near its sacral origin in cats. Study designProspective, randomized, anatomical study. AnimalsA group of 12 feline cadavers. MethodsGross and ultrasound anatomy of the ischiorectal fossa, the pudendal nerve relationship with parasacral structures, and the interfascial plane were described. Computed tomography was employed to describe a cranial transgluteal approach to the pudendal nerve. Bilateral ultrasound-guided injections were performed in eight cadavers using low [(LV) 0.1 mL kg–1] or high volume [(HV) 0.2 mL kg–1] of ropivacaine–dye solution. Dissections were performed to determine successful staining of the pudendal nerve (>1 cm) and inadvertent staining of the sciatic nerve, and any rectal, urethral, or intravascular puncture. Pudendal nerve staining in groups LV and HV were compared using Fisher's exact and Wilcoxon rank-sum test as appropriate (p = 0.05). ResultsThe pudendal nerve and its rectal perineal and sensory branches coursed through the ischiorectal fossa, dorsomedial to the ischiatic spine. The pudendal nerve was not identified ultrasonographically, but the target plane was identified between the sacral transverse process, the ischiatic spine, the pelvic fascia and the rectum, and it was filled with dye solution. Both branches of the pudendal nerve were completely stained 75% and 87.5% in groups LV and HV, respectively (p = 1.00). The dorsal aspect of the sciatic nerve was partially stained in 37% of injections in group HV. Rectal or urethral puncture and intravascular injection were not observed. Conclusions and clinical relevanceIn cats, ultrasound-guided cranial transgluteal injection successfully stained the pudendal nerve in at least 75% of attempts, regardless of injectate volume. Group HV had a greater probability of sciatic nerve staining.

Sixty-Day Pudendal Nerve Stimulation: A Potential Therapy for Refractory Pudendal Neuralgia Case Report

BACKGROUND: Pudendal neuralgia (PN) can cause severe, disabling chronic pain. Though common, PN is frequently unrecognized and misdiagnosed. Historically, the last-resort treatment for PN has been permanent implantation of spinal cord stimulation (SCS), but SCS for PN carries high risk of complications and explantation. We report the first case of temporary (60-day) peripheral nerve stimulation (PNS) treatment for refractory PN. CASE REPORT: A 63-year-old woman presented with one year of chronic bilateral suprapubic vaginal pain radiating to the bilateral proximal medial thighs with concomitant dysuria, urinary frequency, and pain with intercourse. PN was confirmed via diagnostic pudendal nerve block. Using fluoroscopic guidance, we implanted PNS leads on the left and, subsequently, the right pudendal nerves, with explantation at 60 days for each lead. The patient reported continuing pain reduction with 80% improvement in the Visual Analog Scale score at 6 months, resumption of normal activity and functionality, discontinued use of opioids, and high satisfaction with treatment. This case is notable for the sustained pain relief provided by this temporary and minimally invasive treatment. CONCLUSIONS: This case suggests that 60-day PNS with fluoroscopic guidance is a viable treatment for refractory PN in correctly selected patients. This treatment is low-risk, minimally invasive, and may be used early in the care continuum, potentially sparing patients multiple failed treatments and the risks associated with permanently implanted devices. KEY WORDS: Pudendal nerve, peripheral nerve stimulation, neuromodulation, chronic pain, pelvic pain, perineal pain, case report

Surgeon-administered ilio-inguinal and pudendal nerve blocks for major vulval surgery: An observational study with visual analogue pain scoring

Surgical excision of the groin and vulva is a painful procedure. Traditionally following general or regional anaesthesia, local anaesthetic was infiltrated around the wound. Thedistribution varied and the somatic pain control was not reliable. Inspired by the success of the application of peripheral nerve blocks for postoperative pain control with open abdominal procedures, we introduced blockade of the ilioinguinal nerve (IIN) and pudendal nerve (PN) into our vulval surgery to assess the requirement for parenteral and oral analgesia in the postoperative period.This is an observational study of all patients undergoing major vulval and/or related groin surgery. Sampling biopsies were excluded. Levobipuvicaine 0.25% (2.5 mg/ml) or 0.5% (5 mg/ml) was used for and dosage was calculated based on the patient’s weight with no more than 2 mg/kg. For example, using 0.25% of levobupivacaine (2.5 mg/ml) for a 70 kg patient, 56 ml is administered divided into 4, giving 14mls at each site (2 sites abdominally for IIN block and 2 sites for pudendal block).Eighteen women were included in the analysis. Median age was 67 (range 34–81) years and thirteen (72%) were >60 years. Visual analogue scores (VAS) ranged from 0 to 3 for seventeen patients from day 0 to day 1 and fifteen patients from day 2 to day 5. Two patients had pain scores >4 on one or more postoperative days: one had chronic arthralgia and one had received a lower volume of bupivacaine.This observational study demonstrates that ilioinguinal and pudendal nerve LA blocks may be a valuable addition to the multimodal postoperative analgesic pathway for women undergoing major surgical excision in the vulva and groin.

Pudendal nerve block prior to inflatable penile prosthesis implantation: decreased intra-operative narcotic requirements.

The opioid epidemic has proven to be a public health crisis over the past two decades and efforts to decrease opioid exposure are sorely needed. Our objective was to determine whether pudendal nerve block utilization in the immediate pre-operative setting decreases intra-operative opioid analgesic requirements in veteran patients undergoing a primary inflatable penile prosthesis implantation. We performed a retrospective cohort analysis of all patients undergoing penile prosthesis implantation between January 2017 and July 2020 at the Charlie Norwood Veterans Affairs Medical Center in Augusta, GA. Univariable and multivariable gamma regression analyses were performed to evaluate the association between pudendal nerve block utilization and intra-operative opioid analgesic requirements. The study cohort consisted of 110 patients, 35 (31.8%) of whom underwent a pudendal nerve block. Median intra-operative opioid analgesic requirements were significantly lower in the pudendal nerve block group (16.3 versus 25.8 morphine milliequivalents, p = 0.037). Receipt of the nerve block was associated with significantly lower intra-operative opioid analgesic requirements on multivariable (coefficient 0.84, p = 0.038) regression analysis. There was no significant difference in post-operative opioid analgesic requirements (p = 0.18). In conclusion, pre-operative pudendal nerve blocks decrease intra-operative opioid analgesic requirements in veteran patients undergoing a primary inflatable penile prosthesis implantation.

Ultrasound Image-Guided Pudendal Nerve Block on Analgesic Effect of Perineotomy under Optimized Fast Super Resolution Reconstructed Convolutional Neural Network Algorithm

This work was aimed to study the analgesic effect of pudendal nerve block on obstetrics and gynecology under the guidance of ultrasound image based on optimized fast super resolution reconstructed convolutional neural network (FSRCNN) algorithm. A total of 110 primiparas from hospital who gave birth through vagina were randomly rolled into experimental group (55 cases) and control group (55 cases). The optimized FSRCNN algorithm was constructed, compared with the FSRCNN algorithm and the Bicubic algorithm and applied to 110 cases of maternal patients undergoing perineotomy under ultrasound image-guided pudendal nerve block. Visual analogue scoring (VAS), incision suture pain VAS score, occurrence of complications, puerpera labor time, and newborn weight were recorded and compared, so did Apgar score of newborns, numbness of maternal thigh, recovery of puncture site, and satisfaction of maternal analgesia. The results showed that the peak signal-to-noise ratio (PSNR) of the high-resolution image reconstructed by the FSRCNN algorithm was 32.68 dB and that reconstructed by the optimized FSRCNN algorithm was 32.19 dB. The PSNR of the Bicubic algorithm processed image was 28.51 dB. In the lateral resection of episiotomy in the second stage of labor, the visual analog score (2.3 ± 1.5 points) of the experimental group was inferior to that of the control group (7.1 ± 2.6 points) ( P < 0.05 ). The visual analogue score of stitch pain (1.3 ± 0.8 points) was also inferior to that of the control group (5.2 ± 1.9 points) ( P < 0.05 ). Moreover, the satisfaction of the parturients in the experimental group (9.86 ± 0.41 points) was considerably superior to that of the control group (7.36 ± 1.25 points) ( P < 0.05 ). In short, the optimized FSRCNN algorithm had a short training time and good reconstruction effect. Ultrasound-guided pudendal nerve block had a substantial analgesic effect on the second stage of labor and improved parturients’ satisfaction.

Histologic and physiologic analysis of the relationship between the dorsal nerve of the penis and the corpus cavernosum on a rat model. A complementary pathway on the innervation of penile erection?

The dorsal nerve of the penis (DNP) is the terminal branch of the pudendal nerve which is responsible for the somatic innervation of the penis. This study aims to outline any direct role of the DNP in the hemodynamics of erection histologically and physiologically. Fifteen Wistar albino rats were sorted into the electrical activity (n = 6), intracavernous pressure (n = 4), and control (n = 5) groups. The dorsal nerve was electrostimulated and the simultaneous changes in intracavernous pressure and smooth muscle activity were recorded. Penile tissues were collected, fixed, and sectioned, the slides were stained with either hematoxylin-eosin for morphological evaluation or using the indirect immunoperoxidase technique to analyze the distributions of eNOS, iNOS, and nNOS. During electrostimulation, there was a simultaneous statistically significant decrease in the electrical activity inside the corpora in electromyography and an increase in intracavernous pressure. eNOS and iNOS immunoreactivities were higher in the study group than in the control group. nNOS immunoreactivity was moderate in both study and control groups. Some fibers in the dorsal nerve of penis continue into the corpora cavernosa through the tunica albuginea and have an active, direct role in the hemodynamic process of erection, which may be complementary to the main route of innervation.

Ten-Step Surgical Approach to Management of Pathology of the Ischiorectal Fossa—A Review of the Literature and Application in a Rare Pelvic Schwannoma

Objective: The ischiorectal fossa is a key anatomical location with boundaries and internal structures owing distinct contributions to function and quality of life. Methods: We highlight the importance of management of pathology in this deep anatomically complex location. Results: We present a ten-step multidisciplinary surgical approach; achieving en bloc radical excision with primary closure and reassuring outcomes. Schwannomas are benign slow-growing nerve sheath tumors. Conclusions: Pelvic schwannomas are rare with only 3 reported cases of the pudendal nerve. We also offer an overview of this rare pathology whilst acknowledging a paucity of recommendations regarding management of disease of the ischiorectal fossa.

Age is associated with reduced urethral pressure and afferent activity in rat.

Age‐related changes in the lower urinary tract (LUT) can affect the coordination of reflexes and increase the incidence of bladder disorders in elderly. This study examines the age‐related loss of urethral signaling capability by measuring the afferent activity directly. We find that less urethral pressure develops in response to fluid flow in old rats compared to young rats and that pressure and flow evoke less urethral afferent activation. These findings are consistent with our previous study demonstrating that the urethra‐to‐bladder reflex, which is required for efficient voiding, becomes weaker with age. We measured the pudendal afferent response in young (4–7 months) and old (18–24 months) rats to fluid flow in the urethra across a range of flow rates. We used paraffin embedding and hematoxylin and eosin staining to quantify age‐related changes in the sensory branch of the pudendal nerve. Urethral afferent signaling in response to the same urethral flow rates was weaker in older animals. That is, the sensitivity of urethra afferents to flow decreased with age, and higher flow rates were required in older animals to recruit urethra afferents. There was also a reduction in the myelin thickness of pudendal afferents in old rats, which is a possible contributing factor to the sensory activity. Furthermore, the same flow rates evoked less pressure in the urethras of old animals, indicating there is an age‐related change of the urethral tissue that reduces the pressure stimulus to which these afferents respond. These results help characterize the underlying changes in LUT system with age.

Ultrasound-guided transgluteal injection of the pudendal nerve in cats: a cadaveric study

Introduction: Diseases affecting the feline urogenital and anorectal regions are common. This study aimed to develop an ultrasound-guided technique for injection of the pudendal nerve near its sacral origin in cats.

Clinical evaluation of diaphyseal femoral fractures operated in lateral decubitus position with interlocking nail

<p class="abstract"><strong>Background:</strong> The diaphyseal fractures of femur in adults are conventionally treated in supine position on traction table, which carries risk of compartment syndrome, pudendal nerve palsy, whereas in lateral decubitus position these complications can be avoided with additional advantage of easy access to greater trochanter particularly in obese patients. The aim of this study is to evaluate outcomes of femur diaphyseal fractures treated with intramedullary interlocking nail in lateral decubitus position.</p><p class="abstract"><strong>Methods:</strong> In this study 40 patients with femur diaphysea fractures were treated with intramedullary interlocking nail in lateral decubitus position, were studied for a period of 9 months from September 2019 to May 2020.<strong></strong></p><p class="abstract"><strong>Results:</strong> At the end of our study of 40 patients, outcome is graded according Thoresen’s criteria where 22 (55%) patients had excellent results with full, pain-free, function of the extremity and 11 (27.5%) patients had good result; 10 patients had range of motion 120<sup>0</sup> and shortening of femur by 1.5 was observed in 1 patient. There were 6 (15%) patients with fair result; with range of motion 90<sup>0</sup> and 1 poor result (2.5%) had non-union with range of motion <90<sup>0</sup>.</p><p class="abstract"><strong>Conclusions:</strong> Fixation of femur diaphyseal fracture in lateral decubitus position leads to easy access to the proximal femur making it easy to establish an entry point for an intramedullary device and it significantly eliminates the complications caused by other conventionally used methods.</p>

Pudendal Nerve Blocks: An Introduction and How-to Guide

<h3>Study Objective</h3> To provide a stepwise description of the anatomy, evidence, and technique for performing pudendal nerve blocks for the treatment of pudendal neuralgia. <h3>Design</h3> Video demonstration with narrated description. <h3>Setting</h3> Academic tertiary care site. <h3>Patients or Participants</h3> Patients with pudendal neuralgia. <h3>Interventions</h3> Digital transvaginal pudendal nerve blocks and blocks of the terminal peripheral branches of the pudendal nerve, including the perineal and dorsal clitoral branches. <h3>Measurements and Main Results</h3> Pudendal neuralgia can be identified using the Nantes criteria, which includes pain in the distribution of the pudendal nerve, increased pain with sitting, not being awakened by pain, lack of sensory loss, and resolution of pain after pudendal nerve block. Pudendal nerve blocks have been shown to provide relief in over 75% of patients with pudendal neuralgia, with relief potentially lasting from days to months post-procedurally. This video presents both a transvaginal digital approach to pudendal nerve block as well as targeted blocks of the peripheral branches of the pudendal nerve, including the perineal and dorsal clitoral branches. A review of the relevant clinical anatomy, benefits and risks of the procedures, type and toxicity of injectate medications, procedural set up, procedural techniques, and post-procedural follow up care is presented. <h3>Conclusion</h3> Pudendal nerve blocks, when performed through a safe and standardized approach, are a beneficial therapeutic tool for clinicians caring for patients with pudendal neuralgia.

Pelvic Neuroanatomy Learning from Fresh Frozen Cadaveric Dissections: Overview of Commonly Encountered Pelvic Nerves in Neuropelveology

<h3>Study Objective</h3> To describe commonly encountered pelvic nerves and anatomical landmarks in neuropelveologic surgery. <h3>Design</h3> A narrated video explanation of the autonomic nerves and the somatic nerves in the pelvis, their origin, sensory and motor function. <h3>Setting</h3> An anatomic theater for cadaveric dissections and an urban general hospital for in vivo laparoscopy. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> Neuropelveology is new groundbreaking discipline in medicine established by Prof. Marc Possover. Neuropelveology is concerned with the diagnosis of injuries and dysfunctions of the pelvic nerves and with the treatment of the symptoms and diseases caused by them. Sparing the pelvic nerves during surgery requires surgical expertise and an immense understanding of pelvic neuroanatomy. In this video, we educationally reviewed with laparoscopic viewpoint pictures of the superior and inferior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves, sacral splanchnic nerves, femoral nerve, genitofemoral nerve, obturator nerve, lumbosacral trunk, sacral nerve roots (plexus), pudendal nerve (plexus), sciatic nerve, posterior cutaneous nerve of the thigh. Considering the anatomical relationships between these nerves and adjacent structures, we identified the external and iliac vessels, gluteal vessels, internal pudendal vessels, uterine artery, middle rectal artery, ureter, levator ani muscles, coccygeal muscle, piriform muscle, obturator internus muscle, sacrospinous ligament, sacrotuberous ligament, Alcock's canal, ischial rectal (anal) fossa, lesser sciatic foramen, greater sciatic notch, as well as other anatomical structures in the region of those mentioned. <h3>Measurements and Main Results</h3> Cadaveric laparoscopic dissection provided excellent visual information on essential pelvic neural pathways. <h3>Conclusion</h3> The fresh frozen cadaveric dissections are essential tool for acquiring the knowledge of pelvic anatomy, especially the nerve system. The most important nerves groups are the hypogastric plexus and the sympathetic trunk for the autonomic nerve system, and the sacral and the lumbar plexuses for the somatic nerve system. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications.

Pelvic Nerves in Laparoscopy: A Review of Anatomy and Approach to Dissection

<h3>Study Objective</h3> Our objective is to review the anatomic course, sensory and motor functions, and approach to dissection of important pelvic nerves encountered during advanced gynecologic laparoscopy. <h3>Design</h3> Using annotated intraoperative footage, we illustrate surgical approaches to safe dissection of the following pelvic nerves: Ilioinguinal, iliohypogastric, lateral femoral cutaneous, femoral, genitofemoral, obturator, sciatic, hypogastric and pudendal nerves, lumbosacral trunk and sacral nerve roots. <h3>Setting</h3> Patients were placed in dorsal lithotomy position with legs in Yellowfin stirrups. The umbilicus was used for camera port placement, and three accessory ports were placed (in the bilateral lower quadrants and a second to the left of the umbilicus). <h3>Patients or Participants</h3> Patients requiring dissection of the aforementioned nerves for surgical treatment of deep infiltrating endometriosis, adhesiolysis, or treatment of pudendal neuralgia were selected. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Surgeons must have a comprehensive understanding of pelvic anatomy and comfort operating in deep pelvic spaces in order to minimize risk of inadvertent nerve injury. A systematic approach to nerve dissection enables adequate exposure of the operative field and safe space for lysis of adhesions, excision of endometriosis, and surgical treatment of pelvic pain syndromes.

Robot-Assisted Exploration of Somatic Nerves in the Pelvis and Transection of the Sacrospinous Ligament for Alcock Canal Syndrome

<h3>Study Objective</h3> To describe the anatomical and technical highlights of robotic exploration of the somatic nerves in the pelvis and transection of sacrospinous ligament (nerve decompression) for the patient with Alcock canal syndrome. <h3>Design</h3> Stepwise demonstration of a technique. <h3>Setting</h3> An urban general hospital. <h3>Patients or Participants</h3> A 48-year-old woman was referred for severe sitting pain, cyclic pelvic pain, gluteal and perineal pain, all of which were resistant to medication therapy. MRI revealed adenomyosis with neither deep endometriosis nor vascular entrapment. Based on neuropelveological evaluation, the patient was suspected to be suffering from Alcock canal syndrome due to compression of the pudendal nerve (and posterior cutaneous nerve of the thigh) by the sacrospinous ligament. <h3>Interventions</h3> Excluding the step for hysterectomy, the procedure was performed using the following 9 steps with the da Vinci Xi: Step 1, opening the peritoneum along external iliac artery; Step 2, exposure of the external iliac artery; Step 3, development of the lumbosacral space; Step 4, identification of the lumbosacral trunk; Step 5, identification of the superior gluteal nerve; Step 6, identification of the sciatic nerve; Step 7, identification of the inferior gluteal nerve; Step 8, identification of the pudendal nerve; and Step 9, transection of the sacrospinous ligament. <h3>Measurements and Main Results</h3> The surgery was successfully completed without any complications and the postoperative course was uneventful. On follow-up visits, the patient reported a gradual decreased in pain in postoperative 1st and 3rd months, and the neuralgia was finally completely resolved in the 6th month. Neuropelveologic evaluation still continues every 6 months. <h3>Conclusion</h3> When needed, minimally invasive techniques are applied for exploration and treatment with neuropelveological assessment. Robot-assisted transection of the sacrospinous ligament is a feasible, safe technique for selected patients with Alcock canal syndrome. Laparoscopic exploration of the pelvic nerves should be performed for further diagnosis and therapy before prematurely labeling the patient as refractory to the treatment.