INTRODUCTION: Pudendal nerve entrapment is an under-recognized cause of pudendal neuralgia, a chronic neuropathic pain syndrome involving the perineum, external genitalia, and anus. Management is multimodal, including behavioral modification, pelvic floor physiotherapy, analgesics, nerve blocks, and, in refractory cases, surgical decompression. A minimally invasive laparoscopic approach affords excellent visualization, but objective intraoperative indicators of adequate decompression are limited. OBJECTIVE: To present a stepwise laparoscopic technique for pudendal decompression and neurolysis and to introduce the “return of pulsation” sign, resumption of visible pudendal arterial pulsation after decompression, as a potential intraoperative indicator of successful release of the pudendal neurovascular bundle. METHODS: This surgical video reviews pudendal neuralgia (symptoms, disease course, relevant anatomy, treatment options) and demonstrates a left-sided laparoscopic pudendal neurolysis. The lateral ports are positioned more medially than in routine pelvic laparoscopy to optimize access to the ischial spine and deep structures. Key steps include: (1) identification of anatomical landmarks, (2) laparoscopic dissection and controlled transection of the compressive sacrospinous ligament, (3) meticulous neurolysis and medialization of the pudendal nerve, and (4) atraumatic dilation of the entrance to Alcock’s canal. Energy use is minimized near neural structures, and hemostasis is performed away from the nerve. RESULTS: Following decompression, previously dampened arterial pulsation of the internal pudendal artery becomes distinctly visible, constituting the “return of pulsation” sign. This qualitative finding is proposed as an immediate, easily recognized intraoperative marker suggesting relief of mechanical constraint on the neurovascular bundle. CONCLUSIONS: Laparoscopic pudendal neurolysis is a feasible approach for the treatment of pudendal nerve entrapment, which offers excellent visualization of critical landmarks. The “return of pulsation” sign may serve as a practical intraoperative indicator of effective decompression. Prospective correlation with postoperative pain and functional outcomes is needed to validate its predictive value and to inform surgical training and intraoperative decision-making.
Bar-El et al. (Fri,) studied this question.