Minimally Invasive Two-passage Electrical Genital Nerve Stimulation: A Human Cadaver Study of a New Technique.

STUDY OBJECTIVE: To present and evaluate the feasibility of a new technique of lead-electrode stimulation to the genital nerves using a 2-step, double-passage retropubic/retrograde approach. DESIGN: Prospective observational study. INTERVENTIONS: The procedure was initiated in the retropubic passage by placing the electrode from below through a paravulvar/testicular small incision toward the urogenital diaphragm, guided through the retropubic space along the backside of the pubic bone. Through a second passage along the frontside of the pubic bone, the lead-electrode was placed finally at the genital nerves. SETTING: Department of Anatomy, University Bern, Bern, Switzerland PARTICIPANTS: The study was performed in 5 cadavers (bilaterally) and tested by 10 obstetrics and gynecology surgeons. MEASUREMENTS AND MAIN RESULTS: Positions and courses of the lead electrode in relation to the dorsal nerve of the clitoris/penis were evaluated by dissection of the genitals and showed an optimal parallel course of the lead electrodes to the dorsal nerve from the perforation of the urogenital diaphragm to the crura of the clitoris, with area of the dorsal nerve of the clitoris/penis to the electrode never exceeding 2 mm. Participant surgeons self-evaluated reproducibility and difficulty of the procedure by using a score from 1 to 10 (1, easy/safe; 10, extremely difficult/dangerous). Both reproducibility and difficulty achieved a score of 1 by all participants. CONCLUSIONS: The double-passage genital nerve stimulation procedure is a new peripheral nerve stimulation technique that had a high self-evaluated rate of ease and reproducibility for surgeon participants.

Effect of pelvic laparoscopic implantation of neuroprosthesis in spinal cord injured subjects: a 1-year prospective randomized controlled study.

STUDY DESIGN: 1-year prospective RCT. OBJECTIVE: Examine the effect of implantable pulse generator and low-frequency stimulation of the pelvic nerves using laparoscopic implantation of neuroprosthesis (LION) compared with neuromuscular electrical stimulation (NMES) in SCI. METHODS: Inclusion criteria: traumatic spinal cord injury (SCI), age 18-55 years, neurological level-of-injury Th4-L1, time-since-injury >1 year, and AIS-grades A-B. Participants were randomized to (A) LION procedure or (B) control group receiving NMES. PRIMARY OUTCOME MEASURE: Walking Index for Spinal Cord Injury (WISCI-II), which is a SCI specific outcome measure assessing ability to ambulate. SECONDARY OUTCOME MEASURES: Spinal Cord Independence Measure III (SCIM III), Patient Global Impression of Change (PGIC), Penn Spasm Frequency Scale (PSFS), severity of spasticity measured by Numeric Rating Scale (NRS-11); International Spinal Cord Injury data sets-Quality of Life Basic Data Set (QoLBDS), and Brief Pain Inventory (BPI). RESULTS: Seventeen SCI individuals, AIS grade A, neurological level ranging from Th4-L1, were randomized to the study. One individual was excluded prior to intervention. Eight participants (7 males) with a mean age (SD) of 35.5 (12.4) years were allocated to the LION procedure, 8 participants (7 males) with age of 38.8 (15.1) years were allocated to NMES. Significantly, 5 LION group participants gained 1 point on the WISCI II scale, (p < 0.013; Fisher´s exact test). WISCI II scale score did not change in controls. No significant changes were observed in the secondary outcome measures. CONCLUSION: The LION procedure is a promising new treatment for individuals with SCI with significant one-year improvement in walking ability.

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

OBJECTIVE: 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. DESIGN: Video. SETTING: Tertiary referral unit specialized in advanced gynecologic surgery and neuropelveology. INTERVENTIONS: 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. CONCLUSION: 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.

Review: Pelvic nerves - from anatomy and physiology to clinical applications.

A prerequisite for nerve-sparing pelvic surgery is a thorough understanding of the topographic anatomy of the fine and intricate pelvic nerve networks, and their connections to the central nervous system. Insights into the functions of pelvic nerves will help to interpret disease symptoms correctly and improve treatment. In this article, we review the anatomy and physiology of autonomic pelvic nerves, including their topography and putative functions. The aim is to achieve a better understanding of the mechanisms of pelvic pain and functional disorders, as well as improve their diagnosis and treatment. The information will also serve as a basis for counseling patients with chronic illnesses. A profound understanding of pelvic neuroanatomy will permit complex surgery in the pelvis without relevant nerve injury.

Ten-Year Experience With Continuous Low-Frequency Pelvic Somatic Nerves Stimulation for Recovery of Voluntary Walking in People With Chronic Spinal Cord Injury: A Prospective Case Series of 29 Consecutive Patients.

OBJECTIVE: The purpose of this study was to report on long-term effects of low-frequency stimulation of the pelvic somatic nerves in patients with chronic spinal cord injuries who underwent laparoscopic implantation of neuroprosthesis (LION) in the pelvic lumbosacral nerves. DESIGN: Observational case report. SETTING: Tertiary referral unit specialized in advanced gynecologic surgery and neuropelveology. PARTICIPANTS: Patients (N=29) with chronic SCI who underwent a LION procedure to the pelvic lower motor neurons for the recovery of standing and walking motion. Our study is not composed of preselected patients but includes patients across the entire range of SCIs: patients with paraplegia, patients with tetraplegia (except for high tetraplegia), patients with complete and incomplete SCIs, and even patients with flaccid or spastic paralysis. INTERVENTION: Patients underwent in-body functional electrical stimulation-assisted locomotor training and continuous low-frequency pelvic lumbosacral nerve neuromodulation. MAIN OUTCOME MEASURES: Evolution of American Spinal Injury Association (ASIA) sensory score, ASIA Lower Extremity Motor Score, and Walking Index. RESULTS: All patients with incomplete SCI regained some voluntary control of previously paralyzed muscles after a few months of stimulation training. With a follow-up of 9 years, 20 patients (71.4%) were able to demonstrate an electrically assisted voluntary extension of the knee. Twenty-six patients could get to their feet when the pacemaker was switched on (92.8%). Five patients could walk <10 m (17.85%) at the bar. Nineteen patients (Abbreviated Injury Score [AIS] A: n=8; AIS B: n=9; AIS C: n=2) could walk >10 m (67.8%), 8 of them only at the bar (28.5%) and 11 of them with the aid of crutches or a walker and without braces (40%). CONCLUSIONS: The major finding of our study is that 17 of 25 patients with complete motor chronic SCI (68%) developed enough recovery of supraspinal control of leg movements that voluntary walking became feasible, even though a minimal amount of stimulation may be required.

Does low-frequency pelvic nerves stimulation in people with spinal cord injury allow for the formation of electrical pathways responsible for the recovery of walking functions?

Over the last ten years, we have published various manuscripts on the recovery of assisted voluntary walking in people with chronic spinal chord injuries (SCI), following laparoscopic implantation of stimulation electrodes on the pelvic somatic nerves - the LION procedure. Although at the beginning of this research the objective was to allow "robotic" walking by stimulating the muscles, we realized relatively quickly that continuous low frequency stimulation of the pelvic nerves might allow the recovery of voluntary functions of the lower limbs and of the trunk necessary for walking: Seventeen out of a total of twenty-five complete motor chronic SCI-patients (68%) developed enough recovery of supra-spinal control of leg movements, that voluntary walking became feasible, even though a minimal amount of stimulation may be required. All current theories for recovery these voluntary functions below the spinal cord lesion are based on the induced regrowth or reconnection of nerves or at least the recovery of functional anatomical pathways. In this manuscript we formulate the hypothesis that electrical stimulation could be responsible for inducing the formation of "electrical pathways" within the body, which under conditions of electrical stimulation might enable the transport of necessary information from the brain to below the spinal cord lesion allowing voluntary movements of the lower limbs.

The Modified Schauta-Stoeckel Procedure.

STUDY OBJECTIVE: To demonstrate the technique of vaginal radical hysterectomy in the treatment of cervical cancer. DESIGN: Video. SETTING: Tertiary referral unit specialized in advanced gynecologic surgery and neuropelveology. INTERVENTIONS: The modified Schauta-Stoeckel procedure consists of a radical hysterectomy performed vaginally without the need for a Schuchard episiotomy. Our modification consists of the "Click maneuver," an easy and reproducible method that allows an easy exposure of the knee of the ureter and a radical resection of both the supraureteral and infraureteral parts of the bladder pillar. This procedure allows a radical resection of the lower part of the parametrium and the paracolpium, both of which contain the main lymphatic drainage of the cervix. CONCLUSION: The modified Schauta-Stoeckel procedure has been shown in previous studies a high cure for stage IB or IIA cervical cancer.

Neuropelveology: An Emerging Discipline for the Management of Pelvic Neuropathies and Bladder Dysfunctions through to Spinal Cord Injury, Anti-Ageing and the Mars Mission.

Neuropelveology is a new specialty in medicine that has yet to prove itself but the need for it is obvious. This specialty includes the diagnosis and treatment of pathologies and dysfunctions of the pelvic nerves. It encompasses knowledge that is for the most part already known but scattered throughout various other specialties; neuropelveology gathers all this knowledge together. Since the establishment of the International Society of Neuropelveology, this discipline is experiencing an ever-growing interest. In this manuscript, the author gives an overview of the different aspects of neuropelveology from the management of pelvic neuropathic pain to pelvic nerves stimulation for the control of pelvic organ dysfunctions and loss of functions in people with spinal cord injuries. The latter therapeutic option opens up new treatments but also widens preventive horizons not only in the field of curative medicine (osteoporosis and cardio-vascular diseases) but also in preventive medicine and anti-ageing, all the way to future applications in the "Mars mission" project.

Recovery of supraspinal control of leg movement in a chronic complete flaccid paraplegic man after continuous low-frequency pelvic nerve stimulation and FES-assisted training.

INTRODUCTION: More than 30 years ago, functional electrical stimulation (FES) was developed as an orthotic system to be used for rehabilitation for SCI patients. In the present case report, FES-assisted training was combined with continuous low-frequency stimulation of the pelvic somatic nerves in a SCI patient. CASE PRESENTATION: We report on unexpected findings in a 41-year-old man with chronic complete flaccid paraplegia, since he was 18 years old, who underwent spinal stem cell therapy and a laparoscopic implantation of neuroprosthesis (LION procedure) in the pelvic lumbosacral nerves. The patient had complete flaccid sensomotoric paraplegia T12 as a result of a motor vehicle accident in 1998. In June 2011, he underwent a laparoscopic implantation of stimulation electrodes to the sciatic and femoral nerves for continuous low-frequency electrical stimulation and functional electrical stimulation of the pelvic nerves. Neither intraoperative direct stimulation of the pelvic nerves nor postoperative stimulation induced any sensation or muscle reactions. After 2 years of passive continuous low-frequency stimulation, the patient developed progressive recovery of electrically assisted voluntary motor functions below the lesions: he was first able to extend the right knee and 6 months later, the left. He is currently capable of voluntary weight-bearing standing and walking (with voluntary knee movements) about 50 m with open cuff crutches and drop foot braces. DISCUSSION: Our findings suggest that continuous low-frequency pelvic nerve stimulation in combination with FES-assisted training might induce changes that affect both the upper and the lower motor neuron and allow supra- and infra-spinal inputs to engage residual spinal and peripheral pathways.

Five-Year Follow-Up After Laparoscopic Large Nerve Resection for Deep Infiltrating Sciatic Nerve Endometriosis.

OBJECTIVE: To report neurologic follow-up of patients after laparoscopic large resection of deep infiltrating endometriosis of the sciatic nerve. DESIGN: Prospective clinical case series. SETTING: Tertiary referral unit specializing in advanced gynecologic surgery and neuropelveology. PATIENTS: All data for patients who underwent laparoscopic surgery for endometriosis of the sciatic nerve between 2004 and 2016 (n = 259) were documented prospectively. In this study, patients who underwent a large resection of the sciatic nerve (>30% of the nerve) and were followed for at least 5 years were evaluated (n = 46). All patients presented preoperatively with incapacity for normal gait and foot drop. All were suffering from intractable and constant neuropathic sciatic pain (visual analog scale [VAS] score of 9 to 10 despite strong pain medicine), with sensorimotor disorders of the affected leg. INTERVENTIONS: Laparoscopic large resection of endometriosis of the sciatic nerve. MEASUREMENTS AND MAIN RESULTS: All procedures were performed by laparoscopy. Postoperative management included medical treatment with neuroleptic agents and intensive physiotherapy. At the 5-year follow-up, all patients reported significant pain reduction, with a median VAS score of 2.1 (range, 0 to 3) and recovery of normal gait, including the ability to climb stairs. CONCLUSION: In deep infiltrating intraneural endometriosis of the sciatic nerve, patients present with motor disorders before and after surgical resection. The average VAS score was reduced from 9.33 preoperatively to 1.25 at a 3-year follow-up. When full resection of endometriosis including nerve resection is completed, sciatic nerve function recover, but recovery of a normal gait may take at least 3 years and intensive physiotherapy.

Neuropelveology: An Emerging Discipline for the Management of Chronic Pelvic Pain.

Chronic pelvic pain (CPP) is a common condition involving multiple, organ-specific medical specialties, each with its own approach to diagnosis and treatment. Management requires knowledge of the interplay between pelvic organ function and neuro-functional anatomy, and of the neurologic and psychological aspects of CPP, but no current specialty fully encompasses this approach. Neuropelveology is an emerging discipline focusing on pathologies of the pelvic nervous system on a cross-disciplinary basis. It involves a neurological/neurosurgical approach, combining the knowledge required for a proper neurologic diagnosis, confirmation by transvaginal/transrectal examination of the pelvic nerves, and advanced laparoscopic surgery in selected cases of CPP. The management of CPP requires multidisciplinary contributions, and neuropelveology may offer an educational framework for the interdisciplinary exchange of knowledge between clinical physicians and basic researchers.

The LION Procedure to the Pelvic Nerves for Recovery of Locomotion in 18 Spinal Cord Injured Peoples - A Case Series.

We report on unexpected findings in 18 spinal cord injured peoples who underwent a laparoscopic bilateral implantation of neuroprosthesis (LION procedure) to the sciatic/femoral nerves pelvic somatic nerves for functional electrical stimulation (FES)-assisted locomotor training and continuous low-frequency electrical stimulation. Fifteen patients were paraplegics, three low tetraplegics, all of them fully dependent on a wheelchair. After a training period of at least one year, all patients not only started with electrical-assisted standing/stepping using a walker or crutches, but also developed some progressive caudalward recovery of lumbosacral sensoric functions and of supraspinal control of voluntary movements below the lesions. Twelve patients are currently capable of weight-bearing standing and stepping with crutches by simultaneous electrical stimulation (the best of the series for 2.6km), and six of them are capable of walking several meters (the best of the series for 400m) without electrical stimulation. Our findings suggest that FES-assisted locomotor training in combination with continuous low-frequency pelvic nerves in spinal cord injury patients may induce changes that affect the central pattern generator and allows supra- and infraspinal inputs to engage residual spinal or extra spinal pathways for reconnection.

Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression.

BACKGROUND: Some patients have pelvic, pudendal, or low lumbar pain radiating into the legs that is worse while sitting but differs from pudendal neuralgia. The purpose of this study was to present a new clinical entity of neuropathic pelvic pain by pelvic neuro-vascular entrapment. OBJECTIVES: To report about the locations of predilection for pelvic neurovascular entrapment. STUDY DESIGN: Prospective cohort pre- and post-intervention. SETTING: University referral unit specializing in advanced gynecological surgery and neuropelveology. METHODS: Patients, Intervention: In a prospective study, 97 patients presenting with intractable pelvic neuropathic pain (pudendal pain, gluteal pain, vulvodynia, coccygodynia, and sciatic pain) underwent laparoscopic exploration with decompression of compressed pelvic somatic nerves. The population included 76 (78.3%) women and 21 men. Indication for laparoscopic exploration of pelvic nerves suspected to be involved in pain has been indicated after neuropelveological work up, pelvic neuro-magnetic resonance imaging (MRI) and Doppler-sonography. Pain evolution was recorded over 2 years after the procedure. MEASUREMENTS AND MAIN RESULTS: Three entities were isolated: pudendal neuralgie by compression at the less sciatic notch, sacral radiculopathy at S2-4 by compression at the infracardinal level of the sacral plexus, and sciatica L5-S1/2 by compression at the greater sciatic notch. Pain was worse sitting (98%), during menstrual bleeding in women, and during Valsalva maneuver, but the pain did not wake the patients up at night and was not accompanied by neurologic dysfunctions. A decrease in VAS scores (> 50%) at 2 years follow-up was observed in 86 patients (88.6%). CONCLUSIONS: Neuro-vascular entrapment is a pathophysiologic phenomenon implicated in several pelvic neuropathies. The most common are L5-S1 sciatica, pudendal neuralgia, and sacral radiculopathy. After intraoperative confirmation, laparoscopic exploration of the entire sacral plexus is essential to diagnose conflict. Laparoscopic decompression is a treatment of choice, based on the separation of the offending vessel from the nerves. Those procedures are safe, with a high success rate; the neuropelveological approach is essential in order to obtain good treatment results. The laparoscopic approach gives the possibility of reducing morbidity and improving results by providing wider insight into the operating field with smaller intraoperative injury.

Laparoscopic approach to intrapelvic nerve entrapments.

It is long known that a large portion of the lumbosacral plexus is located intra-abdominally, in the retroperitoneal space. However, most of literature descriptions of lesions on this plexus refer to its extra-abdominal parts whereas its intra-abdominal portions are often neglected. The objective of this review article is to describe the laparoscopic anatomy of intrapelvic nerve bundles, as well as the findings and advances already achieved by Neuropelveology practitioners.

Laparoscopic dissection and anatomy of sacral nerve roots and pelvic splanchnic nerves.

STUDY OBJECTIVE: To demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves. DESIGN: Case report (Canadian Task Force classification III). SETTING: Private practice hospital in São Paulo, Brazil. PATIENT: A 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0-10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm. INTERVENTIONS: Standard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4. MEASUREMENTS AND MAIN RESULTS: The surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0-10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves. CONCLUSION: Laparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

Laparoscopic assisted resection of a ilio-sacral chondrosarcoma: A single case report.

INTRODUCTION: Sacral tumor often involves en bloc surgical resection with tumor-free margins and functional reconstruction challenges. Such a management is challenging because of difficulties in accessing the lesion, risks for damages of neighboring organs, and risks for massive blood loss. In posterior approach, because first elevation of the sacrum allows dissection of presacral structures, such risks for damages intrapelvic structures and hemorrhage are especially high. PRESENTATION OF CASE: We report here about a laparoscopic assisted posterior resection of a ilio-sacral chondrosarcoma in a women, 6 weeks after vaginal delivery. Primary laparoscopic approach consisted in dissection of the ureter and of the colon with control to the pelvic vessels and nerves and determination of limits of the resection. The iliac osteotomy was performed from posterior approach with saw and osteotomes at the predetermined extralesional level. The defect was replaced with a structural fresh frozen femoral allograft and stabilization performed by lumbo-ischial screw/rod fixation. DISCUSSION: Surgical time was about 360min. No intra-postoperative complications occurred. Blood loss was estimated to about 1000cm(3). Histologic examination of the specimen showed tumor-free margins. At 8 months follow-up, the patient appears to be without recurrence. Because of the denervation of the nerve root L5 and below, she mostly uses two canes, but she has a functioning quadriceps. Continence and voiding functions for urine and stool have fully recovered. CONCLUSION: Primary laparoscopic approach appeared to be a good way for preparation orthopedics sacroiliac resection to reduce postoperative morbidity, intraoperative blood loss and better assure macroscopic tumor-free margins.

A novel implantation technique for pudendal nerve stimulation for treatment of overactive bladder and urgency incontinence.

Herein is described laparoscopic implantation of a neuroprosthesis to the pudendal nerve for treatment of non-neurogenic bladder overactivity. This case series study was performed at a tertiary referral unit that specializes in advanced gynecologic surgery and neuropelveology. Fourteen consecutive male and female patients underwent laparoscopic implantation of an electrode to the endopelvic portion of the pudendal nerve for pudendal neuromodulation. All procedures were performed successfully via laparoscopy, without any complications. The mean operative time for the entire procedure was 18 minutes. After a successful test phase of external stimulation, 11 patients (78.57%) underwent implantation of a permanent generator. These patients demonstrated a mean (SD) decreased micturition frequency, from 25 (11.7; range, 13-50) per day on average to 10.18 (2.7; range, 7-15) at final evaluation (mean follow-up, 18 months; range 9-49 months). Nocturia decreased from 5.82 (4.2; range, 3-18) to 2.18 (1.08; range, 1-5) micturitions per night. Cystometric bladder capacities increased from 159 mL (53; range, 80-230 mL) to 312 mL (104.9;160-500 mL). Mean incontinence episodes at the initial evaluation, based on a 3-day voiding diary, were 8.1. At final evaluation, 6 patients were completely dry. Number of pads used per day decreased from 7.3 (4.2) to 1.6 (2.3). No lead dislocation or migration occurred. It was concluded that laparoscopic implantation of a neuroprosthesis to the pudendal nerve is an effective, safe, and reproducible day procedure for treatment of intractable non-neurogenic overactive bladder with urinary urgency incontinence.

The LION procedure to the pelvic nerves for treatment of urinary and faecal disorders.

Bladder dysfunctions have been treated for decades through medical treatments or surgical procedures, especially in the context of prolapse conditions and stress incontinence. Over the last decade, sacral nerve modulation (SNM) has been introduced as a further option in the treatment of some urinary and fecal symptoms. Current techniques of percutaneous implantation are limited to superficial extrapelvic nerves that expose patients to lead migration and dislocation or infections, complications that cannot be ignored. Access to endopelvic nerves and plexuses will be mandatory in the future, especially to the sacral plexus area that is the crossroads of all vesical-sphincteric, anorectal, and sexual functions. The endopelvic location of electrodes protects against the above mentioned complications. Some open-surgical approaches have been described in the past, but all of them were extremely laborious and dangerous. All these limitations were overcome with the introduction of laparoscopy into the field of pelvic oncology. Laparoscopic retroperitoneal surgery and the development of video-endoscopy and appropriate instruments allows for access and visibility to all pelvic nerves and plexuses as well as laparoscopic pelvic neurosurgical procedures. One of these methods is the implantation of neuroprothesis-a technique called the "LION procedure"-which permits selective electrical stimulation of pelvic nerves and plexuses. One very interesting site of implantation for treatment of urinary and faecal symptoms is the pudendal nerve (PN). Stimulation of this nerve induces two different actions: a strong contraction of the sphincters-treatment of urinary and faecal incontinence and an inhibitory effect on the bladder-and treatment for bladder overactivity.

A new technique of laparoscopic implantation of stimulation electrode to the pudendal nerve for treatment of refractory fecal incontinence and/or overactive bladder with urinary incontinence.

STUDY OBJECTIVE: To show a new technique of laparoscopic implantation of electrodes for stimulation of the pudendal nerve for treatment of fecal incontinence and/or overactive bladder with urinary incontinence. DESIGN: Step-by-step explanation of the technique using videos and pictures (educative video). SETTING: Hyperactivity of the bladder with urinary incontinence, in particular the non-neurogenic form of the condition, but also fecal incontinence may affect millions of women worldwide without any comorbidities and in particular without any neurologic disorders or prolapsed organs. First-line conservative treatments do not always result in sufficient improvement of symptoms and are often associated with disabling adverse effects leading to treatment failure. Electrical stimulation of the pelvic nerves has emerged as an alternative and attractive treatment in refractory cases. A novel technique of implantation of an electrode to the pudendal nerve has been developed for treatment of fecal incontinence and of hyperactivity of the bladder with urinary incontinence. The laparoscopic approach is the only technique that enables placement of an electrode in direct contact with the endopelvic portion of the pudendal nerve within the protection of the pelvis. INTERVENTION: Laparoscopic transperitoneal implantation of a stimulation electrode to the endopelvic portion of the pudendal nerve. CONCLUSION: This technique of transperitoneal placement of an electrode to the endopelvic portion of the pudendal nerve is an effective, safe, and reproducible day procedure for treatment of intractable hyperactive bladder, urinary incontinence, fecal incontinence, and a combination of both forms of incontinence.