Laparoscopic Management of Sacral Nerve Root Schwannoma With Intractable Vulvococcygodynia: Report of Three Cases and Review of Literature

doi:10.1016/j.jmig.2012.12.011

Journal of Minimally Invasive Gynecology

Volume 20, Issue 3, May–June 2013, Pages 394-397

https://doi.org/10.1016/j.jmig.2012.12.011 Get rights and content

Abstract

Herein we report the feasibility of laparoscopic resection of schwannomas of the sacral nerves roots in 3 women with intractable vulvodynia and coccygodynia. Laparoscopic en bloc resection of the sacral schwannomas was performed, with primary control of the tumor blood supply and with exposure and sparing of the sacral nerve roots. In all 3 patients, laparoscopy was successful, with minimal blood loss and without complications. Histologic examination confirmed the diagnosis of schwannoma without malignant transformation in all 3 women. At mean follow-up of 27.66 months, no patient reported recurrence or worsening of symptoms. All patients are able to walk normally without gait aids. Primary control of the tumor blood supply during laparoscopic surgery to resect deep sacral masses reduces considerably the risk of operative hemorrhage. Compared with classic neurosurgical approaches, laparoscopic exposure of the rectum, ureters, and sacral nerve roots renders the procedure safer and easier, with less risk of postoperative functional morbidity.

Section snippets

Patients and Methods

Between 2008 and 2012, 3 women with sacral schwannomas were treated by one of the authors (M.P.). Mean age of the patients was 31 years. All patients came to our institution for management of intractable vulvodynia and coccygodynia, which had been treated unsuccessfully over the years with oral and topical medicines. Because of suspicion of ankylosing spondylitis resulting in sciatica, 1 patient had also received long-term corticosteroid therapy. All 3 patients also had constipation,

Results

Operative time for all 3 procedures was about 120 minutes, with a mean estimated blood loss <100 mL. There were no intraoperative or postoperative complications. Patients recovered spontaneous bowel activity at postoperative day 3. Hospital stay varied between 4 and 6 days. The suprapubic bladder catheters were removed after 2 weeks of successful bladder training. After several weeks of unilateral genital numbness assessed using the light touch, pin prick test, all 3 patients recovered normal

Discussion

Schwannomas are rare benign sacral tumors. In all 3 patients in our series, the tumors originated from one side of the sacral foramen and extended to adjacent structures. Although lumbosacral pain is the symptom most frequently reported in the literature, the predominant symptoms in our patients were vulvodynia and coccygodynia. These painful conditions are confusing to many gynecologists because symptoms are located in the genital area but results of dermatologic and gynecologic examinations

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Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management
2022, Sexual Medicine Reviews
Citation Excerpt :
Lesions affecting sacral nerve roots L5, S1, and S2 cause sciatica like symptoms radiating down the posterior aspect of the thigh. Sacral schwannomas often irritate sacral nerve roots L5, S1, and S2 together, which helps explain the clinical picture of pudendal nerve pain, sciatica, coccygodynia, and vulvodynia.13 The location of a tumor along the course of the nerve determines how early in the growth curve symptoms occur, with earlier and smaller tumors capable of causing substantial pudendal neuropathy (eg, if the tumor is in the Alcock canal) (Figure 4).
Women with pelvic pain commonly report pain in their ovaries, vagina, uterus, or bladder. These symptoms may be caused by visceral genitourinary pain syndromes but also may be caused by musculoskeletal disorders of the abdomen and pelvis. Understanding neuroanatomical and musculoskeletal factors that may contribute to genitourinary pain is important for evaluation and management.
This review aims to (i) highlight the importance of clinical knowledge of pelvic neuroanatomy and sensory dermatomal distribution of the lower abdomen, pelvis, and lower extremities, exemplified in a clinical case; (ii) review common neuropathic and musculoskeletal causes of acute and chronic pelvic pain that may be challenging to diagnose and manage; and (iii) discuss female genitourinary pain syndromes with a focus on retroperitoneal causes and treatment options.
A comprehensive review of the literature was performed by searching the PubMed, Ovid Embase, MEDLINE, and Scopus databases using the keywords “chronic pelvic pain,” “neuropathy,” “neuropathic pain,” “retroperitoneal schwannoma,” “pudendal neuralgia,” and “entrapment syndromes.”
Retroperitoneal causes of genitourinary pain syndromes have substantial overlap with common conditions treated in a primary care setting. Thus, a comprehensive and systematic history and physical examination, with focused attention to the pelvic neuroanatomy, is key to establishing the correct diagnosis. In the clinical case, such a comprehensive approach led to the unexpected finding of a large retroperitoneal schwannoma. This case highlights the intricacy of pelvic pain syndromes and the complex nature of their possible overlapping causes, which ultimately affects treatment planning.
Knowledge of the neuroanatomy and neurodermatomes of the abdomen and pelvis, in addition to understanding pain pathophysiology, is critical when evaluating patients with pelvic pain. Failure to apply proper evaluation and implement proper multidisciplinary management strategies contributes to unnecessary patient distress, decreased quality of life, and increased use of health care services.
Khalife T, Hagen AM, Alm JEC. Retroperitoneal Causes of Genitourinary Pain Syndromes: Systematic Approach to Evaluation and Management. Sex Med Rev 2022;10:529–542.
Preliminary investigation of bilateral internal iliac artery ligation and anterior tumor separation through laparoscopy before posterior resection of a giant sacral tumor: Laparoscopy assisted resection of giant sacral tumor
2020, Surgical Oncology
Citation Excerpt :
Currently, the laparoscope, which has the advantages of enabling minimally invasive surgery, is widely used for tumor resection, and good clinical efficacy is expected [16–18]. The use of laparoscopic techniques in the resection of sacral tumors has been previously reported in a small number of studies, but the number of cases was small, and the follow-up time was relatively short [17,19]. The main advantage of using a laparoscope is that the anterior portion of the sacral tumor can be effectively separated using an ultrasonic scalpel, and the tumors can be completely exposed after ligation of the bilateral internal iliac artery.
Surgical is the optimal therapeutic strategy for sacral tumors, and complete resection can effectively improve the recurrence and survival rates. However, the specialized anatomy, massive bleeding and adhesion to the anterior tissue, especially that caused by giant sacral tumors, makes complete resection difficult. The laparoscopic technique provides a new method to resect sacral tumors.
34 patients with primary giant sacral tumors who underwent surgical resection were enrolled. After bilateral internal iliac artery ligation and anterior laparoscopic tumor separation, the sacral tumors were successfully resected posteriorly. The clinical, radiological and follow-up data were collected and analyzed.
The average operative time was 276.47 min and that for laparoscopy was 76.24 min. The average intraoperative blood loss was 1757.64 ml. No complications associated with laparoscopic surgery, such as intestinal, urinary tract, or vascular injuries, occurred. Ten patients (29.41%) had perioperative complications, including infection, unhealed wounds, and cerebrospinal fluid leaks in 10, 5 and 2 patients, respectively. Patients with complications had significantly longer total (55.00 ± 34.53 vs 25.13 ± 14.60, P = 0.001) and postoperative (39.10 ± 30.61 vs 14.83 ± 10.00, P = 0.002) hospitalization stays than patients without complications. Postoperatively, bowel and bladder dysfunction, intestinal obstruction, pain, and perianal numbness occurred in 21, 5, 8, and 2 patients, respectively. The recurrence rate was 11.76%.
Laparoscopically assisted sacral tumor resection is a technically feasible and effective surgical method to resect giant sacral tumors, with the advantages of reduced operative blood loss during internal iliac artery ligation and anterior tumor separation.
Laparoscopic resection of schwannoma in the lateral pelvic space based on the fascia plane: how we do it (with video)
2023, Langenbeck's Archives of Surgery
Selective Sacral Nerve Root Block
2022, Regional Nerve Blocks in Anesthesia and Pain Therapy: Imaging-Guided and Traditional Techniques
Neuropelveology: An emerging discipline for the management of pelvic neuropathies and bladder dysfunctions through to spinal cord injury, anti-ageing and the mars mission
2020, Journal of Clinical Medicine
Neuropelveology-the medicine of the pathologies of the pelvic nerves and plexuses
2020, Minimally Invasive Surgery in Gynecological Practice: Practical Examples in Gynecology

View all citing articles on Scopus

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Case ReportLaparoscopic Management of Sacral Nerve Root Schwannoma With Intractable Vulvococcygodynia: Report of Three Cases and Review of Literature

Abstract

Section snippets

Patients and Methods

Results

Discussion

J Minim Invasive Gynecol

J Minim Invasive Gynecol

J Chir (Paris)

Retroperitoneal schwannoma

Am J Roentgenol

Presacral schwannoma with purely cystic form

Spine

Tumorigenic properties of neurofibromin-deficient neurofibroma Schwann cells

Am J Pathol

The clinical significance of Lasegue's sign in the diagnosis of prolapsed lumbar disc: interobserver variation and correlation with surgical finding

Spine

Le signe du fourmillemnt dans les lesions des nerfs peripheriques

Presse Med

Anatomy of the sacral roots and the pelvic splanchnic nerves in women using the LANN technique

Surg Laparosc Endosc Percutan Tech

Voiding dysfunction associated with pudendal nerve entrapment

Curr Bladder Dysfunc Rep

Giant intrasacral schwannomas: report of six cases

Acta Neurochir

Case Report
Laparoscopic Management of Sacral Nerve Root Schwannoma With Intractable Vulvococcygodynia: Report of Three Cases and Review of Literature