Robotic
Pudendal Nerve
Decompression
The pudendal nerve plays a critical role in pelvic sensation and function. Our robotic-assisted approach allows precise identification and decompression of the nerve in areas beyond the reach of traditional surgery.
What Is Pudendal Nerve Entrapment?
Pudendal nerve entrapment occurs when the nerve is compressed along its course, most commonly within Alcock’s canal or at the level of the sacrospinous and sacrotuberous ligaments. In many patients, this compression is driven by underlying inflammation, fibrosis, or endometriosis involving the pelvic sidewall.
Symptoms
Patients may experience:
- Burning, sharp, or electric pain in the perineum
- Pain with sitting (classic hallmark)
- Pain radiating to vagina, rectum, or clitoris
- Dyspareunia
- Urinary urgency or frequency
- Bowel dysfunction or painful defecation
Why This Happens
The most common causes include:
- Deep infiltrating endometriosis
- Post-surgical scarring
- Chronic pelvic inflammation
- Ligamentous compression (sacrospinous / Alcock canal)
Why Traditional Treatments Fail
Many conventional approaches focus on surface-level treatments such as physical therapy, medications, or nerve blocks. While helpful in some cases, they often do not address deep intrapelvic nerve compression, which requires direct visualization and surgical release.
Our Surgical Approach
We utilize a robotic intrapelvic approach, which provides unparalleled visualization and access to the deep pelvic neuroanatomy. This technique allows:
- Direct visualization of the pudendal nerve and pelvic neuroanatomy
- Precise nerve decompression with minimally invasive robotic surgery
- Release of Alcock’s canal and surrounding adhesions
- Treatment of adjacent lumbosacral plexus nerves when needed
- Comprehensive approach to neuropathic pelvic pain
A key advantage of this approach is the ability to achieve direct access and excellent visualization of the entire greater sciatic region. This significantly expands the scope of treatment beyond isolated pudendal nerve decompression.
Through this extended exposure, it becomes possible to evaluate and, when indicated, address adjacent neural structures within the lumbosacral plexus, including regions contributing to:
- Low buttock pain
- Posterior thigh pain
- Radiating neuropathic pelvic pain
These symptoms are often related to inflammation or entrapment of nerves such as the posterior femoral cutaneous nerve and perforating cutaneous nerve, which travel in close proximity to the pudendal nerve.
This comprehensive approach allows for:
- Assessment of the broader neural network
- Release of adhesions affecting multiple nerve pathways
- Reduction of diffuse neuroinflammatory burden within the pelvis
As a result, when clinically indicated, surgery is not limited to a single nerve but instead provides a global decompression strategy of the lumbosacral plexus, addressing the full spectrum of neuropathic pelvic pain generators.
What to Expect
Minimally invasive robotic procedure
Typically outpatient or short stay
Procedure duration varies depending on complexity
Immediate decompression achieved at surgery
Recovery & Nerve Healing
Nerve recovery is gradual:
- Initial improvement may be seen within weeks
- Continued recovery over several months
- Adjunct therapies (medications, neuromodulation, targeted therapy with radiofrequency) may be used to optimize healing
Who is a candidate?
You may be a candidate if you have:
- Chronic pelvic pain with nerve-like symptoms
- Pain worsened by sitting
- Failure of conservative treatments
- Suspected or confirmed pelvic endometriosis
- Prior pelvic surgery with persistent symptoms
Why Robotic Intrapelvic Approach vs Traditional Pudendal Nerve Surgery
Traditional pudendal nerve decompression is commonly performed through transgluteal or transperineal approaches. While these techniques can provide access to portions of the pudendal nerve, they are inherently limited by their external access to the pelvis, restricting full visualization of the underlying pathology.
Limitations of Traditional Approaches
In transgluteal or transperineal surgery:
- The procedure is performed from outside the pelvic cavity, limiting visualization of the entire lumbosacral plexus
- Surgeons often rely on anatomic landmarks rather than direct visualization of the pathology
- Access to the nerve frequently requires wide dissection through gluteal or perineal tissues
- Important supporting structures, such as the sacrotuberous ligament, may need to be transected to reach the pudendal nerve
- These ligaments often require reconstruction, introducing potential risk of pelvic instability
Additionally, this approach may result in:
Most importantly, these approaches may not adequately address the root cause of the patient’s symptoms, as visualization of deeper intrapelvic pathology is limited
- Significant disruption of gluteal musculature
- Increased soft tissue trauma
- Higher postoperative pain levels
- Prolonged recovery time
Advantages of the Robotic Intrapelvic Approach
The robotic-assisted intraperitoneal approach allows direct access from within the pelvic cavity, fundamentally changing both visualization and surgical capability. This approach provides:
- Superior visualization of the entire lumbosacral plexus, including the pudendal nerve and adjacent neural structures
- Targeted, precision-based dissection, avoiding unnecessary disruption of surrounding tissues
- The ability to preserve key ligaments and musculoskeletal structures whenever possible
- Significantly less soft tissue trauma, leading to reduced postoperative pain and faster recovery
Addressing the Root Cause of Nerve Pain
A critical advantage of the intrapelvic robotic approach is the ability to identify and treat the underlying pathology, not just decompress the nerve.
Common causes of pudendal neuralgia and lumbosacral plexopathy include:
- Inflammatory adipose tissue adherent to nerve pathways
- Fibrosis and scar tissue
- Deep infiltrating endometriosis, often extending beyond the greater sciatic region into the pelvic cavity
These pathologies are frequently inaccessible or invisible through traditional external approaches.
With robotic intrapelvic access, the surgeon can:
- Mobilize and remove inflammatory nodules affecting nerve function
- Excise endometriotic lesions throughout the pelvic cavity
- Perform comprehensive neurolysis across multiple nerve pathways when indicated
Comprehensive, Safer, and Less Traumatic Surgery
Unlike traditional techniques that focus on a single segment of the nerve, the robotic approach enables a global assessment of the pelvic neuroanatomy, allowing treatment of both localized and diffuse disease. As a result, patients benefit from:
