Nonabsorbable polymer clip as a cause of chronic perineal pain after radical prostatectomy: Description of a case treated by transperineal approach

The occurrence of persistent perineal pain caused by surgical clips has rarely been described after radical prostatectomy (RP). We describe the case of a patient complaining of chronic perineal pain occurred soon after robotic RP, refractory to conventional medical therapy and exacerbated by the sitting position. Pain was related to a nonabsorbable polymer clip used to secure lateral pedicles. A transpeerineal approach was used to perform an hydrodissection of the rectovesical space at the level of the surgical clip combined with local injection of mepivacaine and betametasone. The patient experienced a clinically significant reduction of pain that remained stable at three months’ follow-up.

A Challenging Case of Ganglion Impar Block in a Patient with Coccygeal Deformity and Rectal Resection from Metastatic Rectal Cancer

The ganglion impar is a solitary retroperitoneal structure that marks the termination of paravertebral sympathetic chains in the presacral space and receives nociceptive inputs from pelvic organs. Chronic perineal pain (CPP) in patients with advanced cancer can be very debilitating. Ganglion impar block can ameliorate CPP and hence, improve quality of life. Here, we describe the case of a 65-year-old woman with a deformed coccyx caused by childhood trauma and rectal resection from rectal cancer who presented with CPP that substantially affected her quality of life. She was unable to tolerate the side effects of World Health Organization Step 3 analgesics. The patient underwent ganglion impar block that was challenging due to anatomical abnormalities. There was significant immediate and long-term improvement in quality of life and disease coping in our patient after the ganglion impar block. She was able to restore physical activity, decrease the need for potent opioids, and improve sleep quality. We conclude that a ganglion impar block can effectively treat CPP, and in palliative settings, neurolytic ablation can be considered. It is often challenging in patients with cancer due to anatomical abnormalities. Further studies are needed in patients with cancer who have CPP given the suggestion of a better quality of life after ganglion impar block. Key words: Ganglion impar, chronic perineal pain, quality of life, cancer pain, coccyx

S3 Dorsal Root Ganglion/Nerve Root Stimulation for Refractory Postsurgical Perineal Pain: Technical Aspects of Anchorless Sacral Transforaminal Lead Placement

Chronic perineal pain limits patients in physical and sexual activities, leading to social and psychological distress. In most cases, this pain develops after surgery in the urogenital area or as a consequence of trauma. Neuromodulation is one of the options in chronic postsurgical perineal pain treatment. We present a case of refractory perineal pain after right sided surgical resection of a Bartholin’s cyst which was treated with third sacral nerve root/dorsal root ganglion stimulation using the transforaminal approach. We describe a new anchorless lead placement technique using a unique curved lead delivery sheath. We postulate that this new posterior foraminal technique of lead placement is simple, safe, and reversible and may lower the occurrence of lead related complications.