Dr. De Bisschop/Transperineal Approach

[winged_cent]

Hi all:

In June of this year, I had a left hip arthroscopy to fix up a labral tear, under the theory that this would help clear up my PN symptoms, which are predominantly left-sided as well. So far, no success on that front - though the hip itself feels great and therefore the arthroscopy was successful on its own terms.

I had the opportunity to visit Dr. Eric de Bisschop in Aubagne, France, and he did his staged sacral reflexes and pelvic ultrasound tests, which showed compression. He recommended decompression surgery.

As you may know, de Bisschop is one of the only physicians (the only other one I know of is Jacques Beco in Belgium) who continues to practice a version of the original "Shafik" transperineal method. He makes a small incision and then manually opens the Alcock's Canal and the fascia around the clamp between the sacrospinous and sacrotuberous ligaments without actually resecting any ligaments. He says that after 2 days in the hospital and a 8-10 day stay in France to recover, I should be ok to take a transatlantic flight and return to work maybe a week later.

I would note that while my PN is quite disturbing for me, it is much less severe than that of many others' on this forum. Basically it is a superficial tingling/burning in the distribution of the pudendal nerve, coupled with some loss of sensation (especially to heat/cold) in the distribution of the left nerve. I also have muscle pain/soreness on the left side of the coccygeal area, but physical therapy has not been sufficient to heal me (and nor did Dr. Andrew's shockwave in Canada help). However, it is fairly unrelenting and has been going on for several years. I feel that it is generally getting worse slowly - I am able to get through days ok because I have a standing desk at work.

Anyway, my thinking on surgery is that, especially since my pain levels are not super high, it would make sense to try the least invasive method which does not resect any ligaments, even if it is a less comprehensive surgery. I do wonder why the transperineal approach have been largely abandoned for the FAR more invasive and bloody TG approach (which is basically all we have in the USA). Dr. Bautrant's TIR approach may be less invasive, but still cuts ligaments and thus raises the specter of SIJD. I understand that the visualization of the nerve is much better in the other approaches, but there must be some class of patients who may be helped by a less drastic surgery

Of course de Bisschop swears that his surgery is almost always successful, but that is what all of the surgeons say, so I don't put much stock in that.

Thanks for any insight.

[chenonceau]

Hi all:

In June of this year, I had a left hip arthroscopy to fix up a labral tear, under the theory that this would help clear up my PN symptoms, which are predominantly left-sided as well. So far, no success on that front - though the hip itself feels great and therefore the arthroscopy was successful on its own terms.

I had the opportunity to visit Dr. Eric de Bisschop in Aubagne, France, and he did his staged sacral reflexes and pelvic ultrasound tests, which showed compression. He recommended decompression surgery.

As you may know, de Bisschop is one of the only physicians (the only other one I know of is Jacques Beco in Belgium) who continues to practice a version of the original "Shafik" transperineal method. He makes a small incision and then manually opens the Alcock's Canal and the fascia around the clamp between the sacrospinous and sacrotuberous ligaments without actually resecting any ligaments. He says that after 2 days in the hospital and a 8-10 day stay in France to recover, I should be ok to take a transatlantic flight and return to work maybe a week later.

I would note that while my PN is quite disturbing for me, it is much less severe than that of many others' on this forum. Basically it is a superficial tingling/burning in the distribution of the pudendal nerve, coupled with some loss of sensation (especially to heat/cold) in the distribution of the left nerve. I also have muscle pain/soreness on the left side of the coccygeal area, but physical therapy has not been sufficient to heal me (and nor did Dr. Andrew's shockwave in Canada help). However, it is fairly unrelenting and has been going on for several years. I feel that it is generally getting worse slowly - I am able to get through days ok because I have a standing desk at work.

Anyway, my thinking on surgery is that, especially since my pain levels are not super high, it would make sense to try the least invasive method which does not resect any ligaments, even if it is a less comprehensive surgery. I do wonder why the transperineal approach have been largely abandoned for the FAR more invasive and bloody TG approach (which is basically all we have in the USA). Dr. Bautrant's TIR approach may be less invasive, but still cuts ligaments and thus raises the specter of SIJD. I understand that the visualization of the nerve is much better in the other approaches, but there must be some class of patients who may be helped by a less drastic surgery

Of course de Bisschop swears that his surgery is almost always successful, but that is what all of the surgeons say, so I don't put much stock in that.

Thanks for any insight.

Hi Winged_cent,

I visited dr. De Bisschop myself a few days ago (i'm french) to get nerve blocks and asked him about the surgery too ; he was reassuring as well. I think it is a silly thing to say that you can return to work after like fifteen days of recovery. I think you should probably take the most time available to recover and move slowly back to activities and working. I know it's not always possible but...

I would say that in France (in terms of number of surgeries), the list goes like this (from most to less) :

Nantes (Robert)
Aix-en-Provence (Bautrant)
St Jean de Luz (Khalfallah)
Aubagne (De Bisschop)
Bordeaux (laparoscopic surgery)

and even smaller numbers in Strasbourg and Amiens.

Which gets you which approach is more popular. Once again, Nantes (Teaching hospital) are kind of leading in terms of research, publications, studies, so I would guess that what they kind of influence other people.

The thing you get from reading the french forums, where i see a good deal of post-surgery people, is that we are really lacking data about the outcome of surgeries. There has been attempts to survey the members on these forums but it's really hard to follow up through the years. Anyway from these attempts it seems that very few people are feeling worse post surgery, the majority are improved to various extents, and it doesn't seem that a patterns exists concerning the surgery technique used.

Concerning De Bisschop, some were improved, some others not. Hard to conclude anything. From the patient point of view i would say that the important thing is to get the surgery corresponding to your case. For instance you say that severing a ligament is bad (which is true) but if this particular ligament is causing the problem on your nerve then if you don't touch it you wouldn't probably improve as much.

[winged_cent]

Thank you for the detailed post!

Of course, there is the possibility that I would not improve if the ligament "clamp" is what is causing the problem. However, there is no reliable way to diagnose before surgery whether it is the Alcock's Canal or the clamp, and it seems that it would make sense to get the least invasive surgery first before going fully in and starting chopping up ligaments. I would also imagine that the fact that he does not cut ligaments and there is no dramatic resection of muscles in the transperineal approach as there is in the TG and TIR approaches would necessarily provide a much faster recovery time than the other methods. The fact that the surgery is less traumatic would also, I imagine, limit post-operative fibrosis.

I did speak to one person on the French board pudendalsite who said that he was improved (though not 100%) and that his post-operative pain was quite manageable. Did you ever encounter any cases where people said that De Bisschop's surgery made them worse?

[chenonceau]

Thank you for the detailed post!

Of course, there is the possibility that I would not improve if the ligament "clamp" is what is causing the problem. However, there is no reliable way to diagnose before surgery whether it is the Alcock's Canal or the clamp, and it seems that it would make sense to get the least invasive surgery first before going fully in and starting chopping up ligaments. I would also imagine that the fact that he does not cut ligaments and there is no dramatic resection of muscles in the transperineal approach as there is in the TG and TIR approaches would necessarily provide a much faster recovery time than the other methods. The fact that the surgery is less traumatic would also, I imagine, limit post-operative fibrosis.

I did speak to one person on the French board pudendalsite who said that he was improved (though not 100%) and that his post-operative pain was quite manageable. Did you ever encounter any cases where people said that De Bisschop's surgery made them worse?

I agree with your way of thinking.
From an extensive search on the french forum, i found some (three or four) but it dates back to several years ago (messages are spanning from 2007 to 2016). I think that several people have followed that path - from less to more invasive surgeries, it's way more logical than the other way around

It's true the TG technique is very invasive, but the given objective is to free the nerve on all of its way so there's not much choice apart from severing everything.

You can read about the published de Bisschop's results here if you haven't already : http://article.sapub.org/10.5923.j.ajmm ... 04.05.html. Also bear in mind that he was working in Aix with Beautrant before practising on his own so if you ask him he can probably tell you what he doesn't like about the TIR approach.

I would imagine that like any surgery (especially neurological) the definitive outcome also depends on general factors not relating to the technique (patient age, duration of symptoms, pre existing fibromyalgia or related condition, etc..).

Btw the Nantes team claims that the TG approach has been done on 2500 patients over the last 20 years.

The worst testimonies I've read recently are about the Bordeaux laparoscopic surgery which seems to be at its beginnings.

[winged_cent]

Yeah, I don't really trust any of the studies, including De Bisschop's. The statistics about high percentage recoveries within two days are just not credible.

He did not give me a very satisfactory response as to why he is virtually the only practitioner using his less-invasive method. Essentially he said that because Professor Robert is a big name at a big teaching hospital and he is not, this meant that the TG approach was widespread - hardly a credible answer. I think the true answer is that his method likely only works for people who have a weaker entrapment at the Alcock's Canal and does not work at all for those who are entrapped between ligaments. But given that the size of this population is likely more than zero, I still remain surprised that there is nobody that practices this method in the USA or elsewhere in Europe (except sort of Beco in Belgium).

Anyway, since nothing is cut and by all accounts he is an experienced practitioner and not a beginner, I think there is limited negative damage he can do with his finger and forceps, no? Which is more than can be said for all the other methods.

Are you considering the Aubagne surgery, chenonceau? If I were to get it, I think it would not be until next August because of my job, and because I want to allow for the possibility that the nerve starts improving spontaneously (I am 5 months after the labral tear surgery in the left hip and there has been no improvement in PN symptoms even as the hip feels almost perfect, but I know that "nerves take a long time to recover").

It's a shame that the laparoscopic method is no good yet. Theoretically it would seem to be the best approach which does not unnecessarily resect muscles to get in there and allows for full visualization of the nerve, but it seems that the skills, methods and results are not there yet. Have you heard of Dr. Possover in Switzerland? Hasn't he been doing laparoscopic pudendal surgeries for many years?

[chenonceau]

Yeah, I don't really trust any of the studies, including De Bisschop's. The statistics about high percentage recoveries within two days are just not credible.

He did not give me a very satisfactory response as to why he is virtually the only practitioner using his less-invasive method. Essentially he said that because Professor Robert is a big name at a big teaching hospital and he is not, this meant that the TG approach was widespread - hardly a credible answer. I think the true answer is that his method likely only works for people who have a weaker entrapment at the Alcock's Canal and does not work at all for those who are entrapped between ligaments. But given that the size of this population is likely more than zero, I still remain surprised that there is nobody that practices this method in the USA or elsewhere in Europe (except sort of Beco in Belgium).

Anyway, since nothing is cut and by all accounts he is an experienced practitioner and not a beginner, I think there is limited negative damage he can do with his finger and forceps, no? Which is more than can be said for all the other methods.

Are you considering the Aubagne surgery, chenonceau? If I were to get it, I think it would not be until next August because of my job, and because I want to allow for the possibility that the nerve starts improving spontaneously (I am 5 months after the labral tear surgery in the left hip and there has been no improvement in PN symptoms even as the hip feels almost perfect, but I know that "nerves take a long time to recover").

It's a shame that the laparoscopic method is no good yet. Theoretically it would seem to be the best approach which does not unnecessarily resect muscles to get in there and allows for full visualization of the nerve, but it seems that the skills, methods and results are not there yet. Have you heard of Dr. Possover in Switzerland? Hasn't he been doing laparoscopic pudendal surgeries for many years?

Please keep in mind that Robert has taught to foreign surgeons too ; and that de Bisschop is not a surgeon, neither a neuro surgeon. I think you shouldn't underestimate the way theses guys are criticizing each other's techniques .

Yes i'm considering it ; i'm currently waiting after a round of steroid injection by de Bisschop to see if it has any effect ; my main problem is that i'm not quite sure that it would address the numbness that i have, which is my main concern (lack of sensation when urinating, difficulty to urinate). Maybe my problem is located "higher" (near the sacral roots).

My pain levels are not that high so i'm kind of in between ; i have never had a surgery in my life (i'm 33) so not really willing to start. I'd like to have a consult from Nantes and Aix too, but i'm getting tired of all these doctors...

For the laparoscopic, it's true that it seems promising in theory ; the main brakes for this technique to spread would be the price of the robot in my opinion ; and the fact that in europe and france specifically it's really hard to get people to pay a lot of money even for surgeries. Possover is french but has a private practise in Switzerland I think he has done a lot of laparoscopic but i don't know if it's pudendal nerve entrapment specifically. Will have to check that.

Take care !

[Gabriel81]

Hi, I'm probably going to De Bisschop surgery too. Have you some news about your experiences? Thanks

[Gabriel81]

I report last e-mail exchange info with dr. De Bisschop:

I:

Dear dr. De Bisshop, I had no improvements after one month after second injections.

Before considering surgical option I whant take time to evaluate, I kindly ask you to answer to this important questions:

1) In my situation (intrapiriform oedema/hyperpressure, ecc.) you will use Trans-perineal approach with balloon probe sparing the ligaments or it is possible that a ligament cut will be necessary?

2) It is possible that my nerve have a "functional/neurological dysfunction" independent of the mechanical compression that can cause synptoms persistence after surgery? How you can estimate it?


Thanks for the attention.


He:

Hello,

I use perineal approach usine a balloon probe
Cutting ligament is for nothing : Thère is never conflict with ligament. 92% of the patients I operated get an improvment better than 80% (more than 2000 patients )

The pn dysfonction is due at the entrapment

Sincerly

[Violet M]

Gabriel, I wonder why these patients who are having such great success from Dr. de Bisschop don't post on the forum. Have you seen any of them posting on the French forum?

Violet

[Jason32]

92% of the patients I operated get an improvment better than 80% (more than 2000 patients )

I'd ask him to produce a randomized, controlled, peer-reviewed study that demonstrates this.

"Extraordinary claims require extraordinary evidence" - Carl Sagan