Pelvic pain is a common condition among reproductive-age women between the ages of 16 and 55. However, the cause of pelvic pain is often misunderstood, leaving many women frustrated after trying numerous treatments that fail to alleviate their symptoms.
According to Khashayar Shakiba, M.D., division director of Urogynecology and Pelvic Reconstructive Surgery at Hackensack Meridian Hackensack University Medical Center, the cause of pelvic pain is often due to inflammation or irritation of the pelvic nerve. Pelvic nerve inflammation can be caused by gynecological conditions such as endometriosis or fibroids, making an accurate diagnosis key to successful treatment.
To advance the medical community’s understanding of this common condition, Dr. Shakiba is using robotic surgical technology to accurately diagnose and treat the underlying cause of pelvic pain and related symptoms of pelvic floor dysfunction.
Women may experience persistent pelvic pain or pelvic pain that comes and goes. Pelvic pain is often accompanied by other symptoms, including urinary frequency and urgency, frequent urination during the night, bowel movement dysfunction, bloating, and pain during sex.
As a result, pelvic neuropathy is often misdiagnosed as irritable bowel syndrome, interstitial cystitis or other bladder disorders, rendering treatments for those conditions ineffective.
According to Dr. Shakiba, these symptoms are often caused by an underlying inflammatory condition that leads to irritation and hyperexcitability of the pelvic nerves. The ongoing inflammatory insult of common diseases such as endometriosis could start a vicious cycle and lead to centralization of the pain and conditions such as allodynia — or the experience of pain from stimuli that isn’t usually painful. That’s why pelvic pain can become more generalized and involve the lower back, lower extremities and beyond.
Unfortunately, these vicious cycles of events also reduce pain tolerance. Therefore, painless stimuli for someone without pelvic nerve inflammation can be perceived as painful for the affected patient.
“Pelvic nerves can become inflamed due to endometriosis, pelvic infection, fibroid tumors, peripheral neuropathy, autoimmune conditions or trauma during childbirth leading to pelvic organ prolapse,” said Dr. Shakiba. “However, inflamed pelvic nerves don’t show up on imaging, so you can’t really see what is going on unless you go in surgically and take a look.”
“It’s critical to diagnose and surgically remove these sources of inflammatory insult early to prevent the cascade of very damaging events on the pelvic nerves,” said Dr. Shakiba. “It’s like replacing the lightbulb when a light isn’t working, but the problem is actually in the wiring.”
Robotic Surgery for Pelvic Pain
The pelvic anatomy contains a complex network of nerves, tissues, and organs — many of which are not fully reachable during traditional open surgery. However, advances in robotic surgical technology have allowed surgeons to safely explore pelvic anatomy during minimally invasive procedures, improving surgeons’ understanding of how certain conditions affect the pelvic nerve.
Hackensack University Medical Center gynecologic surgeons perform robotic surgery procedures using the state-of-the-art da Vinci robotic surgical system. Two to three of the system’s robotic arms hold small surgical instruments, and another arm holds a small video camera. The instruments and camera are inserted into the body through small incisions in the abdomen. The camera transmits a magnified 3D video image of the pelvic anatomy onto a screen at the surgical console, where the surgeon sits and controls the robot.
Hackensack University Medical Center’s gynecological surgeons also have access to the da Vinci SP single-port robotic surgical system, which allows them to perform complex surgical procedures through a single, half-inch incision.
As with any robotic surgery, patients who have robotic surgery to treat pelvic pain can expect a faster recovery due to smaller incisions, improved cosmetic results, and less trauma to the body. But Dr. Shakiba said the magnified view and increased precision provided by the robotic surgical system make it possible to identify and treat many causes of pelvic pain.
“Abnormal tissue growth caused by endometriosis, pelvic peritoneal inflammation, and [benign tumors called] fibroids are a few common causes of pelvic nerve irritation,” said Dr. Shakiba. “When I go in with the robot, I can inspect the pelvic area and remove the tumor, lesion or other source of insult, which reduces the inflammation and can improve pain and other problems caused by pelvic floor dysfunction.”
When used by a skilled surgeon, the precision of robotic surgery also reduces the risk of trauma to the pelvic nerve itself and major vessels and structures such as the ureter, rectum, and bladder.
“It’s tough, complex anatomy, but using the robot makes [the pelvic anatomy, and more specifically the pelvic nerves] much more accessible and allows the surgeon to have a superior visibility and precision to see small lesion and remove it without damaging the underlying nerves,” said Dr. Shakiba.
Advancing Pelvic Pain Treatment
Although there has been significant improvement in the medical community’s understanding of the role of pelvic nerve inflammation in pelvic pain in the past decade, Dr. Shakiba said it’s still an underserved field.
“Lots of women are living with pelvic pain and some of them have seen 10 different specialists, but no one addresses the pelvic nerve,” said Dr. Shakiba.
By conducting research, educating other surgeons on his pioneering robotic surgery techniques, and delivering outstanding surgical outcomes for his patients, Dr. Shakiba is hoping to change that.
“It’s a major quality of life issue,” said Dr. Shakiba. “I have patients who were getting up every hour at night to use the bathroom, and after surgery, the problem goes away.”