Minimally-invasive procedure for pelvic leak points in women

Abstract

Pelvic leak points (PLP) may be responsible for vulvar, perineal and lower limb varicose veins, in women during and/or after pregnancy. The accurate anatomical and hemodynamic assessment of these points, the perineal (PP), inguinal (IP) and clitoral points (CP) and their surgical treatment under local anesthetics as defined by Claude Franceschi is a new therapeutic option. The aim of this study was to assess the reliability and durability of the PLP reflux ablation using a minimally-invasive surgical disconnection at the PLP level in women with varicose veins of the lower limbs fed by the PLP. In this open-label trial 273 pelvic leak points free of pelvic congestion syndrome, with at least a 12-month follow- up, were assessed. 273 PLP treated: PP (n=177), IP (n =91) and CP (n=5). Followup: Period =12 to 92 months (mean =30.51 months). Age from 29 to 77 years (mean=45). The only 3 patients over 70 years (71, 74, 77) showed a high-speed reflux from a I point that fed symptomatic varicose veins of the lower limb. Exclusion criteria: pelvic congestion syndrome, BMI>24, venous malformations, a post thrombotic varicose vein. Diagnosis was performed using echo duplex and PLPs selected for treatment when refluxing at Valsalva + Paraná + squeezing maneuvers. A surgical skin marking of the PLP had been performed using echo duplex before surgery. Surgery consisted of minimally invasive dissection and selective division and ligation with non-absorbable suture of the refluxing veins and fascias at the PP, IP and CP pelvic escape points, under local anesthesia in a single center. The follow-up consisted of an echo duplex ultrasound, searching for reflux at the PLP treated thanks to the Valsalva maneuver, within 2 weeks, after 6 and 12 months and then yearly. The main endpoint of the study was the immediate elimination of the reflux at the PLP treated. The second endpoint was the long-term durability of the reflux ablation at the PLP treated. 267 (97.8%) without PLP reflux redo. 6 (2.2%) PLP reflux recurrences (PP=4, IP=1, CP 1). 3 patients with PLP reflux recurrence undergo a redo surgery (1.1%) where PP=2 (0.7%) and IP=1 (0.3%). This study shows the feasibility and durability of reflux ablation at the PLP level thanks to a minimally-invasive surgical treatment of the PLP and it demonstrates that there is no need for pelvic varicose embolization in patients without clinical signs of pelvic congestion syndrome. The accurate ultrasound assessment of each specific pelvic leak as well as a special surgical technique (vein division, non-absorbable suture of veins and fascias) seems to be the key for satisfactory outcomes.