Postoperative Outcomes after Surgery for Deep Endometriosis of the Sacral Plexus and Sciatic Nerve: A 52-patient Consecutive Series

Abstract

To assess 1-year postoperative outcomes of surgery for deep endometriosis involving the sacral roots and sciatic nerve. Design: Retrospective case series. Setting: Three referral centers. Patients: Fifty-two women. Interventions: Surgery for deep endometriosis involving the sacral roots and sciatic nerve. Measurements and Main Results: Deep endometriosis involved the sacral roots in 49 women (94.2%) and the sciatic nerve in 3 cases (5.8%). Sciatic pain (buttock or leg) was recorded in 43 women (82.7%), pudendal neuralgia in 11 women (21.2%), and leg motor weakness in 14 cases (27%). The surgical procedures carried out on the pelvic nerves included complete release and decompression (92.3%), excision of the epineurium by shaving (5.8%), and intraneural excision (1.9%). Additional major surgical procedures involved the digestive tract in 82.7% of the cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of the cases. Self-catheterization was required in 14 cases (27%) at 3 weeks after surgery and in 3 women (5.8%) 12 months later. One-year follow-up showed significant improvement in quality of life measured using the Short-Form 36 questionnaire and standardized gastrointestinal scores. De novo hypoesthesia, hyperesthesia, or allodynia were recorded in 9 women (17.2%). The cumulative pregnancy rate was 77.2%% after natural conception in 47%. Conclusion: Laparoscopic management of deep endometriosis involving the sacral roots and sciatic nerve improves patients' symptoms and overall quality of life. Although pain reduction may be rapid after surgery, other sensory or motor complaints, including bladder dysfunction, may be recorded over months or years. Journal of Minimally Invasive Gynecology (2020) 00, 1−9.

Stepping safely into the tiger country of endometriosis: approaching sacral endometriosis

“…When compared with patients with DIE alone, those with DIE also involving the lateral parametrium have a higher risk of perioperative complication and need for self-catheterization for urinary retention postoperatively (4). A similar risk of bladder dysfunction has been reported in patients undergoing excision of DIE involving the sacral plexus, although this impairment in bladder function improves over time in many cases (2,5). Rectovaginal and urinary tract fistulae have also been reported (5).…”

“…Deeply infiltrating endometriosis involving the parametrium and pelvic nerves may present with neuropathic pain in the distribution of the affected nerves, bowel or bladder dysfunction and typical pelvic pain, dysmenorrhea, dyspareunia, and dyschezia associated with endometriosis. Additionally, the bowel, bladder, and ureter may also be involved, potentially resulting in associated hydronephrosis or bowel stenosis (2)(3)(4)(5). In these rare cases, surgical treatment of the disease requires knowledge of the relevant anatomy and a structured, thoughtful approach to ensure safety and efficiency.…”

“…Pelvic MRI has a reported sensitivity of 83.3% and specificity of 98.6% in the evaluation of lateral parametrial endometriosis (4). Pelvic MRI can also help identify concomitant DIE involvement of the bowel, bladder, ureter, or vagina, which has been reported to be as high as 87.1%, 21.4%, 24.3%, and 84.6%, respectively (2,5). Specific MRI sequences for targeted evaluation of the sacral plexus and any other nerves suspected to be involved with DIE should also be obtained for optimal perioperative planning.…”

“…Specific MRI sequences for targeted evaluation of the sacral plexus and any other nerves suspected to be involved with DIE should also be obtained for optimal perioperative planning. The use of pelvic ultrasound and computed tomography for the evaluation of these lesions has also been described; however, lesser data are available for these modalities for these specific types of lesions (2).…”

Surgical Management by Disk Excision or Rectal Resection of Low Rectal Endometriosis and Risk of Low Anterior Resection Syndrome: A Retrospective Comparative Study

“…The plexus may be infiltrated by deep endometriosis nodules, particularly when they are located in the parametrium or involve the sacral plexus. In these cases, nerve-sparing may be impossible because the nerves are inside fibrous lesions [37,38]. Injuries of hypogastric plexus or splanchnic nerves by either disease or surgery may be followed by abnormal bowel movements, constipation, or dyschezia.…”