Surgical Neuropelviology: Combined Sacral Plexus Neurolysis and Laparoscopic Laterally Extended Endopelvic Resection in Deep Lateral Pelvic Endometriosis

Abstract

Surgical demonstration of combined sacral plexus neurolysis and laparoscopic laterally extended endopelvic resection for deep lateral infiltrating endometriosis. Design: Video showing principles of neurolysis and laparoscopic laterally extended endopelvic resection applied to endometriotic surgery. Setting: University tertiary referral center. Deep infiltrating endometriosis is an underestimated disease with real medical and clinical issues, recently classified as central pelvic endometriosis and lateral pelvic endometriosis further divided into superficial and deep according to the structures' involvement [1]. The surgical removal of endometriotic foci remains the standard treatment. A wide knowledge of neuroanatomy and high skills in minimally invasive surgery are required to manage this challenging surgical scenario [2]. Interventions: New surgical approach for deep lateral infiltrating endometriosis based on the principles of lateral extended endopelvic resection and neuropelviologic surgery [3,4]. The patient was a 35-year-old woman, para 1, with neuropathic pain radiating to the left leg and a cyclic menstrual disorder. A laparoscopically assisted neuronavigation and subsequent neurolysis allowed the identification of the lateral nodule without damage to the autonomic pelvic innervation [1]. Then, a complete resection of the internal vascular compartment was required to obtain a radical endometriotic eradication. Shaving and bladder resection were also performed to complete removal of the endometriotic foci. Conclusion:The association of neuroanatomic knowledge and surgical oncologic principles applied to minimally invasive surgery should be considered to ensure an adequate surgical radicality and clinical benefit in patients with deep infiltrating endometriosis.

Retroperitoneal Squamous Cell Carcinoma Involving the Pelvic Side Wall Arising from Endometriosis: A Case Report

“…Neuropelveology, an approach which identifies the neurologic pathway and the level of lesion with subsequent evaluation of the anatomical location of the disease, could be a new significant resource in the preoperative case preparation. With improved diagnostic accuracy and lesion expansion localization, the neuropelvelogic findings could help tailor the treatment and choose the most appropriate surgical approach [11, 20, 21]. In this context, in our case neuropelveologic assessment was suggestive of a sacral plexus involvement at a point between the supracardinal and the infracardinal level of sacral nerve roots with partial involvement of the autonomic innervation.…”

“…The incorporation of neuropelveology in cases of malignant endometriosis involving the lateral pelvic side wall could be necessary to ensure adequate surgical planning [13]. Moreover, in an effort to provide an innovative surgical approach to achieve complete resection in this subset of patients, L-LEER, based on the ontogenetic compartment theory, has been proposed [12, 20, 21]. In addition to definitive surgery, a regime of paclitaxel and carboplatin or cisplatin has been described as the treatment with best outcomes [8, 14].…”

Laterally extended endopelvic resection as part of the surgical management of disseminated retroperitoneal leiomyomatosis mimicking low-grade sarcoma in a patient with a solitary kidney

“…LEER was introduced in 1999 and was initially used in patients with recurrent cervical cancer who have had previous pelvic irradiation 17. More recently, this technique has been deployed in the surgical management of a variety of tumours extending into the pelvic sidewall, including lateral pelvic sidewall metastasis, uterine sarcomas and deep lateral pelvic endometriosis 18–20…”

Minimally invasive management for multifocal pelvic retroperitoneal malignant paraganglioma: a neuropelveological approach

“…Then the dissection of the tumour started, without direct manipulation, to avoid hypertensive crisis. A complete laparoscopic-assisted neuronavigation (LANN technique) was performed, following standardized approach [ 5 , 6 ], with isolation of the sciatic nerve and sacral routes, aimed to obtain the complete exposure of the main anatomic landmarks (Fig. 3 ).…”