Laparoscopic management of deep endometriosis involving the sacral roots and the sciatic nerve improves patient symptoms and overall quality of life, according to a retrospective case series.
The study in theJournal of Minimally Invasive Gynecology also concluded that although pain reduction may be rapid following surgery, other sensory or motor complaints might persist for months to years.
“The study assessed 1-year postoperative outcomes in patients managed for big endometriosis nodules involving the sacral plexus, which control bowel and bladder function, motility and sensitivity of perineum, buttock and inferior leg,” said principal investigator Horace Roman, MD, PhD, an endometriosis surgeon at the Endometriosis Center of the Clinic Tivoli-Ducos in Bordeaux, France.
The study comprised 52 women managed by Dr. Roman in three nearby referral centers, for deep endometriosis involving the sacral roots and the sciatic nerve from October 2016 to April 2019.
Deep endometriosis involved the sacral roots in 94.2% of cases and the sciatic nerve in the remaining 5.8% of cases. Sciatic pain (buttock or leg) was observed in 82.7% of cases, pudendal neuralgia in 21.2% and leg motor weakness in 27% of cases.
For surgical procedures of the pelvis nerves, Dr. Roman performed complete releasing and decompression in 48 patients (92.3%), excision of epineurium by shaving in three patients (5.8%) and intraneural excision in one patient (1.9%).
The digestive tract was involved in 82.7% of overall cases and the urinary tract in 46.2%. Rectovaginal fistula occurred in 13.5% of cases.
Self-catheterization was required in 27% of cases at 3 weeks after surgery and in 5.8% of cases at 1 year.
One-year follow up also showed significant improvement in quality of life using the 36-Item Short Form Survey (SF-36) and standardized gastrointestinal scores.
De novo hypoesthesia, hyperaesthesia or allodynia were recorded in 17.2% of cases.
After a mean follow up of 2 years, the cumulative pregnancy rate was 77.2%, with natural conception in 47% of these cases.
“We were satisfied to observe a major improvement of patients’ overall quality of life and pain, as well as favorable fertility outcomes,” Dr. Roman told Contemporary OB/GYN. “However, we were surprised to discover that the impact of these large lesions was not confined to the sacral plexus, but also affected the low rectum, the vagina, the bladder and ureters in a majority of cases.”
These findings resulted in a complex surgical procedure, “where the dissection of pelvic nerves represented only one step of the surgery, and sometimes not the most challenging step,” Dr. Roman said. In addition, major unfavorable postoperative outcomes were related to both nerve dysfunction and complications related to other pelvic organs, particularly to low rectal fistulae.
“Our study provides a good oversight on preoperative baseline complaints in patients with deep endometriosis involving the sacral plexus, as well as on standardized surgical procedures performed in these patients,” Dr. Roman said. “The study also estimated the probability of postoperative clinical improvement, plus the risk of major complications following this particular type of complex surgery.”
The data should be part of the information that patients receive preoperatively and will help with informed choice, according to Dr. Roman.
Furthermore, the study provides the basis to create a standardized step-by-step approach to deep endometriosis involving the sacral plexus, “which are reproducible and feasible in experienced hands, and prevents intraoperative complications,” Dr. Roman said.
Dr. Roman hopes the study will be followed by larger multicenter trials of experienced surgical teams from various countries to provide more detailed data on the reproducibility of complex surgeries worldwide and the risk of rare intraoperative or postoperative complications and their successful management.
Dr. Roman receives personal fees from Plasma Surgical Inc., Ethicon, Olympus and Nordic Pharma for surgeon workshops.