Nerve Sparing and Surgery for Deep Infiltrating Endometriosis: Pessimism of the Intellect or Optimism of the Will

Nerve-sparing surgery is an emerging technique for surgery-related dysfunction. Within the past 15 years, an essential progress in recognition and understanding of the anatomy of the pelvic autonomous nervous system has been made. Surgical preservation of vegetative nerves has become well known in many cancer centers. The technique has led to improvement of the quality of life following oncologic radical procedures. Positive results have led to the adoption of such techniques in the surgical treatment of deep infiltrating endometriosis in an aim to prevent urinary, rectal, and sexual dysfunction. Even though nerve-sparing excision of endometriosis is feasible and offers good outcomes in terms of bladder morbidity; digestive and sexual functions seem to be more complex to assess. Moreover, functional impairment in deep infiltrating endometriosis may preexist prior to surgery and function may not be restored despite nerve preservation. In cases where endometriosis lesions are deeply embedded in the parametrium, nerve-sparing techniques may only be feasible in those with a unilateral involvement. The nerve-sparing surgical approach is therefore a safer radical surgery in the hands of experienced surgeons that has to be tailored to the unique nature of deep infiltrating endometriosis and balanced between the natural aggressiveness of such a debilitating disease and postoperative morbidity. Good knowledge of pelvic nerve anatomy and function allows understanding of related symptoms to reduce morbidity, whenever this goal is still achievable. -

- 1 Ercoli A, Delmas V, Gadonneix P , et al. Classical and nerve-sparing radical hysterectomy: an evaluation of the risk of injury to the autonomous pelvic nerves. Surg Radiol Anat 2003; 25 (3-4): 200-206 - 2 Long Y, Yao DS, Pan XW, Ou TY. Clinical efficacy and safety of nerve-sparing radical hysterectomy for cervical cancer: a systematic review and meta-analysis. PLoS One 2014; 9 (4) e94116 - 3 Zullo MA, Manci N, Angioli R, Muzii L, Panici PB. Vesical dysfunctions after radical hysterectomy for cervical cancer: a critical review. Crit Rev Oncol Hematol 2003; 48 (3) 287-293 - 4 Scotti RJ, Bergman A, Bhatia NN, Ostergard DR. Urodynamic changes in urethrovesical function after radical hysterectomy. Obstet Gynecol 1986; 68 (1) 111-120 - 5 Kim HO, Cho YS, Kim H, Lee SR, Jung KU, Chun HK. Scoring systems used to predict bladder dysfunction after laparoscopic rectal cancer surgery. World J Surg 2016; 40 (12) 3044-3051 - 6 Höckel M, Konerding MA, Heussel CP. Liposuction-assisted nerve-sparing extended radical hysterectomy: oncologic rationale, surgical anatomy, and feasibility study. Am J Obstet Gynecol 1998; 178 (5) 971-976 - 7 Possover M, Stöber S, Plaul K, Schneider A. Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type III. Gynecol Oncol 2000; 79 (2) 154-157 - 8 Li B, Zhang R, Wu LY, Zhang GY, Li X, Yu GZ. A prospective study on nerve-sparing radical hysterectomy in patients with cervical cancer [in Chinese]. Zhonghua Fu Chan Ke Za Zhi 2008; 43 (8) 606-610 - 9 Sun L, Wu LY, Zhang WH, Li XG, Song Y, Zhang X. Preliminary study of nerve sparing radical hysterectomy in patients with cervical cancer [in Chinese]. Zhonghua Zhong Liu Za Zhi 2009; 31 (8) 607-611 - 10 Lemos N, Possover M. Laparoscopic approach to intrapelvic nerve entrapments. J Hip Preserv Surg 2015; 2 (2) 92-98 - 11 Possover M. Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltrating rectovaginal and/or parametric endometriosis. Fertil Steril 2014; 101 (3) 754-758 - 12 Landi S, Ceccaroni M, Perutelli A , et al. Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible?. Hum Reprod 2006; 21 (3) 774-781 - 13 Ceccaroni M, Clarizia R, Bruni F , et al. Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial. Surg Endosc 2012; 26 (7) 2029-2045 - 14 Bonneau C, Zilberman S, Ballester M , et al. Incidence of pre- and postoperative urinary dysfunction associated with deep infiltrating endometriosis: relevance of urodynamic tests and therapeutic implications. Minerva Ginecol 2013; 65 (4) 385-405 - 15 Roman H, Bridoux V, Tuech JJ , et al. Bowel dysfunction before and after surgery for endometriosis. Am J Obstet Gynecol 2013; 209 (6) 524-530 - 16 Cavalini LT, Crispi CP, de Freitas Fonseca M. Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: a systematic review and meta-analysis. Neurourol Urodyn. - 17 Volpi E, Ferrero A, Sismondi P. Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis. Surg Endosc 2004; 18 (7) 1109-1112 - 18 Kavallaris A, Mebes I, Evagyelinos D, Dafopoulos A, Beyer DA. Follow-up of dysfunctional bladder and rectum after surgery of a deep infiltrating rectovaginal endometriosis. Arch Gynecol Obstet 2011; 283 (5) 1021-1026 - 19 Possover M, Quakernack J, Chiantera V. The LANN technique to reduce postoperative functional morbidity in laparoscopic radical pelvic surgery. J Am Coll Surg 2005; 201 (6) 913-917 - 20 Panel P, Huchon C, Estrade-Huchon S, Le Tohic A, Fritel X, Fauconnier A. Bladder symptoms and urodynamic observations of patients with endometriosis confirmed by laparoscopy. Int Urogynecol J Pelvic Floor Dysfunct 2016; 27 (3) 445-451 - 21 Roman H. Colorectal endometriosis and pregnancy wish: why doing primary surgery. Front Biosci (Schol Ed) 2015; 7: 83-93 - 22 Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg 2012; 255 (5) 922-928 - 23 Lee WY, Takahashi T, Pappas T, Mantyh CR, Ludwig KA. Surgical autonomic denervation results in altered colonic motility: an explanation for low anterior resection syndrome?. Surgery 2008; 143 (6) 778-783 - 24 Maytham GD, Dowson HM, Levy B, Kent A, Rockall TA. Laparoscopic excision of rectovaginal endometriosis: report of a prospective study and review of the literature. Colorectal Dis 2010; 12 (11) 1105-1112 - 25 Herbst F, Kamm MA, Morris GP, Britton K, Woloszko J, Nicholls RJ. Gastrointestinal transit and prolonged ambulatory colonic motility in health and faecal incontinence. Gut 1997; 41 (3) 381-389 - 26 Bridoux V, Gourcerol G, Kianifard B , et al. Botulinum A toxin as a treatment for overactive rectum with associated faecal incontinence. Colorectal Dis 2012; 14 (3) 342-348 - 27 Roman H, Milles M, Vassilieff M , et al. Long-term functional outcomes following colorectal resection versus shaving for rectal endometriosis. Am J Obstet Gynecol 2016; S0002-9378(16)30400-8 - 28 Roman H, Moatassim-Drissa S, Marty N , et al. Rectal shaving for deep endometriosis infiltrating the rectum: a 5-year continuous retrospective series. Fertil Steril 2016; S0015-0282(16)62527-X , In press