Real-time nerve mapping for endometriosis involving the sciatic and pudendal nerves

OBJECTIVE: To demonstrate a standardized and reproducible technique utilizing intraoperative neurophysiological monitoring (IONM) with real-time nerve mapping to improve the safety of deep infiltrating endometriosis surgery and facilitate the preservation of deep pelvic nerves. DESIGN: Video article. SUBJECTS: A 36-year-old woman presented with chronic right-sided pelvic pain, including severe sciatic and pudendal nerve symptoms. The patient included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, etc.) and other applicable sites. EXPOSURE: Laparoscopic excision of deeply infiltrative endometriosis performed with the assistance of IONM to preserve motor nerve functions. Motor-evoked potentials were used to continuously assess the functional integrity of the sciatic, obturator, and pudendal nerves. Additionally, the S1 nerve root was indirectly monitored via the H-reflex, providing real-time feedback on sciatic nerve function. To evaluate the sacral roots involved in continence (S2-S4), a custom 3D-printed Foley catheter with embedded electrodes was used to monitor pudendal nerve activity. MAIN OUTCOME MEASURES: The endometriosis excision was completed without complications, with IONM verifying the functional integrity of all major pelvic nerves. RESULTS: The excision procedure was successfully completed without intraoperative complications. Intraoperative neurophysiological monitoring verified continuous functional integrity of the sciatic, obturator, and pudendal nerves throughout the procedure. Postoperatively, the patient reported significant improvement in right-sided neuropathic pain and restored mobility. No new motor or sensory deficits were observed. CONCLUSION: Multimodal IONM enabled safe and effective nerve-sparing excision of deeply infiltrative endometriosis involving the sciatic and pudendal nerves, highlighting the value of this innovative approach in advancing the safety and precision of complex surgery.