Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis

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Abstract
Nerve sparing is suggested for cancer surgery, but no experience is available for deep endometriosis. The aim of this study was to laparoscopically identify the pelvic nerves in the posterior pelvis. A total of 24 patients operated for deep endometriosis were considered. During surgery and on videotapes of the procedures, we evaluated single- or double-sided resection of the uterosacral ligaments and other structure’s visualization of the inferior hypogastric and the splanchnic nerves. The most important objective criteria for resection of the nerves was urinary retention after surgery, which was compared to surgical resection on the videotapes. Visualization of the inferior hypogastric nerves was possible in 20 of 22 patients (90.1%). Eight of the 24 patients had at least one inferior hypogastric nerve resected (33.3%). In seven patients (29.2%) resection of the uterosacral ligaments was bilateral, and in three of these the nerves were resected. Postoperatively, the median residual urine volume after the first spontaneous voiding was 40 ml (range, 20–400). Seven of eight patients (29.2%) with resection of the nerves had urinary retention and self-catheterization at discharge. The difference in urinary residuum after first voiding between patients undergoing self-catheterization and patients released without the catheter was significant (p < 0.01). The median time to resume the voiding function in patients with self-catheterization was 18 days (range, 9–45). Nerve visualization is possible by means of laparoscopic surgery for deep endometriosis in a high rate of patients. Careful technique is necessary, but the laparoscopic approach may help. Even single-sided radical dissection can induce important urinary retention.