[Deep infiltrating endometriosis surgical management and pelvic nerves injury].
OBJECTIVE
Deep pelvic endometriosis surgery may need substantial excisions, which in turn expose to risks of injury to the pelvic nerves. To limit functional complications, nerve-sparing surgical techniques have been developed but should be adapted to the specific multifocal character of endometriotic lesions. The objective was to identify the anatomical areas where the pelvic nerves are most at risk of injury during endometriotic excisions.


METHODS
The Medline and Embase databases have been searched for available literature using the keywords "hypogastric nerve or hypogastric plexus [Mesh] or autonomic pathway [Mesh], anatomy, endometriosis, surgery [Mesh]". All relevant French and English publications, selected based on their available abstracts, have been reviewed. Five female adult fresh cadavers have been dissected to localize the key anatomical areas where the pelvic nerves are most at risk of injury.


RESULTS
Six anatomical areas of high risk for pelvic nerves have been identified, analysed and described. Pelvic nerves can be damaged during the dissection of retrorectal space and the anterolateral rectal excision. Furthermore, before an uterosacral ligament excision, a parametrial excision, a colpectomy or a dissection of the vesico-uterine ligament, the hypogastric nerves, splanchnic nerves, inferior hypogastric plexus and its efferent pathways must be mapped out to avoid injury. The distance between the deep uterin vein and the pelvic splanchnic nerves were measured on four cadavers and varied from 2.5cm to 4cm.


CONCLUSIONS
Six key anatomical pitfalls must be known in order to limit the functional complications of the endometriotic surgical excision. Applying nerve-sparing surgical techniques for endometriosis would lead to less urinary functional complications and a better short-term postoperative satisfaction.
Service de gynécologie obstétrique et de médecine de la reproduction, CHI Poissy-Saint-Germain-en-Laye, 78303 Poissy cedex, France.
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Fermaut
Inserm UMR 1195, université Paris Sud, université Paris-Saclay, 94270 Le Kremlin-Bicetre, France.
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Nyangoh Timoh
Inserm UMR 1195, université Paris Sud, université Paris-Saclay, 94270 Le Kremlin-Bicetre, France.
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Lebacle
Inserm UMR 1195, université Paris Sud, université Paris-Saclay, 94270 Le Kremlin-Bicetre, France.
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Moszkowicz
Inserm UMR 1195, université Paris Sud, université Paris-Saclay, 94270 Le Kremlin-Bicetre, France; Service d'urologie, hôpitaux universitaires Paris-Sud, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France.
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Benoit
Inserm UMR 1195, université Paris Sud, université Paris-Saclay, 94270 Le Kremlin-Bicetre, France; Service d'urologie, hôpitaux universitaires Paris-Sud, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France. Electronic address: thomas.bessede@bct.aphp.fr.
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Bessede
D004715:Endometriosis / Q000601:surgery*; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects*; D006801:Humans; D007001:Hypogastric Plexus / Q000293:injuries*; D016239:MEDLINE; D010388:Pelvis / Q000294:innervation*; D011183:Postoperative Complications; D012307:Risk Factors
Anatomie; Anatomy; Chirurgie; Endometriosis; Endométriose; Hypogastric nerve; Hypogastric plexus; Nerf hypogastrique; Plexus hypogastrique; Surgery