Gynaecology Leaflet: Laparoscopic Procedures for the Treatment of Endometriosis of Pelvic Nerves and Entrapment

Leaflet Details

Patient Information

Introduction

This leaflet aims to help you understand how laparoscopic procedures on pelvic nerves are performed and what potential complications of such surgery are. Please read this carefully and consider all the information contained in this leaflet and ask any questions that you may have from us before making your decision.

What is Neuropelveology?

Neuropelveology is a new branch of medicine which deals with the disease of and surgery on the nerves of the pelvis. The pelvic area is full of very important nerves that supply structures such as bladder, rectum, vagina and it is also the passage that large nerves going to legs pass through. There are also important nerves in this area that are responsible for sexual function.

Surgical access to these nerves is not easy by conventional routes as these nerves are surrounded by the bony pelvis. With the advances in technology and progress in our knowledge of anatomy and as we have become better at performing very advanced gynaecological laparoscopic surgery, we have been able to see these nerves and attempt to perform surgery on these when, for example, they are invaded by endometriosis.

In what circumstances are neuropelviological procedures performed?

Pelvic nerves can be affected by various different diseases. Endometriosis, which is the growth of the tissue that lines the inside of the womb growing outside of the uterus is one. Endometriosis can invade deeply into tissues within the pelvis and other organs, and it can go so deep sometimes that can press on important nerves of the pelvis and may even invade into them starting to destroy these important nerves.

Fortunately, this is relatively rare, however, the more we understand pelvic nerves, the more we are able to recognise the diseases of the nerve and treat them.

A typical patient undergoing neuropelveological procedure often has very significant electric type shooting pain causing severe back pain and leg pain, difficulty in sitting with or without dysfunction in emptying the bladder.

Often all other measures have failed, and medical treatment is not enough to regain the quality of life that the woman needs.

What are neuropelveological procedures?

These can include simply exploring the nerves of the pelvis (neurolysis) to try and find the cause of the pain or removing endometriosis from the surface of pelvic nerves and also may include cutting part of a large nerve that is involved with endometriosis. Sometimes aberrant vessels can press on nerves inside the pelvis causing very severe pain and the neuropelviological procedure releases this pressure and removes the aberrant vessel. This is called “nerve detrapment”.

What does the research say?

Keeping in mind that neuropelveology is a very new branch of medicine, there is still not a great deal of research in the area. However, some studies have been performed and published in this area reporting good results from high quality surgery.

How much experience do we have in our centre performing neuropelveological procedures?

We are at the beginning of the road for performing surgery on pelvic nerves laparoscopically.

We are, however, very experienced in performing very difficult and advanced laparoscopic procedures for endometriosis that has extended deep into the pelvic structures. Neuropelveology is an extension of the same kind of surgery.

Mr Minas and Mr Adamczyk have had formal training at the International School of Neuropelveology under the mentorship of Professor Marc Possover, the pioneer of Neuropelveology. They have worked closely on select cases with Mr Khazali who has introduced Neuropelveology into the UK.

What other potential problems that can occur?

Injury to surrounding structures: Whenever we perform any surgery, there is a risk of unintentional injury to surrounding structures including bowel, bladder, blood vessels and ureters.

This risk is significantly higher when there has been previous surgery or there is severe endometriosis because these causes the organs to lose their normal anatomy and get adhered or glued together making it very difficult to perform the surgery.

This risk is even higher and also includes the risk of injury to nerves whenever we need to operate on the pelvic nerves. If the injury is recognised during the operation, we normally will endeavour to repair the injury, but this may require the big incision and open surgery.

Bleeding: To gain access to the nerves of the pelvis, we will need to work in the deepest areas of pelvis. These areas are not normally accessed during routine operations, including most cancer surgeries. The nerves are often very close to large vessels or complex network of veins, for example, on the sacral bone. Bleeding is not an uncommon complication in any surgery but the problem with bleeding during neuropelveological procedure is that it can often be difficult to control and may need additional procedures to do so.

Pain: Occurs very commonly after any procedure but after neuropelveological procedure having an excruciating pain even worse than the pain before surgery for a few weeks is not uncommon. This is called neuropathic pain and is the result of working around nerves and manipulating with surgical instruments. Normally this pain will require high doses of medication called Pregabalin and in most cases it is self-limiting. It is very important to consider this point very carefully as most patients who are referred from this kind of procedure already have a very high level of pain and imagining pain worse than this may be difficult.

Injury to nerves: Sometimes we will deliberately remove part of a nerve. For example, in case of endometriosis invasion into the sciatic nerve, the treatment may be to cut away part of the nerve (we always try and avoid this scenario if possible). The available research from Professor Possover suggests that this will lead to problems with movement and with walking and the patient may be reliant on crutches or even wheelchairs but in his research all patients have regained their movements, but this has taken up to five years. If this occurs, you will need intensive physiotherapy to make sure that the function is regained.

There is also a small risk of unintentionally cutting nerve that may be important for a function or a movement or sensation.

It is therefore extremely important to consider that neuropelviological procedures carry significantly higher risk than even the most complex of laparoscopic surgery. You need to have an in-depth discussion with your consultant and find answer to all your questions before deciding to go down surgery route.

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