Modified Nerve-Sparing Radical-Like Hysterectomy for Deep Infiltrating Endometriosis

Abstract

Endometriosis is a common gynecologic disease, affecting up to 11 % of premenopausal women. Typical symptoms of endometriosis include dysmenorrhea, dyspareunia and chronic pelvic pain. In its deep invasive form, endometriosis has the potential to infiltrate organs and ligaments, including the recto-vaginal septum, the parametria, the rectosigmoid, the ureters and the bladder. These anatomical structures are in strict contiguity to several autonomic nerves that provide their neural supply to the pelvis, particularly to the vagina, the anal sphincter and the bladder. In order to preserve the function of these organs, surgical treatment for deep infiltrating endometriosis should take into account the distribution of the ortho- and para-sympathetic fibers to the pelvis and in particular the routes of the hypogastric nerves, the pelvic splancnic nerves and the pelvic plexus. The opening and development of the paravesical and pararectal spaces, the isolation of the ureter and the preservation of the neural fibers running in the mesoureter are crucial, to avoid denervation of the pelvis. A nerve-sparing approach to hysterectomy for deep endometriosis is possible, if operators with a thorough anatomical knowledge of the pelvic neural supply and a meticulous surgical technique are available.