Refractory Endometriosis

Definition

Endometriosis is a benign but painful chronic proliferation of the uterine lining (endometrium) outside the uterus. It is particularly painful when it involves the sacral nerve plexus, which contains most of the nerves that innervate the legs and all of the nerves that innervate the pelvic floor (pudendal nerve).

Patients suffering from endometriosis experience severe nerve pain (ischialgia or pudendal pain), especially during menstruation. The sacral plexus is also the starting point for the nerves that are responsible for bladder emptying, intestinal evacuation and sensory perception of the innervated organs. Endometriosis that involves these nerves can adversely affect the perception of an empty or full bladder. Miction disturbance (such as the necessity for pressure by the abdominal muscles) or bowel movement disturbance (such as chronic constipation) may also occur.

Diagnosis is complicated by the fact that such endometriotic foci are rarely identifiable on CT scans or by IRM. As a result, patients affected by endometriosis often receive medication as sole treatment. Their pain is said to be idiopathic because the underlying cause cannot be identified or remains imprecise.

The possibility of this type of endometriosis must be discussed with every woman of child-bearing age who experiences onset or significant worsening of pelvic neuralgia during her menstruation. Laparoscopy is clearly recommended in such cases. If no anomaly is revealed by echography, during pre-operative examination, or through laparoscopic examination of the small pelvis, isolated endometriosis that affects e.g. the sciatic nerve may be considered as a possible cause of the symptoms. A definitive diagnosis often requires more than a laparoscopic examination of the small pelvis. In order to exclude the possibility of such a disorder, precise visualization of the pelvic nerves, particularly the sciatic nerve, is essential.

Patients suffering from nerve endometriosis often undergo pharmacological treatment lasting many years. This often fails to yield satisfactory results and the medication prescribed may cause adverse side effects.

Treatment

Refractory endometriosis is often best treated using laparoscopy. Indeed, microscopic vision and micro neurosurgical methods are the key to successful treatment. Open surgery is inappropriate when operating on fine nerves located deep inside the small pelvis. Prof. Possover has developed and refined a number of different state-of-the-art laparoscopic techniques to treat endometrioses of the fine pelvic nerves.

These techniques rely on detailed knowledge of neurology, neurosurgery, gynaecology and laparoscopic and oncological surgery.