Laparoscopic Nerve-Sparing Radical Parametrectomy for Deep Lateral Parametrial Endometriosis

Abstract

<h3>Study Objective</h3> To demonstrate the anatomical and technical highlights of nerve-sparing radical parametrectomy for deep lateral parametrial endometriosis (LPE). <h3>Design</h3> Stepwise demonstration of this method with narrated video footage. <h3>Setting</h3> An urban general hospital. LPE may involves ureter, internal iliac vessels, inferior hypogastric plexus, pelvic splanchnic nerves, or sometimes sacral nerve roots. Although LPE is not overly rare, isolation of the autonomic nerves from LPE cannot always be guaranteed. In cases where endometriosis lesions are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except in cases with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to pelvic organ dysfunctions, which seriously affects quality of life. <h3>Patients or Participants</h3> A 38-year-old woman, para 1, presented with a five-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. MRI revealed right ovarian endometrioma with LPE reaching the lateral pelvic wall. <h3>Interventions</h3> Laparoscopic surgery. <h3>Measurements and Main Results</h3> Main outcome measures were releasing from severe pain, avoidance of postoperative morbidity and preservation of fertility. The procedure was performed using 8 steps, as follows: Step 1, adhesiolysis and adnexal surgery; Step 2, complete ureterolysis; Step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; Step 4, dissection of internal iliac vessels; Step 5, identification and dissection of sacral roots S2-S4 and pelvic splanchnic nerves; Step 6, complete removal of LPE; Step 7, hemostasis and assessment of tissue perfusion using ICG; and Step 8, application of barrier agents to prevent adhesion. The patient developed no perioperative complications, including postoperative bladder, rectal or sexual dysfunctions. Pain was completely resolved after surgery. <h3>Conclusion</h3> Laparoscopic nerve-sparing radical parametrectomy is technically safe and feasible for selected patients with LPE. Suitably tailored treatment should be provided for each individual, based on both the latest scientific evidence and life planning for the patient.