Multimodal neurophysiological monitoring during laparoscopic pelvic nerve decompression in deep endometriosis: results from a prospective single-center cohort
Main Article Content
Abstract
Objective: To describe the technique and assess the clinical utility of intraoperative neurophysiological monitoring (IONM) during laparoscopic pelvic nerve decompression in women with deep endometriosis, with a focus on its integration into surgical workflow and its role in preserving pelvic neurological function.
Methods: A prospective descriptive case series was conducted at a Latin American tertiary center between January 2024 and May 2025. Fourteen women with MRI-confirmed deep endometriosis and pelvic nerve involvement underwent laparoscopic decompression assisted by a multimodal IONM protocol. Data on demographics, intraoperative findings, neurophysiological alerts, and clinical symptoms were recorded. Postoperative outcomes were assessed at 1, 3, and 6 months. Descriptive statistics were applied.
Results: A prospective follow-up was conducted in 14 patients, with clinical outcomes evaluated from a minimum of 1 month (92.9%) to up to 6 months (85.7%) postoperatively. All patients exhibited preoperative evidence of nerve compression, most commonly affecting the sciatic (57.1%) and pudendal (50%) nerves. Multimodal intraoperative neurophysiological monitoring (IONM) was successfully implemented in all cases (100%) without any major intraoperative complications. At the 1-month follow-up, 78.6% of patients reported symptom improvement, with sustained clinical benefit observed in 75% at 6 months. No permanent motor deficits were noted, and all transient postoperative symptoms resolved spontaneously. The most frequently improved symptoms included dyschezia, urinary dysfunction, and chronic pelvic pain.
Conclusion: Laparoscopic pelvic nerve decompression with real-time IONM is a safe and reproducible technique that may enhance surgical outcomes and neurological preservation in patients with deep endometriosis. The present study provides foundational evidence for its systematic incorporation in Latin American surgical practice, though larger and controlled studies are warranted to confirm these findings and evaluate long-term efficacy.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Gundogdu EC, Kale A, Mercan M, et al. Integration of Intraoperative Neurophysiological Monitoring into Laparoscopic Pelvic Nerve Decompression Surgery: A Novel Technique for Protecting Pelvic Nerves. Clin Exp Obstet Gynecol. 2023;50(9):198. doi:10.31083/J.CEOG5009198/2709-0094-50-9-198/FIG8.PNG
3. Possover M. Neuropelveology: An Emerging Discipline for the Management of Pelvic Neuropathies and Bladder Dysfunctions through to Spinal Cord Injury, Anti-Ageing and the Mars Mission. Journal of Clinical Medicine 2020, Vol 9, Page 3285. 2020;9(10):3285. doi:10.3390/JCM9103285
4. Possover M, Forman A. Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression. Accessed May 10, 2025. www.painphysicianjournal.
5. Kale A, Basol G, Topcu AC, Gundogdu EC, Usta T, Demirhan R. Intrapelvic Nerve Entrapment Syndrome Caused by a Variation of the Intrapelvic Piriformis Muscle and Abnormal Varicose Vessels: A Case Report. Int Neurourol J. 2021;25(2):177. doi:10.5213/INJ.2040232.116
6. NUCELIO LEMOS KKCPSPPAG. Laparoscopic approach to intrapelvic nerve entrapments. Pelviperineology. doi:10.34057/PPJ
7. Possover M, Chiantera V, Baekelandt J. Anatomy of the sacral roots and the pelvic splanchnic nerves in women using the LANN technique. Surg Laparosc Endosc Percutan Tech. 2007;17(6):508-510. doi:10.1097/SLE.0B013E31812F81E4
8. Possover M, Baekelandt J, Flaskamp C, Li D, Chiantera V. Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall. Minimally Invasive Neurosurgery. 2007;50(1):33-36. doi:10.1055/S-2007-970075,
9. Puntambekar S, Manchanda R. Surgical pelvic anatomy in gynecologic oncology. International Journal of Gynecology and Obstetrics. 2018;143: 86-92. doi:10.1002/IJGO.12616,
10. Marc Possover NEUROPELVEOLOGY Latest Developments in Pelvic Neurofunctional Surgery PROGRESS IN PELVIC RESEARCH.
11. Possover M. Five-Year Follow-Up After Laparoscopic Large Nerve Resection for Deep Infiltrating Sciatic Nerve Endometriosis. J Minim Invasive Gynecol. 2017;24(5):822-826. doi:10.1016 /j.jmig.2017.02.027
12. Lemos N, Sermer C, Fernandes G, et al. Laparoscopic approach to refractory extraspinal sciatica and pudendal pain caused by intrapelvic nerve entrapment. Sci Rep. 2021;11(1):1-7. doi:10. 1038/S41598-021-90319-Y;SUBJMETA=308,375,6 17,692;KWRD=MEDICAL+RESEARCH,NEUROLOGICAL+DISORDERS
13. Gundogdu EC, Kale A, Mercan M, et al. Integration of Intraoperative Neurophysiological Monitoring into Laparoscopic Pelvic Nerve Decompression Surgery: A Novel Technique for Protecting Pelvic Nerves. Clin Exp Obstet Gynecol. 2023;50(9):198. doi:10.31083/J.CEOG5009198/2709-0094-50-9-198/FIG8.PNG
14. Allahqoli L, Hakimi S, Momenimovahed Z, et al. Neuropelveology for Endometriosis Management: A Systematic Review and Multilevel Meta-Analysis. J Clin Med. 2024;13(16). doi:10.3390/JCM13164676,
15. Kong X, Chai W, Chen J, Yan C, Shi L, Wang Y. Intraoperative monitoring of the femoral and sciatic nerves during total hip arthroplasty in high-riding developmental dysplasia of the hip. Bone Joint J. 2019;101-B(12):1438–1446. doi: 10.1302/0 301-620X.101B11.BJJ-2019-0341.R2
16. Garry R. Laparoscopic surgery: best practice and research. Clin Obstet Gynecol. 2006;20(1):89–104. doi: 10.1016/j.bpobgyn.2005.10.003
17. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149–158. doi: 10.1016/S0304-3959(01)00349-9
18. Kneist W, Kauff DW, Lang H. Laparoscopic neuromapping in pelvic surgery: areas of application. Surg Innov. 2014;21(2):213–220. doi: 10.1177/1553350613496907
19. Zentner J. Noninvasive monitoring of motor evoked potentials during spinal cord neurosurgery. Neurosurgery. 1989;24(5):709–712. doi:10.1227/0 0006123-198905000-00008
20. Tsutsui S, Yamada H. Basic principles and recent trends of transcranial motor evoked potentials in intraoperative neurophysiological monitoring. Neurol Med Chir (Tokyo). 2016;56 (8):451–456. doi:10.2176/nmc.ra.2015-0307
21. Molin CJ, Punga AR. Compound muscle action potential: an electrophysiological marker of muscle training. Clin Neurophysiol Pract. 2016;33(5):340–345. doi:10.1097/WNP.0000000000000252
22. Possover M. Laparoscopic management of intrapelvic etiologies of pudendal pain in 134 consecutive patients. J Urol. 2009;181(4):1732–1736.