• Deep infiltrating endometriosis
• Laparoscopy
• Pelvic nerves endometriosis
• Robotic-assisted surgery
• Sacral roots endometriosis
• Sciatic nerve endometriosis

Background: Endometriosis is characterized by the presence of endometrial-like gland and stroma outside of the uterine cavity. It causes chronic inflammation, fibrosis, anatomic distortion and adhesion formation. Deep infiltrating endometriosis involving sacral plexus and sciatic nerve is a rare localization. Depending by the degree of nerve involvement, the disease can produce severe symptoms as sciatic or pudendal pain and refractory urinary, anorectal and sexual dysfunction. The aim of the present study is to compare robotic-assisted laparoscopy and conventional laparoscopic for intraoperative, postoperative and functional outcomes among patients undergoing excision of deep infiltrating endometriosis involving sacral plexus and sciatic nerve.
Materials and methods: We performed a retrospective analysis of patients referred to the Institut Franco-Européen Multidisciplinaire d'Endométriose (IFEMEndo), Clinique Tivoli-Ducos, Bordeaux, for deep infiltrating endometriosis involving sacral roots and/or sciatic nerve between September 2018 and June 2023. Patients underwent to surgery for endometriosis eradication by conventional laparoscopic (LPS, n=71) until 2021. After the introduction in our practice of Da Vinci Surgical System X (Intuitive Surgical Inc., Sunnyvale, CA, U.S.), the patients were systematically managed by robotic-assisted laparoscopy (RAL, n=29). In both the surgical approach, the excision of deep infiltrating endometriosis involving sacral plexus and sciatic nerve followed the same standardized surgical procedures. We compared intraoperative, perioperative data and functional outcome after 6 month follow up.
Results: A total of 100 patients met the inclusion criteria for our study. Seventy-one consecutive patients were managed in LPS group, and 29 consecutive patients underwent to RAL group. The two groups were comparable in terms of basal complain and distribution of deep infiltrating endometriosis lesions. Nerve dissection, nerve shaving and intra-nerve dissection were performed respectively in 77.5%, 19.7% and 5.6% of patients in the LPS group, and 82.8%, 17.2% and 6.9% in the RAL group (p=0.43). Mean operative time was respectively 183.785.3 min and 177.477.2 min (p=0.73). In no case we experienced conversion to open surgery. We did not observe a statistically significant difference in intra- operative and early post-operative complication between the two groups. After 6 month follow up, we observed significant reduction of the rate of sciatic pain in both LPS group (39.1 vs 15.6, p<0.0001) and RAL group (37.5 vs 25, p=0.001), without any statistically significant differences in terms of outcomes (p=0.1). The 33.8% of LPS group and the 34.5% of patients of RAL group required self-catheterization after surgery. Digestive function, measured through the Gastrointestinal Quality of Life index (GIQLI) showed a significant improvement in overall gastrointestinal global well-being in both groups. After 6 month follow up, digestive and urinary outcomes outcomes result to be superimposable in the two group (p=ns). After 1 year follow up 5.6% of patient in LPS group still required self-catheterization, meanwhile no patients in the RAL group still required self-catheterization after 1 year (p=0.44).
Conclusion: Conventional and robotic-assisted laparoscopy are feasible and effective approach for the surgical management of DIE involving sacral plexus and sciatic nerve. Both the techniques result in a significant long-term relief of symptoms related to sacral plexus and sciatic nerve endometriosis. Although surgeons found that the robotic assistance improved the quality of the excision of these specific localizations of the disease, our study did not reveal statistically significant advantages in terms of outcomes.