International Medical Conference Endometriosis 2025:
Endometriosis 2025: Your Mother Should Know, Your Doctor Should Know Better!
Mastering the Maze: Navigating the Challenges of Neuropelvic Surgery in Endometriosis - A. Taner Usta, MD
Now we're going to have Dr. Tanner usta, endometriosis surgeon, surgeon of Excellence, SEC University, Istanbul Turkey. He's a board certified board member of the Turkish Gynecology Endoscopy Society and President of Turkish Endometriosis and OSI Society Advisory Board member of European Endometriosis League, department of Trics and Gynecology endometriosis and Chronic Pelvic Baking Center.
Welcome evening to everyone. First of all, I would glad to thank to great friends Tamkin and the Martin for this wonderful meeting for inviting me. My topic is navigating the challenges of neurobiologic surgery endometriosis. I guess that then we'll choose that title but I don't know. I will do my best. So many years ago when you talk about endometriosis, we commonly talk endometrioma, check cyst. It look like this one, but when we look at that one, it's look like the tip of the iceberg. When you see the endometriosis, many people discussed the endometrioma today. There were a lot of comments about when you see the endometriosis partners that say that, and I shahan say that when you see the endometriosis excise that one we have a different comment on it but the main problem is not that one. Yes, we have some problem about the fertility.
When you face that endometrium in a young age is not so easy to manage it if you face a very lower ovarian reserve. But some minutes ago that showed us bladder endometriosis. We commonly face TER endometriosis When you check a kidney it's not so rare and bowel endometriosis and so on. And nowadays we have some information about nerve endometriosis. If you ask me could you show me some simple videos which is showing us the endometriosis, I can show you the first one or the second one is better than the first one. There is some leakage from the endometrioma. You can see the chocolate flute in the pelvis. You see the very severe adhesions with the organs and it is easy to guess that that lady suffer from the pain but we have some problems about management of endometriosis. The first one diagnosis yesterday and today we discussed a lot about diagnosis.
Now we are learning something but it is enough or it is known all around the world. I don't think so and the indication, some people say that when you see the endometriosis, I excised some people afraid of the surgery. They give a medical treatments and so we need the balance, the medical treatments or the surgical treatments or combinations and we need the correct treatments. The other one is who treat endometriosis fertility specialist or a surgeon. I always share this one. This is the ABRA muscle sentence. If you have a hammer you are always looking for a nail. If you are a surgeon you think that if I applied a good surgery I can solve the problem, but if that patients go to the fertility specialist, they commonly focusing on the acid number and the fertility issue but we need the combination of all of this one on the other hands.
One of the most important point is what does the patient expect from the treatments. If I share you this picture, it is easy to understand. S Kim will talk about the complications later but that lady have some history about the complications after the endometrial surgery but this information is not related with that one. That lady applied our international patient units, I only see some reports about that lady. She is 27 years old and she had a surgery. They excised a nole from the pelvis but after the surgery she has some problem about the defecation. There is no urge to defecation and so laxative drugs have no effect in a 27 years old lady and so we know that this is not problem about the bowel. This is not problem about the bladder. I guess that she can have some problem about the bladder. This is the problem about the nerve and the second case, she had a surgeries one years ago after the surgery the surgeon applied this is the surgery belonged to previous surgery surgeon applies the excision surgery.
I know that it's very popular in United States. If you're another excision surgeon, you are not good surgeon I know, but if you excise not only the disease, if you excise some motoric nerve or sympathetic nerve or parasympathetic nerve, we know that you can create a knee problem in that lady. So before the surgery she had a dysmenorrhea nine. After the surgery it's going on but plus dysurea nine before the surgery there's no Drea. After the surgery the pain is going on and there is new pain type and also she has a problem about the bladder and the bowel. We know that it is a very aggressive surgery and it's resolved with some complications. In 2014, mark Pover from established a neurobiology society and she organized a lot of education program online and onsite. It's going on. It's look like black box flight recorder. Second word was the color was black but now it is orange.
We can understand better the pelvis and so we can think that if you look at with the details about pelvic nerve, you can easily understand some pain and some functional conditions and some problem which will happen in future. I do not have a time to go to detail about that one, but we know that there are some functions about motoric. The second one sensory and the last one with the autonomic one. Normally we expect like this one, this is a sacro ligament, this is the hypogastric nerve. Everybody like to see that one, but does it matter for you? Yes, a little bit because it's related with the bladder sensations and we clearly see the ureter but in a daily practice when you phase some obstructions on the posterior compartment, it's not easily see that structures and this is another video again, this is the hypogastric nerve.
We know that the parasympathetic spl nerve coming from the S two to S3 S four and come together this place if you have some lesions there and make some damage with burning or cutting, you can create a new problem in that young ladies, these are some fibers which is parasympathetic nerve fibers. So how can we better manage these conditions? We have to take the detailed history but you have to ask the correct questions and we have to apply to physical examination. I don't know the health association in United States, but in my country many young colleague doesn't use their hands during the examination so some of them applied on the ultrasound. I know that in United States not popular to apply to ultrasound in a gynecology practice but in Europe it is more common issue but they do not want to use their veins but it look like some diagnostic methods when you search about what is the reason of that pain and you have to apply some tests and some imaging modality.
These are standard information about endometriosis but if you suspect with some neuropathic conditions of the nerve problem, we have to guess that if the lady have some bladder problem, atonic bladder or if they have some sciatica or the foot drop, we have to think that that lady can have some problem about the pelvic nerve. We always use the dermatome. Sometimes some clinic explain the patient conditions that lady have a pelvic pain but that pain irradiation or that pain stay in the pelvis. It is so important for us. We always use that mapping like a neurologist. If you see that there's some pain starting on the backside and going to the hill, we guess that that lady can have some problem about the sciatic nerve or there's some irritations on the sciatic nerve.
The pain type is important. Sometimes we ask that do you have a pain? The patient say that yes, but if you go to detail that information give you much more information, very valuable information. If the patient have some vegetative symptom which is related with the autonomic one, we guess that that problem related with the visceral pain. If that lady only the complaint about somatic pain there is directly the irradiation or allodynia or electrical shock. We call that one somatic pain. These are not the same. Yes, that is the pelvic pain but continuous completely difference. When you look at the phase of that lady, it's a typical chronic pelvic pain on the face. Normally the inspection start with the face and when you see the pule you can see that there is some dilatations on the pule and examination I mentioned before it is very important.
This is a clear pelvis and there is no problem but on the right side there is some nole which is affect sacro ligaments. We discuss a lot. Many people think that this is a superficial lesion but this is deep infiltrating nole on the sacro ligaments. If you only burn it, we know that you can burn the superficial compartment, you can leave the disease behind that surface. On the right side, this is a sacral nerve roots endometriosis is a related one. There is no bowel endometriosis, there is only the pulling. If you haven't had a diagnosis before, how can you guess that that pulling is belonged to sacral neuro endometriosis and Anna showed very well yesterday. If you use the ultrasound it's not so easy but it's not so difficult. You can easily understand that structure. Crottin ligaments can have some lesions and you can show with your ultrasound and in some conditions we applied some neurological tests for exclude lumal hernia. It's not so difficult I guess that it look like weird but if you do that one you can easily exclude that one and you need good radiologist. They have to dedicate it to that. They should not only the nerve, they have to know some information about bladders and ular organs.
I mentioned before the examination start with the inspections. When you look at this inspection there is some atrophy on the go tail muscles, okay, that lady had seven surgeries before. She has suffering from the pain. They applied the seven surgery but after that one there's some nole on the bowel. She has a focal denomi alter mayo metri. We know that from the chaperones paper, two of the three cases have some nodules on the bowel and we can guess that there's some problem about retroperitoneal part, especially the superior gal nerve. Because of that, that lady can have some atrophy on the gal muscle and so when you only the look, you can guess that there is a severe addition inside but not only the inside there is some additions are waiting for you on the retroperitoneal area and they can make some entrapments. There's a two mechanism explanations about entrapment syndrome.
One of them is compression, the other one is invasions. There's some good examples like this. One pelvic bone is like this wall and this is the problem. It might be endometriosis, it might be muscular entrapments. It's look like this one make a compression and because of that compression, that patient complained about the pain in the live cases. This is a sciatic nerve, this is the poal nerve. It can be endometriosis going there and make a compression on the very narrow area and create some problem about the sciatic nerve. Because of that we can see some neuropathic pain and at the same time some neuromotor dysfunctions and if you suspect that one, you can apply the EMG but there is no routine recommendations about EMG, especially if the lady have some problem about the sacral nerve roots. We know that S two, S3 and S four related with par and particular you have to do the aerodynamic test because it is very important to medical legal issues before any decision.
I start with the endometriosis. This is the one of the good series about endometriosis and intra pelvic vascular called neuro entrapment syndrome. It was published 2011 by Mark Poso. It's a mixing group. One of them is sciatic nerve, the other one is cycl neuro endometriosis. The other one is the muscular nerve entrapment and only the one cases belong to the PI performance muscles entrapments. That paper is a very good paper. It was published 10 years ago. The SOA and colleagues said that more common endometrial type is sacral nerve endometriosis and the second one was the sciatic nerve. That paper coming from the 2017 by Mark Pover, he published that paper. Some cases needs much more resections on the sciatic nerve. They are coming from their center with the crutches wheelchair and all of them have a foot drop. It is a very severe conditions when that lady have a sciatic nerve which have more invasions with the endometriosis.
Typical feature of that one is like this one. This called lum blockade. There's some instability they can walk out. You can see that there is some abnormal conditions in your office, this examination about that lady, there's some weird walking and the third one is you have to examine the sum motions. You have to give us some directives and they try to do that one and you can easily guess that there's some problem about some muscles which is inated but the nerve and you have to check the reflexes. If you haven't have information before the surgery you can only see there is some pulling like odor endometriosis. This is belong to sciatic neuro endometriosis. We know that before the surgery we discussed a lot with the patients. There's some lesions there. We were so lucky that lesion is not too much Sometimes in the morning session shine showed us very severe case that if that lesion located the deeper plane it is so difficult to perform that surgery.
We know that they can feel very severe pain during or after the surgery. So next one coming from the RAs and RAs In the whole I would like to thank to Horas. He's not only the good surgeon, good person, he always sharing what he know and so it is very valuable all of us. That paper belonged to sacral nerve roots endometriosis. The main difference from the sciatic neuro and the sacral neuro endometriosis, they're related with the urinary problem. Some of them needs to catheterization a little longer than what you expected. These are some samples about this is a normal one. These are some samples belong to isolated sacral nerve endometriosis, but I would like to save our time. This is one the pulling I showed before, maybe I can make it faster.
And there's a sacral nerve roots S3 and S four. This is a hypogastric nerve, a chocolate fluid coming from below the hypogastric nerve. We follow that lesions, take them nole out and the other one is another case. This is an isolated case. Again, there is no nole on the bubble. We collect the whole data in 2022. We publish that data. We commonly see the foot drop in sciatic nerve and it is not so surprise for us. We can see some hydronephrosis kidney atrophy and we have some problem about the urodynamic conditions in the literature and some bladder dysfunctions phase, especially in the ral nerves. Endometriosis, when you look at the other nerve, we collect the other data about alter neuro endometriosis. There's only eight cases in the literature. We collected that one in 2020 T and the rest of them are very rare. Only some case reports.
The other conditions is intra pelvic nerve ENT treatment syndrome. This is another case again, we performed the surgery I guess eight or seven years ago. That lady referred our center for sciatic nerve endometriosis, but we didn't see the endometriosis on the Mr. Neurography. We applied examinations, we see some losing on the right foot and we applied the EMG and EMG showed the same results. We applied neurolysis but I would like to, I wouldn't take your time. We phase some abnormal veins and arteries, which is compressing the sciatic nerve and the lumbosacral trunk. We opened that area in that years we applied to some clips, but now we give up using that clips and then we applied the whole complete neurolysis. The sciatic nerve.
This is the performance, this is the sciatic nerve and we come closer the sacro ligament. This is after the surgery, but maybe you can see that there is some imbalance. We applied to physical therapy six weeks and then it's getting better. We passed seven years or eight years now. There's no problem. We will see in future. So this is another case that lady have some lesions on the rectum. There's a choline insertion before some calling. Think that she has some problem about pelvic congestion syndrome and they applied in another course left ectomy, but that lady have some pelvic pain. DYS peria at the same time left Sia. We guess that there is not only one reason. There's some problem about the left iliolumbar fossa, especially the sciatic nerve and at the same time she had some small nole.
So we applied lys again, I guess that we applied the surgery five years ago. We face severe adhesions, which is related with the previous intervention. We cut some abnormal veins, vessels, arteries, and the veins. And also we cut all fibrotic tissue from the sciatic nerve and at the end of the surgery we go to Douglas Glass, applied the excision of that nole. So sometimes you can see not only the one reason you have to pay attention about that lady can have more than one problem at the same time. I haven't had time because of that. I do not want to take your time. But not only the reason of the pelvic pain is endometriosis. Sometimes we can create some problem. These are some cases about the mesh. I guess that it is very popular in us, but I do not want to take your time. So correct diagnosis is most valuable part of clinical approach.
And neuropathologic approach to historic taking is integral to the diagnosis of ENT treatment by endometriosis, surgery for endometriosis and lack of proper anatomical knowledge and adequ surgical skis are consequently associated with a high risk of injury to the ureter, rectum, and autonomic nerve during surgery is a teamwork. It's not only the one surgeon's issue now we have better than before, but we are learning. This is my take home message. The neurobiologic approach will not only allow for a better diagnosis but also enable better treatments and may reduce the risk of encountering chronic complications after surgical treatments. We spend a lot of time, we are learning, still learning. And so this is our team and I would like to invite all of you to Italy bologna for next EL congress, which will happen 2026. And also I would like to invite all of you to European Society Gynecologic Endoscopy Congress, which will be happening in Istanbul in October this year. Thank you so much. So now not the least. Last speaker is Tamar Kin. He will talk about complications. Nobody wants to talk about complications, but he likes to talk about complication.
