Prof. Prof. DK Prof. Dr. med. Marc Possover, MD, PhD

>500 Surgeries for Endometriosis of the Sciatic Nerve

25 Years of Experience - Why Outcomes Depend on Neuropelveological Mastery

The Possover Weekly Neuropelveological Reference
Prof. Marc Possover

A Rare Disease - Treated in Unprecedented Numbers

Endometriosis of the sciatic nerve is universally considered a rare disease. In classical gynecology, it is still often regarded as anecdotal.

Yet over the last 25 years, more than 500 women have undergone laparoscopic surgery for sciatic nerve endometriosis in our center alone.

This number is not the reflection of a rising prevalence - it is the reflection of historical exclusivity.

I began performing laparoscopic surgery of the pelvic nerves in 2004, at a time when endometriosis of the sciatic nerve was considered almost impossible. Many colleagues predicted that my patients would “leave in a wheelchair.”

The opposite happened.

Today, the concept of sciatic nerve endometriosis surgery has become fashionable.
But in parallel, I now see a growing number of recurrences and failed re-operations performed elsewhere - something that has never occurred in my own patients.

This contradiction reveals a fundamental truth: Sciatic nerve endometriosis is not a gynecologic disease. It is a neuropelveological disease requiring microsurgical nerve and vascular mastery.

What My Long-Term Data Shows

In the largest long-term series ever published on this pathology with  more than 500 cases, including 259 consecutive patients operated between 2004 and 2016, we analyzed neurological and functional outcomes after laparoscopic sciatic nerve surgery.

In the subgroup requiring large intraneural nerve resections (>30% of the nerve), all patients presented preoperatively with:

• Intractable neuropathic pain (VAS 9–10)
• Foot drop and inability to walk normally
• Severe sensorimotor deficits

Despite this, five-year follow-up demonstrated:

• Median VAS reduced to ≈2
• Recovery of normal gait and stair climbing
• Progressive axonal regeneration over 3–5 years
• No long-term deterioration of neurological function
• No recurrence when complete intraneural excision was performed

These outcomes are unique in nerve surgery and impossible to reproduce without deep neuropelveological expertise.

Why Recurrences Occur Elsewhere - And Not in My Patients

Sciatic nerve endometriosis is not superficial pelvic endometriosis.

It is intraneural, perineural and vascular.

The main danger is not the nerve itself, it is the pelvic vessels entangling the nerve and the massive retroperitoneal fibrosis surrounding it.

I was trained as a cardiovascular surgeon before becoming a gynecologic surgeon.
This vascular mastery became the cornerstone of my neuropelveological approach.

Most surgeons performing “modern sciatic endometriosis surgery” are not trained to:

• Perform intrafascicular neurolysis
• Control the sacral, gluteal and obturator vascular plexuses
• Resect intraneural endometriomas
• Manage pelvic hemorrhage at nerve level
• Identify the exact topographic level of sacral plexus involvement

Incomplete surgery = persistent disease = recurrence.

Preoperative Neuropelveologic Diagnosis Is Mandatory

Sciatic nerve endometriosis can involve:

• L5–S2 roots
• Distal sacral plexus
• Endopelvic sciatic nerve
• Pudendal, obturator and gluteal branches

The surgical access route changes completely depending on the topographic level of involvement. Without a neuropelveologic work-up, the surgeon operates blindly.

This is why classical MRI and gynecologic diagnostics frequently fail, and why patients wander for years before diagnosis.

Why This Is Laparoscopic - Not Robotic Surgery

This surgery is not gynecology. It is microsurgical nerve and vascular surgery in the pelvis and requires

• Continuous tactile feedback
• Bipolar micro-hemostasis
• Cold-scissor intrafascicular dissection
• Dynamic nerve palpation

These elements cannot be replaced by robotics. Laparoscopy remains the only approach that allows safe, tactile, neurovascular microsurgery inside the pelvis.

Conclusion

Sciatic nerve endometriosis surgery is not a trend.

It is a discipline. And disciplines require founders, not followers.

For 25 years, neuropelveology has defined the standards that now, belatedly, the world is beginning to discover. What appears “new” today is simply what was built two decades ago.

And what appears “rare” is simply what only one center has truly mastered over the last 20 years.

References

1. Possover M. Laparoscopic morphological aspects and tentative of explanation the etiopathogenesis of isolated endometriosis of the sciatic nerve: a review based on 267 patients. Facts Views Vis Obgyn, 2021;13(4): 331-337
2. Possover M. Laparoscopic management of isolated infiltrating endometriosis of the sciatic nerve. Video-article, Journal of Minimally Invasive Gynecology 2020.
3. Possover M. Five-Year Follow-Up After Laparoscopic Large Nerve Resection for Deep Infiltrating Sciatic Nerve Endometriosis. J Minim Invasive Gynecol. 2017 Jul - Aug;24(5):822-826.
4. Possover M. Pathophysiologic explanation for bladder retention in patients after laparoscopic surgery for deeply infiltration rectovaginal and/or parametric endometriosis. Fertil Steril 2014; 101:754-8
5. Possover M. Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertil Steril 2021; 95(2): 756-8.
6. Possover M. Laparoscopic neurolysis of the sacral plexus and the sciatic nerve for extensive endometriosis of the pelvic wall. Minim Invasive Neurosurg 2007; 50: 33-36.
7. Possover M, Chiantera V. Isolated infiltrative endometriosis of the sciatic nerve: about three cases. Fertil Steril 2007; 87: 417-9.
8. Possover M, Kerstin Rhiem, Vito Chiantera. The “neurologic hypothesis: a new concept in the pathogenesis of the endometriosis? Gynecolog Surge 2005; (2): 107-111.
9. Possover M. Vorgehen bei der ausgedehnten retroperitonealen Endometriose. Gyn Praktische Gynäkologie, 2003, 2:110-124.
10. Possover M, Mallmann P. Follow-up of patients after laparoscopic vaginal resection of the endometriosis of the rectovaginal septum with colorectal anastomosis. Journal of Pelvic Surgery 2002,8: 83-88.
11. Possover M, Diebolder H, Plaul K, Schneider A. Laparoscopic-assisted vaginal resection of recto-vaginal endometriosis. Obstetrics and Gynecology, 2000; 96, 304-307.
12. Possover M, Diebolder H, Stöber S, Schneider A. Laparoskopisch assistierte vaginale Resektion der Endometriose. Ambulant Operieren 1999; 2: 46-50.

— Prof. Marc Possover
Founder of Neuropelveology

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Possover International Medical Center – Zurich
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If you or someone you know is struggling with chronic pelvic pain, pelvic nerve disorders, endometriosis, or consequences of pelvic surgery, please contact us via email at international@possover.com to begin the process. Because we want to avoid the scenario where a patient travels to Zurich, only to discover that we may not be able to offer help for their specific situation, we have Pre-Consultation Zoom process. How does it work?

1. Patients will first receive a Pre-Consultation Form.
2. Based on the information provided, we will assess whether a Zoom consultation is necessary.
3. If indicated, we will schedule a Pre-Consultation Zoom Call to help determine if a full evaluation at our center makes sense for your case.