Possover Marc, MD, PhD

Founder & Life Chairman of the International Society of Neuropelveology – www.theison.org

Director of the International School of Neuropelveology – www.possover-neuropelveology.com

The field of neuropelveology was pioneered by Professor Marc Possover, a gynecological surgeon based in Switzerland. In the early 2000s. He recognized the serious need for a specialized approach to treat chronic pelvic pain and related conditions, which were often linked to nerve damage or dysfunction. Traditional medical disciplines often struggle indeed to effectively diagnose and manage these complex cases, leading to a gap in patient care.

Neuropelveology is thus a relatively new interdisciplinary field of medicine that focuses on the study, diagnosis, and treatment of chronic pelvic pain and dysfunctions related to the pelvic nerves. It combines aspects of neurology, gynecology, urology, and pelvic surgery to address complex conditions that often go undiagnosed or are inadequately treated in conventional medical practice.

In 2004, Pr. Possover developed the Laparoscopic Neuro-Navigation (LANN) technique. This minimally invasive surgical approach allows for precise identification of the functions of the pelvic nerves during surgeries. By combining laparoscopy (a form of keyhole surgery) with advanced neuro-navigation techniques, surgeons could now address nerve-related pelvic issues with greater accuracy and less patient trauma. Pr. Possover performed 2002 the first laparoscopic implantation of a neurostimulator (LION procedure) to the pelvic nerves for the treatment of chronic pelvic pain and in 2003 for the recovery of some motion in a spinal cord injury patient from south Italy. He has since then received in the Italian press the nickname “the hands of angels'". He recognized the need to share his knowledge and research achievements, teaching, and further professional training in diagnostic and therapy of pelvic nerves conditions.

This was the birth of a new field in medicine, which he called Neuropelveology

Over the years, neuropelveology has grown as a specialized area of medicine, drawing interest from various medical disciplines. The field addresses a range of conditions including neuropathic pelvic pain, pudendal neuralgia, endometriosis-related pain and complications from pelvic surgeries. It also encompasses the management of conditions like pelvic organ prolapse, urinary incontinence, and sexual dysfunction, especially when these issues are linked to nerve damage.

Professor Marc Possover is a highly influential figure in the field of gynecology, particularly known for his groundbreaking work in the treatment of cervical cancer and sciatic nerve endometriosis. His contributions have significantly advanced the understanding and management of this rare but debilitating form of endometriosis.

The LANN procedure and Nerve-Sparing Surgery in Gynecology

The introduction and evolution of nerve-sparing techniques in gynecology over the past 30 years have significantly improved the outcomes of surgeries involving the pelvic region, particularly in procedures for treating conditions like endometriosis, gynecological cancers, and pelvic organ prolapse.

Early Developments in Nerve-Sparing Techniques:

The concept of nerve-sparing surgery first gained prominence in urology during the 1980s with the development of techniques to preserve erectile function during prostate cancer surgery. This success inspired similar approaches in gynecology, particularly as surgeons recognized that many women undergoing pelvic surgeries experienced complications related to nerve damage, such as bladder dysfunction, sexual dysfunction, and chronic pain.

Application in Gynecologic Oncology

In the late 1980s and early 1990s, Pr. Possover was the first to adopt nerve-sparing techniques in laparoscopy, particularly in laparoscopic radical hysterectomy for cervical cancer. The pelvic autonomic nerves, which control bladder and bowel function, are at risk during such extensive surgeries. Pr. Possover started a meticulous mapping by using for the first time intraoperative electrical stimulation of pelvic nerves, the so-called LANN technique, for laparoscopic neuro-navigation and preservation of these nerves, leading to improved postoperative outcomes. The laparoscopic nerve-sparing radical hysterectomy became a pivotal advancement in surgery, reducing the incidence of postoperative bladder dysfunction and improving quality of life for patients.

Expansion to Endometriosis and Other Conditions

By the early 2000s, nerve-sparing techniques were also increasingly applied in surgeries for severe endometriosis. This condition often involves extensive pelvic scarring and the entrapment of nerves, leading to chronic pain. Pr. Marc Possover, Pioneer in the field, advanced the understanding of pelvic nerve anatomy and developed specialized techniques to carefully dissect and preserve these nerves during complex endometriosis surgeries.

The nerve-sparing approach in endometriosis surgery aimed to alleviate pain while minimizing the risk of postoperative complications like urinary and fecal incontinence. This represented a significant shift from more radical approaches, that focused primarily on removing diseased tissue without regard for nerve preservation.

Surgeons now have a better understanding of the intricate network of nerves in the pelvic region, allowing them to perform more precise and less invasive surgeries. These advancements have been particularly beneficial in minimally invasive surgery, such as laparoscopic and robotic-assisted procedures.

The continuous evolution of nerve-sparing techniques in gynecology has greatly improved the quality of life for women undergoing pelvic surgeries, reducing the likelihood of debilitating side effects and enhancing recovery. This ongoing refinement is supported by a growing body of research and surgical innovation, ensuring that nerve preservation remains a central consideration in gynecologic surgery today.

Over the last 30 years, nerve-sparing techniques have thus revolutionized gynecologic surgery. By focusing on preserving the pelvic nerves during complex surgeries, these techniques have minimized postoperative complications and significantly improved patient outcomes, particularly in the fields of oncology and endometriosis treatment. As the field continues to evolve, these advancements will likely continue to enhance the quality of care provided to women undergoing pelvic surgeries.

Treatment of Sciatic Nerve Endometriosis

Historical Context

The recognition of sciatic endometriosis as a distinct clinical entity began to gain traction in the latter part of the 20th century, although it had likely been an underdiagnosed condition for many years. Traditionally, endometriosis was thought to primarily affect the pelvic organs, but over time, as more advanced laparoscopic procedures to the pelvic nerves became available, Pr. Possover began identifying cases where endometriotic lesions were affecting the sciatic nerve. This led him to a deeper understanding of the disease's capacity to extend beyond the pelvic organs, affecting nerve structures and causing symptoms that can mimic other neuropathic conditions.

Early Treatment Approaches

In the early days of treating sciatic endometriosis, the focus was largely on managing pain through hormonal therapies aimed at reducing estrogen levels, which can drive the growth of endometriotic tissue. Because of failure of medical treatments with irreversible neurologic damages in these patients, laparoscopic intervention became a key treatment strategy, especially as imaging techniques like MRI improved, allowing for better localization of endometriotic lesions on or around the sciatic nerve. However, surgery in this area is highly complex and extremely dangerous due to the intricate anatomy, major vessels and the risk of nerve damage. Early surgical techniques focused on removing visible endometriotic lesions but often did not fully address the nerve involvement, leading to variable outcomes for the patients.

Possover’s pioneering work and research

By the early 2000s, Possover recognized that traditional gynecological approaches neglected the complex interactions between endometriotic lesions and the pelvic nerves, leading to incomplete treatment and persistent symptoms in many patients. He has been at the forefront of developing and refining surgical techniques to treat sciatic nerve endometriosis. He introduced laparoscopic neurosurgery to the sciatic nerve, allowing him to precisely remove endometriotic lesions from the sciatic nerve, which runs deep in the pelvis - where surgeons had never been before.

Over the past 20 years, not only has Pr. Possover performed more than 500 laparoscopic surgeries for sciatic nerve endometriosis - by far the largest series in the world - he has also demonstrated the difference between sciatic nerve endometriosis and sacral plexus endometriosis - two diseases that share the same name but differ in symptoms and treatment. Additionally, he was the first to describe isolated sciatic nerve endometriosis for which he has evaluated a hypothesis for its development."

From its initial under-recognition to the current era of advanced laparoscopic Neuropelveological procedures to the pelvic nerves, the treatment of sciatic endometriosis has seen significant advancements. These innovations have not only improved the quality of life for affected patients but have also opened new avenues for research and future treatment developments.

The LION and GNS procedures

One of the key innovations in neuropelveology is the development of neurofunctional procedures – the implantation of neurostimulator within the body to the pelvic nerves. These methods aim:

• to reestablish the functions of pelvic nerves for improving pelvic organs functions (Overactive Bladder, Incontinences…),
• to manage pelvic neuropathic pain syndrome
• to recover loss functions as in Spinal Cord injured people and further spinal cord conditions (MS, Spina bifida…).

• The Laparoscopic Implantation of Neuroprosthesis- LION procedure is a pioneering surgical technique primarily developed by Marc Possover. It is designed to address various neurological dysfunctions, particularly in patients with spinal cord injuries (SCI). The procedure involves the minimally invasive implantation of electrodes on specific pelvic nerves, which are then used to deliver targeted electrical stimulation. This stimulation can help restore some motor functions and improve muscle mass, bone density, and overall quality of life for patients suffering from severe nerve damage, including paraplegics and quadriplegics.

Treatment options for SCI patients are limited indeed, often leaving these persons with little hope for significant recovery of mobility or function. Pr. Possover's work, which integrates insights from neurology, neurosurgery, and gynecology, has opened new avenues for treating pelvic nerve pain and dysfunction, particularly in the context of his new medical field, Neuropelveology.

The LION procedure has demonstrated significant benefits. Studies show that patients undergoing the LION procedure experience improvements in muscle mass, bone mineralization, and even the ability to walk with assistance. Additionally, it has shown potential in preventing and treating osteoporosis and pressure ulcers, which are common complications for long-term bedridden patients. The procedure is also being explored for its potential in treating other conditions related to the sympathetic nervous system.

Ongoing research continues to refine the LION procedure, with an emphasis on expanding its applications and further improving patient outcomes. Although the costs associated with the procedure and the neuroprosthesis are currently significant, the long-term benefits, particularly in preventing costly complications such as pressure ulcers, make it a most promising intervention in modern medicine,

• The Genital Nerve Stimulation – GNS procedure is also a pioneering surgical technique primarily developed by Pr. Marc Possover for treatment of overactive bladder (OAB), urinary/fecal incontinence and sexual disorders (especially Erectile Dysfunctions in male). The GNS therapy, which does not require a surgical test-phase and can be performed in outpatient sector in around 15 minutes und local anesthesia, represents a major innovation in pelvic health. It empowers gynecologists—who are traditionally the first point of contact for patients with OAB - to administer neuromodulation treatments effectively, a capability that was previously out of reach for most of them. The GNS therapy is poised to transform the field pelvic neuromodulation by significantly enhancing accessibility, efficacy, and quality of life for the patients.

Founding of the International Society of Neuropelveology www.theison.org

On the initiative of Pr. Possover and a group of committed endoscopists, the International Society of Neuropelveology (ISON) was officially founded 2014 in Brussels/B with following objective:

“Our aim is to provide a platform for the teaching in neuropelveology, exchange of ideas and knowledge related to this groundbreaking discipline. The ISON provides the essential infrastructure and organizational framework for the support and development of Neuropelveological education and research worldwide, and would like to invite you to join us in our mission” - Possover M.

ISON is the first Society for neuropelveology. ISON provides various scientific and educational activities for doctors such as webinars, an e-learning program, workshops and ISON certifications, divided in three levels. The ISON Annual Congress is the largest Neuropelveological meeting in the World (Paris 2024 – Istanbul 2025). It also holds congresses in conjunction with its affiliated societies, which are becoming increasingly popular in Scandinavian, Asia, India, Pacific regions, and South America.

ISON also endeavors to promote the educational exchanges between different societies and countries; more than hundreds of doctors have completed the Certification ISON Level 1 and ISON Level 2. The first training center in neuropelveology has been developed by Possover in Zürich (www.possover-neuropelveology.com).

ISON developed further training centers around the world for all pelvic physicians to have more opportunities to obtain and share the most current knowledge and the latest skills.

Clinical Applications

Neuropelveology has broad applications in both diagnosis and treatment. It provides a framework for understanding the complex interplay between the nervous system and pelvic organs, leading to more accurate diagnoses and targeted therapies. The field has also contributed to a better understanding of how nerve damage can occur during pelvic surgeries, leading to improved surgical techniques and better patient outcomes.

Current Status and Future Directions

Today, neuropelveology is recognized as a vital field for treating chronic pelvic pain and dysfunctions. Ongoing research continues to explore new diagnostic tools, surgical techniques, and treatment modalities. As awareness of neuropelveology grows, more specialists are being trained in this area, and interdisciplinary collaboration is becoming more common.

In the future, neuropelveology is likely to expand further as an indispensable component of comprehensive pelvic health care, with continued innovations aimed at improving patient quality of life.

Conclusion

The International School of Neuropelveology - Global Influence and Teaching

As a leading expert in the field, Pr. Possover is sharing his knowledge with many surgeons worldwide in these advanced techniques, helping to disseminate his methods globally. His work has been published extensively in medical literature, and he frequently presents at international gynecological conferences, further spreading awareness and knowledge about the complexities of treating pelvic nerves pathologies.

Impact on Patient Outcomes:

The impact of Pr. Possover's work on patient outcomes has been profound. Women who previously suffered from severe, intractable pain due to pelvic nerves conditions now have access to effective diagnosed - related surgical options that can dramatically improve their quality of life. His techniques have helped to reduce the recurrence of endometriosis and preserve nerve function, leading to better long-term outcomes.

In summary, Professor Marc Possover has played a pivotal role in transforming the pelvic medicine and implementing neuropelveology in Gynecology and more and more in Neurosurgery. His innovations in surgical techniques, his development of the field of neuropelveology, and his commitment to multidisciplinary care have set new standards for the management of this challenging condition, greatly benefiting patients worldwide.