Nerve-sparing techniques in deeply infiltrating endometriosis: a narrative review

Nerve-sparing gynecologic surgery has evolved as a critical advancement in the management of deeply infiltrating endometriosis, aiming to reduce postoperative dysfunction while preserving surgical efficacy. Historically, procedures such as radical hysterectomy and excision of deeply infiltrating endometriosis carried high risks of urinary, bowel, and sexual dysfunction due to inadvertent injury to pelvic autonomic nerves. Recent developments in pelvic neuroanatomy, enhanced laparoscopic visualization, and operative technique have enabled surgeons to identify and preserve key neural structures during dissection. This review traces the evolution of nerve-sparing surgery, from early radical oncologic techniques to contemporary minimally invasive approaches guided by functional anatomy. We highlight contributions from key innovators and describe standardized terminology for pelvic nerves, fasciae, and retroperitoneal spaces, which aim to improve surgical reproducibility. Surgical techniques including the laparoscopic neuronavigation technique, the Negrar Method, and hypogastric nerve-based dissection are presented in detail, emphasizing both neuroanatomical precision and practical application. The use of anatomical landmarks in settings without advanced equipment is also discussed. Special attention is given to bowel surgery in endometriosis, balancing radicality with preservation of pelvic nerve function. Collectively, these strategies underscore a shift toward personalized, anatomy-guided surgery that prioritizes both disease control and long-term quality of life. As interest in nerve-sparing approaches continues to grow, education, multidisciplinary collaboration, and ongoing refinement of surgical methods will be essential to broadening access and improving patient outcomes for patients with deeply infiltrating endometriosis.