Brought to you by the Society of Gynecologic Surgeons. In this video, the authors demonstrate the surgical management of complex endometriosis involving the sacral nerve roots. The video highlights the critical steps needed to accomplish this task and also highlights the deep retroperitoneal anatomy that surgeons are required to identify and be comfortable with. This includes the internal iliac vein and sacral nerve roots. This clinical scenario requires specialized expertise, and viewers should consider referring such complex cases to minimally invasive gynecologic surgery (MIGS) surgeons comfortable with neuropelveology for subspecialty care.