A double‐blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain

Abstract

Objective To determine the effectiveness of laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain in women with endometriosis and women with no laparoscopic evidence of endometriosis. Design A prospective double-blind randomised controlled trial (RCT).Setting Single-centre, secondary-level gynaecology outpatient service and tertiary-level pelvic pain and endometriosis outpatient service in Auckland, New Zealand. Population One hundred and twenty-three women undergoing laparoscopy for investigation and management of chronic pelvic pain, 56 with no laparoscopic evidence of endometriosis and 67 with endometriosis. Methods Women were randomised from the two populations, firstly those with no evidence of endometriosis and secondly those undergoing laparoscopic surgical treatment for endometriosis, to receive LUNA or no LUNA. Participant and assessor blinding was employed. Follow up for pain outcomes was undertaken at 24 hours, 3 months and 12 months. Main outcome measures Changes in non-menstrual pelvic pain, dysmenorrhoea, deep dyspareunia and dyschezia were assessed primarily by whether there was a decrease in visual analogue score for these types of pain of 50% or more from baseline and additionally whether there was a significantly different change in median visual analogue score. The numbers requiring further surgery or starting a new medical treatment for pelvic pain and complications were also measured. Results There was a significant reduction in dysmenorrhoea at 12 month follow up in women with chronic pelvic pain in the absence of endometriosis who underwent LUNA (median change in visual analogue scale (VAS) from baseline À4.8 versus À0.8 (P ¼ 0.039), 42.1% versus 14.3% experiencing a successful treatment defined as a 50% or greater reduction in visual analogue pain scale for dysmenorrhoea (P ¼ 0.045).There was no significant difference in non-menstrual pelvic pain, deep dyspareunia or dyschezia in women with no endometriosis undergoing LUNA versus no LUNA. The addition of LUNA to laparoscopic surgical treatment of endometriosis was not associated with a significant difference in any pain outcomes. Conclusions LUNA is effective for dysmenorrhoea in the absence of endometriosis, although there is no evidence of effectiveness of LUNA for non-dysmenorrhoeic chronic pelvic pain or for any type of chronic pelvic pain related to endometriosis.

Laparoscopic Uterine Nerve Ethanol Neurolysis (LUNEN) in Patients with Chronic Pelvic Pain

“…However, due to the fact that its pathogenesis is complex, multifactorial and poorly understood, the pain can sometimes continue even though the apparent reason has been removed, and a non-specific treatment is needed [2,4,5,11,12]. A recent meta-analysis showed that the improvement effect of medical treatments on pain and QoL is limited and many medical treatments also bring significant side effects in many patients [28].…”

“…This procedure requires not only a greater degree of surgical skill but also carries a higher risk of intra-operative complications and long-term consequences. On the contrary, LUNA is known as a simple, feasible, and therefore relatively commonly performed surgical procedure [11]. For instance, in the UK, about 50% of gynecological endoscopists perform LUNA routinely during the surgical treatment of endometriosis [12].…”

“…For instance, in the UK, about 50% of gynecological endoscopists perform LUNA routinely during the surgical treatment of endometriosis [12]. Complications reported due to LUNA include injuries of the ureter and the veins that lie just medial to the uterosacral ligament, and long-term consequences such as uterine prolapse and bladder dysfunction [11,13]. In fact, today, it is considered that both LUNA and PSN may have some important complications and thus more feasible methods are needed.…”

Laparoscopy for Diagnosis and Treatment of Endometriosis

“…Laparoscopic uterine nerve ablation (LUNA) and presacral neurectomy were also suggested as a treatment of pain symptoms. LUNA was found beneficial for dysmenorrhoea not associated with endometriosis (Johnson et al, 2004), while presacral neurectomy was found to reduce pain symptoms in endometriosis without significant side effects (Garcia Leon et al, 2003, Zullo et al, 2004.…”

Abordagem da dor pélvica crônica em mulheres

“…Tem sido usada com melhor efi cácia em casos de dor pélvica crônica devido à endometriose severa associada à dismenorréia 54 .…”