Laparoscopic Uterosacral Nerve Ablation for Alleviating Chronic Pelvic Pain&lt;subtitle&gt;A Randomized Controlled Trial&lt;/subtitle&gt;

Daniels, Jane; Gray, Richard; Hills, Robert Kerrin; Latthe, Pallavi; Buckley, Laura; Gupta, Janesh; Selman, Tara; Adey, Elizabeth; Xiong, Tengbin; Champaneria, Rita; Lilford, Richard; Khan, Khalid S.

doi:10.1001/jama.2009.1268

Cited by 130 publications

(72 citation statements)

References 30 publications

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“…In a previous study of a neuroablative technique for CPP, women who were blinded to whether they had the procedure or a sham equivalent all reported an improvement in pain to a comparable extent. 113 A conventional venogram would be required to verify PVI immediately prior to randomisation between a legitimate or a sham embolisation. How the blinding of the woman can be maintained, with the woman only under sedation, is potentially challenging, but it is ethical given its necessity in reducing the risk of bias and the low risk of complications from venography.…”

Section: Implications For Health Carementioning

confidence: 99%

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

Champaneria

Shah

Moss³

et al. 2016

Health Technol Assess

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BackgroundPelvic congestion syndrome (PCS) is described as chronic pelvic pain (CPP) arising from dilated and refluxing pelvic veins, although the causal relationship between pelvic vein incompetence (PVI) and CPP is not established. Non-invasive screening methods such as Doppler ultrasound and magnetic resonance venography are used before confirmation by venography. Percutaneous embolisation has become the principal treatment for PCS, with high success rates often cited.ObjectivesOur proposal aimed to systematically and critically review the definitions and diagnostic criteria of PCS, the association between PVI and CPP, the accuracy of various non-invasive imaging techniques and the effectiveness of embolisation for PVI; and to identify factors associated with successful outcome. We also wished to survey clinicians and patients to assess awareness and management of PCS and gauge the enthusiasm for further research.Data sourcesA comprehensive search strategy encompassing various terms for pelvic congestion, pain, imaging techniques and embolisation was deployed in 17 bibliographic databases, including MEDLINE, EMBASE and Web of Science. There was no restriction on study design.MethodsMethodological quality was assessed using appropriate tools. Online surveys were sent to clinicians and patients. The quality and heterogeneity generally precluded meta-analysis and so results were tabulated and described narratively.ResultsWe identified six association studies, 10 studies involving ultrasound, two studies involving magnetic resonance venography, 21 case series and one poor-quality randomised trial of embolisation. There were no consistent diagnostic criteria for PCS. We found that the associations between CPP and PVI were generally fairly similar, with three of five studies with sufficient data showing statistically significant associations (odds ratios of between 31 and 117). The prevalence of PVI ranged widely, although the majority of women with PVI had CPP. Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited. Early substantial relief from pain symptoms was observed in approximately 75% of women undergoing embolisation, a figure which generally increased over time and was sustained. Reintervention rates were generally low. Transient pain was a common occurrence following foam embolisation, while there was a < 2% risk of coil migration. Confidence in the embolisation technique is reasonably high, although there is a desire to strengthen the evidence base. Even among women with CPP, fewer than half had any knowledge about PCS.ConclusionsThe data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality. There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology, as the six most pertinent drew on clinically disparate populations and defined PVI inconsistently. Embolisation appears to provide symptomatic relief in the majority of women and is safe. However, the majority of included studies of embolism were relatively small case series and only the randomised controlled trial was considered at risk of potential biases. There is scope and demand for considerable further research. The question of the association of PVI and CPP requires a well-designed and well-powered case–control study, which will also provide data to derive a diagnostic standard. An adequately powered randomised trial is essential to provide evidence on the effectiveness of embolisation, but this faces methodological challenges.Study registrationThis study is registered as PROSPERO CRD42012002237 and CRD42012002238.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Implications For Health Carementioning

confidence: 99%

The relationship between pelvic vein incompetence and chronic pelvic pain in women: systematic reviews of diagnosis and treatment effectiveness

Champaneria

Shah

Moss³

et al. 2016

Health Technol Assess

View full text Add to dashboard Cite

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“…Pelvic inflammatory disease, endometriosis, interstitial cystitis, painful bladder syndrome, irritable bowel syndrome pelvic floor myalgia, myofascial pain, and pelvic neuralgia are the most common causes of CPP. In 55-61 % of women presenting with CPP, the cause remains undiscovered, even after deep diagnostic radiological tests and laparoscopy [6,7].…”

Section: Introductionmentioning

confidence: 99%

Pelvic congestion syndrome: the current state of the literature

Borghi

Dell’Atti

2015

Arch Gynecol Obstet

114

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Once the syndrome has been accurately diagnosed, medical, surgical, or minimally invasive endovascular treatments can improve symptoms in a high percentage of cases. This updated nonsystematic review of the literature explores the pathophysiology, clinical features, diagnostic investigations, and treatment option of this complex condition that affects young women with considerable implications for their daily social and psychological condition.

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“…Presacral neurectomy, and nerve transection for mononeuropathy (such as pudendal neuralgia) are the few interventions that have been extensively studied and performed. Laparoscopic utero-sacral nerve ablation (LUNA), which was practiced in the past, has been found ineffective as a robust form of surgical management and thus not recommended for the treatment of CPP [14].…”

Section: Therapeutic Options For Pelvic Painmentioning

confidence: 99%