Surgical pelvic neuroablation for chronic pelvic pain: a systematic review

Abstract

Objective To determine, from the best available evidence, the effectiveness of surgical pelvic neuroablative techniques as treatment for primary and secondary dysmenorrhoea. Design Systematic review of randomized controlled trials (RCTs). Subjects Women with primary or secondary dysmenorrhoea. Interventions Surgical neuroablative techniques including uterine nerve ablation and presacral neurectomy. Main outcome measures Pain relief (both short‐ and long‐term) and adverse effects. Results Laparoscopic uterine nerve ablation (LUNA) has been shown by one small study to be effective for primary dysmenorrhoea up to 12 months. A larger study showed no significant difference between LUNA and laparoscopic presacral neurectomy (LPSN) in pain relief for primary dysmenorrhoea up to 6 months, but LPSN was significantly more effective beyond 6 months. For dysmenorrhoea secondary to endometriosis, two trials found no significant difference in pain relief afforded by LUNA plus conservative laparoscopic surgery for endometriosis vs. conservative laparoscopic surgery alone. Presacral neurectomy (PSN) plus conservative surgery for endometriosis at laparotomy vs. conservative surgery for endometriosis at laparotomy showed no significant difference in overall pain relief, although there was a significant difference in relief of midline abdominal pain. Adverse events overall were significantly more common following PSN; these included constipation, urinary urgency, painless labour and one case necessitating a laparotomy for presacral haematoma 2 days after PSN. Conclusions There is insufficient evidence to recommend the use of surgical pelvic neuroablation in the management of dysmenorrhoea, regardless of cause. Further scientifically rigorous RCTs should be undertaken.

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

“…A power calculation has been undertaken to determine an appropriate sample size to demonstrate what was deemed to be a clinically important treatment effect of LUNA 12 . For women with chronic pelvic pain in the absence of endometriosis, to have 80% power at the 95% confidence level to detect benefit in 50% of women, assuming ‘benefit’ in 10% controls, at least 48 participants would be required for analysis following randomisation.…”

“…It was concluded that there was insufficient evidence to recommend the routine use of LUNA in the management of chronic pelvic pain, but suggested there may be a difference in response between women with endometriosis and those with chronic pelvic pain in the absence of endometriosis. There have been isolated case reports of uterine prolapse 13,14 and bladder dysfunction 15 following LUNA, although the complication rate attributable directly to LUNA appears to be extremely low 12 . Other adverse effects of neuroablation, such as haematoma formation, constipation and subsequent painless labour, appear to be more associated with presacral neurectomy (PSN) than LUNA.…”

“…P Parasympathetic nerve; S sympathetic nerve. Copyright approval for reproduction of this figure has been kindly granted by Blackwell Science, publisher of Gynaecological Endoscopy 12 …”

“…A systematic review of surgical pelvic neuroablation, including four randomised trials of LUNA, 8 -11 found limited evidence that LUNA may provide effective relief from primary dysmenorrhoea but no evidence of effectiveness when LUNA was added to conservative surgery for endometriosis. 12 It was concluded that there was insufficient evidence to recommend the routine use of LUNA in the management of chronic pelvic pain, but suggested there may be a difference in response between women with endometriosis and those with chronic pelvic pain in the absence of endometriosis. There have been isolated case reports of uterine prolapse 13,14 and bladder dysfunction 15 following LUNA, although the complication rate attributable directly to LUNA appears to be extremely low.…”

“…There have been isolated case reports of uterine prolapse 13,14 and bladder dysfunction 15 following LUNA, although the complication rate attributable directly to LUNA appears to be extremely low. 12 Other adverse effects of neuroablation, such as haematoma formation, constipation and subsequent painless labour, appear to be more associated with presacral neurectomy (PSN) than LUNA. Indeed PSN, a more invasive procedure involving the transection of a greater number of nerve fibres than LUNA is associated with a much higher complication rate than LUNA, 12 although a recent randomised trial has supported the effectiveness of laparoscopic PSN for severe dysmenorrhoea related to endometriosis.…”