Page 41 - WJOLS

The Role Laparoscopic Uterine Nerve Ablation (LUNA) and Presacral Neurectomy (PSN) of Pelvic Pain Management
World Journal of Laparoscopic Surgery, September-December 2008;1(3):39-45
The Role of Laparoscopic Uterine Nerve Ablation

(LUNA) and Presacral Neurectomy (PSN) of Pelvic

Pain Management

Ashon Sa’adi
Gynecological Specialist and Laparoscopic Surgeon, Department of Obstetrics and Gynecology, Dr Soetomo Hospital of
Surabaya, Indonesia

Abstract Conclusion: Currently, we have showed that LUNA and PSN can be
an option in primary or secondary menstrual pain without
Background: The chronic pelvic pain as non-cyclical pain is serious endometriosis; LUNA has not been shown to reduce dysmenorrhea
enough to cause disability or lead to medical care. While these treatments and, therefore, should not be advocated as a mainstream treatment
are very successful there is still a 20 to 25% failure rate and surgery except who have persistent dysmenorrhea.
has been an option for such cases. Effectiveness of laparoscopic
uterosacral nerve ablation (LUNA) and presacral neurectomy (PSN) Keywords: Chronic pelvic pain; laparoscopy uterine nerve ablation;
can be useful for alleviating chronic pelvic pain. presacral neurectomy; dysmenorrheal.

Objectives: To assess the effectiveness of surgical interruption of INTRODUCTION
pelvic nerve pathways in primary and secondary dysmenorrheal in
the chonic pelvic pain. The chronic pelvic pains of more than a year’s duration have
been suffering of approximately 15-20 % of women between
Data sources: Various watchfulness sources related to surgically chronic 18 and 50 years of age. Survey in Europe has showed prevalence
pelvic pain treatment from various causes and journals, also involve of dysmenorrhoea (12 studies) is 59% (95% CI 49.1-71%), of
the Cochrane Menstrual Disorders and Subfertility Group Trials dyspareunia (11 studies) is 13.3% (95% CI 8.8-20.3%) and of
Register (9 June 2004), CENTRAL (The Cochrane Library, Issue 2, noncyclical pain (2 studies) is 6.2% (95% CI 3-12.6%). CPP
1,2
2004), MEDLINE (1966 to Nov. 2003), EMBASE (1980 to Nov. refers to menstrual or nonmenstrual pain of at least six months’
2003), CINAHL (1982 to Oct. 2003), MetaRegister of Controlled
Trials, the citation lists of review articles and included trials. duration occurring below the umbilicus. Pain syndromes are
caused by activation of nociceptors and transmission of signals
Methods: Review and analyzed of prospective study of laparoscopy in pain pathways. Thus, they are expected to respond to interrup-
presacral neurectomy / PSN or laparoscopy uterosacral nerve ablation tion or modulation of that transmission at any level above the
/ LUNA (both open and laparoscopic procedures) for the treatment of site of activation. Chronic pelvic pain includes primary and
pelvic pain ( primary and secondary dysmenorrheal). The main outcome secondary dysmenorrhea. 3,4,5
measures were pain relief and adverse effects. Endometriosis is the most common gynecological cause of
Results: We have got 13 sources analysis extracted data on chronic pelvic pain. Other causes of chronic pelvic pain include
characteristics of the study quality and the population, intervention, pelvic inflammatory disease, psychologically stress, pelvic
and outcome independently. Nine randomized controlled trials were congestion syndrome, nerve entrapment related to muscular
included in the systematic review. There were two trials with open spasm, interstitial cystitis, and pelvic floor pain. Treatment for
presacral neurectomy; all other trials used laparoscopic techniques. chronic pelvic pain depends on the underlying cause, severity
For the treatment of primary dysmenorrhea, laparoscopic uterosacral of symptoms, the extent and location of disease, the desire for
nerve ablation at 12 months was better when compared to a control or pregnancy, and the age of the patient. Laparoscopic presacral
no treatment. The comparison of laparoscopic uterosacral nerve ablation neurectomy has been extensively studied and considered as an
with presacral neurectomy for primary dysmenorrhea showed that at effective technique for the treatment of chronic pelvic pain and
12 months follow-up, presacral neurectomy was more effective. In dysmenorrhea in selected cases. If conservative medical treat-
secondary dysmenorrhea, along with laparoscopic surgical treatment ments fail to relieve symptoms, second-line pharmacologics,
of endometriosis, the addition of laparoscopic uterosacral nerve ablation such as hormonal treatment, may be indicated, conservative
did not improve the pain relief, while comparing to presacral surgery ( LUNA or PSN ) and hysterectomy may be considered
neurectomy. Side effects were more common for presacral neurectomy for patients with severe symptoms that do not respond to
than procedures laparoscopy uterine nerve ablation. conservative treatment (20-25% of failure rate). This precise

39