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The Role Laparoscopic Uterine Nerve Ablation (LUNA) and Presacral Neurectomy (PSN) of Pelvic Pain Management

While in neurectomy the plexus is exposed and the nerves are for a few complications reported in the literature. The bowel is
either cut or excised to interrupt the neural input, means the usually not at risk during a LUNA procedure, unless partial or
interruption of the sympathetic innervation of the uterus at the complete obliteration of the cul-de-sac due to endometriosis is
level of the superior hypogastric plexus (see Fig. 1).Adjacent present. In this condition, a LUNA procedure with bowel
vital structures which could be injured include the common adherent to a USL is inappropriate. One complication of a LUNA
iliac veins, the ureters, and the sigmoid mesentery. Presacral procedure would be the risk of damage to the ureter laying
neurectomy is technically more challenging than LUNA because lateral to the uterosacral ligament / USL. Regardless of the
of the presence of large vessels and the ureters near the field of surgical energy being used, damage to the ureter could occur in
dissection. 13,14 at least three ways, each avoidable.

Variations in LUNA Methods First Way
LUNA are the procedure interrupts/ablation of pelvic afferent Damage occurring as a consequence of extending the LUNA
sensory nerve fibers of the Lee-Frankenkauser nerve plexus. In incision too laterally. This complication can be avoided by
a 1955 study of Doyle et al, vaginal transection of the nerves strong anterior placement of the uterus with an intrauterine
was effective for dysmenorrheal. Wide variations in the practice manipulator, which puts the USLs on stretch and helps define
of LUNA have been shown by comparing the UK group with them better.
the rest of Europe. The latter were more likely to completely
transect the uterosacral ligaments (56% vs 36%) at a distance Second Way
2 cm or more from its cervical insertion (50% vs 21%) than the Damage occurring as a consequence of bipolar or monopolar
UK group. Even the tools for ablation varied between these electrocoagulation for hemostasis. Pelvic vessels lie lateral to
2 groups, i.e. laser cutting (3% vs 32%), electrodiathermy (78% the USL. The thick-walled, pulsating uterine artery is usually
vs 75%), scissors cutting (22% vs 15%), and harmonic scalpel easily visible through the peritoneum and usually lies
for cutting (8% vs 11%). There is widespread clinical uncertainty anterolaterally to the location of a LUNA procedure. Irrigation
in the techniques, with insufficient evidence of effectiveness, or retroperitoneal hydroinjection may help protect the ureter
thereby making it both harder to determine the optimal time, during electrocoagulation of a bleeder by providing heat sink
depth, and site of LUNA procedures, and the opinions regarding (a site for cooling of the thermal spread).
its use uncertain and variable. 15

Third Way
Effectiveness Measures of LUNA and PSN
Damage occurring during transection of a uterosacral ligament
A method structured survey was used to analyze gynecologists involved by invasive endometriosis which has resulted in
“prior beliefs” on the effectiveness for LUNA and PSN on pelvic retroperitoneal fibrosis around the ureter. The avoidance of
pain by both numeric response (on a l0-point visual analog this complication is simple: It is inappropriate to transect a USL
scale/VAS) and by responses to a questionnaire. The most invaded by significant nodular endometriosis because the
widely held “prior belief” was that LUNA would have small nodular endometriosis can still transmit pain along unsevered
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beneficial effect on pain. The secondary outcome measures proximal nerves. The proper therapy is resection of the involved
will be assessment of sexual function and quality of life. The portion of the USL, which accomplishes a LUNA procedure
Sexual Activity Questionnaire (SAQ) will replace the Brief Index simultaneously.

of Sexual Satisfaction (BISS) for the assessment sexual LUNA usually should not be repeated for two reasons:
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function. Third measure is health-related quality of life (HRQL) (1) If it was properly performed and did not work the first time,
instruments are becoming powerful tools for outcome assess- there is no reason to think it would work a second time; (2) The
ments in randomised trials. Quality of life has to be defined crater left by previous transection gives a spurious impression
clearly and patient’s perception of normal performance serves that a wide USL is present, and this can lead the transection
a pivotal role in this context. HRQL instruments are administered more lateral.
with questionnaires assessing a number 1of different domains, Laparoscopic presacral neurectomies have been performed
i.e. areas of behavior or experience that the instrument is in over 220 by the author, one patient required repeat laparo-
attempting to measure. 18
scopy to evaluate continuing postoperative pain. A small
hematoma was found in the presacral space which was
Intraoperative and Postoperative Complications
evacuated and the patient recovered uneventfully. There have
The adverse events of PSN were significantly more common been no cases of injury to the bowel, ureter or great vessels. 19
than those of LUNA. In general, LUNA is extremely safe except Long-term complications with PSN are uncommon. An

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