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

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studies. For the treatment of primary dysmenorrhea there is National Institute for Health and Clinical Excellence (NICE, 2007)
some evidence of the effectiveness of uterine nerve ablation concluded: “The evidence on laparoscopic uterine nerve abla-
LUNA when compared to a control of no treatment. Long term tion (LUNA) for chronic pelvic pain suggests that it is not
PSN was shown to be significantly more effective. Neverthless, efficacious and therefore should not be used.” Like in the criteria
the comparison between presacral neurectomy (PSN) with for quality of evidence and classification of recommendations
LUNA for primary dysmenorrhea in the short term showed no for LUNA is III-C (Opinions of respected authorities, based on
significant difference in pain relief. Adverse events were clinical experience, descriptive studies, or reports of expert
significantly more common for presacral neurectomy, however, committees that there is insufficient evidence to support the
the majority were complications such as constipation, which recommendation for use of a diagnostic test, treatment, or inter-
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may spontaneously improve. Adverse events were more vention). 7,34
common for PSN than procedures without PSN (or 14.6; 95% CI
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5-42.5). In the primary dysmenorrhea showed no significant LUNA for other Cases
difference in pain relief of the comparison between LUNA and 30
laparoscopic presacral neurectomy (LPSN) in the short term; Johnson et al revealed no beneficial effect for dyspareunia
however, long-term LPSN was shown to be significantly more and dyschezia by double-blind randomized study of LUNA.
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effective than LUNA. 33 Also, another Vercellini et al randomized study showed that
LUNA had no additional effect for improvements in health-
LUNA for Chronic Pelvic Pain without Endometriosis related quality of life, psychiatric profile, and sexual satisfaction.
On the contrary a pilot study was undertaken to evaluate the
The preliminary randomized study using LUNA as an adjuvant effect of laparoscopic uterosacral nerve ablation (LUNA) for
therapy for treating patients with secondary dysmenorrheal treatment of primary deep dyspareunia between July 2002 and
caused by uterine myoma also showed the effect of LUNA in June 2003, overall, 8 (66.7%) patients in this trial were very
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alleviating pain. Another randomized study by Johnson et al satisfied or satisfied at the initial postoperative evaluation and
included 123 patients with chronic pelvic pain. Both uncontrolled 6 of them (50.0%) remained satisfied at the final evaluation at 12
and randomized double-blind studies had claimed support for months. 31
LUNA with either complete relief or substantial reduction in
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menstrual pain in the majority of patients. In 56 patients with LUNA for Endometriosis
no laparoscopic evidence of endometriosis, there was significant
reduction of dysmenorrheal, with a median change in VAS / In a randomized trial of 180 patients with symptomatic endo-
visual analog scale from baseline – 4.8 versus – 0.8 (p = 0.039), metriosis, the addition of LUNA to conservative laparoscopic
or 42.1% versus 14.3% experiencing successful treatment surgery for endometriosis did not reduce the medium- or long-
(p = 0.045). However, there is no evidence that LUNA is term frequency and severity of recurrent dysmenorrheal. 29
beneficial for non-menstrual pelvic pain. In a recent meta-analysis Another randomized study of 67 patients with chronic pelvic
of 5 randomized trials, the authors have approached a consensus pain and laparoscopic evidence of endometriosis found no
on the effectiveness of LUNA for menstrual pain. Similar significant difference in pain outcome. 30,35 For the treatment of
findings were reported by 4 other randomized trials. 23,26 Tjaden secondary dysmenorrhea the identified RCTs addressed only
et al 1990 : The addition of PSN to standard surgical therapy by endometriosis. The treatment of LUNA combined with surgical
laparotomy enhanced pain relief for midline/central pain. treatment of endometrial implants versus surgical treatment of
However, only eight of 26 patients were randomized and the endometriosis alone showed that the addition of LUNA did not
study was terminated before completion because of significant aid pain relief, the mentioned equal to PSN combined with
reduction in midline pain by the patients undergoing PSN. 22 endometriosis treatment versus endometriosis treatment alone
Nine RCTs were included in the systematic review. There were there was also no overall difference in pain relief, although the
two trials with open presacral neurectomy (PSN); all other trials data suggest a significant difference in relief of midline abdo-
used laparoscopic techniques. For the treatment of primary minal pain. In secondary dysmenorrhea, along with laparos-
dysmenorrhea, laparoscopic uterosacral nerve ablation (LUNA) copic surgical treatment of endometriosis, the addition of LUNA
at 12 months was better when compared to a control or no did not improve the pain relief (OR 0.77; 95% CI 0.43-1.39) while
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treatment (Odds Ratio or OR 6.12; 95% confidence interval /CI PSN did ( OR 3.14; 95% CI 1.59-6.21). A cochrane systematic
1.78-21.03). The comparison of LUNA with PSN for primary evidence review of clinical trials on surgical interruption of pelvic
dysmenorrhea showed that at 12 months follow-up, PSN was nerve pathways for primary and secondary dysmenorrhea found
more effective (OR 0.10; 95% CI 0.03-0.32). 32 there was only limited evidence to support the use of LUNA for
A recently published guidance on Laparoscopic Uterine primary dysmenorrhea. Guidelines on chronic pelvic pain from
Nerve Ablation (LUNA) for Chronic Pelvic Pain from the ACOG (2004) concluded. Adding uterine nerve ablation to

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