Efficacy of laparoscopic pelvic denervation in central-type chronic pelvic pain: A multicenter study

JOURNALOF GYNECOLOGIC SURGERY

MaryAnnLiebert,Inc.

Efficacy

of

_Laparoscopic

Pelvic Denervation in

Central-Type

Chronic Pelvic

Pain:

A

Multicenter

_Study

F.

_ZULLO,

_M.D.,12

M.

_PELLICANO,

_M.D.,2

R. De

_STEFANO,

_M.D.,2

P.

_{MASTRANTONIO,}

_M.D.,1

L.

_MENCAGLIA,

_M.D.,3

A.

_STAMPINI,

_M.D.,4

E.

_ZUPI,

_M.D.,5

and

M.

_BUSACCA,

_M.D.6

ABSTRACT

Our aim

was to

evaluate the

_efficacy

of

_laparoscopic

pelvic

denervation

_(uterosacral

resec-tion

or

presacral neurectomy)

for

the treatment

of chronic

pelvic pain

with

a

predominant

central-type

localization

inwomen

with endometriosis

or

with

no

visible

pathology.

In

a

ret-rospective analysis performed

in

six

_centers,

we

evaluated the data relative

to

58

patients

with midline

_{pelvic pain laparoscopically}

_treated,

with

a

follow-up

of

at least

6

months

in-cluding

a

quantitative

pain

assessment.

The distribution of

_types

of

_{pain (dysmenorrhea,}

deep dyspareunia,

and

_{pelvic pain}

not

related

to menses or

coitus)

was not

different among

stage

I—II

_{endometriosis, stage}

III-IV

_{endometriosis,}

and

no

visible

pathology,

_except

that

deep

dyspareunia

was

significantly (p

<

_0.05)

less

_frequent

in the absence of visible

pathol-ogy

than in moderate

to severe

endometriosis. Both

_types

of

laparoscopic

denervations

sig-nificantly

(p

<

_0.001)

reduced after

6

months the

_intensity

of

midline

_{dysmenorrhea, pelvic}

pain,

and

_{deep dyspareunia}

in

both

endometriosis

_patients

who also had

_undergone

con-servative

_surgery

and

women

without

_any

laparoscopically

visible

pathology.

Presacral

neurectomy

was

significantly

more

effective

than

uterosacral

resection in the relief of

dys-menorrhea. No

_major

adverse effects

were

reported;

and

minor side effects

were

compara-ble between the

two

_techniques.

In

_conclusion,

both

_presacral

_neurectomy

and

_laparoscopic

uterosacral resection

are

highly

effective in

reducing

midline

pelvic pain performed

either

alone or

in

combination with the

classic

ablative

_surgery

for

endometriosis.

(J

GYNECOL

SURG

_{12:35, 1996)}

INTRODUCTION

Chronic

pelvicpain

(CPP)

isa common and

_perplexing

gynecologic problem. Although

its definition

is still

_nebulous,

it

_represents

the reason foratleast 10% of alloffice visitstoa

gynecologist1

and for

approximately

40% of all

_{laparoscopies.2}

_Laparoscopy,

both

_diagnostic

and

_therapeutic,

is

_particularly

use-ful for this

_indication,

_{allowing pathogenetic}

treatmentin the

_majority

of thecauses of CPP.

Operative

la-paroscopy has inducedarenewal of interest in

pelvic

_denervation,

particularly presacral

_neurectomy

_(PSN),

asdescribed

by

Cotte,3

and uterosacral_resection

(USR).4

'Department

of

_Gynecology

and Paediatric Science,

Reggio

Calabria

_University,

Catanzaro,

_Italy.

2Gynecologic

Endoscopy

Service,

Naples, Italy.

3"Florence"Mininvasive

_Surgery

Center, Florence,

Italy.

4Department

of Obstetrics and

_Gynecology,

Riva del Garda Civic

_Hospital,

Trento,

_Italy.

department

of Obstetrics and

_Gynecology,

Tor

_{Vergata University,}

Rome,

Italy.

6Department

ofObstetricsand

_{Gynecology, University}

ofMilan,

Italy.

These

_techniques

of

_pelvic

_denervation,

whose anatomicrationale has beendescribed

elsewhere,34

could have acentral role in the

_management

of midline

pelvic

pain

associated with

endometriosis5-8

orin the ab-senceofa

specific

pathology,910

in view ofthe

frequent

lack of successofconservative treatment of

en-dometriosis and the transienteffect of medical treatment, which has various side effects. The role and

ef-ficacy

ofPSNand USR have notbeen

_clearly

defined.

We,

therefore,

haveevaluated dataabout PSN and USR

_performed

in six

_operative

_laparoscopy

units for midline chronic

_{pelvic pain, particularly}

for those

patients

followed up foratleast 6

months,

using

a

quantitative

pain

_assessment.

MATERIALS AND METHODS

All

_pelvic

denervations

_(PSN

and

_USR)

_{performed laparoscopically}

forchronic

pelvic pain

in six oper-ative

_laparoscopy

units werereviewed. Data were

analyzed

for those cases with a

complete

description

of

the

_history,

_intensity

of

_{pain, responsiveness}

to medical treatment, and localization of the

_pain

and witha

postoperative

follow-up

of at least 6 months.

_Only

those women with

_predominant

midline

pelvic pain,

cyclic

or

acyclic,

_persisting

formore than 6 months and

unresponsive

(or

only temporarily responsive)

to

medical treatment, who had

_{laparoscopically}

assessed endometriosisor novisible

pathology

at

_laparoscopy,

were included in the

study.

Fifty-eight

patients

included in the review underwent

_{gastroenterologic,}

_urologie,

_orthopedic,

and psy-chiatric evaluation before

_laparoscopy

to exclude other causes of

_pelvic

pain. Age,

weight, infertility,

laparoscopic

diagnosis,

type

of

pain,

and distribution of

types

of

pain

depending

onthe

laparoscopic

diag-nosis were_recorded. For each

patient,

the

intensity

ofthe

pain

wasevaluated

by

a

pain

scale,

avisual

ana-log

scale,

or a

pain

diary

witha

pain

relief scale filled in

by

the

patient

before _{surgery. All data} were

con-verted into a 1 to 10 numeric linear scale. The treatment was considered unsuccessful when there was a

reduction of less than 2

_points

in the numeric linear scale score.The

laparoscopic

assessment included

en-dometriosis

stage,

technical modalities of

_pelvic

denervations,

and the

_{intraoperative}

and

_{postoperative}

com-plications.

The conservativetreatmentof endometriosiswas

by

means of

adhesiolisis,

endometriomectomy,

and

ab-lation of all endometriotic

_implants.

USR was

performed

in 29 cases

using

a

bipolar

dissection followed

by

scissortransection of the

_proximal

2 cmof the uterosacral

ligaments.

In 5 cases,asuturebehind and in front of thetransection was

placed by

a2-0 PDS

skyneedle

(Ethicon,

Pomezia,

Italy).

Laparoscopic

PSN was

performed

in 4 cases

following

the

original

Perez

technique.5

In the

remaining

20cases, a

slightly simplified

technique

was

_used,

consisting

ofanumbilical _{scope and three 5-mm}

ancil-lary

ports,

left retraction of the

_sigmoid

colon and

_{retroperitoneal}

vasopressin

infiltration of the sacral

promontory

area,atransverseincision from

_major

vessels orthe ureteronthe

right

tothe

mesentery

of the

sigmoid

on the left and

hydrodissection,

and

bipolar coagulation

and scissortransection of all the

underly-ing

tissue

_layers

_{(including neurotomy)}

down tothe

_periosteum.

We used the r-testfor

_paired

data to_compare

_pain

intensities before and after surgery, thef-testfor

un-paired

datatocompare theA

(io-'f)

valuesmeans,andthe

_Chi-square

test to

_analyze

the

_frequencies.

RESULTS

The _averageage ofthe

_patients

was _30.4 ±4.1 _{years, the average}

_weight

was 63.6

kg

±

_10.5,

and the incidenceof

_infertility

was 36%

(Table 1),

withnodifferencebetween the groups treated

by

means of PSN orUSR.

The

_{laparoscopic diagnosis}

was

_stage

I—IIendometriosisin 16

patients,

_stage

III—IV endometriosis in

24,

andnovisible

pathology

in 18.Thedistribution of

laparoscopic diagnosis

and

types

of

pain

(dysmenorrhea,

deep

dyspareunia,

and

_pelvic

_pain

unrelated tomenses or

coitus)

was not different between the PSN and USR _groups

_{(Table 1).}

The distribution of

_pain

_symptoms

in the differentclinical conditions

_{(Table 2)}

re-vealednodifferences between

_stage

I—II endometriosis and endometriosis moderateto severe,whereas

deep

dyspareunia

was

significantly

(p

<

_0.05)

less

_frequent

in those

_patients

with absence of visible

_pathology

than in

_stage

III—IVendometriosis.

Pain

_intensity,

_{preoperatively}

_evaluated,

was not different between PSN and USR groups and between

Volume_12,Number1, 1996 LaparoscopicPelvic Denervation 37 Table 1. Demographic and Clinical Data

Totalcases PSNà USR

n =58 n=24 n =34

Age

(years)

30.4±4.lb 29.3 ±3.9 31.2 ±4.2

Weight

(kg)

63.6± 10.5 61.8 ±9.4 64.9 ±11.2

Infertility

21

(36)c

9(37) 12 (35)

Endometriosisstage I—II

16(27.6)

5(20.8)

11(32.3)

Endometriosisstage III-IV 24(41.1)

11(45.8)

13(38.2)

No visible

pathology

18

_(31.0)

8

(33.3)

10 (29.4)

Dismenorrhea 56

(96.5)

23

(95.8)

33

(97.1)

Dyspareunia

28

_(48.2)

14

(58.3)

14

(41.2)

Pelvic

_pain

(unrelated tomenses 36

(62.1)

16

(66.6)

20 (58.8) orcoitus)

aPSN,

presacral

neurectomy;USR,ureterosacral resection.

bMeans± SD.

cPercent

_given

in

_parentheses.

and after surgery

(Table 4)

showed a

significant

(p

<

_0.001)

effectiveness forboth_{typesof surgery in} de-creased

_pain

scores for all the

_symptoms

for 6 months.

PSN was unsuccessful in the reliefof

dysmenorrhea

in 8%

(2

of

23)

ofcases and in 12%

(2

of

16)

of

pelvic

pain

unrelatedtomenses orcoitus. USR hadafailurerateof 24% incaseof

dysmenorrhea,

21 % for

deep dyspareunia,

and 15% for other

_pelvic

_pain.

_Evaluating

the differential

_pain

score before and after

surgery

(A

tç,-tf), we determined a

significantly (p

<

_0.001)

_{higher efficacy}

for PSN than for USR in the reliefof

_dysmenorrhea

and

_comparable

results between thetwo

_techniques

for

deep dyspareunia

and

_pelvic

pain

(Table

4).

The

_techniques

were

_comparable

inthe_{relief of}

_pain

_symptoms

in

patients

either with

en-dometriosisor withno visible

pathology

(Table 5).

We hadone acute

_complication

from PSN:

_major

bleeding

(>500 mL)

from midsacral

vessels,

laparo-scopically

resolved but

_requiring

ablood transfusion. The late

complications

were

constipation

in 5 cases

in the PSN group

(20%)

and 4

_patients

_{in the USR group}

_(16%)

and

_urinary

urgency in 2 women treated

by

PSN

_(8%).

DISCUSSION

CPP is one of the most

_{frustrating problems}

for a

gynecologist.

These

patients

often suffer from

alter-ationsin

_daily

_functioning,

_work,

and

_personal

_{relationships.1}

'_{The medicaltreatmentoffers}

_only

temporarily

reliefof the

_symptoms

_and,

because ofthe side

_effects,

should not be considered for

_{long-term therapy.}

Endometriosis,

one of the most

_frequent

causes of

_CPP,

canbe treated

conservatively,

with

improvement

in

_pain

_symptoms.12

_{Unfortunately,}

however,

such surgery isnot

_{always completely}

successful,

_particularly

in the presenceof

_{subperitoneal implants}

and

_microscopic

lesions.13

Table 2. Distribution of Pain Symptomsin Different Clinical Conditions Preoperatively

(r0)

Endometriosis Endometriosis

stageI-II stagelll-IV Novisible

pathology

n=16 _{n=24 n} =₁₈

Dysmenorrhea

16

(100%)

24 (100%) 16 (88%)

Dyspareunia

7

(43%)

16

(66%)*

5 (27%)

Pelvic

_pain

7(43%)

14(58%)

11(61%)

Table3. PainIntensity Degree1*at _t0

Deep

Dysmenorrhea

dyspareunia

Pelvic

pain

n =56 n =28 n =₃₆ Totalcases 6.17± 1.56b 6.60 ±1.38 6.76±0.78 PSNC 7.29± 1.23 5.87 ±1.12 8.0±0.85 USR 5.82 ± 1.56 6.38± 1.53 6.73 ±0.70 Endometriosis 5.97±1.42 6.36± 1.49 6.79±0.83 No visible

_pathology

5.52 ± 2.69 5.75 ±2.65 6.60±0.51

"Degree,

1to10 linear numeric scale.

bMeans ± SD.

CPSN,

personal

neurectomy; USR,ureterosacral resection.

The

_{rapid, widespread}

useof

_{high-tech operative laparoscopy}

has renewed interest in

_pelvic

denervation,

and many observational

reports

have confirmed its

_efficacy

_by

both

PSN514

and

USR.1518

Our

multicen-ter

_{retrospective, stringently}

defined

_analysis

has shown a PSN

_efficacy

rateof92% in the relief of

dys-menorrhea,

100% for

_{deep dyspareunia,}

and 88% for

_{pelvic pain}

unrelated tomenses orcoitus andaUSR success rateof 76% for

_{dysmenorrhea,}

79% for

_dyspareunia,

and 85% for other

_{pelvic pain.}

The inclusion in this

_study

of data relative

_only

to

_patients

witha

quantitative

assessmentof

_pain

has al-lowed us toshowa

highly significant

_(p

<

_0.001)

reduction in the

_pain

score 6 months after surgery. Our

results are consistent with the

improvement

rate in

_dysmenorrhea

in

_patients

with endometriosis

_reported

by

Perez5 (24

of

25),

Nehzat and

_{Nezhat14 (92%}

of57

_patients),

_{Feste15 (72%}

of 32

_{women), Davis16 (92%}

of 146

_patients

with

_dysmenorrhea

and 94% of 109 with

_{dyspareunia),}

_{Daniell17 (75%}

of 80

_cases),

and Sutton and

_{Hill18 (70%}

of 187

_patients).

_However,

in some of these

_reports,

the inclusion criteriawerenot

limited tomidline

_{pelvic pain,}

and in none of them was a

pain

scale used.

Regarding

the

_efficacy

of

_pelvic

denervation in

_patients

with novisible

pathology

at

laparoscopy,10

our

data have shown similar results tothose obtained in endometriosis

_patients

with both

_techniques

_(PSN

and

USR).

This fact could be

_interpreted

as indirect

proof

that the

efficacy

in

pain

relief of

pelvic

denervation

is at least

_{partly independent}

of the ablative treatment of endometriosis.

_{Nevertheless,}

the

_only

well-con-ducted

_(prospective

_randomized)

_laparotomie

_study12

has

_questioned

this

issue,

although

the

_relatively

small size of the series and the better results of the PSN group

(79%

vs 67% relief

_rate),

_although

not

_significant,

do notallow adefinitive

conclusion.19

A

_{significantly (p}

<

_0.001)

_higher

effectiveness of PSN overUSR in

reducing

the

_dysmenorrhea

score

has been

shown,

and this is the first

_{report (to}

ourbest

knowledge)

ofa

_comparison

between thetwo

tech-niques. Only

the

_{laparotomie study by}

Leeet

al.9

showedan

insignificant

_improvement

of PSN results

_by

Table4. Pain Intensity Degree" Preoperatively

(<0)

and 6 Months After

Surgery

(<f)

PSNb USR to tf to

tf

Dysmenorrhea

7.29± 1.23e* 2.87 ± 1.75 5.82± 1.56* 3.02± 1.78

Deep

dyspareunia

5.87 ± 1.12* 1.12 ±0.99 6.38 ± 1.53* 1.11 ±2.21 Pelvic

_pain

8.0±0.85* 2.58 ± 1.08 6.73 ±0.70* 1.86 ± 1.64

A(i0

-tf)

dysmenorrhea

4.63 ± 1.57** 2.50 ± 1.83

A(r0

-if)

_dyspareunia

4.71 ± 1.38 5.38 ±2.30

A(?0

-t()

pelvic pain

4.58 ±2.19 4.86 ± 1.45

"Degree,

1to10 linear numeric scale.

bPSN,

presacral

neurectomy; USR,ureterosocial resection. cMeans ± SD.

*p

<0.001 Student'si-testfor

_paired

data.

Volume12, Number1, 1996 _LaparoscopicPelvic Denervation 39 Tablf. 5. Comparisonof Efficacy ofPSN and USRin Endometriosis andNo Visible Pathology

PSA/" USR

Indication Endometriosis No

pathology

Endometriosis No

pathology

A(i0

-if) dysmenorrhea

4.50± 1.50b 5.0 ± 1.58 2.40± 1.59 3.54 ±2.11

A(/()

-tf)

dyspareunia

4.0± 1.0 5.25 ±1.50 5.11 ±2.23 8.0±0.0

A(f0

-if)

pelvic pain

4.81 ± 1.88 4.80 ±2.28 4.70± 1.33 5.50± 1.76 "PSN.

presacral

neurectomy; USR,ureterosacral resection.

bMeans ±SD.

adding

USR,

but no direct

comparison

was made. We cannot _{say if these results} can be attributed to the

more

frequent incompleteness

ofnerve section

during

USR than

PSN,

particularly

in those endometriosis

patients

in whom the _cul-de-sac

_anatomy

is

_altered,

orto a

higher efficacy

of PSN rather than USR.

Finally,

this

_study

shows that

_laparoscopic

PSN and USR are

highly

effective in

reducing

midline

_pelvic

pain

in

_patients

with _{endometriosis} or with no visible

pathology.

From these

data,

we can

extrapolate,

at

least for CPP

_patients,

a_theoretical

advantage

of

performing

a

pelvic

denervation atthe time of

_diagnostic

laparoscopy

when acorrectexclusion of othercauses of

pain

is

made,

withaclear uterine

_(central)

local-ization of

_pain,

andwhen the

_{laparoscopist}

is

_sufficiently

skilled. The

_{higher efficacy}

ofPSNoverUSR in

the relief of

_dysmenorrhea

_suggeststhe formeras the first choice

technique,

atleast in thosecaseswith

dis-tortion of the cul-de-sac

_anatomy

in which a

complete

uterosacral resection can become

dangerous

for

ureteral and vascular

_injuries.

The conclusions of this

_preliminary

_study,

multicentric and

_{retrospective,}

to be

_definitive,

need future

prospective

randomized studies with a

longer follow-up

(12

months or

_more).

In

_particular,

a

comparison

between ablative

_laparoscopic

_{surgery and ablative}

_laparoscopic

_surgery

_plus

denervation in CPP

_patients

with endometriosis and a

comparison

between

diagnostic laparoscopy plus

denervation vs

diagnostic

laparoscopy plus

medical treatment in CPP

_patients

with no visible

pathology

could be

extremely

useful.

REFERENCES

1. Reiter RC. A

_profile

ofwomenwith chronic

pelvic pain.

Clin Obstet

Gynecol

1990;33:130.

2. HowardFM.The role of

_laparoscopy

in chronic

_pelvic

pain:

Promise and

_pitfalls.

Obstet

Gynecol

Surv 1993;48:357.

3. Cotte G. La

sympathectomie

hypogastrique:a-t-elle

sa

place

dane la

thérapeutique

gynecollogique?

Presse Med

1925:33:98.

4.

Doyle

JB. Paracervicaluterine denervation

by

transection ofthecervical

_plexus

fortherelief of

_{dysmenorrhea.}

Am J Obstet

Gynecol

1955;70:1.

5. PerezJJ.

Laparoscopic

presacral

neurectomy:Resultsof the first 25cases.J

Reprod

Med 1990;35:625.

6. Polan ML,

_DeCherney

A. Presacralneurectomy for

_{pelvic pain}

in

_infertility.

Fértil Steril 1980;34:557.

7.

_Tjaden

B, Schlaff WD. Kimball A,etal.The

efficacy

of

_presacral

neurectomytothe relief ofmidline

dysmenor-rhea. Obstet

Gynecol

1990;76:89.

8. Black WT. Useof

_{presacral sympathectomy}

in the treatment of

dysmenorrhea.

Asecond look after

_twenty-five

years.Am JObstet

_Gynecol

1964;89:16.

9. LeeRB,StoneK,

Magelssen

D,etal. Presacralneurectomyfor chronic

_{pelvic pain.}

Obstet

_Gynecol

1986;68:517.

10. Lichten EM, Bombard J.

_Surgical

treatmentof

primary

dysmenorrhea

with

_laparoscopic

uterine nerve ablation.J

Reprod

Med 1987;32:37.

11. Chronic

pelvic pain.

ACOG Technical BulletinN 129, 1989.

12. Candiani _GB,FedeleL, VercelliniP,BianchiS,Di ÑolaG. Presacral neurectomyfor thetreatmentof

pelvic pain

associated with endometriosis: A controlled

study.

AmJ Obstet

Gynecol

1992;167:100.

13. CandianiGB,Bianchi S.Pelvic denervation for

pelvic pain

associated withendometriosis.In:

Crosignani

PG,Vercellini

P,eds. Endometriosisand

_{pelvic pain:}

Time of review. Carnforth,

England:

Parthenon

_Publishing,

1994:101. 14. NezhatC,Nezhat F.A

_simplified

method of

_{laparoscopic presacral}

neurectomyfor thetreatmentofcentral

_pelvic

pain

duetoendometriosis. Br J Obstet

_Gynaecol

1992;99:659.

15. Feste JR. Laser

laparoscopy:

Anew

_modality.

J

Reprod

Med 1985;30:413.

16. Davis GD.

Management

of endometriosis and its associated adhesions with the

_CO2

laser

_laparoscope.

Obstet

17. DaniellJF.

Fiberoptic

laser

laparoscopy.

Bailleres Clin Obstet

_Gynecol

1989;3:545.

18. SuttonC,HillD. Laser

_laparoscopy

in the treatmentof endometriosis.BrJ Obstet

_Gynaecol

1990;97:181.

19. VercelliniP,Fedele _L, Bianchi S, Candiani GB. Pelvic denervation for chronic

pain

associated with endometrio-sis: Factor

fancy?

Am JObstet

_Gynecol

1991;165:745.

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