Laparoscopic uterosacral nerve ablation in chronic pelvic pain: an overview

Objective To assess the efficacy of laparoscopic uterine nerve ablation (LU NA) in the treatment of chronic pelvic pain, by means of a systematic overv iew of the published literature. Design Relevant papers were identified through electronic scanning of MEDLI NE (1966 1997), EMBASE (1980m 1997), the Science Citation Index and the Coc hrane Library and manual searching of the bibliography of known primary and review articles. Study selection, study quality assessment and data abstra ction were performed independently in duplicate. For controlled studies dat a were used to generate odds ratios (OR) and their confidence intervals (CI ). Subjects These were 555 women included in 11 case series and 250 women incl uded in two controlled observational studies and three randomized trials. Main outcome measure Pain relief measured in general terms or assessed usin g visual analogue or numeric pain scales. Results In the case of pelvic pain with no visible pathological findings at laparoscopy: randomized studies showed that LUNA had a trend towards bette r pain relief compared with no surgical intervention (OR 9.4, 95% CI 0.7 to 472; P = 0.9) but its effect was inferior to presacral neurectomy (OR 0.24 , 95% CI 0.07 to 0.8; P = 0.01). Where there was endometriosis, controlled non-randomized studies showed that with ablative treatment of endometriosis , the outcomes were better with than without LUNA (OR 36.7, 95% CI 3.9 to 1 625; P = 0.001); however, presacral neurectomy did not show better results than LUNA (OR 0.30, 95% CI 0.03 to 1.76; P = 0.1). One randomized controlle d study in patients with endometriosis showed that LUNA plus ablative treat ment was better than no intervention (OR 5.7, 95% CI 1.6 to 20.3; P = 0.003 ), an effect that was not apparent in the subgroup with minimal endometrios is (P = 0.24). Conclusion On theoretical grounds, LUNA has the promise of an efficacious i ntervention in alleviating pelvic pain. However, the pitfalls in the publis hed research that we have identified and evaluated make it impossible for u s to conclude that this intervention is universally effective. At best ther e is a trend indicating effectiveness in relieving primary dysmenorrhoea an d mild to moderate endometriosis. For the majority of women with chronic pe lvic pain, there is not sufficient evidence to guide therapeutic decision m aking with regard to laparoscopic uterine nerve ablation.