Surgical pelvic neuroablation for chronic pelvic pain: a systematic review

Objective To determine, from the best available evidence, the effectiveness of surgical pelvic neuroablative techniques as treatment for primary and secondary dysmenorrhoea. Design Systematic review of randomized controlled trials (RCTs). Subjects Women with primary or secondary dysmenorrhoea. Interventions Surgical neuroablative techniques including uterine nerve ablation and presacral neurectomy. Main outcome measures Pain relief (both short- and long-term) and adverse effects. Results Laparoscopic uterine nerve ablation (LUNA) has been shown by one small study to be effective for primary dysmenorrhoea up to 12 months. A larger study showed no significant difference between LUNA and laparoscopic presacral neurectomy (LPSN) in pain relief for primary dysmenorrhoea up to 6 months, but LPSN was significantly more effective beyond 6 months. For dysmenorrhoea secondary to endometriosis, two trials found no significant difference in pain relief afforded by LUNA plus conservative laparoscopic surgery for endometriosis vs, conservative laparoscopic surgery alone. Presacral neurectomy (PSN) plus conservative surgery for endometriosis at laparotomy vs, conservative surgery for endometriosis at laparotomy showed no significant difference in overall pain relief, although there was a significant difference in relief of midline abdominal pain. Adverse events overall were significantly more common following PSN; these included constipation, urinary urgency painless labour and one case necessitating a laparotomy for presacral haematoma 2 days after PSN. Conclusions There is insufficient evidence to recommend the use of surgical pelvic neuroablation in the management of dysmenorrhoea, regardless of cause. Further scientifically rigorous RCTs should be undertaken.