Uterosacral nerve ablation via laparoscopy failed to improve chronic pelvic pain, dysmenorrhea, dyspareunia, and quality of life in a clinical trial four times larger than any previously published study of the issue.
Laparoscopic uterosacral nerve ablation (LUNA) using either lasers or electrodiathermy has become increasingly popular for chronic pelvic pain, even though systematic reviews have been “inconclusive” as to its benefit. “Clinicians' beliefs about LUNA's effectiveness vary widely, and LUNA remains a controversial procedure,” said Jane Daniels of Birmingham (U.K.) Women's Hospital and her associates.
The investigators performed a randomized study of 487 women with chronic pelvic pain undergoing laparoscopy for a differential diagnosis at 18 British hospitals. Intraoperatively, the women were assigned to undergo immediate LUNA or no nerve ablation.
“The ablation was performed as close to the posterior aspect of the cervix as possible and continued for a minimum of 1 cm posterolaterally on either side with the intended aim of destroying the sensory nerve fibers and the secondary ganglia as they left the uterus and lie within the uterosacral ligaments,” Ms. Daniels and her colleagues noted. “Full or partial transaction of the ligaments was achieved bilaterally with laser or electrodiathermy, according to the surgeon's preference.”
Median follow-up was 69 months. The patients assessed their pain and health-related quality of life at 3 and 6 months, and 1, 2, 3, and 5 years post procedure.
There were no differences between women who had LUNA and those who did not in terms of severity of chronic pelvic pain, dysmenorrhea, or dyspareunia at any time point, Ms. Daniels and her colleagues said (JAMA 2009;302:955–61).
There also was no difference in health-related quality of life. One year after the procedure, the two groups reported a similar number of visits to their general practitioners and a similar number of days off from work. There were eight cases of minor hemorrhaging during LUNA and one case that required conversion to an open surgery.
“LUNA was adopted by many practitioners because afferent nerves from pelvic organs pass through the uterosacral ligament, and it was thought that disruption of these would reduce the perceived pain. Lack of efficacy in our study and in prior studies provides evidence that the anatomical and physiological picture of chronic pelvic pain is more complicated.”
No financial conflicts of interest were reported by the study investigators.