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Presacral Neurectomy — 427
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Grasping forceps
holds hypogastric
Suction irrigator probe
behind hypogastric nerve
to protect laser penetration
Figure 15.1.3. The plexus of nerves is grasped with atraumatic forceps. The nerves are skeletonized, coagulated, and excised. Nerves that
lie within the boundaries of the interiliac triangle are removed along
with the fibers entering the area from underneath the common aortic
arteries. From Nezhat et al.[28]
L. common
iliac vein
Sigmoid
colon
Figure 15.1.4. Transected segments of the pelvicnerve. Sutures are not
required to close the defect. The excised tissue is sent for histologic
examination. From Nezhat et al.[28]
plexus and fibrofatty
tissue
Transected
segment of
hypogastric
nerve plexus
AO
IVC
Laser transects
nerve bundle
Ureter
its branches. Hemostasis is obtained with bipolar electrocoagulation.
The nerve plexusisgrasped withan atraumatic forceps. Using
blunt and sharp dissection, the nerve fibersareskeletonized, coagulated, and excised (Figure 15.1.3). All the nerves that lie within
the boundaries of the interiliac triangle are removed, including
any fibers entering the area from under the common iliac arteries
(Figure 15.1.4). The retroperitoneal space is irrigated, and bleeding points are coagulated. Sutures are not required. The excised
tissue is sent for histologic confirmation of nerve removal. At
second-looklaparoscopy, thepresacralareashouldappearhealed.
Usually, no small bowel is attached to this area. If a mesocolon
detachment is required at the initial procedure, the mesocolon
usually reattaches itself to the presacral area.
RESULTS
Cotte [19] reported favorable results with presacral neurectomy
in 1500 selected patients with only a 2% failure rate. Meigs [20]
reported an85% relief rate. In a review of 2516 patients, Black[5]
noted 70% ofthepatients experienced relief, 19%wereimproved,
and 11% were unimproved. Polanand DeCherney [1]reportedin
1980 that 14 of 20 patients (70%) were relieved of pain after presacral neurectomy. In the control group, 14 of 54 (26%) showed
significant pain relief. Lee and colleagues [21] reported a 74%
success rate, with 14% experiencing a partial cure. There was a
12% failure rate. Perez [6] studied 25 patients and concluded
that 96% experienced pain relief. The mean preoperative score
for patients in the study was 8.5 (on a scale of 0 to 10, with 0
being no pain and 10 being the worst pain), whereas the postoperative mean score was 2.2. In a randomized prospective study
on the efficacy of presacral neurectomy initiated by Tjaden and
colleagues [2], 17 of the 26 patients had a presacral neurectomy.
Fifteen of the 17 (88%) noted relief, whereas two (12%) had no
improvement.Painpersistedinallnineofthepatientswhodidnot
undergo presacral neurectomy. In 1992, Nezhat and Nezhat [22]
described a simplified method of presacral neurectomy in one
of the earliest reports on the laparoscopic approach. The authors
performed laparoscopic presacral neurectomy in 52 patients with
dysmenorrhea unresponsive to medical treatment. The severity
of endometriosis varied among the patients (31 had minimal, 13
had mild, five had moderate, and three had severeendometriosis).
Forty-eight of the 52 patients (92.3%) reported relief of dysmenorrhea, including 27 (51.2%) who reported complete pain relief.
Of the 27 patients reporting complete pain relief, 16 (59%) had
minimal, six (22%)hadmild, three (11%) hadmoderate,and two
(8%) had severe endometriosis. Carter [8] reported on presacral
neurectomy in 20 patients with follow-up of up to 18 months.
The pain level in these women decreased from an average of 9.4
to 2.0 (on a scale of 0 to 10, with 0 being no pain and 10 the
worst).
Chen and coworkers [23] reported on presacral neurectomy
in 67 patients with primary dysmenorrhea who had a poor
responsetomedicaltreatment.The patients weredividedintotwo
groups, with 33 undergoing laparoscopic presacral neurectomy
and 34 undergoing LUNA. The efficacy of the two procedures
was identical after 3 months, but after 12 months, laparoscopic
presacral neurectomy was significantly more effective than
LUNA. The authors concluded that presacral neurectomy was
428 — James E. Carter
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Table 15.1.1: Pain Reduction after Laparoscopic Presacral Neurectomy by Stage of Endometriosis. The Long-Term
Outcome of Laparoscopic Presacral Neurectomy Is Satisfactory in Most Patients
Degree of Improvement
>80% 50–80% <50% None No Response
Pelvic pain
Stage I (n = 53) 18 (34.0) 19 (35.8) 10 (18.9) 5 (9.4) 1 (1.9)
Stage II (n = 22) 13 (59.1) 4 (18.2) 3 (13.6) 2 (9.1) 0
Stage III (n = 7) 2 (28.6) 3 (42.9) 1 (14.3) 1 (14.3) 0
Stage IV (n = 13) 8 (61.5) 3 (23.1) 2 (15.4) 0 0
Total (n = 95) 41 (43.2) 29 (30.5) 16 (16.8) 8 (8.4) 1 (1.1)
Dysmenorrhea
Stage I (n = 53) 12 (22.6) 16 (30.2) 14 (26.4) 5 (9.4) 6 (11.3)
Stage II (n = 22) 10 (45.5) 5 (22.7) 3 (13.6) 2 (9.1) 2 (9.1)
Stage III (n = 7) 2 (28.6) 3 (42.7) 0 2 (28.6) 0
Stage IV (n = 13) 7 (53.8) 2 (15.4) 1 (7.7) 1 (7.7) 2 (15.4)
Total (n = 95) 31 (32.6) 26 (27.4) 18 (18.9) 10 (10.5) 10 (10.5)
preferable to uterine nerve ablation for long-term relief of primary dysmenorrhea. Inaretrospective review of 655 patients who
had laparoscopic conservative surgery and laparoscopic presacral
neurectomy, Chen and Soong [9] found that 527 (80%) reported
significant alleviation of pain. Cure was achieved in 22 (52%) of
the 42 patients with adenomyosis, 75 (73%) of the 103 patients
with moderate to severe endometriosis with dysmenorrhea, 123
(75%) of the 164 patients with minimal to mild endometriosis
with dysmenorrhea, 64 (77%) of the 83 patients with primary
dysmenorrhea, and 84 (62%) of the 135 patients with chronic
pelvic pain. Nezhat et al. [10] evaluated long-term outcomes of
laparoscopicpresacralneurectomy in 176 womenwhounderwent
presacral neurectomyand treatment of endometriosis.More than
50% alleviation of pain was reported in 69.8% of the women
with stage I endometriosis (using the revised classification of
the American Fertility Society), 77.3% of those with stage II,
71.4% with stage III, and 84.6% with stage IV (Table 15.1.1).
The authors concluded that long-term outcome of laparoscopic
presacral neurectomy is satisfactory in most patients, and the
stage of endometriosis is not related directly to the degree of pain
improvement achieved.
Zullo [12] reported on a2-year study of presacral neurectomy
for the treatment of severe dysmenorrhea due to endometriosis.
The frequency and severity of dysmenorrhea, dyspareunia, and
chronic pelvic pain, and quality of life were evaluated at entry
and 24 months postoperatively. At follow-up visit, the 83.3%
cure rate (P ≤ 0.05) was significantly higher in the group with
laparoscopic surgery and presacral neurectomy than the 53.3%
cure rate in the group with only conservative laparoscopic surgical intervention. The frequency and severity of dysmenorrhea,
dyspareunia, and chronic pelvic pain were significantly lower
in both groups compared with baseline values (P ≤ 0.05), and
only severity was significantly lower in the group with presacral
neurectomy and endometriosis surgery (P ≤ 0.05). A significant
improvement in quality of life was observed after surgery in both
groups (P ≤ 0.05) and was significantly better in the presacral
neurectomy group (P ≤ 0.05) compared with the conservative
surgery–only group. Zullo concluded that presacral neurectomy
improveslong-termcureratesandqualityoflifeinwomentreated
with conservative laparoscopic surgery for severe dysmenorrhea
due to endometriosis.
COMPLICATIONS
Bleeding is the most important intraoperative complication of
presacral neurectomy. The middle sacralvesselsare in the midline
between the presacral nerve and the periosteum of the sacral
promontory. Usually, the nerve is dissected anterior to thevessels
and ligation is not necessary. Hemostasis is obtained by ligation
or coagulation. However, an injury to the common iliac vein or
vena cava may require an immediate laparotomy.
Ureteral injury, urinary urgency, and poor bladder emptying
are potential complications. Meigs [20] noted urinary urgency
in some patients that persisted for 7 years postoperatively and
persistent constipation in 32% of the patients. Black [5] reported
the need for catheterization in 13 of 26 patients postoperatively
(four for 1 day, six for 2 days, and one each for 3, 5, and 6 days).
Lee et al. [21] noted bladder problems and urgency and constipation problems in 4% of 50 patients. Eight (18%) of 45 patients
who benefited from presacral neurectomy initially had a return
of bladder pain within 19 months. Jones and Rock [24] cited
vaginal dryness that usually resolved within 6 months as a complication in 10% to 15% of patients. Lee et al. [21] noted one
operative complication involving an estimated 1500-mL blood
loss from a damaged presacral vein. Davis [25] recognized a vascular injury to the left common iliac vein that was repaired.
Cotte [19] reported one incidence of damage to the left ureter
among 1500operations andnoted postoperative bleeding in four
other patients. Two required asecond operation and repair of the
Presacral Neurectomy — 429
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posterior peritoneum. The other two cases, which involved subperitoneal blood infiltrating the posterior rectal areas, resolved
spontaneously. Chen and coworkers [26] reported four cases of
chylous ascites after laparoscopic presacral neurectomy. This rare
complication is caused by intraoperative injury to the retroperitoneal lymphatic plexus. Of the four injuries, two were treated
successfully with bipolar cauterization. One was managed by
compression with Gelfoam (Pharmacia & Upjohn Inc., Peapack,
NJ), and closure of the peritoneum was achieved by laparoscopic
suturing. The fourth patient had persistent chylous leakage from
the drainage tube. This complication was resolvedbyconservative
management, removal of the drainage tube, and a low-fat diet.
Yen [27] reported postlaparoscopic vulvar edema in two cases
after laparoscopic presacral neurectomy. This was associated with
chyloperitoneum. Both cases were managed expectantly. Yen now
closes the presacral neurectomy wound with bipolar coagulation
to seal the cutting edge and the cannula wound with precise and
layer-by-layer repair, and no further cases of chyloperitoneum
and vulvar edema have occurred in 2 years since that modification was introduced.
Zullo [15] reported constipation and urinary urgency as a
complication of presacral neurectomy performed concomitantly
with laparoscopic surgery for endometriosis. Constipation was
reported in 21 (3.3%) and nine patients (14.3%) at 6- and 12month follow-up, respectively. In 15 of 21 cases (71.4%), constipation was treated successfully with medical therapies. At the 6and 12-month follow-up visits, urinary urgency was observed in
three patients (4.8%).
CONCLUSION
Laparoscopic presacral neurectomy is an effective, safe operation
for patients who have incapacitating central dysmenorrhea that
is not relieved by medication. The procedure is empiric because
success rates are not predictable. Complications and mortality
rates have been minimal. Poor patient selection and incomplete
neurectomy due to neurologic variability or failure to remove all
nerve tissue within the interiliac trigone are the most common
reasons for poor results.
REFERENCES
1. Polan M, DeCherney A. Presacral neurectomy for pelvic pain in
infertility. Fertil Steril. 1980;34:557–560.
2. Tjaden B,SchlaffWD, KimballA, RockJA.Theefficacyofpresacral
neurectomyforthe reliefofmidlinedysmenorrhea. Obstet Gynecol.
1990;76:89–91.
3. Jaboulay M. Le traitment de la neuralgie pelvienne par la paralysie
du sympathetique sacre. Lyon Med. 1899;90:102.
4. Ruggi T. Della sympathectamia al collo ed ale avome. Policlinico.
1899;1:193.
5. Black WT. Use of presacral sympathectomy in the treatment of
dysmenorrhea. Am J Obstet Gynecol. 1964;89:16–22.
6. Perez JJ. Laparoscopic presacral neurectomy. Results of the first 25
cases. JReprodMed. 1990;35:625–630.
7. Biggerstaff ED 3rd, Foster SN. Laparoscopic presacral neurectomy
for treatment of midline pelvic pain. J Am Assoc Gynecol Laparosc.
1994;2:31–35.
8. CarterJE. Laparoscopic presacral neurectomy utilizing contact-tip
Nd: YAG laser. KeioJMed. 1996;45:332–335.
9. Chen FP, Soong YK. The efficacy and complications of laparoscopic presacral neurectomy in pelvic pain. Obstet Gynecol. 1998;
91:701–704.
10. Nezhat CR,NezhatFR, LucianoAA,etal. Uterine Surgery in Opera-
tive Gynecologic Laparoscopy:Principles and Techniques.NewYork:
McGraw-Hill; 1995.
11. Kwok A, Lam A, Ford R. Laparoscopic presacral neurectomy: a
review. Obstet Gynecol Surv. 2001;56:99–104.
12. Zullo F, Palomba S, Zupi E, et al. Long-term effectiveness of
presacral neurectomy for the treatment of severe dysmenorrhea
due to endometriosis. J Am Assoc Gynecol Laparosc. 2004, 11:23–
28.
13. Stones RW, Mountfield J. Interventions for treating chronic pelvic
pain in women. Cochrane Database Syst Rev. 2000:CD000387.
14. Jacobson TZ, Barlow DH, Garry R, et al. Laparoscopic surgery for
pelvic pain associated with endometriosis. Cochrane Database Syst
Rev. 2001:CD001300.
15. Zullo F, Palomba S, Zupi E,et al. Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a
1-year prospective randomized double-blind study. Am J Obstet
Gynecol. 2003, 189:5–10.
16. Curtis AH,AnsonBJ,Ashley FL, Jones T. The anatomyof the pelvic
autonomic nerves in relation to gynecology. Surg Gynecol Obstet .
1942;75:743.
17. Rosenshein NB, Rock JA. Surgery in the Retroperitoneal Space.
Philadelphia: JB Lippincott; 1988:31–41.
18. Labate JS.Thesurgicalanatomy ofthesuperiorhypogastric plexus“presacral nerve.” Surg Gynecol Obstet. 1938;67:199.
19. Cotte MG. Technique of presacral neurectomy. Am J Surg.
1949;78:50.
20. Meigs JV. Excision of the superior hypogastric plexus (presacral nerve) for primary dysmenorrhea. Surg Gynecol Obstet .
1939;68:723.
21. Lee RB, Stone K, Magelssen D, et al. Presacral neurectomy for
chronic pelvic pain. Obstet Gynecol. 1986;68:517.
22. Nezhat C, Nezhat F. A simplified method of laparoscopic presacral neurectomy for the treatment of central pelvic pain due to
endometriosis. Br J Obstet Gynecol. 1992;99:659.
23. Chen FP, Chang SD, Chu KK, et al. Comparison of laparoscopic
presacral neurectomy and laparoscopic uterine nerve ablation for
primary dysmenorrhea. JReprodMed
24. Jones HW, Rock JA. Reparative and Constructive Surgery of the
Female Generative Tract . Baltimore: Williams & Wilkins; 1983.
25. Davis AA.Thetechniqueofresectionof thepresacralnerve(Cotte’s
operation). Br J Surg 1933;20:516.
26. Chen FP, Lo TS, Soong YK. Management of chylous ascites following laparoscopic presacral neurectomy. Hum Reprod. 1998;13:
880.
27. Yen CF, Wang CJ, Lin SL, Lee CL, Soong YK. Post-laparoscopic
vulvar edema, a rare complication. J Am Assoc Gynecol Laparosc .
2003;10:123–126.
28. Nezhat C, Siegler A, Nezhat F, Nezhat C, Seidman D, Luciano A.
Operative Gynecologic Laparoscopy. Principles and Techniques. 2nd
Edition. New York: McGraw-Hill; 2000.
. 1996;41:463.
Section 15.2. Uterosacral Transection and Ablation
https://t.me/med1917
James E. Carter
Surgical methodsfor cutting offpain-conducting nerve pathways
in the pelvis include:
1. Presacral neurectomy, involving cutting the T10-L1 sympathetic nerves on the anterior surface of the sacral bone
2. Paracervical uterine denervation, involving transectionof the
uterosacral ligament at its attachmenttotheuterusalong with
cutting the above-mentioned sympathetic nerves and the S1S4 parasympathetic nerves, which transmitpain stimuli from
the supravaginal region into the uterine cervix [1]
Uterosacral transection was developed and popularized as
an alternative to presacral neurectomy with Doyle’s vaginal
approach, involving transection of the uterosacral ligaments.[1]
As described by Sutton and Whitelaw [2]:
Doyle would place a suture through the posterior lip of
the cervix at the apex of the vagina and place traction on
this suture to increase the distance of the cervix from the
ureter. The attachments of the uterosacral ligaments to
the cervix were then divided between Heaney clamps.
To prevent re-growth of the dissected nerve trunks,
the posterior leaf of the peritoneal incision was interposed between them. An abdominal approach was recommended if endometriosis was suspected or any gross
pathology such as fibroids was felt. The pathological tissue
was then excised.Theligamentsweredividedbetweentwo
clamps and the ligaments sutured together with stainless
steel sutures to the isthmus of the cervix in the midline
about 1 cm higher than the original attachment. Doyle
reported complete pain relief in 63out of 73 cases (86%);
35 had primary dysmenorrhea (85.7% success) and 33
had secondary dysmenorrhea (86.8% success).
A more recent technique involves not separation and tran-
section, but ablation of the uterosacral ligaments to achieve pain
control.LichtenandBombard[3] reportedrelief ofincapacitating
primary dysmenorrhea in nine of 11 patients (81%) who underwent laparoscopic uterosacral nerve ablation (LUNA) with no
cure in thecontrol group, which hadonly diagnostic laparoscopy.
However, 1 year later, fewer than half the patients who originally
expressed improvement were pain-free. Gurgan and colleagues
[4] reported that 17 of 23 patients had alleviation of dysmenorrhea, with a mean pain reduction of 33% based on pre- and
postoperative pain scores. In a similar study, Sutton [5] reported
a 63% reduction from the initial average pain score.
In a double-blind randomized, controlled trial of LUNA for
women with chronic pelvic pain in the absence of endometriosis,
Johnson [6] reported a significant reduction in dysmenorrhea at
12-month follow-up. The median reduction on the visual analog
scale (VAS) from baseline was 4.8 points for theLUNA group versus a reduction of 0.8 points for those who did not have LUNA.
A total of 42.1% of the women experienced successful treatment
for dysmenorrhea, defined as a 50% or greater reduction in VAS
scores, versus 14.3% of those who did not undergo LUNA. There
was no significant difference in pain scores in women with nonmenstrual pelvic pain, deep dyspareunia, or dyschezia with no
endometriosis who underwent LUNA versus those who did not
undergo LUNA. The addition of LUNA to laparoscopic surgical
treatment of endometriosis was not associated with a significant
difference in pain outcome. Johnson concluded that LUNA is
effective for dysmenorrhea in the absence of endometriosis and
that there isno evidence for the effectiveness ofLUNA for chronic
pelvic pain without dysmenorrhea or for any type of pelvic pain
associated with endometriosis.
Yen [7] performed an elegant study involving the addition
of LUNA to laparoscopic bipolar coagulation of the uterine vessels. This study, which was performed for women with uterine
myomas and dysmenorrhea, involved 85 patients. Forty of the
41 women (97.6%) underwent successful laparoscopic bipolar
coagulation of uterine vessels with LUNA. Forty-three of the 44
women (97.7%) assigned to laparoscopic bipolar coagulation of
uterine vessels only underwent successful surgery. Eighty women
completed the 1-, 3-, and 6-month follow-ups. The frequency
and severity of postoperative pain were less in the group that
had LUNA than in the group receiving coagulation of the uterine
arteries only (P ≤ 0.05). At 3 months, dysmenorrhea improved
84.2% in the LUNA group versus 61.9% for the group that did
not have LUNA, and improved 92.1% versus 73.8% at 6-month
follow-up. The reduction was more significant in the group that
received LUNA than in the group that did not (P ≤ 0.05). The
results suggest that LUNA may decrease postoperative ischemic
pain and improve dysmenorrhea associatedwith uterine myomas
treated with laparoscopic bipolar coagulation of uterine vessels.
ANATOMY
Uterine nerve ablation involves the cauterization resulting in
transection of the uterosacral ligaments close to their point of
insertion intothe cervix. The procedure interrupts pelvic afferent
sensory nerve fibers of the Lee–Frankenh¨auser nerve plexus.[8]
According to Counseller and Craig [8], the Th10-L1 sympathetic
nerves are included in the hypogastric nerve and run along the
inferior vena cava and the sacral bone. They enter the pelvic cavity and run inside the uterosacral ligaments before ultimately
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entering the uterus. The parasympathetic nerves from S1-S4 are
included in the nervi erigentes,andthey run inside theuterosacral
ligament for a short distance in the lateral part of the pelvis and
then form ganglia on each side of the uterus (Frankenh¨auser
ganglia). Johnson [6] elegantly summarized the anatomy important for an understanding of the LUNA procedure. He pointed
out that “the ideal neuroablative surgical procedure for pelvic
pain would transect all afferent sensory fibers from all the
pelvic organs and leave all other nerves unaffected.” Although
pelvic neuroanatomy is complicated and still not completely
understood, what isknownmakes it clear thatnosuch “ideal neuroablative surgical procedure” exists (Figure 15.2.1). The body of
the uterus is widely considered to be innervated only by sympathetic nerves.[9] The cervix has predominantly parasympathetic
(but also sympathetic) innervation. The afferent sensory nerves
from both the uterus and cervix traverse the cervical division of
the Lee–Frankenh¨auser plexus, which lies within and around the
site of attachment of the uterosacral ligaments to the posterior
aspect of the cervix.[10,11] From the uterosacral ligaments, the
parasympathetic afferent nerves reach the dorsal root ganglia of
OS and O
to T10−T11
S1-S4 via the pelvic splanchnic nerves (nervi erigentes) and inferior hypogastric nerve plexus (also known as the pelvic plexus),
and then the superior hypogastric nerve plexus (also known as
the presacral nerve or hypogastric plexus).[12] The sympathetic
afferent nerves emerging from the Lee–Frankenh¨auser plexus
accompany the uterine, iliac, and inferior mesenteric arteries to
the sacral sympathetic trunk via the sacral splanchnic nerves,
some of which bypass the superior hypogastric nerve plexus.
Afferent nerves accompany both parasympathetic and sympathetic nerves from the ovary. Pain fibers bypass the uterosacral
ligament and course through corresponding plexuses to their cells
of origin in the dorsal root ganglia (T10-T11). Some of the afferent nerves oftheupper ovarian plexus course directly via therenal
and aortic plexuses and bypass the presacral nerve.[6]
It is nosurprise that LUNAhas not beenknownto be an effectiveadjuncttolaparoscopicsurgicalremovalofendometriosis.[6]
The operation interrupts only some of the afferent sensory
nerve fibers from the pelvis, and thus LUNA may be less effective for pelvic pain associated with more extensive pathology.
Careful study of Figure 15.2.1 clarifies why transection of the
P
US to T10−L1
CS to S2−S3
Ovarian
plexus
P
to S1−S4
S
O
S
O
P
O
Uterus
P
O
O
Ovary
S
S
U
S
C
C
Superior
hypogastric
plexus
P
C
Nervi erigentes
(CP and some CS and US)
Sympathetic trunk
Sacral splanchnic nerves
S
and US)
(C
Inferior
hypogastric
plexus
Lee–Frankenhauser
plexus
Figure 15.2.1. Sensory afferent nerve supply of the female pelvic organs. C, afferent nerve supply of cervix
(illustrated on the right side of the diagram); O, afferent nerve supply of the ovary (illustrated on the left
side of the diagram); U, afferent nerve supply of the uterus (illustrated on the right side of the diagram); P,
parasympathetic nerve; S, sympathetic nerve. From Johnson NP et al.[6]
432 — James E. Carter
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Lee–Frankenh¨auser nerve plexus and LUNA could be particularly ineffective for pain arising from the ovary or adjacent tissues, as could be the case in ovarian or paraovarian endometriosis,
because all ovarianafferent nerves bypass theLee–Frankenh¨auser
plexus and many of thepain fibers also bypassthe presacral nerve.
Without performing a periarterial sympathectomy of the iliac,
inferior mesenteric, and ovarian vessels, a number of afferent
fibers will always be left intact. It has been argued persuasively
that the effectiveness of a LUNA procedure for endometriosisrelated pain could be due more to a debulking of endometriotic lesions. The most common site for endometriosis on the
uterosacral ligament is the very site where the uterine nerve ablation is performed.[13]
Fujii et al. [14] investigated the localization of nerves in the
uterosacral ligament to determine the optimal sitefor uterosacral
nerve ablation. In their study, they found that the largest number
of nerve fiber bundles and nerve cells were located 1.65 to 3.30
cm distal to the site of attachment of the uterosacral ligament to
the uterine cervix at a depth of 0.3 to 1.5 cm. A relatively large
number of nerve fiber bundles were found in horizontal sections
at a depth of 1.0 cm. They concluded that this area is the most
appropriate region anatomically for resection of the uterosacral
ligament for the purpose of blocking the pain pathway.
TECHNIQUE
A standard three-puncture technique is suggested.Theprocedure
is performed by placing the uterosacral ligaments on stretch by
anteverting the uterus with the uterine manipulator. A CO
laser
2
(40 to 60 W) or another cutting instrument is employed to transect the ligaments at the points of their insertion into the cervix
using a verticalmotion from medial tolateral(Figure 15.2.2).[15]
Following the recommendation of Fujii [14], the tissue located
approximately 1 to 3 cm along the uterosacral ligament should
be treated to a depth of 1.5 cm. This segment of the uterosacral
ligament is close to the uterine vessels and ureter. The suction–
irrigator serves as a backstop to make the uterosacral ligament
more prominent and protect the ureter. A relaxing incision may
be made along the outer side of the ligament to retract the ureter
laterally before the ligament is transected (Figure 15.2.3). The
blood vessels run along the medial aspect of the uterosacral ligament, and bleeding in this area must be controlled carefully
because of the proximity of the ureter and rectum. Some gynecologists alsovaporize a path along the base ofthe cervix between
the uterosacral ligaments (Figure 15.2.4). Interceed (Gynecare)
may be placed over the transected area (Figure 15.2.5).
Iftheuterosacralligamentsaredifficulttoidentify, uterosacral
transection is not recommended. When the uterosacral ligament
is cut, ablood vessel inside ittends to bleed. To ascertain ifthis has
occurred, uterine traction should be released and pneumoperitoneum should be decreased.
The direction of the ureter should be identified from the
pelvic brim to the bladder because ureteral injury is a serious
complication associated with this procedure.[14] There isusually
a distance of 2 to 3 cm between the ureter and the uterosacral
ligaments; however, this varies.
If the ureter is close to the uterosacral ligaments, as mentioned above, a relaxing incision should be made as described.
The ureterisretractedlaterallybeforetheligamentistransected.If
uterosacral transection is unsuccessful, it is presumed that interruption of the nerve fibers was incomplete or the nerves regenerated. Lichten [16] reported that repeating the procedure did
not relieve dysmenorrhea, implying that the course of the nerve
Uterine vessels
Uterus
Ureter
Figure 15.2.2. Transection at this location maximizes the number of nerve fibers transected because the fibers
disperse as they pass along the uterosacral ligaments. Following the recommendation of Fujii [14], the tissue
approximately 1 to 3 cm along the uterosacral ligament should be treated to a depth of 0.3 to 1.5 cm. From
Nezhat C, Nezhat F.[15]
Suction irrigator
CO
laser
2
Uterosacral Transection and Ablation — 433
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A relaxing incision is made along the
outer side of the uterosacral ligament
Figure 15.2.3. If the ureter is close to the uterosacral ligament, a relaxing incision is made along the outer side of the ligament. The ureter is
retracted laterally before the ligament is transected. Occasionally, the
rectum may appear similar to these ligaments. From Nezhat C, Nezhat
F.[15]
fibers in these individuals may not be normal. Several patients
with failed uterosacral transection have obtained relief from a
subsequent presacral neurectomy.
COMPLICATIONS
Complications of the LUNA procedure include loss of uterine
support, adhesions, and ureteral transections, with loss of uter-
The uterosacral ligaments and
Frankenhauser plexus have been ablated
Figure 15.2.4. The ligaments havebeen transected with ablationof the
combined nerves. From Nezhat C, Nezhat F.[15]
Figure 15.2.5. Interceed is placed over the transected area. From
Nezhat C, Nezhat F.[15]
ine support deserving special mention. Davis [17] noted severe
uterine prolapse in three young female soldiers during or after
undergoing the rigors of airborne training. All three had previously undergone LUNA procedures. No other risk factors for
uterine prolapse could be identified in these cases. He went on
to state that although the etiology of uterine prolapse is complex, and no conclusions as to cause and effect can be made,
these cases suggest that LUNA should be performed with caution
on women whose occupation and lifestyle are associated with
heavy physical labor or exercises producing marked increases in
intra-abdominal pressure. Good [18] reported on uterine prolapse after laparoscopic uterosacral nerve transection in women
who had previous vaginal delivery.
CONCLUSION
A randomized, controlled trial to assess the efficacy of LUNA in
the treatment of chronic pelvic pain isongoingthroughtheLUNA
trial collaborative study.[19] The principal objective of this multicenter prospective randomized, controlled study is to test the
hypothesis that LUNA alleviates pain and improves life quality
in women with chronic pelvic pain and no pathology or mild
endometriosis (American Fertility Society score ≤5). Patients in
the study are randomized to either diagnostic laparoscopy with
LUNA or to no pelvic denervation. The site for the LUNA in this
study is the Lee–Frankenh¨auser plexus (Figure 15.2.6). Assessments are carried out in a blinded fashion, and the protocol calls
for 12-month follow-up.
Latthe et al. [20] reported that among clinicians, there is
widespread variation in the practice and use of LUNA for treatment of chronic pelvic pain. Additionally, they found wide variation in beliefs about the effectiveness of the procedure for pelvic
pain, ranging from substantial benefit to slight harm. The majority of respondents stated that LUNA would benefit patients in
terms of improved VAS scores, but expectations regarding the
levelofbenefitvariedwidely.
434 — James E. Carter
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Uterus
Inferior
hypogastric
plexus
Ovarian
Plexus
P
O
O
Ovary
S
S
U
P
C
S
C
Lee-Frankenhauser
plexuses - sites for
LUNA
Nervi erigentes
(CP and some CS and US)
Figure 15.2.6. Pelvic sensory nerve pathways in site for LUNA. From
LUNA Trial Collaboration.[19]
In a European survey, Latthe et al. [21] found variation in
methods of performing the LUNA procedure. Noting that recent
anatomic studies have demonstrated that the greatest numbers
of nerve fiber bundles are found some distance from the site of
the attachment of uterosacral ligament to the cervix [14], there is
some controversy about theoptimal site forLUNA. The effectiveness of LUNA may depend on the completeness of transection
of the uterosacral ligaments. Latthe [21] found that compared
to the U.K. group, the European group performed LUNA more
frequently and transected the uterosacral ligament completely
more often. The European group also transected the uterosacral
ligament 2 cm or more from the point of cervical insertion more
often.Itisimportant to keepin mind the nerve plexus as described
by Fujii [14] when performing LUNA. It is also helpful to keep in
mind that the lateral nerves will not be affected (Figure 15.2.6).
The studies of Johnson [6] and Yen [7] indicate that LUNA does
have a role to play in the relief of central pelvic pain relief not
related to endometriosis.
REFERENCES
1. Doyle EB. Paracervical uterine denervation by transection of the
cervical plexusfor the relief ofdysmenorrhea. AmJ Obstet Gynecol.
1955;70:11.
2. Sutton C, Whitelaw N. Laparoscopic uterine nerve ablation for
intractable dysmenorrhea. In: Sutton C, Diamond M, eds. Endo-
scopic Surgery for Gynaecologists. London: WB Saunders; 1993:
159–168.
3. Lichten EM, Bombard J. Surgical treatment of primary dysmenorrhea with laparoscopic uterine nerve ablation. JReprodMed.
1987;32:37–41.
4. Gurgan T, Urman B, Aksu T, et al. Laparoscopic CO
laser uterine
2
nerve ablation for treatment of drug-resistant primary dysmenorrhea. Fertil Steril. 1992;58:422.
5. Sutton C. Laser uterine ablation. In: Donnez J, ed. Laser Opera-
tive Laparoscopy and Hysteroscopy. Leuven, Belgium: Nauwelaerts
Printing; 1989:43–52.
6. Johnson NP, Farquhar CM, Crossley S, et al. A double-blind randomized controlledtrial of laparoscopic uterine nerve ablationfor
women with chronic pelvic pain. BJOG. 2004;111:950–959.
7. YenYK, Liu WM, Yuan CC, Ng HT.Addition of laparoscopic uterine nerve ablation to laparoscopic bipolar coagulation of uterine
vessels for women with uterine myomas and dysmenorrhea. JAm
Assoc Gynecol Laparosc. 2001;8:573–578.
8. Counseller VS, CraigW. Thetreatment of dysmenorrhea by resection of the presacral nerves: evaluation of end results. AmJObstet
Gynecol. 1934;28:161–167.
9. Owman C, Rosenbren E, Sjoberg NO. Adrenergic innervation of
the human femalereproductive organs: a histochemical and chemical investigation. Obstet Gynecol. 1967;30:763–773.
10. Frankenhauser G. Die Bewegungenerven der Gebarmutter. ZMed
Nat Wiss. 1864;1:35.
11. Cleland JP. Paravertebral anesthesia in obstetrics. Surg Gynecol
Obstet. 1933;57:51.
12. Williams PL, Warwick R. Reproductive organs of the female. In:
Williams PL, Warwick R,eds. Gray’s Anatomy. 36thed.Edinburgh:
Churchill Livingston; 1980:1423–1431.
13. Jones KD, Sutton C. Arcus Taurinus: the “mother and father” of
all LUNAs. Gynecol Endosc. 2001;10:83–89.
14. Fujii M, Sagae S, Sato T, et al. Investigation of the localization
of nerves in the uterosacral ligament: determination of the optimal site for uterosacral nerve ablation. Gynecol Obstet Invest.
2002;54(suppl 1):11–17.
15. Nezhat C, Siegler A, Nezhat F, Nezhat C, Seidman D, Luciano A.
Operative Gynecologic Laparoscopy. Principles and Techniques. 2nd
Edition. New York: McGraw-Hill; 2000.
16. Lichten E. Three years’ experience with LUNA. Am J Gynecol.
1989;3:9.
17. Davis GD. Uterine prolapse after laparoscopic uterosacral transection in nulliparous airborne trainees. A report of three cases. J
Reprod Med. 1996;41:279–282.
18. Good MC, Copas PR Jr, Voody MC. Uterine prolapse after
laparoscopic uterosacral transection: a case report. JReprodMed.
1992;37:995–996.
19. The LUNA trial collaboration, a randomized controlled trial
to assess the efficacy of laparoscopic uterosacral nerve ablation
(LUNA) in the treatment of chronic pelvic pain: the trial protocol
(ISRCT In 41196151). Department of Obstetrics and Gynecology,
Birmingham Clinical Trials Unit and Department of Public Health
and Epidemiology, University of Birmingham B15 2TT, UK. BMC
Womens Health. 2003;3:6.
20. Latthe PM, Braunholtz DA, Hills RK, et al. Measurement and
beliefs about effectiveness of laparoscopic uterosacral nerve ablation. BJOG. 2005;112:243–246.
21. Latthe PM, Powell RJ, Daniels J, et al. Variation in practice of
laparoscopic uterosacral nerveablation: a European study. JObstet
Gynecol. 2004;24:547–551.
16 GYNECOLOGIC MALIGNANCY
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Section 16.1. Introduction
Farr Nezhat
Laparoscopy has been used for second-look assessments in ovarian cancer since first described in 1973 by Bagley et al.[1] However, it was new developments in equipment and instrumentation, such as videolaparoscopy, high pressure insufflators, and
energy sources, in the late 1980s to early 1990s – combined with
the work of some of the pioneers of laparoscopic surgery – that
made the use of operative laparoscopy in gynecologic oncology
feasible. Dargent and Salvat [2], Querleu et al. [3], and Nezhat
et al. [4] first established the safety and practicability of laparoscopic retroperitoneal and intraperitoneal lymphadenectomy
and radical hysterectomy.Anincreasingnumberof surgeons have
since used advanced operative techniques for evaluation and surgical management of gynecologic cancers.
Laparoscopy has the benefit of image magnification to aid
in identification of metastatic or recurrent disease, especially in
areas such as the upper abdomen, liver and diaphragm surfaces,
posterior cul-de-sac,bowel,and mesenteric surfaces. In addition,
challenging retroperitoneal spaces of the pelvis, such as the paravesical, pararectal, vesicovaginal, and especially the rectovaginal space, can be accessed laparoscopically. Additional benefits
of laparoscopy in gynecologic oncology surgery include limited
bleeding from small vessels due to the pressure established by
pneumoperitoneum, elimination of large abdominal incisions,
shortened hospital stay, and rapid recovery. The ease of recuperation from laparoscopic surgical management thus offers a
smooth transition for patients to then undergo planned adjuvant
therapies. Postoperative chemotherapy or radiation can be initi-
ated earlier, and radiation complications from bowel adhesions
are minimized.
For approximately two decades now, significant progress
has been made in advancing the role of laparoscopy in the
management of gynecologic malignancy, dealing with key
issues such as minimizing radicality of a procedure, management of its complications, disease recurrence, and survival. As expected, these advanced endoscopic procedures must
be carried out by surgeons who have the required skills,
contemporary equipment, and trained ancillary staff. In this
chapter, practiced surgeons address the utility of advanced operative laparoscopy in the management of various gynecologic
malignancies.
REFERENCES
1. BagleyCM,Young RC,ScheinPS, et al. Ovariancancermetastatic to
the diaphragm frequentlyundiagnosedatlaparotomy: apreliminary
report. Am J Obstet Gynecol. 1973;116:247.
2. Dargent D, Salvat J. Lienvahissement Ganglionnaire Pelvien. Paris:
MEDSI; 1989.
3. Querleu D, Leblan E,CatelainB. Laparoscopic pelvic lymphadenec-
tomy. Am J Obstet Gynecol. 1991;164:579.
4. Nezhat CR, Nezhat FR, Ramirez CE, et al. Laparoscopic radical
hysterectomy and laparoscopic assisted radical vaginal hysterectomy with pelvic and paraaortic node dissection. J Gynecol Surg
1993;9:105.
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Section 16.2. Laparoscopic Lymphadenectomy
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Farr Nezhat and M. Shoma Datta
In patients with gynecologic cancer, prognosis correlates with the
stage of disease according to the established Internation Federation of Gynecology and Obstetrics (FIGO) classification systems.
Lymph node status is one of the most important prognostic factors in gynecologic cancer, and surgical removal of pelvic and/or
para-aortic lymphnodesforhistologic assessment is a crucial part
of staging. Furthermore, cytoreduction of bulky lymph nodes
may have therapeutic benefit.
Lymphadenectomy has generally been performed via laparotomy, usinglargeincisionsand oftencausing significantintra-and
perioperative morbidity. Dargent and Salvat [1] in 1989 were the
first todescribelaparoscopicretroperitonealpelvic lymphadenectomy for the management of gynecologic malignancies. In 1991,
Querleu et al.[2] reported laparoscopic pelvic lymphadenectomy
in 39 patients with cervical cancer. The first laparoscopic paraaortic lymphadenectomy was reported by Nezhat et al. [3–5] in
1991 through 1993 in a series of patients with cervical cancer
undergoing laparoscopic radical hysterectomy with pelvic and
para-aortic lymphadenectomy. Since that time, a numberofother
reports have described the safety and accuracy of laparoscopic
lymphadenectomy for cervical, endometrial, and ovarian cancers, as well as for urologic malignancies and some lymphomas.
Numerousreportsdescribebettermagnification,fewercomplications, and superior visualization of the anatomy provided by the
videolaparoscope in comparison with conventional techniques.
In recent years, an expanding literature has become available
regarding outcomes and complications of the laparoscopic lymphadenectomy. Current reports, however, often reflect the developing skill set of the pioneering laparoscopists and the variable
facility support for such advanced laparoscopic procedures.
TECHNIQUE
Pelvic and para-aortic lymphadenectomy can be accomplished before or after hysterectomy and bilateral salpingooophorectomy. Technically, there are many benefits of a
laparoscopic approach specific to pelvic and para-aortic lymphadenectomy. The laparoscope provides a seven- to 10-fold
magnification of the operative field, allowing identification of
small tributary vessels. Furthermore, pneumoperitoneum facilitates development of the pelvic spaces and decreases venous
bleeding, thereby maintaining a clean operative dissection with
good visualization of the nodal bundles.
Pelvic Lymphadenectomy
The initial step to pelvic lymphadenectomy is to expose the anterior and posterior leaves of the broad ligament by incising the
round ligament and dissecting the broad ligament in a cephalad
fashion lateral and parallel to the infundibulopelvic ligament. An
incision is made in the broad ligament lateral or parallel to the
infundibulopelvic ligament to open the posterior peritoneum,
allowing identification of the ureter. Using the suction–irrigator
probe, grasper, and scissors, the paravesical space is created. It
is bordered medially by the obliterated hypogastric artery, bladder, and vagina and laterally by the pelvic side wall. Creating the
avascular paravesical space helpsidentify the obturatornerve and
vessels and the distal portion of the pelvic wall vessels. The obliterated hypogastric artery and external iliac vein are landmarks
to get to the paravesical space (Figure 16.2.1). The spaces lateral
to this vessel and medial to the external iliac vein and obturator
internus muscle are created with bluntand sharp dissection.Electrocoagulation should not be necessary as this space is generally
avascular. Once this spaceis created, thebonylateral side wall,the
levator plate laterally, and the obturator nerve and vessels anteriorly should be visible. The pelvic lymph nodes can now be safely
removed. Starting laterally over the psoas muscle and proceeding
medially provide a safe approach that avoids the genitofemoral
nerve. The external iliac nodes along the external iliac artery and
vein are excisedcaudally from common iliac vessels to the level of
the deep circumflexiliac vein seen crossingoverthe distal portion
of the external iliac artery (Figure 16.2.2).
The obturator spaceis then openedand the nerve is identified
by blunt dissection below and between the obliterated umbilical
artery and the external iliac vein (Figure 16.2.3). Although the
majority of patients have both the obturator artery andveindorsal
to the obturator nerve, 10% will have an aberrant obturator vein
anterior to the nerve, entering the midpoint of the external iliac
vein. The obturator lymphnodes are grasped justunderthe external iliac vein, and traction is applied medially. The node chain is
thereby separated from the obturator nerve and vessels, and the
nodes are dissected cephalad to the hypogastric artery. The nodal
tissue anterior and lateral to the nerve and medial and inferior to
the external iliac vein is removed by blunt and sharp dissection.
Venous anastomosis between the obturator and the external iliac
veins is saved from injury. The obturator fossa lymph nodes are
excised caudally to the pelvic side wall where the obturator nerve
exits the pelvis through the obturator canal and cephalad up to
the bifurcation of the common iliac artery. Before the removal of
each nodal bundle, each pedicle is ligated by electrocoagulation,
endoscopic hemoclips, or harmonic shearstoprevent lymphocyst
formation. The lymphnode packets are removed in a bagthrough
the largest trocar to avoid any contact between potentially malignant lymph node tissue andthe abdominal wall. Using sharp and
blunt dissection, the nodes between the external iliac vessels and
the obliterated hypogastric artery are removed. The nodes along
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