Sunday, January 5, 2014

Uterosacral Nerve Ablation (LUNA)

What is uterosacral nerve ablation (aka LUNA)?
It is where the surgeon destroys the nerve fibers that go from the uterus to the uterosacral ligaments. "Laparoscopic uterine nerve ablation involves the destruction of the uterine nerve fibers that exit the uterus through the uterosacral ligament.  Pre-sacral neurectomy refers to the interruption of the sympathetic innervation of the uterus at the level of the superior hypogastric plexus.  Pre-sacral neurectomy is technically more challenging than LUNA because of the presence of large vessels and the ureters near the field of dissection."

"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."

Does it work?
"After a median follow-up of 69 months, there were no significant differences reported on the visual analogue pain scales for the worst pain (mean difference between the LUNA group and the no LUNA group, −0.04 cm [95% confidence interval {CI}, −0.33 to 0.25 cm]; P = .80), noncyclical pain (−0.11 cm [95% CI, −0.50 to 0.29 cm]; P = .60), dysmenorrhea (−0.09 cm [95% CI, −0.49 to 0.30 cm]; P = .60), or dyspareunia (0.18 cm [95% CI, −0.22 to 0.62 cm]; P = .40). No differences were observed between the LUNA group and the no LUNA group for quality of life.
Conclusion Among women with chronic pelvic pain, LUNA did not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life compared with laparoscopy without pelvic denervation."

"Laparoscopic uterosacral nerve ablation and presacral neurectomy are ancillary procedures meant to further decrease endometriosis-associated pelvic pain symptoms. Presacral neurectomy, involving cutting the T10-L1 sympathetic nerves on the anterior surface of the sacral bone and paracervical uterine denervation, involving transection of the uterosacral ligament at its attachment to the uterus along with cutting the above-mentioned sympathetic nerves and the S1S4 parasympathetic nerves, which transmit pain stimuli from the supravaginal region into the uterine cervix.1 Surgery for the treatment of peritoneal endometriosis includes several options: electrocoagulation, laser ablation, plasmajet  or excision of the lesions, all of which have similar efficacy in the therapy of endometriosis-associated pelvic pain.24  ...There was no significant difference in pain scores in women with non-menstrual 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 is no evidence for the effectiveness of LUNA for chronic pelvic pain without dysmenorrhea or for any type of pelvic pain associated with endometriosis....Awareness of endometriosis as a disease with substantial morbidity is vitally important. Laparoscopic treatment of endometriosis is beneficial for reducing pain and improving fertility. Laparoscopic presacral neurectomy, but not laparoscopic uterosacral nerve ablation, is a useful adjunct to conservative surgery for endometriosis in patients with a midline component of pain."