Laparoscopic Uterosacral Nerve Ablation May Not Be Helpful for Women With Chronic Pelvic Pain

Laurie Barclay, MD

September 01, 2009

September 1, 2009 — Compared with laparoscopy without pelvic denervation, laparoscopic uterosacral nerve ablation (LUNA) does not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life among women with chronic pelvic pain, according to the results of a randomized controlled trial reported in the September 2 issue of the Journal of the American Medical Association.

"Treatments for chronic pelvic pain are often unsatisfactory," write Jane Daniels, MSc, from Birmingham Women's Hospital, University of Birmingham, England, and colleagues from the LUNA Trial Collaboration. "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."

The goal of this study was to determine the efficacy of LUNA in patients with chronic pelvic pain. Between February 1998 and December 2005, consultant gynecologic surgeons from 18 UK hospitals recruited 487 women with chronic pelvic pain of greater than 6 months' duration, without or with minimal endometriosis, adhesions, or pelvic inflammatory disease. Participants were randomly assigned to receive bilateral LUNA or laparoscopy without pelvic denervation and were blinded to treatment assignment. At 3 and 6 months and at 1, 2, 3, and 5 years, follow-up questionnaires were mailed to participants.

The main study endpoint was pain, measured with a visual analog scale and analyzed separately for 3 types of pain (noncyclical pain, dysmenorrhea, and dyspareunia).The worst pain level experienced from any of these 3 types of pain was also determined. The secondary endpoint was health-related quality of life, assessed with a generic instrument (EuroQoL EQ-5D and EQ-VAS).

Visual analog pain scales for the worst pain were not significantly different between groups after a median follow-up of 69 months (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). Quality of life was not different between the LUNA group and the no-LUNA group.

Limitations of this study include lack of follow-up data on all women and possibly inadequate statistical power, which the study authors suggest is unlikely.

"LUNA did not alleviate any type of pain — noncyclical pain, dysmenorrhea, or dyspareunia — or improve quality of life, irrespective of the presence or absence of mild endometriosis," the study authors write.

The Wellbeing for Women charity grant and Birmingham Women's Foundation NHS Trust Research and Development Committee supported this study, with additional support from the Birmingham Clinical Trials Unit, who are funded by the UK Department of Health. The LUNA trial was endorsed by the British Society of Gynaecological Endoscopy. The study authors have disclosed no relevant financial relationships.

JAMA. 2009;302:955-961. Abstract


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