1 Department of Obstetrics and Gynecology and 2 Department of Anesthesiology, Pamukkale University Medical Center, 20100, Denizli and 3 Department of Psychiatry, Hacettepe University School of Medicine, 06200, Ankara, Turkey
4 To whom correspondence should be addressed. e-mail: msoysal{at}superonline.com
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Abstract |
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Key words: endometriosis/neurolysis/pelvic pain/presacral neurectomy
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Introduction |
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In 1990 it was shown by anaesthesiologists that transcutaneous neurolysis of the superior hypogastric plexus is effective and safe in relieving pelvic cancer pain (Plancarte et al., 1990). In the following years the indications expanded and included benign pathologies (de Leon-Casasola, 2000
).
Pain syndromes are caused by activation of nociceptors and transmission of signals in pain pathways. Thus they are expected to respond to interruption or modulation of that transmission at any level above the site of activation. Chemical neurolysis destructs the microscopic neural architecture, and therefore interrupts the transmission function of the nerves. Neurectomy is the surgical procedure that cuts and removes the nerve fibres to interrupt transmission. The superior hypogastric plexus is the main pathway of neural transmission from the pelvis. While in neurectomy the plexus is exposed and the nerves are either cut or excised to interrupt the neural input, in neurolysis their microscopic neural architecture is chemically destroyed to interrupt the neural input.
In 1999 we decided to use chemical neurolysis via laparoscopy in order to treat recurrent and unbearable pelvic pain of minimal and mild endometriosis. It seemed very attractive to us because of the potential simplicity and effectiveness of the procedure.
The aim of this paper is to describe our technique of laparoscopic presacral neurolysis and to report 1-year results of the first 15 prospectively followed cases on symptom resolution, non-opioid analgesic consumption during menses, sexual performance and its side effects.
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Materials and methods |
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A total of 15 patients were treated between August, 1999 and June, 2001. All patients were followed for at least 1 year.
At baseline all patients were screened for depressive and anxiety states by the Hospital Anxiety and Depression Scale (HADS), which is a self assessment mood scale specifically designed for the use of non-psychiatric hospital outpatients to determine the states of anxiety and depression (Zigmond and Snaith, 1983). It has been shown to be a reliable instrument for screening and a valid measure of severity of these mood disorders in patients under investigation of non-psychiatric departments. It consists of 14 items, seven for the anxiety and seven for the depression subscales. Five mutually exclusive answers are provided for each of the questions; they are rated from 0 to 4 according to increasing psychiatric severity. The points are then summed to give anxiety and depression subtotals and a total score. In terms of subscales a score of <7 indicates non psychiatric cases and >11 indicates psychiatric cases, whereas those in between are regarded as doubtful. For the validity and reliability of HADS in our population, the cut of point was found to be 10 and 7 for anxiety and depression subscales respectively. In this trial only non-psychiatric cases were considered to be eligible.
In all non-psychiatric cases, diagnostic laparoscopy and potential presacral neurolysis in patients with rAFS scores <16, were planned in the first postmenstrual week.
Our aim was to assess the effectiveness of laparoscopic presacral neurolysis on symptom resolution, on the need of non-opioid analgesic consumption during menses and on sexual performance. Furthermore the intraoperative and postoperative complications of presacral neurolysis were recorded.
To assess the impact of laparoscopic presacral neurolysis on symptoms, grading of symptoms and physical findings before and after treatment were done on a previously developed and commonly used scale (Biberoglu and Behrman, 1981). We have modified the original scale by excluding the induration. In this modified scale symptoms of dysmenorrhea, dyspareunia, pelvic pain, and the physical finding pelvic tenderness were each scored by the patient as: none (0 points), minimal (1), moderate (2) and severe (3). The sum of these variables comprised the Total Pelvic Symptom Score (TPSS) in this study.
To assess the impact of laparoscopic presacral neurolysis on the consumption of non-opioid analgesic use during menses to cope with dysmenorrhea, all patients were asked to use naproxen sodium 250 mg tablets twice daily whenever necessary throughout menses. They were asked to record the number of tablets during the whole period in the preoperative menstrual period and postoperative menses for 1 year.
Preoperatively all patients completed the questionnaire of the revised Sabbatsberg Sexual Rating Scale (SSRS) to define the impact of treatment on sexual functioning. The revised SSRS is a 12 item questionnaire for the assessment of sexual functioning (Garrat et al., 1995). For each item, there are five possible answers, scored from 0 to 4 points (from the lowest to the highest sexual satisfaction). The scores of 12 items are then summed and transformed to a scale of 0 to 100. This scale is reliable and valid in our patient population and widely used in clinical trials to assess the impact of interventions on sexual functioning. This scale is a general measure of sexual functioning for women and covers both the quantity and quality of sexual experience whilst being relatively brief and not intrusive. It raises simple questions regarding interest, sexual activity, sexual pleasure, orgasmic capacity and importance of sex at present and in the past. Women experiencing pain with sex have significantly lower sexual rating scores (Garrat et al., 1995
). Our rational was to investigate the impact of this surgery in increasing sexual performance via decreasing pain.
Keeping the reported complications of presacral neuorectomy in mind, patients were specifically questioned regarding bowel habits and urinary symptoms (constipation, diarrhoea, stress incontinence, urge incontinence and voiding difficulty).
In volunteers, diagnostic laparoscopy was performed in the first postmenstrual week for rAFS scoring. We performed laparoscopic presacral neurolysis only in cases with rAFS scores <16 to treat symptoms. We did not perform any fulguration, excision of endometriotic foci other than a biopsy for histological confirmation. The patients were discharged the day after the procedure and had an early postoperative visit at the 5th postoperative day.
The technique of laparoscopic presacral neurolysis is a simple one. A 10 mm umbilical port is used for the standard insufflation and video endoscopy. Two additional 5 mm subumbilical standard ports are created for diagnostic and therapeutic purposes. After the diagnostic laparoscopy for rAFS scoring the promontorium is identified. The peritoneum overlying the promontorium is grasped and elevated by a commercially available endoscopic grasper and from the other port, 5 ml of saline was injected retroperitoneally by a commercially available laparoscopic needle used for ovarian cyst puncture. This elevates the peritoneum and endopelvic fascia from the promontorium. Furthermore this space avoids inadvertent injection of phenol to vessels and backflow of phenol to the peritoneal space. Then 10 ml phenol (10% in Urografin, radiographic contrast medium; Shering AG, Germany) is injected slowly to the deeper part of the artificially created retroperitoneal space from another point of entry. Before withdrawing the needle an additional 2 ml of saline was given to avoid i.p. spillage of phenol during the withdrawal of the needle. Afterwards a thorough pelvic lavage was done. The presacral neurolysis itself is a 2 min operation not including the laparoscopic set-up, diagnostic laparoscopy and drug preparation. For demonstration purposes fluoroscopic controls can be used (Figures 1 and 2).
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Patients were re-evaluated at the 3rd, 6th, and 12th month postoperatively. At each of these visits total pelvic symptom score, non-opioid analgesic consumption (as the total number of naproxen sodium 250mg tablets) and SSRS were re-evaluated and noted. Complications were searched and appropriately treated.
Statistical analysis of this trial was done by InStat software for Windows (Graph Pad Inc., USA). After performing the descriptive statistics for our patient population, we have performed repeated measures of Anova with Tukey as the post test if P < 0.05 to analyse the impact of intervention on TPSS, SSRS and non opioid analgesic consumption during the study period. All data passed the normality tests.
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Results |
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Discussion |
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A significant proportion of patients with endometriosis are candidates for sympathectomy. Sympathectomy as presacral neurectomy is not a new idea and dates back to 1899 (Kwok et al., 2001). In 1990 it was shown that this can be done by laparoscopy (Perez, 1990
). However this operation is an advanced endoscopic procedure and it carries major surgical risks even in the hands of experienced surgeons (Chen and Soong, 1997
; Kwok et al., 2001
). Neurolysis of superior hypogastric plexus dates back to 1990. Plancarte from Mexico city was the first pain specialist that performed posterior transcutaneous superior hypogastric plexus neurolysis (Plancarte et al., 1990
). Their group of patients were those with pelvic malignancy at the beginning and it was later shown by them and others that superior hypogastric plexus neurolysis was effective in reducing pelvic pain and daily opioid use in both benign and malignant diseases (Waldman et al., 1991
; de Leon-Casasola et al., 1993
; Plancarte et al., 1997
; Rosenberg et al., 1998
; de Leon-Casasola, 2000
). However their method was technically difficult, required bispatial fluoroscopy and there was an active search in pain literature to simplify the described technique by alternate ways of approach and advanced imaging techniques (Waldman et al., 1991
; Cousins and Bridenbaugh, 1998
; Stevens et al., 2000
; Cariati et al., 2002
). Transvascular approach has been reported (Cousins and Bridenbaugh, 1998
). It was not possible for us to use the standard technique as gynaecologists. Superior hypogastric blocks which are technically the same are used in patients with endometriosis (Wechsler et al., 1995
; Kanazi et al., 1999
). One author used this block during laparoscopic pain mapping in order to select patients for presacral neurectomy (Steege, 1998
). Based on the previous works of these distinguished authors we have realised that injection of neurolytic agent under direct vision via laparoscopy to the presacral retroperitoneal space can be a very simple and effective form of sympathectomy. During our study period the simplicity of the procedure for the average gynaecologist was clearly evident. We noted similar effectiveness as compared with the literature on neurolysis and neurectomy.
Laparoscopic presacral neurolysis is a very simple operation for the average gynaecologist. It is merely injecting 10 ml of neurolytic solution in the retroperitoneal space over the promontorium. Phenol and alcohol are the principle agents used for sympathetic neurolysis. Phenol (carbolic acid) is used extensively in neurolysis, it causes a nonspecific destruction on neural architecture. To date no complications regarding the superior hypogastric plexus neurolysis with phenol is reported in more than 200 transdermally performed cases (Cousins and Bridenbaugh, 1998; de Leon-Casasola, 2000
). However potential theoretical complications that have to be taken into account in transdermal approach are intramuscular (psoas muscle), intravascular, subarachnoid, epidural, intraperitoneal, intravisceral (bowel, ureter) injections. Neurolytic damage of somatic nerves can occur with direct needle trauma or with spillage of neurolytic solutions. Vascular puncture can cause retroperitoneal haematoma formation. None of these theoretically possible complications is reported; however, there are some universal cautions to exercise (Cousins and Bridenbaugh, 1998
). The first is proper needle placement which is checked by the fluoroscopy or advanced imaging in the transdermal approach. Aspiration for blood is important. Intravascular injection of phenol may cause tinnitus, flushing, tremors and convulsions. The recovery is rapid and complete. Unexpected spread to nearby somatic nerves may cause permanent neural deficits. Thus the least possible volume should be chosen. In the first 15 cases we have treated, we used direct laparoscopic approach to the presacral space and achieved the exact anatomic orientation. In other words laparoscopy was the advanced and ultimate imaging technique of proper place selection. We were aware of the retroperitoneal location of major vessels and by raising the peritoneum with retroperitoneally injected saline we stayed away from the middle sacral vein and artery. We were aware of the fact that there was no somatic nerve in this anatomical location. As we injected the least possible volume recorded in the literature for this particular procedure and did not create any weakness of endopelvic fascia structure, we avoided spillage of the solution. Furthermore by injection of the solution from another point of entry, and an additional 2 ml of saline before removal and through pelvic lavage we avoided i.p. spillage of the agent. We observed no intraoperative or postoperative complications related to the procedure itself. However as the neurolysis was effective, one patient developed transient urinary retention and a significant proportion developed constipation as side effects. These are the recorded side effects of neurolysis and presacral neurectomy (Chen and Soong, 1997
; Nezhat et al., 1998
; Perry, 1999
).
In the literature it is very difficult to know how much credit to assign to the presacral neurectomy in the relief of endometriosis symptomatology as the procedure is often performed in conjunction, as an adjunctive measure, with other procedures such as fulguration, excision of endometriotic foci (Kwok et al., 2001). We consider these procedures, as well as the laparoscopic presacral neurolysis-neurectomy, as a symptomatic not a causal form of treatment in patients with endometriosis. Literature also supports the view that endometriosis is a dynamic disease that can be progressive, static or resolving in any given patient (Sutton et al., 1997
). Since currently we are unable to identify those progressive cases in any given time, we have chosen to treat the symptoms by neurolysis in minor degrees of endometriosis. This design was particularly useful to prove the potential impact of laparoscopic presacral neurolysis on symptom relief attributed to endometriosis.
In the study period we noticed how easy it could be to perform a laparoscopic presacral neurolysis. In our opinion surgery should be simple but the surgeon should have expertise and be cautious. Furthermore our results indicated an effective technique that achieved symptom relief. Most probably due to its effectiveness on the control of visceral pain, this technique also decreased analgesic consumption, and improved sexual performance.
In conclusion, laparoscopic presacral neurolysis is feasible and easy to perform. Our data indicates that this novel technique can be considered in the treatment of painful benign pelvic conditions as the only form of symptomatic treatment or as an adjunctive procedure. However more data is needed to support its efficacy and safety. We must emphasize the preliminary nature of the study and we believe randomized controlled trials are necessary before the procedure becomes widely adopted.
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References |
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Submitted on August 9, 2002; accepted on November 26, 2002.