S1082 Endoscopic Ultrasound-Guided Superior Hypogastric Plexus Neurolysis: An Update on a Unique Technique for the Management of Pelvic Pain

Abstract

Introduction: The superior hypogastric plexus is a paired structure located anterior to the sacral promontory, in close proximity to the bifurcation of common iliac vessels. It mediates painful visceral stimuli from most of the pelvic structures. Superior hypogastric plexus neurolysis (SHPN) is a well-recognized treatment for pelvic pain resulting from cancer of sigmoid colon, rectum, prostate, bladder, cervix, and uterus. It is also used to manage pain resulting from benign conditions such as endometriosis, pelvic inflammatory disease, and radiation colitis. The conventional approach used by pain experts is difficult and requires CT guidance. The purpose of this study was to test the hypothesis that endoscopic ultrasound (EUS)-guided SHPN is technically feasible. Methods: Patients with severe pelvic pain due to cancer were eligible for the study. Consecutive patients with pelvic pain secondary to cancer were offered to participate in the study. Pain was graded before and after the procedure and weekly thereafter, by using a visual analog scale graded from 1 to 10. A linear scope was introduced into the rectum and advanced until iliac vessels were identified. In 10 patients, the sacral promontory was identified with fluoroscopy. A 22-gauge needle was passed in the space posterior to the rectum and 10 mL of bupivacaine injected, followed by 10 mL absolute alcohol. In one patient, internal iliac vessels were identified by using EUS and the injections were given anterior to the periosteum; fluoroscopy was not used. Results: SHPN was performed in 11 patients with pelvic pain due to cancer. The procedure was completed successfully in all patients. The mean pain score was 9 before the procedure and 3 after (Table). No complications were encountered. The mean procedure time was 20 minutes. Conclusion: Our study reveals that EUS-guided SHPN is technically feasible. The iliac vessels are well seen by this approach, thus making hemorrhage an unlikely complication. Table 1. - Patient's Clinical profile and Pre-Visual analogue scale and Post-Visual analogue scale scores Number Diagnosis Pre-VAS Post-VAS Duration of Relief (weeks) 1 Rectal Cancer 10 3 6 2 Rectal Cancer 9 2 14 3 Rectal Cancer 8 3 12 4 Prostate Cancer 9 4 6 5 Rectal Cancer 10 2 12 6 Cervix Cancer 9 3 16 7 Sigmoid Cancer 9 5 8 8 Uterine Cancer 8 3 10 9 Rectal Cancer 9 4 24 10 Rectal Cancer 10 2 18 11 Anal Cancer* 10 3 16 *Superior Hypogastric and Ganglion Impar Neurolysis.VAS = Visual analogue scale.