Presacral Neurectomy Research Articles

ROLE OF KUBERAKSHA VATI IN KASHTARTAVA (DYSMENORRHOEA)

Kashtartava (Dysmenorrhoea), or painful menstruation, is one of the leading causes of maximum absenteeism of females from school or the workplace. Though it is not a severe problem, it affects the quality of life and efficiency. The available treatment options include NSAIDs, antispasmodics, OCPs, TENS or surgical interventions like dilatation of the cervical canal, Presacral neurectomy and LUNA. These drugs have their side effects, and not many are convinced to use surgical methods for a minor ailment. Ayurveda, through various drug formulations and Panchkarma procedures, is undoubtedly a better choice. Kuberaksha Vati is one such formulation mentioned in Bharat Bhaishajya Ratnakar. This article is intended to illuminate the role of this drug in Kashtartava.

Dysmenorrhea, a Narrative Review of Therapeutic Options.

Dysmenorrhea is the most common pathology women of childbearing age face. It is defined as painful uterine cramping associated with menstruation. Primary dysmenorrhea occurs in the absence of an organic cause, whereas secondary dysmenorrhea is pelvic pain associated with an underlying pelvic pathology. The purpose of this review is to discuss the pathophysiology of dysmenorrhea and provide a discussion of pharmacologic and non-pharmacologic treatment options. Prostaglandins play a large role in the pathophysiology of dysmenorrhea by causing myometrial contraction and vasoconstriction. The first-line treatment for dysmenorrhea is with nonsteroidal anti-inflammatory drugs due to the inhibition of cyclooxygenase enzymes, thereby blocking prostaglandin formation, as well as hormonal contraception. Other pharmacologic treatment options include Paracetamol, as well as Gonadotrophic Release Hormone Analogs, which are typically used in the treatment for endometriosis. Non-pharmacologic treatments with strong evidence include heat therapy and physical exercise. There are less evidence-based data behind other modalities for treating dysmenorrhea, such as dietary supplements, acupuncture, and transcutaneous nerve stimulation, and these methods should be used in conjunction with first-line therapy after a discussion of risks and benefits. Lastly, for women who fail medical management, surgical options include endometrial ablation, presacral neurectomy, and laparoscopic uterosacral nerve ablation. Further research is needed to measure the socioeconomic burden of dysmenorrhea on the healthcare system and to evaluate the efficacy of treatment combinations, as a multi-modal approach likely provides the most benefit for women who suffer from this condition.

Approach to dysmenorrhoea in primary care.

Approach to dysmenorrhoea in primary care.

8520 Robotic Assisted Single-Site Presacral Neurectomy for Chronic Pelvic Pain in the Setting of Endometriosis

<h3>Study Objective</h3> Demonstrate the approach to presacral neurectomy using the robotic single site platform. <h3>Design</h3> A narrated instructional video. <h3>Setting</h3> A community-academic hospital. <h3>Patients or Participants</h3> Clinical Case-This is a case of a 43-year-old with a history of persistent central pelvic pain despite multiple laparoscopies for endometriosis and a hysterectomy for this indication. The patient had tried multiple medical and adjunctive treatments such as pelvic floor PT, acupuncture, etc., without relief. The patient elected for presacral neurectomy in an attempt to improve her pelvic pain. The patient desired minimal incisions for cosmesis and chose to have the procedure performed via the single site robotic platform. <h3>Interventions</h3> Case Description: Entry to the abdomen was made with a 2.5 cm incision hidden in the umbilicus. The single site port was placed, and the robot was docked. An EEA sizer was used to deviate the colon off the sacral promontory. An incision was made in the presacral peritoneum and carried cephalad toward the aortic bifurcation. The superior hypogastric plexus was coursing over the left common iliac vein. A combination of blunt and sharp dissection was used to isolate this plexus. The proximal portion of the plexus was grasped and sealed with the bipolar forceps and then separate with the hook. The plexus was further dissected down using the monopolar hook to the level of the bifurcation of the hypogastric plexus and the left arm was transected with the monopolar hook. The peritoneum was then reapproximated using a running 3-0 V-loc suture, and the procedure was completed. <h3>Measurements and Main Results</h3> N/A <h3>Conclusion</h3> This surgical video illustrates the feasibility of presacral neurectomy using the single site platform to improve cosmesis, patient satisfaction and reduction in number of incisions

Clinical Implications of Anatomic Variations of the Presacral Space

<h3>Study Objective</h3> To describe the presacral space and the spatial relationship between key anatomic landmarks, demonstrate anatomic variations in the presacral space, and discuss the clinical implications as they relate to minimally invasive surgery. <h3>Design</h3> Video description of key landmarks found in the presacral space, the fundamental steps of a presacral neurectomy, cases with anatomic variations of the presacral space, and clinical implications. Patients provided consent for the video and publication. This video with no identifying patient data was exempt from Institutional Review Boards Approval. <h3>Setting</h3> Video laparoscopy was performed. <h3>Patients or Participants</h3> We present patients with anatomic variations of the presacral space as well as cases demonstrating the clinical implications. <h3>Interventions</h3> Once the presacral space is entered, there are key landmarks to note. In a presacral neurectomy, the peritoneum overlying the sacral promontory is elevated and a small opening is made. The peritoneum is incised horizontally and vertically, and the opening is extended cephalad to the aortic bifurcation. Retroperitoneal lymphatic tissue including the nerve fibers of the hypogastric plexus are skeletonized, desiccated, and excised. All of the nerve fibers within the boundaries of the Triangle of Cotte are removed, including those entering the area from under the common iliac arteries and over the left common iliac vein. <h3>Measurements and Main Results</h3> The procedures that warrant dissection in this area include presacral neurectomy, sacropexy, lymphadenectomy, and certain cases of bowel mobilization. The clinical implications of anatomic variations are important to consider prior to abdominal entry and dissection of the presacral space to decrease the risk of surgical complications<b>.</b> <h3>Conclusion</h3> The anatomic pattern of the presacral space is variable, major vessels may deviate significantly from their expected positions, and prior to entering the space, surgeons should be careful to have full exposure.

Presacral Neurectomy: Literature Update and Surgical Approach

Study Objective This video will summarize the current literature and guidelines regarding presacral neurectomy (PSN), proper patient selection and surgical approach. We will identify the anatomy in the presacral space, relevant pelvic neuroanatomy and surgical pearls for performing PSN. The viewer will be able to apply key points from this video to clinical practice, allowing for optimization of PSN outcomes. Design N/A Setting Academic teaching hospital. Patients or Participants N/A Interventions PSN is a technically advanced pelvic denervation procedure. PSN has utility in addressing chronic pelvic pain and dysmenorrhea that specifically has a midline component. This video highlights the ongoing importance of effective patient selection, knowledge of anatomy and surgical expertise when performing PSN. Measurements and Main Results N/A Conclusion Presacral neurectomy remains a useful tool for the appropriately trained surgeon in the management of chronic pelvic pain.

Endometriosis Pain Management: a Review.

The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis. The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Clinical Utility of Presacral Neurectomy as an Adjunct to Conservative Endometriosis Surgery: Systematic Review and Meta-Analysis of Controlled Studies

The objective of this review was to compare the efficacy and safety of conservative surgery with or without adjunctive presacral neurectomy (PN) for chronic endometriosis-related pelvic pain. In a systematic review with meta-analysis, randomized or nonrandomized controlled studies of conservative endometriosis surgery with or without adjunctive PN were included. Main outcomes were treatment failure (the proportion of women in which surgery failed to adequately resolve midline pain) and the frequency of operative and postoperative complications. A total of 7 studies with 8 group comparisons (3 randomized) representing 503 women (250 PN; 253 Control) were included. Over 34 months median follow-up, crude rates of treatment failure were 15.0% with PN and 40.9% with Controls (risk ratio = 0.43, 95% CI = 0.30 to 0.60, p < 0.001). The risk of postoperative constipation was higher with PN vs. Controls (12.5% vs. 0%, p = 0.024). No treatment group differences were observed for the risk of operative complications (0.6% vs. 0%, p = 0.498), reoperation (4.1% vs. 3.0%, p = 0.758) or urinary incontinence (5.0% vs. 0%, p = 0.195). Overall, in well-selected patients, conservative surgery with adjunctive PN may provide greater relief from midline pain and a similarly low rate of operative complications relative to conservative surgery alone but may increase the risk of constipation postoperatively. However, results were derived from mainly older and lower quality studies. Since then, surgical techniques to treat endometriosis have been improved and the effect of PN observed in prior studies should be confirmed in future studies in women in whom radical excision of deep infiltrating lesions is obtained.

Superior Hypogastric Nerve Block

Video Objective To introduce a presacral nerve block for regional anesthesia in the pelvis. Setting Selected for patients with midline pelvic pain, endometriosis, and dysmenorrhea. The context of these procedures is in a high volume benign minimally invasive gynecologic surgery service with a single advanced laparoscopic surgeon at two hospitals within a health care system in an urban setting. The block is performed as part of an ERAS protocol for patients undergoing elective surgery with the outlined indications. Interventions The authors elected to modify the presacral neurectomy from a permanent transection of the superior hypogastric nerve plexus to a temporary medical neurectomy as a regional block. The block is a component of the regional anesthesia plan within a standardized ERAS protocol. The anesthesia solution used for the block is 10 cc of 0.5% bupivacaine with 1:200,000 epinephrine mixed with 10mg dexamethasone. Conclusion Given the ease in performing the nerve block, the historical context of the presacral neurectomy amongst gynecologic surgeons who care for chronic pelvic pain, the progress being made in ERAS protocols for gynecologic surgery services, and the extremely promising anecdotal experiencing for our institution, further study of this technique is warranted.

2675 Ovarian Vein Thrombosis as Cause of Acute Pelvic Pain After Total Laparoscopic Hysterectomy

Study Objective Reported cases of ovarian vein thrombosis associated with laparoscopic hysterectomy for benign reasons are rare. The majority of cases described have been postpartum; other risk factors include malignancy, sepsis, and recent pelvic/abdominal surgery. We present a case of a 29 y/o G4P2 diagnosed with right ovarian vein thrombosis two weeks status post uncomplicated total laparoscopic hysterectomy (TLH), bilateral salpingectomy, and cystoscopy for chronic pelvic pain and abnormal uterine bleeding related to endometriosis. Design Case report/literature review. Setting Academic affiliated gynecology specialty clinic. Patients or Participants 29 y/o G4P2022 half pack per day smoker with chronic pelvic pain previously treated with levonorgestrel containing IUD, depo medroxyprogesterone, and continuous OCPs without symptom resolution. She previously underwent diagnostic laparoscopies with fulguration and excision of endometriosis, as well as a robotic assisted presacral neurectomy. She underwent an uncomplicated TLH/bilateral salpingectomy/cystoscopy. She presented two weeks post-op with severe right sided pelvic pain and fever. A right ovarian vein thrombosis was discovered on CT scan. Interventions Patient was admitted for antibiotics and therapeutic anticoagulation with enoxaparin, then discharged home at forty-eight hours. Two weeks later she was readmitted for continued vaginal bleeding. Anticoagulation was discontinued and patient was discharged home. Due to continued severe RLQ pain, interventional radiology was contacted for possible thrombectomy but were unable to do so. The patient then underwent a laparoscopic right oophorectomy and right ovarian vein thrombectomy seven weeks after her initial TLH. Measurements and Main Results Right ovarian vein thrombus visualized and dissected out on laparoscopy with resolution of acute localized pelvic pain. Conclusion While multiple etiologies for pelvic pain and fever after TLH exist, it is important not to overlook gonadal vein thrombosis. We recommend pre-/post-operative anticoagulation in patients with high thrombotic risk undergoing any major procedure. This case illustrates a rare diagnosis of ovarian vein thrombosis in a non-pregnant patient after minimally invasive surgery.

Laparoscopic management of retroperitoneal lymphocoele: A late complication of laparoscopic presacral neurectomy

This is the first case report of a symptomatic retroperitoneal lymphocoele formation occurring a decade after laparoscopic presacral neurectomy successfully managed by laparoscopic surgery.

Incidental Finding of Bladder Cancer in a Young Patient Undergoing Presacral Neurectomy

Objective: Bladder cancer is the most common urinary tract malignancy, however, rare in patients younger than 60 with a median age at diagnosis of 71 in women. Risk factors include smoking, environmental chemical exposure, chronic cystitis, HPV. Although extremely rare, bladder cancer can be seen in children and young adults. We present a case of a 24 yo G0 with longstanding chronic pelvic pain, endometriosis, and interstitial cystitis with an incidental finding of bladder cancer at the time of surgery.

The efficacy of laparoscopic presacral neurectomy in dysmenorrhea: is it related to the amount of excised neural tissue?

Objective:To assess the correlation between the number of excised neural fibers and degree of pain relief following laparoscopic presacral neurectomy (LPSN).Materials and Methods:In this before and after study, 20 patients with severe midline dysmenorrhea [Visual Analogue Scale (VAS) >80 mm] unresponsive to medical therapy were consecutively enrolled. All patients underwent LPSN. The superior hypogastric plexus was excised and sent for histologic confirmation. Two pathologists counted the number of neural fibers in the surgically removed tissue. VAS was used for pain assessment before and 2nd, 3rd, 6th, and 12th months after the operations.Results:Out of the initial 20 patients undergoing LPSN, eight were excluded from the final analysis due to intraoperative diagnosis of endometriosis; therefore, the remaining 12 patients were evaluated. The pain scores significantly decreased at each follow-up visit compared with the preoperative period (p=0.002). The pathologists, who were blinded, reported the median (minimum-maximum) neural fiber count as 46 (20-85) and 47 (18-83). No significant correlation was demonstrated between the number of excised neural fibers and the amount of pain relief following LPSN.Conclusion:LPSN is an effective surgical procedure to control primary dysmenorrhea. Our preliminary results revealed that the degree of pain relief in cases of severe midline dysmenorrhea was not related to the amount of excised neural tissue in LPSN.

Pelvic denervation procedures for dysmenorrhea.

Chronic pelvic pain and dysmenorrhea are common conditions affecting reproductive-age women. Surgical pelvic denervation procedures may be a treatment option for women with midline dysmenorrhea, in which medical management is declined by the patient, ineffective at managing symptoms, or medically contraindicated. This review describes the surgical techniques and complications associated with pelvic denervation procedures as well as the current evidence for these procedures in women with primary dysmenorrhea and dysmenorrhea secondary to endometriosis. Presacral neurectomy is the preferred pelvic denervation procedure in patients with primary dysmenorrhea and midline chronic pelvic pain associated with endometriosis. In patients with endometriosis presacral neurectomy is a useful adjunct to excision or ablation of all endometrial lesions to improve postoperative pain relief. There is no additional patient benefit of performing combined presacral neurectomy and uterine nerve ablation procedures. Pelvic denervation procedures can be performed safely and quickly with a low risk of complication if the surgeon is knowledgeable and skilled in operating in the presacral space. Patients should be adequately counseled on expected success rates and potential complications associated with pelvic denervation procedures.

Surgical Management of Endometriosis in Patients with Chronic Pelvic Pain.

Surgical approaches to endometriosis patients with chronic pelvic pain are multimodal and require individualization. Laparoscopic approaches are preferred over laparotomy when conservatively treating endometriosis via excision or ablation/fulguration of lesions. The available data support cystectomy over fenestration or fulguration for endometriomas; however, there may be associated decreases in ovarian reserve with endometrioma treatment. Presacral neurectomy may be useful in patients with midline pain and LUNA is not effective for the treatment of pelvic pain related to endometriosis. Appendectomy may be considered prophylactically at the time of the surgery for pelvic pain, although more studies are needed. For deep infiltrating endometriosis, the risks of aggressive bowel surgery must be weighed against the benefits of clear pain reduction. Postoperative medical suppressive therapy is strongly recommended to prolong symptom-free intervals of this chronic disease. As definitive therapy, hysterectomy can be helpful especially when combined with endometriosis excision. When performing hysterectomy, bilateral oophorectomy should be given careful consideration, as this procedure leads to premature surgical menopause and may not decrease the possibility of reoperation and persistence of symptoms in patients aged 30 to 39 years with chronic pain.

Bowel and bladder dysfunction following surgery within the presacral space: an overview of neuroanatomy, function, and dysfunction.

The presacral space contains a dense and complex network of nerves that have significant effects on the innervation of the pelvic viscera and support structures. The proximity of this space to the bony promontory of the sacrum has lead to its involvement in an array of corrective surgical procedures for pelvic floor disorders including sacrocolpopexy and rectopexy. Other procedures involving the same space include presacral neurectomy which involves intentional transection of the contained neural plexus to relieve refractory pelvic pain and resection of retrorectal or presacral tumors. Potential complications of these procedures are postoperative constipation and voiding dysfunction. Our aim was to review the current published literature on outcomes following a variety of procedures involving the presacral space and review postoperative bowel and urinary function. We also include an overview of the functional and structural anatomy of the presacral space and its corresponding neural plexi. We conclude that quality data are lacking on the short-term and long-term rates for bowel and bladder dysfunction following surgical procedures involving the presacral space.

Presacral Neurectomy: A Review of Anatomy and Surgical Technique

Presacral Neurectomy: A Review of Anatomy and Surgical Technique

Surgical Foundations of Presacral Anatomy

Knowledge of the anatomical relationships within the presacral space is paramount when operating within the interiliac triangle. The purpose of this video is to demonstrate presacral anatomy in relationship to the ureters by observing techniques used in a laparoscopic presacral neurectomy, sacrocolpopexy, and anterior bowel resection. By displaying the anatomy from 3 separate perspectives, the viewer gains an enhanced appreciation of various anatomical structures and their spatial relationships.

Robotic presacral neurectomy – technique and results

The feasibility, safety and outcomes of robotic presacral neurectomy were evaluated. A retrospective analysis was performed of 33 patients with midline chronic pelvic pain, who underwent robotic presacral neurectomy. Data were collected during the period March 2004-March 2010. All patients underwent robotic presacral neurectomy and additional robotic procedures. Mean operating time for robotic presacral neurectomy was 5.8 (range 4.4-6.9) min. Mean blood loss, including concomitant procedures, was 39 (range 15-150) ml. Most patients were discharged the same day (60%) and mean hospital stay was 0.39 (range 0-2) days. There were no conversions or intra-operative complications. There were two postoperative complications: one pelvic abscess and one Clostridium difficile colitis. Pain improvement was reported by 73% (22/30) of patients. Robotic presacral neurectomy is safe and feasible, resulting in improvement of pelvic pain in selected patients.

Laparoscopic Presacral Neurectomy for Chronic Central Lower Abdominal Pain after Previous Cold Knife Conization

We desire to demonstrate an effective laparoscopic technique for presacral neurectomy and to describe an unusual clinical presentation where presacral neurectomy was deemed to be the effective treatment option for chronic central lower abdominal pain. Presacral neurectomy has been performed typically in patients with refractory primary dysmenorrhea and in patients with endometriosis in conjunction with resection of endometriosis. Small studies have demonstrated modest improvement in pain with laparoscopic presacral neurectomy compared to laparoscopic uterosacral nerve ablation for primary dysmenorrhea and compared to surgical treatment of endometriosis alone. Some have proposed a preoperative hypogastric nerve block to determine which patients would be an appropriate candidate for presacral neurectomy. Our patient had chronic central lower abdominal pain after a cold knife conization 4 years previously. She had temporary relief after injection of her superior hypogastric plexus by an interventional pain specialist. One month post-operatively she was pain free.