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Allahqoli L, Hakimi S, Momenimovahed Z, Mazidimoradi A, Rezaei F, Aghamohammadi SZ, Rahmani A, Mansouri G, Hadavandsiri F, Salehiniya H, Alkatout I. Neuropelveology for Endometriosis Management: A Systematic Review and Multilevel Meta-Analysis. J Clin Med 2024; 13:4676. [PMID: 39200818 PMCID: PMC11355340 DOI: 10.3390/jcm13164676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/29/2024] [Accepted: 08/03/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Despite the availability of treatments such as surgery and hormonal therapy, women with endometriosis often endure chronic problems. This review aims to evaluate the effectiveness and safety of neuropelveology. Methods: In a systematic review with a meta-analysis, we searched three electronic databases: MEDLINE (PubMed), Scopus, Embase, and Web of Science (WOS). The search was conducted in January 2024 with no date or language restrictions using a carefully curated set of keywords. We conducted a comprehensive review, including all observational and clinical trials reporting data on neuropelveology approaches in the management of endometriosis, irrespective of geographical location. The studies included in our review were required to be published in peer-reviewed journals and be available in any language, with at least an abstract in English. The data of all included studies were summarized in excel (version 19) and were analyzed by Comprehensive Meta-analysis v3.3 (Biostat) and STATA (version 17). A multilevel meta-analysis was performed on studies with two arms (intervention and control) to evaluate the efficacy of neuropelveology in managing women with endometriosis. Results: After screening 476 records, 30 studies, published from 1952 to 2021, were included in this review, each employing various methodologies. The studies were divided into the following three categories: (a) efficacy of neurectomy or nerve resection (n = 20), (b) efficacy of neurolysis (nerve blocks) (n = 4), and (c) efficacy of neuromodulation (n = 6) in the management of endometriosis. Among the studies evaluating the efficacy of neurectomy or nerve resection, 10 studies (with 18 group comparisons) were included in the random-effects meta-analysis. Treatment success (not occurrence of pain) was higher with neurectomy vs. controls (RR = 0.497, 95% CI = 0.236 to 1.04, p = 0.06 (for experimental studies) and RR = 0.248, 95% CI = 0.14 to 0.43, p < 0.001 (for observational studies)), representing a 50% and 75.2% risk reduction in the recurrence of pain in experimental and observational studies, respectively. Similarly, neurolysis, particularly superior hypogastric plexus blocks and uterine nerve ethanol neurolysis, demonstrated encouraging outcomes in pain reduction and an improved quality of life for women with endometriosis. The efficacy of neuromodulation in managing endometriosis symptoms appears promising but requires further investigation. Conclusions: In conclusion, neuropelveology approaches, such as neurectomy, neurolysis, and neuromodulation, offer significant potential for pain reduction in endometriosis patients, albeit with risks of complications and high recurrence rates, necessitating careful patient selection and long-term monitoring.
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Affiliation(s)
- Leila Allahqoli
- Ministry of Health and Medical Education, Tehran 14357-13715, Iran;
| | - Sevil Hakimi
- Faculty of Health Sciences, Ege University, 35575 Izmir, Türkiye;
| | - Zohre Momenimovahed
- Midwifery Department, Qom University of Medical Sciences, Qom 37136-49373, Iran;
| | - Afrooz Mazidimoradi
- Neyriz Public Health Clinic, Shiraz University of Medical Sciences, Shiraz 71348-14336, Iran;
| | - Fatemeh Rezaei
- Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom 46199-74148, Iran;
| | | | - Azam Rahmani
- Nursing and Midwifery Care Research Centre, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran 14167-53955, Iran;
| | - Ghazal Mansouri
- Department of Obstetrics and Gynecology, School of Medicine, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman 76169-13555, Iran;
| | - Fatemeh Hadavandsiri
- Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Science, Tehran 14167-53955, Iran;
| | - Hamid Salehiniya
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand 97178-53577, Iran;
| | - Ibrahim Alkatout
- Kiel School of Gynaecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
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Clinical Utility of Presacral Neurectomy as an Adjunct to Conservative Endometriosis Surgery: Systematic Review and Meta-Analysis of Controlled Studies. Sci Rep 2020; 10:6901. [PMID: 32327689 PMCID: PMC7181806 DOI: 10.1038/s41598-020-63966-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 04/06/2020] [Indexed: 01/11/2023] Open
Abstract
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.
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Palomba S, Zupi E, Falbo A, Russo T, Tolino A, Marconi D, Mattei A, Zullo F. Presacral neurectomy for surgical management of pelvic pain associated with endometriosis: a descriptive review. J Minim Invasive Gynecol 2007; 13:377-85. [PMID: 16962518 DOI: 10.1016/j.jmig.2006.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 06/07/2006] [Accepted: 06/09/2006] [Indexed: 11/16/2022]
Abstract
Pelvic pain associated with endometriosis is a common clinical problem. In approximately 20% of cases endometriosis-related pelvic pain is either minimally or not responsive to medical treatment; thus surgical treatment seems to be a valid option. The aim of this review is to describe presacral neurectomy surgical techniques, data regarding safety and efficacy of this procedure, its indications, and future research on its applications in clinical practice.
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Affiliation(s)
- Stefano Palomba
- Department of Obstetrics and Gynecology, University Magna Graecia Catanzaro, Rome, Italy.
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Vercellini P, De Giorgi O, Pisacreta A, Pesole AP, Vicentini S, Crosignani PG. Surgical management of endometriosis. Best Pract Res Clin Obstet Gynaecol 2000; 14:501-23. [PMID: 10962639 DOI: 10.1053/beog.1999.0088] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.
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Affiliation(s)
- P Vercellini
- First Department of Obstetrics and Gynaecology, University of Milan, Italy
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Abstract
Studies reveal endometriosis to be present in 38-51% of women undergoing laparoscopy for chronic pelvic pain. Symptoms attributable to endometriosis include dysmenorrhea, dyspareunia, generalized pelvic pain, dyschezia, and radiation of pain to the back or leg. Psychological factors may also contribute to a more intense pain experience. Medical therapy provides symptom relief in 72-93% of patients, although recurrence is common following treatment discontinuation. Surgical therapy has had varying results for long-term pain relief; adequacy of the initial surgical treatment appears to be a critical factor. Important adjunctive measures include presacral neurectomy and excisional techniques to remove deep, fibrotic, retroperitoneal lesions. The quality of life of women with endometriosis will improve with greater focus on achieving the long-term relief of pelvic pain. Limitation of pain recurrence would benefit the patient greatly, by providing symptom relief and preventing the cycle of its probably adverse effects on physical activity, work productivity, sexual fulfilment, and mood.
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Affiliation(s)
- M A Damario
- Emory University School of Medicine, Department of Gynecology and Obstetrics, Atlanta, GA, USA
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Candiani GB, Fedele L, Vercellini P, Bianchi S, Di Nola G. Presacral neurectomy for the treatment of pelvic pain associated with endometriosis: a controlled study. Am J Obstet Gynecol 1992; 167:100-3. [PMID: 1442906 DOI: 10.1016/s0002-9378(11)91636-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Our objective was to evaluate the efficacy of presacral neurectomy combined with conservative surgery for the treatment of pelvic pain associated with endometriosis. STUDY DESIGN In a randomized, controlled study performed in a tertiary institution 71 patients with moderate or severe endometriosis and midline dysmenorrhea were randomly assigned to conservative surgery alone (n = 36) or conservative surgery and presacral neurectomy (n = 35). Main outcome measures were relief of dysmenorrhea, pelvic pain, and deep dyspareunia after surgery according to a multidimensional and an analog pain scale. RESULTS Presacral neurectomy markedly reduced the midline component of menstrual pain, but no statistically significant differences were observed between the two groups in the frequency and severity of dysmenorrhea, pelvic pain, and dyspareunia in the long-term follow-up. After presacral neurectomy, constipation developed or worsened in 13 patients and urinary urgency occurred in three and a painless first stage of labor in two. CONCLUSION Presacral neurectomy should be combined with conservative surgery for endometriosis only in selected cases.
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Affiliation(s)
- G B Candiani
- Department of Obstetrics and Gynecology, University of Milan, Italy
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Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56:628-34. [PMID: 1833246 DOI: 10.1016/s0015-0282(16)54591-9] [Citation(s) in RCA: 195] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the long-term outcome after laparoscopic excision of endometriosis. DESIGN This longitudinal unmatched study evaluated surgical outcome using follow-up questionnaires and evaluation of reoperations with results presented in life table format. SETTING Surgery was performed by a private practitioner at a referral center. PATIENTS All 359 patients undergoing laparoscopic excision of endometriosis between December 12, 1980, and March 31, 1990, were studied. INTERVENTIONS Endometriosis, including deeply invasive disease, was completely excised laparoscopically using 3-mm scissors and graspers. Adjunctive medical therapy was not used. MAIN OUTCOME MEASURES Extent of disease present at reoperation and quarterly rates of reoperation and recurrent/persistent disease are used as indicators of efficacy of surgery. RESULTS Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year. CONCLUSION Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.
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Affiliation(s)
- D B Redwine
- St. Charles Medical Center, Bend, Oregon 97701
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Vercellini P, Fedele L, Bianchi S, Candiani GB. Pelvic denervation for chronic pain associated with endometriosis: fact or fancy? Am J Obstet Gynecol 1991; 165:745-9. [PMID: 1832523 DOI: 10.1016/0002-9378(91)90322-i] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The efficacy of presacral neurectomy and amputation of the uterosacral ligaments in the treatment of chronic pelvic pain has been debated for decades. These procedures used to be done mainly in women with normal pelves, but more recently they have been performed during conservative surgery for treatment of endometriosis. In the 1980s the rapid spread of laparoscopic surgery has led to an increasing number of endoscopic denervations in patients with chronic pelvic pain associated with endometriosis. However, an analysis of literature data has failed to prove that presacral neurectomy and amputation of the uterosacral ligaments are effective and did not demonstrate better results with the use of lasers rather than electrocoagulation. Moreover, no valid comparison has yet been made between laparotomy and laparoscopic methods.
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Affiliation(s)
- P Vercellini
- Department of Obstetrics and Gynecology, L. Mangiagalli, University of Milano School of Medicine, Italy
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Mahmood TA, Templeton AA, Thomson L, Fraser C. Menstrual symptoms in women with pelvic endometriosis. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1991; 98:558-63. [PMID: 1873245 DOI: 10.1111/j.1471-0528.1991.tb10370.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate menstrual symptoms in relation to pelvic pathology. DESIGN A prospective questionnaire-based study. SETTING Aberdeen Royal Infirmary, Scotland. SUBJECTS 1250 questionnaires were sent out prior to planned admission and 1200 women (96%) brought the completed questionnaires. They comprised 598 women undergoing laparoscopic sterilization, 312 having laparoscopy because of infertility, 156 having laparoscopy because of chronic pelvic pain and 134 women undergoing abdominal hysterectomy for dysfunctional uterine bleeding. MAIN OUTCOME MEASURES The occurrence of dysmenorrhoea, menorrhagia, menstrual regularity, premenstrual spotting, deep dyspareunia and pelvic pain in women with either endometriosis and post infective pelvic adhesions or a normal pelvis. RESULTS Menorrhagia, menstrual irregularity and premenstrual spotting occurred with equal frequency in all groups. Deep dyspareunia, pain after intercourse and recurrent pain unrelated to menstruation or coitus was more common in women with endometriosis and those with post infective pelvic adhesions than in those with a normal pelvis. Dysmenorrhoea appears to be more prevalent among women having endometriosis. CONCLUSIONS Menstrual symptoms, while raising a high index of suspicion for endometriosis, are not entirely reliable as indicators of disease. Dysmenorrhoea is the most common reported symptom in endometriosis sufferers. Diagnostic laparoscopy should be considered before institution of treatment in women complaining of pelvic pain and menstrual symptoms.
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Affiliation(s)
- T A Mahmood
- Department of Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Scotland
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Redwine DB, Yocom LB. A serial section study of visually normal pelvic peritoneum in patients with endometriosis. Fertil Steril 1990; 54:648-51. [PMID: 2209885 DOI: 10.1016/s0015-0282(16)53823-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Defined criteria were used to select small samples of visually normal study peritoneum for serial section light microscopy in 45 patients with biopsy-proven endometriosis and 10 patients without endometriosis. A glandular element compatible with possible endometriosis was found in only 1 patient. Visually normal peritoneum does not harbor a high prevalence of invisible microscopic endometriosis.
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Affiliation(s)
- D B Redwine
- St. Charles Medical Center, Bend, Oregon 97701
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Telimaa S, Rönnberg L, Kauppila A. Placebo-controlled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis after conservative surgery. Gynecol Endocrinol 1987; 1:363-71. [PMID: 2972171 DOI: 10.3109/09513598709082709] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
To evaluate the clinical value of postoperative hormone therapy in endometriosis, 60 patients with advanced disease were randomized to receive in a double-blind study danazol (200 mg, 3 times daily), medroxyprogesterone acetate (MPA) (100 mg daily) or placebo post-operatively for 6 months. Treatment efficacy was evaluated clinically and at laparoscopy 6 months after medication. In relation to placebo, danazol and high-dose MPA treatments, which did not differ from each other in efficacy, significantly alleviated pelvic pain. In addition, the peritoneal endometriosis lesions found at 6-months laparoscopy were significantly smaller in the MPA and danazol groups than in the placebo group. Breakthrough bleeding, weight gain and acne complicated danazol treatment but only breakthrough bleeding complicated MPA treatment. These data suggest that postoperative treatment of advanced endometriosis with high-dose MPA or danazol is clinically beneficial.
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Affiliation(s)
- S Telimaa
- Department of Obstetrics and Gynecology, University of Oulu, Finland
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