The Efficacy of Laparoscopic Uterosacral Nerve Ablation (LUNA) in the Treatment of Central Chronic Pelvic Pain

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1 Med. J. Cairo Univ., Vol. 80, No. 2, June: 53-60, The Efficacy of Laparoscopic Uterosacral Nerve Ablation (LUNA) in the Treatment of Central Chronic Pelvic Pain MOHAMED F. SELIM, M.D.* and ALI M. ALI ELNABTITY, M.D.** The Departments of Obstetrics & Gynecology* and Anesthesiology**, Faculty of Medicine, Zagazig University, Egypt Abstract Objective: To determine the effectiveness of laparoscopic uteroscaral nerve ablation (LUNA) for treatment of central chronic pelvic pain in women without visible pelvic pathology. Design: A prospective observational study. Methods: Patients with central chronic pelvic pain (dysmenorrhoea, dyspareunia, and pelvic pain not associated with sexual intercourse or menstruation) with no pelvic pathology underwent LUNA procedure. Main outcomes were pain intensity and Health-related quality of life (HRQoL) at 3, 6 and 12 months post operatively. Change in pain intensity was assessed by a decrease in visual analogue score (VAS) to 3 and additionally by difference in mean visual analogue score. HRQoL was measured by the Short From Health Survey (SF- 36) questionnaire. Results: Of the 17 participants available for statistical analysis 14, 13 and 13 showed improvement in pain intensity (VAS 3) at 3, 6 and 12 months post operatively, mean changes in VAS from preoperative score showed large effect size >0.8 (s ± SD were 3.17± 1.55, 3.35± 1.61 and 3.41 ± 1.69 at 3, 6 and 12 months post-operatively vs 7.64 ±1.11 preoperatively). Also significant improvements were observed in all SF-36 subscale scores (p<0.05) with moderate subscale effect sizes >0.5. Conclusion: Laparoscopic uteroscaral nerve ablation can be associated with improvements in pain intensity and quality of life in patients with central pelvic pain. However more studies with bigger number of patients are needed to support its efficacy and safety before the procedure becomes widely adopted for intractable chronic pelvic pain. Key Words: Chronic pelvic pain Uterosacral nerve ablation L UNA. Introduction A SYSTEMATIC review by the World Health Organization identified chronic pelvic pain (CPP) as an important cause of morbidity in women, but noted that the condition is relatively neglected Correspondence to: Dr. Mohamed Fouad Selim, The Department of Obstetrics and Gynecology, Faculty of Medicine, Zagazig University, Egypt, mfselim@hotmail.com because of the paucity of basic epidemiological data [1]. Chronic pelvic pain is defined as cyclic or acyclic pain in the pelvis, persisting for 6 months or more, and severe enough to cause functional incapacity that requires medical or surgical treatment or both [2]. Chronic pelvic pain is the reason for approximately 10% of all gynecologic consultations, 40% of laparoscopies, and 10% to 15% of hysterectomies, thus representing a clinically significant public health problem [2-4]. CPP may present as dysmenorrhoea (primary or secondary), non-menstrual pain or deep dyspareunia (pain with sexual intercourse) [5]. One in seven women has undetermined etiology of diagnosis of chronic pelvic pain [4]. When definite pathology is found the likely causes are endometriosis (25%) and adhesions (25%) [5]. CPP may result from complex interactions among the gastrointestinal, urinary, gynecologic, musculoskeletal and neurologic systems, as well as being influenced by psychological and sociocultural factors. Management requires good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems [5,6]. Only 20-25% of patients respond to conservative management [6]. When such treatment fails, a diagnostic laparoscopy is usually performed [5,7]. Treatment of the condition is sometimes unrewarding owing to a lack of effective interventions and more radical surgery, such as hysterectomy, often becomes the final option [5]. The nerve plexuses and parasympathetic ganglia in the uterosacral ligaments carry "pain" from the uterus, cervix and other pelvic structures. Pelvic denervation has been proposed for treatment of chronic pelvic pain [8]. The original work by Doyle described vaginal and abdominal approaches to divide the attachments of the uterosacral ligaments to the cervix [9,10]. Operative laparoscopy has 53

2 54 The Efficacy of Laparoscopic Uterosacral Nerve Ablation developed rapidly that makes laparoscopic pelvic denervation a practicable option in the management of chronic pelvic pain. Two approaches have been utilized; PSN and LUNA. LUNA involves the transection of the uterosacral ligaments at their insertion into the cervix; PSN involves total removal of the presacral nerves. PSN interrupts a greater number of nerve pathways compared to LUNA, and is technically more demanding. The adverse events of PSN were significantly more common than those of LUNA [5,6]. A research evidence on LUNA was inconclusive [11], so Cochrane Reviews [12,13] recommend rigorous research to assess surgical interventions in chronic pelvic pain. Fortunately, some reports of randomized controlled studies have clarified some roles of LUNA in the control of pelvic pain [14-16]. There have been isolated case reports of uterine prolapse [17,18] and bladder dysfunction [18] following LUNA, although the complication rate attributable directly to LUNA appears to be extremely low [19]. Other adverse effects of neuroablation, such as hematoma formation, constipation and subsequent painless labor, appear to be more associated with PSN than LUNA [12,18]. Aim of the study: To evaluate the effect of LUNA for treatment of women with central chronic pelvic pain in whom diagnostic laparoscopy reveals no pathology. Material and Methods Between January 2008 and August 2011, this study took place in Jeddah Clinic Hospital, Jeddah, Saudi Arabia, after approval of Ethic Committee. Women who were eligible for this study were those aged between 18 and 45 years who reported menstruating in the previous 6 months and were sexually active. Inclusion criteria: - Pelvic pain of longer than 6-month duration, that is located within the true pelvis. Pelvic pain was defined as any type of pain in the lower part of the abdomen-that is, from the belly button down. Three subtypes of pelvic pain where defined as follows [6]. a- Primary dysmenorrhoea was defined as pelvic pain with periods Primary dysmenorrhea occurs in the absence of an identifiable cause, while secondary dysmenorrhea describes menstrual pain associated with a physical cause. b- Deep Dyspareunia was defined as pelvic pain during intercourse ; and c- Non menstrual pelvic pain was defined as pelvic pain not occurring with periods or intercourse, either on and off or constantly. - Lack of response to medical treatment. - Diagnostic laparoscopy planned. Exclusion criteria: Previous pelvic surgery as; previous surgery for endometriosis or previous hysterectomy. Patients with a previous clinical or endoscopic diagnosis of endometriosis or with other diseases that might cause pelvic pain (Pelvic adhesions, chronic pelvic inflammatory disease, pelvic varices, a diagnosis of gastrointestinal, urological and orthopaedic diseases with potential pain irradiation to the pelvic area and known psychiatric disturbances). Plan for a pregnancy within 12 months, intention to change other medical treatment that could influence pelvic pain scores within 12 months, Eligible women had given consent for diagnostic laparoscopy then LUNA operation. Interventions: Laparoscopic uterosacral nerve ablation was carried out in a uniform manner by one surgeon (Selim MF.) that have been previously published by Sutton (1993) [19]. The aim of the procedure was to destroy the sensory nerve fibers and the secondary ganglia as they leave the uterus and come to lie within the uterosacral ligaments. Three-puncture laparoscopy was performed under general anesthesia. Following pneumoperitoneum, a laparoscope will be used to visualize the pelvis. In addition to the umbilical port used for the laparoscope itself; the conduct of operative laparoscopy for LUNA requires the use of two additional ports, one for delivery of the energy source (diathermy) and another for manipulation. Before embarking on operative laparoscopy an anatomical pelvic assessment will be performed to identify pelvic structures and any pathology. At this stage patients with pathology outlined in the exclusion criteria will be excluded. Clear identification of the uterosacral ligaments was a prerequisite to treatment; the posterior leaf of the broad ligament was carefully inspected to identify the course of the ureters, which on rare occasions could be particularly close to the uterosacral ligaments. Care was also be taken to note thin walled pelvic veins, which often lie lateral to

3 Mohamed F. Selim & Ali M.A. Elnabtity 55 the uterosacral ligaments. If accidentally punctured, they may cause troublesome bleeding requiring further endoscopic endocoagulation. The uterosacral ligaments were identified by manipulation of the uterus in the right and left lateral planes. The ligaments were then be ablated using an electric bipolar instrument (ErbotomACC450, Erbe GmbH, Tubingen, Germany). Electrocautery was applied (bipolar current set at 30W) 0.5cm from the ligamentous insertion to the cervix until the tissue was blanched. Complete transection of the ligaments was then undertaken with laparoscopic scissors and bipolar electrocautery reapplied to the base of the incision to secure haemostasis. No important intra-operative or postoperative complications occurred (specifically, there were no cases of ureteric injury, intra-operative bleeding or post-operative hematoma formation). Outcome measurements: Each patient was asked to complete a questionnaire on the presence and severity of primary dysmenorrhoea, deep dyspareunia and nonmenstrual pelvic pain graded according to a 0- to 3-point multidimensional categorical rating scale modified from the one devised by Biberoglu and Behrman (1981) [20], which defines dysmenorrhoea according to loss of work efficiency and need for bed rest (absence of pain, 0; some loss of work efficiency, mild, 1; in bed part of 1 day, occasional loss of work, moderate, 2 and in bed for 1 or more days, incapacitation, severe, 3), non-menstrual pain according to various degrees of discomfort and use of analgesics (absence of pain, 0; occasional pelvic discomfort, mild, 1; noticeable discomfort for most of the cycle, moderate, 2; pain persisting during the cycle or requiring strong analgesics, severe, 3) and deep dyspareunia according to limitation of sexual activity (no discomfort, 0; tolerated discomfort, mild, 1; intercourse painful to the point of interruption, moderate, 2; intercourse avoided because of pain, severe, 3). The women were also requested to grade the severity of pain using a 10-cm visual analogue scale (VAS) the left extreme (0) of which indicated the absence of pain and the right one (10) pain as bad as it could be; a score of 1-3 was considered mild pain, 4-6 moderate pain and 7-10 severe pain [21]. Changes in pain severity over the study period were quantified (a) dichotomously, with an improvement defined as VAS pain score <_3. (b) A change in mean VAS pain scores from basline [22]. All the women completed a validated Arabic translation of the SF-36 Health Status questionnaire to assess health-related quality of life. It was a brief self-administered questionnaire that generated assessment scores across eight dimensions of health: physical function (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VI), social function (SF), role limitations due to emotional problems (RE), mental health (MH), and one single item dimension on health transition. The score in each category may be from 0 to 100 points (mean value calculated on the basis of individual items encompassed within a given category), which results in a linear dependence-the higher the evaluation of a given category of the quality of life. The SF-36 dimensions can also be divided into two categories: Physical Component Summary (PCS) and Mental Component Summary (MCS), which represent the physical functioning and wellbeing, and emotional wellbeing, respectively. Summary scores for a physical component (physical functioning, role physical, bodily pain and general health perceptions) and a mental component (vitality, social functioning, mental health and role emotional) can also be derived [23-26]. Statistical analysis: Results are reported as means and standard deviations (SD) or unless otherwise specified. Changes in pain over the study period were quantified (a) dichotomously, with an improvement defined as VAS <3 (mild pain) (b) a change in mean VAS pain scores from preoperative and post operative scores. For each scale of the SF-36 component scales and its subscores to assess healthrelated quality of life, we considered that an improvement occurred if the postoperative score was better than the preoperative score. Effect sizes, a quantitative measure of change that standardizes the comparison between groups, were calculated for each VAS and SF-36 subscale by using the difference in mean scores from preoperative to month 3,6 and 12 postoperative that are dividing by the standard deviation of preoperative scores of all participants. Effect size was interpreted as small (0.20), moderate (0.50), or large (0.80) according to the guidelines proposed by Cohen [27]. Differences in mean HRQOL scores (SF-36 component scales and its subscores) between the participants at the separate time points were assessed with the Student t-test. Comparison in preoperative and postoperative of pain intensity (VAS) and SF-36 component scales and its subscores were done using covariance analysis; ANCOVA (a repeated-measures analysis of variance was used to test between-group differences over time in scores.) of preoperative and 3-month, 6-month and

4 56 The Efficacy of Laparoscopic Uterosacral Nerve Ablation 12-month postoperative respectively. All reported p-values are significant at <0.05. Statistical analysis was performed using the statistical program Statistical Package for the Social Sciences 11.5 for Windows (SPSS, Chicago, IL). Results Twenty patients with central pelvic pain underwent LUNA. Three patients (One missed followup and 2 got pregnant within the follow-up period) were excluded; the remaining 17 were available for the analysis. The baseline characteristics of the participants before LUNA are presented in Table (1). The type and severity of pelvic pain and visual analogue scores are showmen in addition to age and parity. Among the 17 participants 14, 13 and 13 of them showed improvement in pain intensity at 3, 6 and 12 months post operatively ; VAS (mean ± SD) were 7.64± 1.11 preoperatively and 3.17 ± 1.55, 3.35 ± 1.61 and 3.41 ± 1.69 at 3, 6 and 12 months post operative respectively. Table (1): Preoperative characteristics of the participants. No. of case Age (y) Parity Primary dysmenorrhea severity Deep dyspareunia severity Non-menstrual pelvic pain severity VAS score Severe Mild No Severe No No Moderate Severe No Mild No Moderate Severe Moderate No Severe No Moderate Moderate No No No Moderate Mild Severe No Moderate No Moderate Severe Severe No Mild No No Moderate Severe No No Moderate No Moderate Severe No No Moderate No No No Moderate Severe 8 Table (2): Successful treatment of pain intensity. No. of case (17) 3 VAS score Post 3 mon 3 VAS score Post 6 mon 3 VAS score Post 12 mon Non menstrual pelvic pain 9/17 6/17 5/17 5/17 Dysmenorrhea 13/17 12/17 12/17 12/17 Dysparunia 6/17 4/17 4/17 3/17 Values given as number PF : Physical function. BP : Bodily pain. RP : Role physical. SF : Social function. GH: General health perception. Preoperative Post 3 mon VI : Vitality. RE : Role emotional. MH : Mental health. MCS: Mental component scale. PCS : Physical component scale. Post 6 mon Post 12 mon 0 PF RP BP GH VI SF RE MH PCS MCS Fig. (1): The mean score of the items of the short-form (SF)-36 health survey preoperative and 3, 6, and 12 month post LUNA. All post operative differences remained significant compared to preoperative scores.

5 Mohamed F. Selim & Ali M.A. Elnabtity 57 Table (2) shows that the number of women with a successful treatment (achieving a 3 VAS score after LUNA) were 6,5 and 5 patients of 9 with non menstrual pelvic pain, 12 patients of 13 with Primary dysmenorrhea and 4, 4 and 3 of 6 patients with dyspareunia at 3, 6 and 12 months post LUNA operation respectively. Pre- and post-operative scores for SF-36 questionnaire evaluating PF, physical function; BP, bodily pain; RP, role physical; SF, social function; GH, general health perception; VI, vitality; RE, role emotional; MH, mental health; MCS, mental component scale; PCS, physical component scale are given in (Fig. 1). All items were significantly improved after LUNA. In all the domains explored by the SF-36 questionnaire, a significant improvement detected compared pre to post operative at 3, 6 and 12 months The post operative improvement was maintained during the 12 months follow-up period; there were no significant differences in scores between 3, 6 and 12 months after LUNA. From Table (3A,B) The mean change in VAS scores from baseline to 3, 6 and 12 months indicates substantial patient improvement. VAS demonstrated large effect sizes (0.80). Similar patterns of patient perceived improvement were found with the SF- 36, although the magnitude of change was less than that observed with VAS. Effect sizes for the SF-36 were ranging from 0.51 to The majority of patient-perceived improvement occurred at 3 months after LUNA, with sustained improvement at 6 and 12 months. Table (4A) shows that the pain intensity by VAS was significantly lower at 3 month post LUNA compared to the Preoperative score 3.17 (95% CI 2.44, 392) versus 7.64 (7.12, 8.18), difference (-5.42,-3.52), p<0.05, after adjustment of VAS at 6 and 12 months for preoperatively score pain intensity was significantly decreased, at 6 month VAS 3.35 (95% CI2.58, 4.12), difference (-5.2,-3.33) from preoperative, p<0.05. Also at 12 month a score of 3.41 (2.6, 4.22), difference (-5.2, -3.27), p<0.05 Similarly, for quality of life (on all SF-36 subscales and both component scores, the 3, 6 and 12 -month improvement was significantly, p<0.05, more pronounced post LUNA; see Table (4B). Table (3A): Effect side of VAS at preoperative, 3, 6 and 12 months postoperatively. Preoperative Post 3 mon Effect size Post 6 mon Effect size Post 12 mon Effect size VAS 7.64± ± ± ± Values as (SD). Table (3B): Effect side of SF-36 scores at preoperative, 3, 6 and 12 months postoperatively. SF-36 Preoperative Post 3 mon Effect size Post 6 mon Effect size Post 12 mon Effect size PF 65.6± ± ± ± RP 59.7± ± ± ± BP 53.7± ± ± ± GH 58.2± ± ± ± VI 41.0± ± ± ± SF 59.3± ± ± ± RE 60.2± ± ± ± MH 51.1 ± ± ± ± PCS 45.7± ± ± ± MCS 38.7± ± ± ± Values as (SD). PF : Physical function. BP : Bodily pain. RP : Role physical. SF : Social function. GH: General health perception. VI : Vitality. RE : Role emotional. MH : Mental health. MCS: Mental component scale. PCS : Physical component scale.

6 58 The Efficacy of Laparoscopic Uterosacral Nerve Ablation Table (4A): Pain intensity for preoperative results compared to postoperative results after 3, 6 and 12 months. Pain score Preoperative Post 3 months Effect size Post 3 months A Post 6 months Post 6 months A Post 12 months Post 12 months A VAS [7.12,8.18] [2.44,3-92] [ 5.42, 3.52] * [2.58,4.12] [ 5.2, 3.33]* [2.6,4.22] [ 5.2, 3.27]* Values as ; adjusted means from ANCOVA adjusted for preoperative values. *p-value <0.05 (significant). Table (4B): Quality of Life measured with SF-36; preoperative results compared to postoperative results after 3, 6 and 12 months. SF-36 Preoperative Post 3 months Post 3 months A Post 6 months Post 6 months A Post 12 months Post 12 months A PF 65.6 [72.7,78.5] 90.5 [87.6,93.4] 24.9 [11.7,19.0]* 91.4 [89.0,93.7] 25.8 [ 10.4, 20.2]* 91.7 [89.3,94.0] 16.1 [ 10.7,22.2]* RP 59.7 [63.7,75.7] 86.8 [80.6,92.9] 27.1 [8.4,25.7]* 82.7 [76.8,88.7] 23.0 [ 8.4;17.1]* 85.1 [79.1,91.1] 15.4 [6.7,19.3]* BP 53.7 [58.2,69.2] 84.0 [78.5,89.5] 30.3 [12.5,28.2]* 81.5 [76.6,86.4] 27.8 [10.7,24.3]* 78.7 [73.7,83.7] 15.0 [8.9,23.8]* GH 58.2 [65.7,70.6] 81.4 [78.9,83.9] 23.2 [7.0,16.8]* 79.3 [76.3,82.2] 21.1 [8.1,14.3]* 79.5 [76.5,82.5] 11.3 [7.8,14.6]* VI 41.0 [44.9,51.2] 60.2 [57.1,63.3] 22.2 [7.8,16.6]* 57.9 [54.8,61.1] 19.9 [ 4.8,14.9]* 58.7 [55.4,61.9] 9.7 [5.1,14.8]* SF 59.3 [65.0,73.6] 84.3 [80.0,88.7] 25.0 [8.9,21.2]* 84.1 [80.6,87.6] 24.8 [8.2,20.9]* 83.8 [80.2,87.5] 14.5 [8.9,20.7]* RE 60.2 [63.9,76.5] 83.5 [77.2,89.9] 23.3 [4.4,22.3]* 84.1 [78.5,89.7] 23.9 [ 8.4, 16.8]* 85.9 [80.2,91.7] 15.7 [7.9,20.2]* MH 51.1 [58.1,64.0] 73.5 [67.6,73.5] 22.4 [5.3,13.7]* 72.6 [67.8,73.4] 22.1 [5.8,14.2]* 72.2 [65.6,71.4] 21.4 [4.9,13.7]* PCS 45.7 [47.5,50.6] 53.1 [51.5,54.7] 7.4 [1.9,6.3]* 52.2 [50.8,53.6] 6.5 [1.8,6.1]* 52.3 [51.0,53.7] 6.6 [1.7, 5.9]* MCS 38.7 [40.6,44.4] 47.6 [45.6,49.5] 8.9 [2.3,7.7]* 48.0 [46.3,49.7] 9.3 [2.4,7.8]* 47.7 [46.0,49.4] 9.0 [2.4,7.6]* Values as ; adjusted means from ANCOVA adjusted for preoperative values. *p-value <0.05 (significant). PF : Physical function. VI : Vitality. BP : Bodily pain. RE : Role emotional. RP : Role physical. MH : Mental health. SF : Social function. MCS: Mental component scale. GH: General health perception. PCS : Physical component scale. Discussion CPP is the bane of existence for many gynecologists: it is difficult to diagnose, and treatments are often of questionable efficacy [28]. Medical therapy is generally the initial therapy; only when this has failed do gynecologists resort to surgical intervention [29]. One approach to reducing central pelvic pain has been to surgically interrupt sympathetic nerve branches and parasympathetic fibers that pass through the uterosacral ligament (LUNA) [30]. In this study, it has found that a significant improvement in pain intensity and quality of life, at 3, 6 and 12 month follow up, have been gained from LUNA in women with central chronic pelvic pain with no pelvic pathology. In this study, assessment and the verification of pain outcomes were by two assessment methods: reduction in VAS of <_3 and mean VAS change from preoperative score. This study has demonstrated that all items of SF- 36 questionnaire on quality of life have been improved after LUNA. Unfortunately, the present study is limited to a single treatment arm with limited number of cases yet, it selected patients without endometriosis, pelvic adhesions or evident pelvic pathology as a cause for CPP. Latthe et al. [31] reported that among clinicians, there is widespread variation in the practice and use of LUNA for treatment of chronic pelvic pain. Additionally, they found wide variation in beliefs about the effectiveness of the procedure for pelvic pain, ranging from substantial benefit to slight harm. The majority of respondents stated that LUNA would benefit patients in terms of improved VAS scores, but expectations regarding the level of benefit varied widely. In a double-blind randomized, controlled trial of LUNA for women with chronic pelvic pain in the absence of endometriosis, Johnson et al. [15]. reported a significant reduction in dysmenorrhea at 12-month follow-up. The median reduction on the visual analog scale (VAS) from baseline was 4.8 points for the LUNA group versus a reduction of 0.8 points for those who did not have LUNA. A total of 42.1% of the women experienced successful treatment for dysmenorrhea, defined as a

7 Mohamed F. Selim & Ali M.A. Elnabtity 59 50% or greater reduction in VAS scores, versus 14.3% of those who did not undergo LUNA. Eldin Shawki H, reported that LUNA can be a last alternative option in well-selected patients for control of chronic pelvic pain without endometriosis; however, its effectiveness may not extend to other indications [33]. Also, preliminary experience in the treatment of primary deep dyspareunia presents a promising perspective on the management of deep dyspareunia, especially if it will involve a team of social, psychological, and gynecological specialists [33]. There was no significant difference in pain scores in women with non-menstrual pelvic pain, deep dyspareunia, or dyschezia with no endometriosis who underwent LUNA versus those who did not undergo LUNA. Vercellini et al. [14] randomized study showed that LUNA had no additional effect for improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Juang et al. [32] reported a very preliminary experience in the treatment of primary deep dyspareunia by LUNA, presenting a promising perspective yet a randomized controlled study with an adequate number of patients is warranted. Among women with chronic pelvic pain, LUNA did not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life compared with laparoscopy without pelvic denervation [34,35]. LUNA originally involves the transection of the uterosacral ligaments as close to their insertion into the cervix as possible [36] ; however, anatomical study by Fujii et al. [37] has demonstrated that the greatest numbers of nerve fiber bundles are found some distance from the site of the attachment of uterosacral ligament to the cervix. Wide variations in the practice of LUNA have been shown by comparing the UK group with the rest of Europe [32]. The latter were more likely to completely transect the uterosacral ligaments (56% vs 36%) at a distance 2 cm or more from its cervical insertion (50% vs 21%) than the UK group. Even the tools for ablation varied between these 2 groups, i.e. laser cutting (3% vs 32%), electrodiathermy (78% vs 75%), scissors cutting (22% vs 15%), and harmonic scalpel for cutting (8% vs 11%) [36]. There is widespread clinical uncertainty in the techniques, with insufficient evidence of effectiveness, thereby making it both harder to determine the optimal time, depth, and site of LUNA procedures, and the opinions regarding its use uncertain and variable. Conclusion: Laparoscopic uterosacral nerve ablation (LUNA) for good selected patients with central pelvic pain was associated with improvements in pain and quality of life. It is feasible and simple procedure but more studies with an adequate number of patients and free of endometriosis, adhesions or specific pelvic pathology are warranted to support its efficacy and safety. Disclosure statement: The author has no commercial associations that might create a conflict of interest in connection with submitted manuscripts. References 1- LATTHE P., LATTHE M., SAY L., et al.: WHO systematic review of prevalence of chronic pelvic pain: Neglected reproductive health morbidity. BMC Public Health, 6: 177, GELBAYA T.A. and EL-HALWAGY H.E.: Focus on primary care: Chronic pelvic pain in women. Obstet. Gynecol. Surv., 56: , HOWARD F.M.: Chronic Pelvic Pain. Obstet. Gynecol., 101: , ZONDERVAN K.T., YUDKIN P.L., VESSEY M.P., et al.: Prevalence and incidence of chronic pelvic pain in primary care: Evidence from a national general practice database. Br. J. Obstet. Gynaecol., 106 (11): , BORDMAN R. and JACKSON B.: Below the belt; Approach to chronic pelvic pain. Can. Fam Physician, 52: , PITTS M.K., FERRIS J.A., SMITH A.M., SHELLEY J.M. and RICHTERS J.: Prevalence and correlates of three types of pelvic pain in a nationally representative sample of Australian women. MJA, 189: , VERCELLINI P., FEDELE L., ARCAINI L., BIANCHI S., ROGNONI M.T. and CANDIANI G.B.: Laparoscopy in the diagnosis of chronic pelvic pain in adolescent women. J. Reprod. Med., 34: , PORPORA M.G. and GOMEL V.: The role of laparoscopy in the management of pelvic pain in women of reproductive age. Fertil. Steril., 68: , DOYLE J.B.: Paracervical uterine denervation by transection of the cervical plexus for the relief of dysmenorrhoea. Am. J. Obstet. Gynecol., 70: 71, DOYLE J.B. and DES ROSIERS J.J.: Paracervical uterine denervation for the relief of pelvic pain. Clinical. Obstet. Gynecol., 6: , KHAN K.S., KHAN S.F., NWOSU C.R., DWARA- KANATH L.S. and CHIEN P.F.W.: Laparoscopic uterosacral nerve ablation in chronic pelvic pain: An overview. Gynaecological Endoscopy, 8: , WILSON M.L., FARQUHAR C.M., SINCLAIR O.J. and JOHNSON N.P.: Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. (Review) (6 refs). Cochrane Database Syst Rev., CD001896, STONES R.W. and MOUNTFIELD J.: Interventions for treating chronic pelvic pain in women. [update of Cochrane

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