Effectiveness of Laparoscopy

All of the risks of laparoscopy might be acceptable if the diagnosis and treatment by laparoscopy was much more successful than medical therapy. In a landmark article, the role of laparoscopy in chronic pelvic pain was evaluated.² Less than 50% of women with chronic pelvic pain were found to be helped by diagnostic and operative laparoscopy. Both physicians and patients must recognize that laparoscopy is not the ultimate evaluation or the panacea for chronic pelvic pain. In fact, about 40% of women with chronic pelvic pain had no apparent pathology laparoscopically.²

Treatment for Negative Laparoscopies

It is important that women with chronic pelvic pain and negative laparoscopies are provided an opportunity for treatment with GnRH agonist because endometriosis is the most likely diagnosis missed in such patients, if their disorder is gynecologic. It is also critical that patients are completely evaluated by psychological, gastrointestinal, urological, gynecological, myofascial and musculoskeletal exams to avoid the risk that they may undergo an unnecessary procedure.

Pelvic Pain in Adolescents

Extensive surgical therapy for the management of pelvic pain in adolescents resulted in improvement in 76% over a follow-up of 1 to 58 months.³³ Pelvic pathology was present in 86%. Endometriosis was treated in 47% and adhesions in 13% of patients in this 1980 report.

Pelvic Adhesions

Treatment of pelvic adhesions by laparoscopy was effective in relieving symptoms in patients with chronic pelvic pain. Cure or improvement was reported by 65% of patients whose chief complaint was chronic abdominal pain, and by 47% of those whose chief complaint was dysmenorrhea.³⁴

In a similar study, 40% of patients with chronic pelvic pain or dysparunia reported continued improvement or resolution of pain during daily activities, and of those without chronic pain syndrome, 75% were better.³⁵ Another study reported that 55 of 65 patients (84%) with chronic lower abdominal pain who underwent laser laparoscopic adhesiolysis experienced symptomatic relief.³⁶ In women with previous abdominal operations with significant pain, enterolysis and adhesiolysis resulted in improvement in 67%.³⁷ Of 35 patients undergoing adhesiolysis for chronic abdominal pain, 18 were asymptomatic and 10 had their symptoms lessened.³⁸ In a prospective study of 58 patients treated for abdominal pain with adhesiolysis, 45% had complete remission of symptoms, 35% had substantial improvement, and 20% had persistence of the complaint.³⁹

However, the role of adhesions in chronic pelvic pain has been questioned. A retrospective study comparing asymptomatic infertile patients with women who had chronic pelvic pain did not reveal a significant difference in the density or location of adhesions.⁴⁰ A randomized clinical trial on the benefits of adhesiolysis by laparotomy showed no benefit in patients with light or moderate pelvic adhesions. Patients with severe adhesions involving the intestinal tract benefited from this procedure.⁴¹

Role of Laparoscopy for Endometriosis

When pain is persistent, a thorough examination is required and all potential causes of pain should be investigated.⁴² However, endometriosis is often the sole finding in women with incapacitating pelvic pain.⁴³ A review of the role of laparoscopic surgery in the treatment of endometriosis concluded that laser laparoscopic cyto-reduction of ectopic endometrial implants offers a reasonable degree of pain relief in mild, minimal, and moderate disease.⁴⁴

Twelve percent of patients who suffered from recurrent disease required repeat laparoscopic surgery. The recurrences arose de novo and rarely occurred at previously treated sites unless the surgeon failed to remove deeply infiltrating disease completely in the uterosacral ligaments or the rectovaginal septum.⁴⁵ These implants can infiltrate up to 15 mm in depth.⁴⁶

Complete surgical eradication of the disease resulted in pain relief in 81% of patients whose pain was due to endometriosis.⁴⁷ However, 19% experienced recurrence of new disease in 5 years.

Ovarian endometriomas are a source of severe chronic pain44 and their removal by stripping techniques or laser photovaporization of the capsule provides gratifying results in terms of relief.⁴⁸

Laparoscopic Uterosacral Nerve Ablation for Pain

The uterosacral ligaments carry many of the afferent sensory nerve fibers to the lower parts of the uterus by way of the Lee-Frankenhauer plexus, which lies in and around the uterosacral ligaments as they insert into the posterior aspect of the cervix. The division of these ligaments relieved pain in patients enrolled not only in retrospective studies^49,50 but also in patients in a randomized prospective study.⁵¹

The efficacy of laparoscopic laser uterine nerve ablation (LUNA) for dysmenorrhea was demonstrated in an initial series of 14 women with dysmenorrhea and menorrhagia who had the procedure combined with transcervical resection of the endometrium. At 16- to 18-month follow-up, 93% of patients reported light or absent menses and improvement or absence of pain.52 Laparoscopic laser treatment of endometriosis with the Nd:YAG sapphire probe combined with LUNA was also effective in reducing or eliminating pain in 80% of patients.⁵³

Conservative resection of the uterosacral nerves was carried out in 15 women with a history of endometriosis and recurrent pelvic pain, whether or not involvement of the ligaments was suspected; 80% of the patients also underwent presacral neurectomy. Histologic evaluation disclosed involvement of endometriosis in the uterosacral nerves in 54% of patients. Dysmenorrhea was relieved in 80% of patients, but in the subset who had histologic endometriosis of the uterosacral ligaments, all had relief of symptoms.⁵⁴ Finally, destruction of endometriosis by electrocoagulation was effective in the management of chronic pelvic pain.⁵⁵

Stage of Endometriosis and Level of Pain Report

The stage and location of endometriosis are not associated with the frequency and severity of dysmenorrhea, pelvic pain, and dysparunia.⁵⁶ However, the total number of ectopic endometrial implants is associated directly with the intensity of dysmenorrhea experienced by patients. Patients with lower pain (dysmenorrhea) scores had significantly fewer implants than those with high scores.⁵⁷ A 5-year prospective study used treatment with GnRH agonists only for patients with pelvic pain and laparoscopically confirmed endometriosis. At the end of 5 years, 74.4% of women with minimal disease were symptom-free, compared with 33.3% of those with severe disease. Overall, 47% of patients had no symptoms 5 years after a 6-month course of GnRH agonist.³⁰

Role of Presacral Neurectomy

For patients with severe disabling central dysmenorrhea, presacral neurectomy was effective in a well-controlled prospective study.⁵⁸ The effectiveness of laparoscopic presacral neurectomy in relieving pain has been demonstrated,^59,60 including when the pain is due to endometriosis.61 However, an evaluation was undertaken of preoperative and postoperative pain assessments by patients who underwent laparoscopic ablation or excision of endometriosis, 76 of whom also underwent presacral neurectomy.⁶² Although significant improvement (by Wilcoxon Signed Rank Test) over preoperative pain levels was found in both groups, degrees of pain relief were comparable.⁶² In fact, presacral neurectomy was associated with a significant improvement in both dysmenorrhea and dysparunia over other procedures.⁶³ In this study the procedure was performed only for women with severe dysmenorrhea or dysparunia. Uterosacral nerves were also resected in all of these patients.

Success rates of 73% in relieving dysmenorrhea, 77% in relieving dysparunia, and 63% in relieving other pelvic pains were achieved by presacral neurectomy in 50 patients treated for chronic pelvic pain after failing to respond to oral contraceptives and nonsteroidal anti-inflammatory medications.⁶⁴ Uterosacral ligament resection did not increase the success rate over presacral neurectomy alone. A 70% mean reduction in chronic cancer related pelvic pain was achieved with neurolytic blockade of the superior hypogastric nerve plexus, confirming a role for presacral neurectomy in the treatment of pelvic pain.⁶⁵

Role of Hysterectomy

Hysterectomy with bilateral oophorectomy was effective in women who failed to obtain long-term relief of pain with oral contraceptives and nonsteroidal anti-inflammatory medications. These women were diagnosed with pelvic congestion syndrome, although pathology revealed that 25% had adenomyosis.⁶⁶ Of 99 women who underwent hysterectomy for chronic pelvic pain of at least 6 month’s duration, and whose disease by symptoms and examination was confined to the uterus, 77.8% had significant improvement and 22.2% had persistent pain.⁶⁷

Role of Appendectomy

Appendicopathy does exist and can be the cause of chronic lower abdominal pain. In five recent reports^11,21-24 appendectomy resulted in relief of symptoms of right lower quadrant pain in selected patients. In addition there does not appear to be a correlation between visible pathology, histopathology and complaints of pain relieved by appendectomy.

Pelvic Pain Therapy

After laparoscopic evaluation and treatment in a series of 65 women with chronic pelvic pain, 78% of patients had decreased pain and 45% were pain free.⁶⁸ Endometriosis was present in 38% and adhesions in 34% of these women. Neither uterosacral nerve ablation nor presacral neurectomy was performed in this group. No hernias were reported.

With application of all currently available laparoscopic modalities, 80% of women with chronic pelvic pain reported a decrease of pain to below 5 on a linear scale.¹¹ This significant reduction in pain was achieved and maintained for up to 3 years. Seventy-three percent of these patients had endometriosis as their primary diagnosis.

Individual factors contributing to pain cannot be determined, although the frequency of endometriosis dictates that its complete treatment be attempted. The beneficial effect of uterosacral nerve ablation may be as much due to treatment of occult endometriosis in the uterosacral ligaments as to transection of the nerve fibers themselves. The benefit of the presacral neurectomy appears to be definite but strictly limited to midline pain. Appendectomy, herniorraphy, and even hysterectomy are all appropriate therapies for selected patients with chronic pelvic pain.

Even with all laparoscopic procedures employed, fully 30% of patients experience unsatisfactory results. A diagnostic-therapeutic trial of GnRH agonist prior to laparoscopic intervention in women with clinically diagnosed pelvic pain related to endometriosis is cost effective and efficacious.

Psychology vs Pathology

Patients with chronic pelvic pain are often depressed.⁶⁹ Whether the pain contributes to the depression or the depression to the pain is irrelevant to them. Selected referrals to an integrated pain center with psychological assistance together with judicious prescription of antidepressant drugs will likely benefit both women who respond to medical or surgical intervention and those who do not.

Women in whom a thorough exclusion work-up, including laparoscopy, does not disclose a likely etiology of pain, who have a history of major psychosexual trauma, or who have a history of consultation and therapy for several unrelated somatic symptoms, should be referred for skilled psychologic evaluation and therapy.⁷⁰ Chronic pelvic pain does not constitute a single well-defined category of symptoms and findings. An integrated approach that devotes attention to somatic, psychologic, dietary, emotional, and physiotherapeutic factors will likely show improvement over simply surgical or medical intervention.⁷¹ In that study however, no abnormalities were found in the laparoscopies of 65% of the patients in the surgical treatment arm, and in only four of these was endometriosis diagnosed. This multidisciplinary approach resulted in significant symptomatic improvement in approximately 75% of the patients with a mean duration of follow-up of 1.6 years.⁷²

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