Presacral neurectomy (PSN)
Written by Patrick Yeung Jr. MD
Director, Saint Louis University Center for Endometriosis
There are only 3 randomized controlled trials that address the effectiveness of PSN in addition to conservative surgical treatment of endometriosis (Tjaden et al 1990, Candiani et al 1992, Zullo et al 2003). The first two studies were done by laparotomy, and the last was done laparoscopically. All three studies found that the addition of PSN to the surgical treatment of endometriosis by significantly enhanced pain relief for midline pain.
Regarding Zullo et al 2003, in particular, cure rate was defined as no dysmenorrhea or dysmenorrhea that did not require medical treatment. Cure rates were significantly higher in the group that received PSN up to twelve months (85.7% vs. 57.1%). These results were maintained at 24 months (83.3% vs 53.3%) in a subsequent study
Adverse side effects of PSN may be intraoperative or postoperative. There were no major
intraoperative complications in any of the randomized trials mentioned above. The most
common postoperative complications noted in the studies above were constipation and urinary urgency in the patients receiving PSN; these complications did not occur in those patients receiving conservative surgery alone. Constipation was reported to develop or worsen in 14.3% - 34.2% of patients within a twelve month period. In 71.4% of cases in the Zullo study, constipation was treated successfully with medical therapies. Urinary urgency was reported to occur in 4.8%5 - 7.8%4 of patients.
In summary, careful selection of patients and informed consent are crucial in the performance of PSN as an adjunct to conservative surgery for endometriosis. Palombo et al (2006)7 recommend “that the pivotal characteristics of the pelvic pain that is to be treated by PSN should be severity, duration (>6 months), poor response to medical treatment, the presence of a midline component, and attribution to endometriosis”. Indeed, the American College of Obstetricians & Gynecologists (ACOG), in its Practice Bulletin (2004) states, “presacral neurectomy may be considered for treatment of centrally located dysmenorrhea”.
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