Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea

 

Abstract

Background

Dysmenorrhoea is the occurrence of painful menstrual cramps of uterine origin and is a very common gynaecological complaint with negative effect on a sufferer's quality of life. Medical therapy for dysmenorrhoea includes oral contraceptive pills (OCP) and nonsteroidal anti-inflammatory drugs (NSAIDs) which both act by suppressing prostaglandin levels. While these treatments are very successful there is still a 20 to 25% failure rate and surgery has been an option for such cases. Uterine nerve ablation (UNA) and presacral neurectomy (PSN) are two surgical treatments that have become increasingly utilised in recent years due to advances in laparoscopic procedures. These procedures both interrupt the majority of the cervical sensory pain nerve fibres. Observational studies have supported the use of these procedures for primary dysmenorrhoea. However, both operations only partially interrupt the cervical sensory nerve fibres in the pelvic area and, therefore, this type of surgery may not always benefit women with dysmenorrhoea.

Objectives

To assess the effectiveness of surgical interruption of pelvic nerve pathways as treatment for primary and secondary dysmenorrhoea, and to determine the most effective surgical treatment.

Search methods

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 9 June 2004), CENTRAL (The Cochrane Library Issue 2, 2004), MEDLINE (1966 to Nov 2003), EMBASE (1980 to Nov 2003), and CINAHL (1982 to Oct 2003). Attempts were also made to identify trials from the metaRegister of Controlled Trials and the citation lists of review articles and included trials. In most cases the first or corresponding author of each included trial was contacted for additional information.

Selection criteria

The inclusion criteria were randomised comparisons of surgical techniques of interruption of the pelvic nerve pathways (using both open and laparoscopic procedures) for the treatment of primary and secondary dysmenorrhoea. The main outcome measures were pain relief and adverse effects.

Data collection and analysis

Eleven randomised controlled trials (RCTs) were identified that initially appeared to fulfil the inclusion criteria for this review. Two trials were subsequently excluded (Garcia Leon 2003; Sutton 1991). Of the remaining nine trials, eight were included in the meta-analysis. The results of one trial were included in the text of the review for discussion because the data were not available in a form that allowed them to be combined in the meta-analysis. Five trials investigated laparoscopic uterine nerve ablation (LUNA), two trials laparoscopic presacral neurectomy (LPSN) and two open presacral neurectomy (PSN).

Main results

For the treatment of primary dysmenorrhoea there was some evidence of the effectiveness of laparoscopic uterine nerve ablation (LUNA) when compared to a control or no treatment. The comparison between LUNA and laparoscopic presacral neurectomy (LPSN) for primary dysmenorrhoea showed no significant difference in pain relief in the short term; however, long-term LPSN was shown to be significantly more effective than LUNA. For the treatment of secondary dysmenorrhoea six identified RCTs addressed endometriosis and one included women with uterine myomas. The treatment of LUNA combined with surgical treatment of endometrial implants versus surgical treatment of endometriosis alone showed that the addition of LUNA did not aid pain relief. For PSN combined with endometriosis treatment versus endometriosis treatment alone there was an overall difference in pain relief although the data suggests this may be specific to laparoscopy and for midline abdominal pain only. Adverse events were significantly more common for presacral neurectomy; however, the majority were complications such as constipation, which may spontaneously improve.

Authors' conclusions

There is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhoea, regardless of cause. Future methodologically sound and sufficiently powered RCTs should be undertaken.

 

Plain language summary

Not enough evidence to support the use of surgical nerve interruption for dysmenorrhoea

Dysmenorrhoea (painful menstrual cramps) is a common problem. The contraceptive pill and anti-inflammatory drugs (NSAIDs) are effective treatments in 80% of women with dysmenorrhoea but for others surgery is a considered option. Uterine nerve ablation (UNA) and presacral neurectomy (PSN) both involve surgical interruption of the sensory nerve fibres near the cervix to block the pain pathway. The review of trials found there was only limited evidence to support the use of surgery for primary dysmenorrhoea and little evidence for its use in women with endometriosis. No adverse effects were found with UNA but PSN was found to cause treatable constipation. More research is needed.

 

摘要

背景

為了原發性與續發性經痛而對骨盆的神經系統進行手術阻斷

經痛是經期時子宮痙攣所引起的疼痛，是婦科中非常普遍的症狀，會對於發病者的生活品質產生負面的影響。針對經痛所用的醫學治療方法，包括了口服的避孕藥(OCP)以及非類固醇類的抗發炎藥物(NSAIDs))，而這二種藥物都可以發揮抑制前列腺素濃度的作用。目前這些治療方法都已經非常成功，但是仍然有20% 到25% 的失敗比率，對於這病例外科手術是另一治療的選擇。由於腹腔手術的進步，子宮神經的燒除及骨叢神經的切除術在近幾年已廣泛被使用。 這兩種手術皆可阻斷子宮頸大部分的疼痛感覺神經纖維。 對於原發性的經痛而言，觀察型的研究支持使用這些手術。然而，這二種手術都只能夠部分阻斷骨盆腔中子宮頸感覺神經纖維，因此，對於受經痛所苦的婦女們而言，這種類型的手術不是一定都有益處。

目標

評估以手術阻斷骨盆腔神經路徑以治療原發性及次發性經痛的效果，並決定最有效的手術治療方式。

搜尋策略

我們搜尋 Cochrane Menstrual Disorders以及Subfertility Group Trials Register (searched 9 2004年6月)、CENTRAL (Cochrane Library Issue 2, 2004)、MEDLINE (1966年2003年11月)、EMBASE (1980年2003年11月)、以及CINAHL (1982 年2003年10月)。 並試著透過metaRegister of Controlled Trials、回顧文章及所納入之試驗的參考文獻清單以找出相關試驗。並聯絡多數被納入的試驗第一或是通訊作者以獲得補充資訊。

選擇標準

納入的標準是隨機比較以外科技術阻斷骨盆腔神經路徑(包含開放式與腹腔鏡手術)以治療原發性與次發性經痛。主要的結果測量方式為疼痛紓解與副作用。

資料收集與分析

十一個隨機對照試驗(RCTs)，初步被認定符合本篇回顧所要求的收集標準。有二個試驗(Garcia Leo 003；Sutton 1991)後來被排除在外。在剩下的9個試驗當中，有8個被納入了統合分析裡面。有一個試驗的結果，被收集在本篇回顧的文章內容之中以用於討論事項，因為這些資料的格式無法被併入到統合分析當中。有5個試驗曾經探討了腹腔鏡的子宮神經切除術(LUNA)，有二個試驗探討了腹腔鏡的骨叢神經切除術(LPSN)，另外還有二個試驗探討了開放式的骨叢神經切除術(PSN)。

主要結論

針對原發性經痛的治療方式而言，若是跟某個對照組或是不採取治療比較起來，有些證據顯示腹腔鏡的子宮神經切除術(LUNA)是有效的。針對原發性經痛的治療方式而言，腹腔鏡的子宮神經切除術與腹腔鏡的骨叢神經切除術(LPSN)，比較的結果顯示，它們在短期間內對於紓解疼痛方面並沒有什麼顯著的差異；然而就長期結果而言，腹腔鏡的骨叢神經切除術比腹腔鏡的子宮神經切除術更有效。針對續發性經痛的治療方法而言，共有六個隨機對照試驗提到了子宮內膜異位症，及一個包含了患有子宮肌瘤的婦女們。若是跟單獨使用子宮內膜異位症的手術治療方法比較起來，腹腔鏡的子宮神經切除術合併子宮內膜植入片的手術治療結果顯示額外加了腹腔鏡的子宮神經切除術時，並不會增加紓解疼痛的功能。就整體的疼痛緩解而言，若骨叢神經切除術合併子宮內膜異位症的治療與單獨使用子宮內膜異位症的治療比較起來有差異，雖然說資料顯示這些差異可能源自於腹腔鏡術及腹部中線的疼痛。針對骨叢神經切除術而言，不良事件很明顯地變得更多了；然而，大部分的併發症如便秘，可能會自動地獲得改善。

作者結論

沒有足夠的證據建議使用神經阻斷來治療任何原因的經痛。未來，應該要採取方法上更為完備、又具備足夠檢力的隨機對照試驗。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有足夠的證據支持使用外科神經阻斷術來治療經痛。經痛(劇痛的月經性痙攣)是一種常見的問題。對於患有經痛的婦女們而言， 0% 對避孕藥與抗發炎藥物(非類固醇類的抗發炎藥物)的治療有效，但是其他人，的考慮選擇為手術治療。子宮神經切除術(UNA)與骨叢神經切除術(PNA)這二種方法，都是以外科方式阻斷子宮頸附近的感覺神經纖維以阻斷疼痛的傳導路徑。本篇試驗的回顧發現，若是要對原發性經痛使用手術的話，只能找到有限的證據能夠加以支持，而且若是要找到使用在患有子宮內膜異位症婦女們身上的情況，就只有非常少的證據提到過這樣的對象。使用子宮神經切除術的時候，並沒有發現到任何的副作用，但是使用骨叢神經切除術的時候，可能造成可治療的便秘現象。還需要有更多的研究。