We have not had any major complications, but the slight risk of vascular injury and the possible need to convert to laparotomy is something that patients should be informed of.
Long-term complications with presacral neurectomy are uncommon. Urinary urgency, poor bladder emptying, and constipation have been reported occasionally, as has vaginal dryness during sexual arousal.
We have not had any major complications such as vascular injury, gastrointestinal injury, or genitourinary injury in any of our presacral neurectomy procedures. Nor did any of these cases require conversion to laparotomy or transfusion.
Our initial (1992) study revealed no major intraoperative or immediate postoperative complications.
However, of the 52 women followed after 1 year, seven women reported either constipation (three patients), urinary urgency (one), vaginal dryness (one), or “painless labor” (two). These are all among the issues that we routinely cover in our patient counseling.
In conclusion, procedural failure, of course, is an important long-term complication, but the most common reasons for failure—poor patient selection and incomplete neurectomy because of neurologic variability or failure to remove all nerve tissue within the interiliac triangle—can, in most cases, be avoided with proper training and preparation.
Within the Triangle of Cotte, the common iliac artery is on the right; the common iliac vein is on the left. Courtesy Dr. Ceana Nezhat
The presacral tissue is identified, and the nerve plexus is grasped with an atraumatic forceps.
All the nerve fibers that lie within the boundaries of the interiliac triangle have been removed.
Presacral space on second look: The area heals completely on follow-up. Photos courtesy Dr. Ceana Nezhat
Presacral Neurectomy
In previous Master Class articles, we have explored the diagnosis and work-up of chronic pelvic pain (OB.GYN. NEWS, Feb. 1, 2007, p. 28; April 1, 2007, p. 25). Moreover, we presented an excellent technique in surgical extirpation of endometriosis (OB.GYN. NEWS, April 1, 2007, p. 38).
Despite a thorough evaluation and medical and surgical treatment, midline pelvic pain, dysmenorrhea, and/or dyspareunia may persist. Not only can this be caused by conditions such as primary dysmenorrhea or adenomyosis, but it may persist despite adequate surgical treatment of endometriosis and pelvic adhesions.
When midline pelvic pain, dysmenorrhea, and/or dyspareunia are not alleviated with treatment, ancillary surgical procedures should be considered. Unfortunately, the most commonly performed procedure—transection of the uterosacral nerves—has proved to be ineffective over time.
On the other hand, if performed by a skilled surgeon who understands the anatomy below the bifurcation of the aorta at the level of the sacral promontory, presacral neurectomy has proved quite effective long term.
I once performed this technique via laparotomy, but for nearly 20 years now I have used a purely laparoscopic technique. With the same indications, I have noted similar results to those explained here by Dr. Ceana Nezhat, the invited author of this Master Class article.
Dr. Ceana Nezhat is in private practice in Atlanta and is one of three brothers who are extraordinary gynecologic laparoscopic surgeons. Dr. Camran Nezhat, of Stanford (Calif.) University, has been an innovator in the laparoscopic treatment of endometriosis for a quarter of a century. Dr. Farr Nezhat, who is a gynecologist at Mount Sinai School of Medicine, New York, has been a leader in the use of laparoscopy to perform gynecologic oncology procedures. Dr. Ceana Nezhat is known not only for his laparoscopic treatment of endometriosis, but also for pelvic floor reconstruction. He is a prolific author and an international lecturer, and it is with great admiration that we bring you Dr. Ceana Nezhat, discussing the laparoscopic approach to presacral neurectomy.