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Presacral neurectomy
Presacral neurectomy WARREN M. JACOBS, M.D. J. STANLEY CONNER, M.D. STANLEY F. ROGERS, M.D. Houston, Texas
I N 1 9 2 5 , Cotte 1 reported 300 cases in which presacral neurectomy was done for primary dysmenorrhea; obviously, his indications were very broad. The indications for the operation in the United States have been fairly rigid. Our attitude has been conservative regarding its use for primary dysmenorrhea, but rather liberal as an adjunctive procedure in conservative operations for endometriosis. Since the value of this procedure is not universally accepted, we felt that a review of the postoperative results in a significant number of cases would be in order.
12 years, while in those with secondary infertility the duration was from 2 to 10 years. Table I presents the postoperative diagnosis correlated with preoperative symptomatology. Table II presents the surgical procedures performed in addition to the neurectomy (most patients had more than one additional procedure). It should be noted that histologic confirmation of removed nerve tissue was obtained in all cases. Results
All of these patients were followed for a minimum of one year to a maximum of 8 years. If presacral sympathectomy is done because of pelvic pain, its value is ascertained by relief of pain. Since most patients had one or more additional procedures (suspension, resection of implants, etc.) in addition to the neurectomy, it is difficult to know which is most responsible for relief of symptoms. Endometriosis. There were 54 patients with endometriosis, all of whom complained of various combinations of dysmenorrhea. dyspareunia, and generalized pelvic pain. Of this group, 50 patients experienced complete or almost complete relief of pain while 4 experienced only partial relief. Of special interest in this group are the 40 patients complaining of infertility ranging in duration from 2 to 12 years. All had adequate infertility studies prior to operation. Twentyseven of these conceived within the first year following operation and 6 of these have had additional pregnancies at this writing. Pelvic congestion syndrome. There were
Materials
One hundred and two presacral neurectomies, either primary or in connection with other conservative pelvic procedures, comprise this report. These were performed at Methodist Hospital, Houston, Texas, over a 7 year period ( 1954 through 1960). During the same period, there were 7,969 gynecologic admissions. Indications for operation
The indications for the operation were various types of pelvic pain (dysmenorrhea, dyspareunia, backache, etc.). Forty-eight patients also complained of infertility; 38 patients had never been pregnant, and 10 were experiencing secondary infertility. The duration of infertility in the 38 patients who had never been pregnant ranged from 3 to From the Department of Obstetrics and Gynecology, Baylor University College of Medicine and The Methodist Hospital.
437
I .1, I~Jt)')
F~bruaq
438 Jacobs, Conner, and Rogers
\m.
J. ObsL
,~
(;yne.-
Table I Symptoms
Diagnosis
No
Dysmenorrhea Lower abdominal pain Deep dyspareunia Infertility
Endometriosis
Pelvic congestion syndrome with retroverted uterus
25
Dysmenorrhea Lower abdominal pain Dyspareunia Infertility
6
Dysmenorrhea Lower abdominal pain Dyspareunia Infertility
Pelvic inflammatory disease
Dysmenorrhea Lower abdominal pain Dyspareunia Infertility
Postoperative adhesions
13
Primary dysmenorrhea
Dysmenorrhea Lower abdominal pain
1\
,, (l
*Most patients had multiplicity of complaints.
Table II. Additional surgical procedures Uterine suspension Dilatation and curettage Incidental appendectomy Excision of endometrial implants Lysis of adhesions Unilateral salpingo-oophorectomy Conization of cervix
67 37 51 54 12 11 4
25 patients with all the symptoms and pelvic findings of the congestion syndrome. All 25 complained of generalized pelvic pain and dyspareunia but not dysmenorrhea. None of them were infertile. These 25 had a uterine suspension in addition to the neurectomy. All these patients experienced complete relief of symptoms. Pelvic inflammatory disease. Six patients were found to have varying degrees of pelvic inflammatory disease. The preoperative diagnosis had been pelvic congestion. Two patients had uterine suspension, lysis of all adhesions, and presacral sympathectomy, while the other 4 had unilateral salpingooophorectomy in addition to the aforementioned procedures. AU 6 experienced complete relief of symptoms. All complained
of infertility but only 2 have become pregnant. Primary dysmenorrhea. There were 13 cases of primary dysmenorrhea. All 13 experienced relief of the symptoms following presacral neurectomy. It is felt that this type of case can usually be handled by less drastic means. Subsequent labor and delivery. Twentynine patients complaining of infertility became pregnant, 6 have had additional pregnancies; therefore, there was a total of 35 pregnancies. All of these were delivered from one to 3 weeks prior to term and it was noted by the various physicians that the cervices of these patients were partially dilated and effaced many weeks prior to the onset of labor. Labor records indicate rapid, smooth, uneventful labors with particular emphasis given to the fact that the first stage of labor was almost pain free in all cases. Comment
From this review of cases, it would seem that our opinion regarding presacral neurectomy should be stated in this way: It
Volume 85 Number 4
should be done as an integral part of any conservative operation performed upon young women in whom pelvic pain is a prominent feature, particularly if such pain is referred to the general area of the uterus. In our opinion, the most common indication for presacral neurectomy would be as part of a conservative operation for endometriosis.
Although relief of primary dysmenorrhea is marked after presacral sympathectomy, this symptom can usually be handled by less drastic means. From this series of cases, we cannot
Presacral neurectomy
439
ascribe any complications to the procedure itself, although troublesome bleeding is not infrequent. Needless to say, great care should be taken to expose and identify both ureters. Labor and delivery are uneventful and lack of pain, particularly in the first stage, is prominent. Because of this phenomenon plus the tendency of labor to begin early, frequent pelvic examinations in the last trimester are in order.
REFERENCE
l. Cotte, Gaston: Presse med. 33: 98, 1925.
I N 1 9 2 5 , Cotte 1 reported 300 cases in which presacral neurectomy was done for primary dysmenorrhea; obviously, his indications were very broad. The indications for the operation in the United States have been fairly rigid. Our attitude has been conservative regarding its use for primary dysmenorrhea, but rather liberal as an adjunctive procedure in conservative operations for endometriosis. Since the value of this procedure is not universally accepted, we felt that a review of the postoperative results in a significant number of cases would be in order.
12 years, while in those with secondary infertility the duration was from 2 to 10 years. Table I presents the postoperative diagnosis correlated with preoperative symptomatology. Table II presents the surgical procedures performed in addition to the neurectomy (most patients had more than one additional procedure). It should be noted that histologic confirmation of removed nerve tissue was obtained in all cases. Results
All of these patients were followed for a minimum of one year to a maximum of 8 years. If presacral sympathectomy is done because of pelvic pain, its value is ascertained by relief of pain. Since most patients had one or more additional procedures (suspension, resection of implants, etc.) in addition to the neurectomy, it is difficult to know which is most responsible for relief of symptoms. Endometriosis. There were 54 patients with endometriosis, all of whom complained of various combinations of dysmenorrhea. dyspareunia, and generalized pelvic pain. Of this group, 50 patients experienced complete or almost complete relief of pain while 4 experienced only partial relief. Of special interest in this group are the 40 patients complaining of infertility ranging in duration from 2 to 12 years. All had adequate infertility studies prior to operation. Twentyseven of these conceived within the first year following operation and 6 of these have had additional pregnancies at this writing. Pelvic congestion syndrome. There were
Materials
One hundred and two presacral neurectomies, either primary or in connection with other conservative pelvic procedures, comprise this report. These were performed at Methodist Hospital, Houston, Texas, over a 7 year period ( 1954 through 1960). During the same period, there were 7,969 gynecologic admissions. Indications for operation
The indications for the operation were various types of pelvic pain (dysmenorrhea, dyspareunia, backache, etc.). Forty-eight patients also complained of infertility; 38 patients had never been pregnant, and 10 were experiencing secondary infertility. The duration of infertility in the 38 patients who had never been pregnant ranged from 3 to From the Department of Obstetrics and Gynecology, Baylor University College of Medicine and The Methodist Hospital.
437
I .1, I~Jt)')
F~bruaq
438 Jacobs, Conner, and Rogers
\m.
J. ObsL
,~
(;yne.-
Table I Symptoms
Diagnosis
No
Dysmenorrhea Lower abdominal pain Deep dyspareunia Infertility
Endometriosis
Pelvic congestion syndrome with retroverted uterus
25
Dysmenorrhea Lower abdominal pain Dyspareunia Infertility
6
Dysmenorrhea Lower abdominal pain Dyspareunia Infertility
Pelvic inflammatory disease
Dysmenorrhea Lower abdominal pain Dyspareunia Infertility
Postoperative adhesions
13
Primary dysmenorrhea
Dysmenorrhea Lower abdominal pain
1\
,, (l
*Most patients had multiplicity of complaints.
Table II. Additional surgical procedures Uterine suspension Dilatation and curettage Incidental appendectomy Excision of endometrial implants Lysis of adhesions Unilateral salpingo-oophorectomy Conization of cervix
67 37 51 54 12 11 4
25 patients with all the symptoms and pelvic findings of the congestion syndrome. All 25 complained of generalized pelvic pain and dyspareunia but not dysmenorrhea. None of them were infertile. These 25 had a uterine suspension in addition to the neurectomy. All these patients experienced complete relief of symptoms. Pelvic inflammatory disease. Six patients were found to have varying degrees of pelvic inflammatory disease. The preoperative diagnosis had been pelvic congestion. Two patients had uterine suspension, lysis of all adhesions, and presacral sympathectomy, while the other 4 had unilateral salpingooophorectomy in addition to the aforementioned procedures. AU 6 experienced complete relief of symptoms. All complained
of infertility but only 2 have become pregnant. Primary dysmenorrhea. There were 13 cases of primary dysmenorrhea. All 13 experienced relief of the symptoms following presacral neurectomy. It is felt that this type of case can usually be handled by less drastic means. Subsequent labor and delivery. Twentynine patients complaining of infertility became pregnant, 6 have had additional pregnancies; therefore, there was a total of 35 pregnancies. All of these were delivered from one to 3 weeks prior to term and it was noted by the various physicians that the cervices of these patients were partially dilated and effaced many weeks prior to the onset of labor. Labor records indicate rapid, smooth, uneventful labors with particular emphasis given to the fact that the first stage of labor was almost pain free in all cases. Comment
From this review of cases, it would seem that our opinion regarding presacral neurectomy should be stated in this way: It
Volume 85 Number 4
should be done as an integral part of any conservative operation performed upon young women in whom pelvic pain is a prominent feature, particularly if such pain is referred to the general area of the uterus. In our opinion, the most common indication for presacral neurectomy would be as part of a conservative operation for endometriosis.
Although relief of primary dysmenorrhea is marked after presacral sympathectomy, this symptom can usually be handled by less drastic means. From this series of cases, we cannot
Presacral neurectomy
439
ascribe any complications to the procedure itself, although troublesome bleeding is not infrequent. Needless to say, great care should be taken to expose and identify both ureters. Labor and delivery are uneventful and lack of pain, particularly in the first stage, is prominent. Because of this phenomenon plus the tendency of labor to begin early, frequent pelvic examinations in the last trimester are in order.
REFERENCE
l. Cotte, Gaston: Presse med. 33: 98, 1925.