A double-blind randomised controlled trial of laparoscopic uterine nerve ablation for women with chronic pelvic pain

Patient-Reported Outcome Measures Used in Randomized Controlled Trials Following Surgical Intervention for Endometriosis: A Structured Review from the AAGL Practice Guidelines Group

OBJECTIVE

No consensus currently exists regarding patient-reported outcome measure (PROM) instruments. This structured review was conducted to identify the PROMs used by randomized controlled trials (RCTs) that evaluated surgical treatment in patients with endometriosis.

DATA SOURCES

Two parallel searches were conducted by a medical librarian using Ovid MEDLINE, Ovid Embase, and Cochrane Library for RCTs published from 2000 to July 2022. One search focused on studies reporting quality of life (QoL), and the second search focused on studies reporting pain and sexual, bowel, and bladder function.

METHOD OF STUDY SELECTION

During the title and abstract screening and reference check, 600 results were identified on PROMs relating to QoL and 465 studies on PROMs relating to pain and sexual, bowel, and/or bladder function and an evaluation of 17 and 12 studies conducted, respectively. The inclusion criteria involved selecting RCTs that focused on surgical intervention and assessing QoL, pain, and sexual, bowel, and/or bladder function using PROMs.

TABULATION, INTEGRATION, AND RESULTS

Covidence software was used to organize and identify duplicate articles through screening. We developed a data extraction form to collect key information about each included study, as well as the pertinent PROMs used in the study. Assessment of the risk of bias of each study was also performed. A total of 19 studies were identified involving 2089 participants and a total of 16 PROMs used across the studies; 9 of 19 studies (47%) were rated as having a low risk of bias. There were no high-risk studies identified in this review.

CONCLUSION

This study identified a large number of RCTs in surgical treatment of endometriosis that used various PROMs to assess QoL, pain, and bladder, bowel, and sexual function. The PROMs used by high-quality RCTs for QoL include Endometriosis Health Profile-30, Endometriosis Health Profile-5, Short-Form 36, Short-Form 12, and EQ-5D; for bowel-related symptoms Knowles-Eccersley-Scott-Symptom Questionnaire, Gastrointestinal Quality of Life Index, and Cleveland Clinic Fecal Incontinence Severity Scoring System/Wexner; for bladder-related function Bristol Female Lower Urinary Tract Symptoms, International Prostate Symptom Score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, and Urinary Symptom Profile; and finally for sexual function Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and Sexual Activity Questionnaire. Unlike other domains, only one tool (visual analog scale) was the dominant PROM used for the assessment of pain. In addition, the use of more than one PROM in each study to assess different aspects of patient's health and pain symptoms did not become prevalent until after 2015.

Surgical interventions for the management of chronic pelvic pain in women

BACKGROUND

Chronic pelvic pain (CPP) is a common gynaecological condition accounting for 20% of all gynaecological referrals. There are wide ranges of causes with overlapping symptomatology, therefore the management of the condition is a formidable challenge for clinicians. The aetiology of CPP is heterogeneous and in many cases, no clear diagnosis can be reached. It is in this scenario that the label of chronic pelvic pain syndrome (CPPS) can be applied. We defined women with CPPS as having a minimum duration of pain of at least 6 months, including with a diagnosis of pelvic congestion syndrome, but excluding pain caused by a condition such as endometriosis. Many surgical interventions have been tried in isolation or in conjunction with non-surgical interventions in the management with variable results. Surgical interventions are invasive and carry operative risks. Surgical interventions must be evaluated for their effectiveness prior to their prevalent use in the management of women with CPPS.

OBJECTIVES

To review the effectiveness and safety of surgical interventions in the management of women with CPPS.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase and PsycINFO, on 23 April 2021 for any randomised controlled trials (RCT) for surgical interventions in women with CPPS. We also searched the citation lists of relevant publications, two trial registries, relevant journals, abstracts, conference proceedings and several key grey literature sources.

SELECTION CRITERIA

RCTs with women who had CPPS. The review authors were prepared to consider studies of any surgical intervention used for the management of CPPS. Outcome measures were pain rating scales, adverse events, psychological outcomes, quality of life (QoL) measures and requirement for analgesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated studies for inclusion and extracted data using the forms designed according to Cochrane guidelines. For each included trial, we collected information regarding the method of randomisation, allocation concealment, blinding, data reporting and analyses. We reported pooled results as mean difference (MDs) or odds ratios (OR) and 95% confidence interval (CI) by the Mantel-Haenszel method. If similar outcomes were reported on different scales, we calculated the standardised mean difference (SMD). We applied GRADE criteria to judge the overall certainty of the evidence.

MAIN RESULTS

Four studies met our inclusion criteria involving 216 women with CPP and no identifiable cause. Adhesiolysis compared to no surgery or diagnostic laparoscopy We are uncertain of the effect of adhesiolysis on pelvic pain scores postoperatively at three months (MD -7.3, 95% CI -29.9 to 15.3; 1 study, 43 participants; low-certainty evidence), six months (MD -14.3, 95% CI -35.9 to 7.3; 1 study, 43 participants; low-certainty evidence) and 12 months postsurgery (MD 0.00, 95% CI -4.60; 1 study, 43 participants; very low-certainty evidence). Adhesiolysis may improve both the emotional wellbeing (MD 24.90, 95% CI 7.92 to 41.88; 1 study, 43 participants; low-certainty evidence) and social support (MD 23.90, 95% CI -1.77 to 49.57; 1 study, 43 participants; low-certainty evidence) components of the Endometriosis Health Profile-30, and both the emotional component (MD 32.30, 95% CI 13.16 to 51.44; 1 study, 43 participants; low-certainty evidence) and the physical component of the 12-item Short Form (MD 22.90, 95% CI 10.97 to 34.83; 1 study, 43 participants; low-certainty evidence) when compared to diagnostic laparoscopy. We are uncertain of the safety of adhesiolysis compared to comparator groups due to low-certainty evidence and lack of structured adverse event reporting. No studies reported on psychological outcomes or requirements for analgesia. Laparoscopic uterosacral ligament ablation or resection compared to diagnostic laparoscopy/other treatment We are uncertain of the effect of laparoscopic uterosacral ligament/nerve ablation (LUNA) or resection compared to other treatments postoperatively at three months (OR 1.26, 95% CI 0.40 to 3.93; 1 study, 51 participants; low-certainty evidence) and six months (MD -2.10, 95% CI -4.38 to 0.18; 1 study, 74 participants; very low-certainty evidence). At 12 months post-surgery, we are uncertain of the effect of LUNA on the rate of successful treatment compared to diagnostic laparoscopy. One study of 56 participants found no difference in the effect of LUNA on non-cyclical pain (P = 0.854) or dyspareunia (P = 0.41); however, there was a difference favouring LUNA on dysmenorrhea (P = 0.045) and dyschezia (P = 0.05). We are also uncertain of the effect of LUNA compared to vaginal uterosacral ligament resection on pelvic pain at 12 months (MD 2.00, 95% CI 0.47 to 3.53; 1 study, 74 participants; very low-certainty evidence). We are uncertain of the safety of LUNA or resection compared to comparator groups due to the lack of structured adverse event reporting. Women undergoing LUNA may require more analgesia postoperatively than those undergoing other treatments (P < 0.001; 1 study, 74 participants). No studies reported psychological outcomes or QoL.

AUTHORS' CONCLUSIONS

We are uncertain about the benefit of adhesiolysis or LUNA in management of pain in women with CPPS based on the current literature. There may be a QoL benefit to adhesiolysis in improving both emotional wellbeing and social support, as measured by the validated QoL tools. It was not possible to synthesis evidence on adverse events as these were only reported narratively in some studies, in which none were observed. With the inadequate objective assessment of adverse events, especially long-term adverse events, associated with adhesiolysis or LUNA for CPPS, there is currently little to support these interventions for CPPS.

The Role of Trauma and Mental Health in the Treatment of Chronic Pelvic Pain: A Systematic Review of the Intervention Literature

Chronic pelvic pain (CPP) is a widespread health issue with unclear etiology that has been linked to a history of trauma among women. This condition is known to be highly comorbid with, and potentially exacerbated by psychiatric conditions, as well as other gynecological concerns and functional pain syndromes. Many comorbid conditions are also related to a history of trauma, and cases of CPP with comorbidity are known to be resistant to treatment. While the prevalence of a traumatic history among females with CPP has been established, less is known about how the role of trauma is addressed in the intervention literature. The purpose of this systematic review was to explore how the role of trauma, and to a lesser extent, mental health, is addressed in modern intervention studies for females with CPP. All qualitative and quantitative studies providing primary or secondary results of an intervention for females with CPP published between January 1998 and May 2018 were included and coded independently by two reviewers. Twenty-eight articles met inclusion criteria. Of these, none focused exclusively on patients with a history of trauma; one study implicitly focused on trauma-specific symptoms as an outcome, while two studies screened patients for a history of trauma. Of the 10 studies with a focus on mental health, only three simultaneously addressed trauma. To address this gap in the literature, future studies can prioritize intervention designs that place emphasis on the role of trauma in regard to patient characteristics and outcome variables.

No. 345-Primary Dysmenorrhea Consensus Guideline

OBJECTIVE

This guideline reviews the investigation and treatment of primary dysmenorrhea.

INTENDED USERS

Health care providers.

TARGET POPULATION

Women and adolescents experiencing menstrual pain for which no underlying cause has been identified.

EVIDENCE

Published clinical trials, population studies, and review articles cited in PubMed or the Cochrane database from January 2005 to March 2016.

VALIDATION METHODS

Seven clinical questions were generated by the authors and reviewed by the SOGC Clinical Practice-Gynaecology Committee. The available literature was searched. Guideline No. 169 was reviewed and rewritten in order to incorporate current evidence. Recommendations addressing the identified clinical questions were formulated and evaluated using the ranking of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Primary dysmenorrhea is common and frequently undertreated. Effective therapy is widely available at minimal cost. Treatment has the potential to improve quality of life and to decrease time lost from school or work.

GUIDELINE UPDATE

This guideline is a revision and update of No. 169, December 2005.

SPONSORS

SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Recurrence-associated factors of laparoscopic adenomyomectomy for severely symptomatic adenomyoma

The present study aimed to identify which patients with adenomyoma would benefit from sparing the uterus and which patients should undergo a hysterectomy to avoid secondary surgery. Patients with pathology-proven adenomyoma admitted to Beijing Chao-Yang Hospital between November 2005 and November 2015 were retrospectively reviewed. Relief and reappearance of dysmenorrhea following laparoscopic adenomyomectomy were evaluated. All 49 patients (mean age, 40.6±5.2 years; age range, 26-51 years) presented with severe dysmenorrhea prior to surgery. Dysmenorrhea was identified to be relieved in 83.7% (41/49) of patients at the 6-month follow-up. No factors were revealed to have a significant effect on the surgical outcome. The median follow-up period was 4.6 (1-11) years; and 24.5% (12/49) of patients experienced recurrence of dysmenorrhea. Multivariate analysis identified preoperative serum cancer antigen 125 (CA 125) levels [hazard ratio (HR), 2.356; 95% confidence interval (CI), 1.271-3.570; P=0.011], postoperative gonadotropin-releasing hormone agonist (GnRH-a) treatment (HR, 0.540; 95% CI, 0.241-0.873; P=0.017) and accompanying endometriosis (HR, 2.182; 95% CI, 1.556-3.031; P=0.003) as independent risk factors for relapse. Laparoscopic adenomyomectomy is effective for alleviating dysmenorrhea in patients with adenomyoma. Patients with lower preoperative serum CA 125 levels without accompanying endometriosis benefited greater from adenomyomectomy compared with all other patients. Postoperative GnRH-a treatment strengthens therapeutic effects.

Everolimus as an mTOR Inhibitor Suppresses Endometriotic Implants: an Experimental Rat Study

Introduction Mammalian target of rapamycin is a pathway to block apoptosis. Recent studies showed that the activity of mammalian target of rapamycin pathway increases in endometriotic lesions. Aim of the present study was to study the effect of everolimus agent, a rapamycin analog, in an experimental endometriosis model. Materials and Methods Endometriosis established by the autotransplantation of uterine tissue in the peritoneal cavity was confirmed in 24 rats. The animals were then randomly divided into three groups to receive either everolimus (1.5 mg/kg/day, p. o.), anastrozole (0.004 mg/day, p. o.), or normal saline (0.1 mL, i. p.) for 14 days. Endometriotic foci were excised, stained with hematoxylin and eosin, and endometriosis was scored semiquantitatively. In addition, immunohistochemical examination were performed using primary antibodies of vascular endothelial growth factor, CD117, and Bax. Results Both anastrozole and everolimus lowered endometriosis scores. Significant decreases in ovarian follicles were observed following anastrozole treatment but not everolimus treatment. Conclusion Through its apoptosis-promoting effect, everolimus suppressed endometriotic foci without negatively affecting ovarian reserve. These findings support the hypothesis that everolimus merits further study on the way to developing a new endometriosis drug.

ISPOG European Consensus Statement - chronic pelvic pain in women (short version)

To date there is no international guideline on chronic pelvic pain available that focuses on medical, psychosomatic and psychological diagnostics and treatment of this complicated disease pattern. In this paper, a European working group, which was established in October 2010, aims to bridge this gap. The working group decided to use the current German guideline as source text and to transform it into a European consensus statement by deleting parts that apply only to the conditions of the German health system. The literature search included papers published up to and including December 2010, using Medline search and by adding some new search terms. This manuscript reports the essential facts of the above-mentioned consensus statement. Within this article we use the term "psychosomatic" as the integrated concept of medical and psychosocial aspects of a disease.

Chronic Pelvic and Vulvar Pain in Women

Peripheral generators and the central nervous system have a role in the production of visceral and somatic hypersensivities and hyperalgesias.More generalised symptoms often exist and efferent activity from the CNS may also be responsible for abnormal visceral and muscular function.It is important to dissect out the symptoms and as well as treating peripheral generators to consider interventions of the central mechanisms aimed at the cognitive behavioural aspects of the patients' condition.

Measures used to assess chronic pelvic pain in randomized controlled clinical trials: a systematic review

RATIONALE

Many types of pain assessment are available to researchers carrying out clinical trials in chronic pelvic pain (CPP), ranging from a single-item scale to multidimensional inventories.

AIM

Our objective was to investigate which assessments of pain are more commonly used in clinical trials on CPP.

METHOD

We have reviewed articles published between 1991 and 2014. A total of 74 studies out of 1299 original research articles reviewed met the selection criteria by containing at least one method of pain assessment. The selected studies were classified according to the dimensions of pain evaluated, the type of scale and the descriptors used.

RESULTS

The instruments most frequently used were single-item VAS and Biberoglu and Behrman pain score, while multidimensional inventories were used in few studies. The results of clinical studies in CPP are more frequently based on one-dimensional measurements. Valuable results from clinical studies in CPP might have been omitted because of incomplete outcome measurements.

CONCLUSION

We believe the authors of clinical studies should report their results in a comprehensive way including in the outcomes of the measurement of one-dimensional and multidimensional pain characteristics.

WITHDRAWN: Interventions for treating chronic pelvic pain in women

This review has been replaced by published review 'Non‐surgical interventions for the management of chronic pelvic pain'. It will also be replaced by current protocol 'Surgical interventions for the management of chronic pelvic pain in women' when the full review is published.

The editorial group responsible for this previously published document have withdrawn it from publication.

Systematic review of endometriosis pain assessment: how to choose a scale?

BACKGROUND

Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain.

METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336).

RESULTS

A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID.

CONCLUSIONS

When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response.

A double-blind, randomized, controlled trial on surgery for chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome

OBJECTIVE

To clarify the role of a surgical neurectomy on pain in refractory patients after conservatively treated anterior cutaneous nerve entrapment syndrome (ACNES).

BACKGROUND

ACNES is hardly ever considered in the differential diagnosis of chronic abdominal pain. Treatment is usually conservative. However, symptoms are often recalcitrant.

METHODS

Patients older than 18 years with a diagnosis of ACNES were randomized to undergo a neurectomy or a sham procedure via an open surgical procedure in day care. Both the patient and the principal investigator were blinded to the nature of surgery. Pain was recorded using a visual analog scale (1-100 mm) and a verbal rating scale (score 0-5; 0 = no pain, 5 = severe pain) before surgery and 6 weeks postoperatively. A reduction of at least 50% in the visual analog scale score and/or 2 points on the verbal rating scale was considered a "successful response."

RESULTS

Forty-four patients were randomized between August 2008 and December 2010 (39 women, median age = 42 years; both groups, n = 22). In the neurectomy group, 16 patients reported a successful pain response. In contrast, significant pain reduction was obtained in 4 patients in the sham group (P = 0.001). Complications associated with surgery were hematoma (n = 5, conservative treatment), infection (antibiotic and drainage, n = 1), and worsened pain (n = 1).

CONCLUSIONS

Neurectomy of the intercostal nerve endings at the level of the abdominal wall is an effective surgical procedure for pain reduction in ACNES patients who failed to respond to a conservative regimen.

Chronic pelvic pain in endometriosis: an overview

Chronic pelvic pain (CPP) could be considered nowadays a deep health problem that challenges physicians all over the world. This because its aetiology is still unclear, the course of the disease could vary a lot among different patients and through time in the same patient, and the response to treatments is not every time successful. Among women who underwent laparoscopy for CPP, endometriosis is found in about 1/3 of the cases, while only 25% of women with histological confirmed endometriosis are asymptomatic. A wide range of variables may exert their influence on the resulting pain syndrome in endometriosis; for example, score according to American society for reproductive medicine (rASRM), size of the sub-peritoneal and pelvic wall implants, Douglas obliteration, previous surgery. It is widely accepted nowadays that central nervous system (CNS) and peripheral nervous system (PNS) seems to influence each other and this interconnection play a key role in pain modulation. Moreover, the phenomena induced by endometriosis in the pelvis, including the breakdown of peritoneal homeostasis and the induction of the production of proinflammatory and proangiogenic cytokines, are responsible of altered innervations and modulation of pain pathways in these patients. There are many proposed medical and surgical approach to treat this painful syndrome, although there is necessity of more efforts to create new non-invasive strategies that set a more accurate diagnosis of the causes of endometriotic-related CPP, and therefore facilitate its eradication.

Evaluation of transvaginal peritoneal surgery in young female patients

BACKGROUND

The transvaginal approach is being used for natural orifice transluminal endoscopic surgery (NOTES), and reports of the clinical use of transvaginal NOTES have increased rapidly. However, hasty use of a transvaginal route may cause unexpected complications. Infertility or dyspareunia after transvaginal NOTES in young women is one of the most important issues to be resolved. The purpose of this study was to assess long-term complications, including infertility and dyspareunia, after transvaginal peritoneal surgery.

METHODS

An anonymous questionnaire was sent to 73 young patients who had undergone ovarian cystectomy using a transvaginal approach from 2003 to 2011. The questionnaire contained 15 questions; 6 dealt with fertility, and 8 dealt with discomfort after surgery. A 5-point scale was used to evaluate patients' overall satisfaction with surgery.

RESULTS

Forty-four (60 %) questionnaires were returned. The patients' mean age was 33.0 years, and the mean postoperative follow-up period was 16.5 months. Of responders younger than age 40 years, 24 did not use contraception, and 9 (38 %) conceived. The pregnancy rate among women younger than age 30 years was 60 %. Two (5 %) women reported temporary dyspareunia 1 month after surgery, but none developed permanent dyspareunia. The average patient satisfaction score was 4.12.

CONCLUSIONS

There was no evidence to suggest that transvaginal peritoneal surgery causes infertility or dyspareunia. The majority of patients gave a high evaluation to vaginal ovarian cystectomy, suggesting the usability of a transvaginal approach for intraperitoneal surgery in young premenopausal women.

Surgical treatment of endometriosis

In this review, the pitfalls that still exist with the surgical treatment of endometriosisassociatedpelvic pain have been discussed and the best evidence regarding various aspects of surgical techniques have been reviewed. When laparoscopy is performed to evaluate a woman with pelvic pain symptoms, it is important she be counseled that the primary function of the surgery is to confirm the presence (and allow surgical treatment) of endometriosis, and that it is not the penultimate diagnostic modality for her pelvic pain. There are many etiologies of pelvic pain that present with symptoms resembling those of endometriosis-associated pelvic pain that are not diagnosable with laparoscopy, such as interstitial cystitis and irritable bowel syndrome. It is unfortunate that many women are left with the belief that if a laparoscopy fails to provide a diagnosis of a pain generator, then it means there are no diagnoses other than that the “pain is in her head,” often disparagingly termed “supratentorial” byclinicians. In fact, the pain-related diagnoses that are amenable to and possibly require a laparoscopy are quite limited, a group of diagnoses that this author terms the “dirty dozen” because there are just 12, and only the first 4 have good evidence to clearly associate them with chronic pelvic pain:1. Endometriosis 2. Ovarian remnant syndrome 3. Pelvic inflammatory disease 4. Tuberculous salpingitis 5. Adhesions 6. Benign cystic mesothelioma 7. Postoperative peritoneal cysts 8. Adnexal cysts (nonendometriotic)9. Chronic ectopic pregnancy 10. Endosalpingiosis 11. Residual accessory ovary 12. Hernias: ventral, inguinal, femoral, spigelian.I would argue that diagnostic laparoscopy in modern gynecology has a limited, if any role, and that when laparoscopy is planned for women with chronic pelvic pain, it should be with a very high suspicion of a diagnosis and with plans to treat the disease operatively. In this era, a negative diagnostic laparoscopy should be a rare event.

Defining a minimal clinically important difference for endometriosis-associated pelvic pain measured on a visual analog scale: analyses of two placebo-controlled, randomized trials

BACKGROUND

When comparing active treatments, a non-inferiority (or one-sided equivalence) study design is often used. This design requires the definition of a non-inferiority margin, the threshold value of clinical relevance. In recent studies, a non-inferiority margin of 15 mm has been used for the change in endometriosis-associated pelvic pain (EAPP) on a visual analog scale (VAS). However, this value was derived from other chronic painful conditions and its validation in EAPP was lacking.

METHODS

Data were analyzed from two placebo-controlled studies of active treatments in endometriosis, including 281 patients with laparoscopically-confirmed endometriosis and moderate-to-severe EAPP. Patients recorded EAPP on a VAS at baseline and the end of treatment. Patients also assessed their satisfaction with treatment on a modified Clinical Global Impression scale. Changes in VAS score were compared with patients' self-assessments to derive an empirically validated non-inferiority margin. This anchor-based value was compared to a non-inferiority margin derived using the conventional half standard deviation rule for minimal clinically important difference (MCID) in patient-reported outcomes.

RESULTS

Anchor-based and distribution-based MCIDs were-7.8 mm and-8.6 mm, respectively.

CONCLUSIONS

An empirically validated non-inferiority margin of 10 mm for EAPP measured on a VAS is appropriate to compare treatments in endometriosis.

The efficacy of laparoscopic uterosacral nerve ablation (LUNA) in the treatment of unexplained chronic pelvic pain: a randomized controlled trial

The aim of this work is to explore the efficacy , safety, and patients' satisfaction of laparoscopic uterosacral nerve ablation (LUNA) in relief of pain in women with chronic pelvic pain in whom diagnostic laparoscopy reveals either no pathology or mild endometriosis (AFS score ≤5). The study was a prospective, single-blind, randomized trial with 12 months follow-up. It was conducted at the endoscopy unit of the Gynecology Department of El Minia University Hospital, Egypt. One hundred ninety Egyptian women consented to participate in the study. These eligible patients were randomized using computer-generated tables and were divided into two equal groups, including the control group (diagnostic laparoscopy with no pelvic denervation) and the study group (diagnostic laparoscopy plus LUNA). Diagnostic laparoscopy with or without laparoscopic uterosacral nerve ablation was done. There were no statistically significant difference between both groups regarding the efficacy and the overall success rate (between group I and group II, it was 77.64%, 76.47%, and 74.11% versus 79.06%, 75.58%, and 73.25% at 3, 6, and 12 months, respectively) and the cumulative patients' satisfaction rate (it was 74.11%, 74.11%, and 71.76% versus 75.58%, 75.58%, and 72.09% at 3, 6, and 12 months between group I and group II, respectively; P ≤ 0.05). There was no statistically significant difference between both groups as regards the effectiveness of LUNA in the treatment of primary (spasmodic) and secondary (congestive) dysmenorrhea (P ≤ 0.05), while there was a statistically significant difference between both groups in the treatment of dyspareunia (P ≥ 0.05). LUNA can be a last alternative option in well-selected patients for control of chronic pelvic pain without endometriosis; however, its effectiveness may not extend to other indications. Also, preliminary experience in the treatment of primary deep dyspareunia presents a promising perspective on the management of deep dyspareunia, especially if it will involve a team of social, psychological, and gynecological specialists.

Individual patient data meta-analysis of randomized evidence to assess the effectiveness of laparoscopic uterosacral nerve ablation in chronic pelvic pain

BACKGROUND

There have been conflicting results in randomized trials of the effects of laparoscopic uterosacral nerve ablation (LUNA) in chronic pelvic pain. Our objective was to perform a meta-analysis using individual patient data (IPD) to provide the most comprehensive and reliable assessment of the effectiveness of LUNA.

METHODS

Electronic searches were conducted in the Medline, Embase, PsycInfo and Cochrane Library databases from database inception to August 2009. The reference lists of known relevant papers were searched for any further articles. Randomized trials comparing LUNA with no additional intervention were selected and authors contacted for IPD. Raw data were available from 862 women randomized into five trials. Pain scores were calibrated to a 10-point scale and were analysed using a multilevel model allowing for repeated measures.

RESULTS

There was no significant difference between LUNA and No LUNA for the worst pain recorded over a 12 month time period (mean difference 0.25 points in favour of No LUNA on a 0-10 point scale, 95% confidence interval: -0.08 to 0.58; P = 0.1).

CONCLUSIONS

LUNA does not result in improved chronic pelvic pain.

Laparoscopic management of endometriosis: comprehensive review of best evidence

STUDY OBJECTIVE

To provide a comprehensive review of the best evidence available in the laparoscopic management of endometriosis for pain and/or fertility and to provide practical recommendations based on this information.

DESIGN

Review article of randomized controlled trials.

PATIENTS

Women with endometriosis.

METHODS

A systematic search was performed of the Cochrane Library and MEDLINE database for randomized controlled trials relating only to laparoscopic management of endometriosis. The information from 7 Cochrane review articles and 35 original randomized trials is presented in a clinically relevant question-and-answer format.

CONCLUSIONS

Awareness of endometriosis as a disease with substantial morbidity is vitally important. Laparoscopic treatment of endometriosis is beneficial for reducing pain and improving fertility. Laparoscopic presacral neurectomy, but not laparoscopic uterosacral nerve ablation, is a useful adjunct to conservative surgery for endometriosis in patients with a midline component of pain. Preoperative hormonal suppression with gonadotropin-receptor hormone analogue may be helpful in decreasing endometriosis disease scores. Postoperative hormonal suppression with either a gonadotropin-receptor hormone analogue or progestin (including the levonorgestrel intrauterine system) may be helpful in reducing pain and increasing time to recurrence of symptoms. Excisional cystectomy is the preferred method to treat endometrial cysts for both pain and fertility and may be aided by the use of mesna and initial circular excision. An absorbable adhesion barrier (Interceed), 4% icodextrin solution (Adept), and a viscoelastic gel (Oxiplex/AP, FzioMed, Inc., San Luis Obispd, CA; not available in the United States) are safe and effective products to help prevent adhesions in laparoscopic surgery to treat endometriosis.

Gynaecological surgery from art and craft to science?

Randomised controlled trials are applied more readily to medical than surgical interventions. There are even more barriers to randomised trials of surgical interventions than to other randomised trials. These include reluctance among surgeons to undertake trials (owing to concern over expressing equipoise, surgical training and surgical learning curve issues, restrictions of funding and time for research, even financial conflict of interest), reluctance of patients to participate in surgical trials owing to fears over 'experimental surgery', failure of randomised trials to detect rare surgical complications and the almost universal failure of those conducting surgical trials to examine important long-term outcomes. Rapid advances in surgical fields mean that new surgical techniques are rapidly superseded and clinical questions surrounding new techniques may linger only until the next new technique becomes available. Nonetheless randomised controlled trials remain the cornerstone of evaluating the effectiveness of surgical interventions. Genuine progress has been made in this field. However, large multicentre collaborative randomised trials that have been prospectively defined in trial registries will be required in the future to answer the important clinical questions regarding gynaecological surgical interventions.

Repetitive surgery for recurrent symptomatic endometriosis: what to do?

In spite of the increasing number of operative laparoscopies performed for endometriosis associated pelvic pain, postoperative symptomatic recurrences are very common. Reoperation is often considered the best treatment option, but the extent and duration of the effect of second-line surgery is still unclear. The best available evidence has been reviewed in order to define the results of repetitive conservative surgery, the effects of pelvic denervating procedures and postoperative medical treatments, as well as the long-term outcome of definitive surgery. Because of the paucity of published data, estimating the real risk of symptomatic recurrence and need for reoperation after repetitive conservative surgery for endometriosis is very difficult. Based on the limited information available, the long-term outcome appears suboptimal, with a cumulative probability of pain recurrence between 20% and 40%, and of a further surgical procedure between 15% and 20%. These figures are probably an underestimate related to drawbacks in study design, exclusions of dropouts, and publication bias and should be considered with caution. Systematic complementary performance of denervating procedures in addition to reoperation cannot be recommended, as only a few symptomatic patients complain of predominantly midline, hypo-gastric pain. The outcome of hysterectomy for endometriosis-associated pain at medium-term follow-up seems quite satisfactory. Nevertheless, about 15% of patients had persistent symptoms, and 3-5% experienced worsening of pain. Concomitant bilateral oophorectomy reduced the risk of reoperation due to recurrent pelvic pain by six times. However, at least one gonad should be preserved in young women, especially in those with objections to the use of oestrogen-progestogens. Medical treatment appears to have limited and inconsistent effects when used for only a few months after conservative procedures. Data on the benefit of prolonged drug regimens with oral contraceptives or progestogen are lacking. The risk of recurrence of endometriosis during hormone replacement therapy seems marginal if combined preparations or tibolone are used and oestrogen-only treatments are avoided. The opportune surgical solution in women with recurrent symptoms after previous conservative procedures for endometriosis should be based on the desire for conception as well as on psychological characteristics. Studies on surgical management of recurrent rectovaginal endometriosis are warranted, due to the peculiar technical difficulties as well as the high risk of complications associated with this challenging disease form.

Medical, surgical and alternative treatments for chronic pelvic pain in women: a descriptive review

Several causes of chronic pelvic pain (CPP) are recognised, but in many women a definite diagnosis cannot be made. Few randomised controlled trials on treatment of CPP have been conducted. In a Cochrane systematic review, only medroxy-progesterone acetate, counselling, a multidisciplinary approach and lysis of deep adhesions had a proven benefit. The aim of this descriptive review is to describe the management of CPP, which can focus on treating the pain itself, the underlying cause, or both. Combination drug therapy with medications with different mechanisms of action may improve therapeutic results. Pelvic denervating procedures should be indicated in selected circumstances, as the magnitude of the effect is undefined. Several alternative non-invasive treatments have been proposed including exercise programmes, cognitive and behavioural medicine, physical therapy, dietary modification, massage and acupuncture. When the woman has completed her family and particularly when pelvic varices have been demonstrated, hysterectomy can be considered after a careful pre-operative assessment. However, substantial pain relief may be achieved in no more than 60-70% of the cases. A minority of patients (3-5%) will experience worsening of pain or will develop new symptoms after surgery. Treatment of CPP, generally, requires acceptance of the concept of managing rather than curing symptoms.

Pelvic denervation procedures: a current reappraisal

The introduction of minimally invasive techniques over recent years has led to the resurgence of pelvic denervation procedures such as presacral neurectomy and uterine nerve ablation being performed for women with dysmenorrhea and pelvic pain. Women who have failed medical therapy with persistent and debilitating symptoms may certainly benefit from these procedures. However, presacral neurectomy and uterine nerve ablation are distinct procedures that require appropriate patient selection in order to optimize pain relief. Whereas presacral neurectomy may be effective for both primary dysmenorrhea and endometriosis-related pelvic pain, the role of uterine nerve ablation should be reserved for patients with primary dysmenorrhea only, as evidenced by several randomized trials.

Treatment of chronic pelvic pain in men and women

Chronic pelvic pain syndrome (CPPS) is a common condition that is encountered by a variety of healthcare professionals. Unfortunately, physicians often misdiagnose this problem or recommend inappropriate and sometimes dangerous treatments that offer little hope of successful outcome. In addition, CPPS is typically a multifaceted disorder, simultaneously compromising psychological, peripheral nerve, autonomic, central nervous, visceral, connective tissue, hormonal and other systems. Thus, solo practitioners who may correctly diagnose CPSS are often ill-equipped to provide adequate comprehensive, multidisciplinary treatment. This article is intended as an overview of the most recent literature in support of various treatment modalities for chronic pelvic pain in men and women. We advocate a team-oriented approach in the treatment of CPPS, which employs the coordinated efforts of multiple practitioners, ideally in a subspecialty care setting.

Conservative surgical management of endometriosis in women with pelvic pain

Endometriosis is a common cause of pelvic pain in women. This article addresses the conservative surgical treatment of endometriosis for this indication.

Presacral neurectomy for surgical management of pelvic pain associated with endometriosis: a descriptive review

Pelvic pain associated with endometriosis is a common clinical problem. In approximately 20% of cases endometriosis-related pelvic pain is either minimally or not responsive to medical treatment; thus surgical treatment seems to be a valid option. The aim of this review is to describe presacral neurectomy surgical techniques, data regarding safety and efficacy of this procedure, its indications, and future research on its applications in clinical practice.

Histopathologic findings on uterosacral ligaments in women with chronic pelvic pain and visually normal pelvis at laparoscopy

STUDY OBJECTIVE

To determine the prevalence and type of microscopic findings on laparoscopically resected uterosacral ligaments in women with chronic pelvic pain and no visible pelvic disease. The effect of this procedure on the patients' level of pain also was assessed as a secondary objective.

DESIGN

Prospective follow-up (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Twenty-seven premenopausal women undergoing diagnostic laparoscopy for chronic pelvic pain had a normal pelvis on visual inspection. All patients underwent resection and histologic evaluation of the uterosacral ligaments. Pain relief was evaluated by use of a questionnaire administered before and at 3, 6, and 12 months after surgery.

MEASUREMENTS AND MAIN RESULTS

Microscopic examination identified endometriosis in 2 (7.4%), endosalpingiosis in 3 (11.1%), and inflammation in 14 (51.9%) patients. Laparoscopic uterosacral ligament resection was associated with a reduction in dysmenorrhea (p < or = .001), with 14 (52%) patients reporting improved or resolved symptoms. There was a statistically significant decrease in dyspareunia (p < or = .01) and in the severity of noncyclical pain (p < or = .002). Thirty-five percent of patients no longer required medication for pain control (p < or = .005). The number of days needed off work also decreased.

CONCLUSION

Despite normal laparoscopic appearance, microscopic endometriosis, endosalpingiosis, and inflammatory changes were found in uterosacral ligaments in 17 (63%) women with chronic pelvic pain. Laparoscopic resection of uterosacral ligaments improved dysmenorrhea, dyspareunia, and noncyclical pain and decreased the number of days lost from work, as well as the proportion of patients who required medication for pain control.

Outcomes and treatment options in rectovaginal endometriosis

PURPOSE OF REVIEW

This review aims to explore the recent literature surrounding the role of colorectal surgery in rectovaginal endometriosis.

RECENT FINDINGS

Recent findings would suggest that excision of a portion of the rectum along with complete excision of surrounding endometriosis is beneficial in terms of improvement in quality of life and recurrence of disease. However, further randomized controlled trials are needed to clarify this finding.

SUMMARY

The optimal management of women with deeply infiltrating rectovaginal endometriosis remains a challenge to physicians involved in this disease process. The choice between medical and surgical treatments is not clearly defined, and neither is the role of adjunctive medical therapy prior to or following surgery. It is only when these questions have been asked in the context of well conducted clinical trials, with good outcome data, can the answers be given.

Chronic pelvic pain: aetiology and therapy

Chronic pelvic pain (CPP) is a common condition in women and rates of consultation for CPP in general practice are similar to those for asthma and migraine. US and UK population-based studies, together with data from UK hospital settings demonstrate a substantial impact of CPP on health-related quality of life. In this review, we will examine the current evidence on the aetiology and management of CPP, focussing on the randomised controlled trials (RCTs) that are available to date. CPP is a heterogeneous condition and causation is often unclear. There are associations with specific pathological processes but a barrier to understanding is that many studies have data that are not comparable. In the community setting, as many as 60% of women with CPP have not received a specific diagnosis and up to 20% have not undergone any investigation. The factor most commonly associated with CPP in the community is irritable bowel syndrome, although in a tertiary setting with laparoscopy, pathology associated with CPP in ascending order of frequency is endometriosis (33%), adhesions (24%) and 'no pathology' (35%). Current RCT evidence provides some support for the use of ultrasound scanning as an aid to counselling and reassurance, progestogen (medroxyprogesterone acetate) or goserelin for pelvic congestion and a multidisciplinary approach to assessment and treatment. Adhesiolysis is not shown to be of benefit other than in women with extensive adhesions. While studied in relation to dysmenorrhoea rather than CPP, the short term results for presacral neurectomy (PSN) and laparoscopic utero-sacral nerve ablation (LUNA) seem to be similar, although PSN has better results in the long term. Selective serotonin reuptake inhibitor (SSRI) antidepressants have not been shown to be of benefit in CPP. Most of these conclusions are based on the outcome of single randomised trials and therefore need replication.

Pelvic pain in women and men: recent findings

PURPOSE OF REVIEW

All Pubmed-listed articles generated by the search terms 'pelvic' and 'pain' from the year 2004 (plus or minus 6 months) were examined for relevance to pain management therapeutics. An emphasis was given to clinical studies related to chronic pain disorders.

RECENT FINDINGS

Use of the descriptive diagnosis 'pelvic pain', traditionally limited to gynecological pains, has now been generalized to include male populations with similar symptom complexes arising from organs of reproduction and other pelvic organ systems such as the gastrointestinal tract and urological structures. Clinical studies have sought to refine or test existing 'standard' therapies for current pain groupings, and have frequently obtained frustrating results because many therapies appear to be effective in only a subset of patients. Notably, the same therapeutics appear to be effective in similar subsets of patients with other protean disorders.

SUMMARY

A commonality of symptoms suggests a commonality of pathophysiology, although this has not proved to be globally true. The success of therapeutic options appears to depend upon a stratification of previous pain groupings into overlapping subsets each with their effective treatment. Current studies are still defining these subsets and finding monotherapies to be inadequate for whole populations.

No more surrogate end-points in randomised trials: The PCOSMIC trial protocol for women with polycystic ovary syndrome using metformin for infertility with clomiphene

Current data supporting the effectiveness of metformin as a fertility treatment for women with polycystic ovary syndrome have been misinterpreted. Still unproven for women with polycystic ovary syndrome is, first, whether metformin adds to the standard first-line fertility management in all women, second, whether metformin is an effective fertility treatment for overweight women, and third, the relative fertility efficacy of metformin and clomiphene citrate as a first-line treatment in women with a lower body weight. The PCOSMIC (polycystic ovary syndrome: metformin for infertility with clomiphene) trial is an ongoing New Zealand multicentre double-blind placebo-controlled parallel randomised trial assessing these questions.

Laparoscopic uterosacral nerve ablation and chronic pelvic pain

Chronic pelvic pain is a complicated syndrome comprised of different types of pain, including dysmenorrhea, deep dyspareunia, and intermenstrual pain, which can make interpretation difficult. Therefore, investigation of this complex syndrome requires very careful consideration. Accumulating data from several randomized studies, we have now come to realize that LUNA can be an option in a few circumstances, especially for control of menstrual pain without endometriosis; however, its effectiveness may not extend to other indications, such as alleviating secondary dysmenorrhea associated with endometriosis (although it could, however, be reached by presacral neurectomy). Juang et al's article reports a very preliminary experience in the treatment of primary deep dyspareunia, presenting a promising perspective yet without sufficient evidence on the management of deep dyspareunia. A randomized controlled study with an adequate number of patients is warranted.