{"paper_id":"2dc3f28b-6f85-4467-b21f-e849eede2c2d","body_text":"1 Tepecik Trainin and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey \n2 Erzincan University, School of Medicine, Department of Obstetrics and Gynecology, Erzincan, Turkey\nCorrespondence: Umit Nayki, \nErzincan University, School of Medicine, Dept. Obstetrics & Gynecology, Erzincan, Turkey    Email: drumit75@hotmail.com\nReceived: 06.12.2015, Accepted: 27.01.2016\nCopyright © JCEI / Journal of Clinical and Experimental Investigations 2016, All rights reserved\nJCEI /  \nJournal of Clinical and Experimental Investigations \n2016; 7 (1): 7-13 \nDOI: 10.5799/jcei.328658\nRESEARCH ARTICLE\nLaparoscopic Uterine Nerve Ethanol Neurolysis (LUNEN) in Patients with Chronic \nPelvic Pain\nSeyhan Sönmez1, Ümit Naykı2, Paşa Uluğ2, Cenk Naykı2, Ferhan Sönmez1, Şivekar Tınar1, Yusuf Yıldırım2\nABSTRACT\nObjective: To investigate the efficacy of laparoscopic uterine nerve ethanol neurolysis (LUNEN) for pain management \nin patients with chronic pelvic pain (CPP).\nMethods: LUNEN, as a chemical neurolysis procedure, was performed on 22 subjects, and these were compared with \n20 controls that had a diagnostic laparoscopy alone. Pre-treatment and postoperative 6th month Visual Analogue Scale \n(VAS) scores were estimated and a subjective pain evaluation questioning patients’ satisfaction about pain relief in the \n6th month after surgery was also performed.\nResults: A total of 31 (73.8%) out of 42 CPP patients had a laparoscopic pelvic pathology. Preoperative VAS scores were \nsimilar in the groups; however, the mean postoperative VAS score was significantly lower in the LUNEN group than in \nthe control group (3.18 ± 2.88 vs. 5.35 ± 3.09; p=0.02). In the LUNEN group, the number of patients who stated that their \npain was relieved partially or completely was also significantly higher than in the control group (82% vs. 40%, p=0.019).\nConclusion: LUNEN is a feasible, safe and effective surgical alternative to traditional surgical methods in patients suf -\nfering from CPP . J Clin Exp Invest 2016; 7 (1): 7-13\nKey words: Chronic pelvic pain, uterine nerve neurolysis, laparoscopy, ethanol\nKronik Pelvik Ağrılı Hastalarda Laparoskopik Uterin Sinir Etanol Nörolizisi (LUNEN)\nÖZET\nAmaç: Kronik pelvik ağrılı (KPA) hastalarda ağrı tedavisinde laparoskopik olarak uterin sinirin etanol ile nörolizisinin \n(LUNEN) etkinliğinin araştırılması\nYöntemler: Kimyasal bir nörolizis prosedürü olan LUNEN, 22 hastaya uygulandı ve bunlar sadece tanısalk laparoskopi \nyapılan 20 kontrol hastayla karşılaştırıldı. Tedavi öncesi ve tedavi sonrası altıncı ayda Vizüel Analog Skalası (VAS) değer-\nlendirildi, Ayrıca, ağrı kontrolünde hasta memnuniyetini sorgulayan subjektif bir ağrı değerlendirmesi yapıldı.\nBulgular: 42 kronik KPA’lı hastadan 31’inde (%73,8) laparoskopik olarak pelvik patoloji izlendi. Gruplar arası preoperatif \nVAS skorları benzerdi. Ancak, postoperatif ortalama VAS skoru LUNEN grubunda anlamlı olarak daha azdı (3,18 ± 2,88 \nvs. 5,35 ± 3,09; p=0,02). Kontrol grubuna göre, kısmen veya tamamen ağrısının geçtiğini bildiren hasta sayısı LUNEN \ngrubunda anlamlı olarak fazlaydı(%82 vs. %40, p=0.019).\nSonuç: LUNEN, kronik pelvik ağrıdan şikayetçi hastalarda uygun, güvenilir, etkili cerrahi bir yöntem olarak geleneksel \ncerrahi yöntemlere alternatiftir.\nAnahtar kelime: Kronik pelvik ağrı, uterin sinir nörolizisi, laparoskopi, etanol\nINTRODUCTION\nChronic pelvic pain (CPP), which is commonly de-\nscribed as continuous or intermittent pain in the lower \nabdomen lasting for at least 6 months, continues to be \none of the most difficult and perplexing health condi -\ntions [1,2]. It is also considered that this is a common \nclinical problem which accounts for as much as 25% \nof routine gynecological office visits and 20% of re -\nferrals to gynecology clinics [3,4]. CPP has a major \nimpact on health-related quality of life, work produc -\ntivity and health care utilization. Living with CPP may \n\nSönmez S, et al. Laparoscopic Uterine Nerve Ethanol Neurolysis\n8\nJ Clin Exp Invest  www.jceionline.org  Vol 7, No 1, March 2016\nlead to anxiety, depression, sexual dysfunction and de-\ncreased quality of life (QoL) [5].\nDuring the last few years, the development and \nthe widespread use of endoscopic techniques make \nlaparoscopy better procedure for patients with CPP. In \nfact, CPP is the indication for 40% of all gynecologi -\ncal laparoscopies in the United States [6]. The laparo-\nscopic approach makes not only the detection but also \nthe treatment of the underlying pathology of the pelvic \npain feasible [6-9]. \nThe nerve plexuses and parasympathetic gan -\nglia in the uterosacral ligaments, which were first de -\nscribed in the last century [10], carry pain from the \nuterus and other pelvic structures to the brain. Pelvic \npain syndromes are caused by several pathologies in \nrelation to activation of nociceptors and transmission \nof signals in these pathways. Thus they are expected \nto respond to treatment of underlying disease or inter-\nruption of that transmission at any level. The surgi -\ncal approach to the management of CPP is based on \ninterruption of this transmission pathway, which can \nbe achieved by transection of uterosacral ligaments. \nAlthough hysterectomy is an option for women who \nhave completed their fertility; in women desiring fu -\nture fertility or preservation of their uteruses, more \nconservative approaches are needed. Pelvic denerva -\ntions, which consist of the interruption of cervical and \nuterine sensory nerve fibers, involve uterosacral liga-\nment resection, also called laparoscopic uterine nerve \nablation (LUNA), and presacral neurectomy (PSN). \nPSN is a surgical technique that can be performed only \nby surgeons who are highly experienced in retroperito-\nneal space surgery. This procedure requires not only a \ngreater degree of surgical skill but also carries a higher \nrisk of intra-operative complications and long-term \nconsequences. On the contrary, LUNA is known as a \nsimple, feasible, and therefore relatively commonly \nperformed surgical procedure [11]. For instance, in the \nUK, about 50% of gynecological endoscopists per -\nform LUNA routinely during the surgical treatment \nof endometriosis [12]. Complications reported due to \nLUNA include injuries of the ureter and the veins that \nlie just medial to the uterosacral ligament, and long-\nterm consequences such as uterine prolapse and blad -\nder dysfunction [11,13]. In fact, today, it is considered \nthat both LUNA and PSN may have some important \ncomplications and thus more feasible methods are \nneeded. \nChemical neurolysis destroys the microscopic \nneural architecture, and therefore interrupts the trans -\nmission function of the nerves. The use of chemicals \nto destroy nerve cells for the treatment of pain has \nbeen used since the beginning of the 20th century. For \nthis purpose, ethyl alcohol (ethanol) is a commonly \nused agent. Ethanol shows its effect by causing phos -\npholipid, cerebrocide and cholesterol output from the \nneuronal tissues and leading to lipoprotein and muco -\nprotein precipitation. It was first used as a neurolytic \nagent in 1902 in order to treat trigeminal neuralgia \n[14]. In 1933, Labat and Greene reported that injection \nof 33.3% alcohol can produce satisfactory analgesia \n[15]. Today, although chemical neurolysis techniques \nthat use ethanol or other agents are frequently applied \nfor the treatment of various pain syndromes and in or-\nder to block nerves and plexus in patients with cancer; \nthere is no clinical study in the literature evaluating \nits role in the treatment of CPP. The aim of this study, \ntherefore, is to investigate the efficacy of laparoscopic \nuterine nerve chemical neurolysis with the administra-\ntion of ethanol as a neurodestructive agent in patients \nwith CPP.\nMETHODS\nA total of 42 women with persistent pelvic pain of at \nleast 6 months’ duration were consecutively enrolled; \n22 of them comprising the laparoscopic uterine nerve \nethanol neurolysis (LUNEN) group and 20 the con -\ntrol group. Laparoscopy followed by injection of etha-\nnol to the uterosacral ligaments was performed in the \nstudy group. CPP patients selected as a control group \nunderwent only laparoscopy without ethanol neuroly -\nsis. Subjects were blinded to the therapy methods that \nwere administered. All patients were followed up for \nsix months and preoperative and postoperative pain \nstatuses were recorded.\nAn accurate history was recorded using the Inter-\nnational Pelvic Pain Society (IPPS) form and a com -\nplete physical examination was performed. At admis -\nsion, each woman underwent a gynecological pelvic \nexamination and trans-vaginal ultrasound (TVUS). \nWhen non-gynecologic causes of CPP were suspected \npreoperatively, the patients selectively underwent gas-\ntroenterological, urological, orthopedic, and neurolog-\nical examinations. \nPatients with endometriomas, huge intramural \nmyomas, large ovarian cysts and masses, pelvic organ \nprolapse, pelvic immobility with a fixed retroversion \nuterus and / or uterosacral or douglas nodularity and a \nsuspicion of pelvic malignancy were excluded. Wom-\nen under the age of 18 and over the age of 45 and those \n\nSönmez S, et al. Laparoscopic Uterine Nerve Ethanol Neurolysis\n9\nJ Clin Exp Invest  www.jceionline.org  Vol 7, No 1, March 2016\nin the postmenopausal period were excluded. Patients \nwho had a history of hysterectomy or other pelvic sur-\ngery excluding cesarean section were also excluded.\nAll procedures followed were in accordance with \nthe ethical standards of the responsible committee on \nhuman experimentation (institutional and national) \nand with the Helsinki Declaration of 1975, as revised \nin 2000 and 2008. The subjects enrolled in the study \nwere informed about the study and then, written in -\nformed consent was obtained by all of them. The In -\nstitutional Review Board (IRB) and Ethics Committee \nof our center approved the study protocol (14.2.2007-\n2007/1-16). \nAll surgical interventions were performed by the \nsame surgical team. After induction of general anes -\nthesia, the patient was placed in the low lithotomic \nposition in order to perform pelvic laparoscopy. Im -\nmediately before surgery, each patient received a sin -\ngle dose of 1g IV of Cefazoline (Sefazol ®, Mustafa \nNevzat, Istanbul, Turkey) as a prophylactic antibiotic. \nA Foley catheter was inserted into the bladder. Af -\nter executing a pneumoperitoneum with the use of a \nVerres needle, a 10-mm videolaparoscope was insert -\ned umbilically, followed by the lateral insertion of two \n5-mm ancillary trocars. After careful inspection of the \npelvis to exclude organic diseases, the posterior leaf of \nthe broad ligament was carefully inspected bilaterally \nto identify the course of the ureter. Uterosacral liga -\nments were also identified and grasped and elevated \nby an endoscopic grasper. A Verres needle was inserted \nmidline halfway between the umbilicus and pubis and \n5 ml 50% ethanol was slowly injected into each sacro-\nuterine ligament about 2 cm distally to the attachment \nof the ligaments to the cervix. After withdrawing the \nneedle, hemostasis was controlled carefully and pelvic \nlavage was performed. Before completing the surgery, \npatients underwent ablation/excision of endometriosis \nor lysis of adhesions if necessary. The women were \nallowed to eat and drink the evening after surgery and \ncould ambulate as soon as they felt comfortable. All \nsurgical interventions were performed as an outpatient \nprocedure unless there was a surgical complication. \nSeverity of pain was estimated using a 10 cm vi -\nsual analogue scale (V AS) ranging from ‘‘least pos -\nsible pain’’ to ‘‘worst possible pain’’ and expressed \nas continuous numerical values [3]. The pain was \narbitrarily considered severe in the event of a pain \nscore with a value of 5 or more. The preoperative 7th \nday and postoperative 6th month V AS scores of the \nLUNEN group were compared with those of the con -\ntrol group. Additionally, a subjective pain evaluation \nby one of the study researchers was performed ques -\ntioning patients’ satisfaction with pain relief in the 6th \nmonth after surgery. \nDescriptive statistics were first generated with \nunivariate analysis to determine the profile of the two \ngroups. Bivariate analysis was performed using the \nPearson chi-square test, Student’s t-test, and Mann-\nWhitney’s U-test as appropriate to compare mean \nvalues for parametric and nonparametric variables. \nFor all statistical evaluations, the SPSS-14 (Statisti -\ncal Package for Social Sciences version 14.0 for Win-\ndows) program (SPSS Inc., Chicago, IL) was used. \nStatistical significance was set at P < 0.05. \nRESULTS\nThe characteristics of the subjects are reported in Ta -\nble 1. No significant difference was detected between \nthe two groups in age, BMI, or duration of CPP. Mean \nparity in the study and control groups was 3.0± 1.63 \nand 1.74 ± 1.24 respectively (p=0.028) (Table 1).\nLUNEN group\n(n=22)\nControl group\n(n=20) p\nAge (year) 37.05±8.42 33.75 ±6.53 0.163\nBMI (kg/m2) 24.7±3.13 23.06±1.83 0.008\nParity (no., mean ± SD ) 3.0±1.63 1.74 ±1.24 0.028\nPrevious CS (n, %) 5 (22.7%) 4 (25%) 0.640\nDuration of CPP (month) 38.18±30.06 27.35±25.3 0.218\nPainful days per month (mean ± SD) 24.7±3.13 23.06±1.83 0.152\nNumber of previous hospital admissions (mean ± SD) 4.27±2.52 3.65±1.89 0.370\nLUNEN: Laparoscopic uterine nerve ethanol neurolysis, BMI: Body mass Index, CS: Cesarean section, CPP: \nChronic pelvic pain, SD: Standard deviation\nTable 1. Patient’s \ncharacteristics\n\nSönmez S, et al. Laparoscopic Uterine Nerve Ethanol Neurolysis\n10\nJ Clin Exp Invest  www.jceionline.org  Vol 7, No 1, March 2016\nA total of 15 cases (68.2%) out of 22 patients in \nthe LUNEN group had laparoscopically positive find-\nings while there were 16 patients (80 %) with positive \nfindings in the control group. The most common pa -\nthology was adhesion (45.4%) in the LUNEN group; \nand endometriosis (40%) in the control group. The \ndistribution of pelvic pathologies detected in diagnos-\ntic laparoscopy is listed in Table 2.\nLUNEN group\n(n=22)\nControl group\n(n=20) Total\nAdhesion (n, %) 9 (40.9) 5 (25) 14 (33.3)\nEndometriosis (n, %) 1 (4.5) 4 (20) 5 (11.9)\nOvarian Cyst (n, %) 2 (9.1) 2 (10) 4 (9.5)\nPelvic Congestion (n, %) 1 (4.5) 0 (0) 1 (2.4)\nUterine Fibroid (n, %) 1 (4.5) 1 (4.5) 2 (4.8)\nOvarian cyst +Adhesion (n, %) 1 (4.5) 0 (0) 1 (2.4)\nEndometriosis + Adhesion (n, %) 0 (0) 2 (10) 2 (4.8)\nEndometriosis + Fibroid (n, %) 0 (0) 2 (10) 2 (4.8)\nNo pathology (n, %) 7 (31.8) 4 (20) 11 (26.2)\nLUNEN: Laparoscopic uterine nerve ethanol neurolysis \nTable 2. Distribution of pelvic pa-\nthologies detected by laparoscopy\nAll patients who had adhesion (n = 17) under -\nwent adhesiolysis; and in all patients diagnosed with \nendometriosis (n = 9), excision and cauterization of \nthe implants were performed. Ovarian cystectomy was \nperformed in five cases (in one the frozen section was \nstudied and showed no malignancy). In all cases with \nfibroids, an intramural fibroid of less than 2 cm was \npresent. In two patients whose fibroids were located \nclose to the serosa, a myolysis with electrocautery was \napplied while no additional surgical procedure was \nperformed on the other two patients whose fibroids \nwere deep-seated. All except one of the laparoscopies \nwere completed successfully, and one case was con -\nverted to laparotomy due to unsuccessful visualization. \nIn one case, a trocar site hematoma followed by subse-\nquent abscess developed. There was no postoperative \nbladder dysfunction. As postoperative treatment, two \npatients with a diagnosis of endometriosis received \nprogesterone and one received GnRH analogue.\nMean preoperative V AS scores in the LUNEN \nand control groups were 7.59 ± 1.29 (range 6-10) and \n7.90 ± 1.58 (range 5-10) respectively (p=0.49). After \nsix months follow up the mean postoperative V AS \nscores were significantly lower in the LUNEN group \nthan in the control group (3.18 ± 2.88 versus 5.35 ± \n3.09; p=0.02) (Table 3).\nWhen asked about subjective assessment of pain \nin the 6th month, six patients in the LUNEN group \n(27%) stated that pain had totally disappeared after \nsurgery, twelve (55%) stated that pain had lessened, \nand four (18%) stated that there had been no change \nin pain. In the control group, while only two patients \n(10%) stated that pain had completely disappeared, six \n(30%) stated that pain was reduced and twelve (60%) \nstated that there was no change in the pain (p= 0.019) \n(Figure 1).\nTable 3. Preoperative and postoperative VAS scores (mean \n± Standard deviation)\nLUNEN group\n(n=22)\nControl group\n(n=20) p\nPre-operative \nVAS score 7.59±1.29 7.90±1.58 0.49\nPost-operative \nVAS score 3.18±2.88 5.35±3.09 0.02\nLUNEN: Laparoscopic uterine nerve ethanol neurolysis, VAS: \nVisual Analog Scale\nDISCUSSION\nCPP is a problematic syndrome that is seen in ap -\nproximately 15% of women of reproductive age, has \na multifactorial and complex etiology involving psy -\ncho-social and biological factors, and is quite difficult \nto resolve [16]. Developments in noninvasive methods \nsuch as TVUS and invasive techniques such as lapa -\nroscopy provide us with some opportunities to reveal \naccompanying pathologies that could be a cause of \npain in patients with CPP, but they do not always allow \n\nSönmez S, et al. Laparoscopic Uterine Nerve Ethanol Neurolysis\n11\nJ Clin Exp Invest  www.jceionline.org  Vol 7, No 1, March 2016\nus to solve the problem. In recent years, even though \ntechnological developments in endoscopy have made \nlaparoscopy a useful method in the differential diag -\nnosis and sometimes the surgical treatment of CPP, \nthe negative laparoscopy finding rate has ranged from \n8.2% to 63% [17-22]. In our study, 26.2% of the pa -\ntients showed normal pelvic findings in laparoscopy \n(31.8% of the LUNEN group versus 20% of the con -\ntrol group). Although these were selected cases we \nfound a relatively high rate of pelvic pathology cor -\nresponding to 73.8%. The two most common pelvic \npathologies were adhesion (40.5%) and endometriosis \n(21.4%). Although our study population composed of \nonly women without a history of pelvic surgery ex -\ncept for cesarean section, adhesion was still in the first \nplace. In the literature, the most frequent coexistence \nis with adhesion, as well [23-26]. Kontoravdis et al. \nperformed laparoscopy on 1629 patients with CPP and \nidentified adhesion in 577 (35.4%) of them [23]. How-\never, the mechanism of pain and the clinical benefit of \nadhesiolysis in pain relief are unclear in CPP patients \nwith pelvic adhesion. While there is no consensus, \nlocation, vascularity, thickness, and size of adhesions \nand the extent of restriction of movements of organs \ncaused by adhesions are considered the most important \nparameters involved in pain formation and its severity. \nWe performed adhesiolysis in all cases of adhesion. \nA recent study has shown that in patients with CPP, \ntreatment of concomitant adhesions (adhesiolysis) \nsignificantly improved six month postoperative V AS \nand QoL scores compared with the control group [25]. \nWhen it comes to endometriosis, this is known to be a \npathology affecting approximately 10% of women of \nreproductive age. Generally, although the severity of \npain is not well correlated with the severity of endo -\nmetriosis (AFS stage), it is positively correlated with \nthe total number of implants and with deep lesions es-\npecially with rectovaginal endometriosis [27]. Vercelli \net al. were able to identify endometriosis in 32.5% of \npatients [18]. In this study, despite excluding fixed \nretroverted uterus, uterosacral and Douglas nodularity \nand endometrioma, we still found a high rate of endo-\nmetriosis. Once again, these findings indirectly reveal \nthe importance of endometriosis and pelvic adhesions \nin the etiology of CPP.\nAlthough the management of CPP is challenging, \ntreatment should be first directed at the underlying \ncause. However, due to the fact that its pathogenesis \nis complex, multifactorial and poorly understood, the \npain can sometimes continue even though the ap -\nparent reason has been removed, and a non-specific \ntreatment is needed [2, 4, 5, 11, 12]. A recent meta-\nanalysis showed that the improvement effect of medi-\ncal treatments on pain and QoL is limited and many \nmedical treatments also bring significant side effects \nin many patients [28]. Although there are several well-\ndefined invasive approaches for the treatment of CPP \nin the literature, well-organized prospective random -\nized controlled studies are few [2, 11]. Traditionally, \nPSN and uterosacral resection techniques such as \nLUNA have been used to relieve pain in this group \nof patients, with differing success rates. Johnson et al. \nreported that LUNA was effective for dysmenorrhoea \nin the absence of endometriosis, although there was \nno evidence of the effectiveness of LUNA for non-\ndysmenorrhoeic CPP or for any type of CPP related to \nendometriosis [11]. While PSN is more effective than \nLUNA, this surgical technique can be applied only by \nexperienced surgeons who familiar with the anatomy \nof the retro-peritoneum, because skill is required in \naddition to the presence of a significant degree of op -\nerative risk. The surgical procedure is more complex \nand the operation time is also longer in PSN. For these \nreasons, LUNA is currently a preferable process [2, \n6, 11, 12]. While in surgical procedures the nerves \nare either cut or excised to interrupt the neural input, \nin neurolysis their microscopic neural architecture \nis chemically destroyed to interrupt the neural input \n[7, 14, 15, 29, 30, 31, 32]. In gynecological practice \ngenerally, neurolytic blocks are used in cancer-related \nCPP and in the form of percutaneous neurolytic supe-\nrior hypogastric plexus block [29]. Chemical neuroly-\nsis of the superior hypogastric plexus has occasionally \nbeen performed for non-cancer pelvic pain. Pollitt et \nal. presented a woman with endometriosis-related se -\nvere CPP, who was successfully treated with chemi -\ncal neurolysis of the superior hypogastric plexus [30]. \nAs for uterine nerve chemical neurolysis on the other \nhand, only one case of uterine nerve ethanol neuroly -\nsis, published by Walid and Heaton, has been reported. \nIn this paper, the authors reported the successful treat-\nment of a case of pelvic pain caused by trigger points \nin the uterosacral stumps, using alcohol neurolysis. \nThey highlighted the risk of voiding dysfunction after \nthe procedure and recommended a two-step approach \nwith an interval of two to three months [31]. In our \nseries, ethanol at 50% concentration and total dose of \n10 ml was used, and procedures were performed in \none step. No problem directly associated with the neu-\nrolysis procedure was observed; including urinary or \nother local complications or systemic toxicity. In the \nliterature on chemical neurolysis (intrathecal neuroly-\n\nSönmez S, et al. Laparoscopic Uterine Nerve Ethanol Neurolysis\n12\nJ Clin Exp Invest  www.jceionline.org  Vol 7, No 1, March 2016\nsis, sympathetic blockade, celiac plexus blockade and \nchemical hypophysectomy, etc.) alcohol is generally \nused in concentrations of 50% to 100%. Around 99% \nof the absorbed ethanol is rapidly metabolized by the \nliver enzymes, so in limited doses a systemic effect is \nnot expected and alcohol neurolysis is generally seen \nas a safe procedure [32]. \nThis study has several limitations. First, the sam-\nple size was relatively small, with a limited number \nof patients in both the study and control groups. Sec -\nond, there was a lack of randomization of the groups. \nThird, our follow up time was also short and we were \nnot able to have a reason to evaluate long-term pain \noutcomes of this method. Furthermore, the possible \ninfluence on QoL and physicosocial and sexual func -\ntions were not evaluated. Due to the surgical treatment \nof accompanying heterogeneous pelvic pathologies \nsuch as adhesion, endometriosis, fibroids and ovarian \ncysts, the conclusions drawn from this study are dif -\nficult for us to attribute to the results of ethanol neu -\nrolysis alone. Finally, some patients, especially those \nwith severe endometriosis, received postoperative \nGnRH analogue or progesterone which could reduce \nthe mean pain scores in this group of patients. Despite \nthis, our study also has strength aspects. First of all, \nthis is the first and only study evaluating the influence \nof LUNEN on pain scores in women with CPP. Sec -\nond, this was a controlled study design. Additionally, \nas well as an objective assessment of pain with V AS, \nwe also made a subjective evaluation by questioning \nthe patients’ satisfaction relative to the pre-treatment \npain condition. \nIn conclusion, this study once again confirmed \nthe importance of diagnostic laparoscopy in patients \nwith CPP by showing a concomitant pelvic pathology \nin most cases. In patients suffering CPP; LUNEN, in \ncombination with a specific treatment for underly -\ning or concomitant pelvic pathology if present, is a \nsimple, cheap, safe, and effective procedure that can \nbe practiced by all gynecological laparoscopists. We \nconsider it to be a very attractive procedure because \nof its potential simplicity and effectiveness. Neverthe-\nless, large prospective randomized controlled studies \nare needed comparing LUNEN with other conserva -\ntive methods, and especially with LUNA.\nDeclaration of Conflicting Interests: The authors de-\nclare that they have no conflict of interest. \nFinancial Disclosure: No financial support was re -\nceived.\nREFERENCES\n1. Duffy S. Chronic pelvic pain: defining the scope of the prob-\nlem (2001) Int J Gynaecol Obstet 2001;74:3-7.\n2. Palomba S, Russo T, Falbo A, et al. Laparoscopic uterine \nnerve ablation versus vaginal uterosacral ligament resec -\ntion in postmenopausal women with intractable midline \nchronic pelvic pain: A randomized study. Eur J Obstet Gy-\nnecol Reprod Biol 2006;129:84–91.\n3. Zondervan KT, Yudkin PL, Vessey MP, et al. Chronic pelvic \npain in the community symptoms, investigation, and diag -\nnoses. Am J Obstet Gynecol 2001;184:1149–1155.\n4. Stein SL. Chronic pelvic pain. Gastroenterol Clin North Am \n2013;42:785-800. \n5. Weijenborg PT, Greeven A, Dekker FW, et al. Clinical course \nof chronic pelvic pain in women. Pain 2007;132:117–123.\n6. Porpora MG, Gomel V . The role of laparoscopy in the man-\nagement of pelvic pain in women of reproductive age. Fertil \nSteril 1997;68:765–779.\n7. Carter JE. Surgical treatment for chronic pelvic pain. JSLS \n1998;2:129–139.\n8. Sharma D, Dahiya K, Duhan N, Bansal R. Diagnostic \nlaparoscopy in chronic pelvic pain. Arch Gynecol Obstet \n2011;283:295-297\n9. Demir F, Ozcimen EE, Oral HB. The role of gynecological, \nurological, and psychiatric factors in chronic pelvic pain. \nArch Gynecol Obstet 2012;286:1215-1220.\n10. Frankenhauser G. Die Bewegungenerven der Gebarmutter. \nZ Med Nat Wiss 1864;1:35.\n11. Johnson NP, Farquar CM, Crossley S, et al. A double-\nblind randomized controlled trial of laparoscopic uterine \nnerve ablation for women with chronic pelvic pain. BJOG \n2004;111:950–959.\n12. Daniels J, Gray R, Khan KS, Gupta J. Laparoscopic uterine \nnevre ablation: a survey of gynaecological practice in UK. \nGynecol Endosc 2000;9:157–159.\n13. Davis GD. Uterine prolapse after laparoscopic uterosac -\nral transection in nulliparous airborne trainees: a report of \nthree cases. J Reprod Med 1986;41:279-282.\n14. Patt RB. Cancer pain. In Patt RB(ed):Cancer Pain. Lippin -\ncott, Philadelphia, 1993, pp377-425.\n15. Rowe DS. Neurolytic techniques for pain management. \nPain Clin 1995; 8:107-115.\n16. Mathias SD, Kuppermann M, Liberman RF, et al. Chronic \npelvic pain: prevalence, health-related quality of life, and \neconomic correlates. Obstet Gynecol 1996;87:321–327.\n17. Kresch AJ, Seifer DB, Sachs LB, Barrese I Laparoscopy \nin the evalution of 100 women with chronic pelvic pain. \nObstet Gynecol 1984;64:672.\n18. Vercellini P, Fedele L, Molteni P, et al. Laparoscopy in the \ndiagnosis of gynecologic chronic pelvic pain. Int J Gynae -\ncol Obstet 1990;32:261-265.\n19. Levitan Z, Eibschitz I, de Vries K, et al. The value of lapa -\nroscopy in women with chronic pelvic pain and a “normal \npelvis”. Int J Gynaecol Obstet 1985;23:71-74. \n\nSönmez S, et al. Laparoscopic Uterine Nerve Ethanol Neurolysis\n13\nJ Clin Exp Invest  www.jceionline.org  Vol 7, No 1, March 2016\n20. Florido J, Pérez-Lucas R, Navarrete L. Sexual behavior and \nfindings on laparoscopy or laparotomy in women with se -\nvere chronic pelvic pain. Eur J Obstet Gynecol Reprod Biol \n2008;139:233-236.\n21. Drozgyik I, Vizer M, Szabo. Significance of laparoscopy in \nthe management of chronic pelvic pain. Eur J Obstet Gyne-\ncol Reprod Biol 2007;133:223-226\n22. Cox L, Ayers S, Nala K, Penny J. Chronic pelvic pain and \nquality of life after laparoscopy. Eur J Obstet Gynecol Re -\nprod Biol 2007;132:214-219\n23. Kontoravdis A, Chryssikopoulos A, Hassiakos D, et al. The \ndiagnostic value of laparoscopy in 2365 patients with acut \nand chronic pelvic pain. Int J Gynecol Obstet 1996;52;243-\n248.\n24. Carter JE. Laparoscopic finding in patients with chronic pel-\nvic pain. J Am Assoc Gynecol Laparoscopy 1994;2:43-47.\n25. Roseff SJ, Murphy AA. Laparoscopy in the diagnosis \nand therapy of chronic pelvic pain. Clin Obstet Gynecol \n1990;33:137-141.\n26. Cheong YC, Reading I, Bailey S, et al. Should women \nwith chronic pelvic pain have adhesiolysis? BMC Womens \nHealth 2014;14:36. \n27. Cornillie FJ, Oosterlynck D, Lauweryns J, Konnicks PR. \nDeeply infiltrating pelvic endometriosis; histology and \nclinical significance. Fertil Steril 1993;53:978-983.\n28. Cheong YC, Smotra G, Williams AC (2014) Non-surgical \ninterventions for the management of chronic pelvic pain. \nCochrane Database Syst Rev 2014 5;3: CD008797.\n29. De Leon-Casasola OA, Kent E, Lema MJ. Neurolytic su-\nperior hypogastric plexus block for chronic pelvic pain as -\nsociated with cancer. Pain 1993;54:145–151.\n30. Pollitt CI, Salota V , Leschinskiy D. Chemical neurolysis \nof the superior hypogastric plexus for chronic non-cancer \npelvic pain. Int J Gynaecol Obstet 2011;114:160-161.\n31. Walid MS, Heaton RL. Neurolysis with alcohol for deep \ndyspareunia caused by trigger points in the uterosacral \nstumps. J Minim Invasive Gynecol 2009;16:485-486. \n32. Singler RC. An improved technique for alcohol neurolysis \nof the celiac plexus. Anesthesiology 1982;56:137-141.","source_license":"CC0","license_restricted":false}