Presacral neurectomy

Most of the sensory pathways from the pelvic viscera pass through the superior hypogastric plexus and inferior hypogastric plexus to the spinal columns. The excision of presacral nerve trunk results in the obstruction of the pain pathway from the hypogastric plexi to the spinal cord. Presacral neurectomy denervates the uterus and causes loss of some bladder sensation.[3] It is believed that pain fibers from the ovary and distal fallopian tubes travel through the ovarian plexus to the vagus nerve, and therefore, bypass the superior hypogastric plexus.[1]

First, a surgical incision is made of the peritoneum overlying the Sacrum#Promontory and extending this incision toward the aortic bifurcation. The inferior mesenteric artery is then identified as the left lateral border of the dissection. A surgical plane can then be carefully developed between the inferior mesenteric artery and the left common iliac vein.[1] The sacral promontory area is identified and can be infiltrated with vasoconstrictive solution or with the use of electrosurgery to reduce blood loss.[4]

Laparotomy or laparoscopy is the preferred route for PSN procedures. A PSN procedure can be safely completed in under an hour and patients discharged the day of surgery.[1][4]

Rarely chylous ascites (0.6%). 10–15% of patients experience minor bowel and urinary complaints.[1]

Presacral neurectomy is offered to patients for whom medical therapy for chronic pain relief has failed. The efficacy of the procedure is around 75-80%. Less than 1% of all patients suffer from major complications following the surgery.[5] There is no additional patient benefit of performing combined presacral neurectomy and uterine nerve ablation procedures.[1]