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An Ancillary Treatment for Midline Pelvic Pain


Presacral neurectomy—the resection of the hypogastric nervous plexus that innervates the uterus—is a safe and effective alternative for these women.

It can be done alone or concomitantly with any surgical treatment of coexisting endometriosis or other pelvic pathology.

Presacral neurectomy is not a simple procedure, however, and should not be attempted without appropriate training and preparation, or without careful patient selection.

The procedure does not alleviate adnexal pain or pelvic pain that is more lateral, and is indicated when medical management has failed.

Nonetheless, when patients are carefully selected, and when the procedure is performed by a skilled surgeon who follows the principles and technique described more than 80 years ago by Dr. M.G. Cotte, it can be effectively carried out with good long-term outcomes for the majority of patients who have disabling midline dysmenorrhea and deep central, chronic pelvic pain.

More and more, the procedure is being done laparoscopically with a lower rate of postoperative morbidity. Indeed, advances in minimally invasive surgery have renewed interest in the procedure after a period starting in the 1960s in which the introduction of nonsteroidal anti-inflammatory drugs and various regimens of hormonal suppression caused interest to wane.

Moreover, despite the fact that the data on presacral neurectomy historically have covered women with dysmenorrhea, nonetheless within modern medicine dyspareunia has become an additional indication for the procedure.

Cotte's Technique

Dr. M. Jaboulay first described the severance of sacral sympathetic afferent fibers for serious dysmenorrhea (using a posterior extraperitoneal approach) in 1899, and a variety of other procedures for nerve interruption subsequently evolved.

It took until 1937, however, for a description of presacral neurectomy to emerge.

Dr. M.G. Cotte is credited with performing the first presacral neurectomy in 1924, and 13 years later he reported 98% success after transection of the superior hypogastric plexus in 1,500 patients.

Dr. Cotte emphasized that the only nerve tissue that should be resected is that within what he called the interiliac triangle (now known as the “Triangle of Cotte”), and that resection of all nerve elements in the triangle is essential in order to maximize effectiveness and minimize complications.

This triangle is extremely important. Unfortunately, because of the perilous location of the sensitive plexus, there have been modifications made in the procedure throughout the years.

Results have thus been variable, and some groups have reported recurrence rates of pelvic pain after presacral neurectomy that are significantly higher than the rates achieved by Cotte and the rates that we—and others—are now achieving.

It is difficult to analyze these results and ascertain exactly what the problems were and why the procedures failed.

However, because those surgeons who follow Cotte's principles and technique are indeed achieving good long-term results, I suspect that patient selection in the other studies wasn't optimal, or that the procedure was performed in a manner different from that originally described by Cotte.

The Anatomy

The presacral nerve is actually almost always a plexus of nerves known as the superior hypogastric plexus. It is a direct extension of the aortic plexus below the aortic bifurcation.

The plexus spreads out behind the peritoneum in the loose areolar tissue lying over the fourth and fifth lumbar vertebrae.

Between the vertebrae and the presacral nerve lies the middle sacral artery. On the right of the presacral nerve lie the right ureter and the common iliac vein and artery. On the left lie the sigmoid colon, inferior mesenteric vessels, left iliac vessels, and the left ureter.

Within the Triangle of Cotte, then, the common iliac artery and ureter are on the right, and the common iliac vein is on the left. The inferior mesenteric, superior hemorrhoidal, and midsacral arteries are in the center of the prelumbar space.

The triangle is defined caudally by the sacral promontory and laterally by the common iliac arteries. The superior edge of the triangle is delineated by the aortic bifurcation.

Centrally and to the left, the multiple nerve fibers representing the presacral nerve—sometimes in bundles—run caudally from the aortic plexus above and through the interiliac triangle to form the superior hypogastric plexus. These fibers are buried in loose areolar tissue. They display no particular patterns and vary among individuals.

In fact, surgeons must be prepared to encounter variable anatomical findings, in addition to being prepared for potential bleeding problems that can result from the sensitive proximity to the aortic bifurcation, vena cava, and iliac vessels.

The Procedure

In our Cotte-based procedure, an operating laparoscope is inserted through a 10-mm cannula placed through an umbilical incision.

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