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Presacral Neurectomy

Presacral neurectomy, is the removal of a section of the superior hypogastric plexus (the group of nerves that conducts the pain signal between the uterus and the brain.) Although first described in the 19th century, the procedure was modified by Dr. M.G. Cotte in 1938 and described as complete removal of the tissue within the interiliac triangle, now known as the triangle of Cotte.

Laparoscopic presacral neurectomy (LPSN) following Cotte’s technique is the recommended treatment for central pelvic pain resistant to medication. Central pelvic pain, usually associated with endometriosis, is found in about 15% of cases of chronic pelvic pain. It has been shown that up to 74% of women undergoing a diagnostic procedure for cyclic pelvic pain are found to have endometriosis.

It is critical to note that presacral neurectomy should be done ONLY in selected patients with intractable, central pelvic pain. The procedure will not successfully treat pain on the right or left sides. If presacral neurectomy is performed on an improperly selected patient or Cotte’s technique is not followed explicitly, the procedure will not have the desired outcomes.


Images of Laparoscopic Presacral Neurectomy

Anatomy of Cotte’s Triangle

Presacral space after incision

Elevated nerve bundle

Left common iliac vein exposed

Healed presacral space


Dr. Nezhat’s publications on Presacral Neurectomy

Br J Obstet Gynaecol 1993 Feb;100(2):182.



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