Uterosacral Nerve Ablation (LUNA) in India and UAE | Complete Patient Guide

• Women aged 18–50 with moderate-to-severe primary dysmenorrhea that has failed at least 3–6 months of first-line medical therapy (NSAIDs such as mefenamic acid or naproxen, and/or combined oral contraceptive pills or progestins)

• Patients with laparoscopically or histologically confirmed endometriosis (ASRM Stage I–IV) experiencing central, midline pelvic pain

• Women with adenomyosis-associated dysmenorrhea who wish to preserve uterine function (as an alternative or bridge to hysterectomy)

• Patients with chronic pelvic pain of central uterine origin unresponsive to GnRH agonists (e.g., leuprolide acetate) or levonorgestrel-releasing IUD therapy

• Candidates must have pain that is clearly midline and central in distribution; lateral pelvic pain is a contraindication and may indicate the need for Presacral Neurectomy instead

Required Diagnostic Workup Prior to LUNA:

• Transvaginal ultrasound (TVUS) to assess uterine morphology, endometrial thickness, and adnexal pathology

• MRI pelvis (with contrast if adenomyosis or deep infiltrating endometriosis is suspected) for precise anatomical mapping

• CA-125 serum levels (as a baseline marker for endometriosis activity, not diagnostic alone)

• Diagnostic laparoscopy with biopsy (gold standard for endometriosis staging per ASRM classification)

• Complete blood count (CBC), coagulation profile (PT/INR, aPTT), renal and hepatic function panels, and anaesthesia fitness assessment

• Cervical cytology (Pap smear) to exclude cervical pathology

• Urodynamic assessment if bladder symptoms are present (to establish baseline before any potential parasympathetic nerve disruption)

Contraindications:

• Lateral or unilateral pelvic pain not consistent with central uterine origin

• Active pelvic inflammatory disease (PID) or unresolved tubo-ovarian abscess

• Suspected or confirmed pelvic malignancy (requires oncologic evaluation prior to any nerve ablation)

• Severe uterine retroversion with dense adhesions obscuring safe uterosacral ligament identification

• Pre-existing bladder dysfunction or bowel dysmotility (LUNA may risk worsening parasympathetic innervation)

• Patients who have completed childbearing and are candidates for definitive surgery (hysterectomy ± bilateral salpingo-oophorectomy) may be better served by a more definitive procedure

• Coagulopathy or inability to withstand general anaesthesia

LUNA is exclusively performed under general anaesthesia via a laparoscopic approach. The following techniques and platforms are available at GAF Healthcare partner institutions:

1. Standard Laparoscopic LUNA (Electrosurgical Transection): The most widely performed technique. A 10–12 mm umbilical port is established using a Veress needle or Hassan open entry technique, followed by two 5 mm accessory ports in the lower quadrants. The uterosacral ligaments are identified at their insertion into the posterior cervix, lateral to the midline. A 1–2 cm segment of each ligament is excised or coagulated using bipolar electrosurgery (e.g., LigaSure or Gyrus PK system) or monopolar scissors. The retroperitoneal course of both ureters must be visualized or identified by transillumination prior to energy application to prevent ureteric injury. CO2 laser vaporization (10,600 nm wavelength, focused beam) may be used as an alternative energy modality, offering precise tissue ablation with 0.1–0.5 mm lateral thermal spread, reducing collateral damage.

2. CO2 Laser Laparoscopy: Preferred in centers with advanced laser gynecology infrastructure (common in UAE tertiary centers and select Indian NABH-accredited hospitals). The laser is delivered through a dedicated laparoscopic coupler and allows simultaneous ablation of endometriotic implants, adhesiolysis, and LUNA in a single operative session. Tissue penetration depth is controlled by pulse duration and power settings (typically 15–30 W in superpulse mode), minimizing thermal artifact on adjacent peritoneum and neurovascular bundles.

3. Robotic-Assisted Laparoscopic LUNA (da Vinci System): Available at select JCI-accredited centers in India (Apollo, Fortis, Manipal) and UAE (Cleveland Clinic Abu Dhabi, Mediclinic City Hospital Dubai). Robotic assistance provides 3D stereoscopic visualization (10–15× magnification), articulated Endowrist instruments with 7 degrees of freedom, and tremor filtration — particularly advantageous when LUNA is combined with deep infiltrating endometriosis (DIE) excision, ureterolysis, or rectovaginal nodule resection. Robotic LUNA is the preferred approach when significant parametrial adhesions or anatomical distortion is anticipated.

4. LUNA Combined with Laparoscopic Excision of Endometriosis (LEE): Contemporary evidence (RCOG Green-top Guideline, ESHRE Endometriosis Guidelines 2022) supports performing LUNA as an adjunct — never as a standalone procedure — particularly when endometriosis is the underlying etiology. Combining LUNA with complete excision (not just fulguration) of endometriotic lesions using cold scissors or CO2 laser has demonstrated superior pain outcomes compared to LUNA alone, with NRS pain reduction of 40–60% at 12 months in published series.

5. Medical Bridge Therapy (Adjunct to LUNA): Preoperative GnRH agonist therapy (leuprolide acetate 3.75 mg IM monthly × 3 months) may be used to reduce endometriotic implant vascularity and lesion volume, facilitating safer surgical dissection. Postoperatively, patients are typically maintained on continuous combined oral contraceptives, progestin-only therapy (dienogest 2 mg/day — preferred for endometriosis), or a levonorgestrel-releasing IUS (Mirena) to suppress recurrence and consolidate the pain relief achieved by the ablation.

PHASE 1 — PRE-TRAVEL & CONSULTATION (Weeks 1–3 Before Procedure):

• GAF Healthcare assigns a dedicated medical coordinator who reviews your complete medical records, imaging (TVUS, MRI pelvis), prior surgical reports, and pain history

• A virtual consultation is arranged with the treating gynecologist (laparoscopic or robotic surgery specialist) at the partner hospital in India or UAE

• Diagnostic gaps are identified: if diagnostic laparoscopy has not been previously performed, LUNA may be planned as part of a combined diagnostic-operative session

• Pre-travel medical clearance checklist issued; patients discontinue anticoagulants (if any) 5–7 days prior per anesthesiologist guidance

• E-Medical Visa (India) or UAE entry visa processing initiated by GAF Healthcare

PHASE 2 — ARRIVAL & PRE-OPERATIVE ASSESSMENT (Day 1–2 in Country):

• Airport pickup by GAF Healthcare's ground team; transfer to hospital or partner accommodation

• In-hospital pre-operative workup: CBC, coagulation panel, renal/liver function, ECG, anaesthesia assessment, and repeat TVUS if required

• Bowel preparation may be prescribed if combined endometriosis excision or adhesiolysis is planned

• Informed consent process with surgeon and anaesthesiologist; operative plan confirmed

• NPO (nil per os) from midnight before the procedure

PHASE 3 — THE PROCEDURE (Day 2 or 3):

• General endotracheal anaesthesia administered; Trendelenburg positioning (15–20°) established

• Laparoscopic entry and pneumoperitoneum (CO2, 12–15 mmHg) established

• Systematic pelvic survey: bilateral adnexa, uterus, cul-de-sac, bladder peritoneum, and appendix assessed

• Uterosacral ligaments identified bilaterally; ureters confirmed safe via direct visualization or transillumination

• LUNA performed (electrosurgical, laser, or robotic technique per preoperative plan); if combined with endometriosis excision, all visible lesions addressed

• Operative time: 30–60 minutes for LUNA alone; 60–180 minutes for combined procedures

• Intraoperative photographs and video documentation provided to patient

PHASE 4 — IMMEDIATE POST-OPERATIVE RECOVERY (Day 3–4):

• Recovery in PACU (Post-Anaesthesia Care Unit) for 2–4 hours

• Multimodal analgesia: IV paracetamol, ketorolac, and low-dose opioid rescue as needed

• Urinary catheter removed within 4–6 hours post-procedure; ambulation encouraged same day

• Diet resumed: clear liquids on Day 1 post-op, soft diet by evening

• Hospital discharge typically Day 1 post-procedure (23-hour stay) unless combined procedure requires overnight monitoring

PHASE 5 — IN-COUNTRY RECOVERY BEFORE FLYING (Days 4–14):

• GAF Healthcare accommodation (serviced apartment or hotel) arranged near the hospital for patient and one attendant

• Follow-up clinic visit on Day 5–7: wound check, histopathology results review (if biopsies taken), and bladder/bowel function assessment

• Light walking encouraged from Day 1; avoid strenuous activity, heavy lifting (>5 kg), and sexual intercourse for 4 weeks

• Bloating and mild shoulder-tip pain (referred from residual CO2 gas) resolve within 48–72 hours

• Postoperative hormonal therapy (dienogest or COC) initiated as prescribed

• Fit-to-fly assessment performed at Day 7–10 follow-up visit; international flight approved if no complications (wound healing satisfactory, no urinary symptoms, no fever)

PHASE 6 — LONG-TERM RECOVERY AT HOME (Weeks 2–8):

• Return to desk work: 1–2 weeks post-procedure

• Return to moderate physical activity (yoga, swimming): 3–4 weeks

• Return to full physical exercise: 4–6 weeks

• First menstrual period post-LUNA may be heavier or irregular; expected to normalize over 2–3 cycles

• Pain reassessment at 3, 6, and 12 months post-procedure via GAF Healthcare's teleconsultation follow-up program

• If dysmenorrhea recurrence is noted beyond 6 months, reassessment for residual endometriosis or consideration of Presacral Neurectomy (PSN) is recommended