Introduction: Obturator Nerve Injury (ONI) is a rare complication reported in 0.2% to 5.7% of pelvic surgeries. The most significant risk factor for ONI is pelvic lymph node dissection (PLND). ONI can be classified as crush and transection injuries, which have different management strategies. We present a series of robotic ONI and how each injury was managed.
Methods: Crush injury with a clip is managed with its removal, and transection injury with epineural end-to-end anastomosis using 7-0 polypropylene suture. However, re-approximation of the nerve can be challenging. If a difficult repair is encountered, the hip flexion maneuver or the use of a cadaveric nerve graft can be used. If the transection injury is difficult to locate, medialization of the external iliac vessels can be performed.
Results: Five cases of ONI are presented. The first case demonstrates a right distal crush ONI with Hem-o-lok® during right PLND in a robotic-assisted laparoscopic prostatectomy (RALP). The clip was safely removed by grasping the clip firmly near the tip and prying it open. The second case demonstrates a left proximal transection ONI with cold scissors during left PLND in a RALP. Re-approximation was feasible without tension for adequate anastomosis. The third case demonstrates a right proximal transection ONI with EndoWrist® stapler during lateral bladder pedicle dissection in a robotic-assisted radical cystectomy (RARC). Initial attempts to approximate both cut nerve endings were unsuccessful. The patient was repositioned intraoperatively: the legs were flexed at the hip out of extended lithotomy in Trendelenburg, this allowed both nerve endings to be approximated for adequate anastomosis. The fourth case demonstrates a right distal transection ONI with EndoWrist® stapler during lateral bladder pedicle dissection in a RARC. Despite several attempts to approximate both cut nerve endings, the use of a cadaveric nerve graft for anastomosis was required. The last case demonstrates a right proximal transection ONI with hot scissors during right PLND in a RALP. The injury location was not precise. Medialization of the external iliac vessels revealed a longer nerve course and a complete proximal transection. The epineural end-to-end anastomosis was completed.
Conclusions: Proper identification of the anatomy and the critical areas for nerve injury may prevent an ONI. Timely recognition and prompt repair give patients the best chances for recovery without sequela.