Obturator Nerve Injury in Robotic Pelvic Surgery: Scenarios and Management Strategies

Abstract

BackgroundObturator nerve injury (ONI) is an uncommon complication of pelvic surgery, usually reported in 0.2–5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). ObjectiveTo describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies. Design, setting, and participantsWe retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers. Surgical procedureONI was identified during PLND and managed according to the type of nerve injury. Results and limitationsThe management approach varies with the type of injury. Crush injury frequently occurs at an advanced stage of PLND. For a crush injury to the obturator nerve caused by a clip, management only requires its safe removal. Three situations can occur if the nerve is transected: (1) transection with feasible approximation and tension-free nerve anastomosis; (2) transection with challenging approximation requiring certain strategies for proper nerve anastomosis; and (3) transection with a hidden proximal nerve ending that may initially appear intact, but is clearly injured when revealed by further dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. ConclusionsONI is a preventable complication that requires proper identification of the anatomy and high-risk areas when performing pelvic lymph node dissection. Prompt intraoperative recognition and repair using the management strategies described offer patients the best chance of recovery without sequelae. Patient summaryWe describe the different ways in which the obturator nerve in the pelvic area can be damaged during urological or gynecological surgeries. This is a preventable complication and we describe how it can be avoided and different management options, depending on the type of nerve injury.