Obturator Nerve Research Articles

V10-11 INTRAOPERATIVE COMPLICATIONS OF ROBOTIC-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL URINARY DIVERSION

You have accessJournal of UrologyLower Tract Reconstruction (V10)1 Sep 2021V10-11 INTRAOPERATIVE COMPLICATIONS OF ROBOTIC-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL URINARY DIVERSION David G. Ortega, Michael Chevinsky, Ryan Powers, Anibal La Riva, Laura C. Perez, Aref S. Sayegh, Erik P. Castle, John W. Davis, Monish Aron, Mihir M. Desai, Inderbir S. Gill, and Rene Sotelo David G. OrtegaDavid G. Ortega More articles by this author , Michael ChevinskyMichael Chevinsky More articles by this author , Ryan PowersRyan Powers More articles by this author , Anibal La RivaAnibal La Riva More articles by this author , Laura C. PerezLaura C. Perez More articles by this author , Aref S. SayeghAref S. Sayegh More articles by this author , Erik P. CastleErik P. Castle More articles by this author , John W. DavisJohn W. Davis More articles by this author , Monish AronMonish Aron More articles by this author , Mihir M. DesaiMihir M. Desai More articles by this author , Inderbir S. GillInderbir S. Gill More articles by this author , and Rene SoteloRene Sotelo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002061.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic-assisted radical cystectomy with intracorporeal urinary diversion (RARC-ICUD) is now widely considered a standard of care treatment for muscle invasive bladder cancer with equivalent oncologic and functional outcomes compared to traditional open radical cystectomy with extracorporeal urinary diversion. RARC and ICUD each pose their own unique set of intraoperative challenges, which must be overcome and may contribute to its high complication rate. In one study of 132 patients who underwent RARC-ICUD, 30-day and 30 to 90-day complication rates were 47% and 27%, respectively. Herein, we present some of the most common intraoperative complications during RARC-ICUD and describe how to recognize and avoid them. METHODS: A compilation of video clips was collected anonymously from several surgeons to demonstrate the different intraoperative complications during RARC-ICUD. Complications were divided into those which arise during the RARC and those which arise during the ICUD. The cystectomy complications shown are multiple rectal injuries during the posterior plane dissection, sponge-stick inadvertently placed in the rectum instead of the vagina, obturator nerve injury while stapling the bladder pedicles. The reconstructive complications included right iliac artery injury during the mesenteric window creation, bowel serosa injury due to excessive traction, and several stapling complications during the ileo-ileal anastomosis such as ureter stapling to the bowel, adjacent bowel stapling, inadvertent stapling outside the lumen of the bowel, and staple line bleeding. RESULTS: Increases in operative time of patients experiencing an intraoperative complication are expected. Higher blood loss can be seen if vascular structures are involved. Increases in length of hospital stay may occur depending on the type of complication, and sequelae can occur. CONCLUSIONS: Many of the common intraoperative complications of RARC-ICUD can be easily recognized and often avoided when careful attention is paid to each step of the surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e758-e758 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information David G. Ortega More articles by this author Michael Chevinsky More articles by this author Ryan Powers More articles by this author Anibal La Riva More articles by this author Laura C. Perez More articles by this author Aref S. Sayegh More articles by this author Erik P. Castle More articles by this author John W. Davis More articles by this author Monish Aron More articles by this author Mihir M. Desai More articles by this author Inderbir S. Gill More articles by this author Rene Sotelo More articles by this author Expand All Advertisement Loading ...

Anesthesia for knee arthroscopy: which nerves should be blocked?

Nowadays knee arthroscopy is the most common orthopedic procedure. It is used to diagnose and treat various pathological conditions. Usually knee arthroscopy can be performed using spinal anesthesia. The article presents a successful experience of using a combined technique, which consist in a unilateral subarachnoid anesthesia with additional adductor canal block and blocks of the articular branches of the sciatic and obturator nerves.

Cadaveric investigation of the minimum effective volume for ultrasound-guided suprainguinal fascia iliaca block

BackgroundThis cadaveric dose-finding study investigated the minimum effective volume of dye in 90% of cases (MEV90), required to stain the femoral, lateral femoral cutaneous and obturator nerves for ultrasound-guided suprainguinal...

Transurethral resection of bladder tumor surgery conducted using epidural anesthesia and obturator nerve block in an elderly multimorbid male

Epidural Anesthesia (EA) is mainly used for perioperative and postoperative analgesia, usually combined with Spinal Anesthesia (SA) or General Anesthesia (GA). It is safe, easy to perform, and has multiple applications. The benefits of Regional Anesthesia (RA) over general anesthesia include superior analgesia, reduced opioid consumption, reduced pulmonary complications, improved gastrointestinal function, early mobilization, a reduced need for thrombo-prophylaxis, early discharge, and higher patient satisfaction. Anesthesia for urological surgeries has unique problems due to patient factors and procedure complexity. An 84-year older man with a known history of hypertension/ Coronary Artery Disease (CAD)/ complete Left Bundle Branch Block (LBBB)/ dilated cardiomyopathy/ glottic carcinoma/ mixed airway disease, with an ejection fraction of 30%, was scheduled to undergo Transurethral Resection of Bladder Tissue (TURBT) for carcinoma bladder mass. It was done under EA and an ipsilateral obturator nerve block.

Gross post-mortem and histological features in 27 horses with confirmed lumbosacral region pain and five control horses: A descriptive cadaveric study.

There is a lack of understanding of the pathological and/or physiological nature of lumbosacral region pain. To describe the gross variations of the osseous and soft tissues of the lumbosacral region and report the histological findings of sections of nerve tissue in affected and control horses. Descriptive post-mortem case series. All horses had undergone full clinical and gait assessment, including ridden exercise. Horses with a substantial response to infiltration of local anaesthetic solution around the sacroiliac joint regions were included in the affected group (n=27). Horses for which the source(s) of pain was confirmed by diagnostic anaesthesia to be distant to the lumbosacral region were included in the control group (n=5). The pelvic regions were isolated and the soft tissues were assessed grossly. Sections of the lumbosacral plexus and cranial gluteal, sciatic and obturator nerves were examined histologically. The osseous specimens were evaluated for anatomical variants and abnormalities. Data were analysed using descriptive statistics. Gross discolouration of the sciatic or obturator nerves was observed in 7 (26%) affected and no control horses. Grade 3/3 histological abnormality scores were assigned in 22% of nerve sections from affected horses compared with 3% from control horses. Several osseous variants (bifid sacral spinous processes, straight-shaped sacroiliac joint surface, short arrow-shaped sacral alae, left-right asymmetry of sacral alae, sacral curvature, absence of the fourth to fifth and ankylosis of the fifth to sixth lumbar articular process joints, left-right asymmetry of caudocranial position of the fourth to fifth and lumbar-sacral articular process joints) and abnormalities (sacroiliac enthesopathy, extra ventral sacroiliac joint surface, lumbosacral symphyseal periarticular modelling, lumbosacral intertransverse joint pitting lesions) were more frequently observed in affected horses. Both control and affected horses may have had preclinical abnormalities. Lumbosacral region pain may reflect the presence of a number of pathological changes. Neural pain may play an important role in some horses.

Groin Pain - Weightlifter

HISTORY: A 25 y.o. male weightlifter presented for progressive R groin pain over the past 4 months. He describes gradual onset of intermittent sharp pain located over the anterior groin with radiation down the anterior thigh to the knee. Associated with numbness/tingling in the same distribution and swelling in the R groin. The pain and numbness recently began radiating to the R low back and waking him up at night. Symptoms are aggravated by prolonged standing, sitting, squatting and lifting. He denies focal weakness, change in bowel/bladder function, fevers, chills, night sweats or weight loss. PHYSICAL EXAMINATION: Gait: Normal. Inspection: Unremarkable. Palpation: TTP in the RLQ and groin with fullness. ROM: Full and symmetrical. Strength: Painful 5/5 hip flexion, abduction and adduction. Positive Thomas test. Negative femoral log roll, FADIR, FABER, Trendelenberg. Negative SLR. Neuro: Decreased sensation to light touch over anterior thigh. 2+ patellar and achilles DTR. Intact heel/toe walk. Vascular: DP pulses 2 + . DIFFERENTIAL DIAGNOSIS: 1. Lumbar radiculopathy 2. Meralgia paresthetica 3. Hip flexor/iliopsoas strain 4. Athletic pubalgia 5. Pelvic mass TEST AND RESULTS: XR: Unremarkable. US GROIN: Benign b/l lymphadenopathy w/o hernia or suspicious findings. MR L-SPINE: Unremarkable L-spine. Partially-imaged large R retroperitoneal lesion. CT ABD/PELVIS W CONTRAST: Heterogeneous mass arising from the R psoas muscle (8.5 x 6.4 x 7.5 cm) with calcifications at the inferior aspect. The mass displaces and compresses the R common iliac a/v and encases the R external iliac a/v. CT CHEST WO CONTRAST: No evidence of intrathoracic metastatic disease. FINAL WORKING DIAGNOSIS: Right retroperitoneal pelvic sarcoma with involvement of right external iliac artery and vein TREATMENT AND OUTCOMES: Core needle biopsy showed a low grade spindle cell myofibroblastic neoplasm. Given the lesion’s aggressive appearance, however, this likely represented a sampling of reactive tissue adjacent to an unsampled high grade sarcoma. He underwent radical resection of retroperitoneal pelvic mass with segmental resection and anastomosis of the R external iliac artery and vein, extensive ureterolysis of R ureter and neurolysis of R femoral and obturator nerve. Pathology results are pending and will guide further multimodality treatment.

QS2: Schwann Cell Characteristics, Myelination Parameters and Histomorphometric Analysis of Nerve Biopsies in Polyneuropathy Patients Compared to Controls

Purpose:Polyneuropathy is a debilitating condition characterized by distal sensory and motoric deficits. Common risk factors in Western countries include diabetes, alcohol abuse, cytostatic drugs and cardiovascular disease. Vascular and neurochemical factors affect cells of the peripheral nervous system. Schwann cell dysfunction and impaired nerve regeneration are important pathophysiological mechanisms that are associated with changes in cellular metabolism, signal transduction and neurotrophic signaling. In experimental models of polyneuropathy, Schwann cell dysfunction and altered myelination were described. Clinically, there is very limited knowledge about Schwann cell characteristics and function in polyneuropathy patients. In this study, we investigated Schwann cell characteristics, nerve fibers and myelination parameters in nerve biopsies obtained from polyneuropathy patients compared to controls.Methods:Nerve tissue was obtained from polyneuropathy patients (n = 10) undergoing diagnostic sural nerve biopsies. Biopsies of healthy peripheral nerves (n = 10) were harvested during reconstructive procedures (e.g. sural nerve grafts, denervation of muscle flaps). Exclusion criteria for the healthy control group included recent neurological trauma, diabetes, neurological and cardiovascular disease, as well as treatment with cytotoxic medication in the previous 12 months. The over-all architecture of nerve sections and myelination parameters were histomorphometrically analyzed. Immunofluorescent imaging was used to evaluate Schwann cell phenotypes, senescence markers and myelination parameters. Immunofluorescent signals were quantified using NIS-Elements imaging software (Nikon Instruments Inc.).Results:The mean age of the included polyneuropathy patients (7 male and 3 female) undergoing diagnostic sural nerve biopsy was 57.3 years (SD 13.04; range 29 - 76 years). Control biopsies were obtained from patients undergoing reconstructive procedures. Three sural nerves, 3 obturator nerves, 2 thoracodorsal nerves, 1 superficial peroneal nerve and 1 medial antebrachial cutaneous nerve were analyzed. In the control group which included 2 male and 8 female patients, the mean age was 46 years (SD 13.384; range 28 - 64 years). Histomorphometric analysis of nerve biopsies showed a significant reduction in axon numbers from 3184 in the control group to 1373.3 in the polyneuropathy group (p = 0.035). Axon density and G-ratio were also significantly lower in polyneuropathy patients (p = 0.001 and p = 0.015, respectively). Immunofluorescent staining concurred with histomorphometric findings, as S-100 (p = 0.0017) and Neurofilament-H (p < 0.0001) signals were significantly reduced compared to controls. Immature p75-positive Schwann cells were identified in nerve biopsies of polyneuropathy patients. Myelin-basic protein was significantly reduced in the polyneuropathy group compared to the control (p < 0.0001).Conclusion:Significantly lower axon numbers, reduced myelination and the presence of immature Schwann cell phenotypes were identified in nerve biopsies of polyneuropathy patients compared to control patients. This underlines the clinical importance of Schwann cell dysfunction in polyneuropathy.

Obturator nerve block does not provide analgesic benefits in total hip arthroplasty under multimodal analgesic regimen: a randomized controlled trial

Background and objectivesAlthough regional analgesia is considered an important component of optimal pain management, use of peripheral nerve blocks for total hip arthroplasty remains controversial. Since the obturator nerve innervates...

Anatomical Reasoning for Atraumatic Trocar Placement during Implantation of a Transobturator Suburethral Sling

The aimof this research was to study the variant anatomy of the obturator complex in terms of surgical treatment of stress urinary incontinence, as well as to determine the most atraumatic technique for conducting a surgical trocar for a transobturator suburethral sling.Material and methods.A suburethral sling was implanted on 40 sagittally dissected samples of the female pelvis with preserved soft tissues using two techniques: the conventional one based on the use of external landmarks and the technique of the trocar rotation around the lower branch of the pubic bone developed at the University Clinic of St. Petersburg. After implantation of a transobturator suburethral sling, the probability of injury to the branches of the obturator nerve was assessed by precision preparation for each of the presented techniques using 40 samples. It was also suggested to develop a protocol for atraumatic placement ofa sling for stress urinary incontinence.Results. Based on the results obtained and study of the topographic relationships of the trocar and branches of the obturator nerve, it is concluded that the obturator complex has significant anatomical variability. This relates to both the muscular component –the internal and external obturator muscles, and neurovascular structures. The obturator nerve has two types of branching: joint and separate. The latter is a risk factor for intraoperative nerve injury. The technique of suburethral sling implantation by rotating the surgical trocar around the inferior branch of the pubic bone is atraumatic and safe.Conclusions.Variant anatomy of the obturator complex influences the probability of trauma in a transobturator suburethral sling implantation. In particular, the separate branching of the obturator nerve is a risk factor for its intraoperative injury. Further clinical studies are required to assess the outcomes of surgical t reatment of stress urinary incontinence taking into account the variant anatomy of the true pelvis.

An Unusual Complication of Retropubic Midurethral Sling Placement: Obturator Neuralgia

Midurethral sling placement is a common treatment for female stress urinary incontinence. We report a case of a woman with a 9-month history of significant pelvic and right lower extremity pain following synthetic retropubic sling placement at an outside facility. On evaluation, she had unilateral obturator neuropathy and underwent combined vaginal, and robotic excision of the right arm of the sling. During surgery, the sling was adherent to the obturator nerve and passed laterally through the obturator fossa. Following removal, her pain completely resolved. This case highlights strategies for preventing, diagnosing, and managing an unusual complication of retropubic sling placement, obturator neuralgia.

Cooled Radiofrequency Ablation of the Articular Sensory Branches of the Obturator and Femoral Nerves using Fluoroscopy and Ultrasound Guidance: A Large Retrospective Study

We previously reported on a combined technique and initial data of hip denervation using an anterior approach and cooled radiofrequency. A large retrospective study to evaluate the long-term effectiveness of cooled radiofrequency ablation (CRFA) in the general chronic hip pain population. Retrospective electronic chart review. A single specialty private practice. Retrospective chart review of 235 consecutive (CRFA) in 136 patients with chronic hip pain. Out of 235 CRFA, 178 (96 initial procedures and 82 repeats) were performed in 84 patients with 12 or more months follow-up. The average decrease in visual analog scale (VAS) pain scores was 7.3 ± 1.3 to 2.3 ± 1.5 and 2.48 ± 1.5 for the first and second diagnostic block, respectively, and was statistically significant (P < 0.001). Similarly, the average decrease in VAS pain scores at 6 and 12 months after CRFA denervation was 3.44 ± 2.5 and 4.23 ± 2.5, respectively; P < 0.001. Out of the 96 initial procedures in 84 patients, 66 procedures (69%) provided more than 50% relief at 6 months, and 50 (52%) at 12 months. There were 82 repeat denervations in 36 patients. Repeated procedures in the same patients provided a similar degree of pain relief with no statistically significant difference in the median pain scores (2.8 ± 2.1 cm vs 3.1 ± 1.7 cm ; P = 0.197) or time interval of pain relief (12.7 ± 10.9 vs 10.3 ± 4.7; P = 0.508). There were 3 minor complications. Retrospective nature of the study. Improvements in pain scores and longevity of pain relief from chronic hip pain using a simple, anterior approach to radiofrequency denervation of the lateral obturator and lateral femoral nerves justifies further randomized prospective trials. Repeated CRFAs demonstrated consistency in pain relief and absolute safety of repeated denervation.

Revisiting the Muscular Innervation of the Obturator Nerve: Application to Neurotization Procedures.

Our goal was to revisit the innervation of the adductor muscles of the thigh and add new evidence to currently existing knowledge. Ten thighs from five fresh frozen cadavers were dissected. Obturator nerve innervation to the pectineus, obturator externus, adductor brevis, adductor magnus, adductor longus, and gracilis was documented. The adductor longus and gracilis were innervated by the anterior branch in 100%, and the adductor magnus was innervated by the posterior branch in 100%. The adductor brevis was supplied by both the anterior and posterior branches in 90%. The obturator externus was innervated by the posterior branch in 60% and a direct branch from the main trunk in 10%. No innervation of the obturator externus by the obturator nerve was found in 30%. The obturator externus and adductor brevis need to be explored further to clarify their innervation.

Morphologic classification and innervation patterns of the pectineus muscle.

The purpose of this study was to identify the frequency of pectineal hiatus and of pectineus innervations, including femoral, obturator, and/or accessory obturator nerves. Also, this study sought to detailed intramuscular nervous distributions, with a particular focus on the relationship of nerves in multi-innervated pectineus. One hundred (49 right and 51 left) thighs from 52 cadavers (25 men and 27 women) were dissected. The morphology and innervations of the pectineus were investigated. Modified Sihler's whole-mount nerve-staining method was employed for visualization of the intramuscular nerve-distribution patterns of the pectineus. Variation of the pectineus forming a hiatus was identified in 18% of the specimens. The femoral innervations to the pectineus were identified in all specimens. Additional innervation either by the obturator or the accessory obturator branch to the pectineus was identified in 10% or 2% of specimens, respectively. No case of triple innervation to the pectineus was observed. In cases of dually innervated pectineus, two nerves formed a communication system inside the muscle. Among the three nerves supplying the pectineus, the femoral nerve branched more than the other two nerves and covered the greatest area in the muscle. The pectineal hiatus appears to be a common variation. The femoral nerve branch in a dually innervated pectineus is the dominant nerve component that supplies the muscle when considering frequency, branching pattern, and area, even though cooperation between two nerve components is implied. This study serves to advance the existing anatomical knowledge about the pectineus muscle, which is of clinical value.

Sciatic-to-Femoral Nerve End-to-End Coaptation for Proximal Lower Extremity Function in Patients With Acute Flaccid Myelitis: Technical Note and Review of the Literature.

Acute flaccid myelitis (AFM) is an acute-onset anterior horn disease resulting in flaccid paralysis of extremities, trunk, facial, and cervical musculature in children following upper respiratory or gastrointestinal viral illness. Nerve transfer procedures have been shown to restore function. To present a technical description of sciatic-to-femoral nerve transfers in 4 children with AFM. Retrospective review of relevant cases was performed. A total of 4 cases are presented of young children with persistent quadriparesis in the setting of AFM, presenting between 4 and 15 mo following initial diagnosis. Electromyography showed denervation of muscles innervated by the femoral nerve, with sparing of the sciatic distribution. The obturator nerve was also denervated in all patients. We therefore elected to pursue sciatic-to-femoral transfers to restore active knee extension. These transfers involved end-to-end coaptation of a sciatic nerve fascicle to the femoral nerve motor branches supplying quadriceps muscles. We present technical descriptions of bilateral sciatic-to-femoral nerve neurotization for the restoration of quadriceps function in 4 patients with AFM. The sciatic nerve fascicles are a reasonable alternative donor nerve for patients with proximal muscle paralysis and limited donor options in the lower extremity.

A COMPARATIVE STUDY BETWEEN CLASSIC AND INTERADDUCTOR APPROACH OF OBTURATOR NERVE BLOCK WITH ROPIVACAINE IN PATIENTS UNDERGOING TRANSURETHRAL RESECTION OF BLADDER TUMOUR UNDER SPINAL ANAESTHESIA.

Background: The most signicant use of ONB i.e., obturator nerve block is to prevent adductor muscle contraction associated with Transurethral resection of bladder tumours (TURBT). Adductor jerk during TURBT may cause serious injury to urinary bladder like laceration with involvement of blood vessels, severe bleeding, bladder wall tear and perforation and even partial resection of bladder tumour due to frequent distraction and interruption to the surgeon.1 So, there is need for evaluation and comparison of different techniques of ONB in view of safety and efcacy. We have conducted a randomized clinical study to compare the classic pubic and inter adductor approach for ONB with spinal anaesthesia for transurethral resection of bladder wall tumour masses. Method: A total number of 50 patients of either sex of ASA physical status I or II, of age group 30-75 years, who were posted for TURBT operation under spinal anaesthesia, were included in this study. A Prospective single blind randomised controlled trial and cross over study was conducted. Peripheral nerve stimulator to localize the nerve and Inj. Ropivacaine 0.5% ,15 ml on each side was used in this study. Result: The overall success rate in classic pubic approach was slightly lower than interadductor approach which was statistically insignicant. There were more instances of vessel puncture in pubic approach, which was statistically signicant (p value = 0.016). There was no incidence of other signicant complications. Conclusion: In terms of ease of obturator nerve block and incidence of complications the interadductor approach is better than classic pubic approach.

Excision of Deep Endometriosis Nodules of the Sciatic Nerve in 10 Steps

To present 10 standardized and reproducible surgical steps allowing for complete excision of deep endometriosis nodules involving the sciatic nerve. Surgical education video. The local institutional review board confirmed that the video met the ethical criteria required for publication. Patient consent was obtained. Tertiary referral center. The excision of deep endometriosis involving the sciatic nerve may be performed following 10 steps: (1) Longitudinal incision of the peritoneum covering the external iliac artery, from the hypogastric vessels to the round ligament and the identification of the genitofemoral nerve. (2) Dissection of the iliolumbar space identified laterally by the psoas muscle and medially by the external iliac artery and vein [1-5]. (3) Identification of the obturator nerve. The dissection is performed on contact with the psoas muscle; when the nerve is surrounded by the nodule, its releasing is progressively carried out. (4) Identification of the obturator vessels, which cross the obturator nerve beneath and follow a lateral direction. (5) Opening of the lumbosacral space, below the level of the obturator nerve, and the identification of the sciatic nerve, resulting from the confluence of L4 to S3 roots. During this step, the deep endometriosis nodule is identified on contact with the greater sciatic foramen. (6) Opening of the broad ligament, between the external iliac vessels and the umbilical artery, and identification of the obturator nerve, as it is usually performed in pelvic lymphadenectomy. The surgeon may either perform a separate incision of the posterior leaf of the broad ligament and medial to the infundibulo-pelvic ligament or prolong medially the incision made at step 1. (7) Identification of the sciatic nerve, which is seen below and medially from the obturator nerve and obturator vessels. During this step, the posterior limit of the nodule is identified. (8) Identification of sacral roots S1, S2, and S3 [6]. The pudendal nerve and the posterior femoral cutaneous nerve may be identified below the S3 and medially from the sciatic nerve and before their exit through the greater sciatic foramen. The posterior and medial limit of the nodule is progressively released [7]. (9) The dissection is continued laterally, on contact with the ischium, down to the ischial spine and the coccygeus muscle. The lateral limit of the nodule is identified and released. (10) The anterior limit of the nodule is identified and, when required, is separated from the bladder. The latter 3 steps are less standardized, and the surgeon may alternate lateral, medial, posterior, and anterior dissection of the nodule, depending on the intraoperative circumstances. In most cases, the nerves are compressed but not infiltrated inside the epineurium, and their complete releasing is followed by significant or complete relief of pain and motor problems [6]. When the nodule infiltrates the nerves inside the epineurium, the excision may be performed into the nerve. Laparoscopic excision of deep endometriosis nodules involving the sciatic nerve is a challenging procedure, requiring good anatomic knowledge, surgical skills, preliminary specific training, and multidisciplinary postoperative care. Teaching such a complex procedure is a mandatory but delicate task. By following 10 sequential steps, the surgeon may reduce the risk of hemorrhage originating from the external iliac, obturator, and pudendal vessels; preserve somatic nerves; and successfully excise deep endometriosis nodules. Although the 10 steps attempt to standardize the surgical approach in a challenging localization of deep endometriosis, they are not mandatory and should be adapted to the patient.

Origin and Distribution of the Lumbosacral Plexus Anatomy in Van Cats

The innervation of the pelvic limbs of the Van cat is investigated in this research. The origins of the nerves, the innervated muscles and nerve diameters were shown in a table. Five cat cadavers were used in the study. The pudendal nerve originated from the S1-S2 spinal nerves. The femoral nerve consisted of the ventral branches of the 5th and 6th lumbar nerves in 4 cats The ischiatic nerve was composed of the 6th and 7th lumbar (L6-L7) and S1 spinal nerves in all cadavers. The ischiatic nerve was the thickest branch of sacral plexus (the average diameter on the right side was 3.31 ± 0.27 mm and the average diameter on the left side was 3.28 ± 0.29 mm). The lumbosacral plexus was formed by the ventral branches of the L4-S3 spinal nerves. N.genitofemoralis consisted of only the ventral branches of L4 in all cadavers. N. femoralis did not give rise to a branch to the m. iliopsoas. N.plantaris lateralis was found to give a branch to the 3th finger. The quadriceps femoris muscles did not take any branches from either the ischiadicus nerve or the pudendal nerve. The obturator nerve did not receive any branches from the L4 spinal nerves. There was no branch to the skin from the caudal gluteal nerve. The thinnest nerve was the pudendal nerve. Due to the scarcity of studies on the lumbosacral plexus of cats, it is thought that this study will complete a gap in the field of veterinary anatomy.

Monopolar versus bipolar transurethral resection of lateral wall-located bladder cancer under obturator nerve block: a single center prospective randomized study.

ABSTRACTIntroduction:The aim of the present prospective-randomized study was to compare perioperative outcomes and complications of bipolar and monopolar TURBT for lateral wall-located non-muscle invasive bladder cancers (NMIBC) under obturator nerve block (ONB).Patients and Methods:80 patients who underwent TURBT for lateral wall-located primary bladder tumors under ONB from March, 2016 to November, 2019 were included in the present study. The patients were randomized equally into two groups; monopolar TUR (M-TURBT) and bipolar TUR (B-TURBT). The primary and secondary outcomes were safety (obturator jerk and bladder perforation) and efficacy (complete tumor resection and sampling of the deep muscle tissue).Results:Obturator jerk was detected in 2 patients (5%) in M-TURBT while obturator jerk was not observed during B-TURBT (p=0.494). Bladder perforation was not observed in both groups. All of the patients underwent complete tumor resection. There was no significant difference in muscle tissue sampling (67.5% vs. 72.5%, p=0.626) and thermal tissue damage rates (12.5% vs. 25%, p=0.201). The majority of complications were low-grade and the differences in Clavien grade 1-3 complications between groups were not statistically significant.Conclusion:In the treatment of lateral-wall located NMIBCs, either M-TURBT or B-TURBT can be safely and effectively performed by combining spinal anesthesia with ONB. Even so, it should be taken into consideration that low-grade postoperative hemorrhagic complications may occur in patients who undergo M-TURBT.

Complications of Acute Acetabular Fractures Surgical Treatment: Systematic Review

Background.The combination of classical anterior and posterior approaches, as well as their modifications, is recognized as the most effective in acetabular fractures surgical treatment. The use of classical and modified approaches is accompanied by serious intra- and postoperative complications associated primarily with the duration of surgery, significant blood loss, tissue trauma, surgical site infection. The aim of review — to determine the main and most frequent complications associated with surgical approaches to the acetabulum. material and methods. Access to literature sources is carried out in the information systems and databases PubMed/Medline, Embase, Scopus, Сochran Library, eLibrary, Wiley Online Library. Keywords: acetabular fractures, surgical treatment, approach to the acetabulum, total hip replacement.Results. The most common intraoperative complications are incorrect fragments reduction, sciatic nerve injury, less often — intraarticular implant position, damage to the superior gluteal artery and other vessels, among the early postoperative complications - wound infection, both superficial and deep, less often — venous thrombosis. Late postoperative complications are mainly represented by the development of heterotopic ossification, post-traumatic coxarthrosis, less often revealed aseptic necrosis of the femoral head, residual protrusion and secondary femoral head lesion. Conclusion. The main approach to the acetabulum are the ileo-inguinal and the Kocher-Langenbeck approach, as well as their combination.Complications were more common using two approaches, especially in cases of simultaneous use. The main intraoperative complications are the sciatic nerve and the superior gluteal artery injury with posterior approaches, the femoral lateral cutaneous nerve with expanded ilio-femoral approach, and the obturator nerve with anterior approaches.

Green-light laser en bloc resection versus conventional transurethral resection for initial non-muscle-invasive bladder cancer: A randomized controlled trial.

To compare the safety and outcomes between green-light laser en bloc resection and transurethral resection of bladder tumor. A single-center, randomized controlled trial was carried out from August 2014 to September 2018. Patients with initial non-muscle-invasive bladder cancer were randomized to green-light laser en bloc resection or transurethral resection of bladder tumor. The primary outcomes were pathological findings and perioperative events. The secondary outcome was tumor recurrence. A total of 233 patients were randomized to the transurethral resection of bladder tumor group (117 patients) and the green-light laser en bloc resection group (116 patients). The resection time was longer in the green-light laser en bloc resection group (P=0.022); however, no differences were identified in overall operative time (P=0.255). Nine patients (7.7%) had an obturator nerve reflex during transurethral resection of bladder tumor. The estimated volume of blood loss was significantly lower in the green-light laser en bloc resection group (P=0.012). The green-light laser en bloc resection group had a higher rate of T1 bladder cancer (P=0.031). A total of 104 patients (89.7%) treated with green-light laser en bloc resection had detrusor muscle presence in the specimen, whereas 37 (31.9%) patients had the presence of muscularis mucosae, which was significantly higher than the corresponding number of transurethral resection of bladder tumor patients (P=0.005 and 0.002, respectively). After a median follow-up period of 48months, just five patients had tumor recurrence (three in the transurethral resection of bladder tumor group and two in the green-light laser en bloc resection group), and there was no difference between these two groups. Compared with transurethral resection of bladder tumor, green-light laser en bloc resection is more effective due to less obturator nerve reflex and the same recurrence rate. Most importantly, green-light laser en bloc resection can provide better tumor specimens for pathological examinations.