Prevention of Obturator Nerve Stimulation During Transurethral Surgery

Abstract

The obturator nerve passes in close proximity to the inferolateral bladder wall, bladder neck and lateral prostatic urethra. During a transurethral operation resection in these areas may result in stimulation of the obturator nerve, causing violent adductor contraction and possible inadvertent bladder perforation. To block this reaction d-tubocurarine and succinylcholine can be used during general anesthesia. However, it often is preferable to use spinal anesthesia during transurethral operations. Local anesthetic blockade of the obturator nerve as it passes through the obturator canal if effective for adductor spasm during spinal anesthesia. We herein describe the anatomy, pharmacology, technique and results of local obturator nerve blockade.

Effectiveness of spinal anesthesia combined with obturator nerve blockade in preventing adductor muscle contraction during transurethral resection of bladder tumor

“…[16] Various strategies have been adopted to avoid these complications during surgery such as use of GA with succinylcholine or d-tubocurarine which is commonly advocated, the use of laser resectors, reducing the intensity of the current of the resectoscope, change in the site of inactive electrode, use of saline irrigation, ONB, ultrasound guided ONB, superficial resection with low current and cutting with bipolar resectoscope, blind ONB with or without nerve stimulator and periprostatic infiltrations have been applied with various success. [1,13,[16][17][18][19][20][21] However, a selective ONB still remains the safest and most effective alternative to this problem. [22,23] It should be mentioned that SA with selective ONB is considered an appropriate option for aged patients undergoing such surgeries.…”

“…The obturator nerve arises from the second, third, and fourth lumbar plexus and it passes over fibers of the psoas major muscle which is adjacent to the obturator fascia and ultimately goes into the medial aspect of the thigh and innervates muscles responsible for adducting the thigh and also the skin on the paramedian part of the thigh. [1] Incidental stimulation of the obturator nerve induces adductor spasms which are among significant concerns during numerous surgical operations, and particularly, during transurethral resection (TUR) procedures. Accidental adductor muscle spasm during these procedures will induce though infrequent but catastrophic complications such as excessive bleeding, bladder wall perforation, vessel laceration, vascular injury, hematomas and incomplete tumor resection.…”

“…Accidental adductor muscle spasm during these procedures will induce though infrequent but catastrophic complications such as excessive bleeding, bladder wall perforation, vessel laceration, vascular injury, hematomas and incomplete tumor resection. [1][2][3][4] Therefore various strategies have been implemented to preclude these intraoperative complications such as decreasing the intensity of the current of the resectoscope, application of general anesthesia with muscle relaxants, applying laser resectors, and obturator nerve blockade (ONB), etc. [5,6] But applying spinal anesthesia for transurethral operations has been considered desirable.…”

Impact of nerve stimulator-guided obturator nerve block on the short-term outcomes and complications of transurethral resection of bladder tumour: A prospective randomized controlled study

“…The success rate of the transperineal ONB using the "blind anatomic approach" is 83.8 to 85.7%. 5,9,17 There are many ways to increase the efficacy of ONB. The success rate is 84% to 96% using the "nerve stimulation technique."…”

“…The success rate is 84% to 96% using the "nerve stimulation technique." [16][17][18][19] In our study we used the "nerve stimulation technique," described by Parks and Kennedy in 1967. 6 Using this technique, our success rate was 88.6% and this rate was attributed to the accessory obturator nerve or its abnormal branching.…”