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

Background: Obturator nerve injury (ONI) is an uncommon complication of pelvic sur-gery, usually reported in 0.2-5.7% of cases undergoing surgical treatment of urological and gynecological malignancies involving pelvic lymph node dissection (PLND). Objective: To describe how an ONI may occur during robotic pelvic surgery and the corresponding management strategies.Design, setting, and participants: We retrospectively analyzed video content on intraoperative ONI provided by robotic surgeons from high-volume centers.Surgical procedure: ONI was identified during PLND and managed according to the type of nerve injury.Results and limitations: The 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 cer-tain 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 fur-ther dissection. Each case has different management strategies with a common aim of prompt repair of the anatomic disruption to restore proper nerve conduction. Conclusions: ONI 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 summary: We 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.(c) 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Automated summary

This study retrospectively analyzed video content provided by robotic surgeons from high-volume centers to describe the ways in which obturator nerve injury occurs during pelvic surgery and the corresponding management strategies. Proper identification of the anatomy and high-risk areas, prompt recognition, and repair of obturator nerve injury can prevent this complication and offer patients the best chance of recovery.