Is It Possible to Draw a Risk Map for Obturator Nerve Injury During Pelvic Lymph Node Dissection? The Heilbronn Experience and a Review of the Literature

The effect of physical therapy and mechanical stimulation on dysfunction of lower extremities after total pelvic exenteration in cervical carcinoma patient with rectovesicovaginal fistula induced by radiotherapy: a case report

BACKGROUND

Total pelvic exenteration is the ultimate solution for rectovesicovaginal fistula caused by radiation therapy, yet total pelvic exenteration frequently causes intraoperative complications and postoperative complications. These complications are responsible for the dysfunction of lower extremities, impaired quality of life, and even the high long-term morbidity rate, thus multidisciplinary cooperation and early intervention for prevention of complications are necessary. Physical therapy was found to reduce the postoperative complications and promote rehabilitation, yet the effect on how physiotherapy prevents and treats complications after total pelvic exenteration and pelvic lymphadenectomy remains unclear.

CASE PRESENTATION

A 50-year-old Chinese woman gradually developed perianal and pelvic floor pain and discomfort, right lower limb numbness, and involuntary vaginal discharge owing to recurrence and metastasis of cervical cancer more than half a year ago. Diagnosed as rectovesicovaginal fistula caused by radiation, she received total pelvic exenteration and subsequently developed severe lower limb edema, swelling pain, obturator nerve injury, and motor dysfunction. The patient was referred to a physiotherapist who performed rehabilitation evaluation and found edema in both lower extremities, right inguinal region pain (numeric pain rate scale 5/10), decreased temperature sensation and light touch in the medial thigh of the right lower limb, decreased right hip adductor muscle strength (manual muscle test 1/5) and right hip flexor muscle strength (manual muscle test 1/5), inability actively to adduct and flex the right hip with knee extension, low de Morton mobility Index score (0/100), and low Modified Barthel Index score (35/100). Routine physiotherapy was performed in 2 weeks, including therapeutic exercises, mechanical stimulation and electrical stimulation as well as manual therapy. The outcomes showed that physiotherapy significantly reduced lower limb pain and swelling, and improved hip range of motion, motor function, and activities of daily living, but still did not prevent thrombosis.

CONCLUSION

Standardized physical therapy demonstrates the effect on postoperative complications after total pelvic exenteration and pelvic lymphadenectomy. This supports the necessity of multidisciplinary cooperation and early physiotherapy intervention. Further research is needed to determine the causes of thrombosis after standardized intervention, and more randomized controlled trials are needed to investigate the efficacy of physical therapy after total pelvic exenteration.

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

BACKGROUND

Obturator 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).

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 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.

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.

A narrative review of pelvic lymph node dissection in prostate cancer

Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician.

Neuropathic painful complications due to endopelvic nerve lesions after robot-assisted laparoscopic prostatectomy: Three case reports

RATIONALE

Robot-assisted laparoscopic prostatectomy (RALP) is the most frequent strategy used for the surgical remedy of patients with localized prostate cancer. Although there is awareness about potential patient positioning nerve injuries, iatrogenic nerve lesions are less described in the literature. Here, we report 3 cases of patients who presented with neuropathic painful complications due to RALP-associated nerve lesions.

PATIENT CONCERNS

A 62-year-old patient (case 1), a 72-year-old male (case 2), and a 57-year-old patient (case 3) presented at the clinic with symptoms of neuropathic pain after RALP surgery.

DIAGNOSIS

Patients were diagnosed with a potential injury of different branches of the pudendal nerve (cases 1 and 2), and left obturator nerve (case 3).

INTERVENTIONS

Patients underwent multimodal pharmacologic treatment through pregabalin, weak opioids, strong opioid, paracetamol, and adjuvants. In cases 2 and 3, a multidisciplinary approach was needed. As the patients responded to conservative treatment, invasive approaches were not necessary.

OUTCOMES

After treatment, the patients of case 1 showed pain relief after 4 days, paresthesia resolved in 15 days, whereas the anal crushing sensation lasted for approximately 1 month. In case 2, after 4 weeks of treatment, the patient experienced a considerable decrement in pain intensity with complete response after 4 months. In case 3, pain relief was achieved after 2 days, motor symptoms recovery after 2 weeks, and neuropathic features resolved completely after 5 weeks although the obturator sign resolved within 2 months.

LESSONS

The RALP-associated neurologic injuries may occur even when performed by highly experienced surgeons. A better understanding of the potential iatrogenic nerve lesions can surely allow an improvement in the surgical technique. A multidisciplinary approach and early multimodal pain strategy are mandatory for managing these complications.

Embarking with laparoscopic radical prostatectomy and dealing with the complications and collateral problems: A single-center experience

OBJECTIVE

The aim of the present study was to report our single-center initial experience in laparoscopic radical prostatectomy (LRP) with special emphasis on the complications and collateral problems and their management.

MATERIAL AND METHODS

A total of 48 patients (mean age 64 years) underwent LRP in our institution between August 2014 and July 2018. Two surgeons completed a fellowship training program for LRP before. Mentored operations started after the first 10 cases. The patients were divided in two groups of 30 (group I) and 18 (group II) patients. Demographic, preoperative, peroperative, and postoperative data were collected prospectively. Anesthesiology and nurses' team performances, as well as problems and their management, were reviewed.

RESULTS

The demographic data for both groups (group I vs. group II) were similar. Estimated blood loss (695.5±139.23 vs. 398±339.39 mL) and intraoperative complication rates (36.66% vs. 5.55%) were significantly (p<0.05) higher in group I. Conversion to open surgery occurred in 7 (20%) patients in group I and in 1 (5.55%) patient in group II. Continence rates at 12 (83%) months were similar in both groups. Positive surgical margins were 8.33% for pT2 and 27.1% for pT3 stages.

CONCLUSION

A validated fellowship program before starting LRP and performing the first cases under mentorship are helpful. The complication and conversion rates decrease after 30 cases in addition to the improved experience also with improved cooperation with the anesthesiologist and scrub nurse.

Concurrent primary repair of obturator nerve transection during pelvic lymphadenectomy procedure via laparoscopical approach

•

Laparoscopic early stage nerve repair is a feasible method in gynecological surgery.

•

Early nerve repair, short-term clinical and long-term neurological consequences are usually curative.

•

In laparoscopic gynecologic malignancy surgery, laparoscopic management of complications is a minimally invasive procedure.

Introduction

Obturator nerve is barely injured during gynecological surgeries. The risk for obturator nerve injury is increased during pelvic lymphadenectomy procedures of gynecological malignancies. In case of any obturator nerve injury, surgical management involve laparoscopic approaches suchas end-to-end anastomosis in very early period.

Case

A 63-year-old woman, with G3P3, presented with the complaint of abnormal uterine bleeding. She was diagnosed with stage IA endometrial adenocarcinoma. obturator nerve was transected during obturator lymph node dissection in the right side during retroperitoneal lymph node dissection. Subsequently end-to-end anastomosis of the thermally injured areas was performed by epineural sutures. Any significant loss of functions in adductor muscle wasn't observed in the postoperative period. Likewise, any permanent neurological finding wasn't developed at the end of postoperative 6th month.

Discussion

During pelvic lymphadenectomy; obturatory nerve, especially the proximal part, should be concerned. Early intraoperative repair should be performed in case of possible nerve injuries.

Conclusion

Immediate laparoscopic repair is possible in full-thickness injury of obturator nerve, occurred in a gynecological surgery and results with rapid and complete neurological recovery.

Current controversies on the role of lymphadenectomy for prostate cancer

Lymph node dissection is part of the standard treatment protocol for various cancers, but its role in prostate cancer has been debatable for some time. Pelvic lymphadenectomy has been shown to better help stage prostate cancer patients, but has yet to be definitively proven to be of any benefit for survival. Various templates for lymph node dissections exist, and though some national guidelines have endorsed an extended pelvic node dissection, the choice of template is still controversial. Pelvic lymphadenectomy may lead to a slightly higher rate complications and operative time, and their use must be judiciously applied to patients with a high enough risk of lymph node involvement. We present a comprehensive review of the literature regarding the benefits and harms of lymph node dissection in prostate cancer.

Management of obturator nevre injury during pelvic lymph node dissection

OBJECTIVE

Obturator nerve injuries may be seen during pelvic lymph node dissection in oncological surgery and although not common it is an important complication. According to the shape and location of the injury, tingling and loss of sensation may develop on the inner surface of the leg, together with loss of motor function of the adductor muscles. In this study an evaluation was made of these complications encountered in our clinic and the management strategies applied to these patients.

MATERIAL AND METHODS

The data were retrospectively reviewed of 843 patients who underwent open radical retropubic prostatectomy between January 2002 and May 2016. To confirm obturator nerve palsy, electrophysiological investigation (ENG-EMG) was performed immediately postoperatively and 3 weeks later.

RESULTS

A total of 6 obturator nerve injuries occurred during pelvic lymphadenectomy (0.7%). Reapproximation end to end with sutures was applied in 3 case and sural nerve graft in 1. In the other 2 patients, just clips were placed and these were removed early during the operation. After the treatment period, neurotropic medications or physiotherapy were given in some cases according to the neurological examinations.

CONCLUSION

Obturator nerve injury can be prevented by having a comprehensive knowledge of pelvic anatomy, and avoiding the use of electrocautery during lymph node dissection. The repair should be performed as soon as possible, with a tension-free reapproximation of the ends, using electrophysiological tests with a multidisciplinary approach and benefit should be taken from physiotherapy and medical treatment when needed.

Concurrent Inguinal Hernia Repair in Patients Undergoing Minimally Invasive Radical Prostatectomy: A National Surgical Quality Improvement Program Study

OBJECTIVE

To compare perioperative 30-day outcomes between minimally invasive radical prostatectomy (MIRP) with and without concurrent inguinal hernia repair (IHR) using a national database.

METHODS

The National Surgical Quality Improvement Program database was queried for MIRP from 2012 to 2015. Concurrent IHR was identified using relevant Current Procedural Terminology codes. Primary outcomes were overall complications, reoperations, unplanned readmissions, and mortality within 30 days of MIRP. Secondary outcomes included operative time (OT), length of stay (LOS), prolonged length of stay (PLOS, >2 days), and discharged to continued care (DCC). Multivariable logistic regression was performed to identify the association between concurrent IHR and outcomes.

RESULTS

A total of 18,065 patients were included; 375 (2.1%) had concurrent IHR. The unadjusted comparison showed no significant difference in overall complication, reoperation, unplanned readmission, or mortality rates between MIRP+IHR and MIRP only groups. OT was longer in the MIRP+IHR group (229 vs 195 minutes, p < 0.001) but no differences were found in LOS, PLOS, or DCC rates. Multivariable logistic regression showed concurrent IHR was not associated with increased odds of overall complication (odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.49-1.40, p = 0.479), reoperation (OR = 0.57, 95% CI = 0.14-2.30, p = 0.426), unplanned readmission (OR = 0.92, 95% CI = 0.51-1.64, p = 0.771), PLOS (OR = 1.19, 95% CI = 0.86-1.63, p = 0.297), or DCC (OR = 1.94, 95% CI = 0.70-5.34, p = 0.202).

CONCLUSIONS

Concurrent IHR with MIRP was associated with longer OT, but there were no increased 30-day adverse outcomes within the National Surgical Quality Improvement Program (NSQIP) database. These data support the safety of performing concurrent IHR at the time of MIRP and it should be considered to spare men an additional procedure.

Robotic resection of an obturator schwannoma with preservation of normal nerve fascicles and function

An asymptomatic pelvic tumor was incidentally found in a 27-year-old man. A CT-guided needle biopsy with a pathologic examination confirmed the diagnosis of a benign schwannoma. We describe the complete robotic resection with the conservation of normal fascicles. The postoperative course was uneventful. No neurological deficit occurred, and the electromyogram was normal 6 weeks and 7 months later.