Gözen Ali Serdar, Aktoz Tevfik, Akin Yigit, Klein Jan, Rieker Philip, Rassweiler Jens
1 Department of Urology, SLK-Kliniken, University of Heidelberg , Heilbronn, Germany .
2 Department of Urology, Trakya University School of Medicine , Edirne, Turkey .
J Laparoendosc Adv Surg Tech A. 2015 Oct;25(10):826-32. doi: 10.1089/lap.2015.0190. Epub 2015 Sep 29.
Obturator nerve injury (ONI) is a rare complication during pelvic lymph node dissection (PLND), in extraperitoneal laparoscopic radical prostatectomy (e-LRP), and/or extraperitoneal robotic-assisted laparoscopic radical prostatectomy (e-RALP). It is important to recognize ONI during the initial operation, maximizing the feasibility of simultaneous repair. Here we report our experience with ONI during e-LRP/e-RALP procedures and draw an injury risk map.
Between December 1999 and November 2014, 2531 e-LRPs and 1027 e-RALPs were performed. Five patients (3 during e-LRP, 2 during e-RALP) experienced ONI in the proximal part of the nerve. Obturator nerves were clipped during the 3 e-LRP cases. Clips were immediately removed, and patients received physiotherapy with medical treatments in the postoperative period. During e-RALP, two obturator nerves were transected and subsequently repaired using the robotic Da Vinci(®) Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). ONI types were investigated in detail in these patients, and current published studies were analyzed in order to draw a risk map.
Mean follow-up was 18.8 ± 2.7 months. In total, 3558 cases (2531 e-LRPs, 1027 e-RALPs) were performed. ONI occurred in 3 e-LRP (0.1%) and 2 e-RALP (0.1%) patients. Simultaneous repair was performed successfully in all cases, as clips were removed in e-LRP cases and obturator nerves were repaired using 6/0 polypropylene (Prolene(®); Ethicon, Somerville, NJ) suture in e-RALP cases. There was no complication associated with obturator nerve functions such as adductor function and/or neurologic deficiency during long-term follow-up. In view of published studies in the literature, the proximal part of the obturator nerve is at highest risk for injury during PLND, representing 77.8% of reported cases of ONI.
According to our ONI risk map, the proximal part of the obturator nerve is at higher risk for injury during PLND. Careful dissection and a good knowledge of pelvic anatomy are essential for preventing ONI. Successful ONI management can be performed simultaneously in experienced hands.
闭孔神经损伤（ONI）是盆腔淋巴结清扫术（PLND）、腹膜外腹腔镜根治性前列腺切除术（e-LRP）和/或腹膜外机器人辅助腹腔镜根治性前列腺切除术（e-RALP）中一种罕见的并发症。在初次手术时识别ONI很重要，这能最大程度提高同期修复的可行性。在此，我们报告我们在e-LRP/e-RALP手术中处理ONI的经验并绘制损伤风险图。
1999年12月至2014年11月期间，共进行了2531例e-LRP手术和1027例e-RALP手术。5例患者（3例在e-LRP手术中，2例在e-RALP手术中）在神经近端发生ONI。在3例e-LRP手术中闭孔神经被夹闭。夹子立即被移除，患者在术后接受物理治疗及药物治疗。在e-RALP手术中，两条闭孔神经被横断，随后使用达芬奇（®）手术系统（直观外科公司，加利福尼亚州桑尼维尔市）进行修复。对这些患者的ONI类型进行了详细研究，并分析了当前已发表的研究以绘制风险图。
平均随访时间为18.8 ± 2.7个月。总共进行了3558例手术（2531例e-LRP手术，1027例e-RALP手术）。3例e-LRP（0.1%）和2例e-RALP（0.1%）患者发生了ONI。所有病例均成功进行了同期修复，e-LRP病例中移除了夹子，e-RALP病例中使用6/0聚丙烯（普理灵（®）；爱惜康公司，新泽西州萨默维尔市）缝线修复了闭孔神经。在长期随访中，未出现与闭孔神经功能相关的并发症，如内收肌功能障碍和/或神经功能缺陷。鉴于文献中已发表的研究，闭孔神经近端在PLND期间损伤风险最高，占报告的ONI病例的77.8%。
根据我们的ONI风险图，闭孔神经近端在PLND期间损伤风险较高。仔细的解剖操作和对盆腔解剖结构的充分了解对于预防ONI至关重要。在经验丰富的医生手中，可以同期成功处理ONI。
