Ultrasound-guided selective block of the anterior branch of the obturator nerve for transurethral resection of bladder tumour

Abstract

Introduction:

Bladder perforation is a serious complication of transurethral resection of bladder tumour (TURBT). One of the risk factors is an “obturator jerk”, caused by stimulation of the obturator nerve, causing powerful adduction of the leg. As almost half of all bladder tumours are located on the lateral wall and 55–100% of resections on the lateral wall can result in obturator jerk; this is not an insignificant risk.

Patients:

We have introduced regional anaesthetic nerve block of the anterior branch of the obturator nerve in patients with known lateral wall tumours undergoing TURBT.

Methods:

This procedure was performed by two consultant anaesthetists in our unit. Patients are positioned supine with the leg slightly abducted and laterally rotated. Ultrasound (US) is used to identify the anterior branch of the adductor longus, brevis and magnus muscles in the medial thigh, 2–3 cm inferior to the inguinal crease. The obturator nerve is situated in the plane between adductor longus and adductor brevis, medial to pectineus. An insulated needle is passed under US guidance and a nerve stimulator is used to elicit a twitch. Levobupivicaine is used to infiltrate the anterior branch of the obturator nerve to achieve motor block of the adductor brevis, adductor longus and gracillis muscles. TURBT is then performed.

Results:

This prospective pilot series includes 18 TURBT procedures. These were performed under spinal anaesthetic (n=16) or general anaesthetic without muscle relaxant (n=2). Tumours characteristics were; large flat areas of re-resection (n=5), flat bladder lesions (n=1) or exophytic lesions (n=12). There were no incidences of obturator jerk observed during TURBT (0/18). There were no intra or post-operative complications.

Conclusion:

This simple technique can be easily applied to patients undergoing TURBT. Larger studies are required, but our series supports the use of this technique to reduce obturator jerk, which is an important risk factors for bladder perforation.

Keywords

Bladder tumour obturator nerve regional anaesthesia TURBT resection obturator jerk bladder perforation

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References

Rodrigues

Moxzon

Alvarez

RCG

. An alternative technique to prevent of obturator nerve stimulation during lateral bladder tumour transurethral resection. Actas Urol Esp 2005; 29: 445–447.

Balbay

Cimentepe

Unsal

. The actual incidence of bladder perforation following transurethral bladder surgery. J Urol 2005; 174: 2260–2262.

Tukgul

Divrik

Turan

. Impact of obturator nerve block on the short-term recurrence of superficial bladder tumours on the lateral wall. J Urol 2014; 11: 1248–1252.

Juo

. Prevention of obturator jerk during transurethral resection of bladder tumour. JTUA 2008; 19: 27–31.

Labat

. Regional Anesthesia: Its technique and clinical application. Philadelphia, PA: Saunders Company, 1922.

Patel

Shah

Patel

. Contribution of the obturator nerve block in the trans-urethral resection of bladder tumours. Ind J Anaesth 2004; 48: 47–49.

Wasseff

. Interadductor approach to obturator nerve blockade for spastic conditions of adductor thigh muscles. Reg Anaesth 1993; 8:13–17.

Pladzyk

Jureczko

Lazowski

. Over 500 obturator nerve blocks in the lithotomy position during transurethral resection of bladder tumour. Cent European J Urol 2012; 65: 67–70.

Kakinohana

Taira

Saitoh

. Tineradductor approach to obturator nerve block for transurethral resection procedure: Comparison with traditional approach. J Anaesth 2002; 16: 123–126.

10.

Khorrami

Javid

Saryazdi

. Thransvesical blockade of the obturator nerve to prevent adductor contraction in transurethral bladder surgery. J Endourol 2010: 1651–1654.

11.

Choquet

Capdevila

Bennourine

. A new inguinal approach for the obturator nerve block: Anatomical and randomized clinical studies. Anaesthesiology 2005; 103: 1238–1245.

12.

Moningi

Durga

Ramachandran

. Comparison of inguinal versus classic approach for obturator nerve block undergoing transurethral resection of bladder tumours under spinal anaesthetic. J Anaesth Clin Pharmacol 2014; 10: 41–45.

13.

Kwon

J-K

Kim

J-S

. Selective blocking of the anterior branch of the obturator nerve in children with cerebal palsy. Am J Phys Med Rehabil 2009; 88: 7–13.

14.

O’Donnell

. Peripheral nerve block and local anaesthetic dose, how much is enough? Anaesthesia 2014; 69: 655–668.

15.

Casati

Baciarello

Di Cianni

. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth 2007; 98: 823–827.