Avoiding the Obturator Jerk during TURBT

Abstract

Introduction: Bladder cancer is the seventh most common cancer in the UK. Transurethral resection of bladder tumor (TURBT) is a relatively common procedure used to treat cancer of the bladder. A serious complication of TURBT is bladder perforation, the risk of which is greatly increased in the presence of an “obturator jerk”. Methods: A literature search was performed on PubMed using the following search criteria “obturator nerve block”, “obturator nerve block in transurethral resection of bladder tumor”, “adductor spasm during transurethral resection of bladder tumor”, “bi-polar diathermy obturator nerve”, and “transvesical obturator nerve block”. Articles describing surgical and anesthetic techniques for reducing adductor spasm during resection of bladder tumors were included. Discussion: TURBT is a relatively common urological operation performed to remove tumors of the bladder. Every measure should be taken to avoid serious complications from both anesthesia and surgery. Surgical measures to reduce the likelihood of an obturator jerk include reducing the diathermy current, avoiding over-distention bladder, and using bipolar diathermy as opposed to monopolar diathermy (although there is conficting evidence for this in the literature). Anesthetists should consider the use of neuromuscular blockade or an obturator nerve block to reduce the incidence of obturator jerk and risk of bladder perforation.

Comparison of Two Different Bipolar Energy Resources in Transurethral Resection of Bladder Tumors

“…When the electric current transmitted by the resectoscope directly stimulates the obturator nerve, an obturator reflex may occur [9]. The result of this reflex is adductor muscle contraction which may lead to bladder perforation [10]. The most notable finding in our study is that the incidence of bladder perforation observed in the PK group was about half that in the TURis group.…”

Monopolar versus bipolar transurethral resection of lateral wall-located bladder cancer under obturator nerve block: a single center prospective randomized study

“…During the resection of the bladder tumors, it is common to see the occurrence of obturator reflex. Obturator jerk increases the risk of some complications, such as incomplete resection, bladder perforation, the inability to give intravesical chemotherapeutic agents, extravesical dissemination of the tumor, and vascular injuries (12). Most urologists are concerned about some possible complications that may occur during resection of lateral wall-located bladder tumors when obturator nerve is close to lateral wall in its intrapelvic course (19).…”

“…Obturator nerve originates from the lumbar plexus of L2 to L4 and both motor and sensory nerve fibers passes through the obturator foramen of the pubis to innervate the adductor muscles of the thigh. It comes to close proximity to the prostatic urethra, bladder neck, and inferolateral bladder wall (12). Garcia Rodriguez et al reported that 46.8% of all bladder tumors are located at the lateral wall of the bladder (13).…”

“…At this point, involuntary leg movements are caused. These involuntary leg movements increase the risk of developing complications, such as incomplete resection, bladder perforation, extravesical dissemination of the tumor, and vascular injuries (12). Prentiss et al developed obturator nerve block (ONB) technique in 1965 in order to avoid involuntary leg movements during TURBT (14).…”

Changing urological practice during COVID-19

“…[ 23 ] Although most urologists prefer GA for endoscopic renal surgery, RA has equivalent efficacy and safety outcomes with possibly reduced operative time, hospitalization stay, blood transfusion rates, and postoperative pain without compromising stone clearance rates. [ 24 25 26 27 ]…”