Life‐threatening haemorrhage following obturator artery injury during transurethral bladder surgery: a sequel of an unsuccessful obturator nerve block

Abstract

In spite of prior blockade of the obturator nerve with 1% mepivacaine (8 ml) utilizing a nerve stimulator, violent leg jerking was evoked during transurethral electroresection of a bladder tumour approximately 1 h after the blockade in a 68-year-old man. The patient became severely hypotensive immediately following the jerking, and a large lower abdominal swelling concurrently developed. The urgent laparotomy indicated that the left obturator artery was severely injured by the resectoscope associated with the bladder perforation, causing acute massive haemorrhage. The patient recovered uneventfully after adequate surgery. Investigation of the literature suggested that both our nerve stimulation technique and anatomical approach were appropriate. It was therefore unlikely that our block resulted in failure because of an inappropriate site for deposition of the anaesthetic. However, consensus does not appear to have been obtained as to the concentration and volume of the anaesthetic necessary for prevention of the obturator nerve stimulation during the transurethral procedures. The concentration and volume of mepivacaine we used might have been too low and/or small, respectively, to profoundly block all the motor neuron fibres of the nerve. Alternatively, stimulation of the obturator nerve might occur because of the presence of some anatomical variant, such as the accessory obturator nerve or its abnormal branching. In conclusion, some uncertainty appears to exist in the effectiveness of the local anaesthetic blockade of the obturator nerve. In order to attain profound blockade of the motor neuron fibres of the obturator nerve and thereby prevent the thigh-adductor muscle contraction which can lead to life-threatening situations, we recommend, even with a nerve stimulator, to use a larger volume of a higher concentration of local anaesthetic with a longer duration in the obturator nerve block for the transurethral procedures.

Impact of nerve stimulator-guided obturator nerve block on the short-term outcomes and complications of transurethral resection of bladder tumour: A prospective randomized controlled study

“…The success rate of the transperineal ONB using the "blind anatomic approach" is 83.8 to 85.7%. 5,9,17 There are many ways to increase the efficacy of ONB. The success rate is 84% to 96% using the "nerve stimulation technique."…”

“…It is debatable whether stimulation of the accessory obturator nerve can occur during TUR. 5 Failure of the blockade can also be due to operator error. In experienced hands, location of the obturator nerve may be easy and the blockade can be done successfully.…”

“…3 Involuntary movement of the legs due to adductor spasm can cause incomplete tumour resection, bladder perforation, and extravesical dissemination of the cancer cells and vascular injuries. 3,5 In this prospective randomized controlled study, we investigated the effect of obturator nerve block (ONB) on adductor spasm and short-term complication rates in the patients who underwent TURBT for bladder tumours on the lateral bladder wall.…”

The Effect Of Obturator Nerve Block On Complications During Transurethral Resection Of Lateral Wall Located Bladder Tumours

“…Ancak unutmamak gerekir ki literatürde obturator sinir bloğuna bağlı ciddi kanama, konvülsiyon gibi komplikasyonlar da bildirilmiştir (17)(18).…”

Ultrasound-guided obturator block experience from past year at Kocaeli University Hospital

“…[1][2][3] Bu nedenle, bu ameliyatların kas gevşeticilerinin de kullanıldığı genel anestezi uygulaması altında yapılması önerilmiştir. [1] Obturator sinir blokajı (OSB) ilk kez Labat [4] tarafından tariflenmiş; 1965 yılında ise Prentiss ve ark.…”