title: 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.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 1 Department of Urology, SLK-Kliniken, University of Heidelberg , Heilbronn, Germany .
authors.forename: Ali Serdar
authors.initials: AS
authors.lastname: Gözen
authors.affiliation: 2 Department of Urology, Trakya University School of Medicine , Edirne, Turkey .
authors.forename: Tevfik
authors.initials: T
authors.lastname: Aktoz
authors.affiliation: 1 Department of Urology, SLK-Kliniken, University of Heidelberg , Heilbronn, Germany .
authors.forename: Yigit
authors.initials: Y
authors.lastname: Akin
authors.affiliation: 1 Department of Urology, SLK-Kliniken, University of Heidelberg , Heilbronn, Germany .
authors.forename: Jan
authors.initials: J
authors.lastname: Klein
authors.affiliation: 1 Department of Urology, SLK-Kliniken, University of Heidelberg , Heilbronn, Germany .
authors.forename: Philip
authors.initials: P
authors.lastname: Rieker
authors.affiliation: 1 Department of Urology, SLK-Kliniken, University of Heidelberg , Heilbronn, Germany .
authors.forename: Jens
authors.initials: J
authors.lastname: Rassweiler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D008197:Lymph Node Excision / Q000009:adverse effects* / Q000379:methods; D008297:Male; D008875:Middle Aged; D009776:Obturator Nerve / Q000293:injuries* / Q000601:surgery; D010388:Pelvis; D059348:Peripheral Nerve Injuries / Q000209:etiology* / Q000601:surgery; D011468:Prostatectomy / Q000009:adverse effects* / Q000379:methods; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects; D016896:Treatment Outcome