CASE REPORT

Bilateral Obturator Neuropathy After Transobturator Vaginal Sling: A Case Report Derrick J. Sanderson, DO( and Ali Ghomi, MD

Abstract: Transobturator tape procedure is a popular and effective minimally invasive technique to treat stress urinary incontinence. We report a case of transient obturator neuropathy caused by transobturator tape placement for stress urinary incontinence. Findings on physical examination were significant for bilateral obturator neuropathy resulting in significant motor deficit, prompting removal of the sling to avoid the potential of prolonged or permanent morbidity. There was immediate complete resolution of neuropathy with the return of motor function after surgical removal of the sling. Key Words: transobturator tape, transobturator sling, neuropathy, complication (Female Pelvic Med Reconstr Surg 2015;21: e21Ye22)

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idurethral sling procedures provide a common and minimally invasive means to treat female stress urinary incontinence. Transobturator slings have been available in the United States since the early 2000s and have quickly gained popularity due the reduced risk of retropubic space complications including bladder and bowel injuries and pelvic hematomas.1Y3 Complications associated with transobturator tape include mesh erosions, urethral injury, neuralgia, bleeding, and infection.1Y3 Neuralgia, which is often transient, typically occurs in the inguinal and medial thigh along the distribution of the obturator nerve.4 Obturator neuropathy can occur due to nerve damage or entrapment.5Y7 Herein we describe a rare case of bilateral obturator neuropathy.

CASE A 59-year-old nulligravid female patient underwent a transobturator sling (Align Halo, Bard Medical, Covington, Ga) under general anesthesia without intraoperative complications. The estimated blood loss was minimal. Ten milliliters of 1:100,000 lidocaine with epinephrine solution was used for suburethral hydrodissection. Local anesthetic was not injected into the obturator foramen. The transobturator sling was placed via an ‘‘outside-to-inside’’ approach in the usual fashion. Foley catheter was removed intraoperatively. The patient reported bilateral thigh pain in postoperative recovery. She was discharged to home 5 hours after surgery upon spontaneous voiding. On postoperative day 0, she called reporting severe bilateral thigh pain and muscle weakness, especially upon standing up and adduction of the thighs. This was attributed to transient postoperative pain and paresthesia. Her symptoms became more pronounced the next day, with an inability to get From the Department of Obstetrics and Gynecology, Sisters of Charity Hospital, Buffalo, NY. Reprints: Ali Ghomi, MD, Department of Obstetrics and Gynecology, Sisters of Charity Hospital, 2121 Main St, Buffalo, NY, 14214. E-mail: [email protected] The authors have declared they have no conflicts of interest. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000129

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out of bed or stand from a sitting position. Once standing, gait was unaffected. She was evaluated emergently on postoperative day 1. She was afebrile. Vital signs were within normal limits. Neurologic examination of the lower extremities was pertinent for 2 out of 5 muscle strength during adduction and abduction bilaterally. Passive range of motion of the lower extremities was unaffected. Deep tendon reflexes were within normal limits. The sensory examination finding was intact. The vaginal examination result was negative for suburethral hematoma. The sutures were intact. The obturator incision sites were intact without any signs of hematoma. Repeat hemoglobin was essentially unchanged from before surgery. The patient was diagnosed with transobturator neuropathy secondary to transobturator sling. After counseling the patient, it was decided to proceed with removal the transobturator sling to avoid potential longterm morbidity associated with obturator neuropathy. Surgery was performed under spinal anesthesia. Removal of the sling was uneventful and was accomplished by applying downward traction on the sling after suburethral dissection. There was no evidence of hematoma or infection. Blood loss was minimal. Postoperatively, there was immediate resolution of symptoms, with full return of muscle strength.

DISCUSSION Obturator nerve injury is manifested by neuropathy, neuralgia, or a combination of both. Neuropathy is the preferred diagnosis when the predominating symptoms are motor dysfunction, characterized by a loss of adduction of the lower extrimities.5,6 The term obturator neuralgia is preferred when neuropathic pain predominates in the region of obturator nerve distribution, localized over the inguinal area and medial thigh.6 Primary nerve injury occurs when a nerve is damaged as a direct result of a surgical intervention.4 Secondary nerve entrapment occurs as a result of perimesh fibrosis, mesh shrinkage, entrapment, or chronic compression or internal obturator muscle spasm.5,6 Persistent obturator neuropathy is a known complication of transobturator sling procedures.1Y7 A conservative approach to management would start with oral or locally injected nonsteroidal anti-inflammatory drugs or analgesics and physical therapy, with surgical exploration and removal reserved for severe refractory cases.4,7 Early removal of the mesh has also been suggested when the symptomatology cannot be explained by postoperative pain in an otherwise uncomplicated surgery.6,7 Iatrogenic transient obturator neuropathy has also been reported after local anesthesia of the obturator foramen.1 Because of the early onset, severity of neuropathy, and bilateral nature, surgical revision was chosen as first-line management. We sought to avoid progression to secondary nerve entrapment and amyotrophy by complete mesh removal. In our judgment, this allowed for the best chance for reversal of any damage to the obturator nerve. To our knowledge, this is the first reported case of bilateral obturator neuropathy after transobturator sling. We speculate that the sling was placed in too close of proximity to the

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Sanderson and Ghomi

obturator nerve, probably due to aberrant obturator nerve anatomy.8 Decreased abduction muscle strength cannot be explained by obturator nerve injury as the abductors are innervated by the superior and inferior gluteal nerves. This was most likely a paininduced finding as opposed to being due to a true neuropathy. The case highlights a rare complication of transobturator sling and a treatment option for its management. Early diagnosis and vaginal revision surgery need to remain an important treatment option for patients with severe disease to take advantage of the reversible nature of primary nerve injury. This negates any cumulative damage that may occur as a result of the body’s natural response to a foreign body during a trial of conservative management. REFERENCES

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3. Novara G, Galfano A, Boscolo-Berto R, et al. Complication rates of tension-free midurethral slings in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials comparing tension-free midurethral tapes to other surgical procedures and different devices. Eur Urol 2008;53:288Y309. 4. Reynolds WS, Kit LC, Kaufman MR, et al. Obturator foramen dissection for excision of symptomatic transobturator mesh. J Urol 2012;187:1680Y1684. 5. Possover M, Lemos N. Risks, symptoms, and management of pelvic nerve damage secondary to surgery for pelvic organ prolapse: a report of 95 cases. Int Urogynecol J 2011;22(12):1485Y1490. 6. Van Ba OL, Wagner L, de Tayrac R. Obturator neuropathy: an adverse outcome of a trans-obturator vaginal mesh to repair pelvic organ prolapse. Int Urogynecol J 2014;25:145Y146.

1. Park AJ, Fisch JL, Walters MD. Transient obturator neuropathy due to local anesthesia during transobturator sling placement. Int Urogynecol J Pelvic Floor Dysfunct 2009;20(2):247Y249.

7. Hazewinkel MH, Hinoul P, Roovers JP. Persistent groin pain following a trans-obturator sling procedure for stress urinary incontinence: a diagnostic and therapeutic challenge. Int Urogynecol J Pelvic Floor Dysfunct 2009;20(3):363Y365.

2. Boyles SH, Edwards R, Gregory W, et al. Complications associated with transobturator sling procedures. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:19Y22.

8. Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a trans-obturator sling. Int Urogynecol J Pelvic Floor Dysfunct 2004;15(4):223Y226.

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Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Bilateral obturator neuropathy after transobturator vaginal sling: a case report.

Transobturator tape procedure is a popular and effective minimally invasive technique to treat stress urinary incontinence. We report a case of transi...
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