Adductor Muscle Contraction Under Deep Neuromuscular Blockade During TURBT Under General Anesthesia: Is Obturator...

Background and Objectives: Obturator reflex during transurethral resection of bladder tumors (TURBT) can cause serious complications, such as bladder perforation, hemorrhage, and incomplete resection. Although obturator nerve block (ONB) is routinely recommended under spinal anesthesia, it is often omitted under general anesthesia (GA) based on the assumption that neuromuscular blockade (NMB) alone prevents adductor muscle contractions. However, clinical observations suggest that the obturator reflex may still occur under deep NMB. This study aimed to determine whether adductor longus muscle (ALM) contraction persists under GA with deep NMB during TURBT. Materials and Methods: Thirty patients scheduled for TURBT under GA were prospectively enrolled. A selective ONB was performed under ultrasound and nerve stimulator guidance. After establishing the baseline current intensity for ALM contraction, neuromuscular monitoring was initiated, and rocuronium (0.6 mg/kg) was administered. Stimulation thresholds required to induce ALM contraction were sequentially assessed at decreasing Train-of-Four ratio (TOFr) stages (90% to 10%) and Train-of-Four count (TOFc) stages (3 to 0). Final measurements were repeated 1 min after achieving TOFc 0. Changes in stimulation intensity were analyzed using a linear mixed-effects model (LMM). Results: As NMB deepened, the current intensity required to provoke ALM contraction progressively increased: 0.51 ± 0.25 mA at TOFr 90%, 1.66 ± 0.53 mA at TOFr 10%, 2.04 ± 0.66 mA at TOFc 0, and 2.61 ± 0.29 mA at 1 min after TOFc 0. Notably, all patients demonstrated ALM contraction at TOFc 0 and thereafter, confirming the persistence of the obturator reflex despite complete NMB. LMM analysis revealed a significant trend of increasing stimulation thresholds with progressive NMB depth (β = 0.133, p < 0.001). Conclusions: Adductor muscle contractions in response to obturator nerve stimulation persist even under deep NMB. These findings raise concerns that deep NMB alone may be insufficient to prevent obturator reflex and suggest that ONB should be considered as an adjunctive practice during TURBT under GA in patients at risk.