Neuroprotection due to irrigation during bipolar cautery

Complete resection versus functional preservation in resection of cystic vestibular schwannoma in a 56-year-old female: case report and literature review

Surgery for vestibular schwannoma presents unique challenges to the surgeon, given that the primary objectives are achieving complete resection while preserving both facial nerve and hearing function. Consequently, a comprehensive preoperative and perioperative assessment of the tumor is essential to determine its extent, particularly in cases involving dumbbell-shaped lesions. This case report describes our experience in managing a patient with a dumbbell-shaped vestibular schwannoma, where we achieved near-total resection while successfully preserving the patient's facial nerve and hearing function. The early postoperative evaluation revealed no morbidity, and the patient experienced a significant improvement in their symptoms.

A case series title: femoral nerve injury with an episode of motor neuropathy caused by gynecological surgery: a case series

Background

Although iatrogenic nerve injury is sometimes diagnosed after gynecological surgery, its incidence is underestimated because most cases are self-limiting and underreported. Herein, we report on six cases of femoral nerve injury after gynecological surgery with both sensory and motor neuropathy.

Methods

We retrospectively analyzed 785 patients with gynecological cancer requiring surgery, including lymph node dissection, between 2012 and 2016 at our center. The functional damage due to femoral nerve injury was postoperatively assessed and classified according to the Medical Research Council (MRC) scale by an orthopedist and a physiatrist. The eligibility criteria were grade 3 or less hip joint bending and muscular weakness due to nerve injury. Patients were excluded if they had been diagnosed with an isolated sensory disorder.

Results

We found six cases (0.76%) of femoral motor neuropathy resulting from gynecological surgery. All six patients underwent laparotomy using energy devices under general anesthesia with epidural anesthesia in the lithotomy position. Four of them recovered fully within 8 months from surgery with either physical therapy or no treatment, while the other two died within a year post-treatment; thus, recovery evaluation could not be accurately performed.

Conclusion

Postoperative femoral nerve injury can be diagnosed based on gait disturbances and difficulties climbing stairs. It is difficult to identify risk factors for femoral nerve injury as they may involve a combination of features, such as intraoperative compression with self-retaining retractors, the lithotomy position, and the use of energy devices. The surgeon should be familiar with the nature of energy devices, make every effort to understand the necessary anatomy, and make every effort to avoid femoral nerve injury. Iatrogenic femoral nerve injury caused by gynecological surgery should be further investigated regarding the patients' quality of life postoperatively.

Haemostatic efficacy and inflammatory response of a novel beta-chitin patch in a cerebral small vessel injury model - A pilot study

OBJECTIVE

Rapid and efficacious haemostasis is paramount in neurosurgery. Assessing the efficacy and short- and long-term safety of haemostatic agents utilised within cerebral tissue is essential. This pilot study investigates the haemostatic efficacy and long-term safety of a novel beta-chitin patch against traditionally used agents, bipolar and Floseal, within cerebral tissue.

METHODS

Eighteen Merino sheep underwent standardised distal cortical vessel injury via temporal craniotomy. Sheep were randomised to receive 2 mls Floseal, 2 cm novel beta-chitin patch, or bipolar cautery to manage bleeding. All sheep underwent cerebral magnetic resonance imaging (MRI) at three months, before euthanasia and brain harvesting for histological assessment.

RESULTS

Beta-chitin demonstrated a trend towards a faster mean time to haemostasis (TTH) compared to Floseal (223.3 ± 199 s v. 259.8 ± 186.4 s), albeit non-significant (p = 0.234). Radiologically, cerebrocortical necrosis (p = 0.842) and oedema (p = 0.368) were noted slightly more frequently in the beta-chitin group. Histologically, severe fibrotic (p = 0.017) and granulomatous changes at the craniotomy sites were only present in the beta-chitin group (p = 0.002). Neuronal degeneration was seen in all with Floseal, but beta-chitin showed a trend towards more severe reaction when present. Bipolar use predominantly showed an inflammatory cortical reaction with substantial microvascular proliferation, and Floseal showed worse severity and depth of subpial oedema, however no statistical significance was reached.

CONCLUSION

All haemostats controlled bleeding, with beta-chitin demonstrating a non-inferior TTH compared to Floseal. However, it resulted in intense granulomatous and fibrotic changes, including degenerative neuronal reactions. More extensive studies are needed to assess these trends, to make further clinical inferences.

Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes

BACKGROUND

The use of surgical clips for athermal dissection of the lateral prostatic pedicles and ligation during pelvic lymph node dissection (PLND) while performing robotic-assisted radical prostatectomy (RARP) has been the gold standard. Clips are used to prevent thermal injury of the unmyelinated nerve fibers and lymphceles, respectively.

OBJECTIVE

To compare oncological and functional outcomes of a new technique of clipless, lateral pedicle control and PLND with RARP with bipolar energy (RARP-bi) versus the standard RARP technique with clips (RARP-c).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted among 338 men who underwent RARP between July 2018 and March 2020.

SURGICAL PROCEDURE

RARP-c versus RARP-bi.

MEASUREMENTS

We prospectively collected data and retrospectively compared demographic, clinicopathological, and functional outcome data. Urinary as well as sexual function was assessed using the Expanded Prostate Cancer Index for Clinical Practice, and complications were assessed using Clavien-Dindo grading. Multivariable regression modeling was used to examine whether the technical approach of RARP-bi versus RARP-c was associated with positive surgical margins (PSMs) or sexual and urinary function scores.

RESULTS AND LIMITATIONS

A total of 144 (43%) and 194 (57%) men underwent RARP-bi and RARP-c, respectively. Overall, there were no differences in functional and oncological outcomes between the two approaches. On multivariable regression analysis, the RARP-bi technique was not associated with significant differences in PSMs (odds ratio [OR] = 1.04, 95% confidence interval [CI] 0.6-1.8; p = 0.9), sexual function (OR = 0.4, 95% CI 0.1-1.5; p = 0.8), or urinary function (OR = 0.5, 95% CI 0.2-1.4; p = 0.2). The overall 30-d complication rates (12% vs 16%, p = 0.5) and bladder neck contracture rates (2.1% vs 3.6%, p = 0.5) were similar between the two groups. There was no difference in lymphocele complications (1.4% vs 0.52%, p = 0.58). All complications were of Clavien-Dindo grade I-II.

CONCLUSIONS

Despite the concerns for an increased risk of nerve injury secondary to the use of bipolar energy for prostatic pedicle dissection, we demonstrate that this technique is oncologically and functionally similar to the standard approach with surgical clips. There was no difference in complications or lymphocele formation for techniques with versus without clips.

PATIENT SUMMARY

We describe a modified technique for prostatic pedicle dissection during robotic-assisted radical prostatectomy, which utilizes bipolar energy and is associated with shorter operative time, without compromising functional or oncological outcomes.

Feasibility study of a novel rectal cooling system for hypothermic radical prostatectomy in a swine model

Thermal damage and inflammatory responses of the sphincter and neurovascular bundles (NVBs) are responsible for post-prostatectomy incontinence and erectile dysfunction. Intraoperative hypothermia in the pelvic cavity may reduce the occurrence of these complications. We evaluated the feasibility of a novel rectal cooling system using an animal model. A novel rectal cooling system consisting of a cooling console and a multi-lumen rectal balloon was developed. We conducted animal tests on male pigs to evaluate the efficacy and safety of the system. The primary endpoint was to maintain the temperature of the NVBs at 25℃ (±5℃) during and after the electrocauterization of the bladder neck for 10 seconds. The safety endpoint was device-related complications or significant changes in the core body temperature of the pigs. The NVB temperature was below 30℃ within 3 minutes of activation of the rectal balloon. The temperature of the proximal NVB was consistently maintained below 25℃ in all cases. The temperature 1 cm from the bladder neck did not rise above 38°C and dropped to the initial level within 1 minute after electrocauterization. During cooling, the minimum temperature at the apex of the prostate was reduced to 10.1℃. There were no device-related complications or significant changes in core body temperature throughout the experiment. Animal tests suggest the feasibility and safety of this novel rectal cooling system. A first-in-human trial to assess the safety and efficacy of this system during radical prostatectomy is warranted.

Retrospective Concomitant Nonrandomized Comparison of "Touch" Cautery Versus Athermal Dissection of the Prostatic Vascular Pedicles and Neurovascular Bundles During Robot-assisted Radical Prostatectomy

BACKGROUND

During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and "touch" monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed.

OBJECTIVE

To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had "thin" pedicles, easily suitable for suture ligation. TC was based on "thick" pedicles (n = 230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n = 180).

SURGICAL PROCEDURE

Single-surgeon RARP.

MEASUREMENTS

Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; "are erections firm enough for penetration?" and "are the erections satisfactory?"), IIEF-5 scores 15-25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery.

RESULTS AND LIMITATIONS

In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p = 0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15-25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously.

CONCLUSIONS

During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT.

PATIENT SUMMARY

Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.

Carbon dioxide gas endoscopy of the deep gluteal space

The treatment of hip and pelvic pain associated with abnormalities of the deep gluteal space has evolved and increasingly involves endoscopic techniques with a saline expansion medium. This investigation presents a surgical technique utilizing carbon dioxide as the insufflation medium for deep gluteal space endoscopy in 17 cadaveric hips. This technique was successful in 94% (16/17) of the hips, allowing for visualization of the sciatic nerve, posterior femoral cutaneous nerve, pudendal nerve, branch of the inferior gluteal artery crossing the sciatic nerve, piriformis muscle, hamstring tendon origin, and lesser trochanter. Our experience suggests that gas expansion presents several advantages over fluid expansion.

Prevention of Nerve Root Thermal Injury Caused by Bipolar Cauterization Near the Nerve Roots

STUDY DESIGN

This was a controlled, interventional animal study.

OBJECTIVE

This study aimed to investigate the thermal injury of nerve root by cauterization near the nerve root and to identify the prevention or rescue procedure of nerve root injury.

SUMMARY OF BACKGROUND DATA

In spine surgery, bipolar cauterization of epidural venous plexus near the nerve root is an essential procedure to control bleeding. Although a potential risk of neurological thermal damage exists, the underlying mechanism and prevention have not been elucidated.

METHODS

Temperature measurement and histological evaluation after bipolar cauterization near the posterior branch of the nerve root were performed using a rabbit model. Subsequently, the effect of saline irrigation or changing the direction of bipolar forceps to reduce thermal elevation during bipolar cauterization was evaluated. Finally, the effectiveness of locally injected corticosteroid after bipolar cauterization was evaluated.

RESULTS

After bipolar cauterization, temperature of the surrounding site reached 60.9 °C, and 47.8% of the nerves were histologically injured. Using saline irrigation, thermal elevation was significantly suppressed up to 42.7 °C (P < 0.01), and no nerve was histologically injured. When bipolar cauterization was performed in the perpendicular direction, temperature of the surrounding site reached only 40.4 °C (P < 0.01). Locally injected corticosteroid reduced the incidence of nerve injury to 25.0%. However, a significant increase in nerve damage remained compared with the sham group (P < 0.01).

CONCLUSION

Bipolar cauterization near the nerve roots can increase the temperature of nerve roots and cause thermal nerve root injury, despite no accidental direct nerve root injury. Using saline irrigation, or setting bipolar forceps perpendicular to nerve roots, thermal elevation could be suppressed and nerve injury could be prevented. Therefore, it is recommended that surgeons set bipolar forceps perpendicular to nerve roots or use saline irrigation for the prevention of nerve root injury.

LEVEL OF EVIDENCE

N/A.

A Randomized Control Trial Of Anti-Inflammatory Regional Hypothermia On Urinary Continence During Robot-Assisted Radical Prostatectomy

The present study seeks to present a single-blind, randomized control trial of a hypothermic anti-inflammatory device, the endorectal cooling balloon (ECB), to assess whether regional hypothermia could improve 90-day and time to pad-free continence following robot-assisted radical prostatectomy (RARP). Five high-volume surgeons at three institutions had patients randomized (1:1) to regional hypothermia with ECB versus control. Patients were blinded to device use, as it was inserted and removed intraoperatively. Knowledge of device use was restricted to the operating room personnel only; recovery room and ward nursing staff were not informed of device use and instructed to indicate such if a patient inquired. An independent and blinded data acquisition contractor assessed outcomes via components of the EPIC and IPSS. The primary outcome was categorical pad-free continence at 90-days and the secondary outcome was a Kaplan-Meier time-to pad-free continence at 90 days. 100 hypothermia and 99 control patients were included. The primary outcome of 90-day pad-free continence was 50.0% (27.8-70.0%) in the hypothermia group versus 59.2% (33.3-78.6%) in the control (p = 0.194). The secondary outcome of Kaplan Meier analysis for time to 90-day continence was not statistically significant. At one year, there were also no statistically significant differences in continence recovery. Post-hoc analysis revealed a trend towards improvement in continence in one of three sites. Overall, the trial demonstrated no benefit to regional hypothermia either in our primary or secondary outcomes. It is suggested that surgical technique and prevention of surgical trauma may be more advantageous to improving continence recovery.

Liquid-Infused Surfaces on Electrosurgical Instruments with Exceptional Antiadhesion and Low-Damage Performances

Electrosurgery based on electrosurgical instruments plays an important role in clinical surgery owing to its advantages of ease of operation, low damage, and less pain to the patient. But soft tissue adhesion on electrosurgical instruments is still a major obstacle to improve the operation efficiency and achieve a better surgical result, regardless of so many developed methods to enhance the antiadhesion performance. In this paper, we successfully demonstrated that liquid-infused surfaces (LISs) can significantly improve the antiadhesion performance of electrosurgical instruments. We developed a microcontact printing method to assist the structure fabrication on the small instrument tip to prepare a firmly liquid-held surface. Soft tissue cutting experiments showed that LIS could not only significantly reduce the adhesion force between the tissue and the instrument tip but also lead to a much smaller charring wound. The underlying mechanism was discussed, and further experiments concluded that LIS have a better duration capability. Our study provides a new insight into the antiadhesion design for electrosurgical instruments.

Preparation and High-temperature Anti-adhesion Behavior of a Slippery Surface on Stainless Steel

Anti-adhesion surfaces with high-temperature resistance have a wide application potential in electrosurgical instruments, engines, and pipelines. A typical anti-wetting superhydrophobic surface easily fails when exposed to a high-temperature liquid. Recently, Nepenthes-inspired slippery surfaces demonstrated a new way to solve the adhesion problem. A lubricant layer on the slippery surface can act as a barrier between the repelled materials and the surface structure. However, the slippery surfaces in previous studies rarely showed high-temperature resistance. Here, we describe a protocol for the preparation of slippery surfaces with high-temperature resistance. A photolithography-assisted method was used to fabricate pillar structures on stainless steel. By functionalizing the surface with saline, a slippery surface was prepared by adding silicone oil. The prepared slippery surface maintained the anti-wetting property for water, even when the surface was heated to 300 °C. Also, the slippery surface exhibited great anti-adhesion effects on soft tissues at high temperatures. This type of slippery surface on stainless steel has applications in medical devices, mechanical equipment, etc.

Perineal midline vertical incision verses inverted-U incision in the urethroplasty: which is better?

OBJECTIVE

To compare postoperative outcomes between the perineal inverted-U and the vertical midline incision approaches of the urethroplasty and clarify them via gross anatomy.

PATIENTS AND METHODS

A total of 461 male patients, from Jan. 2006 to Jun. 2014, who underwent the urethroplasty via perineal midline vertical or inverted-U incision approach were recruited retrospectively. By match pairing for etiology and stricture length, 410 patients from two groups (205 for each group) were selected. Anatomy experiments were also performed. Outcome measurements and statistical analysis: the Chi-square, Student's t and binary logistic regression analyses were performed to compare the operative and postoperative data on the two groups.

RESULTS

With regard to patients with bulbar urethral stricture, the rate of surgical site infection (SSI) in perineal inverted-U group was 18.6% while 1.9% in the midline vertical group (p < 0.001). As for patients with posterior urethral stricture, the rate of SSI in the perineal inverted-U group was 16.4% while 3.1% in the midline vertical group (p = 0.001). Mean hospital stay between both groups were 15.8 ± 9.0 vs. 12.7 ± 3.8 days (p < 0.001). Anatomy experiments showed the number of damaged vessels and nerves involved in the inverted-U incision were approximately 1.6 to 2.0 folds more than the vertical midline, but the visual operation fields are similar between two approaches.

CONCLUSIONS

The perineal midline vertical incision is a safer approach with fewer SSI and shorter hospital stay than the perineal inverted-U incision for bulbar and posterior urethroplasty.

The efficacy of bipolar sealer on blood loss in spine surgery: a meta-analysis

OBJECTIVE

The purpose of this meta-analysis of randomized controlled trials (RCTs) and non-RCTs was to gather data to evaluate the efficacy and safety of bipolar sealer versus standard electrocautery in the management of spinal disease.

METHODS

The electronic databases including Embase, PubMed and Cochrane library were searched to identify relevant studies published from the time of the establishment of these databases up to January 2017. The primary outcomes were total blood loss, requirement of transfusion (rate and amount), and operation time. The secondary outcomes were length of hospital stay and postoperative wound infection. Data analysis was conducted with RevMan 5.3 software.

RESULTS

A total of five studies involving 500 patients (261 patients in the BS group and 239 in the control group) were included in the meta-analysis. The pooled results revealed that application of bipolar sealer could decrease the total blood loss in spine surgery [WMD = -467.49, 95% CI (685.47 to -249.51); p < 0.05; I ² = 91%]. Compared with standard electrocautery, bipolar sealer was associated with lower rates of need for transfusion [OR = 0.30, 95% CI (0.16-0.55), p < 0.05; I ² = 0%]. In addition, patients in the BS group were likely to receive less amount of blood transfusion compared with patients in the control group[WMD = -0.73, 95% CI (-1.37 to -0.09), p < 0.05; I ² = 76%]. The mean operative time was shorter in the BS groups compared with the control group [SMD = -0.36, 95% CI (-0.60 to -0.13), p < 0.05; I ² = 0%]. There was no significant difference in terms of length of hospital stay [WMD = -0.73, 95% CI (-1.96 to 0.51), p = 0.25; I ² = 67%] and postoperative wound infection [OR = 0.88, 95% CI (0.31-2.48), p = 0.81; I ² = 0.0%] between both groups.

CONCLUSIONS

The available evidence suggests that bipolar sealer is superior to standard electrocautery with less blood loss, shorter operation time and less transfusion requirement. There is no significant difference between both groups regarding length of hospitalization and wound infection. Hence, bipolar sealer is recommended in spine surgery. Because of the limitation of our study, more well-designed RCTs with large sample are required to provide further evidence of safety and efficacy between bipolar sealer and standard electrocautery in the treatment of spinal disease.

Radiofrequency bipolar hemostatic sealer reduces blood loss, transfusion requirements, and cost for patients undergoing multilevel spinal fusion surgery: a case control study

Background

A relatively new method of electrocautery, the radiofrequency bipolar hemostatic sealer (RBHS), uses saline-cooled delivery of energy, which seals blood vessels rather than burning them. We assessed the benefits of RBHS as a blood conservation strategy in adult patients undergoing multilevel spinal fusion surgery.

Methods

In a retrospective cohort study, we compared blood utilization in 36 patients undergoing multilevel spinal fusion surgery with RBHS (Aquamantys®, Medtronic, Minneapolis, MN, USA) to that of a historical control group (n = 38) matched for variables related to blood loss. Transfusion-related costs were calculated by two methods.

Results

Patient characteristics in the two groups were similar. Intraoperatively, blood loss was 55% less in the RBHS group than in the control group (810 ± 530 vs. 1,800 ± 1,600 mL; p = 0.002), and over the entire hospital stay, red cell utilization was 51% less (2.4 ± 3.4 vs. 4.9 ± 4.5 units/patient; p = 0.01) and plasma use was 56% less (1.1 ± 2.4 vs. 2.5 ± 3.4 units/patient; p = 0.03) in the RBHS group. Platelet use was 0.1 ± 0.5 and 0.3 ± 0.6 units/patient in the RBHS and control groups, respectively (p = 0.07). The perioperative decrease in hemoglobin was less in the RBHS group than in the control group (−2.0 ± 2.2 vs. –3.2 ± 2.1 g/dL; p = 0.04), and hemoglobin at discharge was higher in the RBHS group (10.5 ± 1.4 vs. 9.7 ± 0.9 g/dL; p = 0.01). The estimated transfusion-related cost savings were $745/case by acquisition cost and approximately 3- to 5-fold this amount by activity-based cost.

Conclusions

The use of RBHS in patients undergoing multilevel spine fusion surgery can conserve blood, promote higher hemoglobin levels, and reduce transfusion-related costs.

Monopolar radiofrequency use in deep gluteal space endoscopy: sciatic nerve safety and fluid temperature

PURPOSE

The purpose of this study was to evaluate the temperature at the sciatic nerve when using a monopolar radiofrequency (RF) probe to control bleeding in deep gluteal space endoscopy, as well as assess the fluid temperature profile.

METHODS

Ten hips in 5 fresh-frozen human cadaveric specimens from the abdomen to the toes were used for this experiment. Temperatures were measured at the sciatic nerve after 2, 5, and 10 seconds of continuous RF probe activation over an adjacent vessel, a branch of the inferior gluteal artery. Fluid temperatures were then measured at different distances from the probe (3, 5, and 10 mm) after 2, 5, and 10 seconds of continuous probe activation. All tests were performed with irrigation fluid flow at 60 mm Hg allowing outflow.

RESULTS

After 2, 5, or 10 seconds of activation over the crossing branch of the inferior gluteal artery, the mean temperature increased by less than 1°C on the surface and in the perineurium of the sciatic nerve. Considering the fluid temperature profile in the deep gluteal space, the distance and duration of activation influenced temperature (P < .05). Continuous delivery of RF energy for 10 seconds caused fluid temperature increases of 1.2°C, 2°C, and 3.1°C on average at 10 mm, 5 mm, and 3 mm of distance, respectively.

CONCLUSIONS

This study found the tested monopolar RF device to be safe during use in vessels around the sciatic nerve after 2, 5, and 10 seconds of continuous activation. The maximum fluid temperature (28°C) after 10 seconds of activation at 3 mm of distance is lower than the minimal reported temperature necessary to cause nerve changes (40°C to 45°C).

CLINICAL RELEVANCE

Monopolar RF seems to be safe to the neural structures when used at more than 3 mm of distance and with less than 10 seconds of continuous activation in deep gluteal space endoscopy with fluid inflow and outflow.

Robotic-assisted radical prostatectomy after the first decade: surgical evolution or new paradigm

Early studies indicate that robotic-assisted radical prostatectomy (RARP) has promising short-term outcomes; however, RARP is beyond its infancy, and the long-term report cards are now beginning. The important paradigm shift introduced by RARP is the reevaluation of the entire open radical prostatectomy experience in surgical technique by minimizing blood loss and complications, maximizing cancer free outcomes, and a renewed assault in preserving quality of life outcomes by many novel mechanisms. RARP provides a new technical “canvas” for surgical masters to create upon, and in ten years, has reinvigorated a 100-year-old “gold standard” surgery.

Influence of intraoperative neurophysiologic monitoring on the development of surgical dissection techniques

Intraoperative neurophysiologic monitoring (IONM) is essential in the preservation of function of nervous system. IONM is thus becoming the gold-standard method in nerve-sparing surgical procedures. Apart from spine and brain surgery, IONM is essential in significantly reducing morbidity in colorectal surgery, prostate and thyroid surgery, as well as in hip replacement, to name a few. IONM measures weak electric nerve potentials and, therefore, it is easily disturbed by other electromagnetic sources. Surgical dissection techniques and devices interfering with IONM make this technique useless because this is dissection that mainly endangers nerve structures. Therefore, there is a need to take into consideration the influence of various dissection techniques on IONM, and to develop or modify inert techniques that are currently not widely used.

The application of regional hypothermia using transrectal cooling during radical prostatectomy: mitigation of surgical inflammatory damage to preserve continence

Preservation of continence and sexual function continues to be a formidable quality-of-life issue regarding outcomes after radical prostatectomy. There is little argument that physical preservation of the nerves and sphincters is a critical component to achieving success in these domains. Previously demonstrated factors such as advancing age, deteriorating physical health status, and subnormal baseline potency negatively impact outcomes. Our hypothesis, however, has been that inflammatory response to surgery has a large impact on surgical outcomes of prostatectomy. Trauma-induced inflammation could account for variation in recovery despite nearly identical surgery on many patients, especially in high-volume surgeons. In other words, we suggest and maintain that younger and healthier patients tolerate and/or recover better from the trauma/inflammation of surgery. Those who do not recover as well may have altered inflammatory response to injury. A common response to decrease inflammation in response to physical injury would be as simple as to cool the injury with ice. Previous neurologic studies have suggested that using ice during surgical intervention can reduce the inflammatory damage. Therefore, we applied this concept that preemptive hypothermia could reduce inflammation to the robot-assisted prostatectomy procedure to potentially lead to improved continence and potency outcomes. In 2009, we introduced the concept of regional hypothermia via an endorectal cooling balloon during robot-assisted radical prostatectomy (RARP). We have published our single institution data demonstrating a significant reduction of overall incontinence. Defining continence as zero-pads, our overall 1-year incontinence has been reduced by 70% (from 13% to 4%). Severe incontinence, defined as two or more pads, was likewise reduced by 70% (from 2.9% to 0.9%). Regional hypothermia used during the time of surgery represents a novel strategy for minimizing inflammation and subsequent muscle and nerve damage in RARP.

Comparison of the effects of different electrocautery applications to peripheral nerves: an experimental study

BACKGROUND

This study was designed to investigate the effects of bipolar and mononopolar electrocauterization on peripheral nerve tissue. The comparison on the deleterious effects of the different cautery modalities and the importance of probe tip placement are evaluated using electrophysiological, electron microscopic and biochemical assessment parameters.

METHODS

Ninety-eight male Wistar albino rats, each weighing 250-275 g, were randomly divided into 14 groups. Each group consisted of seven animals. Monopolar and bipolar electrocautery were performed at 15 watts. The application was performed either directly on the nerve or 1 mm lateral to the longitudinal axis of the nerve for 'near the nerve groups', respectively.

RESULTS

The electrophysiological findings showed that the mean amplitudes were at the lowest value in the first day for all the groups. At the end of the 3rd week, we recognised that the electrophysiological recovery continued. Electron microscopic evaluation showed myelin disruption in all groups. Myelin disruption of healthy neurons was at the highest level in the 1st day of application in accordance with the electrophysiological findings. Biochemical evaluation revealed statistical significance between the control and the two of the 'near the nerve groups' (GIII and GV) for NO (nitrite and nitrate) serum level.

CONCLUSION

The data of the present study might suggest that electrocautery, independent of the type and form of application, may result in significant damage in histological and electrophysological basis. Although the relative proportions cannot be ascertained, the time course of recovery suggests that both axon and myelin damage have occurred. The probable electrocautery damage may be of substantial importance for the situation that the nerves are displaced by tumor masses or atypical neural traces.

Basis for the use of localized hypothermia during radical pelvic surgery

Controlled tissue cooling, or hypothermia, has been used therapeutically for decades to mitigate the negative effects of traumatic, ischemic, and surgical insults. When applied systemically, moderate hypothermia can attenuate or prevent the extent of neurologic sequelae. Localized hypothermia, on the other hand, has the capacity to reduce tissue edema, suppress inflammation, and minimize the severity of peripheral nerve injury. Therapeutic hypothermia has been used in critical care, neurosurgery, ophthalmology, otolaryngology, cardiothoracic surgery and most recently in urology. Nerve injury during radical pelvic surgery can result in urinary incontinence or retention, impotence and bowel dysfunction. Localized hypothermia during radical prostatectomy has demonstrated improved recovery of urinary continence and erectile function, and similar benefits might be observed in other types of radical pelvic surgery.

Principles and initial experience of a new device for dissection and hemostasis

Electrosurgery is a commonly used technology in laparoscopy. Electrosurgical devices are being used in many medical subdisciplines in order to coagulate, cut, and ablate tissue and to produce hemostasis. The latest advance in electrosurgery is the introduction of novel simultaneous hemostatic sealing and cutting bipolar devices that minimize force by delivering energy as high current and low voltage output. One of these systems is the Gyrus Plasma Trissector (GPT), (Gyrus Group PLC, Gyrus International, Ltd.UK), a novel radiofrequency (RF) system based on bipolar technology, which consists of a proprietary PlasmaKinetic (PK) generator and specific instruments, designed as a system. The instrument consists of a 17 mm long gold-coated curved jaw with a ceramic insulated cutting element. The PK system uses high-powered pulsed bipolar energy to produce a plasmakinetic field around the working elements and is designed to operate at temperatures that allow effective tissue dissection but result in minimal collateral damage and adherence to tissue. The GPT was used with the Gyrus G400 WorkStation generator in laparoscopic radical prostatectomies (LRP). Our initial experience with this novel bipolar device demonstrates it to be safe and effective in dissection and hemostasis. The GPT permits us to act quickly when bloody fields are present, improves coagulation, reduces or eliminates sticking, seals large vessels such as dorsal vein complex (DVC) and allows secure grasping and dissecting of tissue. The urologist is familiar with electrosurgery, as we have become comfortable using GPT to dissect, cut, and coagulate tissue. We feel that the GPT can be used in a variety of laparoscopic procedures in urology.

Current Technological Advances of Bipolar Coagulation

Background:

Heat has been used to control bleeding for thousands of years. In the 1920s, this concept was applied to the development of electrosurgical instruments and was used to control hemorrhage during surgical procedures. In the time that has passed since its first use, electrosurgery has evolved into modernday bipolar technology, involving a diverse group of coagulation instruments.

Methods:

We review the evolution and advances in electrosurgery, specifically bipolar coagulation, and the current technologies available for intraoperative hemorrhage control.

Results:

Electrosurgery has evolved to include highly accurate devices that deliver thermal energy via nonstick and noncontact methods. Over time, the operative range of coagulation instruments has increased dramatically with the incorporation of irrigating pathways, a wide range of instrument tips to perform various functions, and the application of bipolar technology to microforceps and microscissors for minimally invasive procedures.

Conclusion:

Electrosurgical devices and techniques, especially bipolar coagulation, have developed significantly with the availability of new technologies. This has led to better intraoperative coagulation control while minimizing iatrogenic damage associated with heat spread and tissue adherence, thus potentially improving outcomes for neurosurgical procedures.

Impact of Cautery versus Cautery-Free Preservation of Neurovascular Bundles on Early Return of Potency

PURPOSE

To update our short-term potency outcomes from a cautery-free (CFT) versus bipolar cautery technique to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (RLP).

PATIENTS AND METHODS

Previously, we reported on 3-month potency outcomes in 23 men, which we now extend to 51 men. All men met three criteria: age <66 years, Sexual Health Inventory in Men (SHIM-5) score of 22 to 25, and either unilateral or bilateral NVB preservation at LRP. Group 1 (N = 51), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. The average age and preoperative SHIM scores were similar for the two groups. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration. All men were asked to estimate the fullness of erections compared with baseline (preoperative).

RESULTS

The average age and preoperative SHIM scores were similar for both groups. The rate of potency at 3 months was 47% (24/51) in group 1 versus just 8.3% (3/36) in group 2 (P < 0.001). Additionally, only 9 of 25 CFT patients (36%) reported zero fullness compared with 15 of 22 patients (68%) in the bipolar cauterytreated group (P = 0.03).

CONCLUSIONS

With expanded experience, there was no change in 3-month return of sexual function (47%) compared with our initial publication. This result further supports the importance of avoiding cautery when controlling the vascular pedicle and dissecting the NVB.

Rapid Communication:Early Potency Outcomes with Cautery-Free Neurovascular Bundle Preservation with Robotic Laparoscopic Radical Prostatectomy

PURPOSE

To report short-term potency outcomes with a cautery-free technique (CFT) to preserve the neurovascular bundles (NVB) during robotic laparoscopic radical prostatectomy (LRP).

PATIENTS AND METHODS

All men were <66 years of age and had a Sexual Health Inventory in Men (SHIM) score of 22 to 25. They underwent unilateral or bilateral dissections. Group 1 (N = 23), the study group, had preservation of the NVB with CFT. Group 2 (N = 36) had traditional dissection using bipolar cautery. Data were collected prospectively via validated questionnaires. Potency was defined as an erection adequate for vaginal penetration.

RESULTS

At 3 months, 10 patients (43%) in the CFT group reported potency versus just 3 (8.3%) in the bipolar-cautery group (P = 0.003). Additionally, only 2 (18%) of those having CFT reported zero penile fullness compared with 15 (68%) in the bipolar-cautery group (P = 0.01).

CONCLUSIONS

The technique of controlling the vascular pedicle of the prostate and dissecting the NVB without cautery produced significant improvement in potency outcomes at just 3 months.

Nerve sparing radical prostatectomy: effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model

PURPOSE

To preserve sexual function following radical prostatectomy, one must avoid injury to the neurovascular bundles (NVBs). In the conventional open surgical technique, the use of energy sources for hemostasis is avoided to prevent damage to the cavernous nerves. In contrast, during laparoscopic radical prostatectomy, electrosurgical and ultrasonic energy sources are frequently used for hemostasis during dissection of the prostate. In this study, we evaluated the acute and chronic physiological effects of various hemostatic energy sources on cavernous nerve function in the canine model.

MATERIALS AND METHODS

A total of 12 dogs were divided into 4 groups based on the type of energy source used for hemostasis during unilateral dissection of the NVB. The groups included conventional dissection with suture ligatures (group 1), monopolar (group 2) or bipolar (group 3) electrosurgery and ultrasonic shears (group 4). The contralateral NVB was left undissected as a control. Erectile function was assessed acutely and after 2 weeks of survival by measuring peak intracavernous pressures in response to cavernous nerve stimulation.

RESULTS

Following conventional techniques of nerve sparing, the erectile response to nerve stimulation was unaffected. In contrast, the use of energy sources in proximity to the NVB during nerve preservation was associated with a substantial decrease in erectile response both acutely (74% to 91% decrease compared to controls) and after 2 weeks (93% to 96% decrease).

CONCLUSIONS

In the chronic canine model, use of hemostatic energy sources in proximity to the prostate during dissection of the neurovascular bundle is associated with a significantly decreased erectile response to cavernous nerve stimulation.