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Mandel A, Das C, Ting R, Kaufmann B, Tewari A. Intraoperative Fluorescent Image Guidance for Nerve-Sparing Prostatectomy: A Review of Historical Context and Current Research. J Endourol 2024; 38:30-39. [PMID: 37850492 DOI: 10.1089/end.2023.0480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
Fluorescent probes in the near-infrared (NIR) range have immense potential to improve observation of positive margins, lymph nodes, and nerves in prostatectomy. Development of fluorescent dyes and mechanisms of cellular uptake paved the way for the current emerging technologies. However, intracellular transport of fluorophores proved to be logistically challenging with respect to intraoperative deployment. Peptide-based probes with high specificity for nerves enabled broader and more rapid labeling. Key features of the ideal probe include selectivity, minimal background noise, safety, and low cost. Human neuropeptide 401 (HNP401) and oxazine-based probes perform well in these categories. As for tumor-specific labeling, prostate specific membrane antigen is relatively selective for the prostate and can be conjugated to a fluorophore. NIR spectrum emission is an ideal range for clinical imaging use, as fluorescence occurs outside the field of visible light, and tissue optical properties diverge significantly at the visible-NIR transition. Indocyanine, carbocyanine, and fluorescein derivatives are common fluorophore conjugates for the probes. Finally, to harness the power of fluorescence intraoperatively, the surgeon must look through a specialized lens. Multiphoton microscopy, optical coherence tomography, and confocal laser endomicroscopy have emerged as frontrunners in this arena. As with any evolving technology, ongoing research is expanding the applications of fluorescent intraoperative imaging in prostate surgery. Innovations in camera technology, dye selection, and image processing are refining the technique's capabilities. A core challenge of these technologies translating into the operating room relates to size and the ability to view objects at vastly different magnifications. Dual modality zoom settings are promising solutions. Furthermore, interdisciplinary collaboration between surgeons, imaging specialists, and researchers continues to drive advancements. In conclusion, fluorescent intraoperative imaging has the potential to usher in a new era of precision and safety in prostate surgery.
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Affiliation(s)
- Asher Mandel
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chandan Das
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Basil Kaufmann
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Ashutosh Tewari
- The Milton and Carroll Petrie Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Abstract
OBJECTIVE This review details the agents for fluorescence-guided nerve imaging in both preclinical and clinical use to identify factors important in selecting nerve-specific fluorescent agents for surgical procedures. BACKGROUND Iatrogenic nerve injury remains a significant cause of morbidity in patients undergoing surgical procedures. Current real-time identification of nerves during surgery involves neurophysiologic nerve stimulation, which has practical limitations. Intraoperative fluorescence-guided imaging provides a complimentary means of differentiating tissue types and pathology. Recent advances in fluorescence-guided nerve imaging have shown promise, but the ideal agent remains elusive. METHODS In February 2018, PubMed was searched for articles investigating peripheral nerve fluorescence. Key terms used in this search include: "intraoperative, nerve, fluorescence, peripheral nerve, visualization, near infrared, and myelin." Limits were set to exclude articles exclusively dealing with central nervous system targets or written in languages other than English. References were cross-checked for articles not otherwise identified. RESULTS Of the nonspecific agents, tracers that rely on axonal transport showed the greatest tissue specificity; however, neurovascular dyes already enjoy wide clinical use. Fluorophores specific to nerve moieties result in excellent nerve to background ratios. Although noteworthy findings on tissue specificity, toxicity, and route of administration specific to each fluorescent agent were reported, significant data objectively quantifying nerve-specific fluorescence and toxicity are lacking. CONCLUSIONS Fluorescence-based nerve enhancement has advanced rapidly over the past 10 years with potential for continued utilization and progression in translational research. An ideal agent would be easily administered perioperatively, would not cross the blood-brain barrier, and would fluoresce in the near-infrared spectrum. Agents administered systemically that target nerve-specific moieties have shown the greatest promise. Based on the heterogeneity of published studies and methods for reporting outcomes, it appears that the development of an optimal nerve imaging agent remains challenging.
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Xu H, Chen J, Feng Z, Fu K, Qiao Y, Zhang Z, Wang W, Wang Y, Zhang J, Perdanasari AT, Hanasono MM, Levin LS, Yang X, Hao Y, Li Y, Wo Y, Zhang Y. Shortwave infrared fluorescence in vivo imaging of nerves for minimizing the risk of intraoperative nerve injury. NANOSCALE 2019; 11:19736-19741. [PMID: 31626258 DOI: 10.1039/c9nr06066a] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Here, we present a novel nerve specific imaging agent for preventing intraoperative nerve injuries based on SWIR QD-based in vivo imaging, which not only provides real-time and long-time SWIR images to intraoperatively identify nerves but can also markedly minimize the risk of iatrogenic nerve injuries during surgeries.
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Affiliation(s)
- Heng Xu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jun Chen
- Department of Orthopedic Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | - Zhujun Feng
- Department of Anatomy and Physiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kan Fu
- Silicon Products Group, Applied Materials Inc., Sunnyvale, CA, USA
| | - Yusen Qiao
- P. Roy and Diana T. Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, Philadelphia, PA, USA
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Wenjin Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yueming Wang
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jian Zhang
- Department of Orthopedic Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | | | - Matthew M Hanasono
- Department of Plastic Surgery, the University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Xing Yang
- Department of orthopedics, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215500, Jiangsu, China.
| | - Yuefeng Hao
- Department of orthopedics, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215500, Jiangsu, China.
| | - Yunxia Li
- Department of Orthopedic Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | - Yan Wo
- Department of Anatomy and Physiology, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China. and National Engineering Research Center for Nanotechnology, Shanghai, China
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Hingorani DV, Whitney MA, Friedman B, Kwon JK, Crisp JL, Xiong Q, Gross L, Kane CJ, Tsien RY, Nguyen QT. Nerve-targeted probes for fluorescence-guided intraoperative imaging. Theranostics 2018; 8:4226-4237. [PMID: 30128049 PMCID: PMC6096382 DOI: 10.7150/thno.23084] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 04/27/2018] [Indexed: 12/22/2022] Open
Abstract
A fundamental goal of many surgeries is nerve preservation, as inadvertent injury can lead to patient morbidity including numbness, pain, localized paralysis and incontinence. Nerve identification during surgery relies on multiple parameters including anatomy, texture, color and relationship to surrounding structures using white light illumination. We propose that fluorescent labeling of nerves can enhance the contrast between nerves and adjacent tissue during surgery which may lead to improved outcomes. Methods: Nerve binding peptide sequences including HNP401 were identified by phage display using selective binding to dissected nerve tissue. Peptide dye conjugates including FAM-HNP401 and structural variants were synthesized and screened for nerve binding after topical application on fresh rodent and human tissue and in-vivo after systemic IV administration into both mice and rats. Nerve to muscle contrast was quantified by measuring fluorescent intensity after topical or systemic administration of peptide dye conjugate. Results: Peptide dye conjugate FAM-HNP401 showed selective binding to human sural nerve with 10.9x fluorescence signal intensity (1374.44 ± 425.96) compared to a previously identified peptide FAM-NP41 (126.17 ± 61.03). FAM-HNP401 showed nerve-to-muscle contrast of 3.03 ± 0.57. FAM-HNP401 binds and highlight multiple human peripheral nerves including lower leg sural, upper arm medial antebrachial as well as autonomic nerves isolated from human prostate. Conclusion: Phage display has identified a novel peptide that selectively binds to ex-vivo human nerves and in-vivo using rodent models. FAM-HNP401 or an optimized variant could be translated for use in a clinical setting for intraoperative identification of human nerves to improve visualization and potentially decrease the incidence of intra-surgical nerve injury.
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Hussain T, Nguyen LT, Whitney M, Hasselmann J, Nguyen QT. Improved facial nerve identification during parotidectomy with fluorescently labeled peptide. Laryngoscope 2016; 126:2711-2717. [PMID: 27171862 PMCID: PMC5107163 DOI: 10.1002/lary.26057] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 03/14/2016] [Accepted: 04/04/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Additional intraoperative guidance could reduce the risk of iatrogenic injury during parotid gland cancer surgery. We evaluated the intraoperative use of fluorescently labeled nerve binding peptide NP41 to aid facial nerve identification and preservation during parotidectomy in an orthotopic model of murine parotid gland cancer. We also quantified the accuracy of intraoperative nerve detection for surface and buried nerves in the head and neck with NP41 versus white light (WL) alone. STUDY DESIGN Twenty-eight mice underwent parotid gland cancer surgeries with additional fluorescence (FL) guidance versus WL reflectance (WLR) alone. Eight mice were used for additional nerve-imaging experiments. METHODS Twenty-eight parotid tumor-bearing mice underwent parotidectomy. Eight mice underwent imaging of both sides of the face after skin removal. Postoperative assessment of facial nerve function measured by automated whisker tracking were compared between FL guidance (n = 13) versus WL alone (n=15). In eight mice, nerve to surrounding tissue contrast was measured under FL versus WLR for all nerve branches detectable in the field of view. RESULTS Postoperative facial nerve function after parotid gland cancer surgery tended to be better with additional FL guidance. Fluorescent labeling significantly improved nerve to surrounding tissue contrast for both large and smaller buried nerve branches compared to WLR visualization and improved detection sensitivity and specificity. CONCLUSIONS NP41 FL imaging significantly aids the intraoperative identification of nerve braches otherwise nearly invisible to the naked eye. Its application in a murine model of parotid gland cancer surgery tended to improve functional preservation of the facial nerve. LEVEL OF EVIDENCE NA Laryngoscope, 126:2711-2717, 2016.
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Affiliation(s)
- Timon Hussain
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, San Diego, California, U.S.A
- Department of Otorhinolaryngology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Linda T Nguyen
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, San Diego, California, U.S.A
| | - Michael Whitney
- Department of Pharmacology, University of California, San Diego, San Diego, California, U.S.A
| | - Jonathan Hasselmann
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, San Diego, California, U.S.A
| | - Quyen T Nguyen
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego, San Diego, California, U.S.A
- Moores Cancer Center, University of California, San Diego, San Diego, California, U.S.A
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Massaad CA, Zhang G, Pillai L, Azhdarinia A, Liu W, Sheikh KA. Fluorescently-tagged anti-ganglioside antibody selectively identifies peripheral nerve in living animals. Sci Rep 2015; 5:15766. [PMID: 26514366 PMCID: PMC4626805 DOI: 10.1038/srep15766] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 09/29/2015] [Indexed: 12/20/2022] Open
Abstract
Selective in vivo delivery of cargo to peripheral nervous system (PNS) has broad clinical and preclinical applications. An important applicability of this approach is systemic delivery of fluorescently conjugated ligands that selectively label PNS, which could allow visualization of peripheral nerves during any surgery. We examine the use of an anti-ganglioside monoclonal antibody (mAb) as selective neuronal delivery vector for surgical imaging of peripheral nerves. Systemic delivery of an anti-ganglioside mAb was used for selective intraneuronal/axonal delivery of fluorescent agents to visualize nerves by surgical imaging in living mice. In this study, we show that intact motor, sensory, and autonomic nerve fibers/paths are distinctly labeled following a single nanomolar systemic injection of fluorescently labeled anti-ganglioside mAb. Tissue biodistribution studies with radiolabeled mAb were used to validate neuronal uptake of fluorescently labeled mAb. Implications of this proof of concept study are that fluorescent conjugates of anti-ganglioside mAbs are valuable delivery vectors to visualize nerves during surgery to avoid nerve injury and monitor nerve degeneration and regeneration after injury. These findings support that antibodies, and their derivatives/fragments, can be used as selective neuronal delivery vector for transport of various cargos to PNS in preclinical and clinical settings.
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Affiliation(s)
- Cynthia A Massaad
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Gang Zhang
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Laila Pillai
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Ali Azhdarinia
- Institute of Molecular Medicine-Center for Molecular Imaging, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Weiqiang Liu
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Kazim A Sheikh
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Whitney MA, Crisp JL, Nguyen LT, Friedman B, Gross LA, Steinbach P, Tsien RY, Nguyen QT. Fluorescent peptides highlight peripheral nerves during surgery in mice. Nat Biotechnol 2011; 29:352-6. [PMID: 21297616 PMCID: PMC3364105 DOI: 10.1038/nbt.1764] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 01/04/2011] [Indexed: 11/09/2022]
Abstract
Nerve preservation is an important goal during surgery because accidental transection or injury leads to significant morbidity, including numbness, pain, weakness or paralysis. Nerves are usually identified by their appearance and relationship to nearby structures or detected by local electrical stimulation (electromyography), but thin or buried nerves are sometimes overlooked. Here, we use phage display to select a peptide that binds preferentially to nerves. After systemic injection of a fluorescently labeled version of the peptide in mice, all peripheral nerves are clearly delineated within 2 h. Contrast between nerve and adjacent tissue is up to tenfold, and useful contrast lasts up to 8 h. No changes in behavior or activity are observed after treatment, indicating a lack of obvious toxicity. The fluorescent probe also labels nerves in human tissue samples. Fluorescence highlighting is independent of axonal integrity, suggesting that the probe could facilitate surgical repair of injured nerves and help prevent accidental transection.
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Affiliation(s)
- Michael A Whitney
- Department of Pharmacology, University of California at San Diego, La Jolla, California, USA
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Wu AP, Whitney MA, Crisp JL, Friedman B, Tsien RY, Nguyen QT. Improved facial nerve identification with novel fluorescently labeled probe. Laryngoscope 2011; 121:805-10. [PMID: 21328585 PMCID: PMC3364140 DOI: 10.1002/lary.21411] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 08/12/2010] [Indexed: 12/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS By phage display, we have developed a novel peptide (NP41) that binds selectively to nerves following systemic administration. We evaluated the pattern of facial nerve labeling with fluorescently-labeled NP41 (F-NP41). We also tested whether F-NP41 highlights facial nerves well enough to identify nerve stumps accurately several weeks after nerve transection. STUDY DESIGN Forty-seven wild-type mice were studied prospectively. One surgeon performed the nerve transection, reanastomosis, and monitoring of functional recovery. METHODS Fluorescent labeling: F-NP41 was administered intravenously (20 mice). Nerve labeling was studied with fluorescence microscopy. Transection and reanastomosis: the right facial nerve was transected (25 mice). Three weeks after transection, F-NP41 was administered intravenously and fluorescence microscopy was used to identify the nerve stumps and reanastomosis in one group. Nerve identification and reanastomosis was performed with white light in another group without F-NP41. The control group underwent sham surgery. Time to nerve identification was recorded. Functional recovery was monitored for at least 8 weeks. RESULTS We found excellent labeling of intact and transected facial nerves following F-NP41 administration. Several weeks following nerve transection, F-NP41 provided accurate identification of the proximal and distal nerve stumps. Following reanastomosis, time to recovery and level of functional recovery was similar in the absence and presence of F-NP41. CONCLUSIONS We show improved visualization of facial nerves with a novel systemically applied fluorescently labeled probe. Use of F-NP41 resulted in accurate identification of facial nerve stumps several weeks following transection. Functional recovery was similar with and without the use of F-NP41.
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Affiliation(s)
- Amy P Wu
- Division of Otolaryngology-Head and Neck Surgery, University of California-San Diego, San Diego, California 92093-0647, USA
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Chen P, Song J, Luo LH, Zhong G, Xiao HJ, Gong SS. Abnormal motor reflexes and dormant facial motor neurons in rats with facial-facial anastomosis. J Int Med Res 2009; 37:705-16. [PMID: 19589254 DOI: 10.1177/147323000903700314] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
After facial nerve injury, some post-paralysis sequelae, such as synkinesis, hemispasm and 'crocodile tears' syndrome appear. The psychosocial impact of these sequelae is unavoidable. Despite recent advances and the growing popularity of this field, the pathophysiological mechanisms of facial nerve injury and regeneration are still not well understood. In this report, an abnormal motor reflex coincident with synkinetic facial movement was examined in a rat model using the blink reflex technique. Some dormant facial motor neurons were found which could not innervate through the suture site but remained alive. These results suggest that such dormant neurons might exert roles distinct from those of re-innervated neurons during facial nerve injury and regeneration. Further study is required to elucidate the biomolecular structure and electrophysiological features of such neurons.
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Affiliation(s)
- P Chen
- Department of Otorhinolaryngology, Head and Neck Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Multiple neuroanatomical tract-tracing using fluorescent Alexa Fluor conjugates of cholera toxin subunit B in rats. Nat Protoc 2009; 4:1157-66. [PMID: 19617887 DOI: 10.1038/nprot.2009.93] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cholera toxin subunit B (CTB) is a highly sensitive retrograde neuroanatomical tracer. With the new availability of fluorescent Alexa Fluor (AF) conjugates of CTB, multiple neuroanatomical connections can be reliably studied and compared in the same animal. Here we provide a protocol that describes the use of AF-CTB for studying connections in the central nervous system of rats. The viscous properties of CTB allow small and discreet injection sites yet still show robust retrograde labeling. Furthermore, the AF conjugates are extremely bright and photostable, compared with other conventional fluorescent tracers. This protocol can also be adapted for use with other neuroanatomical tracers. Including a 7-d survival period, this protocol takes approximately 11 to 12 d to complete in its entirety.
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