Selective Pelvic Autonomic Nerve Stimulation with Simultaneous Intraoperative Monitoring of Internal Anal Sphincter and Bladder Innervation

Kneist, W.; Kauff, Daniel W.; Koch, Klaus Peter; Schmidtmann, Irene; Heimann, Axel; Hoffmann, K.; Lang, Hauke

doi:10.1159/000323558

Cited by 9 publications

(5 citation statements)

References 53 publications

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“…Since nearly 75% of the values were higher than the arithmetic mean and median value at 50 Hz, both 10 Hz and 30 Hz were considered more appropriate than 50 Hz, despite the higher dispersion. As the stimulation frequency of 30 Hz showed the highest arithmetic mean and median value, it was chosen for further evaluation, which is in agreement with the literature on direct pelvic nerve stimulation in a clinical setting 13 , 20 , 23 .…”

Section: Resultssupporting

confidence: 56%

“…Since then, several approaches have been evaluated and mainly one method has been adopted until today: intraoperative cystomanometry and online-processed electromyography of the internal anal sphincter (IAS) during autonomic nerve stimulation with a hand-guided probe. A series of studies has been published fby the research group Kauff and Kneist et al 15 , 20 , 23 . Recently published studies indicate that pelvic intraoperative neuromonitoring performed with cystomanometry and EMG of the IAS is associated with lower rates of new-onset urinary dysfunction and fecal incontinence 21 , 26 .…”

Section: Discussionmentioning

confidence: 99%

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A new method of intraoperative pelvic neuromonitoring: a preclinical feasibility study in a porcine model

Schuler

Goos

Langer³

et al. 2022

Sci Rep

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Low anterior resections (LAR) are frequently associated with complications such as urinary and fecal incontinence as well as sexual disorders. Typical risk factors are rectal cancer with low tumor location, preoperative radiotherapy, and surgery-related damage of pelvic autonomic nerves. As preserving the pelvic autonomic nerves without any technical assistance is challenging, the objective of this preclinical study was to investigate the technical feasibility of a new method for intraoperative pelvic neuromonitoring. Twelve female pigs undergoing low anterior resections were involved in a prospective preclinical study. Intraoperative pelvic neuromonitoring included direct pelvic nerve stimulation and tissue impedance measurement on the urinary bladder and the rectum for the identification of efferent pelvic nerves in the surgical area. Immunohistochemistry was used to verify the results. Smooth muscle contraction of the urinary bladder and/or the rectum in response to direct stimulation of the innervating nerves was detectable with impedance measurement. The macroscopic contraction of both the urinary bladder and the rectum correlated with a change in tissue impedance compared to the status before contraction. Thus, it was possible to identify pelvic nerves in the surgical area, which allows the nerves to be preserved. The results indicate a reliable identification of pelvic autonomic nerves, which allows nerve damage to be prevented in the future.

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Section: Resultssupporting

confidence: 56%

Section: Discussionmentioning

confidence: 99%

A new method of intraoperative pelvic neuromonitoring: a preclinical feasibility study in a porcine model

Schuler

Goos

Langer³

et al. 2022

Sci Rep

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“…For continuous neurostimulation, the pelvic splanchnic nerves were chosen as they are easier to identify and appear earlier than the inferior hypogastric plexus during the operation similar to our surgical procedure in the clinical practice. Moreover, a comparison of stimulation sites (pelvic splanchnic nerves vs. inferior hypogastric plexus) in a previous study demonstrated a trend towards higher amplitude levels of internal anal sphincter activity during stimulation of pelvic splanchnic nerves than among stimulation of the inferior hypogastric plexus [20]. The applied stimulation electrode for continuous neuromonitoring had a tripolar configuration, which reduced the occurrence of stray currents and permitted selective nerve stimulation.…”

Section: Discussionmentioning

confidence: 94%

Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery

Kauff

Kempski

Koch

et al. 2012

Langenbecks Arch Surg

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Purpose: The aim of this study was to develop a methodological setup for continuous intraoperative neuromonitoring with intent to improve nerve-sparing pelvic surgery. Methods: Fourteen pigs underwent low anterior rectal resection. Continuous stimulation of pelvic autonomic nerves was carried out with a newly developed tripolar surface electrode during lateral, anterolateral, and anterior mesorectal dissection. Neuromonitoring was performed under electromyography of the autonomic innervated internal anal sphincter. Results: Continuous neuromonitoring resulted in significantly increased electromyographic amplitudes of the internal anal sphincter, confirming intact innervation throughout the whole dissection in each animal (median 0.9 V, interquartile range 0.5; 1.5 vs. median 3.4 V, interquartile range 2.1; 4.7) (p < 0.001). The median dissection time in each animal was 10 min within a median number of ten (range 8-13) tripolar electric stimulations. Conclusion: The pres ent study is the first to demonstrate that continuous intraoperative monitoring of pelvic autonomic nerves during low anterior rectal resection is feasible

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“…Classically, the PSNs are described as parasympathetic nerves involved in bladder contraction, but anatomic studies have reported multiple sympathetic fibers within the PSNs [33]. Moreover, a physiologic study found that selective stimulation of the PSNs increased intravesical pressure and did not differ from IHP stimulation [34]. Even if the specific function of the PSNs still remains unclear, PSN sparing should have a positive impact on postoperative bladder function.…”

Section: Discussionmentioning

confidence: 99%

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

Soares

Mimouni

Oppenheimer

et al. 2021

Journal of Minimally Invasive Gynecology

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Evaluate the feasibility and risk−benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity. Design: Observational before (2012−2014)−and−after (2015−2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. Setting: Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. Patients: This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions. Interventions: For the patients in group 1 (2012−2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015−2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves. Measurements and Main Results: Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 § 105 minutes in group 2 vs 219 § 71 minutes in group 1), as were intra-and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031). Conclusion: Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.

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Selective Pelvic Autonomic Nerve Stimulation with Simultaneous Intraoperative Monitoring of Internal Anal Sphincter and Bladder Innervation

Cited by 9 publications

References 53 publications

A new method of intraoperative pelvic neuromonitoring: a preclinical feasibility study in a porcine model

A new method of intraoperative pelvic neuromonitoring: a preclinical feasibility study in a porcine model

Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection: an innovative approach for observation of functional nerve integrity in pelvic surgery

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

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