The Application of Regional Hypothermia Using Transrectal Cooling During Radical Prostatectomy: Mitigation of Surgical Inflammatory Damage to Preserve Continence

Abstract

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 robotassisted 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 robotassisted 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.

Monocyte Chemotactic Protein-1 (MCP-1) as a Predictor of Prolonged Urinary Incontinence After Radical Prostatectomy

“…Likewise, the same mechanism may be tested in a preprostatectomy cohort investigating urinary outcomes. Another evolving concept regarding reducing inflammation is hypothermia of the prostate via a rectal balloon at the time of surgery [16]. Our previous study is quite remarkable because all patients who received hypothermia during prostatectomy, had a significant reduction in post prostatectomy incontinence [17].…”

Erectile Function Outcomes after Robot‐Assisted Radical Prostatectomy: Is It Superior to Open Retropubic or Laparoscopic Approach?

“…, who found that a cautery‐free nerve sparing improved early return of EF by 4.7‐fold. In the subsequent years, several studies confirmed the advantages of athermal dissection on EF outcomes .…”

“…As thermal energy is considered a potential risk factor for nerve damage, application of hypothermia before dissection of the NVB has also been studied as a method to avoid tissue damage through decreased metabolic rate and oxygen demands . In a prospective study, Finley et al.…”

Hypothermic Cooling Measured by Thermal Magnetic Resonance Imaging; Feasibility and Implications for Virtual Imaging in the Urogenital Pelvis

“…The heat transfer fluid is circulated in closed-loop fashion through the catheter for the purpose of removing heat from the pelvic space. 4 To make the cooling system completely MR compatible several modifications were made including 1. An electrically isolated ECB thermistor removed, 2.…”

“…4 However measuring the point surface temperatures made by the thermal camera requires open surgery and is truly impractical: due to the bulky size of the camera and great difficulty for reliable and reproducible thermal photography of gradients especially laterally and ventrally. Preliminary studies by Chopra et al 5 in a study of tissue damage generated by heating of a laser induced hyperthermia on focal prostate cancer provided conceptual proof that MRI thermal mapping of the prostate is viable.…”