Watson Matthew J, Koch Brandon, Tonzi Michael, Xu Raymond, Heath Gregory, Lute Brandon, Singh Amar
Department of Urology, University of Tennessee Erlanger, 979 East Third Street, Suite C-925, Chattanooga, TN, 37403, USA.
Medsurant Health, Philadelphia, PA, USA.
J Robot Surg. 2020 Oct;14(5):733-738. doi: 10.1007/s11701-020-01047-w. Epub 2020 Jan 29.
Risk of intraoperative neuropathic injury in minimally invasive surgery has been established as a leading complication. Continuous intraoperative neuromonitoring (IONM), such as upper extremity somatosensory evoked potentials (ueSSEPs), to decrease peripheral nerve injury due to positional stress has been described. Robotic-assisted laparoscopic prostatectomy (RALP) requires steep Trendelenberg, which may predispose patients to upper extremity neuropraxia. Subdermal stimulating electrodes were placed on the patients' bilateral wrists over the ulnar nerve and the nerve was stimulated. Realtime waveforms were compared to baseline data to prevent and detect injury to the ulnar nerve. Established intervention criteria, indicating risk for neuropathic damage necessitating intraoperative patient repositioning, was a 50% loss in amplitude or a 10% increase in latency. One hundred and forty three patients received RALP with IONM. 17 of 143 patients (11.8%) met ueSSEP intervention criteria. Only weight was significantly different between the two groups (p = 0.04). Mean reduction in amplitude was 79.9% (SE 4.1). Average amplitude loss duration was 22 min (SE 4.0). Weight and BMI were correlated to the degree of amplitude reduction (p = 0.03 and < 0.01), while operative time and DM approached significance (p = 0.09 and p = 0.14). This is the first study to use IONM to reduce the risk of nerve injury during genitourinary surgery. Realtime nerve monitoring using ueSSEP allowed for upper extremity intraoperative monitoring and repositioning. This may decrease the risk of upper extremity neuropraxia due to malpositioning during RALP. Weight and BMI were identified as risk factors for possible nerve injury. Further data collection and analysis to preoperatively stratify patients for application of IONM during RALP is currently ongoing.
微创外科手术中发生术中神经性损伤的风险已被确认为主要并发症。已有研究描述了通过持续术中神经监测（IONM），如上肢体感诱发电位（ueSSEPs），来减少因体位压力导致的周围神经损伤。机器人辅助腹腔镜前列腺切除术（RALP）需要采用头低脚高位，这可能使患者易患上肢神经失用症。将皮下刺激电极置于患者双侧手腕的尺神经上方并进行神经刺激。将实时波形与基线数据进行比较，以预防和检测尺神经损伤。既定的干预标准为，振幅损失50%或潜伏期增加10%，这表明存在神经性损伤风险，需要在术中对患者重新定位。143例患者接受了IONM辅助的RALP手术。143例患者中有17例（11.8%）符合ueSSEP干预标准。两组之间仅体重存在显著差异（p = 0.04）。振幅平均降低79.9%（标准误4.1）。平均振幅损失持续时间为22分钟（标准误4.0）。体重和体重指数与振幅降低程度相关（p = 0.03和<0.01），而手术时间和糖尿病接近显著相关（p = 0.09和p = 0.14）。这是第一项使用IONM降低泌尿生殖系统手术中神经损伤风险的研究。使用ueSSEP进行实时神经监测可实现上肢术中监测和重新定位。这可能降低RALP手术期间因体位不当导致上肢神经失用症的风险。体重和体重指数被确定为可能发生神经损伤的风险因素。目前正在进一步收集和分析数据，以便在RALP手术期间对患者进行术前分层，以应用IONM。
