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Gudeloglu A, Brahmbhatt JV, Allan R, Parekattil SJ. Hydrodissection for improved microsurgical denervation of the spermatic cord: prospective blinded randomized control trial in a rat model. Int J Impot Res 2020; 33:118-121. [PMID: 32862193 DOI: 10.1038/s41443-020-00351-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/13/2020] [Accepted: 08/20/2020] [Indexed: 11/09/2022]
Abstract
Microsurgical denervation of the spermatic cord (MDSC) can provide up to an 86% improvement in pain in patients with chronic orchialgia (CO) who have failed conservative management. Failures in MDSC could be due to small diameter nerves (≤1 mm) left behind on the spermatic cord. The objective of this study was to assess if hydrodissection (HD) of the spermatic cord after MDSC could decrease the number of residual nerve fibers without compromising blood flow. Prospective blinded randomized control trial: bilateral MDSC was performed on 22 adult rats (44 cords). HD of the spermatic cord was performed on one side of each rat (side randomized) using the ERBEJET2. The contralateral cord (no HD) was the control for each animal. Blood flow through the vessels was monitored using a micro-Doppler probe. After completion a cross-section of the residual cord was sent to pathology (blinded to technique) to assess for small diameter nerves and signs of damage in vascular integrity. Blood flow had been maintained in the vessels when the ERBEJET2 was set to 6 bar (87 psi). The cord where HD had been performed had a significantly lower total median residual nerve count of 5 (0-10), compared to 8 (2-12) on the non-HD side (p = 0.007). No structural damage was seen in the vessels in the spermatic cord that had undergone HD (gross exam and histology). HD of the spermatic cord significantly decreases residual nerve density without compromising vascular integrity in a rat model.
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Affiliation(s)
- Ahmet Gudeloglu
- Department of Urology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Calixte N, Kartal IG, Tojuola B, Gudeloglu A, Etafy M, Brahmbhatt JV, Mendelson RA, Chetta M, Parekattil SJ. Salvage Ultrasound-guided Targeted Cryoablation of The Perispermatic Cord For Persistent Chronic Scrotal Content Pain After Microsurgical Denervation Of The Spermatic Cord. Urology 2019; 130:181-185. [PMID: 31063763 DOI: 10.1016/j.urology.2019.04.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/14/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assesses the efficacy of ultrasound-guided targeted cryoablation (UTC) of the perispermatic cord as a salvage treatment for patients who failed microsurgical denervation of the spermatic cord. METHODS Retrospective review of 279 cases (221 patients: 58 bilateral) undergoing UTC between November 2012 and July 2016, performed by 2 fellowship trained microsurgeons. UTC was performed using a 16-gauge cryo needle (Endocare, HealthTronics, Austin, TX). Branches of the genitofemoral, ilioinguinal, and inferior hypogastric nerves were cryoablated medial and lateral to the spermatic cord at the level of the external inguinal ring. Level of pain was measured preoperatively and postoperatively using the visual analog scale and Pain Index Questionnaire-6 (QualityMetric Inc., Lincoln, RI). RESULTS Median age was 43 years, operative duration 20 minutes, and postoperative follow-up 36 months (24-60). Subjective visual analog scale outcomes: 75% significant reduction in ain (11% complete resolution and 64% ≥50% reduction in pain). Objective Pain Index Questionnaire-6 outcomes: 53% significant reduction at 1 month (279 cases), 55% at 3 month (279 cases), 60% at 6 month (279 cases), 63% at 1 year (279 cases), 65% at 2 years (275 cases), 64% at 3 years (232 cases), 59% at 4 years (128 cases) and 64% at 5 years (53 cases) post-op. COMPLICATIONS 2 wound infections, 4 penile pain cases (resolved in a few months). CONCLUSION UTC of the perispermatic cord is a safe potential treatment option for the salvage management of persistent chronic scrotal pain in patients who have failed microsurgical denervation of the spermatic cord.
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Affiliation(s)
- Nahomy Calixte
- Personalized Urology & Robotics Clinic, South Lake Hospital, Clermont, FL
| | | | - Bayo Tojuola
- Personalized Urology & Robotics Clinic, South Lake Hospital, Clermont, FL
| | - Ahmet Gudeloglu
- Personalized Urology & Robotics Clinic, South Lake Hospital, Clermont, FL
| | - Mohamed Etafy
- Personalized Urology & Robotics Clinic, South Lake Hospital, Clermont, FL
| | - Jamin V Brahmbhatt
- Personalized Urology & Robotics Clinic, South Lake Hospital, Clermont, FL; University of Central Florida, Orlando, FL
| | | | - Michael Chetta
- University of Central Florida, Orlando, FL; Talent Metrics Inc., Orlando, FL
| | - Sijo J Parekattil
- Personalized Urology & Robotics Clinic, South Lake Hospital, Clermont, FL; University of Central Florida, Orlando, FL.
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Etafy M, Gudeloglu A, Brahmbhatt JV, Parekattil SJ. Review of the role of robotic surgery in male infertility. Arab J Urol 2017; 16:148-156. [PMID: 29713546 PMCID: PMC5922003 DOI: 10.1016/j.aju.2017.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/27/2017] [Accepted: 11/04/2017] [Indexed: 02/07/2023] Open
Abstract
Objectives To present the current state of the art in various robot-assisted microsurgical procedures in male infertility and review the latest literature, as the technology in infertility procedures has substantially developed since the incorporation of the Vinci® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Materials and methods The search strategy in this review was conducted in accordance with Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search strategy was conducted in MEDLINE, PubMed and the Cochrane electronic databases (from 2000 to present) to identify studies that included both robotic and male infertility. Results In all, 23 studies were found, 12 of which met our inclusion criteria. Articles were excluded if the study did not include both male infertility and robotics. Conclusions Robotic assistance for microsurgical procedures in male infertility appears to be safe and feasible. It has several advantages including elimination of tremor, multi-view magnification, additional instrument arms, and enhanced dexterity with articulating instrument arms. It also has a short learning curve with a small skin incision. However, larger, prospective studies are needed to establish the clinical benefits over standard microsurgery.
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Key Words
- 3D, three-dimensional
- ART, assisted reproductive technology
- FDA, USA Food and Drug Administration
- MeSH, Medical Subject Heading
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RAVE, robot-assisted microsurgical vasoepididymostomy
- RAVV, robot-assisted vasovasostomy
- RAVx, robot-assisted microsurgical varicocelectomy
- RCT, randomised controlled trial
- Robotic testicular sperm extraction
- Robotic varicocelectomy
- Robotic vasectomy reversal
- Robotic vasoepididymostomy (RAVE)
- Robotic vasovasostomy
- TESE, testicular sperm extraction
- US, ultrasonography
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Affiliation(s)
- Mohamed Etafy
- The Personalized Urology and Robotics (PUR) Clinic, South Lake Hospital, Clermont, FL, USA.,Department of Urology, AlAzhar University Hospital, Assiut, Egypt
| | - Ahmet Gudeloglu
- Department of Urology, Hacettepe University Hospital, Ankara, Turkey
| | - Jamin V Brahmbhatt
- The Personalized Urology and Robotics (PUR) Clinic, South Lake Hospital, Clermont, FL, USA
| | - Sijo J Parekattil
- The Personalized Urology and Robotics (PUR) Clinic, South Lake Hospital, Clermont, FL, USA
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Abstract
Idiopathic male infertility can be diagnosis in approximately one-third of infertile males. The empirical medical treatment with or without assisted reproductive techniques appears common in male infertility practice. This type of management can be classified as hormonal treatment including gonadotropins, antiestrogens, and aromatase inhibitors and support with antioxidant supplements such as carnitine, lycopene, glutathione, and vitamin E. This review investigates the evidence of commonly used empirical medical management of male infertility when there is no demonstrable diagnosis.
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Affiliation(s)
- Ahmet Gudeloglu
- The PUR Clinic, Personalized Urology and Robotics, Ankara, Turkey
| | | | - Sijo J Parekattil
- The PUR Clinic, Personalized Urology and Robotics, Clermont, Florida
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Gudeloglu A, Brahmbhatt JV, Parekattil SJ. Robotic microsurgery in male infertility and urology-taking robotics to the next level. Transl Androl Urol 2014; 3:102-12. [PMID: 26816758 PMCID: PMC4708299 DOI: 10.3978/j.issn.2223-4683.2014.01.08] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/24/2014] [Indexed: 12/21/2022] Open
Abstract
The initial reports of robotic assisted microsurgery began to appear in the early 1990s. Animal and early human studies were the initial publications. Larger series papers have recently been published from a few institutions. The field of robotic assisted microsurgery is still in evolution and so are adjunctive tools and instruments. It is clearly a different and unique skill set-is it microsurgery or is it robotic surgery, or both. It is clear from history that the art of surgery evolves over time to encompass new technology as long as the outcomes are better for the patient. Our current robotic platforms may not be ideal for microsurgery, however, the use of adjunctive tools and instrument refinement will further its future potential. This review article presents the current state of the art in various robotic assisted microsurgical procedures in male infertility and urology. Some novel applications of taking microsurgery to areas not classically accessible (intra-abdominal vasovasostomy) and adjunctive tools will also be presented.
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Abstract
Robotic-assisted microsurgery can be utilized for either intracorporal or extracorporeal surgical procedures. Three-dimensional high-definition magnification, a stable ergonomic platform, elimination of physiologic tremor, and motion scaling make the robotic platform attractive for microsurgeons for complex procedures. Additionally, robotic assistance enables the microsurgeon to take microsurgery to challenging intracorporeal locations in a minimally invasive manner. Recent adjunctive technological developments offer the robotic platform enhanced optical magnification, improved intraoperative imaging, and more precise ablation techniques for microsurgical procedures. The authors present the current state-of-the art tools available in the robotic-assisted microsurgical platform.
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Affiliation(s)
- Ahmet Gudeloglu
- The PUR Clinic (Personalized Urology & Robotics) & South Lake Hospital, Clermont, Florida
- The PUR Clinic (Personalized Urology & Robotics), Ankara, Turkey
| | - Jamin V. Brahmbhatt
- The PUR Clinic (Personalized Urology & Robotics) & South Lake Hospital, Clermont, Florida
| | - Sijo J. Parekattil
- The PUR Clinic (Personalized Urology & Robotics) & South Lake Hospital, Clermont, Florida
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Parekattil SJ, Gudeloglu A, Brahmbhatt JV, Priola KB, Vieweg J, Allan RW. Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia. J Urol 2013; 190:265-70. [PMID: 23353047 DOI: 10.1016/j.juro.2013.01.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.
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Affiliation(s)
- Sijo J Parekattil
- Winter Haven Hospital and University of Florida, Winter Haven, Florida 33881, USA.
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DiBlasio CJ, Kurta JM, Botta S, Mehrazin R, Brahmbhatt JV, Wan JY, Derweesh IH, Aleman MA, Patterson AL, Wake RW. PEYRONIE'S DISEASE HAS A NEGATIVE IMPACT ON THE DURABILITY AND COMPONENT MALFUNCTION RATES IN PATIENTS UNDERGOING INFLATABLE PENILE PROSTHESIS IMPLANTATION. J Urol 2009. [DOI: 10.1016/s0022-5347(09)60803-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Brahmbhatt JV, Mehrazin R, DiBlasio CJ, Wake RW, Aleman MA. INTER-AND INTRA-SPECIALTY ANALYSIS OF “DEAD OF DISEASE” VERSUS “DEAD WITH DISEASE” IN PROSTATE CANCER: IS THIS A MEANINGFUL STUDY END-POINT? J Urol 2009. [DOI: 10.1016/s0022-5347(09)60471-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Siwik DA, Kuster GM, Brahmbhatt JV, Zaidi Z, Malik J, Ooi H, Ghorayeb G. EMMPRIN mediates β-adrenergic receptor-stimulated matrix metalloproteinase activity in cardiac myocytes. J Mol Cell Cardiol 2008; 44:210-7. [PMID: 17869266 DOI: 10.1016/j.yjmcc.2007.07.054] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 07/06/2007] [Accepted: 07/17/2007] [Indexed: 01/08/2023]
Abstract
Extracellular matrix metalloproteinase inducer (EMMPRIN) expression is increased in myocardium from patients with dilated cardiomyopathy and animal models of heart failure. However, little is known about the regulated expression or functional role of EMMPRIN in the myocardium. In rat cardiac cells, EMMPRIN is expressed on myocytes but not endothelial cells or fibroblasts. Therefore, we tested the hypothesis that EMMPRIN expression regulates matrix metalloproteinase (MMP) activity in rat ventricular myocytes in vitro. In adult rat ventricular myocytes (ARVM), beta-adrenergic receptor (betaAR) stimulation and H(2)O(2) (24 h) each increased EMMPRIN expression as assessed by immunoblotting. Pretreatment with a catalase/superoxide dismutase mimetic or adenoviral-mediated expression of catalase or a dominant-negative c-jun N-terminal kinase-1 (JNK) mutant inhibited the betaAR- and H(2)O(2)-stimulated increases in EMMPRIN expression suggesting that EMMPRIN expression is regulated via a reactive oxygen species-dependent JNK pathway. To determine whether EMMPRIN expression regulates matrix metalloproteinase (MMP) activity, EMMPRIN activity was inhibited by adenoviral expression of an inhibitory mutant of EMMPRIN. Expression of mutant EMMPRIN inhibited the betaAR-stimulated increases in MMP2 expression and zymographic MMP activity. Thus, in cardiac myocytes betaAR stimulation induces the expression of EMMPRIN via the ROS-dependent activation of JNK. The resulting increase in EMMPRIN activity stimulates MMP expression and activity. These findings suggest that in the myocardium the regulated expression of EMMPRIN is a determinant of MMP activity and may thus play a role in myocardial remodeling.
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Affiliation(s)
- Deborah A Siwik
- Myocardial Biology Unit, Boston University School of Medicine, 650 Albany Street, X740, Boston, MA 02118, USA.
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