Interpositional Nerve Graft Research Articles

Nerve Conduit Enhancement with Vomeronasal Organ Improves Rat Sciatic Functional Index in a Segmental Nerve Defect Model

ABSTRACT Background Segmental nerve loss presents a challenge to the reconstructive surgeon. The best regenerative results are obtained by using autologous interpositional nerve grafts. While this method can be successful, it necessitates a second surgical step, sacrifices donor nerve function and depends upon a finite supply of potential donor nerves. Collagen nerve conduits are commercially available for reconstruction of segmental nerve defects. However, no conduit-based reconstructive strategy has been as successful as autograft reconstruction. We hypothesized that collagen nerve conduits used to bridge a sciatic nerve defect may be enhanced by grafting with vomeronasal organ (VNO), owing to the unique capacity for regeneration of this mammalian olfactory tissue. Methods 21 rats underwent resection of a 1.0 cm segment of sciatic nerve. Seven rats underwent repair of the resultant nerve defect using a commercially available collagen nerve conduit (NeuraGen, Integra Life Sciences, Plainsboro NJ, USA). Seven rats underwent immediate repair of the nerve defect using the conduit filled with freshly harvested VNO allograft. An additional Seven rats underwent resection of a 4 mm segment of sciatic nerve and direct epineural repair. At 14 weeks postoperatively, all animals underwent walking track analysis. Toe prints were analyzed morphometrically to permit calculation of sciatic functional index (SFI). At 16 weeks postoperatively, rats were sacrificed and tissues were processed for histomorphometric analysis. This analysis included quantification of the number and diameter of myelinated axons as well as calculation of the axon density. Results All animals survived treatment without any serious surgical complications. All sciatic nerves were in continuity at sacrifice. All animals showed signs of sciatic denervation (decubitus ulcers, muscle atrophy) postoperatively. At 14 weeks, the mean sciatic functional index (SFI) was significantly higher in the VNO-enhanced group (p = 0.006) and the epineural repair (ER) groups (p = 0.004) than the conduit-only (CO) group. SFI was equivalent between VNO and ER groups (p = 0.338). Axon density was greater in the VNO (p = 0.013) and ER groups (p = 0.048) than in the CO group. Axon density was equivalent between the VNO and ER groups (p = 0.306). Conclusions In a rat sciatic nerve segmental defect model, modification of collagen nerve conduits to contain the pluripotent neuroepitheilial tissue vomeronasal organ (VNO) improves functional recovery and offers increased axon density relative to reconstruction with an empty conduit (CO).

Periocular cosmesis

Abstract Purpose Facial nerve paralysis is one of the most devastating peripheral nerve injuries which implies severe functional, cosmetic and psychological consequences to the patients. The periocular area can be improved cosmetically by raising the tissues that have been drooped. These techniques are brow lift for the forehead‐ brow area, midface lift for the mid part of the face and face lift for restoring the contour of the tissues of the lower face. These are static techniques and support the tissues that are not any more innervated and are atrophied and drooped by the force of gravity. Methods In particular brow lift can be achieved by direct incision over the brow, by endoscopic forehead‐brow lift using anchoring systems or alternatively by small incision non endoscopic forehead brow lift through an eyelid incision. Midface lift can be achieved by subperiosteal or pre‐periosteal lift of the tissues or by using a suspension system. Face lift can be achieved with a deep planar rhytidectomy which can lift the tissues of the mid and lower face. Combination of forehead, midface and face lift can be necessary for the maximal possible symmetry of the face in a static position. There is a limitation of these techniques in regards to the dynamic reanimation of the face. There are several dynamic procedures helping at this direction. Results In particular, in case of a transected facial nerve, the disrupted facial nerve can be restored by α) direct end–to‐end coaptation or by β) cable nerve graft interposition Other techniques include: • Temporalis muscle transfer • Free nerve‐muscle grafts • Ipsilateral nerve transposition • Facial nerve‐cross face anastomosis. Conclusion The above available dynamic procedures may provide some degree of facial tone or voluntary facial movement.

Microanatomical and immunohistochemical study of the human lateral antebrachial cutaneous nerve of forearm at the antecubital fossa and its clinical implications

Changes in the intraneural anatomy with age can cause poor prognosis of nerve repair in patients after nerve injury. The occurrence of Complex Regional Pain Syndrome-Type II, secondary to peripheral nerve injury, is common. The purpose of this study is to asses changes in cross-sectional anatomy of the lateral antebrachial cutaneous nerve of forearm (LCNF) at the antecubital fossa in the fascicular, nonfascicular components (adipose and nonadipose tissue), and sympathetic fibers area with respect to age. For the purpose of the study, 32 human (37-88 years) fresh cadaveric LCNF were collected from left-antecubital fossae and processed for histological, morphometric analysis [total cross-sectional (Asc), fascicular (Af), and nonfascicular area (Anonf)], and immunohistochemical method (tyrosine hydroxylase) for sympathetic fibers. The LCNF's average total cross-sectional area was 3.024 mm(2), and fascicular area was 0.582 mm(2). The average number of fascicles per mm(2) was 3.09. The cross-sectional area in the nerve was mainly occupied by nonfascicular connective tissue (80.75%). There was increased adipose tissue deposition (48.48% of Asc) and decreased collagen fibers (32.24% of Asc) in interfascicular domains without any definite relationship with age. The average sympathetic fiber area was 0.026 mm(2) within the nerve fascicular area without any correlation with age. In LCNF, there was more adipose tissue and less collagen fibers deposition in the interfascicular domains of all age cases, and this may act as an obstacle for nerve fiber regeneration on using LCNF as an interpositional nerve graft.

Sensory Restoration by Lateral Antebrachial Cutaneous to Ulnar Nerve Transfer in Children with Global Brachial Plexus Injuries

Selective peripheral nerve transfers represent an emerging reconstructive strategy in the management of both pediatric and adult brachial plexus and peripheral nerve injuries. Transfer of the lateral antebrachial cutaneous nerve of the forearm into the distal ulnar nerve is a useful means to restore sensibility to the ulnar side of the hand when indicated. This technique is particularly valuable in the management of global brachial plexus birth injuries in children for which its application has not been previously reported. Four children ages 4 to 9years who sustained brachial plexus birth injury with persistent absent sensibility on the unlar aspect of the hand underwent transfer of the lateral antebrachial cutaneous nerve to the distal ulnar nerve. In three patients, a direct transfer with a distal end-to-side repair through a deep longitudinal neurotomy was performed. In a single patient, an interposition nerve graft was required. Restoration of sensibility was evaluated by the "wrinkle test."

Laryngeal reinnervation after vagal paraganglioma resection: a case report

1. Case report A 36-year-old man presented to the clinic with a 3-month history of an enlarging right-sided neck mass. He had some associated pain in the region but denied any dysphonia, dysphagia, flushing, palpitations, diarrhea, or previous syncopal episodes. He denied a history of tobacco use, chronic alcohol use, or a family history of paragangliomas. Physical examination demonstrated a right-sided level II neck mass measuring approximately 5 cm in anteriorposterior dimension that was tender to touch. Palpation of the neck did not reveal any additional lymphadenopathy. All cranial nerves were functional with particular attention to cranial nerve X: he had symmetric palatal elevation and normal laryngeal function on fiberoptic nasopharyngolaryngoscopy. The mucosal surface of the entire upper aerodigestive tract was unremarkable. Magnetic resonance imaging (MRI)/magnetic resonance angiography demonstrated a 3.9 × 3.6 × 5.0-cm multilobulated parapharyngeal mass displacing the carotid artery anteromedially and the jugular vein posteromedially with slight compression (Fig. 1), most consistent with a glomus vagale tumor. When compared with a previous MRI performed 3 months earlier, there was interval growth of the mass of approximately 0.5 cm. A whole-body octreotide scan failed to show any additional areas of uptake. The patient was presented at our multidisciplinary tumor board. After extensive discussion of the options in treating vagal paragangliomas along with the functional sequela of surgical resection and the reconstructive options, the patient decided against pursuing a radiation oncology consult but rather opted for a surgical resection. A vascular surgery consult was obtained, and the patient underwent preoperative embolization of the right ascending pharyngeal artery with an Onyx injection (ethylene vinyl alcohol copolymer) less than 24 hours before the procedure. Surgical resection involved a right parapharyngeal space dissection along with a selective neck dissection (levels 2–3) via a modified Blair incision with a cervical extension. External jugular nodes were sent for frozen pathology and were found to be negative. Cranial nerves IX, XI, and XII and the sympathetic chain were identified and preserved, with X being sacrificed. The ansa hypoglossal nerve was significantly attenuated precluding its use for purposes of reinnervation. The stylohyoid and digastric muscles were divided to provide access to the proximal portion of the tumor at the level of the skull base. The tumor was removed en bloc without complication, requiring sacrifice of the superior laryngeal nerve (SLN). Reconstitution of the anticipated defects involved the following: a left ansa cervicalis to right recurrent laryngeal nerve (RLN) neuroplasty; a right greater auricular nerve to right SLN neuroplasty, and a free nerve interposition graft from the left cricothyroid muscle to the right cricothyroid muscle (Fig. 2). The contralateral ansa cervicalis nerve was used because of the attenuation found along the ipsilateral nerve, and a cut branch of the vagus that was found to be histologically normal on frozen section was used for the interposition graft.

Median to Radial Nerve Transfer to Restore Wrist and Finger Extension

Traditional methods for restoring finger and wrist extension following radial nerve palsy include interposition nerve grafting or tendon transfers. We have described the utilization of distal nerve transfers for the restoration of radial nerve function in the forearm. We review the neuroanatomy of the forearm and outline the steps required for the implementation of this transfer. We use a step-by-step procedural outline and detailed photographs, line drawings, and video to describe the procedure. This approach is technically feasible and is a reconstructive option for patients with this nerve deficit.

The use of roll vein graft in treatment of neuroma in continuity in sensory nerves

A neuroma-in-continuity is a neuroma that results from failure of the regenerating nerve growth cone to reach peripheral targets and remain lost in the extraepineural environment. This is attributed to scar tissue formation which occurs at the site of nerve transection. The supporting structure of the nerve may be preserved. The nerve no longer functions properly. There may be local tenderness, disabling pain, hyperesthesia of the overlying dermatome and functional impairment. Neuroma formation is a major problem in nerve surgery and consensus about its treatment has not been reached. One of well-established techniques for treatment of such condition is resection of the neuroma and repair with interpositional nerve graft which may restore some degree of nerve function. The major drawback of this technique is that it sacrifices the remaining viable axons present in neuromas in-continuity. Roll vein graft technique was used in this study in 11 patients with neuroma-in-continuity. Exploration and neurolysis were done with 3.5 X magnification. Vein graft was rolled around the neuroma site. Postoperative follow up has shown marked relief of symptoms as regards spontaneous pain and hyperesthesia. Results suggest the success and ease of this technique in treatment of neuroma-in-continuity

Axillary Nerve Reconstruction in 176 Posttraumatic Plexopathy Patients

In posttraumatic brachial plexus palsy, shoulder stabilization is of utmost importance before reanimation of the distal upper extremity. The aim of this study was to present the authors' experience with axillary nerve reconstruction in 148 patients with posttraumatic plexopathy. Functional outcomes were assessed and correlated with the following factors: severity score, denervation time, and donor nerve used. The medical records of 176 patients who underwent axillary nerve reconstruction performed by a single surgeon between 1978 and 2006 were reviewed. The results were analyzed in 148 patients who had adequate follow-up (>24 months). Nerve reconstruction was performed using 94 intraplexus donor nerves and 55 extraplexus donor nerves; axillary-to-axillary repair was performed in 13 patients, and 15 patients had microneurolysis. One hundred forty patients had interposition nerve grafts. A total of 135 patients had concomitant neurotization of the suprascapular nerve. Results were good or excellent in 45.95 percent of patients. The intraplexus donors yielded significantly better shoulder function than the extraplexus donors. The length of the nerve graft had a direct influence on deltoid recovery. Patients with a severity score higher than 10 attained significantly better results than patients with multiple root avulsions. Surgery earlier than 4 months yielded significantly better functional outcomes than delayed operation of more than 8 months. Early primary axillary nerve reconstruction offers rewarding glenohumeral joint stability and an acceptable range of shoulder function. Concomitant neurotization of the suprascapular nerve yielded improved outcomes in shoulder abduction and external rotation.

Total obstetric brachial plexus palsy: Results and strategy of microsurgical reconstruction

From 2000 to 2006, 35 infants with total obstetric brachial plexus palsy underwent brachial plexus exploration and reconstruction. The mean age at surgery was 10.8 months (range 3-60 months), and the median age was 8 months. All infants were followed for at least 2.5 years (range 2.5-7.3 years) with an average follow-up of 4.2 years. Assessment was performed using the Toronto Active Movement scale. Surgical procedures included neurolysis, neuroma excision and interposition nerve grafting and neurotization, using spinal accessory nerve, intercostals and contralateral C7 root. Satisfactory recovery was obtained in 37.1% of cases for shoulder abduction; 54.3% for shoulder external rotation; 75.1% for elbow flexion; 77.1% for elbow extension; 61.1% for finger flexion, 31.4% for wrist extension and 45.8% for fingers extension. Using the Raimondi score, 18 cases (53%) achieved a score of three or more (functional hand). The mean Raimondi score significantly improved postoperatively as compared to the preoperative mean: 2.73 versus 1, and showed negative significant correlation with age at surgery. In total, obstetrical brachial plexus palsy, early intervention is recommended. Intercostal neurotization is preferred for restoration of elbow flexion. Tendon transfer may be required to improve external rotation in selected cases. Apparently, intact C8 and T1 roots should be left alone if the patient has partial hand recovery, no Horner syndrome, and was operated early (3- or 4-months old). Apparently, intact nonfunctioning lower roots with no response to electrical stimulation, especially in the presence of Horner syndrome, should be neurotized with the best available intraplexal donor.

Experimental studies on post-transectional facial nerve regrowth and functional recovery of paralyzed muscles of the face in rats and mice

Insufficient recovery after peripheral nerve injury has been attributed to (i) lack of axonal navigation and poor pathfinding of regrowing axons to improper targets, (ii) excessive collateral axonal branching at the lesion site and (iii) polyneuronal reinnervation of the neuromuscular junctions (NMJ). The facial nerve transection model in rat and mice has been used to measure the restoration of function after varying therapies and to examine the mechanisms underlying their effects. Since it is still very difficult to combat the first reason and control/correct the navigation of several thousand axons, several groups of scientists concentrated our efforts on the postlesional branching (extremely strong in adult rats) and NMJ-polyinnervation. Since polyneuronal innervation of muscle fibers is activity-dependent attempts to reduce it were performed applying electrical stimulation. Unfortunately, the highly recommended intraoperative electrical stimulation of the proximal nerve fragment (square 0.1 ms pulses at 20 Hz using suprathreshold amplitudes) prior to suture and the postoperative electrical stimulation (square 0.1 ms pulses at 5 Hz) not only did not improve functional outcome, but reduced the number of innervated NMJ to approximately one fifth of normal values. Finally, recent experiments demonstrated that it was the mechanical (but not electrical) stimulation of denervated facial muscles (vibrissal and orbicularis oculi) which improved motor performance. This beneficial effect of mechanical stimulation was also detected after hypoglossal-facial anastomosis and inter-positional nerve grafting. The beneficial effect of manual stimulation on target muscle reinnervation was not present in mice deficient in the expression of insulin-like growth factor 1 and also eliminated or even reversed when trigeminal afferent inputs were abolished. All these findings raise hopes that clinically feasible and effective therapies could be soon designed and tested.

Predictors of Recovery of Erectile Function after Unilateral Cavernous Nerve Graft Reconstruction at Radical Retropubic Prostatectomy

Although studies have reported a benefit to bilateral cavernous nerve graft (NG) interposition, the role of unilateral NG interposition in recovery of erectile function (EF) after radical prostatectomy (RP) with unilateral neurovascular bundle (NVB) resection is more controversial. To determine the probability and predictors of EF recovery after unilateral cavernous NG at RP with unilateral NVB resection. We retrospectively reviewed the records of preoperatively potent men who underwent RP with unilateral NVB resection and ipsilateral NG without prior radiation or hormonal therapy from 1999 to 2007. Postoperative EF was defined in two ways: (i) physician interview-based assessment (level 3: erections sometimes sufficient for intercourse; level 2: erections routinely sufficient for intercourse; level 1: normal erections; all with or without oral phosphodiesterase-5 inhibitor use); and (ii) according to the sum Q3 + Q4 on the International Index of Erectile Function (IIEF) questionnaire. EF recovery based on physician interview-based scale and IIEF questionnaire. In all, 131 men underwent unilateral NG. Median follow-up was 37.3 months. The 5-year actuarial probability of EF recovery was 46, 30, and 12% for levels 3, 2, and 1, respectively, and 40, 34, and 22% for IIEF Q3 + Q4 sum > or =6, > or =8, and = 10, respectively. On multivariate analysis, patient age, specimen weight, and plastic surgeon were predictive of EF recovery based on physician-interview whereas patient age, ethnicity, and plastic surgeon were predictive of EF recovery based on the IIEF questionnaire. The impact of plastic surgeon on EF recovery with unilateral NG would suggest that technical factors play a role in EF recovery after unilateral NG. Meticulous surgical technique with proper identification of proximal and distal recipient nerve endings may improve the chance of EF recovery. The variation in recovery rate among plastic surgeons would imply that there is a benefit to unilateral NG in EF recovery.

DISTAL MEDIAN TO ULNAR NERVE TRANSFERS TO RESTORE ULNAR MOTOR AND SENSORY FUNCTION WITHIN THE HAND

ULNAR NERVE INJURIES can be severely debilitating and result in weakness of wrist flexion, loss of hand intrinsic function, and ulnar-sided hand anesthesia. When these injuries produce a Sunderland fourth- or fifth-degree injury, surgical intervention is necessary for functional recovery. Traditional methods for restoring hand intrinsic function after ulnar nerve palsy include interposition nerve grafting for timely presentations or tendon transfers for either complex injuries or late presentations. Distal median to ulnar nerve transfer to restore ulnar intrinsic nerve muscle function was first performed in 1991. We continue to find it advantageous for recovery of ulnar intrinsic function in patients with proximal ulnar nerve injuries by significantly reducing denervation time and directing motor fibers into this critical motor distribution. Several case reports have been published discussing the concept behind this approach, but none have outlined the specific steps involved in this operation. As such, this article discusses our operative methodology behind the distal median to ulnar neurotization, which includes a Guyon canal release, identification of donor median and recipient ulnar nerve fascicular anatomy within the forearm, and an operative tutorial on proper technique for neurotization to restore both ulnar motor and sensory function. We present the technical nuances of the following nerve transfers to restore ulnar nerve function within the hand: anterior interosseous nerve to deep motor branch of ulnar nerve, third webspace sensory contribution of median nerve to volar sensory component of ulnar nerve, and end-to-side reinnervation of ulnar dorsal cutaneous to the remaining median sensory trunk.

Outcome Following Spinal Accessory to Suprascapular (Spinoscapular) Nerve Transfer in Infants with Brachial Plexus Birth Injuries

The purpose of this study is to evaluate the value of distal spinal accessory nerve (SAN) transfer to the suprascapular nerve (SSN) in children with brachial plexus birth injuries in order to better define the application and outcome of this transfer in these infants. Over a 3-year period, 34 infants with brachial plexus injuries underwent transfer of the SAN to the SSN as part of the primary surgical reconstruction. Twenty-five patients (direct repair, n = 20; interposition graft, n = 5) achieved a minimum follow-up of 24months. Fourteen children underwent plexus reconstruction with SAN-to-SSN transfer at less than 9months of age, and 11 underwent surgical reconstruction at the age of 9 months or older. Mean age at the time of nerve transfer was 11.6months (range, 5-30months). At latest follow-up, active shoulder external rotation was measured in the arm abducted position and confirmed by review of videos. The Gilbert and Miami shoulder classification scores were utilized to report shoulder-specific functional outcomes. The effects of patient age at the time of nerve transfer and the use of interpositional nerve graft were analyzed. Overall mean active external rotation measured 69.6°; mean Gilbert score was 4.1 and the mean Miami score was 7.1, corresponding to overall good shoulder functional outcomes. Similar clinical and shoulder-specific functional outcomes were obtained in patients undergoing early (<9months of age, n = 14) and late (>9months of age, n = 11) SAN-to-SSN transfer and primary plexus reconstruction. Nine patients (27%) were lost to follow-up and are not included in the analysis. Optimum results were achieved following direct transfer (n = 20). Results following the use of an interpositional graft (n = 5) were rated satisfactory. No patient required a secondary shoulder procedure during the study period. There were no postoperative complications. Distal SAN-to-SSN (spinoscapular) nerve transfer is a reliable option for shoulder reinnervation in infants with brachial plexus birth injuries. Direct transfer seems to be the optimum method. The age of the patient does not seem to significantly impact on outcome.

Results after delayed axillary nerve reconstruction with interposition of sural nerve grafts

Satisfactory results after repair of isolated axillary nerve lesions using sural nerve autografts have been reported, but a delay between injury and surgical repair exceeding 6 months was one of the most important negative predictors of functional outcome. From our experience, we hypothesize that good results can be obtained even after a delay exceeding 6 months and we opted in this study to assess the value of delayed axillary nerve reconstruction. We evaluated clinical outcome and donor-site morbidity in 12 patients (mean age, 37; range, 19-66 years) who underwent axillary nerve repair with sural nerve graft with an average 11.25-month a delay between trauma and surgery (range, 8-20 months). Follow-up examination at least 24 months after treatment included assessment of shoulder range of motion, deltoid muscle strength in near full extension, deltoid extension lag, and sensibility. Constant Score, subjective shoulder value, and the Disabilities of Arm, Shoulder and Hand score were also assessed. All patients showed an improved deltoid function of at least M3. Postoperative extension lag, as the most specific sign of isolated deltoid function, improved from 57.5 degrees to 14.2 degrees. All stated that they would have identical elective surgery again. Relevant donor-site morbidity was not observed. Our data indicate that even delayed axillary nerve grafting may lead to satisfactory functional results with a low morbidity and should therefore be done in selected patients.

Repair of Partial Nerve Injury by Bypass Nerve Grafting with End-to-Side Neurorrhaphy

The purpose of this study was to investigate the efficacy of bypass nerve grafting with end-to-side neurorrhaphy in repair of the partial nerve injury in a rabbit model. Thirty-six adult male New Zealand rabbits were divided into three groups. A partial nerve injury was created by removal of a segment of the lateral fascicle of the left peroneal nerve. In group one, the injured nerve was repaired with nerve graft bypassing the injury site in an end-to-side fashion 4 weeks after injury. In group two, the injured nerve was repaired with end-to-end interpositional nerve grafting 6 weeks after injury. The injured nerve without repair was used as the control. Sixteen weeks after nerve repair, in groups one and two, and 20 weeks after the initial nerve injury in the control group, the nerves were dissected for electrophysiological examination and biopsied for histology and molecular markers expression. The nerve repair with interpositional nerve grafting achieved maximal functional recovery. However, motor nerve conduction velocity and compound motor action potential in nerve repair with bypass nerve grafting were significantly higher than that in the nerve injury without repair. Histologically, the regenerated myelinated axons and unmyelinated axons were present in the distal peroneal nerves in the bypass nerve grafts. The axon counts in nerve repair with the bypass nerve grafting were also significantly higher than that in the nerve injury without repair. The comparisons of the ciliary neurotrophic factor and the calcitonin gene-related peptide gene expressions between nerves with and without repair were significantly different. End-to-side bypass nerve grafting can significantly improve functional recovery in the nerve with partial injury and may be a useful repair strategy in neuromas-in-continuity.

Reconstructive Urology

Purpose: The use of cavernous nerve interposition grafting to preserve erectile function in men who require neurovascular bundle resection for cancer control is controversial. We report outcomes and predictors of cavernous nerve interposition grafting in men undergoing unilateral grafting during radical prostatectomy or bilateral grafting during radical cystectomy and prostatectomy with autologous nerve grafts.Materials and Methods: We retrospectively reviewed the electronic records of 36 patients who underwent cavernous nerve interposition grafting between 2003 and 2006. Postoperatively erectile function was assessed with the International Index of Erectile Function 15-item questionnaire. Predictors of potency, including age at surgery, time since surgery and prostate specific antigen at surgery, were assessed by univariate analysis.Results: A total of 33 patients (92% response rate) were followed for a median of 32, 25 and 11 months after bilateral grafting during radical cystectomy (10), unilateral gra...

Recovery of Erectile Function After Unilateral and Bilateral Cavernous Nerve Interposition Grafting During Radical Pelvic Surgery

The use of cavernous nerve interposition grafting to preserve erectile function in men who require neurovascular bundle resection for cancer control is controversial. We report outcomes and predictors of cavernous nerve interposition grafting in men undergoing unilateral grafting during radical prostatectomy or bilateral grafting during radical cystectomy and prostatectomy with autologous nerve grafts. We retrospectively reviewed the electronic records of 36 patients who underwent cavernous nerve interposition grafting between 2003 and 2006. Postoperatively erectile function was assessed with the International Index of Erectile Function 15-item questionnaire. Predictors of potency, including age at surgery, time since surgery and prostate specific antigen at surgery, were assessed by univariate analysis. A total of 33 patients (92% response rate) were followed for a median of 32, 25 and 11 months after bilateral grafting during radical cystectomy (10), unilateral grafting during radical prostatectomy (20), and bilateral grafting during radical cystectomy and prostatectomy (3), respectively. The rate of potency, defined as the ability to attain and maintain erection sufficient for penetration at least 50% of the time with or without phosphodiesterase-5 inhibitors, was 31% (5 of 13 men) for unilateral grafts, 38% (5 of 16) for bilateral grafts and 30% (3 of 10) for bilateral grafts during radical cystectomy. Age at surgery was the only significant determinant of potency and it showed an inverse relationship in the bilateral nerve graft group (p = 0.02). Cavernous nerve interposition grafting appears to have a role in the recovery of erectile function. To our knowledge this study represents the largest series of cavernous nerve interposition grafting during cystectomy and it suggests that this should be considered during bilateral neurovascular bundle resection.

Cholesteatoma invasion into the internal auditory canal

Cholesteatoma invasion into the internal auditory canal (IAC) is rare and usually results in irreversible, complete hearing loss and facial paralysis on the affected side. This retrospective study examines the clinical characteristics of seven patients with cholesteatoma invading the IAC, analyzes possible routes of the cholesteatoma's extension and describes the surgical approaches used and patient outcome. Extension to the IAC was via the supralabyrinthine route in most patients. A subtotal petrosectomy, a translabyrinthine approach or a middle cranial fossa approach combined with radical mastoidectomy were required for the complete removal of the cholesteatoma. All seven patients presented with some preoperative facial nerve palsy. The facial nerve was decompressed in four patients and facial nerve repair was performed in three others, two by hypoglossal-facial anastomosis and one by a greater auricular nerve interposition grafting. All patients ended up with total deafness in the operate ear. At 1 year following surgery, the facial nerve function was House-Brackmann grade III in six cases and grade II in one. In conclusion, cholesteatoma invading the IAC is a separate entity with characteristic clinical presentations, require a unique surgical approach, and result in significant morbidity, such as total deafness in the operated ear and impaired facial movement.

Intracranial facial nerve grafting after removal of vestibular schwannoma

Objective The objectives of this study were to evaluate outcomes from facial nerve (FN) cable grafting in patients who experienced FN transection during vestibular schwannoma removal and to compare the FN outcomes of patients who underwent FN grafting by using fibrin glue with those of patients who underwent FN grafting by using microsuture. Material and methods We retrospectively evaluated a series of 33 patients in whom FN grafting was achieved either by using microsuture (8 cases) or fibrin glue (25 cases). Immediate repair of the FN was performed in all cases at the time of initial resection. The patients FN function was assessed preoperatively, in the immediate postoperative period, and at 3, 6, 9, and 12 months or more postoperatively using the House-Brackmann grading system. All patients had at least 1-year follow-up. Results At 12 months, a House-Brackmann grade III was achieved in 75% of those who underwent cable nerve graft interposition by using microsuture and in 76% of those who underwent cable nerve graft interposition by using fibrin glue. Analysis of final FN function outcomes demonstrated no statistically significant difference in FN outcomes between the 2 groups ( P = .891, Mann-Whitney U test; P = .1, Fisher exact test). Conclusions The functional results after FN cable grafting by using fibrin glue exclusively were equivalent to those obtained with microsuture. However, the technique of FN repair by means of fibrin glue is technically simple, less time-consuming, and imparts less trauma on the nerve than does the traditional suture method.

Long-Term Functional and Oncological Outcomes of Patients Undergoing Sural Nerve Interposition Grafting during Robot-Assisted Laparoscopic Radical Prostatectomy

For men with high-volume or high-grade prostate cancer, wide excision of the ipsilateral neurovascular bundle is commonly performed. The concept of nerve reconstruction is intriguing as a feasible approach to preserve sexual function (SF). We sought to evaluate the functional, pathologic, and oncologic outcomes of men who underwent robot-assisted sural-nerve graft (SNG) interposition. Between February 2003 and May 2007, 1175 consecutive men underwent robot-assisted laparoscopic radical prostatectomy (RLRP). Database analysis identified 27 men who had SNG: 4 bilateral (BL) and 23 unilateral (UL). SF was prospectively evaluated preoperatively and at 1, 3, 6, 12, and 24 months postoperatively using validated questionnaires. Positive surgical margins (PSMs), biochemical recurrence (BCR), and potency were evaluated. Compared with RLRP patients without SNG, patients with SNG were younger (57.2 v 61.8 years, P=0.02), had a higher Gleason score (P=0.02), and had a higher clinical and pathologic stage (P<0.001 for both). Mean surgical time was significantly longer (349 v 195 min, P<0.001) in patients with SNG. With a mean follow-up of 26.1 months, 11 (47.8%) patients with UL-SNG and zero men with BL-SNG regained potency. No significant difference in SF was observed between UL nerve sparing and no SNG (56%) compared with UL nerve sparing with UL-SNG (P=0.44). Rates of return-to-baseline SF (RTB-SF) at 6, 12, and 24 months were 11%, 36% and 45% for UL-SNG, respectively, which were also comparable to UL nerve sparing only (P>0.05). No patient (0%) in the BL-SNG group ever achieved RTB-SF status at any time point. PSMs were observed in 37% (10/27) of all patients. BCR occurred in nine patients (33.3%), seven of whom had PSM (78%); treatment failure occurred within 6 months of surgery, necessitating androgen deprivation therapy. Despite optimism regarding SNG, long-term functional outcomes have been disappointing, particularly for BL nerve interposition. UL-SNG functional outcomes do not appear to improve outcomes when compared with men with UL nerve preservation. With the greater risk of PSM and BCR in patients who are considered candidates for SNG, newer treatment modalities are needed to cure their disease while preserving SF.