Intraoperative Adjuncts
Intraoperative adjuncts are substances applied at the operating table to visualize anatomy, control hemostasis, or seal tissue — distinct from systemic medications used elsewhere in this pharmacology section and from long-term implanted devices catalogued in Biomaterials. The reconstructive urologist and urogynecologist uses these agents across nearly every case: ICG for perfusion and ureter mapping, methylene blue for ureteral-orifice identification and fistula localization, fibrin sealants for watertight closures, flowable hemostatic matrices for raw-surface oozing, and collagen-fibrinogen patches for tunical defect sealing.
This subsection catalogs the most clinically relevant agents.
- Visualization Agents (Dyes & Fluorophores)ICG (indocyanine green), methylene blue, indigo carmine, sodium fluorescein, and the novel NIR agent pudexacianinium (ASP-5354). Applications in perfusion assessment, ureteral identification, lymphatic mapping, fistula localization, and bladder-flap viability.
- Hemostatic AgentsOxidized regenerated cellulose (Surgicel), microporous polysaccharide hemospheres (Arista), gelatin matrices (Gelfoam, Surgiflo), flowable gelatin-thrombin (FloSeal), and topical thrombin (Evithrom, Recothrom). For capillary-to-venous oozing and broad raw surfaces.
- Tissue Sealants & AdhesivesFibrin sealants (Tisseel, Evicel, Artiss), collagen-fibrinogen sealing patches (TachoSil, Evarrest), cyanoacrylates (Dermabond, Histoacryl), and PEG-based sealants (CoSeal). For watertight closures, anastomotic reinforcement, and skin approximation.
- Tranexamic AcidAntifibrinolytic used systemically, topically, and intracavitarily in reconstructive urology for perioperative blood-loss reduction.
- VasoconstrictorsEpinephrine, phenylephrine, and vasopressin for local hemostasis and hydrodissection adjuncts.
- Hydrodissection AgentsSaline, dilute vasoconstrictor solutions, and local-anesthetic cocktails used to separate tissue planes during dissection.
- Liposomal BupivacaineExtended-release bupivacaine formulation for prolonged postoperative analgesia; intraoperative field infiltration and TAP block applications.
Framework — Which Adjunct, When?
| Clinical need | First-line adjunct |
|---|---|
| See the ureter in the operating field | ICG (IV or retrograde) or pudexacianinium (IV NIR) |
| Identify the ureteral orifice endoscopically | Methylene blue injection |
| Locate a small VVF or UVF | Methylene blue instilled into the bladder |
| Assess bowel / flap / anastomosis perfusion | ICG near-infrared fluorescence |
| Confirm watertight urethral anastomosis | Methylene blue bladder fill |
| Stop diffuse capillary oozing on raw renal surface | FloSeal (flowable gelatin-thrombin) |
| Control venous bleeding on a surface you can pack | Surgicel (oxidized regenerated cellulose) |
| Seal a tunical defect after Peyronie's plaque excision | TachoSil / collagen-fibrinogen patch |
| Reinforce a high-tension urethral or bladder anastomosis | Fibrin sealant (Tisseel, Evicel) |
| Close skin cosmetically at the end of the case | Dermabond / 2-octyl cyanoacrylate |
| Obliterate pelvic dead space after exenteration | Fibrin glue + omental flap combination |
| Reduce systemic blood loss in major reconstruction | Tranexamic acid (IV / topical) |
| Prolonged postoperative analgesia | Liposomal bupivacaine (field block, TAP) |
Relation to other Foundations subsections
| Subsection | Role |
|---|---|
| Instruments | Physical instruments used intraoperatively |
| Biomaterials | Implanted devices and indwelling materials (mesh, IPP, catheters, stents) |
| Intraoperative Adjuncts (this section) | Substances applied at the table to visualize, control bleeding, or seal tissue |
| Pharmacology (other subsections) | Systemic pharmaceutical therapy — antibiotics, PDE5i, anticholinergics, α-blockers, hormonal therapy |
| Gear | Surgeon's personal equipment (loupes, radiation protection, ergonomics) |
| Robotics | Surgical robot platforms — NIRF imaging hardware (Firefly, SPY, Rubina) |
The boundaries are not always sharp — fibrin sealants stay in the body for 10–14 days, which technically qualifies them as biomaterials. They are catalogued here because the defining mental model is "used intraoperatively as a sealing adjunct" rather than "implanted for long-term function."