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 as selected closure adjuncts, flowable hemostatic matrices for raw-surface oozing, and selected hemostatic patches for tunical reconstruction.
This subsection catalogs the most clinically relevant agents.
- Visualization Agents (Dyes & Fluorophores)ICG (indocyanine green), methylene blue, indigo carmine, sodium fluorescein, and the investigational 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), fibrinogen/thrombin patches (TachoSil on collagen; Evarrest on oxidized regenerated cellulose/polyglactin 910), cyanoacrylates (Dermabond, Histoacryl), and PEG-based sealants (CoSeal). For selected adjunctive hemostasis, sealing, or skin approximation; product indications differ.
- Tranexamic AcidAntifibrinolytic used systemically, topically, and intracavitarily in reconstructive urology for perioperative blood-loss reduction.
- HydrodissectionSaline and vasoconstrictor injectates (epinephrine, vasopressin, ornipressin) for tissue-plane development and hemostasis in vaginal and pelvic surgery — the home for the local-vasoconstrictor agents.
- Liposomal BupivacaineExtended-release bupivacaine formulation for prolonged postoperative analgesia; intraoperative field infiltration and TAP block applications.
Framework — Which Adjunct, When?
| Clinical need | Possible adjunct and limits |
|---|---|
| See the ureter in the operating field | Direct identification, with retrograde ICG as an off-label adjunct; IV ICG assesses exposed-tissue perfusion and pudexacianinium is investigational |
| Assess ureteral efflux endoscopically | BLUDIGO or a selected off-label alternative; visible efflux does not exclude every injury |
| Evaluate a suspected VVF or UVF | Intravesical dye can demonstrate a bladder communication; upper-tract leakage needs a complementary test and anatomical evaluation |
| Assess bowel / flap / anastomosis perfusion | ICG near-infrared fluorescence |
| Test a urinary anastomosis for leakage | Gentle saline or dilute-dye fill matched to the repair; does not prove durable healing |
| 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) |
| Cover a tunical defect in selected Peyronie's surgery | Graft/patch choice belongs to the procedure pathway; TachoSil use is off-label |
| Support a urinary closure | First ensure tension-free, viable tissue approximation; sealant does not rescue a high-tension anastomosis |
| Close skin cosmetically at the end of the case | Dermabond / 2-octyl cyanoacrylate |
| Manage pelvic dead space | Select appropriate vascularized tissue reconstruction; fibrin glue alone does not replace a flap |
| Reduce bleeding in a selected operation | Consider TXA under a procedure-specific protocol, with renal, thrombotic and urinary-drainage assessment |
| Postoperative analgesia | Multimodal plan; liposomal bupivacaine is not routinely superior to standard formulations, and TAP is off-label for EXPAREL |
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 — sealant persistence varies by product and application. They are catalogued here because the defining mental model is "used intraoperatively as a sealing adjunct" rather than "implanted for long-term function."