Optical Stimulation of the Prostate Nerves: A Potential Diagnostic Technique
There is wide variability in sexual potency rates (9 - 86%) after nerve-sparing prostate cancer surgery due to limited knowledge of the location of the cavernous nerves (CN's) on the prostate surface, which are responsible for erectile function. Thus, preservation of the CN's is critical in preserving a man's ability to have spontaneous erections following surgery. Nerve-mapping devices, utilizing conventional Electrical Nerve Stimulation (ENS) techniques, have been used as intra-operative diagnostic tools to assist in preservation of the CN. However, these technologies have proven inconsistent and unreliable in identifying the CN's due to the need for physical contact, the lack of spatial selectivity, and the presence of electrical artifacts in measurements. Optical Nerve Stimulation (ONS), using pulsed infrared laser radiation, is studied as an alternative to ENS. The objective of this study is sevenfold: (1) to develop a laparoscopic laser probe for ONS of the CN's in a rat model, in vivo; (2) to demonstrate faster ONS using continuous-wave infrared laser radiation; (3) to describe and characterize the mechanism of successful ONS using alternative laser wavelengths; (4) to test a compact, inexpensive all-single-mode fiber configuration for optical stimulation of the rat CN studies; (5) to implement fiber optic beam shaping methods for comparison of Gaussian and flat-top spatial beam profiles during ONS; (6) to demonstrate successful ONS of CN's through a thin layer of fascia placed over the nerve and prostate gland; and (7) to verify the experimentally determined therapeutic window for safe and reliable ONS without thermal damage to the CN's by comparison with a computational model for thermal damage. A 5.5-Watt Thulium fiber laser operated at 1870 nm and two pigtailed, single mode, near-IR diode lasers (150-mW, 1455-nm laser and 500-mW, 1550-nm laser) were used for non-contact stimulation of the rat CN's. Successful laser stimulation, as measured by an intracavernous pressure (ICP) response in the penis, was achieved with the laser operating in CW mode. CW optical nerve stimulation provides a significantly faster ICP response time using a lower laser power laser than conventional pulsed stimulation. An all-single-mode fiber design was successfully tested in a rat model. The CN reached a threshold temperature of ~ 42 oC, with response times as short as 3 s, and ICP responses in the rat penis of up to 50 mmHg compared to a baseline of 5 - 10 mmHg. Chemical etching of the distal single-mode-fiber tip produced a concave shape and transformed the Gaussian to a flat-top spatial beam profile, resulting in simplified alignment of the laser beam with the nerve. This novel, all-single-mode-fiber laser nerve stimulation system introduces several advantages including: (1) a less expensive and more compact ONS configuration; (2) elimination of alignment and cleaning bulk optical components; and (3) improved spatial beam profile for simplified alignment. For the fascia layers over the CN's (240 - 600 µm), the 1550 nm laser with an optical penetration depth of ~ 930 µm in water was substituted for the 1455 nm laser. Successful ONS was achieved, for the first time, in fascia layers up to 450 µm thick which is critical for future clinical translation of this method for intra-operative identification and preservation of CN's during prostate cancer surgery. In order to define the upper limit of the therapeutic window for ONS of CN in a rat model, in vivo, identification of the thermal damage threshold for the CN after laser irradiation was investigated by direct comparison of the visible thermal damage data with a theoretical thermal damage calculation utilizing a standard Arrhenius integral model.