Intraoperative Adjuncts
Intraoperative adjuncts are agents administered or applied during surgery to visualize anatomy, develop tissue planes, control bleeding, seal tissue, or provide perioperative analgesia; long-term implanted devices are 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, methylene blue and other dyes for checking perfusion, finding the ureter and localizing fistulas.
- Hemostatic AgentsTopical hemostatic products for oozing and raw surfaces, and how the main product types differ.
- Tissue Sealants & AdhesivesFibrin sealants, sealant patches, skin glues and PEG sealants: what each is approved for and where it helps.
- Tranexamic AcidAntifibrinolytic studied IV for perioperative bleeding in mixed urologic surgery[1]; topical PCNL and intravesical hematuria uses are covered on the linked page.
- 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 for surgical-site infiltration; TAP block use is off-label, with little opioid-sparing benefit over plain bupivacaine in TAP-block trials.[2][3]
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 |
| 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 |
| Stop diffuse capillary oozing on raw renal surface | FloSeal (flowable gelatin-thrombin) when conventional hemostasis is ineffective or impractical and blood flow is active; never inject or compress it into vessels or leave it in the renal pelvis or ureters. It swells, so irrigate and suction away excess not incorporated in the clot.[4] |
| Control venous bleeding on a surface you can pack | Surgicel (oxidized regenerated cellulose): apply dry, remove excess, and do not combine with thrombin |
| Cover a tunical defect in selected Peyronie's surgery | TachoSil use is off-label |
| Support a urinary closure | First ensure tension-free, viable tissue approximation |
| Close clean, dry, easily approximated external skin | Dermabond Advanced (2-octyl cyanoacrylate) after needed deep closure; avoid mucocutaneous junctions, regularly wet skin, and unsupported high-tension sites.[5] |
| Manage pelvic dead space | Select appropriate vascularized tissue reconstruction |
| 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) |
Sealant persistence varies by product and application.
References
1. Tikkinen KAO, Marcucci M, Halme ALE, et al. "Safety and efficacy of tranexamic acid in urologic surgery: results from the international, randomized, placebo-controlled POISE-3 trial." Eur Urol. 2026;90(2):140–149. doi:10.1016/j.eururo.2026.03.019
2. Pacira Pharmaceuticals. EXPAREL (bupivacaine liposome injectable suspension) prescribing information. DailyMed, published December 2025.
3. Liu S, Zhang C, Zhao J, Sun Q. "Comparison of liposomal bupivacaine and regular bupivacaine in the transversus abdominis plane for postoperative analgesia: an updated systematic review and meta-analysis." BMC Anesthesiol. 2026;26(1):340. doi:10.1186/s12871-026-03852-6
4. Baxter Healthcare Corporation. FLOSEAL Hemostatic Matrix, 5 mL: instructions for use. FLOSEAL with RECOTHROM kit, US product labeling, revised April 2022.
5. Ethicon. DERMABOND ADVANCED Topical Skin Adhesive: instructions for use. LAB0012189v5, released April 2016.