Nov. 20, 2020

To better serve patients, surgical care must be ever evolving. Mayo Clinic Urology has a long-standing history of expertise and innovation. A great example of its evolution comes from the department's Men's Health team, a group of physicians, advanced-practice providers and nurses who are focused on providing expert-level care for men with sexual dysfunction, urinary symptoms and infertility. Since 2015, the team has led the push to bring many of its operative procedures out of the operating room and into the clinic.

"Urologists routinely perform in-office cystoscopy and transrectal prostate biopsies and vasectomies in the office with minimal or no sedation. What we want to do here at Mayo Clinic is to expand the complement of surgeries that we are able to perform in the office," says Matthew (Matt) J. Ziegelmann, M.D., a fellowship-trained urologist specializing in male sexual dysfunction at Mayo Clinic in Rochester, Minnesota.

Examples of procedures that are routinely performed in the office today by Men's Health surgeons include testicular sperm extraction (for infertility), circumcision, scrotoplasty, orchiopexy, hydrocelectomy, and spermatocelectomy or epididymal cyst excision and epididymectomy. More than 95% of vasectomy reversals are carried out in the office, and many other microsurgical procedures, such as varicocelectomy or spermatic cord microdenervation for chronic testicular pain, are carried out in office with increasing frequency.

Nitrous oxide sedation

The key to success, Dr. Ziegelmann suggests, is a combination of factors that includes patient counseling, thoughtful application of local anesthetics and the use of oral anxiolytics. "However, the real boon to our practice has been our recent implementation of nitrous oxide sedation," says Dr. Ziegelmann.

Nitrous oxide, or N2O, is a short-acting inhaled anesthetic that is used routinely in other areas of medicine, including dental offices and the emergency room. Research has shown that N2O sedation is associated with improvements in both anxiety and pain levels when used at the time of invasive procedures.

"The benefits of this anesthetic are its excellent safety profile and minimal requirements for peri-procedural monitoring. It can be readily administered by a trained nurse or the performing clinician," says Dr. Ziegelmann. "Also, the fast clearance from systemic circulation means that patients are able to recover quicker and without the typical post-anesthesia fog that accompanies moderate sedation and general anesthesia. These attributes make it a clear choice for many office-based procedures.

"There are fewer pre-procedural restrictions such as the typical 'nothing to eat or drink after midnight' routine. Also, because of N2O's rapid-on, rapid-off attributes, patients are able to drive themselves home that same day, which opens up more options for those patients who may not be able to find a family member or friend to transport them to and from the clinic, particularly on short notice. In fact, we can often add procedures on the same day to enhance convenience for our patients, many of whom travel a great distance to see us."

Despite the clear potential of N2O sedation, a review article published in Urology in 2020 by authors from Mayo Clinic showed that very few studies are available describing outcomes with N2O for urologic procedures.

"With N2O, a patient has the ability to control his own anesthesia by breathing the gas through a mask held to the face by the patient himself. The mask is held in place as long as desired," says Dr. Ziegelmann. "Many patients elect to use N2O during portions of a procedure that are typically more uncomfortable, such as when local anesthesia is being given through needle and syringe. Once the local anesthesia has set in, many patients find that additional sedation is unnecessary and they can instead breathe oxygen or room air as an alternative."

Tobias S. Kohler, M.D., M.P.H., director of Men's Health, is an expert in erectile dysfunction and surgical treatments for benign prostate enlargement. "While we can say anecdotally that our patients seem to have good pain control, we want to be rigorous in our assessments so that we can show others that nitrous sedation is making patients more comfortable" says Dr. Kohler. "Since implementing nitrous sedation nearly one year ago, we have been prospectively collecting data on pain scores for men receiving in-office steam-based therapy to treat benign prostate enlargement that is often done in the operating room, but routinely performed in the office in our practice."

Dr. Kohler and the Men's Health team have found that men who use N2O during their procedures have a lower pain score reported during the procedure, leading to enhanced satisfaction overall.

Moving procedures into the office setting offers multiple benefits:

• Health care expenditures are on the rise, and office-based procedures avoid some of the facility- and anesthesia-related costs. "This cost-effectiveness is particularly relevant for procedures that are not routinely covered by insurance plans, such as those associated with fertility," says Sevann Helo, M.D., a fellowship-trained microsurgeon in Urology at Mayo Clinic in Rochester, Minnesota.
• In-office procedures offer the opportunity to minimize anesthesia-related complications. Serious anesthesia-related complications, while rare, may have devastating effects for otherwise healthy individuals. Also, many patients with other serious medical conditions may be considered poor candidates for anesthesia but may still benefit from a urologic procedure.
• Operating room space in busy hospital practices and surgery centers is a hotly contested commodity. Office-based procedures open up availability for other surgical procedures that absolutely require monitored or general anesthesia.

N2O is not for everyone. For example, nitrous-based sedation should not be administered in patients with a history of pneumothorax or pulmonary blebs, because N2O rapidly disseminates within air-filled spaces and can potentially exacerbate these conditions. Other contraindications include history of tympanoplasty (ear drum grafting), intestinal obstruction and impaired consciousness.

Patients at Mayo Clinic are thoroughly screened for these and other conditions that may impact their ability to safely tolerate N2O. In these circumstances, alternative forms of oral anxiolysis or monitored (deeper) anesthesia in the operating room may be needed. Side effects tend to be mild and self-limited and include nausea and vomiting, euphoria, headache and dizziness.

The Men's Health team is enthusiastic about the prospects that N2O introduces to their practice. "Since we started this practice, I have transitioned the bulk of my scrotal surgeries to the office with high levels of patient satisfaction," says Dr. Ziegelmann. "The key is patient counseling and patient selection. Not everyone, if given the chance, will select a procedure in the office, but many will. We just want to be able to continue to give our patients options as we provide them with the highest level of urologic care."

For more information

Men's Health. Mayo Clinic.

Gopalakrishna A, et al. Use of nitrous oxide in office-based urologic procedures: A review. Urology. 2020;143:33.