Education / Lap & Robotics / Surgical Innovations
Introduction & Objective :
Indocyanine green (ICG) has been utilized as a real-time intraoperative contrast agent to facilitate identification of the ureter and localization of ureteral stricture margins during robotic ureteral reconstruction. However, the use of ICG during robotic ureteroenteric stricture repair has yet to be reported. We describe our technique for using intraureteral and intraurinary diversion ICG during robotic ureteroenteric reimplantation and report our outcomes.
We retrospectively reviewed 8 patients who underwent 10 robotic ureteroenteric reimplantations by a single surgeon between August 2013 and July 2017. ICG (25 milligrams in 10 milliliters of distilled water) was injected antegrade and/or retrograde into the lumen of the ureter via a percutaneous nephrostomy tube and/or ureteral catheter, and retrograde into the lumen of the urinary diversion via a Foley catheter. All patients consented to off-label use of ICG. Postoperatively, all patients were assessed for: clinical success: the absence of flank pain attributable to ureteral pathology; and radiological success: the absence of obstruction on renal scan and/or loopogram.
Visualization of ICG under near-infrared fluorescence allowed for precise identification of the strictured ureter and urinary diversion, which fluoresced green; and localization the anastomotic stricture margins, which poorly fluoresced green compared to healthy ureter. Five of 8 (62.5%) patients underwent a Bricker anastomosis, 1/8 (12.5%) patients underwent a Wallace anastomosis, 1/8 (12.5%) patients underwent an appendiceal interposition, and 1/8 (12.5%) patients underwent a left to right transureteroureterostomy. The median operative time was 208 minutes (IQR 191-299), estimated blood loss was 125 milliliters (IQR 69-150), and length of stay was 6 days (IQR 1-8). Three of 8 (37.5%) patients suffered a minor (Clavien ≤2), and 2/8 (25.0%) patients suffered a major (Clavien >2) post-operative complication within 90 days of surgery. There were no complications related to ICG use. At a median follow-up of 29 months (IQR 21-38), 8/10 (80.0%) ureteroenteric reimplantations were clinically and radiologically successful.
Intraureteral and intraurinary diversion ICG may be utilized as a real-time contrast agent during robotic ureteroenteric reimplantation to facilitate identification of the strictured ureter(s) and urinary diversion, and delineation of the ureteroenteric stricture margins. Despite this, robotic ureteroenteric reimplantation remains a significantly morbid procedure.