V12-05: Indocyanine Green for Ureteral Identification During Non-Urologic Robotic Surgery: Mayo Clinic Pilot Experience
Ureteral injury during non-urologic abdominoperineal surgery can occur in up to 10% of cases. Surgeons often use additional techniques for identification of the ureter including stents, lighted stents, or post-operative cystoscopy. While it may appear that ureteral stenting is a benign procedure, there is minimal data to suggest it prevents injury; and, in fact, iatrogenic ureteral injury can occur during stent placement. Indocyanine green (ICG) is a fluorochrome that can be injected intravascularly to visualize vascular and lymphactic channels. Early reports have suggested that intraureteral ICG is a beneficial adjunctive maneuver for ureteral identification during robotic assisted surgery. We present our initial experience with intraureteral ICG during robotic colorectal surgery.
Patients who would potentially benefit from adjunctive ureteral identification during robotic colorectal surgery were prospectively identified. Our technique has evolved through our initial experience. Currently, we perform rigid cystoscopy (22 Fr) and a 5 Fr open-ended ureteral catheter is inserted up to 20 cm. 5 mL of 2.5 mg/mL ICG is gently injected as the ureteral catheter is withdrawn to the ureteral orfice. No stent is left in place. Intraureteral ICG is detected using near-infrared laser fluorescence technology (Firefly®).
Intraureteral ICG enhanced ureteral identification was performed in 12 renal moieties of 6 patients under robotic colorectal surgery. ICG ureteral identification was successful in 5 of 6 patients (10 of 12 moieties). ICG remained visible for up to 11 hours following instillation. No intraoperative ureteral injuries occurred. ICG Failure occurred in 1 patient with an atretic duplicated collecting system undergoing sigmoid colectomy. ICG was injected at level of ureteral orfices due to inability to advance a 6 Fr ureteral catheter. There was immediate extravasation of ICG into surrounding tissue in the setting of severe peri-ureteral inflammatory reaction from associated diverticulitis. There was no evidence of ureteral perforation on further evaluation.
Intraureteral ICG effectively augments ureteral identification during robotic assisted surgery. Even with lengthy operative times, durable results were feasible with a modified retrograde technique and no stenting. ICG extravasation may occur with severe peri-ureteral inflammation or high pressure instillation technique.