V1860: Novel use of ICF-NIRF for identification of sentinel lymph nodes and mesenteric angiography during robotic radical cystectomy with intracorporeal urinary diversion

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Introduction and Objectives
ICG has previously been described in the urologic literature during partial nephrectomy using an intravenous technique and resultant differential mass-parenchymal fluorescence. Further urologic applications of the dye exist based on its ability to act as an intravenous contrast agent to perform real time fluorescence angiography, a technique well described in thousands of patients in the ophthalmologic literature. Additionally,interstitial injection can be used to perform real time fluorescence lymphangiography, a technique well described in breast cancer, GI malignancy, and now recently in several pilot series in prostate cancer. We describe the first clinical series of ICG use in bladder cancer in which we utilize its ability to perform lymph node mapping and mesenteric angiography in 5 consecutive patients undergoing robotic cystectomy with intracorporeal urinary diversion.

Methods
We utilize direct injection around the bladder tumor using a cystoscopic injection needle to perform a real-time fluorescence lymphangiography to identify sentinel drainage from the bladder. We then also utilize an intravenous technique during intracorporeal urinary diversion to allow visualization of vascular arcades supplying the bowel segment of interest by performing real time angiography.

Results
In all five patients, we were able to visualize the lymphatic drainage of each bladder tumor identifying the potential sentinel lymph nodes. During intracorporeal urinary diversion, we were able to successfully identify the vascular arcades guiding placement of vascular staples in an effort to improve blood flow to the ileal conduit. No adverse reactions or problems with pathologic interpretation were observed.

Conclusions
In conclusion, we demonstrate a safe, reliable, cheap and reproducible way to perform real time lymphangiography and angiography during lymph node dissection and intracorporeal urinary diversion during robotic radical cystectomy. We believe this technique may enable more precise lymphadenectomy with improved pathologic staging and oncologic outcomes and may minimize risks of bowel ischemia of the urinary diversion.

Funding: None