V6-09: A novel use of near-infrared fluorescence imaging during robotic surgery without indocyanine green

Video

Introductions and Objectives
In addition to enhanced magnification, the da Vinci® Surgical System offers the ability to display near-infrared fluorescent (NIRF) imaging. NIRF imaging has previously been described in conjunction with the administration of the fluorophore indocyanine green (ICG). The principle urologic application of NIRF imaging has been to distinguish normal parenchyma from tumor during partial nephrectomy with intravenous ICG. We describe a novel use of NIRF imaging without ICG to identify intraluminal areas of interest during RAL surgery marked by the white light (WL) of endoscopic instruments.

Methods
A single surgeon performed RAL surgery on five patients aided by NIRF imaging to visualize areas of interest marked by the WL of endoscopic instruments. Patient 1 underwent RAL partial ureterectomy with psoas hitch and Boari flap reconstruction with left ureteroscopy for refractory ureteral stricture. Patients 2 and 3 underwent RAL partial cystectomy with diverticulectomy and bilateral pelvic lymph node dissection (BPLND) with cystoscopy for urothelial cell carcinoma (UCC) limited to bladder diverticula. Patient 4 underwent RAL partial cystectomy and BPLND with cystoscopy for focally invasive UCC. Patient 5 underwent RAL nephroureterectomy with cystoscopy for upper tract UCC.

Results
The use of NIRF imaging with marking by WL from endoscopic instruments enabled more precise identification of important areas and successful completion of RAL surgery in these five patients. The light source from the endoscopes could not be seen well with standard RAL imaging. Turning the intraabdominal RAL light source off eliminates the surrounding field of vision. By filtering light wavelengths below near-infrared, NIRF imaging caused the WL of the endoscopes to illuminate green while allowing simultaneous vision of the surrounding tissues. The increased precision enabled by this technique maximized the healthy tissue preserved in these procedures.

Conclusions
Our case series represents, to the best of our knowledge, the first description of a novel technique using NIRF imaging to identify otherwise obscured intraluminal areas of interest marked by the WL of endoscopic instruments and aid in successful completion of RAL surgery. This technique has been effectively utilized to improve precision in four disparate types of urologic RAL surgery.

Funding: none