V7-01: Use of Indocyanine Green (ICG) for Complex Robotic Reconstruction Involving Bowel Urinary Diversions

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Introductions and Objectives
Complications after urinary diversion or reconstruction using bowel segments are challenging operative scenarios. The distinction between ureter, bowel and bowel based urinary diversion segments are difficult to demarcate due to distorted anatomy and postoperative adhesions. We present our method of real-time intraoperative localization and reconstruction of ureteral-ileal anastomotic strictures with the assistance of Indocyanine Green (ICG) using near infrared (NIR) imaging on the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA).

Methods
Our technique was performed in three patients operated on by a single surgeon (DDE) between August and October 2013. Consent was obtained for off-label use of ICG after full disclosure. Intraoperative localization of ureteral-ileal anastomotic strictures involved retrograde instillation of ICG (25 mg in 10 mL of saline) through an ileal conduit, ileal neobladder and ileal ureter replacement and in antegrade fashion through percutaneous access. Fluorescent tracer was detected as a green color using the NIR imaging modality.

Results
Patient 1 with bilateral strictures after ileal conduit underwent left-to-right transureteroureterostomy and revision of right ureteral ileal anastomosis, omental interposition wrap and placement of bilateral ureteral stents. Combined console time including parastomal hernia repair by general surgery was 508 minutes. Estimated blood loss (EBL) was 150 mL. Length of stay (LOS) was 5 days. Patient 2 underwent revision and reimplantation of the right ureter to neobladder with ureteral stent placement. Console time was 138 minutes. EBL was 75 mL. LOS was 2 days. Patient 3 underwent revision of a strictured right ileal ureter replacement anastomosis with omental interposition wrap and stent placement. Console time was 193 minutes. EBL was 200. LOS was 3 days.

Conclusions
Use of ICG during complex robotic reconstruction allows for localization and demarcation of bowel and ureteral segments to improve lysis of adhesions and ureterolysis when needed. This is a safe and feasible option for robotic revision of ureteral-ileal anastomotic strictures.

Funding: None.