V7-09: Pediatric Robot-assisted Lower Pole Heminephrectomy with Intraureteral Indocyanine Green in a Duplicated Collecting System Not Following Weigert-Meyer Law
Duplicated collecting systems that violate Weigert-Meyer law are rare, and have only been reported in a handful of case reports. Indocyanine green (ICG), a dye that can be visualized under near-infrared fluorescence, may be used as a real-time contrast agent in the surgical management of patients with atypical ureteral anatomy. We describe a robot-assisted lower pole heminephrectomy with intraureteral ICG in a 13 year old pediatric patient with a duplicated collecting system not following Weigert-Meyer law.
Magnetic resonance urography demonstrated that the lower moiety renal pelvis was severely dilated proximal to a ureteropelvic junction obstruction and that the ectopic lower moiety ureter inserted into the prostatic urethra. Renal scan demonstrated an essentially functionless left lower moiety. The patient’s family consented to off-label use of ICG after full disclosure. Intraoperatively, 10 milliliters of indocyanine green solution (25 milligrams indocyanine green in 10 milliliters distilled water) was injected into the lower moiety ureter through a ureteral catheter. Near-infrared fluorescence was toggled on and off throughout the procedure to visualize the green-fluoresced ureter throughout the case.
The patient’s left lower pole moiety kidney and ectopic ureter were removed en-bloc. Use of intraureteral ICG allowed for definitive identification and precise dissection of the lower moiety ureter. Operative time was 235 minutes and estimated blood loss was 450 milliliters. On postoperative day one, the patient’s Foley catheter was removed and the patient was discharged. There were no intraoperative or postoperative complications.
Exceptions to Weigert-Meyer law are uncommon. In such cases, the use of intraureteral ICG may be used as a contrast agent to definitively delineate ureteral anatomy intraoperatively.