Intraoperative Fluorescent Ureter Visualization in Complex Laparoscopic or Robotic-Assisted Gynecologic Surgery

Abstract

This study aimed to demonstrate the feasibility of ureteral navigation using intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS). Twenty-six patients at high risk of ureteral injury with complex pelvic pathology (CPP) due to pelvic organ prolapse (POP), multiple myomas, large intraligamentary or cervical myoma, severe pelvic adhesions, or cervical atresia underwent LRAGS. All patients underwent cystoscopic intraureteral ICG instillation before LRAGS and ureteral navigation under NIRF imaging intraoperatively. Both ureteral pathways were identified from the pelvic brim downwards through NIRF imaging in all patients, even though some were not visualized under the white light mode. The fluorescent ureters were visualized immediately after the beginning of surgery and typically lasted for >5 h during surgery. There were no cases of iatrogenic ureteral injury. The hemoglobin decrement was 1.47 ± 1.13 g/dL, and no transfusion was required. In our study, both ureters in all patients were identified with ICG-NIRF imaging during LRAGS, and these techniques made surgeries easier and safer. Despite the CPP, there was no ureteral injury or transfusion following surgery. Further prospective studies are needed to introduce intraoperative ureteral guidelines for ICG-NIRF imaging during LRAGS with CPP.

Keywords: indocyanine green; laparoscopic or robotic-assisted gynecologic surgery; near-infrared fluorescence imaging; real-time ureter.

Figure 1

Cystoscopic view: intraureteral 6-Fr open-ended catheter insertion into the left ureteral orifice for indocyanine green (ICG) instillation (A). Laparoscopic bilateral ureteral visualization under ICG and near-infrared fluorescence (NIRF) imaging (B).

Figure 2

Bilateral fluorescent ureter identification during robotic-assisted total hysterectomy. Left ureter under ICG-NIRF imaging (A). Left uterine artery (bottom arrow) crossing over the left ureter (*) by lateral approach (B). Right ureter under the ICG-NIRF imaging (C). Right uterine artery (right arrow) crossing over the right ureter (**) by lateral approach (D).