Intraoperative Fluorescent Navigation of the Ureters, Vessels, and Nerves during Robot-Assisted Sacrocolpopexy

Abstract

In this study, we aimed to demonstrate the feasibility and safety of navigating the ureters, middle sacral artery (MSA), and superior hypogastric nerve (SHN) using indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during robot-assisted sacrocolpopexy (RSCP). Overall, 15 patients who underwent RSCP for apical vaginal prolapse were retrospectively enrolled. All patients underwent cystoscopic intraureteric instillation of 5 cc ICG (2.5 mg/mL) before RSCP and intravenous injection of 3 cc ICG during presacral dissection and mesh fixation. In all patients, the fluorescent right ureter was clearly identified in real time. The MSA was visualized on ICG-NIRF images in 80% (13/15) of patients. The mean time from ICG injection to MSA visualization was 43.7 s; the mean duration of the arterial phase was 104.3 s. Fluorescent SHN was detected in 73.3% (11/15) of patients. The time from ICG injection to SHN fluorescence was 48.4 s; the duration of fluorescence was 177.2 s. There was no transfusion, iatrogenic ureteral injury, or bowel or urinary dysfunction. Our results indicated that intraoperative ureter, MSA, and SHN mapping using ICG-NIRF images during RSCP is a valuable and safe technique to avoid iatrogenic ureteral, vascular, and neural injuries and to simplify surgical procedures. Nonetheless, further studies are required.

Keywords: apical vaginal prolapse; indocyanine green; middle sacral artery; near-infrared fluorescence imaging; real-time ureter; robot-assisted sacrocolpopexy; superior hypogastric nerve.

Figure 1

Robot-assisted bilateral ureteral visualization using indocyanine green and near-infrared fluorescence imaging. Right ureter (a). Right ureter, with the white arrow showing the retroperitoneal incision from the sacral promontory along the right pelvic side wall to the cul-de sac (b).

Figure 2

Middle sacral artery on the sacral promontory (indicated by the black arrow). White-light mode (a); near-infrared fluorescence imaging using indocyanine green (b).

Figure 3

Presacral space. The white arrow indicates the middle sacral artery; the black arrow indicates the superior hypogastric and inferior hypogastric nerves. White-light mode (a); near-infrared fluorescence imaging using indocyanine green (b).

Figure 4

Sacral venous plexus below the sacral promontory (indicated by the black arrow). White-light mode (a); near-infrared fluorescence imaging using indocyanine green (b).