Indocyanine Green Ureteral Mapping in Complex Pelvic Surgery.

Abstract

Introduction and hypothesis: Visual feedback using retrograde ureteral indocyanine green (ICG) instillation and near-infrared (NIR) fluorescence is an effective and reproducible option for ureteral identification in robotic pelvic surgeries. The purpose of this video is to discuss risks for intraoperative ureteral injury, demonstrate ICG ureteral mapping, review pelvic and ureteral anatomy, and common sites of ureteral injury during complex hysterectomies and reconstructive surgeries.

Methods: Three robotic pelvic surgeries are presented with ICG and NIR fluorescent live ureteral mapping. Steps for ICG ureteral mapping and surgical technique are demonstrated.

Results: Cases included a 51-year-old with enlarged uterine leiomyomata and adhesive disease undergoing a total robotic hysterectomy (TRH), a 54-year-old with leiomyomata and stage 2 uterovaginal prolapse undergoing TRH with uterosacral ligament suspension, and a 61-year-old with stage 2 post-hysterectomy prolapse undergoing a robotic sacrocolpopexy. Procedure duration ranged from 116 to 183 min. Patients were discharged home the day of surgery and remained complication-free at their 6-week postoperative appointment.

Conclusion: Bilateral ureters were demonstrated via ICG with NIR fluorescence throughout the duration of all cases. ICG ureteral mapping complements careful surgical techniques to reduce iatrogenic ureteral injury. More data with larger prospective studies are needed to determine if ICG ureteral mapping significantly reduces iatrogenic ureteral injury.