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

Area of Science:

• Urology
• Gynecologic Surgery
• Medical Imaging

Background:

• Ureteral injury is a significant risk during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS), especially with complex pelvic pathology (CPP).
• Accurate intraoperative visualization of ureters is crucial for preventing iatrogenic injury.

Purpose of the Study:

• To assess the feasibility and effectiveness of intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging for ureteral navigation during LRAGS in patients with CPP.
• To evaluate the safety and impact of ICG-NIRF imaging on preventing ureteral injury.

Main Methods:

• Twenty-six high-risk patients undergoing LRAGS for CPP received cystoscopic intraureteral ICG instillation.
• Ureteral navigation and visualization were performed using NIRF imaging throughout the surgical procedures.
• Surgical outcomes, including ureteral identification, operative time, blood loss, and complications, were recorded.

Main Results:

• Bilateral ureteral pathways were successfully identified in all patients using ICG-NIRF imaging, even when not visible under white light.
• Fluorescence persisted for over 5 hours, aiding continuous intraoperative navigation.
• No cases of iatrogenic ureteral injury or need for blood transfusion were reported, with a mean hemoglobin decrement of 1.47 g/dL.

Conclusions:

• Intraoperative ICG-NIRF imaging is a feasible and effective method for ureteral navigation during LRAGS in patients with CPP.
• This technique significantly enhances surgical safety by enabling clear ureteral visualization, thereby preventing injury and transfusions.
• Further prospective studies are warranted to establish definitive intraoperative guidelines for ICG-NIRF imaging in these complex cases.