Intraureteral indocyanine green augments ureteral identification and avoidance during complex robotic-assisted colorectal surgery.

AIM Up to 10% of patients undergoing non-urologic abdominopelvic operations suffer a ureteral injury. While preoperative ureteral stenting to facilitate ureteral identification is common, it does not reduce the incidence of intraoperative ureteral injury and is not without risk. As we continue to broaden the application of minimally invasive surgical techniques, a new form of ureteral identification and avoidance, which does not rely on tactile feedback, is needed. We report our initial experience with intraureteral indocyanine green (ICG) for ureteral identification and avoidance during complex robotic-assisted colorectal surgery. METHODS Patients undergoing adjunctive ureteral identification during robotic-assisted colorectal surgery were prospectively identified. Each patient underwent intraureteral ICG administration using rigid cystoscopy (22 Fr). A 5 Fr open-ended ureteral catheter was inserted up to 20 cm and used to inject 5 mL of 2.5 mg/mL ICG as the catheter was withdrawn to the ureteral orifice. Intraureteral ICG was then detected using near-infrared laser fluorescence technology (Firefly® ). RESULTS Successful ICG-enhanced ureteral identification and avoidance was performed in 15 of 16 (94%) patients undergoing robotic-assisted colorectal surgery. Median ICG instillation time was 11.5 minutes (range: 4-21 minutes), and median operative time with ICG visualization was 489 minutes (8 hrs & 9 mins) (range: 268-738 minutes [4 hrs & 28 minutes-12 hrs & 18 minutes]). No patient experienced intraoperative ureteral injury and there were no adverse sequelae or complications associated with intraureteral ICG administration. CONCLUSION Intraureteral ICG is a safe and effective method of intraoperative ureteral identification and avoidance during complex robotic-assisted colorectal surgery. Precise and prolonged ureteral visualization was achieved, allowing for long operative times compatible with complex robotic-assisted operations.