The Ureters Are Lit: Intraureteral Injection of Indocyanine Green for Identification of Ureters in Laparoscopic Surgery

Brian Bassiri-Tehrani, MD, Netanel Alper, MD, Jeffrey S Aronoff, MD, Yaniv Larish, MD. Lenox Hill Hospital

Ureteral stents have historically been used in pelvic surgery when anatomical or clinical considerations warrant urological expertise to aid in identifying the ureters. In the colorectal and gynecologic surgery literature, prophylactic ureteral stents appear to increase the ability to detect ureteral injuries while not being shown to prevent such injuries. With the increasingly widespread use of laparoscopy and the robotic platform in complex colorectal and pelvic surgery, the utility of stents remains unclear. One of the limiting factors regarding the use of ureteral stents in minimally invasive surgery is the lack of tactile feedback; the inability of the surgeon to directly palpate the stents. One proposed method to overcome this deficiency has been the use of lighted ureteral stents. Increased operating time, increased cost, and need for specialized equipment are potential drawbacks of lighted stents.

An alternative to using lighted stents in minimally-invasive surgery is to directly inject indocyanine green (ICG) into the ureters after cystoscopy-guided placement of ureteral stents. Intraoperative visualization of the ureters is acheived by using either the PINPOINT Endoscopic Fluorescence Imaging System in laparoscopy, or FIREFLY integrated with the robotic platform. It is hoped that the risk of inadvertent ureteral injuries during colorectal and pelvic operations will be minimized using this technique, due to improved visualization of the ureters throughout the procedure.

In this case presentation, we describe a novel use of ICG in a patient undergoing a laparoscopic surgery for resection of a 6.7 x 8.0 x 5.1cm pelvic mass abutting the bladder, sigmoid colon and left ureter. Preoperatively, there was concern that the mass would be intimately adherent to, or even invading, the bilateral ureters based on CT scan findings. After ureteral injection of ICG, visualization of both ureters was easily achieved at the time of operation, and the procedure proceeded with careful and safe dissection of the mass with visualization of the ureters at all times.

Though there is a paucity of studies evaluating the use of ICG in the laparoscopic modality, this technique was safe, easy to employ, inexpensive and very useful to visualize the ureters intraoperatively. Indeed, larger studies with appropriate sample sizes would help to further validate this novel use of ICG.