The use of indocyanine green during robotic ureteroenteric reimplantation for the management of benign anastomotic strictures.

PURPOSE: We describe our technique for using intraureteral and intraurinary diversion indocyanine green (ICG) during robotic ureteroenteric reimplantation and report our outcomes.

METHODS: We retrospectively reviewed eight patients who underwent ten robotic ureteroenteric reimplantations between August 2013 and July 2017. ICG was injected antegrade and/or retrograde into the lumen of the ureter, and retrograde into the lumen of the urinary diversion. All patients consented to off-label use of ICG. Postoperatively, all patients were assessed for: clinical success: the absence of flank pain; and radiological success: the absence of obstruction on renal scan and/or loopogram.

RESULTS: Visualization of ICG under near-infrared fluorescence allowed for precise identification of the strictured ureter and urinary diversion, which fluoresced green; and localization the ureteroenteric stricture margins, which poorly fluoresced green. The median operative time was 208 min (IQR 191-299), estimated blood loss was 125 ml (IQR 69-150), and length of stay was 6 days (IQR 1-8). Three of eight (37.5%) patients suffered a minor (Clavien ≤ 2), and 2/8 (25.0%) patients suffered a major (Clavien > 2) post-operative complication. There were no complications related to ICG use. At a median follow-up of 29 months (IQR 21-38), 8/10 (80.0%) ureteroenteric reimplantations were clinically and radiologically successful.

CONCLUSIONS: Intraureteral and intraurinary diversion ICG may be utilized as a real-time contrast agent during robotic ureteroenteric reimplantation to assist with identification of the strictured ureter and urinary diversion, and delineation of the ureteroenteric stricture margins. Despite this, RUER remains a technically difficult and morbid procedure.