title: Fluorescence-enhanced robotic radical cystectomy using unconjugated indocyanine green for pelvic lymphangiography, tumor marking, and mesenteric angiography: the initial clinical experience.
abstract: OBJECTIVE
  To describe the initial feasibility of fluorescence-enhanced robotic radical cystectomy (FERRC) using real-time cystoscopic injection of unconjugated indocyanine green (ICG) for tumor marking and identification of sentinel lymphatic drainage with additional intravenous injection for mesenteric angiography.
  
  
  METHODS
  Ten patients with clinically localized high-grade bladder cancer underwent FERRC. Before robot docking, rigid cystoscopy was performed, during which a 2.5-mg/mL ICG solution was injected in the bladder submucosa and detrusor circumferentially around the tumor. After robot docking, parameters describing the time course of tissue fluorescence and pelvic lymphangiography were systematically recorded. Lymphatic packets containing fluorescent lymph nodes were considered the sentinel drainage. Eight patients underwent intracorporeal ileal conduit urinary diversion, during which an additional 2-mL ICG solution was given intravenously for mesenteric angiography, allowing maximal preservation of bowel vascularity to the conduit and remaining bowel segments.
  
  
  RESULTS
  Bladder tumor marking and identification of sentinel drainage were achieved in 9 of 10 (90%) patients. The area of bladder tumor was identified at a median of 15 minutes after injection, whereas sentinel drainage was visualized at a median of 30 minutes. Mesenteric angiography was successful in 8 of 8 (100%) patients at a median time of <1 minutes after intravenous injection and enabled identification of bowel arcades before intracorporeal bowel stapling.
  
  
  CONCLUSIONS
  FERRC using combined cystoscopic and intravenous injection of ICG is safe and feasible. FERRC allows for reliable bladder tumor marking, identification of sentinel lymphatic drainage, and identification of mesenteric vasculature in most patients.
authors.affiliation: Department of Urology, Wake Forest University, Winston-Salem, NC.
authors.forename: Ted B
authors.initials: TB
authors.lastname: Manny
authors.affiliation: Department of Urology, Wake Forest University, Winston-Salem, NC. Electronic address: akhaiims@gmail.com.
authors.forename: Ashok K
authors.initials: AK
authors.lastname: Hemal
mesh_terms: D000368:Aged; D000792:Angiography / Q000379:methods*; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery*; D015653:Cystectomy / Q000379:methods*; D003558:Cystoscopy / Q000379:methods; D004322:Drainage; D005240:Feasibility Studies; D005260:Female; D005453:Fluorescence; D006801:Humans; D007208:Indocyanine Green / Q000737:chemistry*; D008198:Lymph Nodes / Q000473:pathology; D008207:Lymphatic Metastasis / Q000473:pathology; D008220:Lymphography / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010388:Pelvis / Q000601:surgery; D012371:Robotics; D012680:Sensitivity and Specificity; D013997:Time Factors; D001749:Urinary Bladder Neoplasms / Q000473:pathology / Q000601:surgery*
chemical_list: D007208:Indocyanine Green