title: Use of indocyanine green during robot-assisted ureteral reconstructions.
abstract: BACKGROUND
  Although there are reports of robot-assisted ureteral reconstructions (RURs) with excellent safety and efficacy, the procedures remain technically challenging. In the robotic setting the surgeon must rely on visual cues in the absence of tactile feedback. Indocyanine green (ICG) is a dye that can be visualized under near-infrared fluorescence (NIRF).
  
  
  OBJECTIVE
  To describe our novel technique, which utilizes intraureteral injection of ICG and subsequent visualization under NIRF to facilitate RUR, and report our outcomes after these procedures.
  
  
  METHODS
  This is a retrospective review of 25 patients who underwent 26 RURs for various ureteral pathologies between June 2012 and October 2013.
  
  
  METHODS
  After full disclosure, all patients consented to off-label use of ICG. A ureteral catheter and/or percutaneous nephrostomy tube were used to inject 10ml of ICG into the diseased ureter, above and below the stricture. Intraoperatively, NIRF was activated to assist in identification of the ureter and to localize the margins of ureteral strictures.
  
  
  METHODS
  Postoperatively, RURs were assessed for clinical success (absence of symptoms attributable to ureteral pathology) and radiological success (absence of a ureteral stricture on imaging).
  
  
  CONCLUSIONS
  Our technique provided visual cues and aided in successful performance of 26 RURs in 25 patients. The procedures included ureterolysis (n=4), pyeloplasty (n=8), ureteroureterostomy (n=9), and ureteroneocystostomy (n=5). There were no perioperative complications attributable to ICG use. At a mean overall follow-up of 12 mo, all procedures were clinically and radiologically successful. This study is limited by the small sample size and short-term follow-up.
  
  
  CONCLUSIONS
  Intraureteral injection of ICG and subsequent visualization under NIRF facilitates RUR by aiding in rapid and accurate identification of the ureter, and precise localization of the proximal and distal ureteral stricture margins. In our experience, our technique is safe, easy to perform, and reproducible.
  
  
  RESULTS
  In this report, we describe a new technique to facilitate robot-assisted ureteral reconstructions using intraureteral injection of ICG and subsequent visualization under near-infrared fluorescence. More specifically, our technique allows for rapid and accurate identification of the ureter, and precise localization of ureteral strictures.
authors.affiliation: Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA.
authors.forename: Ziho
authors.initials: Z
authors.lastname: Lee
authors.affiliation: Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA.
authors.forename: Blake
authors.initials: B
authors.lastname: Moore
authors.affiliation: Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Giusto
authors.affiliation: Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA. Electronic address: daniel.eun@tuhs.temple.edu.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Eun
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005456:Fluorescent Dyes / Q000008:administration & dosage*; D006801:Humans; D007208:Indocyanine Green / Q000008:administration & dosage*; D007267:Injections; D007430:Intraoperative Care; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*; D055815:Young Adult
chemical_list: D005456:Fluorescent Dyes; D007208:Indocyanine Green
keywords: Indocyanine green; Near-infrared light; Robot-assisted surgery; Ureteral reconstruction