NARUS 2018: Can Indocyanine Green Fluorescence Angiography Eliminate Ureteral Strictures after Robotic Radical Cystectomy?

Las Vegas, NV (UroToday.com) Dr. Nariman Ahmadi from the USC Institute of Urology presented their institution’s experience with indocyanine green (ICG) fluorescence angiography during robotic radical cystectomy as it relates to possibly decreasing ureteral strictures. Ureteroileal strictures are diagnosed in 3-10% of patients following robotic assisted radical cystectomy (RARC) and intracorporeal urinary diversion, and poor vascularity of the distal ureter is a well-known risk factor for stricture. Whether the use of ICG assists with assessing tissue vascularity during robotic surgery has not been extensively evaluation. As such, the objective of this study was to report the USC initial experience with using ICG prior to performing ureteroileal anastomosis during RARC.

The authors identified 26 patients (51 ureters) where ICG was used during RARC and intracorporeal urinary diversion from April 2016 to February 2017. Intravenous ICG (25 mg) was administered prior to anastomosis to assess vascularity, and the non-perfused distal ureters were excised prior to ureteral spatulation. Each anastomosis was performed with 4-O vicryl sutures over ureteral stents. 

Among the 26 patients, the median age was 65 years (range 44-92), 88% were male, median BMI was 27 (range 15-32), 50% were underwent a neobladder and 50% an ileal conduit, and median operative time was 480 minutes (range 400-625 min). There were 13 (50%) patients that demonstrated poorly perfused distal ureters in at least one ureter; one patient underwent concomitant nephroureterectomy due to urothelial carcinoma in the distal ureter. Distal ureteral resection was performed in 20 of 51 ureters evaluated (39%), with a median resected length of 2 cm (range 1-8cm). There were nine ureters (17.6%) excised of 4 cm or more and seven patients (27%) underwent bilateral ureteral resection. Importantly, at a median follow-up of 7 months (range 3-14 months), no ureteral strictures were diagnosed in this cohort. 

In conclusion, the authors note that ICG assisted imaging is a promising tool for providing a more objective evaluation of the vascularity of distal ureters in patients undergoing RARC with intracorporeal urinary diversion. However, longer follow-up and larger cohorts are required to confirm these findings and the potential long-term benefits of ICG in preventing ureteroenteric strictures.


Presented By: Nariman Ahmadi, Institute of Urology, University of Southern California, Los Angeles, CA

Co-Authors: Daniel Freitas, Carlos Fay, Neal Patel, David Hatcher, Fatima Husain, Toshitaka Shin, Mihir Desai, Inderbir Gill, Andre Berger, Monish Aron

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV