Surgeon’s Corner
ajog.org
Indocyanine green for intraoperative localization of ureter Sam Siddighi, MD; Junchan Joshua Yune, MD; Jeffrey Hardesty, MD
Problem: ureter injury, a well-known complication Injury to the urinary tract is a wellknown complication of gynecologic surgery with reported rates for bladder injury that range from 0.2e1.8% and for ureteral injuries from 0.03e1.5%.1-3 High-risk reconstructive pelvic surgery has up to 11% risk of ureteral injury.4 Many intraoperative injuries go unrecognized and may result in serious complications and possible medical-legal action.5 The efficacy of routine prophylactic ureteral stents to prevent the ureteral injury has been questioned in the previous studies.6,7 Selective use of ureteral stents may reduce the risk of ureter injury during high-risk procedures. In robot-assisted cases, the use of prophylactic ureteral stents is limited because of the lack of tactile feedback. Visual identification, such as with lighted ureteral stents, can be more useful for robotic and laparoscopic surgeries.8 However, many gynecologists are not comfortable with performing ureteral catheterization, and stenting is associated with iatrogenic injury from ureteral catheterization. Our solution Patients were scheduled to undergo robotassisted laparoscopic sacrocolpopexy. All
From the Departments of Female Pelvic Medicine and Reconstructive Surgery, Loma Linda University School of Medicine, Loma Linda, CA. Received Feb. 3, 2014; revised May 9, 2014; accepted May 12, 2014. The authors report no conflict of interest. Reprints: Junchan J. Yune, MD, Loma Linda University, Ob/Gyn, FPMRS, 11234 Anderson St., Loma Linda, CA 92354. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.05.017
Click Supplementary Content under the article title in the online Table of Contents
Intraurethral injection of indocyanine green (ICG; Akorn, Lake Forest, IL) and visualization under near-infrared (NIR) light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Patients were scheduled to undergo robot-assisted laparoscopic sacrocolpopexy. Before the robotic surgery started, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10-mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The ICG reversibly stained the inside lining of the ureter by binding to proteins on urothelial layer. During the course of robotic surgery, the NIR laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used to excite ICG molecules, and infrared emission was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed its definitive identification throughout the entire case. In all cases of >10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness that depended on the depth of the ureter from the peritoneal surface. For example, in a morbidly obese patient, the ureters were not as bright green. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of ureter and allowed a safe approach to tissues that were adjacent to the urinary tract. The advantage of our technique is that it requires the insertion of just the tip of ureteral catheter. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous and intrabiliary ICG. Intraurethral injection of ICG and visualization under NIR light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Key words: anatomy, indocyanine green (ICG), robotic surgery, ureter Cite this article as: Siddighi S, Yune JJ, Hardesty J. Indocyanine green for intraoperative localization of ureter. Am J Obstet Gynecol 2014;211:436.e1-2.
patients consented to off-label use of indocyanine green (ICG; Akorn, Lake Forest, IL) after full disclosure. Institutional review board approval was received. ICG is a Food and Drug Administrationeapproved fluorescent dye that is injected intravenously for various indications that include retinal angiography, determination of tissue viability, and cardiac and hepatic function testing. Before the robotic surgery began, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The
436.e1 American Journal of Obstetrics & Gynecology OCTOBER 2014
ICG reversibly stained the inside lining of the ureter by binding to proteins.9 During the course of robotic surgery, the near-infrared (NIR) laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used intermittently throughout the case to fluoresce the ICG inside the ureter. The NIR laser at 805 nm penetrated into the ureter without damage to it. The ICG molecules fluoresced at 830 nm and the emitted NIR light was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed definitive identification of the ureter throughout the entire case (Figures 1 and 2). In all cases of
Surgeon’s Corner
ajog.org
our technique is that it requires the insertion of just the tip of ureteral catheter, and gynecologists may be more comfortable with this technique compared with ureteral catheterization. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous11 and intrabiliary12 ICG. -
FIGURE 1
View in absence of near-infrared light
REFERENCES
Siddighi. ICG for intraoperative localization of ureter. Am J Obstet Gynecol 2014.
>10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness, depending on the depth of ureter from the peritoneal surface. For example, in morbidly obese patients, the ureters were not as bright green. At the end of procedure, routine cystoscopy was performed to confirm ureteral patency. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation.
Lee et al10 reported intraurethral injection of ICG to localize ureteral stenosis during ureteroureterostomy cases and found it useful for ureter repair. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of the ureter for prevention of injury during gynecologic cases. It does not require special equipment other than Firefly Fluorescence Endoscope system (Intuitive Surgical, Inc), and 25 mg of ICG cost approximately $100. The advantage of
FIGURE 2
Ureter identification under near-infrared light with green fluorescence
Siddighi. ICG for intraoperative localization of ureter. Am J Obstet Gynecol 2014.
1. Liapis A, Bakas P, Giannopoulos V, Creatsas G. Ureteral injuries during gynecological surgery. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:391-3. 2. Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, Hernandez E. Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:427-31. 3. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998;92:113-8. 4. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol 2000;183:1402-11. 5. Sack RA. The value of intravenous urography prior to abdominal hysterectomy for benign gynecologic disease. Am J Obstet Gynecol 1979;134:208-12. 6. Kuno K, Menzin A, Kauder HH, Sison C, Gal D. Prophylactic ureteral catheterization in gynecologic surgery. Urology 1998;52: 1004-8. 7. Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomization trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:689-93. 8. Siddighi S, Carr RC. Lighted stents facilitate robotic-assisted laparoscopic ureterovaginal fistula repair. Int Urogynecol J 2012;24:515-7. 9. Frangioni JV. In vivo near-infrared fluorescence imaging. Curr Opin Chemical Biol 2003;7: 626-34. 10. Lee Z, Simhan J, Parker DC, et al. Novel use of indocyanine green for intraoperative, real time localization of ureteral stenosis during robotassisted ureteroureterostomy. Urology 2013; 82:729-33. 11. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg 2010;125: 1065-73. 12. Sakaguchi T, Suzuki A, Unno N, et al. Bile leak test by indocyanine green fluorescence images after hepatectomy. Am J Surg 2010; 200:e19-23.
OCTOBER 2014 American Journal of Obstetrics & Gynecology
436.e2
ajog.org
Indocyanine green for intraoperative localization of ureter Sam Siddighi, MD; Junchan Joshua Yune, MD; Jeffrey Hardesty, MD
Problem: ureter injury, a well-known complication Injury to the urinary tract is a wellknown complication of gynecologic surgery with reported rates for bladder injury that range from 0.2e1.8% and for ureteral injuries from 0.03e1.5%.1-3 High-risk reconstructive pelvic surgery has up to 11% risk of ureteral injury.4 Many intraoperative injuries go unrecognized and may result in serious complications and possible medical-legal action.5 The efficacy of routine prophylactic ureteral stents to prevent the ureteral injury has been questioned in the previous studies.6,7 Selective use of ureteral stents may reduce the risk of ureter injury during high-risk procedures. In robot-assisted cases, the use of prophylactic ureteral stents is limited because of the lack of tactile feedback. Visual identification, such as with lighted ureteral stents, can be more useful for robotic and laparoscopic surgeries.8 However, many gynecologists are not comfortable with performing ureteral catheterization, and stenting is associated with iatrogenic injury from ureteral catheterization. Our solution Patients were scheduled to undergo robotassisted laparoscopic sacrocolpopexy. All
From the Departments of Female Pelvic Medicine and Reconstructive Surgery, Loma Linda University School of Medicine, Loma Linda, CA. Received Feb. 3, 2014; revised May 9, 2014; accepted May 12, 2014. The authors report no conflict of interest. Reprints: Junchan J. Yune, MD, Loma Linda University, Ob/Gyn, FPMRS, 11234 Anderson St., Loma Linda, CA 92354. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.05.017
Click Supplementary Content under the article title in the online Table of Contents
Intraurethral injection of indocyanine green (ICG; Akorn, Lake Forest, IL) and visualization under near-infrared (NIR) light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Patients were scheduled to undergo robot-assisted laparoscopic sacrocolpopexy. Before the robotic surgery started, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10-mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The ICG reversibly stained the inside lining of the ureter by binding to proteins on urothelial layer. During the course of robotic surgery, the NIR laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used to excite ICG molecules, and infrared emission was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed its definitive identification throughout the entire case. In all cases of >10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness that depended on the depth of the ureter from the peritoneal surface. For example, in a morbidly obese patient, the ureters were not as bright green. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of ureter and allowed a safe approach to tissues that were adjacent to the urinary tract. The advantage of our technique is that it requires the insertion of just the tip of ureteral catheter. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous and intrabiliary ICG. Intraurethral injection of ICG and visualization under NIR light allows for real-time delineation of the ureter. This technology can be helpful to prevent iatrogenic ureteral injury during pelvic surgery. Key words: anatomy, indocyanine green (ICG), robotic surgery, ureter Cite this article as: Siddighi S, Yune JJ, Hardesty J. Indocyanine green for intraoperative localization of ureter. Am J Obstet Gynecol 2014;211:436.e1-2.
patients consented to off-label use of indocyanine green (ICG; Akorn, Lake Forest, IL) after full disclosure. Institutional review board approval was received. ICG is a Food and Drug Administrationeapproved fluorescent dye that is injected intravenously for various indications that include retinal angiography, determination of tissue viability, and cardiac and hepatic function testing. Before the robotic surgery began, the tip of a 6-F ureteral catheter was inserted into the ureteral orifice. Twenty-five milligrams of ICG was dissolved in 10mL of sterile water and injected through the open catheter. The same procedure was repeated on the opposite side. The
436.e1 American Journal of Obstetrics & Gynecology OCTOBER 2014
ICG reversibly stained the inside lining of the ureter by binding to proteins.9 During the course of robotic surgery, the near-infrared (NIR) laser on the da Vinci Si surgical robot (Intuitive Surgical, Inc, Sunnyvale, CA) was used intermittently throughout the case to fluoresce the ICG inside the ureter. The NIR laser at 805 nm penetrated into the ureter without damage to it. The ICG molecules fluoresced at 830 nm and the emitted NIR light was captured by the da Vinci filtered lens system and electronically converted to green color. Thus, the ureter fluoresced green, which allowed definitive identification of the ureter throughout the entire case (Figures 1 and 2). In all cases of
Surgeon’s Corner
ajog.org
our technique is that it requires the insertion of just the tip of ureteral catheter, and gynecologists may be more comfortable with this technique compared with ureteral catheterization. Despite our limited cohort of patients, our findings are consistent with previous reports of the excellent safety profile of intravenous11 and intrabiliary12 ICG. -
FIGURE 1
View in absence of near-infrared light
REFERENCES
Siddighi. ICG for intraoperative localization of ureter. Am J Obstet Gynecol 2014.
>10 patients, we were able to visualize bilateral ureters with this technology, even though there was some variation in brightness, depending on the depth of ureter from the peritoneal surface. For example, in morbidly obese patients, the ureters were not as bright green. At the end of procedure, routine cystoscopy was performed to confirm ureteral patency. There were no intraoperative or postoperative adverse effects attributable to ICG administration for up to 2 months of observation.
Lee et al10 reported intraurethral injection of ICG to localize ureteral stenosis during ureteroureterostomy cases and found it useful for ureter repair. In our experience, this novel method of intraurethral ICG injection was helpful to identify the entire course of the ureter for prevention of injury during gynecologic cases. It does not require special equipment other than Firefly Fluorescence Endoscope system (Intuitive Surgical, Inc), and 25 mg of ICG cost approximately $100. The advantage of
FIGURE 2
Ureter identification under near-infrared light with green fluorescence
Siddighi. ICG for intraoperative localization of ureter. Am J Obstet Gynecol 2014.
1. Liapis A, Bakas P, Giannopoulos V, Creatsas G. Ureteral injuries during gynecological surgery. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:391-3. 2. Dandolu V, Mathai E, Chatwani A, Harmanli O, Pontari M, Hernandez E. Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:427-31. 3. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol 1998;92:113-8. 4. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol 2000;183:1402-11. 5. Sack RA. The value of intravenous urography prior to abdominal hysterectomy for benign gynecologic disease. Am J Obstet Gynecol 1979;134:208-12. 6. Kuno K, Menzin A, Kauder HH, Sison C, Gal D. Prophylactic ureteral catheterization in gynecologic surgery. Urology 1998;52: 1004-8. 7. Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12-year randomization trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:689-93. 8. Siddighi S, Carr RC. Lighted stents facilitate robotic-assisted laparoscopic ureterovaginal fistula repair. Int Urogynecol J 2012;24:515-7. 9. Frangioni JV. In vivo near-infrared fluorescence imaging. Curr Opin Chemical Biol 2003;7: 626-34. 10. Lee Z, Simhan J, Parker DC, et al. Novel use of indocyanine green for intraoperative, real time localization of ureteral stenosis during robotassisted ureteroureterostomy. Urology 2013; 82:729-33. 11. Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg 2010;125: 1065-73. 12. Sakaguchi T, Suzuki A, Unno N, et al. Bile leak test by indocyanine green fluorescence images after hepatectomy. Am J Surg 2010; 200:e19-23.
OCTOBER 2014 American Journal of Obstetrics & Gynecology
436.e2
