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Journal of Peking University (Health Sciences) ›› 2020, Vol. 52 ›› Issue (4): 651-656. doi: 10.19723/j.issn.1671-167X.2020.04.010

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Application of indocyanine green in complex upper urinary tract repair surgery

Bing-wei HUANG1,2,Jie WANG1,Peng ZHANG2,Zhe LI2,Si-cheng BI2,Qiang WANG2,Cai-bo YUE2,Kun-lin YANG1,△(),Xue-song LI1,△(),Li-qun ZHOU1   

  1. 1. Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
    2. Department of Urology, Emergency General Hospital, Beijing 100028, China
  • Received:2020-04-19 Online:2020-08-18 Published:2020-08-06
  • Contact: Kun-lin YANG,Xue-song LI E-mail:yangkunlin12345@163.com;pineneedle@sina.com

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Abstract:

Objective: To evaluate the clinical application of indocyanine green (ICG) visualization by near infrared fluorescence laparoscopy (NIFL) in complex upper urinary tract reconstructions surgery. Methods: This was a retrospective study of 7 patients who underwent complex surgeries of ureteral reconstruction between May 2019 and October 2019. There were 6 males and 1 female with the age ranging from 24 to 57 years (median age was 47 years). There were 5 cases of right ureteral strictures, of which 3 were proximal ureteral strictures and 2 were multiple and long ureteral strictures caused by radiotherapy. There were 2 cases of left ureteral strictures, of which 1 was ureteropelvic junction stricture and 1 was proximal ureteral stricture. There were 4 cases of secondary repair operations and 3 cases of primary operations. All the patients underwent laparoscopic surgery via the abdominal approach. ICG was injected into the ureter via nephrostomy tube during the operations, and the diseased ureter was identified by NIFL. Among the patients, 2 cases underwent IUPU (Institute of Urology, Peking University) modified ileal ureter replacement, 2 cases underwent ureteroureterostomy, 2 cases underwent appendiceal onlay flap ureteroplasty, and 1 case underwent lingual mucosa onlay flap ureteroplasty. Results: All the operations were successfully completed without open conversion. The localization and separation of ureteral lesions were completed under NIFL. The mean operative time was 187 (135-300) min. The duration of ureteral separation was 15-27 min, and the mean time was 18 min. The estimated blood loss was 15-200 mL, the mean estimated blood loss was 50 mL. There was one patient with ileal ureter replacement who had fever after surgery and responded well to antibiotics. The mean (range) length of postoperative hospital stay was 7 (6-10) days and no postoperative complications of a high grade (Clavien-Dindo Ⅲ and Ⅳ) occurred. Up to now, the mean follow-up duration was 9 (6-11) months, and no indocyanine green toxicity occurred. All D-J stents and nephrostomy were removed successfully 2 months after the operation. Ultrasound showed no obvious hydronephrosis, and CTU (computed tomography urography) showed that the urinary tract was unobstructed and the kidney function was normal. Conclusion: The application of ICG in the complex upper urinary tract reconstructive surgery is a safe and easy method to help surgeon to identify the ureter which may reduce the risk of iatrogenic damage and protect the ureteral blood supply.

Key words: Indocyanine green, Near-infrared fluorescence laparoscopy, Ureteral stricture, Upper urinary tract reconstruction

CLC Number: 

  • R693.5

Table 1

Demographic and preoperative characteristics"

Cases Gender Age/years Injury etiology Stenosis location Stenosis
length/cm		 Preoperative
nephrostomy		 Nephrostomy
indwelling/months
1 Female 54 Holmium laser lithotripsy Multiple segments Yes 7.0
2 Male 57 Radiotherapy Multiple segments Yes 12.0
3 Male 28 Holmium laser lithotripsy Proximal 2.0 Yes 1.0
4 Male 47 Rectal cancer operation Proximal 2.5 Yes 1.0
5 Male 27 Pyeloplasty failed Proximal 0.5 Yes 1.0
6 Male 24 Pyeloplasty failed Proximal 1.5 Yes 4.0
7 Male 49 Holmium laser lithotripsy Proximal 4.0 Yes 6.0
Mean 47 2.0 4.5

Figure 1

Preoperative urography and retrograde urography radiography of case 1 and case 2 A, case 1 preoperative antegrade urography showed ureteral stenosis (white arrow); B, case 1 preoperative retrograde urography showed ureteral stenosis (white arrow); C, case 2 preoperative antegrade urography showed ureteral stenosis (white arrow); D, case 2 preoperative retrograde urography showed ureteral stenosis (white arrow)."

Table 2

Intraoperative and postoperative parameters"

Cases Operations Operation
time/min		 Estimated blood
loss/mL		 Exposure time of
ureteral stenosis/min		 Early postoperative
complications		 Postoperative
hospital stay/d
1 Ileal ureter replacement 300 200 17 Fever 10
2 Ileal ureter replacement 180 50 15 None 9
3 Appendiceal onlay flap ureteroplasty 150 15 18 None 6
4 Tongue mucosal onlay flap ureteroplasty 240 20 27 None 8
5 Ureteroureterostomy 140 15 16 None 6
6 Ureteroureterostomy 135 20 15 None 6
7 Appendiceal onlay flap ureteroplasty 160 50 20 None 7
Mean 187 50 18 7

Figure 2

Intraoperative separation process of ureter of case 1 A, location of estimated ureter in white light vision which between the black dashed lines; B, real location of ureter; C, D, ureter was dissected from the around fibrosis; E. Ureter in the single fluorescence pattern, the healthy ureter with green fluorescing; F, ureter in the multi fluorescence pattern."

Figure 3

Intraoperative separation process of ureter of case 2 A, B, C, location of ureter in white light vision; D, E, ureter stricture was identified by fluorescence; F, diseased ureter was incision."

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