Ziho Lee

Use of Indocyanine Green During Robot-assisted Ureteral Reconstructions

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. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective review of 25 patients who underwent 26 RURs for various ureteral pathologies between June 2012 and October 2013. SURGICAL PROCEDURE 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. MEASUREMENTS Postoperatively, RURs were assessed for clinical success (absence of symptoms attributable to ureteral pathology) and radiological success (absence of a ureteral stricture on imaging). RESULTS AND LIMITATIONS 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. PATIENT SUMMARY 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.

Novel Use of Indocyanine Green for Intraoperative, Real-time Localization of Ureteral Stenosis During Robot-assisted Ureteroureterostomy

OBJECTIVE To present a novel method to intraoperatively localize ureteral strictures during robot-assisted ureteroureterostomy via indocyanine green (ICG) visualization under near-infrared (NIR) light. MATERIALS AND METHODS Seven patients underwent robot-assisted ureteroureterostomy for ureteral stricture by a single surgeon (D.D.E.). Intraoperative localization of ureteral stricture involved instilling ICG (25 mg in 10 mL distilled water) above and below the level of stenosis through a ureteral catheter or a percutaneous nephrostomy tube, or both. The fluorescent tracer was detected as a green color using the NIR modality on the da Vinci Si (Intuitive Surgical, Sunnyvale, CA). All patients consented to off-label use of ICG after full disclosure. RESULTS Intraoperative ICG injection and visualization under NIR light assisted in the performance of a tension-free anastomosis in all patients. At the time of surgery, mean age was 55.7 ± 12.4 years and mean body mass index was 30.3 ± 5.8 kg/m(2). Mean operative time was 171.3 ± 52.4 minutes, mean estimated blood loss was 175.0 ± 146.5 mL, and mean length of ureteral excision on pathologic analysis was 1.6 ± 0.7 cm. There were no immediate or delayed adverse effects attributable to intraureteral ICG administration. Mean hospital length of stay was 1.6 ± 1.5 days, with no postoperative complications. Mean follow-up was 5.9 ± 1.5 months, and all cases were clinically and radiographically successful at last follow-up. CONCLUSION Intraureteral injection of ICG with visualization under NIR light allows for real-time delineation of the ureter. Additionally, ICG administration aids in discerning healthy ureter from diseased tissue, further assisting successful robotic ureteral repair.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery

Prevention of iatrogenic ureteral injuries during robotic gynecologic surgery: a review.

Iatrogenic ureteral injuries, more than half of which occur during gynecologic surgery, may have devastating consequences for both patients and physicians. Gynecologists have employed various techniques such as cystoscopy, ureteral stents, and lighted ureteral stents to prevent ureteral injuries. The emergence and increasing prevalence of robotic surgery necessitates that we not only reevaluate the utility of these techniques, but also develop new ones specific for the robotic modality. In the robotic setting, the surgeon lacks tactile feedback and must rely primarily on visual cues. The use of intraureteral indocyanine green and subsequent visualization under near-infrared fluorescence appears to be a promising technique to primarily and secondarily prevent ureteral injuries during robotic gynecologic surgery.

Stone Formation from Nonabsorbable Clip Migration into the Collecting System after Robot-Assisted Partial Nephrectomy

We describe a case in which a Weck Hem-o-lok clip (Teleflex, Research Triangle Park, USA) migrated into the collecting system and acted as a nidus for stone formation in a patient after robot-assisted partial nephrectomy. The patient presented 2 years postoperatively with left-sided renal colic. Abdominal computed tomography scan showed a 10 millimeter renal calculus in the left middle pole. After using laser lithotripsy to fragment the overlying renal stone, a Weck Hem-o-lok clip was found to be embedded in the collecting system. A laser fiber through a flexible ureteroscope was used to successfully dislodge the clip from the renal parenchyma, and a stone basket was used to extract the clip.

Robotic Ureteral Reconstruction Using Buccal Mucosa Grafts: A Multi-institutional Experience

BACKGROUND Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. OBJECTIVE To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. DESIGN, SETTING, AND PARTICIPANTS This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. SURGICAL PROCEDURE RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. CONCLUSIONS RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. PATIENT SUMMARY We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

A Review of Buccal Mucosa Graft Ureteroplasty

Purpose of ReviewWe review the buccal mucosa graft (BMG) ureteroplasty literature to evaluate its utility in the management of ureteral strictures, identify indications for which it is particularly useful, and highlight refinements in surgical technique.Recent FindingsRecent reports have described the efficacy of robotic BMG ureteroplasty and the utilization of near-infrared fluorescence to assist with precise identification of the ureteral stricture margins.SummaryBMG ureteroplasty is well-suited for ureteral reconstruction as it allows for minimal disruption of the delicate ureteral blood supply and facilitates a tension-free anastomosis. This technique is particularly useful in patients with long ureteral strictures not amenable to ureteroureterostomy and in patients with a recurrent ureteral stricture after a previously failed ureteral reconstruction.

Robotic Appendiceal Interposition With Right Lower Pole Calycostomy, Downward Nephropexy, and Psoas Hitch for the Management of an Iatrogenic Near-complete Ureteral Avulsion

Although iatrogenic ureteral injuries are rare, they have potentially devastating consequences for both patients and physicians, and their management remains challenging. We report a case of a 51-year-old morbidly obese (body mass index = 63) woman who suffered an iatrogenic 15-cm right ureteral avulsion during hysteroscopic biopsy. Preoperative antegrade and retrograde pyelograms demonstrated no true renal pelvis and a 3-cm blind-ending distal ureteral stump. The patient underwent a right robotic downward nephropexy, psoas hitch, lower pole calycostomy, and 11-cm appendiceal interposition. At 6 months postoperatively, renal scan demonstrated stable right renal function with no evidence of obstruction.