Study question Feasibility of (ICG)-enhanced fluorescence in visualizing the atypical course of the ureter during surgery for (DIE) of pelvic sidewall with a concomitant crossed renal ectopia. Summary answer Near-infrared fluorescence after transurethral injection of ICG enables localization of the ureter during surgery, thus facilitating complete excision of the lesions while enhancing patient’s safety. What is known already Existing case series refer to the transurethral injection of ICG and visualization under near-infrared (NIR) light during robotic surgery for real-time delineation of the ureter, which helps to prevent iatrogenic ureteral injury during complex surgery. The ICG reversibly stains the inside lining of the ureter by binding to proteins on urothelial layer. The consequent green fluorescence allows its identification throughout the entire case. The presented case of a DIE of pelvic side wall along with an ipsilateral concomitant crossed renal ectopia (residual function 27%) resembles an utmost challenge for surgery. To our knowledge no similar case has been reported in literature. Study design, size, duration Demonstration of the Robotic technique by means of a step-by-step tutorial Participants/materials, setting, methods 29-year-old patient referred after preceding laparoscopic surgery for DIE of left pelvic sidewall and abortion of surgery due to lack of accessibility/ severeness of the case. We performed renal scintigraphy, pelvic MRI and urological consultation. Surgery was performed using an XI-da-Vinci robotic system. After cystoscopic placement of mono-Js we injected 4 ml. of ICG-solution (2,5 mg/ml). Visualization of the pelvic kidney was achieved 4 minutes after injection and of the complete ureter after 7–8 Minutes. Main results and the role of chance The robotic surgery could be completed safely and achieve a complete resection of the DIE of the pelvic sidewall including adhesiolysis of a broadly adherent bowel, opening of the rectovaginal space, ureterolysis of the distal portion of the ureter, partial excision of the left sacrouterine ligament and deperitonealization of the pelvic sidewall. Postoperative controle revealed normal renal function and an adequate postoperative course. Limitations, reasons for caution ICG cannot be used in patients with iodine allergy. Wider implications of the findings: Our report underlines the possibility to utilize indocyanine green (ICG)-enhanced fluorescence to localize the ureter during complex surgery for DIE, even in cases with atypical anatomy of the lower urinary tract. Trial registration number Not applicable

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