Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study.

Abstract

To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded. Design: Prospective case series study. Setting: Tertiary level referral center for endometriosis and minimally invasive gynecology. Patients: Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis. Interventions: After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded. Measurements and Main Results: A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful. Conclusion: NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies.

Indocyanine green in the surgical management of endometriosis: A systematic review

“…Inter‐operator agreement regarding NIR‐ICG evaluation was high, both using WL (Cohen’s kappa coefficient [ κ ] = 0.87, 95% confidence interval [CI] 0.70‐1.0] and NIR‐ICG ( κ = 1.0, 95% CI 1.0‐1.0), respectively. At the 3‐month follow up, all procedures were clinically and radiologically successful 25 …”

“…(B) Risk of bias graph about each risk of bias item presented as percentages across all included studies. (Raimondo 2020 (a): reference 25; Raimondo 2020 (b): reference 18)…”

“…These 17 studies included six video‐articles (8 patients), 19‐22,26,27 one case report (1 patient), 16 one case series (6 patients), 14 two retrospective observational studies (57 patients), 12,24 seven prospective longitudinal studies, 8,11,13,15,18,23,25 one of which randomized 15 within‐subject (196 patients). When insufficient information was reported in the available papers, if necessary, we consulted the authors for further completing data; any disagreement was discussed and resolved by consensus.…”

“…Three studies reported the application of ICG in the case of ureteral involvement and the usefulness of ureteral fluorescence during endometriosis surgery 23‐25 . Mandrova et al 23 used cystoscopic‐guided intraureteral ICG immediately before the laparoscopic pelvic surgery, although only three patients were affected by endometriotic lesions.…”

“…Starting from the same concept, its use has also been reported for the evaluation of ureteral vascularization after ureterolysis for parametrial endometriosis, proving to be more sensitive than WL observation 25 . A better evaluation of the ureteral arterial microcirculation could allow more rational use of the positioning of a “protection” ureteral stent after ureterolysis for DIE 25 .…”