Use of indocyanine green to minimise uretero‐enteric strictures after robotic radical cystectomy

Abstract

Objective To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero‐enteric stricture formation after robot‐assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). Patients and methods We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non‐ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90‐day complications and readmissions), and the rate of uretero‐enteric stricture were compared between the two groups. The two groups were compared using the t‐test for continuous variables and the chi‐squared test for categorical variables. A P < 0.05 was considered statistically significant. Results A total of 132 and 47 patients were in the non‐ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero‐enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow‐up was 14 and 12 months in the non‐ICG and ICG groups, respectively. The ICG group was associated with no uretero‐enteric strictures compared to a per‐patient stricture rate of 10.6% and a per‐ureter stricture rate of 6.6% in the non‐ICG group (P = 0.020 and P = 0.013, respectively). Conclusion The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero‐enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow‐up are needed to confirm our findings.

Modified Wallace anastomotic technique reduces ureteroenteric stricture rates after ileal conduit urinary diversion

“…The long-term incidence of UAS after ileal conduit diversion ranges widely, between 2-22% (14)(15)(16)(17). While the exact mechanisms of benign stricture formation are not known, it is thought to be predominantly due to ischaemia and subsequent scarring at the anastomosis (18). Although poor surgical technique and extensive ureteral mobilization could be major risk factors for UAS, it is evident that other factors may jeopardize the blood supply to the distal tract of the ureter, increasing the risk of stricture (3).…”

Robot-assisted radical cystectomy: state of art and future perspectives

“…Moreover, the role of ICG technique to easily recognize tissue vascular perfusion was used to prevent ischemic ureteral complications, such as strictures. Ahmadi et al [34] reported a significant reduction in the per-patient rate of uretero-enteric anastomotic stricture from 10, 6% to 0% (p = 0.020).…”

Editorial Comment

“…Robotic cystectomy improves perioperative outcomes while maintaining cancer control. [1][2][3] Currently, most of the controversy comes from deciding on the urinary diversion and reconstructive technique after RARC: extracorporeal urinary diversion (ECUD) vs intracorporeal urinary diversion (ICUD). 4 More recently, studies have compared the incidence of long-term complications between ORC and RARC, with a special attention to the development of benign ureteroenteric stricture (UES).…”

“…1 As the early learning period for RARC may be more susceptible to stricture complications, the current study highlights the need to maintain established surgical principles to optimize a well-perfused ureteral anastomosis irrespective of the approach. The impact of diversion technique and effect of adjunctive tools such as fluorescence imaging 2 to help minimize ischemia should continue to be prospectively evaluated.…”