Do indocyanine green (ICG) or lighted stents reduce ureteral injuries during laparoscopic surgery?

From the Guidelines

The use of ICG fluorescence imaging is recommended to decrease ureteral injuries during laparoscopic surgery, as it allows for real-time visualization of the ureters and has been shown to be effective in identifying ureters in 98.5% of patients 1.

Key Points

• ICG fluorescence imaging involves injecting the dye directly into the lumen of the ureter, which then fluoresces under near-infrared light, making the ureters more visible against surrounding tissues 1.
• The dosage of intraureteral ICG varies from 5.0 to 12.5 mg, and the procedure involves cystoscopy, ureteral stenting, and injection of ICG into the ureteral orifice before or during surgery 1.
• A recent systematic review on ICG-guided intra-operative identification of ureters in colorectal surgery identified seven retrospective studies published between 2020 and 2022, and collectively, 142 patients who underwent robotic surgery and laparoscopic surgery using ICG were analyzed, with ureters identified in 140 patients (98.5%) 1.
• Intraoperative ureteral injury was reported in one patient who underwent stent placement and ICG injection, and fourteen other adverse events were reported, including left ureteral stenosis requiring double-J stent placement, prostatic bleeding from instrumentation, and twelve transient hematuria 1.

Comparison with Lighted Stents

• Lighted ureteral stents provide illumination from within the ureter, creating a visible landmark during surgery, and should be considered as a valuable strategy for ureteral IUTI prevention and identification in selected, high-risk patients undergoing open and minimally invasive emergency digestive surgery 1.
• However, the current evidence comprises retrospective cohort studies and case series with a limited number of patients and at high risk of bias, particularly in participant selection, and there are no comparative studies of fluorescent agents to conventional methods of ureteral identification or ureteral stenting to date 1.

Recommendations

• ICG fluorescence imaging is recommended for use in laparoscopic surgery to decrease ureteral injuries, particularly in complex pelvic surgeries where the risk of ureteral injury is higher due to distorted anatomy or extensive adhesions 1.
• Lighted ureteral stents should be considered as a useful tool during minimally invasive surgery, particularly in selected, high-risk patients 1.
• These technologies should complement, not replace, thorough knowledge of pelvic anatomy and careful surgical technique.

From the Research

Ureteral Injury Prevention in Laparoscopic Surgery

The use of Indocyanine Green (ICG) and lighted stents has been explored as methods to decrease ureteral injuries in laparoscopic surgery.

• Studies have shown that ICG can be used to visualize ureters in real-time during laparoscopic pelvic surgeries, making it easier to identify and avoid them 2, 3, 4.
• The use of ICG has been found to be safe and effective, with no reported intraoperative or postoperative complications attributed to its administration 2, 3, 4.
• Lighted ureteral stents have also been used to prevent ureteral injuries during laparoscopic colon surgery, with one study reporting no intraoperative ureteral injuries in 402 cases 5.
• The use of ICG and lighted stents can provide real-time visualization of the ureters, allowing surgeons to avoid them and reduce the risk of injury 2, 3, 5, 4.

Comparison of ICG and Lighted Stents

• Both ICG and lighted stents have been shown to be effective in visualizing ureters and preventing injuries during laparoscopic surgery 2, 3, 5, 4.
• ICG has the advantage of being a non-invasive method that can be used in conjunction with near-infrared fluorescence technology to provide real-time visualization of the ureters 2, 3, 4.
• Lighted stents, on the other hand, require the insertion of a catheter into the ureter, but have been shown to be safe and effective in preventing ureteral injuries during laparoscopic colon surgery 5.

Clinical Applications

• The use of ICG and lighted stents has been explored in various laparoscopic procedures, including pelvic surgeries, colon resections, and living-donor nephrectomies 2, 3, 5, 4, 6.
• ICG fluorescence imaging has been found to be a useful tool in providing real-time visualization of blood flow and anatomy during laparoscopic procedures, and may become a standard in the near future 6.