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14 Use ofFluorescence Guidance inCardiothoracic Surgery
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33. Hills KD, Smith PK, Bittl JL, et al. 2100 ACCF/AHA Guidelines for
coronary artery bypass graft surgery. A report of the American College of
Cardiology Foundation/American Heart Association task force on practice guidelines. Developed in collaboration with the American Association
for Thoracic Surgery. Society of Cardiovascular Anesthesiologist, and
Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58(24):e123–
210.
34. Kogon B, Fernandez J, Kanter K, et al. The role of intraoperative
Indocyanine green uorescence angiography in pediatric surgery. Ann
Thorac Surg. 2009;88:632–6.
35. Feins EN, Si MS, Baird CW, Emani SM.Intraoperative coronary artery
imaging for planning. Semin Thorac Cardiovasc Surg Pediatr Card Surg
Annu. 2021;23(C):11–6.
36. Muehrcke DD, Shimp W, Casillas M.Intraoperative angiogrphy to nd
an intramyocardial artery. Clin Surg. 2021;6:3025.
433
Bibliography
PREVENT IV Investigators. Efcacy and safety of edifoligide, an E2F tran-
scription factor decoy, for prevention of vein graft failure following coronary artery bypass graft surgery—PREVENT IV: a randomized controlled
trial. JAMA. 2005;294:2446–54.
Taggart DP.Biochemical assessment of myocardial injury after cardiac sur-
gery: effects of a platelet activating factor antagonist, bilateral internal
thoracic artery grafts, and coronary endarterectomy. J Thorac Cardiovasc
Surg. 2000;120:651–9.
Yusuf S, Zucker D, Peduzzi P, etal. Effect of coronary artery bypass graft
surgery on survival: overview of 10-year results from randomized trials by
the coronary artery bypass graft surgery trialists collaboration. Lancet.
1994;344:563.
Lytle B, Blackstone E, Loop F, etal. Two internal thoracic artery grafts are
better than one. J Thorac Cardiovasc Surg. 1999;117:855.
Taggart DP, D’Amico R, Altman DG.Effect of arterial revascularization on
survival: a systematic review of students comparing bilateral and single
internal mammary arteries. Lancet. 2001;358:870–5.
Lytle BW, Loop FD, Taylor PC, etal. Vein graft disease: the clinical impact
of stenosis in saphenous vein bypass grafts to coronary arteries. J Thorac
Cardiovasc Surg. 1992;103(5):831–40. [PubMed: 1569763].
Halabi AR, Alexander JH, Shaw LK, etal. Relation of early saphenous vein
graft failure to outcomes following coronary artery bypass surgery. Am J
Cardiol. 2005;96:1254–9.
Use ofFluorescence Guidance
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inUrologic Surgery
DavidZekan, AndrewWilliams,
AmrElbakry, andAdamLuchey
Introduction
Anastomoses are a vital part of urologic surgery cases, used for
urinary diversions, ureteral reimplantation, and other upper and
lower urinary tract reconstruction. However, a considerable complication that can arise is anastomotic leak and stricture. While
many factors have been implicated, a major cause of anastomotic
leak and strictures is poor blood ow leading to tissue ischemia
[1, 2]. The quality of organ perfusion is often only assessed by the
surgeon’s impression, taking into account the active bleeding
margin, palpable pulsation, and lack of discoloration [3, 4], which,
unfortunately, have low predictive value for risk of anastomotic
leakage [5]. Recent advancements have led to a promising alternative: SPY uorescence imaging. SPY-ELITE and its portable
handheld model SPY-PHI are uorescent imaging machines that
are able to better assess blood ow in vessels and tissue when
15
D. Zekan (*) · A. Elbakry · A. Luchey
West Virginia University Department of Urology,
Morgantown, WV, USA
e-mail: dszekan@hsc.wvu.edu
A. Williams
West Virginia University School of Medicine, Morgantown, WV, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
N. Szoka et al. (eds.), The SAGES Manual of Fluorescence-Guided
Surgery, https://doi.org/10.1007/978-3-031-40685-0_15
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used with near-infrared uorescent dyes [1]. Such assessment of
perfusion is widely applicable in urologic surgery, expanding uses
far beyond just anastomotic analysis. The most commonly used
immunouorescent dye is indocyanine green (ICG), most commonly given intravenously (IV) and active for only 150–180 s
before being excreted into the bile [6]. The IV dose of ICG has
very low rates of adverse side effects with only 0.05% of patients
having mild allergic reactions [7]. With the use of ICG and SPY,
the recommended dose is 0.02mg/kg body weight, but this can
vary based on intended use as outlined below [8]. ICG is water
soluble and binds almost exclusively to plasma proteins concentrating the uorescence mostly to vasculature [4]. The uorophore
operates within the near-infrared spectrum, absorbing light in the
805nm wavelength and emitting at 835nm [4]. Most human tissue is relatively transparent at these wavelengths allowing for
visualization depth of 10–20mm, which is generally sufcient for
use in urologic surgery [4]. The various camera recording options
available on the SPY systems allow for detection of even small
perfusion decits within tissues and anastomoses while offering
beautifully crisp images of the organs [4]. When ICG rst became
available, it was described as a “hammer looking for a nail,” and
its intended function was well-established in its ability to nd and
display perfusion; however, its clinical benet and overall practicality were still underreported [6]. Recently, ICG and SPY technologies have been utilized in urologic surgery in an attempt to
improve patient outcomes and streamline surgeries [6]. Here, we
outline the various uses of ICG and SPY technologies in urologic
cases and specic methods for replicability.
D. Zekan et al.
Ureteral Identication
Although a majority of its uses are intravenous, ICG injected retrograde into the ureters also provides promise for ureteral identication. This is crucial when working in conjunction with
colorectal and gynecologic surgery, who traditionally rely on ureteral stent placement for ureteral identication and prevention of
iatrogenic ureteral injuries. However, stenting vs. no stenting
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shows no difference in prevention of ureteral injury but aids in
identication of an injury after it occurs. These injuries are
increasing in incidence with use of laparoscopic and robotic technology to aid in pelvic surgeries [9]. Bilateral ureters are known
to uoresce green when injected intraluminally with methylene
blue. However, studies vary with respect to reliability of uorescence, reporting 50–91% visualization when viewed under NIRF
(near-infrared uorescence). The use of intraluminal ICG as
described below (with injection through an open-ended ureteral
catheter, nephrostomy tube, or both) boasts a 100% success rate
for ureteral visualization in both colorectal and gynecologic surgery [9].
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Ureteral Reconstruction
The use of ICG in upper tract reconstruction comes in two forms:
intraluminal use of ICG to visualize ureters and areas of stricture
and IV use to determine ureteral viability prior to reconstruction.
Bjurlin etal. describe its IV use in robotic pyeloplasties, ureteral
reimplants, ureterolysis, and ureteroureterostomies (UU) per the
protocol outlined below. In all cases described (42in total), they
boast an overall 95.2% success rate with a 100% symptomatic
(ank pain) and radiographic (hydroureteronephrosis) success
rate in included cases aside from ureterolysis (71.4%), which is
known to be less efcacious at baseline. Clavien grade 1–3 complications occurred in 14.3% of patients, including transient lower
extremity weakness (one patient), enterotomy requiring small
bowel resection (one patient), ureteral stone requiring nephrostomy tube (one patient), postoperative bleed requiring surgical
exploration (one patient), and ureteral stent migration requiring
repositioning (two patients) [10] (Fig.15.1).
Lee et al. describe use of intraluminal ICG in UUs treating
short ureteral strictures robotically in the hands of a single surgeon. Intraluminal injection was performed as described below,
with injection above and below the level of stricture using a ureteral catheter, nephrostomy tube, or combination of the two. In a
case series including seven patients with short mid-ureteral stric-
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Fig. 15.1 Intraluminal
injection of ICG for
ureteral identication
under NIRF [11]
Fig. 15.2 Use of NIRF with IV ICG to differentiate diseased (ischemic) ureteral segment from healthy ureteral segment during robotic ureteral reimplantation for benign uretero-anastomotic stricture [13]
D. Zekan et al.
tures, they demonstrate the ability to delineate disease from
healthy ureteral segments in all patients, with mean excision
length of 1.6±0.7cm. A single patient with dense peri-hepatic
adhesions experienced gallbladder laceration at the time of surgery, requiring robotic cholecystectomy, with no attributable
complications to ICG administration. At follow-up (mean
5.9 ± 1.5 months), no patient had clinical or radiographic evidence of continued stricture [12]. Thus, both IV (Fig.15.2) and
intraluminal (Fig.15.3) use of ICG during benign ureteral reconstruction is feasible, and its addition to the case presents minimal,
if any, risk to the patient. Needed are long-term studies comparing
outcomes (persistence and recurrence of stricture) between open,
laparoscopic, and robotic techniques for benign reconstruction
with and without the use of ICG.
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439
Fig. 15.3 Use of NIRF
to differentiate diseased
from healthy ureter
during UU [12]
a
b
c
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D. Zekan et al.
Partial Nephrectomy
The use of ICG and SPY angiography for upper tract pathology
extends beyond just pyeloplasties and UUs, also aiding in partial
nephrectomies. Partial nephrectomy offers superior functional
outcomes compared to radical nephrectomy in small renal masses
[14]. To minimize ischemia to healthy tissue, SPY angiography
can be used to properly identify hilar vessels and tumor-specic
vasculature to be clamped before resection [15]. Furthermore,
tumors are often well demarcated on the SPY imaging, appearing
hypouorescent compared to surrounding parenchyma [15]. The
use of ICG dye allows for better localization of malignant tissue
for more precise resections [16]. Mitsui etal. utilized ICG dye
and uorescent imaging to visualize the tumor margins during
surgery and validated these margins ex vivo. They found that
even in complex cases, ICG allowed for easy discrimination
between normal and cancerous tissues [16]. Their case series
demonstrates 100% exvivo differentiation within 60min of ICG
injection in 16 cases, with 14 of 16 tumors showing hypouorescence invivo. The remaining two were endophytic with overlying normal parenchyma. High and low uorescence were both
used to rule out residual tumor, which was conrmed on pathologic specimens [16]. Similarly, Angell etal. describe the ability
to achieve differential uorescence between renal tumors and
surrounding normal parenchyma with a test dose of ICG and then
re-dose at the time of tumor resection. Differential uorescence
was achieved in 65 of 70 tumors (82%), excluding tumors that
could not be visualized as they were completely endophytic [17].
While the difference in tissue uorescence between tumors and
normal kidney parenchyma is easily discernable, tissue uorescence of the tumor itself cannot adequately determine malignant
and benign masses [18].
The use of uorescent imaging also allows for better postoperative renal function when compared to conventional methods
[14, 19]. Borofsky etal. utilized ICG dye to visualize renal vasculature during partial nephrectomy allowing them to more specically cross-clamp distal vessels feeding the tumor (“zero
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ischemia” partial nephrectomy), rather than conventional crossclamping of the main renal artery [14]. They demonstrated successful selective clamping in 27 of 34 patients (79.4%). While this
method did lead to increased operating time, it also led to signicantly better postoperative kidney function with a reduction in
glomerular ltration rate (GFR) of only 1.8% compared to 14.9%
reduction in the renal artery cross-clamp at a mean follow-up of
about 13days [14]. Shao et al. found similar signicant results
with 3-month postoperative GFR decrease of 16.7% in multiple
feeder clamping compared to 26.2% decrease in GFR for renal
artery clamping [19]. Fluorescent imaging also allows the surgeon to conrm that the tumor vasculature has been restricted following arterial clamping by assessing the change in parameters
produced with SPY imaging analysis (quantitatively) and the
visual uorescence of the tissue [14]. When all the feeders to the
tumor are properly cross-clamped, the tumor and surrounding
parenchyma should hypouoresce. Overall, uorescent imaging
of renal vasculature during partial nephrectomies allows for a
more directed approach for tumor resection, leading to less overall damage to normal kidney parenchyma and better patient outcomes.
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Urothelial Carcinoma andUrinary Diversion
Fluorescent imaging has two main potential uses in urothelial carcinoma of the bladder: the rst is to map out regional lymph nodes
associated with resected masses and the other is to ensure wellvascularized anastomoses, viable bowel, and identication of
stricture should they occur at the anastomotic site.
Standard treatment for muscle-invasive bladder cancer
remains radical cystectomy with pelvic lymph node dissection
(PLND) [20]. SPY angiography may allow for quicker and
more easy identication of SLN.ICG can be administered IV
to visualize vasculature, but it can also be injected into the submucosa and smooth muscle to be taken up into the lymphatics
[21]. This technique allows for easy identication of sentinel
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D. Zekan et al.
lymph nodes, which require resection in all cystectomies performed for malignancy [22].
Manny etal. describe the use of submucosal and detrusor ICG
injected circumferentially with a cystoscope in 10 patients undergoing robotic radical cystectomy. Intraoperative identication of
tumor was possible in 90% of patients using NIRF, only not
achieved in a single patient noted to have circumferential bladder
wall thickening, with bladder wall measuring >2cm in thickness.
Sentinel lymph node drainage was also identied in 90% of
patients, all of whom had multiple areas of drainage, with bilateral sentinel drainage in eight of nine patients. Importantly, of the
three patients with node positive disease on nal pathology, nodal
uorescence was 100% sensitive, but only 47% specic for identication of node positivity [21]. While this technique does allow
for a quick and simple understanding of tissue, its use for extended
lymph node dissections may be less dependable [23]. The main
constraint of ICG in identifying lymph nodes is its ability to ow
easily through the lymphatic vessels. One potential problem with
high tumor burden is that vessels may become obstructed by metastatic disease, leading to areas of hypo-uorescence where
metastases are present [23]. The sensitivity for ICG and uorescent dye’s use in SNL dissection ranges widely from 44% to
100% depending on the study and for that reason should not be
used alone for identication and resection lymph nodes [23–25].
Overall, uorescent imaging of tissue lymphatics is an emerging
eld, and as more advancements in technology and surgical technique arise, its practicality and utility will become more apparent.
As often used intraoperatively by general surgeons, IV ICG
can be utilized to visualize mesenteric vasculature in both the
laparoscopic and open setting when performing urinary diversion,
be it in the form of a neobladder, ileal conduit, or otherwise. The
above group who utilized submucosa ICG for sentinel node identication also describes use of IV ICG for identication of mesenteric arcades when performing robotic intracorporeal diversion.
Real-time visualization of vasculature guides stapling of the
bowel and mesentery, and in 100% of cases (eight total), no complications related to diversion ischemia were observed, including
anastomotic stricture and stomal stenosis [21].
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443
Another advancing use of SPY imaging is allowing for better
visualization and quantitative assessment of vasculature in anastomoses. For instance, ureteroenteric strictures (UES) are a common consequence of radical cystectomies and any surgery
involving ureteral diversions [1]. Various surgical techniques have
been developed to reduce stricture, but few have led to any
substantial risk reduction, maintaining a complication rate of
approximately 9% [1, 26, 27]. Ischemia is thought to be a major
contributing factor to the development of UES.Thus, it was theorized that by assessing distal perfusion at each on the anastomoses
using SPY angiography, fewer strictures may occur [1]. Shen
et al. compared UES rates before (47 patients) and after (47
patients) implementing SPY into their practice for radical cystectomies. The stricture rate for patients prior to SPY implementation was 7.5%, diagnosed with either hydronephrosis, lack of
reux on loopogram, or Lasix renal scan showing t
1/2
>20min.
After implementation of SPY and ICG, 0% of cases developed
UES over a 12-month period. Through the use of SPY’s vasculature analysis, their team identied poor distal perfusion in 34.4%
of ureters requiring a more proximal anastomosis; however, use of
SPY did not lead to a signicantly more proximal anastomosis
[1]. Doshi etal. conducted a similar study assessing rates of stricture in patients with or without the use of SPY imaging (n= 31
and 30, respectively). They found that only 3.2% of patients
(n=1) developed stricture when uorescent imaging was used,
compared to 13% (n = 5) with conventional methods [28].
Robotic-specic data is provided by Ahmadi etal., who analyzed
179 patients who underwent robotic-assisted laparoscopic radical
cystectomy with intracorporeal diversion. When comparing the
132 patients in the non-ICG group to the 47in the ICG group,
those in the ICG group were likely to have more ureter excised
based on concern for ischemia and were more likely to have long
segment (>5cm) ureteral excision. However, at 14 and 12months
average follow-up, respectively, no UESs were noted in the ICG
group, compared to a per-patient stricture rate of 10.6% and perureter stricture rate of 6.6% in the non-ICG group [29]. This practice for assessing ureteral anastomoses can also be applied when
creating a neobladder to prevent anastomotic leak.
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