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Bowel anastomotic leak develops in 5–19% of urinary diversion cases and leads to signicant increases in hospital stays,
healthcare cost, and morbidity and mortality [2, 3, 30]. Like UES,
they are thought to be caused by a variety of factors, one of which
is tissue ischemia [2]. The use of uorescent imaging may allow
for better assessment of the vasculature to ensure healthy bowel
prior to anastomosis, potentially leading to better outcomes. De
Nardi etal. conducted a randomized controlled trial (n=240) to
assess leakage rates between patients who received intraoperative
ICG uorescent imaging, with those evaluated using conventional
methods. While they did nd 5% of the ICG patients (compared
to 9% in the control) developed anastomotic leak, it did not reach
statistical signicance [2]. Interestingly, 11% of the ICG patients
required additional resection due to poor perfusion, and none of
these patients went on to develop anastomotic leak. Another case
series assessed leakage rates using SPY angiography (n= 139)
and found rates to be only 1.4%, again demonstrating that no
patients who required additional resection (8% (n=11)) went on
to develop leaks [30]. While these surgeries focus on the gastrointestinal rather than genitourinary tract, their conclusions can still
be extrapolated for neobladder formation and bowel anastomoses.
Overall, the evidence regarding the clinical benet of SPY angiography for anastomoses is still conicting; however, its use has
minimal side effects, low cost, and no increase in operative time
and can still providing quality assessment of tissue perfusion,
which can be benecial to the surgeon and the patient.
D. Zekan et al.
Prostate Cancer
The utilization of SPY angiography in prostate surgery is still
relatively new. As in urothelial cell carcinoma of the bladder, ICG
dye can be injected directly into the prostatic tissue to visualize
regional nodes requiring resection. One study found that uorescent imaging allowed detection of lymph nodes outside of the
standard region of excision in 18.5% of cases during prostatectomy [31]. Eleven patients were injected preoperatively with
radiotracer-tagged ICG via transrectal ultrasound. In these cases,
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gamma camera images were fused with SPECT/CT to identify
sentinel nodes, and a combination of imaging, laparoscopic
gamma probe, and NIRF was used for node dissection. Fifty-ve
percent of patients had nodes identied on imaging 15minutes
following injection, which increased to 91% after 2h. Of the 27
nodes identied preoperatively, only 1 was unidentiable
intraoperatively using the gamma probe and NIRF, while four
(15%) could not be identied on NIRF alone. This was attributed
to overlying fat, blood, and tissue, which obscured lymph nodes,
as NIRF was reliable in the last millimeter to centimeter in areas
where the radiotracer had weak signal on gamma probe [31].
Although technically complex, ICG and its combination with
radiotracer provide promise in pelvic lymph node identication
and dissection in adenocarcinoma of the prostate.
Another emerging use for prostatic surgery is to identify the
landmark artery for the neurovascular bundle when conducting
nerve-sparing prostatectomies for preservation of erectile function [32]. Visualization of the artery allows surgeons to better
identify and avoid damage to reduce risk of damage and improve
nerve function postoperatively. ICG utilization for landmark
artery identication is still very new, with most publications only
being case reports and proof of concept. However, Mangano etal.
describe use of IV ICG in 26 consecutive patients with visualization of the neurovascular bundle in 100% of patients. No complications related to use of ICG occurred, and in the hands of a single
surgeon, no increased operative time was noted with addition of
ICG [33]. Although no functional outcomes are provided in the
above study, it provides the groundwork for further studies evaluating long-term effects of increased visualization of the NVB
using ICG.Uses of ICG in prostate cancer, and potentially benign
prostate surgeries, abound.
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Lymphatic-Sparing Varicocelectomy
When performing varicocelectomy, be it for pain, subfertility, or
testicular undergrowth, the concept of structural identication and
avoidance of the testicular artery and lymphatics are paramount.
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Such sparing reduces the risk of postoperative hydrocele profoundly, which is known to be an all-too-common complication,
particularly in pediatric patients. Esposito etal. describe use of
intratesticularly injected ICG during laparoscopic Palomo varicocelectomy in 25 patients, with an average age of 13.7years. They
report reliable illumination under NIRF of the lymphatics of the
spermatic cord 20–30s after injection in 100% of patients. Two or
three lymphatics were able to be identied in all patients, allowing for effective sparing. No adverse events related to ICG were
reported, and no patient reported pain related to the testicular
injection site. Importantly, at 18months follow-up, no recurrence
or persistence of varicocele occurred and no hydroceles were
observed. This is in comparison to larger datasets showing a
20–30% postoperative hydrocele rate in allcomers, often requiring repeat surgical intervention [34].
Similarly, Fukui etal. describe a case of IV ICG use intraoperatively (in combination with intratesticular ICG as above) for
identication of the gonadal artery and vein. Specically, they
note illumination of the artery 20–30s following IV injection and
illumination of the vein about 20s following that, allowing efcient division of the artery from the surrounding veins, which
were to be ligated with the addition of very little time to the case
[35]. Obviously, both percutaneous and IV use of ICG present
opportunity for use in urologic cases and the above highlight uses
in both pediatric and adult patients.
D. Zekan et al.
Kidney Transplant
Healthy kidneys available for transplantation are a scarce resource.
Sufcient organ perfusion is a main prognostic factors for proper
allograft function and is vital to ensure proper vessel anastomosis
intraoperatively [8]. Hypoperfusion may not be apparent intraoperatively with only visual inspection. While angiography, duplex
sonography, and renal tissue oxygenation can be used to assess
the quality of anastomosis, they have been found to be more
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expensive, time-consuming, and less practical when compared to
using ICG and SPY [8]. Rother et al. quantitatively compared
SPY uorescent angiography to intrarenal resistance index from
duplex sonography during kidney transplants and found that ICG
serves as a good alternative with a more objective assessment of
microperfusion [36]. They found that a lower intrarenal resistance
index (RI) correlated with a signicantly higher ingress (IN) and
ingress rate (InR) (objective representations of inow of blood to
the organ) on SPY imaging analysis. Interestingly, these ndings
were only signicant for the upper pole of the kidney and not the
lower. However, while IN and InR are objective measurements
from the imaging equipment (derived from the SPY’s analysis of
the tissue), RI depends on the skill of the operator and may vary
based on the surgeon’s experience. They went on to compare histological changes of the kidney, measured by the interstitial brosis and tubular atrophy score (IFTA), to SPY analyses and found
a signicant inverse correlation between IFTA scores and IN and
InR, showing that with decreased blood ow into the kidney, there
was increased histological brosis and atrophy [36]. This study
demonstrates how a quantitative measure derived from SPY angiography and imaging correlates to microvascular changes and is a
cheap and more accessible alternative to past methods. ICG dosing is estimated to cost only $8–80 per patient, depending on how
many doses of ICG can be given per vial [16, 18], and only
requires a few minutes during surgery to capture high-quality,
informative images [4]. Furthermore, given the anatomy of kidney vasculature and the supercial distribution of renal arteries,
the 10–20mm visualization depth given by ICG and SPY is sufcient to view most microvascular hypoperfusion [4]. SPY imaging provides the surgeon with a real-time qualitative assessment
of potential occlusion or problems with the graft while also providing computational analysis to further assess tissue quantitatively [37]. Overall, the utilization of SPY during kidney
transplants allows for quick and easy subjective and objective
measurement of kidney vasculature to assess intraoperative success of the transplantation.
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D. Zekan et al.
Technical Considerations
Ureteral Identication
Efcient ureteral identication is crucial not only in urologic procedures involving its reimplantation or ligation but also in colorectal and gynecologic cases, in which identication can help prevent
iatrogenic ureteral injury. Currently, placement of open-ended
ureteral catheters, double-J ureteral stents, and lighted ureteral
stents is common practice for ureteral identication. However,
these methods often only facilitate identication, as opposed to
prevention, of ureteral injuries, particularly in laparoscopic/
robotic cases in which tactile sensation is limited. Current practices involve creating a solution of 10–25mg ICG in sterile water
and injecting 10 cc of this solution through a 6 Fr open-ended
ureteral catheter advanced 3–5cm into the ureteral orice cystoscopically. Should signicant resistance be met or immediate
efux of the injected ICG be appreciated, we recommend obtaining retrograde pyelogram through the same open-ended catheter.
If no signicant ureteral stricture is visualized on retrograde
pyelogram, a sensor wire can be used to facilitate advancement of
the open-ended catheter to the level of the renal pelvis. ICG injection can be performed as a slow infusion over 5min, or as a bolus.
Maximal uorescence can be expected between 9 and 20min following injection and is known to persist for up to 3 h postinjection. It is likely that uorescence continues beyond this time,
but our experience in this area is limited. Maintaining the openended ureteral catheter after injection is not necessary but can further facilitate ureteral identication by direct palpation. Should
this be performed, we recommend placement of the ureteral catheter into an Edelman urethral catheter [9] (Fig.15.1).
Ureteral Reconstruction
Ureteral reimplantation, although used for a large variety of
pathologies within urology, has a common dreaded complication:
anastomotic stricture. Distal ureteral ischemia, generally caused
by compromising blood supply during skeletonization, is a con-
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tributing factor to anastomotic stricture. This is further complicated by a history of pelvic radiation in many instances as the
etiology of distal stricture. Distal ureteral ischemia is also of concern in the creation of urinary diversions in any context (oncologic or otherwise) as distal ureteral dissection is essentially
always performed to allow adequate ureteral length for diversion
anastomosis. The use of laparoscopic/robotic technology in
ureteral reimplantation is another complicating factor, as a “no
touch technique” and meticulous tissue handling is more difcult
without delicate tactile feedback. Thus, use of ICG in assessment
of distal ureteral viability is becoming increasingly accepted and
utilized in assessment of perfusion following skeletonization and
ligation. To assess this, following distal ureteral dissection and
ligation, 3mL of ICG is injected intravenously followed by 10cc
saline with use of color-segmented uorescence mode to provide
a “heat map” view of the distal ureter. This can be repeated following anastomosis to ensure adequate perfusion. Should there be
concern for distal ureteral ischemia on heat map, we recommend
marking the distal most area of adequate ureteral perfusion with a
stitch and performing proximal ligation of the ureter [1].
Intraluminal injection of ICG in the setting of benign ureteral
strictures has also been reported for visualization of the extent of
ureteral stricture when performing ureteroureterostomy. In this
setting, 10 mL of 2.5 mg/mL ICG is injected via a 6 Fr openended ureteral catheter above and below the level of ureteral stenosis, unless the patient also has nephrostomy tube, in which case
5mL is injected antegrade and 5mL retrograde. The ureteral catheter is then clamped. This allows for visualization of the healthy
ureteral segments under NIRF vision with a robotic or laparoscopic camera, as these segments will uoresce under NIRF, prior
to transection [12].
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Partial Nephrectomy
The widely accepted gold standard for identication of tumor during robotic-assisted laparoscopic partial nephrectomy is intraoperative ultrasound. However, use of ICG for tumor identication
has been described. One advantage in this context is that ICG also
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D. Zekan et al.
allows for assessment of renal artery anatomy and facilitates
selective clamping should anatomy be conducive. In this context,
we recommend injection of 5–7.5mg of ICG following proximalto- distal hilar dissection with use of topical papaverine if vasospasm is encountered and clamping the vessel likely supplying
the tumor with a bulldog clamp. ICG injection allows for
visualization of ow in both the main renal artery and vein as well
as the tumor and adjacent parenchyma. After ensuring the area of
planned resection (the tumor and surrounding normal parenchyma) is hypoperfused, it is safe to proceed with resection.
Should persistent perfusion of the tumor and surrounding parenchyma be encountered, we recommend clamping of the main
renal artery. In both cases, re-bolusing of the above dose of ICG is
recommended following resection and removal of the bulldog
clamp to ensure adequate reperfusion of the remaining parenchyma [38] (Fig.15.4).
Similar dosing should be used in tumor differentiation using
ICG.In this context, the kidney should be defatted and the tumor
margin scored using electrocautery under ultrasound guidance.
Two doses of ICG are often used in this context. One test dose
should be given immediately when the tumor and a small amount
of surrounding parenchyma are identied to anticipate the amount
that should be given during tumor resection. This dose is typically
1.25mg but can be as small as 0.625mg in smaller patients. After
administration of ICG, the tumor should not uoresce, while normal parenchyma should have adequate ICG uptake and uoresce
Fig. 15.4 ICG-guided selective clamping during robotic-assisted laparoscopic partial nephrectomy [13]
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under NIRF.Following administration and prior to clamping, the
scored area should be conrmed adequate or rescoring performed
if the tumor margins (areas of hypouorescence) protrude beyond
the area marked under ultrasound guidance. Alternating between
the NIRF camera and white light camera at the deep margin can
be helpful in conrming resection of all gross tumor present. The
entire resection bed should be “green” under near-infrared camera, and any area that appears to be hypoperfused should be
resected [17] (Fig.15.5).
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Urothelial Carcinoma andUrinary Diversion
As highlighted previously, distal ureteral viability will determine
the fate of a urinary diversion, regardless of whether or not it
involves a bowel segment, and can be the difference between
long-term indwelling diversions stents secondary to anastomotic
stricture and a naturally patent anastomosis. It is also crucial in
the avoidance of another more acute and often more complicated
issue: anastomotic breakdown and urine leak. However, another
potential cause of reoperation that is often overlooked by urologists is bowel viability, whether used for an ileal conduit, Indiana
pouch, or neobladder. Bowel ischemia in these cases can also
cause breakdown and lead to urine/bowel leak and stomal stenosis. Thus, it is crucial to prove viability following division of the
mesentery prior to ureteral anastomosis. In urothelial cell carcinoma, ICG is not only valuable in avoidance of surgical complications but also tumor identication and sentinel node dissection.
Tumor identication is performed cystoscopically, with injection of 2mL of 2.5mg/mL ICG solution through an 18 Fr cystoscopic injection needle. This solution should target supercial
detrusor and submucosa, to minimize risk of perforation and
tumor spillage. Foley catheter placement is recommended following injection to facilitate decompressor and minimize possible
bladder injury while gaining access endoscopically. The recommendation is then to perform examination of the surgical eld
every 5min with a NIRF camera to document sentinel node drainage and to ensure adequate nodal dissection. The area occupied by
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D. Zekan et al.
Fig. 15.5 ICG-guided renal mass resection during robotic-assisted laparoscopic partial nephrectomy with hypouorescence of mass and normal perfusion of renal parenchyma [13]
bladder tumor is typically identiable in 15min (Fig.15.6), while
sentinel nodes generally take 30min to illuminate under NIRF
(Fig.15.7). However, complete node dissection using a traditional
template should not be omitted [21].
ab
cd
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Fig. 15.6 Robotic view after immediate docking of robot following interstitial cystoscopic injection of tumor margins with ICG [21]
Fig. 15.7 Right common iliac lymph node packet in the setting of muscleinvasive bladder cancer following interstitial injection of tumor margins cystoscopically prior to robotic-assisted laparoscopic radical cystectomy with
pelvic lymph node dissection [21]
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Mesenteric angiography can be performed similarly by intravenous injection of 2mL of 2.5mg/mL ICG.Mesenteric arteries
should transilluminate under NIRF within 30s, assisting in harvest of a well-vascularized segment for conduit or other urinary
diversions. Similar angiography can be repeated following stapling of the bowel to assess the viability of the proximal and distal
ends of the conduit as well as the bowel anastomosis [21]
(Figs. 15.8 and 15.9). Distal ureteral evaluation is also well
dened and should be performed prior to spatulation and anastomosis, but after transfer of the left ureter to the right side through
a retro-mesenteric window. A similar concentration to the above
is recommended, but 10 mL given intravenously is the recom-
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