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Fig. 15.8 Mesenteric angiography during creation of ileal conduit with ICG using NIRF to ensure preservation of mesenteric arcades (blood supply to conduit and anastomotic site) [21]
D. Zekan et al.
Fig. 15.9 NIRF-guided assessment of ileal segment used for conduit follow­ing ICG injection during robotic-assisted laparoscopic radical cystectomy with ileal conduit [13]
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Fig. 15.10 Assessment of distal ureteral viability/vascularity during robotic­assisted laparoscopic radical cystectomy [13]
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mended dose. To assess both the arterial and perfusion phases of the ICG, assessment of the distal ureters at 30s and~5min is recommended using NIRF.In segments that do not demonstrate good arterial angiography, proximal transection is recommended prior to uretero-enteric anastomosis to minimize the risk of stric­ture [29] (Fig.15.10).
Prostate Cancer
Although cancer control is of upmost importance when perform­ing radical prostatectomy, conservation of erectile function generally remains a high priority. This cannot be overlooked by surgeons, and novel techniques for preservation of erectile func­tion must be explored. Injection of 1.25mL ICG following inci­sion of the bladder neck and dissection of the seminal vesicles allows for optimal visualization and sparing of the “benchmark artery,” which should theoretically lead to a more optimal nerve spare by improving hemostasis and visualization of the neurovas­cular bundle (NVB). Importantly, use of ICG for NVB identica­tion has been not been shown to lengthen operative times and or lead to any identiable complication in a series of 26 patients, eliminating possible drawbacks of its use [33].
Techniques for use of ICG in sentinel pelvic lymph node dis­section abound. This is of particular importance for patients with unfavorable intermediate- or high-risk prostate cancer, in whom pelvic lymph node dissection is universally recommended at the
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time of RALP.Various protocols have been shown to increase the yield of positive nodes. Van der Poel etal. describe use of ICG noncovalently bound to
99m
Tc-nanocolloid, a commonly used
radioactive tracer, to create a hybrid radioactive and uorescent
99m
tracer.
Tc-Nanocoll is generated by mixing 1mL pertechnetate in saline to a vial containing Nanocoll (albumin colloidal parti­cles) and allowing for 30minutes of incubation. 1mL of this solu­tion is mixed with 0.050mL (0.250mg) ICG (solution of 25mg solid ICG in 5mL sterile water). 0.4mL of this solution is injected to the peripheral zone of the prostate 3 h preoperatively under transrectal ultrasound guidance and ushed with 0.7mL saline. A portable gamma camera is used to conrm adequate concentration within the prostate, and gamma camera images are further obtained at 15 min and 2 h post-injection. SPECT/CT is per­formed at 2h and fusion of images is performed. This allows for dissection in accord with imaging using a laparoscopic gamma probe combined with high-denition laparoscopic uorescence imaging [31]. Filters allowing for this imaging in the context of a white light background for anatomic delineation provide an effec­tive measure to optimize and ensure adequate lymph node dissec­tion. Effectively, use of
99m
Tc-nanocolloid offers the ability to both use lymphoscintigraphy and single-SPECT/CT imaging for preoperative nodal mapping (Fig.15.11). In the absence of
99m
Tc­nanocolloid, ICG can be used alone, with 5mg injected transperi­neally in the preoperative setting (Fig.15.12).
Lymphatic-Sparing Varicocelectomy
Laparoscopic repair of varicocele, particularly in pediatric patients, is an important treatment modality used to address both testicular hypotrophy and symptomatic varicoceles. A commonly used and efcacious route for repair of varicoceles is the Palomo technique, which boasts a success rate of >95%. However, a com­mon complication is postoperative hydrocele, which occurs in 20–30% of patients. Lymphatic-sparing surgery is known to reduce the rate of hydrocele and have better andrological out­comes, increasing its use among surgeons. Technically, this
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Fig. 15.11 Intraoperative sentinel lymph node detection during robotic­assisted laparoscopic prostatectomy following intraprostatic injection of ICG preoperatively using transrectal ultrasound guidance. (I) Using NIRF­laparoscopic D-light angiouorescence system and (II) using da Vinci TilePro system [31]
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involves diluting a vial of ICG (5mg/dL) with 10cc sterile water and injection of 2cc of this solution into the body of the ipsilateral testicle with a 23G needle. This provides almost immediate visu­alization of lymphatic vessels in near-infrared mode on a laparo­scopic camera and green appearance of lymphatics under standard white light mode, allowing for efcient identication and ligation of the spermatic bundle and sparing of lymphatics [34].
Similarly, a combination of both intravenous and subcutaneous injection of ICG for visualization of the spermatic vessels has been described to ensure laparoscopic ligation of only the sper-
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Fig. 15.12 NIRF-guided lymphadenectomy following intraprostatic of ICG during radical prostatectomy [13]
matic veins. To perform this, ICG is dissolved in sterile water at
2.5 mg/mL. 1 mL of this solution is injected intravenously for each desired angiography. The gonadal arterial ow can be visual­ized about 20–30s following a shot, and 20s following that, the gonadal vein is observed. At this concentration and volume, mul-
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tiple angiographies can be performed during dissection with tog­gling between white light and near-infrared uorescence to optimize dissection visualization. Lymphatic drainage can be effectively visualized by injection of 1mL of solution subcutane­ously in the desired hemiscrotum prior to cut and another 1mL about 10min prior to desired visualization to allow for reliable visualization [35].
Conclusion
Herein, we describe use of near-infrared technology in urologic surgery, oncologic and otherwise. Its use in both assessment of ureteral location and viability is crucial for pelvic surgeons and provides a method of limiting ureteral ischemia and minimizing risk of anastomotic strictures in urologic reconstruction. In partial nephrectomy, uorescence guidance is helpful in identifying hilar vasculature and tumor margins and ensuring tumor and parenchy­mal ischemia following clamping prior to resection. Direct injec­tion of ICG is imperative in lymph node dissections for nodal identication in urothelial carcinoma and prostatic adenocarci­noma. It is also being used for identication of the neurovascular bundle in nerve-sparing radical prostatectomy. Similarly, ICG can be used for lymphatic-sparing in varicocelectomy to limit the risk of hydrocele postoperatively. The uses of ICG in urologic surgery abound and will only continue to enhance surgical technique and further minimize risk of intra- and postoperative complications.
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Use ofFluorescence
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Guidance inGynecology
LioudmilaLipetskaia, BarbaraDianeGillis, andCourtneyGriths
Introduction
Gynecological surgery in the United States comprises about 25% of inpatient surgical procedures for women over the last 20years, with 64% classied as solely obstetric, 29% as solely gyneco­logic, and 7% as both [1]. Up to one third of all women in the United States undergo hysterectomy by age 60 [2]. This massive surgical eld is also growing with the increased incidence of gynecologic cancer, specically endometrial cancer whose rates have steadily risen since the 1990s [3]. Endometrial cancer is closely linked with obesity, with approximately 57% of endome-
L. Lipetskaia (*) Division of Urogynecology, Department of Obstetrics and Gynecology, Cooper Medical School for Rowan University, Camden, NJ, USA e-mail: lipetskaia-lioudmila@cooperhealth.edu
B. D. Gillis West Virginia University School of Medicine, Morgantown, WV, USA e-mail: bdg0001@mix.wvu.edu
C. Grifths Division of Gynecology Oncology, Cooper Medical School for Rowan University, Camden, NJ, USA e-mail: grifths-courtney@cooperhealth.edu
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© 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_16
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