Near-infrared fluorescence imaging: emerging applications in robotic upper urinary tract surgery

Abstract

Background: Near-infrared fluorescence (NIRF) imaging is a technology with emerging applications in urologic surgery.

Objective: To describe surgical techniques and provide clinical outcomes for robotic partial nephrectomy (RPN) with selective clamping and robotic upper urinary tract reconstruction featuring novel applications of NIRF imaging.

Design, setting, and participants: Data from 90 patients who underwent successful RPN with selective clamping or upper urinary tract reconstruction utilizing NIRF imaging between April 2011 and October 2012 were reviewed.

Surgical procedure: We performed RPN utilizing NIRF imaging to aid with selective clamping and upper tract reconstruction with NIRF imaging, the details of which are outlined in this paper and the accompanying video.

Outcome measurements and statistical analysis: Patient characteristics, perioperative outcomes, and complications were analyzed.

Results and limitations: Of the 48 RPN patients for whom selective clamping was attempted successfully, median estimated blood loss was 200.0 ml, warm ischemia time was 17.0 min, and median change in estimated glomerular filtration rate was -6.3%. There was a 12.5% complication rate, and all complications were Clavien grade 1-3 (14.3%). The upper urinary tract reconstruction utilizing NIRF imaging was performed in 42 patients and included pyelopasty (n=20), ureteral reimplant (n=13), ureterolysis (n=7), and ureteroureterostomy (n=2). Radiographic and symptomatic improvement was observed in 100% of the pyeloplasty, ureteral reimplant, and ureteroureterostomy patients and 71.4% of ureterolysis patients, for an overall success rate of 95.2%. This study is limited by the small sample size, the short follow-up period, and the lack of a comparative cohort.

Conclusions: Our technique of RPN with selective arterial clamping and robotic upper urinary tract reconstruction utilizing NIRF imaging is presented. This technology provides real-time intraoperative angiogram to confirm selective ischemia and may be an adjunct technology to confirm well-perfused tissue within a reconstruction anastomosis. Further investigation is needed to evaluate long-term outcomes of NIRF imaging in robotic upper urinary tract surgery and to delineate its indications.

Keywords: Indocyanine green; Near-infrared fluorescence imaging; Robotic partial nephrectomy; Surgical technique; Upper urinary tract reconstruction; reconstruction.