Use of Intraoperative Indocyanine Green to Facilitate Robot-Assisted Laparoscopic Upper Pole Partial Nephroureterectomy

Abstract

Introduction:

During partial nephrectomy, identifying and occluding the appropriate segmental vessels that supply the diseased parenchyma before resection are critical to minimizing blood loss. While it is sometimes possible to identify vascular changes visually, the presence of complicated renal vascular anatomy may complicate appropriate identification of polar vessels. We now report the use of near-infrared fluorescence (NIRF) with intravenous indocyanine green (ICG) to confirm appropriate vascular occlusion before parenchymal resection during a robot-assisted laparoscopic partial nephroureterectomy.

Materials and Methods:

A left robot-assisted laparoscopic upper pole partial nephroureterectomy was performed for an obstructed, minimally functional left upper pole moiety in the setting of persistent left flank pain using the da Vinci Si System. The patient was positioned, prepped, draped, and trocars placed in the typical manner. The colon was reflected medially. A complex renal hilum was identified during initial dissection. After occlusion of an early branching upper pole artery, 5 mL of ICG was administered and NIRF used to visualize the renal parenchyma and allow demarcation of the avascular plane.

Results:

Continued perfusion of the upper pole was identified following initial vessel ligation. Further hilar dissection revealed a tertiary branch of a segmental artery that provided collateral blood supply to the left upper pole. This was ligated with a bulldog clamp and repeat administration of 5 mL of ICG confirmed upper pole ischemia. The vessel was then clipped and transected. The upper pole and associated ureter were then extirpated without incidence.

Conclusion:

In patients identified to have complex renal vascular anatomy during robot-assisted laparoscopic extirpative cases, the use of ICG and NIRF can aid in confirming parenchymal ischemia before resection.

No competing financial interests exist.

Runtime of video: 7 mins 48 secs