BackgroundIatrogenic ureteric injury is a serious complication of colorectal surgery. Incidence is estimated to be between 0.3 and 1.5%. Of all ureteric injuries, 9% occur during colorectal procedures. Ureteric stents are utilised as a method to reduce the risk of injury; however, these are not without risk and do not guarantee prevention of injury. Fluorescence is a safe and effective alternative for intraoperative ureteric localisation. This proof of principle study aims to assess the use of methylene blue to fluoresce the ureter during colorectal surgery.MethodPatients undergoing elective colorectal surgery were included in this open label, non-randomised study. Methylene blue was administered intravenously at varying doses (0.25–1 mg/kg) over 5 min, 10–15 min prior to entering ‘ureteric territory.’ Fluorescence was assessed using the PINPOINT Deep Red laparoscopic system at fixed time points by the surgeon and an independent observer.Results42 patients received methylene blue; 2 patients were excluded from analysis. Of the 69 ureters assessed, 64 were seen under fluorescence. Of these, 14 were not visible under white light. 50 ureters were observed with both fluorescence and white light with 14 of these being seen earlier with fluorescence. In ten cases, fluorescence revealed the ureter to be in a different location than suspected.ConclusionFluorescence is a promising method to allow visualisation of the ureter, where it is not identified easily under standard operative conditions, thereby improving safety and reducing operative time and difficulty.Electronic supplementary materialThe online version of this article (10.1007/s00464-018-6219-8) contains supplementary material, which is available to authorized users.
BackgroundUrethral injury is a complication feared by surgeons performing transanal TME (TaTME) or abdominoperineal excision (APE) procedures. Injury during TaTME occurs when the prostate is inadvertently mobilised or as a direct injury similar to the direct injury during the perineal dissection of APE procedures. We performed a proof of principle study to assess the feasibility of using indocyanine green (ICG) to fluoresce the urethra in human cadavers.MethodsIndocyanine green at varying doses was mixed with Instillagel and infiltrated into the urethra of male human cadavers. The urethra was exposed through either a perineal incision or by mobilisation of the prostate during a TaTME dissection and fluorescence observed using a PINPOINT laparoscope (NOVADAQ). Brightness was assessed on the images using ImageJ (National Institute of Health). ResultsEight cadavers were included in the study. Fluorescence was visualised in the urethra in all eight cadavers. Minimal dissection was required to obtain fluorescence transperineally. In one cadaver, the urethra was demonstrated under fluorescence using a simulated TaTME with additional fluorescence also being observed in the prostate. There was no correlation between brightness and dosing.ConclusionsThis novel proof of principle study demonstrates a simple way in which the urethra may be easily identified preventing it from injury during surgery.Electronic supplementary materialThe online version of this article (doi:10.1007/s10151-017-1615-y) contains supplementary material, which is available to authorized users.
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