Intraoperative angiography of the neurovascular bundle using indocyanine green and near-infrared fluorescence improves anatomical dissection during robot-assisted radical prostatectomy: initial clinical experience

Abstract

Background: Landmark artery identi cation in the neurovascular bundle (NVB) is important for nervesparing in radical prostatectomy. We aimed to investigate intraoperative angiography using indocyanine green and near-infrared uorescence (ICG-NIRF) during robot-assisted radical prostatectomy (RARP) to identify the NVB, visualise vascularisation and haemostasis, and preserve erectile function.Methods: Retrospective, unicentric study of 91 consecutive localised prostate cancer RARP patients (stage T1/T2, prostate speci c antigen <10 ng/ml) who underwent ICG-NIRF angiography in France (2016)(2017)(2018)(2019)(2020)(2021). When ready to dissect the NVB, the anaesthesiologist intravenously injected ICG (3 ml); the surgeon used alternating standard light or uorescence to optimise NVB visualisation and facilitate microdissection. Primary outcomes: safety and feasibility of ICG-NIRF. Secondary outcomes: functional erectile dysfunction (Sexual Health Inventory for Men questionnaire) over 9 months, proportion of bilateral NVBs identi ed, ICG-related complications. Standard descriptive statistics were used; t-test determined the signi cance of changes in SHIM scores versus baseline.Results: Ninety-one patients received intraoperative angiography. The NVB was identi ed in all cases, without di culties. No ICG-related complications or allergies were observed. There was no signi cant difference in the SHIM score at 9 months compared with baseline (p=0.331), and erectile dysfunction returned to baseline levels in almost all patients.Conclusions: Intraoperative, real-time ICG-NIRF angiography is simple, non-invasive, and improves identi cation of key anatomical landmarks to optimise micropreservation of the NVB during RARP and preserve erectile function. Larger clinical studies should con rm preliminary results.

Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques

“…More recently, in 2023, Amara et al [ 59 ] published a retrospective study on a total of 91 RARP. According to the authors’ perceptions, fluorescence provided not only a real-time visualization of the NVB, but even a better understanding of its “over traction” during dissection.…”

Surgery of the alimentary tract for benign and malignant disease with the novel robotic platform HUGOTM RAS. A first world report of safety and feasibility

“…The enhanced vision and improved ergonomics, the wider range of motion and flexibility of the instruments, and the lack of physiologic tremor are well-known benefits of the robotic approach. The many technological features such as augmented reality 1 or indocyanine green (ICG)-aided fluorescent angiography or cholangiography 2,3 supported by the interface (computer)-based robotic platform have further contributed to this thriving trend.…”