Intraoperative assessment of ureter perfusion after revascularization of transplanted kidneys using intravenous indocyanine green fluorescence imaging

Abstract

Background: Kidney transplantation is the most valuable renal replacement therapy. One of the most common urologic complications following kidney transplantation is ureter anastomosis leakage, which leads to high morbidity along with kidney graft loss. We hypothesized that indocyanine green (ICG) fluorescence videography can assess ureter perfusion after revascularization of transplanted kidneys.Methods: We conducted a prospective cross-sectional study in end-stage renal disease patients who underwent deceased donor kidney transplantation at Ramathibodi Hospital from September 2019 to January 2020. The segments of transplanted ureters were categorized as having good or poor perfusion based on the percentage from ICG fluorescence videography images. Then the results from ICG fluorescence videography were compared with histopathology which is considered the gold standard.Results: Thirty-one sections of dissected ureters were evaluated from 10 patients. Compared with pathological diagnosis of ureteral ischemia, ICG videography had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive likelihood ratio of 100%, 92.6%, 66.7%, 100%, and 14, respectively. Accuracy was 93.6%. The area under the curve of ICG fluorescence videography was 0.96. The average ureter length that maintained good perfusion was 14 cm from the ureteropelvic junction.Adverse events from ICG were not observed in this study. Conclusions:We conclude that ICG fluorescence videography is beneficial for detection of early ureteral ischemia in kidney transplantation patients, with negligible adverse events. However, further studies with larger numbers of patients are necessary to confirm our results and clinical outcomes regarding complication rates.

Repurposing indocyanine green: exploring the potential of an old drug in modern medicine

“…Such innovative designs contribute to the development of more effective and ingenious therapeutic strategies. 1,41–54…”

“…1 Clinical ICG does not participate in body metabolism, has a high safety, and can provide accurate navigation during surgery. ICG can intuitively indicate the closure and permeability of the channel during vascular or intestinal surgery, evaluate the risk of anastomotic leakage, assess ureter perfusion after revascularization of transplanted liver 44 and kidneys, 45 and reduce the occurrence of postoperative complications. In microsurgery, blood vessel anastomosis, finger replantation, skin avulsion reconstruction and flap transplantation can be evaluated by NIR imaging.…”

Ureterovesical Anastomosis Complications in Kidney Transplantation: Definition, Risk Factor Analysis, and Prediction by Quantitative Fluorescence Angiography with Indocyanine Green

“…Fluorescence angiography is an emerging tool for this purpose that fulfills the requirements of allowing real-time, in situ, noninvasive, quantitative tissue perfusion measurements without exposing the patients to the relevant side effects. A recently published study comparing the results of intraoperative ureteral ICG perfusion assessment with histopathological findings of 31 sections of dissected ureters showed that ICG fluorescence angiography had a sensitivity of 100% and a specificity of 93% for the detection of ureteral ischemia [ 13 ]. According to the authors, optimal perfusion was only maintained in the proximal 14 cm of the ureters.…”

“…It has been demonstrated that delayed graft function after kidney transplantation can be predicted intraoperatively by applying this technique [ 12 ]. A recently published study yielded encouraging results for the detection of early ureteral ischemia [ 13 ].…”

Indocyanine Green tattooing for marking the caudal excision margin of a full-thickness vaginal endometriotic nodule

“…In benign gynaecology, ICG can be used intravenously to assess the vascularisation of bowel anastomosis following segmental or disc resection ( Blanco-Colino and Espin-Basany, 2018 ) and of ureters following ureterolysis. ICG can also be instilled into the ureteric lumen using a ureteric catheter to identify the course of the ureter laparoscopically ( Kanammit et al, 2021 ). It can also be used instead of methylene blue (MB) in a number of scenarios (tubal patency test, bladder integrity test etc).…”