Real-time indocyanine green angiography with the SPY fluorescence imaging platform decreases benign ureteroenteric strictures in urinary diversions performed during radical cystectomy

Abstract

Background: Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. Methods: A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher’s exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. Results: Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs ( p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion ( p < 0.0001). No complications attributable to the use of SPY were noted. Conclusion: Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.

Effect of intracorporeal urinary diversion on the incidence of benign ureteroenteric stricture after cystectomy

“…reviewed outcomes of 94 patients who underwent RARC. 21 For the 47 patients who had the procedure carried out with ICG fluorescence, the rate of UES development was significantly lower after a median follow-up period of 12.0 months (0% vs 7.5%; P = 0.01). A study by Ahmadi et al reviewed 179 patients undergoing RARC-ICUD, in which 47 patients underwent surgery with the use of ICG.…”

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis

“…Recent work by Shen et al has demonstrated potential for the use of intraoperative fluorescent angiography during open urinary diversion in reduction of ureteroenteric stricture rates. In a series of 47 patients, no ureteroenteric strictures were detected in the experimental group [ 20 ]. These studies show promise for widespread reduction in ureteroenteric stricture rates by assessing ureteral perfusion prior to making ureteroenteric anastomosis, as the technique will not be limited to robotic only approach.…”

Fluorescence‐guided cancer surgery—A new paradigm

“…ICG can also be used for perfusion assessment for liver segments, 33 ureters [34][35][36] (Table 4 and Figure 3) and during various flap reconstructive procedures.…”