Efficiency of the Firefly System for Mesenteric Vessel Identification During Total Intracorporeal Urinary Diversion Following Radical Cystectomy Using the Da Vinci Xi Robot

Abstract

Objective: To show the feasibility and efficiency of near-infrared fluorescence using indocyanine green (ICG), in identifying and preserving mesenteric perfusion during total intracorporeal urinary and digestive reconstruction after radical cystectomy using the Da Vinci Xi robot. Methods: After approval by the institutional review board, we studied all consecutive patients who underwent robot-assisted radical cystectomy (RARC) and intracorporeal urinary derivation with the Da Vinci Xi robot using ICG and the Firefly system, in our institution from January 1, 2018 to September 15, 2018. Primary endpoint was adequate mesenteric vessel identification after injection of 0.2 mg/kg of ICG (Infracyanine®; Laboratoire Serb, Paris, France) before each bowel division. Secondary endpoint were ischemia-related complications and return of bowel function. Results: After a median follow-up of 4.6 months (interquartile range [IQR] 3.2–7.5), we prospectively included 25 patients. ICG allowed adequate mesenteric identification in all the cases. Complementary intraoperative resection of bowel segment for inadequate perfusion in Firefly mode was performed in two cases (8%). Median return to bowel function was 3 days for gas (IQR 2–5) and 5 days for stool (IQR 3–6). Only one patient (4%) presented with postoperative bowel obstructive syndrome. There were 2 (8%) urinary leaks. There were no digestive fistulas recorded. Nine patients (36%) were readmitted within 30 days for complications. Conclusions: Total intracorporeal urinary diversion during RARC using ICG and the Firefly system of the Da Vinci Xi allowed adequate vessel identification and seemed to allow a quicker bowel function recovery and to lower urinary and digestive complications. This might be explained by better vascularization of the ileal conduit and the digestive anastomosis by using ICG in the dissection phase, therefore avoiding ischemia. A limitation that surgeons should be careful about is when blood containing ICG spills over tissue making it light up permanently making the dissection more difficult. Larger randomized controlled studies evaluating ICG are needed to confirm the usefulness of ICG use for total intracorporeal urinary diversion during in radical cystectomy. No competing financial interests exist. Runtime of video: 7 mins 36 secs Previously presented at the French Congress of Urology 2018 (video in French), in Paris, France, on November 20, 2018, and at the EAU Congress 2019 (video in English), in Barcelona, Spain, on March 15, 2019.