High Rates of Discordant Ureteral Perfusion During Open Ureteral Reconstruction with Indocyanine Green: Does Near-Infrared Fluorescence Imaging Change Management or Stricture Outcomes?

Abstract

OBJECTIVETo determine the role of near-infrared fluorescence imaging (NIFI) combined with indocyanine green (ICG) to assess ureteral tissue perfusion in a benign genitourinary reconstruction cohort with a high prevalence of prior abdominopelvic radiation and surgery. MATERIALS AND METHODSA prospective, single-surgeon series, between June 2018 and April 2022, of patients who underwent open genitourinary reconstructive surgeries in which NIFI/ICG was utilized to intraoperatively assess ureteral tissue perfusion prior to ureteral anastomosis. Primary outcome was ureteroanastomotic stricture (UAS). Secondary outcomes included impact of NIFI/ICG on surgical decision-making and ureter resection length. RESULTS39 patients, median age 66, underwent 40 multimodality reconstructive surgeries during which NIFI/ICG was utilized in the open setting. Radiation-induced etiology was present in 32 of 40 (80%) patients. UAS occurred in 1 of 57 (1.8%) anastomoses with median follow-up 23.4 months. Use of NIFI/ICG changed intraoperative decision-making in 63% of cases. Change in intraoperative decision-making was more common in patients with prior abdominopelvic radiation (66%) compared to non-radiated patients (13%), p=0.007. Discordance between subjective (white-light) and objective (NIFI/ICG) ureteral perfusion (white-light) occurred in 61% of ureters. Mean length of resected ureter was higher following objective assessment with NIFI/ICG (3.6 cm) versus subjective assessment (white light) conditions (1.8 cm), p=0.001. CONCLUSIONSUse of NIFI/ICG was associated with low rates of UAS at 2 years follow-up in a cohort with high prevalence of prior radiation. NIFI/ICG was associated with longer lengths of ureter resection and ureteral perfusion assessment discordance compared to subjective surgeon assessment under white-light conditions.