Indocyanine Green Fluorescence-Guided Laparoscopic Ureterolysis for Complex Gynecological Surgeries

Abstract

Background: To identify and safeguard the ureters of patients with deep infiltrating endometriosis or complex pelvic adhesion (obliterated cul-de-sac) using indocyanine green (ICG) during laparoscopic surgery. Methods: Stepwise surgical demonstration using narrated video footage. The stepwise procedures were: (1) Explore the abdominal cavity, resect pelvic adhesions, remove the right ovarian endometrioma cysts, and open the peritoneum to locate the fluorescence. (2) Place bilateral 5-Fr ureteral catheters through the cystoscope, inject ICG retrogradely, and clip the catheter to retain the ICG. (3) Identify the course of ureters and perform ureterolysis with real-time visualization under Near-infrared fluorescence. Resect the para-ureteral endometriosis and other pelvic endometriosis. Results: The patient was discharged on the 4th postoperative day with satisfactory surgical effect and without any complications. Conclusions: For complex gynecologic surgeries whereby ureterolysis might be challenging, ICG fluorescence imaging could be used to quickly identify the course of the ureter, prevent ureteral injury and reduce the risks of perioperative and postoperative complications. This case demonstrates that intraureteral ICG provided quick visualization of the ureter and allowed surgeons to safely perform ureterolysis. The proposed technique could be considered in complex gynecological cancer, pelvic floor disorder or endometriosis surgery.