The Role of Indocyanine Green for Robotic Partial Nephrectomy: Early Results, Limitations and Future Directions

Zachary Klaassen,Rabii Madi,Martha Terris,Qiang Li

doi:10.3390/robotics3030281

Zachary Klaassen, Rabii Madi + Show 2 more

Open Access

https://doi.org/10.3390/robotics3030281

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Journal: Robotics	Publication Date: Jul 16, 2014
Citations: 23	License type: CC BY 4.0

Affiliation: Augusta University

Abstract

The surgical management of small renal masses has continued to evolve, particularly with the advent of the robotic partial nephrectomy (RPN). Recent studies at high volume institutions utilizing near infrared imaging with indocyanine green (ICG) fluorescent dye to delineate renal tumor anatomy has generated interest among robotic surgeons for improving warm ischemia times and positive margin rate for RPN. To date, early studies suggest positive margin rate using ICG is comparable to traditional RPN, however this technology improves visualization of the renal vasculature allowing selective clamping or zero ischemia. The precise combination of fluorescent compound, dose, and optimal tumor anatomy for ICG RPN has yet to be elucidated.

Highlights

Nephron sparing surgery (NSS) has been advocated as the surgical treatment of choice for the management of small renal masses, secondarily improving renal function and long-term survival [1].Increasingly, robotic surgery has been utilized across many centers in the United States as the preferred NSS modality given the dexterity afforded by the robot and the ability of the surgeon to resect the mass and cover the renal defect
We have identified other limitations for the use of indocyanine green (ICG) in robotic partial nephrectomy (RPN)
The initial institutional studies using near infrared fluorescent imaging of ICG dye demonstrate safety and feasibility when performing RPN

Summary

Introduction

Nephron sparing surgery (NSS) has been advocated as the surgical treatment of choice for the management of small renal masses, secondarily improving renal function and long-term survival [1]. Robotic surgery has been utilized across many centers in the United States as the preferred NSS modality given the dexterity afforded by the robot and the ability of the surgeon to resect the mass and cover the renal defect. The latest robotic surgery technology has attempted to circumvent these visual drawbacks, most commonly using near infrared fluorescence imaging, (i.e., intravenous injection of indocyanine green (ICG) (©Akorn, Incorporated, Lake Forest, IL, USA)) to delineate perfusion and uptake of normal renal parenchyma during RPN (Figure 1) [4]. Renal cortical tumors have reduced expression of bilitranslocase, a carrier protein for ICG in normal parenchyma proximal tubule cells, leading to a reduction in near infrared fluorescence imaging in these tumors and delineation from normal parenchyma [6]. RPN, to address limitations and clinical situations when ICG may not be useful, and to highlight future directions of near infrared fluorescent imaging

ICG RPN Institutional Studies

Limitations of ICG

Future Directions

Findings

Conclusions