Intraoperative imaging of the ureters to prevent ureteral injury. The majority of lower urinary tract injuries are not recognized during the operation. And most lower urinary tract injuries occur during uncomplicated benign gynecological surgery. The rate of ureteral injury is 3.4 per 1,000 of patients undergoing laparoscopic hysterectomy. The rate of urinary tract injury is higher for ureteral gynecological procedures, approaching 10% for utero-sacral ligament-culpa suspension. The mechanism of how this works. Once the ICG lines the inside of the ureter, the laser beam emits a light at 805 nanometers, which is in the infrared range. This light travels from the tip of the scope and penetrates the tissue and enters the ureter to excite the ICG molecule inside the ureter. Once the molecule becomes excited, the molecule emits a wavelength that is greater than 805 and fluoresces. The fluorescence at the infrared range is then detected by the lens and camera of the DAVINCI system and then converted into computer signals, which show the area as green. We use a 70-degree scope with a 22 French sheath and an albarin bridge to deflect the stent. The open-ended ureteral catheter is threaded through the nipple and into the sheath of the cystoscope. The deflection of the ureteral stent with the albarin bridge is demonstrated. 50 milligrams of ICG powder is mixed with 20 milliliters of injectable saline. The air bubbles are removed by tapping the syringe. The stent is preloaded before cystoscopy begins. Before starting surgery, cystoscopy is performed and the catheter is inserted into the right ureteral orifice up to 2 centimeters and 10 milliliters of the mixture are injected. The same procedure is performed on the opposite side. The ICG reversibly stains the inside lining of the ureter for several hours, and this ICG becomes stimulated by the infrared laser beam. One can also inject ICG at the ureteral orifice using the cone-tipped catheter. In this example, lysis of adhesion is being performed near the right pelvic sidewall. A large portion of the right ureter can be visualized due to this technology. In this example, a large portion of the right ureter can be visualized due to this technology. In this example, a large portion of the right ureter can be visualized due to this technology. Here, you can visualize the left ureter. Fluorescent ICG is also helpful for visualization of the bladder. Fluorescent ICG is also helpful for visualization of the bladder. Fluorescent ICG is also helpful for visualization of the bladder. Fluorescent ICG is also helpful for visualization of the bladder. This final example demonstrates the usefulness of detecting ureteral deviation and kinking. This final example demonstrates the usefulness of detecting ureteral deviation and kinking. This final example demonstrates the usefulness of detecting ureteral deviation and kinking. This final example demonstrates the usefulness of detecting ureteral deviation and kinking. During closure of the peritoneum over the mesh during the sacrocovalpexy, the right ureter has been pulled medially towards the suture line. One can appreciate this by the triangular shape of the green area. The use of intraureteral ICG to delineate and visualize the ureter can be useful for preventing ureteral injury.

intraoperative imaging

ureters

ureteral injury

gynecological surgery

indocyanine green