Robotic-assisted Laparoscopic Ureterolysis for Deep Infiltrating Endometriosis using Indocyanine Green Under Near-Infrared Fluorescence

Study Objective: To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green (ICG) under near-infrared fluorescence (NIRF) on the robotic platform. Design: Stepwise demonstration using narrated video footage. Setting: An academic tertiary care hospital. A 43 year old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for 2 aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention. Interventions: In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous ICG has previously been described to assist with resection of endometriosis [1-3]. Alternatively, we describe a technique that allows for easier identification of ureters using ICG injection retrogradely in ureteral stents while visualized under NIRF [4,5]. In summary: 1. Perform cystoscopy and place bilateral open-ended 5-French ureteral catheters. Inject ICG retrogradely in each ureteral catheter, and place caps to seal the catheters to maximize ICG retention [4]. 2. Once robotic-assisted laparoscopic surgery is started, use NIRF to identify the ureter. The ureter will emit green fluorescence, whereas the surrounding tissue will not. 3. Once the ureter is identified, NIRF is intermittently used to safely follow the course of the ureter and perform ureterolysis, while excising endometriosis. The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3 week postoperative visit, pelvic pain had completely resolved. Conclusions: This case demonstrates the use of intraureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis. (C) 2022 AAGL. All rights reserved.