Introduction/Background*Pelvic exenteration performed for recurrent cervical cancer has been associated to urological short- and long-term morbidity, due to altered vascularization of tissues for previous radiotherapy. The aim of the present video is to demonstrate the use of intravenous indocyanine green (ICG) to assess vascularity of Bicker ileal conduit after pelvic exenteration for recurrent cervical cancer and to evaluate the feasibility and safety of this technique.

Methodology The patient was a 64-year-old woman who underwent exclusive chemoradiation for FIGO stage IIB cervical SCC. Seven months after the end of the radiotherapy she was diagnosed with an isolated central pelvic recurrence involving bladder wall. The patient underwent open total pelvic exenteration with Bricker ileal conduit urinary diversion and end sigmoid colostomy. After performing the anastomoses, the perfusion of tissues was analyzed with intravenous injection of 3 ml of ICG and a (1.25 mg/ml) and a near infra-red SPY Portable Handheld Imager (SPY-PHI) (Stryker, Kalamazoo, Michigan, US). After ICG injection, a four-tier (+++ versus ++- versus +-- versus ---) classification was used to assess the vascularity of each anastomosis: ileum-ileum, right and left ureter with small bowel. The classification of ICG perfusion of anastomoses was independently performed by the urologist and the gynecologic oncologist.

Result(s)*Intravenous injection did not cause any adverse event. After ICG injection, the left ureter-ileal conduit demonstrated sub-optimal vascularization (---), the right ureter-ileal conduit and the ileum-ileum showed optimal vascularization (+++). ICG perfusion is demonstrated with three different modalities: Overlay Fluorescence Mode, Color Segmented Fluorescence Mode, Contrast Fluorescence Mode. Patient developed benign left ureteric stricture which was diagnosed with a CT-scan 45 days after the radical surgery and was treated with anterograde ureteric stenting.

Conclusion*The use of ICG to intra-operatively assess the anastomoses perfusion at time of pelvic exenteration for gynecologic malignancy is a feasible and safe technique. The different vascularization of anastomotic stumps may be related to anatomical sites and to previous radiation treatment and it may be useful to predict post-operative complications. This approach could be of support in selecting patients at higher risk of complications, who may need personalized follow up.