Introduction We introduce a novel technique for intra-operative identification of the ureters during surgery for gynecologic malignancies. Retroperitoneal dissection and ureterolysis are often required for identification of sentinel lymph nodes or radical dissection for advanced stage disease. Minimally invasive and robotic surgery are increasingly the surgical approach of choice to increase visualization, reduce blood loss, hospital stay, and patient morbidity. Pre-procedure cystoscopic-guided retrograde instillation of ICG dye into ureters stains the ureters with indocyanine green (ICG) dye and facilitates transperitoneal and retroperitoneal identification of the ureter.

Description Using a 30-degree cystoscope, ureters are cannulated with a 5-French angled Whistle Tip Ureteral Catheter to a depth of 10 cm, followed by retrograde injection of 10 mL, ICG dye 2.5 mg/dL, over 30 seconds with a 30-second pause to stain the ureteral epithelium. Abdominal access is obtained, and the robot is ‘docked.’ Near-infrared (NIR) imaging using Firefly® technique enables visualization of the ureters by using the hand-controlled toggle switch, enabling quick identification of ureters trans-peritoneally and without dissection. In a retrospective pilot study of 40 matched cases comparing matched before and after technique implementation, there was no statistical difference in OR time or Procedure Duration resulting from addition of this technique. 96.5% of ureters were identified.

Conclusion/Implications Retrograde instillation of indocyanine green dye using near-infrared imaging on the robotic platform facilitates identification of the ureters without increasing surgical time, enabling real-time identification of ureters, reducing risk of ureteral injury and increasing patient safety.