Indocyanine green use in Urology.

PURPOSE: Indocyanine green (ICG) is being used more and more in Urology along with advances in minimal invasive surgery, guiding excision and reconstruction, highlighting anatomic structures and functional features with oncologic guidance still being debatable. The purpose of this paper was to explore ICG use in urologic procedures. METHODS: We present our experience (37 cases) of using ICG fluorescence guidance in urologic operations performed using 3D laparoscopy and FireFly® fluorescence imaging mode of Da Vinci X robot. The operations were the following: pelvic lymphadenectomy in radical prostatectomy, totally intracorporeal orthotopic ileal neobladder reconstruction, vesicovaginal fistula repair, partial nephrectomy and pyeloplasty. Barnard's test was used to compare postoperative complications (digestive fistula, ureteral stricture) for totally intracorporeal ileal neobladders performed with (group e, 27 cases) vs. without (group 2, 28 cases) ICG guidance. RESULTS: ICG under near-infrared fluorescence offered a precise identification of ischemic structures- vaginal wall, distal ureteral end, ileal loop, along with vascularized tissues allowing an optimal pyeloplasty and nephron sparing surgery with partial unclamping. It also allowed the identification of a lymph node during radical prostatectomy that otherwise would not have been excised during the routinely performed pelvic lymphadenectomy. There were no complications of ICG usage and the complication rate (digestive fistula, ureteral strictures) was significantly lower (p=0.002716) for group 1 compared with group 2. CONCLUSIONS: ICG facilitates the identification of key elements (anatomy and pathological structures) in the laparoscopic and robotic treatment of both malignant and benign urologic diseases, with possible impact on perioperative complications, along with oncologic and functional postoperative outcomes.

Laparoscopic radical cystectomy and nephroureterectomy en bloc resection with lomboaortic and pelvic lymph node dissection.

BACKGROUND AND AIMS: In patients with recurrent high grade or muscle-invasive bladder cancer and concomitant upper urinary tract tumors or non-functional kidney laparoscopic radical cystectomy and nephroureterectomy with lomboaortic and pelvic lymph node dissection can be performed. We present our initial experience. METHODS: Between 2018 and 2019, 4 patients underwent laparoscopic radical cystectomy and unilateral nephroureterectomy en bloc resection with lomboaortic and pelvic lymph node dissection. The nephroureterectomy was the first part of the surgery. It was followed by radical cystectomy with lymphadenectomy. All the specimens were removed en bloc in an endobag through a midline incision. RESULTS: The patients' demographic characteristics and perioperative outcomes were retrospectively collected and evaluated. All surgeries were completed laparoscopically. There was no need for conversion to open surgery. The mean operative time was 286,25 min with minimal blood loss (260 ml). No major complications were reported. The mean follow-up period was 8.75 months. CONCLUSION: Laparoscopic radical cystectomy and nephroureterectomy en bloc resection with lomboaortic and pelvic lymph node dissection can be safe and feasible in selected cases as an alternative approach to the open surgery, offering good oncological and functional results.

Totally intracorporeal 3D laparoscopic orthotopic neobladder reconstruction following radical cystectomy for infiltrative bladder tumors: the experience of modified Studer and modified Y-shaped ileal reconstruction techniques.

PURPOSE: We report our experience with 23 cases in utilizing ileum to perform totally intracorporeal 3D laparoscopic neobladder reconstruction using two different surgical techniques. METHODS: Patients candidates for reconstructive surgery were in a good biological status with a body mass index (BMI) in the range of 18.5-25 and presented a muscle-infiltrative bladder tumor with negative nodal frozen sections performed during the operation. Twenty-one modified Studer neobladder and 2 modified Y-shaped neobladder techniques for totally intracorporeal 3D laparoscopic ileal neobladder cases were performed using drawings and intra-operative images. An emphasis was made on different tips and tricks that can be applied when using ileum for the neobladder reconstruction, to avoid surgical complications and obtain optimal functional results. RESULTS: The operations were performed in a mean time of 5 h, with a mean blood loss of 350 ml and grade II postoperative Clavien Dindo complications. The 23 patients were discharged after a mean hospital stay of 21 days and had a functional ileal neobladder after a mean of 30 days. The results were monitored also on the long-term, taking into account functional results and possible complications from utilizing ileum as a urinary reservoir. CONCLUSION: Resecting a digestive segment and using it as a urinary reservoir may lead to multiple complications. Therefore, laparoscopic technical adaptations and highly skilled surgical teams are required for performing a totally intracorporeal 3D laparoscopic orthotopic ileal neobladder reconstruction.