Intraoperative ICG-Fluorescence as a Method to Prevent Postoperative Strictures of Uretero-Ileal Anastomoses in Robot-Assisted Radical Cystectomy

Abstract

   Introduction. Radical cystectomy with urine diversion is recognized as the standard for the treatment of muscle-invasive bladder cancer. One of the dangerous complications in the postoperative period is the stricture of uretero-ileal anastomosis leading to hydroureteronephrosis, renal failure, and urosepsis. One of the factors in the development of the anastomotic stricture is ischemia. In order to reduce possible ischemic injury, the following manipulations are performed: careful treatment of tissues in the area of future anastomosis, preservation of periureteral adventitia, minimal mobilization of ureters before implantation into conduit. Intraoperative assessment of ureteral and intestinal tissue perfusion using ICG-fluorescence is a promising area.   Materials and methods. The study enrolled 56 patients who underwent a robotic-assisted radical cystectomy with intracorporeal urine diversion from January 2021 to March 2022 at the Bashkir State Medical University Clinic. Patients were divided into two groups: group 1 (22 patients) underwent intraoperative ICG-imaging, and group 2 (34 patients) — imaging without fluorescence. The median follow-up period was 14 months for group 1 and 12 months for group 2. The comparison criteria between the groups were demographic indicators, perioperative outcomes (including 30- and 90-day complications), and the incidence of strictures of uretero-ileal anastomoses. The groups were compared using a test for equality of means and a test for sampling distributions.   Results and discussion. No statistically significant differences between patients were reported during the time of surgery, estimated blood loss, and duration of hospital stay. No significant differences were also detected in the incidence of 30- and 90-day complications and the number of readmissions among patients in group 1 and group 2 (p = 0.477 and p = 0.089, respectively). The incidence of strictures of uretero-ileal anastomosis in group 1 demonstrated a statistically significant decrease, as compared with group 2 (0/34 [0 %] and 7/68 [10.3 %], p = 0.020).   Conclusion. The ICG-fluorescence imaging to assess vascularization of the distal ureter during robotic-assisted radical cystectomy with intracorporeal urine diversion may reduce the risk of postoperative uretero-ileal anastomotic ischemic strictures.