Evaluation of Long-Term Outcomes Utilizing Indocyanine Green to Decrease Ureteroenteric Anastomotic Stricture During Robotic Radical Cystectomy and Extracorporeal Urinary Diversion

Abstract

Our results demonstrate that the use of indocyanine green (ICG) during ureteroenteric anastomosis (UA) for urinary diversion was significantly associated with a lower risk of UA stricture. Our study represents the largest 1:1 comparison of ICG use in this setting with the longest follow-up to date. Intravenous indocyanine green (ICG) allows assessment of ureteral perfusion when performing ureteroenteric anastomosis. Our aim was to evaluate the impact of ICG use and clinical factors on the risk of ureteroenteric anastomotic stricture (UAS) following robot-assisted radical cystectomy (RARC) and extracorporeal urinary diversion (ECUD). We conducted a retrospective review of patients who underwent RARC + ECUD with or without ICG use between 2011 and 2022 at a single tertiary center. For cases with a clinical suspicion of UAS, a nephrostomy tube was placed and an antegrade nephrostogram was performed for confirmation. Kaplan-Meier and logistic regression analyses were performed to estimate stricture rates and to identify risk factors for UAS incidence. A total of 392 consecutive cases were included. No ICG was used for the first 196 cases (50%), while ICG was used for the subsequent 196 cases (50%). ECUDs included 234 ileal conduits (60%), 110 neobladders (28%), and 48 Indiana pouches (12%). The risk of UAS was 2% at 6-months and 3% at 24-months in the ICG group, and 12% at 6-months and 14% at 24-months in the non-ICG group. No UAS occurred beyond 19-months. Multivariable analysis revealed that ICG use significantly reduced UAS risk (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.08–0.50; p < 0.001), whereas a history of diabetes mellitus significantly increased the risk of UAS (HR 3.07, 95%CI 1.47–6.41; p = 0.003). There were no adverse events related to ICG use. ICG fluorescence imaging is a safe technique that can facilitate efforts to reduce the risk of UAS following RARC and ECUD. Narrowing of the connection between the ureter and the segment of intestine used to create a new urinary reservoir is a serious complication after bladder removal for bladder cancer. We found that using a fluoroscent agent that identifies tissue blood supply at the time of urinary reconstruction may reduce the risk of this complication.