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AUA2024 BEST VIDEO Near-Infrared Fluorescence: An Intraoperative Tool to Manage Lymphorrhea After Radical Prostatectomy
By: Marco Martiriggiano, MD, IRCCS Ospedale Policlinico San Martino, University of Genoa, Italy; Paolo Dell’Oglio, MD, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; Stefano Tappero, MD, IRCCS Ospedale Policlinico San Martino, University of Genoa, Italy; Michele Barbieri, MD, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; Francesca Ambrosini, MD, IRCCS Ospedale Policlinico San Martino, University of Genoa, Italy; Alberto Olivero, MD, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; Enrico Vecchio, MD, IRCCS Ospedale Policlinico San Martino, University of Genoa, Italy; Silvia Secco, MD, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; Carlo Terrone, MD, IRCCS Ospedale Policlinico San Martino, University of Genoa, Italy; Aldo Massimo Bocciardi, MD, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy; Antonio Galfano, MD, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy | Posted on: 31 Aug 2024
Introduction and Objectives
Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has emerged as a safe and feasible tool for an enhanced surgical experience. NIRF/ICG assists in the identification of key anatomical landmarks and surgical targets, either for oncological or nononcological scopes. According to the site of distribution (ie, bloodstream, lymphatic stream, organs’ parenchyma), the diffusion pattern of ICG emphasizes the areas of interest (ie, blood vessels, lymphatic vessels, nodal stations). Specifically, the purpose of the current video was to describe the intraoperative use of NIRF/ICG to manage a case of massive lymphorrhea, which occurred after robot-assisted radical prostatectomy.
Materials and Methods
We present the case of a 72-year-old man who underwent Retzius-sparing robot-assisted radical prostatectomy and extended pelvic lymphadenectomy in March 2021. After 6 months, the patient presented to the emergency department with asthenia, dyspnea, and weight loss. CT scan showed severe ascites. No suspected abdominal lesions were detected. The patient underwent a complete clinical evaluation without evidence of pathological findings. Lymphoscintigraphy with 99mTc nanocolloid detected a deficit of lymphatic superficial drainage, with tracer accumulation in the inguinal region and abdomen. A massive lymphorrhea due to lymphatic drainage damage was suspected. Therefore, the patient was submitted to robot-assisted explorative laparoscopy and real-time lymphangiography with ICG. Intuitive da Vinci Xi system was used, given the availability of Firefly vision. One milliliter of diluted ICG was injected subcutaneously in the interdigital space and on the sole of each foot, 15 minutes before the surgery. The procedure consisted of the following: (1) ICG injection before the beginning of the surgery; (2) robotic trocars placement; (3) intraoperative lymphangiography using NIRF imaging; (4) lymphatic leakage identification; (5) double clips application and sealing of the leaking lymphatic vessels; (6) drainage placement; (7) peritoneum reconstruction.
Results
The postoperative follow-up period was uneventful. The output of each drainage gradually decreased to 0 cc in 10 days. At 6 months after surgery, a CT scan revealed no residual lymphorrhea. An asymptomatic pelvic lymphocele of approximately 5 cm was detected. PSA was undetectable at the last follow-up.
Conclusion
Real-time lymphangiography with ICG allowed accurate intraoperative identification of the lymphatic leakage, which had resulted in massive lymphorrhea. Future studies are warranted to corroborate the role of NIRF/ICG in such a clinical scenario.
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