Real-time Intraoperative Fluorescent Lymphography: A New Technique for Lymphatic Sparing Surgery

Surgical and Infectious Complications Following Kidney Transplantation: A Contemporary Review

Kidney transplantation significantly improves outcomes in patients with end-stage renal disease; however, postoperative complications remain a substantial concern. This review summarizes the incidence, risk factors, and management strategies for common complications after kidney transplantation. Reported incidence varies widely due to differences in definitions, diagnostic methods, and study designs. Ureteral stenosis occurs in 2.8-18.0% of recipients, vesicoureteral reflux in 0.5-86%, and urinary leakage in 1.1-7.2%. Lymphatic complications, including lymphocele and lymphorrhea, range from 0.6% to 35.2%, with one-third of complications requiring intervention. The incidence of urinary tract infections ranges from 20 to 43%, while asymptomatic bacteriuria is reported in up to 53% of recipients. Surgical site infections have a median incidence of 3.7%, and incisional hernias develop in 2.5-10% of cases, depending on follow-up duration. Vascular complications affect approximately 10% of recipients, with renal artery stenosis and thrombosis being the most prevalent. Neurologic complications, such as femoral nerve palsy and immunosuppression-related neurotoxicity, though less frequent, can impair recovery. Management strategies vary depending on severity, ranging from observation to surgical intervention. Preventive measures-including optimized ureteral stenting protocols, early catheter removal, careful immunosuppression, and appropriate antimicrobial use-play a crucial role in reducing complication risk. Despite advances in transplantation techniques and perioperative care, these complications continue to affect graft survival and patient outcomes. Further research is needed to standardize definitions and establish evidence-based protocols.

Near-infrared imaging with indocyanine green fluorescence for intraoperative lymphatic assessment in rectal cancer surgery: a systematic review

INTRODUCTION

At present, harvesting more lymph nodes is considered more conducive to the prognosis of colorectal cancer surgery. The recent development of enhanced surgical visualization has led to the wide employment of indocyanine green (ICG) to assist minimally invasive surgery. This systematic review aims to provide a wide and critical overview of the current state of the art of ICG lymphography during rectal surgery, by focusing on the most relevant literature on this topic.

EVIDENCE ACQUISITION

After validation and registration in the PROSPERO international prospective register of systematic reviews on the 5th May 2024 (ID: CRD42024539426), 8 publications have been considered relevant for the research query and have been divided into two groups: lateral pelvic lymph node dissection (LPLND) and lateral pelvic sentinel lymph node biopsy (LPSLNB). A meta-analysis has not been performed due to the low statistical significance.

EVIDENCE SYNTHESIS

ICG lymphography seems to improve the number of harvested lateral pelvic lymph nodes, to reduce intraoperative blood loss and hospital length of stay during LPLND. In LPSLNB the detection rate of lateral pelvic sentinel lymph nodes ranged from 91.3% to 92%.

CONCLUSIONS

ICG lymphography for fluorescence guidance for LLND is a feasible and safe technique, with promising application in terms of the number of harvested lymph nodes and post-operative outcomes improvement during rectal oncological surgery. As some of these benefits have been already suggested by the current literature, they need to be confirmed in larger and randomized clinical.

Advances in optical molecular imaging for neural visualization

Iatrogenic nerve injury is a significant complication in surgery, which can negatively impact patients' quality of life. Currently, the main clinical neuroimaging methods, such as computed tomography, magnetic resonance imaging, and high-resolution ultrasonography, do not offer precise real-time positioning images for doctors during surgery. The clinical application of optical molecular imaging technology has led to the emergence of new concepts such as optical molecular imaging surgery, targeted surgery, and molecular-guided surgery. These advancements have made it possible to directly visualize surgical target areas, thereby providing a novel method for real-time identification of nerves during surgery planning. Unlike traditional white light imaging, optical molecular imaging technology enables precise positioning and identifies the cation of intraoperative nerves through the presentation of color images. Although a large number of experiments and data support its development, there are few reports on its actual clinical application. This paper summarizes the research results of optical molecular imaging technology and its ability to realize neural visualization. Additionally, it discusses the challenges neural visualization recognition faces and future development opportunities.

Indocyanine green for radical lymph node dissection in patients with sigmoid and rectal cancer: randomized clinical trial

BACKGROUND

D3 lymph node dissection is recommended for patients with advanced sigmoid and rectal cancer in Japan. This trial aimed to investigate the feasibility of indocyanine green (ICG) as a tracer to increase the nodal harvest during D3 lymph node dissection in patients with sigmoid and rectal cancer.

METHODS

This prospective randomized clinical trial was performed between May 2021 and April 2022. The inclusion criteria were patients with stage I-III sigmoid or rectal cancer eligible for laparoscopic resection. Patients were 1: 1 randomized to either the ICG group (endoscopic ICG injection at the tumour site and intraoperative imaging to guide dissection) or the control group (routine laparoscopic white-light imaging). All patients were treated with D3 dissection, and the primary outcome was the number of harvested lymph nodes at the D3 level.

RESULTS

Out of 210 patients screened, a total of 66 patients were enrolled and randomized. Patients in the two groups presented similar ages and clinical stages (ICG group versus control group, median age of 58.0 versus 58.5 years; stage III 36.4 per cent versus 36.4 per cent, whereas the rate of rectal cancer was 27.3 per cent versus 48.5 per cent respectively). ICG imaging was helpful for completely dissecting D3 lymph nodes and could identify a median of more than 2 (range 1-6) D3 lymph nodes neglected by routine laparoscopic white-light imaging during surgery. The median number of D3 lymph nodes harvested in the ICG group was significantly higher than that in the control group (7.0 versus 5.0, P = 0.003); however, there was no significant difference in the median numbers of positive D1, D2, and D3 lymph nodes between the two groups.

CONCLUSION

ICG is safe and feasible to guide D3 lymph node dissection and can increase the number of harvested D3 lymph nodes in patients with sigmoid and rectal cancer. Registration number: NCT04848311 (http://www.clinicaltrials.gov).

Combined robotic inguinal and iliac‐obturator lymphadenectomy for stage III skin cancers: Surgical technique and preliminary results

Background

Ilio‐inguinal lymphadenectomy for stage III melanoma and skin cancers still represents the best therapeutic option for a subset of patients, although the incidence of post‐operative complications is dramatically high. Only a paucity of papers on robotic approach have been published, reporting experiences on isolated pelvic or inguinal lymphadenectomy, and no series on combined dissections have been described yet. We present the preliminary results achieved with combined robotic approach, with special emphasis on lymph nodal mapping, dissection technique and postoperative complications linked with the lymphatic system.

Methods

Between September 2019 and September 2021, 10 patients were submitted to robotic inguinal and iliac‐obturator lymphadenectomy.

Results

Post‐operative course was characterised by early mobilisation and minimal post‐operative pain. Only one lymphoedema occurred and lymph nodal harvesting was more than satisfactory.

Conclusions

Robotic surgery provides meticulous lymph nodal dissections, with promising functional and oncologic outcomes. Further series are advocated to confirm these preliminary results.

Prophylactic Peritoneal Fenestration during Kidney Transplantation Can Reduce the Type C Lymphocele Formation

Lymphocele is a common complication following kidney transplantation (KTx). We aimed to evaluate the preventive effect of peritoneal fenestration during KTx in reducing lymphocele. From January 2001, the data of all KTx were prospectively gathered in our digital data bank. From 2008, preventive peritoneal fenestration was performed as a routine procedure for all patients with KTx. Between 2001 and 2008, 579 KTx were performed without preventive peritoneal fenestration. To compare the results between with and without peritoneal fenestration, the same number of patients after 2008 (579 patients) was included in this study. The pre-, intra-, and postoperative data of the patients in these two groups were analyzed and compared, especially regarding the postoperative different types of lymphocele formation. The mean recipient age was 52.6 ± 13.8, and 33.7% of the patients were female. Type C lymphocele was significantly lower in the group with preventive fenestration (5.3% vs. 8.8%, p = 0.014 for 31/579 vs. 51/579). Peritoneal dialysis and implantation of the kidney in the left fossa were independently associated with a higher rate of type C lymphocele (OR 2.842, 95% CI 1.354–5.967, p = 0.006 and OR 3.614, 95% CI 1.215–10.747, p = 0.021, respectively). The results of this study showed that intraoperative preventive peritoneal fenestration could significantly reduce type C lymphocele.

Indocyanine Green Angiography for Quality Assessment of the Kidney During Transplantation: An Outcome Predictor Prospective Study

BACKGROUND

Microvascular damage is the main cause of delayed graft function (DGF) after kidney transplant. Assessing its extent may be helpful in predicting DGF to achieve better postoperative management, especially in terms of an immunosuppressive regimen. Our aim was to explore the capability of intraoperative indocyanine green (ICG) angiography to examine the microvasculature of the kidney.

METHODS

We conducted a prospective cohort study on 37 kidney transplant recipients in a high-volume kidney transplant center. During surgery, after graft implant, an ICG angiography was performed through a high-definition Storz camera system (Karl Storz GmbH, Tuttlingen, Germany) with successive quantitative assessment of fluorescence using Icy bioimage analysis.

RESULTS

All transplanted kidneys that showed immediate recovery of their function had a fluorescent intensity ≥49.953 with a mean of 96.930 ± 21. The fluorescence intensity for kidneys that showed a delayed recovery of their function never exceeded 55.648, and the mean was 37.718 ± 13. The difference between the 2 groups was statistically significant with a P value < .001. The only kidney that never recovered showed a fluorescence intensity consistently <25.220, the lowest detected.

CONCLUSIONS

This study demonstrates that intraoperative ICG angiography may be used to assess the microvasculature of the graft. A statistically significant difference in terms of fluorescent intensity can be highlighted between kidneys that immediately recover their function and those with delayed recovery. Further larger studies are needed to confirm the capability of the technique to predict DGF to optimize the transplanted patients' management.

Multifunctional Indocyanine Green Applications for Fluorescence-Guided Laparoscopic Colorectal Surgery

Indocyanine green (ICG) could be applied for multiple functions such as fluorescent tumor localization, fluorescence lymph node mapping (FLNM), and intraoperative angiography in colorectal cancer surgery. With the near-infrared (NIR) systems, colonoscopic ICG tattooing can be used to define the early colorectal cancer that cannot be easily distinguished through the serosal surface. The lymphatic pathways can be visualized under the NIR system when ICG is injected through the submucosal or subserosal layer around the tumor. Intraoperative ICG angiography can be applied to find a favorable perfusion segment before the colon transection. Although all fluorescence functions are considered essential steps in image-guided surgery, it is difficult to perform multifunctional ICG applications in a single surgical procedure at once because complex protocols could interfere with each other. Therefore, we review the multifunctional ICG applications for fluorescent tumor localization, FLNM, and ICG angiography. We also discuss the optimal protocol for fluorescence-guided colorectal surgery.

PREventive effect of FENestration with and without clipping on post-kidney transplantation lymphatic complications (PREFEN): study protocol for a randomised controlled trial

INTRODUCTION

Peritoneal fenestration is an effective preventive method for reducing the rate of lymphatic complications in kidney transplantation (KTx). The size of the fenestration plays an important role in its effectiveness. A large peritoneal window is no longer indicated, due to herniation and difficulties in performing biopsies. Small preventive fenestration is effective but will be closed too early. The aim of this study is to evaluate whether metal clips around the edges of a small fenestration result in optimal effects with minimum fenestration size.

METHODS AND ANALYSIS

This trial has been initiated in July 2019 and is expected to last for 2 and a half years. All patients older than 18 years, who receive kidneys from deceased donors, will be included. The kidney recipients will be randomly allocated to either a control arm (small fenestration alone) or an intervention arm (small fenestration with clipping). All fenestrations will be round, maximum 2 cm, and close to the kidney hilum. Clipping will be performed with eight metal clips around the peritoneal window (360°) in every 45° in an oblique position. The primary endpoint is the incidence of symptomatic post-KTx lymphatic complications, which require interventional treatment within 6 months after KTx. Secondary endpoints are intraoperative and postoperative outcomes, including blood loss, operation time, severity grade of lymphocele/lymphorrhea and relative symptoms.

ETHICS AND DISSEMINATION

This protocol study received approval from the Ethics Committee of the University of Heidelberg (Registration Number S-318/2017). A Standard Protocol Items: Recommendations for Interventional Trials checklist is available for this protocol. The results will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03682627).

Near-Infrared fluorescence imaging using indocyanine green (ICG): Emerging applications in pediatric urology

BACKGROUND

Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has been recently adopted in pediatric minimally invasive surgery (MIS) in order to improve intra-operative visualization of anatomic structures and facilitate surgery.

OBJECTIVE

This study aimed to report our preliminary experience using ICG technology in pediatric urology using laparoscopy and robotics.

STUDY DESIGN

ICG technology was adopted in 57 laparoscopic or robotic urological procedures performed in our unit over a 24-month period: 41 (38 laparoscopic - 3 robotic) left varicocele repairs with intra-operative lymphography and 16 renal procedures (12 laparoscopic - 4 robotic) including 9 partial nephrectomies, 3 nephrectomies and 4 renal cyst deroofings.

RESULTS

The ICG solution was injected intravenously in renal procedures or into the testis body in case of varicocele repair. Regarding the timing of the administration, the ICG injection was performed intra-operatively in all cases and allowed the visualization of the anatomic structures in a matter of 30-60 s. The dosage of ICG was 0.3 mg/mL/kg in all indications. All procedures were completed laparoscopically or robotically without conversions. No adverse and allergic reactions to ICG and other complications occurred postoperatively.

DISCUSSION

This paper describes for the first time in pediatric urology that ICG-guided NIRF imaging may be helpful in laparoscopic and robotic procedures. In case of varicocele repair, ICG-enhanced fluorescence allowed to perform a lymphatic-sparing procedure and avoid the risk of postoperative hydrocele. In case of partial nephrectomy, ICG-guided NIRF was helpful to visualize the vascularization of the non-functioning moiety, identify the dissection plane between the two moieties (Fig. 1) and check the perfusion of the residual parenchyma after resection of the non-functioning pole. In case of renal cyst deroofing, ICG-guided NIRF aided to identify the avascular cyst dome and to guide its resection. No real benefits of using ICG-enhanced fluorescence were observed during nephrectomy.

CONCLUSION

Our preliminary experience confirmed the safety and efficacy of ICG technology in pediatric urology and highlighted its potential advantages as adjunctive surgical technology in patients undergoing laparoscopic or robotic urological procedures. Use of NIRF was also cost-effective as no added costs were required except for the ICG dye (cost 40 eur per bottle). The most common and useful applications in pediatric urology included varicocele repair, partial nephrectomy ad renal cyst deroofing. The main limitation is the specific equipment needed in laparoscopy, that is not available in all centers whereas the robot is equipped with the Firefly® software for NIRF.

Value of indocyanine green pelvic lymph node mapping in the surgical approach of cervical cancer

PURPOSE

Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients and relevant for therapeutic strategies. We evaluated the clinical value of indocyanine green (ICG) by measuring the sensitivity and negative predictive value of sentinel lymph node mapping compared with the gold standard of complete lymphadenectomy in detecting lymph node metastases for cervical cancer.

METHODS

We utilized the near-infrared imaging agent ICG to detect tumor-infested lymph nodes in the pelvis analogue to a classical sentinel lymph node procedure by analyzing data from 20 patients who had undergone surgery for cervical cancer at our institution. A laparoscopic lymph node mapping procedure by means of ICG, followed by a complete pelvic lymphadenectomy with or without paraaortic lymphadenectomy was done in all patients.

RESULTS

Histological examination identified seven patients with tumor-positive pelvic nodes, whereas mapping with ICG identified only five of these patients. Detection rate of positive nodes by ICG mapping and false negative rate was 71.4% and 28.6%, respectively; bilateral detection rate was 83.3%. One of the two false negative patients additionally suffered from deep infiltrating endometriosis.

CONCLUSIONS

Our results indicate that ICG can identify the relevant pelvic nodes independent of tumor size, provided bilateral detection is achieved and additional, related diseases are excluded.

TRIAL REGISTRATION

This trial is registered within the German Clinical Trial Register (DRKS-ID: DRKS00014692).

[Application progress of indocyanine green angiography in lymphedema]

OBJECTIVE

To summarize the application progress of indocyanine green (ICG) angiography in diagnosis and treatment of lymphedema.

METHODS

The literature related to dynamic imaging tracing of lymphedema at home and abroad was reviewed extensively. And the research status and progress of ICG angiography in diagnosis and treatment of lymphedema were retrospectively analyzed.

RESULTS

ICG angiography can be used as the gold standard for the diagnosis of lymphedema at present and the classification of lymphedema severity, selection of surgical incisions and methods, and intraoperative operation. It can also be used to observe lymphatic drainage and regeneration within 1.5 cm of subcutaneous and determine the prognosis.

CONCLUSION

Compared with traditional methods, ICG angiography has more obvious advantages and value in diagnosis and treatment of lymphedema. However, it also has problems such as slow development speed and difficulty in developing deep lymphatic vessels (nodes).