A case report of use of ICG in visualization of Ureter in a Case of Enlarged Multifibroid Uterus

Recent years have seen an increase in the diagnosis of benign gynaecological disorders, which has been linked to increased awareness and developments in diagnostic procedures. Minimally invasive surgery due to its cosmetic benefits and better postoperative recovery has become a preferred choice for the surgical management of these conditions. However, the absence of tactile feedback in the laparoscopic method presents a remarkable challenge for surgeons in the intraoperative identification and ongoing monitoring of important anatomical structures. This challenge is further augmented in patients with complex pelvic anatomy, including a large multifibroid uterus and late-stage endometriosis, which have limited visibility and increased cognitive load.

Thus, to overcome challenges of intraoperative visualisation and navigation of important structures, water-soluble fluorescent dye indocyanine green (ICG) can be used successfully in gynaecological laparoscopic surgery. The current case study appraised the role of ICG in ureter identification in a patient of enlarged multifibroid uterus.

A 54-year-old woman presented with a history of polyuria, urge and stress incontinence, abnormal uterine bleeding, and pelvic pressure. 

Her past medical history comprised of a tubular adenoma discovered on colonoscopy, previous left ovarian cyst, and an open appendectomy. 

Ultrasound investigation of the pelvis showed a large pedunculated leiomyoma in the posterior aspect of the uterus. While magnetic resonance imaging confirmed a 150 × 130 × 150 mm leiomyoma with central cystic change displacing uterus left posteriorly, and mild distention and dilatation of both ureters.

The patient was started on a LHRH analogue while a total laparoscopic hysterectomy and bilateral salpingectomy were planned. It was expected that access and visibility of crucial structures would be hampered by the larger uterus. As a result, the patient gave consent for ICG to be used for ureter visualisation via cystoscopy and ureteral catheterisation.

A total 5 ml of diluted ICG was administered bilaterally into the ureters using cystoscopy and ureteral catheterisation during the surgery. Initially, visibility of laparoscopic views was poor because of a large uterus occupying the entire pelvic cavity, posing a significant challenge in viewing important anatomical structures. Then ICG was introduced to visualize the ureters, allowing for their safe and efficient dissection, which decreased the cognitive burden on the surgeons.

Hence, the use of ICG improved precision and safety throughout the surgical procedure, resulting in the completion of the hysterectomy and bilateral salpingectomy in a lesser surgical timeframe with no intraoperative complications. The patient was discharged the day after surgery and a follow up after 8 months revealed complete resolution of urinary symptoms with no further complications.

Source: Menezes SD, Rao T. Innovative ICG Application in Benign Gynaecological Surgery: Enhancing Safety and Precision. Case Rep Obstet Gynecol. 2024 Jul 26;2024:1642315. doi: 10.1155/2024/1642315. PMID: 39105141; PMCID: PMC11300066.