The Role of Intraoperative Indocyanine Green in Robot-assisted Partial Nephrectomy: Results from a Large, Multi-institutional Series

Background: In recent years, novel technologies have been implemented in order to improve the surgical outcomes of robot-assisted partial nephrectomy (RAPN). Intraoperative administration of indocyanine green (ICG) has been proposed to assess kidney perfusion intraoperatively. Objective: To confirm, on a large scale, the effectiveness of near-infrared fluorescence ICG-guided RAPN in leading the surgeon strategy and to provide hints to the use of this tool. Design, setting, and participants: The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group collected data from 737 patients subjected to RAPN between 2010 and 2016 at three tertiary care referral centers. Of them, 318 had complete demographic and clinical data, and underwent ICG-guided RAPN for clinically localized kidney cancer. Surgical procedure: Patients were subjected to RAPN with intraoperative intravenous ICG injection. Measurements: Optimal surgical outcomes, defined according to both the margin, ischemia, and complication (MIC), and the trifecta score, were assessed. Results and limitations: A total of 194 (61%) patients were male and 124 (39%) were female. The median patient age was 61 yr and median preoperative tumor size was 30 mm. Median operative time, estimated blood loss, and warm ischemia time were, respectively, 162 min, 100 ml, and 17 min. In total, 228 (71.7%) and 254 (79.9%) individuals, respectively, were selected as optimal surgical patients defined according to MIC and trifecta. The univariate and multivariable logistic regression models showed that tumor complexity nephrometry scores were independent predictors of both trifecta and MIC. The main limitation of this study is the lack of a control group. Conclusions: We report the largest population of patients who underwent ICG-guided RAPN. Intraprocedural ICG administration represents a useful tool where the vascular anatomy is challenging, and it could be implemented to maximize the adoption of RAPN. Patient summary: We demonstrated that indocyanine green (ICG) is a reliable tool for guiding the surgeon strategy during robot-assisted partial nephrectomy. ICG may help in procedure tailoring, especially in cases with challenging vascularization or impaired renal function. (C) 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.