Technical standardization of ICG near-infrared fluorescence (NIRF) laparoscopic partial nephrectomy for duplex kidney in pediatric patients

Clinical Consensus Statement on the Use of Indocyanine Green Fluorescence-guided Surgery in Pediatric Patients

BACKGROUND AND AIMS

Indocyanine Green Fluorescence (ICG-F)- guided surgery is becoming an increasingly helpful tool in pediatric surgical care. This consensus statement investigates the utility of ICG-F in various pediatric surgical applications, primarily focusing on its evidence base, safety, indications, use across different surgical specialties and dosing strategies. The aim is to establish an international consensus for ICG-F use in pediatric surgery.

METHODS

An international panel of 15 pediatric surgeons from 9 countries was assembled. The structured process consisted of a rapid scoping review, iterative discussion sessions, mixed-methods studies with key stakeholders, and voting rounds on individual statements to create draft consensus statements.

RESULTS

100 articles were identified during the review and summarized by application. Based on this condensed evidence, consensus statements were generated after 3 iterative rounds of anonymous voting. Key areas of agreement were quality of evidence, the safety of ICG, pediatric surgical indications, utilization per surgical specialty, and dosing of ICG.

CONCLUSION

This consensus statement aims to guide healthcare professionals in managing ICG-F use in pediatric surgical cases based on the best available evidence, key stakeholder consultation, and expert opinions. Despite ICG-F's promising potential, the need for higher-quality evidence, prospective trials, and safety studies is underscored. The consensus also provides a framework for pediatric surgeons to utilize ICG-F effectively.

LEVEL OF EVIDENCE

III.

Indocyanine green (ICG) fluorescence technology in pediatric robotic surgery

This study aimed to report our experience in indocyanine green (ICG) fluorescence-guided surgery (FGS) in pediatric robotics. The data of 55 patients (35 boys and 20 girls), who underwent robotic surgery using ICG fluorescence in three institutions over the last 7 years, were retrospectively reviewed. The following robotic procedures were included: pyeloplasty (n = 21), complex Lich-Gregoir ureteral reimplantation (n = 8), varicocelectomy (n = 7), adnexal pathology resection (n = 8), partial nephrectomy (n = 4), nephrectomy (n = 4), renal cyst removal (n = 2), and excision of prostatic utricle (n = 1). The ICG was injected intravenously in all indications except for varicocele where intratesticular injection was done, and prostatic utricle or paraureteral diverticulum where trans-catheter injection was done. The ICG dosage was 0.2-0.3 mg/mL/kg. All the procedures were performed using da Vinci Xi platform. Firefly® allowed to switch form bright light to ICG-NIRF view and vice versa. All the procedures were accomplished in robotics without conversions to laparoscopy or open surgery. No episodes of allergy or anaphylaxis to ICG were recorded. An excellent ICG-NIRF view of target organs was obtained in all procedures. Based on our experience, we believe that application of ICG FGS in pediatric robotics enhances the identification of critical anatomical elements and pathological structures, thereby positively impacting both oncological and functional outcomes. This technique is safe, feasible, and versatile. We advocate the consideration of ICG as the standard of care in certain procedures such as partial nephrectomy, varicocele repair, tumor resection, and ovarian torsion. Nonetheless, further investigations are warranted to explore its potential broader applications in pediatric urology.

Preoperative three-dimensional modelling and virtual reality planning aids nephron sparing surgery in a child with bilateral Wilms tumour

Bilateral Wilms tumour (BWT) is a surgically challenging condition. Virtual reality (VR) reconstruction aids surgeons to foresee the anatomy ahead of Nephron Sparing Surgery (NSS). Three-dimensional (3D) visualisation improves the anatomical orientation of surgeons performing NSS. We herewith report a case of BWT where VR planning and 3D printing were used to aid NSS. Conventional imaging is often found to be inadequate while assessing the tumour-organ-vascular anatomy. Advances like VR and 3D printing help surgeons plan better for complex surgeries like bilateral NSS. Next-generation extended reality tools will likely aid robotic-assisted precision NSS and improve patient outcomes.

Indocyanine Green-Loaded Nanobubbles Targeting Carbonic Anhydrase IX for Multimodal Imaging of Renal Cell Carcinoma

Background and Purpose

The early diagnosis and differential diagnosis of renal cell carcinoma (RCC) has always been a clinical difficulty and a research focus. Carbonic anhydrase IX (CA IX) is highly expressed on the cell membrane of RCC but is not expressed in normal renal tissues. In this study, nanobubbles (NBs) targeting CA IX with ultrasound and photoacoustic multimodal imaging capabilities were prepared to explore a new method for the diagnosis and differential diagnosis of RCC.

Methods

Indocyanine green (ICG)-loaded lipid NBs (ICG-NBs) were prepared by using the filming rehydration method, and anti-CA IX polypeptides (ACPs) were attached to their surfaces to prepare CA IX-targeted NBs (ACP/ICG-NBs). The particle size, zeta potential and ICG encapsulation efficiency of these nanobubbles were measured, and their specific targeting and binding abilities to RCC cells were determined. The in vitro and in vivo ultrasound, photoacoustic and fluorescence imaging characteristics of these nanobubbles were also assessed.

Results

The particle size of the ACP/ICG-NBs was 475.9 nm in diameter, and their zeta potential was -2.65 mV. Laser confocal microscopy and flow cytometry both confirmed that ACP/ICG-NBs had specific binding activity and ideal affinity to CA IX-positive RCC cells (786-O) but not to CA IX-negative RCC cells (ACHN). The intensities of the in vitro ultrasound, photoacoustic and fluorescence imaging were positively correlated with the concentrations of ACP/ICG-NBs. In in vivo ultrasound and photoacoustic imaging experiments, ACP/ICG-NBs exhibited specific enhanced ultrasound and photoacoustic imaging effects in 786-O xenograft tumors.

Conclusion

The ICG- and ACP-loaded targeted nanobubbles that we prepared had the capability of ultrasound, photoacoustic and fluorescence multimodal imaging and could specifically enhance the ultrasound and photoacoustic imaging of RCC xenograft tumors. This outcome has potential clinical application value for the diagnosis of RCC at the early stage and the differential diagnosis of benign and malignant kidney tumors.

Evaluating the Development Status of Fluorescence-Guided Surgery (FGS) in Pediatric Surgery Using the Idea, Development, Exploration, Assessment, and Long-Term Study (IDEAL) Framework

Fluorescence-guided surgery (FGS) is used in many pediatric subspecialties but there are currently no standard guidelines or outcome data. We aimed to assess the current status of FGS in pediatrics using the Idea, Development, Exploration, Assessment, and Long-term study (IDEAL) framework. Clinical papers on FGS in children published from January 2000 to December 2022 were systematically reviewed. The stage of research development was measured considering seven fields of application: biliary tree imaging, vascular perfusion for gastrointestinal procedures, lymphatic flow imaging, tumor resection, urogenital surgery, plastic surgery, and miscellaneous procedures. Fifty-nine articles were selected. For each field of application, the overall IDEAL stage was determined to be 2a for biliary tree imaging (10 publications, 102 cases), 1 for vascular perfusion for gastrointestinal procedures (8 publications, 28 cases), 1 for lymphatic flow imaging (12 publications, 33 cases), 2a for tumor resection (20 publications, 238 cases), 2a for urogenital surgery (9 publications, 197 cases), and 1-2a for plastic surgery (4 publications, 26 cases). One report did not belong to any categories. FGS in children is still in an early phase of adoption and development. We recommend using the IDEAL framework as a guide and suggest developing multicenter studies to define the standard guidelines, effectiveness, and outcomes.

Application of Indocyanine Green in Combination with Da Vinci Xi Robot in Surgeries on the Upper Urinary Tract: A Case Series Study

BACKGROUND

To explore the application value of intraoperative imaging by indocyanine green (ICG) injection through the collection system of the urinary tract for Da Vinci Xi robot navigation in complex surgeries on the upper urinary tract.

METHODS

Data of 14 patients who underwent complex surgeries of the upper urinary tract post-ICG injection through the collection system of the urinary tract in combination with Da Vinci Xi robot navigation in the Tianjin First Central Hospital between December 2019 and October 2021 were analyzed in this retrospective study. The operation duration, estimated blood loss, and exposure time of ureteral stricture to ICG were evaluated. The renal functions and tumor relapse were evaluated after surgery.

RESULTS

Of the fourteen patients, three had distal ureteral stricture, five had ureteropelvic junction obstruction, four presented duplicate kidney and ureter, one had a giant ureter, and one presented an ipsilateral native ureteral tumor after renal transplantation. The surgeries in all patients were successful, with no conversion to open surgery. In addition, no injury to the surrounding organs, anastomotic stenosis or leakage, or ICG injection-related side effects were detected. Imaging at 3 months post-operatively revealed improved renal functions compared to those before the operation. No tumor recurrence or metastasis was observed in patient 14.

CONCLUSION

Fluorescence imaging compensating for the inadequacy of tactile feedback in the surgical operating system has advantages in identifying the ureter, determining the site of ureteral stricture, and protecting the blood flow for the ureter.

Applications of Indocyanine Green-Guided Near-Infrared Fluorescence Imaging in Pediatric Minimally Invasive Surgery Urology: A Narrative Review

Background: Indocyanine green (ICG) is a fluorescent dye used for several indications in adult surgery, and, more recently, adopted also in the pediatric patients. This study aimed to review the literature published on the use of ICG near-infrared fluorescence (NIRF) in pediatric urology, to address its shortcomings and disadvantages and to detect the future perspectives. Materials and Methods: An electronic literature search of PubMed on all studies reporting use of ICG-NIRF in pediatrics was performed. We included only studies reporting ICG-NIRF application in minimally invasive surgery (MIS) for pediatric urology indications. Results: Forty-two articles reporting MIS procedures performed using ICG-NIRF in children were obtained, but only 15 studies that focused on urological applications of ICG-NIRF in children were included in this review. The included studies described use of ICG-NIRF for kidney malformations such as duplex system, kidney tumors, renal cysts, ureteral pathology, bladder malformations, varicocele, and lymph node sampling in tumors. The pediatric urological applications in which ICG-NIRF provided significant advantages included partial nephrectomy, lymphatics sparing varicocele repair, and oncological procedures. The ICG-NIRF use was clinically safe, without reported adverse systemic reactions in all pediatric series. The main drawback of this technology is the need of specific laparoscopic equipment such as camera system, light sources, and telescopes or the da Vinci Xi Robot, with the software for ICG-NIRF, Firefly^®, already integrated within. Conclusions: ICG-enhanced fluorescence-guided surgery is gaining growing popularity among pediatric surgeons due to the excellent results that have been published until now. ICG-NIRF technology has proven to be safe, easy to use, not time-consuming, cheap, and very effective to improve intraoperative view and surgical ability. Nonetheless, further evidence, including larger series, longer follow-up, and more specific assessments, is necessary to confirm the preliminary results and enlarge the applications.

Fluorescence-Guided Surgery and Novel Innovative Technologies for Improved Visualization in Pediatric Urology

Fluorescence-guided surgery (FGS), three-dimensional (3D) imaging technologies, and other innovative devices are rapidly revolutionizing the field of urology, providing surgeons with powerful tools for a more complete understanding of patient-specific anatomy. Today, several new intraoperative imaging technologies and cutting-edge devices are available in adult urology to assist surgeons in delivering personalized interventions. Their applications are also gradually growing in general pediatric surgery, where the detailed visualization of normal and pathological structures has the potential to significantly minimize perioperative complications and improve surgical outcomes. In the field of pediatric urology, FGS, 3D reconstructions and printing technologies, augmented reality (AR) devices, contrast-enhanced ultrasound (CEUS), and intraoperative magnetic resonance imaging (iMRI) have been increasingly adopted for a more realistic understanding of the normal and abnormal anatomy, providing a valuable insight to deliver customized treatments in real time. This narrative review aims to illustrate the main applications of these new technologies and imaging devices in the clinical setting of pediatric urology by selecting, with a strict methodology, the most promising articles published in the international scientific literature on this topic. The purpose is to favor early adoption and stimulate more research on this topic for the benefit of children.

The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

Purpose: Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging technique used to assess tissue vascularization and guide intraoperative decisions in many surgical fields including plastic surgery, neurosurgery, and general surgery. While this technology is well-established in adult surgery, it remains sparsely used in pediatric surgery. Our aim was to systematically review and provide an overview of all available evidence on the perioperative use of indocyanine green fluorescence angiography in pediatric surgical patients. Methods: We conducted a systematic review with narrative synthesis in conformity with the PRISMA guidelines using PubMed, Medline, All EBM Reviews, EMBASE, PsycINFO, and CINAHL COMPLETE databases to identify articles describing the perioperative use of ICG-FA in pediatric patients. Two independent authors screened all included articles for eligibility and inclusion criteria. We extracted data on study design, demographics, surgical indications, indocyanine green dose, and perioperative outcomes. We developed a risk of bias assessment tool to evaluate the methodological quality of included studies. Results: Of 1,031 articles retrieved, a total of 64 articles published between 2003 and 2020 were included reporting on 664 pediatric patients. Most articles were case reports and case series (n = 36; 56%). No adverse events related to ICG-FA were reported in the included articles. Risk of bias was high. We did not conduct a meta-analysis given the heterogeneous nature of the populations, interventions, and outcome measures. A narrative synthesis is presented. Conclusion: Indocyanine green fluorescence angiography is a safe imaging technology and its use is increasing rapidly in pediatric surgical specialties. However, the quality of evidence supporting this trend currently appears low. Case-control and randomized trials are needed to determine the adequate pediatric dose and to confirm the potential benefits of ICG-FA in pediatric surgical patients. Systematic Review Registration: This study was registered on Prospero a priori, identifier: CRD42020151981.