Use of ICG-guided fluorescence imaging in pediatric laparoscopic and robot-assisted surgery: a single-center retrospective study

Abstract

Background: Indocyanine green (ICG) fluorescence imaging represents a recent advancement in pediatric minimally invasive surgery (MIS), offering superior visualization of critical anatomical structures. Despite its growing application, evidence on its specific utility in pediatric urology remains limited. This study aimed to evaluate the safety, efficacy, and broader applications of ICG-guided fluorescence imaging in pediatric robotic and laparoscopic surgery, with an emphasis on refining surgical precision and improving outcomes. Building on our previous research on ICG applications, this work expands the focus to include a larger cohort and a diverse range of procedures to establish standardized protocols.

Methods: The records of all patients undergoing robotic or laparoscopic urological surgery with ICG-NIRF assistance over a 7-year period (2018–2024), were analyzed retrospectively. ICG was administered using tailored protocols for each procedure type, with fluorescence imaging applied to enhance intraoperative navigation and decision-making. The ICG dosage ranged between 0.035 and 0.5 mg/kg.

Results: Patient cohort included 278 patients with median age of 9.2 years (range 1-18). Laparoscopic procedures with ICG-NIRF were performed in 181 patients (65.1%), including pyeloplasty (n = 11), varicocelectomy (n = 118), adnexal pathology resection (n = 33), partial nephrectomy (n = 10), nephrectomy (n = 6), and urachal cyst excision (n = 3). The remaining 97 patients (34.9%) underwent robot-assisted procedures, including pyeloplasty (n = 22), varicocelectomy (n = 34), adnexal pathology resection (n = 17), partial nephrectomy (n = 4), nephrectomy (n = 4), excision of periureteral diverticulum and dismembered extravesical ureteral reimplantation (n = 13), renal cyst removal (n = 2), and prostatic utricle cyst excision (n = 1). All procedures were completed successfully without conversions to open surgery. Clear visualization of target anatomy was achieved in all cases, with no intraoperative complications. The median hospital stay was 2.7 days (range 1-7). The complication rate (Clavien 3b) was 0.7%, with no allergic reactions reported.

Conclusion: The findings of this study highlight the potential of ICG fluorescence as an innovative tool in the pediatric urology field. While the current evidence supports its safety, feasibility, and ability to enhance intraoperative visualization, prospective, controlled trials are needed to validate its efficacy, investigate functional outcomes, and compare its utility with existing standard practices.

Keywords: ICG, fluorescence, robotics, laparoscopy, urology, imaging, pediatrics