Infrared Ureteric Catheters in Total Laparoscopic Hysterectomy: Method, Advantages, and Disadvantages

Dr. Mumtaz
MBBS; MS; MRCS; M.MAS

Abstract:

The use of infrared ureteric catheters has been gaining attention as a valuable adjunct in total laparoscopic hysterectomy (TLH) for the intraoperative identification and protection of the ureters. This comprehensive review discusses the method of using infrared ureteric catheters during TLH, along with the associated advantages and disadvantages, to provide a balanced perspective on this emerging technology.

I. Introduction

A. Background on total laparoscopic hysterectomy
B. Rationale for ureteral protection during TLH
C. Emergence of infrared ureteric catheters as a potential solution

II. Method of Using Infrared Ureteric Catheters in TLH

A. Preoperative preparation

Indications and patient selection
Obtaining informed consent
Preoperative imaging and planning

B. Intraoperative steps

Patient positioning and establishment of pneumoperitoneum
Insertion of laparoscopic ports and trocars

Placement of the infrared ureteric catheters
a. Retrograde or antegrade technique
b. Proper positioning and confirmation

Activation of the infrared imaging system

Intraoperative identification and protection of ureters during TLH
a. Dissection and mobilization of the uterus
b. Uterine artery and ligament coagulation and transection
c. Vaginal cuff closure and specimen retrieval
d. Removal of the infrared ureteric catheters

C. Postoperative care and follow-up

Monitoring for complications
Early mobilization and pain management
Patient education and postoperative instructions

III. Advantages of Infrared Ureteric Catheters in TLH

A. Enhanced intraoperative visualization

Real-time identification of ureters during surgery
Prevention of iatrogenic ureteral injury
Improved surgeon confidence during complex dissections

B. Versatility and adaptability

Applicability in various gynecological and urological procedures
Compatibility with existing laparoscopic and robotic platforms

C. Real-time ureteral monitoring

Assessment of ureteral integrity and function during surgery
Early detection and management of potential complications

D. Potential cost savings

Reduction in the incidence of ureteral injuries and subsequent interventions
Decreased morbidity and associated healthcare costs

IV. Disadvantages of Infrared Ureteric Catheters in TLH

A. Technical limitations

The limited penetration depth of infrared fluorescence
Signal interference from ambient light or surrounding tissues

B. False-positive and false-negative findings

Variability in catheter fluorescence and signal intensity
Influence of patient factors and clinical context

C. Learning curve and adoption barriers

Surgeon familiarity and experience with infrared ureteric catheters
Cost and availability of infrared imaging systems

D. Potential complications

Ureteral trauma during catheter insertion or removal
Infection or urinary retention associated with catheter use

V. Clinical Outcomes and Comparative Studies

A. Summary of existing literature on infrared ureteric catheters in TLH
B. Comparison with traditional ureteral stents and catheters
C. Impact on surgical outcomes, safety, and cost-effectiveness

VI. Future Directions and Potential Applications

A. Advances in infrared imaging and visualization technologies
B. Integration with other imaging modalities for enhanced surgical guidance
C. Broader applications in gynecological and urological surgery

D. Development of targeted fluorescent probes for ureteral imaging

VII. Method of insertion of catheter:

Inserting an infrared ureteric catheter during a total laparoscopic hysterectomy (TLH) involves several steps to ensure proper placement, visualization, and ureteral protection. Here's a step-by-step guide to inserting an infrared ureteric catheter during TLH:

Patient preparation: Prior to surgery, ensure the patient has been appropriately prepped, positioned, and anesthetized. Establish pneumoperitoneum and insert the laparoscopic ports and trocars in their standard positions.
Cystoscopy (optional): Although not always necessary, performing a cystoscopy before inserting the infrared ureteric catheter can help confirm the absence of any ureteral abnormalities or obstruction that may complicate the procedure.
Choose insertion technique: Decide whether to use a retrograde or antegrade technique for catheter insertion. The retrograde technique is the most common and involves inserting the catheter through the urethra and bladder, while the antegrade technique involves inserting the catheter through a small incision near the ureteropelvic junction. The choice depends on the surgeon's preference and the specific surgical context.
Retrograde insertion technique:

a. Perform a cystoscopy to visualize the bladder and ureteral orifices. b. Use a guidewire to cannulate each ureteral orifice under direct visualization. c. Advance the guidewire into the ureter until it reaches an appropriate depth. d. Insert the infrared ureteric catheter over the guidewire, following it up the ureter. e. Confirm the proper placement of the catheter using fluoroscopy or by visualizing the catheter tip during laparoscopy. f. Secure the catheter in place and remove the guidewire.
Antegrade insertion technique (less common):

a. Identify the ureteropelvic junction laparoscopically. b. Make a small incision near the junction to access the ureter. c. Advance a guidewire into the ureter under direct visualization or fluoroscopy. d. Insert the infrared ureteric catheter over the guidewire and advance it into the ureter. e. Confirm the proper placement of the catheter using fluoroscopy or by visualizing the catheter tip during laparoscopy. f. Secure the catheter in place and remove the guidewire.
Activate the infrared imaging system: Once the infrared ureteric catheters are in place, activate the infrared imaging system to visualize the ureters during the TLH procedure. Adjust the system settings as needed to optimize visualization and reduce interference from ambient light or surrounding tissues.
Proceed with TLH: Continue with the standard steps of the TLH procedure, using infrared ureteric catheters to identify and protect the ureters throughout the surgery.
Catheter removal: After completing the TLH procedure and ensuring there are no ureteral injuries, carefully remove the infrared ureteric catheters. If the retrograde technique was used, the catheters can be removed through the urethra, while the antegrade technique requires removing the catheters through the original incisions.

Remember that inserting an infrared ureteric catheter is a specialized technique that requires training and experience. It is essential to familiarize yourself with the equipment and practice the procedure to ensure patient safety and achieve optimal outcomes.

VIII. Conclusion

Infrared ureteric catheters have shown promise in total laparoscopic hysterectomy, offering enhanced intraoperative visualization, versatility, real-time monitoring, and potential cost savings. However, there are also disadvantages, such as technical limitations, false findings, learning curve challenges, and potential complications. The existing literature suggests that infrared ureteric catheters can improve surgical outcomes and reduce the risk of iatrogenic injury during TLH, but further research is needed to understand their impact on patient care fully and to address current limitations and challenges.

As advances in imaging technology continue to emerge, the role of infrared ureteric catheters in total laparoscopic hysterectomy and other gynecological and urological surgeries is expected to evolve, potentially leading to safer and more effective surgical practices. The integration of infrared ureteric catheters with other imaging modalities and the development of targeted fluorescent probes for ureteral imaging may further enhance surgical precision and outcomes in the future. Ultimately, the use of infrared ureteric catheters in TLH has the potential to transform the surgical landscape and improve patient care.