Fluorescence-Guided Bladder and Ureter Visualization in Benign Robotic Gynecologic Surgery: A Series of Five Cases

Indocyanine green (ICG) near-infrared fluorescence imaging is well established in gynecologic oncology, but its role in benign minimally invasive surgery is still limited and not standardized. Increasing cesarean section and endometriosis rates elevate the risk of urinary tract injury, highlighting the need for improved intraoperative visualization. This case series evaluates the practical use and reliability of ICG fluorescence for bladder and ureteral identification during benign robotic gynecologic procedures. Two patients undergoing robotic hysterectomy using the Da Vinci Xi Firefly system (Intuitive Surgical, Sunnyvale, California, United States) for benign indications had a history of prior cesarean deliveries. Intravesical ICG was administered to delineate the bladder. However, fluorescence was patchy and unreliable, with only partial bladder wall visualization despite adequate technique. In contrast, two patients with deep infiltrating endometriosis involving the ureter underwent cystoscopic retrograde instillation of ICG, which provided consistent and clear fluorescence-guided ureteral mapping, facilitating safe dissection and preservation. A fifth case involved a patient with symptomatic adenomyosis and an endometriotic ovarian cyst, in whom preoperative imaging also revealed an ectopic left kidney, requiring careful retroperitoneal assessment and ureteral identification during robotic hysterectomy. All surgeries were completed robotically without complications. Ureteral visualization with ICG was reproducible and effective, while bladder demarcation using intravesical ICG showed variable fluorescence, likely due to fibrosis and impaired diffusion in scarred tissue. Fluorescence-guided robotic surgery using ICG is a valuable adjunct for ureteral identification in benign gynecology, particularly in advanced endometriosis. However, its application for bladder demarcation after multiple cesarean sections appears less reliable, showing the need for protocol improvement and further evaluation before routine use.