Indocyanine green for intraoperative ureteral identification in gynecologic surgery: A preliminary systematic review of feasibility, safety, and surgical outcomes

BACKGROUND: Intraoperative ureteral injury, although uncommon, can result in significant morbidity and medicolegal consequences, particularly during complex gynecologic procedures such as endometriosis excision and prolapse repair. Conventional ureteral identification techniques, including stents and methylene blue, have recognized limitations. Indocyanine green (ICG) with near-infrared fluorescence (NIRF) imaging enables real-time ureter visualization, but clinical evidence remains scattered. OBJECTIVE: To systematically evaluate the feasibility, safety, and outcomes of intraureteral ICG for ureteral identification in gynecologic surgery. SEARCH STRATEGY: A systematic literature search of multiple databases was performed for studies published between 2000 and 2025 using keywords related to ICG, ureter, gynecologic surgery, and intraoperative fluorescence. SELECTION CRITERIA: Studies reporting intraureteral ICG use for ureteral identification during gynecologic surgery were eligible. Studies involving fewer than 10 patients were excluded. DATA COLLECTION AND ANALYSIS: Data were extracted on ureter visualization success, ureteral injury, ICG-related complications, and operative outcomes. Risk of bias was assessed using the ROBINS-I, and certainty of evidence was evaluated using GRADE. RESULTS: Of 778 records identified, seven studies comprising 299 patients met the inclusion criteria. All studies reported successful ureter visualization, with no ureteral injuries or ICG-related complications. Secondary outcomes, including estimated blood loss and operative time, were inconsistently reported, with very low certainty of evidence. CONCLUSIONS: Intraureteral ICG appears to consistently enable safe, real-time visualization during gynecologic surgery, including complex cases. Although safety and visualization outcomes are encouraging, the evidence is limited. Prospective observational studies with standardized outcome reporting are needed to inform future practice. PROSPERO REGISTRATION: CRD420251110017.