Retrograde intraureteral injections of indocyanine green versus ureteral stents to reduce urinary tract complications during pelvic surgery: Systematic review and meta-analysis

Introduction Failure to successfully delineate ureters during pelvic surgery carries significant risks. The ureters are the most commonly injured retroperitoneal structures, and ureteral injuries are associated with prolonged hospital stays, higher health care costs, and increased morbidity. In this meta-analysis, we compared the retrograde ureteral injection of indocyanine green and ureteral stents to visualize ureters and prevent ureteral injury and other urinary tract complications during pelvic surgery. Methods Thorough reviews of PubMed, Embase, and Scopus were conducted to identify all studies evaluating the efficacy of retrograde ureteral indocyanine green injections and/or ureteral stents for ureteral injury prevention. Strict inclusion criteria were applied, incorporating a Modified Downs and Black Assessment score. Because no studies comparing these 2 approaches directly were identified, indirect comparisons were performed contrasting rates of successful stent or indocyanine green placement, ureteral injury, and urinary tract complications, including the Pearson χ 2 or Fisher exact test and odds ratios with 95% confidence intervals. Results Twenty and 17 studies were eligible for meta-analysis for stents and indocyanine green, encompassing 25,784 and 569 patients, respectively. All 1,009 ureters that were injected with indocyanine green were injected successfully versus the successful insertion of only 99.1% of the 5,202 ureteral stents for which this approach was reported ( P = .001). Ureteral injuries and other urinary tract complications occurred in 0.18% and 2.16% of ICG patients versus 1.12% and 11.58% of stent patients ( P = .02 and P < .001), respectively. Conclusion Although direct comparisons remain necessary, evidence suggests that retrograde intraureteral injections of indocyanine green are at least as good at preventing ureteral injury as stents, with a much lower rate of other urinary tract complications.