Double trouble: incidental finding of a duplicated ureter using intraureteral indocyanine green during laparoscopic colorectal surgery

Ureteric injury is a feared complication in colorectal surgery. Anomalous genitourinary anatomy is common, with duplication of the ureter present in up to 6% of patients. This may increase the risk of inadvertent injury. We describe a laparoscopic anterior resection performed for recurrent sigmoid diverticulitis, where there were difficulties visualizing the left ureter. Intraureteral indocyanine green (ICG) was instilled via a temporary ureteric stent to assist with its identification. This unexpectedly revealed a previously unrecognized narrow-caliber bifid ureter, and enabled both branches of the ureter to be protected from injury. The ureteric stent was removed at completion of the case. The patient experienced transient hematuria post-stent removal, with no other adverse events. Intraureteral ICG is a safe and effective method for intraoperative identification of the ureter, and should be considered particularly in cases where unfavorable anatomy or dense inflammatory adhesions prevent adequate visualization and safe dissection.