Fluorescence Angiography using Indocyanine Green in Subinguinal Varicocelectomy

Subinguinal varicocelectomy: trans operative fluorescence angiography using indocyanine green. We present our stablished protocol for real-time, trans operative fluorescence angiography using indocyanine green for subinguinal varicocelectomy.

We dilute 25mg of indocyanine green in 10mL of sterile water, in the operating room, immediately before starting surgery.

For most of our procedures, we prefer to use the (*brand hidden*) near infrared equipment, which has the best fluorescence imaging for open surgery, based on our experience.

Subinguinal varicocelectomy is performed according to the standard technique (it  may be performed with 3.5x loupe magnification, or microscope equipment) a 1 to 2cm incision is performed in the subinguinal region, directly over the palpable spermatic cord, inferior to the external inguinal ring, with blunt and monopolar dissection until spermatic cord identification.

The spermatic cord is dissected, and its anatomical components are macroscopically identified, then, 1mL (2.5mg) of indocyanine green is applied intravenously.

Using either the grayscale or the overlay filter (although we recommend using the grayscale), we will eventually observe, first, the arterial phase, between 20 to 40 seconds after Indocyanine Green IV injection, then, we will see a venous phase, between 40 and 80 seconds after injection. In some cases we may even observe the venous reflux of the dilated veins.

We may perform the exact same procedure in the contralateral varicocele, for bilateral varicocelectomies. However, we recommend waiting at least 25 minutes before applying additional 1ml IV doses of Indocyanine Green to have a better fluorescence angiographic view.

Alan de Jesus Martinez-Salas. Urology and Minimally Invasive Urological Surgery.