Introduction: Robotic microsurgical varicocelectomy has emerged as a feasible alternative compared to the traditional operating microscope due to enhanced visualization, improved ergonomics, and the utilization of indocyanine green (ICG) for testicular artery identification and preservation. ICG angiography (ICGA) provides clear visualization of the artery; has fast onset and offset; is less time-intensive, more objective, and less expensive than the microvascular Doppler; and can be used for documentation purposes. In this video, we demonstrate the use of ICGA both for arterial identification and for confirmation of patency at the conclusion of the case. Methods: Our institution performs varicocelectomies via the robotic microsurgical approach. The spermatic cord is first identified and isolated through a subinguinal incision, then the Da Vinci robot is docked extracorporeally. The cremasteric fibers are divided and the external spermatic fascia is entered. The vas deferens is isolated and preserved with a vessel loop. After ligation of superficial veins, ICGA is utilized to visualize the testicular artery. One ml of ICG (2.5 mg/ml) is injected intravenously for identification of the artery. The varicocelectomy is completed, then an additional 1 ml of ICG is injected intravenously to confirm arterial patency. Results: ICGA successfully identifies the testicular artery within 30 seconds and is washed out within 1 minute, allowing for multiple administrations throughout the procedure, including confirmation of arterial patency at the conclusion of the case. Due to the clear visualization of arterial blood supply with ICGA, picture and/or video may be taken and preserved for documentation of arterial patency after the varicocelectomy is completed. Conclusions: Due to the complexity of vascular anatomy within the spermatic cord, distinguishing arteries from veins may be challenging and time-intensive when using a Doppler ultrasound probe alone during microsurgical varicocelectomy. ICG is an excellent tool in robotic microsurgical varicocelectomy, assisting in identification of the testicular artery and in demonstrating patency of the artery after the varicocelectomy is completed, without adding significant time or complication. Further studies are needed to assess if ICGA alone can be used for identification and confirmation of arterial blood supply during robotic microsurgical varicocelectomy. SOURCE OF Funding: None
