Intraoperative indocyanine green fluorescence guidance to reduce ureteroenteric anastomotic strictures during robot-assisted radical cystectomy. A systematic review and meta-analysis.

Ureteroenteric anastomotic stricture (UAS) is a clinically relevant complication of robot-assisted radical cystectomy (RARC), primarily driven by ureteral ischemia. Indocyanine green (ICG) fluorescence has been proposed to identify ischemic segments prior to anastomosis. This systematic review and meta-analysis aimed to evaluate UAS incidence with ICG versus no ICG during RARC. PubMed, Embase, and Cochrane were searched up to February 2026. Eligible studies were comparative observational studies on adults undergoing RARC exclusively. Random-effects models were used to pool risk ratios (RR) and mean differences (MD) with 95% confidence intervals. Four observational studies were included (n = 886 patients; 1,739 ureters): 369 (41.6%) underwent ICG - guided assessment and 517 (58.4%) standard assessment without ICG. Pooled analysis showed no statistically significant reduction in UAS per ureter (RR 0.31, 95% CI 0.08-1.16; P = 0.08; I² = 76.4%). Sensitivity analysis excluding the highest-bias study eliminated heterogeneity and shifted results in favor of ICG (RR 0.20, 95% CI 0.09-0.46; I² = 0%), suggesting that the primary pooled estimate is unstable and heavily influenced by between-study heterogeneity. No significant differences were observed in ureteral excision length, node positivity, or operative time. Current evidence is limited to non-randomized studies with serious risk of bias and very low certainty. The instability of the pooled estimate highlights the inadequacy of the current evidence base and the need for prospective randomized studies to define the true clinical benefit of ICG. PROSPERO: CRD420261322254.