Real-time transrectal ultrasound guidance during nerve sparing laparoscopic radical prostatectomy: pictorial essay.

PURPOSE We report that real-time TRUS can visualize prostate/periprostatic anatomy and provide intraoperative navigation during nerve sparing LRP. Real-time TRUS navigation during radical prostatectomy, whether open or laparoscopic, is a novel application about which little is known. MATERIALS AND METHODS Transperitoneal LRP with TRUS guidance has been performed in 77 consecutive men since March 2003. Gray-scale ultrasound (7.5 MHz) and power Doppler ultrasound were used. Real-time TRUS monitoring was performed preoperatively, intraoperatively and immediately postoperatively. Emphasis was placed on identifying the neurovascular bundles, defining the prostate apex contour and evaluating the location and extent of any hypoechoic cancer nodules. RESULTS Intraoperative TRUS navigation appeared to be helpful for certain specific technical aspects of LRP, including 1) the identification of hypoechoic prostate cancer nodules, 2) precision during lateral pedicle transection and neurovascular bundle release, 3) calibrated, wider dissection at the site of suspected extracapsular extension of cancer nodules to achieve negative margins, 4) tailored dissection according to the individual prostate apex and (5) facilitation of posterior bladder neck transection for the novice. Real-time TRUS monitoring of the location of the laparoscopic scissors tip (hyperechoic spot) in regard to the safe dissection plane at the concerned anatomical site was feasible. Blood flow in the neurovascular bundles before, during and after nerve sparing LRP was documented. CONCLUSIONS Real-time rectum based monitoring such as TRUS navigation has the potential to enhance intraoperative surgical precision during LRP. A pictorial essay highlighting the various aspects of intraoperative TRUS is presented.