Ukimura Osamu, Gill Inderbir S, Desai Mihir M, Steinberg Andrew P, Kilciler Mete, Ng Christopher S, Abreu Sidney C, Spaliviero Massimiliano, Ramani Anup P, Kaouk Jihad H, Kawauchi Akihiro, Miki Tsuneharu
Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
J Urol. 2004 Jul;172(1):112-8. doi: 10.1097/01.ju.0000128914.21240.c8.
We describe the technical aspects of real-time transrectal ultrasound (TRUS) monitoring and guidance during laparoscopic radical prostatectomy (LRP). Furthermore, we describe the TRUS visualized anatomy of periprostatic structures during LRP.
In 25 consecutive patients undergoing transperitoneal LRP, baseline preoperative, real-time intraoperative and immediate postoperative TRUS evaluations were performed. To define periprostatic anatomy precisely TRUS measurements were obtained with specific reference to the neurovascular bundle (NVB), prostate apex, membranous urethra, bladder neck, rectal wall and any cancer nodule. Conventional gray scale, power Doppler, harmonic imaging and 3-dimensional ultrasound functions were used.
Real-time TRUS navigation facilitated 3 technical aspects of LRP. 1) It identified the correct plane between the posterior bladder neck and prostate base, allowing quick laparoscopic identification of the vasa and seminal vesicles. 2) It identified the occasional, difficult to see distal protrusion of the prostate apex posterior to the membranous urethra, thus enhancing apical dissection with negative margins. 3) It provided visualization of any hypoechoic nodule abutting the prostate capsule, alerting the laparoscopic surgeon to perform wide dissection at that location. TRUS measured various anatomical parameters including i) the mean distance +/-SD between the NVB and the lateral edge of the prostate a) at apex (1.9 +/- 0.9 mm), b) base (2.5 +/- 0.8 mm) and c) tip of seminal vesicle (4.0 +/- 1.6 mm), ii) the dimensions of the NVB a) before (4.5 x 3.9 mm), b) after (4.2 x 3.6 mm) nerve sparing LRP and c) after nonnerve sparing LRP (0.9 x 0.9 mm), iii) arterial blood flow resistive index within NVB a) before (0.83 +/- 0.04), b) after (0.84 +/- 0.03) nerve sparing LRP and c) after nonnerve sparing LRP (0), iv) and the length of membranous urethra a) before (12.2 +/- 1.1 mm) and b) after (11.7 +/- 1.0 mm) surgery. Focal distortion of the prostate surface by an exophytic nodule was visualized on TRUS in 3 patients, necessitating ipsilateral nerve resection at LRP and contributing to negative surgical margins.
This initial experience suggests that real-time intraoperative TRUS guidance may enhance anatomical performance of LRP. This improved understanding of periprostatic anatomy has the potential to improve functional and oncological outcomes. Such corroboration is awaited.
我们描述了腹腔镜根治性前列腺切除术（LRP）期间实时经直肠超声（TRUS）监测和引导的技术方面。此外，我们描述了LRP期间TRUS可视化的前列腺周围结构的解剖情况。
对25例连续接受经腹LRP的患者进行了术前基线、术中实时和术后即刻的TRUS评估。为了精确界定前列腺周围的解剖结构，TRUS测量特别参考了神经血管束（NVB）、前列腺尖、膜性尿道、膀胱颈、直肠壁以及任何癌结节。使用了传统灰阶、能量多普勒、谐波成像和三维超声功能。
实时TRUS导航有助于LRP的三个技术方面。1）它确定了膀胱颈后部与前列腺基部之间的正确平面，使腹腔镜能快速识别输精管和精囊。2）它识别出膜性尿道后方偶尔难以看到的前列腺尖远端突出，从而提高了切缘阴性的尖部解剖效果。3）它能显示任何紧邻前列腺包膜的低回声结节，提醒腹腔镜外科医生在该部位进行广泛解剖。TRUS测量了各种解剖参数，包括：i）NVB与前列腺外侧缘之间的平均距离±标准差，a）在尖部（1.9±0.9毫米），b）在基部（2.5±0.8毫米），c）在精囊尖端（4.0±1.6毫米）；ii）NVB的尺寸，a）保留神经的LRP术前（4.5×3.9毫米），b）保留神经的LRP术后（4.2×3.6毫米），c）未保留神经的LRP术后（0.9×0.9毫米）；iii）NVB内动脉血流阻力指数，a）保留神经的LRP术前（0.83±0.04），b）保留神经的LRP术后（0.84±0.03），c）未保留神经的LRP术后（0）；iv）膜性尿道长度，a）手术前（12.2±1.1毫米），b）手术后（11.7±1.0毫米）。3例患者的TRUS显示前列腺表面因外生性结节而出现局灶性变形，这使得LRP时需要进行同侧神经切除，并有助于实现阴性手术切缘。
这一初步经验表明，术中实时TRUS引导可能会提高LRP的解剖操作水平。对前列腺周围解剖结构的这种更好理解有可能改善功能和肿瘤学结局。期待进一步的证实。
