Case Series of the Month Robotic Transrectal Ultrasonography During Robot-Assisted Radical Prostatectomy Andrew J. Hung, Andre ´ Luı´s De Castro Abreu, Sunao Shoji, Alvin C. Goh, Andre K. Berger, Mihir M. Desai, Monish Aron, Inderbir S. Gill, Osamu Ukimura * USC Institute of Urology, Center for Image-Guided Surgery and Center for Advanced Robotic and Laparoscopic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA 1. Case report Robot-assisted prostatectomy (RAP) has become an accept- ed and popular approach to radical prostatectomy (RP). Nonetheless, certain aspects of the procedure remain challenging. In addition to the inherent learning curve associated with robotic surgery [1], the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) lacks haptic feedback. As such, certain critical steps of the procedure, including posterior bladder neck transection, neurovascular bundle (NVB) preservation, and apical dissection, are performed solely with visual cues. Furthermore, cancer abutting the prostate capsule or focally extending into periprostatic tissue increases the risk of positive surgical margins (PSMs). Transrectal ultrasound (TRUS) is widely used for diagnostic and therapeutic purposes for prostate cancer (PCa). Previously, we described the use of real-time TRUS EUROPEAN UROLOGY 62 (2012) 341–348 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted April 10, 2012 Published online ahead of print on April 17, 2012 Keywords: Prostate neoplasm Robot Surgical guidance Ultrasound Abstract We evaluate the use of robotically manipulated transrectal ultrasound (TRUS) for real- time monitoring of prostate and periprostatic anatomy during robot-assisted prosta- tectomy (RAP). Ten patients with clinically organ-confined prostate cancer undergoing RAP underwent preoperative and real-time intraoperative biplanar TRUS evaluation using a robotically manipulated TRUS device (ViKY System; EndoControl Medical, Grenoble, France). Median patient age was 66 yr (range: 54–88), baseline prostate- specific antigen (PSA) was 5.3 (range: 1.3–17.9), and four patients (40%) had clinical high-grade and high-stage disease. Bilateral or unilateral nerve sparing was performed in nine patients (90%). Median time for ViKY System setup to insertion of the TRUS probe was 7 min (range: 4–12). Complete robotic TRUS evaluation was successful in all patients. Five patients (50%) had TRUS-visible hypoechoic lesions, confirmed cancerous on preoperative biopsy. Relevant intraoperative TRUS findings were relayed in real time to the robotic surgeon, particularly during dissection of the bladder neck and prostatic apex, during neurovascular bundle preservation, and when hypoechoic prostate lesions approximated nerve-preserving dissection. Negative margins were achieved in nine patients (90%), including cases where significant intraprostatic lesions abutted or extended through the prostate capsule. No complications occurred. We concluded that real-time robotic TRUS guidance during RAP is feasible and safe. Robotic TRUS can provide the console surgeon with valuable anatomic information, thus maximizing functional preservation and oncologic success. # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. USC Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA. Tel. +1 323 865 3700; Fax: +1 323 865 0120. E-mail address: ukimura@usc.edu (O. Ukimura). 0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2012.04.032