case_images: PMC11693108_01
case_images: (a) The patient's body position. The patient was placed in a low lithotomy position with a 25-degree head-down tilt. A fingertip type probe was inserted transrectally. (b) A picture of the fingertip type of TRUS probe. (c) The scheme of the port position. Using the Open Hasson technique, the da Vinci camera port ("Arm 2") was placed 18 cm above the suprapubic border in the midline through a 3-cm transverse incision. The da Vinci port for "Arm 1" and "Arm 3" were placed symmetrically on the left and right side, 7.5 cm away from the camera port, at the same transverse level as the camera port. The da Vinci port for extra arm ("Arm 4") was placed on the right side, 7.5 cm away from the "Arm 3" port, 2 cm above the right anterior superior iliac spine. Two assistant ports were placed on the left side of the patient: a 5-mm trocar at 5 cm above the midpoint of the camera port and the da Vinci "Arm 1" port, and a 12-mm trocar (Airseal , CONMED, the United States) on the left side, 7.5 cm away from the "Arm 1" port, 2 cm above the left anterior superior iliac spine. A 12-mm assistant's trocar was placed on the right side of the patient, at 5 cm above the center of the da Vinci "Arm 3" and extra arm. The red circle represents camera port. The blue circles represent the da Vinci port (8 mm). The yellow circles represent assistant ports.
case_images: IJU5-8-28-g001.jpg
case_images: PMC11693108_01_IJU5-8-28-g001.jpg
case_images: iju512799-fig-0001
case_images: Surgical technique: Under general anesthesia, the patient was placed in a low lithotomy position with a 25-degree head-down tilt (Fig. 1a). He underwent RARC using the da Vinci Xi System  (Intuitive Surgical, USA) with a fingertip type of TRUS probe (EUP-F334 , FUJIFILM Healthcare Corporation, Japan) to guide a rectovesical space (Fig. 1a,b). Port position is described in Fig. 1c.
case_images: Intraoperative images. The upper images show the endoscopic images and the lower images show the TRUS image displayed on the TILEPRO . By checking the TRUS image displayed on the TILEPRO  when the scissors have been tapped, the boundaries between the rectal wall and the bladder can be visualized. (a) The dissection between the lavetor ani muscle and the bladder. (b) The dissection of the rectovesical space before saline injection into the bladder. (c, d) The dissection of the rectovesical space after saline injection into the bladder. (e, f) The dissection around the vesicourethral anastomotic site.
case_images: IJU5-8-28-g002.jpg
case_images: PMC11693108_01_IJU5-8-28-g002.jpg
case_images: iju512799-fig-0002
case_images: Adhesion between the lavetor ani muscle and the bladder was moderate (Fig. 2a). However, it was extremely difficult to see the dissection line, especially around the vesicourethral anastomotic site, due to strong adhesion of the rectovesical space (Fig. 2b). We also injected saline into the bladder, which made it easier to visualize the border of the bladder and rectum (Fig. 2c,d). As strong adhesion prevented blunt dissection around the vesicourethral anastomotic site, we dissected the rectovesical space through athermal cold incision (Fig. 2e,f).