Critical appraisal of management of rectal injury during radical prostatectomy

Objectives: To critically evaluate the perioperative management of rectal injury during radical prostatectomy. Methods: Rectal injuries were identified from the departmental morbidity and mortality records and radical prostatectomy databases. The electronic patient records were reviewed for management and outcomes. Results: From January 1997 to August 2007, 11 452 men underwent radical prostatectomy. Of these men, 10 183 underwent radical retropubic prostatectomy (RRP) and 1269, laparoscopic retropubic prostatectomy (LRP) with or without robotic assistance. Rectal injury occurred in 18 men12 in the RRP group (0.12%) and 6 in the LRP group (0.47%). Of these rectal injuries, 16 were recognized intraoperatively and primarily repaired in multiple layers without a diverting colostomy. A pedicle of omentum was used as an interposing layer in 4 of these cases. Despite primary repair, 2 patients without omental interposition developed a rectourethral fistula. In 1 man in the RRP group, the fistula closed with prolonged catheterization (9 weeks). In the other patient, in the LRP group, the fistula persisted; thus, a diverting colostomy was performed. Eventually, a transrectal advancement flap was required. Two rectal injuries (1 each in the RRP and LRP groups) were unrecognized during radical prostatectomy but were discovered within 4 days. Despite conservative management, the rectourethral fistulas persisted in both men, requiring subsequent repair with a transrectal advancement flap. Conclusions: Rectal injury is an infrequent complication of radical prostatectomy. When recognized intraoperatively and primarily repaired, rectourethral fistula was prevented in 87.5% of men. Primary repair performed with vascularized tissue interposition prevented rectourethral fistula development. In men with unrecognized rectal injury, the rectourethral fistula tended to persist and eventually required delayed surgical repair.