Debasish Sundi, MD
Misop Han, MD
BASICS
DESCRIPTION
• Rectal injury is a rare, potential complication of radical prostatectomy or radical cystoprostatectomy, with a reported incidence ranging from 0.1–1.7%
– Reported for radical prostatectomy: Retropubic perineal, laparoscopic, and robotically assisted laparoscopic approaches
– Reported for radical cystectomy: Open and robotically assisted approaches
• Intraoperative recognition of the rectal injury is paramount; this will allow primary repair in layers and minimize the chance of subsequent rectourethral fistula
• Occasionally the problem will not be identified until the postoperative period
EPIDEMIOLOGY
Incidence
• The rate of rectal injury during urologic pelvic procedures varies by procedure and approach
• For radical prostatectomy, rectal injury rates are quite low, ranging from 0.1–0.5% (open retropubic, pure laparoscopic, or robot assisted) (1,2)[C]
– Rectal injury rates are higher for radical cystoprostatectomy (up to 1.7%) (3)[C], and highest for perineal prostatectomy (8–11%) (4)[C]
Prevalence
Extrapolating from the number of procedures performed annually in US, the prevalence of rectal injury for radical prostatectomy ranges from 80–400 cases per yr, and for radical cystectomy, up to 150 cases per yr
RISK FACTORS
History of pelvic radiation therapy or prior pelvic surgery
Genetics
N/A
PATHOPHYSIOLOGY
N/A
ASSOCIATED CONDITIONS
• Prior pelvic radiation or surgical procedures may increase the risk of rectal injury
• Extensive transurethral resection of bladder floor for urothelial carcinoma
• Inflammatory bowel disease
• Locally advanced malignancy
GENERAL PREVENTION
• Adequate intraoperative hemostasis to aid visualization
• Bowel preparation has not been proven to reduce the risk of intraoperative bowel injury but may limit contamination in the event of an injury
• Placement of a rectal tube at the start of the procedure may aid in the identification of the rectal wall in difficult cases (ie, salvage prostatectomy following radiation)
• Careful identification of the anterior and posterior layers of Denonvilliers fascia will aid in avoiding rectal injury
DIAGNOSIS
HISTORY
• After removal of the specimen (open surgery), inspection of the surgical bed using posterior traction to efface folds of tissue will typically reveal a rectal injury by direct visualization
– Obtaining good hemostasis will aid visualization
– Copious irrigation of the pelvis with sterile saline may also reveal air bubbles emanating from the rectal vault (2)[C]
• Symptoms may include abdominal or pelvic pain; nausea and vomiting may also be present
PHYSICAL EXAM
Postoperative manifestations may include exam findings that may include tenderness to palpation, fever, tachycardia, hypotension, ileus (2)[C]
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Acute injury may not manifest any lab abnormalities
• An unrecognized postoperative injury may demonstrate leukocytosis
Imaging
• Postoperatively CT ± cystourethrography
– Free air in pelvis and/or peritoneum
– Contrast communicating between rectum and bladder/urethra
Diagnostic Procedures/Surgery
• After removal of the specimen (laparoscopic or robotic surgery) from the prostatic fossa, a suspected rectal injury can be confirmed by flooding the pelvis with saline irrigant and gently insufflating the rectum with air injected via a Foley catheter
– A rectal enterotomy will be evident by air bubbling through the irrigant
Pathologic Findings
A through-and-through injury will involve both the rectal serosa and mucosa
DIFFERENTIAL DIAGNOSIS
• Intraoperative differential diagnosis is limited
• Postoperative differential includes:
– Small bowel or large perforation (iatrogenic)
– Colonic perforation secondary to pathologic distension such as in colonic pseudoobstruction, or Ogilvie syndrome
– Pelvic abscess
TREATMENT
GENERAL MEASURES
• When a rectal injury is diagnosed postoperatively, management depends on the patient’s clinical picture
• Patients who are minimally symptomatic and have a small injury radiographically may be initially managed conservatively by indwelling urethral catheter, with reassessment by cystogram after 2–3 mo (5)[C]
• The GI tracts of patients who are symptomatic, septic, or have a history of prior pelvic radiation should be diverted with an end colostomy (5)[C]
– These patients’ GI tracts can be brought back in continuity if a cystogram and/or Gastrografin enema are negative in 2–3 mo. If these patients have persistent fistulas, they should be surgically repaired with a transrectal advancement flap (2)[C].
MEDICATION
First Line
• 7–14 days of antimicrobial therapy (4)[C]
– Antibiotic regimen should cover both gram-negatives and anaerobes (such as ciprofloxacin and metronidazole)
Second Line
N/A
SURGERY/OTHER PROCEDURES
• When a rectal injury is diagnosed intraoperatively, it should be repaired immediately, closing the rectal mucosa and serosa in separate layers
– Suture choice includes mucosal layer with 3-0 chromic and the serosa with 3-0 silk or other suitable alternatives (2)
– An additional flap of vascularized tissue (omentum or peritoneum) should be interposed between the rectal repair and the bladder/urethra. Immediate repair minimizes the risk of subsequent rectourethral fistula.
If a rectourethral fistula does form in spite of immediate repair, management options are conservative treatment via Foley catheterization or surgical repair via diverting colostomy and, if necessary, a transrectal advancement flap (6)[C]
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Among patients undergoing immediate intraoperative repair, there is a 12.5% incidence of subsequent rectourethral fistula (6)[C]
– Rectal injuries of increasing length are associated with a higher risk of rectourethral fistulae, as are those recognized and repaired in delayed fashion
COMPLICATIONS
• Need for temporary colostomy diversion
• Rectourethral fistula
• With delayed rectoanastomotic fistula after radical prostatectomy: incontinence (7)
• Sepsis
FOLLOW-UP
Patient Monitoring
• After repair, routine monitoring on a regular surgical floor with daily labs is appropriate
– Prior to routine Foley catheter removal after radical prostatectomy, perform cystogram to rule out fistula at 14 days after surgery
If rectourethral fistula is demonstrated, continue Foley catheter, as resolution of fistula with period of catheterization up to 9 wk has been demonstrated
Patient Resources
None
REFERENCES
1. Lepor H, Nieder AM, Ferrandino MN. Intraoperative and postoperative complications of radical retropubic prostatectomy in a consecutive series of 1,000 cases. J Urol. 2001;166(5):1729–1733.
2. Evans CP. Complications of cystectomy and partial cystectomy Chapter 32. In: Complications of Urologic Surgery. 3rd ed. Philadelphia, PA: Saunders; 2001.
3. Lawrentschuk N, Colombo R, Hakenberg OW, et al. Prevention and management of complications following radical cystectomy for bladder cancer. Eur Urol. 2010;57(6):983–1001.
4. Lassen PM, Kearse WS Jr. Rectal injuries during radical perineal prostatectomy. Urology. 1995;77(4):266–269.
5. Borland RN, Walsh PC. The management of rectal injury during radical retropubic prostatectomy. J Urol. 1992;147(3):163–166.
6. Roberts WB, Tseng K, Walsh PC, et al. Critical appraisal of management of rectal injury during radical prostatectomy. Urology. 2010;76(5):1088–1091.
7. Pfalzgraf D, Isbarn H, Reiss P, et al. Outcomes after recto-anastomosis fistula repair in patients who underwent radical prostatectomy for prostate cancer. BJU Int. 2014;113(4):568–573.
ADDITIONAL READING
• Blumberg JM, Lesser T, Tran VQ, et al. Management of rectal injuries sustained during laparoscopic radical prostatectomy. Urology. 2009;73(1):163–166.
• Kheterpal E, Bhandari A, Siddiqui S, et al. Management of rectal injury during robotic radical prostatectomy. Urology. 2011;77(4):976–979.
• Sugihara T, Yasunaga H, Horiguchi H, et al. Does mechanical bowel preparation ameliorate damage from rectal injury in radical prostatectomy? Analysis of 151 rectal injury cases. Int J Urol. 2014;21(6):566–570.
See Also (Topic, Algorithm, Media)
• Fistula, Enterovesical
• Fistula, Rectourethral
CODES
ICD9
• 599.1 Urethral fistula
• 863.45 Injury to rectum, without mention of open wound into cavity
• 998.2 Accidental puncture or laceration during a procedure, not elsewhere classified
ICD10
• K91.72 Acc pnctr & lac of a dgstv sys org during oth procedure
• N36.0 Urethral fistula
• S36.60XA Unspecified injury of rectum, initial encounter
CLINICAL/SURGICAL PEARLS
• Rectal injury during radical urologic pelvic surgery is a rare but serious complication.
• This injury can occur during open, laparoscopic and robotically assisted laparoscopic pelvic surgery.
• When recognized intraoperatively, immediate primary repair assures the best outcomes.
• When immediate repair is not possible or contraindicated, the patient may be temporized with a diverting colostomy until the rectal injury heals and the GI tract can be brought back into continuity.
• Rectourethral fistula is a delayed complication of rectal injury repair, the chance of which can be minimized with immediate recognition and repair of rectal injury.