Management of rectal injury during laparoscopic radical prostatectomy

Abstract

Purpose: Because laparoscopic radical prostatectomy remains a challenging procedure, rectal injury is always a potential complication. We review the incidence of rectal injuries at our institution in the first 110 consecutive laparoscopic extraperitoneal radical prostatectomies. Materials and Methods: Nine (8%) out of the first 110 laparoscopic extraperitoneal radical prostatectomies performed between December 2001 and February 2004, were complicated by rectal injury. Mean patient age was 64.9 years (range 52 to 74) and mean prostate specific antigen was 11.45 ng/mL (range 4.8 to 37.4). Median preoperative Gleason score was 6 (range 4 to 8) and clinical stage was T1c, T2a, T2b in 6, 2 and 1 patient, respectively. Mean operative time was 228 minutes (range 150 to 300). Results: From 9 injuries, 6 were diagnosed and repaired intraoperatively and 3 were diagnosed postoperatively. From the 6 cases of intraoperative diagnosis and repair, 3 patients healed primarily without colostomy and a recto-urinary fistula was evidenced by pneumaturia in the remaining three. These 3 patients were managed conservatively with urethral catheterization during 30 days. One of the patients required secondary fistula repair by anterior transphincteric, transanal surgical approach (ASTRA). Urinary fistula was diagnosed postoperatively on 3 patients. A diverting colostomy was performed on one patient with secondary fistula repair by ASTRA. Another patient required laparotomy due to peritonitis and urinary fistula was later managed with ASTRA. On the third patient conservative management with urethral catheter was successful. All fistulas repaired with ASTRA evolved uneventfully. There was no perioperative mortality. Conclusions: Rectal injury during laparoscopic radical prostatectomy can be managed intraoperatively or by a minimally invasive procedure without the need of colostomy. Laparoscopic radical prostatectomy is a challenging procedure and is associated with a very flat learning curve; the incidence of rectal injuries is prone to diminish with experience.

Rectal injury during radical prostatectomy

“…Indeed, Heinzer et al [5] reported a rectal injury rate of 2% among patients who were operated upon later in the study compared with 7.8% in the group of patients who were operated upon at the beginning of the study. Similarly, Castello et al [6] reported an 8% rectal injury rate in patients operated upon during the period when surgeons were still familiarizing themselves with the technique of radical prostatectomy.…”

“…In general, colostomy may be necessary in certain cases with larger defects, intraoperatively unrecognized defects, fistula development, or in salvage radical prostatectomy procedures. [1,6,13,16,17] There is a consensus among most authors about the importance of recognizing rectal injuries during the operation. The presence of a defect in the rectal wall may be tested by checking for a loss of gas through the rectal wall.…”

“…The most important complications are urorectal fistulas, peritonitis, infections related to the operation site, anastomotic strictures, and urinary incontinence. [6,9,20] Previous studies have shown that unrecognized traumas resulting from the use of thermal energy, electrical energy or cautery, especially in laparoscopic surgery, are particularly vulnerable to fistula development. [6] McLaren et al [9] reported the development of rectourethral fistulas in four out of 27 cases of rectal injury in which rectal trauma had been recognized and repaired intraoperatively.…”

“…[6,9,20] Previous studies have shown that unrecognized traumas resulting from the use of thermal energy, electrical energy or cautery, especially in laparoscopic surgery, are particularly vulnerable to fistula development. [6] McLaren et al [9] reported the development of rectourethral fistulas in four out of 27 cases of rectal injury in which rectal trauma had been recognized and repaired intraoperatively. In addition, Fichtner et al [20] reported the development of fistulas in four out of 22 cases of intraoperatively recognized and repaired rectal trauma, and three patients required a colostomy procedure.…”

Iatrogenic Rectal Injury During Radical Prostatectomy: Is Colostomy Inevitable End?

“…After surgery the most important complications are rectourinary fistulas, peritonitis, infections related to the operation site, urinary incontinence, anastomotic strictures, sepsis and even death [13,5]. During the operation when we suspect rectal trauma we used digital rectal examination and insufflation air with a syringe into the rectum while filling the pelvis with irrigation fluid as described by some authors [9,14]. Intraoperatively these easy applicable maneuvers help identifying the site of laceration, diagnosing missed injuries if IRI exist and removing blood clots that might obscure any actively bleeding vessels so that hemostasis can better be achieved.…”