Rectal Injury During Radical Prostatectomy

Rectal injury during radical prostatectomy converts the case from a clean contaminated to a contaminated procedure and may increase the risk of septic complications, such as wound infection, pelvic abscess, peritonitis, rectourethral fistula, and death. The reported incidence of rectal injury during open radical prostatectomy ranges from 0% to 9%. The average incidence of rectal injuries reported in the larger series of laparoscopic radical prostatectomies is 1.7% (28/1647 procedures) (42). Guillonneau et al. reported 13 rectal injuries (1.3%) in their first 1000 laparoscopic transperitoneal radical prostatectomies (42). None of these patients had previous prostatic surgery, or had received preoperative radiotherapy or hormonal therapy. Of the 13 rectal injuries, 11 were diagnosed intraoperatively and primarily repaired. Of the 11 intraoperative rectal repairs, nine healed primarily without colostomy. Two patients who had intraoperative rectal repair by a single-layer closure developed fever and abdominal pain. Both were explored and required resuturing of small rectal defect without colostomy in one and the other required colostomy. Rectal injury was diagnosed postoperatively in two patients. Both of them presented with umbilical pain, fever, and abdominal distension after three and four days. One had a small rectal perforation, which was managed by colostomy only. The other patient had colostomy only, but developed a rectourethral fistula, which required perineal repair after three months. In the majority of the above cases (10/11), rectal injury occurred during non-nerve-sparing radical prostatectomy. Ten of 11 rectal injuries were recognized intraoperatively, the injuries occurred during the dissection of the posterior surface of the prostatic apex and in one during wide excision of the neurovascular bundle.

The management of rectal injuries during laparoscopic radical prostatectomy depends on the nature of the injury and the surgeon's experience. Minor rectal injuries identified intraoperatively may be closed laparoscopically if the surgeon is comfortable with laparoscopic reconstructive technique. Larger rectal injuries require laparotomy and bowel diversion.

Once rectal injury is recognized intraoperatively, the operative field is copiously irrigated with saline and povidone iodine, and the prostatectomy is completed. Thereafter, the margins of the rectal defect are clearly identified with an intrarectal metallic bougie or by digital rectal examination. The rectal wall mucosa and muscular layers are defined. The rectal wall is then closed in two layers, inner mucosa and outer seromuscular layer, with continuous sutures with a 3-0 polyglactin 17 mm half circle needle. The integrity of the repair is then checked by filling the rectum with air after it has been obstructed more proximally. Air is instilled via a rectal catheter to distend the rectal lumen, and the field is inspected. Filling the pelvis with sterile saline will help identify air bubbles. After irrigating the pelvic cavity again, vesicourethral anastomosis is performed. The posterior sutures are placed with careful attention not to incorporate the rectal wall, and the water tightness of the anastomosis is confirmed by filling the bladder with 180 mL of normal saline through the urethral catheter. Abbou and cowork-ers also report their experience of successful primary closure of rectal injury by laparo-scopic intracorporeal suturing (43). In addition, these authors describe reinforcement of double-layered closure of rectal injury by a fat flap made from omentum for a transperi-toneal approach or perirectal fat for an extraperitoneal approach.

A drain is placed posterior to the bladder close to the rectal repair and a second drain is placed anteriorly in the space of Retzius. Anal dilation is not required. Broad-spectrum antibiotics (third-generation cephalosporins and metronidazole) are given for five to seven days. Oral liquids are started the day after surgery and after passing flatus and a low-residue diet is initiated. A voiding cystourethrogram is performed after 10 to 14 days, and the urethral catheter is removed if there is no evidence of anastomotic leak or passage of flatus through the Foley catheter.

Rectal injury can occur when the Denonvilliers' fascia is not properly incised at the base of the prostate during the retrovesical dissection or more often during the apical dissection.

Early in one's experience, the use of an intrarectal bougie may facilitate detection of the plane of Denonvilliers' fascia and allow better detection of the limits of the rectal wall by movement of the rectum and tactile sensation produced by the bougie. Extreme care should be taken during prostate dissection in patients who had neoadjuvant hormonal ablation treatment, previous transurethral prostatectomy, previous rectal surgery, pelvic radiation, infection, and in those patients who have undergone multiple prostate biopsies or saturation biopsy of the prostate. In these patients, the natural planes of dissection are likely to be poor.

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