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Management of Rectal Injuries During Radical Cystectomy
0022-534 7/89 /1425-1204$02.00 /0 THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL AssOCIAT!ON, INC.
Vol. 142, November Printed in U.S.A.
MANAGEMENT OF RECTAL INJURIES DURING RADICAL CYSTECTOMY MIKE KOZMINSKI, JOHN W. KONNAK
AND
H. BARTON GROSSMAN*
From the Department of Surgery, Section of Urology, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
We reviewed the incidence and management of intraoperative rectal injuries in patients who underwent radical cystectomy from January 1980 through July 1988 to assess the role of primary repair without diverting colostomy as definitive therapy. During this interval 163 radical cystectomies were performed and 125 charts were available for review. The incidence of rectal injuries was 9.6% (12 of 125 patients). The rate of rectal injury in patients who had previously received definitive pelvic radiation was 27% (3 of 11). The incidence of injury in patients who received 2,000 rad preoperative radiation (11 %, 2 of 17) was similar to that noted in individuals who were not irradiated (7%, 7 of 97). Of the 12 patients with rectal injury 9 underwent primary closure without diverting colostomy. The remainder were treated with an initial colostomy. Only 1 patient who had not received prior radiation required a colostomy after initial treatment with primary closure. The 8 successful primary rectal closures were done in 2 patients who underwent definitive pelvic radiation, 2 who had received 2,000 rad preoperatively and 4 who had not been irradiated. (J. Ural., 142: 1204-1205, 1989) Radical cystectomy continues to be a commonly used treatment for high stage, localized bladder cancer. Although the current operative mortality rate is less than 5%, this procedure is associated with significant morbidity. 1 - 4 Rectal injuries remain a significant concern for urological surgeons who perform this procedure. Nevertheless, relatively little information is available regarding the management of this intraoperative complication in irradiated and nonirradiated patients. We document the incidence of these injuries and the management approach used at our medical center. MATERIALS AND METHODS
Between January 1980 and July 1988 radical cystectomy was performed in 163 patients with bladder cancer at our medical center. Available records permitted review in 125 of these patients. Mean postoperative followup was 11 months. Median patient age was 67 years, with a range of 46 to 85 years. All patients were started on a clear liquid diet 2 days preoperatively and received a mechanical bowel preparation preoperatively, which usually consisted of 6 1. of a polyethylene glycol solution (GoLYTELY) along with oral erythromycin and neomycin 1 day preoperatively. In addition, periprocedural intravenous antimicrobials were used frequently. Of the 125 patients 28 (22%) received radiation before cystectomy; 17 were given 2,000 rad preoperatively. Eight patients had salvage cystectomy following failed definitive external beam radiation therapy for bladder cancer. 5 One patient received definitive radiation therapy (6,000 rad) for the treatment of prostate cancer and 2 had previously received pelvic irradiation for cervical cancer. All rectal injuries were identified at operation. Based on the severity of the rectal injury, primary rectal closure was performed with or without diverting colostomy. The rectal injuries were closed in 2 layers, usually with an inner layer of 3-zero chromic and an outer layer of 3-zero silk. When possible, redundant sigmoid colon was placed in the pelvis. The type of pelvic drainage used varied depending on the preference of the Accepted for publication May 17, 1989. *Requests for reprints: 1500 E. Medical Center Dr., Ann Arbor, Michigan 48109-0330.
surgeon. The anal sphincter was routinely dilated postoperatively. RESULTS
Of the 125 patients reviewed 12 (9.6%) had intraoperative rectal injuries. Patients with primary closures were younger (54 to 79 years, median 65 years) than those undergoing an initial colostomy (69 to 81 years, median 71 years). Three patients had large bowel procedures related to tumor extension: 1 underwent sigmoid resection and 2 underwent abdominoperineal resection. In all 3 patients convalescence was uneventful. Three of 11 patients (27%) who received therapeutic pelvic radiation (2 for bladder cancer and 1 for prostate cancer) and 2 of 17 (11 %) who received 2,000 rad preoperatively had rectal injuries during cystectomy. The rate of rectal injury in patients receiving definitive pelvic radiation was significantly higher than in nonirradiated patients (chi square, p = 0.03, see table). The incidence of injury in patients who received 2,000 rad preoperatively (11 %, 2 of 17) was similar to that noted in individuals who were not irradiated (7%, 7 of 97). Of the 12 rectal injuries 9 were repaired primarily with a double layer bowel closure without a diverting colostomy. Of these patients 7 (1 salvage cystectomy and 2 after 2,000 rad preoperatively) had no postoperative complications. One patient who underwent salvage cystectomy had a delayed ureteral leak and abscess apparently unrelated to the rectal injury. This was the only patient with a rectal injury who died of postoperative complications. One patient who underwent primary repair of a rectal injury along with sigmoid resection for gross tumor extension had a postoperative rectal leak and pelvic abscess with subsequent diverting colostomy. Three patients initially were treated with diverting colostomy and in all 3 convalescence was uneventful. DISCUSSION
Historically, rectal injuries have been associated with high morbidity and mortality. However, most of the available data are based on war-related injuries in which unprepared bowel, contaminated penetrating trauma, and delays in the identification and repair of the rectal injuries contributed to a poor
1204
MANAGEMENT OF RECTAL INJURIES DURING RADICAL CYSTECTOMY
Rectal injury rate by history of previous irradiation Previous Irradiation
None 2,000 rad preoperatively Definitive therapy
Total No. Pts.
Rectal Injury No.(%)
97 17
7 (7) 2 (11) 3 (27)
11
P Value
Not significant 0.03
outcome. During World War I rectal injuries were associated with a 45.2% mortality rate. With improved surgical techniques, improved anesthesia and the availability of antibiotics, mortality rates were less then 15% during the Vietnam War. 6 During cystectomy the conditions during which rectal injuries occur are more controlled. These patients have had preoperative bowel preparation and are able to undergo prompt identification and repair of the rectal laceration. The question remains whether rectal lacerations identified under these situations can be treated safely and with lower morbidity by direct repair without diverting colostomy. Primary closure is of particular concern in previously irradiated patients because of the possibility of delayed wound healing in irradiated tissue resulting in a fecal leak and abscess. The reported rate of rectal injury in several large series of patients undergoing salvage cystectomy ranges from 2 to 8%, with a mean of 4%. 7- 10 We noted an increased rate of rectal injuries in patients who failed previous definitive irradiation. In our series the salvage cystectomy patients were almost 4 times more likely to have a rectal injury than the nonirradiated patients (27 and 7%, respectively). Primary closure of rectal lacerations during radical cystectomy without proximal diversion is not new. In 1973 Winter and Gluesenkamp reported the successful use of primary closure in 3 patients. 11 Of the patients 2 had received prior radiation therapy. Eisenkraft and Pontes also reported the successful primary closure of 4 rectal injuries. 12 Despite these favorable results, most investigators have used proximal fecal diversion as part of the initial treatment plan. In 3 large series of patients treated with salvage cystectomy, 4 patients were treated with initial colostomy and 3 had primary closure only. 7 - 9 However, all of the latter 3 patients subsequently required delayed diverting colostomy for early postoperative complications. In our series 9 of 12 patients had primary closure of the rectal injuries without a diverting colostomy, and only 1 had a complicated
1205
postoperative course. Diverting colostomy was subsequently required in a nonirradiated patient who had undergone primary repair of a rectal injury and sigmoid resection. It should be noted that the 3 patients who underwent colostomy at the time of rectal injury also did well. Although radiation increased the rate of rectal injury in our patients, it did not affect the outcome of selected cases in which primary repair without diverting colostomy was used. We conclude that small injuries in well vascularized, adequately prepared bowel can be repaired primarily with a low incidence of complications. Prior pelvic radiation is not an absolute contraindication to this treatment approach. REFERENCES
1. Terry, W. J. and Bueschen, A. J.: Complications of radical cystec-
2.
3. 4.
5.
6. 7.
8.
9. 10. 11.
12.
tomy and correlation with nutritional assessment. Urology, 27: 229, 1986. Bredin, H. C. and Prout, G. R., Jr.: One-stage radical cystectomy for bladder carcinoma: operative mortality, cost/benefit analysis. J. Urol., 117: 447, 1977. Freiha, F. S.: Complications of cystectomy. J. Urol., 123: 168, 1980. Johnson, D. E. and Lamy, S. M.: Complications of a single stage radical cystectomy and ilea! conduit diversion: review of 214 cases. J. Urol., 117: 171, 1977. Konnak, J. W. and Grossman, H. B.: Salvage cystectomy following failed definitive radiation therapy for transitional cell carcinoma of bladder. Urology, 26: 550, 1985. Trunkey, D., Hays, R. J. and Shires, G. T.: Management of rectal trauma. J. Trauma, 13: 411, 1973. Smith, J. A., Jr. and Whitmore, W. F., Jr.: Salvage cystectomy for bladder cancer after failure of definitive irradiation. J. Urol., 125: 643, 1981. Swanson, D. A., von Eschenbach, A. C., Bracken, R. B. and Johnson, D. E.: Salvage cystectomy for bladder carcinoma. Cancer, 4 7: 2275, 1981. Freiha, F. S. and Faysal, M. H.: Salvage cystectomy. Urology, 22: 496, 1983. Lindell, 0.: Salvage cystectomy. Review of 19 cases. Eur. Urol., 13: 17, 1987. Winter, C. C. and Gluesenkamp, E.W.: Management of intraoperative proctotomy incidental to total cystectomy for bladder carcinoma. J. Urol., 109: 62, 1973. Eisenkraft, S. and Pontes, J. E.: Radical cystectomy at Roswell Park Memorial Institute. Preoperative and post operative observations. Prag. Clin. Biol. Res., 162A: 393, 1984.
Vol. 142, November Printed in U.S.A.
MANAGEMENT OF RECTAL INJURIES DURING RADICAL CYSTECTOMY MIKE KOZMINSKI, JOHN W. KONNAK
AND
H. BARTON GROSSMAN*
From the Department of Surgery, Section of Urology, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
We reviewed the incidence and management of intraoperative rectal injuries in patients who underwent radical cystectomy from January 1980 through July 1988 to assess the role of primary repair without diverting colostomy as definitive therapy. During this interval 163 radical cystectomies were performed and 125 charts were available for review. The incidence of rectal injuries was 9.6% (12 of 125 patients). The rate of rectal injury in patients who had previously received definitive pelvic radiation was 27% (3 of 11). The incidence of injury in patients who received 2,000 rad preoperative radiation (11 %, 2 of 17) was similar to that noted in individuals who were not irradiated (7%, 7 of 97). Of the 12 patients with rectal injury 9 underwent primary closure without diverting colostomy. The remainder were treated with an initial colostomy. Only 1 patient who had not received prior radiation required a colostomy after initial treatment with primary closure. The 8 successful primary rectal closures were done in 2 patients who underwent definitive pelvic radiation, 2 who had received 2,000 rad preoperatively and 4 who had not been irradiated. (J. Ural., 142: 1204-1205, 1989) Radical cystectomy continues to be a commonly used treatment for high stage, localized bladder cancer. Although the current operative mortality rate is less than 5%, this procedure is associated with significant morbidity. 1 - 4 Rectal injuries remain a significant concern for urological surgeons who perform this procedure. Nevertheless, relatively little information is available regarding the management of this intraoperative complication in irradiated and nonirradiated patients. We document the incidence of these injuries and the management approach used at our medical center. MATERIALS AND METHODS
Between January 1980 and July 1988 radical cystectomy was performed in 163 patients with bladder cancer at our medical center. Available records permitted review in 125 of these patients. Mean postoperative followup was 11 months. Median patient age was 67 years, with a range of 46 to 85 years. All patients were started on a clear liquid diet 2 days preoperatively and received a mechanical bowel preparation preoperatively, which usually consisted of 6 1. of a polyethylene glycol solution (GoLYTELY) along with oral erythromycin and neomycin 1 day preoperatively. In addition, periprocedural intravenous antimicrobials were used frequently. Of the 125 patients 28 (22%) received radiation before cystectomy; 17 were given 2,000 rad preoperatively. Eight patients had salvage cystectomy following failed definitive external beam radiation therapy for bladder cancer. 5 One patient received definitive radiation therapy (6,000 rad) for the treatment of prostate cancer and 2 had previously received pelvic irradiation for cervical cancer. All rectal injuries were identified at operation. Based on the severity of the rectal injury, primary rectal closure was performed with or without diverting colostomy. The rectal injuries were closed in 2 layers, usually with an inner layer of 3-zero chromic and an outer layer of 3-zero silk. When possible, redundant sigmoid colon was placed in the pelvis. The type of pelvic drainage used varied depending on the preference of the Accepted for publication May 17, 1989. *Requests for reprints: 1500 E. Medical Center Dr., Ann Arbor, Michigan 48109-0330.
surgeon. The anal sphincter was routinely dilated postoperatively. RESULTS
Of the 125 patients reviewed 12 (9.6%) had intraoperative rectal injuries. Patients with primary closures were younger (54 to 79 years, median 65 years) than those undergoing an initial colostomy (69 to 81 years, median 71 years). Three patients had large bowel procedures related to tumor extension: 1 underwent sigmoid resection and 2 underwent abdominoperineal resection. In all 3 patients convalescence was uneventful. Three of 11 patients (27%) who received therapeutic pelvic radiation (2 for bladder cancer and 1 for prostate cancer) and 2 of 17 (11 %) who received 2,000 rad preoperatively had rectal injuries during cystectomy. The rate of rectal injury in patients receiving definitive pelvic radiation was significantly higher than in nonirradiated patients (chi square, p = 0.03, see table). The incidence of injury in patients who received 2,000 rad preoperatively (11 %, 2 of 17) was similar to that noted in individuals who were not irradiated (7%, 7 of 97). Of the 12 rectal injuries 9 were repaired primarily with a double layer bowel closure without a diverting colostomy. Of these patients 7 (1 salvage cystectomy and 2 after 2,000 rad preoperatively) had no postoperative complications. One patient who underwent salvage cystectomy had a delayed ureteral leak and abscess apparently unrelated to the rectal injury. This was the only patient with a rectal injury who died of postoperative complications. One patient who underwent primary repair of a rectal injury along with sigmoid resection for gross tumor extension had a postoperative rectal leak and pelvic abscess with subsequent diverting colostomy. Three patients initially were treated with diverting colostomy and in all 3 convalescence was uneventful. DISCUSSION
Historically, rectal injuries have been associated with high morbidity and mortality. However, most of the available data are based on war-related injuries in which unprepared bowel, contaminated penetrating trauma, and delays in the identification and repair of the rectal injuries contributed to a poor
1204
MANAGEMENT OF RECTAL INJURIES DURING RADICAL CYSTECTOMY
Rectal injury rate by history of previous irradiation Previous Irradiation
None 2,000 rad preoperatively Definitive therapy
Total No. Pts.
Rectal Injury No.(%)
97 17
7 (7) 2 (11) 3 (27)
11
P Value
Not significant 0.03
outcome. During World War I rectal injuries were associated with a 45.2% mortality rate. With improved surgical techniques, improved anesthesia and the availability of antibiotics, mortality rates were less then 15% during the Vietnam War. 6 During cystectomy the conditions during which rectal injuries occur are more controlled. These patients have had preoperative bowel preparation and are able to undergo prompt identification and repair of the rectal laceration. The question remains whether rectal lacerations identified under these situations can be treated safely and with lower morbidity by direct repair without diverting colostomy. Primary closure is of particular concern in previously irradiated patients because of the possibility of delayed wound healing in irradiated tissue resulting in a fecal leak and abscess. The reported rate of rectal injury in several large series of patients undergoing salvage cystectomy ranges from 2 to 8%, with a mean of 4%. 7- 10 We noted an increased rate of rectal injuries in patients who failed previous definitive irradiation. In our series the salvage cystectomy patients were almost 4 times more likely to have a rectal injury than the nonirradiated patients (27 and 7%, respectively). Primary closure of rectal lacerations during radical cystectomy without proximal diversion is not new. In 1973 Winter and Gluesenkamp reported the successful use of primary closure in 3 patients. 11 Of the patients 2 had received prior radiation therapy. Eisenkraft and Pontes also reported the successful primary closure of 4 rectal injuries. 12 Despite these favorable results, most investigators have used proximal fecal diversion as part of the initial treatment plan. In 3 large series of patients treated with salvage cystectomy, 4 patients were treated with initial colostomy and 3 had primary closure only. 7 - 9 However, all of the latter 3 patients subsequently required delayed diverting colostomy for early postoperative complications. In our series 9 of 12 patients had primary closure of the rectal injuries without a diverting colostomy, and only 1 had a complicated
1205
postoperative course. Diverting colostomy was subsequently required in a nonirradiated patient who had undergone primary repair of a rectal injury and sigmoid resection. It should be noted that the 3 patients who underwent colostomy at the time of rectal injury also did well. Although radiation increased the rate of rectal injury in our patients, it did not affect the outcome of selected cases in which primary repair without diverting colostomy was used. We conclude that small injuries in well vascularized, adequately prepared bowel can be repaired primarily with a low incidence of complications. Prior pelvic radiation is not an absolute contraindication to this treatment approach. REFERENCES
1. Terry, W. J. and Bueschen, A. J.: Complications of radical cystec-
2.
3. 4.
5.
6. 7.
8.
9. 10. 11.
12.
tomy and correlation with nutritional assessment. Urology, 27: 229, 1986. Bredin, H. C. and Prout, G. R., Jr.: One-stage radical cystectomy for bladder carcinoma: operative mortality, cost/benefit analysis. J. Urol., 117: 447, 1977. Freiha, F. S.: Complications of cystectomy. J. Urol., 123: 168, 1980. Johnson, D. E. and Lamy, S. M.: Complications of a single stage radical cystectomy and ilea! conduit diversion: review of 214 cases. J. Urol., 117: 171, 1977. Konnak, J. W. and Grossman, H. B.: Salvage cystectomy following failed definitive radiation therapy for transitional cell carcinoma of bladder. Urology, 26: 550, 1985. Trunkey, D., Hays, R. J. and Shires, G. T.: Management of rectal trauma. J. Trauma, 13: 411, 1973. Smith, J. A., Jr. and Whitmore, W. F., Jr.: Salvage cystectomy for bladder cancer after failure of definitive irradiation. J. Urol., 125: 643, 1981. Swanson, D. A., von Eschenbach, A. C., Bracken, R. B. and Johnson, D. E.: Salvage cystectomy for bladder carcinoma. Cancer, 4 7: 2275, 1981. Freiha, F. S. and Faysal, M. H.: Salvage cystectomy. Urology, 22: 496, 1983. Lindell, 0.: Salvage cystectomy. Review of 19 cases. Eur. Urol., 13: 17, 1987. Winter, C. C. and Gluesenkamp, E.W.: Management of intraoperative proctotomy incidental to total cystectomy for bladder carcinoma. J. Urol., 109: 62, 1973. Eisenkraft, S. and Pontes, J. E.: Radical cystectomy at Roswell Park Memorial Institute. Preoperative and post operative observations. Prag. Clin. Biol. Res., 162A: 393, 1984.