- Email: [email protected]
Management of Rectal Injuries Sustained During Laparoscopic Radical Prostatectomy
Surgical Techniques in Urology Management of Rectal Injuries Sustained During Laparoscopic Radical Prostatectomy Jeremy M. Blumberg, Timothy Lesser, Viet Q. Tran, Sherif R. Aboseif, Gary C. Bellman, and Maher A. Abbas OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
To report on a treatment algorithm for the management of rectal injures. Rectal injuries during laparoscopic radical prostatectomy (LRP) are rare. In the first 200 cases of LRP performed at our institution, 2 (1%) rectal injuries occurred. Our experience prompted collaboration with our colorectal surgery colleagues to develop a treatment algorithm for the management of such injuries. We report on the management of rectal injuries sustained during LRP at our institution. We describe the intraoperative laparoscopic repair of a rectal tear using a 2-layer interrupted closure with absorbable suture. The conservative, nonoperative, management of a rectourethral fistula in a patient who presented after LRP is also described. Collaboration with our colorectal surgery colleagues resulted in the formulation of a treatment algorithm for intraoperative and postoperative presentations of rectal injury during LRP. The algorithm is presented. Of the first 200 cases of LRP at our institution 2 (1%) were complicated by rectal injury. Injuries recognized intraoperatively should be managed laparoscopically if the operating surgeon is adept at intracorporeal suturing. Small rectourethral fistulas can be managed conservatively with urinary catheterization or diversion and antibiotics as needed. Rarely, rectal injuries sustained during LRP will require fecal diversion; injuries that fail to heal despite fecal diversion require operative repair. Rectal injuries incurred during LRP are rare but must be managed successfully to minimize morbidity. Rectal tears recognized intraoperatively can be managed laparoscopically. The development of a rectourethral fistula is a potential complication of LRP. Most fistulas can be managed conservatively with urinary catheterization or diversion. Rarely, rectal injuries that occur during LRP require fecal diversion or definitive operative repair. UROLOGY 73: 163–166, 2009. © 2009 Elsevier Inc.
T
o date, few studies have examined the occurrence and outcome of iatrogenic rectal injury sustained during laparoscopic radical prostatectomy (LRP). The purpose of our study was to review our experience with LRP with regard to such injuries and to propose a treatment algorithm (Fig. 1) created from our personal experience in managing LRP-related rectal injuries and fistulas and from a review of published studies.
MATERIAL AND METHODS We conducted a retrospective review of prospectively collected data at Kaiser Permanente Los Angeles Medical Center, a tertiary academic institution with a urology residency program. We examined the data from 200 consecutive LRPs performed at our hospital from August 2002 to August 2006. All operations were conducted by, or under the supervision of, 1 of us
(G.C.B.). The operative records and postoperative course of all patients were reviewed. The surgical technique has been previously described by Guillonneau and Vallancien1 and consists of an initial transperitoneal dissection of the seminal vesicles. All of our patients underwent preoperative mechanical bowel preparation. Nervesparing dissection was routinely performed using athermal techniques, except for in patients with high-volume disease or a high preoperative Gleason score, who underwent ipsilateral neurovascular bundle transection. After complete dissection and isolation of both seminal vesicles, Denonvilliers fascia was incised to expose the posterior capsule of the prostate. Care was taken to avoid entering the posterior leaflet of Denonvilliers fascia to minimize trauma to the anterior rectal wall. In creating the algorithm, we also reviewed our treatment of 7 patients with post-LRP rectourethral fistulas who had been referred to our medical center for treatment (Table 1).
RESULTS From the Department of Urology and Section of Colorectal Surgery, Kaiser Foundation Hospital, Los Angeles, California Reprint requests: Jeremy M. Blumberg, M.D., Department of Urology, Kaiser Permanente, 4900 Sunset Boulevard, Los Angeles, CA 90027. E-mail: Jeremy. [email protected] Submitted: April 9, 2007, accepted (with revisions): August 11, 2008
© 2009 Elsevier Inc. All Rights Reserved
Of the first 200 LRPs performed at our institution, 2 cases (1%) were complicated by a rectal injury. One injury was discovered intraoperatively, and the other patient presented with a postoperative rectourethral fistula. The following is a summary of both cases. 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.08.473
163
Rectal Injury Intraoperative Recognition?
YES Laparoscopic Repair if Feasible Or, Open Repair of Rectal Tear
2 Layer, Interrupted Generous Tissue Bites
-Cysto-urethrogram -CT Scan
Percutaneous Drainage
NO YES
No Fecal Diversion
Postoperative Recognition of Rectourethral Fistula
Abscess On CT
Adequate Repair? YES
NO
Patient Septic or Very Symptomatic? Hx of Pelvic Radiation?
Fecal Diversion Reassess in 3 Months
YES
Observation -Urinary Catheterization -Antibiotics PRN -Symptom Relief
Gastrograffin Enema
Healed?
NO
Reassess in Cystogram 2-3Months
NO
Close Stoma
NO Operative Management
Healed? YES
Treatment Completed
Figure 1. Treatment algorithm for rectal injury in laparoscopic radical prostatectomy. Table 1. Management of referred cases of rectourethral fistula secondary to LRP Patient Injury Noted Age (y) Intraoperatively?
Initial Management
Presenting Symptoms
67
No
Fecaluria and pelvic abscess
61
No
52 59
No Yes
61
No
Urine per rectum and febrile UTI Fecaluria and urorrhea No symptoms; fistula revealed on postoperative cystogram Abdominal pain and fever
62 57
No Yes
Urine per rectum Urine per rectum
Surgical Management
Fistula Closed Successfully?
Open drainage of Endorectal abscess and advancement flap attempted RUF repair (failed) Foley catheter drainage None
Yes
Foley catheter drainage Laparoscopic 2-layer closure of rectotomy and Foley catheter drainage End colostomy and Foley catheter drainage Foley catheter drainage Conversion to open RRP with 2-layer closure of rectotomy and Foley catheter drainage
Yes No (surgical repair pending at last follow-up)
None Diverting loop colostomy
Yes
Cystectomy with ileal Yes conduit creation None Diverting loop colostomy with subsequent takedown
Yes Yes
LRP, laparoscopic radical prostatectomy; RUF, rectourethral fistula.
Patient 1 After the seminal vesicle dissection and during the development of the posterior plane, a 2-cm anterior longitudinal rectal tear was encountered in a 60-year-old man with Stage T1c, Gleason score 6 carcinoma of the prostate. The injury appeared to involve only the superficial layers of the rectum, and the lumen of the bowel was not visualized. The patient had undergone preoperative mechanical bowel preparation. No gross contamination was 164
noted. The tear was managed laparoscopically with a 2-layer closure using 2-0 Vicryl sutures in a single interrupted fashion. The integrity of the repair was verified by insufflating the rectum transanally with air after submerging its anterior wall in sterile saline. No gas leak was noted. Anal dilation was not performed. No intravenous antibiotics were administered. The patient received oral intake starting on postoperative day 2, and the surgical drain was removed after 4 days. On postoperative day 14, UROLOGY 73 (1), 2009
the urethral catheter was removed after normal urethrocystography findings. The patient had an uneventful recovery and continued to do well 8 months after LRP.
Patient 2 A 62-year-old man with Stage T1c underwent LRP. He had undergone preoperative mechanical bowel preparation. The vesicourethral anastamosis was challenging because of a short urethral stump. The closed suction drain and urethral catheter were removed on postoperative day 3 and 10, respectively. Shortly thereafter, the patient presented with frequent, loose, and watery bowel movements. His stool stained orange after an oral phenazopyridine challenge. The cystography findings on postoperative day 14 confirmed a narrow rectourethral fistula. The presumed etiology of the fistula was injury to the anterior rectal wall during placement of the posterior sutures of the vesicourethral anastomosis. The urethral catheter was reinserted, and the patient was instructed to consume a low-residue diet. No pelvic abscess was seen on computed tomography. Three weeks later, the urethral catheter was removed after normal cystography findings documenting full healing of the fistula. At 22 months of follow-up, the patient was well without evidence of recurrent rectourethral fistula.
COMMENT Rectal injury during LRP is a rare, but potentially, serious complication. Numerous studies have reported an incidence of 0.5%-9%.2,3 LRP has been gaining momentum as a viable alternative to open retropubic prostatectomy. Although associated with a shorter hospital stay and faster recovery compared with the traditional open operation, LRP confers the risk of similar complications, including the risk of rectal injury.2-4 Despite good intraoperative visualization laparoscopically, the proximity of the rectum to the dissection plane can lead to trauma to its anterior wall. Castillo et al.4 from Chile reported their experience with extraperitoneal LRP. From 2001 to 2004, 110 patients underwent the procedure. All patients underwent preoperative mechanical bowel preparation and received intravenous antibiotics. Of their 110 patients, 9 (8%) experienced a rectal injury. Seven injuries occurred during the first 50 cases. Six were recognized intraoperatively and a 2-layer repair of the rectum was used. Of these 6 injures, the repair of 3 failed and a rectourethral fistula developed. Three patients with unrecognized intraoperative injury presented with postoperative rectourethral fistula. Of a total of 6 rectourethral fistulas, 3 healed spontaneously with prolonged urethral catheterization and 3 required trans-sphincteric repair. Only 1 patient required fecal diversion with a stoma. All patients healed.4 Similarly, Katz et al.5 described their experience from France with 300 LRPs performed from 1998 to 2002. All patients had undergone bowel prepaUROLOGY 73 (1), 2009
ration and received intravenous antibiotics. Six patients (2%) had a rectal injury. Of these 6 injures, 5 were recognized intraoperatively and closed with a 2-layer repair with either an omental or perirectal flap. Only 1 patient underwent fecal diversion in their group. One patient presented with a postoperative rectourethral fistula and was treated with prolonged urethral catheterization and a diverting stoma. All patients healed. Finally, Guillonneau et al.6 reported on another French series of 1000 transperitoneal LRPs performed from 1998 to 2002. Of the 1000 patients, 13 (1.3%) had a rectal injury, 11 of which were recognized intraoperatively. The mean laceration length was 20 mm. A 2-layer repair was performed in most cases, and the patients received 1 additional week of intravenous antibiotics. Emergent reoperation with fecal diversion was required in 4 patients: 2 with a missed intraoperative injury and 2 in whom the initial repair had failed (1 with a single-layer repair). All patients healed, including 1 who developed a chronic rectourethral fistula that required surgical repair.6 In our series of 200 LRPs, 2 patients (1%) had a rectal injury. One injury was recognized intraoperatively and successfully repaired and the second patient presented with a postoperative rectourethral fistula. Healing of the fistula was accomplished with urethral catheterization for an additional 3 weeks. The mechanism of injury was direct trauma to the anterior wall during posterior dissection in 1 patient and suturing of the vesicourethral fistula in the second patient. We propose a treatment algorithm for this rare injury using our experience with these 2 cases, other open radical prostatectomy cases, and several referred traumatic or radiation-induced rectourethral fistulas successfully treated by our multidisciplinary tertiary team of urologic and colorectal surgeons (Fig. 1). Injuries recognized intraoperatively should be repaired laparoscopically if the surgeon is comfortable in doing so. Conversion to open repair can be undertaken, depending on the situation. A colorectal surgeon can be involved, if needed. The operative field should be irrigated with copious amount of saline and the rectum with Betadine. A 2-layer repair is preferable, using single interrupted absorbable sutures. The entire laceration should be clearly delineated to ensure full closure of both edges. This may necessitate careful mobilization of the surrounding tissues for visualization. If feasible, an omental flap brought transperitoneally or a perirectal fat flap should be considered. The repair should be tested by insufflating the rectum transanally with air and checking for a gas leak after filling the pelvis with fluid. Fecal diversion is recommended if any concern exists about the adequacy of the repair, poor tissue quality, a history of radiation to the pelvis, or significant fecal contamination in the field. A 19F Blake drain should be left in place. Patients in whom intraoperative repair fails or who sustain an unrecognized injury can present with a post165
operative rectourethral fistula. Symptoms can vary from fecaluria, pneumaturia, recurrent polymicrobial urinary tract infection, pain, and rectal bleeding to pelvic sepsis and/or necrotizing fascitis. Patients with a history of radiotherapy and those with sepsis or severe symptoms should undergo immediate fecal and urinary diversion. Stable patients can be investigated with cystourethrography, cystoscopy, Gastrografin enema, flexible sigmoidoscopy, and computed tomography of the pelvis. Although computed tomography is recommended for all patients to exclude the presence of a pelvic abscess, not every patient requires all of the mentioned studies. In our practice, we obtain a cystourethrogram to document the rectourethral fistula and, if inconclusive, we proceed with other studies. If a pelvic abscess is present, percutaneous drainage should be done. Urethral catheterization should be performed in all patients. Suprapubic catheters should be placed selectively. The rectourethral fistula can be reassessed by cystourethrography as early as 1 month for small uncomplicated fistula or 2-3 months for patients with a large defect or a more complicated postoperative course. The urethral catheter should be removed once resolution of the fistula has been documented. Patients who have undergone fecal diversion should undergo flexible sigmoidoscopy or Gastrografin enema before closure of the stoma. Persistent rectourethral fistula is a complex and difficult problem. Definitive surgical treatment should not be considered for ⱖ3 months from the injury to allow for the inflammation to subside. Definitive repair undertaken sooner carries a high failure rate. The treatment options include additional observation in some cases, permanent fecal and urinary diversion for patients with significant comorbidities or a short life expectancy, and definitive surgical repair. Numerous surgical techniques are available to repair this complex fistula and include transabdominal, trans-sacral, trans-sphincteric, transanal, transperineal, and transpubic approaches.7-17 Each case should be selected individually according to the mechanism and etiology of the injury, size and location of the fistula, history of radiotherapy, previous surgical history, presence of residual cancer and positive margins, and the surgeon’s expertise. Patients with a history of radiotherapy require closure with a vascularized tissue such as the gracilis or rectus abdominus muscle flap. A multidisciplinary approach should be undertaken involving urology and colon and rectal surgery, and these complex cases are best managed in centers with expertise.
166
CONCLUSIONS Rectal injury during LRP is uncommon. Rectal laceration recognized intraoperatively should be repaired in a 2-layer fashion, and the adequacy of the repair should be tested. Fecal diversion should be considered when concern exists about the adequacy of the repair or viability of the tissue, history of radiotherapy, or a large amount of contamination. Postoperative rectourethral fistula can be successfully managed with prolonged urethral catheterization. Most rectal injuries associated with LRP heal. Persistent rectourethral fistula can be approached by different surgical techniques. References 1. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: The Montsouris technique. J Urol. 2000;163:1643-1649. 2. Guillonneau B, El-Fettouh H, Baumert H, et al. Laparoscopic radical prostatectomy: Oncological evaluation after 1,000 cases at Montsouris Institute. J Urol. 2003;169:1261-1266. 3. Rassweiler J, Sentker L, Seemann O, et al. Laparoscopic radical prostatectomy with the Heilbronn technique: An analysis of the first 180 cases. J Urol. 2001;166:2101-2108. 4. Castillo OA, Bodden E, Vitagliano G. Management of rectal injury during laparoscopic radical prostatectomy. Int Braz J Urol. 2006;32: 428-433. 5. Katz R, Borkowski T, Hoznek A, et al. Operative management of rectal injuries during laparoscopic radical prostatectomy. Urol Int. 2006;77:216-221. 6. Guillonneau B, Gupta R, El-Fettouh H, et al. Laparoscopic management of rectal injury during laparoscopic radical prostatectomy. J Urol. 2003;169:1694-1696. 7. Nyam DC, Pembreton JH. Management of iatrogenic rectourethral fistula. Colon Rectum. 1999;42:994-997. 8. Trippitelli A, Barbagli G, Lenzi R, et al. Surgical treatment of rectourethral fistulae. Eur Urol. 1985;11:388-391. 9. Wilbert DM, Buess G, Bichler KH, et al. Combined endoscopic closure of rectourethral fistula. J Urol. 1996;155:256-258. 10. Thompson IM, Marx AC. Conservative therapy of rectourethral fistula: Five-year follow-up. Urology. 1990;35:533-536. 11. Bukowski TP, Chakrabarty A, Powel IJ, et al. Acquired rectourethral fistula: Methods of repair. J Urol. 1995;153:730-733. 12. Culkin DJ, Ramsey CE. Urethrorectal fistula: Transanal, transsphincteric approach with locally based pedicle interposition flaps. J Urol. 2003;169:2181-2183. 13. Dreznik Z, Alper D, Vishne TH, et al. Rectal flap advancement—A simple and effective approach for the treatment of rectourethral fistula. Colorectal Dis. 2003;5:53–53. 14. Loughlin KR, Orgill DP. The use of a rectus muscle flap in the repair of a prostate-rectal fistula. J Urol. 2001;166:620-621. 15. Zmora O, Potenti F, Wexner SD, et al. Gracilis muscle transposition for iatrogenic rectourethral fistula. Ann Surg. 2003;237:483487. 16. Hata F, Yasoshima T, Kitagawa S, et al. Transanal repair of rectourethral fistula after a radical retropubic prostatectomy. Surg Today. 2002;32:170-173. 17. Boushey RP, Mcleod RS, Cohen Z. Surgical management of acquired rectourethral fistula. Can J Surg. 1998;41:241-244.
UROLOGY 73 (1), 2009
METHODS
RESULTS
CONCLUSIONS
To report on a treatment algorithm for the management of rectal injures. Rectal injuries during laparoscopic radical prostatectomy (LRP) are rare. In the first 200 cases of LRP performed at our institution, 2 (1%) rectal injuries occurred. Our experience prompted collaboration with our colorectal surgery colleagues to develop a treatment algorithm for the management of such injuries. We report on the management of rectal injuries sustained during LRP at our institution. We describe the intraoperative laparoscopic repair of a rectal tear using a 2-layer interrupted closure with absorbable suture. The conservative, nonoperative, management of a rectourethral fistula in a patient who presented after LRP is also described. Collaboration with our colorectal surgery colleagues resulted in the formulation of a treatment algorithm for intraoperative and postoperative presentations of rectal injury during LRP. The algorithm is presented. Of the first 200 cases of LRP at our institution 2 (1%) were complicated by rectal injury. Injuries recognized intraoperatively should be managed laparoscopically if the operating surgeon is adept at intracorporeal suturing. Small rectourethral fistulas can be managed conservatively with urinary catheterization or diversion and antibiotics as needed. Rarely, rectal injuries sustained during LRP will require fecal diversion; injuries that fail to heal despite fecal diversion require operative repair. Rectal injuries incurred during LRP are rare but must be managed successfully to minimize morbidity. Rectal tears recognized intraoperatively can be managed laparoscopically. The development of a rectourethral fistula is a potential complication of LRP. Most fistulas can be managed conservatively with urinary catheterization or diversion. Rarely, rectal injuries that occur during LRP require fecal diversion or definitive operative repair. UROLOGY 73: 163–166, 2009. © 2009 Elsevier Inc.
T
o date, few studies have examined the occurrence and outcome of iatrogenic rectal injury sustained during laparoscopic radical prostatectomy (LRP). The purpose of our study was to review our experience with LRP with regard to such injuries and to propose a treatment algorithm (Fig. 1) created from our personal experience in managing LRP-related rectal injuries and fistulas and from a review of published studies.
MATERIAL AND METHODS We conducted a retrospective review of prospectively collected data at Kaiser Permanente Los Angeles Medical Center, a tertiary academic institution with a urology residency program. We examined the data from 200 consecutive LRPs performed at our hospital from August 2002 to August 2006. All operations were conducted by, or under the supervision of, 1 of us
(G.C.B.). The operative records and postoperative course of all patients were reviewed. The surgical technique has been previously described by Guillonneau and Vallancien1 and consists of an initial transperitoneal dissection of the seminal vesicles. All of our patients underwent preoperative mechanical bowel preparation. Nervesparing dissection was routinely performed using athermal techniques, except for in patients with high-volume disease or a high preoperative Gleason score, who underwent ipsilateral neurovascular bundle transection. After complete dissection and isolation of both seminal vesicles, Denonvilliers fascia was incised to expose the posterior capsule of the prostate. Care was taken to avoid entering the posterior leaflet of Denonvilliers fascia to minimize trauma to the anterior rectal wall. In creating the algorithm, we also reviewed our treatment of 7 patients with post-LRP rectourethral fistulas who had been referred to our medical center for treatment (Table 1).
RESULTS From the Department of Urology and Section of Colorectal Surgery, Kaiser Foundation Hospital, Los Angeles, California Reprint requests: Jeremy M. Blumberg, M.D., Department of Urology, Kaiser Permanente, 4900 Sunset Boulevard, Los Angeles, CA 90027. E-mail: Jeremy. [email protected] Submitted: April 9, 2007, accepted (with revisions): August 11, 2008
© 2009 Elsevier Inc. All Rights Reserved
Of the first 200 LRPs performed at our institution, 2 cases (1%) were complicated by a rectal injury. One injury was discovered intraoperatively, and the other patient presented with a postoperative rectourethral fistula. The following is a summary of both cases. 0090-4295/09/$34.00 doi:10.1016/j.urology.2008.08.473
163
Rectal Injury Intraoperative Recognition?
YES Laparoscopic Repair if Feasible Or, Open Repair of Rectal Tear
2 Layer, Interrupted Generous Tissue Bites
-Cysto-urethrogram -CT Scan
Percutaneous Drainage
NO YES
No Fecal Diversion
Postoperative Recognition of Rectourethral Fistula
Abscess On CT
Adequate Repair? YES
NO
Patient Septic or Very Symptomatic? Hx of Pelvic Radiation?
Fecal Diversion Reassess in 3 Months
YES
Observation -Urinary Catheterization -Antibiotics PRN -Symptom Relief
Gastrograffin Enema
Healed?
NO
Reassess in Cystogram 2-3Months
NO
Close Stoma
NO Operative Management
Healed? YES
Treatment Completed
Figure 1. Treatment algorithm for rectal injury in laparoscopic radical prostatectomy. Table 1. Management of referred cases of rectourethral fistula secondary to LRP Patient Injury Noted Age (y) Intraoperatively?
Initial Management
Presenting Symptoms
67
No
Fecaluria and pelvic abscess
61
No
52 59
No Yes
61
No
Urine per rectum and febrile UTI Fecaluria and urorrhea No symptoms; fistula revealed on postoperative cystogram Abdominal pain and fever
62 57
No Yes
Urine per rectum Urine per rectum
Surgical Management
Fistula Closed Successfully?
Open drainage of Endorectal abscess and advancement flap attempted RUF repair (failed) Foley catheter drainage None
Yes
Foley catheter drainage Laparoscopic 2-layer closure of rectotomy and Foley catheter drainage End colostomy and Foley catheter drainage Foley catheter drainage Conversion to open RRP with 2-layer closure of rectotomy and Foley catheter drainage
Yes No (surgical repair pending at last follow-up)
None Diverting loop colostomy
Yes
Cystectomy with ileal Yes conduit creation None Diverting loop colostomy with subsequent takedown
Yes Yes
LRP, laparoscopic radical prostatectomy; RUF, rectourethral fistula.
Patient 1 After the seminal vesicle dissection and during the development of the posterior plane, a 2-cm anterior longitudinal rectal tear was encountered in a 60-year-old man with Stage T1c, Gleason score 6 carcinoma of the prostate. The injury appeared to involve only the superficial layers of the rectum, and the lumen of the bowel was not visualized. The patient had undergone preoperative mechanical bowel preparation. No gross contamination was 164
noted. The tear was managed laparoscopically with a 2-layer closure using 2-0 Vicryl sutures in a single interrupted fashion. The integrity of the repair was verified by insufflating the rectum transanally with air after submerging its anterior wall in sterile saline. No gas leak was noted. Anal dilation was not performed. No intravenous antibiotics were administered. The patient received oral intake starting on postoperative day 2, and the surgical drain was removed after 4 days. On postoperative day 14, UROLOGY 73 (1), 2009
the urethral catheter was removed after normal urethrocystography findings. The patient had an uneventful recovery and continued to do well 8 months after LRP.
Patient 2 A 62-year-old man with Stage T1c underwent LRP. He had undergone preoperative mechanical bowel preparation. The vesicourethral anastamosis was challenging because of a short urethral stump. The closed suction drain and urethral catheter were removed on postoperative day 3 and 10, respectively. Shortly thereafter, the patient presented with frequent, loose, and watery bowel movements. His stool stained orange after an oral phenazopyridine challenge. The cystography findings on postoperative day 14 confirmed a narrow rectourethral fistula. The presumed etiology of the fistula was injury to the anterior rectal wall during placement of the posterior sutures of the vesicourethral anastomosis. The urethral catheter was reinserted, and the patient was instructed to consume a low-residue diet. No pelvic abscess was seen on computed tomography. Three weeks later, the urethral catheter was removed after normal cystography findings documenting full healing of the fistula. At 22 months of follow-up, the patient was well without evidence of recurrent rectourethral fistula.
COMMENT Rectal injury during LRP is a rare, but potentially, serious complication. Numerous studies have reported an incidence of 0.5%-9%.2,3 LRP has been gaining momentum as a viable alternative to open retropubic prostatectomy. Although associated with a shorter hospital stay and faster recovery compared with the traditional open operation, LRP confers the risk of similar complications, including the risk of rectal injury.2-4 Despite good intraoperative visualization laparoscopically, the proximity of the rectum to the dissection plane can lead to trauma to its anterior wall. Castillo et al.4 from Chile reported their experience with extraperitoneal LRP. From 2001 to 2004, 110 patients underwent the procedure. All patients underwent preoperative mechanical bowel preparation and received intravenous antibiotics. Of their 110 patients, 9 (8%) experienced a rectal injury. Seven injuries occurred during the first 50 cases. Six were recognized intraoperatively and a 2-layer repair of the rectum was used. Of these 6 injures, the repair of 3 failed and a rectourethral fistula developed. Three patients with unrecognized intraoperative injury presented with postoperative rectourethral fistula. Of a total of 6 rectourethral fistulas, 3 healed spontaneously with prolonged urethral catheterization and 3 required trans-sphincteric repair. Only 1 patient required fecal diversion with a stoma. All patients healed.4 Similarly, Katz et al.5 described their experience from France with 300 LRPs performed from 1998 to 2002. All patients had undergone bowel prepaUROLOGY 73 (1), 2009
ration and received intravenous antibiotics. Six patients (2%) had a rectal injury. Of these 6 injures, 5 were recognized intraoperatively and closed with a 2-layer repair with either an omental or perirectal flap. Only 1 patient underwent fecal diversion in their group. One patient presented with a postoperative rectourethral fistula and was treated with prolonged urethral catheterization and a diverting stoma. All patients healed. Finally, Guillonneau et al.6 reported on another French series of 1000 transperitoneal LRPs performed from 1998 to 2002. Of the 1000 patients, 13 (1.3%) had a rectal injury, 11 of which were recognized intraoperatively. The mean laceration length was 20 mm. A 2-layer repair was performed in most cases, and the patients received 1 additional week of intravenous antibiotics. Emergent reoperation with fecal diversion was required in 4 patients: 2 with a missed intraoperative injury and 2 in whom the initial repair had failed (1 with a single-layer repair). All patients healed, including 1 who developed a chronic rectourethral fistula that required surgical repair.6 In our series of 200 LRPs, 2 patients (1%) had a rectal injury. One injury was recognized intraoperatively and successfully repaired and the second patient presented with a postoperative rectourethral fistula. Healing of the fistula was accomplished with urethral catheterization for an additional 3 weeks. The mechanism of injury was direct trauma to the anterior wall during posterior dissection in 1 patient and suturing of the vesicourethral fistula in the second patient. We propose a treatment algorithm for this rare injury using our experience with these 2 cases, other open radical prostatectomy cases, and several referred traumatic or radiation-induced rectourethral fistulas successfully treated by our multidisciplinary tertiary team of urologic and colorectal surgeons (Fig. 1). Injuries recognized intraoperatively should be repaired laparoscopically if the surgeon is comfortable in doing so. Conversion to open repair can be undertaken, depending on the situation. A colorectal surgeon can be involved, if needed. The operative field should be irrigated with copious amount of saline and the rectum with Betadine. A 2-layer repair is preferable, using single interrupted absorbable sutures. The entire laceration should be clearly delineated to ensure full closure of both edges. This may necessitate careful mobilization of the surrounding tissues for visualization. If feasible, an omental flap brought transperitoneally or a perirectal fat flap should be considered. The repair should be tested by insufflating the rectum transanally with air and checking for a gas leak after filling the pelvis with fluid. Fecal diversion is recommended if any concern exists about the adequacy of the repair, poor tissue quality, a history of radiation to the pelvis, or significant fecal contamination in the field. A 19F Blake drain should be left in place. Patients in whom intraoperative repair fails or who sustain an unrecognized injury can present with a post165
operative rectourethral fistula. Symptoms can vary from fecaluria, pneumaturia, recurrent polymicrobial urinary tract infection, pain, and rectal bleeding to pelvic sepsis and/or necrotizing fascitis. Patients with a history of radiotherapy and those with sepsis or severe symptoms should undergo immediate fecal and urinary diversion. Stable patients can be investigated with cystourethrography, cystoscopy, Gastrografin enema, flexible sigmoidoscopy, and computed tomography of the pelvis. Although computed tomography is recommended for all patients to exclude the presence of a pelvic abscess, not every patient requires all of the mentioned studies. In our practice, we obtain a cystourethrogram to document the rectourethral fistula and, if inconclusive, we proceed with other studies. If a pelvic abscess is present, percutaneous drainage should be done. Urethral catheterization should be performed in all patients. Suprapubic catheters should be placed selectively. The rectourethral fistula can be reassessed by cystourethrography as early as 1 month for small uncomplicated fistula or 2-3 months for patients with a large defect or a more complicated postoperative course. The urethral catheter should be removed once resolution of the fistula has been documented. Patients who have undergone fecal diversion should undergo flexible sigmoidoscopy or Gastrografin enema before closure of the stoma. Persistent rectourethral fistula is a complex and difficult problem. Definitive surgical treatment should not be considered for ⱖ3 months from the injury to allow for the inflammation to subside. Definitive repair undertaken sooner carries a high failure rate. The treatment options include additional observation in some cases, permanent fecal and urinary diversion for patients with significant comorbidities or a short life expectancy, and definitive surgical repair. Numerous surgical techniques are available to repair this complex fistula and include transabdominal, trans-sacral, trans-sphincteric, transanal, transperineal, and transpubic approaches.7-17 Each case should be selected individually according to the mechanism and etiology of the injury, size and location of the fistula, history of radiotherapy, previous surgical history, presence of residual cancer and positive margins, and the surgeon’s expertise. Patients with a history of radiotherapy require closure with a vascularized tissue such as the gracilis or rectus abdominus muscle flap. A multidisciplinary approach should be undertaken involving urology and colon and rectal surgery, and these complex cases are best managed in centers with expertise.
166
CONCLUSIONS Rectal injury during LRP is uncommon. Rectal laceration recognized intraoperatively should be repaired in a 2-layer fashion, and the adequacy of the repair should be tested. Fecal diversion should be considered when concern exists about the adequacy of the repair or viability of the tissue, history of radiotherapy, or a large amount of contamination. Postoperative rectourethral fistula can be successfully managed with prolonged urethral catheterization. Most rectal injuries associated with LRP heal. Persistent rectourethral fistula can be approached by different surgical techniques. References 1. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: The Montsouris technique. J Urol. 2000;163:1643-1649. 2. Guillonneau B, El-Fettouh H, Baumert H, et al. Laparoscopic radical prostatectomy: Oncological evaluation after 1,000 cases at Montsouris Institute. J Urol. 2003;169:1261-1266. 3. Rassweiler J, Sentker L, Seemann O, et al. Laparoscopic radical prostatectomy with the Heilbronn technique: An analysis of the first 180 cases. J Urol. 2001;166:2101-2108. 4. Castillo OA, Bodden E, Vitagliano G. Management of rectal injury during laparoscopic radical prostatectomy. Int Braz J Urol. 2006;32: 428-433. 5. Katz R, Borkowski T, Hoznek A, et al. Operative management of rectal injuries during laparoscopic radical prostatectomy. Urol Int. 2006;77:216-221. 6. Guillonneau B, Gupta R, El-Fettouh H, et al. Laparoscopic management of rectal injury during laparoscopic radical prostatectomy. J Urol. 2003;169:1694-1696. 7. Nyam DC, Pembreton JH. Management of iatrogenic rectourethral fistula. Colon Rectum. 1999;42:994-997. 8. Trippitelli A, Barbagli G, Lenzi R, et al. Surgical treatment of rectourethral fistulae. Eur Urol. 1985;11:388-391. 9. Wilbert DM, Buess G, Bichler KH, et al. Combined endoscopic closure of rectourethral fistula. J Urol. 1996;155:256-258. 10. Thompson IM, Marx AC. Conservative therapy of rectourethral fistula: Five-year follow-up. Urology. 1990;35:533-536. 11. Bukowski TP, Chakrabarty A, Powel IJ, et al. Acquired rectourethral fistula: Methods of repair. J Urol. 1995;153:730-733. 12. Culkin DJ, Ramsey CE. Urethrorectal fistula: Transanal, transsphincteric approach with locally based pedicle interposition flaps. J Urol. 2003;169:2181-2183. 13. Dreznik Z, Alper D, Vishne TH, et al. Rectal flap advancement—A simple and effective approach for the treatment of rectourethral fistula. Colorectal Dis. 2003;5:53–53. 14. Loughlin KR, Orgill DP. The use of a rectus muscle flap in the repair of a prostate-rectal fistula. J Urol. 2001;166:620-621. 15. Zmora O, Potenti F, Wexner SD, et al. Gracilis muscle transposition for iatrogenic rectourethral fistula. Ann Surg. 2003;237:483487. 16. Hata F, Yasoshima T, Kitagawa S, et al. Transanal repair of rectourethral fistula after a radical retropubic prostatectomy. Surg Today. 2002;32:170-173. 17. Boushey RP, Mcleod RS, Cohen Z. Surgical management of acquired rectourethral fistula. Can J Surg. 1998;41:241-244.
UROLOGY 73 (1), 2009