2008 Annual Meeting Abstracts
Management of Rectal Injury During Radical Prostatectomy
Wilmer B Roberts, Kenneth Tseng*, Patrick C Walsh, Misop Han
Johns Hopkins, Baltimore, MD
We desired to critically evaluate the contemporary incidence and management of rectal injury (RI) during radical prostatectomy (RP).
RIs during RP were identified from departmental Morbidity and Mortality records. Electronic patient records were reviewed to evaluate the subsequent management and outcomes.
From 1/1997-8/2007, 11,452 men underwent RP: 10,183 men by the radical retropubic approach (RRP), 1,269 by the laparoscopic approach (LRP) with or without robotic assist. RI occurred in 18 men - 12 in RRPs (0.12%) and 6 in LRPs (0.47%). Sixteen RIs were recognized intraoperatively and primarily repaired in 2 or 3 layers without a diverting colostomy. A pedicle of omentum was used as an interposing layer in 4 cases. Despite primary repair without interposed omentum and a diverting colostomy, 2 patients developed a rectourethral fistula. In one (RRP), the fistula closed with prolonged catheterization (9 weeks). In the other (LRP), the fistula persisted, and a transrectal advancement flap was required.
Two RIs (1 RRP, 1 LRP) were unrecognized at the time of RP but presented within 4 days. Despite conservative management, the rectourethral fistulas persisted in both men requiring subsequent repair via transrectal advancement flap.
In intraoperatively recognized RI, primary repair without diverting colostomy prevented subsequent rectourethral fistula formation in 87.5%. RI discovered postoperatively should be primarily repaired with omental interposition and a diverting colostomy. Without primary repair, the rectourethral fistula most likely will persist, requiring delayed surgical repair.