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
Introduction:
We desired to critically evaluate the contemporary incidence and management of rectal injury (RI) during radical prostatectomy (RP).
Methods:
RIs during RP were identified from departmental Morbidity and Mortality records. Electronic patient records were reviewed to evaluate the subsequent management and outcomes.
Results:
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.
Conclusions:
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.
