Management Of Rectal Injuries Research Articles

Management of rectal injury and rectourinary fistula from radical prostatectomy

This study aimed to demonstrate our management of rectal injury (RI) and rectourinary fistula (RUF) from radical prostatectomy (RP) and identify a possible factor that increased the chance of developing RUF. Between January 2011 and December 2019, a total of 14 cases of RI were retrospectively reviewed and analyzed, including preoperative, perioperative, and postoperative information. In all 14 cases of RI, the average age at RP was 66.3 years (54-77). During the study period, 8 of 14 cases of RI occurred in our hospital, and the incidence of RI was 0.42%. RI was intraoperative recognition in 8 cases and delayed diagnosis in 6 cases. For immediate recognition, 4 of 8 cases were primarily repaired without developing RUF and did not require diverting colostomy and suprapubic cystostomy. RUF occurred in 10 cases including 4 cases of intraoperative recognition and all cases of delayed diagnosis. In a subgroup analysis of RI that occurred in our hospital, the timing for diagnosis was clinically and statistically significant difference (P = 0.029). Instantly detected RI during RP and intraoperative rectal repair resulted in no postoperative complication. Among all 10 cases of RUF, 5 cases were successfully repaired by modified York-Mason procedure with dartos tissue flap interposition. No major complications were reported. Incidence of RI was 0.42% and intraoperative recognition of RI was a key to prevent the development of RUF. Modified York-Mason procedure with dartos tissue flap interposition was an effective treatment for RUF.

Postoperative Outcomes after Penile Inversion Vaginoplasty: Prevention and Management of Rectal Injury

Postoperative Outcomes after Penile Inversion Vaginoplasty: Prevention and Management of Rectal Injury

Diversion Remains the Standard of Care for Modern Management of War-Related Rectal Injuries

Management of rectal injuries in war-injured patients has evolved over time. Retrospective review of records of patients sustaining war-related rectal injuries admitted to Walter Reed Army Medical Center from Iraq and Afghanistan. From 2003 to 2011, 67 males ages 18 to 40 sustained rectal injuries after secondary blast (64%), gunshot (33%), motor vehicle crash (1%), or helicopter crash (1%). Injuries were extraperitoneal (72%), intraperitoneal (25%), or both (3%). Rectal abbreviated injury score mean was 3 ± 1. Surgical management included end colostomy (66%), loop colostomy (28%), and no diversion (4%). Distal washout (24%) and drain placement (33%) were performed. Colostomy closure occurred in 79% of patients at an average of 237 days after injury. Diversion is the preferred treatment of war-related rectal injuries. Loop colostomy is acceptable unless there is potential for evolving rectal injury. Routine use of presacral irrigation and drainage was not supported.

Commentary on “Management of rectal injury during robotic radical prostatectomy.” Kheterpal E, Bhandari A, Siddiqui S, Pokala N, Peabody J, Menon M, Vattikuti Urology Institute, Henry Ford Health System, Henry Ford Hospital, Detroit, Michigan: Urology 2011;77:976–9

Commentary on “Management of rectal injury during robotic radical prostatectomy.” Kheterpal E, Bhandari A, Siddiqui S, Pokala N, Peabody J, Menon M, Vattikuti Urology Institute, Henry Ford Health System, Henry Ford Hospital, Detroit, Michigan: Urology 2011;77:976–9

VID-07.07 Recognition and Management of Rectal Injury During Robotic Prostatectomy

VID-07.07 Recognition and Management of Rectal Injury During Robotic Prostatectomy

Management of Rectal Injury During Robotic Radical Prostatectomy

To review the incidence and management of rectal injury in 4400 consecutive cases of robotic radical prostatectomy at a single institution. From September 2001 to September 2009, 4400 patients underwent robotic radical prostatectomy. We reviewed the intraoperative and postoperative data from patients with rectal injuries. Once recognized, the rectal injuries were closed in 2 layers. Clear liquids were started the day after surgery. Healing of the vesicourethral anastomosis was confirmed by cystography 5-14 days postoperatively. Rectal injuries were identified in 10 patients (0.2%). The mean patient age was 58.6 years (range 44-68), and the mean body mass index was 25.8 kg/m(2) (range 22-29). The mean prostate-specific antigen level was 7.1 ng/mL (range 0.9-14.8), and the mean prostate weight was 58.9 g (range 22-102). The clinical stage was T1c, T2a, and T2c in 7, 2, and 1 patient, respectively. The preoperative Gleason score was 6, 7, and 8 in 3, 3, and 4 patients, respectively. All rectal injuries were diagnosed and repaired intraoperatively. Of the 10 patients, 9 had an uneventful postoperative course. The average urethral catheterization time for these patients was 14 days (range 6-21). One patient had gross fecal spillage and developed a rectourethral fistula requiring a delayed diverting colostomy. No perioperative mortality occurred. We found a low incidence of rectal injury during robotic radical prostatectomy. We have also demonstrated that rectal injuries can be managed primarily with meticulous closure with minimal morbidity.

Editorial Comment

The present series illustrates important points regarding contemporary management of prostate cancer and renal transplant recipients. First, patients who have been successfully treated for end-stage renal disease by renal transplantation are healthy, have an excellent life expectancy, and are subject to acquiring further medical conditions that will require definitive management. This includes prostate cancer, which will be frequently found. These patients should be screened and treated for prostate cancer. Second, radical prostatectomy is a feasible and reasonable option for solid organ transplant recipients. The current finding of a high incidence of severe prostatitis, which resulted in rectal injury, is a novel and important observation. We have not observed this phenomenon. It certainly deserves more scrutiny to identify preoperative factors that may predict surgical difficulty. There does not appear to be any smoking gun in the present series, which correlates to the complications observed. In management of rectal injury, we strongly advise reducing the patient's immunosuppressive therapy as much as possible to encourage healing. Rapimmune has greater potential than Cellcept for impairing closure of the rectal injury. Consideration should, therefore, be given to changing the patient's medication regimen to reduce the possibility of serious complications. Laparoscopic Radical Prostatectomy in Renal Transplant RecipientsUrologyVol. 74Issue 3PreviewTo report our experience with 9 consecutive laparoscopic radical prostatectomy (LRP) on renal transplant recipients (RTR) and to compare it with other LRPs performed during the same period by the same surgeons. Retropubic radical prostatectomy has widely been described in RTR, whereas LRP has rarely been studied. Full-Text PDF

Repair of Rectal Injury During Robotic-Assisted Laparoscopic Prostatectomy

Rectal injury is a potential devastating complication in radical prostatectomy. We reviewed the incidence and management of rectal injuries with robotic-assisted laparoscopic radical prostatectomy performed by a single surgeon. Of the first 251 robotic-assisted laparoscopic radical prostatectomies performed, 2 (0.8%) were complicated by rectal injury. All patients underwent bowel preparation and received preoperative intravenous antibiotics. Both rectal injuries were detected intraoperatively and treated robotically. The rectotomy was closed in two layers of absorbable sutures and imbricated with a nonabsorbable suture. The rectum was then tacked to the levator fibers on one side with nonabsorbable suture to pull the injury away from the vesicourethral anastomosis. An omental flap was developed and tacked posterior to the urethra to cover the repair. A closed suction drain was placed. After surgery, the patients received broad-spectrum intravenous antibiotics and resumed oral intake on postoperative day 1. At 2 weeks, the Foley catheter was removed after voiding cystourethrography confirmed no extravasation. Rectal injury during robotic-assisted laparoscopic radical prostatectomy can be identified and managed intraoperatively without requiring open conversion. A three-layer closure tacked away from the vesicourethral anastomosis and reinforced by an omental flap resulted in an uneventful recovery.

Outcomes and management of rectal injuries in children

In the pediatric population, rectal injuries usually occur as a result of motor vehicle collisions. There has been an increased interest in selective diversion of rectal injuries in adults and increased utilization of laparoscopy both as a diagnostic and therapeutic adjunct. The aim of the study was to review our institutional experience with rectal injuries to determine if there was a subset of patients who could be managed with selective diversion. The medical records of children admitted with a rectal injury to Hospital for Sick Children, Toronto, over the last 20 years (1984-2004) were retrospectively reviewed. Data abstraction included patient demographics, mechanism of injury, injury severity score, associated injuries, presenting symptoms, methods of diagnosis, treatment and resultant complications. Nine patients with rectal injuries were identified. The average injury severity score (ISS) was 19.3. Two patients with penetrating injuries underwent laparoscopy. Laparoscopy was able to define the intraperitoneal extension of injuries and guide the colostomy. Primary repair without a diverting colostomy was performed in 3 patients (2 intraperitoneal and 1 extraperitoneal injury) without complications. Based on the limited sample size, one should avoid making any definitive recommendations but, it appears, primary repair without fecal diversion can be performed safely in select children in spite of a longer time to surgery. Laparoscopy may be used for the immediate management of the penetrating trauma patient to rule out intraperitoneal extension, repair a perforation and guide the colostomy if necessary.

Management of rectal injury during laparoscopic radical prostatectomy

Because laparoscopic radical prostatectomy remains a challenging procedure, rectal injury is always a potential complication. We review the incidence of rectal injuries at our institution in the first 110 consecutive laparoscopic extraperitoneal radical prostatectomies. Nine (8%) out of the first 110 laparoscopic extraperitoneal radical prostatectomies performed between December 2001 and February 2004, were complicated by rectal injury. Mean patient age was 64.9 years (range 52 to 74) and mean prostate specific antigen was 11.45 ng/mL (range 4.8 to 37.4). Median preoperative Gleason score was 6 (range 4 to 8) and clinical stage was T1c, T2a, T2b in 6, 2 and 1 patient, respectively. Mean operative time was 228 minutes (range 150 to 300). From 9 injuries, 6 were diagnosed and repaired intraoperatively and 3 were diagnosed postoperatively. From the 6 cases of intraoperative diagnosis and repair, 3 patients healed primarily without colostomy and a recto-urinary fistula was evidenced by pneumaturia in the remaining three. These 3 patients were managed conservatively with urethral catheterization during 30 days. One of the patients required secondary fistula repair by anterior transphincteric, transanal surgical approach (ASTRA). Urinary fistula was diagnosed postoperatively on 3 patients. A diverting colostomy was performed on one patient with secondary fistula repair by ASTRA. Another patient required laparotomy due to peritonitis and urinary fistula was later managed with ASTRA. On the third patient conservative management with urethral catheter was successful. All fistulas repaired with ASTRA evolved uneventfully. There was no perioperative mortality. Rectal injury during laparoscopic radical prostatectomy can be managed intraoperatively or by a minimally invasive procedure without the need of colostomy. Laparoscopic radical prostatectomy is a challenging procedure and is associated with a very flat learning curve; the incidence of rectal injuries is prone to diminish with experience.

Management of rectal injuries

Rectal injuries result from a variety of insults and cause a heterogeneous spectrum of injuries to patients. Historically, many of these injuries were devastating, with high morbidity and mortality. They often required an aggressive approach to treatment including fecal stream diversion, distal rectal washout, and presacral drainage. Contemporary surgical care and a better understanding of the management of these injuries have dramatically improved outcomes. Although aggressive management including diversion is still the gold standard for treatment of severe injuries, some civilian injuries may require less aggressive management, including nonoperative management. By examining most studies published on rectal injuries in the last 50 years, this comprehensive review examines the incidence, demographics, mechanisms, associated injuries, diagnostic methods, and treatment recommendations. Rectal injuries remain a complex and challenging problem for the surgeon, and a thorough understanding of this disease process as well as the treatment options available is necessary to ensure a safe and successful outcome for the patient.

Laparoscopic Management Of Rectal Injury During Laparoscopic Radical Prostatectomy

Rectal injury is a potential complication of radical prostatectomy. Because laparoscopic radical prostatectomy is still a challenging procedure, we review the incidence and management of rectal injury in 1,000 cases of consecutive laparoscopic radical prostatectomy performed at our institution. Of the first 1,000 laparoscopic transperitoneal radical prostatectomies performed between January 1998 and April 2002, 13 (1.3%) were complicated by rectal injury. Mean patient age was 66.5 years (range 58 to 76) and mean prostate specific antigen was 12.9 ng./ml. (range 2.9 to 26). Clinical stage was T1c, T2a and T2b in 5, 7 and 1 patient, respectively. Mean preoperative Gleason score was 5.8 (range 3 to 8). Once recognized the rectal defect was closed laparoscopically in 2 layers and tested for the absence of leakage. Broad-spectrum intravenous antibiotics were given for 7 days. Oral liquids were started the day after surgery with a low residue diet, and a regular diet was started on postoperative day 5. Healing of the vesicourethral anastomosis was confirmed by voiding cystourethrogram on postoperative day 5. All patients underwent a non-nerve sparing procedure except 1 in whom unilateral neurovascular bundle preservation was done. Of 13 injuries 11 were diagnosed and repaired intraoperatively, and 2 were diagnosed postoperatively. Of the 11 cases of intraoperative diagnosis and repair 9 healed primarily without colostomy and peritonitis was diagnosed in the remaining 2 on days 3 and 4, respectively. Of the latter 2 patients 1 required repair of a small rectal defect without colostomy while the other required colostomy. Colostomy was performed in the 2 patients with delayed diagnosis on days 3 and 4 but even then a rectourethral fistula developed in 1, necessitating secondary repair. Average urethral catheterization time was 8.6 days for the 9 patients with an uneventful immediate postoperative course and mean hospital stay was 6.8 days. For the remaining 4 patients urethral catheterization duration was 12, 13, 15 and 120 days, and hospital stay was 7, 16, 21 and 27 days, respectively. There was no perioperative mortality. Rectal injury during laparoscopic radical prostatectomy requires meticulous intraoperative repair in 2 layers, which allows primary healing without diversion colostomy. For injury prevention scrupulous attention is required during non-nerve sparing radical prostatectomy, particularly at the posterior surface of the prostatic apex.

Incidence and Management of Rectal Injury Associated With Radical Prostatectomy in a Community Based Urology Practice

Incidence and Management of Rectal Injury Associated With Radical Prostatectomy in a Community Based Urology Practice

Management of rectal injury during perineal prostatectomy.

109 patients with locally confined prostate cancer underwent radical perineal prostatectomy. In 12 (11%) patients a rectal laceration was noted intraoperatively and closed in two layers. No patient had complications or prolonged hospital stay associated with the laceration.

New technique for repair of rectal injury

Injury to the rectum is a potentially serious complication of pelvic surgery. The management of rectal injury is controversial. We present a technique of using flaps of endopelvic fascia to reinforce the repair and isolate the injury site. We have utilized this approach in 4 men undergoing retropubic prostatectomy without complications.

The Management of Rectal Injury During Radical Retropubic Prostatectomy

From May 1982 through March 1991, 10 rectal injuries were identified in 1,000 men who underwent radical retropubic prostatectomy for clinically localized adenocarcinoma. All rectal injuries occurred in nonirradiated patients. Of these patients 9 were identified during surgery and 1 was diagnosed on postoperative day 2. The 9 patients in whom the injury was recognized at operation underwent successful primary closure without a diverting colostomy. The patient who underwent delayed closure was treated with a temporary diverting colostomy. As a preoperative routine, all patients received a Fleet enema without preoperative antibiotics. In all patients the rectal injury was closed in 2 layers, the anal sphincter was dilated, and a pedicle of omentum was mobilized through a small opening in the peritoneum and placed through the rectovesical cul-de-sac to cover the suture line. All patients received 7 to 14 days of broad-spectrum antibiotics. Postoperatively, no patient had a wound infection, pelvic abscess or urethrorectal fistula. Overall hospital stay was increased by an average of 2 days. Rectal injuries recognized during surgery in previously nonirradiated patients undergoing radical retropubic prostatectomy can be managed successfully with primary closure alone, avoiding the morbidity of a diverting colostomy.

Management of Rectal Injuries During Radical Cystectomy

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. Urol., 142:1204-1205, 1989)

Management of Rectal Injuries

Diagnosis, evaluation, and management of the various grades of rectal tears is discussed. Surgical techniques, which include direct closure, diverting colostomies, and placement of temporary rectal liners, are detailed. Also, rectal prolapses and various methods of repair are outlined.

Management of rectal injury during cystectomy

Rectal injury during radical cystectomy for bladder malignancy occurs in about 4 per cent of cases. Between 1975 and 1980, we performed 70 cystectomies; 5 rectal injuries occurred. The plan of management based on this experience includes careful inspection, good nutrition, avoidance of sepsis, adequate drainage, and decompression of the disruption often requiring a sigmoid loop colostomy.

Management of Rectal Injury and Rectourethral Fistulas following Radical Retropubic Prostatectomy

No AccessJournal of Urology1 Nov 1972Management of Rectal Injury and Rectourethral Fistulas following Radical Retropubic Prostatectomy Arthur M. Smith, and Ralph J. Veenema Arthur M. SmithArthur M. Smith More articles by this author , and Ralph J. VeenemaRalph J. Veenema More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)60866-8AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Management of Rectal Injury and Rectourethral Fistulas following Radical Retropubic Prostatectomy." The Journal of Urology, 108(5), pp. 778–779 © 1972 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByWedmid A, Mendoza P, Sharma S, Hastings R, Monahan K, Walicki M, Ahlering T, Porter J, Castle E, Ahmed F, Engel J, Frazier H, Eun D and Lee D (2018) Rectal Injury During Robot-Assisted Radical Prostatectomy: Incidence and ManagementJournal of Urology, VOL. 186, NO. 5, (1928-1933), Online publication date: 1-Nov-2011.Thomas C, Jones J, Jäger W, Hampel C, Thüroff J and Gillitzer R (2018) Incidence, Clinical Symptoms and Management of Rectourethral Fistulas After Radical ProstatectomyJournal of Urology, VOL. 183, NO. 2, (608-612), Online publication date: 1-Feb-2010.GUILLONNEAU B, GUPTA R, EL FETTOUH H, CATHELINEAU X, BAUMERT H and VALLANCIEN G (2018) Laparoscopic Management Of Rectal Injury During Laparoscopic Radical ProstatectomyJournal of Urology, VOL. 169, NO. 5, (1694-1696), Online publication date: 1-May-2003.Harpster L, Rommel F, Sieber P, Breslin J, Agusta V, Huffnagle H and Pohl C (2018) Incidence and Management of Rectal Injury Associated With Radical Prostatectomy in a Community Based Urology PracticeJournal of Urology, VOL. 154, NO. 4, (1435-1438), Online publication date: 1-Oct-1995.Borland R and Walsh P (2018) The Management of Rectal Injury During Radical Retropubic ProstatectomyJournal of Urology, VOL. 147, NO. 3 Part 2, (905-907), Online publication date: 1-Mar-1992.Teichman J, Lilly J and Schmidt J (2018) Rectourethral Fistula Caused by Kaposi’s SarcomaJournal of Urology, VOL. 145, NO. 1, (144-145), Online publication date: 1-Jan-1991.Zimmern P and Cukier J (2018) Prostatic and Membranous Urethrorectal Fistulas: A New Technique of Surgical ClosureJournal of Urology, VOL. 134, NO. 2, (355-357), Online publication date: 1-Aug-1985.Duckett J (2018) Editorial CommentJournal of Urology, VOL. 134, NO. 2, (357-357), Online publication date: 1-Aug-1985.Veenema R, Gursel E and Lattimer J (2018) Radical Retropubic Prostatectomy for Cancer: A 20-Year ExperienceJournal of Urology, VOL. 117, NO. 3, (330-331), Online publication date: 1-Mar-1977.Catane R, Kaufman J, Mittelman A and Murphy G (2018) Combined Therapy of Advanced Prostatic Carcinoma with Estramustine and PrednimustineJournal of Urology, VOL. 117, NO. 3, (332-336), Online publication date: 1-Mar-1977.Morgan C (2018) Dorsal Rectotomy and Full Thickness Skin Graft for Repair of Prostatic Urethrorectal FistulaJournal of Urology, VOL. 113, NO. 2, (207-209), Online publication date: 1-Feb-1975. Volume 108Issue 5November 1972Page: 778-779 Advertisement Copyright & Permissions© 1972 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Arthur M. Smith More articles by this author Ralph J. Veenema More articles by this author Expand All Advertisement Loading ...