0022-534 7/92/14 73-0905$03.00/0 VoL 147, 905-907, Ma,ch 1992
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
THE MANAGEMENT OF RECTAL INJURY DURING RADICAL RETROPUBIC PROSTATECTOMY R. NEILL BORLAND*
AND
PATRICK C. WALSH
From the James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland
ABSTRACT
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. KEY WORDS: rectum, wounds and injuries, prostatectomy
The risk of rectal injury during a radical pelvic operation has long been a concern of urologists. Rectal injury has been reported in O to 9% of the cases from series encompassing perinea! and retropubic approaches. 1- 5 Conservative and staged management strategies have been advocated, and many physicians recommend proximal fecal diversion in addition to rectal repair. 6- 10 Also, because of concern over possible bowel injury there is widespread use of extensive preoperative bowel preparations and perioperative antibiotics. We review the incidence and management of rectal injuries encountered in 1,000 consecutive radical retropubic prostatectomies. Based on this experience recommendations for preoperative preparation and intraoperative management have been formulated. MATERIALS AND METHODS
Patients. Of 1,000 radical retropubic prostatectomies performed for clinically localized adenocarcinoma between May 1982 and March 1991, 10 (1 %) were complicated by rectal injury. Mean patient age was 59 years (range 47 to 68 years). Five patients had clinical stage Bl disease, 3 had clinical stage B2 disease and 2 were diagnosed by ultrasound guided biopsy. No patient had received preoperative radiation or hormonal therapy. Standard preoperative preparation included only a Fleet enema. No preoperative antibiotics were used. All injuries were full thickness rectal lacerations less than 2 cm. long. Of the 10 injuries 9 occurred during division of the posterior aspect of the striated urethral sphincter at a point where there was fibrosis and fixation to the rectum. One of the 10 injuries occurred during wide excision of the neurovascular bundle. In 9 patients rectal injury was recognized during the operation and primary repair was done as described. In 1 patient the injury was diagnosed on postoperative day 2 with the development of fever and fecaluria. In this patient exploration with rectal repair plus a diverting sigmoid colostomy were performed. Patients were treated with broad-spectrum intravenous antibiotics (typically ampicillin, gentamicin and metronidazole) begun at recognition of the injury. Eight patients received Accepted for publication June 7, 1991. * Requests for reprints: Department of Urology, The Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, Maryland 21205. 905
antibiotics for 7 to 8 days and 1 for 10 days, while the patient who required reexploration was treated for 14 days. Surgical technique. When an injury to the rectum is discovered during the course of prostatectomy, no attempt is made immediately to close or manipulate the rectum. Radical prostatectomy is completed, the bladder neck is reconstructed and sutures are placed in the urethra as previously described. 11 Then, the anal sphincter is dilated to 3 fingerbreadths by the assistant. With the added exposure gained by the assistant's fingers in the rectum, the injury is closed in 2 layers with an inner layer of continuous 2-zero chromic and an outer layer of 2-zero silk or chromic Lembert sutures (part A of figure). The pelvis is thoroughly irrigated with antibiotic solution. Without extending the incision, a small peritoneal opening is made above the bladder and the greater omentum is inspected. A properly sized pedicle is then identified and tapered. Care should be taken to preserve blood vessels when dividing omental tissue. If significant additional length is needed, the midline incision could be extended, and the omentum separated from the colon and mobilized off the stomach as described by Turner-W arwick. 12 This degree of mobilization has not been necessary in our serieso After adequate mobilization of the omentum a hand is passed behind the bladder into the rectovesical cul-de-sac, and the thin layer of peritoneum remaining between the bladder and rectum is identified. A 3 to 4 cm. transverse incision is then made in this peritoneal reflection and the omentum is brought through it into the pelvis (part B of figure). The omentum is tacked down with interrupted 2-zero chromic sutures so as to cover the area of repair completely. After copious irrigation, the standard urethrovesical anastomosis is completed by placing the bladder neck sutures and tying them over a 20F urethral catheter (part C of figure). Closed suction drains are placed into the lateral paravesical spaces, and the peritoneum and midline incision are closed. Broad-spectrum intravenous antibiotics are given for 7 to 14 days with drains usually removed within 5 to 7 days. Nasogastric suctioning is not used and no attempt is made to induce constipation. Oral fluids are given after the passage of flatus, usually around postoperative day 4, and the patient is advanced to a regular diet during the next 3
906
BORLAND AND WALSH
cut-de-sac
B A, 2-layer closure of rectal injury. Note stay sutures in urethra. NVB, neurovascular bundle. B, omental pedicle is brought through rectovesical cul-de-sac into pelvis and placed over repair. Blad., bladder. C, omentum is tacked to rectal serosa and urethrovesical anastomosis is completed.
days. Bowel softeners (docusate sodium) and mineral oil are used for 6 weeks. In the event of a delayed diagnosis, as in 1 patient from this series, immediate re-exploration through the incision is indicated. Takedown of the urethrovesical anastomosis should reveal the source of the rectal leak. If not, a finger gently passed from below through the anus and used as a probe is helpful to locate the injury. Otherwise repair is done as described previously with copious irrigation at each step. In such a case diverting loop colostomy is recommended due to more widespread fecal contamination. The colostomy may be performed after the urethrovesical anastomosis is completed and is most easily placed in the left lower quadrant, well away from the omental pedicle. The colostomy is taken down 3 months postoperatively. RESULTS
All patients underwent successful closure via the omental interposition technique and were without evidence of disease at a mean followup of 24 months (range 6 to 54 months). Postoperatively, there were no wound infections, pelvic abscesses or fistulas. Overall hospital stay was increased by an average of 2 days with the majority of patients discharged from the hospital on postoperative day 9 or 10 (range 9 to 24 days). Two patients required a subsequent operation, 1 for incision and dilation of a bladder neck contracture and 1 for routine colostomy takedown. There have been no abdominal or gastrointestinal complications. DISCUSSION
The complications of rectal injury usually result from breakdown of the rectal closure with fistula or abscess formation. Experience with such failed closures as well as with other
rectourethral fistulas has identified several principles important for successful initial closure. Large series of congenital, iatrogenic and traumatic fistulas have been reported and at least 15 techniques of repair have been described. 13• 14 Among these techniques the avoidance of apposing suture lines, and the interposition of healthy tissue between urinary and alimentary tracts are stressed. Goodwin et al described the interposition of levator ani muscles, 15 while Culp and Calhoon placed "any tissue available" between the urethra and rectum. 16 While the use of local tissue may be possible with perineal based repairs of established fistulas, such coverage is not possible during a radical retropubic operation. The use of distant tissue such as the omentum in the treatment of urinary fistulas was described by Turner-Warwick and is the basis of our repair. As the body's natural defense against infection, the omentum has several characteristics that make it well suited for use in the pelvis. The omentum can provide 1) support for healing tissue; 2) enhanced vascular supply in areas where healing is impaired by infection, irradiation or diabetes; 3) supple surrounding tissue allowing urodynamic mobility, since the omentum retains its normal vascularity and never becomes fibrotic, and 4) an easily separable tissue plane, facilitating any subsequent reexploration. 11 A sound and reliable repair of rectal injury is possible using an omental interposition technique that can be easily applied through the lower midline incision at radical prostatectomy. This 1-stage repair for injuries discovered during surgery has added only the minimal morbidity of postoperative antibiotics to the recovery. Diverting colostomy has not been necessary in the population of nonirradiated patients repaired intraoperatively. Diversion does have a role in more complicated cases, such as the patient with delayed diagnosis in our series in whom fecal contamination was evident, and certainly in patients
MANAGEMENT OF RECTAL INJURY DURING RADICAL RETROPUBIC PROSTATECTOMY
irradiated preoperatively or with otherwise impaired healing potential. Extensive preoperative bowel preparation has not been necessary, since we have found that a properly administered Fleet enema given the night before surgery effectively empties the lower colon. In the small percentage of cases in which a rectal injury has occurred there have not been any infection related complications. In summary, primary repair of rectal injury with the greater omentum and without a diverting colostomy has been safe, effective and associated with minimal patient morbidity. REFERENCES
1. Middleton, A. W., Jr.: Pelvic lymphadenectomy with modified
2. 3. 4. 5.
retropubic prostatectomy as a single operation: technique used and results in 50 consecutive cases. J. Urol., 125: 353, 1981. Nichols, R. T., Barry, J.M. and Hodges, C. V.: The morbidity of radical prostatectomy for multifocal stage I prostatic adenocarcinoma. J. Urol., 117: 83, 1977. Paulson, D. F., Robertson, J. E., Daubert, L. M. and Walther, P. J.: Radical prostatectomy in stage A prostatic adenocarcinoma. J. Urol., 140: 535, 1988. Elder, J. S., Gibbons, R. P., Correa, R. J., Jr. and Brannen, G. E.: Morbidity of radical perinea! prostatectomy following transurethral resection of the prostate. J. Urol., 132: 55, 1984. Veenema, R. J., Gursel, E. 0. and Lattimer, J. K.: Radical retropubic prostatectomy for cancer: a 20-year experience. J. Urol., 117: 330, 1977.
907
6. Smith, A. M. and Veenema, R J .: Management of rectal injury and rectourethral fistulas following radical retropubic prostatectomy. J. Urol., 108: 778, 1972. 7. Swanson, D. A., von Eschenbach, A. C., Bracken, R. B. and Johnson, D. E.: Salvage cystectomy for bladder carcinoma. Cancer, 47: 2275, 1981. 8. Freiha, F. S.: Complications of cystectomy. J. Urol., 123: 168, 1980. 9. Smith, J. A., Jr. and Whitmore, W. F., Jr.: Salvage cystectomy for bladder cancer after failure of definitive irradiation. J. Ural., 125: 643, 1981. 10. Dahl, D. S., Howard, P. M. and Middleton, R. G.: The surgical management of rectourinary fistulas resulting from a prostate operation: a report of 5 cases. J. Urol., 111: 514, 1974. 11. Walsh, P. C.: Retropubic prostatectomy for benign and malignant diseases. In: Operative Urology, 1st ed. Edited by F. F. Marshall. Philadelphia: W. B. Saunders Co., chapt. 38, pp. 264-289, 1991. 12. Turner-Warwick, R.: The use of the omental pedicle graft in urinary tract reconstruction. J. Urol., l 16: 341, 1976. 13. Olsson, C. A., Willscher, M. K., Krane, R. J. and Austen, G., Jr.: Management of prostatic fistulas. Urol. Surv., 26: 135, 1976. 14. Weyrauch, H. M.: A critical study of surgical principles used in repair of urethrorectal fistula: presentation of a modern technique. Stanford Med. Bull., 9: 2, 1951. 15. Goodwin, W. E., Turner, R. D. and Winter, C. C.: Rectourinary fistula: principles of management and a technique of surgical closure. J. Urol., 80: 246, 1958. 16. Culp, 0. S. and Calhoon, H. W.: A variety of rectourethral fistulas: experiences with 20 cases. J. Urol., 91: 560, 1964.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
THE MANAGEMENT OF RECTAL INJURY DURING RADICAL RETROPUBIC PROSTATECTOMY R. NEILL BORLAND*
AND
PATRICK C. WALSH
From the James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland
ABSTRACT
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. KEY WORDS: rectum, wounds and injuries, prostatectomy
The risk of rectal injury during a radical pelvic operation has long been a concern of urologists. Rectal injury has been reported in O to 9% of the cases from series encompassing perinea! and retropubic approaches. 1- 5 Conservative and staged management strategies have been advocated, and many physicians recommend proximal fecal diversion in addition to rectal repair. 6- 10 Also, because of concern over possible bowel injury there is widespread use of extensive preoperative bowel preparations and perioperative antibiotics. We review the incidence and management of rectal injuries encountered in 1,000 consecutive radical retropubic prostatectomies. Based on this experience recommendations for preoperative preparation and intraoperative management have been formulated. MATERIALS AND METHODS
Patients. Of 1,000 radical retropubic prostatectomies performed for clinically localized adenocarcinoma between May 1982 and March 1991, 10 (1 %) were complicated by rectal injury. Mean patient age was 59 years (range 47 to 68 years). Five patients had clinical stage Bl disease, 3 had clinical stage B2 disease and 2 were diagnosed by ultrasound guided biopsy. No patient had received preoperative radiation or hormonal therapy. Standard preoperative preparation included only a Fleet enema. No preoperative antibiotics were used. All injuries were full thickness rectal lacerations less than 2 cm. long. Of the 10 injuries 9 occurred during division of the posterior aspect of the striated urethral sphincter at a point where there was fibrosis and fixation to the rectum. One of the 10 injuries occurred during wide excision of the neurovascular bundle. In 9 patients rectal injury was recognized during the operation and primary repair was done as described. In 1 patient the injury was diagnosed on postoperative day 2 with the development of fever and fecaluria. In this patient exploration with rectal repair plus a diverting sigmoid colostomy were performed. Patients were treated with broad-spectrum intravenous antibiotics (typically ampicillin, gentamicin and metronidazole) begun at recognition of the injury. Eight patients received Accepted for publication June 7, 1991. * Requests for reprints: Department of Urology, The Johns Hopkins Hospital, 600 N. Wolfe St., Baltimore, Maryland 21205. 905
antibiotics for 7 to 8 days and 1 for 10 days, while the patient who required reexploration was treated for 14 days. Surgical technique. When an injury to the rectum is discovered during the course of prostatectomy, no attempt is made immediately to close or manipulate the rectum. Radical prostatectomy is completed, the bladder neck is reconstructed and sutures are placed in the urethra as previously described. 11 Then, the anal sphincter is dilated to 3 fingerbreadths by the assistant. With the added exposure gained by the assistant's fingers in the rectum, the injury is closed in 2 layers with an inner layer of continuous 2-zero chromic and an outer layer of 2-zero silk or chromic Lembert sutures (part A of figure). The pelvis is thoroughly irrigated with antibiotic solution. Without extending the incision, a small peritoneal opening is made above the bladder and the greater omentum is inspected. A properly sized pedicle is then identified and tapered. Care should be taken to preserve blood vessels when dividing omental tissue. If significant additional length is needed, the midline incision could be extended, and the omentum separated from the colon and mobilized off the stomach as described by Turner-W arwick. 12 This degree of mobilization has not been necessary in our serieso After adequate mobilization of the omentum a hand is passed behind the bladder into the rectovesical cul-de-sac, and the thin layer of peritoneum remaining between the bladder and rectum is identified. A 3 to 4 cm. transverse incision is then made in this peritoneal reflection and the omentum is brought through it into the pelvis (part B of figure). The omentum is tacked down with interrupted 2-zero chromic sutures so as to cover the area of repair completely. After copious irrigation, the standard urethrovesical anastomosis is completed by placing the bladder neck sutures and tying them over a 20F urethral catheter (part C of figure). Closed suction drains are placed into the lateral paravesical spaces, and the peritoneum and midline incision are closed. Broad-spectrum intravenous antibiotics are given for 7 to 14 days with drains usually removed within 5 to 7 days. Nasogastric suctioning is not used and no attempt is made to induce constipation. Oral fluids are given after the passage of flatus, usually around postoperative day 4, and the patient is advanced to a regular diet during the next 3
906
BORLAND AND WALSH
cut-de-sac
B A, 2-layer closure of rectal injury. Note stay sutures in urethra. NVB, neurovascular bundle. B, omental pedicle is brought through rectovesical cul-de-sac into pelvis and placed over repair. Blad., bladder. C, omentum is tacked to rectal serosa and urethrovesical anastomosis is completed.
days. Bowel softeners (docusate sodium) and mineral oil are used for 6 weeks. In the event of a delayed diagnosis, as in 1 patient from this series, immediate re-exploration through the incision is indicated. Takedown of the urethrovesical anastomosis should reveal the source of the rectal leak. If not, a finger gently passed from below through the anus and used as a probe is helpful to locate the injury. Otherwise repair is done as described previously with copious irrigation at each step. In such a case diverting loop colostomy is recommended due to more widespread fecal contamination. The colostomy may be performed after the urethrovesical anastomosis is completed and is most easily placed in the left lower quadrant, well away from the omental pedicle. The colostomy is taken down 3 months postoperatively. RESULTS
All patients underwent successful closure via the omental interposition technique and were without evidence of disease at a mean followup of 24 months (range 6 to 54 months). Postoperatively, there were no wound infections, pelvic abscesses or fistulas. Overall hospital stay was increased by an average of 2 days with the majority of patients discharged from the hospital on postoperative day 9 or 10 (range 9 to 24 days). Two patients required a subsequent operation, 1 for incision and dilation of a bladder neck contracture and 1 for routine colostomy takedown. There have been no abdominal or gastrointestinal complications. DISCUSSION
The complications of rectal injury usually result from breakdown of the rectal closure with fistula or abscess formation. Experience with such failed closures as well as with other
rectourethral fistulas has identified several principles important for successful initial closure. Large series of congenital, iatrogenic and traumatic fistulas have been reported and at least 15 techniques of repair have been described. 13• 14 Among these techniques the avoidance of apposing suture lines, and the interposition of healthy tissue between urinary and alimentary tracts are stressed. Goodwin et al described the interposition of levator ani muscles, 15 while Culp and Calhoon placed "any tissue available" between the urethra and rectum. 16 While the use of local tissue may be possible with perineal based repairs of established fistulas, such coverage is not possible during a radical retropubic operation. The use of distant tissue such as the omentum in the treatment of urinary fistulas was described by Turner-Warwick and is the basis of our repair. As the body's natural defense against infection, the omentum has several characteristics that make it well suited for use in the pelvis. The omentum can provide 1) support for healing tissue; 2) enhanced vascular supply in areas where healing is impaired by infection, irradiation or diabetes; 3) supple surrounding tissue allowing urodynamic mobility, since the omentum retains its normal vascularity and never becomes fibrotic, and 4) an easily separable tissue plane, facilitating any subsequent reexploration. 11 A sound and reliable repair of rectal injury is possible using an omental interposition technique that can be easily applied through the lower midline incision at radical prostatectomy. This 1-stage repair for injuries discovered during surgery has added only the minimal morbidity of postoperative antibiotics to the recovery. Diverting colostomy has not been necessary in the population of nonirradiated patients repaired intraoperatively. Diversion does have a role in more complicated cases, such as the patient with delayed diagnosis in our series in whom fecal contamination was evident, and certainly in patients
MANAGEMENT OF RECTAL INJURY DURING RADICAL RETROPUBIC PROSTATECTOMY
irradiated preoperatively or with otherwise impaired healing potential. Extensive preoperative bowel preparation has not been necessary, since we have found that a properly administered Fleet enema given the night before surgery effectively empties the lower colon. In the small percentage of cases in which a rectal injury has occurred there have not been any infection related complications. In summary, primary repair of rectal injury with the greater omentum and without a diverting colostomy has been safe, effective and associated with minimal patient morbidity. REFERENCES
1. Middleton, A. W., Jr.: Pelvic lymphadenectomy with modified
2. 3. 4. 5.
retropubic prostatectomy as a single operation: technique used and results in 50 consecutive cases. J. Urol., 125: 353, 1981. Nichols, R. T., Barry, J.M. and Hodges, C. V.: The morbidity of radical prostatectomy for multifocal stage I prostatic adenocarcinoma. J. Urol., 117: 83, 1977. Paulson, D. F., Robertson, J. E., Daubert, L. M. and Walther, P. J.: Radical prostatectomy in stage A prostatic adenocarcinoma. J. Urol., 140: 535, 1988. Elder, J. S., Gibbons, R. P., Correa, R. J., Jr. and Brannen, G. E.: Morbidity of radical perinea! prostatectomy following transurethral resection of the prostate. J. Urol., 132: 55, 1984. Veenema, R. J., Gursel, E. 0. and Lattimer, J. K.: Radical retropubic prostatectomy for cancer: a 20-year experience. J. Urol., 117: 330, 1977.
907
6. Smith, A. M. and Veenema, R J .: Management of rectal injury and rectourethral fistulas following radical retropubic prostatectomy. J. Urol., 108: 778, 1972. 7. Swanson, D. A., von Eschenbach, A. C., Bracken, R. B. and Johnson, D. E.: Salvage cystectomy for bladder carcinoma. Cancer, 47: 2275, 1981. 8. Freiha, F. S.: Complications of cystectomy. J. Urol., 123: 168, 1980. 9. Smith, J. A., Jr. and Whitmore, W. F., Jr.: Salvage cystectomy for bladder cancer after failure of definitive irradiation. J. Ural., 125: 643, 1981. 10. Dahl, D. S., Howard, P. M. and Middleton, R. G.: The surgical management of rectourinary fistulas resulting from a prostate operation: a report of 5 cases. J. Urol., 111: 514, 1974. 11. Walsh, P. C.: Retropubic prostatectomy for benign and malignant diseases. In: Operative Urology, 1st ed. Edited by F. F. Marshall. Philadelphia: W. B. Saunders Co., chapt. 38, pp. 264-289, 1991. 12. Turner-Warwick, R.: The use of the omental pedicle graft in urinary tract reconstruction. J. Urol., l 16: 341, 1976. 13. Olsson, C. A., Willscher, M. K., Krane, R. J. and Austen, G., Jr.: Management of prostatic fistulas. Urol. Surv., 26: 135, 1976. 14. Weyrauch, H. M.: A critical study of surgical principles used in repair of urethrorectal fistula: presentation of a modern technique. Stanford Med. Bull., 9: 2, 1951. 15. Goodwin, W. E., Turner, R. D. and Winter, C. C.: Rectourinary fistula: principles of management and a technique of surgical closure. J. Urol., 80: 246, 1958. 16. Culp, 0. S. and Calhoon, H. W.: A variety of rectourethral fistulas: experiences with 20 cases. J. Urol., 91: 560, 1964.
