Вы находитесь на странице: 1из 4

EUF-268; No.

of Pages 4

E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X

available at www.sciencedirect.com
journal homepage: www.europeanurology.com/eufocus

Brief Correspondence

Incidence, Risk Factors, Management, and Complications of


Rectal Injuries During Radical Prostatectomy

Philipp Mandel a,b,y,*, Anna Linnemannstöns a,y, Felix Chun b, Thorsten Schlomm a,b,
Raisa Pompe a, Lars Budäus a, Clemens Rosenbaum b, Tim Ludwig b, Roland Dahlem b,
Margit Fisch b, Markus Graefen a, Hartwig Huland a, Derya Tilki a,b, Thomas Steuber a
a b
Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital
Hamburg-Eppendorf, Hamburg, Germany

Article info Abstract

Article history: Rectal injury (RI) during radical prostatectomy (RP) is a severe complication. So far, only
Accepted January 19, 2017 limited data describing the incidence, risk factors, management, and complications of RI
are available. In an analysis of data for 24 178 patients, we identified 113/24 076 patients
Associate Editor: (0.47%) undergoing open or robotic RP and 7/102 patients (6.86%) after salvage RP who
James Catto experienced an RI. Besides salvage RP, local tumor stage, Gleason grade, lymph node
status, and surgical experience, but not surgical approach (robotic vs open), could be
identified as risk factors for RI in univariate and multivariate analysis. Intraoperative
Keywords: management of RI comprised closure with two to three layers. In 13/109 patients (11.9%),
Radical prostatectomy a diverting colostomy/ileostomy was carried out. Some 12% of men with closure of an
Rectal injury RI developed a recto-anastomosis fistula, and 57% of those who had an additional
diverting enterostomy. Thus, the overall incidence of recto-anastomosis fistula after RP
Recto-anastomosis fistula was <0.1%. The extent of rectal laceration, prior radiation, and intraoperative signs
of rectal infiltration were associated with the development of a subsequent recto-
anastomosis fistula. Some 83% of patients with a recto-anastomosis fistula needed
further intervention.
Patient summary: We analyzed the incidence, risk factors, management, and complica-
tions of rectal injury during radical prostatectomy. Overall, the incidence of rectal injury
and subsequent development of recto-anastomosis fistulas is low unless the patient has
significant risk factors.
© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

y
These authors contributed equally to this work.
* Corresponding author. MartiniKlinik Prostate Cancer Center, University Hospital Hamburg-
Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Tel./Fax: +49 40 741000.
E-mail address: p.mandel@uke.de (P. Mandel).

Prostate cancer is the most frequent cancer among males in (open, laparoscopic, or robotic RP; Table 1) [2–8]. Thus,
Europe and other developed countries. According to current uncertainty remains regarding the incidence, risk factors,
guidelines, radical prostatectomy (RP) is a recommended best intraoperative management, and further complications
treatment option for patients with localized disease and a of RI in a large consecutive series. We analyzed data for
life expectancy of >10 yr [1]. Rectal injury (RI) during RP is a 24 178 patients (19 965 open RP, 4111 robotic RP, and
rare but severe complication. So far, most studies in the 102 salvage RP) who underwent RP at the Martini-Klinik
literature analyzed small samples of patients with RI, Prostate Cancer Center from January 1992 to June 2016. To
with reporting restricted to only one surgical approach identify patients with RI, all operative notes, discharge

http://dx.doi.org/10.1016/j.euf.2017.01.008
2405-4569/© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Mandel P, et al. Incidence, Risk Factors, Management, and Complications of Rectal Injuries
During Radical Prostatectomy. Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.01.008
EUF-268; No. of Pages 4

2 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X

Table 1 – Overview of selected studies with 1000 cases involving rectal injury (RI) during radical prostatectomy (RP).

Study Year RP technique RPs (n) RIs, n (%) RAFs (n)

Wedmid et al [5] 2011 RARP 6650 11 (0.17) 4


Kheterpal et al [4] 2011 RARP 4400 10 (0.23) 1
Coelho et al [3] 2010 RARP 2500 2 (0.08) –
Guillonneau et al [8] 2003 LARP 1000 13 (1.30) 1
Lepor et al [6] 2001 ORP 1000 5 (0.50) 0
McLaren et al [7] 1993 ORP 2212 27 (1.22) 4
Borland et al [2] 1992 ORP 1000 10 (1.00) 0
a
Present study 2016 ORP 19 965 104 (0.52) 24
RARP 4111 9 (0.22)
SRP 102 7 (6.86)

RAF = recto-anastomosis fistula; RARP = robot-assisted RP; LARP = laparoscopic RP; ORP = open RP; SRP = salvage RP.
a
Of the total 24 RAFs, 13 were with and 11 without intraoperative RI.

letters, and medical reports were electronically searched or pN1 status had a significantly higher risk of RI (all
for the occurrence of RI and fistulas (Supplementary Fig. 1). p < 0.001). By contrast, patient characteristics such as
For patients with RI and/or recto-anastomosis fistula, age, body mass index, and prostate volume did not differ
the patient and tumor characteristics, intraoperative and between the groups (all p > 0.05). Gleason grade, pT stage,
postoperative management, and further complications due pN1 status, and salvage RP were also confirmed as risk
to the injury were evaluated. To determine significant dif- factors in univariable and multivariable logistic regression
ferences between patients with and without RI, t tests, analyses (Supplementary Table 1). In addition, surgical
Mann-Whitney U tests, x2 tests, and multivariate logistic experience was inversely associated with RI (odds ratio
regression analysis were performed (for variables included for additional 100 prior RPs 0.95, 95% confidence interval
in multivariate regression see Supplementary Table 1). 0.92–0.97; p < 0.001; Supplementary Table 1). The risk of RI
RI was defined as intraoperative confirmed RI through also decreased over time (2.1% in 1992–2000, 0.5% in 2001–
the whole rectal wall or a recto-anastomosis fistula without 2010, and 0.3% in 2011–2016; p < 0.01) as surgeon experi-
intraoperative recognition of an injury within early follow- ence increased. Moreover, robot-assisted RP was associated
up. Overall, RI occurred in 113/24 056 (0.47%) patients with a lower risk of RI compared to an open approach in
undergoing RP other than salvage RP. In patients undergoing univariable tests (0.27% vs 0.55%; p < 0.028), but not in
salvage RP (following radiotherapy), RI incidence was multivariable regression analysis (p = 0.65). This is in line
significantly higher (7/102 patients, 6.86%; p < 0.001). To with other comparative studies and can be explained by the
identify further risk factors for RI, tumor and patient fact that robotic RP was systematically introduced at our
characteristics stratified by RI status are summarized in institution in 2008, when a majority of the surgeons had
Table 2. Patients with higher pT stage, higher Gleason grade, already partly complete their learning curve [9].

Table 2 – Characteristics of patients with and without rectal injury (RI) during radical prostatectomy (RP).

RI (n = 120) No RI (n = 24 058) p value

Age (yr) 63.2 (58.9–67.6) 63.5 (59.1–68.6) 0.6247


Prostate volume (ml) 43 (31–55) 44 (30–52) 0.8516
Body mass index (kg/m2) 26.6 (23.9–28.1) 26.6 (24.4–28.4) 0.9885
D’Amico risk group (%) <0.001
Low 10.3 33.2
Intermediate 41.4 47.0
High 48.3 19.8
Preoperative PSA (ng/ml) 17.2 (5.7–18.8) 10.1 (4.9–10.7) 0.004
Tumor stage (%) <0.001
pT2 32.5 66.1
pT3 64.2 33.4
pT4 3.3 0.5
Pathologic GG (%) [11] <0.001
1 12.5 20.7
2 41.2 55.8
3 20.8 16.8
4 2.5 0.9
5 22.5 5.8
Node status pN1 (%) 25.8 8.3 <0.001
PSM (%) 33.3 17.5 <0.001
Robotic RP (%) 9.2 16.8 0.025

PSA = prostate-specific antigen; GG = Gleason grouping; PSM = positive surgical margin.


Data are presented as mean (interquartile range) for continuous variables.

Please cite this article in press as: Mandel P, et al. Incidence, Risk Factors, Management, and Complications of Rectal Injuries
During Radical Prostatectomy. Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.01.008
EUF-268; No. of Pages 4

E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X 3

Intraoperative management of RI at our institution did salvage RP, but not as a standard of care in all patients with
not significantly change over time. Once an injury occurred intraoperative RI.
(RI size ranged from 2 mm to 4 cm) it was closed with
two (59.4%) or three (41.6%) layers of mostly 3-0 Vicryl Author contributions: Philipp Mandel had full access to all the data in the
sutures. In addition, in 13 cases a diverting colostomy/ study and takes responsibility for the integrity of the data and the
ileostomy was performed within the same operation, accuracy of the data analysis.Study concept and design: Mandel, Chun,
mainly in patients with aggravating factors (larger defects, Steuber, Huland, Dahlem.
Acquisition of data: Linnemannstöns, Mandel, Rosenbaum, Ludwig.
rectal infiltration, prior radiotherapy). Postoperatively, all
Analysis and interpretation of data: Mandel, Steuber, Tilki.
patients received penicillin or cefuroxime plus metronida-
Drafting of the manuscript: Mandel.
zole and the transurethral catheter was left in place for
Critical revision of the manuscript for important intellectual content:
more than 14 d. Schlomm, Budäus, Fisch, Graefen, Steuber, Tilki, Chun, Pompe.
Within further follow-up, 11/106 patients (10.4%) with a Statistical analysis: Mandel.
documented intraoperative RI after non-salvage RP and 2/3 Obtaining funding: None.
patients (66.6%) after salvage RP developed a recto-anasto- Administrative, technical, or material support: None.
mosis fistula, despite a diverting enterostomy in eight of Supervision: Fisch, Graefen.
these 13 patients. The size of the RI (>2 cm) and intraoper- Other: None.
ative signs of adherence to the rectum due to suspicion of
rectal tumor infiltration (n = 6) or prior transurethral resec- Financial disclosures: Philipp Mandel certifies that all conflicts of inter-
est, including specific financial interests and relationships and affilia-
tion of the prostate (n = 1) were risk factors for development
tions relevant to the subject matter or materials discussed in the manu-
of a recto-anastomosis fistula following RI. The numbers of
script (eg, employment/affiliation, grants or funding, consultancies,
layers (2 or 3) used for RI closure was not a significant factor
honoraria, stock ownership or options, expert testimony, royalties, or
in preventing fistula. patents filed, received, or pending), are the following: None.
An additional 11 patients developed a recto-anastomosis
fistula postoperatively without observation of an intraop- Funding/Support and role of the sponsor: None.
erative RI (5 after open RP, 4 after salvage RP, and 2 after
robotic RP).
Overall, the risk of recto-anastomosis fistula was 0.07% Appendix A. Supplementary data
(18/24 076) for men with non-salvage RP and 5.9% (6/102)
for salvage RP. Details of further (surgical) management in Supplementary data associated with this article can be
different hospitals for these 24 patients with recto-anasto- found, in the online version, at http://dx.doi.org/10.1016/j.
mosis fistulas are listed in Supplementary Table 2. Overall, euf.2017.01.008.
four patients (16.6% of those with fistula) experienced
spontaneous closure of their fistula under 3 mo of urinary
drainage with or without a temporary diverting enteros-
tomy, while the others underwent further surgery for fistula References
repair (mostly via a muscle and/or fat flap and prior colos- [1] Mottet N, Bellmunt J, Briers E, et al. EAU guidelines on prostate
tomy). Despite invasive surgical fistula repair, the fistula cancer. Arnhem, The Netherlands: European Association of Urology;
could not successfully be closed in 9/24 patients (37.5%), 2016.
often resulting in a permanent urinary or bowel diversion. [2] Borland R, Walsh P. The management of rectal injury during radical
One-third of these patients with an unfavorable course had retropubic prostatectomy. J Urol 1992;147:905–7.
undergone prior salvage RP. [3] Coelho RF, Palmer KJ, Rocco B, et al. Early complication rates in a
single-surgeon series of 2500 robotic-assisted radical prostatecto-
The main limitations of our study are its retrospective
mies: report applying a standardized grading system. Eur Urol
design and the low power due to the low RI incidence rate.
2010;57:945–52.
Nevertheless, all operative notes, discharge letters, and
[4] Kheterpal E, Bhandari A, Siddiqui S, Pokala N, Peabody J, Menon M.
medical reports were available in an electronic form and Management of rectal injury during robotic radical prostatectomy.
thus were electronically searchable. Therefore, our inci- Urology 2011;77:976–9.
dence rates for RI and fistula should not be strongly biased [5] Wedmid A, Mendoza P, Sharma S, et al. Rectal injury during robot-
by the retrospective character, as better documentation assisted radical prostatectomy: incidence and management. J Urol
might increase the incidence observed [10]. 2011;186:1928–33.
In conclusion, RI during RP is a very rare complication. [6] Lepor H, Nieder AM, Ferrandino MN. Intraoperative and postopera-
Risk factors are advanced and more aggressive tumors, tive complications of radical retropubic prostatectomy in a conse-
lower surgeon volume, and prior radiation. Despite intra- cutive series of 1,000 cases. J Urol 2001;166:1729–33.
[7] McLaren RH, Barrett DM, Zincke H. Rectal injury occurring at radical
operative closure of the defect with two or three layers, the
retropubic prostatectomy for prostate cancer: etiology and treat-
risk of recto-anastomosis fistula with the need for further
ment. Urology 1993;42:401–5.
surgical intervention is high for defects >2 cm, salvage RP, or
[8] Guillonneau B, Gupta R, El Fettouh H, Cathelineau X, Baumert H,
suspicion of rectal infiltration. Diverting colostomy seems to Vallancien G. Laparoscopic management of rectal injury during
be unnecessary in patients with non-aggravating factors, laparoscopic radical prostatectomy. J Urol 2003;169:1694–6.
and therefore should only be recommended in cases with [9] Tewari A, Sooriakumaran P, Bloch DA, Seshadri-Kreaden U,
infiltration of the rectum, prior prostate surgery, large RI, or Hebert AE, Wiklund P. Positive surgical margin and perioperative

Please cite this article in press as: Mandel P, et al. Incidence, Risk Factors, Management, and Complications of Rectal Injuries
During Radical Prostatectomy. Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.01.008
EUF-268; No. of Pages 4

4 E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 17 ) X X X – X X X

complication rates of primary surgical treatments for prostate can- complications after robotic-assisted laparoscopic radical prostatec-
cer: a systematic review and meta-analysis comparing retropubic, tomy. Eur Urol 2010;57:363–70.
laparoscopic, and robotic prostatectomy. Eur Urol 2012;62:1–15. [11] Epstein JI, Zelefsky MJ, Sjoberg DD, et al. A contemporary prostate
[10] Novara G, Ficarra V, D’Elia C, Secco S, Cavalleri S, Artibani W. cancer grading system: a validated alternative to the Gleason score.
Prospective evaluation with standardised criteria for postoperative Eur Urol 2016;69:428–35.

Please cite this article in press as: Mandel P, et al. Incidence, Risk Factors, Management, and Complications of Rectal Injuries
During Radical Prostatectomy. Eur Urol Focus (2017), http://dx.doi.org/10.1016/j.euf.2017.01.008

Вам также может понравиться