title: Rectal injury during robot-assisted radical prostatectomy: incidence and management.
abstract: OBJECTIVE
  Rectal injury during robot-assisted radical prostatectomy is a rare but significant complication. Since the Clavien grading classification of complications does not include intraoperative injury without further sequelae, rectal injury may be underreported in the literature. We present what is to our knowledge the largest retrospective review to date of rectal injury and subsequent management.
  
  
  METHODS
  We reviewed the records of 6,650 patients who underwent robot-assisted radical prostatectomy at a total of 6 institutions. Patient characteristics, perioperative parameters, pathological findings and rectal injury management were tabulated and analyzed for intraoperative predictors of outcome and subsequent management.
  
  
  RESULTS
  A total of 11 rectal injury cases were identified of the 6,650 robot-assisted radical prostatectomies for a combined 0.17% incidence of rectal injury. Of rectal injuries 72.7% were identified intraoperatively and most did well with primary closure. Delayed recognition injury presented as rectourethral fistula without septic complications and required delayed fistula repair after primary diversion. We found no conclusive association of rectal injury with any patient parameter, intraoperative differences, pathological finding or surgeon experience. Posterior prostate plane dissection, including seminal vesicle dissection, is the crucial stage when rectal injury can occur and be identified.
  
  
  CONCLUSIONS
  Our review of the records at 6 centers revealed a combined 0.17% incidence of rectal injury. This compares favorably to the incidence in modern open and laparoscopic radical prostatectomy series. No preoperative, intraoperative or pathological differences correlated with injury. Cases in which rectal injury was identified intraoperatively required fewer surgical repeat interventions but ultimately each group had acceptable long-term urinary and bowel function results.
authors.affiliation: University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
authors.forename: Alexei
authors.initials: A
authors.lastname: Wedmid
authors.forename: Pierre
authors.initials: P
authors.lastname: Mendoza
authors.forename: Saurabh
authors.initials: S
authors.lastname: Sharma
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Hastings
authors.forename: Kelly P
authors.initials: KP
authors.lastname: Monahan
authors.forename: Mary
authors.initials: M
authors.lastname: Walicki
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Ahlering
authors.forename: James
authors.initials: J
authors.lastname: Porter
authors.forename: Erik P
authors.initials: EP
authors.lastname: Castle
authors.forename: Faisal
authors.initials: F
authors.lastname: Ahmed
authors.forename: Jason D
authors.initials: JD
authors.lastname: Engel
authors.forename: Harold A
authors.initials: HA
authors.lastname: Frazier
authors.forename: Daniel
authors.initials: D
authors.lastname: Eun
authors.forename: David I
authors.initials: DI
authors.lastname: Lee
mesh_terms: D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology* / Q000601:surgery; D008297:Male; D011468:Prostatectomy / Q000009:adverse effects* / Q000379:methods*; D012003:Rectal Fistula / Q000453:epidemiology; D012007:Rectum / Q000293:injuries* / Q000601:surgery; D012371:Robotics; D014548:Urinary Fistula / Q000453:epidemiology