The Successful Use of Endoscopic Vacuum Therapy for Repair of Rectal Perforation After Prostatectomy

Introduction: Rectal perforation is a known complication of radical prostatectomy reported to occur in 0.3-3.8% of cases. Primary closure and diverting ileostomy are immediately performed; however, it is not uncommon to see a persistent rectal defect after surgical repair. The use of endoscopic vacuum therapy (EVT) has shown increasingly favorable results with gastrointestinal (GI) perforations. EVT is most commonly used for esophageal leaks and perforations given abundant literature demonstrating successful outcomes. However, its use in rectal defects remains limited. This case highlights the successful use of EVT for repair of a rectal perforation after prostatectomy. Case Description/Methods: A 67 year old male with diabetes mellitus and localized prostate adenocarcinoma underwent robotic radical prostatectomy. The procedure was complicated by rectal injury during posterior dissection. The rectal defect was closed with an omental flap and a diverting ileostomy was created. On post-op day 17, a flexible sigmoidoscopy was performed revealing a 9 mm perforation at the repair site. The patient remained stable without signs or symptoms of sepsis. The gastroenterology team was consulted to attempt EVT for closure of the perforation. An EVT device was created by cutting a 1x1x1 cm cube of polyurethane foam. The sponge was sutured to the tip of a nasogastric tube which was inserted via endoscopic guidance to the perforated area. The tubing system was placed in continuous suction at 125 mmHg. The EVT device was replaced every 3-4 days for a total of 5 sessions. After 19 days of EVT, there was complete closure of the rectal defect. Follow up endoscopic evaluation revealed persistent closure of the perforation at 2 and 4 months. The ileostomy was reversed after 5 months and the patient is without symptoms after 2 years. Discussion: This is the first case to demonstrate the successful closure of a rectal perforation with EVT after a complicated radical prostatectomy. EVT can be a minimally invasive approach to treatment of this highly morbid complication. Clifford et al. demonstrated an 88.8% closure rate of EVT for 197 patients with colorectal anastomotic leaks. Some studies even suggest that fecal diversion may not be needed for lower GI EVT. Koperen et al. demonstrated improved outcomes if lower GI EVT is performed within 6 weeks of initial insult. Given its high efficacy, limited morbidity, and widespread availability, EVT should be highly considered for lower GI leaks and perforations in selected patients.Figure 1.: Endoscopic image demonstrating 9 mm rectal perforation after prostatectomy (A), endoscopic image of EVT device placed at site of rectal perforation (B), endoscopic image of 2 mm residual rectal defect after serial EVT (C), endoscopic image of complete closure of rectal perforation after 19 days of EVT (D), endoscopic image of rectal scar tissue at 4 months follow up (E), supplies used to create EVT device (F).