Management of iatrogenic rectal injury following radical prostatectomy: a 10-year experience from a regional Australian hospital and an algorithm for management.

BACKGROUND: Iatrogenic rectal injury following radical prostatectomy or cystoprostatectomy is a rare but significant complication associated with significant morbidity, including sepsis, rectourethral or rectovesical fistulas, and death. The management of these injuries remains highly heterogeneous, particularly in regional contexts where surgical rescue expertise is varied. This case series explores a decade of regional Australian experience in the management of rectal injuries following radical prostatectomy and proposes a practical management algorithm for multidisciplinary decision-making. METHODS: A retrospective consecutive case series was conducted at a regional Australian tertiary hospital. Adult patients diagnosed with an iatrogenic rectal injury following a radical prostatectomy between January 2015 and December 2025 were identified. Demographic, operative, diagnostic, management, and outcome data were collected and analysed descriptively. RESULTS: Eight patients were included. Rectal injuries were identified intraoperatively in three patients (37.5%) and postoperatively in five (62.5%), with delayed presentation ranging from 5 days to 2.5 years. Injury size ranged from <1 to 4 cm, and all defects involved a full-thickness rectal wall injury. Management strategies varied according to the timing of diagnosis, defect characteristics, tissue quality, and fistula formation. Immediate injuries were successfully managed with primary repair, with or without faecal diversion. Three patients developed rectourethral or rectovesical fistulas, requiring staged reconstruction using a transperineal approach with interposition of a pedicled gracilis flap. All patients achieved successful healing without mortality, and all diverting stomas were ultimately reversed. CONCLUSIONS: Rectal injury following prostatectomy requires prompt recognition and individualised multidisciplinary management. Early diagnosis facilitates simpler repair strategies, whereas delayed recognition is associated with fistula formation and the need for complex reconstructive procedures.