Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery

INTRODUCTION — The safety of colorectal surgery, as performed in patients with colorectal cancer and inflammatory bowel disease, has improved dramatically over the last 50 years due to improvements in preoperative preparation, antibiotic prophylaxis, surgical technique, and postoperative management. (See "Overview of the management of primary colon cancer" and "Surgical treatment of rectal cancer" and "Surgical management of ulcerative colitis".)

Despite these advances, complications continue to occur. The risks, management, and outcomes of nonanastomotic intra-abdominal, pelvic, and genitourinary complications of colorectal surgery will be reviewed here. The management of anastomotic complications is reviewed elsewhere. (See "Management of anastomotic complications of colorectal surgery".)

INTRA-ABDOMINAL INJURIES AND COMPLICATIONS — Intra-abdominal complications during colorectal surgery include injury to adjacent organs, bleeding, and infection [1]. The incidence, risks, management, and outcomes of intra-abdominal injuries and complications are described here.

Splenic injury — The operative risk of splenic injury ranges from 0.4 to 8 percent of colonic procedures [2-4]. Injury occurs because of the close proximity of the colon to the spleen [2]. During mobilization of the splenic flexure of the colon, excessive traction on the peritoneal attachments and omentum can lead to avulsion of a portion of the splenic capsule [5]. In a review of 93,633 colorectal resections from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, splenic flexure mobilization increased the risk of an incidental splenic procedure (odds ratio [OR] 3.59, 95% CI 2.15-4.31) [6]. The risk of incidental splenic procedures was significantly greater for open compared with laparoscopic colorectal resection (OR 6.58, 95% CI 3.59-13.5). Other factors that increase the risk for iatrogenic splenic injury include previous abdominal surgery, midline incision, obesity, and advanced age [6,7].

Management of an intraoperative splenic injury includes splenic salvage (primary repair, splenorrhaphy) or splenectomy. Splenic salvage should be the first maneuver to control bleeding and a splenectomy reserved for cases when bleeding cannot be controlled by the previously described techniques. However, in a retrospective review of 975,825 patients undergoing a colorectal resection between 2006 and 2008, a splenectomy was performed for approximately 85 percent of patients (7963 of 9367) with a splenic injury rather than using a conservative splenic salvage procedure [4]. In a single-institution review of 13,897 colectomies with 59 splenic injuries, the most common methods of initially managing splenic injuries included hemostatic agents (31 patients), packing (12), electrocautery (8), and suture ligatures (7) [2]. Multiple attempts at splenic salvage occurred in 30 patients, and 21 patients (36 percent of total splenic injuries) required a splenectomy. The 30 day major morbidity and mortality rates were 34 and 17 percent, respectively, with sepsis being the most frequent complication [2]. The initial and final management of the splenic injury was not associated with short-term adverse outcomes. (See "Surgical management of splenic injury in the adult trauma patient", section on 'Splenectomy versus salvage'.)

There is conflicting evidence as to the impact of splenectomy on outcome after colorectal cancer resection, with some studies reporting higher mortality and others showing no effect [2,8-12]. In a retrospective review of 50,000 colorectal cancer cases requiring 241 splenectomies from the California Cancer Registry, splenectomy significantly increased the length of hospital stay (13 versus 8 days) and the probability of death by 40 percent compared with cancer patients who did not require splenectomy [12].

The prevention of sepsis and the management of sepsis in the asplenic patient are discussed elsewhere. (See "Prevention of infection in patients with impaired splenic function" and "Clinical features, evaluation, and management of fever in patients with impaired splenic function".)

Small bowel and duodenal injury — The incidence of small bowel injury during colorectal surgery is between less than 1 and 3 percent for open and laparoscopic techniques [13,14]. The risk of an inadvertent enterotomy increases with previous abdominal surgery [14], while injury to the duodenum is most likely to occur during right colon mobilization. Injury to the small bowel with the laparoscopic technique occurs in fewer than 1 percent of cases [15].

The therapeutic approach varies with the type and extent of injury:

●Veress needle injury to the small bowel rarely requires further intervention and can be managed conservatively. In contrast, a trocar injury to the small bowel requires primary operative repair, either laparoscopically or open.

●Full-thickness small bowel enterotomies are repaired in one or two layers. In contrast, a segmental resection with a primary anastomosis should be performed if multiple enterotomies occur in a short segment or the small bowel mesentery is compromised.

●Serosal tears are repaired with imbricating seromuscular sutures.

●Technically, the most challenging repair is of an enterotomy of the duodenum. A primary repair should not compromise the duodenal lumen. If a primary repair cannot be safely performed, a duodenal to jejunal anastomosis is performed.

A variety of complications can occur:

●An unrecognized enterotomy can lead to peritonitis in the first few postoperative days, necessitating prompt surgical intervention. The diagnosis is typically made by the clinical evaluation and can be confirmed with radiographic imaging. A computed tomography (CT) scan with oral and intravenous contrast can be obtained to identify the presence of intra-abdominal fluid and extravasation of oral contrast.

●An unrecognized enterotomy may present as an intra-abdominal abscess or an enterocutaneous fistula in the later postoperative period. An intra-abdominal abscess is percutaneously drained if technically feasible. (See "Enterocutaneous and enteroatmospheric fistulas".)

●Missed duodenal injuries can have disastrous consequences, including free perforation or the development of difficult duodenal fistulas, and are associated with high rates of mortality. These complications are identified soon after surgery. (See "Enterocutaneous and enteroatmospheric fistulas".)

Pancreatic injury — Iatrogenic pancreatic injuries occur in 1 to 3 percent of intra-abdominal procedures, primarily in splenic resections [15-17]. Pancreatic injuries are avoided by adequate mobilization of the spleen and ligating the splenic vessels close to the splenic parenchyma. A pancreatic injury can also occur while repairing a splenic injury that may be induced during mobilization of the left colon; if such an injury is suspected, a closed drain should be placed. (See 'Splenic injury' above.)

Gastric injury — Injuries to the stomach occur in fewer than 1 percent of colectomies and are more likely to occur during a salvage splenectomy or with dissection of dense adhesions, excessive use of electrocautery, and/or failure to develop an adequate plane [16]. Full-thickness injuries are repaired in two layers, and serosal tears are repaired by imbricating seromuscular sutures only.

Major vessel injury — Major vessel injury during an open or laparoscopic colectomy is rare, but the following types of injury can occur:

●Injuries can occur with traction on mesenteric vessels and splenic vessels during mobilization of the bowel with an open technique.

●A Veress needle used during laparoscopic resections rarely causes major hemorrhage and is treated by simple ligation of vessels [18].

●A trocar can cause fatal hemorrhage when inserted into the aorta or common iliac vessels; this occurs in fewer than 1 percent of laparoscopic cases [15]. A vessel lacerated by a trocar usually requires immediate conversion to an open procedure for control of the bleeding vessel; however, there have been reports of successful laparoscopic management of major vascular injuries sustained during colectomy [19].

Surgical site infection — Colorectal operations are clean-contaminated procedures with an inherent risk of gross contamination of the peritoneal cavity and incision that can result in a surgical site infection (SSI) [20]. SSIs are classified as incisional or intra-abdominal (organ/space) (figure 1 and table 1). The clinical criteria used to define an SSI include any of the following:

●A purulent exudate draining from a surgical site

●A positive fluid culture obtained from a surgical site that was closed primarily

●The surgeon's diagnosis of infection

●A surgical site that requires reopening to drain the infected fluid

The rate of SSIs following colorectal surgery varies in different reports from less than 1 to 30 percent [20-26]. In addition, superficial SSI may be more common in left compared with right colectomies (8.2 versus 5.9 percent) [27]. This wide range depends upon the definition of SSI, time period for assessment of SSI, types of procedures, and inclusion of infections occurring after discharge [24].

In general, laparoscopic colon surgery is associated with a lower SSI rate than open colon surgery. In a database study of over 200,000 patients undergoing colon procedures, the mean SSI rates were 4.1 percent (procedure-specific range 3.9 to 5.1 percent) for the laparoscopic approach and 7.9 percent (procedure-specific range 7.4 to 10.2 percent) for the open approach [28]. Among the full study population, adjusted model results showed a significant association of laparoscopic colon surgery with lower odds of SSI (OR 0.43, 95% CI 0.41-0.46).

Multiple studies have been performed to assess the risk factors associated with SSIs with varying results. The largest experience comes from data from the American College of Surgeons NSQIP. In a prospective study of 59,365 patients who underwent colon resection from 2007 to 2009, the overall infection rate was 13 percent; the rates of superficial, deep, and organ space infections were 8, 1.4, and 3.8 percent, respectively [29].

The risk factors for SSIs related to colorectal surgery include [21,24,29]:

●Perioperative blood transfusion

●American Society of Anesthesiology (ASA) score grade 2 or 3

●Male sex

●Surgeons

●Types of operation

●Creation of an ostomy

●Contaminated wound

●Use of a drain

●Obesity

●Long duration of operation

A "bundled" approach to SSI prevention has been shown to significantly decrease the rate of superficial SSIs (5.7 versus 19.3 percent) and sepsis (2.4 versus 8.5 percent) after colorectal surgery [30]. The preventive SSI bundle consists of existing evidence-based measures such as mechanical bowel preparation with oral antibiotics, antibiotic prophylaxis with ertapenem, preparation of the surgical field with chlorhexidine, maintenance of euglycemia, and maintenance of normothermia during the perioperative period. It also includes common sense measures that have not been studied in randomized trials, such as gown and glove change before fascial closure and daily washings of incisions with chlorhexidine [31]. Further studies are required before all measures contained in the preventive SSI bundle can be recommended for colorectal surgeries.

In addition to the measures included in the preventive SSI bundle, the choice of surgical dressing may also affect the incidence of SSIs. As an example, a randomized trial involving 147 patients undergoing elective open colorectal surgery for colorectal cancer compared the efficacy of three different dressings in preventing SSIs [32]. In that trial, application of mupirocin ointment dressings significantly lowered the rates of SSI compared with ionic silver-containing dressings and standard surgical dressings (4.1 versus 18.4 and 20.4 percent, respectively).

The pathogenesis, risks, and measures to reduce SSI rates are further discussed elsewhere. (See "Risk factors for impaired wound healing and wound complications", section on 'Infection' and "Overview of control measures for prevention of surgical site infection in adults" and "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Overview of the evaluation and management of surgical site infection".)

Management of an SSI depends upon the site of the infection. An intra-abdominal SSI can be treated by percutaneous catheter drainage or operative drainage. A multicenter prospective study was conducted to determine the success rate of percutaneous catheter drainage of an intra-abdominal abscess in 96 patients, 27 of whom had an abscess following colorectal surgery [33]. Twenty-one of the 27 colorectal surgery patients (78 percent) had complete resolution of the abscess after a single attempt at percutaneous catheter drainage. Patients who failed catheter drainage were managed by an open operative procedure. Treatment for incisional SSIs is discussed elsewhere. (See "Complications of abdominal surgical incisions", section on 'Treatment' and "Overview of the evaluation and management of surgical site infection", section on 'Wound exploration and debridement'.)

Perioperative mortality rates are significantly higher in patients with an intra-abdominal abscess following colorectal surgery. This was illustrated in a retrospective review of 428 patients undergoing an open or laparoscopic colorectal procedure in which the perioperative mortality for patients with an intra-abdominal abscess was significantly higher than in patients without an intra-abdominal infection (19 versus 4 percent) [24]. There was no increase in perioperative mortality with SSI of the incision. The median duration of hospital stay was significantly longer for patients with either type of SSI (17 versus 8 days).

Postoperative ileus — There is general consensus among surgeons that some degree of postoperative ileus is a normal obligatory and physiologic response to nonabdominal and abdominal surgery. This issue is discussed in detail elsewhere. (See "Postoperative ileus".)

Early postoperative small bowel obstruction — Small bowel obstruction (SBO) is the most frequent complication in the early postoperative period after colorectal surgery with a reported incidence that ranges from 1.2 to 8.1 percent [34,35]. Inflammatory peritoneal adhesions account for the majority of cases. In a prospective study of 1002 patients who underwent open colorectal surgery, development of an early postoperative SBO was found to be an independent risk factor for the development of subsequent adhesive SBO [36]. Early postoperative SBO, defined as occurring within the first 30 days following surgery, can be differentiated from a postoperative ileus on both clinical and radiographic grounds. The clinical manifestations, diagnosis, causes, and management of SBO, and the prevention of postoperative peritoneal adhesions, are discussed elsewhere. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults" and "Postoperative peritoneal adhesions in adults and their prevention" and "Management of small bowel obstruction in adults".)

Not all patients with an early postoperative SBO require an operative intervention [35-37]. In a prospective study of 504 patients undergoing colorectal surgery, 8.1 percent developed a symptomatic SBO (eg, nausea, vomiting, abdominal pain), and all but 0.6 percent resolved spontaneously or with conservative management [35]. Immediate reoperation for early postoperative SBO should be avoided because of both the high rate of spontaneous resolution and the intense inflammatory response within the abdominal cavity in the perioperative period (from 10 days to 6 weeks). Indications for surgery should be limited to unresolved obstruction after prolonged nasogastric tube drainage, high-grade SBO, or suspected ischemic small bowel.

In contrast to the approach following open surgery, early SBO following laparoscopic surgery usually requires early operative intervention. The cause of an SBO is more likely to be a peritoneal defect with herniation created by trocar placement or a peritoneal incision, not an inflammatory adhesion that generally results from an open procedure [38].

Complications of stomas — The creation, management, and resultant complications of an ostomy are discussed elsewhere. (See "Ileostomy or colostomy care and complications" and "Parastomal hernia".)

PELVIC AND GENITOURINARY INJURIES — Pelvic and genitourinary structures (eg, blood vessels, ureters, bladder) can be injured during colorectal surgery [1]. The manifestations vary with the type and location of injury.

Presacral bleeding — Presacral bleeding results from injury to the presacral venous plexus or to the internal iliac vessels or their branches [39]. The bleeding can be massive since the presacral complex contains large-caliber veins and produces high-pressure bleeding when disrupted. Intraoperative presacral bleeding occurs in approximately 4 to 7 percent of procedures and is the most common complication during a proctectomy [40-43]. Tumors fixed to the sacrum, preoperative radiation, previous pelvic surgery, a distal location of the tumor, and surgical maneuvers that violate the presacral fascia increase the risk of presacral bleeding [41,44].

Bleeding from the fragile presacral vessels can be life-threatening [40]. Morbidity and mortality is high when surgery is required to manage presacral bleeding [42,44,45].

Control of presacral bleeding is difficult because of the anatomy of the pelvis and the fragility of the venous plexus. Attempts to electrocauterize or suture ligate the vessels will lead to further vascular injury and increased bleeding. The initial management is to apply direct pressure over the bleeding site to achieve temporary control. This allows the anesthesia team time to resuscitate and replace volume loss and prepare for possible additional blood loss.

Once the patient is stable, the most common technique after digital pressure to control the bleeding involves the application of sterile thumbtacks or occluder pins that are driven at right angles into the sacrum directly over the site of bleeding [42-44,46,47]. If occluder pins are not available, bone wax or bone cement is an effective alternative [48]. An epiploic flap and an omental flap have also been used to serve as plugs [43]. In our experience, we have also found a pledgeted suture repair with a UR-6 (curved 26 mm) needle placed just above the site of injury to be an effective approach to achieving hemostasis.

If the above approaches do not adequately control the bleeding, the following options are available. There are no comparative data among these modalities, and the experience of the surgeon is often the deciding factor.

●A rectus abdominis muscle flap can be rotated into the pelvis with the inferior epigastric pedicle intact. The flap is secured to the sacrum with heavy sutures that compress the flap against the sacral wall to tamponade the bleeding [49]. The muscle fragment welding technique involves applying electrocautery to the muscle flap, which produces a secure coagulum on the surface of the bleeding venous plexus [49,50].

●Spray diathermy is a technique that delivers a high-frequency electrical current and is applied slightly above the target bleeders at the presacral fascia [51].

●Balloon tamponade, either by a saline bag or breast implant, involves applying direct mechanical pressure to the bleeding site. The patient is observed in the intensive care unit, and the balloon is slowly deflated over the next 24 to 48 hours. The balloon is removed in the operating room [52-54].

●Hemostatic sponges with cyanoacrylate adhesive [55,56] or a combination of a hemostatic matrix with an absorbable hemostat have been used successfully to control presacral hemorrhage in small series of patients [57].

If the above measures fail, pelvic bleeding may be controlled with tight pelvic packing with laparotomy pads. The abdomen is closed, and the laparotomy pads are removed 24 to 48 hours later, after patient stabilization in the intensive care unit [58].

Ureteral injury — The incidence of intraoperative ureteral injury with open or laparoscopic surgery ranges from <1 to 8 percent [13,59,60]. In a retrospective review of more than 2.1 million colorectal procedures identified from a United States nationwide database, the risk to ureters was 0.28 percent [60]. Ureteral injuries were independently associated with higher mortality (odds ratio [OR] 1.45, p <0.05), higher morbidity (OR 1.66, p <0.001), and longer length of hospital stay (mean difference 3.65 days, p <0.001). Risk factors for injury included rectal cancer, adhesions, malnutrition, and performance of procedure in a teaching hospital. Protective factors included laparoscopic approach and right and transverse colectomies.

Identification of the ureters during pelvic and colorectal surgery is strongly advised to avoid injury. The ureters rest on the psoas muscle in the inferior medial course and are crossed obliquely by the spermatic vessels and the genitofemoral nerve posteriorly (picture 1 and figure 2) [61]. The ureter crosses the pelvic brim in front of or just lateral to the bifurcation of the common iliac artery.

In colorectal surgery, injury to the ureter usually occurs during:

●High ligation of the inferior mesenteric artery

●Mobilization of the upper mesorectum near the sacral promontory

●Dissection deep in the pelvis in the plane between the lower rectum, pelvic sidewall, and bladder base

●Dissection of the most cephalad portion of the perineal dissection in an abdominoperineal resection

The role of prophylactic ureteral catheterization is controversial. Although ureteral stents (catheters) facilitate intraoperative recognition of ureteral injuries, they do not appear to decrease the incidence of ureteral injury, and catheter placement is associated with a 1 percent risk of ureteral injury [62]. We use ureteral catheters in patients who have had severe diverticulitis or those undergoing reoperative pelvic surgery. Lighted ureteral stents may be useful for laparoscopic colectomies [63]. Only 20 to 30 percent of ureteral injuries are recognized during the operation [64]. Repair includes use of a stent or, in cases of more extensive damage, advanced surgical repair. (See "Urinary tract injury in gynecologic surgery: Identification and management".)

Bladder injury — Bladder injuries are rare (<1 percent) during colorectal surgery [13]. Bladder injury usually occurs when dissecting densely adherent rectosigmoid tumors or diverticular disease from the bladder wall.

Immediate repair is performed as a two-layer primary closure, and a Foley catheter is left in place for 7 to 10 days. A cystogram is performed prior to removing the catheter to assess for leaks. Injuries at the base of the bladder are technically more difficult to repair as the distal ureters are at risk for inadvertent suture ligature of the orifices. The repair is facilitated by making a cystotomy at the dome of the bladder and passing ureteral catheters in a retrograde fashion through the ureteral orifices. Injuries that are not recognized at the time of operation present with urine peritonitis or may result in the development of urinary tract fistulas. A primary repair is generally performed except in severe cases, when a temporary fecal or urinary diversion is performed [39,65]. (See "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Bladder injury'.)

Urethral injury — Iatrogenic injury to the urethra is rare (<1 percent) but can occur during the perineal portion of an abdominoperineal resection [66].

Intraoperative recognition of the injury usually occurs with visualization of the Foley catheter in the perineal defect. Primary repair of small injuries is preferred, with the urinary catheter left in place for two to four weeks to stent the repair.

In the postoperative period, injuries may present with urine draining from the perineal wound. A retrograde urethrogram may identify the level of injury. Management involves temporary urinary diversion (suprapubic catheterization) and delayed repair performed by an experienced urologist. Failure to diagnose and repair a urethral injury may lead to strictures, incontinence, and erectile dysfunction.

GENITOURINARY COMPLICATIONS — Pelvic dissection is associated with a significant risk of urinary dysfunction, sexual dysfunction, and, in women, infertility.

Urinary dysfunction — The incidence of urinary dysfunction after proctocolectomy, primarily manifested as difficulty voiding, ranges between 30 and 60 percent, with the greatest risk following abdominoperineal resection [67]. Urinary dysfunction persisting beyond the early (30 day) postoperative period has been reported in 12 percent of patients [68]. For all low anterior or abdominoperineal resections, a Foley catheter remains in place for a minimum of five to seven days, or longer if symptomatic bladder dysfunction persists.

Urinary dysfunction is the result of one or both of two factors: anatomic changes in the pelvis and autonomic nerve injury leading to impairments in parasympathetic innervation to the detrusor muscle and/or sympathetic innervation to the bladder neck, trigone, and urethra. Urodynamic studies may reveal a significant postoperative decrease in effective bladder capacity and increases in first sensation to void and residual urinary volume compared with the preoperative evaluation [69].

Autonomic sparing procedures can be effectively performed when dissecting the pelvis [70]. A prospective study of 20 patients undergoing a total mesorectal excision (TME) with an autonomic nerve preservation (ANP) technique and sphincter preservation found no significant difference between preoperative and postoperative mean residual volume after micturition [70].

The extensiveness of the dissection in the pelvis is an important risk factor for both the presence and duration of postoperative urinary symptoms. The following observations illustrate the range of findings:

●A prospective study of 47 patients undergoing TME with autonomic nerve preservation found that no patients developed major incontinence of urine [71]. Minor incontinence occurring at six months, one year, and two years was reported in three (10 percent), four (13 percent), and nine (33 percent) patients, respectively.

●A retrospective review of two studies found no postoperative urinary dysfunction in patients undergoing a restorative proctocolectomy for ulcerative colitis, which involves a less extensive dissection than that performed during cancer surgery [72].

●An abdominoperineal resection (APR) is associated with an increased risk of postoperative urinary symptoms. This was illustrated in a prospective study that evaluated the incidence of postoperative urinary and sexual dysfunction in women with rectal cancer: 222 were treated with an APR, and 73 were treated with a low anterior resection (LAR) [73]. At one year, women treated with an APR had significantly higher rates of urinary urgency (55 versus 36 percent), urinary retention (39 versus 18 percent), and incontinence (37 versus 18 percent) compared with those treated with an LAR. However, over time, symptoms worsened for women in the LAR group. Additional significant risk factors for urinary symptoms included tumor ≤5 cm from the anal verge, preoperative radiation therapy, age ≥65 years, and intra-abdominal sepsis.

●There appears to be no difference in the incidence of urinary dysfunction after laparoscopic or open rectal resection for cancer [74,75].

●A prospective survey of 74 patients undergoing a fully robotic resection for rectal cancer found no change in grade of incontinence one year after surgery compared with a preoperative assessment [76]. In male patients, there was no significant deterioration of voiding or incontinence at any point during the study. In female patients, rates of incontinence were increased one month after surgery but returned to baseline after one year.

The diagnostic evaluation and management of urinary incontinence are discussed elsewhere. (See "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment" and "Urinary incontinence in men" and "Urinary tract injury in gynecologic surgery: Identification and management", section on 'Postoperative urinary retention'.)

Sexual dysfunction — Sexual dysfunction following rectal surgery is related to the extent of pelvic nerve dissection and occurs in both sexes.

In men, damage to the sympathetic nerves during high ligation of the inferior mesenteric artery or posterior dissection at the sacral promontory can lead to retrograde ejaculation. In addition, damage to the parasympathetic plexus (nervi erigentes) during lateral and anterior dissection can lead to erectile dysfunction.

The pathophysiology of sexual dysfunction in women is likely multifactorial and includes damage to the parasympathetic nerves during deep pelvic dissection as well as postoperative mechanical changes in the pelvis, which contribute to loss of sexual desire, vaginal dryness, altered orgasm, and dyspareunia. Sexual dysfunction is more difficult to diagnose in women, in part because the presence of incontinence often discourages women from engaging in sexual activity. The evaluation and management of sexual dysfunction is discussed elsewhere. (See "Evaluation of male sexual dysfunction" and "Treatment of male sexual dysfunction" and "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation" and "Overview of sexual dysfunction in females: Management" and "Complications of gynecologic surgery", section on 'Sexual dysfunction'.)

The development of sexual dysfunction following colorectal surgery has been studied in patients with inflammatory bowel disease:

●A meta-analysis found that the proportion of patients with sexual dysfunction (dyspareunia, fear of leakage, and diminished sexual satisfaction) increased from 8 percent preoperatively to 25 percent postoperatively in women who underwent restorative proctocolectomy for ulcerative colitis (7 studies, 419 patients) [72].

●Another study found 3.8 percent of men (6/156) to be totally impotent and 13.5 percent (21/156) partially impotent after colorectal surgery for inflammatory bowel disease [77]. Age over 50 was significantly associated with the risk of impotence, while the choice of surgical techniques (mesorectal versus close rectal dissection) was not.

Sexual dysfunction is most common following rectal surgery for cancer because of the more extensive dissection required. Reported rates of sexual dysfunction in such patients range from 23 to 69 percent in men and from 19 to 62 percent in women [78]. Here, the major risk factors for sexual dysfunction include advanced age, surgical technique (especially APR), and use of radiotherapy [71,73,79,80]:

●In a study of 295 women who underwent rectal cancer surgery, those who had APR compared with anterior resection were less likely to be sexually active (25 versus 50 percent), and those who were sexually active reported a lower frequency of intercourse [73]. APR was also associated with increased dyspareunia (odds ratio 5.75; 95% CI 1.87-17.6) postoperatively.

●For male patients, the incidence of sexual dysfunction after rectal surgery could be lowered by employing the ANP technique during TME. This is because for male patients, impotence was associated with sacrifice of the inferior hypogastric plexus, and ejaculatory disorders were associated with sacrifice of the superior hypogastric plexus [71]. In a series of 134 male patients who underwent autonomic nerve-preserving operations for rectal cancer, 88 and 67 percent of the patients were able to maintain erectile and ejaculatory potencies, respectively [80].

●Sexual dysfunction was also studied for patients undergoing robotic surgery for rectal cancer [76]. The analyses of 74 patients who underwent robotic nerve-sparing TME showed that sexual function and general sexual satisfaction decreased significantly one and six months after intervention, respectively. However, at one year after surgery, patients' sexual function and satisfaction returned to the baseline. Further studies are required to determine the optimal minimally invasive technique (robotic versus laparoscopic) best suited for rectal cancer surgery in terms of outcomes and cost.

The above studies suggest that sexual function can be preserved in patients undergoing rectal cancer surgery if nerve-sparing techniques are used. However, for patients with advanced rectal cancer (T3 or N+), combined modality treatment (including radiotherapy) is required. In those patients, the expected rate of sexual dysfunction can be much higher [73,78,79]. The complications of radiotherapy are discussed elsewhere. (See "Neoadjuvant therapy for rectal adenocarcinoma" and "Adjuvant therapy for resected rectal adenocarcinoma in patients not receiving neoadjuvant therapy".)

Female infertility — Female infertility is defined as one year of unprotected intercourse without conception in women of childbearing age. The infertility rate for women with inflammatory bowel disease prior to surgery is similar to that of the general population (less than 10 percent). (See "Overview of infertility", section on 'Prevalence and influencing factors'.)

The rate of infertility following a restorative proctocolectomy is significantly increased, ranging in different studies from 26 to 48 percent [72,81-83]. The cause of the increase in infertility is most likely mechanical, including fallopian tube occlusion and scarring, and not the disease process. A totally laparoscopic approach may reduce the risk of infertility in women undergoing ileal pouch anal anastomosis [84]. Women should be counseled preoperatively regarding the risk of infertility. If medically feasible, women with inflammatory bowel disease may choose to delay elective restorative proctectomy until their child bearing is complete.

The evaluation and management of female infertility are discussed elsewhere. (See "Female infertility: Evaluation" and "Female infertility: Treatments".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colorectal cancer" and "Society guideline links: Colorectal surgery for cancer".)

SUMMARY AND RECOMMENDATIONS — The safety of colorectal surgery, as performed in patients with colorectal cancer and inflammatory bowel disease, has improved dramatically over the last 50 years due to improvements in preoperative preparation, antibiotic prophylaxis, surgical technique, and postoperative management.

●Management of an intraoperative splenic injury includes splenic salvage (primary repair, splenorrhaphy) or splenectomy. Splenic salvage should be the first maneuver to control bleeding and a splenectomy reserved for cases when a splenorrhaphy is not possible. (See 'Splenic injury' above.)

●Multiple enterotomies in a segment of small bowel are repaired by segmentectomy and primary anastomosis. A single enterotomy is repaired in a one- or two-layer closure. (See 'Small bowel and duodenal injury' above.)

●Control of presacral bleeding is difficult because of the anatomy of the pelvis and the fragility of the venous plexus. Attempts to electrocauterize or suture ligate the vessels will lead to further vascular injury and increased bleeding. The initial management is to apply direct pressure over the bleeding site to achieve temporary control. This allows the anesthesia team time to resuscitate and replace volume loss and prepare for possible additional blood loss prior to definitive control of the hemorrhage. (See 'Presacral bleeding' above.)

●Identification of the ureters during pelvic dissection and colorectal surgery is strongly advised to avoid injury. Repair of an injured ureter includes use of a stent or, in cases of more extensive damage, advanced surgical repair. (See 'Ureteral injury' above.)

●Pelvic dissection is associated with a significant risk of urinary dysfunction, sexual dysfunction, and, in women, infertility. The risk of urinary dysfunction persisting beyond the early (30 day) postoperative period is low. Sexual dysfunction following proctocolectomy is related to the extensiveness of the dissection of the pelvic nerves. Since the infertility rate for women with inflammatory bowel disease increases following proctocolectomy, a delay in surgery until after child bearing may be considered if medically possible. (See 'Female infertility' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Lara J Williams, MD, MSc, FRCSC, who contributed to an earlier version of this topic review.