Endoscopic treatment of postoperative hemorrhage from a stapled colorectal anastomosis

We present the sixth reported case of endoscopic electrocoagulation to successfully treat postoperative hemorrhage from a stapled colorectal anastomosis. A literature review revealed 17 patients with postoperative hemorrhage from a combined total of 775 patients (1.8 per cent) after stapled colorectal anastomosis requiring blood transfusion and/or emergency surgery. Twelve of the 17 cases involved a circular stapler (71 per cent) used during an anastomosis to the rectum (69 per cent). Nonoperative therapy was successful in 14 of the 17 patients (82 per cent), using endoscopic electrocoagulation in six patients (43 per cent) and blood transfusion alone in another six patients (43 per cent). In follow-up there was one death (cardiac) and two anastomotic fistulas (one requiring temporary colostomy) in the nonoperative group. Both anastomotic fistulas occurred following hemorrhage from an anastomosis to the rectum using the circular stapler, one after endoscopic electrocoagulation and the second after blood transfusion alone. In summary, postoperative hemorrhage from a stapled colorectal anastomosis, although rare, is most likely to occur in a colorectal anastomosis constructed with the circular stapler. Nonoperative treatment is usually successful. Endoscopic electrocoagulation may be safely and effectively used in the early postoperative period to cease unremitting anastomotic hemorrhage.     

Anterior resection following posterior transsacral stapling and transection of the anal canal for low-lying rectal cancer in males

In anterior resection with anastomosis using the double-staple technique for low-lying rectal cancer in male patients, the approach to the anal canal with a stapling instrument via the abdominal area is limited by the narrow pelvis. The stapling and transection of the anal canal via the posterior transsacral approach prior to performing an anterior resection thus enables the lower rectum and anal canal to be visualized, so that the anal canal can be accurately stapled and transected even in male patients with a narrow pelvis.     

Laparoscopic +proctopexy

BACKGROUND: Although not common, rectal prolapse in adults can often be a debilitating conditions. Its only effective treatment is surgical. Among the many procedures described for the treatment of rectal prolapse, abdominal rectopexy is one of the preferred. It consists of fixation of the rectum to the sacrum and does not require any intestinal resection or anastomosis. However, like all open abdominal surgery associated with a large incision this operation may result in significant morbidity which is exacerbated by the advanced age of the patient. METHODS: An abdominal rectopexy carried out completely laparoscopically is described. The rectum is fully mobilised down to the pelvic floor and then fixed to the sacrum employing a polypropylene mesh. The mesh is first stapled to the sacral hollow and then sutured on both sides of the rectum. Thus the mesh is wrapped around the lateral aspects of the rectum, but the anterior rectal wall is left free. Laparoscopic techniques have been applied to a wide range of benign and malignant colorectal procedures. RESULTS: However most of colorectal laparoscopic techniques involving bowel resection, are technically demanding and require often an abdominal incision to deliver the specimen and fashion the anastomosis. CONCLUSIONS: Without the need for bowel resection, the laparoscopic rectopexy may constitute an optimal application of laparoscopic colorectal techniques and may soon become the gold standard for the treatment of rectal prolapse.     

Rectal washout eliminates exfoliated malignant cells

PURPOSE: Irrigation of the rectal stump before anastomosis after resection for carcinoma is accepted colorectal surgical practice. However, not all surgeons perform this routinely, and it has never been established conclusively that irrigation of the rectal stump eliminates exfoliated malignant cells or even reduces local recurrence. The patients of a surgeon whose standard surgical practice involved rectal irrigation were compared with those of a surgeon who does not routinely practice rectal irrigation. METHOD: Ten patients were given rectal washout with 200 to 500 ml of normal saline introduced via a Foley catheter per rectum. Ten patients were not given rectal washout. In both groups the anastomosis was performed with a circular stapler, and the stapler and donuts were rinsed in 200 ml of normal saline. The saline was sent for cytologic examination and classified as malignant cells seen or no malignant cells seen. The cytopathologist was blinded to the washout status. RESULTS: Of the ten patients who had rectal washout performed, none had malignant cells seen. Of the ten patients who did not have rectal washout performed, eight had malignant cells seen in the cytology (P = 0.007; two-tailed Fisher's exact probability test). CONCLUSION: Rectal washout eliminates exfoliated malignant cells in the rectum in the vicinity of the anastomosis.     

Serial evaluation of anorectal function following low anterior resection of the rectum

PURPOSE: This prospective study was performed to serially assess the changes in anorectal function after low anterior resection of the rectum, and to elucidate the mechanisms of functional impairment and the recovery process. MATERIALS AND METHODS: Thirty-two patients undergoing low anterior resection for rectal cancer were evaluated prospectively. Standardized interviews concerning anorectal function and physiologic studies consisting of manometry and balloon proctometry were performed preoperatively, then at 1, 3, and 6 months, and 1 year after the operation. Depending on the length of the residual rectum, patients were divided into two groups: (1) shorter than 4 cm (the short group, n = 18), and (2) longer than or equal to 4 cm (the long group, n = 14). RESULTS: Postoperatively, stool frequency increased and urgency to defecate occurred, which continued until 3-6 months had passed and was more remarkable in the short group. Overall incontinence score increased, which was more remarkable in the short group. Anal resting pressure showed a moderate reduction after 3 months, whereas squeeze pressure did not decrease significantly. Rectoanal inhibitory reflex was postoperatively abolished in almost all patients in the short group, which showed nearly no recovery for 1 year. In the long group, it persisted postoperatively in half the cases, and the reflex returned in a few cases within 1 year. Balloon proctometry revealed overall reduction in rectal capacity and compliance. Although the values tended to recover steadily, they did not reach the preoperative level for 1 year. Urgent volume and maximal tolerable volume remarkably declined, which continued for 1 year and for 6 months, respectively. Rectal compliance also decreased considerably, which continued for 6 months. Most values of rectal capacity tended to be smaller in the short group. CONCLUSION: Impairment of continence after low anterior resection seemed multifactorial, including diminished rectal capacity and compliance, impaired internal anal sphincter tone, and loss of rectoanal inhibitory reflex. Clinical outcome was better and reduction in rectal capacity was less in patients whose rectum remained more than 4 cm. Most of the functional impairments clinically recovered by 6 months postoperation. In the process of clinical recovery of continence, restoration of rectal capacity and compliance and internal anal sphincter tone seemed to contribute a significant degree, while the rectoanal inhibitory reflex did not contribute as much.     

Colovaginal anastomosis: a unique complication of end-to-end anastomosis stapler use in low anterior resection

Anastomotic staplers have been used in colorectal surgery for several years. End-to-end stapler use for low anterior resection, as well as for other procedures, is common in surgical practice. These staplers have allowed more extended, lower resections of the colorectum without loss of bowel continuity or sphincter function. There have been reported complications of stapler use, with anastomotic stricture and leakage being the most common. We report here a unique complication of direct colovaginal anastomosis using the end-to-end stapler during a low anterior resection of an early-stage rectal adenocarcinoma.     

Paradoxical sphincter reaction is influenced by rectal filling volume

PURPOSE: Paradoxical sphincter reaction is frequently found in constipated patients but sometimes also in incontinent patients and in asymptomatic subjects. Its significance in defecation disorders has, therefore, been debated. The aim of the present study was to investigate whether paradoxical sphincter reaction is influenced by rectal filling volume. PATIENTS AND METHODS: Eighteen patients with defecation disorders and paradoxical sphincter reaction shown by electromyography were reinvestigated with an extended electromyographic investigation while in the lying position and while in the sitting position, with 50-ml, 100-ml, and 150-ml water-filled rectal balloons. RESULTS: All 18 patients showing paradoxical sphincter reaction in the first investigation also showed the reaction at the second investigation in the lying position with a 0-ml volume of rectal contents. In the sitting position, with a volume of 150 ml of rectal contents, the increase in electromyographic activity disappeared in seven patients (39 percent) and no longer showed paradoxical sphincter reaction. Electromyography showed decreased activity in one patient and unchanged activity in six patients during straining. A closing reflex was seen after completed straining in all of these seven patients. CONCLUSIONS: The present study demonstrates that paradoxical sphincter reaction diagnosed by electromyography is influenced by the rectal filling volume and might diminish when the rectum is filled with contents. The conventional electrophysiologic technique in the diagnosis of paradoxical sphincter reaction might, therefore, overdiagnose this condition.     

Successful retransplantation of mouse-to-rat cardiac xenografts under immunosuppressive monotherapy with cyclosporine

BACKGROUND: Total mesorectal excision (TME) is advocated for rectal cancer but the indications and extent of resection vary widely between surgeons. METHODS: Seventy-six consecutive patients (61 elective, 15 acute admission) with rectal or rectosigmoid cancer were admitted to a unit where TME was the preferred surgical option for potentially curative cancer at all levels of the rectum. RESULTS: Procedures undertaken were anterior resection (38 patients), abdominoperineal resection (18), Hartmann's procedure (ten) and transanal excision (one). Six patients had proximal faecal diversion alone and surgery was withheld in three. Anastomotic leaks occurred in six of 37 patients who had anterior resection with primary anastomosis, resulting in one early death. The presence of a proximal stoma did not influence the rate or seriousness of anastomotic dehiscence. After potentially curative TME in 45 patients, there have been eight local recurrences, four associated with systemic metastases and four which occurred in isolation (median follow-up 34 months). CONCLUSION: Curative TME was deemed appropriate in 59 per cent of unselected patients with rectal cancer. It was associated with few local recurrences but a morbidity rate that questions its role in treatment of upper third tumours.     

Usefulness of ultrasound-guided prostate biopsy in the diagnosis and treatment of localized prostate cancer

OBJECTIVE: To evaluate the safety and efficacy of stapled anastomosis in left sided colorectal reconstructions. DESIGN: Prospective study. SETTING: District hospital, UK. SUBJECTS: 218 Consecutive patients who underwent elective colorectal reconstructions with stapled anastomoses between July 1980 and July 1994. INTERVENTIONS: 154 Anterior resections of the rectum using single or double stapled anastomoses, 37 rejoining after Hartmann's operations, and 28 restorative proctocolectomies with formation of J pouch ileoanal anastomoses. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There were 5/154 clinical anastomotic leaks after anterior resection of the rectum and 1/28 after stapled J pouch ileoanal anastomoses. There were no leaks after rejoining of Hartmann's. The overall clinical leak rate was therefore 3%. 11/154 tumours recurred locally after anterior resection of the rectum (7%) during a mean follow up of 18 months, and 8 (73%) developed within 2 years of operation. All but one recurrence developed after single stapled anastomosis. Dukes' staging remains the most reliable prognostic indicator of the local recurrence of the tumour. There were five postoperative deaths after anterior resection but none after Hartmann's procedure or J pouch ileoanal anastomosis, giving an overall postoperative mortality of 2.3%. CONCLUSION: The use of stapling instruments in left sided colorectal anastomosis is safe and technically easy, with a low clinical anastomotic leak rate and an acceptable rate of local recurrence after anterior resection of the rectum.     

Coordinated activity of the new "rectum" and anal sphincter after sphincter-saving resection of the rectum for colitis or carcinoma

PURPOSE: The aim of this study was to determine whether coordinated activity exists across a stapled enteroanal anastomosis. METHODS: Twenty-nine patients were studied for a median of one year after complete excision of the rectum and stapled enteroanal anastomosis; 12 patients underwent low anterior resection with coloanal anastomosis for carcinoma, and 17 patients underwent restorative proctocolectomy with ileoanal anastomosis. RESULTS: Maximum anal resting pressures were slightly lower after coloanal anastomosis than after ileoanal anastomosis [median range, 56 (11-60) cm H2O, cf 69 (40-107) cm H2O, P = NS]. During distention of the neorectum, anal sphincter pressures at 2.5, 1.5, and 0.5 cm from the anal verge were significantly lower after coloanal anastomosis compared with after ileoanal anastomosis (P < 0.01 at each station). The volume of neorectal distention required to produce maximal inhibition of the anal sphincter was significantly less after coloanal anastomosis at 50 (range, 20-60) ml of air than after ileoanal anastomosis at 240 (range, 100-420) ml of air (P < 0.01). Minor fecal leakage and urgency of bowel action were significantly more common after coloanal anastomosis (P < 0.01). CONCLUSION: Alterations in the dynamic response of the anal sphincter to distention of the neorectum may explain why the clinical results were better after ileal pouch-anal anastomosis than after coloanal anastomosis.     

Physiopathology and therapy of vertigo or dizziness due to cerebrovascular disorders

PURPOSE: The aim of this study is to demonstrate the feasibility and usefulness of mechanical suturing in children for low rectal anastomosis. METHODS: The study group includes 31 children operated on from January 1993 to July 1996 by the same senior surgeon, performing the modified Duhamel procedure for Hirschsprung's disease in 17 children, intestinal neuronal dysplasia in seven, and the Knight-Griffen procedure in seven pediatric patients with chronic ulcerative colitis. RESULTS: In all the cases the technique of "viscero-synthesis" was performed using the mechanical stapler. A circular stapler has been used for the end-to-end and the end-to-side anastomosis between the anal canal or the back wall of the rectum with the pulled viscus, while a linear endoscopic stapler (GIA) has been used for the consolidation of the rectocolic wall in the modified Duhamel technique. CONCLUSIONS: The results obtained demonstrate that the mechanical staplers in children are safe and effective in low rectal anastomosis, sparing operative time and reducing the risk of anastomotic dehiscence; however, the size of circular instruments limits its use in neonates and small infants.     

A modification of single stapled colorectal anastomosis using the transanal insertion device (TAIS)

A modification of single stapled colorectal anastomosis utilizing a reusable stapler head (transanal insertion device [TAIS]) is described. This modification minimizes the time that the proximal bowel is open by allowing early placement of the circular stapler head, and minimizes the risk of rectal injury that may be associated with the passage of a circular stapling device without the head in situ.     

Surgical treatment of adenocarcinoma of the rectum

OBJECTIVE: The authors' aim was to determine survival and recurrence rates in patients undergoing resection of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant therapy. SUMMARY BACKGROUND DATA: The surgery of rectal cancer is controversial; so, too, is its adjuvant management. Questions such as preoperative versus postoperative radiation versus no radiation are key. An approach in which the entire mesorectum is excised has been proposed as yielding low recurrence rates. METHODS: Of 1423 patients with resected rectal cancers, 491 patients were excluded, leaving 932 with a primary adenocarcinoma of the rectum treated at Mayo. Eighty-six percent were resected for cure. Surgery plus adjuvant treatment was performed in 418, surgery alone in 514. These 514 patients are the subject of this review. Among the 514 patients who underwent surgery alone, APR was performed in 169, CAA in 19, AR in 272, and other procedures in 54. Eighty-seven percent of patients were operated on with curative intent. The mean follow-up was 5.6 years; follow-up was complete in 92%. APR and CAA were performed excising the envelope of rectal mesentery posteriorly and the supporting tissues laterally from the sacral promontory to the pelvic floor. AR was performed using an appropriately wide rectal mesentery resection technique if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. The mean distal margin achieved by AR was 3 +/- 2 cm. RESULTS: Mortality was 2% (12 of 514). Anastomotic leaks after AR occurred in 5% (16 of 291) and overall transient urinary retention in 15%. Eleven percent of patients had a wound infection (abdominal and perineal wound, 30-day, purulence, or cellulitis). The local recurrence and 5-year disease-free survival rates were 7% and 78%, respectively, after AR; 6% and 83%, respectively, after CAA; and 4% and 80%, respectively, after APR. Patients with stage III disease, had a 60% disease-free survival rate. CONCLUSIONS: Complete resection of the envelope of supporting tissues about the rectum during APR, CAA, and AR when tumors were low in the rectum is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. Appropriate "tumor-specific" mesorectal excision during AR when the tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. However, the overall failure rate of 40% in stage III disease (which is independent of surgical technique) means that surgical approaches alone are not sufficient to achieve better long-term survival rates.     

Organ preservation in anal and rectal cancers

For the past 10 to 15 years, radiation therapy and chemotherapy have played an increasingly important role in the treatment of various gastrointestinal malignancies, most prominently in anal and rectal cancer. Critical issues in the care of patients with anal and rectal cancer include not only local control and survival but organ preservation as well. For patients with carcinoma of the anal canal, external-beam irradiation with 5-fluorouracil and chemotherapy with mitomycin C have replaced surgery as primary therapy. Current studies are optimizing this therapy. In contrast, the management of distal rectal cancer is in evolution. Although the abdominoperineal resection has been long regarded as the definitive treatment of distal rectal cancer, it is associated with substantial morbidity (loss of anorectal function with a permanent colostomy and a high incidence of sexual and genitourinary dysfunction). As an alternative, treatment programs utilizing sphincter-preserving procedures with radiation therapy and chemotherapy are under active investigation. In selected patients, these strategies appear promising, and there have been reports of satisfactory local control and survival, as well as preservation of sphincter integrity.     

An assessment of the anatomical relationship between the pelvic plexus and the rectal wall to determine the indications for its preservation in surgery for rectal cancer

Preservation of the pelvic plexus in surgery for rectal cancer could shorten the distance between the cancer and the lateral resection margin, whereby the curability of the operation may be reduced. To clarify the indications for preserving the pelvic plexus in such surgery, the relationship of the pelvic plexus to the rectum and rectal cancer was investigated anatomically in 12 autopsied specimens and 12 surgical specimens. The rectum and anus were dissected with all the pelvic organs from autopsied cadavers and transverse sections were prepared at 10-mm intervals after fixation. The location of the pelvic plexus was then measured on the tissue preparations, and compared to that of surgical specimens from rectal cancers with concurrent resection of the pelvic plexus. The pelvic plexus was located from 3.3 +/- 1.2 cm above to 2.3 +/- 1.9 cm below the peritoneal reflection in the autopsied specimens. The average distances between the muscularis propria and the pelvic plexus in the autopsied specimens and surgical specimens were 8.3 +/- 3.5 mm and 14.7 +/- 4.5 mm, respectively, showing a significant difference (P < 0.05). Pelvic plexuses were located about 10 mm from the outer margin of rectal muscularis propria. These findings indicate that concurrent resection of the pelvic plexus may be required to secure sufficient surgical clearance in pT3 rectal cancers, especially those invading deeply beyond the muscularis propria (a2).     

Clinical and molecular prognostic factors in sphincter-preserving surgery for rectal cancer

As many as a third of patients with rectal cancers may be candidates for sphincter preservation surgery. The goal of the conservative management of adenocarcinoma of the distal rectum is to preserve rectal sphincter function without sacrificing local tumor control. To achieve this goal, a combined modality approach is necessary because multimodality therapy for more advanced disease has improved both local control and survival. Candidates for local excision are those with adenocarcinomas with a maximal diameter of less than 4 cm, mobile, and not poorly differentiated or mucinous and within 10 cm of the anal verge--usually within 6 cm. These criteria should be defined objectively by biopsy combined with state-of-the-art endorectal imaging. Newer molecular markers that are associated with prognosis and response to therapy may also be important for assessing prognosis, probability of local recurrence, and whether conservative treatment is appropriate. Patients with T0-3 N0 lesions meeting these standard clinicopathologic criteria have been treated successfully with wide local excision combined with chemotherapy and radiotherapy. Patients with larger or more advanced lesions may undergo low anterior resection with coloanal anastomosis. After resection, radiotherapy to at least 45 to 50 Gy is delivered to the pelvis and tumor bed often with concomitant chemotherapy. The overall rate of local failure in prospective single-institution trials in which local excision is performed with postoperative chemoradiotherapy has been 5% for T1 lesions, 7% for T2 lesions and 24% for T3 lesions. Although single-institution studies have supported the concept of conservative therapy, the safety and efficacy of this approach must still be confirmed in a multicenter, prospective trial, such as that underway in several of the cooperative oncology groups, before it may be considered a standard of practice.     

Posterior sagittal resection for rectal aganglionosis: preliminary results of a new approach

BACKGROUND: There is no general agreement about how patients who have short-segment Hirschsprung's disease should be treated. METHODS: Ten patients with Hirschsprung's disease, seven with rectal and three with rectosigmoidal aganglionosis, were operated on through a posterior sagittal incision. In nine patients, a primary rectal resection and coloanal anastomosis was performed. In one patient, a longitudinal posterior myectomy of the rectum was performed as a primary procedure, but the procedure was eventually converted to a rectal resection and coloanal anastomosis through the same incision. RESULTS: One early and one late anastomotic complication occurred. Both were successfully treated with a temporary fecal diversion (left-sided colostomy for 6 to 8 weeks). The functional results as evaluated with anorectal manometry were similar to a group of Hirschsprung's patients treated with transabdominal pull-through resection and coloanal anastomosis. CONCLUSION: This approach might prove to be a useful alternative both to the transabdominal resection and the posterior longitudinal rectal myectomy in Hirschsprung's disease with rectal aganglionosis.     

Significance of asymptomatic microhaematuria in men

Injuries of the colon and rectum are common surgical problems. Lesions can be classified into four groups according to the site of damage and the presence of sphincter tears: 1. intraperitoneal perforation without sphincter damage 2. intraperitoneal perforation with sphincter damage 3. extraperitoneal perforation without sphincter damage 4. extraperitoneal perforation with sphincter damage From 1990 to 1998, 11 patients, 7 males and 4 females presenting an anal and/or rectal trauma were admitted in Geneva University Hospital. 8 patients were admitted as an emergency, the 3 others had been transferred to correct an incontinent post traumatic pathology. No mortality. A terminal colostomy was performed in all patients with intraperitoneal injury and in 5 patients with combined extraperitoneal and anal sphincter injury. All sphincter lesions were sutured as an emergency (6 cases). In 3 patients we performed an overlapping sphincteroplasty. 2 patients with persisting incontinence were cured by a dynamic stimulated graciloplasty. The choice of treatment of anorectal trauma includes broad spectrum antibiotherapy, cleaning of the rectum, sphincter repair. A terminal diverting colostomy and laparotomy must be achieved in case of intraperitoneal injury, large extraperitoneal lesion, severe perineal laceration with or without pelvic fracture.     

Transanal endoscopic microsurgery: a single surgeon's experience

OBJECTIVE: To evaluate a single surgeon's experience with transanal endoscopic microsurgery (TEM) with regard to incidence of complications, recurrence rate of benign and malignant lesions, and impact on the treatment of rectal cancer. DESIGN: Prospective tumor registry. SETTING: Tertiary care university hospital. PATIENTS: Seventy-three patients undergoing TEM between January 1991 and November 1996. MAIN OUTCOME MEASURES: Complications, recurrence rates, and use of this technique with respect to radical operations. RESULTS: The arrival of TEM was associated with an increase in the number of operations for rectal cancer; however, the use of TEM remained constant relative to radical resections. Use of TEM resection alone is appropriate for all adenomas and cancers staged Tis and T1. Use of TEM alone is not an appropriate treatment for T2 cancers. Four patients (5%) experienced fecal soilage, which was long lasting in only 1 (1%). CONCLUSIONS: Transanal endoscopic microsurgery is a safe technique and provides improved access to lesions in the middle and upper rectum. Thus far, it has not had a significant impact in the overall treatment of rectal cancer.     

Late rectal bleeding following combined X-ray and proton high dose irradiation for patients with stages T3-T4 prostate carcinoma

PURPOSE: Dose escalation for prostate cancer by external beam irradiation is feasible by a 160 MeV perineal proton beam that reduces the volume of rectum irradiated. We correlated the total doses received to portions of the anterior rectum to study the possible relationship of the volume irradiated to the incidence of late rectal toxicity. METHODS: We have randomized 191 patients with stages T3 and T4 prostatic carcinoma to one of two treatment dose arms. These were: 1) 75.6 Cobalt-Gy-equivalent (CGE), 50.4 Gy delivered by 107-25 MV photons followed by 25.2 CGE delivered perineally by protons (Arm 1) or 2) 67.2 CGE delivered by 10-25 MV photons (Arm 2). RESULTS: With a median follow-up of 3.7 years, post-irradiation rectal bleeding (grades 1 and 2 only, none requiring surgery or hospitalization) from telangiectatic rectal mucosal vessels has occurred in 34% of 99 Arm-1 patients and 16% of 92 Arm-2 patients (p = 0.013). Dose-volume histograms (DVHs) for the anterior rectal wall, the posterior rectal wall and the total rectum in 41 patients treated on Arm 1 were calculated from the three dimensional dose distributions. Rectal bleeding has occurred in 14 or 34% of the 41 DVH-analyzed subset of Arm-1 patients. Both the fractional volume of the anterior rectum and the total dose received by fractional volumes of the anterior rectum significantly correlate with the actuarial probability of bleeding. CONCLUSIONS: Clinicians planning dose escalation to men with localized prostate cancer should approve with caution treatment plans raising more than 40% of the anterior rectum to more than 75 CGE without additional effort to protect the rectal mucosa because this late sequela data indicate that more than half of these men will otherwise have rectal bleeding.