INTRODUCTION The suprapubic cystostomy (SPC) is a common urological procedure to drain the bladder in a wide variety of patho- logical processes. Suprapubic catheter can be placed either through a punch trocar, after localization of the bladder by palpation, or by using other safer techniques like the appli- cation of the Lowsley retractor, Seldinger technique using peel away sheath introducer or image guidance using ultra- sonography (USG) guidance. Local anesthesia is usually enough in most cases of SPC insertion except some special circumstances, like in patients with spinal cord injuries, in which general or regional anesthesia is indicated (1). Additionally, in uncooperative or agitated patients, seda- tion might be necessary along with local anesthesia (2). Although the SPC is a safe procedure, it is not devoid of complications such as site bleeding, catheter blockade, malpositioning, dislodgment, or bowel injury. Bowel perforation is the most dreaded complication of SPC insertion with an incidence rate of 2.4 to 2.7% in two 101 Archivio Italiano di Urologia e Andrologia 2013; 85, 2 CASE REPORT Iatrogenic direct rectal injury: An unusual complication during suprapubic cystostomy (SPC) insertion and its laparoscopic management Rakesh Rajmohan, Bernardo Aguilar-Davidov, Theodoros Tokas, Jens Rassweiler, Ali Serdar Gözen Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany. Suprapubic cystostomy (SPC) is commonly used, instead of indwelling urethral catheter- ization, as indicated in many pathological conditions. Although considered to be a safe procedure that can be easily performed in an outpatient basis several complications have been reported in international literature. Bowel injury can be a serious complication with the small intestine affected in the majority of cases. We present a case of an acci- dental rectal injury by a suprapubic catheter misplacement, in a 76 year old demented patient with prostatic hyperplasia and chronic urinary retention. The injury was confirmed by cystogra- phy and injection of contrast meterial through the suprapubic catheter, and successfully treated laparoscopically by an extraperitoneal approach. The patient was discharged after 10 days with- out any complications. The above method, in experienced hands, can be an effective primary treatment option for such rare but devastating complications. The case and management is unique as, to our knowledge, as no similar cases have been presented. KEY WORDS: Suprapubic cystostomy (SPC); Ultrasonography (USG); Benign prostatic hyperplasia (BPH). Submitted 11 February 2013; Accepted 30 April 2013 No conflict of interest declared Summary different series (3, 4), The most commonly affected part is the small bowel and several cases have been reported (5, 6). In contrast, only a single case of rectal injury has been reported in international literature (7). It is of utmost importance to recognize a bowel injury immediately, since primary repair represents the best ther- apeutic option (8, 9). Laproscopic radical prostatectomy is a well established operative therapy for localized prostate cancer in the era of minimally invasive surgery. Rectal injuries during laparoscopic radical prostatectomy can be managed suc- cessfully intraoperatively without requiring any conver- sion to open surgery (10, 11). We present a case of rectal injury during SPC insertion, as well as its subsequent management by laparoscopy using an extra peritoneal approach. Its presentation and successful management is unique as, to our knowledge, as no similar cases have been presented.