Is the question what did you do, what could you do, or what should you do? The trouble is that this problem could come to any of us tomorrow. You suggests he has done something different to what we assume - probably right - but I have spent a couple of days and sleepless nights agonising over this one. What would I do?
1. Defunction bowel and clear the distal end.
2. Divert urine, but how? I would like to think he could eventually be fully reconstituted, which rules out cystectomy and diversion. Diversion to an ileal loop urostomy is rather a big op in one who is septic. Bilateral percutaneous nephrostomy is less invasive, but will not totally divert the urine, and will leave a large cavity of bladder, prostatic cavity and rectum for the Mother of all abscessses. I think I will go for the bilateral nephrostomies.
3. Wait. Give it a month to see if there is any attempt at healing. If radiotherapy was given before, there probably won't be much change, in which case resection of the rectum and anastomosis may be unwise. Perhaps this is another situation where an omental swing with omental interposition between the missing posterior prostatic capsule and the missing anterior rectal wall might just work? Or use two ileal "patches" (one for prostate and one for rectum) would be preferable. If these techniques worked, close colostomy and remove nephrostomies. If they failed, ileal loop urinary diversion as a permanent companion to the colostomy.
What do I think he did? - I think he did a one stage procedure - but I cannot think what.