How to manage post-ureteroscopic lithotripsy (URSL) hematuria?

Management of Post-URSL Hematuria

Post-ureteroscopic lithotripsy (URSL) hematuria should be managed conservatively in most cases with hydration, rest, and monitoring, as mild hematuria is an expected complication that typically resolves spontaneously within 24-48 hours.

Assessment of Hematuria Severity

When evaluating post-URSL hematuria, it's important to distinguish between expected mild hematuria and clinically significant bleeding:

Expected Findings (Mild Hematuria)

• Pink to light red urine that gradually clears
• No clots or minimal small clots
• No significant pain beyond expected post-procedural discomfort
• No signs of infection (fever, chills)
• Stable vital signs

Concerning Findings (Severe Hematuria)

• Bright red blood with clots
• Persistent bleeding beyond 48 hours
• Associated flank pain
• Fever or signs of infection
• Hemodynamic instability

Management Algorithm

For Mild Hematuria (Most Common)

1. Increased Fluid Intake

   • Encourage oral hydration (2-3 liters daily)
   • Helps flush the urinary tract and prevent clot formation

2. Rest and Activity Modification

   • Relative rest for 24-48 hours
   • Avoid strenuous activity for 1 week

3. Pain Management

   • NSAIDs (if not contraindicated)
   • Acetaminophen as needed

4. Monitoring

   • Patient education about expected course
   • Instructions to return if hematuria worsens or persists beyond 48-72 hours

For Moderate to Severe Hematuria

1. Urgent Evaluation

   • Immediate clinical assessment
   • Laboratory tests: CBC, coagulation profile, renal function

2. Imaging

   • Consider renal/bladder ultrasound or CT scan to evaluate for complications

3. Interventions Based on Findings

   • Placement of larger urinary catheter if clot retention occurs
   • Continuous bladder irrigation if significant clots
   • Intravenous hydration

4. Specialist Consultation

   • Urologic consultation for persistent or severe bleeding

Special Considerations

Patients on Anticoagulation

Patients on anticoagulation therapy are at higher risk for clinically significant hematuria after URSL 1. These patients require:

• Closer monitoring
• Lower threshold for intervention
• Consideration of anticoagulation management in consultation with appropriate specialists

Delayed Hematuria

Delayed gross hematuria (occurring 7-14 days post-procedure) may indicate rare but serious complications such as arteriovenous fistula formation 2. This requires:

• Immediate evaluation
• Consideration of angiography and potential embolization

Risk Factors for Severe Hematuria

Several factors increase the risk of significant post-URSL hematuria:

1. Procedural Factors

   • Longer operative duration (>90 minutes significantly increases risk) 3
   • Extensive laser lithotripsy
   • Ureteral wall injury during procedure

2. Stone Factors

   • Larger stone size (>10mm)
   • Impacted stones
   • Increased ureteral wall thickness at stone site 4

3. Patient Factors

   • Coagulopathy or anticoagulant use 1
   • Renal insufficiency
   • History of urinary tract infections

Prevention Strategies

To minimize risk of significant post-URSL hematuria:

• Antibiotic Prophylaxis: Recommended for all URSL procedures to prevent infectious complications 5
• Proper Stenting: Consider stenting after complicated procedures or when ureteral injury occurs 5
• Operative Duration: Minimize operative time when possible, as complication rates increase with procedures >90 minutes 3
• Hospital Volume: Higher-volume centers have lower complication rates 3

When to Seek Emergency Care

Patients should be instructed to seek immediate medical attention if they experience:

• Heavy bleeding with large clots
• Inability to urinate due to clots
• Severe flank pain
• Fever >101°F (38.3°C)
• Signs of hemodynamic instability (dizziness, syncope)

Follow-up Recommendations

• Routine follow-up within 1-2 weeks
• Imaging (KUB X-ray or ultrasound) to confirm stone clearance
• Urine culture if infection is suspected
• Stent removal if applicable (typically 1-2 weeks post-procedure)

By following this structured approach to post-URSL hematuria management, clinicians can effectively distinguish between expected post-procedural bleeding and more serious complications requiring intervention.