What is the management of postoperative hematuria?

Management of Postoperative Hematuria

The management of postoperative hematuria requires prompt assessment of severity, insertion of a large-bore catheter (20-24 Fr), and continuous bladder irrigation to prevent clot formation, with urgent urological consultation for severe or persistent bleeding.

Initial Assessment and Monitoring

• Severity assessment:

  • Quantify blood loss using standard methods (suction canisters, surgical sponges) 1
  • Monitor vital signs for hemodynamic stability 1
  • Check hemoglobin/hematocrit if significant blood loss is suspected 1
  • Monitor for signs of inadequate perfusion (tachycardia, hypotension) 1

• Hemodynamic monitoring:

  • Assess for signs of hypovolemia (tachycardia, hypotension, decreased urine output)
  • Monitor fluid balance with documentation of input and output 1
  • Check for signs of congestion (crackles, edema, JVD) 1

Immediate Management

1. Catheter management:

   • Insert a large-bore urinary catheter (20-24 Fr) if not already present
   • Perform gentle bladder irrigation with normal saline to prevent clot formation 1
   • Consider continuous bladder irrigation for patients at risk of clot retention 1

2. Fluid resuscitation:

   • Administer balanced crystalloids if signs of hypovolemia are present 1
   • Target maintenance fluid rate of 1-1.5 mL/kg/hr 1
   • Aim for mildly positive fluid balance (1-2L) in the immediate postoperative period 1

3. Blood transfusion:

   • Consider blood transfusion if hemoglobin drops below 7-8 g/dL 1
   • Transfuse red blood cells when hemoglobin is less than 6 g/dL 1
   • Monitor response to transfusion with repeat hemoglobin checks

Management Based on Severity

Mild Hematuria

• Continue monitoring
• Ensure adequate hydration
• Remove urinary catheter as soon as clinically appropriate 1

Moderate Hematuria

• Continuous bladder irrigation
• Monitor clot formation
• Consider tranexamic acid administration (10 mg/kg IV 3-4 times daily) 2
• Infuse tranexamic acid no more than 1 mL/minute to avoid hypotension 2

Severe Hematuria with Clot Retention

• Urgent urological consultation for potential cystoscopy and clot evacuation 1
• Manual bladder irrigation with large-bore catheter
• Continuous bladder irrigation at higher flow rates
• Blood transfusion if hemodynamically unstable
• Consider angiography and embolization if bleeding persists despite conservative measures 3

Special Considerations

• Anticoagulation management:

  • For patients on anticoagulants, consider continuing aspirin perioperatively for those with high thromboembolic risk 4
  • Patients on dual antiplatelet therapy within 12 months of drug-eluting stent placement or 3 months of bare metal stent placement should not have therapy withdrawn 4

• Renal impairment:

  • Reduce tranexamic acid dosage in patients with renal impairment 2
  • Monitor renal function with urine output and creatinine levels

• Contraindications to tranexamic acid:

  • Active intravascular clotting 2
  • Subarachnoid hemorrhage 2
  • Severe hypersensitivity to tranexamic acid 2

Prevention of Further Complications

• Early mobilization to prevent venous thromboembolism 1
• Pain management with multimodal analgesia (paracetamol, NSAIDs) 1
• Use opioids sparingly to avoid urinary retention 1
• Monitor for signs of infection (fever, increased WBC)

When to Escalate Care

• Persistent hematuria despite conservative measures
• Hemodynamic instability
• Significant drop in hemoglobin
• Development of flank pain (suggesting upper tract bleeding)
• Inability to maintain catheter patency despite irrigation

Follow-up

• Remove urinary catheter when hematuria resolves
• Follow hemoglobin until stable
• Consider outpatient urology follow-up to identify underlying cause if not already known

Postoperative hematuria is a common complication that can range from mild self-limiting bleeding to severe hemorrhage requiring urgent intervention. The key to successful management is prompt assessment, appropriate catheter placement with irrigation, and early urological consultation for severe cases.