How to manage bleeding post-Transurethral Resection of the Prostate (TURP)?

Management of Post-TURP Bleeding

Immediate management of post-TURP bleeding requires continuous bladder irrigation with a large-caliber urethral catheter (20-24 Fr), and if conservative measures fail, proceed directly to endoscopic intervention with fulguration of bleeding vessels, reserving arterial embolization or open prostatic packing for refractory cases. 1, 2, 3

Initial Conservative Management

• Place or upsize to a large-caliber three-way urethral catheter (20-24 Fr) immediately to enable continuous bladder irrigation and prevent clot retention 2, 3
• Initiate continuous bladder irrigation with normal saline to maintain clear or light pink effluent and prevent catheter obstruction by blood clots 3, 4
• Apply gentle traction on the catheter for 15-30 minutes to compress the prostatic fossa against the bladder neck, which can tamponade venous bleeding 3
• Correct any underlying coagulation defects including thrombocytopenia, coagulopathy, or anticoagulation reversal if applicable 5, 6
• Monitor hemodynamic status closely with serial vital signs and hemoglobin measurements to detect ongoing blood loss 3, 4

Timing and Severity Assessment

Early bleeding (first 24-48 hours) is typically due to inadequate hemostasis or capsular perforation rather than fibrinolysis, requiring mechanical or surgical intervention 7

Delayed bleeding (7-14 days post-surgery) may occur as eschar sloughs from the prostatic fossa and can be managed similarly to early bleeding 3

Endoscopic Intervention

If conservative measures fail within 2-4 hours or the patient becomes hemodynamically unstable, proceed immediately to cystoscopy with fulguration 3

• Return to the operating room for cystoscopy under anesthesia to identify and fulgurate specific bleeding vessels in the prostatic fossa 3
• Use monopolar or bipolar electrocautery to achieve hemostasis of identifiable bleeding points 3
• Evacuate clots from the bladder to improve visualization and prevent bladder distention 3
• This endoscopic approach successfully controls bleeding in approximately 95% of cases requiring intervention 3

Advanced Interventions for Refractory Bleeding

Arterial Embolization

For patients who fail endoscopic management or are poor surgical candidates, superselective arterial embolization is the next step 5

• Perform angiography to identify the bleeding prostatic artery (typically branches of the internal iliac artery) 5
• Superselective embolization can achieve hemostasis while preserving bladder and rectal blood supply 5
• This is particularly useful in patients with significant comorbidities who cannot tolerate repeat surgery 5
• Success rates approach 90-95% when performed by experienced interventional radiologists 5

Open Prostatic Packing

When both endoscopic management and embolization fail or are unavailable, open exploration with prostatic packing is life-saving 3

• Perform a suprapubic cystotomy to access the prostatic fossa 3
• Pack the prostatic cavity tightly with gauze or hemostatic agents to achieve tamponade 3
• Leave packing in place for 24-48 hours before removal under controlled conditions 3
• This technique is reserved for life-threatening hemorrhage but can be definitive when other measures fail 3

Special Considerations for Anticoagulated Patients

Patients on chronic anticoagulation have higher bleeding risk but can be managed successfully with careful perioperative planning 1, 6

• Patients on warfarin should be bridged with LMWH perioperatively, with LMWH held 24 hours before surgery and resumed at least 24 hours postoperatively or when bleeding has subsided 1
• Delay resumption of anticoagulation by 24-48 hours if any concern for ongoing bleeding exists 1, 6
• The risk of VTE (including DVT) is relatively low (19.4% superficial venous thrombosis, with only some progressing to DVT) compared to bleeding risk in the immediate postoperative period 6
• Patients on antiplatelet therapy (aspirin) have only modestly increased minor bleeding without significantly increased transfusion requirements 1

Pharmacologic Adjuncts

Intravesical aminocaproic acid (0.5%) may be considered for delayed recurrent bleeding thought to be due to fibrinolysis, though it has limited efficacy for early post-TURP bleeding 7

• Early post-TURP bleeding is mechanical, not fibrinolytic, so antifibrinolytic agents are generally ineffective in the first 72 hours 7
• Systemic antifibrinolytics are not recommended due to thromboembolic risk without proven benefit 7

Transfusion Thresholds

Transfuse packed red blood cells for hemoglobin <7 g/dL in stable patients or <8 g/dL in patients with cardiovascular disease or ongoing bleeding 4

• TURP and TURBT are not considered high-risk bleeding procedures in contemporary practice, with major bleeding rates <5% 4
• Most postoperative anemia resolves without transfusion with conservative management 4

Common Pitfalls to Avoid

• Do not delay endoscopic intervention if conservative measures fail within 2-4 hours, as continued bleeding leads to clot retention and bladder distention 3
• Do not restart anticoagulation too early (before 24 hours) as this coincides with peak bleeding risk and transfusion requirements 1, 6
• Do not use small-caliber catheters (<20 Fr) as they cannot accommodate adequate irrigation and are prone to clot obstruction 2, 3
• Do not attribute all bleeding to coagulopathy—most cases are due to inadequate surgical hemostasis or capsular perforation requiring mechanical intervention 5, 7