What to do if there's hematuria after a Transurethral Resection of the Prostate (TURP) procedure?

Management of Hematuria After TURP

Initiate continuous bladder irrigation through a large-caliber urethral catheter (20-24 Fr) immediately, and if bleeding persists despite conservative measures, proceed directly to endoscopic fulguration of bleeding vessels. 1

Immediate Assessment and Initial Management

First-Line Conservative Approach

• Place or upsize to a 20-24 Fr three-way urethral catheter with continuous bladder irrigation to prevent clot formation and maintain hemostasis 1
• Apply brief catheter traction (10 minutes may be sufficient for prostates <65g) to tamponade bleeding from the prostatic fossa 2
• Monitor vital signs, urine output color, and hemodynamic stability closely 3

Timing Considerations

• Post-TURP bleeding typically occurs either immediately postoperatively or as delayed hemorrhage (7-13 days post-surgery) 4
• The incidence of significant bleeding requiring endoscopic intervention is approximately 4.3% (19/437 TURP cases) 4

Escalation Algorithm When Conservative Measures Fail

Second-Line: Endoscopic Intervention

• Return to the operating room for cystoscopy with fulguration of identifiable bleeding vessels if continuous irrigation fails to clear hematuria or patient becomes hemodynamically unstable 1, 4
• This approach successfully manages the majority of post-TURP bleeding cases 4

Third-Line: Advanced Interventions for Refractory Bleeding

• Arterial embolization should be considered for persistent bleeding unresponsive to endoscopic management 1
• Open prostatic packing is reserved as a life-saving measure when all other interventions fail 1, 4
• In the rare cases requiring open exploration, the prostatic cavity is packed to achieve hemostasis 4

Special Considerations for Anticoagulated Patients

Warfarin Management

• Hold warfarin and reverse anticoagulation if bleeding is significant 5
• For patients on bridging LMWH, ensure it was held 24 hours preoperatively 5, 1
• Delay resumption of anticoagulation by 24-48 hours beyond the standard postoperative timeframe if any concern for ongoing bleeding exists 1
• Standard protocol calls for LMWH resumption at least 24 hours postoperatively or when bleeding has subsided, but extend this window with active hematuria 5, 1

Antiplatelet Therapy

• Patients on aspirin have modestly increased minor bleeding risk but without significantly increased transfusion requirements 5, 1
• The bleeding is typically manageable with conservative measures in aspirin users 5

Novel Oral Anticoagulants (NOACs)

• NOACs (apixaban, dabigatran, rivaroxaban) should have been discontinued 2-5 days before TURP depending on bleeding risk 5
• If bleeding occurs in a patient on NOACs, consider specific reversal agents if available 5

Common Pitfalls to Avoid

• Do not delay endoscopic intervention if continuous irrigation fails to clear the urine within several hours or if the patient requires transfusion 4
• Avoid premature catheter removal before ensuring adequate hemostasis and urine clarity 4
• Do not restart anticoagulation on the standard schedule (24 hours postoperatively) if there is any evidence of ongoing bleeding; wait an additional 24-48 hours 1
• Recognize that prostate regrowth is the most common cause (63%) of late hematuria after TURP, not necessarily surgical complications 6

Long-Term Bleeding (Weeks to Months Post-TURP)

• Late hematuria (beyond 2 weeks) is most commonly due to vascular regrowth of prostatic tissue (63% of cases) 7, 6
• Consider initiating a 5-alpha reductase inhibitor (finasteride) for recurrent hematuria from prostatic regrowth, which successfully manages 51% of cases 7
• Re-evaluation with cystoscopy is warranted to rule out malignancy (found in 23.5% of patients with post-TURP hematuria) 6