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

Management of Persistent Post-TURP Bleeding

Initiate immediate continuous bladder irrigation with a large-caliber urethral catheter (20-24 Fr), and if conservative measures fail within a reasonable timeframe, proceed directly to endoscopic intervention with fulguration of bleeding vessels. 1

Initial Conservative Management

• Establish continuous bladder irrigation (CBI) immediately using a three-way Foley catheter (20-24 Fr minimum) to prevent clot formation and maintain clear drainage 1
• Apply catheter traction for 10 minutes to 4-6 hours to tamponade bleeding vessels at the prostatic fossa, though shorter duration (10 minutes) may be sufficient if hemostasis was adequate intraoperatively 2
• Correct any underlying coagulopathy before proceeding with further interventions, as this is critical for achieving hemostasis 3

Anticoagulation Management

• For patients on warfarin: Hold the medication and reverse anticoagulation if bleeding is significant; if the patient was on bridging LMWH, ensure it was held 24 hours preoperatively 1
• Delay resumption of anticoagulation by 24-48 hours if any concern for ongoing bleeding exists 1
• For patients on aspirin: Bleeding is typically manageable with conservative measures, as transfusion requirements are not significantly increased 1
• For novel oral anticoagulants (NOACs): Consider specific reversal agents if bleeding occurs 1

Escalation to Endoscopic Intervention

If continuous bladder irrigation fails to control bleeding within several hours or if the patient develops hemodynamic instability, proceed immediately to cystoscopy with fulguration. 1, 4

• Perform cystoscopy under anesthesia to identify and fulgurate specific bleeding vessels in the prostatic fossa 4
• This endoscopic approach successfully controls bleeding in the majority of cases (19 of 20 TURP patients in one series required only endoscopic intervention) 4
• Do not delay endoscopic intervention if bleeding persists, as rapid deterioration can occur 4

Refractory Bleeding: Advanced Interventions

When endoscopic fulguration fails to achieve hemostasis, two definitive options exist:

Selective Arterial Embolization (Preferred for High-Risk Surgical Candidates)

• Superselective prostatic artery embolization is safe and effective for severe prostatic hemorrhage refractory to conservative measures and fulguration 3, 5
• This approach is particularly valuable in patients with significant comorbidities who are poor candidates for open surgery 5
• Bilateral selective arterial prostatic embolization may be required in cases complicated by TURP syndrome and disseminated intravascular coagulopathy 5
• CT angiography and pelvic arteriography should be performed to guide the embolization procedure 5

Open Prostatic Packing (Life-Saving When All Else Fails)

• Open exploration and packing of the prostatic cavity is indicated when both endoscopic management and arterial embolization are insufficient or unavailable 4
• This technique may be life-saving in cases of intractable hemorrhage leading to hypovolemic shock 4, 3
• Reserve this approach for the most severe cases where less invasive methods have definitively failed 4

Critical Pitfalls to Avoid

• Do not underestimate the severity of post-TURP bleeding, as it remains a potentially life-threatening complication requiring prompt treatment to prevent rapid deterioration 4
• Avoid prolonged attempts at conservative management in patients with persistent heavy bleeding or hemodynamic instability 4
• Ensure adequate selection of patients preoperatively and proper resection technique to prevent postoperative bleeding 3
• Do not resume anticoagulation prematurely in patients who required it preoperatively; wait at least 24-48 hours after bleeding has completely resolved 1