What is the management for hematuria after Transurethral Resection of the Prostate (TURP) with catheter discontinuation?

Management of Hematuria After TURP with Catheter Discontinuation

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

Initial Conservative Management

• Reinsertion of a large-caliber urethral catheter (20-24 Fr) with continuous bladder irrigation is the first-line intervention for post-TURP hematuria after catheter removal 1
• Hematuria after TURP is a recognized complication occurring in more than 5% of patients, and can present as delayed bleeding during the first month post-procedure due to sloughing of necrotic tissue 2
• The median time for delayed hematuria requiring rehospitalization is around the 11th postoperative day (range: 2nd week most common) 3
• Most cases of post-catheter removal hematuria can be managed conservatively with catheter reinsertion and irrigation without requiring reoperation 3

Escalation of Management

If continuous bladder irrigation fails to control bleeding or clot retention develops, proceed immediately to endoscopic intervention:

• Cystoscopy with fulguration of bleeding vessels is the next step when conservative measures fail 1, 4
• Approximately 4.3% of TURP patients (19 of 437 in one series) required endoscopic intervention for postoperative bleeding 4
• Reserve arterial embolization or open prostatic packing only for refractory cases where endoscopic management is insufficient 1, 4

Special Considerations for Anticoagulated Patients

Anticoagulation management is critical and must be addressed immediately:

• If the patient is on warfarin, hold the medication and consider reversal if bleeding is significant 1
• For patients who were bridged with LMWH perioperatively, ensure LMWH was held 24 hours preoperatively and delay resumption by 24-48 hours if any concern for ongoing bleeding exists 1
• Patients on aspirin typically have only modestly increased minor bleeding without significantly increased transfusion requirements, and bleeding is usually manageable with conservative measures 2, 1
• For patients on novel oral anticoagulants (NOACs), consider specific reversal agents if bleeding is significant 1

Monitoring and Transfusion Thresholds

• Monitor hemoglobin levels and vital signs closely 4
• Blood transfusion may be required in approximately 8% of cases with significant bleeding 5
• Two patients in one series required transfusion for delayed hematuria managed conservatively 3

Common Pitfalls to Avoid

• Do not delay catheter reinsertion and irrigation - early intervention prevents clot retention and rapid deterioration 4
• Do not prematurely resume anticoagulation - wait at least 24-48 hours after bleeding has subsided before restarting anticoagulation 1
• Do not attempt prolonged conservative management if clot retention develops - this indicates need for endoscopic intervention 4
• Recognize that bleeding requiring intervention is uncommon but potentially life-threatening, and prompt treatment prevents rapid deterioration 4

When Bleeding is Controlled

• Once hematuria resolves with conservative management, the catheter can typically be removed after 24-48 hours of clear urine 6
• Patients should be counseled that minor hematuria may recur intermittently during the first month but rarely requires intervention 3