What should be done for a male patient in his 60s with a history of BPH, who is experiencing sudden bleeding 2 months after HoLEP (Holmium Laser Enucleation of the Prostate) surgery?

Management of Sudden Bleeding 2 Months Post-HoLEP

This patient requires urgent urological evaluation with cystoscopy to identify and treat the bleeding source, as delayed bleeding after HoLEP—though uncommon—can indicate significant complications requiring intervention. 1

Immediate Assessment and Management

Initial Evaluation

• Assess hemodynamic stability and obtain complete blood count to quantify blood loss, as transfusion was required in 1.4-2.8% of HoLEP patients in large series 2, 3
• Review anticoagulation status immediately, as delayed bleeding is more pronounced in patients on anticoagulant/antiplatelet therapy, with 7 of 34 patients (23%) requiring early postoperative transfusion when anticoagulation was restarted 1
• Determine bleeding severity: frank hematuria with clots versus minor spotting, as cystoscopy with clot evacuation was needed in 0.7% of cases 2

Anticoagulation Management

• If patient is on warfarin, LMWH, or antiplatelet agents, these medications significantly increase delayed bleeding risk and should be held if clinically safe 1
• Assess thromboembolic risk before stopping anticoagulation—patients with recent stents, atrial fibrillation with high CHADS2 score, or recent stroke/DVT require careful risk-benefit analysis 1
• For high thromboembolic risk patients, coordinate with cardiology before medication cessation, as the literature documents 2 sudden cardiac deaths (1.8%) in small series when anticoagulation was managed perioperatively 1

Diagnostic Approach

Cystoscopic Evaluation

• Perform cystoscopy to identify bleeding source, which may include:
  • Residual prostatic tissue with exposed vessels
  • Bladder neck contracture (occurs in 0.35% of cases) 2
  • Bladder mucosal injury site (occurred in 3.9% of cases) 2
  • Urethral stricture (1.9-2.1% incidence) that may cause trauma 2, 3

Rule Out Alternative Diagnoses

• Obtain urine culture to exclude urinary tract infection (3.2% incidence post-HoLEP), which can cause bleeding 2
• Consider bladder pathology unrelated to HoLEP, particularly in this age group where bladder cancer must be excluded
• Assess for trauma from catheterization or instrumentation if patient has had recent urological procedures

Treatment Algorithm

Conservative Management (Mild Bleeding)

• Continuous bladder irrigation with three-way catheter if clots are present
• Hold anticoagulation if medically appropriate until bleeding resolves 1
• Increase oral hydration to maintain dilute urine and prevent clot formation

Interventional Management (Moderate to Severe Bleeding)

• Cystoscopy with fulguration of bleeding vessels is the primary intervention 2
• Clot evacuation under anesthesia if bladder is filled with organized clots 2
• Blood transfusion if hemoglobin drops significantly (mean drop was 1.3 g/dL in large series) 2, 4

Refractory Bleeding

• Repeat HoLEP or conversion to alternative technique may be necessary in rare cases
• Angiography with selective embolization can be considered for persistent arterial bleeding unresponsive to endoscopic management

Critical Pitfalls to Avoid

Common Errors

• Do not assume bleeding is normal at 2 months post-op—while HoLEP has excellent hemostatic properties, bleeding this late suggests a specific complication requiring identification 1
• Do not restart anticoagulation until bleeding source is identified and treated, as this was the precipitating factor in most delayed bleeding cases requiring transfusion 1, 4
• Do not delay cystoscopy in patients with significant hematuria, as early intervention prevents complications like clot retention and bladder distension 2

Anticoagulation-Specific Considerations

• Patients who underwent HoLEP specifically because of anticoagulation (as HoLEP is recommended for high bleeding risk patients) are at highest risk for delayed bleeding when anticoagulation is resumed 1
• LMWH should be held at least 24 hours before any intervention and not restarted until bleeding has "almost completely subsided" per consensus protocols 1
• Bridging protocols may need revision if patient experienced delayed bleeding, as standard resumption timing may be too aggressive for this individual 1

Expected Outcomes

Prognosis

• Most delayed bleeding episodes resolve with conservative or minor interventions based on the low overall transfusion rate (1.4-2.8%) in large HoLEP series 2, 3
• Mortality risk is extremely low with appropriate management, though historical data showed 1.8% sudden cardiac death rate when anticoagulation management was suboptimal 1
• Long-term outcomes remain excellent after bleeding is controlled, with HoLEP maintaining superior functional results regardless of this complication 3, 5