Endoscopic Control of Bleeding After TURP Procedure

Transurethral Resection of the Prostate (TURP) remains a cornerstone treatment for benign prostatic hyperplasia (BPH), offering significant relief from lower urinary tract symptoms. While generally safe and effective, TURP is associated with potential postoperative complications, bleeding being among the most concerning. Postoperative bleeding can range from minor spotting to substantial hemorrhage requiring intervention. Prompt recognition and management of these bleeding episodes are crucial to prevent morbidity and ensure favorable patient outcomes. This article will delve into the endoscopic methods employed for controlling bleeding following a TURP procedure, focusing on both preventative strategies and active interventions when bleeding occurs, acknowledging that each case demands individualized assessment and treatment approaches.

The incidence of significant postoperative bleeding after TURP varies widely in literature, influenced by factors such as surgical technique, prostate size, patient comorbidities, and the use of adjunctive hemostatic agents. Managing this complication effectively requires a thorough understanding of potential causes – including incomplete cauterization of vessels during resection, delayed bleeding from damaged capillaries, and coagulopathy – as well as access to appropriate endoscopic equipment and expertise. The goal isn’t simply to stop the bleeding but also to minimize further trauma to the urethra and bladder neck while restoring patient stability. A multidisciplinary approach involving urologists, anesthesiologists, and potentially interventional radiologists often provides the best results in complex cases.

Postoperative Bleeding: Prevention Strategies

Preventing postoperative bleeding is arguably more effective than treating it. Several intraoperative techniques aim to minimize blood loss during TURP itself. Meticulous surgical technique, including careful cauterization of bleeding vessels as they are encountered during resection, forms the foundation of preventative care. Electrocautery remains the gold standard for achieving hemostasis during TURP, though newer technologies like bipolar electrocautery offer advantages such as reduced water absorption and decreased risk of urethral injury. Beyond surgical technique, consideration should be given to adjunctive therapies.

• Tranexamic acid (TXA), an antifibrinolytic agent, is frequently used both intraoperatively and postoperatively to reduce bleeding by inhibiting the breakdown of blood clots. Its use has become increasingly common due to its demonstrated efficacy in minimizing postoperative hemorrhage without significantly increasing the risk of thromboembolic events when used appropriately.
• The judicious use of irrigation during TURP is also important. Excessive irrigation can dilute clotting factors, potentially contributing to increased bleeding; conversely, insufficient irrigation hinders visualization and may lead to incomplete cauterization.
• Finally, careful patient selection and pre-operative optimization are vital. Identifying patients with underlying coagulopathies or those on anticoagulant medications requires careful consideration and potential modification of their medication regimen prior to surgery (always in consultation with the prescribing physician).

Postoperative care also plays a significant role. Patients should be closely monitored for signs of bleeding, including hematuria, blood clots in the urine, and decreased urinary flow. Clear instructions regarding activity levels – typically advocating for light activity and avoiding strenuous exertion – are provided to minimize stress on the surgical site. A Foley catheter is usually left in situ for a period ranging from 24-72 hours postoperatively to facilitate drainage and allow clot evacuation.

Endoscopic Management of Early Postoperative Bleeding

Early postoperative bleeding, typically occurring within the first 24 hours after TURP, often arises from incomplete cauterization or capillary bleeding. This type of bleeding is usually less severe than delayed bleeding and can frequently be managed endoscopically in an outpatient setting. The initial step is a thorough assessment to rule out other causes of hematuria, such as urinary tract infection.

1. The patient should be placed in the lithotomy position with adequate anesthesia (local or general depending on severity).
2. A cystoscope is then introduced into the urethra to visualize the surgical site and identify the source of bleeding.
3. Bleeding points can often be controlled directly using electrocautery through the cystoscope. Low-power coagulation is preferred initially to avoid further tissue damage.

If direct cauterization isn’t sufficient, several other endoscopic options are available: – Fibrin sealant application can provide a temporary barrier and promote clot formation. – A balloon catheter can be inflated at the bleeding site to mechanically compress vessels and achieve hemostasis. – Irrigation with cold saline or epinephrine can constrict blood vessels and reduce bleeding. It’s important to avoid excessive irrigation, as mentioned previously, and carefully monitor the patient’s hemodynamic status throughout the procedure.

Delayed Postoperative Bleeding: A More Complex Scenario

Delayed postoperative bleeding, occurring more than 24 hours after TURP, is often more challenging to manage. This type of bleeding frequently originates from deeper vessels or involves larger areas of tissue necrosis. It may present as significant hematuria with clot formation, requiring urgent intervention. Unlike early bleeding which can sometimes be managed in an outpatient setting, delayed bleeding typically necessitates hospital admission and a more aggressive endoscopic approach.

The management of delayed bleeding mirrors the initial steps for early bleeding – cystoscopic evaluation to identify the source. However, the treatment options may need to be escalated. If direct cauterization is ineffective due to extensive bleeding or difficult visualization, techniques such as argon plasma coagulation (APC) can be employed. APC delivers energy through a gas jet, providing more superficial and widespread hemostasis with less risk of tissue penetration compared to traditional electrocautery. Another option involves the use of endoloop ligation – applying small ligatures around bleeding vessels. This technique is particularly useful for larger vessels that are difficult to cauterize effectively.

Addressing Significant Hemorrhage & Alternative Interventions

In cases of significant hemorrhage unresponsive to endoscopic interventions, alternative strategies must be considered. These might include prolonged catheter drainage with continuous irrigation to evacuate clots and monitor bleeding rate. If bleeding persists despite these measures, more invasive procedures may become necessary. Selective arterial embolization – performed by an interventional radiologist – can selectively block blood flow to the prostate, effectively stopping the bleeding. Rarely, open surgical intervention (e.g., suprapubic cystostomy or even a formal open procedure) is required for life-threatening hemorrhage.

It’s crucial to remember that any patient experiencing significant postoperative bleeding should be closely monitored for signs of hypovolemic shock. This includes assessing vital signs, urine output, and hemoglobin levels. Fluid resuscitation and blood transfusions may be necessary in severe cases. The decision regarding the optimal management strategy is highly individualized, taking into account the patient’s overall health status, the severity of bleeding, and the available resources. A prompt and coordinated multidisciplinary approach is paramount to ensuring successful outcomes.