Intractable Haematuria post-PTCA Managed Successfully

A 78-year-old man admitted for coronary artery disease (CAD) with single vessel disease underwent Percutaneous Transluminal Coronary Angioplasty (PTCA) with stenting. He developed frank haematuria the next day. Urgent urology opinion was sought, and ultrasonography of kidneys, ureters and urinary bladder (KUB) was done. It showed a bladder clot (around 60 ml) along with a 62 gm prostate.

Bladder irrigation was started, and the patient was managed conservatively because of ongoing antiplatelet medications and increased risk of bleeding. Even after two days, haematuria continued on continuous bladder irrigation. In patients who have undergone a recent cardiac procedure and are on antiplatelet therapy, it is a challenge if the patient develops hematuria, as any kind of surgery in these patients needs cessation of  anticoagulant therapy and is considered very high-risk. But in view of continued ongoing blood loss, the patient was taken up for Cystopanendoscopy with Bladder Clot Evacuation and Fulguration of bleeding vessels. Intra-operatively, trilobar prostatic enlargement with large median lobe and lateral lobes bulging proximal to the veru was seen, with  increased vascularity and oozing blood, which were cauterised. 

Post-operatively, the patient's haematuria did not improve despite continuous bladder irrigation. After discussing with the cardiologist, anaesthetists and patient's relatives and explaining all the risks involved, a decision was made to go for holmium laser enucleation of the prostate (HoLEP) surgery. 

HoLEP was done using 2 lobe technique, the prostate was enucleated and removed via morcellation. Meticulous haemostasis was performed, and continuous irrigation was started. Haematuria again started on the next day and continued for the next two days. Suprapubic catheter (SPC) was done to maintain continuous bladder drainage, but eventually, it also got blocked because of the bladder clots.

A plan was made for bilateral internal iliac artery embolisation, and the patient was taken up for the same by the cardiology team. Gradually haematuria improved, but ultrasound showed the presence of bladder clots. The patient was again taken up for bladder clot evacuation.

Bladder clots were organised, and they had to be morcellated for evacuation. Post-operatively, haematuria had fully settled, and the patient passed clear urine thereafter. SPC was removed the next day, and Foley's catheter was removed two days later. He was discharged in a stable condition with the resumption of anticoagulants.