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Investig Clin Urol
Investig Clin Urol
ICU
Investigative and Clinical Urology
2466-0493
2466-054X
The Korean Urological Association

39249926
10.4111/icu.20240228
Letter
Pelvic hematoma post prostatic urethral lift: A need to be vigilant in high-risk patients
https://orcid.org/0000-0003-2397-1160
Shubhankar Gautam
https://orcid.org/0000-0001-6441-6775
Panwar Vikas Kumar
https://orcid.org/0000-0002-5773-1029
Singhal Avin
Mittal Ankur
Department of Urology, All India Institute of Medical Science (AIIMS), Rishikesh, India.
Corresponding Author: Vikas Kumar Panwar. Department of Urology, All India Institute of Medical Science (AIIMS), Virbhadra Road, Rishikesh 249 203, India. TEL: +91-8427040755, FAX: +91-8427040755, vikaspanwar446@gmail.com
9 2024
29 8 2024
65 5 518521
02 7 2024
16 7 2024
19 8 2024
© The Korean Urological Association
2024
The Korean Urological Association
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Graphical Abstract
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pmcINTRODUCTION

Prostatic urethral lift (PUL) is an emerging daycare procedure for patients with benign enlargement of the prostate. It is usually done in patients with multiple comorbidities who can’t tolerate regional or general anaesthesia as the procedure can be done in local anaesthesia. However, this doesn’t make PUL immune to complications. One of the rare complications is a post-procedure pelvic hematoma, having an incidence of 0.0135% amongst over 200,000 patients treated with PUL. According to the U.S. Food and Drug Administration (FDA), there have been 27 reports of pelvic hematoma after PUL [1]. We, hereby report, another case of pelvic hematoma post-PUL in a male in his late 70s on dual antiplatelet medications for recent percutaneous coronary angiography (PTCA) with stenting.

Informed and written consent had been taken from all the patients before the study. The manuscript has been prepared with strict observation of the research and publication ethics guidelines. All studies including human subjects or human data have been reviewed and approved. Principles embodied in the Declaration of Helsinki (2013) for all investigations involving human materials have been followed.

CASE HISTORY

A male in his late 70s was diagnosed with benign prostatic enlargement (BPE) with lower urinary tract symptoms (LUTS) with failure of medical therapy. Additionally, the patient had undergone PTCA with stenting a year prior and was on dual antiplatelet therapy (low dose aspirin 75 mg and clopidogrel 75 mg) for coronary artery disease. Considering his interest in minimally invasive procedures and on account of his being unfit for elective procedures like transurethral resection of the prostate or laser therapies, the PUL was discussed as an option as it could be done in local anaesthesia.

The patient was on indwelling per urethral catheter (PUC) for the last 3 months in view of his bothersome LUTS. The preoperative assessment revealed a prostate size of 27 cc with normal kidney function tests and a sterile urine culture. As advised by the cardiology department, aspirin was continued while clopidogrel was stopped two days prior. Intraoperatively, the patient was found to have a high bladder neck. The patient underwent the PUL procedure under mild sedation, during which three implants were placed—two on the right and one on the left—in the anterolateral position. Post-procedure cystoscopy confirmed a patent anterior urethral channel without significant bleeding at the implant sites. The perurethral catheter was retained postoperatively.

The first two postoperative days were uneventful. On postoperative day (POD) 3, the PUC was removed, clopidogrel was resumed, and a voiding trial was conducted. However, the patient experienced increased urinary frequency and urgency, with a functional bladder capacity of 80 mL. By evening, he began complaining of severe suprapubic pain, and bladder spasms and had one episode of vomiting.

Laboratory results showed a significant rise in leukocytes from 5,400 to 13,500, serum creatinine from 0.90 to 1.60 mg/dL, and a drop in haemoglobin from 13 to 11 g/dL. An ultrasound revealed a prevesical space collection measuring 6 cm×7 cm with internal septations. A non-contrast computed tomography of the kidneys, ureters, and bladder indicated a hematoma of size 3.4 cm×7.7 cm×6.3 cm in the prevesical and left paravesical spaces, extending into the bladder dome and bilateral spermatic cords (Figs. 1, 2).

A PUC was reinserted, and the patient was managed conservatively. Antibiotics were intensified, leading to the normalization of white blood cell count and serum creatinine levels. Repeat ultrasound showed no increase in hematoma size and stable haemoglobin levels.

DISCUSSION

Pelvic hematoma following a PUL is a rare but significant complication that warrants a nuanced understanding of its etiologies and clinical implications. Eighteen such case reports have been published in the literature till now. However, data from the FDA have documented a total of 27 cases of post-PUL pelvic hematoma worldwide till now. Predisposing factors of pelvic hematoma post-PUL in those cases were multiple. According to a study by Roehrborn et al. [2], small arterial or venous tears can lead to significant bleeding, resulting in the formation of a hematoma. The PUL procedure involves the placement of implants that compress the lateral lobes of the prostate, thereby enlarging the urethral lumen. This manipulation can inadvertently cause vascular injury, particularly in patients with friable or altered vascular anatomy due to prior surgeries or comorbid conditions. Patients on anticoagulants or antiplatelet agents are at increased risk of bleeding complications. Even with the temporary cessation of clopidogrel, the continued use of aspirin can impair platelet function and delay clot formation, exacerbating bleeding risks. A study by Ong et al. [3] highlights the management challenges of these medications in the context of recent coronary interventions, where stopping them can increase the risk of thrombotic events while continuing them raises the risk of bleeding. Anatomical variations in the bladder and prostate can also contribute to the risk of hematoma formation. Singh and Bolla [4] noted that a high bladder neck or significant prostate enlargement can alter normal anatomical relationships, making surgical manipulation more challenging and increasing the risk of injury to adjacent structures. The artery of the Flock branches off the prostatic arteries, typically situated at the 10 and 2 o’clock positions relative to the urethra. This anatomical position makes them vulnerable to injury during the PUL procedure, which involves the insertion of implants into the lateral lobes of the prostate [12345].

Early diagnosis is crucial and can be facilitated by imaging studies such as ultrasound and computed tomography (CT) scans. Yoon et al. [6] found that ultrasound is particularly useful for initial assessment and follow-up, providing detailed information on the size, location, and characteristics of the hematoma. Non-contrast CT is valuable for delineating the extent of the hematoma and its relationship with surrounding structures. Conservative management is often the first line of treatment, especially in hemodynamically stable patients. This includes the reinsertion of a urinary catheter, administration of antibiotics to prevent or treat infection and close monitoring of hematologic parameters [6]. According to Glick et al. [7], adjusting or temporarily halting anticoagulant or antiplatelet therapy is also a key aspect of management, balanced against the risk of thrombotic complications. In cases where the hematoma does not resolve or increases in size, interventional radiology or surgical intervention may be necessary to control the bleeding and evacuate the hematoma [7].

So, the factors associated with the increased risk of pelvic hematoma post-PUL can be divided into:

Patient-related: anatomical abnormalities like short prostatic urethra and small prostatic fossa and arterial aberrations near the bladder neck. Furthermore, a large size prostate would need more implants to create adequate channel and therefore more tissue injury increasing the risk of hematoma especially in patients on dual antiplatelet medications.

Disease related: patients on antiplatelets/anticoagulant or any bleeding diathesis disorder

Surgery related: deploying of implants very close to the bladder neck and inappropriate compression of the instrument over the prostate during firing. Also, the higher the number of implants fired especially in patients on dual antiplatelet medications, the more would be tissue trauma predisposing the patient to develop a pelvic hematoma.

In patients harbouring any of the risk factors, getting an ultrasound pelvis to look for any collection as a routine at the earliest (e.g., POD 1) would help in diagnosing pelvic hematoma early before the onset of symptoms and treatment can be directed to prevent further expansion of such hematoma. This would include modifying or stopping the antiplatelet medications after cardiac consultation, delaying voiding trials and continuing broad-spectrum antibiotics with strict vitals and serial haemoglobin/haematocrit level monitoring. In the majority of cases, conservative management usually resolves the hematoma within weeks to months but in a few situations’ hemodynamic instability or a significant persistent drop in haemoglobin levels, an exploratory laparotomy to drain the pelvic hematoma and ensure haemostasis may be needed.

In our case, given the patient's cardiac status, the continuation of aspirin 75 mg till the day of surgery and intraoperative high bladder neck were the two high-risk factors that might have led to the above scenario. The patient improved on conservative management and was discharged under stable conditions. Also, managing BPE via surgery is an elective procedure. So, for patients on dual antiplatelet medications, if they can tolerate a long-term catheter till their cardiac condition is better and they can be allowed to stop the antiplatelet medications before surgery by the cardiology team, it’s worth waiting. On the other hand, for patients having a poor quality of life on PUC with recurrent urinary tract infections, it is better to go ahead with PUL to free them from the catheter. So, a clinician should always weigh the risk-benefit ratio before planning such patients for PUL.

CONCLUSIONS

Pelvic hematoma, though rare, is a potentially life-threatening complication following a PUL. High vigilance is essential, particularly in patients on antiplatelet medications, especially when these medications have not been stopped preoperatively due to recent coronary interventions. A routine pelvic ultrasound at the earliest (e.g., POD 1) for patients harbouring any of the risk factors associated with increased risk of developing hematoma post-PUL can help diagnose hematomas before the onset of symptoms, allowing for proactive management. Delaying the usual voiding trial and implementing early treatment strategies like modifying or stopping the antiplatelet medications after cardiac consultation, delaying voiding trials and continuing broad-spectrum antibiotics with strict vitals and serial haemoglobin/haematocrit level monitoring can prevent complications and improve patient outcomes. This proactive strategy not only ensures patient safety but also enhances the overall success and efficacy of the PUL procedure, emphasising the need for diligent postoperative monitoring and individualised patient care.

Fig. 1 Coronal section non-contrast computed tomography of the kidneys, ureters, and bladder showing a hyperdense pelvic collection (red arrow).

Fig. 2 Sagittal section non-contrast computed tomography of the kidneys, ureters, and bladder showing a hyperdense pelvic collection (red arrow).

CONFLICTS OF INTEREST: The authors have nothing to disclose.

FUNDING: None.

AUTHORS’ CONTRIBUTIONS: Research conception and design: all authors.

Data acquisition: all authors.

Statistical analysis: all authors.

Data analysis and interpretation: all authors.

Drafting of the manuscript: all authors.

Critical revision of the manuscript: all authors.

Administrative, technical, or material support: all authors.

Supervision: all authors.

Approval of the final manuscript: all authors.
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