[55] Persistent haematuria and intra-prostatic haematoma following prostate biopsy: A novel method of management

Objective To report on an unusual case of life-threatening haematuria after transrectal prostate biopsy requiring intervention. After transrectal needle biopsies bleeding in the form of haematuria, haematospermia or haematochezia are common but typically self-limiting. Severe haematuria is uncommon and in large study of 2049 men only 0.05% had haematuria necessitating a blood transfusion. Methods A 66-year-old man was referred with an elevated prostate-specific antigen level of 5.4 ng/mL. Routine evaluation was normal except for mild thrombocytopaenia. The prostate was 68 g with a Prostate Imaging - Reporting and Data System (PI-RADS) 4 lesion. He underwent a systematic 12-core biopsy with a 16-G needle. He was on regular aspirin, which was stopped 5 days prior to the biopsy. He developed severe urethral bleeding and haematuria 2 h after the biopsy. Initially conservative measures in the form of catheterisation and irrigation were initiated. Bleeding persisted and the patient developed tachycardia/hypotension and was stabilised with a blood transfusion. Contrast-enhanced computed tomography showed hyper-densities suggestive of haematomas within the prostate, predominantly on the right side of the gland, and a small 13 × 11 mm right apical extra-prostatic haematoma. In the arterial phase prominent arterial twigs were seen traversing the right part of the gland, and coursing medially towards the prostatic urethra, with a small area of blush observed at the level of the verumontanum posteriorly. Results As he continued to bleed, cystoscopy was performed, which showed spurting bleeding in the prostatic urethra to the right of the verumontanum. Coagulation was done using a resectoscope and the bleeding stopped. Conclusion Severe haematuria and intra-prostatic haematoma after transrectal prostate biopsy requiring intervention is rare and so experience in management is limited. Prostatic artery embolisation has been described in the past for these patients. To the best of our knowledge, this is the first report of successful cystoscopic fulguration in order to control the bleeding.