Bladder clot and prostate mass morcellation and enucleation

Abstract

Objective: Advanced age, anticoagulation, and frailty are common risk factors for gross hematuria with clot obstruction [1,2]. Conservative management is preferred, however, patients with refractory bleeding frequently require invasive interventions. We present a case of endoscopic clot evacuation assisted by morcellation after failed conservative management. We aim to demonstrate the safety and efficacy of this technique as an alternative to open cystotomy. Patients and surgical procedure: Our patient is a 90-year-old male with a history of atrial fibrillation (on anticoagulation), metastatic prostate cancer on androgen deprivation therapy, recurrent hematuria, and urinary retention managed with suprapubic tube. He presented to the emergency department with gross hematuria and clot retention (Fig. 1) Initial management with cessation of anticoagulation, cystoscopy, and clot evacuation failed due to the size and density of blood products. The patient declined open clot evacuation due to concern about morbidity and opted for repeat endoscopic intervention. We used a 550-micron holmium laser fiber to release the prostate and adherent clot. Next, the clot was morcellated with Wolf® Piranha™ system at 2500 RPM (Fig. 2). Morcellation time was 35 min due to a lack of engagement and suction leading to divots which decreased efficiency. Care must be taken to optimize visualization during clot morcellation as poor visualization is a common cause of bladder injury during morcellation. After evacuation, excellent hemostasis was achieved. Results: Postoperatively, continuous bladder irrigation was weaned on day 1, and catheter was removed on day 2. The patient was discharged without any notable complications. Final pathology of morcellated tissue was 446 mL of poorly differentiated prostatic adenocarcinoma admixed with clot. Conclusion: Large volume clot removal assisted by morcellation represents a safe endoscopic alternative to open clot evacuation when other techniques fail. Care must be taken to ensure good visibility, distended bladder, and anticipation of differing tissue characteristics while morcellating.