Case report: Can fibrinolytics effectively manage gross hematuria and clot retention in an elderly patients, leading to the diagnosis of lymphoma?

Background: The prostatic urethral lift (PUL) procedure is a novel therapeutic method to treat lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). Gross hematuria after this procedure has been reported to be mild and transient. This report highlights a case of refractory transfusion-dependent hematuria after the PUL procedure in addition to its management with selective prostatic arterial embolization (PAE). Case Presentation: A 78-year-old Caucasian man with a history of myelodysplastic syndrome, thrombocytopenia, and intermittent urinary retention secondary to BPH underwent a PUL procedure. Before the procedure he received a platelet transfusion making his platelet count 58,000/μL. The day after the procedure he was admitted to a hospital for gross hematuria with clot retention. He was started on continuous bladder irrigation and taken to the operating room for clot evacuation and fulguration of prostate. His thrombocytopenia and anemia were managed with transfusions. He was treated with desmopressin, aminocaproic acid, and intravesical 1% alum without improvement. He returned to the operating room for clot evacuation in addition to photoselective vaporization of the prostate laser ablation of the prostatic fossa. He eventually required a total of four transurethral fulgurations without improvement in transfusion-dependent hematuria. Ultimately, resolution of the hematuria was achieved through bilateral PAE with Embosphere® Microspheres performed by interventional radiology. He was discharged home 2 days after the embolization procedure without recurrence of hematuria or urinary retention at a 6-month follow-up visit. Conclusion: The PUL procedure has been shown to be an effective alternative to more invasive surgical options for LUTS caused by BPH. Despite careful consideration in an attempt to alleviate urinary retention, PUL still resulted in significant bleeding in this patient with thrombocytopenia. This is the first report to highlight the use of bilateral PAE as a method for achieving control of severe refractory hematuria after PUL.

BackgroundLaser lithotripsy of vesical calculi in tetraplegic subjects with long-term urinary catheters is fraught with complications because of bladder wall oedema, infection, fragile urothelium, bladder spasms, and autonomic dysreflexia. Severe haematuria should be anticipated; failure to institute measures to minimise bleeding and prevent clot retention can be catastrophic. We present an illustrative case.Case presentationA tetraplegic patient underwent laser lithotripsy of vesical stone under general anaesthesia. During lithotripsy, severe bladder spasms and consequent rise in blood pressure occurred. Bleeding continued post-operatively resulting in clot retention. CT revealed clots within distended but intact bladder. Clots were sucked out and continuous bladder irrigation was commenced. Bleeding persisted; patient developed repeated clot retention. Cystoscopy was performed to remove clots. Patient developed abdominal distension. Bladder rupture was suspected; bed-side ultrasound scan revealed diffuse small bowel dilatation with mild peritoneal effusion; under-filled bladder containing small clot. Patient developed massive abdominal distension and ileus. Two days later, CT with oral positive contrast revealed intra-peritoneal haematoma at the dome of bladder with perforation at the site of haematoma. Free fluid was noted within the peritoneal cavity. This patient was managed by gastric drainage and intravenous fluids. Patient's condition improved gradually with urethral catheter drainage. Follow-up CT revealed resolution of bladder rupture, perivesical haematoma, and intra-peritoneal free fluid.ConclusionIf bleeding occurs, bladder irrigation should be commenced immediately after surgery to prevent clot retention. When bladder rupture is suspected, CT of abdomen should be done instead of ultrasound scan, which may not reveal bladder perforation. It is debatable whether laparotomy and repair of bladder rupture is preferable to nonoperative management in tetraplegics. Anti-muscarinic drugs should be prescribed prior to lithotripsy to control bladder spasms; aspirin and ibuprofen should be omitted. If significant bleeding occurs during lithotripsy, procedure should be stopped and rescheduled. Percutaneous cystolithotripsy using a wide channel could be quicker to clear stones, as larger fragments could be retrieved; lesser stimulant for triggering autonomic dysreflexia, as it avoids urethral manipulation. But in patients with small, contracted bladder, and protuberant abdomen, percutaneous access to urinary bladder may be difficult and can result in injury to bowels.

Hematuria and clot retention after transvaginal oocyte aspiration: a case report

The large bladder diverticulum in children

To evaluate the efficacy and safety of plasmakinetic resection of the prostate (PKRP) versus transurethral resection of the prostate (TURP) for the treatment of patients with benign prostate hyperplasia (BPH), a meta-analysis of randomized controlled trials was carried out. We searched PubMed, Embase, Web of Science and the Cochrane Library. The pooled estimates of maximum flow rate, International Prostate Symptom Score, operation time, catheterization time, irrigated volume, hospital stay, transurethral resection syndrome, transfusion, clot retention, urinary retention and urinary stricture were assessed. There was no notable difference in International Prostate Symptom Score between TURP and PKRP groups during the 1-month, 3 months, 6 months and 12 months follow-up period, while the pooled Qmax at 1-month favored PKRP group. PKRP group was related to a lower risk rate of transurethral resection syndrome, transfusion and clot retention, and the catheterization time and operation time were also shorter than that of TURP. The irrigated volume, length of hospital stay, urinary retention and urinary stricture rate were similar between groups. In conclusion, our study suggests that the PKRP is a reliable minimal invasive technique and may anticipatorily prove to be an alternative electrosurgical procedure for the treatment of BPH.

Treatment patterns and outcomes in elderly patients with multiple myeloma

MP40-09 MOVING TOWARDS ZERO SEPSIS; OUR REGISTRARS CAN DO IT! AN ANALYSIS OF 214 CASES OF TRANSPERINEAL PROSTATE BIOPSY OVER THREE YEARS

PD45-02 UROLIFT VERSUS REZUM FOR BENIGN PROSTATIC HYPERPLASIA: A REAL-WORLD SINGLE-INSTITUTION ANALYSIS

Very-late-onset multiple sclerosis (VLOMS), defined as disease onset after the age of 60, is a rare and often diagnostically challenging entity that may present with atypical features. We describe the case of a 67-year-old man who presented with progressive urinary symptoms culminating in obstructive uropathy and acute kidney injury (AKI), ultimately diagnosed as progressive multiple sclerosis (MS). The patient had a three-year history of left upper limb weakness and gait difficulty, which had been previously unexplored. He presented acutely following a fall, with new-onset left-sided facial droop and worsening lower limb weakness. Laboratory investigations revealed severe hyperkalemia (serum potassium: 9.8 mmol/L), uremia, and elevated creatinine (731 µmol/L), indicating significant renal impairment (estimated glomerular filtration rate (eGFR): 7 mL/min/1.73 m²). Urinary tract imaging revealed bilateral hydronephrosis and a trabeculated bladder, suggestive of chronic urinary retention; the prostate was enlarged but without significant prostate-specific antigen (PSA) elevation. Catheterization led to immediate bladder decompression, and the patient received medical treatment for hyperkalemia. Neuroimaging (MRI brain and spine) revealed multifocal demyelinating lesions involving periventricular, temporal, pontine, and cervical cord regions, while a lumbar puncture confirmed the presence of oligoclonal bands in both CSF and serum. Neurological examination demonstrated upper motor neuron signs, including facial asymmetry, limb spasticity, and pyramidal weakness, further supporting a central nervous system etiology. Despite the presence of benign prostatic hyperplasia (BPH) and cervical spondylosis, the degree of neurological impairment, distribution of MRI lesions, and cerebrospinal fluid analysis collectively pointed to a diagnosis of progressive MS with neurogenic bladder dysfunction. This led to urinary retention, obstructive uropathy, and subsequent AKI. While lower urinary tract dysfunction is a common complication of MS, its initial manifestation as acute renal failure is rare, especially in patients without a prior diagnosis. This case highlights the diagnostic complexity in elderly patients where structural (BPH, spinal stenosis) and neurological causes may overlap. It also underscores the importance of a high index of suspicion for demyelinating disease in patients with unexplained bladder dysfunction, progressive motor deficits, and renal impairment. Early multidisciplinary involvement, including neurology, urology, nephrology, and rehabilitation, is essential for prompt diagnosis, bladder decompression, and prevention of irreversible renal damage. Long-term catheterization was instituted, with outpatient follow-up arranged to assess suitability for clean intermittent self-catheterization and continued neurological monitoring. This case illustrates that in older adults, especially men, attributing urinary symptoms solely to common urological conditions may overlook more insidious neurologic diseases such as MS. Timely recognition and appropriate intervention can significantly alter prognosis by preserving renal function and optimizing functional outcomes.

Diagnosis and Treatment of Glomerular Diseases in Elderly Patients

PurposeTransurethral procedures, including transurethral resection of the prostate (TURP) and laser prostatectomy, are often linked to emergency room (ER) visits for postoperative bleeding. Although some studies have been conducted, the risk factors associated with these ER visits are not completely understood. This retrospective cohort study identified potential risk factors associated with ER visits for postoperative bleeding.Patients and MethodsPreoperative assessment data and operational and postoperational parameters recorded at Chang Gung Memorial Hospital, Taiwan between December 2015 and January 2017 for patients who underwent elective transurethral procedures were analyzed to identify potential risk factors. The primary endpoint was ER visits for gross hematuria within three months following operation, and the secondary endpoint was ER visits for blood clot-induced urinary retention (clot retention) within three months following operation.ResultsA total of 665 patients who underwent elective transurethral procedures were enrolled. The transurethral procedures included monopolar transurethral resection of the prostate (M-TURP), bipolar TURP (B-TURP), greenlight photoselective vaporization of the prostate (PVP), thulium laser enucleation of the prostate (ThuLEP) and thulium laser transurethral vaporesection of the prostate (ThuVARP). Regarding ER visits for clot retention within three months, multivariable logistic regression revealed significantly lower rates of clot retention in patients who received B-TURP than in those who underwent ThuVARP (AOR, 0.18; 95% confidence interval [CI], 0.04–0.82, p = 0.027). Moreover, significantly higher clot retention was observed in patients who underwent two or more rounds of manual irrigation (AOR, 9.51; 95% CI, 1.66–54.43, p = 0.011).ConclusionMultiple manual irrigations shortly after operation can be considered a novel predictor of postoperative clot retention-related ER visits. Among the transurethral procedures, ThuVARP was associated with a higher risk of clot retention-related ER visits than was B-TURP.

Simple, Safe, and Successful Evacuation of Severe Organized Clot Retention Using a Catheter Connected With Wall Suction: Suction and Fishing Method

Editorial II: Time to light the grey touchpaper! The challenge of anaesthesia in the elderly

Background Immunoglobulin A nephropathy (IgAN) has been well studied among young people, but few data on clinicopathological characteristics, treatment response and outcomes for elderly IgAN patients are available. Methods A cohort study of elderly IgAN patients was performed. The combined endpoints of renal outcome were a 50% decline in eGFR compared with the time of renal biopsy, end-stage kidney disease and/or death. Risk factors associated with poor renal outcomes were then determined. The benefits of immunosuppressant therapies were also evaluated by Kaplan-Meier survival curve analysis. Results This study ultimately included 126 elderly patients with IgAN. Comparison between the endpoint and non-endpoint groups indicated that patients with poor outcomes had more severe clinical features, such as worse kidney function, severe hematuria and lower albumin levels. Cox regression analysis indicated that age (HR 1.15, 95% CI 1.02–1.29, p = 0.021), male gender (HR 9.71, 95% CI 1.00–97.56, p = 0.050), and urine red blood cells (HR 1.003, 95% CI 1.000–1.006, p = 0.029) were independent risk factors for poor renal outcome in elderly IgAN patients. To explore possible reasons accounting for the predictive value of age and sex, patients were divided into two groups based on these two variables. Patients in the geriatric group had lower serum albumin, estimated glomerular filtration rate, hemoglobin and aspartate aminotransferase levels than those in the quinquagenarian group. Male patients tended to have higher hemoglobin, higher alanine aminotransferase, and lower triglycerides and cholesterol levels than female patients. To investigate different treatment responses, patients were classified into two groups depending on treatment strategies (renin-angiotensin system inhibitors and immunosuppressive therapy), and the survival analysis indicated no significant difference in kidney outcome between the two groups (p > 0.05). This result still holds after adjusting for age, sex, eGFR, hematuria, and proteinuria. Conclusion Advanced age, male, and hematuria might be independently associated with poor kidney outcomes in elderly patients with IgAN. Immunosuppressive therapy might confer no overall benefit to older IgAN patients.

Aggressive angiomyxoma is a rare locally invasive mesenchymal neoplasm of unknown pathogenesis arising predominantly in pelvic and perineal tissues of adult women. Surgical excision is the classical management but is associated with the risk of recurrence, especially with incomplete excision. There is a proposed role for adjuvant hormonal therapy. We report a very rare case of urethral aggressive angiomyxoma, managed by surgical excision, in a 40-year-old woman who presented with severe hematuria with clot retention.