Practical management of hematuria after endoscopic surgery for benign prostatic obstruction

Postoperative hematuria following transurethral prostate procedures ranges from self-limited bleeding to life-threatening hemorrhage. Clinically significant hematuria occurs in approximately 13-22% of patients after transurethral resection of the prostate (TURP), with clot retention in 1-5%. Bleeding risk increases with prostate size, and transfusion rates approach 9% for glands exceeding 60 g. This perspective synthesizes current evidence on the prevention and management of postoperative hematuria across transurethral prostate procedures, including standard TURP, laser techniques, and office-based minimally invasive surgical treatments (MISTs). Prevention begins preoperatively with risk stratification, anticoagulation management, and consideration of 5α-reductase inhibitors to reduce prostatic vascularity. Intraoperatively, bipolar energy and laser vaporization provide improved hemostasis compared with monopolar resection, while MISTs such as UroLift and Rezūm carry distinct bleeding profiles that warrant tailored postoperative management. Postoperative management follows a stepwise approach: large-lumen catheterization with continuous bladder irrigation, balloon traction for tamponade, antispasmodics for bladder spasm control, and tranexamic acid for pharmacologic hemostasis. Surgical escalation with cystoscopic clot evacuation, fulguration, or prostatic artery embolization is reserved for refractory cases. We present a device-agnostic outpatient workflow (Figure 1) applicable to ambulatory and office-based procedures. Most patients recover with conservative measures, and protocolized care improves safety and outcomes. Future research should focus on standardizing management pathways, identifying predictors of clinically significant bleeding, and exploring the role of AI-based risk stratification and novel hemostatic agents.