Clot retention: evacuation and endoscopic haemostasis

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. The patient before the catheter Clot retention is painful and frightening and can hide a big bleed. Before anything is done to the catheter: pulse, blood pressure, a large-bore line, haemoglobin, clotting, group and save or crossmatch, and the drug chart for the anticoagulant or antiplatelet that is held and, if the bleeding is serious, reversed with the haematologist. The abdomen is examined for the bladder and for peritonism. The history is taken: what was done to the bladder or prostate and when, what has bled before, the tumour, the radiotherapy, the infection.
2. The bedside washout A large catheter, at least 20 French and three-way if one is being changed, and a 50 ml bladder syringe: saline in, drawn back, and the clot comes with it, repeated until the return is clear. The washout is gentle and the bladder is never filled hard; the clot is broken up by the syringe, not forced through. Most clot retention clears this way and continuous irrigation through a three-way catheter keeps it clear. A catheter that blocks again within the hour, a return that stays red, or clot that will not come is the failure that goes to theatre.
   where it bites: a bladder syringe pushed hard into a bladder that cannot drain perforates it; the syringe aspirates, it does not pump.
3. To theatre Consent names cystoscopy, evacuation of clot, diathermy of bleeding points, a possible return to the prostatic bed or a tumour resection, a catheter with irrigation, and the chance of a return to theatre. Blood is available. A general or spinal anaesthetic, lithotomy, the diathermy plate on if monopolar. On the trolley: a 26 French resectoscope sheath with its visual obturator, the widest channel there is for clot; the Ellik evacuator and a Toomey syringe; the loop, for breaking up old clot and for a resection if a tumour is the cause; the button or roller electrode; a 22 French three-way catheter; and the irrigation set for continuous flow.
4. The red field The sheath goes in under vision on the visual obturator; the prostatic bed is passed with care because it is where the bleeding may be. In the bladder the view is red and the field is full of clot, some fresh and jelly-like, some old and rubbery. The irrigation is set to run but not high, and nothing is coagulated yet: diathermy in a red field burns whatever the electrode lands on, which may be the orifice or the wrong wall, and does not find the point that matters.
5. The Ellik The telescope and bridge come out of the sheath and the Ellik evacuator goes onto it, its chamber full of saline and free of air. Squeeze and release: the clot is drawn into the chamber and settles, and the process is repeated until the return is clear. Old clot that will not come through the sheath is broken up with the loop, without current, and drawn out in pieces; a Toomey syringe finishes the last of it. Each squeeze fills the bladder, so it is emptied between cycles and never over-distended.
   where it bites: the Ellik fills the bladder with every squeeze; three days after a resection the wall is thin and a distended bladder splits at the dome.
6. The survey With the telescope back in and the irrigation slowed, the bladder is surveyed first, wall by wall, because the cause may be there: a tumour, a perforation, a radiation-damaged wall, the ulcer of a catheter balloon. Both orifices are found and their jets seen; the trigone is inspected. Only then the neck and the prostatic bed: the cavity is looked at sector by sector with the irrigation slowed until the point that is bleeding declares itself. A bleeding point is watched until it is certain, not guessed.
7. The source An arterial jet spurts across the field in a pulse; it is coagulated at its point with the button electrode on coagulation, a short burst until it whitens, and the bed around it is not painted. The commonest place after a TURP is the bladder neck at five and seven o'clock where the arteries enter, and the coagulation there is done with the orifices in mind. Venous ooze from the bed is dark and welling and is not chased, because coagulating a sinus opens it: the catheter and the irrigation control it. A bleeding tumour is resected down to a clean base and the base coagulated.
   where it bites: the arteries at five and seven o'clock sit close to the orifices; the point is coagulated, never the sector.
8. The check The irrigation is turned off for a moment and the field watched: what fills it now is what the catheter has to control, and a jet that appears when the pressure drops is coagulated. Both orifices are looked at again with their jets, because coagulation at the neck was near them. The bladder is emptied through the sheath and the sheath withdrawn under vision.
9. The catheter and the note A 22 French three-way catheter goes in over the bed with 30 ml in the balloon and continuous irrigation running until the effluent is rosé. For venous ooze the balloon is pulled down onto the bladder neck and the catheter taped to the thigh under traction, which is released within a few hours because a balloon left on the neck erodes it. The note records what was found, the clot burden, what was coagulated and where, the orifices seen with efflux, the catheter and the irrigation plan, and the question still open: why it bled, with the imaging, the cystoscopy or the anticoagulation review that answers it.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance