CASE REPORT Angioemboliziation of Internal Pudendal Artery for Treatment of Long Lasting Gross Hematuria After Transurethral Resection of the Prostate Behkam Rezaeimehr1, Mona Modanloo2, Mahdi Davoodi3, Sayed mohammad Sakhaei4, Hossein Farsavian3, Mehdi Younesi Rostami1* Keywords: hematuria; prostatectomy; angio-embolization INTRODUCTION To our knowledge, vascular lesions such as pseu-doaneurysm and arteriovenous fistula in the ar- terial supply of the prostate are very rare. Although, bleeding is a known complication in prostate surgical procedures such as transurethral resections, however, it is manageable at the time of surgery(1). Open surgery is difficult for management of pseudoaneurysm. Whereas 1Department of Urology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. 2Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran. 3Department of Vascular Surgery, Imam Khomeini Hospital, Mazandaran University of Medical Sciences, Sari, Iran. 4Department of Radiology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. *Correspondence: Department of Urology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Tel: +98 9111159120. E-mail: springbah8@gmail.com. Received June 2018 & Accepted September 2018 To present a case of recurrent gross hematuria after transurethral resection of the prostate that was refractory to endoscopic and open hemostatic interventions at the bladder neck and prostatic fossa. After performing angiographic evaluation of the pelvic vessels and finding the pseudoaneurysm, percutaneous embolization of arterial supply of the pseudoaneurysm was done. The location and type of lesion were successfully determined by angiography and controlled by angio-embolization of the internal pudendal artery. It seems that angiography can be helpful in the diagnosis and management of refractory bleeding after prostatectomy. endovascular procedures are the first line of treatment in the management of this complication(2-5). We describe a patient who had recurrent massive hema- turia following transurethral resections of the prostate. The location and type of lesion were determined by an- giography and controlled by angio-embolization. Figure 1. Angiographic evaluation of the pelvic vessels Urology Journal/Vol 16 No. 5/ September-October 2019/ pp. 517-518. [DOI: 10.22037/uj.v0i0.4657] CASE REPORT We present a 73-year-old man who was under treatment of tamsulosin and finasteride for three years because of obstructive urinary symptoms. In spite of medical treat- ment, he experienced multiple episodes of gross hema- turia. After imaging studies and ruling out urinary tract infection, the patient became candidate for cystoscopy. Pre-operative laboratory test results including blood coagulation tests and hemoglobin level were normal. During cystoscopy, we found that the bleeding site orig- inated from the prostatic fossa and observed engorged veins in the bladder neck. Transurethral resection of the prostate was done at the same time and about 55 grams of prostatic tissue was resected and was sent to pathology which revealed benign prostatic hyperplasia. The patient was discharged one day after the surgery. But, 4 days later, patient was readmitted because of clot retention. Cystoscopy was done and after the evacua- tion of clots, there were not any arterial bleeding or any significant active bleeding in the prostatic fossa. However, the hematuria repeated again after 4-5 days and we evacuated old clots but we did not observe any active bleeding during cystoscopy. After 2 other ep- isodes of bleeding and receiving 48 units packed red blood cell and 13 bag of fresh frozen, we decided to do an open exploration but we did not find any active bleeding so we ligated the arterial supply of the prostate at the bladder neck. Unfortunately, after the surgery, he- maturia recurred in a 4-5 days intervals. Finally, angiographic evaluation of the pelvic vessels was performed and a pseudoaneurysm was found in the internal pudendal artery (Figure 1). Hematuria ceased immediately after percutaneous embolization of arterial supply of this pseudoaneurysm. The patient was dis- charged five days after the procedure and now after six months, the patient is asymptomatic. DISCUSSION Internal pudendal artery pseudoaneurysm is a rare con- dition and usually associated with surgical procedures (6,7). In our case, the patient had recurrent gross hema- turia following transurethral resection of the prostate. Eventually, the diagnosis was made using angiography. Concerning the presence of pseudoaneurysm in the internal pudendal artery, angio-embolization was per- formed for this patient and after the procedure, he had no hematuria. To our knowledge, in the literature, there are some reported cases of internal pudendal artery pseudoaneurysm following prostate surgery presenting with late recurrent hematuria. For example, Celtikci et al. reported a 79-year-old patient with massive hema- turia following transurethral resection of the prostate for benign prostatic hyperplasia. Doppler US and angi- ography revealed a pseudoaneurysm and arteriovenous fistula originating from the right internal pudendal ar- tery. It was successfully treated with coil embolization (2). Beckley et al. treated delayed hemorrhage from an accessory internal pudendal artery pseudoaneurysm after robotic radical prostatectomy using microcoils following super selective catheterization(1). In Jeong et al. study, a total of 4 among 563 (0.7%) patients had postoperative bleeding after radical prostatectomy that fit the inclusion criteria. CT angiography revealed ac- tive bleeding in all cases. All patients were successful- ly treated with transarterial embolization without any additional treatment, such as surgical exploration, and there was no treatment-related adverse event(8). In conclusion, results of our study and other studies confirmed that embolization is an efficient method of managing post-operative bleeding due to prostate op- erations. CONFLICT OF INTEREST The authors report no conflict of interest. REFERENCES 1. Beckley I, Patterson B, Hamaday M, Vale J, Hrouda D. 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