Acute hemorrhage with huge extraperitoneal hematoma following transrectal prostate biopsy: indication for emergency prostatectomy – a case report

Abstract Prostate biopsy is generally safe, and extraperitoneal hematomas are extremely rare. We report the first known case of ongoing post-biopsy bleeding managed with emergency robot-assisted radical prostatectomy. A 77-year-old man developed acute hemodynamic instability several hours after a transrectal MRI/US-fusion biopsy. Computed tomography revealed a large left-sided extraperitoneal hematoma displacing the bladder without arterial extravasation. Despite resuscitation, hemoglobin continued to decrease, suggesting persistent venous bleeding. Preliminary histology confirmed well-differentiated acinar adenocarcinoma. Given hematoma size, instability, and confirmed malignancy, interdisciplinary consensus favored surgical management. Within 24 h, the patient underwent extraperitoneal bilateral nerve-sparing radical prostatectomy with complete hematoma evacuation. The procedure was uncomplicated, recovery stable, continence satisfactory, and final pathology showed pT2c Gleason 3 + 3 = 6 cancer with negative margins. This case underscores the need for vigilance regarding atypical post-biopsy symptoms and shows that emergency prostatectomy may offer both hemostasis and definitive oncologic treatment.