Gross hematuria is a common urologic problem which often requires surgical intervention. While generally a safe procedure, clot evacuation can have serious complications. Here we describe the case of an 85-year-old male who developed extensive subcutaneous emphysema following a small extraperitoneal bladder perforation during a clot evacuation. While our patient did well with expectant management, subcutaneous emphysema can lead to serious complications and any endourologic procedure should be stopped once crepitus is noted.