Independent plasma levels of sodium and glycine during transurethral resection of the prostate

Transurethral resection of the prostate syndrome: almost gone but not forgotten

Transurethral resection of the prostate (TURP) syndrome is a rare but potentially fatal syndrome with multifactorial pathophysiology that is now better understood. Unfortunately, despite this improved understanding, it is not yet obsolete and still remains a risk. Many reviews of TURP syndrome have been presented from an anesthetic perspective; this review reflects more the urologic perspective with emphasis on the importance of multidisciplinary management of this complex syndrome. We present a review of TURP syndrome that specifically assesses advances in the understanding of risk factors, pathophysiology, and techniques used to prevent this syndrome. The databases Medline, Embase, Cochrane Controlled Trial Register, and Database of Abstracts of Reviews of Effects were systematically reviewed from inception to April 2009 for the keywords TUR (P), TUR (P) syndrome, and transurethral resection of prostate. There was no language restriction for our search. Randomized controlled trials, review articles and case series were included in our search. Our review showed a declining trend in the incidence of TURP syndrome despite TURP remaining the gold standard for the management of benign prostatic obstruction. Technologic advances using an array of laser techniques, the use of bipolar circuitry, together with advances in training techniques have helped minimize the risk of development of this syndrome. This review demonstrates the complexity of TURP syndrome. Even with a greater understanding of the pathophysiology, it highlights the unpredictability of the syndrome from presenting symptoms, preventative measures, and management. TURP syndrome cannot be protocol driven and the need for vigilance, a high index of suspicion, intensive monitoring, and a multidisciplinary approach is vital.

Changes in amino acids, ammonium, and coagulation factors after transcervical resection of the endometrium with a glycine solution used for uterine irrigation

OBJECTIVE

Transcervical resection of the endometrium with the use of 1.5% glycine for irrigation is associated with postoperative nausea in some patients. This could be because of hyponatremia or toxic effects of glycine and its metabolites. Moreover, 1.5% glycine is hypoosmolar, and hemolysis and fibrinolysis are possible. Changes in plasma factors related to these potential complications of transcervical resection of the endometrium were measured.

STUDY DESIGN

In 101 patients undergoing transcervical resection of the endometrium sodium, ammonium, and coagulation factors were measured preoperatively and postoperatively at intervals. In the initial 30 patients glycine and 28 other amino acids were measured at the same intervals. The results were correlated with the patients' clinical status and operative parameters.

RESULTS

Glycine and nine other amino acids and ammonia showed increased postoperative plasma levels; these changes were correlated with the absorption of the irrigating glycine solution and the development of hyponatremia. Minor activation of fibrinolysis and hemolysis was also seen.

CONCLUSION

Nausea after transcervical resection of the endometrium with 1.5% glycine for irrigation may be partly explained by toxic effects of glycine and its secondary metabolites in addition to the effects of water intoxication and hyponatremia. Minor, clinically insignificant changes in the coagulation system may also occur. Studies on alternatives to glycine for creation of near-isotonic irrigating solutions are encouraged.

[Transient arrhythmia disclosing major glycine poisoning during hysteroscopy]

We report the case of a 41-year-old ASA I patient who experienced during endometrial resection a transient idioventricular cardiac rhythm with hypotension related to a major glycine intoxication. The total volume of absorbed irrigating fluid was over six liters when these clinical signs occurred. The biological data were as following: Na = 89 mmol.L-1, Cl = 60 mmol.L-1 and osmolarity = 215 mOsm.L-1. Simultaneously, the glycine concentration in the plasma was 54.6 mmol.L-1, i.e 160 times higher than the normal value. The clinical course was unremarkable except vomiting. The treatment included only the administration of a diuretic agent, as the correction of the disorder took place spontaneously. The paucity of clinical symptoms when compared to the severity of the biological disorders explain why preventive measures are essential in this type of surgery.

The effect of prostatic capsule perforation on the absorption of irrigating fluid during transurethral resection

Thirty patients undergoing transurethral resection of the prostate using ethanol-tagged irrigating fluid were investigated in order to study the effects of a breach in the prostatic capsule. Measurements were made of end-tidal ethanol (ET-ethanol) in the expired air, serum glycine and sodium, haemoglobin, blood loss and volumetric determination of irrigating fluid absorption. Perforation of the prostatic capsule occurred in 13 patients (Group P), with 17 judged to have no perforation (Group NP). In all Group NP patients the ET-ethanol remained below 0.05/1000, serum sodium decreased by < or = 3 mmol/l and serum glycine remained < 1.5 mmol/l. ET-ethanol was significantly increased in Group P, rising to between 0.1 and 0.45/1000 in 5 patients, 3 of whom showed a reduction in serum sodium > 5 mmol/l. Five patients in Group P demonstrated significantly raised serum glycine concentrations up to 15 mmol/l. These findings suggest that perforation of the prostatic capsule may lead to rapid absorption of irrigating fluid, and that ET-ethanol monitoring is a useful method of detecting this quickly.

[Glycine poisoning after percutaneous kidney surgery]

We describe two cases of altered consciousness associated with nausea and vomiting after renal surgery. These events occurred respectively one and two hours after surgery. They are believed to be caused by the transfer of large amounts of irrigating solution containing glycine 1.5%. The effects of hyponatraemia (132 and 129 mmol.L-1) and glycinaemia (3518 and 8589 mmol.L-1) are discussed. We conclude on the importance of an early clinical diagnosis completed by biological investigation to allow an adequate symptomatic management.

[Biological changes in intra-uterine resections under glycine irrigation]

This study was carried out to assess the relations between plasma glycine concentrations and the biochemical changes occurring during intra-uterine resections (IUR) under glycine irrigation. Sixty patients with benign uterine conditions were included. They were all ranked ASA 1 or 2. The biological parameters were assessed before surgery (T0), at the end of surgery (T1) and 60 min afterwards (T2). They included the blood count and blood concentrations of sodium, potassium, chloride, proteins, bicarbonates, glucose, urea nitrogen, creatinine and glycine. Plasma osmolarity was calculated. The irrigation of the uterine cavity resulted in an increase of glycine concentrations (28% of cases), and a decrease of sodium (22% of cases), proteins and haematocrit (32% of cases). Mean osmolarity remained unchanged. Blood glycine concentrations were directly correlated with the volume of irrigating solution, as well as with the duration of surgery. Protidaemia was inversely related to the blood glycine concentration. Multiparous patients had lower glycine concentrations than nulliparous patients. This was probably due to the uterine cavity being less compliant in the latter. On the other hand, there was no correlation with the uterine pathological condition. In this series, five cases of uterine perforation occurred with very large biological variations, especially a decrease in haematocrit and osmolarity. In these cases a clinical and biological water intoxication syndrome may occur as a result of large volumes of irrigating fluid passing into the peritoneal cavity.

[Prostate transurethral resection syndrome]

The "transurethral resection of prostate" syndrome (TURPS) is the clinical manifestation of the resorption into the patient's body of a large amount of glycocolle-containing irrigating fluid used for this procedure. The full clinical picture, which is seldom seen, consists of dyspnoea, nausea, arterial hypertension, an increased central venous pressure, cerebral oedema, cardiogenic shock and renal failure. Improved surgical techniques, as well as incomplete and atypical forms of the syndrome could explain this low incidence. Absorption into the blood stream may be rapid, by way of the prostatic venous plexi, or slower, from the spaces around the prostate and under the peritoneum. The present-day pathophysiological theory explains this syndrome by an acute hyponatraemia, sometimes dissociated from the hypoosmolality, the toxicity of glycocolle, and the neurological effects of hyperammonemia. Acute hyponatraemia, with blood sodium concentrations below 115 to 120 mmol.l-1, should be considered as potentially serious. The different mechanisms involved may act alone or together, thus explaining that the minor forms of the syndrome mostly consist of a neurological picture. The emergency treatment depends on the natraemia. It includes diuretics and progressive reloading of the patient with sodium in case of severe hyponatraemia with seizures. The best prevention is a correct surgical indication and technique. The resection should not last for more than 90 to 120 min. The major problem remains the early diagnosis of TURPS. Carrying out this surgery under regional anaesthesia is helpful for this purpose, but, in the near future, the best means might be the monitoring of expired ethanol concentrations.

The use of a bladder pressure warning device during transurethral prostatic resection decreases absorption of irrigation fluid

During a period of 4 weeks 102 patients underwent transurethral prostatic resection (TURP). Of these, 50 were randomly allocated to the use of an intravesical pressure device which warned the surgeon at a pressure elevation of 1.5 kPa. Ethanol (1%) was used as a marker in the irrigation fluid (glycine 2.2%), and absorption of ethanol-tagged irrigation fluid was detected by measurements in the expired air. In 28 patients absorption took place (in 8 of the 50 patients equipped with the warning device and in 20 of the 52 without the device). The greatest absorption was seen in the group without the device. No differences were found between the groups with regard to age, resected mass, resection time, resection speed, or haemorrhage. Patients who absorbed irrigation fluid were slightly older and bled more, and the resected mass was larger. The use of a pressure warning device reduces the amount of irrigation fluid absorbed and the number of patients who absorb irrigation fluid, and minimises the risk of the TUR syndrome.

Use of ethanol as marker substance to increase patient safety during transurethral prostatic resection. Screening investigation of irrigating fluid absorption in four hospitals and comparison of experienced and inexperienced urologists

Of 472 patients at four different hospitals electively undergoing transurethral resection of the prostate (TURP), 192 received Sorbitur as an irrigating fluid with 2% ethanol (w/v) as a marker. Using a breath analyzer (Alcol-meter), the amount of ethanol in expired air was measured regularly during the operation to detect the absorption of irrigating fluid. The ethanol concentration in expired air was plotted against time. The time-ethanol concentration product was used as a measurement of absorbed ethanol marked irrigating fluid. A unit of more than 2.5 was considered to be a major absorption with possible clinical significance. This criterion was fulfilled in 24 percent of the patients. Postoperative serum sodium was shown to decrease more in patients with major absorption than in patients with minor absorption in comparison to preoperative values. The weight of resected tissue and the bleeding per resected gram of tissue was higher in the patients with major absorption, but the resected tissue per operating time was the same in both groups. The experienced urologists had as many patients with absorption as did the inexperienced ones. Ethanol-marked irrigating fluid is a simple, safe, noninvasive, rapid, and cheap method of detecting absorption of irrigating fluid thus increasing patient safety during TURP. This method indicates absorption before clinical signs and symptoms of the TUR syndrome occur. It also provides an easy method for estimating the frequency of absorption of irrigating fluid routinely in clinical work.

Absorption of irrigating fluid during transurethral prostatic resection as measured by ethanol, radioisotopes, and regular-interval monitoring

Ethanol monitoring is a novel noninvasive method for immediate detection of absorption of irrigating fluid during transurethral prostatic resection. Its accuracy was evaluated during thirteen resections using 5% mannitol +2% ethanol as the irrigating fluid. The ethanol concentration in the expired breath correlated strongly with the degree of absorption of intravascular irrigating fluid as determined by a radioisotope technique, and fluid volume measurements, and with the changes in the serum sodium concentration. Extravascular absorption of the irrigating fluid resulted in prolonged elevation of the ethanol concentration and gave smaller changes in the serum sodium concentration.

[Coma during transurethral resection of the prostate]

Two cases of coma occurring during transurethral resection of the prostate are reported. The 76 and 85-year-old patients lapsed into coma, ranking 9 and 8 on the Glasgow scale, respectively 90 and 120 min after the start of the resection, without any previous haemodynamic alterations. In one patient, coma occurred when the urethral catheter became blocked with fragments of prostates. In the other, coma was initiated by a rupture of the prostatic capsule, with passage of washing fluid (1.5% glycine solution) into the peritoneal cavity. The role played by acute hyponatraemia (128 and 123 mmol.l-1 respectively) and glycine poisoning (10,188 and 11,840 mmol.l-1 respectively) are discussed. These cases underline the interest of regional anaesthetic techniques, allowing an early diagnosis and a rapid surgical procedure which will avoid a worsening of the condition.

The TURP syndrome

This article discusses the presentation, aetiology, treatment and prevention of central nervous system disturbances after transurethral resection of the prostate. Nausea and vomiting, visual symptoms, and altered states of consciousness have been reported as complications due to intravascular absorption of irrigating fluid. Hypotonicity after absorption of the irrigating fluid causes cerebral oedema. Hyperglycinaemia may cause visual disturbances and hyperammonaemia may cause delayed coma.

Transient postoperative blindness as a possible effect of glycine toxicity

This case report of transient blindness after bilateral knee arthroscopy postulates glycine toxicity as a possible cause of postoperative blindness. The orthopaedic surgeon should be aware of this dose-related effect, and should use glycine irrigant selectively and sparingly for electrosurgical applications.

Consequences of fluid absorption during transurethral resection of the prostate using distilled water or glycine 1.5 per cent

This prospective and randomized study compared the consequences of two irrigating fluids, distilled water and glycine for transurethral prostatectomy. Forty-nine consecutive unselected patients undergoing transurethral resection of the prostate with spinal anaesthesia were investigated. The irrigating fluid was either distilled water (group A, 24 patients) or glycine 1.5 per cent (group B, 25 patients). The absorption of irrigating fluid was measured, all surgical events and any clinical signs of TURP syndrome during and after surgery were recorded. Early signs of TURP syndrome were observed in one patient in group A and in four in group B without further consequence. From all the biological variables, only plasma protein concentration, haematocrit, free plasma haemoglobin and free bilirubin concentrations were found to have changed. Plasma protein concentration and haematocrit decreased significantly during and after surgery in the two groups. Free plasma haemoglobin increased significantly with time: a significantly higher concentration was observed in group A than group B. Free bilirubin concentration increased with time in the two groups and was statistically greater in group A. With the two irrigating fluids, we observed a significant amount of haemolysis and haemodilution without clinical consequences. A low irrigating fluid pressure, a short resection time, and the use of spinal anaesthesia seems to us to be essential. Close observation of patients following transurethral prostatectomy is needed but the choice of the irrigating fluid does not seem to be important.

Glycine and transurethral resection

Fifty patients undergoing transurethral resection of the prostate were studied for evidence of glycine absorption and haemodilution. Plasma glycine levels increased substantially in nine patients and, in five, calculated irrigant fluid absorption ranged from 619-1582 ml; another patient had absorbed 1360 ml fluid with only a small rise in plasma glycine. Two illustrative case histories are presented. The role of glycine as an inhibitory neurotransmitter is discussed and the possibility of toxic mechanisms other than dilutional hyponatraemia is mentioned. Intravenous diuretics, hypertonic saline, and perhaps calcium salts, are recommended for the overt transurethral resection syndrome.