Transurethral vaporisation of the prostate and irrigating fluid absorption

Irrigation fluid absorption during transurethral bipolar and laser prostate surgery: a systematic review

PURPOSE

Transurethral endoscopic procedures using bipolar current, or laser energy are nowadays widely accepted and have replaced the traditional monopolar resection. A major advantage of these techniques is the utilization of isotonic saline as irrigation solution, which minimizes side effects such as symptoms associated to classical transurethral resection syndrome (TUR-syndrome). Nonetheless, clinically significant IFA also occurs with saline and is determined by pressure gradients, systemic resistance and by the amount of irrigation fluid. We aimed to investigate the extend of IFA and symptoms due to volume overload during bipolar transurethral resection (bTUR) and laser procedures of the prostate.

METHODS

We performed a systematic literature search using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Search terms were TUR, transurethral, laser, HoLEP, ThuLEP, greenlight, enucleation, fluid absorption, fluid uptake, and TUR-syndrome.

RESULTS

Mean and maximum IFA during bTURP ranges between 133 and 915 ml and 1019 ml and 2166 ml, respectively. Absorption during laser procedures can be significant with maximum values up to 4579 ml and mainly occurs during prostate vaporization techniques. Incidence of moderate to severe symptoms from iso-osmolar volume overload reaches 9%.

CONCLUSIONS

Irrigation fluid absorption during bTUR and laser surgery of the prostate is not negligible. Iso-osmolar overhydration with development of non-classical TUR-syndrome should be identified peri- and postoperatively and surgical teams should be aware of complications. Breath ethanol, venous pH, serum chloride, and bicarbonate could be markers for detecting dangerous events of IFA with saline.

Case Report: Diabetic urinary auto-brewery and review of literature

Background: Although candiduria is an expected encounter and should not be surprising in uncontrolled diabetes with glucose-enriched urine, urinary auto-brewery is rarely thought of by diabetologists. Moreover, endogenous ethanol production in humans from gut microbiome, urinary tract fungi and bacteria, and intermediary metabolism, has been reported for a long time, particularly in diabetics. 

Case description: To alert physicians to the overlooked implication of endogenously produced ethanol both as a biomarker for poor control of diabetes and as a complicating factor, we report this case of an elderly male smoker alcohol-abstinent insulin-dependent Type 2 diabetic patient. Because of circumstantial treatment and incompliance for one week, he developed endogenously produced alcohol intoxication. We proposed candidal urinary auto-brewery evidence sourced from the case history, urinalysis, and culture/identification tests - without excluding other sources. Fortunately, his diet and glycemic control were fairly controlled and, liver and kidney functions were almost normal. Amphotericin B I/V for five days, insulin, and a fluid therapy regimen greatly improved the case and cleared both the candiduria and ethanol from the urine and blood and the patient regained his base-line normal life.  

Conclusion: Symptoms of alcohol intoxication should be expected in patients with uncontrolled diabetes that most often correlates with candiduria and/or constipation. These symptoms can be exaggerated in those already suffering a degree of dementia and/or comorbid psychiatric/neurologic affections. Direct wet mount examination of urine under phase contrast microscopy would show the budding yeast cells.  Appropriate antifungal, insulin and fluid therapies regained the base-line norms.

Relevance of intravesical pressures during transurethral procedures

PURPOSE

Endourology has undergone fundamental changes over the last 2 decades. Maintaining low intrarenal pressure (IRP) during upper urinary tract procedures is an established concept. However, researchers have not yet studied the concept of reduced intravesical pressures (IVPs) during transurethral (TUR) surgery as thoroughly. Low IVP is supposed to decrease complications as fluid retention, TUR syndrome, and incidence of fever. The study aims to give an overview of the contemporarily existing concepts and specify the term of low IVP to avoid TUR-related complications and optimize TUR-related results.

METHODS

A literature search was performed using PubMed, restricted to original English-written articles, including animal, artificial model, and human studies. Different keywords were transurethral resection, transurethral enucleation, transurethral vaporization, pressure, fluid absorption, and TUR syndrome.

RESULTS

Analyzed mean IVPs during TUR vary between 11 and 35 cmH₂O but are mostly kept below 30 cmH₂O. Mean maximum IVPs during TUR range from 20 to 55 cmH₂O. Maximum IVPs seem to be lower when surgeons utilize continuous flow resection, and irrigation pressures are kept low. The results demonstrate a strong correlation between IVP levels and fluid absorption.

CONCLUSIONS

IVP increase remains a neglected predictor of transurethral procedure complications, and endourologists should consider its intraoperative monitoring. Further research is necessary to quantify generated pressures and introduce means of controlling them.

Acute renal failure after continuous flow irrigation in patients treated with potassium-titanyl-phosphate laser vaporization of prostate

Cases of acute renal failure after transurethral resection of the prostate have been reported since the late 1940s. The pathogenic mechanisms postulated were acute hemolysis, renal interstitial edema, ischemic tubular injury, and rhabdomyolysis, resulting from the absorption of irrigating fluid. Because of the excellent hemostasis of the new laser techniques, absorption of irrigation fluid is supposed to be minimal. Potassium-titanyl-phosphate laser vaporization is regarded as the most recent advance in the treatment of patients with benign prostate hyperplasia, with excellent hemostatic properties. We report 3 cases of acute renal failure after continuous flow irrigation in patients treated with potassium-titanyl-phosphate laser vaporization. Renal failure occurred on postoperative day 1, all patients became oligoanuric, 2 patients required hemodialysis therapy, and incomplete recovery of renal function was seen within 1 month. Biopsy findings were similar in all patients, consisting of widening of tubular lumens; partly containing Tamm-Horsfall protein casts, but neither hemoglobin nor myoglobin casts; flattened tubular epithelial cells with loss of brush borders; and variably edematous interstitium. During laser vaporization, irrigation pressure usually is higher than the physiological intravesical pressure and ranges from 60 to 100 mm Hg. High intravesical pressure may facilitate not only irrigating fluid absorption, but also transient urinary stasis or even vesicoureteral reflux. The latter may directly damage tubular epithelial cells and cause acute renal failure. Thus, intravesical pressure should be kept as low as possible, even during laser prostatectomy.

Comparison of hemodynamic profiles in transurethral resection of prostate vs transurethral resection of urinary bladder tumors during spinal anesthesia: a bioimpedance study

STUDY OBJECTIVE

Transurethral resection of prostate (TURP) is more frequently associated with perioperative fluid and electrolyte disturbances than transurethral resection of bladder tumors (TURT) because of irrigating fluid absorption. Because fluid overload may cause hypertension, we compared the patients' intraoperative hemodynamic profiles (including the incidence of hypertension) during TURP vs TURT, both performed during spinal anesthesia, by using the bioimpedance method.

DESIGN

Prospective single-blind study.

SETTING

University hospital.

PATIENTS

80 (40 in each group) men, ASA physical status I and II.

INTERVENTIONS

Patients underwent TURP or TURT surgery with spinal anesthesia.

MEASUREMENTS

Mean arterial pressure, heart rate, cardiac index, and systemic vascular resistance were compared between the 2 groups. A mean arterial pressure greater than 30% from the baseline value was considered as hypertension. Plasma sodium was measured preoperatively, intraoperatively, and postoperatively.

MAIN RESULTS

Transurethral resection of prostate patients received more irrigating fluid (7900 +/- 2310 vs 5650 +/- 21560, P < 0.05) and had a higher calculated volume of fluid absorbed: 638 +/- 60 vs 303 +/- 40 mL for the TURT patients (P < 0.05). Mean arterial pressures were higher with TURP, 30 minutes after the onset of surgery and at the end of the procedure (111 +/- 15 vs 100 +/- 10 and 109 +/- 14 vs 99 +/- 14 mmHg, respectively; P < 0.05). However, there was no hypertension in either group. There were no differences in hemodynamic measurements of hyponatremic vs normonatremic patients. Plasma sodium decreased postoperatively more in the TURP group (140.4 +/- 2.6 mEq/L baseline to 134.1 +/- 3.5 mEq/L, P < 0.05) and was lower postoperatively in the TURP group compared with TURT (134.1 +/- 3.5 vs 137.2 +/- 2.9 mEq/L, P = 0.04).

CONCLUSIONS

Although more irrigating fluid was absorbed in the TURP group, there were no episodes of hypertension in either group.