Transurethral resection of the prostate (TURP) syndrome: a review of the pathophysiology and management

Impact of Duration of Catheterization on the Success Rate of Trial Without Catheter in Acute Urinary Retention Due to Benign Prostatic Enlargement

BACKGROUND

The most common cause of acute urinary retention in men over 50 is benign prostate enlargement (BPE). Following the urethral catheterization, a trial without a catheter (TWOC) under the cover of alpha-blockers is given. The timing of TWOC varies from Day 3 to Day 7 of the retention episode. There is a need to study the improvement in the success rate of TWOC with the increasing number of days of catheterization.

OBJECTIVE

To measure the success rate of TWOC in acute urinary retention due to benign prostatic enlargement with increasing days of catheterization.

METHOD

The study was conducted in Social Security Teaching Hospital Lahore. Patients who presented with acute urinary retention due to benign prostatic enlargement were catheterized and given alpha-blockers. The patients were divided into two groups, one group having TWOC after three days and the other having TWOC after seven days. The success rate of TWOC was calculated and compared in the two groups. All patients included in the study had the first episode of acute retention with a moderately enlarged prostate and no element of second pathology or neurological deficit.

RESULTS

A total of 48 patients were included in the study, divided into two groups of 24 patients each. In the first group who underwent TWOC after seven days of catheterization, 15 out of 24 patients had successful TWOC with a success rate of 62.5%. In the second group of 24 patients, who had TWOC after three days of catheterization, only 11 patients had successful TWOC with a success rate of 45.8%.

CONCLUSION

There was a marked improvement in the success rate of TWOC with increasing days of catheterization after an acute retention episode, secondary to BPE.

Combination of transurethral resection of the prostate and flexible and rigid ureteroscopy for benign prostatic hyperplasia and ureteral calculus

Background

Combination of transurethral resection of the prostate (TURP) and flexible and rigid ureteroscopy (URS/RIRS) is a successful approach for patients with benign prostatic hyperplasia (BPH) and ureteral calculus (UC), and the sequence is URS/RIRS followed by TURP. This research aims to compare TURP followed by URS/RIRS with URS/RIRS followed by TURP in terms of clinical efficiency and safety.

Methods

From June 2009 to June 2021, 173 patients with BPH and upper urinary tract stones were recruited through the Harrison International Peace Hospital and were divided into intervention (TURP followed by URS/RIRS) and control groups (URS/RIRS followed by TURP). We collected demographic data, primary outcomes including urinary function, and secondary outcomes including surgical parameters and complications. SPSS 21.0 was used to analyze data.

Results

When comparing the surgical parameters, the intervention group showed better results than the control group regarding surgery time and length of hospitalization. When comparing urinary function and complications, there were no differences between the intervention and control groups.

Conclusions

Although the intervention of TURP followed by URS/RIRS had similar clinical effects compared with URS/RIRS followed by TURP in the control group; the intervention saves surgery time, and decreases the length of stay and medical costs. It may therefore be a good choice for patients with BPH and UC.

Syndrome of Inappropriate Antidiuretic Hormone Secretion and Trimethoprim-Related Hyponatremia Following Transurethral Bladder Wall Biopsy

Postoperative hyponatremia is common. It results from the physiological antidiuretic hormone (ADH) response to surgery and associated exacerbating factors. Common exacerbating factors include medications, excessive fluid administration, and syndrome of inappropriate antidiuretic hormone (SIADH) secretion. High-dose trimethoprim can cause transient salt-losing nephropathy, resulting in SIADH-like hyponatremia associated with hypovolemia, hyperkalemia, and metabolic acidosis. We present a patient who developed symptoms of vomiting, loss of appetite, fatigue, and abdominal discomfort six days after having a transurethral bladder wall biopsy. He had also started a course of trimethoprim two days prior to the onset of the symptoms. Initial investigations demonstrated severe hyponatremia, concentrated urine, and compensated metabolic acidosis. These results suggested postoperative SIADH possibly exacerbated by trimethoprim-related hyponatremia. Cautious IV normal sodium chloride infusion resulted in a rapid recovery. While raising the awareness of postoperative hyponatremia, this case also highlights the difficulty distinguishing between SIADH and trimethoprim-related hyponatremia.

Hyperchloremic metabolic acidosis during bipolar transurethral resection of the prostate: a report of two cases

Compared with monopolar transurethral resection of the prostate (TURP), which requires electrolyte-free irrigation fluid, normal saline can be used as the irrigation solution in bipolar and laser TURP. The risk of TURP syndrome and severe electrolyte disturbance is minimized when normal saline is used as the irrigation fluid. However, the use of isotonic saline also causes acid-base imbalance and electrolyte disturbance. We experienced two patients who developed hyperchloremic metabolic acidosis during bipolar TURP. After proper intervention, hemodynamic instability resolved, and laboratory test results normalized. Anesthesiologists must pay attention to acid-base and electrolyte status when rapid absorption of excessive isotonic solution is suspected, even during bipolar and laser TURP, which use normal saline as the irrigation fluid.

Successful Treatment of Pulmonary Edema Caused by Transurethral Resection of the Prostate Syndrome

BACKGROUND

Transurethral resection of the prostate (TURP) syndrome is a complication of transurethral resection of the prostate procedure. The incidence of TURP syndrome ranges from 0.78% to 1.4%. This syndrome is caused by excessive absorption of electrolyte-free and hypotonic washing solution. The fluids absorb into the circulation, which leads to heart failure, hyponatremia, and a decrease in serum osmolality. Cerebral edema, coma, pulmonary edema, cardiovascular collapse, and even death are common complications.

CASE PRESENTATION

We report a patient who suffered severe TURP syndrome after transurethral resection of the prostate procedure. Clinical manifestations were pulmonary edema and respiratory failure. The concentration of Na+ was 112.6 mmol/l, which was severe hyponatremia. The serum osmolality pressure was 234mOsmol/kg, pH was 7.23, pO2 was 45mmHg and pCO2 was 44mmHg. The patient had successfully recovered after being used CPAP-PSV Pro breathing through a mask with + 5cmH2O of PEEP, 8cmH2O of supporting pressure, 70-100% of FiO2, 20mg furosemide of intravenously, 150 mL of 3% NaCl, and 100mL natribicarbonate 8.4%.

CONCLUSION

TURP syndrome is a life-threatening complication of transurethral resection of the prostate procedure, which is caused by excessive absorption of electrolyte-free and hypotonic washing solution. Therefore, the patient should be monitored seriously, diagnosed early, and treated promptly.

Visual clarity of irrigants used during flexible ureterorenoscopy: an in vitro comparison

Introduction

Saline solution is the standard irrigant used during ureteroscopy. However, there is an opinion that water has better visual clarity. We aimed to compare the visual clarities of saline, water, and 5% mannitol as an irrigant during ureteroscopy.

Material and methods

An in vitro model consisting of an irrigant-filled container and a fiberoptic flexible ureteroscope was designed. A 1951 USAF Resolution Test Target and color checker within irrigants were used to evaluate the clarity of vision. The visual clarity was compared for 0.9% saline, distilled water and 5% mannitol solution with screen resolution and color contrast. The tests were repeated after adding human blood (2/400 ml) and contrast (20/400 ml) to the irrigants.

Results

There was no significant difference in resolution values of three plain irrigants at a distance of 10 mm. However, when blood was added to the irrigants, a better resolution of 29.3% for water and 20.6% for mannitol was achieved compared to saline. At 20 mm of distance, it was observed that the difference was more pronounced in irrigants with blood. Water and mannitol had 55.6% and 37.1% better resolution than saline, respectively. In the color reproduction test, there was no significant difference in the three plain irrigants, however, water had better color contrast compared to the others.

Conclusions

Water and 5% mannitol did not provide a significant image clarity advantage compared to saline. However, when blood was added to the irrigants, water provided significantly better visual clarity compared to saline. The use of water during various clinical scenarios in flexible ureteroscopy should be further investigated.

Assessment of Complications of Transurethral Resection of the Prostate Using Clavien-Dindo Classification in South Eastern Nigeria

BACKGROUND

Benign prostatic hyperplasia is one of the most common diseases in aging males. For men that need surgical treatment, transurethral resection of the prostate (TURP) is the gold standard. The aim of this article is to retrospectively review the complications of TURP over a 3-year period in Nnamdi Azikiwe University Teaching Hospital Nnewi and a Specialist Urology Center in Awka all in Anambra South-East Nigeria using Clavien-Dindo classification.

PATIENTS AND METHODS

The study was a retrospective review of consecutive TURPs done over a 3-year period. Patients' information and complications arising from the procedure were collected and graded using the Clavien-Dindo classification with a pro forma designed for the study and analyzed with the Statistical Package for the Social Sciences software version 20.0.

RESULTS

Ninety-seven patients had TURP during the period of this study. Twenty-nine complications were noted in 24 patients. The postoperative morbidity rate was 24.74%, and no mortality was recorded. Most of the complications were grade 2 (55%), followed by grade 1 and 3 (20.69%) each. Grade 4a complication accounted for only 3.45%. No grade 5 complication was recorded.

CONCLUSION

TURP is safe, with minimal life-threatening morbidity even in a resource-poor economy where TURP is gradually gaining grounds.

Usefulness of non-invasive cardiac output monitoring in elderly patients undergoing monopolar transurethral resection of the prostate: a pilot study

Objective

To assess the impact of irrigating fluid on hemodynamic profiles using real-time non-invasive cardiac output monitoring (NICOM) in elderly patients undergoing monopolar transurethral resection of the prostate (TURP).

Methods

Twenty patients between 65 and 80 years of age who were scheduled for monopolar TURP and received spinal anesthesia up to T10 were enrolled. Irrigating fluid (2.7% sorbitol with 0.5% mannitol solution) was used. Hemodynamic profiles including cardiac index, and stroke volume variation (SVV) using NICOM were obtained. Estimated irrigating fluid absorption was indirectly calculated.

Results

The median amount of irrigating fluid used was 6000 mL. The median SVV was 11%, which increased to 12% at 10 minutes after initiating surgery. No significant changes in the cardiac index were observed. The estimated absorption of irrigating fluid was almost zero.

Conclusions

Although the estimated amount of irrigating fluid that was absorbed was negligible, the increase in SVV may indicate intravascular volume depletion with diuresis resulting from mannitol in the irrigating fluid early during irrigation. Therefore, even during short irrigating times, intensive hemodynamic monitoring should be performed to monitor the possibility of intravascular volume depletion as well as volume overload, especially immediately after large amounts of irrigating fluid are used.

Prophylaxis versus Treatment against Transurethral Resection of Prostate Syndrome: The Role of Hypertonic Saline

BACKGROUND

This study aimed at investigating the usage and effects of prophylactic hypertonic saline (HS) to prevent the occurrence of transurethral resection of the prostate (TURP) syndrome.

MATERIALS AND METHODS

Sixty American Society of Anesthesiologists physical status classes I-III candidates for TURP using the monopolar resectoscope were randomized into three groups 20 patients each. Group A received 4 mL.kg-1.h-1 HS 3%; Group B received 2 mL.kg-1.h-1 HS 3%; and Group C received 6 mL.kg-1.h-1 normal saline. Hemodynamics, vasopressors need, electrolytes (sodium, potassium, and chloride), osmolality, and arterial-blood gas (ABG) were recorded. The incidence of transurethral resection syndrome, intensive care unit (ICU) admission, postoperative ventilation, hospital stay as well as any adverse events were noted.

RESULTS

Hypernatremia was detected in six patients (P = 0.002) of Group A only, while hyponatremia occurred in five patients (P = 0.009) of Group C alone. Serum sodium in Group C showed a significant decrease starting from T2 (1 h postresection) till Tp3 (48 h postoperative). In Group C, five patients experienced hypotension and bradycardia; hypertensive episodes also occurred in five patients and a hypervolemic state was noted in seven patients. TURP syndrome was confirmed in only five patients, all in Group C (P = 0.009). Postoperative ICU admission was needed for seven patients of C Group, five of which required assisted ventilation. The overall hospital stay was longer for Group C patients.

CONCLUSION

Prophylactic administration of HS during TURP is superior to conventional treatment of an occurred TURP syndrome. Low dose (2 mL.kg-1.h-1 HS 3%) is effective without adverse effects or risk of contrary hypernatremia.

The effect of a mixture of 2.7% sorbitol-0.54% mannitol solution on blood coagulation: an invitro, observational healthyvolunteer study using rotational thromboelastometry (ROTEM)

Background

We investigated the effect of irrigation fluid on coagulation according to the hemodilution level using rotational thromboelastometry (ROTEM).

Methods

Venous blood was taken from 12 healthy volunteers and divided into four specimen tubes that were diluted to various levels (0%, 10%, 20%, and 40%) using an irrigation fluid composed of 2.7% sorbitol and 0.54% mannitol.

Results

Significant prolongation of clotting time was observed in the 40% diluted sample using both INTEM (P = 0.009) and EXTEM (P = 0.001) assays. However, the clot formation time was prolonged significantly in the 10%, 20%, and 40% diluted samples using both INTEM (P < 0.001) and EXTEM (P = 0.002, P < 0.001, and P < 0.001, respectively) assays. A significant decrease of α-angle of INTEM and EXTEM were observed in the 10% (P < 0.001), 20% (P < 0.001 and P = 0.001, respectively), and 40% (P < 0.001) groups compared with the 0% dilution group. The maximum clot firmness (MCF) of INTEM decreased significantly in the 20% (P < 0.001) and 40% (P < 0.001) diluted samples. In the MCF of EXTEM and FIBTEM assays, 10% (P = 0.009 and P = 0.015, respectively), 20% (P = 0.001), and 40% (P < 0.001) samples showed a significant decrease compared with the 0% sample. Nevertheless, most of the ROTEM values were within the reference range, except the 40% sample.

Conclusions

Blood became hypocoagulable when it was diluted in vitro with a fluid composed of 2.7% sorbitol and 0.54% mannitol.

Suprapubic cystostomy versus nonsuprapubic cystostomy during monopolar transurethral resection of prostate: a propensity score-matched analysis

We aim to reassess the safety of the monopolar transurethral resection of the prostate (M-TURP) without suprapubic cystostomy at our institution over the past decade. This retrospective study was conducted in patients who underwent M-TURP at Peking University First Hospital between 2003 and 2013. A total of 1680 patients who had undergone M-TURP were identified, including 539 patients in the noncystostomy group and 1141 patients in the cystostomy group. After propensity score matching, the number of patients in each group was 456. Smaller reductions in hemoglobin and hematocrit (10.9 g vs 17.6 g and 3.6% vs 4.7%, respectively) were found in the noncystostomy group. In addition, patients undergoing surgery without cystostomy had their catheters removed earlier (4.6 days vs 5.2 days), required shorter postoperative stays in the hospital (5.1 days vs 6.0 days), and were at lower risk of operative complications (5.7% vs 9.2%), especially bleeding requiring blood transfusion (2.9% vs 6.1%). Similar findings were observed in cohorts of prostates of 30-80 ml and prostates >80 ml. Furthermore, among patients with a resection weight >42.5 g or surgical time >90 min, or even propensity-matched patients based on surgical time, those with cystostomy seemed to be at a higher risk of operative complications. These results suggest that M-TURP without suprapubic cystostomy is a safe and effective method, even among patients with larger prostates, heavier estimated resection weights, and longer surgical times.

The impact of irrigating fluid absorption on blood coagulation in patients undergoing transurethral resection of the prostate: A prospective observational study using rotational thromboelastometry

Although endoscopic transurethral resection of the prostate (TURP) is a well-established procedure as a treatment for benign prostatic hyperplasia, its complications remain a concern. Among these, coagulopathy may be caused by the absorption of irrigating fluid. This study aimed to evaluate such phenomenon using a rotational thromboelastometry (ROTEM).A total of 20 patients undergoing TURP participated in this study. A mixture of 2.7% sorbitol-0.54% mannitol solution and 1% ethanol was used as an irrigating fluid, and fluid absorption was measured via the ethanol concentration in expired breath. The effects on coagulation were assessed by pre- and postoperative laboratory blood tests, including hemoglobin, hematocrit, platelet count, international normalized ratio of prothrombin time (PT-INR), activated partial thromboplastin time, electrolyte, and ROTEM.INTEM-clotting time (INTEM-CT) was significantly lengthened by 14% (P = 0.001). INTEM-α-angle was significantly decreased by 3% (P = 0.011). EXTEM-clot formation time was significantly prolonged by 18% (P = 0.008), and EXTEM-maximum clot firmness (EXTEM-MCF) was significantly decreased by 4% (P = 0.010). FIBTEM-MCF was also significantly decreased by 13% (P = 0.015). Moreover, hemoglobin (P < 0.001), hematocrit (P < 0.001), platelet counts (P < 0.001), potassium (P = 0.024), and ionized calcium (P = 0.004) were significantly decreased, while PT-INR (P = 0.001) was significantly increased after surgery. The amount of irrigating fluid absorbed was significantly associated with the weight of resected prostatic tissue (P = 0.001) and change of INTEM-CT (P < 0.001).As shown by the ROTEM analysis, the irrigating fluid absorbed during TURP impaired the blood coagulation cascade by creating a disruption in the coagulation factor activity or by lowering the coagulation factor concentration via dilution.

Spinal Anesthesia Facilitates the Early Recognition of TUR Syndrome

OBJECTIVES

To investigate what clinical features typically present in transurethral resection (TUR) syndrome and to see which classically present first. The purpose of the study was to establish whether or not a particular method of anesthesia is preferred in detecting this syndrome in its early stages.

METHODS

A total of 1,502 transurethral resection of the prostate (TURP) over a 15 year period were reviewed to see which, if any, went on to experience this complication. Of these cases, 48 developed TUR syndrome. The case records were reviewed retrospectively and the presenting clinical features were analysed. All TURPs were routinely performed under spinal anesthesia and followed a standardised set up. The irrigation fluid used in all operations was Glycine 1.5%.

RESULTS

Forty eight patients displayed clinical features of TUR syndrome giving an incidence of 3.2%. Trainees of varying experience caused all but one case. Median resection time, resection weight and volume of intraoperative glycine irrigation fluid were 55 minutes (range 40-75 minutes), 44 grams (range 24-65 g), and 28 l (24-48 l) respectively. Only 16/48 TURPs had a recorded capsular perforation. Pre- vs. post-operative median hematocrit, hemoglobin and serum sodium were 0.42 vs. 0.33, 14.2 g/dl vs. 10.1 g/dl and 142 mmol/l vs. 121 mmol/l respectively. Patients presented with nausea 44/48, vomiting 28/48, visual disturbance 29/48, apprehension 37/48, disorientation 17/48, breathing difficulties 17/48, and bradycardia 19/21. The earliest observed sign was nausea 21/48, then bradycardia 11/48, apprehension 11/48, and visual disturbance 10/48; after which the procedure was abandoned. None of the patients developed stupor, coma or seizures. Out of the 48 patients, 9 were admitted to high dependency units and all of these were treated with IV furosemide. One patient required a blood transfusion. All patients recovered within 48 hours (range 18-48 hours) and none had any long term complications on follow up.

CONCLUSION

The features most associated with the early presentation of TUR syndrome require the patient to be conscious for detection. The use of spinal anaesthesia is therefore desirable to facilitate its early recognition.

Change in serum sodium level predicts clinical manifestations of transurethral resection syndrome: a retrospective review

BACKGROUND

Patients undergoing transurethral resection (TUR) of the prostate are at risk of TUR syndrome, generally defined as having cardiovascular and/or neurological manifestations, along with serum sodium concentrations less than or equal to 125 mmol/l. As these symptoms can also occur in patients with serum sodium greater than 125 mmol/l, this study aimed to investigate the relationship between serum sodium concentrations and neurological manifestations of TUR syndrome.

METHODS

Data on patients who underwent TUR of the prostate under local anesthesia over an 8-year period were retrospectively reviewed. Based on their cardiovascular and neurological manifestations, patients were divided into two groups: a symptomatic and an asymptomatic group. Logistic regression analysis was used to detect the risk factors for being symptomatic. Receiver operator characteristic (ROC) curve analysis was used to determine the optimal cutoff value of estimated change in serum sodium level that could predict the development of clinical manifestation of TUR syndrome.

RESULTS

Of the 229 patients, 60 showed symptoms. Serum sodium level correlated with neurological score (Spearman's correlation coefficient > 0.5). Logistic regression detected that the risk factors for being symptomatic were serum sodium level variables, operation time longer than or equal 90 min, and presence of continuous drainage from the bladder. ROC curve analysis showed that a change in serum sodium level of 7.4 mmol/l was the optimal cutoff value, with a sensitivity of 0.72, a specificity of 0.87, and an area under the curve (AUC) of 0.87. ROC curve analysis also showed that a 7.0% change in serum sodium level was optimal for this parameter, with a sensitivity of 0.70, a specificity of 0.89, and an AUC of 0.87.

CONCLUSIONS

Changes in serum sodium concentration of > 7 mmol/l and of > 7% could predict the development of cardiovascular and neurological manifestations, which were assumed to be symptoms of TUR syndrome.

Prediction of clinical manifestations of transurethral resection syndrome by preoperative ultrasonographic estimation of prostate weight

Background

This study aimed to investigate the relationship between preoperative estimated prostate weight on ultrasonography and clinical manifestations of transurethral resection (TUR) syndrome.

Methods

The records of patients who underwent TUR of the prostate under regional anesthesia over a 6-year period were retrospectively reviewed. TUR syndrome is usually defined as a serum sodium level of < 125 mmol/l combined with clinical cardiovascular or neurological manifestations. This study focused on the clinical manifestations only, and recorded specific central nervous system and cardiovascular abnormalities according to the checklist proposed by Hahn. Patients with and without clinical manifestations of TUR syndrome were compared to determine the factors associated with TUR syndrome. Receiver operating characteristic curve analysis was used to determine the optimal cutoff value of estimated prostate weight for the prediction of clinical manifestations of TUR syndrome.

Results

This study included 167 patients, of which 42 developed clinical manifestations of TUR syndrome. There were significant differences in preoperative estimated prostate weight, operation time, resected prostate weight, intravenous fluid infusion volume, blood transfusion volume, and drainage of the suprapubic irrigation fluid between patients with and without clinical manifestations of TUR syndrome. The preoperative estimated prostate weight was correlated with the resected prostate weight (Spearman’s correlation coefficient, 0.749). Receiver operator characteristic curve analysis showed that the optimal cutoff value of estimated prostate weight for the prediction of clinical manifestations of TUR syndrome was 75 g (sensitivity, 0.70; specificity, 0.69; area under the curve, 0.73).

Conclusions

Preoperative estimation of prostate weight by ultrasonography can predict the development of clinical manifestations of TUR syndrome. Particular care should be taken when the estimated prostate weight is > 75 g.

Atypical presentation of acute hyponatremia in transurethral resection of prostate surgery: A case report

We report a case of unusual presentation of transurethral resection of prostate (TURP) syndrome. A 58-year-old male patient with grade III benign hypertrophic hyperplasia was scheduled for TURP under spinal anesthesia. At 120 min of surgery, the patient presented with atypical symptoms of tightness in the chest with difficulty in breathing. The electrolyte analysis revealed an acute hyponatremia (serum Na⁺ 95 mEq/l). Patient was successfully treated with rapid infusion of 3% hypertonic saline along with furosemide.

Transurethral resection syndrome in elderly patients: a retrospective observational study

BACKGROUND

Transurethral resection of the prostate (TURP) involves the risk of transurethral resection (TUR) syndrome owing to hyponatremia. Irrigation fluid type, duration of operation, and weight of resected mass have been evaluated as risk factors for TUR syndrome. The purpose of the present study was to identify risk factors related to TUR syndrome in the elderly.

METHODS

After obtaining approval from the Institutional Review Board, data on all elderly males (aged 70 years and older) who underwent TURP under regional anesthesia over a 6-year period at our institution were retrospectively reviewed. TUR syndrome was defined as evidence of a central nervous system disturbance such as nausea, vomiting, restlessness, confusion, or even coma with a circulatory abnormality both intra- and post-operatively. Patients were divided into two groups, positive and negative, for the occurrence of the syndrome. Data such as previous medical history, preoperative and postoperative serum data, weight of resected mass, duration of operation, irrigation fluid drainage technique, anesthetic technique, operative infusion and transfusion volume, and neurological symptoms were collected. Only observational variables with p < 0.05 on univariate analyses were included in the multivariate logistic regression model to ascertain their independent effects on TUR syndrome.

RESULTS

Of the 98 patients studied, 23 had TUR syndrome (23.5%, 95% confidence interval [CI] 14.9-32.0%). Multivariate regression analysis revealed that volume of plasma substitute ≥ 500 ml (odds ratio [OR] 14.7, 95% CI 2.9-74.5), continuous irrigation through a suprapubic cystostomy (OR 4.7, 95% CI 1.3-16.7), and weight of resected mass > 45 g (OR 4.1, 95% CI 1.2-14.7) were associated with significantly increased risks for TUR syndrome (Hosmer-Lemeshow test, p = 0.94, accuracy 84.7%).

CONCLUSIONS

These results suggest that the use of a plasma substitute and continuous irrigation through a suprapubic cystostomy must be avoided during TURP procedures in the elderly.

TURP syndrome and severe hyponatremia under general anaesthesia

Transurethral resection of prostate (TURP) syndrome is a complication characterised by symptoms changing from an asymptomatic hyponatremic state to convulsions, coma and death due to absorption of irrigation fluid during TURP. The syndrome appears to be related to the amount of fluid that enters the circulation via the blood vessels in the resection area. The first step in the course of action for therapy is to control bleeding and suspend the operation. In the case presented, we aimed to emphasise the importance of an early diagnosis and treatment of TURP syndrome in a patient that developed hyponatremia (90 mmol/l) while under general anaesthesia during a TURP procedure. In addition, multiple cystoscopic applications in the same session may facilitate development of the TURP syndrome.

Electrolyte changes: An indirect method to assess irrigation fluid absorption complications during transurethral resection of prostate: A prospective study

Context:

Fluid absorption is inevitable complication of transuretheral resection of prostate and serum electrolytes changes can indirectly assess the irrigation fluid absorption.

Aims:

To monitor the extent of 1.5% glycineirrigation fluid absorption during transurethral resection of prostate (TURP), by measuring the changes of serum sodium and potassium levels peri-operatively.

Settings and Design:

This is a randomized prospective cohort observational study.

Materials and Methods:

The 86 male patients of ASA grades I to III in the age group of 50 to 80 years, scheduled for elective TURP surgery under central neuraxial block, were studied. Their preoperative and post-operative serum sodium, potassium and calcium levels were measured. When duration of surgery exceeds 60 min, serum sodium and potassium levels were done intra-operatively with venous blood samples by using blood gas analyser. The height of irrigation fluid column was kept constant at 60 cm. These changes were correlated with the volume of irrigating fluid used, duration of procedure and the volume of prostate gland resected.

Statistical Analysis used:

The values of pre and postoperative sodium, potassium and calcium serum levels were compared and statistical significance of the difference in values was assessed using Student’s paired t test.

Results:

Statistically significant reduction of serum sodium levels (hyponatremia) and elevation of serum potassium levels (hyperkalemia) were observed post-operatively, which was directly proportional to volume of irrigating fluid used, duration of procedure and volume of prostate gland resected. No significant changes in serum calcium level were observed.

Conclusions:

To measure serum electrolytes changes during TURP surgery, it is simple and economical method for indirect assessment of fluid absorption for early identification of TURP syndrome.

[The gynecological TURP syndrome. Severe hyponatremia and pulmonary edema during hysteroscopy]

Fluid overload and dilutional hyponatremia are rare but typical complications of endoscopic transurethral resection of the prostate gland (TURP syndrome). Less commonly, this complication caused by excessive absorption of hypotonic, electrolyte-free non-conductive distention solution, may also occur during endoscopic surgery of the uterus, e.g. operative hysteroscopy. A case report is presented of a 44-year-old woman scheduled for operative hysteroscopy for intracavital myoma under general anaesthesia, suffering from severe absorption syndrome leading to hyponatremia of 106 mEq/l and pulmonary edema necessitating subsequent admission to ICU. Anatomical and physiological as well as technical aspects of this syndrome are discussed. Recommendations for anesthesiology management are offered and a possible treatment of acute hyponatremia is discussed.

The use of distilled water in the achievement of local hemostasis during surgery

Distilled water is used worldwide to check on hemostasis at the end of pelvic oncological operations. Nevertheless, reports about this method are lacking. The aim of this study was to explain the method and to discuss possible side effects. After the addition of distilled water to the surgically exposed pelvis, rapid lysis of erythrocytes results in a transparent fluid in which a small source of bleeding is easily recognizable. A possible side effect of the lavage might be contribution to the formation of peritoneal adhesions by confusing the abdominal defence system. Systemic side effects are not to be expected. Although tumour cells might suffer from hypotonic distilled water lavage, the current use of distilled water at the end of surgery is probably not effective to lyse tumour cells. Our findings support the ongoing use of distilled water lavage to achieve hemostasis after extensive pelvic surgery.

[Extremely rapid development of transurethral resection of the prostate syndrome]

BACKGROUND

The transurethral resection of the prostate (TURP) syndrome is reported after ureteroscopic procedures with irrigating solutions. TURP syndrome may occur quickly or up to 24 hours postoperatively. TURP syndrome affects many systems and manifests itself mainly through acute changes in intravascular volume and plasma solute concentrations.

CASE REPORT

We reported a 72-year-old patient with benign prostatic hyperplasia, diabetes mellitus and angina pectoris who underwent TURP under spinal anesthesia. Unusual marked somnolence, bradycardia (38 beats/min), disorientation and face edema indicated a diagnosis of TURP syndrome only 15 minutes after the operation had started. The diagnosis confirmed by arterial gas analyses (metabolic acidosis, pH was 7.29) and hyponatremia (96 mmol/l). Agressive and adequate therapy with diuretic and bicarbonates decreased symptoms and saved patient's life.

CONCLUSION

Very fast development of TURP syndrome is possible. Continuous patient monitoring is necessary to provide fast recognition of TURP syndrome. Adequate therapy can prevent considerable complications.

Bipolar Transurethral Resection of Prostate in Saline: Preliminary Report on Clinical Efficacy and Safety at 1 Year

PURPOSE

To determine the clinical efficacy and safety profile of the bipolar transurethral resection in saline (TURIS) system (Olympus Japan) in the treatment of men with benign prostate hyperplasia (BPH).

PATIENTS AND METHODS

We prospectively evaluated 45 patients with a mean age of 66 years (range 50-87 years) who had clinically significant BPH and were treated with transurethral resection of prostate using the TURIS system beginning December 2003. Acute retention of urine was the indication in 49% of the patients. Patients had outpatient follow-ups at 1, 3, 6, and 12 months.

RESULTS

A mean weight of 25.3 g of prostatic tissue was resected in a mean time of 42 minutes (range 15-75 minutes). The mean decrease in hemoglobin and sodium was 1.4 g/dL and 2.2 mmol/L, respectively. The mean follow-up period was 10 months. The mean International Prostate Symptom Score decreased from 22.6 preoperatively to 6.5 at 12 months and the mean Q(max) increased from 6.5 to 18.3 mL/sec at 12 months. Postoperative hemorrhage was seen in 6.6% of the patients, including 2 primary hemorrhages that necessitated blood transfusion (4.4%). Other complications were prolonged catheterization (11.1%), urinary-tract infection (8.9%), and bulbar urethral stricture (4.4%).

CONCLUSIONS

This pilot study indicates that TURIS is a safe and efficacious treatment for BPH at 1 year.

Topical radiant heating in wound healing: an experimental study in a donor site wound model*

The importance of temperature in the wound-healing process is rapidly being recognised as a novel way in which to manipulate the wound-healing environment. In this study, we aimed to investigate the direct effect of topical radiant heating (TRH), using a novel bandaging system (Warm-Up, Arizant Health care Inc., Eden Prairie MN, USA; Augustine Medical, USA), on wound healing at a physiological and cellular level. Experimental bandages were positioned over split-thickness skin graft donor site wounds of 12 patients undergoing graft harvesting from the anterior thigh. The experimental group (n=6) underwent intermittent heating for 5 hours (three 1-hour heating cycles at 38 degrees C, separated by two 1-hour rest periods), whilst the control group (n=6) received no radiant heating. Physiological blood-flow recordings both in the control group and the topical radiant heat cohort were undertaken using Laser Doppler Imaging (LDI). Skin biopsies were obtained at identical time points, and immunohistochemical analysis was undertaken using antibodies against neutrophils (NP57), lymphocytes (CD3) and macrophages (CD68). We found that TRH significantly increased local dermal blood flow (P<0.001) by up to 100% in both injured and intact skin. Furthermore, this increase in flow was associated with a significant (P<0.05) increase in CD3 immunoreactivity on day 1 postoperatively. This study demonstrates that TRH increases local blood flow and lymphocyte (CD3) extravasation, and we postulate that these changes may enhance local innate immunity within the healing wound environment.

Sensitive and specific photometric determination of mannitol in human serum

Mannitol is an osmotically active polyalcohol often present in fluids used for irrigation of exposed tissue during minimal invasive surgery. Since this polyol normally is not detected in human plasma to any significant extent, it may be used as a laboratory marker of absorption of mannitol-containing irrigative fluids during surgery. For this aim, we developed a photometric assay of mannitol in human blood or serum that may be performed in a near-patient setting. Following deproteinization of the sample with trichloroacetic acid, the supernatant is mixed with NAD+ and a commercially available preparation of mannitol 2-dehydrogenase and is incubated at pH 7.8 and at 37 degrees C for 30 to 60 minutes. At the end of the incubation period the solution is appropriately diluted and the concentration of NADH formed by oxidation of mannitol is determined photometrically at 340 nm. The limit of detection of serum mannitol with this assay is 0.05 mmol/l, the linear range of measurement extends to about 3 mmol/l. At analyte concentrations of 0.48, 1.38 and 3.48 mmol/l, coefficients of inter-assay variation of 12.1, 6.7 and 4.9%, respectively, were obtained. The analytical recovery of mannitol added to serum samples was close to 100%. Of 27 polyalcohols, monosaccharides and oligosaccharides tested, none exhibited a measurable substrate activity and only D-fructose significantly inhibited the oxidation of mannitol at sample concentrations above 10 mmol/l; the enzymatic reaction, however, was strongly affected by EDTA. The suitability of the assay as a routine diagnostic tool for detection and quantification of intraoperatively absorbed irrigation fluid was demonstrated by analyzing mannitol in serum samples obtained from 24 patients undergoing transurethral prostatectomy.