Bladder irrigation and urothelium disruption: a reminder apropos of a case of fatal fluid absorption

Transurethral Resection of the Prostate-Like Syndrome After Double-J Replacement in a Patient with Chronic Spinal Cord Injury: Case Report

Background: Transurethral resection of the prostate (TURP) syndrome is a rare, but extremely dangerous complication. We present an even rarer case of a spinal cord injured patient who developed "TURP-like syndrome" after cystoscopy with Double-J replacement, under general anesthesia. Case Presentation: A 39-year-old man, American Society of Anesthesiologists III, tetraplegic, was scheduled for cystoscopy with bilateral Double-J replacement. Preoperative values of serum sodium were 133 mmol/L and potassium 5 mmol/L. To prevent autonomic dysreflexia, we performed general anesthesia. During cystoscopy, 0.9% NaCl irrigating fluid reservoir was fixed 50 cm above patient level and pressure was applied at urologist's request. The balance between inflow and outflow of irrigation fluids showed no significant difference. Procedure lasted 25 minutes, without any complications. Patient was transferred, awake, to postanesthesia care unit and discharged 1 hour later to the ward. Four hours later, patient referred nausea, headache, and abdominal pain. Acetaminophen and ondansetron were administered. Arterial blood gas sample revealed metabolic acidosis, hyponatremia, and hyperkalemia. A fluid resorption syndrome was assumed, furosemide was given, 0.9% NaCl was loaded, followed by 3% NaCl, and 1.4% NaHCO₃ for metabolic acidosis. A 5% glucose solution with 10 U insulin was started for hyperkalemia correction. In 24 hours, patient's clinical state improved and serum sodium and potassium values returned to baseline levels. A week after surgery, patient was discharged home, without neurologic damage. Conclusion: Excessive absorption of irrigation fluids during cystoscopy may occur and manifestations may be delayed in up to 24 hours postoperatively. Anesthesiologists and urologists must be aware of this life-threatening situation. Preventive measures, rapid detection, and treatment are imperative and may prevent complications and, ultimately, death.

First Reported Case of Hyperchloremic Non-Anion Gap Metabolic Acidosis in a Patient Undergoing Continuous Bladder Irrigation for Hemorrhagic Cystitis

Radiation cystitis can present as gross hematuria and occurs secondary to irritation of the bladder urothelium. Continuous bladder irrigation (CBI) is commonly used for the treatment of hemorrhagic cystitis for evacuation of blood clots and to maintain catheter drainage. Most commonly, CBI is performed using 0.9% sodium chloride. We report a 77-year-old female who developed hyperchloremic non-anion gap metabolic acidosis (H-NAGMA) and pulmonary edema secondary to absorption of 0.9% normal saline (NS) from CBI. In such cases, ringer lactate with low concentration (109 mEq) of chloride as compared to NS (154 mEq) can prove to be a suitable alternative.

Sulfated glycosaminoglycans in bladder tissue and urine of rats after acute exposure to paraoxon and cyclophosphamide

Glycosaminoglycans (GAGs) in the urine of Wistar rats, and on the surface of the epithelium and lamina propria of the bladder, were quantitatively assessed before and after acute intoxication with paraoxon or cyclophosphamide. Paraoxon was administered subcutaneously (s.c.) twice with an interval of 1h to a final dose of 275mg/kg; cyclophosphamide was administered intraperitoneally (i.p.) with a single dose of 100mg/kg or to a final dose of 240mg/kg (three times per 80mg/kg every 12h). GAGs on the surface of the epithelium and lamina propria of the urinary bladder of rats were quantitatively determined by Alcian blue dye staining. GAGs in the urine were determined spectrophotometrically with 1-9-dimethyl methylene blue. By 48-96h after intoxication with either paraoxon or cyclophosphamide, statistically significant increases in the concentration of GAGs were obtained both for the tissues of the bladder and the urine of rats. Cyclophosphamide, in contrast to paraoxon, caused the development of hemorrhagic cystitis in the animals. The synthesis of GAGs is considered to be compensatory response to the toxic xenobiotics.