TURP SYNDROME

A 74-year-old man with a past medical history of coronary artery disease with stable angina and
hypertension was scheduled to undergo transurethral resection of the prostate (TURP) for benign
prostatic hypertrophy.
Current medications included metoprolol, 50 mg twice a day, and amlodipine, 10 mg once a day.
The physical examination was unremarkable. Heart rate was 74 beats per minute, blood pressure
was 160/75 mm Hg, and respiratory rate was 12 breaths per minute. The patient was 177.5 cm tall
and weighed 72 kg.

1. What is TURP syndrome, and what is the treatment?

 TURP syndrome is a collection of signs and symptoms that occur when excessive amounts of
irrigating fluids are absorbed through the opened prostatic venous sinusoids.
 Absorption of fluids may result in
Water intoxication,
Hyponatremia, and
Hypoosmolality.
 Although most commonly associated with TURP, this syndrome may also occur with:
 Transurethral resection of bladder tumors,
 Diagnostic cystoscopy,
 Percutaneous nephrolithotomy, and
 Endoscopic gynecologic procedures.
 The incidence 0.78%–1.4%.
 The mortality rate in severe cases is 25%.
 The syndrome may be observed minutes after resection starts up to 24 hours postoperatively.
 The decrease in serum sodium (Na+) levels during TURP ranges from 3.65–10 mEq/L.
 Several mechanisms for this decrease in Na+ have been postulated.
 Hyponatremia may be due to either :
 Simple dilution by the irrigating solution or
 Diffusion of Na+ into the irrigating solution at the surgical site or into the periprostatic or
retroperitoneal spaces.
 The degree of hyponatremia is related to the rate of absorption of the irrigating fluid and not to
the absolute amount absorbed.

Effects of TURP syndrome on the central nervous system include:

 Headache,
 Restlessness,
 Agitation,
 Confusion,
 Seizures
 Coma .

 These findings are thought to be caused by cerebral edema, with a concomitant ↑ICP.
 If coma occurs, it usually resolves within hours to days, but it can be permanent.

The incidence of neurologic injury is more closely related to the rate of Na+ decrease rather than
the degree of hyponatremia.

 Hyponatremia and fluid overload have deleterious consequences on the heart.

 The initial cardiovascular effects of fluid overload include hypertension and bradycardia.
 However, serum Na+ levels of 120 mEq/L are associated with negative inotropic effects on the
heart causing:
  Hypotension,
 Pulmonary edema, and
 Congestive heart failure.
 Serum Na+ levels of less than 115 mEq/L are associated with electrocardiogram (ECG) changes,
such as
 A widened QRS complex,
 Ventricular ectopy, and
 T-wave inversion.
 When serum Na+decreases to ,100 mEq/L,
 Respiratory and
 Cardiac arrest may occur

 If the patient develops signs and symptoms of TURP syndrome,

 Surgery should be concluded as soon as possible.
 Treatment should be directed at increasing the serum Na+ level .
 Correcting volume overload by fluid restriction .
 Administration of a loop diuretic, such as furosemide.
 In severe cases of hyponatremia, administration of a hypertonic saline solution (3%–5% sodium
chloride) may be necessary.
 All other treatment is dictated by the patient’s symptoms.
 Supplemental oxygen should be considered,
 The patient may require tracheal intubation and mechanical ventilation.
Rapid correction of hyponatremia has been associated with cerebral edema and central pontine
myelinolysis.

2. What other complications can occur during transurethral resection of the prostate?
 Approximately 7% of all patients undergoing TURP experience a major complication.
 The 30-day mortality rate has been estimated to be 0.2%–0.8%.
 Patients undergoing TURP are often elderly and have coexisting cardiopulmonary disorders
making them more likely to experience complications.
 Because many patients are on long-term diuretic therapy, they are often dehydrated and present
with electrolyte abnormalities preoperatively.
 Other complications associated with this procedure are described next .
Bladder Perforation:
 Bladder perforation occurs in approximately 1% of all TURP procedures.
 It may be caused by overdistention of the bladder with irrigating fluid or surgical instrumentation.
 An early sign of bladder perforation is decreased return of irrigating fluid.
 The abdomen becomes distended and often rigid.
 If the procedure is performed under regional anesthesia, patients may complain of pain or
experience nausea and vomiting.
 Hypotension followed by hypertension is common.
 Most perforations are extraperitoneal and benign in nature.
 This type of perforation causes pain in the periumbilical region.
 However, pain in the upper abdomen or referred pain to the shoulder may be a sign of
intraperitoneal perforation, a potentially fatal complication.

 Diagnosis :
 Should be confirmed quickly by cysto-urethro-graphy, and
 Treatment should be with a suprapubic cystostomy.

Bleeding:
 The prostate is a highly vascular organ.
 Because large amounts of irrigation fluid are used, blood loss is difficult to assess.
  Intraoperative blood loss corresponds to the size of the gland and resection time.
 Blood loss is generally considered to occur at a rate of 2–5 mL per minute of resection time and
20–50 mL/g of prostate tissue.
 Blood loss is linearly related to prostate size up to 35 g, at which point blood loss tends to exceed
the linear correlation.
 Patients with resection times of greater than 90 minutes or a prostate size of .60 g have been found
to have a significant increase in morbidity associated with bleeding.

Coagulopathy:
 Subclinical coagulopathy occurs in approximately 6% of patients undergoing TURP,
 Clinical coagulopathy occurs approximately 1% of the time.
 This condition seems to correlate with the mass of resected prostatic tissue.
 It is a more likely event if the resected tissue is .35 g.
 Coagulopathy may be due to dilution of coagulation factors and platelets.
 Primary fibrinolysis has also been implicated as a cause of coagulopathy.
 Plasminogen activator, which is responsible for converting plasminogen into plasmin, is released
during these procedures.
 The treatment of choice for primary fibrinolysis is aminocaproic acid.
 Secondary fibrinolysis may occur as a result of DIC.
 DIC is caused by systemic absorption of prostate tissue, which is rich in thromboplastin.
 Consistent with this theory are the low levels of plasminogen activator, platelets, and fibrinogen
that are commonly found in DIC and that frequently accompany TURP.
 If DIC is suspected, the treatment is symptomatic:
 Fluid and blood products are administered as needed.
 Heparin administration may be beneficial.

Transient Bacteremia and Septicemia:

 The prostate, rich in pathogens, may cause postoperative bacteremia via prostatic venous
sinusoids.
 Indwelling urinary catheters enhance the risk.
 Approximately 6%–7% of patients go on to develop sepsis.
 Treatment consists of antibiotics and supportive care.

Toxicity of Irrigating Fluids:

 The major toxicity of irrigation fluids used today is related to massive absorption causing:
 Fluid overload,
 Hyponatremia, and
 Hypoosmolality.
 The incidence of hypoosmolality and its associated neurologic sequelae has decreased since the
use of nonelectrolyte isoosmotic irrigating solutions.
 However, fluid overload and hyponatremia still remain a problem.
 During TURP, 8 L of irrigating fluid may be absorbed causing an average weight gain of about 2
kg.
 Some of this fluid (20%–30%) is absorbed directly into the vascular space.
 The remainder is absorbed into the periprostatic and the peritoneal space (interstitial space).
 Several factors contribute to the rate of absorption of irrigating fluid, including:
 Prostate size,
 Integrity of the Prostatic capsule, and
 Height of the irrigating fluid container.
 Greater amounts of irrigating fluid are absorbed when the prostate is large because of its richer
blood supply and when the prostate capsule is violated.
 Certain maneuvers can limit the amount of irrigating fluid absorbed.
  The first is to restrict the height of the fluid container above the surgical field; this decreases
hydrostatic pressure driving fluid into sinuses.
 When the bag is ˃60 cm above the patient, absorption is greatly enhanced.
 The second maneuver is to limit resection times to ˂150 minutes because 10–30 mL of irrigation
fluid is absorbed per minute of resection.
 Sorbitol and mannitol, both sugar alcohols, have been associated with the development of lactic
acidosis and hyperglycemia.
 Specific effects of glycine are discussed later.

Hypothermia:
 Patients may develop hypothermia under either general or neuraxial anesthesia.
 The hypothermia can be exacerbated by using room temperature irrigating fluids.
 Using warmed irrigating fluid decreases heat loss and shivering.
 A theoretical concern exists that warming the irrigation fluids would cause vasodilation,
increasing blood loss;however, this has not been shown to be a clinical problem.
 Because hypothermia may cause shivering, which increases venous pressure, there may be
increased blood loss if the irrigating fluids are not warmed.
 BOX 36-1
Complications of Transurethral Resection of the Prostate
• Bladder perforation:
 Extraperitoneal or intraperitoneal
• Bleeding:
 Related to size of gland and resection time
• Coagulopathy:
 Dilution of coagulation factors
 Primary fibrinolysis
 Disseminated intravascular coagulopathy
• Transient bacteremia and septicemia
• Toxicity of irrigating fluids:
 Hypervolemia
 Hyponatremia
• Hypothermia
• Glycine toxicities:
 Transient blindness
 Hyperammonemia
 Nausea and vomiting
 Coma
• Myocardial depression
• Electrocardiogram changes
BOX 36-2
3. What types of irrigating fluids have been used for transurethral resection of the prostate?
 The ideal irrigating fluid would be
 Isotonic,
 Electrically inert,
 Nontoxic, and
 Transparent;
however, this type of solution does not exist.
 Originally, distilled water was used, but absorption of distilled water caused hyponatremia and
hemolysis of red blood cells.
 This severe complication led to the use of isoosmotic solutions such as saline or lactated
Ringers solution.
 However, because these solutions are highly ionized, they caused dispersion of high-frequency
current from resectoscopes.
 The present generation of irrigating fluids is electrically inert and isotonic.
  These solutions include :
 Glycine and
 Amixture of sorbitol and mannitol (Cytal), which are the most commonly used.
 Glucose,
 Mannitol,
 Urea,
 Sorbitol

4. What toxicities are associated with glycine?

 Intravascular absorption of 1.5% glycine solution has been implicated as a cause for many
neurologic manifestations associated with TURP, including transient blindness.
 Glycine, a nonessential amino acid, readily crosses the blood-brain barrier.
 It has a distribution similar to g-aminobutyric acid, a naturally occurring inhibitory
neurotransmitter.
 Transient blindness may result from
 Inhibitory effects of glycine on the central nervous system or
 A direct inhibitory effect on the retina.
 Glycine retinal toxicity appears to be unrelated to its plasma concentration.
 Glycine is metabolized to ammonia, which may lead to hyperammonemia in some patients.
 Common signs and symptoms of ammonia toxicity include nausea and vomiting.
 As the ammonia level increases to ˃500 mmol/L,coma may occur.
 Coma typically resolves when the ammonia level decreases to ˂150 mmol/L.
 The cardiovascular effects of glycine are:
 Myocardial depression and
 Nonspecific ECG changes, such as T-wave depression.

5. What are the anesthetic options for a patient undergoing transurethral resection of the prostate?
 Regional anesthesia has long been considered the anesthetic of choice for TURP.
 Regional anesthesia allows for monitoring of mental status changes, irritability,and headache, the
early signs of hyponatremia.
 If signs of hyponatremia occur, serum Na+ levels are checked and treated expeditiously.
 Intraoperative irritability or combativeness could result from hyponatremia.
 If caused by hyponatremia or hypoxia, deepening the sedation level could be counterproductive.
 Benefits of Regional Anesthesia:
 Early detection of TURP syndrome
 Detection of bladder perforation
 Decreased blood loss
 Decreased incidence of deep vein thrombosis
 Postoperative pain control
 As discussed earlier, another potentially fatal complication of TURP is bladder perforation.
 A T10 level of sensory blockade would allow the patient to complain of abdominal or shoulder
pain, which are symptoms of bladder perforation.
 As with other pelvic procedures, regional anesthesia has been shown to decrease blood loss and
the incidence of deep vein thrombosis.
 Another clear advantage of regional anesthesia is postoperative pain control.
 Good postoperative pain control also protects against sympathetic responses to pain, such
as tachycardia and hypertension, which could increase the likelihood of myocardial ischemia in
susceptible patients.
 Comorbid conditions may necessitate general anesthesia.
 General anesthesia hides the early neurologic signs and symptoms associated with
hyponatremia, hypoosmolality,or bladder perforation.
 When a general anesthetic is chosen,a smooth emergence is desirable.
  If the patient awakens coughing and “bucking” on the endotracheal tube,venous pressure
increases, and bleeding may develop.

6. If a regional anesthetic is selected, what level of anesthesia is required?

 The level of anesthesia required depends on the anatomy and sensory innervation of involved
structures .
 The structures that need to be blocked are the bladder,prostate, penis, and urethra.
 The dome of the bladder receives its sensory innervation via T11-L2, whereas the neck of the
bladder receives its sensory innervation via S2-S4.
 The prostate receives its sensory innervation via T11-L2 and S2-S4.
 Finally, a sensory block of the penis and scrotum requires blocking S2-S4.
 Based on this anatomy, a block to the level of T10 is usually sufficient for TURP.
 If a lower level is attained,bladder stretching from irrigation fluids would be uncomfortable.
 Because a block at the level of S4 is also required, spinal anesthesia is preferred over epidural
anesthesia.
 Epidural anesthesia sometimes results in incomplete block of the sacral nerve roots.
Sensory Innervation:
• T11-L2:
 Bladder dome
 Prostate
• S2-S4:
 Bladder neck
 Prostate
 Penis
 Scrotum

7. The patient’s serum sodium level is 102 mEq/L 1 hour and 15 minutes into the procedure;how
would you correct the sodium level to 135 mEq/L?
The Na+ deficit must first be calculated using the following equation:
Na+ deficit mEq = TBW x (Na+ desired - Na+ observed)
TBW is total body water and constitutes 60% of lean body weight in the average man and 50% of lean
body weight in the average woman.
In this example, the patient’s Na+deficit is:
1425.6 mEq = (72 kg x 0.6) x(135 - 102)
Hypertonic saline (3% sodium chloride) contains 513 mEq/L of Na+.
The volume of hypertonic saline required to replace a Na+ deficit of 1425.6 mEq is 2.78 L.
The maximum safe rate of increase in serum Na+ is 0.5 mEq/L per hour.
In this case, the serum Na+ should be corrected over 66 hours.
Thus, the hypertonic saline should run at a rate of 1425.6/66 = 21.6 mL per hour.
In situations of significant hyponatremia associated with seizures or progressive neurologic deterioration,
it may be necessary to correct the Na+ deficit more rapidly (3 mEq/L per hour).
This rapid correction should not exceed 2 hours and should be stopped if neurologic symptoms resolve
sooner.

8. What surgical measures can minimize the incidence of TURP syndrome?

Several measures have been undertaken in an attempt to minimize TURP syndrome.
The primary goal is to reduce the volume of irrigating fluid that is absorbed during resection; this may
be achieved by one or a combination of methods:
• Decreasing hydrostatic pressure within the bladder and prostatic venous pressure:
 Using reduced pressure irrigation and lowering the fluid bag’s height (although there is some
controversy concerning whether the height of the bag is significant) decrease hydrostatic
pressure.
 Patient positioning on the operating table also has an effect on irrigation absorption.
  Intravesical pressure needed to initiate absorption of irrigating fluid is lower in the
Trendelenburg position compared with the horizontal position.
 Trendelenburg position increases the risk of TURP syndrome.
• Limiting operative time to ,90 minutes:
 Operating times longer than 90 minutes have been shown to increase the incidence of TURP
syndrome and intraoperative bleeding.
• Restricting TURP to prostate glands ,45 g:
 Larger glands require longer resection times resulting in increased irrigant absorption and
increased blood loss.
• Injecting intraprostatic vasopressin:
 Blood loss and amount of irrigant fluid absorbed are reduced with vasopressin injection.

9.What chronic medical conditions are common in patients who have undergone TURP?
 TURP patients often are elderly and suffer from cardiac, pulmonary, vascular, and
endocrinologic disorders .
 The incidence of :
 Cardiac disease is 67%,
 Cardiovascular disease, 50%,
 Abnormal electrocardiogram (ECG),
 77% chronic obstructive pulmonary disease,
 2 9% and diabetes mellitus,
 8%. Occasionally, these patients are dehydrated and depleted of essential electrolytes because of
long-term diuretic therapy and restricted fluid intake.

10. What intravenous fluid would you use during TURP?
 The intravenous fluid of choice perioperatively is normal saline that contains sodium, 154 mEq
per L.
 It is important to remember, however, that circulatory overloading from absorbed irrigant is
common in patients who have undergone monopolar or bipolar electrode TURP (but not laser
TURP); therefore, the amount of intravenous fluid administered during surgery should be
carefully monitored.

11. Why is plain distilled water rarely used for irrigation during TURP? What types of irrigation
solutions are available?
 Although distilled water is totally transparent and electrically inert and was regularly used decades
ago for irrigation during monopolar TURP, it is extremely hypotonic.
 Therefore, when it is absorbed, it may cause hemolysis, shock, and renal failure.
 Over the years, a number of isotonic and nearly isotonic irrigation solutions have been introduced
and they have almost totally replaced plain distilled water:
 The most commonly used solution is currently Glycine ( 1.2% and 1.5%).
 Mannitol (3%),
 Glucose (2.5 % to 4%),
 Cytal (a mixture of sorbitol 2.7% and mannitol 0. 54%), and
 Urea ( 1 %) solutions are also occasionally used.
 For maintenance of their transparency, these solutions are purposely prepared moderately
hypotonic.
 Sterile water and glycine have been used as the bladder irrigation solution in laser resection TURP
because they are minimally absorbed, but TURP syndrome has been reported when bladder
perforation or urethral trauma occurred.

12.What is the effect on body temperature of continuous bladder irrigation during TURP?
 Several liters of irrigation solution pass through the bladder during TURP.
  This can reduce body temperature at the rate of 10C per hour.
 Approximately half the patients undergoing TURP become hypothermic and shiver at the
conclusion of surgery.

13.What are the causes, signs, symptoms, and preventive measures for bladder explosion during
TURP?
 A rare but extremely dangerous complication of TURP is gas explosion inside the bladder during
surgery.
 Various explosive gases, particularly hydrogen, are generated by the cauterization of prostatic or
bladder tissue during TURP.
 The explosion is triggered by the hot metal loop of the resectoscope.
 After a loud thump, the patient complains of sudden abdominal pain.
 This is accompanied by an abrupt decline in the return of irrigation solution.
 The concentration of oxygen in the bladder is usually too low to support combustion or explosion.
 However, if air is allowed to enter the irrigation system during surgery, oxygen concentration in
the bladder will rise and this in turn may trigger an explosion.
 Strict precautions should be taken to prevent entry of air into the bladder during TURP.
 If air is observed in the bladder at the beginning of surgery, it must be evacuated before
cauterization starts .
 The bladder should be emptied regularly in order to avoid accumulation of explosive gases during
surgery.

14.What gynecologic procedure has been associated with a syndrome similar to TURP syndrome?
 Hysteroscopy has been associated with symptoms not unlike those o f TURP syndrome.
 The procedure involves visualization of the interior lining of the uterus for diagnostic purposes
and, on occasion, for transcervical resection of the endometrium or submucous myomectomy.
 The latter often requires electrical cauterization.
 As withTURP, hysteroscopy requires irrigation with nonionic isotonic solutions .
 Commonly used solutions contain either glucose or glycine.
 Side effects such as hyponatremia,hyperglycemia, circulatory overloading, and coagulopathy have
been reported.
15. What are the clinical characteristics, causes, and prognosis of TURP-related blindness?
 Transient blindness is one of the more alarming complications of TURP.
 The patient complains of blurred vision and of seeing halos around objects.
 This can occur either during surgery or later in the recovery room.
 Although it is sometimes accompanied by other TURP-related complications, the blindness
usually occurs as an isolated symptom.
 Examination of the eyes reveals dilated and unresponsive pupils.
 Postoperatively, TURP-related blindness gradually recedes and eyesight returns to normal
within 8 to 48 hours of surgery.
 The cause of TURP-related blindness is unclear.
 The intraocular pressure and optic discs remain normal.
 The clinical signs of TURP-related blindness are consistent with retinal rather than cortical
dysfunction. Unlike cortical blindness, TURP-related blindness allows perception of light and the
blink reflex is preserved.
 TURP-related blindness is most likely caused by a toxic effect of glycine on the retina.
 This theory is supported by the fact that glycine is a known inhibitory neurotransmitter.

1.A 72-year-old man has massive venous hemorrhage during a radical prostatectomy. Blood
pressure decreases from 110/60 to 75/30 mmHg and central venous pressure decreases from 12 to 4
mmHg. PetC02 decreases from 34 to 24 mmHg during constant minute ventilation. The most
appropriate next step should be to:
(A) apply positive end-expiratory pressure to the breathing circuit
(B) attempt to aspirate air from the central venous catheter
(C) expand intravascular volume
(D) place the patient in the Trendelenburg position
(E) turn the patient to the left lateral decubitus position

2.A patient is bleeding excessively after routine transurethral resection of the prostate. Re-
exploration discloses diffuse oozing. The most appropriate management is administration of
(A) platelets
(B) fresh frozen plasma
(C) desmopressin
(D) epsilon-aminocaproic acid
(E) cryoprecipitate

3.After the first 70 minutes of a transurethral resection of the prostate, a 70-year-old man becomes
confused and has tachycardia, hypertension, and shortness of breath. Serum sodium concentration
is 116 mEq/L. After informing the surgeon that the procedure should be terminated as soon as
possible, the most appropriate next step would be to
(A) administer furosemide
(B) administer labetalol
(C) administer 3% sodium chloride
(D) change the irrigating solution to normal saline
(E) induce general endotracheal anesthesia

4.Which of the following is a complication of glycine used for irrigation during transurethral
resection of the prostate?
(A) Epileptiform activity on EEG
(B) Peripheral neuropathy
(C) Tachycardia
(D) Transient blindness
(E) Transient deafness