The effect of the choice of irrigation fluid on cardiac stress during transurethral resection of the prostate: a comparison between 1.5% glycine and 5% glucose

PURPOSE: Variable amounts of irrigation fluid are absorbed during transurethral prostate resection. Previous studies suggest that cardiac stress occurs as a result of transurethral prostate resection, possibly due to glycine absorption. We performed a prospective, blinded, randomized trial comparing 1.5% glycine with 5% glucose irrigating solution. We assessed whether glycine or glucose irrigation for transurethral prostate resection is associated with cardiotoxicity, as measured by troponin I and echocardiogram changes. MATERIALS AND METHODS: Between December 2001 and March 2003, 250 patients were recruited. Changes in immediate postoperative vs preoperative echocardiogram and serum cardiac troponin I indicated perioperative myocardial stress. Intraoperative irrigating fluid absorption was measured with 1% ethanol as a marker. Operative details recorded were anesthesia type, resection time, resected tissue weight and temperature change. Blood loss was measured with transfusions considered. Postoperatively blood assessments included serum glycine assay. RESULTS: Five patients (4%) in the glycine group and 3 (2%) in the glucose group had significantly increased troponin I after surgery. Of these men 1 per group had myocardial infarction and the remainder had transient ischemia. Logistic regression was used to identify factors associated with an unfavorable outcome, which was recorded as a significant increase in troponin I or ischemic changes on echocardiography. Increasing patient age and blood loss were associated with an unfavorable outcome (OR 1.84 and 1.24, respectively). We noted no significant differences in the 1.5% glycine and 5% glucose groups with regard to troponin I/echocardiogram. However, when the glycine assay was compared with adverse outcomes, an increased glycine assay was found to be associated with echocardiogram changes (p = 0.001) and with increased troponin I levels (relative risk 10.71). CONCLUSIONS: Transurethral prostate resection has an effect on the myocardium perioperatively. Glycine absorption causes echocardiogram changes and it is associated with increased troponin I. Increasing patient age and blood loss are associated with myocardial insult. The risk of increased blood loss was accumulative with each unit lost. Unrecognized blood loss or glycine absorption may explain the increase in morbidity and mortality previously reported in patients who undergo transurethral prostate resection.     

Visual disturbances, serum glycine levels and transurethral resection of the prostate

Transient visual disturbances have been noted in patients undergoing transurethral resection of the prostate. It has been suggested recently that these visual aberrations were secondary to high serum concentrations of glycine from the intravasation of irrigant solutions used during the procedure. We prospectively studied visual acuity, serum electrolytes, glucose, ammonia and glycine concentrations in 18 patients undergoing transurethral resection of the prostate. Of our patient population 22% experienced significant decreases in visual acuity. We found that all patients had significantly elevated serum glycine concentrations but that there was no correlation of visual symptomatology with serum electrolyte or glucose concentrations. Our data further suggest that impeded metabolism of glycine may be more important than the absolute serum concentration in symptomatic patients.     

Bipolar transurethral resection in saline--an alternative surgical treatment for bladder outlet obstruction?

PURPOSE: The transurethral resection in saline system uses bipolar energy for transurethral prostate resection, thus, avoiding the need for glycine irrigation and its associated complications. We compared the clinical efficacy and safety of bipolar transurethral resection in saline and of monopolar transurethral prostate resection for symptomatic benign prostate hyperplasia. MATERIALS AND METHODS: From January 2005 to June 2006, 238 consecutive patients with symptomatic benign prostate hyperplasia were randomized into a prospective, controlled trial comparing the 2 treatment modalities. Patient demographics, operative time, hospital stay and complications were noted. Serum hemoglobin and electrolytes were determined in all patients immediately before and after the endoscopic procedure. RESULTS: During 18 months 120 patients were randomized to the conventional transurethral prostate resection group and 118 were randomized to the transurethral resection in saline group. Patient profiles, weight of resected prostatic tissue and duration of hospitalization were similar in the 2 groups. The decrease in serum sodium and serum chloride was statistically significantly greater in the transurethral prostate resection group than in the transurethral resection in saline group (each p = 0.05). The transurethral resection in saline procedure required significantly more time (mean 56 vs 44 minutes, p <0.01). There was 1 case (0.8%) of transurethral resection syndrome in the transurethral prostate resection group but none in the transurethral resection in saline group. Postoperative bleeding did not significantly differ between the 2 groups. Clot retention was observed in 6 (5%) and 4 patients (3%) in the transurethral prostate resection and transurethral resection in saline group, respectively. Two repeat interventions were required in the transurethral prostate resection group. CONCLUSIONS: The bipolar transurethral resection in saline system is as efficacious as monopolar transurethral prostate resection but it is safer than the latter because of the lesser decrease in postoperative hypernatremia and the smaller risk of transurethral resection syndrome. However, probably due to technical reasons, transurethral resection in saline operative time is significantly longer.     

Hyperammonemia after transurethral resection of the prostate: a report of 2 cases

We report on 2 patients who became deeply comatose after transurethral resection of the prostate. Both patients were severely hyponatremic and hyperammonemic but the course of the comas followed serum ammonia concentrations more closely than serum sodium concentrations. The genitourinary irrigant used in both procedures was a 1.5 per cent glycine solution. Serum amino acid analyses in 1 patient suggested that the postoperative hyperammonemia was due to catabolism of glycine absorbed during surgery. The inadequate activation of normal pathways of ammonia metabolism in this patient may have been caused by a partial deficiency of the urea cycle enzyme argininosuccinate synthetase. We believe that hyperammonemia should be considered as a cause of encephalopathy after transurethral resection of the prostate. The 1.5 per cent glycine genitourinary irrigating solution may not be as nontoxic as generally believed.     

Isotonic hyponatremia following transurethral prostate resection.

The proper treatment of hyponatremia during transurethral resection of the prostate continues to be controversial. Two cases of isotonic hyponatremia are reported here, and the literature regarding the incidence and treatment of hyponatremia during transurethral resection of the prostate is reviewed. In each case, the patient developed neurologic changes during complicated transurethral prostate resection. Despite the rapid decrease in the serum sodium concentration, serum osmolality remained normal due to the resorption of the bladder irrigant glycine. Therefore, etiologies other than cerebral edema are postulated as the cause of the neurologic manifestations. Also, the role of the osmolar gap in directing appropriate therapy is emphasized in an effort to avoid unnecessary use of hypertonic saline. Finally, an appropriate differential diagnosis of the neurologic changes seen during the transurethral resection of the prostate syndrome is discussed.     

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.     

Transient blindness: unusual initial symptom of transurethral prostatic resection reaction.

Transient blindness was seen in 2 patients undergoing transurethral resection (TUR) of the prostate as the initial symptom of a severe TUR reaction. Cerebral edema of the occipital cortex is the most probable mechanism. Both fully recovered their vision when appropriately treated. Patients with visual disturbances during transurethral prostatectomy should be suspected of having a TUR reaction.     

Resorption of the lavage fluid during transurethral resection of the prostate. Apropos of 13 cases

The authors report on thirteen patients who developed a variety of symptoms after transurethral resection of the prostate; confusion, seizures, blurred vision with mydriasis, nausea and vomiting, bradycardia, and hypotension. This post-resection syndrome is caused by resorption of a large amount of the hypotonic solution used during the surgical procedure and containing 1.5% glycine. Postoperative sodium levels were assayed in all patients and consistently found to be low (105 to 124 mEq/l). Serum glycine was measured in three patients and the very high levels found suggest that absorption of glycine during transurethral resection of the prostate may contribute to the symptoms of encephalopathy.     

A COMPARISON OF 1.5% GLYCINE AND 2.7% SORBITOL-0.5% MANNITOL IRRIGANTS DURING TRANSURETHRAL PROSTATE RESECTION

PURPOSE: We performed a prospective randomized trial comparing glycine 1.5% with 2.7% sorbitol-0.5% mannitol irrigating solution. We evaluated blood loss, fluid absorption, temperature change, cardiac effects and postoperative symptoms. MATERIALS AND METHODS: Between April 1998 and July 1999, 205 treated patients were included in the statistical analysis. Intraoperative irrigating fluid absorption was measured with the patient on the operating table. Serum cardiac troponin I was used as a marker of perioperative myocardial damage. Operative details were recorded, including the type of anesthesia, resection time and the weight of resected tissue. Postoperative symptoms were documented prospectively. RESULTS: Mean patient age was not significantly different in the glycine and sorbitol-mannitol groups. (72.1 versus 73.7 years). American Society of Anesthesiologists grade was also comparable. Median resection time was 27 minutes and resected tissue weighed a mean of 21 gm. The median resection rate was 0.8 gm. per minute. Blood loss and temperature changes during resection were similar in the 2 groups. Overall median blood loss was 216 ml. and irrigant absorption was 140 ml. In the sorbitol-mannitol group significantly less fluid was apparently absorbed during resection (median 88.2 versus 184.4 ml.). Analysis of the incidence of symptoms of the transurethral prostate resection syndrome did not show any differences in the irrigant groups. Cardiac damage measured using troponin I also showed no significant difference in the 2 groups, although there was a high overall incidence of 7.5%. CONCLUSIONS: We noted no significant differences in 1.5% glycine and 2.7% sorbitol-0.5% mannitol as an irrigating solution for transurethral prostate resection.     

Osmotic and metabolic sequelae of volumetric overload in relation to the TUR syndrome

In an attempt to understand the pathophysiology of the transurethral resection syndrome this prospective metabolic study was conducted on 100 consecutive patients undergoing transurethral resection of the prostate (TURP). The volume of glycine absorbed, intravenous fluid given and blood loss were calculated, and serum osmolality, sodium and glycine were measured before, during and after operation. The mean volume of glycine absorbed, fluid gain and blood loss were 0.6, 1.57 and 0.356 litres respectively. The mean weight of prostate resected was 30.8 g and resection time was 56.5 min. The mean serum osmolality dropped from 291 to 286 mOsm/l, sodium dropped from 138 to 132 mmol/l and glycine concentration increased from 293 to 3599 mumol/l post-operatively. Ten patients developed signs suggestive of the TURP syndrome. Multiple regression analysis showed that the most consistent statistically significant factors in relation to the syndrome were volumetric gain and hypo-osmolality. The latter proved to be the only significant factor later post-operatively. The increase in serum glycine and drop in serum sodium concentrations were the best serological markers, reaching significance only after excluding volumetric gain and osmolality from the analysis.     

Surgical outcomes for men undergoing laparoscopic radical prostatectomy after transurethral resection of the prostate

PURPOSE: We reviewed outcomes for men with a history of transurethral prostate resection who underwent laparoscopic radical prostatectomy for prostate cancer. MATERIALS AND METHODS: Between January 26, 1998 and December 2006, 3,061 men underwent laparoscopic radical prostatectomy at our institution. A retrospective review showed that 119 had a history of transurethral prostate resection. These men were compared to randomized matched controls with regard to operative and postoperative outcomes. The matching criteria used to randomly select patients were clinical stage, preoperative prostate specific antigen and biopsy Gleason score. RESULTS: Mean +/- SD age in the groups with and without transurethral prostate resection was 66.2 +/- 5.6 and 60.7 +/- 7.0 years, respectively (p <0.01). Mean estimated blood loss, transfusion rate, pathological prostate volume and reoperation rate were statistically similar between the groups. Mean length of stay for the groups with and without transurethral prostate resection was 6.5 +/- 3.0 and 5.29 +/- 2.3 days, respectively (p <0.01). Mean operative time for the groups with and without transurethral prostate resection was 179 +/- 44 and 171 +/- 38 minutes, respectively (p = 0.02). Positive margins were seen in 21.8% and 12.6% of the patients with and without transurethral prostate resection, respectively (p = 0.02). A total of 64 complications were seen in patients with a history of transurethral prostate resection compared to 34 in those without such a history (p <0.01). CONCLUSIONS: We report that patients with a history of transurethral prostate resection who undergo laparoscopic radical prostatectomy have worse outcomes with respect to operative time, length of stay, positive margin rate and overall complication rate. This subset of patients should be made aware of these potential risks before undergoing laparoscopic radical prostatectomy.     

Bladder neck resection and transurethral resection of the prostate: a randomized prospective trial

Transurethral resection of the prostate and bladder neck incision are accepted methods in the treatment of obstructive prostatic hyperplasia. Bladder neck incision is particularly useful in cases of small prostates. We have modified the method of bladder neck incision to bladder neck resection. A randomized prospective trial was done to compare the results of conventional transurethral resection of the prostate (30 patients) and the new method of bladder neck resection. Bladder neck resection was comparable to transurethral resection of the prostate with respect to postoperative hospital stay, maximal flow rates and postoperative complications. Bladder neck resection was better than transurethral resection with respect to the operating time, transfusion requirement, volume of irrigation fluid and postoperative urinary infection. We conclude that bladder neck resection is the operation of choice in patients with a prostate of 30 gm. or less.     

Safety and efficacy of a 1,5% glycine solution as an irrigation medium in prostatic surgery

The safety and efficacy of irrigation with a 1,5% glycine solution during transurethral resection of the prostate gland for benign hyperplasia were studied in 21 patients. Absorption of the irrigation solution during the procedure resulted in raised plasma glycine levels immediately after the operation, but these had virtually returned to normal within 24 hours. No adverse effects were noted and all the patients recovered uneventfully. This study demonstrates that glycine is well tolerated as an irrigation medium and appears to be free of complications.     

Venous air embolism during transurethral resection of the prostate

Venous air embolism during transurethral surgery is a rare event. There have been case reports in the anesthesia and urology literature of fatal air embolism during transurethral prostate resection and transurethral incision of the bladder neck. We present a case of nonfatal venous air embolism during transurethral prostate resection in which incorrect assembly of the bladder irrigation-resectoscope-drain system led to a rapid entrainment of air into the open venous channels of the prostate bed.     

Morbidity of radical perineal prostatectomy following transurethral resection of the prostate

Radical prostatectomy in patients who have had prior transurethral resection of the prostate has been reported to result in significant morbidity. From 1974 to 1982, 30 patients who had had previous transurethral resection of the prostate underwent radical perineal prostatectomy for localized prostatic cancer. Operative time and blood loss were similar to a group of patients who had not had prior transurethral resection of the prostate. Over-all, 3 patients (10 per cent) had total incontinence and 3 (10 per cent) had stress incontinence requiring a pad or device. No patient undergoing radical prostatectomy less than 4 weeks or more than 4 months after transurethral resection of the prostate had postoperative incontinence. When radical perineal prostatectomy was performed between 4 weeks and 4 months after transurethral resection of the prostate the incidence of incontinence was 50 per cent. Five patients experienced prolonged perineal urinary drainage, all but 1 of whom healed spontaneously. Of the 6 patients with incontinence 3 had prolonged drainage. No patient had a rectal injury and there was no operative mortality. Two patients died without cancer and 1 has evidence of disease recurrence. We conclude that radical prostatectomy may be performed safely with acceptable morbidity following transurethral resection of the prostate and that if 4 weeks has elapsed since resection it might be advantageous to wait 4 months before performing radical surgery to lessen the risk of incontinence.     

Transurethral resection of the prostate, serum glycine levels, and ocular evoked potentials

Complications of transurethral resection of the prostate (TURP syndrome) when glycine is used as the irrigating fluid include cardiovascular and central nervous system abnormalities that occasionally include transient blindness. Serum sodium, glycine, potassium, chloride, ammonia, osmolality, carbonate, and blood urea nitrogen of 17 patients having TURP and 10 having cystoscopic examination were measured. Electroretinograms and visually evoked potentials (VEPs) were recorded in the preanesthetic preparatory area and in the recovery room immediately after surgery. Four patients reported visual aberrations coincident with increases in serum levels of glycine from a mean before surgery of 137.7 +/- 45.1 to 7,812.2 +/- 2,486.6 microM/l, mean +/- SD, after TURP. These patients also showed a reduction of serum sodium from 138 +/- 4.5 to 122 +/- 8.6 mEq/l that correlated significantly with serum levels of glycine (rho = -0.81). There were no statistically significant changes of serum ammonia and osmolality. Electroretinograms consistently demonstrated complete loss of oscillatory potentials. Thirty hertz flicker-following was also abolished. VEPs were more variably affected with prolongation of component "P100" latency found in both groups and probably resulting from sedative effects of diazepam. Patients experiencing the TURP syndrome showed abolishment of 30 Hz flicker-following in their VEPs. The elevated serum levels of glycine may contribute directly to visual aberrations resulting from glycine's role as an inhibitory transmitter in the retina.     

Bipolar transurethral resection of prostate: a new reference standard?

PURPOSE OF REVIEW: Transurethral resection of prostate is the gold standard for the surgical management of benign prostate hyperplasia. Bipolar devices allow transurethral resection of prostate with saline irrigation, which lessens water intoxication and negates the need for diathermy pad and unwanted stimulation of the obturator nerves and cardiac devices. Several randomized clinical trials compare the various bipolar devices with conventional monopolar ones. For this review, we search all peer-reviewed published literature databases and present the evidence from them to substantiate its advantages and disadvantages. RECENT FINDINGS: Of the various types of bipolar devices, Gyrus has the longest clinical experience. Bipolar transurethral resection of prostate overcomes the shortcomings of bipolar transurethral prostate vaporization, which includes the absence of histology, postop irritative urinary symptoms and nondurable clinical outcomes. With bipolar transurethral resection of prostate, there is lesser bleeding which leads to shorter resection time and lower fluid absorption. This also enables shorter cathterization time and hospital stay. Transurethral resection syndrome has not been observed. SUMMARY: Bipolar transurethral resection of prostate has demonstrated similar clinical efficacy as monopolar transurethral resection of prostate with shorter catheterization and hospital stay. It eliminates the occurrence of transurethral resection syndrome and minimizes bleeding risk. Long term outcomes from these randomized clinical trials will determine the durability of its clinical efficacy and incidence of urethral strictures.     

Erectile Dysfunction Following Transurethral Resection of the Prostate

Purpose

We objectively measured the incidence of erectile dysfunction following transurethral resection of the prostate.

Materials and Methods

A total of 56 men completed a questionnaire detailing perceived sexual dysfunction, and underwent nocturnal penile tumescence testing for 3 nights before transurethral resection of the prostate and again at 3 months postoperatively.

Results

Complete data were available for 40 men. No significant difference was found in penile tumescence, number of erectile events and duration of events before and after surgery. Preoperative and postoperative rigidity was statistically different, with a slight improvement after transurethral resection of the prostate (p less than 0.05). A subjective decrease in quality of erection after transurethral resection of the prostate was reported in 27.5 percent of the patients. However, on further questioning, 63.6 percent of these patients equated retrograde ejaculation with decreased potency.

Conclusions

We demonstrated no decrease in objective parameters of erectile function studies following transurethral resection of the prostate. Previous estimates of impotence after transurethral prostatectomy may have been tainted by subjective patient reports equating retrograde ejaculation with erectile dysfunction.     

Endocrine therapy for bladder outlet obstruction from carcinoma of the prostate

The optimum treatment of bladder outlet obstruction from prostatic cancer is controversial. Although transurethral resection of the prostate may provide immediate relief of the obstruction, there are attendant surgical and anesthetic risks, as well as accumulating clinical evidence to suggest that transurethral resection of the prostate may cause tumor dissemination and diminish patient survival. Orchiectomy, which can be performed safely with local anesthesia, provides definitive endocrine therapy and has been used at our institution in preference to transurethral resection to relieve bladder outlet obstruction from carcinoma of the prostate. There were 35 patients between 51 and 96 years old in urinary retention from carcinoma of the prostate. Patients were treated with orchiectomy and suprapubic or urethral catheter drainage, and subsequently were given voiding trials. If a patient failed to void satisfactorily within 60 days transurethral resection of the prostate was performed. Over-all, 24 of 35 patients (68.6 per cent) were relieved of bladder outlet obstruction by orchiectomy alone. Neither tumor stage nor grade correlated significantly with the response to orchiectomy. We conclude that transurethral resection of the prostate may be held in reserve for patients who do not respond to endocrine therapy or those who do not wish to risk sexual impotence.     

Dose-dependent half-life of glycine

Summary The serum concentration of glycine was measured at hourly intervals after administration of between 10 and 91 g glycine to 17 patients undergoing transurethral resection of the prostate and of between 15 and 22 g glycine to 18 volunteers by intravenous infusion. The apparent half-life of glycine varied 10-fold (range 26–245 min) and increased in direct proportion to the amount of glycine given. This result can be explained by assuming a marked intracellular accumulation of a surplus of glycine. The dose-dependent half-life means that patients who absorb large amounts of irrigating fluid are exposed to excessive blood levels of glycine for a prolonged period of time.