Monitoring of irrigating fluid absorption during transurethral prostatectomy

A simple, reliable method to detect absorption of irrigating fluid during transurethral prostatectomy is to tag irrigating fluids with 1% ethanol and monitor expired breath ethanol concentrations. This method correlated well (n = 0.79) with other existing methods of absorption monitoring in 20 anaesthetised patients. Ethanol (1%) tagging does not alter the optical quality of the irrigating fluid and is harmless to the patient. The technique is non-invasive, repeatable, cheap and gives instant results. It can be used in anaesthetised or awake patients and can detect absorption of as little as 100-150 ml in any 10-minute period.     

Central pontine myelinolysis: sequele of hyponatremia during transcervical resection of endometrium

Transcervical resection of endometrium is an alternative to hysterectomy for women with menorrhagia. The procedure involves the use of cutting loop diathermy to resect the endometrium while the uterine cavity is irrigated with 1.5% glycine which can absorb consequent fluid and electrolyte shifts. Severe hyponatremia leading to central pontine myelinolysis is an extremely rare complication of this procedure. We report a case of a young female undergoing transcervical resection of endometrium for menorrhagia, who developed central pontine myelinolysis but made a complete recovery after three months.     

Transurethral vaporisation of the prostate and irrigating fluid absorption

Transurethral vaporisation of the prostate gland (TUVP) is an emerging surgical alternative to conventional electroresection (TURP). This study examined vesical pressure and fluid absorption during TUVP in 35 patients with benign prostatic hypertrophy. The irrigating fluid was a solution of glycine 1.5% and ethanol 1%. Intraoperative intravesical pressure was monitored continuously and absorption of irrigating fluid was detected by ethanol analysis in expired breath. The incidence of absorption during TUVP was 34%. Intravesical pressures were higher amongst patients who went on to absorb than amongst patients who did not. Combining data from the current study and from 35 patients in our previous investigation into TURP (Gray et al.: Anaesthesia 2001; 56: 461-4), urological trainees operated at higher mean pressure and for longer than their consultant colleagues and their resections were significantly more likely to result in absorption. The incidence of irrigating fluid absorption during trainees' operations appeared to be less using TUVP than using conventional TURP.     

Ethanol monitoring of the transurethral resection syndrome

Ethanol monitoring is a fairly new method of assessing fluid absorption during transurethral resection of the prostate (TURP). By using an irrigating fluid containing a trace amount of ethanol, the absorption can be measured by expired-breath tests. We describe a TURP in which large-scale absorption of irrigating fluid occurred despite the use of a pressure-warning device set at 10 cm H₂O. The surgeon decided to terminate the operation because 1.0 liters of fluid had been absorbed over 10 minutes, and another 1.0 liter was absorbed during the 10 minutes required to conclude the surgery. The high absorption rate suggests that continued resection would have promoted a severe transurethral resection syndrome. This was prevented by the indication given by the breath test, whereas the pressure-warning device failed to do so.     

Blood glucose after ethanol monitoring of irrigating fluid absorption in transurethral surgery

The purpose of this study was to assess the risk of alcohol-induced hypoglycaemia from the use of irrigating fluids containing ethanol in transurethral surgery. In the first part of the study, seven healthy male volunteers, aged between 26 and 36, received 1000 ml of irrigating fluid by intravenous infusion. The results confirm the existence of an alcohol-induced decrease in blood glucose when ethanol is given together with 1.5% glycine. In the second part of the study, 40 patients, between 56 and 88 years of age, underwent epidural anaesthesia and a transurethral resection of the prostate (TURP) in which the irrigating fluid used contained 1.5% glycine and either 1% or 2% ethanol. The results suggest that the use of ethanol-containing irrigating fluids is often followed by a slight reduction of the blood glucose level, but the magnitude of this change is too small to be of clinical importance.     

Ethanol monitoring of irrigating fluid absorption in transurethral prostatic surgery

The ethanol concentration in expired breath (EB-ethanol(A] was repeatedly measured in 50 patients undergoing transurethral prostatic surgery in which the irrigating fluid was 1.5% glycine + 2% ethanol in water. EB-ethanol(A) was compared at 10-min intervals to the serum sodium concentration, the serum glycine concentration, and the absorbed volume of irrigant. The EB-ethanol(A) was found to be related directly to the serum glycine concentration (R2 = 0.75) and, inversely, to changes in the serum sodium concentration (R2 = 0.81). The cumulative absorbed volume of irrigant could be predicted from a single EB-ethanol(A) reading at the end of each 10-min interval (R2 = 0.82); the reliability was improved by taking into account the absorption time (R2 = 0.89). Extravasation of irrigating fluid was indicated by a stable or increasing EB-ethanol(A) after the ethanol-tagged irrigant had been discontinued. Ethanol monitoring is a simple and inexpensive method of testing for the presence, and measuring the degree, of irrigant absorption in transurethral prostatic surgery.     

Various methods of determining irrigating fluid absorption during transurethal resection of the prostate

Summary A review is presented of all methods, nonquantitative as well as quantitative, applied in the determination of absorption of irrigating fluids used during transurethral resection of the prostate. The nonquantitative methods are clinical observations of pulmonary edema, cerebral edema, cardiac failure, mental agitation, hypertension, hemolysis, large postoperative diuresis, unexplained decrease in hematocrit, transient bacteremia, osteomyelitis, hyperglycemia, and extravasation of contrast medium. To determine total absorption in clinical practice the volumetric or gravimetric methods are the most reliable. The use of radioindicators added to the irrigation fluid is recommended for discrimination between intravascular and extravascular absorption. For this purpose 131 I-macroaggregated human serum albumin has the most advantages: low radiation hazard with good sensitivity, possibility of quantitative external monitoring of intravascular absorption, short time delay of the activity accumulation, and additional quantitative measurement of extravascular absorption.This work was supported in part by the Deutsche Forschungsgemeinschaft.     

Visual evoked potentials and visual acuity after transurethral resection of the prostate

Changes in visual evoked potentials, visual acuity, blood ammonia levels and serum electrolytes (Na+ and K+) after transurethral resection of the prostate using glycine as an irrigating fluid performed under subarachnoid block were studied in 12 patients, in the pre-operative and immediate postoperative periods. Visual evoked potentials (p100 latency), recorded by shift of a checkerboard pattern, increased significantly from a pre-operative value of mean (SEM) 101.18 (1.63) msec in the right eye, and 102.5 (1.47) msec in the left eye to 108.91 (1.8) msec (p less than 0.01) and 108.08 (2.53) msec (p less than 0.01) respectively in the postoperative phase. There were no changes in visual acuity as assessed by a Snellen's chart, blood ammonia levels and serum electrolyte concentrations. The amount of glycine used intra-operatively for irrigation ranged from 3 to 31 litres.     

Duodenum-preserving resection of the head of the pancreas

Summary. Duodenum-preserving resection of the head of the pancreas was developed 25 years ago by Beger. This procedure is indicated in patients suffering from chronic pain in combination with inflammation of the head of the pancreas, common bile duct obstruction, pancreatic duct obstruction and/or obstruction of the retropancreatic vessels. At the Inselspital in Berne, 74 patients underwent this operation between 1993 and 1996. The median length of the operation was 380 min, with the need for transfusion in a median of 0 units (0–6). There was no postoperative mortality. Total postoperative morbidity was 13 %. One patient needed relaparotomy on day 17 for small bowel obstruction. Median length of hospital stay was 11 days. Postoperatively, two patients developed diabetes. Duodenum-preserving resection of the head of the pancreas represents an organ-preserving principle of surgery. This procedure treats the complications of chronic pancreatitis and provides long-term pain relief in more than 80 % of patients.      

1％乙醇标记法连续定量监测TURP术灌洗液吸收的初步研究

目的　用 1%乙醇标记经尿道前列腺切除 (TURP)术灌洗液 ,研究呼出气乙醇浓度与血管内吸收量的关系。方法　 2 5例TURP术患者 ,3%甘露醇膀胱灌洗液加乙醇 (终浓度 1% ) ,采用偶联酶法和Evan氏蓝染料稀释法测定呼出气乙醇浓度和血浆容量 ,以血浆容量变化值估计血管内吸收量 ,分析吸收量与呼出气乙醇浓度的相关性。结果　吸收量与呼出气乙醇浓度明显相关 (r =0 842 ,P <0 0 1) ,回归方程R2 =0 90 2 ,P <0 0 0 1;将冲洗时间加入多元分析 ,回归方程R2 =0 92 7,P <0 0 0 1。结论　乙醇标记监测法安全、简便、无创、无污染 ,与灌洗液吸收入血量相关性好 ,考虑时间因素的多元回归方程可用于临床定量监测TURP术灌洗液吸收。     

ECG and cardiac enzymes after glycine absorption in transurethral prostatic resection

The electrocardiogram (ECG) was recorded and the serum levels of creatine kinase (CK), aspartate transaminase (ASAT) and prostatic acid phosphatase (PAP) were measured in 22 patients undergoing transurethral resection of the prostate (TURP) under spinal or epidural anaesthesia. The irrigating fluid consisted of 1.5% glycine and 1 % ethanol, and absorption of the fluid was monitored by detection of alcohol in the expired breath. The results show that nine of the 11 patients (82%) who absorbed more than 1, 000 ml of irrigating fluid had developed ECG changes 24 h after the operations. The most common alteration was depression of the T wave. This sign was only seen in one (9%) of the patients who absorbed none or very small amounts of irrigating fluid ( P < 0.001). The serum activity of CK and ASAT increased in five patients who also developed ECG changes, and the highest values were recorded 24 h after TURP. The CK–MB isoenzyme was detected in 85% of the samples with elevated total CK, but the criteria for myocardial infarction were never fulfilled. In contrast, PAP increased in all patients and the highest level occurred at the end of TURP. The activity–time profiles suggest that CK and ASAT entered the circulation by a mechanism different from that of PAP. We conclude that absorption of glycine solution during TURP is frequently followed by nonspecific ECG signs of altered cardiac function and also that the serum activities of CK and ASAT increase is some of these patients.     

不同体位对经尿道前列腺等离子双极电切术患者术中冲洗液吸收的影响

目的:观察头低足高截石体位(LP)对接受经尿道前列腺等离子双极电切术(PKRP)患者术中冲洗液吸收的影响。方法:80例BPH患者,择期在腰硬联合麻醉下行PKRP术,随机分为两组,每组40例:0°LP组,常规截石体位,手术床保持水平;-10°LP组,常规截石体位,手术床头低足高倾斜10°。采用含1%乙醇的生理盐水溶液作为术中冲洗液。手术开始即刻,以及随后每10 min应用数字乙醇检测仪对患者呼出气中乙醇浓度进行测试并记录。同时记录两组手术时间,手术期间静脉输注晶体及胶体液量和切除前列腺组织的重量。监测并记录患者的平均动脉血压(MAP)和心率(HR),比较两组患者手术开始前5 min,开始后30 min,手术结束时的MAP和HR。通过动脉血气分析,测定手术开始前、开始后1 h动脉血Na^+、K^+、Cl^-、Ca^2+浓度。结果:两组患者年龄、身高、体重、前列腺体积等无显著差异,术中各时间点MAP和HR亦无显著差异。与术前5 min相比,0°LP组患者手术开始后1 h测得K^+及Ca^2+浓度显著低于术前水平[K^+:(3.49±0.33)mmol/L vs(3.64±0.29)mmol/L,P=0.002;Ca^2+:(1.13±0.04)mmol/L vs(1.16±003)mmol/L,P=0.001],Cl-浓度显著高于术前水平[(108.7±2.3)mmol/L vs(106.9±2.2)mmol/L,P=0.006],而Na^+浓度无明显变化[(139.4±1.6)mmol/L vs(139.7±1.5)mmol/L,P=0.231]。-10°LP组患者Ca^2+浓度低于术前[(1.13±0.04)mmol/L vs(1.14±0.04)mmol/L,P=0.016],Na^+[(140.0±2.0)mmol/L vs(140.3±1.8)mmol/L,P=0.156]、K+[(3.47±0.34)mmol/L vs(3.49±0.36)mmol/L,P=0.506]及Cl^-[(109.1±2.5)mmol/L vs(108.2±2.6)mmol/L,P=0.071]浓度均无明显变化。0°LP组有6例患者(15%),-10°LP组有4例(10%)患者术中冲洗液吸收量>1500 ml,两组比较无统计学差异。结论:头低足高倾斜10°截石位,显著减轻PKRP手术导致的K^+降低,Cl^-升高,但不影响其他电解质变化。     

Intravesical pressure during irrigating fluid absorption in transurethral resection of the prostate

OBJECTIVE: In order to control fluid absorption, various approaches are used to reduce intravesical pressure during transurethral resection of the prostate (TURP). With a view to finding a target pressure for such efforts, pressure and fluid absorption were compared in a meta-analysis of four previous studies comprising three different irrigation techniques. MATERIALS AND METHODS: Intravesical pressure was recorded during TURP in which the irrigating fluid was evacuated intermittently (n = 48) by a suprapubic tube (n = 23) or a trocar (n = 30). Fluid absorption was compared with the mean and maximum pressures and the duration of excessive pressure (>2 kPa) over 10-min periods. RESULTS: Mean bladder pressure during fluid absorption was between 1.0 and 2.5 kPa. The maximum pressure during absorption varied greatly during the first 30 min of TURP, but thereafter it ranged between 2 and 3 kPa. Only the duration of pressures >2 kPa increased with fluid absorption (p < 0.02). The maximum pressures were highest with the intermittent technique, while the other indices of intravesical pressure showed the highest values when the suprapubic tube was used. The lowest pressures usually occurred when the trocar was used, but fluid absorption still occurred, as the pressure was much higher during some of these operations. CONCLUSIONS: Fluid absorption occurred at moderate intravesical pressures with all three irrigation techniques. The best strategy for reducing fluid absorption is to keep the pressure below 2 kPa for as long as possible during TURP.     

Hypertonic saline for intraoperative fluid therapy in transurethral resection of the prostate

We tested hypertonic saline solution (HS) to determine its effectiveness in surgical procedures for prostatic hypertrophy. We randomly selected 40 patients undergoing elective transurethral resection of the prostate for either infusion of HS (3% NaCl) at 4ml·kg⁻¹·min⁻¹ (HS group) or lactated Ringer's solution (LR) at 8 ml·kg⁻¹·min⁻¹ (LR group). Anesthesiologists regulated the intraoperative infusion rate as needed to maintain blood pressure. There were no differences in systolic blood pressure, heart rate, central venous pressure, or arterial blood oxygenation between the two groups. In the HS group, plasma sodium, chloride, and osmolality, measured in the recovery room, were significantly increased; however, they returned to preanesthetic levels the day after surgery. In the LR group, in contrast, plasma sodium decreased significantly and this lower value persisted for 1 day. An osmolar gap exceeding 10mOsm·kg⁻¹ was observed in 2 patients in the HS group, but plasma sodium remained at normal values. However, in the 1 patient in the LR group whose osmolar gap exceeded 10mOsm·kg⁻¹, plasma sodium was 115 mEq·I⁻¹. HS, at a low dose, is useful in the intraoperative management of transurethral resection of the prostate.     

经尿道前列腺电切术后出血原因分析及处理

目的探讨经尿道前列腺电切术(TURP)后出血的原因及处理方法。方法对行TURP术的316例患者的临床资料进行回顾性分析。结果316例患者中,28例术后出血,其中术后早期出血23例,迟发性出血5例;26例经保守治疗治愈,2例经电切镜止血。结论术中确切止血及术后引流通畅是预防TURP术后出血的关键;术后及时发现出血并正确处理可避免再次手术,对膀胱内充满血块不能吸出者电切镜下止血是一种安全有效的方法。     

Contemporary outcomes of palliative transurethral resection of the prostate in patients with locally advanced prostate cancer

Background

Advanced prostate cancer may cause significant local complications which affect quality of life, including bladder outlet obstruction and hematuria. We performed a detailed review of our outcomes of palliative transurethral resection of the prostate (pTURP) in the era of taxane chemotherapy and potent androgen receptor antagonists at our tertiary-care institution.

Monitoring of fluid absorption with nitrous oxide during transurethral resection of the prostate

Background: The fluid absorption that occurs during transurethral resection of the prostate (TURP) can be indicated and quantified by the ethanol method. Recently, nitrous oxide (N₂O) was tested in animals and volunteers and seemed to be more accurate and safe. The present study compared these two methods in surgical patients.
Methods: Eighty-six TURPs were performed at two hospitals using an irrigating fluid that contained 3% mannitol, 1% ethanol and 0.004% N₂O (40 ml/l). The ethanol concentration was measured by end-expiratory tests every 10 min. The N₂O concentration was measured by a flared nasal cannula every second. Fluid absorption was calculated based on a regression equation (ethanol method) from the area under the curve based on the samples where CO₂ >median (N₂O method).
Results: Thirteen patients (15%) absorbed >300 ml of fluid as indicated by the ethanol method. The median volume was 707 ml (range 367–1422). Ethanol yielded higher figures for fluid absorption up to 700–800 ml, whereafter the N₂O method indicated that the absorption was larger. Over the entire range, the mean difference between the two methods at the end of any 10-min period of TURP was only +45 ml, although the 95% limits of agreement were quite separated (−479 to +569 ml).
Conclusions: The N₂O method does not require forced breath sampling and was successfully apply clinically. However, there was a dose-dependent difference in result between the ethanol and N₂O methods, which markedly separated the limits of agreement for a wider range of fluid absorption events.     

经尿道前列腺等离子双极电切术与普通电切术中失血量比较

目的比较经尿道前列腺等离子双极电切术与普通电切术中失血量。方法自2007年10月至2008年3月,收治的30例BPH患者行经尿道等离子双极电切（PKRP）;自2008年4月至7月,收治的30例BPH患者行普通电切（TURP）。分析这60例患者的临床资料。PKRP组年龄（74．2±7．0）岁,前列腺体积（49．3±33．1）ml;TURP组年龄（73．2±7．2）岁,前列腺体积（51．1±23．2）ml。收集术中所有冲洗液,测冲洗液体积,混匀后精确测血红蛋白浓度。结果PKRP组手术时间（111．3±42．5）min,切除前列腺组织重量（20．1±14．3）g,失血量（86．3±79．9）ml,每克前列腺组织平均失血量（3．7±1．9）ml／g;TURP组手术时间（108．0±42．2）min,切除前列腺组织重量（23．6±13．1）g,失血量（201．8±178．7）ml,每克前列腺组织平均失血量（8．3±6．1）ml／g。PKRP组和TURP组手术时间及切除前列腺组织重量差异无统计学意义（P〉0．05）。PKRP组术中失血量少于TURP组（P〈0．01）。PKRP组每克前列腺组织平均失血量少于TURP组（P〈0．01）。结论经尿道前列腺等离子双极电切术中失血量少于普通电协。