Changes in serum Na+ and blood hemoglobin levels during three types of transurethral procedures for the treatment of benign prostatic hypertrophy

BACKGROUND: Transurethral holmium YAG laser resection of the prostate (HoLR-P) and transurethral electrovaporization of the prostate (TUV-P) have recently received increasing attention as an effective minimally invasive approach for the treatment of prostatic hypertrophy. However, less information is available regarding the intraoperative changes in the serum Na+ and blood hemoglobin levels during either HoLR-P or TUV-P. METHODS: Intraoperative changes in serum Na+ and blood hemoglobin levels were investigated in 17 patients undergoing transurethral resection of the prostate (TUR-P, n = 7), HoLR-P (n = 7) or TUV-P (n = 3). The 3% D-sorbitol solution was used as the irrigating fluid in all the patients. RESULTS: In three patients, severe hyponatremia (118-123 mEq x l(-1)) developed abruptly (< or = 15 min) at various time points during TUR-P with (n = 1) or without (n = 2) cystostomy. However, no clinical symptoms were observed after development of the hyponatremia in those awake patients. No large (> 10 mEq x l(-1)) decreases in the Na+ level were observed in any of the patients undergoing HoLR-P or TUV-P. In patients undergoing TUR-P and HoLR-P, percent changes in serum Na+ level significantly correlated with those in blood hemoglobin level, but not with the resection time; the slopes were significantly larger than unity. CONCLUSIONS: The TUR syndrome is less likely to occur during HoLR-P or TUV-P. During TUR-P, the onset of severe hyponatremia appears to be unpredictable, and may not necessarily be accompanied by clinical symptoms. Frequent measurements of the serum Na+ level appear essential for early detection of severe hyponatremia.     

Coma from hyponatremia following transurethral resection of prostate

Even though hyponatremia may occur following transurethral resection of the prostate (TURP), only 14 patients of a large TURP population deteriorated to a comatose state as a result of hyponatremia. These patients were generally older, with larger prostates, and longer resection times than the average for transurethral resection of the prostate. They also consistently had serum sodium levels postoperatively of near 120 mEq./L. or below. It was noted that obtundation can occur immediately or be delayed several hours. Even though no deaths occurred, awareness of the possibility of post-TURP hyponatremia and prompt treatment with hypertonic saline were shown to reduce morbidity significantly.     

Transurethral prostatectomy complicated by intraperitoneal extravasation of irrigating fluid

A patient underwent transurethral resection of the prostate (TURP), which was complicated at the outset of the procedure by an inadvertent puncture wound of the dome of the bladder and the peritoneum. Shortly after resection was initiated, the patient developed shoulder pain and a tensely distended abdomen, although at this time the serum sodium concentration remained normal. Over the next several hours the patient developed significant hyponatremia. The prolonged and gradual time course of this development suggests that fluid and electrolyte shifts occurred via diffusion across the peritoneal membrane. This case illustrates a rare but potentially dangerous complication of TURP that requires recognition prior to initiation of appropriate therapy.     

Severe hyponatremia without severe hypoosmolality following transurethral resection of the prostate (TURP) in end-stage renal disease

A 55-year-old man on chronic hemodialysis underwent a transurethral resection of the prostate (TURP), during which 3% sorbitol solution was used for urethral irrigation. Following the procedure, he developed symptomatic hyponatremia (serum sodium, 106 mEq/L), but had only mild hypoosmolality (serum osmolality, 269 mosm/kg). The "osmolal gap" was 47 mosm/kg, probably from sorbitol absorbed systemically during the TURP. Hemodialysis raised the serum sodium to 118 mEq/L, and the serum osmolality to 284 mosm/kg, while lowering the osmolal gap to 26 mosm/kg. The presence of severe hyponatremia with only modest hypoosmolality may occur in patients with renal failure following the systemic absorption of hypotonic fluids containing solutes such as sorbitol and mannitol. Hemodialysis offers the advantages of correcting the hyponatremia while removing the unmeasured solute, thus preventing rapid increases in the serum osmolality.     

Hyponatraemia after transurethral resection of the prostate

Transurethral resection (TUR) syndrome is a complication of transurethral resection of the prostate characterized by bradycardia, hypotension and postoperative confusional state, which is generally attributed to hyponatraemia occurring during or immediately after operation. In a prospective study of 100 consecutive patients undergoing transurethral resection of the prostate, changes in serum sodium were estimated before and after operation and correlated with various parameters including weight of prostate resected, volume of irrigant fluid and resection time. Seven patients showed a significant drop (greater than 10 mmol/litre) in serum sodium: two of these had the clinical features of TUR syndrome and one of them died. The pathogenesis and management of this syndrome are discussed.     

Hyponatremia during transurethral resection of the prostate

In a retrospective study of 222 patients who underwent transurethral resection of the prostate under spinal anesthesia, plasma sodium levels during the operation were examined. The weight of prostate resected, the volume of irrigating fluid used and the duration of the operative procedure influenced the changes in plasma sodium levels. But, these changes were not statistically significant. The rise in central venous pressure values was associated with the absorption of irrigating fluid as evidenced by a drop in plasma sodium. The central venous pressure was monitored in 77 patients. There was a statistically significant correlation between the degree of hyponatremia and the rise in central venous pressure (P less than 0.001). The rise in central venous pressure reflected a change in the patient's cardiovascular status and it was, therefore, possible to treat the hyponatremia quickly and effectively. Central venous pressure monitoring is helpful in determining hyponatremia before it becomes clinically manifest.     

Das gynäkologische „TUR-Syndrom“

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.     

Spinal versus epidural anesthesia during transurethral resection of the prostate.

The operative superiority of epidural anesthesia during transurethral resection of the prostate (TURP) stimulated this study. Twenty patients scheduled for TURP were randomly allocated to receive either spinal anesthesia (n = 10) with 8 ml bupivacaine 0.5%+ 5ml lignocaine 2%. During and after the operative procedure, PR, BP, ECG, and pulse oximetry were monitored, and blood Hb and Hct, plasma free Hb, and serum sodium and potassium levels were measured. Both techniques resulted in similar PR and BP changes. TURP with spinal anesthesia resulted in more prolonged period of hyponatremia and more increased duration of raised plasma free Hb.     

Transurethral resection syndrome detected and managed using transesophageal Doppler

Transurethral resection syndrome during transurethral resection of the prostate (TURP) results from excessive absorption of electrolyte-free irrigation fluids causing acute hypervolemia and hyponatremia. Neuraxial anesthesia is often recommended for TURP procedures because early signs of neurological deterioration can be detected. However, in patients requiring general anesthesia, other continuous and noninvasive measures are needed. Acute intravascular hypervolemia should be reflected by changes in hemodynamic values. Transesophageal Doppler ultrasonography of the aorta allows determination of stroke volume and other advanced hemodynamic variables related to intravascular volume status. We describe the first case of intraoperative detection of a TURP syndrome by noninvasive Doppler monitoring of hemodynamic variables during TURP.     

经食道多普勒超声对于经尿道电切综合征的发现和处理

经尿道前列腺切除术（TURP）中发生的电切综合征是由于过度吸收不含电解质的灌洗液,导致的急性血容量超负荷和低钠血症。椎管内神经阻滞麻醉常被推荐用于TURP,这样可以及时发现神经系统损伤的早期征象。但是对于那些需要全身麻醉的患者则需要有其他持续的无创监测。急性血容量超负荷可以通过血流动力学参数的改变来反映。对主动脉进行经食道多普勒超声成像监测可以测定每搏量和其他与血容量状态相关的血流动力学参数。本文中我们报道第1例在TURP术中通过无创多普勒超声监测血流动力学参数,而发现TURP综合征的情况。     

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.     

Anaesthesia and prostate surgery

OBJECTIVES: To review the current data about anaesthetic management in prostate surgery with special regards on analysis and prevention of specific risks, appropriate anaesthetic procedure keeping with surgery and patient, recognition and treatment of adverse events. DATA SOURCES AND EXTRACTION: The Pubmed database was searched for articles (1990-2004) combined with references analysis of major articles on the field. DATA SYNTHESIS: It is strongly recommended to settle germfree urine in the preoperative period. The thromboembolic risk of radical retropubic prostatectomy for cancer parallels lower abdomen oncologic surgery and is prolonged. Preoperative evaluation of cardiovascular, respiratory, neurological and metabolic comorbidity is a source of prognostic information and an essential tool in the management of elderly patients with prostate disease. Extreme patient positioning applied in prostate surgery induces haemodynamic and respiratory changes and are associated with severe muscular and nervous injuries. The laparoscopic access for radical prostatectomy is a growing alternative to the open surgical procedure. Acute normovolaemic haemodilution is a consistent and cost-effective blood conservation strategy in reducing allogenic blood transfusion for radical retropubic prostatectomy. Whether open transvesical or transurethral prostatectomy for treatment of benign hypertrophy depends on the size of the gland: transurethral resection is safe up to 80 g. Intrathecal anaesthesia with a T9 cephalad spread of sensory block, produces adequate conditions for transurethral prostatectomy and allows a rapid diagnosis of irrigating fluid absorption syndrome. In spite of recommended preoperative antibiotic prophylaxis, bacteriemias are frequent during transurethral prostate resection.     

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.     

Ethanol monitoring of transurethral prostatic resection during inhaled anesthesia.

The purpose of this study was to examine the precision of a method of breath-alcohol analysis used to monitor absorption of irrigating fluid during transurethral resection of the prostate performed under inhaled anesthesia. A breath-alcohol analyzer (Alcolmeter SD-2) was placed between the endotracheal tube and the Bains' circuit. The concentration of ethanol in the breath, serum sodium concentration, and volumetric fluid balance were measured at 10-min intervals during 38 operations when the irrigating fluid contained 1.5% glycine and 1% ethanol. Ethanol monitoring detected absorption rates that exceeded 14 +/- 8 mL/min (mean +/- SD). In 17 patients in whom hyponatremia developed immediately in connection with absorption, the volume of irrigating fluid absorbed (up to 1950 mL) could be predicted from a single expired-breath test with a standard error of 325 mL. When the alcohol measurements were corrected for absorption time, the standard error was 215 mL. Seven other patients received 2.2% wt/vol glycine as irrigating fluid, and ethanol (0.35 g/kg) was administered by intravenous infusion. The direct and indirect measurements of the blood-alcohol concentration agreed well. These results confirm that ethanol monitoring is a viable technique during inhaled anesthesia for transurethral resection of the prostate.     

Changes in the serum concentrations of sodium,potassium, and free haemoglobin during transurethral resection of the prostate — parts of the TUR-syndrome?

Summary In 133 patients undergoing transurethral resection of the prostate under standardized conditions the concentration of serum sodium decreased, and the concentration of free plasma haemoglobin increased significantly after the operation. Such changes were not found in a control group of 31 patients undergoing cystoscopy or bladder biopsy. The changes in the operated group are believed to be caused by the absorption of water used as irrigating fluid during the resection.     

Time to rebrand transurethral resection of the prostate?

PURPOSE OF REVIEW: Transurethral resection of the prostate remains the gold standard treatment for benign prostatic obstruction. Owing to the significant morbidity traditionally associated with the procedure, a large number of expensive, high-energy alternative treatments have been developed, which have enjoyed varying degrees of success. At the same time, transurethral resection of the prostate has evolved into a safer operation whilst maintaining its excellent efficacy. This review aims to outline the major advances that have occurred recently in transurethral resection of the prostate. RECENT FINDINGS: Optimizing each stage of transurethral resection of the prostate can result in reduced morbidity. Preoperative treatment with oral antiandrogens and 5-reductase inhibitors appears to reduce intraoperative bleeding, appropriate prophylactic antibiotic regimens reduce postoperative infection rates, improved instrumentation and diathermy delivery can reduce intraoperative bleeding and hence reduce postoperative irrigation requirements, and alcohol monitoring of irrigant absorption can eliminate transurethral resection syndrome. Careful patient selection, meticulous surgical technique combined with an aggressive postoperative irrigation and catheter removal policy can result in transurethral resection of the prostate being performed safely on a day-case basis. SUMMARY: Whilst our attention has been distracted by the many alternative treatments brought to the market over the past decade or so, transurethral resection of the prostate has been undergoing a quiet evolution. With fine tuning of all aspects of the patient journey we can now offer a procedure with excellent long-term efficacy combined with reduced morbidity and inpatient stay.     

Technological advances in transurethral resection of the prostate: bipolar versus monopolar TURP

One of the most significant recent advancements in transurethral resection of the prostate (TURP) is the incorporation of bipolar technology. Bipolar circuitry allows TURP to be performed in a normal saline environment, which addresses a fundamental concern of conventional monopolar TURP (i.e., the use of hypo-osmolar irrigation). As a result, the risks of dilutional hyponatremia and transurethral resection (TUR) syndrome are eliminated, allowing for longer and safer resection. This review discusses the principles and applications of electrosurgery in conventional monopolar as well as new bipolar saline-based TURP systems. This review also addresses the positive impact on patient safety and resident training.     

Isotonic hyponatremia and cerebrospinal fluid sodium during and after transurethral resection of the prostate

We examined the effects on the central nervous system of hyponatremia during transurethral resection of the prostate (TURP). Initially, a prospective study was done on 165 consecutively treated patients undergoing TURP, to evaluate symptoms related to the serum osmolality. There were ten patients with hyponatremia below 120 mEq·L⁻¹, and in whom the serum sodium decreased to 111.9±6.4 mEq·L⁻¹ (mean±SD) postoperatively, the measured serum osmolality remained near normal. The calculated osmolality decreased to 237.4±11.9 mOsm·kg⁻¹ and the estimated osmolar gap was 33.5±10.4 mOsm·kg⁻¹ due to absorption of the irrigating sorbitol. Neurological symptoms were mild and complications such as seizures or loss of consciousness nerver occurred. There were five other patients with hyponatremia (serum sodium 118.0±6.7 mEq·L⁻¹) from whom lumbar cerebrospinal fluid (CSF) was collected before and after TURP through a single puncture. CSF sodium did not decrease throughout 1.5 h after TURP, and there was a CSF-to-serum sodium gradient. Our study shows that in cases of acute dilution hyponatremia during and after TURP, symptoms are mild because the serum osmolality remains near normal and CSF sodium does not decrease despite severe postoperative hyponatremia.     

Rotoresection versus transurethral resection of the prostate: short-term evaluation of a prospective randomized study

PURPOSE: We compared in a prospective fashion the short-term outcome of rotoresection to transurethral resection of the prostate. MATERIALS AND METHODS: A total of 50 patients with bladder outlet obstruction secondary to benign prostatic hyperplasia were randomized into 2 groups, rotoresection and transurethral resection of the prostate. Mean+/-SD patient age was 60.76+/-5.85 years in the rotoresection and 64.24+/-6.84 in the transurethral resection groups. All patients had an International Prostate Symptom Score of 8 or more, maximum free flow rate less than 15 ml per second, prostate volume 20 to 100 ml and prostate specific antigen 1 to 4 ng/ml. Pressure flow study revealed bladder outlet obstruction (Schafer's grade 3 or more). Patients were assessed at 1, 3 and 6 months by International Prostate Symptom Score, maximum free flow rate, transrectal ultrasound, pressure flow study, hemoglobin and urinalysis. RESULTS: At 6 months International Prostate Symptom Score decreased from 26.2+/-4.06 to 5.32+/-1.52 in the rotoresection group and from 22.84+/-4.56 to 7+/-1.4 in the transurethral resection group. Maximum free flow rate increased from 7.87+/-2.24 to 25.29+/-10.39 ml per second in the rotoresection group and from 9.44+/-2.29 to 25.2+/-5.8 ml per second in the transurethral group. Prostate volume decreased from 41.2+/-16.58 to 17.24+/-7.61 ml in the rotoresection group and from 40.6+/-16.93 to 18.28+/-8.75 ml in the transurethral group. Detrusor pressure at maximum flow and Schafer grade decreased from 79.84+/-26.8 cm H2O and 4.24+/-0.97 to 38.8+/-18.8 cm H2O and 1.24+/-0.93 in the rotoresection group, and from 63.04+/-21.08 cm H2O and 3.48+/-0.65 to 34.16+/-12.7 cm H2O and 1+/-0.7 in the transurethral group. Dilutional hyponatremia was higher with transurethral resection of the prostate (p=0.005) but no patient showed manifestations of the transurethral syndrome. Mild stress urinary incontinence was noted in 4 patients in the rotoresection group and in 3 in the transurethral group. CONCLUSIONS: Rotoresection is a safe and effective method of treating bladder outlet obstruction resulting from benign prostatic hyperplasia, and its efficacy is comparable to transurethral resection of the prostate.     

Therapeutic approach to hyponatremia

Hyponatremia is a relatively common disorder occurring in up to 6% of hospitalized patients and can occur through any mechanism that produces a relative excess of body water to body sodium. Although most hyponatremia patients are asymptomatic, severe symptomatic hyponatremia is a medical emergency that may lead to cerebral edema, tentorial herniation and death. More aggressive therapy is indicated in these patients. However, in some patients, the treatment itself may result in central nervous system demyelination that may be associated with permanent neurologic sequelae. The therapeutic strategy that should guide optimal treatment of hyponatremia requires attention to the following four factors: the patient's volume status, the presence or absence of symptoms, duration of hypo-osmolality, and the presence or absence of risk factors for the development of neurologic complication. An initial categorization according to the clinical ECF volume status of the patient will allow a determination of the appropriate initial therapy in the majority of cases. The importance of duration of hyponatremia and the presence or absence of symptoms relates to how well the brain has adapted to the hyponatremia. The severity of hyponatremia is also an important consideration because osmotic demyelination is rarely seen in patients with the initial serum sodium greater than 120 mEq/l. Clinical surveys have identified subgroups of patients at greatest risk for developing neurologic complication of hyponatremia. Optimal therapy of these patients must consider balancing the risks of hyponatremia against the risks of correction for each patient individually. Although individual variability in response to treatment is considerable, consensus guidelines for treating hyponatremic patients allow a rational and safe therapeutic approach to minimize the neurologic complications.