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.     

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.     

Serum amino acid patterns and toxicity symptoms following the absorption of irrigant containing glycine in transurethral prostatic surgery

The relationships between the serum concentrations of amino acids, the volume of irrigating fluid absorbed and symptoms of glycine toxicity were analysed in 18 patients who had undergone transurethral resection of the prostate and in whom intravascular absorption of irrigating fluid containing 2.2% glycine had been recorded. A mean of 7% of the transferred glycine could be detected in the serum within 10 min of irrigant absorption. The half-life of glycine in serum was twice as long when the volume of irrigant absorbed exceeded 1500 ml (100 min; n = 6), and the serum levels of alanine, aminobutyrate, proline and serine were significantly more elevated, than when the volume of irrigant absorbed was between 900 and 1300 ml (n = 6). Where the amount of glycine transferred exceeded 0.5 g.kg-1, symptoms of glycine toxicity developed, their onset coinciding with a rapid increase in the serum levels of non-essential amino acids other than glycine.     

Ethanol monitoring of irrigating fluid absorption in transcervical resection of the endometrium

Background . We evaluated the precision in using ethanol to indicate and quantify absorption of irrigating fluid during transcervical resection of the endometrium.
Methods . The ethanol concentration in the expired breath, the serum sodium level, the blood loss and the volumetric fluid balance were measured over 10-min periods during 62 operations. A solution containing glycine 1.5% and ethanol 1% was used to irrigate the uterus.
Results . Most principles previously outlined for ethanol monitoring in transurethral prostatic surgery could also be applied in endometrial resection.
In the 21 patients who showed the intravascular pattern of ethanol changes, the breath alcohol measurement corrected for absorption time predicted the volume of irrigant absorbed {up to 2,531 ml) with a standard error of 230 ml at the end of any 10-min period of absorption. Repeated measurement of serum sodium indicated intravascular fluid absorption with practically the same precision as the breath test.
Extravascular absorption was found in 14 patients. In these operations, the volume of irrigant absorbed (up to 1,767 ml) could be predicted with a standard error of 92 ml from the ethanol concentration at the plateau level attained after absorption had occurred.
Conclusion . Ethanol monitoring is precise enough to allow monitoring of irrigating fluid absorption in endometrial 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.     

SMOKING INCREASES THE RISK OF LARGE SCALE FLUID ABSORPTION DURING TRANSURETHRAL PROSTATIC RESECTION

PURPOSE: We studied the association between smoking habits and absorption during transurethral prostatic resection in healthy patients, and in those with medical disease and prostate cancer. MATERIALS AND METHODS: Smoking habits and the presence of medical disease and prostate cancer in 1,034 patients who underwent transurethral prostatic resection were compared with fluid absorption levels. These levels were measured by the ethanol method and surgical blood loss, as determined by a photometer. RESULTS: The incidence of fluid absorption greater than 1,000 ml. was 15.7% in the present smokers, 15.5% in the past and present smokers, and 8.8% in those who had never smoked. Compared to nonsmokers, the relative risk of 1,000 to 2,000 ml. fluid absorbed in past and present smokers was 1.8 (95% confidence interval 1.1 to 2.9). The corresponding relative risk of absorption greater than 2,000 ml. was 2.1 (95% confidence interval 1.1 to 4.3), with the greatest excess risk in present smokers, which was 2.8 (1.3 to 5.9). These differences between smokers and nonsmokers were even greater in the healthiest patients, while being relatively smaller in those with medical disease or prostate cancer. Fluid absorption correlated with the amount of blood lost but the demonstrated association between smoking and fluid absorption (p <0.024) could not be explained by an effect on blood loss. CONCLUSIONS: Past and present smoking increases the risk of large scale fluid absorption during transurethral prostatic resection. A possible reason is that smoking alters vascular growth in the gland.     

Ethanol-glycine irrigating fluid for transurethral resection of the prostate in practice

OBJECTIVE: To evaluate the usefulness of a tracer of 1% ethanol in 1. 5% glycine in the early detection of irrigation fluid absorption during transurethral resection of the prostate (TURP). PATIENTS AND METHODS: Patients (120) undergoing TURP were irrigated with 1% ethanol in 1.5% glycine solution and their expired air tested for alcohol every 10 min during the procedure. RESULTS: In all, 112 patients were assessed; over half of the patients absorbed the irrigation fluid and they had a significantly lower postoperative serum sodium concentration (P < 0.002). Fourteen patients (12.5%) absorbed over 500 mL and two (1.8%) developed clinical features of the TUR syndrome. The experience of the surgeon, the weight of resected chips and the operative duration were not significantly predictive of absorption. CONCLUSION: A tracer amount of ethanol in the irrigant is reliable for detecting absorption. Irrigating fluid absorption was unpredictable, thus supporting the case for routine monitoring.     

Irrigating fluid absorption and blood loss during transurethral resection of the prostate studied with a regular interval monitoring (RIM) method

A method for the study of physiological events during transurethral resection of the prostate (TUR) is described. Measurements of volumetric irrigating fluid balance, blood loss, central venous pressure (CVP) as well as blood haemoglobin and serum levels of sodium and glycine were performed at 10-min intervals. This regular interval monitoring (RIM) method offers the possibility to retrospectively correlate changes that occur during TUR at discrete time intervals. In 20 patients undergoing TUR, irrigating fluid absorption occurred throughout the procedure although the risk of having an absorption increased 30 min after surgery commenced. Increase of blood loss coincided with intravascular but not with extravascular absorptions. If there was a rapid massive intravascular absorption of about 500 ml/10 min, the CVP increased greater than 2 mmHg. The total intraoperative blood loss was not greater in patients with large absorption volumes. RIM will detect absorption greater than the urine excretion in any given period of time. If absorption occurs during a limited time of the TUR, RIM allows a partial correction for the urinary excretion in the volumetric fluid balance.     

A comparison of fluid absorption during transurethral resection and transurethral vaporization for benign prostatic hyperplasia

OBJECTIVES: To compare the absorption of irrigant fluid during transurethral vaporization of the prostate (TUVP) and transurethral resection of the prostate (TURP). PATIENTS AND METHODS: Thirty patients with clinical benign prostatic hyperplasia were randomly assigned to undergo TURP or TUVP; 1.5% glycine +1% ethanol solution was used as the irrigating solution. The volume of irrigant absorbed during surgery was estimated from the ethanol concentration in the patient's expired breath, sampled every 10 min. RESULTS: In both groups, the estimated absorbed fluid volume increased with the duration of surgery (P < 0.05). At the end of surgery, the mean (median, range) fluid absorption during TUVP was 672 (606, 0-1400) mL and during TURP was 1347 (975, 453-2965) mL; the difference was statistically significant (P < 0.05). CONCLUSION: Although TURP has a greater associated risk of fluid absorption than TUVP there may still be severe fluid absorption with the latter. Even though TUVP is potentially less harmful than TURP in poor-risk patients, ethanol monitoring is beneficial for increasing patient safety.     

Comparison of transurethral resection and plasmakinetic transurethral resection applications with regard to fluid absorption amounts in benign prostate hyperplasia

INTRODUCTION: We compare the absorption of irrigant fluid during gyrus plasmakinetic transurethral prostatectomy (PK-TURP) and transurethral resection of the prostate (TURP). PATIENTS AND METHODS: 42 patients with clinical benign prostatic hyperplasia were randomly assigned to undergo PK-TURP or TURP. In the PK-TURP group 0.9% NaCl was used as an irrigation fluid and 1.5% glycine in the TURP group. By adding ethanol to the irrigation fluids 1% ethanol-containing solutions were formed. All operations were carried out under spinal anesthesia and alcohol concentration of the ventilated air measurements were made just at the beginning of the operation, every 10 min peroperatively and at the end of the operation by using an alcoholmeter. RESULTS: There was no difference in age, prostate volume and the length of operation time in either group. In both groups, the estimated absorbed fluid volume increased with the duration of surgery (p < 0.05). The difference between mean fluid absorption during PK-TURP and during TURP was the statistically significant (p < 0.01). CONCLUSION: PK-TURP operation causes lesser absorption of the irrigation fluid than the TURP operation. The lesser absorption of irrigation fluid and using saline instead of glycine decreases the risk of TUR syndrome.     

The use of a bladder pressure warning device during transurethral prostatic resection decreases absorption of irrigation fluid.

During a period of 4 weeks 102 patients underwent transurethral prostatic resection (TURP). Of these, 50 were randomly allocated to the use of an intravesical pressure device which warned the surgeon at a pressure elevation of 1.5 kPa. Ethanol (1%) was used as a marker in the irrigation fluid (glycine 2.2%), and absorption of ethanol-tagged irrigation fluid was detected by measurements in the expired air. In 28 patients absorption took place (in 8 of the 50 patients equipped with the warning device and in 20 of the 52 without the device). The greatest absorption was seen in the group without the device. No differences were found between the groups with regard to age, resected mass, resection time, resection speed, or haemorrhage. Patients who absorbed irrigation fluid were slightly older and bled more, and the resected mass was larger. The use of a pressure warning device reduces the amount of irrigation fluid absorbed and the number of patients who absorb irrigation fluid, and minimises the risk of the TUR syndrome.     

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.     

Blood ammonia concentrations resulting from absorption of irrigating fluid containing glycine and ethanol during transurethral resection of the prostate

In 30 patients the blood ammonia concentration was measured 30 min was after transurethral resection of the prostate during which absorption of irrigating fluid containing 1.5% of glycine and 1% of ethanol had been indicated by serial expired breath tests. The volume of irrigating fluid that had been absorbed was either measured volumetrically (n = 25) or estimated from the ethanol concentration in the expired breath (n = 5); the median volume of irrigating fluid absorbed was 1.3 litres (range 0.2-4.3). There was no consistent rise in the blood ammonia concentration, nor was there any correlation between the blood ammonia concentration and the volume of irrigating fluid absorbed. No patient developed symptoms that could be clearly related to hyperammonaemic glycine toxicity, but 18 of the 30 patients developed other signs of the "TURP syndrome". The present results suggest that irrigating fluid containing both glycine and ethanol does not significantly increase blood ammonia concentration or produce symptoms of glycine toxicity.     

Is using ethanol–glycine irrigating fluid monitoring and ‘good surgical practice’ enough to prevent harmful absorption during transurethral resection of the prostate?

OBJECTIVE: To evaluate the utility of using a tracer of 1% ethanol in 1.5% glycine for the early detection of irrigation fluid absorption during transurethral resection of the prostate (TURP). PATIENTS AND METHODS: In all, 126 men undergoing TURP were irrigated with a solution of 1% ethanol and 1.5% glycine; their expired air was tested for ethanol every 20 min, and again at the end of the procedure. Maximum absorption by the breath-ethanol reading was compared with the serum concentration of absorbed glycine (analysed by anion-exchange chromatography). RESULTS: Complete data on 120 men were assessed; 75% of the men absorbed irrigation fluid, with glycine levels above the normal range. The sodium levels tended to decrease with increasing glycine levels (Spearman's rank correlation coefficient, - 0.57; 120 men) and five men (4%) developed clinical features of the TUR syndrome. There was a weak correlation between breath-ethanol levels and serum glycine levels (Spearman's rank correlation coefficient, 0.54). The experience of the surgeon, the weight of the resected chips, and the operative duration were not significantly predictive of irrigation fluid absorption. CONCLUSIONS: A rising breath-ethanol level indicates irrigation fluid absorption. However, irrigating fluid absorption is unpredictable, supporting the case for alternative, potentially safer irrigants.     

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.     

Prevention of TUR syndrome by detection of trace ethanol in the expired breath

Previous studies suggest that severe symptoms of the 'TUR syndrome' occur from transurethral prostatic resection only when the volume of irrigant absorbed exceeds 2000 ml. An ethanol-containing irrigating fluid was used in this study of 100 transurethral resections so that the irrigant absorption could be monitored by measuring ethanol in expired air. Fluid absorption was found in 41 patients, and in nine of them the volume of irrigant absorbed exceeded 1000 ml. Four of these operations were terminated promptly when the ethanol monitoring indicated rapid massive absorption that threatened to exceed 2000 ml. There were few and only mild adverse effects of the irrigant by following this regimen. It is concluded that ethanol monitoring makes it possible to prevent the TUR syndrome by selective termination of those operations in which large amounts of irrigant is absorbed.     

Glycine irrigation and urinary oxalate excretion

The short-term effect of glycine supplementation on urinary oxalate excretion was studied. An intravenous infusion of 1 litre of a solution of 2.2% glycine, 1.5% glycine + 1% ethanol or 5% mannitol (control) was given on 13 occasions to 5 healthy volunteers. Glycine irrigation was used in 9 patients undergoing transurethral prostatic resection and the absorption of irrigant was measured volumetrically (range 0-2.71). The results suggest that glycine irrigation in transurethral prostatic surgery does not raise the urinary oxalate level in the early post-operative period.     

Early detection of the TUR syndrome by marking the irrigating fluid with 1 % ethanol

The ethanol concentration in the expired breath (EB-ethanol), the volumetric fluid balance and the serum sodium concentration were measured in the course of 60 transurethral resections of the prostate in which the irrigating fluid was 1.5% glycine + 1% ethanol. Measurement of EB-ethanol indicated absorption of irrigant at a rate of more than 150 ml in 10 min, as measured volumetrically. There was a significant direct linear relationship between EB-ethanol and the cumulative volume of irrigant absorbed (R2 = 0.83); this correlation was stronger when the duration of absorption was taken into account (R2 = 0.90). EB-ethanol was inversely related to the overall change in the serum sodium concentration during the operation (R2 = 0.88). Symptoms that are recognized components of the TUR syndrome developed in 8 of the 13 patients absorbing more than 11 of irrigant, while the ethanol exerted no adverse effects. The results of the study indicate that 1% ethanol is a suitable marker for monitoring irrigant absorption by means of the expired breath test in routine transurethral surgery. At this concentration the sensitivity of the test is adequate for detecting absorption, while the ethanol is less toxic than the irrigant fluid itself.     

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.     

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.