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.     

Effects of sodium benzoate on the complications of 1.5% glycine solution using two different intravesical pressures during bladder irrigation

BACKGROUND: In this experimental study we researched the effects of sodium benzoate on the complications of 1.5% glycine solution using with two different intravesical pressures during bladder irrigation. METHODS: Thirty-six male adult New Zealand rabbits with body weight ranging from 1500 to 2800 g were used in the experiments. The rabbits were randomly allocated to four groups. In groups 1 and 2, 500 ml of 1.5% gylcine was used as irrigating fluid during 30 min, but only group 2 received 500 mg kg(-1) of sodium benzoate treatment by oral route immediately after irrigation. In groups 3 and 4, 500 ml of 1.5% glycine was used as irrigating fluid during 60 min, but only group 4 received the same treatment as group 2. Ammonia, urea, sodium, potassium, hemoglobin, hemotocrit and platelet levels were studied at preirrigation and postirrigation on the 4 h and 24 h. Also electrocardiographic (ECG) changes were monitored at the same time with blood parameters. RESULTS: At 4 h postirrigation, Na+ levels were decreased significantly in group 1 and non-significantly in group 3 when compared with preirrigation levels. But these levels were not changed in groups 2 and 4. Both at 4 h and 24 h, ammonia and urea levels were significantly increased in groups 1 and 3. Ammonia level was decreased but the urea level was not changed in groups 2 and 4 at the same time points. K+ level was significantly changed only in group 1 at 4 h and 24 h. Hemoglobin and hemotocrit concentrations were decreased both at 4 h and 24 h compared with preirrigation levels in all groups. Also there were ECG changes between the treated and untreated groups. CONCLUSION: Sodium benzoate was very effective against the complications of 1.5% glycine during bladder irrigation experimentally. But this needs further investigation, especially for the applicability of this new treatment model in human TURP syndrome.     

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.     

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.     

Effects of isosmotic and hyperosmotic glycine solutions on the fluid balance in conscious sheep

Glycine 0.55 g.kg-1 was given as an isosmotic (285 mosmol.kg-1) and a hyperosmotic (approx. 3,000 mosmol.kg-1) solution by intravenous infusion during 30 min to six euhydrated ewes. Urine and blood samples were collected, and the distribution of the administered water between the intra- and extracellular fluids (ICF and ECF) was calculated for up to 150 min after the infusions. Both solutions produced an osmotic diuresis with a marked increase of the urinary excretion of sodium, potassium, and amino acids. A paradoxical increase of the plasma vasopressin concentration occurred from the isosmotic but not from the hyperosmotic glycine solution. At the end of the follow-up period, the isosmotic glycine solution had resulted in hyperhydration of the ICF and the hyperosmotic solution in dehydration of the ICF, whereas with both fluids, the ECF resumed the same volume as before the experiments.     

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.     

Lactated Ringer with 1% dextrose: an appropriate solution for peri-operative fluid therapy in children

Peri-operative blood glucose, total protein, and electrolytes values were measured in children (3–120 months) scheduled for minor surgery and randomly assigned to three groups according to the type of fluids administered during anaesthesia: children of RL group (n= 27) received lactated Ringer, those of RLD1 group (n= 25), 1% dextrose in lactated Ringer, and those in RLD2.5 group (n= 27), 2.5% dextrose in 0.4 N saline (50% D5, 50% RL) (63 mmol·l^-1). Infusion rate was set according to children's age and weight. Fluids were infused throughout the study with volumetric infusion pumps. Blood samples were obtained at induction (T0), at the end of surgery (T1), 30 and 60 min later (T2, T3). Pre-operative blood values were within the normal ranges except for high total protein values in all groups of children and for asymptomatic hypoglycaemia (2.3 and 2.5 mmol·l^-1) in two children. Blood glucose increased significantly in the three groups post-operatively (P < 0.001), and this increase was related to the amount of glucose infused. Glucose values differed significantly between groups at T1 and T2, while blood glucose values were back to the normal ranges at T2 and T3 in the RL group. Sodium values remained unchanged post-operatively in both RL and RLD1 groups, while a significant decrease was observed in the RLD2.5 group (P < 0.001). Total protein decreased in the three groups post-operatively (P < 0.001) towards normal values. These data suggest that RLD1 is appropriate for peri-operative fluid therapy in children. Its administration at the infusion rate used in this study, resulted in moderate post-operative hyperglycaemia while avoiding the risk of peri-operative hypoglycaemia, maintaining a constant extracellular fluid composition and correcting pre-operative fluid deficit.     

经尿道前列腺电切术和汽化电切术并发症48例分析

目的 分析经尿道前列腺电切术（TURP）与经尿道前列腺汽化电切术（TVP）术中、术后常见并发症的原因、预防及治疗，提高手术安全性和有效性。方法 回顾性分析1999年5月-2006年6月我院TURP和TVP术48例并发症患者的临床资料。结果 平均手术时间75min，平均切除组织41g。术中、术后出血20例，电切综合征（TURS）5例，暂时性尿失禁11例，膀胱颈部挛缩5例，尿道狭窄8例，尿路感染7例，膀胱穿孔1例。结论 TURP和TVP是良性前列腺增生症安全有效的外科治疗方法，术前详细采集病史，术中正确操作。术后对病人正确指导及处理可有效减少手术并发症。     

简化TUVP在高危前列腺增生症治疗中的应用(附63例报告)

目的探讨简化经尿道前列腺汽化电切术(TUVP)治疗高危前列腺增生症的疗效及安全性。方法采用简化TUVP治疗高危前列腺增生症患者63例。结果63例平均手术时间18min,平均术中失血量32ml,无一例输血和发生TURS,术后5~7d拔除导尿管除1例排尿不畅外,其余均能通畅排尿。随访3~28个月,均未出现迟发性出血、急性尿潴留等并发症。术后3个月国际前列腺症状评分(IPSS)由术前(27.6±4.1)分下降至(10.6±2.5)分,生活质量评分(QOL)从(4.8±0.6)分降至(2.6±0.4)分,最大尿流率(Qmax)由(7.2±2.3)ml/s增加至(15.3±2.1)ml/s,残余尿(PVR)从(143.0±51.8)ml下降为(45.0±21.5)ml(P<0.05)。结论简化TUVP是一种操作简便、安全有效的治疗高危前列腺增生症的手术方法。     

超高龄BPH患者的手术风险和术后生存状况

目的评估85岁以上超高龄BPH患者经尿道前列腺电汽化切除术(TUVRP)的手术风险和术后生存状态.方法55例85岁以上施行TUVRP患者(A组)与228例80岁以下患者(B组和C组)进行回顾性比较.A组55例85~97岁,平均年龄(87.91±2.70)岁;B组137例71~80岁;C组91例60~70岁.结果美国麻醉学会(ASA)评分A组高于B组和C组,与B组和C组相比,差异均具统计学意义(P≤0.05);手术时间A组为(40.03±18.90) min,与B组和C组比较差异无统计学意义(P>0.05).A组术后34例存活者日常生活和行为能力(Barthel)指数(66.0±17.46),其中18例(52.94%)评分>60;10例(29.41%)评分41~60;6例(17.65%)评分<40.A组31例国际前列腺症状评分(IPSS)11.35±7.04,与B组比较差异无统计学意义(P>0.05).与C组相比具统计学意义(P<0.01).生活质量评分(QoL)1.23±0.76,均低于B组和C组,差异均具统计学意义P<0.05.结论85岁以上BPH患者手术风险高于80岁以下.大部分患者术后可获得满意排尿功能和保持较好的日常生活能力.一次安全的TUVRP手术能够改善85岁以上BPH患者的日常生活能力和生活质量.     

经尿道气化电切术治疗前列腺增生100例

目的 探讨治疗前列腺增生症(BPH)的有效手术方法。方法 采用经尿道前列腺电切术（TURP)结合气化术（TUVP)治疗BPHl00例。结果 手术时间40-120min，平均70min；平均切除腺体24g；术中出血少，术后排尿良好；2例术后继发性出血；2例术后3月出现膀胱颈挛缩；无电切综合征（TURS)发生。结论 TURP与TUVP的联合应用，对治疗BPH是一种安全有效的手术方法。     

PKRP与TURP治疗良性前列腺增生症的疗效比较

目的观察经尿道前列腺等离子切除术（PKRP）治疗良性前列腺增生症（BPH）的疗效及并发症,并与经尿道前列腺电切术（TURP）进行比较。方法回顾分析采用PKRP、TURP治疗的768例BPH患者,分别收集两组患者年龄、国际前列腺症状评分（IPSS）、剩余尿量（RUV）、最大尿流率（Qmax）、生活质量评分（QOL）、手术时间、术中出血量、术后尿管留置时间、住院天数、术后并发症发生率资料并进行统计分析。结果两组病例年龄、前列腺重量及术前IPSS、RUV、Qmax和QOL比较差异均无统计学意义（P〉0.05）。两组在手术成功率、平均住院时间、术后平均留置尿管时间、术中出血量和冲洗时间方面无统计学差异（P〉0.05）;两组在手术时间、并发症发生率方面有统计学差异（P〈0.05）。结论PKRP治疗BPH的近期临床疗效与TURP相当,临床上可根据患者情况和适应证选择不同方法,以获得更好的临床疗效。     

伴有2型糖尿病的前列腺增生患者TURP术中应用5%葡萄糖溶液进行冲洗的安全性评价

目的研究伴有2型糖尿病的良性前列腺增生症（BPH）患者行经尿道前列腺切除术（TURP）时,5%葡萄糖溶液作为TURP冲洗液的安全性。方法收集伴有2型糖尿病行TURP术的BPH患者21例,随机收集同期非糖尿病行TURP术的BPH患者52例作为对照。采集病历资料,统计年龄、国际前列腺症状评分（IPSS）、B超计算前列腺重量。术中采用5%GS作冲洗液行TURP术,统计分析两组患者术前、术中30 min、术后30 min和术后1 d即刻血糖,进一步分析两组在手术时间、冲洗液用量、切除腺体重量方面的差异。结果两组患者组内比较,血糖值均随手术时间延长逐渐升高,与术前相比有显著性差异（P〈0.01）,但术前、术中及术后血糖比较,组间无显著性差异（P〉0.05）。无糖尿病相关的严重并发症发生。结论 TURP术中应用5%葡萄糖溶液作为冲洗液可引起血糖升高,但在充分术前准备和熟练手术操作情况下其作为冲洗液对于糖尿病患者也是相对安全的。     

Comparison of photoselective vaporization and standard transurethral resection of the prostate on urodynamics in patients with benign prostatic hyperplasia

Objectives:   To compare photoselective vaporization of the prostate (PVP) and transurethral resection of the prostate (TURP) in patients with benign prostatic hyperplasia.
Methods:   Patients were enrolled in a prospective non-randomized trial and underwent PVP ( n  = 78) and TURP ( n  = 51). Primary outcome variables included: International Prostate Symptom Score, quality-of-life score, urinary peak flow and post-void residual urine volume at 3, 6 and 12 months postoperatively. Secondary outcomes were urodynamic variables, including the index of bladder outlet obstruction (BOO) and detrusor contractility.
Results:   Improvement in all outcome variables after PVP was comparable to that after TURP within 12 months. Outcome based on urodynamic parameters was also similar. Pre/post median value of the BOO index was 63/2 in the PVP group and 61/5 in the TURP group. Pre/post rate of detrusor overactivity was 49%/27% in the PVP and 53%/29% in the TURP group. There was minimal change in detrusor contractility. Overall, morbidity was comparable in the two groups.
Conclusions:   The 12-month outcome after PVP is similar to that of TURP with an effective relief from BOO and detrusor overactivity and minimal change in detrusor contractility.     

Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate, in patients with benign prostatic hypertrophy

One hundred patients with benign prostatic hypertrophy (BPH) were randomized to transurethral incision (TUIP) or transurethral resection of the prostate (TURP). The average prostate weight before operation was not more than 30.0 g. Indications for the operations were based on the disease history, physical examination, digital rectal examination, laboratory values, and pressure-flow examination. All operations were performed with patients under spinal anesthesia. TUIP was performed with a Collins knife, and TURP was performed with a resectoscope. Follow-up was performed 24 months after the operations. After treatment there were statistically significant daytime and nocturnal reduction in voiding frequencies of 2.9 and 1.7, respectively, after TUIP, and 2.0 and 1.5 after TURP. In both groups, there occurred significantly better maximal flow rate from 7.6 mL/s to 16.9 mL/s in group I and from 6.9 mL/s to 17.6 mL/s in group II. The mean values of linearized passive urethral resistance relation in both groups significantly decreased from 3.6 +/- 0.6 to 1.0 +/- 0.5 after TUIP and from 3.9 +/- 04 to 1.4 +/- 0.5 after TURP. The TUIP procedure is effective and safe for patients with a small number of complications.     

前列腺电切术后腺窝结石形成的原因及对策

目的:探讨前列腺电切术后腺窝结石形成的原因、临床表现和防治对策。方法:报道前列腺电切术后腺窝结石患者11例,患者曾行经尿道前列腺电切术或经尿道前列腺等离子双极电切术,术后反复出现尿频、尿急、尿痛等症状,伴尿路感染,部分伴排尿梗阻症状,抗感染治疗效果不理想。膀胱镜检查见前列腺腺窝结石形成,部分可见焦痂、坏死物质、电切创面不平整及小憩室形成。确诊后行钬激光碎石及再次前列腺电切术1例,其余患者在膀胱镜下用异物钳将结石取出,给予抗感染治疗1～2周。结果:11例患者尿常规均恢复正常,尿频、尿急、尿痛等症状消失。随访3～6个月,未再出现膀胱刺激症状、梗阻症状及尿路感染。结论:前列腺电切术后反复尿频、尿急、尿痛、尿路感染者,应考虑到腺窝结石可能,行膀胱镜检查可明确诊断。治疗可采取膀胱镜下取石或碎石术,必要时可再次行前列腺电切术。预防上应注意创面修平整、控制感染及避免过度电凝。     

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.     

改良AdVance吊带术治疗中重度男性压力性尿失禁的疗效初探

目的：初步探讨改良后的AdVance吊带（经闭孔球部尿道悬吊）术对男性TURP术后尿失禁的治疗效果。方法：2012年11月间将2例TURP术后压力性尿失禁（SUI）患者纳入本研究,尿失禁程度通过手术前后国际尿失禁许询委员会尿失禁问卷简表（ICI—Q-SF）评分和尿垫使用量（日常生活活动漏尿量）来评定。1例为中度SUI,1例为重度SUI,均采用改良后的AdVance吊带术治疗。患者生活质量通过健康生活质素调查问卷（SF-12）在术前和术后6个月回访时获得。结果：中度SUI患者术前SF-12评分为13分,ICI-Q-SF评分为14分,生活质量（QOL）评分为6分,术前最大尿流率（Qmax）26．6ml／S．膀胱剩余尿量（PVR）0ml;术后6个月SF-12评分为6分,ICI—Q-SF评分为0分,Q（）I。评分为2分,Qmax16．5ml／s,剩余尿量0ml。患者整个随访期间临床表现稳定,尿失禁未随着时间推移复发加重。术后未发现伤口感染,尿道无侵蚀,患者对手术效果满意。熏度SUI患者术前SF-12评分为18分,ICI—Q-SF评分为14分,Q（）I,评分为6分,因无法憋尿无法行尿流率测定;术后6个月SF一12评分为7分,ICI—Q-SF评分为4分,Q（）I。评分为2分,术后Qmax30．2ml／s,剩余尿量15ml。术后偶有少许尿液流出（每周1次．〈20ml／次）。术后未发现伤口感染．尿道无侵蚀．患者对手术效果满意。结论：改良后的Ad—Vance吊带术是治疗男性TURP术后尿失禁的有效方法。     

三种经尿道前列腺切除术的比较研究

目的 探讨三种经尿道前列腺切除术的优缺点。方法 回顾性分析经尿道前列腺电切术(TtmP)400例、经尿道前列腺汽化术(TUVP)20例、经尿道前列腺汽化电切术(TVRP)400例的临床资料。结果 3种手术方法的适应证、禁忌证基本相同。并发症略有差异：术后出血TURP12例(3％)，TUVP2例(10％)，TUVRP10例(2．5％)；冲洗液外渗TURP8例(2．0％)，TUVP1例(5％)，TUVRP6例(1．5％)；迟发性出血TURP10例(2．5％)，TUVP2例(10％)，TUVRP6例(1．5％)；尿道狭窄TURP6例(1．5％)，TUVP 1例(5％)，TUVRP2例(0．5％)。结论 TURP和TUVRP的适应证宽，并发症少，安全性高，疗效确切；比TUVP更具临床实用价值。