Sorbitol concentrations in plasma in connection with transurethral resection of the prostate using sorbitol solution as an irrigating fluid

20 patients undergoing transurethral resection of the prostate (TURP) using 5% sorbitol (N = 13) or Cytosol (N = 7) (5% sorbitol and 0.25% acetic acid) as an irrigating fluid were studied. The sorbitol concentration was determined in serum (plasma), as were sodium, prostatic acid phosphatase protein (PAP) and osmolality, as possible indicators of absorption of irrigating fluid. The plasma level of sorbitol immediately postoperatively, the increase in serum PAP and the decrease in serum sodium all reflect the amount of irrigating fluid absorbed during TURP. The three variables are intercorrelated. The plasma osmolality was not significantly changed. The maximum sorbitol concentration immediately postoperatively in any patient was 6.0 g/l (33.5 mmol/l). The mean for the series was 1.2 g/l (6.8 mmol/l). The mean serum PAP increase was 31 micrograms/l. The serum sodium decrease ranged between 0 and 14 mmol/l, mean 5.0 mmol/l. The mean half-life of sorbitol in plasma was short: 35 min, reflecting rapid metabolism. An estimate of the volume of fluid absorbed was made from the plasma sorbitol levels observed. A fluid absorption up to 2.3 l (mean 0.6 l) was found. A marked diuretic effect up to 14.1 ml/min (mean 7.8 ml/min) was observed in some cases when irrigation with sorbitol was combined with intravenous furosemide given postoperatively.     

Plasma haemoglobin concentrations and other influx variables in blood in connection with transurethral resection of the prostate using distilled water as an irrigating fluid

Eight patients undergoing transurethral resection of the prostate (TURP) using sterile distilled water as an irrigating fluid were studied. The concentrations of plasma haemoglobin, serum sodium, serum prostatic acid phosphatase protein (PAP) and plasma osmolality were determined as possible indicators of absorption of irrigating fluid. In 3 patients there was a marked increase in plasma haemoglobin immediately postoperatively with a maximum of 3.3 g haemoglobin/l plasma. In the remaining 5 patients the plasma haemoglobin level did not exceed 0.7 g/l immediately postoperatively. In all cases there was a fairly rapid return of the elevated plasma haemoglobin level to preoperative values. There was also a postoperative increase in the serum PAP level which was not correlated with the simultaneous increase in plasma haemoglobin concentration. There was no significant change in the sodium, potassium or albumin concentration in serum nor in plasma osmolality postoperatively. There was some decrease in the postoperative serum creatinine and uric acid levels. The preoperative serum creatinine concentration was within reference limits in 7 patients and borderline high in 1 patient. The haemoglobin binding plasma protein haptoglobin showed a slight non-significant increase immediately postoperatively and a significant decrease in concentration 2 hours postoperatively. The mean plasma haemoglobin concentration immediately postoperatively did not exceed the mean preoperative haemoglobin binding capacity of serum. The mean preoperative haemoglobin binding capacity was 1.2 g/l and the mean plasma haemoglobin level was 1.2 g/l immediately postoperatively. Two hours later the mean plasma haemoglobin level was 0.8 g/l. The mean serum haptoglobin concentration was 2.4 g/l preoperatively, 2.6 g/l immediately postoperatively and 2.0 g/l 2 hours later.(ABSTRACT TRUNCATED AT 250 WORDS)     

Absorption and elimination of mannitol solution when used as an isotonic irrigating agent in connection with transurethral resection of the prostate

12 patients were studied in connection with transurethral resection of the prostate using the intermittent technique and isotonic 5% mannitol solution as an irrigating fluid. No diuretics were given postoperatively. The serum creatinine concentrations were normal in 10 patients and slightly elevated in 2. The plasma mannitol levels were followed for four hours postoperatively. The highest concentration observed in the series was 6,275 mg/l (34.9 mmol/l) immediately postoperatively. The maximum level was observed immediately postoperatively in all patients (mean 2,140 mg/l, 11.9 mmol/l). The mean half-life of mannitol in plasma was 163 min (10 patients). The patient with the highest serum creatinine concentration preoperatively (138 mumol/l) showed a marked prolongation of the half-life (692 min). The mean intravenous fluid absorption calculated from the immediate postoperative mannitol concentrations was 0.68 l (range 0.05-1.78 l). A decrease in the serum sodium concentration was observed immediately postoperatively (mean 5.4 mmol/l, range 0-19 mmol/l). There was a correlation between the decreases in the serum sodium concentration and the simultaneous plasma mannitol concentration. There was no significant change in plasma osmolality. Mannitol elimination in urine was followed for 24 hours postoperatively in 7 patients. The mean absorbed volume of irrigating fluid was calculated from the elimination data and was found to be 0.481, which should be compared with the figure obtained from the calculation based on the immediate postoperative plasma mannitol concentration, which gave 0.49 l (mean) in the same 7 patients. This shows that, in spite of the theoretical assumptions made in the calculation of absorbed fluid volume from the plasma mannitol concentration, this method of calculation is valid.(ABSTRACT TRUNCATED AT 250 WORDS)     

Glycine solution as an irrigating agent during transurethral prostatic resection. Glycine concentrations in blood plasma

In 17 men undergoing transurethral resection of the prostate (TURP), an isosmotic solution of 2.2% glycine was used for irrigation. The plasma glycine concentration was determined before and immediately after TURP and 2, 6, 24 and 48 hours later. The serum concentrations of sodium, albumin and prostatic acid phosphatase protein (PAP) were used as indicators of fluid absorption. Calculation of the absorbed fluid volume was based on the plasma concentration of glycine, and the disappearance rate of glycine from plasma was estimated. The mean disappearance rate (T 1/2) was 85 min, which was midway between previously observed rates for sorbitol and mannitol. The observed plasma glycine increase after TURP correlated well with fall in serum sodium and rise in serum PAP, with the blood loss during and up to 15 min after TURP, and also with the weight of the resected tissue. The plasma glycine level, highest immediately after TURP, normalized 24-48 hours postoperatively. No signs of ammonia intoxication or marked serum urea increase were seen in these patients, although some had very high plasma glycine values after TURP (mean 10.2, maximum 23 mmol/l) as compared with the preoperative levels (mean 0.2 mmol/l). There was some increase of plasma serine (a normal metabolite of glycine) after TURP. The authors conclude that the irrigating fluid should have a minimal concentration of glycine, near to the level of haemolysis onset, to minimize the plasma dilution effects, including hyponatraemia, and the appearance of metabolites when the irrigating fluid is absorbed.     

Experience with hypotonic 2.5% sorbitol solution as an irrigating fluid in transurethral resection of the prostate

19 patients were studied in connection with transurethral resection of the prostate using the intermittent technique and hypotonic 2.5% sorbitol solution as an irrigating fluid. No diuretics were given postoperatively. In 2 patients there was a slight elevation of the serum creatinine level preoperatively but in 17 patients serum creatinine was within the reference limits. The plasma sorbitol concentration was determined at 20-min intervals for two hours. The mean plasma concentration of sorbitol immediately postoperatively was 379 mg/l (2.1 mmol/l) and the highest level observed was 1,900 mg/l (10.6 mmol/l). The half-life for sorbitol in plasma was 21 min (mean calculated in 11 cases). The range was 11-33 min. With increasing immediate postoperative plasma sorbitol levels there was also an increase in the half-life, corresponding to saturation of the sorbitol metabolizing enzyme system. The absorbed fluid volumes were calculated from the immediate postoperative plasma concentration of sorbitol, which gave a mean of 0.23 1 and a maximum of 1.01. Haemodilution effects with decrease in the serum sodium and serum albumin concentrations were noted, but they were much less marked than when 5% sorbitol solution was used as an irrigating fluid. There were only insignificant increases in the plasma haemoglobin concentrations postoperatively, which were probably due to heat decomposition of red blood cells in the bladder during the operation. About 7% of the absorbed amount of sorbitol was eliminated in the urine (mean). The highest value observed was 18% in the case showing the highest plasma sorbitol concentration immediately postoperatively (1,900 mg/l). Sorbitol was eliminated in the urine over a period of 6 hours postoperatively.     

Absence of lactate accumulation on transurethral resection of the prostate using 2.5% sorbitol solution as an irrigating fluid

19 patients with benign hyperplasia of the prostate were studied. During transurethral resection of the prostate, 2.5% sorbitol solution was used as an irrigating fluid. Blood samples were taken preoperatively, immediately postoperatively, and 60 and 120 min postoperatively. Samples were analysed for sorbitol metabolites (fructose, glucose, lactate and pyruvate) and inorganic phosphate. The series was divided into two groups, one with low absorption and one with high absorption of irrigating fluid. The limit for the plasma sorbitol concentration immediately postoperatively, dividing the groups, was 1.0 mmol/l, corresponding to an absorbed fluid volume of about 0.1 l. There was a slight increase in lactate and a significant decrease in pyruvate in the blood in both groups postoperatively. Blood fructose was zero in the group with low absorption of irrigating fluid whereas there was a slight increase in the group with high absorption, with a maximum of 0.53 mmol fructose/l. Blood glucose did not show any significant changes postoperatively. Inorganic phosphate in serum showed a significant decrease postoperatively in both groups. There were no significant differences between the groups at the various postoperative sampling times with regard to lactate, pyruvate, glucose or inorganic phosphate in the blood. Thus, we did not observe any accumulation of lactate in the blood when using 2.5% sorbitol solution as an irrigating fluid with absorbed fluid volumes up to 1 litre (corresponding to 25 g sorbitol).     

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.     

The use of distilled water as an irrigating fluid in patients undergoing transurethral resection of the prostate

Thirty patients undergoing transurethral resection of the prostate using distilled water as an irrigating fluid were studied. There was no significant change in the serum concentration of the variables studied (preoperatively compared to postoperatively) as possible indicators of haemolysis or absorption of irrigating water such as sodium, potassium, albumin, total protein, creatinine, uric acid, urea, haemoglobin, haematocrit and haptoglobin. The mean value of plasma haemoglobin (P-Hb), observed immediately postoperatively and reflecting the magnitude of haemolysis, was delta 294.8 mg/l. There was a good correlation between P-Hb and the inflowing irrigating distilled water (r = 0.69). The P-Hb variation (delta) correlated with resection time and with the weight of the resected prostate (r = 0.54 and r = 0.52, respectively). A good correlation was also found between resection time and delta body weight which reflects the amount of water absorbed (r = 0.67) and between delta body weight and the inflowing irrigating water (r = 0.61). Our study shows that distilled water can be used as an irrigating fluid quite safely. The advantages of distilled water outweigh the disadvantages which can be avoided easily if proper attention is given.     

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.     

Water and electrolytes in muscle tissue and free amino acids in muscle and plasma in connection with transurethral resection of the prostate. II. Isotonic 2.2% glycine solution as an irrigating fluid.

Seventeen patients undergoing transurethral resection of the prostate using isotonic 2.2% glycine solution as an irrigating fluid were studied. The extra- and intracellular distribution of water, the total content of water, and the concentrations of electrolytes and free amino acids in muscle tissue were determined together with the concentrations of free amino acids in plasma preoperatively, immediately postoperatively and 2, 6, 24 and 48 hours postoperatively in two groups with separate sampling periods. There were no significant changes in water content and sodium or chloride concentrations in muscle tissue postoperatively. Potassium and magnesium concentrations decreased late in the postoperative phase. In plasma there was a fifty-fold increase immediately postoperatively in the glycine concentration (mean fluid absorption 0.71) followed by a six-fold increase in muscle tissue 6 hours postoperatively. The glycine metabolite serine also increased in plasma and muscle. Other muscle amino acid concentrations decreased immediately postoperatively probably due to the massive glycine entrance into the cells. Later postoperative changes in some muscle amino acids (glutamine, glutamate, alanine, tyrosine and arginine) may be explained more by the operative trauma than by the influence of glycine. Two different types of metabolic effects are seen in this material. The first is that of the glycine infusion and the metabolic effects of glycine. The second is the catabolic influence of the surgical trauma. Accumulation of glycine in tissues in some patients with the possible production of ammonia and the effects of glycine as an inhibitory neurotransmitter must be considered as risk factors when choosing glycine as an irrigating fluid.     

Changes in oncotic pressure, osmolality and electrolytes following transurethral resection of the prostate using glycine as irrigating solution

Thirteen patients undergoing resection of benign prostatic hyperplasia were given furosemide 40 mg at the end of the procedure. The changes in body weight, colloid oncotic pressure (COP), osmolality, electrolyte concentrations and several haematological variables were compared with the values of 13 patients treated similarly, but without furosemide. During the operation there was an estimated mean absorption of 300 ml of irrigating fluid (glycine 1.5%). There was a significant peroperative decrease in serum sodium concentration, osmolality, COP, and haemoglobin concentration in both groups. The furosemide group had a more rapid return of COP towards preoperative values, and this group did also approach the preoperative weight more rapidly than the control group. In 10 selected patients variations in the total aminoacid pattern were measured. There was a significant increase in glycine concentration, with the maximum increase ten times the preoperative value. In the absence of uncontrolled bleeding, the resorption of fluid during TUR leads to hypervolemia and reduction in serum sodium and COP. This may lead to the TUR syndrome, as illustrated by one of our patients. Treatment in the symptomatic patient consists of reduction of circulating blood volume and when this is achieved, hypertonic saline may be beneficial if there are neurological symptoms.     

Water and electrolytes in muscle tissue and free amino acids in muscle and plasma in connection with transurethral resection of the prostate. I. Distilled water as an irrigating fluid.

10 patients undergoing transurethral resection of the prostate using sterile distilled water as an irrigating fluid were studied. The extra- and intracellular distribution of water, the total content of water and electrolytes and the free amino acid concentrations in muscle tissue were determined together with the concentrations of free amino acids in plasma preoperatively, immediately postoperatively and 2 hours postoperatively. The content of water and concentrations of electrolytes in skeletal muscle did not change significantly from the preoperative to the postoperative period with the exception of the potassium concentration, which decreased 2 hours postoperatively. The following free amino acid concentrations in muscle tissue showed significantly decreased values 2 hours postoperatively compared with the preoperative values: taurine, serine, glutamate, proline and leucine. The concentrations of non-essential amino acids in muscle decreased significantly 2 hours postoperatively. This may be interpreted as a dilution effect. An increased concentration of some amino acids in plasma postoperatively may be explained as a haemoconcentration effect due to the use of a postoperative diuretic.     

Analysis of the absorcion's factors of irrigating fluid during transurethral resection of the prostate

ObjetivesIn this study it was our intention to evaluate the relation between the reabsorption of irrigating fluid and three variables: time of the intervention, volume of solution of glicina employee and weight of the fragments, during the RTU of prostate fulfilled to low hydraulic pressure.Material and methodWe Study 74 patients that RTU of prostate was performed with suprapúbica derivation with Amplatz’s pod 30 ch. The ethanol was monitored in expired air every 15 minutes during the intervention. Likewise we annotated the time of the intervention, the volume of glicina used and the weight of the fragments extracted. Statistically Anova’s text was in use for comparison of averages.Results13,6 % of the patients absorbed irrigating fluid in some quantity. The range of absorption belongs to 100 cc until 2.000 cc. We did not find a statistically significant difference in the averages of time of resection, volume of glicina and weight of the fragments between the group of patients that had absortion of irrigating fluid and they that didn´t had.ConclusionsOur data show that the operative time, the volume of irrigating fluid and the weight of the resected fragments do not influence the reabsorption of liquid of irrigation when a RTU is realized to low hydraulic pressure.