An Experience of TURP Syndrome at CPR

Hospital, Kolhapur and Sir J J Group of

Hospitals, Mumbai.
Dr. Ullhas S. Misal

MD

Associate Professor in Anesthesia,

Government Medical College, Miraj.

 This is a common operation performed in elderly males in LITHOTOMY

position with slight head down tilt through a modified cystoscope.
(Resectoscope)
 Irrigating fluids are used during the procedure
 Prostatic tissue is resected using an electrically energized wire loop in
the form of small chippings.
 Bleeding is controlled with a ball like diathermy.
Introduction:
 The institutes where the facilities and expertise are available, the age
old Frayer’s Prostatectomy has almost been replaced by TURP

 The surgery is usually performed under regional anesthesia (mostly

spinal) but in select patients General Anesthesia is required.

 As the patients are very old males, there is a high incidence of

concomitant diseases, especially of cardio respiratory system in these
patients.

 There is also a risk of septicemia in those patients with UTI, stones in

the bladder or an indwelling catheter.

Irrigation fluids WHY?

 Continuous irrigation is needed during TURP to -

1. Distend the bladder

2. Clear the surgical site

3. Wash away blood and resected prostatic tissue

Ideal Irrigation fluid –WHICH?

 Should be

 isotonic,

 electrically inert,
  non toxic,

 transparent,

 easy to sterilize and

 inexpensive.

 Unfortunately, no solution satisfies this criteria.

 The choice differs from center to center and with the preference of
surgeon

Irrigation fluids used:

 Range from distilled water to a variety of non hemolytic and near
osmotic solutions viz.

1. Glycine 1.5 % and 1.2 %

2. Sorbitol 3.5 %

3. Mannitol 5 %

4. Cytal (Sorbitol 2.7 % & Mannitol 0.54 %)

5. Glucose 2 %

6. Urea

Distilled water:
 Distilled water is

 electrically inert,

 inexpensive and has

 excellent optical properties.

 However, it is extremely hypotonic.

When absorbed into the circulation in large amounts, it causes hemolysis,

shock and renal failure

Glycine:
 Glycine 1.5 % is a non essential amino acid and has excellent optical
properties, non electrolytic solution.

 It is near iso-osmotic hence the chances of hemolysis are reduced.

  However, when absorbed in large quantities it also causes
hyponatremia and thereby resultant hypo-osmolality.

 It is a inhibitory neurotransmitter like GABA and may lead to retinal

symptoms.

 It is metabolized to ammonia by liver and hyper ammonemia may

cause CNS symptoms.

TURP syndrome:
 It is a complex syndrome which encompasses

1. hypo-osmolality,

2. hyponatremia,

3. intravascular fluid shifts,

4. hyperglycenemia (when glycine is used),

5. hyperammonemia (when glycine is used), etc.

 These changes are caused by absorption of irrigating fluid through

open prostatic veins.

 Neurologic manifestations such as

1. Restlessness

2. Agitation

3. Confusion

4. Altered sensorium

5. Seizures

6. Coma

Result from water intoxication and dilutional hyponatremia which

collectively produce cerebral edema.

 Neurologic manifestations such as

1. Restlessness

2. Agitation

3. Confusion
 4. Altered sensorium

5. Seizures

6. Coma

Result from water intoxication and dilutional hyponatremia which

collectively produce cerebral edema.

Observations:

1. All patients who were presented with S/S of TURP syndrome were given
Spinal.

2. Out of 4 patients who had TURP syndrome at CPR Hospital Kolhapur, 3

were operated by surgeon. (and not urologist) and with operative time
of more than 90 min

3. Remaining 1 was operated by experienced urosurgeon and he

developed the symptoms within 25 min of surgery in the form of
distention of abdomen, pain in abdomen, tightness in chest,
restlessness, bradycardia.

4. He was explored immediately to rule out perforation. No perforation

was found. Inj furusemide 40 mg IV given along with Dexa and
Hydrocort and aminophylline. Patient became comfortable after 30
min. His Sr. sod was found to be 122 mEq/L.

5. Out of 6 patients at Sir JJ group of hospitals, Mumbai, all patients were

operated by residents in urology and they took around 60-80 min for
the procedure.

6. 6. Every patient who presented with symptoms at both the institutes

had normal serum sodium levels preoperatively. But they do have
hyponatremia after surgery. (Sr.Sodium less than 122 mEq/L or less)

7. . Two patients at CPRH Kolhapur had visual disturbances in the form of

blurring of vision which were normalized after 10-12 hrs. of treatment.
(Sr.Sod 118-120 mEq/L immediate postop and around 134-140 after 12
hrs)

8. 7. One patient at Sir JJ had ventricular ectopics after 20 min of the

procedure along with fine basal crepts. Inj lasix 40mg and inj xylocard
60 mg was given and he became normal after 10 min.

This is not a scientific analysis of the cases but only the sharing of my
experience with you.
We did not have the facilities to calculate blood levels of glycine, ammonia
etc and osmolality.

We also had not investigated the patients to look for hemolysis as the
symptoms were relatively mild and patients responded well to the treatment
within 30 min.

CONCLUSIONS:

 Frequency of TURP syndrome occurrence was more where distilled

water was used as irrigation but the signs and symptoms were
relatively mild and response to t/t was also immediate.

 Frequency of TURP syndrome occurrence was less with Glycine as

irrigant but the severity of the s/s was more and it required aggressive
management to get rid of them.

 When the time taken for the surgery was more and resultant volume of
the irrigation used was more the symptoms were of more severity.

Recommendations:
 Limit the height of the irrigation fluid at 70 cm from the table.

 Time of resection should be less than 60 min at one sitting to avoid

complications.

 Avoid distilled water as irrigation fluid as it frequently causes some

symptoms.

 The amount of irrigation fluid should be kept minimum (less than 15 lit
if possible)

 Monitor the irrigation fluid going inside and coming out to have a rough
idea of absorption.

 Be alert when an inexperienced surgeon is operating.

 Think of the TURP syndrome at the appearance of first symptom (may

be just restlessness, hypertension)

 Monitor both ECG as well as Pulse oximetry

 Treat aggressively to avoid further consequences.