An Experience Of Turp Syndrome At Cpr Hospital
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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The institutes where the facilities and expertise are available, the age old Frayer’s Prostatectomy has almost been replaced by TURP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 hyponatremia and thereby resultant hypo-osmolality.
also
causes
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.
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 hyponatremia and thereby resultant hypo-osmolality.
also
causes
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.
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