Transurethral resection of the prostate syndrome

• Restlessness
• Headache
• Nausea and vomiting
• Confusion
• Visual disturbances
• Cerebral edema
• Convulsions
• Coma

• Bradycardia
• Hypotension or hypertension
• Tachypnoea
• Hypoxia
• Cyanosis
• Pulmonary edema

• Hypothermia
• Abdominal pain and distension.[2]

Absorption of small volumes of irrigating fluid via the prostatic venous sinuses will inevitably occur in most TURP operations. The average rate of absorption is 20ml/min, and therefore length of surgery may have an effect on the total volume absorbed. Fluid absorption leads to rapid volume expansion, which causes hypertension and reflex bradycardia. The oncotic pressure of blood will decrease as a result of the dilution of serum proteins, and this coupled with hypertension will push fluid from the intra-vascular to the interstitial compartment causing pulmonary and cerebral edema. Patients with impaired left ventricular function may furthermore develop pulmonary edema as a result of the acute circulatory overload.

The excessive absorption of fluid will rapidly dilute the serum sodium concentration. This fall in sodium concentration will create an osmotic gradient between intra- and extra- fluid within the brain, leading to net fluid shift away from intra-vascular compartment resulting in cerebral oedema and raised intra-cranial pressure. The symptoms resulting from hyponatraemia will depend on both the severity of the drop as well as the speed at which the concentration decreased. Sodium concentration below 120mMol/L defines severe TURP syndrome. The normal range of sodium is 135-145mMol/L

Glycine, a commonly used fluid for irrigation, gains entry to the intra-vascular compartment via the prostatic venous sinuses, and is then metabolized in the portal bed and kidneys. Ammonia is a major by-product of glycine metabolism. Encephalopathy may ensue if ammonia serum concentration rise sufficiently.

Bladder irrigation is a significant source of heat loss. Body core temperature may fall if the irrigating fluids used are instilled at room temperature for a prolonged period of time during the operation.[3]

Regional anaesthesia is preferred, as it allows for detection of early signs of TURP syndrome such as confusion, restlessness and altered consciousness.[4]

Fluids containing glycine can be toxic to the cardiovascular and central nervous systems if infused in large amounts and should be avoided.

Length of surgery should be reduced as much as is safely possible, and ideally be kept under 1 hour. Surgical experience is therefore paramount in order to minimize the time of surgery.

The patient should be kept horizontal, as assuming the Trendelenburg position (head tilt down 20°) reduces the intra-vesical pressure required to initiate absorption, and therefore increases the risk of irrigation fluid absorption.

Large prostates should be resected in staged procedures to avoid prolonged operative times, and care should be taken to avoid damage to the prostate capsule.

The height of the irrigating fluid above the patient should not be excessive. It has been suggested [where] that the optimum height is 60 cm above the patient. This is so to minimize hydrostatic pressure of the fluid

The patient should receive supplemental high-flow 100% oxygen through a non-rebreathe mask. Endotracheal intubation and positive pressure ventilation may be necessary where pulmonary oedema has developed.

Blood pressure should be monitored via insertion of a central line and arterial line. Inotropes may be employed judiciously to support blood pressure. Plasma expansion may be necessary if hypotension and low cardiac output develop.

Asymptomaic Hyponatraemia does not necessarily have to be treated. If a patient has normal renal function, the excess fluid will be cleared.

Hypertonic saline may be given intravenously. The risk of central pontine myelinolysis does not apply assuming the hypoatraemia is acute. Generally, 100 mL of hypertonic saline given as a bolus will increase the serum sodium 2-3 mEq/L. Concurrently the slow administration of intravenous diuretics such as furosemide can correct the sodium by diuresis, however these should be given with caution as they may paradoxically cause a reduction in serum sodium concentration.

Nausea and vomiting can be treated with intravenous anti-emetics. Seizures and convulsions may be managed with benzodiazepines.

Disseminated intravascular coagulation must be managed by careful transfusion of packed red cells, fresh frozen plasma, fibrinogen and platelets, but this rarely helps and can be deleterious by "adding fuel" to microvascular thrombosis. Regular blood tests will be necessary to monitor improvement in clotting status.