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TURP syndrome

Syndrome precipitated by symptoms and signs related to acute dilutional hyponatraemia, secondary to excess intravascular absorption of irrigation fluid.

Incidence quoted at 1-2 %.

 

Pathophysiology

During TURP, the glycine irrigant is absorbed directly into periprostatic veins, and also slowly into retroperitoneal space and perivesical spaces.

 

  1. Fluid overload
  • Excess absorption of volume of irrigation fluid
  • Causes pulmonary oedema, hypertension and heart failure

 

  1. Dilutional hyponatraemia
  • Excess fluid causes drop in intravascular sodium concentration
  • Drives water out of plasma into tissues including brain – can lead to cerebral oedema and herniation in severe cases

 

  1. Glycine toxicity
  • Glycine is metabolised in liver (90 %) and kidneys (10 %) into ammonia, glycolic acid and water
  • It is an inhibitory neurotransmitter in the CNS – slow down neurotransmission from retina to brain, causing visual disturbances, and further cerebral toxicity
  • Glycine can also cause cardiac toxicity, and ammonia build-up can cause encephalopathy

 

Risk factors for TURP syndrome

  • Long resection time > 60 – 90 minutes
  • Large glands
  • Glycine / monopolar procedure
  • Open venous sinuses during resection
  • Excessive pressure from elevated bag height

 

Prevention of TURP syndrome

  • Bipolar saline resection
  • Keep irrigation bag height < 60 cm H2O
  • Prompt resection
  • Avoid capsular perforation or opening venous sinuses
  • Spinal anaesthetic to allow early detection of symptoms
  • In large glands, consider hemi-resection, or alternative procedures (bipolar, HoLEP, open)
  • High index of suspicion
  • Check pre-operative sodium, consider alternative in patients with pre-existing hyponatraemia

 

Symptoms and signs

Neurological – confusion, nausea, vomiting, visual changes, restlessness

Cardiorespiratory – hypertension, bradycardia/tachycardia, tachypnoea, hypoxia, arrhythmias

Prickling sensations, facial warmth and flushing

Late / severe – seizures, coma, death

 

Symptoms usually seen once sodium < 120 mmol/L

 

Management

  • Close communication with anaesthetist
  • High index of suspicion if input and outputs of irrigation doesn’t match, any cardiorespiratory changes – bloods to check sodium. Consider CXR to assess for overload.
  • Stop resection ASAP once safe and bleeding controlled
  • Well patients with mild hyponatraemia – will usually diurese enough themselves.
  • Supportive cares – warming, oxygen.
  • Frusemide 40 mg – relatively more water is lost cf. sodium.
  • If severe – early involvement of ICU, with careful slow correction of hyponatraemia as rapid correction can cause central pontine myelinolysis
  • Hypertonic saline with careful monitoring, fluid restriction and frusemide.

 

 

Properties of glycine which make it an ideal irrigation fluid:

  • Good visibility and transparent
  • Cheap
  • Non-ionic and conducts electricity
  • Non haemolytic (water can cause haemolysis, with renal tubular obstruction from haemoglobin)

Glycine used is 1.5 % and osmolality is 230 mOsm/L compared to serum which is 290 mOsm/L (i.e., glycine is hypotonic).