TRANSURETHRAL RESECTION OF THE PROSTATE

SYNDROME

Usman Saleem, MD MSPTDownstate MCApril 4, 2008

TURP SYNDROME

TURP SYNDROME: OVERVIEW

1. ANATOMY OF PROSTATE 2. TURP INTRODUCTION3. TURP SYNDROME DEFINITION4. TURP EPIDEMIOLOGY5. DIFFERENTIAL DIAGNOSIS6. IRRIGATION FLUID7. PREOPERATIVE MANAGEMENT

8. ANESTHETIC TECHNIQUE

9. CLINICAL MANIFESTATIONS

10. PATHOPHYSIOLOGY11. PREVENTION12. TREATMENT13. CORE COMPETENCIES14. REFLECTIVE PRACTICE15. REFERENCES

TURP SYNDROME:ANATOMY OF PROSTATE

TURP SYNDROME:SURGICAL PROCEDURE

Operation is performed through a modified cystoscope

Prostatic tissue is resected using an electrically energized wire loop.

the Prostatic capsule is usually preserved.

Continuous irrigation is necessary to distend the bladder and to wash away blood and dissected prostatic tissue.

TURP SYNDROME: SURGICAL PROCEDURE

EPIDEMIOLOGY

TURP can be associated with a number of complications: • TURP Syndrome

(2%) • Hemorrhage • Bladder perforation

(1%) • Hypothermia • Septicemia (6%) • DIC

the main challenges are blood loss and TURP Syndrome due to excessive absorption of irrigant fluid

Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989;141(2):243-7.

TURP SYNDROME: DEFINITION

TURP syndrome: constellation of signs and symptoms caused by the absorption of large volumes of isotonic irrigating fluids through prostatic veins or breaches in the prostatic capsule.

The syndrome is characterized by • hypervolemia, • hyponatremia • hypo-osmolarity

TURP SYNDROME: DIFFERENTIAL DIAGNOSIS

The differential diagnosis of hypotension following

TURP should always include 1. Hemorrhage2. TURP syndrome3. Bladder perforation4. Myocardial infarction or ischemia 5. Septicemia6. Disseminated intravascular coagulation

(DIC).7. Anaphylaxis

TURP SYNDROME: EPIDEMIOLOGY

Irrigant absorption may occur in up to 46% of resections

5-10% of patients absorbing 1 liter or more observed in 2-10% of all prostate resections Of approximately 400,000 TURP procedures

each year, 10% to 15% incur TURP syndrome and the mortality is 0.2% to 0.8%

Syndrome may occur as quickly as 15 minutes after resection starts or up to 24 hours postoperatively

A simple canalization or balloon dilation of the urethra or a staged TURP is less likely to provoke TURP syndrome.

Jensen V: The TURP Syndrome. Canadian Journal of Anesthesia 1991/ 38:1/ pp90-7

TURP SYNDROME: IRRIGATION FLUID

The irrigation solution enters the bloodstream directly through open prostatic venous sinus• primarily when prostatic capsule is

violated during surgery. As many as 8L of irrigation solution can be

absorbed by the patient during TURP. The average rate of aborption is 20mL per

minute and my reach 200mL per minute average weight gain by the end of surgery is

2 kg.

TURP SYNDROME: IRRIGATION FLUID

Ideally the irrigation solution should be:

Isotonic electrically inert Nontoxic Transparent inexpensive

Osmolality of irrigation solutions used for transurethral resection of

the prostate

Solution Osmolality (mOsm/kg)

Glycine, 1.2% 175

Glycine, 1.5% 220

Sorbitol, 3.5% 165

Mannitol, 5% 275

Cytal 178

Glucose, 2.5% 139

Urea, 1% 167

TURP SYNDROME: IRRIGATION FLUID

Distilled water is transparent and electrically inert. • Extremely Hypotonic: may cause

hemolysis, shock and renal failure. Several nearly isotonic irrigation solutions

that have replaced plain distilled water.• The more commonly used solution today is

Glycine. • Cytal is a solution occasionally used.

To maintain their transparency, these solutions are prepared moderately hypotonic.

TURP SYNDROME: IRRIGATION FLUID

Glycine has direct toxic effects on the: Heart: decrease of 17.5 % in cardiac output,

arginine reversed myocardial depression Retina: transient visual disturbance

(blindness) Encephalophathy & seizures: via NMDA

potentiation• Magnesium exerts a negative control on

the NMDA receptor• hypomagnesemia caused by dilution may

increase the susceptibility to seizures.

TURP SYNDROME: IRRIGATION FLUID

The most common metabolites of glycine are ammonia and oxalic acids.

Hyperoxaluria could compromise renal function in patients with coexisting renal disease

Hyperammonemia occurs secondary to arginine deficiency.

TURP SYNDROME: IRRIGATION FLUID

Hyperammonemia manifestations appear within 1 hour after surgery.

Blood ammonia level > 500 mmol/L. • nauseated, vomits, and then

becomes comatose. Ammonia level < 150 mmol/L pt

awakensGravenstein D: Transurethral resection of prostate (TURP) syndrome: A review of pathophysiology and management.  Anesth Analg  1997; 84:438

TURP SYNDROME: IRRIGATION FLUID

Transient blindness is likely caused by toxic effect of Glycine inhibition of the visional pathways of the retina

Severity of the is directly related to Glycine blood level

The patient complains of blurred vision and halos

Eyes dilated and unresponsive pupils.

Vision improves as the Glycine level declines

TURP SYNDROME: IRRIGATION FLUID

Cytal is a mixture of sorbitol and mannitol

Bacterial containmination: This is secondary to the sugars in the cytal solution make it a rich medium for bacteria

Exacerbate hyperglycemia in diabetic patients

pulmonary edema in cardiac patients: mannitol rapidly expands the blood volume

TURP SYNDROME: PREOPERATIVE MANAGEMENT

Patients for TURP are frequently elderly with coexistent diseases.• cardiac disease 67%• abnormal

electrocardiogram (ECG) 77%

• chronic obstructive pulmonary disease 29%

• diabetes mellitus 8%Dodds C and Murray D. Preoperative assessment of the elderly. BJA CEPD Reviews

(2001) 1,6: 181-184

TURP SYNDROME: PREOPERATIVE MANAGEMENT

Fluid and electrolyte imbalance should be corrected • sodium concentrations >130 mEq/L are

safe for GA. • Lower concentrations manifest

intraoperatively as decrease in MAC Long standing urinary obstruction can lead to

impaired renal function and chronic urinary infection.• About 30% of TURP patients have infected

urine preoperatively.

TURP SYNDROME: PREOPERATIVE MANAGEMENT

Normal saline is the preferred solution because it contains sodium (154mEq/L)

For most patients T&S is sufficient Blood should be crossmatched for

anemic patients and patients with large glands (> 40 g).• Keep in mind: the transfusion rate for

TURP-surgery is about 6%.

Malhotra V. Transurethral resection of the prostate. Anesthesiol Clin North Am 2000 Dec;18(4);883-897

TURP SYNDROME:ANESTHETIC TECHNIQUE

spinal anesthesia is the technique of choice

sensory supply to the bladder is from T10 - T12.

sensory supply to the urethra, prostate and bladder neck is from S2 - S4.

for satisfactory anesthesia, a block to T10 is required.

Spinal anesthesia dose of Bupivacaine 0.75% is 1.6 ml

Jensen V: The TURP Syndrome. Canadian Journal of Anesthesia 1991/ 38:1/ pp90-7

Malhotra V. Transurethral resection of the prostate. Anesthesiol Clin North Am 2000 Dec;18(4);883-897

TURP SYNDROME:REGIONAL ANESTHESIA

Subarachnoid anesthesia is preferred to epidural • It is technically easier to perform in the

elderly• the duration of surgery is generally not

very long. • the incomplete block of sacral nerve roots

that occasionally occurs with extradural technique is avoided with subarachnoid anesthesia.

Regional anesthesia does not abolish the obturator reflex. • The reflex blocked by muscle paralysis

during general anesthesia or obturator nerve block

TURP SYNDROME:ANESTHETIC TECHNIQUE

Regional anesthesia is the anesthetic of choice:

monitoring of the patients mentation

vasodilation and peripheral pooling of blood

It reduces blood loss It provides postoperative

analgesia. reinfarction rate for SA has been

reported to be less than 1%, versus 2% to 8% for GA.

Decreaseed hypercoagulable tendency in the postoperative period

homeostasis of the neuroendocrine system

TURP SYNDROME: GENERAL ANESTHESIA

Advantage • Uncooperative

patients or in patients who require hemodynamic or ventilatory support.

• Abolish Obturator Reflex

Disadvantage • inability to monitor

the patient’s level of mentation

TURP SYNDROME: SIGNS AND SYMPTOMS

TURP SYNDROME: PATHOPHYSIOLOGY

TURP SYNDROME: PATHOPHYSIOLOGY

TURP SYNDROME: CARDIAC SIGNS AND

SYMPTOMS

<120mEq/L :• signs of cardiovascular depression

<115mEq/L: • bradycardia, widening of the QRS complex,

ST-segment elevation, ventricular ectopic beats, and T wave inversion.

<110 mEq/L :• VT or VF• can develop respiratory and cardiac arrest

Barash PG, Cullen BF, Stoelting RK, ed. Clinical Anesthesia,  2nd ed.. Philadelphia: JB Lippincott; 1992:1125-1156.

TURP SYNDROME: MANIFESTATION UNDER GENERAL ANESTHESIA

Presenting signs are a rise and then fall in BP, respiratory arrest, and bradycardia.

The ECG may show nodal rhythm, ST-segment changes U waves, and widening of the QRS complex.

Recovery from general anesthesia is usually delayed.

Gravenstein D: Transurethral resection of prostate (TURP) syndrome: A review of pathophysiology and management.

 Anesth Analg  1997; 84:438

TURP SYNDROME: PATHOPHYSIOLOGY

TURP SYNDROME: NEUROLOGICAL

MANIFESTATIONS

CNS dysfunction is due to acute hypoosmolarity.• the blood brain barrier is impermeable to

sodium but freely permeable to water. Cerebral edema caused by acute

hypoosmolality can increase intracranial pressure: • Bradycardia + hypertension by the

Cushing reflex. The rise in intracranial pressure is

directly related to the gain in body weight during TURP.

TURP SYNDROME: NEUROLOGICAL

MANIFESTATIONS

In some cases, moderate hyponatremia is associated with severe neurologic symptoms; in others, severe hyponatremia causes no symptoms. • The determining factor is the rate at which

the serum sodium level falls rather than the total.

• faster the fall the greater the incidence of CNS symptoms.

• There may be accompanied EEG abnormalities • loss of alpha-wave activity and irregular

discharge of high-amplitude slow-wave activity.

TURP SYNDROME: NEUROLOGICAL

MANIFESTATIONS

Na <120 meq/L: • confusion and restlessness

Na <115 meq/L: • Somnolence and nausea

Na <110 meq/L: • Tonic-clonic seizures and coma.

TURP SYNDROME: PREVENTION

TURP SYNDROME: RISK FACTORS

TURP syndrome is more likely to occur:

1. The hydrostatic pressure of the irrigation solution is high.

2. An excessively distended bladder

3. Prostatic gland is large.4. The Prostatic Capsule is

violated during surgery. 5. Duration of surgery

(>60mins)

TURP SYDROME: Prediction and early diagnosis of TURP

Syndrome

Objectives: To determine the correlation of resection time, irrigant volume and prostatic weight with the incidence of TURP syndrome and to evaluate the role of resection experience in the occurrence of the syndrome among 579 patients

Prediction and early diagnosis of Transurethral Prostatectomy SyndromeANDRES S. M Et Al, National Kidney and Transplant Institute Division of Urology, QC, Philippines

Incidence of TURP Syndrome at Identified Risk Categories

Incidence of TURP syndrome In Combination of Various Risk

Categories

Comparison of TURP syndrome Between Resident and Consultant

TURP SYDROME: Prediction and early diagnosis of Syndrome

Prolonged resection time,high prostatic weight and high irrigant volume are important risk factors in the development of TURP syndrome particularly when resection time exceeds 60 mins, prostatic weight is heavier than 30 grams and irrigant volume is greater than 30 liters.

The risk is enhanced by the presence of more than one of these risk categories. Additionally, lack of resection experience remains an important factor in its causation.Prediction and early diagnosis of Transurethral Prostatectomy Syndrome

ANDRES S. M Et Al, National Kidney and Transplant Institute Division of Urology, QC, Philippines

TURP SYNDROME: BIPOLAR SALINE TURP

Conventional TURP uses a monopolar electrocautery in which the current passes from the electrode on the resectoscope through the pt’s body to the return plate.

This current passage can result in stimulation of nerves or muscles, burns, and problems with cardiac pacemakers.

TURP SYNDROME: BIPOLAR SALINE TURP

The Bipolar technique allows the use of saline as the irrigation fluid, eliminating the risk of transurethral resection syndrome

Several clinical trials have proved that bipolar TURP is as effective as conventional TURP, but with a shorter hospital stay, earlier catheter removal, and fewer complications

Paula Bishop "Bipolar transurethral resection of the prostate—a new approach". AORN Journal. . FindArticles.com. 03 Apr. 2008.

TURP SYNDROME: EARLY DETECTION

Thirty ASA physical status I–III patients (mean age 62 yr) were assesed for the role of monitoring ethanol content of the expired breath and its relationship in diagnosing TURP syndrome

irrigant used: 30 L of 5% mannitol + 1% ethanol

alcohol concentration within breathing air (by an alcolmeter) was monitored at 5–15-min intervals.

They concluded, the addition of ethanol to irrigation fluid and follow-up of expiratory breath ethanol concentration is a simple and inexpensive method that allows early detection of TURP syndrome (P < 0.05)

Checketts MR, Duthine WH. Expired breath ethanol measurements to calculate irrigating fluid absorption during transurethral resection of the prostate: experience in a district general hospital. British Journal of Urology 1996;77:198-202.

TURP SYNDROME: TREATMENT

Ensure oxygenation and circulatory support Notify surgeon and terminate procedure Consider invasive monitors if CV instability

occurs Send blood for electrolytes, creatinine,

glucose, ABG Obtain 12 lead ECG Seizures

• Use short acting anticonvulsant (midazolam), Next a barbiturate or phenytoin can be added. last resort, use muscle relaxant

Restlessness and incoherence are particularly ominous signs • GA in the presence of TURP syndrome can

lead to severe complications and even death.

TURP SYNDROME: TREATMENT

Treat mild symptoms: Na>120 mEq/L• Fluid restriction and loop diuretic

(furosemide 20mg) Treat severe symptoms: Na< 120

mEq/L• 3% NaCl IV at a rate of <100ml/hr• Discontinue 3% NaCl when Na > 120

mEq/L Rate of Na increase should not exceed

12 mEq/L in 24 hr period

TURP SYNDROME: TREATMENT

Rapid administration of hypertonic saline has been associated with central pontine myelinolysis

To reduce the hazards of saline administration, serum osmolarity should be monitored and corrected aggressively only until symptoms substantially resolve • then hyponatremia should be corrected at

a rate no faster than 1.5 mEq/L per hourGravenstein D: Transurethral resection of prostate (TURP) syndrome: A review of pathophysiology and management.  Anesth Analg  1997; 84:438

TURP SYNDROME: TREATMENT

ie. 100-kg man • Na of 118 mEq/L. • How much NaCl must be given to raise his

Na to 130 mEq/L?• (100 x 0.6) x (130-118) = 720 mEq• 720 mEq/ 154 mEq = 4.7 liters of NS

Barash PG, Cullen BF, Stoelting RK, ed. Clinical Anesthesia,  2nd ed.. Philadelphia: JB Lippincott; 1992:1125-1156.

REFLECTIVE PRACTICE

Be aware of TURP syndrome preventive measures and communicate these measure to urology team

No postoperative CXR was done on this patient to rule out pulmonary edema

Restrict IV fluids, use NS instead of LR

CORE COMPETENCIES

Patient Care: provided medical care to TURP patient

Medical Knowledge: reviewed current literature to establish management plan for TURP syndrome

Practice-based learning and improvement: assimilated scientific evidence pertinent to this case; provided reflective practice for future improvement in patient care

Interpersonal and Communication skills: discussed the complication with the patient’s family and urology team

Professionalism: showed respect for patient’s circumstance and provided follow-up care to the patient

Systems-based practice: coordinated care between Urology and Anesthesia services.

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THANK YOU

REFERENCES

Cunningham AJ, McKenna JA, Skene DS. Single injection spinal anaesthesia with amethocaine and morphine for transurethral prostatectomy. Br J Anaesth 1983; 55: 423–7

Gravenstein D: Transurethral resection of prostate (TURP) syndrome: A review of pathophysiology and management.  Anesth Analg  1997; 84:438

Barash PG, Cullen BF, Stoelting RK, ed. Clinical Anesthesia,  2nd ed.. Philadelphia: JB Lippincott; 1992:1125-1156.

Roesch RP, Stoelting RK, Lingeman JE, et al: Ammonia toxicity resulting from glycine absorption during a transurethral resection of the prostate.  Anesthesiology  1983; 58:577.

Checketts MR, Duthine WH. Expired breath ethanol measurements to calculate irrigating fluid absorption during transurethral resection of the prostate: experience in a district general hospital. British Journal of Urology 1996;77:198-202.

Malhotra V. Transurethral resection of the prostate. Anesthesiol Clin North Am 2000 Dec;18(4);883-897

Desmond J. Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatremia during transurethral resection. Can J Surg 1970;13:116-21.

REFERENCES

Hahn RG, Ekengren JC. Patterns of irrigating fluid absorpstion during transurethral resection of the prostate as indicated by ethanol. Journal of Urology 1993;149:502-6

Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989;141(2):243-7.

Hahn RG. Early detection of the TUR syndrome by marking the irrigating fluid with the 1% ethanol. Acta Anaesthesiol Scand 1989;33:146-51.

Ghanem AN, Ward JP. Osmotic and metabolic sequelae of volumetric overload in relation to the TUR syndrome. Br J Urol 1990;66:71-8

Agius AM, Cutajar CL. Hyponatremia after transurethral resection of the prostate. J Royal College Surgeons Edinburgh 1991;36(2):109-112.

Henry Ho, Sidney K.H. Yip, Christopher W.S. Cheng, K.T. Foo Journal of Endourology. April 1, 2006: 244-247

Jensen V: The TURP Syndrome. Canadian Journal of Anesthesia 1991/ 38:1/ pp90-7

Casthley I’, Ramanathan S, Chalon J, Turndorf H. Decreases in electric thoracic impedance during transurethral resection of the prostate: an index of early water intoxication. J Urol 1981;125: 347-9..