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  • 1. Original Article Sterile Water as an Irrigating Fluid for Transurethral Resection of the Prostate: Anesthetical View of the Records of 1600 Cases Reza Shariat Moharari, MD, Mohammad Reza Khajavi, MD, Peyman Khademhosseini, MD, Seyed Reza Hosseini, MD, and Atabak Najafi, MD Since 1955, these clinical features have been known as trans- Objectives: Absorption of the fluid used for bladder irrigation during urethral resection syndrome.3 Although the safety of water as transurethral resection of prostate (TURP) may disturb the circulatory an irrigating solution in TURP remains controversial, this system and lead to clinical symptoms known as the transurethral resec- fluid has been commonly used in our center (Sina University tion syndrome. The purpose of this study was to evaluate the changes Hospital) for many years. The purpose of this study was to in electrolytes in patients who had undergone TURP. report the clinical and the laboratory findings in the patients Methods: For all the cases with benign prostatic hypertrophy en- undergoing TURP by administering sterile water. rolled in the present study, TURP was performed as recommended in Miller’s Anesthesia, the sixth edition. Sterile water was used as an Patients and Methods irrigating fluid for bladder washing. Laboratory tests were performed In this study, the records of 1,600 patients who had un- before and immediately after the surgery. dergone TURP in Sina University Hospital (Tehran, Iran) during January 1992 to December 2004 were reviewed. The Results: No statistically significant changes were reported in the indication for performing TURP was as follows: (1) Acute serum sodium, blood urea nitrogen, creatinine, and hematocrit. The urinary retention, (2) Recurrent/persistent urinary tract infec- most common complications were hypotension (8.3%), hyperten- tion, (3) Significant symptoms from bladder outlet obstruc- sion (7.8%), nausea (6.4%), and vomiting (2.8%). Hyponatremia, tion not responsive to medical treatment, (4) Recurrent gross decreased hematocrit, and increased blood urea nitrogen/creatinine hematuria, (5) Pathophysiologic changes of the kidneys, ure- were rarely reported (2.5, 1.0, and 0.9%, respectively). thra, or bladder secondary to prostatic obstruction, and (6) Conclusion: Sterile water has been shown to be a safe irrigating Bladder calculus secondary to obstruction.4 fluid for TURP. All the patients were in good general health. All the patients signed an informed consent and also accepted that the results Key Words: anesthesia complications, fluid and electrolyte balance, and medical files would be reviewed for research activities. spinal anesthesia, transurethral resection of prostate Based on the medical condition of each patient, spinal anesthesia was induced at the level of T8 –T10 by isobaric T ransurethral resection of prostate (TURP) is the gold stan- dard of surgical management in benign prostatic hyper- trophy. Although glycine 1.5% is the most popular irrigating Key Points fluid in this surgery, it results in several complications such • Absorption of the fluid used during TURP may dis- as hypotension, bradycardia, confusion, and chest pain.1,2 turb the circulatory system and lead to transurethral resection syndrome. • Using sterile water as irrigating fluid, there were no From the Departments of Anesthesiology, Emergency Medicine, and Urol- statistically significant changes in serum sodium, ogy, Sina Hospital, Medical Sciences/University of Tehran, Tehran, Iran. blood urea nitrogen, creatinine, and hematocrit before Reprint requests to Reza Shariat Moharari, MD, Sina Hospital, Hassan Abad Square, Tehran, Iran. Email: and after the operation. This study was conducted after the approval in ethical board committee of • Hypotension, hypertension, nausea, and vomiting were our hospital. the most common complications; hyponatremia, de- Accepted August 20, 2007. creased hematocrit, and increased blood urea nitrogen/ Copyright © 2008 by The Southern Medical Association creatinine were rarely reported. 0038-4348/0 2000/10100-0001 Southern Medical Journal • Volume 101, Number 4, April 2008 1
  • 2. Moharari et al • Sterile Water as an Irrigating Fluid lidocaine 5% (100 mg) or hyperbaric bupivacaine 0.5% (10 Table 1. Changes in biochemical indicators of patients mg). Patients who were anesthetized using other methods, throughout the operation such as general anesthesia due to anatomic problems or the patients’ refusal were excluded from the study. This very Paired t test group included 4% of all of the cases. A standardized TURP Preoperation Postoperation operation5 was performed on all of the subjects using con- Mean SD Mean SD t P tinuous flow resectoscope. The operations were done by sev- Na (mEq/L) 138 8 137 9 1.100 NS eral experienced urologists who were the academic staff of BUN (mg/dL) 14 6 15 5 1.111 NS the hospital. Cr (mg/dL) 1.0 0.6 1.1 0.5 0.511 NS Serum sodium (Na), blood urea nitrogen (BUN), creati- Hct (%) 38 8 37 9 0.812 NS nine (Cr), and hematocrit (Hct) of each patient were recorded before and immediately after the operation (maximally 1 NS, nonsignificant; Na, serum sodium; BUN, blood urea nitrogen; Cr, cre- atinine; Hct, hematocrit; SD, standard deviation. hour). All of the tests were carried out in a unique laboratory (Sina University Hospital). Besides the body temperature, pulse rate and noninvasive blood pressure, electrocardiogram not intend to show that sterile water is the best irrigating monitoring, and pulse oximetry were observed during the fluid, but emphasize the point that it is safe and cheap. course of operation. The reliability of the results was estab- Sterile water is a historical and traditional fluid used to lished in a pilot study. Sterile water (37°C) localized 85 cm irrigate the bladder during TURP. It is accepted that transurethral above the patients’ beds was administered for all of the cases. resection syndrome caused by dilutional hyponatremia results The volume of the irrigating fluid used and reflected was secondary to the absorption of at least 3000 mL of irrigating recorded to compute the absorbed fluid. The patients’ urine fluid.3,6 According to the present study, smaller absorbed vol- was collected and its volume was calculated as milliliter per umes may elicit milder forms of the syndrome; as a matter of hour. The operation time (from the induction of anesthesia fact, the amount of absorbed fluid was neglectable and hypona- until the time the patient was transferred from the recovery tremia (Na 130 mEq/dL) was rare (2.5%). room) and also the proper weight of the resected tissues were According to the results of the present study, there were recorded. The definition of unpleasant biochemical events no statistically significant changes in the serum Na, BUN, Cr, and the cardiovascular evaluation are based on Miller’s An- and Hct. This finding is probably achieved due to the small esthesia, the sixth edition.5 amount of irrigating fluid absorbed. Previous studies have The statistical analysis was done using SPSS 10.0 soft- shown the higher amount of absorbed fluid to be accompa- ware. Biochemical indicators were recorded as mean and stan- nied with more frequent complications and more severe dard deviation (SD) and comparison of pre- versus postop- changes in electrolytes and Hct.2 eration variables was done with paired t test. As was set at Absorption of the fluid used for bladder irrigation during 0.05, P 0.05 was considered significant. TURP may disturb the circulatory system and lead to clinical Table 2. Frequency of unpleasant events and Results complications during or immediately after TURP The mean age of the patients ( SD) was 66.8 6.4 years with the median age of 67, ranging from 54 to 84 years. Complications Frequency Percent The mean operation time ( SD) was 40 4 minutes (median of 38). The mean weight of the resected tissue and the resec- Hyponatremia 40 2.5 tion rate ( SD) were 31 5 g and 16 2 g/min, respectively. Increased BUN/Cr 15 0.9 The mean irrigating absorption ( SD) was 293 25 mL. Oliguria 1 0.0 Table 1 shows no significant differences between pre- Decreased Hct ( 30%) 16 1.0 and immediately postoperation quantities of biochemical in- Active bleeding 3 0.0 dicators of serum. Reported complications and unpleasant Nausea 103 6.4 events are listed in Table 2. Vomiting 45 2.8 Hypertension 125 7.8 Hypotension (includes orthostatic) 132 8.3 Discussion Bradycardia 32 2.0 The present study reports the results of a wide range of Other arrhythmias (eg, PAC, PVC, etc) 78 4.9 patients who were candidates for TURP. This study is unique Change in body temperature 22 1.4 because of the large sample size used; moreover, due to being Mortality 0 0.0 conducted in a referral academic hospital, the findings are PAC, premature atrial contraction(s); PVC, premature ventricular contrac- independent of the surgeons’ experience. This case study does tion(s); BUN, blood urea nitrogen; Cr, creatinine; Hct, hematocrit. 2 © 2008 Southern Medical Association
  • 3. Original Article symptoms, known as the transurethral resection syndrome. Few cases of fever or hypothermia were reported in our The prevalence of the syndrome varies in different studies, study. According to Hahn et al,2 postoperative fever was which might be related to factors including the type of chem- common in those who absorbed irrigating fluid (21%) com- ical fluid used for irrigation (eg, sterile water, mannitol, gly- pared with only 3% of the nonabsorbing patients. They sug- cine, etc), the osmotic characteristic of the irrigating fluid gested that fluid absorption promotes bacteremia after TURP. (hypo-, normo-, or hyperosmolar fluids), the patient’s condi- The nature of the prostatic hypertrophy, elective surgery, and tion, and the amount of fluid absorbed.2,3,7,8 According to hygienic methods of surgery may reduce the abovementioned Hagstrom3, the susceptibility of patients to develop these events. symptoms varies according to their age and physical condi- tions. Some investigators have shown that the fluid’s temper- Conclusion ature interacts with the complications.1 The fluid bags with TURP with sterile water is safe and inexpensive. Signif- the room temperature of 37°C, which were traditionally used icant hyponatremia and fluid absorption did not occur, and in our center, prevent some cardiovascular changes and hypo- there was no mortality. or hyperthermia. Some authors suggested that hypertension is caused by Acknowledgments the fluid overload in the clinical syndrome during and after We thank all patients who let us use their information. TURP, though it maybe followed by dilutional hyponatremic Also, we thank all urologists, anesthesiologists, and their res- shock.1 The results of Hahn et al’s2 research showed that idents for helping us. We gratefully acknowledge Dr. Patricia hypertension occurred in approximately 20% of the patients Khashayar for reviewing this manuscript and providing help- who underwent TURP regardless of the amount of the ab- ful comments. sorbed fluid. On the contrary, hypotension was strongly as- sociated with the increase of absorption during and after the procedure. The cause of hypotension is not as clear as the References 1. Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection cause of hypertension, but it maybe the result of acute hypo- syndrome using glycine as the irrigant. J Urol 1995;154:123–128. natremia,6 dissemination of vasoactive substances from the 2. Hahn RG, Sanfeldt L, Nyman CR. Double blind randomized study of operating field,9 and the circulation itself.10 Significant hem- symptoms associated with absorption of glycine 1.5% or monitol 3% orrhage also increases the risk of intraoperative decreases in during transurethral resection of the prostate. J Urol 1998;160:397– 401. the arterial pressure. In our study, hypertension was reported 3. Hagstrom RS. Studies on fluid absorption during transurethral prostatic in 7.8% of the cases, which maybe related to other situations resection. J Urol 1955;73:852– 859. such as the prevalence of hypertension in the elderly in Iran. 4. Wein AJ, Kavoussi LR, Novick AC, et al. Campbell Walsh Urology. Hypotension was somewhat more frequent, but it may not be Philadelphia, Saunders Elsevier, 2007, ed 9. a serious problem, as many cases only had the transient form, 5. Malhotra V, Sudheendra V, Diwan S. Anesthesia and the renal and genitourinary system, in Miller RD (ed): Miller’s Anesthesia. Philadel- probably due to some amounts of bleeding. This condition phia, Elsevier Churchill Livingstone, 2005, ed 6, pp 2189 –2194. could be easily managed by serum therapy and the re-balanc- 6. Harrison RH, Boren JH, Robinson JR. Dilutional hyponatremic shock: ing of the body fluids. Also, the frequency of cardiac arrhyth- another concept of the transurethral prostatic resection. J Urol 1956;75: mias maybe related to the patients’ age; the most frequent 95–110. forms were premature atrial contraction and premature ven- 7. Shih HC, Kang HM, Yang CR, et al. Safety of distilled water as an tricular contraction, which are more common in the elderly irrigating fluid for transurethral resection of the prostate. Zhonghua Yi individuals. As mentioned above, body temperature was con- Xue Za Zhi 1999;62:503–508. trolled during the operation and the fluid of the normal body 8. Hahn RG. Early detection of the transurethral resection syndrome by marking the irrigating fluid with 1% ethanol. Acta Anaesthesiol Scand temperature was used. This might lead to a significant reduc- 1989;33:146 –151. tion in the occurrence of cardiac arrhythmias. Olsson et al1 9. Verrili RA, Uhlman RC, Viek NF, et al. The hypotensive effect of showed the symptoms of bradycardia, hypotension, and im- prostatic extract. J Urol 1962;87:184 –186. paired diuresis after transurethral resection of the prostate 10. Hahn R, Stalberg H, Carlstrom K, et al. Plasma atrial natriuretic peptide were associated with each other. In our study, oliguria was concentration and rennin activity during overhydration with 1.5% gly- seen in only one patient. cine solution in conscious sheep. Prostate 1994;24:55– 61. Southern Medical Journal • Volume 101, Number 4, April 2008 3