Transurethral resection (TUR) syndrome is a rare but serious complication resulting from fluid absorption during TUR procedures, leading to symptoms like hyponatremia, fluid overload, and varied neurological and cardiovascular effects. Diagnosis is based on suspicion due to nonspecific symptoms and critical lab findings such as severe hyponatremia. Prevention strategies include choosing appropriate irrigation fluids, minimizing operative time, and using regional anesthesia to detect early signs of syndrome development.

1. T RA NS UR E T H RA L
RESECTION SYNDROME
By
D r ANEES PUTHAWALA

2. INTRODUCTION
●
Transurethral resection (TUR) syndrome is a rare but potentially
life-threatening complication of a transurethral resection
procedure.
It occurs as a consequence of the absorption of the fluids used
to irrigate the bladder during the operation into the prostatic
venous sinuses.
Symptoms and signs are varied and unpredictable, and result
from fluid overload and disturbed electrolyte balance and
hyponatremia.
Treatment is largely supportive and relies on removal of the
underlying cause, and organ and physiological support. Pre-
operative prevention strategies are extremely important.
●

3. SYMPTOMS AND SIGNS
The clinical picture of TUR syndrome will vary according to its severity, and
may further be influenced by the type of irrigant used.
There is no classical presentation for TUR syndrome, indeed signs and
symptoms are often vague and non-specific, therefore in the correct
clinical context the clinician should have a high index of suspicion.
Most of the manifestations are secondary to fluid overload

4. CENTRAL NERVOUS
SYSTEM
• Restlessness
• Headache
• Nausea and vomiting
• Confusion
• Visual disturbances
• Cerebral edema
• Convulsions
• Coma

5. CARDIO-
RESPIRATORY
• Bradycardia
• Hypotension or hypertension
• Tachypnoea
• Hypoxia
• Cyanosis
• Pulmonary edema

6. SYSTEMIC
• Hypothermia
• Abdominal pain and distension.

7. PATHOPHYSIOLOGY
The pathophysiology of TUR syndrome is complex and does not
always follow the same sequence of events, which explains why the
set of signs and symptoms are variable and non-specific.
The type of irrigation fluid used will also have a bearing on the
pathophysiological events: normal saline or Hartmann's fluid do not
cause harm when absorbed into the circulation, however they may
dissipate current from the resectoscope and cause injury to the patient.
Commonly used fluids for TURP procedures include glycine, sterile
water and glucose solution

8. FLUID OVERLOAD
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

9. HYPONATREMIA
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 TUR
syndrome.
The normal range of sodium is 135-145mMol/L

10. HYPERAMMONEMIA
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.

11. HYPOTHERMIA
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.

12. DIAGNOSIS
There are no definite criteria to diagnose TUR syndrome.
The clinician must have a high index of suspicion for diagnosing TUR
syndrome in a patient who becomes unwell following a TUR procedure.
The symptoms and signs have been listed and are varied and non-
specific, however the following findings soon after a TUR procedure
would be strongly suggestive of a TUR syndrome diagnosis
• acutely unwell, confused patient with a reduced Glasgow Coma
Scale score
• hyponatraemia: Na < 120 mmol/L
• hyperkalemia: K > 6.0 mml/L
• glycine toxicity
• intra-vascular haemolysis, disseminated intravascular coagulation
(reduced platelet count, increased fibrin degradation products)

13. PREVENTION
Due to the severe morbidity and mortality associated with the TUR
syndrome, precautions must be taken to reduce the risk of this
developing in so far as possible.
REGIONAL VS. GENERAL ANAESTHESIA
Regional anaesthesia is preferred, as it allows for detection of early
signs of TURP syndrome such as confusion, restlessness and altered
consciousness.
CHOICE OF IRRIGATION FLUID
Fluids containing glycine can be toxic to the cardiovascular and central
nervous systems if infused in large amounts and should be avoided.
• OPERATIVE TIME
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.

14. PATIENT POSITIONING ON OPERATING TABLE
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.
PROSTATE SIZE
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.
IRRIGATING FLUID BAG HEIGHT
The height of the irrigating fluid above the patient should not be
excessive. It has been suggested that the optimum height is 60 cm
above the patient. This is so to minimize hydrostatic pressure of the
fluid

15. IRRIGATION FLUIDS
-Properties of ideal Irrigation Solution-
Transparent- allows visualization.1
Isotonic.2
.Electrically non conductive- allows diathermy to work.3
Non-hemolytic.4
Non metabolised.5
Non-toxic.6
Inexpensive.7
Easy to sterilize.8

16. NO SUCH
IRRIGATION
SOLUTION
CURRENTLY
EXISTS

17. -Commonly used Irrigation Solutions are
SOLUTION (OSMOLALITY (mOsm/Kg
%Glycine, 1.2 175
%Glycine, 1.5 220
%Sorbitol, 3.5 165
Mannitol, 5% 275
Cytal
(Sorbitol 2.7% + Mannitol 0.54%)
178
Glucose, 2.5% 139
Urea, 1% 167

18. COMPLICATIONS OF
IRRIGATION FLUIDS
-Glycine-
Normal plasma glycine levels are 13 to 17 mg/L-
.Transient blindness is attributed to glycine toxicity-
Glycine is a major inhibitory-transmitter acting in the spinal cord and brain--
.stem
Glycine also has been implicated in the myocardial depression and-
.hemodynamic changes associated with TURP syndrome
-Ammonia Toxicity-
Absorption of glycine can result in CNS toxicity because-
.of oxidative bio-transformation of glycine to ammonia

19. -Mannitol-
Rapidly expands blood volume and causes pulmonary edema in cardiac-
.patients
-Glucose-
Causes severe hyperglycemia in diabetic patients-
Distilled Water is electrically inert and inexpensive and has excellent optical
properties.
-Extremely Hypotonic.
-When absorbed into the circulation in large amounts,
plain water causes Hemolysis, Shock, and Renal failure.
-Thus Isotonic fluids are preferred- ) these solutions are kept slightly
hypotonic to preserve transparency(

20. -TUR syndrome is a term applied to a constellation of symptoms and
signs caused primarily by excessive absorption of irrigating fluid.
-Occurs in up to 8% of cases in mild form, but is severe in 1-2% of
cases.
-Resection of prostatic tissue opens an extensive network of
venous sinuses, which allows the irrigation fluid to be absorbed
into the systemic circulation.

21. :Simple principles govern the amount of absorption
-Duration of the procedure-1
10 to 30 mL of fluid is absorbed per minute of resection time, with as
much as 6 to 8 L absorbed in some procedures lasting up to 2
hours.
Height of the irrigation fluid bag above the patient (increased height-2
implies increased hydrostatic pressure driving the fluid
) intravenously
Vascularity of the diseased prostate-3
Capsular or bladder perforation allowing large volumes of irrigation-4
fluid into peritoneal cavity from where it is absorbed

22. Factors which increase the risk of TURP syndrome-
Pre-existing hyponatraemia or pulmonary oedema-1
Prostate size larger than 60-100g-2
Reduced venous pressure-3
Procedures longer than 1 hour-4
(Hydrostatic pressure > 60cm H2O (height of bag above patient-5
Inexperienced or slow surgeon-6

23. -:Classical triad of features of TURP syndrome
Hypertension- 1
Bradycardia- 2
Altered mental status- 3

24. -Investigations required for diagnosis-
.Serum Sodium- levels below 120mEq/l - symptomatic-1
- 2
ECG – QRS widening, ST segment elevation, T wave inversion
( below sodium levels of 115 mEq/l)
Hyperammonemia ( by-product of glycine metabolism)- 3

25. Management of TURP syndrome
Initial management follows the airway, breathing and circulation-
(ABC( guidelines. Awake patients need to be sedated and
. ventilated
Anesthetised patients with mask airways may need intubation
and- positive pressure ventilation
Surgeon should be informed and surgery terminated

26. Initial management of fluid overload and hyponatraemia involves
.stopping IV fluids
. Inj frusemide 40mg IV to promote diuresis
. Patients should be closely monitored on an intensive care unit
Hypertonic saline solutions ( 3% or 5%) should be used to increase
the serum sodium level by about 1 mmol/l/hour (not exceeding an)
increase of 20mmol/l in the first 48 hours of therapy
Sodium levels should be checked every few hours. Therapy with
hypertonic saline should be stopped when symptoms cease or the
. sodium level reaches 124-132mmol/l
Rapid correction has been implicated as a cause of central pontine
myelinolysis, which causes irreversible brain damage

27. Convulsions should be acutely treated with a benzodiazepine (e.g.
diazepam 5-10mg) or small doses of thiopentone (25 - 100mg)
In the presence of intractable seizures, the sodium level may be
corrected more rapidly at a rate of up to 8-10mmol/l/hour for the first
4 hours of therapy

28. THANK YOU