Post TURP syndrome which is essential for every urology resident and how to manage it.

1. TURP SYNDROME
DR Sai kishore

2. • Transurethral resection of the prostate (TURP) syndrome is
fluid overload and iso-osmolar hyponatraemia during TURP
from large volumes of irrigation fluid being absorbed through
venous sinuses
• TUPR syndrome can also occur in other procedures requiring
large volumes of irrigation, such as hysteroscopy

4. THE IDEAL IRRIGATION FLUID
No such thing exists but it would have these features:
• Transparent (for good visibility)
• Electrically non-conductive (to prevent dispersion of
the diathermy current)
• Isotonic
• Non-toxic
• Non-haemolytic when absorbed
• Easy to sterilize
• Inexpensive

5. Glycine 1.5% in H2O is used as the irrigation fluid as it is
• Hyposmolar at 220mmol/L
• Non-conductive, non-haemolytic and has a neutral visual
density

6. PATHOPHYSIOLOGY
Patients usually absorb around 20mL/min, average
absorption during a case is ~ 1.5L and depends on:
• Pressure of infusion (keep bag at <60cm height)
• Venous pressure
• Exposed vascular bed
• Duration of irrigation

7. Mechanism of clinical manifestations
• Symptoms primarily arise from the effects of
glycine, which acts as an inhibitory CNS
neurotransmitter at GABA receptors and
paradoxically potentiates NMDA receptors
• Increased plasma ammonia may also contribute
• Not (usually) from increased brain water!
• Glycine also has cardiodepressant effects
and may have renal toxicity

8. • SIGNS AND SYMPTOMS:
1. NEUROLOGIC: Nausea, restlessness, headache, confusion,
somnolence, visual disturbance, seizure, coma
2. CARDIOVASCULAR: Hypertension, reflex bradycardia,
pulmonary edema, hypotension, CHF
ECG: wide QRS complex, elevated ST, ventricular
tachyarrhytmia or fibrillation
3. RESPIRATORY: Hypoxia, Cyanosis, tachypnea, Cheyne stokes
breathing
4. HEMATOLOGIC: DIC, hemolysis
5. Acute renal failure
6. Metabolic :Hyponatremia, hyperglycinemia,
hyperammonemia

9. FLUID OVERLOAD:
• Uptake of 1L fluid into circulation in 1hr decreases Na
concentration by 5-8mmol/l
• Hypertension and reflex tachycardia due to rapid
volume expansion
• Patients with poor LV function will develop pulmonary
edema
• Hypertension may not be present in profuse bleeding
• Hypertension with hyponatremia leads to net water
move out of intravascular space into pulmonary
interstitium triggers pulmonary edema and
hypovolemic shock

10. • HYPONATREMIA:
–Symptoms are related to severity by which plasma Na concentration falls
–Mild symptoms like nausea, agitation with stable hemodynamics-monitor till
symptoms resolve.
–Supportive therapy including anti emetics
–Bradycardia and hypotension-atropine and adrenergic drugs
–Severe hyponatremia(<120mmol/l)-hypertonic saline 3%.combats cerebral
swelling ,expands plasma volume, reduces cellular swelling and increases urinary
excretion
–Rapid correction may lead to central pontine mylenolysis
–Raising Na conc. 1mmol/l/hr is considered safe

11. • HYPOOSMOLALITY:
Cause of CNS deterioration is not hyponatremia itself, but
acute hypoosmolality
Brain edema and development of cerebral herniation few hrs
postoperatively is the major cause of death
• HYPERAMMONEMIA:
Hyperammonemic encephalopathy develops as a result of
formation of glyoxylic acid and ammonia
Normal range 10-35 µmol/l
Concentration over 100µmol/l causes neurological signs and
symptoms

12. • RISK FACTORS
• Surgical time > 1 hr
• Height of bag > 70cm
• Resected > 60g
• Large blood loss
• Perforation of the bladder (leads to rapid
absorption from the peritoneal cavity)
• Large amount of fluid used
• Poorly controlled CHF

13. INVESTIGATIONS
• Hyponatraemia (dilutional effect of a large volume of absorbed
irrigation fluid, but later due to natriuresis)
• Iso -osmolar (or mildly hypo-osmolar)
• Increased osmolar gap from absorbed glycine
• Hyperglycinaemia (up to 20 mM; normal is 0.15-0.3mmol/L)
• Hyperserinaemia (major metabolite of glycine)
• Hyperammonaemia (due to deamination of glycine and serine)
• Hyperoxaluria and hypocalcaemia (glycine is metabolised to
glycoxylic acid and oxalic acid, the latter forms calclium oxalate
crystals in the urinary tracts and may contribute to renal failure)
• Metabolic acidosis
• Haemodilution and haemolysis

14. Prevention
• Early diagnosis and prompt treatment
• Correction of fluid and electrolytes preoperatively
• Operative time within 30-60 mins, risk increases >90mins
• Prostate gland size less than 60gm
• Fluid bag height at 60cm.(60-100cm)
• Experienced surgeon
• Low pressure irrigation
• Bipolar TURP
• Laser prostatectomy using photoselective vaporization,HoLEP

15. • MANAGEMENT
• Resuscitation
• Attend to ABCs and address life threats:
– O2 +/- intubation (or airway protection) and
ventilation
– invasive monitoring
• Lasix: furosemide 40mg IV
• Seizures : benzodiazepines +/- other anti-
epileptics; consider magnesium (stabilises NMDA
receptors)

16. • Hyponatraemia:
– hypertonic saline is only indicated for neurological
manifestations if measured serum osmolality is < 260
mOsmol/kg
– Aim to raise Na+ by no more than 10-12 mmol/24 hours)
– A rapid increase in plasma sodium is not concerning (this
often happens with glycine metabolism), unless there is a
sudden change in osmolality (measured osmolality usually
changes little as the hyponatremia resolves)
– Check for serum sodium
– If <120mmol/l,give 3% Nacl

17. • Severe cases may require renal replacement
therapy
• Treat acute pulmonary oedema and dysrhythmias
as required
• Treat hypocalcaemia
• Treat underlying cause
• Stop surgery as soon as possible
• Coagulate bleeding points
• Stop IV fluid
• Monitor Hb

18. • Additional information
• In some centres, ethanol 1% is added to the irrigation solution
and the patient’s breath tested for ethanol every few
minutes:
• A positive test indicates a significant quantity of fluid has been
absorbed

19. THANK YOU