Fluid Management and TURP Syndrome
Transurethral resection of the prostate (TURP) syndrome is a potentially life-threatening complication that arises due to the excessive absorption of irrigation fluids used during the procedure. The irrigation fluids used, such as glycine, mannitol, or sorbitol, are hypotonic and can lead to severe dilutional hyponatremia and hypo-osmolality when absorbed in large amounts. With bipolar or laser resection in saline, hyponatremia does not occur, but absorbed saline can still produce volume overload and pulmonary edema. Early signs of TURP syndrome include changes in consciousness, bradycardia, hypertension, or hypotension, and in severe cases, seizures and coma. Under spinal anesthesia, these symptoms can be detected earlier due to the patient's ability to communicate. However, under general anesthesia, these symptoms are masked, making vigilant intraoperative monitoring essential.
Careful control of irrigation fluid usage and monitoring the duration of the procedure are critical in preventing excessive absorption. The longer the surgery, the greater the risk of fluid absorption. It is recommended that the resection time not exceed 60 minutes, as fluid absorption rates increase significantly after this period. When TURP syndrome is suspected, rapid intervention is necessary. Ask the surgeon to stop resecting, secure hemostasis and finish; send serum sodium, osmolality, hemoglobin and a blood gas; give oxygen and support the airway, intubating if consciousness is depressed or pulmonary edema develops; and stop any hypotonic intravenous fluid. Treat seizures with a benzodiazepine such as midazolam. A loop diuretic such as furosemide is appropriate only when the patient is hypervolemic (hypertension, raised venous pressure, pulmonary edema); in a hypotensive patient it worsens the hypotension and does little for the osmolality. Hypertonic 3% saline is the treatment for symptomatic hyponatremia: give 100 mL intravenously over about 10 minutes, repeat up to twice more at 10 minute intervals if seizures or coma persist, and aim for a rise of 4 to 6 mEq/L in the first few hours, which is enough to relieve cerebral edema. Then slow down: total correction should not exceed 8 to 10 mEq/L in any 24 hour period, with sodium rechecked every 1 to 2 hours, because overcorrection risks osmotic demyelination. Hyponatremia that developed over an hour carries far less demyelination risk than chronic hyponatremia, but the limit is still respected. Vasopressors rather than fluid for hypotension, and intensive care observation afterward, complete the plan.
Bladder Perforation
Perforation of the bladder or prostatic capsule occurs in about 1 percent of resections, and the extraperitoneal variety is far more common than the intraperitoneal one. The awake patient reports lower abdominal pain, often with nausea, pallor, sweating and hypotension; pain referred to the shoulder tip means irrigant has reached the diaphragm and the perforation is intraperitoneal. Under general anesthesia the clues are unexplained hypotension or hypertension, abdominal distension, and irrigant that goes in but does not come back. Extraperitoneal perforations are usually managed with catheter drainage and ending the case early; intraperitoneal perforation or continuing bleeding needs open or laparoscopic repair. Fluid that has extravasated keeps being absorbed for hours, so TURP syndrome can follow a perforation after an apparently uneventful case.
Hemorrhage
Blood loss is an inevitable consequence of TURP, with an estimated average loss of 500 mL, or roughly 2 to 5 mL per minute of resection and 20 to 50 mL per gram of tissue removed. Bleeding is exacerbated in patients with larger prostates, prolonged surgeries, or coexisting infections. Blood loss during TURP is difficult to quantify due to the large volume of irrigation fluid, making hemoglobin monitoring essential. Excessive bleeding may occur if the prostatic capsule is perforated, requiring more aggressive interventions such as retroperitoneal drainage or, in rare cases, reoperation to control bleeding. The prostate is rich in plasminogen activators (urokinase and tissue plasminogen activator) that are released into the circulation during resection and drive primary fibrinolysis, and prostatic thromboplastin can trigger disseminated intravascular coagulation; bleeding that continues despite surgical hemostasis should prompt a coagulation screen and a fibrinogen level. In cases of significant blood loss, a bolus of tranexamic acid may be administered to reduce hemorrhage by inhibiting fibrinolysis. Warmed irrigation also limits bleeding, since hypothermia impairs platelet function and coagulation.
Hypothermia
Liters of room-temperature irrigant flowing through the prostatic fossa, plus the fluid that is absorbed, cool the patient quickly; core temperature commonly falls 1 to 2 degrees C over a standard resection and more in long cases. Shivering raises oxygen consumption in patients with little cardiac reserve, hypothermia increases bleeding, and spinal anesthesia removes the vasoconstriction below the block that would otherwise slow the heat loss. Warmed irrigation fluid, warmed intravenous fluid, forced-air warming of the upper body and core temperature monitoring are routine.
Cardiovascular Complications
Elderly patients undergoing TURP are at increased risk of myocardial ischemia, with incidences reported as high as 25%. This can be exacerbated by hemodynamic instability due to fluid overload, hypothermia, or the stress of the surgery. Continuous ECG monitoring is essential, and if myocardial ischemia or infarction occurs, prompt management with appropriate pharmacologic agents and possible transfer to intensive care is required.
