Position: Lithotomy
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)

Maintenance Paralytic: No

Bleeding can be hard to asses due to the high volume of irrigation. Ask the circulator to calculate I&O.

TURP syndrome is a big complication of these procedures. There are different side effects depending on the irrigation used:
Glycine (hyper-ammonemia, coma, visual disturbances)
Distilled water (hemolysis, hyponatremia/hypo-osmolality)
Mannitol (osmotic diuresis)
Sorbitol (hyperglycemia)

The BEST way to monitor for TURP syndrome is by having an awake patient to assess neuro function. For this reason spinal anesthesia is preferred. However, practically speaking, most TURP’s are done under general anesthesia.

Patients can absorb 20-30 ml in a single minute and 6 liters in 2 hours. If the surgery is longer than an hour or two, draw labs to assess their status.

Resection time should be limited to 1 hour (limit the irrigation absorption), and the irrigation fluids should hang no higher than 30cm above the OR table at the beginning of the case, and 15cm towards the end of the case

Postoperatively, the patient may complain about the “need to pee”. This is from involuntary contraction of the detrusor muscle in the bladder. You can reassure the patient that this is a normal sensation after this procedure.

Benign prostatic hyperplasia (BPH) leads to persistent urostasis, hematuria, recurrent UTI’s.

Transurethral approach is good for prostate volume < 40-50ml. Otherwise an open approach is required.

TURP syndrome:
This would present as Restlessness, headache, tachypnea, bradycardia, prolonged QRS, hypo/hypertension. May progress to respiratory distress, hypoxia, pulmonary edema, nausea, confusion and coma. Most common derangement is hypo-osmolality because the BBB is impermeable to sodium but freely permeable to water. Evaluation of mental status in the awake patient is the best monitor for early detection of TURP syndrome. Under GETA, mental status will be impossible to evaluate – so watch your vitals and hemodynamics closely.

Treatment for TURP syndrome:
Ensure oxygenation and circulatory support, Notify surgeon and terminate procedure, Consider insertion of invasive monitors, Labs for electrolytes, serum glucose and ABG’s, 12-lead EKG, Treat mild symptoms (Na + <120) with lasix and fluid restriction, Treat severe symptoms (Na < 115) with 3% NaCl rate not to exceed 100ml/hr. Discontinue 3% NaCl when Na + exceeds 120mEq/L. Valium or versed for seizures, endotracheal intubation.