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1. TRANSURETHRAL RESECTION SYNDROME By Dr 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 ) H yperammonemia ( 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

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