Uro instruments- irrigation fluids.

Uro instruments- irrigation fluids.

1. IRRIGATION FLUIDS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. ROLE IN UROLOGY
•Gently dilate the mucosal spaces
•Remove blood, cut tissue and debris from the
operating field
•Enable better vision
Dept Of Urology, KMC and GRH, Chennai 3

4. IDEAL IRRIGANT FLUID
•Minimally conductive
–to avoid current dissipation from the electrode
–to maximize the current at its point of contact with the tissues
•Has to be harmless when absorbed in the intravascular space
•Does not interfere with diathermy
•Has a high degree of translucency
•Has similar osmolarity to the serum
•User friendly
•Easy to sterilize
•Inexpensive


Such a fluid does not exist
Dept Of Urology, KMC and GRH, Chennai 4

5. NON IONIC IRRIGANTS
•The original M-TURP requires the use of a
non-ionic irrigant to carry the current through
the cutting loop into the tissue (and through
the patient) to the grounding pad electrode


Dept Of Urology, KMC and GRH, Chennai 5

6. IRRIGANTS
Dept Of Urology, KMC and GRH, Chennai 6

7. NON IONIC IRRIGANTS
•Sterile water
•Glycine 1.2%, 1.5%. 2.2%
•Mannitol 3%
•Glucose 2.5% - 4%
•Cytal
•Urea 1%

Dept Of Urology, KMC and GRH, Chennai 7

8. STERILE WATER
•Poor conductor of electricity
•Disadvantage
–Extreme hypotonicity, causing
•Hemolysis
•Dilutional hyponatremia
•Shock
•Renal failure.

Dept Of Urology, KMC and GRH, Chennai 8

9. GLYCINE
•1.2%, 1.5%, 2.2%
•Glycine is a colorless, sweet-tasting, simplest
amino acid
•Advantages
–Low cost
–Isotonic with plasma- 2.2%, but the side effects- more
–Cause less hemolysis and renal failure than sterile
water

Dept Of Urology, KMC and GRH, Chennai 9

10. GLYCINE
Disadvantages:
•Glycine is an amino acid that inhibits
neurotransmission in the retina, spinal cord,
and midbrain
•Liberation of ammonia from metabolic
pathways leading to immediate or delayed
encaphalopathic symptoms
Dept Of Urology, KMC and GRH, Chennai 10

11. MANNITOL
•Type of sugar alcohol
•Advantages:
–Does not have the toxicities of glycine

•Disadvantages
–Cost higher compared to glycine.
–The elimination of mannitol through kidney will be
decreased in patients with impaired renal
function.
Dept Of Urology, KMC and GRH, Chennai 11

12. GLUCOSE
•Not a widely used irrigating fluid
•Produces tissue charring at the site of
resection
•Associated hyperglycemia produced when
glucose is absorbed into the circulation.
•It also causes stickiness of surgeons' gloves
and instruments
Dept Of Urology, KMC and GRH, Chennai 12

13. CYTAL
•Mixture of sorbitol 2.7% and mannitol 0.54%

•Widely used in USA as an irrigating fluid
•Not gained popularity in India due to its high
cost and nonavailability.
•In the body, sorbitol is metabolised to
fructose, which may present problems in a
patient with hypersensitivity to fructose.

Dept Of Urology, KMC and GRH, Chennai 13

14. UREA
•This produces urea crystallisation on the in-
struments during resection and hence not
preferred.
Dept Of Urology, KMC and GRH, Chennai 14

15. ETHANOL
•Ethanol monitoring is a fairly new method of
assessing fluid absorption during TURP.
•By using an irrigating fluid containing a trace
amount of ethanol, a pocket-sized
breathalyzer can measure the patient’s end-
expiratory ethanol concentration.
•Ethanol 1% is the standard strength
–2% offers higher sensitivity and is suitable for
research purposes
Dept Of Urology, KMC and GRH, Chennai 15

16. IONIC IRRIGANTS
•Normal saline 0.9%
–154 mmol Na + , 154 mmol Cl
–osmolality 308 mosm/L
•It is the irrigant of choice for
–Diagnostic procedures (including cystoscopy)
–Bladder irrigation postoperatively.
•Suitable for use with bipolar TURP.
Dept Of Urology, KMC and GRH, Chennai 16

17. NORMAL SALINE
BIPOLAR
•Resecting loop that incorporates
both the active and the return
portions of the circuit on the same
electrode.
•Consequently, the current does not
need to run through the patient to
a return electrode (in the form of a
grounding pad), and current is kept
at the site of the resection
MECHANISM
Dept Of Urology, KMC and GRH, Chennai 17

18. NORMAL SALINE
Plasma molecules are now able to be excited for use in resection.
Additional energy from the loop then converts the gas to plasma.
The saline is vaporized into gas around the loop
Energy is initially transmitted from the loop into the surrounding saline
Dept Of Urology, KMC and GRH, Chennai 18

19. NORMAL SALINE
•Although this seems like a dynamic and
explosive process, it actually allows tissue
resection at lower temperatures with a lower
voltage.
•The excited sodium ions of the plasma give
this technology the characteristic orange glow.
Dept Of Urology, KMC and GRH, Chennai 19

20. TUR SYNDROME
•Aberrations CNS, CVS and other systems
which manifest due to the absorption of
irrigating fluids during TUR are together
known as TUR Syndrome
Dept Of Urology, KMC and GRH, Chennai 20

21. PATHOPHYSIOLOGY
•Circulatory Overload
•Water Intoxication
•Hyponatremia
•Glycine Toxicity
Dept Of Urology, KMC and GRH, Chennai 21

22. CIRCULATORY OVERLOAD
•The uptake of small amounts of irrigating
fluids has been shown to occur during almost
every TURP

through the venous network of
prostatic bed

Dept Of Urology, KMC and GRH, Chennai 22

23. CIRCULATORY OVERLOAD
PROSTATIC
VENOUS SYSTEM
PRESSURE
TUR SYNDROME
Dept Of Urology, KMC and GRH, Chennai 23

24. CIRCULATORY OVERLOAD
Expired breath ethanol tests
•Done after the addition of ethanol up to a
concentration of 1 % to the irrigating fluid.

•The average rate of fluid absorption during TURP
is 20 ml/min.
•The uptake of I litre of fluid within one hour,
which corresponds to an acute decrease in the
serum sodium concentration of 5-8 mmols/l, is
the volume above which the risk of absorption
related symptoms is statistically increased
Dept Of Urology, KMC and GRH, Chennai 24

25. CIRCULATORY OVERLOAD
absorbed fluid
dilutes the serum
proteins and
decreases the
oncotic pressure of
blood
Due to circulatory
overload, the blood
volume increases,
systolic and
diastolic pressures
increase
Drives fluid from
the vascular to
interstitial
compartment
causing pulmonary
and cerebral
edema.
Dept Of Urology, KMC and GRH, Chennai 25

26. CIRCULATORY OVERLOAD
•In addition to direct absorption into the cir-
culation,
–upto 70% of the irrigation solution has been found
to accumulate interstitially, in
•Periprostatic
•retroperitoneal spaces.
•For every 100 ml of fluid entering the
interstitial compartment, 10-15 meq of so-
dium also moves with it.
Dept Of Urology, KMC and GRH, Chennai 26

27. CIRCULATORY OVERLOAD
RISK FACTORS
•Larger glands
–greater than 45 g
•Longer resections
–greater than 90 minutes
•Hydrostatic pressure at the prostatic bed
Dept Of Urology, KMC and GRH, Chennai 27

28. CIRCULATORY OVERLOAD
•Hydrostatic pressure at the prostatic bed
–depends on the height of irrigating fluid column
and the pressure inside the bladder during
surgery.
•Ideal height of the fluid is 60 cm above the
patient
•10 cm above this leads to increased pressure
in the prostatic fossa and a greater than 2 fold
increase in systemic fluid absorption
Dept Of Urology, KMC and GRH, Chennai 28

29. CIRCULATORY OVERLOAD
height to
maintain
good vision
excessive
systemic fluid
absorption
Dept Of Urology, KMC and GRH, Chennai 29

30. WATER INTOXICATION
•Neurological disorder caused by increased water
content of the brain.
•The symptoms of water intoxication appear when
serum sodium level falls 15 - 20 meq/l below normal
level.
•SYMPTOMS:
–Incoherence, restless, seizures, coma
•SIGNS:
–Clonus, positive Babinski responses.
–Papilloedema, with dilated, sluggishly reacting pupils
•The EEG will show low voltage, bilaterally.
Dept Of Urology, KMC and GRH, Chennai 30

31. HYPONATREMIA
Loss of sodium into
pockets of irrigation
solution ac-
cumulated in the
periprostatic and
retroperitoneal
spaces
Loss of sodium into
the stream of the
irrigation fluid from
the prostatic
resection site
Dilution of serum
sodium through
excessive absorp-
tion of irrigation
solution
HYPONATREMIA
Larger amounts of
glycine stimulate
the release of ANP-
natriuresis.

MECHANISM
Dept Of Urology, KMC and GRH, Chennai 31

32. HYPONATREMIA
The symptoms of hyponatremia:
•Below 120 meq/L
–hypotension and reduced myocardial contractility
occur.
•Below 115 meq/L
–bradycardia and widening of QRS complexes,
ventricular ectopics and T wave inversion occur.
•Below 100 meq/L
–generalised seizures, coma, respiratory arrest,
Ventricular Tachycardia (VT), Ventricular Fibrillation
(VF) and cardiac arrest occur.
Dept Of Urology, KMC and GRH, Chennai 32

33. GLYCINE TOXICITY
•Excess of glycine- toxic to heart and retina and
may lead to hyperammonemia.


•Associated with subacute effects on the
myocardium, manifested as
–Depression or inversion of the T wave on the
electrocardiogram 24 hr after surgery.

•Absorption exceeding 500 ml has been shown
to double the long-term risk of acute
myocardial infarction.

Dept Of Urology, KMC and GRH, Chennai 33

34. GLYCINE TOXICITY
•Depress myocardial function, particularly
–operative duration exceeds 1 hr

–0.5%- develop acute myocardial ischemia
–20%-transient myocardial ischemia.
•Dilutional hypocalcemia has also been
implicated as a source.


Dept Of Urology, KMC and GRH, Chennai 34

35. GLYCINE TOXICITY
•Glycine is known to be a major inhibitory
neurotransmitter in the spinal cord and in the
brain stem
–acts in the same manner as gamma amino butyric acid
on the chloride ion channel.
•Too high a concentration may therefore cause
severe depressant effect on the CNS and visual
disturbances.
•Glycolic acid, formate and formaldehyde are
other metabolites of glycine and these too can
cause visual disturbances.
Dept Of Urology, KMC and GRH, Chennai 35

36. GLYCINE TOXICITY
•Arginine
–nonessential amino acid
–added to the glycine infusion, the toxic effect of glycine on
the heart is blunted.
–The mechanism by which arginine protects the heart is
unknown.
•The normal value of serum glycine in man is 13-17
mg/l.
•Glycine toxicity is very uncommon in TURP patients
probably because most of the absorbed glycine is
retained in the periprostatic and retroperitoneal
spaces, where it has no systemic effect
Dept Of Urology, KMC and GRH, Chennai 36

37. GLYCINE TOXICITY
Ammonia
•Major by-product of glycine metabolism
•High ammonia concentration suppresses
norepinephrine and dopamine release in the
brain.
•This causes the encephalopathy of TURP
syndrome.
•Ammonia toxicity is rare
Dept Of Urology, KMC and GRH, Chennai 37

38. GLYCINE TOXICITY
Ammonia
•Characteristically the toxicity occurs within
one hour after surgey.
•Blood ammonia rises above 500 micromols/L
(normal value is 11-35 micromols/L).
•Hyperammonemia lasts for over ten hours
postoperatively, probably because glycine
continues to be absorbed from the
periprostatic space.
Dept Of Urology, KMC and GRH, Chennai 38

39. TREATMENT
•Diagnosed per op: Procedure should be
terminated as early as possible
•Diuretics
–Frusemide
•Administered in a dose of 1 mg/kg intravenously.
•Drawback: increases sodium excretion.
–15% mannitol
•Suggested as a better choice
•Action independent of sodium excretion and its
tendency to increase extracellular osmolality.
Dept Of Urology, KMC and GRH, Chennai 39

40. TREATMENT
HYPONATREMIA
•Fluid restriction
•Administration of hypertonic (3%) saline (about
1 mL/kg/hr).
•The serum sodium concentration should be
raised to no more than 25 mEq/L in the first 48
hours
•Rate of no more than 2 mEq/L per hour
•Target goal should be 120 to 125 mEq/L.
Dept Of Urology, KMC and GRH, Chennai 40

41. TREATMENT
•Total sodium deficit to reach this point can be
calculated as


•Where volume of distribution
–0.5 for men
–0.6 for women
•Rapid administration of saline leads to pulmo-
nary edema and central pontine myelinolysis

Dept Of Urology, KMC and GRH, Chennai 41

42. PREVENTIVE MEASURES
•Limiting the height of the irrigation bottle to
60 cm above the prostate
•Limiting the duration to lesser than 90
minutes
•Leaving a rim of tissue on the capsule until the
end of the procedure, where it can be left if
signs of TUR syndrome are evident, may
reduce the risk of absorption due to opening
of prostatic sinuses
Dept Of Urology, KMC and GRH, Chennai 42

43. REFERENCES
•Campbell- Walsh-wein Urology, 12
th
edition
•Blandy, Notley, Reynard: Transurethral resection, 5
th

Edition.
•Keane, Graham: Glenn’s urologic surgery, 8
th
edition.
•Smith, Preminger, Kavoussi, Badlani: Smith’s Textbook of
Endourology, 4
th
Edition.
•Reynard, Mark, Turner, Armenakas, Feneley, Sullivan:
Urological Surgery, 1st Edition
•Sabnis, Patwardhan, Ganpule: Urology Instrumentation A
Comprehensive Guide
•Moorthy H K, Philip S. TURP syndrome - current concepts in
the pathophysiology and management. Indian J Urol
2001;17:97-102

Dept Of Urology, KMC and GRH, Chennai 43

44. THANK YOU
Dept Of Urology, KMC and GRH, Chennai 44