Complications of TURP 1. Case presentation 2. TURP syndrome 3. Prevention and treatment Ri 陳昭勳

Brief History 陳X傑 63y/o male Symptoms of urinary frequency and urgency OPD follow-up and controlled by Hytrin

Past History Coronary artery disease s/p stenting controlled by Aspirin Hypertension controlled by Norvasc ASA Class III

Incidence of systemic dz in TURP patients Disease Incidence % Cardiac disease 67 Cardiovascular 50 COPD 29 DM 8

Brief History 2 weeks ago difficulty in urination Foley catheterizations several times Cystostomy on 91-2-18 DC Tapal Admission for TURP on 91-2-25

麻醉過程 Please see 實物投影機

Irrigation Solution Ideal: isotonic, electrically inert, nontoxic, transparent, easy to sterilize,inexpensive Traditional: distilled water Modern: Glycine (1.2% and 1.5) Mannitol ( 3%) Urea ( 1%)

Definition of TURP syndrome Following complications have been reported: hypervolemia, hyponatremia, water intoxication, pulmonary edema, hemolysis, caogulopathy, bladder perforation

TURP syndrome: a problem of Volume and Solute Intravascular volume: volume expansion and volume loss Plasma solute: hyponatremia hypoosmolality hyperglycinemia Plasma osmolality=2xNa+Glu/18+BUN/2.8

Hyponatremia Mechanism for hyponatremia in TURP Na is essential for cerebral and cardiac function <120 meq/L cardiovascular depression <115meq/L bradycardia,ECG change <100meq/L generalized seizure Average fall in Na 3.65-10 meq/L Incidence 7%-26%

Hypoosmolality Derangement of CNS function due to cerebral edema Clinical signs: decerebrate posture, positive Babinski sign, low-voltage EEG, comatose

Hemolysis 30-70% of patients, who use water as irrigation solution Clinical signs: chills, clammy skin, tight chest, bronchospasm Oxygen carrying capacity decrease Free hemoglobin increase Hyperkalemia

Bladder Perforation Caused by instrumentation, overdistension or explosion of hydrogen Most bladder perforation is retroperitoneal Clinical signs: return of irrigation solution decrease, abdominal distension

Prevention of TURP syndrome Surgical technique 術前矯正electrolyte and fluid imbalance Special attention to cardiac p’t Height of irrigation solution bag Duration of surgery

Treatment of TURP syndrome Terminate surgery Administer Lasix Hypertonic saline (3-5%) for hyponatremia Intubation for pulmonary edema Diazepam for seizure

References Transurethral Resection of the Prostate Syndrome: A Review of the Pathophysiology and Management Anesthesia and Analgesia Feb ’97 438 Anesthesia for Renal and Genito-Urologic surgery Complications of Urologic Surgery

Estimation of Fluid Absorption Serum Sodium Dilution [(Pre-Op Na)/ (Post-op Na) –1] x ECF Breath-alcohol level Patient’s weight gain