TURP syndrome

Take home messages

• Transurethral resection of the prostate (TURP) usually involves irrigation with fluid to improve visualisation for the surgeon, and excessive systemic absorption of this fluid can lead to TURP syndrome
• TURP syndrome is thought to occur in between 1 and 8% of TURPs
• Symptoms are neurological and cardiovascular in nature, with agitation, seizures, coma and fluid overload being the main issues
• Hypo-osmolality is more important than hyponatraemia as a cause of central nervous system symptoms
• The most important treatment is recognising the problem and stopping the fluid irrigation as soon as possible

Anatomy

The prostate is an approximately 20g lump of glandular and non-glandular tissue encircling the male urethra as it leaves the bladder.

It has a mixture of secretory acini and smooth muscle and it produces seminal fluid.

It is split into four McNeal zones:

TURP

• TURP remains the surgical gold standard for the treatment of benign prostatic hyperplasia (BPH)
• It works well if the prostate is less than 60g in size
• If the prostate is larger than 80g, then HoLEP (Holmium laser enucleation of prostate) is better

Anaesthetic Technique

• If you are asked in an exam what the gold standard anaesthetic technique for TURP is - say spinal
• If you are asked by your consultant for the TURP list that you're doing tomorrow, what technique you're going to use, probably go with 'GA and IGel'
• (clearly, don't just spout this answer for every patient, but the reality is that many sites do TURP under GA)
• There's little evidence between superiority of spinal vs GA
• Note that the surgeon often uses lithotomy position with head down tilt, so GA may require intubation

What is TURP syndrome?

During TURP, the irrigation fluid is absorbed by the bladder and urethra, at a rate of approximately 20ml per minute.

Clearly, therefore, this can lead to quite significant volume overload in susceptible patients with cardiac disease, especially with prolonged surgery.

Furthermore, if the fluid used is glycine 1.5%, which is hypotonic, then it will steadily drop the sodium concentration as well as the osmolarity of the blood. It is mostly the drop in osmolarity that then leads to the neurological symptoms seen in TURP syndrome.

To compound this effect, the added intravascular volume leads to a natriuresis, which further contributes to the hyponatraemia

How common is it?

Probably more than we realise

Given every patient will absorb at least a moderate (around a litre) amount of fluid, and many of theses procedures are done under general anaesthesia, it is likely that many of the patients with mild symptomatic TURP syndrome go unrecognised.

That being said, the estimated incidence of mild to moderate TURP syndrome is up to 8%, which carries a mortality of less than 1%.

Severe TURP syndrome meanwhile carries a 25% mortality.

How can we reduce the risk of TURP syndrome?

Symptoms and severity of TURP syndrome correlate directly with the volume of fluid absorbed, so the aim of the game is to reduce how much is absorbed into the systemic circulation.

What should I do if my patient develops symptoms of TURP syndrome?

This is one of those cases where you would politely request that the surgeon stops the procedure if it is safe to do so, and more importantly stop the irrigation.

• Depending on your personal level of experience and confidence, you might call for help early, or crack on an manage it yourself - but probably best to at least let someone know...

Treat any bradycardia and hypotension as you would normally, and convulsions can be managed with benzodiazepines and magnesium as required.

Treat a sodium level of less than 120mmol per litre.

If the patient develops pulmonary oedema of signs of overload then judicious use of furosemide can help, and hypertonic saline is the back up option.

Most TURPs are now done using bipolar diathermy and saline or other crystalloids as irrigation fluid, so hopefully TURP syndrome is on the decline, however the FRCA exam loves a bit of glycine...

References and Further Reading

Anaesthesia for transurethral resection of the prostate

Approximately 40 000 transurethral resections of the prostate (TURP) are performed annually in the UK. TURP remains the surgical gold standard for the treatment

OUP AcademicAidan M. O’Donnell, BSc MB ChB FRCA

TURP syndrome

Transurethral resection of the prostate (TURP) syndrome is fluid overload and iso-osmolar hyponatraemia during TURP from large volumes of irrigation fluid being absorbed through venous sinuses

Life in the Fast Lane • LITFLChris Nickson

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