Urology Case Reports 26 (2019) 100982

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Urology Case Reports

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Endourology

TUR syndrome - A report T

∗
Vinay Kumar, Kumar Vineet , Adiveeth Deb
Department of General Surgery, GSVM Medical College & LLR Hospital, Kanpur, India

A B S T R A C T

We report a case of transurethral resection of prostate (TURP) syndrome. A 80-year-old man with grade III Prostatomegaly was scheduled for transurethral resection
of the prostate under spinal anesthesia. Just after the end of the surgery, the patient presented signs of TURP syndrome with bradycardia, arterial hypertension,
hypoxemia and dizziness-confusion. The electrolytes analysis revealed an acute hyponatremia (sodium concentration 120.6 mmol/L) and hyperkalemia (potassium
concentration 6.48 mmol/L). Medical treatment consisted of hypertonic saline solution 3% and nebulization with levosalbutamol. The presented case describes a
typical TURP syndrome, which was diagnosed and treated early. The patient was discharged from hospital without any complications.

1. Introduction instrument. The height of the irrigating fluid reservoir was fixed at 70
cm height from patient's bed. The total intraoperative bleeding was
Transurethral resection of prostate (TURP) syndrome is a systemic estimated at 250 ml. The amount of 1.5% glycine used intraoperatively
complication of transurethral resection of the prostate or bladder tu- was 24 L. The average preoperative blood pressure was 130/80 mmHg
mours, caused by excessive absorption of electrolyte-free irrigation and heart rate 80 bpm. During surgery, which lasted for 68 min, the
fluids. This syndrome may potentially cause neurologic disturbance, patient had been given 1500 ml ringer's lactate solution by intravenous
pulmonary edema, cardiovascular compromise, and death.1 Normal infusion. 5 min after the end of operation, patient suddenly developed
saline cannot be used as irrigation solution with conventional mono- in post-op room with dizziness-confusion, pain, alteration of vision, pin-
polar resection Glycine solution is almost universally used as an irri- point pupil, hypoxemia (spO2 84%), hypertension (166/90 mmHg) and
gation solution in traditional therapeutic endoscopic urologic proce- bradycardia (52 bpm). The abdomen and lung auscultation were
dures. The incidence of this complication is between 0.78% and 1.4%.2 normal. He was nebulised with levosalbutamol. He was loaded with
The surgeon should be informed immediately, the intervention stopped 500 ml of saline 0.9%, 300mg paracetamol inducing normalization of
as quick as possible and the treatment should start without delay. hemodynamics. The TURP syndrome was subsequently confirmed by an
immediately electrolyte analysis revealed a decrease in serum sodium
2. Patient and observation concentration from 131 mmol/L to 120.6 mmol/L and increase in po-
tassium concentration from 5.2mmol/L to 6.48mmol/L “Table 2” [b].
We report the case of a 80-year-old male patient, who presented a The measurement of all irrigating fluids showed that 3 L had been ab-
severe TURP syndrome 5 minutes after surgery with severe hypona- sorbed. Blood ammonemia and glycinemia concentrations weren't
tremia. Patient under observation a 80-year-old man, on medication for measured. The blood pressure and heart rate were gradually stabilized
same disease, body weight 45 Kg, prostate weight 69 g and dimension at 120/70 and 80 bpm. A chest x-ray of the lungs and ECG were normal.
57 × 45*50mm on ultrasonography and complaints of difficulty in He was loaded with 200 ml 3% normal saline over 6 hours. Twelve
urination and blood in urine underwent transurethral resection of hours later, the sodium concentration increased and potassium con-
prostate under spinal anesthesia with 3 ml of hyperbaric bupivacaine centration decreased “Table 3” [c]. The second postoperative day, so-
(0.5%) that extended to the T10 level, as tested by pin prick. The heart dium concentration and potassium concentration was normalised
rate at the start of the operation was 84 bpm, blood pressure 132/ within normal limits. He was discharged from the hospital later on in a
76 mmHg, electrocardiogram normal and spo2 was 98%. The patient good condition.
was positioned in lithotomy posture. And the TURP surgery was started.
The preoperative values of serum sodium was 131 mmol/L, potassium 3. Discussion
5.2 mmol/L “Table 1” [a]. A routine monitoring of fluid absorption by
expired breath tests is not practiced in our hospital. The irrigation fluid Transurethral resection syndrome during transurethral resection of
used by urologist was glycine 1.5%. TURP was performed by monopolar the prostate (TURP) results from excessive absorption of electrolyte free

∗
Corresponding author.
E-mail address: [email protected] (K. Vineet).

https://doi.org/10.1016/j.eucr.2019.100982
Received 19 June 2019; Received in revised form 23 July 2019; Accepted 26 July 2019
Available online 26 July 2019
2214-4420/ © 2019 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
V. Kumar, et al. Urology Case Reports 26 (2019) 100982

Table 1 Several new procedures, such as laser ablation, laser enucleation,

Table is showing pre-op electrolytes values of concerned patient. photoselective vaporization and bipolar resection in saline may be a
Serum Sodium Serum Potassium Serum Calcium good surgical alternative for preventing this complication especially in
critically ill patients.5
131 mmol/l 5.2 mmol/l 4.65 mg/dl
4. Conclusion

Table 2 The systemic absorption of such an irrigating fluid may be asso-

Table is showing immediate post-op electrolytes values of concerned patient.
ciated with serious complications. The best prevention method can be
Serum Sodium Serum Potassium Serum Calcium obtained by adopting a correct surgical technique and optimizing the
patient's conditions preoperatively. At the moment, the bipolar resec-
120.6 mmol/l 6.48 mmol/l 4.44 mg/dl
tion in saline and laser TURP may be a good alternative procedure.

Table 3 Conflicts of interest

Table is showing electrolytes values of concerned patient after 12 hours.
The authors declare no competing interests.
Serum Sodium Serum Potassium Serum Calcium

135.2 mmol/l 3.87 mmol/l 4.16 mg/dl Authors’ contributions

All the authors have contributed in the report of this case. All the
irrigation fluids causing acute hypervolemia and hyponatremia. The authors have read and approved the final version of the manuscript.
clinical spectrum ranges from asymptomatic hyponatremia to electro-
cardiographic changes, nausea, vomiting, convulsions, coma, altera- Appendix A. Supplementary data
tions of vision, pulmonary edema, cardiovascular compromise and
death.3 The role of irrigation solution is to distend the bladder, clear the Supplementary data to this article can be found online at https://
surgical site and wash away resected tissue and blood. Various irriga- doi.org/10.1016/j.eucr.2019.100982.
tion fluids (Glycine, sorbitol, mannitol and normal saline) have been
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