Anest turp

Anesthesia for TURP
Claudio Melloni
Servizio di Anestesia e Rianimazione
Ospedale di Faenza(RA)

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Anesthesia for Turp is not
always routine
Major KO: 2.5 - 20% of patients
perioperative mortality rate :0.5 - 6%,
Holtgrewe HL, Valk VVL. Factors influencing the mortalityand morbidity
of transurethral prostatectomy: a study of 2,015 cases.J.Urol 1962; 87:
450‑9.
Roos, N. P., Wennberg, J. E., Malenka, D. J. et al: Mortality
and,.re‑operation after open and transurethral resection of the prostate
for benign prostatic hyperplasia. N Engl J Med, 320: 1120,1989
Malenka, D. J., Roos, N., Fisher, E. S. et al: Further study of the
increased risk of mortality following transurethral resection of the
prostate: a chart‑based analysis. J Urol, 144: 224, 19
Seagroatt, V.: Mortality after prostatectomy: selection and surgical
approach. Lancet, 346: 1521, 1995


Risk factors in anesthesia for
TURP
Patients,their intrinsic risk factors and
anesthesia related risks
Surgical Procedure;its complication,some
peculiar to the technique used;
Utilization of irrigating fluids.


Turp Syndrome
Cardiovascular;hypotension,hypertension,dysryth
mias,shock,pulmonary edema,cardiac arrest….
Respiratory;tight feeeling in the chest or throat
,shortness of
breath,hyperventilation,dyspnea,pulmonary edema….
Cerebral;dizziness,mental confusion, and lethargy
lapsing into coma,headaches,nausea, ,restlessness
,retching,blindness,twitches and seizures. ;
bacteremia…... e Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia

Late Turp syndrome
4 - 24 hours later
Some of these cases could be ascribed to instrumental perforation of
the prostatic capsule ( and more rarely of the bladder)
fluid deposited in a pool in the retroperitoneal space
the fluid may comprime the caval veins and diffuse through the
peritoneal membrane again creating flows according the Starling
laws;electrolytes entering the pool of fluid and solutes contributing to
plasma volume decrease as the solute travel in the opposite
direction,i.e.toward the cell,where they are metabolized or accumulate
In these case moderate hyponatremia and hypoosmolality develop with
a time delay ,some hours following the operation.Clinically there is a
tendency toward an increased incidence of abdominal

pain,bradycardia eand hypotension di Faenza(RA)
Servizio di Anestesia Rianimazione Ospedale

TURP symptoms associated with 2000 or + ml glycine
absorption(Hahn et al.J.Ethanol monitoring of the TURS.Clin.Anesth.1996;8:652-655)
Intraop symptoms
freq(20-60%):BP
,HR,BP
common(1020%):prickling
skin,nausea,tirednes
s.uneasiness
rare (<10%):blurred
vision,chest
pain,confusion

Postop symptoms
confusion,BP,nause
a,transient anuria
bradyc,diarrhea,free
zing,vomiting
blurred
vision,depressed
consciousness,abdo
minal pain


Ideal requirements of an
Irrigating solution
♦Purpose:give the surgeon a clear view of the
operating field by removing blood and pieces of
resected tissues.
♦Electrolyte free to allow cutting with a resectoscope
♦Isotonic
♦electrically inert
♦non toxic,
♦clear transparent
♦easy to sterilize and handle
♦not too expensive….

Irrigating fluids
H2O distilled
glycine 1.2-1.5%
mannitol 3%
mannitol –sorbitol(2.7-0.54 %
respectively)mixtures.


Toxicity of irrigating fluids
♦glycine :
♦significant cardiac and retinal toxicity
♦may cause hyperammonemia because its
metabolites overload the urea synthesis cycle

♦ glucose may cause severe hyperglycemia

♦mannitol and sorbitol may cause lactic
acidosis and hyerglycemia due to shifts in the
glycolysis pathways


Volume absorption
the intravesical pressure (governed by the height of
the irrigation bag above the prostatic sinuses)
the number of prostatic sinuses opened
retroperitoneal and paravescical spaces,even in
absence of surgical perforation
– length of the procedure,
– experience of the surgeon(or inexperience)
– difficult resections

entrainment of the solution
Circulatory overload
haemodilution
hypotonia and hypoosmolality
…………. haemolysis,shock ,renal failure……..
acidosis
hypoperfusion shock
circulatory
failure
hypoxemia


Vol.absorbed= ((preop serum Na/postop
serum NA)*ECF in KG))-ECF in KG.
P es,if a preop sodium was 140 and postop
is 110,the calculation yelds for an estimate
of EC as 30% of body weight for a 70 kg
man=21 kg:
1)140/110=1,2
2)1,2*21=26,6
3)26,6-21=5.6,volume gain in KG(or lt).

Hypotension-hypertension...
Perioperative hypotension during TURP is sometimes
preceded by hypertension . Profound hyponatremia
by itself does not explain the hypotension;however,
hyponatremia with hypertension may lead to net water
flux along osmotic and hydrostatic pressure gradients
out of the intravascular space and into the lungs,
which triggers pulmonary edema and hypovolemic
shock . This concept is consistent with the findings of
Hahn(17) who hypothesized that the absorption of
fluids derives from two sources;one from direct
Servizio di Anestesia e Rianimazione Ospedale di phase?)and the
absorption into the circulation(early Faenza(RA)

Atallah et al.Does spinal anesthesia affect cerebral
oxygenation during transurethral
prostatectomy?.Reg.Anesth.Pain med. 1998;23:115-8.
100

12

90
11,5
80
11

70
60

10,5

jug.bulb O2 sat
art-jug O2 diff

50

CPP
10

40
30

9,5

20
9
10
0

8,5
basal

after spi

chri 30

chirend

post30

post60

post120


jug bulb O2 content

Atallah et al.Does spinal anesthesia affect cerebral
oxygenation during transurethral
prostatectomy?.Reg.Anesth.Pain med. 1998;23:115-8.

CPP decrease and SjbO2 decrease,a-jbO2
increase:CBF decrease,CMRO2
unaffected:impaired cerebral oxygenation
patients with symptoms more affected by decrease in
SjbO2


Biphasic absorption of fluids
H 2 0 e n t r a in m e n t
H y p o o s m o la lit y

Ca++

N A

d iu r e s is

B P

Atrial natriuretic
factor

H 2 O in t e r s t
A P O edem a

glycine

H y p o v o le m ic s h o c k


Hypoosmolality >
hyonatremia
In a series of 72 patients undergoing TURP,
serum sodium concentration decreased by 10
to 54 mmol/L in 19 (26%), while osmolality
changed in only two (3%): the 2 patients who
had both hyponatremia (serum sodium
concentration decreases of 27 and 30
mmol/L) and hypoosmolality (serum
osmolality of 260 and 256 mmol/L) developed
pulmonary edema and encephalopathy. The
five patients in this series with the largest
decreases in serum sodium concentration (by
34 to 54 mmol/L) had no changes in serum
osmolality and no signs of TURP syndrome.
(Desmond J. Serum osmolality and plasma
electrolytes in patients who develop dilutional
hyponatremia during transurethral resection.
Can J Surg 1970; 13:116-21).

A review of

a series of 2000 consecutive patients(
Henderson DJ,Middleton RG.Coma from
hyponatremia following transurethral resection of
prostate.Urology 15;267-71,1980) revealed 14
coma cases potoperatively,with sodium levels 1520 meq/lt below normal level:the coma was ,at that
time , correctly,ascribed to water intoxication and
associated surgical risk factors were
identified,because in 9 of these cases the
prostatic capsule was surgically violated or large
venous sinuses were opened;all 14 patients
eventually awoke without sequelae.


Blood loss
Total blood loss after TURP is significantly correlated
with the prostatic tissue weight
but when the tissue weight resected exceeds 35
gr,blood loss was in excess of the linear
correlation(Smyth R, Cheng D, Asokumar B et al. Coagulopathies in patients
after transurethral resection of the prostate: spinal versus general anaesthesia. Anesth
Analg 1995; 81: 680‑5)


Smyth R, Cheng D, Asokumar B et al. Coagulopathies in
patients after transurethral resection of the prostate: spinal
versus general anaesthesia. Anesth Analg 1995; 81: 680‑ 5
. There was no significant difference in measured coagulation variables
(fibrinogen, factor V, plasminogen, antithrombin III, and FDP) between
the spinal and GA groups, but there were significant decreases

in postoperative fibrinogen and Factor V levels compared
to preoperative values in both spinal and general anesthesia
groups.
3 pts (6%) had increased FDP levels 1 h postop. The prostatic tissue
weight and the surgical duration was significantly higher in these
patients.
The authors concluded that perioperative blood loss in TURP patients is
not affected by the anesthetic technique,but 6% of TURP patients
developed subclinical intravascular coagulopathies which correlated
with mass of resected prostate tissue.

Therapy of Turp syndrome

diuretics?
Saline
hypertonic saline?
Inotropes/vasopressors(?)
The most feared complication of correcting
hyponatremia is central pontine myelinolysis (CPM


Treatment of symptomatic hyponatremia

Safest treatment;symptomatic
slow therapy ( <=0.7 mmolLt/h) , has been associated with a
higher morbidity and mortality than has rapid correction
(=>1.0 mmol/lt/hr)
Many reports suggesting that a 1.5- to 2.0-mmol /Lt/hr
correction rate is safe have failed to consider changes in
osmolality. Several investigators have suggested that osmotic
stress is probably greater when correcting chronic compared
with acute hyponatremia
a prompt treatment with increases in the serum Na
concentration not > 2 mmol/lt/hr;in general the correction

Hyperglycinemia

Incidence and severity of circulatory and nervous
symptoms(nausea, vomiting, headache, malaise
weakness,seizures, from blurred vision to complete
blindness…) proportional to the amount of glycine
absorbed:
» serum glycine concentration threshold for symptomatic
visual impairment (>4000 mmol/L) and blindness (>13,734
mmol/L)


Glycine toxicity
Retina
cardiomyocites
kidney(Hyperoxaluria from metabolism into oxalate and glycolate)
hyperammoniemia


Treatment of hyperglycinemia
Mg?
NMDA antagonists
L-arginine


Olsson J, Nilsson A, Hahn RG. Symptoms of the
transurethral resection syndrome using glycine as the
irrigant. J Urol 1995; 154: 123‑ 8
6
5
4

0-300
1-2 lt
>3 lt

%3
2
1
0

glycine absorption


Nilsson A,Olsson J,Hahn RG.Symptoms of the TURP
syndrome using glycine as the irrigant.J Urol 1995;154:123-128

glycine

Fluid absorption during TURP;influence of operating

time(Hahn RG, Ekengren J. Patterns of irrigating fluid absorption during

transurethral resection of the prostate as indicated by ethanol. I Urol 1993:
149: 502‑6
60
50
40

>2000
1001-2000
501-1000
151-500

30
20
10
0

op-time <= 60 min

op time > 60 min


Urine composition 90 min after i.v infusion of 15 ml/kg of
irrigating fluids(10 healthy male volunteers)

Nilsson A, Randmaa 1,
Hahn RG. Haemodynamic effects of irrigating fluids studied by Doppler ultrasonography
in volunteers. Br I Urol 1996; 77: 541‑6

Osmotic gap represents negatively
charged ions not measured


Urinary excretion of sodium during and after iv infusion of
glycine solution in sheep and humans.

(Hahn RG Trapping of

electrolytes during fluid absorptionin transurethral resection of the prostate. Scand j Urol
Nephrol, in press)


Trepanier,CA,Lessard,MR,Brochu,J,Turcotte,G.Another
feature of TURP syndrome:hyperglycemia and lactic acidosis
caused by massive absorption of sorbitol.Brit. J. Anaesth.
87;316-9:2001

hyperglycaemia and lactic
acidosis


Gehring et al.Irrigation fluid absorption during TURP;spinal
vs general anesthesia.AAS 1999;43:458-63.
Blood ethanol maximum
levels

Blood ethanol area under
the curve

Blood ethanol absorption rate

Estimated volume of absorption(Hah


Gehring et al.Irrigation fluid absorption during
TURP;spinal vs general anesthesia.AAS 1999;43:45863.

Extent of irrigating fluid absorption
significantly higher in absorption
afflicted patients undergoing spinal
anesthesia….;lower CVP may be the
cause


Why regional anesth.is to be
preferred
It allows the appearance of the full clinical
manifestation of symptoms
» (under GA only rise and fall in blood pressure ,respiratory
arrest and severe bradycardia,with a variety of ECG
modifications)

possibility of early detection of TUR syndrome


significant fluid absorption has taken
place when ethanol concentration in
plasma exceeeds 0.1/1000.Plasma and
exhaled ethanol demonstrated a linear
correlation ,while plasma ethanol
correlated inversely with plasma sodium
.The measurements were consistent
both in patients under spinal and ga
,undergoing mechanical ventilation;but
ethanol levels were not predictive of

Recommendations for anesth.
continuous warming of i.v. fluids
(warming of the patient)
lab monit :Hb,Na ,glyc ;coag in susp.cases
PVC?
NIBP,SaO2,etcO2,ethanol
EGA,lactate
consciousness

be vigilant

Recommendations for surgery
Minimize absorption
» Limiting the height of the irrigation bag to 40 cm above the
prostate
» use continuous irrigating resectoscopes
» use suprapubic trocar drainage

keep intravesical pressure < 15 cm H2O
continuous warming of irrigating fluid
Resection time < 1 hour
leave a rim of tissue on the capsule until near the end
of the procedure Rianimazione Ospedale di Faenza(RA)
Servizio di Anestesia e

Difficulties for the anesthesiologist who wants to introduce a
method for monitoring of fluid absorption in their hospital

Urologist often regard fluid absorption as a
complication indicating poor operative skills
» address this point cautiously because this determines the
success of the project...

many clinicians believe TUR syndrome is too rare to
warrant routine monitoring:
» prepare by reading some prospective studies where the
incidence of the mild form of the syndrome have actually
been studied….
– Hahn,RG,Editorial.The transurethral resection syndromenot yet a finished story.Reg.Anesth.Pain Med.1998;23:115Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

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