TURP & TURP Syndrome

 

 

Considerations

 

  • Coexisting disease common in this population

    • Coronary disease, acute kidney injury, elderly

  • Considerations of intraoperative complications:

    • TURP syndrome ~2%

    • Fluid overload/pulmonary edema; electrolyte abnormalities; dysrhythmias hyperglycinemia (blindness), hyperammonemia (encephalopathy), hypothermia

    • Concealed hemorrhage 

    • Bladder perforation ~ 1%

    • Septicemia (usually gram negative)

    • DIC (rare complication associated with prostate cancer)

  • Positioning: lithotomy with nerve injury; hemodynamic & respiratory effects of trendelenberg position 

  • Choice of anesthetic: GA or spinal

 

 

Goals & Conflicts

 

  • Optimization of co-existing diseases

  • Prevention or early recognition of TURP syndrome

  • Attention to blood loss & appropriate replacement

  • Conflict: preference for neuraxial technique to monitor CNS symptoms vs. any contraindications to neuraxial

  • Problems in PAR include: post-op delirium, hypotension, respiratory distress (need to consider comorbidities)

 

 

TURP Syndrome

 

  • Presentation: due to fluid overload & hyponatremia: 

    • Classic triad: hypertension, bradycardia, & mental status changes

    • Pulmonary: pulmonary edema, ↑ JVP 

    • Cardiovascular: arrhythmias, hypertension 

    • CNS: pupillary reflex sluggish or absent with glycine toxicity but intact with cerebral edema

  • Prevention:

    • Appropriate irrigation agent, minimize resection time, hemostasis, avoid high irrigating pressures (limit bag height to 30-40cm, frequent drainage), avoid hypotonic IV fluids, check electrolytes in patients with renal failure (metabolic abnormalities, hyponatremia)

  • Treatment: 

    • Inform surgeon to terminate procedure ASAP

    • Oxygenation & circulatory support

    • Consider invasive monitoring if hemodynamically unstable (arterial line, CVP)

    • Blood work (electrolytes, creatinine, glucose, CBC, ABG)

    • 12 lead ECG

  • Correction of hyponatremia:

    • Near-normal serum osmolality & asymptomatic: no interventions to correct serum sodium are recommended even in the presence of hyponatremia

    • Mild symptoms (serum Na > 120 mEq/L): fluid restriction & loop diuretic (furosemide 40-120 mg)

    • Symptomatic, life-threatening hypoosmolality & serum Na < 120 mEq/L (rare with modern techniques) can be treated with hypertonic saline (rarely necessary):

      • Start @ 100cc bolus & assess for resolution of symptoms or Na > 120 mEq/L

      • Can give 2 more boluses 

      • Start at rate of 50-100 cc/h (do not exceed correction of > 1.5 mEq/L/h because rapid correction of serum sodium is associated with central pontine myelinolysis (osmotic demyelination syndrome) & cerebral edema

      • Diuresis with furosemide & fluid restriction:

        • Stop 3% saline once symptoms subside or serum Na > 120 mEq/L: treat remaining hyponatremia with diuresis & normal saline or fluid restriction

    • Seizure treatment as necessary 

    • Transfer to ICU for ongoing care in severe cases

    • q1h blood work (Na, K) 

    • Frequent CNS assessment