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Complications of Transurethral Surgery


Case Synopsis

An otherwise healthy 70-year-old man undergoes combined transurethral resection of the prostate (TURP) and transurethral resection of a bladder tumor (TURBT) under spinal anesthesia with sedation. His blood pressure is 130/90 mm Hg, heart rate is 68 beats per minute, respirations are 16 breaths per minute, and hematocrit is 38%. Ninety minutes into surgery, the patient becomes restless. His blood pressure is 180/100 mm Hg and his heart rate is 40 beats per minute. The electrocardiogram (ECG) shows depressed T waves. Laboratory values are as follows: hematocrit 27%, sodium 123 mEq/L, potassium 3.0 mEq/L, and chloride 95 mEq/L.

Problem analysis

Definition

TURP syndrome is a general term used to describe a wide range of neurologic and cardiopulmonary symptoms and signs caused by intravascular absorption of hypotonic bladder-irrigating fluids during transurethral procedures, especially TURP. In conscious or sedated patients, the sudden onset of restlessness should raise the suspicion for TURP syndrome. Hypertension is indicative of hypervolemia. Reflex bradycardia occurs in response to the increased blood pressure. T-wave depression on the ECG is caused by glycine in the irrigating fluid. Hyponatremia is yet another sign of hypotonic irrigant absorption ( Table 52.1 ).

TABLE 52.1
Hypotonic Irrigants Used for Transurethral Resection of the Prostate or a Bladder Tumor
Solution Osmolality (mOsm/kg)
Water 0
Glucose, 2.5% 139
Sorbitol, 3.5% 165
Urea, 1% 167
Glycine, 1.2% 175
Cytal (sorbitol 2.7% and mannitol 0.54%) 178
Glycine, 1.5% 220
Mannitol, 5% 275

A reduced hematocrit is most likely due to a combination of blood loss and hemodilution. Bradycardia may also occur after bladder perforation. In this case bradycardia is an efferent vagal response to peritoneal stimulation secondary to any extravasated fluid. Abdominal or shoulder pain and hypotension usually accompany the bradycardia.

Recognition

The case synopsis illustrates three significant complications of transurethral surgery: (1) TURP syndrome, (2) severe hemorrhage, and (3) bladder perforation.

TURP Syndrome

TURP syndrome is a constellation of signs and symptoms that result from the following circumstances or conditions:

  • Circulatory overload

  • Water intoxication or hypo-osmolality

  • Hyponatremia

  • Glycine toxicity

  • Ammonia toxicity

  • Hemolysis

  • Coagulopathy

These signs and symptoms may occur simultaneously ( Table 52.2 ). The clinical presentation may be further complicated by bacteremia or septicemia, which causes chills, hypotension, and tachycardia.

TABLE 52.2
Pathophysiology and Clinical Features of TURP Syndrome
Pathophysiology Clinical Features
Fluid overload Hypertension; bradycardia; arrhythmia; angina; pulmonary edema and hypoxemia; ventricular failure and hypotension
Water intoxication or hypo-osmolality Confusion and restlessness; twitching or seizures; lethargy or coma; dilated, sluggish pupils; papilledema; low-voltage EEG; hemolysis
Hyponatremia CNS changes as above; reduced inotropy; widened QRS complex; low-voltage ECG; T-wave inversion on ECG
Glycine toxicity Nausea and vomiting; headache; transient blindness; loss of light and accommodation reflexes (blink reflex preserved); myocardial depression; ECG changes
Ammonia toxicity Nausea and vomiting; CNS depression
Hemolysis Anemia; acute renal failure; chills, clammy skin; chest tightness and bronchospasm; hyperkalemia resulting in malignant arrhythmias or bradyasystole
Coagulopathy Severe bleeding; primary fibrinolysis; disseminated intravascular coagulation
CNS, Central nervous system; ECG, electrocardiogram; EEG, electroencephalogram; TURP, transurethral resection of the prostate gland.

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