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Chapter 209. Transurethral Resection of the Prostate (TURP) Syndrome

Sonali Mantoo, MD; Roopa Kohli-Seth, MD

Transurethral resection of the prostate (TURP) syndrome is the result of complex changes in intravascular volume, solute, and neurophysiologic function.

TURP syndrome has been reported after endoscopic procedures performed under irrigation:

  • Transurethral resection of the prostrate and bladder tumors
  • Diagnostic cystoscopy
  • Percutaneous nephrolithotomy
  • Other ureteroscopic procedures
  • Endometrial ablation
  • Arthroscopy

The acute changes in intravascular volume and plasma solute concentrations occur as a result of irrigation fluid entering the intravascular space through the prostate venous plexus or more slowly absorbed from the retroperitoneal and perivesical spaces.

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Risk Factors for TURP and Prevention Measures
Factors associated with irrigating fluid absorptionPrevention measures
  • Length of procedure
  • Limit duration of surgery to <60 min
  • Hypotonic irrigating fluid
  • Absorption >1 L of glycine solution is associated with an increased risk of symptoms (5–20% of the TURP)
  • Use isoosmotic fluids for irrigation
  • Bipolar TURP is performed using NS as irrigant
  • Intravesical pressure >30 mm Hg resulting from high irrigating pressure (governed by the height of the irrigation bag above the prostatic sinuses)
  • Limit the position of the irrigation bag to maximum 60 cm above the surgical field to minimize hydrostatic pressure of the fluid (controversial)
  • Perform TURP under low pressure irrigation (<2 kPa)
  • Number of persistently open venous prostate sinuses increases the surface area from where absorption can take place
  • Minimize exposure to open venous sinuses by careful surgical resection
  • Limit extent of bladder distension by frequent drainage of the bladder (to avoid increased absorption through open venous sinuses)
  • Maintain adequate blood pressure and therefore normal periprostatic venous pressure
  • Preferably operate on glands <45 g

Older studies report incidence between 0.5% and 8% with a mortality of 0.2–0.8%. Newer studies have shown lower incidence rates of 0.78–1.4% with much lower mortality rates

Syndrome can start from 15 minutes to 24 hours after procedure starts. Indicators of volume gain are:

  • Serum sodium dilution
  • CVP trending up
  • Plasma electrolyte concentrations (lower magnesium and calcium)
  • Transthoracic impedance change
  • Weight gain

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Clinical Manifestations of TURP Syndrome
Central nervous systemCardiovascular and respiratory systemsMetabolic and renal systems
  • Restlessness
  • Headache
  • Confusion
  • Convulsions
  • Coma
  • Visual disturbances
  • Nausea, vomiting
  • Hypertension
  • Tachycardia
  • Tachypnea
  • Hypoxia
  • Frank pulmonary edema
  • Hypotension
  • Bradycardia
  • Hyponatremia
  • Hyperglycinemia
  • Intravascular hemolysis
  • Acute renal failure

If 1% ethanol marker is added to irrigation fluids, fluid absorption during TURP can be diagnosed by measuring the ethanol concentration in the patient's breath. This technique is not used routinely.

GA and regional anesthesia result in comparable outcomes.

However, spinal anesthesia is the technique of choice:

  • May reduce the risk of pulmonary edema
  • Decreases blood loss
  • Permits early detection of mental status changes
  • Reduces CVP, potentially resulting in greater absorption of irrigating fluid

Once TURP syndrome has been detected, ...

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