Transurethral Resection of the Prostate (TURP) syndrome is a rare but serious complication associated with a common urological surgery. This article clarifies its causes, symptoms, and management.
The TURP Procedure
Transurethral Resection of the Prostate is a surgical procedure commonly performed to alleviate urinary problems caused by an enlarged prostate gland. This condition, known as benign prostatic hyperplasia (BPH), can lead to symptoms such as frequent urination, a weak urine stream, or difficulty emptying the bladder. During the procedure, a surgeon inserts a slender instrument called a resectoscope through the urethra, the tube that carries urine out of the body.
The resectoscope is equipped with a camera and an electrical loop, allowing the surgeon to visualize and trim away excess prostate tissue that is obstructing urine flow. As the tissue is removed, irrigation fluid is continuously flushed through the surgical area to maintain clear visibility and wash away the resected tissue fragments. These fragments are then collected and removed at the end of the operation.
Defining TURP Syndrome
TURP syndrome occurs when a substantial amount of the irrigation fluid used during the surgery is absorbed into the patient’s bloodstream through open venous sinuses in the prostate. This absorption can lead to two primary physiological disturbances: fluid overload and a significant drop in blood sodium levels, a condition known as hyponatremia.
Many irrigation fluids, such as 1.5% glycine solution, are hypotonic, meaning they have a lower concentration of dissolved particles than blood. When large volumes of this fluid enter the circulation, it dilutes the blood, leading to a decrease in the concentration of electrolytes, especially sodium. Normal blood sodium levels typically range between 135 and 145 milliequivalents per liter (mEq/L). In TURP syndrome, these levels can fall below 135 mEq/L, and severe symptoms may manifest when levels drop below 120 mEq/L.
The rapid influx of fluid also overwhelms the body’s fluid regulation systems, causing circulatory overload. This combination of fluid excess and low sodium can lead to cellular swelling, particularly in the brain, as water shifts from the bloodstream into cells to balance the osmotic pressure. This cellular swelling is responsible for many of the syndrome’s characteristic signs.
Identifying the Symptoms
The symptoms of TURP syndrome can vary widely in severity and onset, appearing anywhere from 15 minutes into the procedure to up to 24 hours afterward. Neurological symptoms are frequently observed due to brain cell swelling caused by hyponatremia. These can include restlessness, headache, dizziness, nausea, vomiting, confusion, and disorientation. In more severe cases, patients may experience visual disturbances, seizures, or even fall into a coma.
Cardiovascular signs are also prominent, resulting from the fluid overload and electrolyte imbalances. Patients might develop hypertension, an abnormally high blood pressure, or experience bradycardia, which is a slower than normal heart rate. In advanced stages, respiratory distress, hypoxia, or pulmonary edema, a condition where fluid accumulates in the lungs, can occur.
Managing TURP Syndrome
Effective management of TURP syndrome relies on prompt recognition and immediate medical intervention once symptoms are identified. The first step involves stopping the surgical procedure as quickly as possible and ensuring any bleeding points are controlled. Attention then shifts to supporting the patient’s vital functions, which may include providing oxygen and circulatory support.
Treatment strategies focus on correcting the fluid and electrolyte imbalances. Fluid administration is restricted, and diuretics, such as furosemide, are often given to help the body excrete excess absorbed fluid and reduce circulatory overload. For severe hyponatremia, particularly when neurological symptoms are present, hypertonic saline solution may be administered cautiously to raise blood sodium levels. Throughout this process, close monitoring of the patient’s vital signs and electrolyte levels is essential to guide treatment and prevent further complications.
Reducing the Risk
Medical teams implement several strategies to minimize the risk of TURP syndrome. One measure is to limit the duration of the surgery, as longer procedures increase the likelihood of fluid absorption. The pressure at which irrigation fluid is delivered is also controlled, often by keeping the fluid bag height below 60 to 70 centimeters above the patient. This helps to reduce the rate of fluid absorption into the bloodstream.
Careful monitoring of fluid intake and output throughout the procedure helps identify early signs of fluid absorption. The choice of irrigation fluid has also evolved; while hypotonic solutions like 1.5% glycine have been widely used, newer techniques with bipolar resectoscopes allow the use of isotonic saline solutions, which significantly reduce the risk of hyponatremia. Performing the procedure under regional anesthesia can also allow for earlier detection of neurological symptoms, as the patient remains conscious.