Transurethral Resection of the Prostate Syndrome

Overview

Transurethral Resection of the Prostate (TURP) syndrome is a potentially life-threatening complication that can occur during or after the surgical procedure known as TURP, which is performed to relieve urinary obstruction due to benign prostatic hyperplasia (BPH). TURP syndrome results from excessive absorption of irrigation fluids used during the procedure, leading to fluid overload and electrolyte imbalances, particularly hyponatremia (low serum sodium levels). The syndrome manifests as a combination of cardiovascular, neurologic, and respiratory symptoms. Although rare due to improved surgical techniques and the use of isotonic irrigation fluids, it remains an important concern for urologists and anesthesiologists.

Causes

TURP syndrome is caused by the intravascular absorption of large volumes of hypotonic irrigation fluid used to maintain a clear surgical field during the transurethral resection. Key causative factors include:

• Absorption of irrigation fluids: Fluids can enter the bloodstream through opened venous sinuses in the prostate during resection.

• Type of irrigation fluid: Non-electrolyte, hypotonic solutions like glycine 1.5%, sorbitol 3%, or mannitol 5% are often used with monopolar electrosurgical instruments. These fluids lack sodium and can lead to dilutional hyponatremia when absorbed.

• Duration and pressure of irrigation: Longer surgeries and higher intravesical pressures increase the risk of fluid absorption.

• Size of the prostate: Larger prostates are more vascular and have a greater risk of fluid absorption.

The typical volume of fluid absorbed during TURP ranges from 10 to 30 mL per minute of resection, which can become dangerous over the course of a long procedure.

Symptoms

The symptoms of TURP syndrome usually develop intraoperatively or within hours after the procedure. The clinical presentation reflects the effects of fluid overload and hyponatremia and may include:

• Neurological symptoms: Restlessness, confusion, headache, visual disturbances, seizures, and in severe cases, coma.

• Cardiovascular symptoms: Hypertension, bradycardia, arrhythmias, and circulatory collapse due to volume overload and electrolyte imbalances.

• Respiratory symptoms: Dyspnea, hypoxia, and pulmonary edema due to fluid overload.

• Gastrointestinal symptoms: Nausea and vomiting.

• Other signs: Low serum sodium (often <125 mmol/L), low serum osmolality, and positive fluid balance.

Symptoms can escalate rapidly and must be recognized and treated immediately to prevent permanent damage or death.

Diagnosis

Diagnosis of TURP syndrome is based on clinical suspicion, especially during or after a TURP procedure, and confirmed through laboratory and imaging studies. Key diagnostic components include:

• Clinical assessment: Sudden onset of neurologic or cardiovascular symptoms during or shortly after surgery.

• Serum sodium levels: Hyponatremia is the hallmark finding, often <125 mmol/L in severe cases.

• Serum osmolality: Low due to dilution by hypotonic fluids.

• Arterial blood gases: May reveal metabolic acidosis or hypoxemia.

• Chest X-ray: Can show signs of pulmonary edema in severe cases.

• Electrocardiogram (ECG): May show arrhythmias or bradycardia due to electrolyte disturbances.

Early diagnosis is crucial, as delays in recognition and treatment can lead to serious outcomes, including cerebral edema, cardiac arrest, or death.

Treatment

Management of TURP syndrome focuses on stabilizing the patient, correcting electrolyte imbalances, and preventing further absorption of irrigation fluids. Treatment strategies include:

• Immediate cessation of the procedure: To prevent further fluid absorption if symptoms arise during surgery.

• Fluid restriction: To limit ongoing volume overload.

• Hypertonic saline: Carefully administered 3% sodium chloride solution is used to correct severe hyponatremia and reduce cerebral edema. It must be given under close monitoring to avoid rapid correction.

• Diuretics: Loop diuretics like furosemide can help eliminate excess fluid and relieve pulmonary congestion.

• Oxygen supplementation or mechanical ventilation: In cases of respiratory compromise due to pulmonary edema.

• Hemodynamic support: Vasopressors may be needed if hypotension or circulatory collapse occurs.

• ICU admission: For severe cases with neurologic symptoms or significant hemodynamic instability.

Prognosis

With early recognition and appropriate treatment, the prognosis of TURP syndrome is generally favorable, and most patients recover fully without long-term complications. However, delayed diagnosis or severe hyponatremia can lead to serious outcomes such as:

• Seizures and cerebral edema

• Cardiovascular collapse

• Permanent neurological deficits

• Death in severe untreated cases

Preventive strategies, such as limiting resection time, using bipolar resection systems with isotonic saline, and careful intraoperative monitoring of fluid input and output, have significantly reduced the incidence of TURP syndrome in modern urological practice.