Turp and tur syndrome

Surgical approach

• Transurethral resection of prostate for bladder outlet obstruction (BPH); performed via resectoscope passed through urethra
  • Resection of prostatic tissue using diathermy loop; chips evacuated; haemostasis with coagulation
  • Continuous irrigation required for vision and to clear blood/debris
• Irrigation fluid depends on energy system
  • Monopolar diathermy: non-electrolyte fluids (e.g. 1.5% glycine, sorbitol 3%, mannitol 5%)
  • Bipolar diathermy: isotonic saline (reduces classic TUR syndrome risk)
• Risk factors for fluid absorption
  • Open venous sinuses in prostatic bed + hydrostatic pressure from irrigation (bag height)
  • Long resection time, large prostate, capsular perforation/extravasation
• End of case: 3-way catheter for continuous bladder irrigation; potential traction to reduce bleeding

Anaesthetic management (overview)

• Type of anaesthesia: regional (spinal) commonly preferred; GA also acceptable depending on patient/surgeon factors
  • Spinal advantages: early detection of TUR syndrome (neurological symptoms), less blood loss, avoids airway instrumentation in elderly comorbid patients
  • GA advantages: controlled ventilation (hypercapnia), immobility, easier management if prolonged/complex; but may delay recognition of TUR syndrome
• Airway: if GA, usually ETT (often lithotomy, irrigation fluid absorption, potential for prolonged case); SGA possible in short uncomplicated cases but less ideal if aspiration risk/need for controlled ventilation
• Duration: typically 30–90 min; aim to limit resection time (often <60 min) to reduce absorption risk (institution dependent)
• Pain: usually mild–moderate; discomfort from bladder distension/catheter/irrigation; spinal to T10 generally adequate
• Monitoring: standard + consider invasive BP in significant cardiac disease; temperature; fluid balance; consider serial sodium if prolonged/high risk

Indications and patient factors

• Indications: LUTS from BPH, urinary retention, recurrent UTIs, bladder stones, renal impairment from obstruction
• Typical patient: older male with cardiovascular disease, anticoagulants/antiplatelets, chronic kidney disease, OSA, frailty
• Pre-op assessment focus
  • Cardiorespiratory reserve; heart failure/valvular disease (fluid shifts), arrhythmias
  • Baseline electrolytes (Na+), renal function; Hb/iron deficiency; group & save/crossmatch per local policy
  • Anticoagulation plan (bleeding risk vs thrombosis); neuraxial safety (ASRA/ESAIC + local guidance)

Key physiology and intraoperative issues

• Lithotomy position risks
  • Reduced FRC, V/Q mismatch; nerve injury; compartment syndrome (rare); venous return changes on positioning
• Bleeding
  • Can be significant; concealed by irrigation; consider Hb drop, hypotension, tachycardia, clot retention
• Irrigation fluid absorption mechanisms
  • Intravascular absorption via venous sinuses → acute dilutional hyponatraemia, hypervolaemia, hypo-osmolality
  • Extravasation (capsular perforation) → abdominal distension, pain, delayed absorption, respiratory compromise
• Temperature: large volumes of room-temperature irrigation → hypothermia, coagulopathy, shivering, delayed recovery

TUR syndrome: definition and pathophysiology

• Clinical syndrome from systemic absorption of irrigation fluid during endoscopic urological surgery (classically monopolar TURP)
• Core pathophysiology
  • Acute dilutional hyponatraemia + hypo-osmolality → cerebral oedema → neurological symptoms/seizures/coma
  • Hypervolaemia → hypertension, bradycardia, pulmonary oedema, heart failure (especially in elderly)
  • Specific solute toxicity depends on fluid
    • Glycine: inhibitory neurotransmitter → visual disturbance, encephalopathy; metabolised to ammonia → hyperammonaemia; can cause ECG changes
    • Sorbitol/mannitol: less neurotoxicity but still cause dilutional hyponatraemia and volume effects
• Timing: often intra-op or within first few hours post-op (especially if ongoing absorption/extravasation)

Clinical features of TUR syndrome

• Early neurological features (more apparent under spinal)
  • Restlessness, confusion, headache, nausea/vomiting, dizziness
  • Blurred vision/temporary blindness (glycine), seizures, reduced consciousness
• Cardiorespiratory features
  • Hypertension and reflex bradycardia early; later hypotension if myocardial depression/arrhythmias/bleeding
  • Dyspnoea, hypoxaemia, pulmonary oedema; wheeze/crepitations
  • Arrhythmias: AF, ventricular ectopy; ECG changes may reflect hyponatraemia/hypocalcaemia (dilutional) and ischaemia
• Other clues
  • Unexpected fall in SpO2, rising airway pressures (GA), hypothermia
  • Low measured serum sodium and osmolality; haemodilution (fall Hb); metabolic acidosis possible

Differential diagnosis (important in viva)

• High spinal/total spinal (hypotension, bradycardia, respiratory compromise)
• Local anaesthetic toxicity (if regional), sedative/opioid excess
• Bleeding/hypovolaemia (may coexist): hypotension, tachycardia, low Hb
• Bladder perforation/extravasation: abdominal pain/distension, shoulder tip pain, ventilatory difficulty
• MI/arrhythmia, PE, anaphylaxis, sepsis

Prevention strategies

• Surgical/technical
  • Prefer bipolar TURP with saline irrigation where appropriate
  • Limit irrigation pressure (bag height), minimise resection time, meticulous haemostasis
• Anaesthetic
  • Consider spinal with minimal sedation to allow symptom reporting; maintain communication
  • Strict fluid balance; consider ethanol-tagged irrigation with breath ethanol monitoring where used (institution-specific)
  • Baseline Na+; repeat Na+/ABG if prolonged case, large prostate, unexpected instability, or symptoms
  • Warm irrigation fluids/active warming to reduce hypothermia

Immediate management of suspected TUR syndrome (stepwise)

• Call for help; inform surgeon; stop resection and irrigation if possible; consider terminating procedure
• ABCDE approach
  • Airway/Breathing: high-flow O2; support ventilation; consider intubation if reduced consciousness, seizures, pulmonary oedema, or severe acidosis
  • Circulation: ECG, BP; treat arrhythmias; consider invasive monitoring; avoid excessive IV fluids (often hypervolaemic)
• Investigations
  • ABG/VBG: Na+, osmolality surrogate, Hb, glucose, lactate; U&E; consider ammonia if glycine suspected and neuro features persist
  • CXR if pulmonary oedema; consider bedside ultrasound (lung B-lines/IVC) if available
• Treat volume overload/pulmonary oedema
  • Furosemide IV (e.g. 20–40 mg, titrate) if hypervolaemic with pulmonary oedema and adequate perfusion
  • NIV/CPAP if appropriate; intubation/PEEP if severe
• Treat hyponatraemia based on symptoms and acuity (this is acute)
  • If severe symptoms (seizures, coma, severe confusion) or very low Na+: give hypertonic saline 3% in controlled boluses
  • Common approach: 3% saline 100 mL over 10 min, repeat up to 2 more times aiming for initial rise 4–6 mmol/L to control symptoms; then slow correction with close monitoring (local protocols vary)
  • If mild symptoms and stable: fluid restriction + loop diuretic; monitor Na+ frequently
  • Avoid overly rapid correction (risk of osmotic demyelination), but note TUR syndrome is acute—initial controlled rise is appropriate when symptomatic
• Seizure management
  • Benzodiazepine (e.g. midazolam) + airway protection; correct sodium; consider ICU
• Post-op disposition
  • Symptomatic TUR syndrome, pulmonary oedema, seizures, significant Na+ derangement, or ongoing bleeding → HDU/ICU for monitoring and serial electrolytes

Anaesthetic technique details (spinal vs GA)

• Spinal anaesthesia
  • Aim sensory block to ~T10 (some prefer up to T9–T8); avoid excessively high block in elderly
  • Sedation: minimal; maintain verbal contact to detect neurological symptoms
  • Treat hypotension with vasopressors (metaraminol/phenylephrine/ephedrine per context) and judicious fluids
• General anaesthesia
  • ETT often preferred; controlled ventilation; consider arterial line in significant cardiac disease or anticipated long case
  • Recognition of TUR syndrome relies on physiological changes (BP/HR, SpO2, airway pressures) and labs—lower threshold for ABG sodium
• Analgesia
  • Paracetamol ± small opioid; avoid heavy opioids in frail/OSA; catheter discomfort common post-op
• PONV
  • Nausea may be early TUR syndrome sign; still provide prophylaxis (e.g. ondansetron/dexamethasone as appropriate) but investigate if unexpected

Postoperative care

• Observe for delayed TUR syndrome, bleeding, clot retention, sepsis, pain, hypothermia
• Check electrolytes if intra-op concerns, prolonged case, symptoms, or significant irrigation volumes; monitor urine output and catheter patency
• Restart anticoagulants/antiplatelets per surgical plan and bleeding status; VTE prophylaxis as per local policy