The aim of this case report is to present our experience in the intensive care unit with patients with transurethral resection of the prostate (TURP) syndrome. Three patients undergoing transurethral prostatectomy under epidural analgesia had been transferred intubated in our ICU from the operating room because of mental confusion, discomfort, hypoxemia, acute pulmonary edema, bradycardia, hypotension, electrolyte disorders, anuria and elevated creatinine levels. All three patients were successfully resuscitated with mechanical ventilation, inotropic agents, diuresis and other supportive measures of the ICU. After treatment’s initiation, patients’ clinical picture improved significantly and they were released from the ICU on the third day of hospitalization. We underline the importance of: a) early diagnosis, b) good communication between surgical and ICU teams, c) role of irrigating fluid used and, d) immediate initiation of proper treatment in order to have an optimal outcome.
Massive irrigation fluid absorption during transurethral prostatic resection may give rise to life-threatening disturbances of cardiovascular and cerebral function [1,2]. Transurethral Resection of Prostate (TURP) is usually performed under epidural analgesia and it is the preferred mode of treatment of benign prostatic hyperplasia in the case of elderly patients, or in patients with cardiovascular and respiratory instability where general anesthesia and laparotomy are relatively contraindicated. During this operation as an irrigating fluid may be used normal saline water, isotonic fluid of mannitol hypotonic (3%) or isotonic (5%) and isotonic fluid of glycine .
The experience from the TURP application confirms a method with good therapeutical results and with rare complications. A well-recognized but rare complication of this procedure is the TURP syndrome. It is usually characterized by overhydration, and hyponatraemia. Many of its pathophysiological mechanisms remain unknown  although, as principal causes hypo-osmolality, increase of the pressure in the prostatic venous network and absorption of the liquid from the transurethral prostatectomy are widely recognized .
Three patients with medical history of benign prostatic hyperplasia for two years were admitted during the last year to our hospital with urinary retention. After having undergone the previous day TURP for prostatic hyperplasia with chronic outflow obstruction they were transferred intubated from the operating room to our ICU because of mental confusion, discomfort, hypoxemia, acute pulmonary edema, bradycardia, hypotension, electrolyte disorders (mild hyponatremia and hyperkalemia), anuria and elevated creatinine levels (see table 1).
Table 1. Clinical signs at the time of arrival in the ICU.
Physical examination of the respiratory system revealed the following: pulmonary rales and scattered rhonchi bilaterally, mainly at lungs’ bases, positive hepatojugular reflux sign, edema of lower limbs, contracted abdomen, sensitive to palpation, with positive rebound. Chest x-ray showed opacification of both lungs with increasing density towards the lung bases due to a combination of air space shadowing and pleural effusions, picture compatible with pulmonary edema. Subsequently other laboratory tests were performed. Specifically, sputum and blood cultures proved negative to common bacteria while tests for Australian antigono were positive. Urinanalysis revealed rare pyosfairia, many red cells, rare squamous epithelia and album tracks.
Due to continuous deterioration, patients were put under mechanical ventilation and resuscitated through supportive measures of the ICU. Blood pressure was monitored via insertion of a central line and arterial line. Patients were administered inotropic agents, diuresis and bronchodilators with simultaneous reduction of the volume of fluid administered (saline solution). Precisely, inotropes were employed to support blood pressure. Hypertonic saline has been given intravenously at a rate of 1 mmol/L/hour in order to avoid a rapid increase in serum sodium concentration which might have led to central pontine myelinolysis. Concurrently the slow administration of intravenous diuretics also corrected the sodium by diuresis. Nausea and vomiting were treated with intravenous anti-emetics.
The abdomen remained contracted and sensitive. In that sense, cystography with contrast fluid was performed and revealed no escape. Abdominal ultrasound was also performed and it revealed ascites and bilateral pleural effusion. Therefore, abdominal puncture was performed and both ascites and bilateral transudative pleural effusion were eliminated.
Table 2. Clinical signs after 24 hours from arrival in the ICU
Patients’ clinical situation started to change immediately after treatment’s initiation and it presented significant improvement 24 hours after their arrival in the ICU (see table 2). They were released from the ICU on the third day of hospitalization.
Even though some medical treatment options such as α-adrenergic antagonists and 5α-reductase inhibitors as well as minimally invasive techniques such as laser or microwave application have challenged TURP during the last 15 years, it still is one of the most common operations in the Western world .
However, TURP may be associated with a broad spectrum of complications [7, 8]. Among these, some authors report traces of turbid urine, exit of fluid in the enetrocele, entrance of water in the capillaries because of variation in osmotic pressure and electrolyte disturbance (especially sodium). The most common view of the TURP syndrome is that the symptoms are caused by dilutional hyponatremia, which results from absorption of at least 3,000 ml irrigating fluid. Some authors confirm that the both incidence and severity of symptoms increase dramatically when the amount of fluid absorbed exceeds this limit, with patients to require treatment in the intensive care unit, at least overnight .
Other studies suggest as the most common complications of TURP the myocardial infarction, the pulmonary edema, the blood loss and hyperhydration while it has been reported the appearance of the syndrome as non cardiogenic pulmonary edema (ARDS) during a difficult operation with the use of isotonic glycine as an irrigating fluid . The suggested pathophysiologic mechanism is the decrease of blood osmolality, resulting in extravasation of glycine solution to the alveoli of the lungs.
Other authors believe that the quantity of fluid which enters the systemic circulation is associated with the size of the prostatic tissue which was resected. The rate and amount of fluid absorption may be calculated by adding ethanol 2% in the irrigating fluid and then by measuring ethanol concentration in the expired tidal volume of the patient .
In the case of our patients saline solution was used as an irrigating fluid (7,000 ml). According to previous studies, the entrance of the irrigating fluids in the circulation, probably through the open venous sinuses of the prostatic fossa may load the circulation long enough to lead to cardiogenic pulmonary edema, ascites, and respiratory failure [12, 13]. More so, abdominal muscles’ contraction and the ascites had been attributed to the peritoneal irritation due to the entrance of fluid in the peritoneal cavity . In contrast to the above-mentioned case reports, the fact that the chosen fluid was saline solution explains why we didn’t have severe electrolyte disturbances (severe hyponanatremia) [15,16]. This might also explain the good reaction of the to diuresis as well as patients’ quick recovery.
To conclude, we underline the great importance of early diagnosis of the TURP syndrome. In this respect, good communication between surgical and ICU teams is essential in order to alert emergency team about complications that may occur (such as sudden absorption of irrigating fluid into the systemic circulation due to capsular perforation of the prostate). More so, the use of normal saline as irrigating fluid decreases the risk of severe electrolyte disturbances (severe hyponanatremia). Last but not least, immediate initiation of proper treatment is crucial in order to have an optimal outcome (i.e. gradual restoration of creatinine levels, electrolytes’ balance, acid-base homeostasis, blood oxygen levels and other supportive measures of the ICU).
There are no acknowledgments of technical help, financial or material support.
Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
4. Silber JS. Transurethral resection. Appleton CenturyCrofts New York, 1977, 81-98.
6. Yousef AA, Suliman GA, Elashry OM, Elsharaby MD, Elgamasy AK. A randomized comparison between three types of irrigating fluids during transurethral resection in benign prostatic hyperplasia. BMC Anesthesiol. 2010, 10: 7.
7. Swaminathan R, Torney WP. Fluid absorption during transurethral prostatectomy. Brit. Med. Journal. 1981, 282-317.
8. Weiss L, Danielson BG, Wilkstrom B. Continuous arteriovenous hemofiltration in the treatment of 100 critically ill with acute renal failure. Report on clinical outcome and nutritional aspects. Clin. Nephrol. 1989, 31(4): 184-189.
14. Weber S, Acuff J, Mazloomdoost M, Kirimli B. Transurethral prostatectomy complicated by intraperitoneal excavation of irrigation fluid. Can. J. Anaesth.. 1987, 34: 193-195.
15. Logie JR, Keenan RA, Whiting RH, Steyn JH. Fluid absorption during transurethral prostatectomy. Br. J. Urol. 1980, 52(6): 526-528. 16. Gregorakos L, Bastas A, Konstantinidou K, Tzoumani A, Karakonstandis E et al. TURP syndrome. Medical Annals. 1990, 13(10): 751-754.
16. Gregorakos L, Bastas A, Konstantinidou K, Tzoumani A, Karakonstandis E et al. TURP syndrome. Medical Annals. 1990, 13(10): 751-754.