Change in serum sodium level predicts clinical manifestations of transurethral resection syndrome: a retrospective review

Serum copeptin as a predictor of risk of hyponatremia after transurethral prostatectomy

Background: Transurethral resection of the prostate gland (TURP) frequently leads to the de-velopment of dilutional serum sodium decrease. Copeptin has been established as a surrogate marker of vasopressin and is measured for clinical assessment of various sodium and water dis-turbances. This study aims to assess the utility of serum concentration of copeptin and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) for prediction of post-TURP al-terations of serum sodium concentration.Methods: Forty-three patients with benign prostatic hyperplasia undergoing TURP were enrolled. Serum sodium and copeptin were measured before the procedure, then 12 hours after its com-pletion. NT-proBNP was assessed at baseline. The total amount of fluids and sodium adminis-tered intravenously and used to flush the bladder during TURP was calculated in each patient. Receiver operator characteristic (ROC) curve analysis was used to determine value of copeptin and NT-proBNP for prediction of serum sodium decrease after TURPResults: In forward stepwise multiple regression analysis of serum copeptin before surgery and the duration of TURP explained the significant portion of the sodium concentration variation 12 hours from the start of the surgery. ROC curve analysis showed that serum copeptin before sur-gery predicted development of hyponatremia 12 hours after TURP (area under the curve, 0.775; 95% confidence interval, 0.62–0.89; p < 0.001) with a cut-off point of >78.6 pg/mL with 77% sensitivity and 64.7% specificity. Serum NT-proBNP before surgery did not predict hypo-natremia 12 hours after TURP.Conclusion: Serum copeptin before TURP surgery, but not NT-proBNP, may be a clinically use-ful marker of the risk of serum sodium decrease after TURP.

Non dilated obstructive uropathy secondary to tur-syndrome in patient with solitary kidney

Non-dilated obstructive uropathy (NDOU) is a condition of renal insufficiency characterized by functional kidney failure and inability of collective system to dilate because of several causes, e.g. hypotension, severe oliguria or dehydration. TUR-syndrome is a complication of bladder resection possibly leading to this condition through electrolytic disequilibrium after fluids reabsorption. We present the case of a patient with solitary kidney suffering from this uropathy regardless of mild electrolytic disorders and small bladder perforations. Prompt diagnosis and management with ureteral stent or nephrostomy tube are imperative in this setting.

Irrigation fluid absorption syndrome during HoLEP: A case study

The classical transurethral resection syndrome as described with monopolar prostate resection has become rare since the switch to bipolar resection and even more so since the introduction of HoLEP. We report a case of a 74-year-old male patient who presented with an irrigation fluid absorption syndrome during a HoLEP for benign prostate hypertrophy. Biochemically this presented as metabolic acidosis and hyperchloremia instead of hyponatremia. He was treated with diuretics and had a swift recovery.

Usefulness of bicarbonate Ringer's solution as perfusate during transurethral resection of the prostate

Transurethral resection of the prostate (TURP) is the most common standard surgical procedure used for benign prostatic hyperplasia. Transurethral resection in saline (TURis) is a bipolar electrosurgery system used to prevent TURP (or TUR) syndrome. The bicarbonate Ringer's solution is not generally used as perfusate for TURP. Hence, we compared the efficacy of the bicarbonate Ringer's solution with that of physiological saline as perfusate during TURP. This prospective, multicenter, cooperative study was conducted on 40 adult patients admitted to a medical college hospital. After obtaining informed consent from all the patients, they were divided into two groups (20 patients per group). For patients of one group, bicarbonate Ringer's solution, and for other group, physiological saline was used as perfusate. Compared to the physiological saline, the electrolyte composition of the bicarbonate Ringer's solution was closer to that of plasma. Hence, the group using bicarbonate Ringer's solution as perfusate was exhibited less variation in plasma electrolytes and blood gas data. The primary endpoints were adverse events of grade 1 or higher according to the JCOG postoperative complication criteria ver. 2.0, unintended diseases, or related signs in patients who underwent the protocol therapy. The secondary endpoints were changes in blood pH, bicarbonate ion level, anion gap (AG), base excess (BE), and chloride (C1), which occurred during and after the surgeries. Therefore, bicarbonate Ringer's solution has superior with that of physiological saline as perfusate during TURP which is directly administered into the blood vessels as an infusion solution.Bicarbonate Ringer's solution is directly administered into the blood vessels as an infusion solution.

Efficacy of Goreisan in Preventing Transurethral Resection Syndrome in Transurethral Resection of the Prostate: A Randomized-Controlled Study

Objectives: Nonconductive irrigation fluids used during transurethral resection (TUR) of the prostate can cause fluid overload and dilutional hyponatremia. TUR syndrome is generally defined as serum sodium at or below 125 mmol/L with cardiovascular and neurologic symptoms. The aim of this study was to evaluate the effects of Goreisan, a traditional Japanese Kampo medicine, on serum sodium levels and the occurrence of TUR syndrome in patients undergoing TUR of the prostate. Design: This was a randomized-controlled trial. Settings/Location: This trial was conducted at the Osaka Medical College Hospital and Keneikai Sanko Hospital. Subjects: Fifty patients scheduled for TUR of the prostate were included. Interventions: Patients in the Goreisan group (n = 23) received 2.5 g Goreisan orally on the night before surgery and on the morning of surgery. The control group (n = 27) did not receive Goreisan. Surgical procedures, perioperative management, and patient monitoring were otherwise the same in both groups. Outcome Measures: The primary outcome was occurrence of TUR syndrome. The secondary outcome was serum sodium level. Results: Serum sodium remained above 125 mmol/L in all patients, so none of the patients met the criteria for TUR syndrome. However, the Goreisan group had significantly higher intraoperative sodium levels (p < 0.001) and significantly higher intraoperative (p = 0.008) and postoperative (p = 0.02) hemoglobin levels than the control group. Conclusions: These findings indicate that preoperative Goreisan administration can help maintain serum sodium levels in patients undergoing TUR of the prostate.

Cardiovascular Collapse During Transurethral Resection of Bladder Tumor: A Case Report

Despite innovative modalities, transurethral resection (TUR) procedures are the primary surgical intervention for bladder tumor and enlarged prostate. TUR syndrome, a major complication of TUR procedures, leads to derangement in electrolytes, hemodynamic compromise, and possible cardiac arrest. This case report describes cardiovascular collapse in a 60-year-old male during TUR of a bladder tumor under general anesthesia. The patient developed hypoxia, which progressed to cardiovascular collapse. Electrolyte analysis revealed acute hyponatremia. The patient was resuscitated successfully, transferred to intensive care unit, and discharged from the hospital without any complications. This case report of a cardiovascular collapse during transurethral resection of bladder tumor offers insight of the risks in urologic procedures and highlights the importance of clear communication as well as early recognition and successful management of complications.

Prophylaxis versus Treatment against Transurethral Resection of Prostate Syndrome: The Role of Hypertonic Saline

BACKGROUND

This study aimed at investigating the usage and effects of prophylactic hypertonic saline (HS) to prevent the occurrence of transurethral resection of the prostate (TURP) syndrome.

MATERIALS AND METHODS

Sixty American Society of Anesthesiologists physical status classes I-III candidates for TURP using the monopolar resectoscope were randomized into three groups 20 patients each. Group A received 4 mL.kg-1.h-1 HS 3%; Group B received 2 mL.kg-1.h-1 HS 3%; and Group C received 6 mL.kg-1.h-1 normal saline. Hemodynamics, vasopressors need, electrolytes (sodium, potassium, and chloride), osmolality, and arterial-blood gas (ABG) were recorded. The incidence of transurethral resection syndrome, intensive care unit (ICU) admission, postoperative ventilation, hospital stay as well as any adverse events were noted.

RESULTS

Hypernatremia was detected in six patients (P = 0.002) of Group A only, while hyponatremia occurred in five patients (P = 0.009) of Group C alone. Serum sodium in Group C showed a significant decrease starting from T2 (1 h postresection) till Tp3 (48 h postoperative). In Group C, five patients experienced hypotension and bradycardia; hypertensive episodes also occurred in five patients and a hypervolemic state was noted in seven patients. TURP syndrome was confirmed in only five patients, all in Group C (P = 0.009). Postoperative ICU admission was needed for seven patients of C Group, five of which required assisted ventilation. The overall hospital stay was longer for Group C patients.

CONCLUSION

Prophylactic administration of HS during TURP is superior to conventional treatment of an occurred TURP syndrome. Low dose (2 mL.kg-1.h-1 HS 3%) is effective without adverse effects or risk of contrary hypernatremia.

[Delirium in geriatric urology patients]

BACKGROUND

Delirium is a common but often undiagnosed complication in geriatric patients following a major or minor operation. With 14-56% in patients over 70 years of age, it is one of the most frequent complications seen in hospitals. The link between the prescription of drugs with antimuscarinic effects and cognitive disturbance is also well known.

METHODS

Recognizing the presence of delirium and the criteria to establish the diagnosis of delirium will improve a clinician's ability to detect this complication. Treating delirium with non-pharmacologic, reduces the incidence and side effects of postoperative delirium. The purpose of this article is to describe the diagnosis and treatment of postoperative delirium.

RESULTS

A sudden rise following fluctuating symptoms with decreased attentiveness, awareness and thinking are typical symptoms of delirium. The organic origin is not focused and must be considered. Transurethral resection (TUR) of the prostate and the bladder can increase the risk of bleeding, delirium and TUR syndrome. As simple instruments to assess signs and symptoms, the Clinical Assessment Method (CAM) and the Nurses Delirium Screening Scale (Nu-DESC) in the clinical setting are well examined.

CONCLUSIONS

Preoperatively screening and execution of a geriatric assessment to detect vulnerable elderly could be a first step in reduction of complication. Regularly screening for delirium reduces the pre-, post-, and perioperative complications in patients with delirium.