Learning objectives

• Definition of transurethral resection of the prostate (TURP) syndrome 
• Management of TURP

Definition and mechanisms

• Benign prostatic hyperplasia (BPH) occurs in over
• 40% of men aged over 60 years and prostate resection is the second-line treatment if BPH symptoms are resistant to medical management
• Transurethral resection of the prostate (TURP) syndrome is a rare but potentially life-threatening complication of transurethral resection of the prostate procedure
• During the procedure, the prostate at the bladder neck is shaved away
• As the body of the prostate is removed, veins are exposed, but the capsule is maintained
• The exposed veins can bleed, causing significant blood loss, and can also absorb large amounts of irrigation fluid resulting (1.5% glycine solution) in TURP syndrome
• Treatment is largely supportive and relies on the removal of the underlying cause and organ and physiological support
• Mortality is 0.2-0.8%
• Pre-operative prevention strategies are extremely important

Signs and symptoms

• Signs and symptoms are often vague and non-specific as there is no classical TURP presentation
• Symptoms result from fluid overload and disturbed electrolyte balance, and hyponatremia

Complications of TURP procedure

• Retrograde ejaculation
• Urinary incontinence
• Erectile dysfunction
• Urethral strictures (narrowing of the urethra)
• Bleeding
• Urinary tract infection
• Urinary retention

Risk factors

• The size of the opened venous sinuses
• The amount of irrigation fluid used
• The use of excess amounts of hypotonic intravenous fluids
• Duration of the resection (> 1 hour)
• Perforation of the bladder

Diagnosis

• Acutely unwell, confused patient with a reduced Glasgow Coma Scale score
• Hyponatremia: Na < 120 mmol/L
• Hyperkalemia: K > 6.0 mml/L
• Glycine toxicity
• Intravascular hemolysis
• Disseminated intravascular coagulation

Prevention

• Regional anesthesia is preferred over general anesthesia
• Avoid large amounts of glycine-containing fluid infusion
• Keep the length of surgery under 1 hour
• Keep the patient horizontal and avoid the Trendelenburg position
• Resect large prostates in staged procedures to avoid prolonged operative times
• The optimal height of the irrigation fluid bag above the patient is 60 cm

Management

From diagnosis to recovery.
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Treatment of TURP syndrome

• Stop the procedure as soon as possible
• Provide oxygenation (intubation) & circulatory support (inotropes)
• Perform invasive monitoring if hemodynamically unstable
• Treat hypotension
• Correct hyponatremia
• Treat fluid overload with diuretics
• Manage disseminated intravascular coagulation
• Perform regular blood tests to monitor improvement in the clotting status
• Control seizures with benzodiazepines
• Treat nausea and vomiting with antiemetics

Suggested reading

• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• Nakahira, J., Sawai, T., Fujiwara, A., Minami, T., 2014. Transurethral resection syndrome in elderly patients: a retrospective observational study. BMC Anesthesiology 14, 30.
• Demirel I, Ozer AB, Bayar MK, Erhan OL. TURP syndrome and severe hyponatremia under general anaesthesia. BMJ Case Rep. 2012;2012:bcr-2012-006899.
• O’Donnell AM, Foo I. 2009. Anaesthesia for transurethral resection of the prostate. Continuing Education in Anaesthesia Critical Care & Pain. 9;3:92-96.