What is Transurethral Resection of the Prostate (TURP) syndrome?

TURP Syndrome: Definition, Pathophysiology, and Management

TURP syndrome is a potentially life-threatening complication characterized by dilutional hyponatremia that occurs when irrigant solution is absorbed into the bloodstream during transurethral resection of the prostate (TURP) procedures. 1

Pathophysiology

TURP syndrome develops through several key mechanisms:

• Absorption of irrigation fluid: Electrolyte-free and hypotonic irrigation solutions enter the circulation through open prostatic blood vessels during resection 2, 3
• Dilutional hyponatremia: Excessive fluid absorption leads to decreased serum sodium concentration and reduced serum osmolality 2
• Volume overload: Rapid absorption causes acute hypervolemia 4
• Complex pathophysiology: Involves four mechanisms 3:
  1. Circulatory distress from rapid fluid absorption
  2. Adverse effects of glycine (when used as irrigant)
  3. Dilution of protein and electrolyte concentrations
  4. Disturbance of renal function

Clinical Presentation

TURP syndrome presents with a spectrum of symptoms affecting multiple systems:

• Neurological: Altered mental status, confusion, agitation, seizures, coma 2, 5
• Cardiovascular: Hypotension, bradycardia, hypertension, arrhythmias 6, 4
• Respiratory: Pulmonary edema, respiratory failure, hypoxemia 2
• Metabolic: Severe hyponatremia (sodium levels can drop below 115 mmol/L) 2, 5

Incidence and Risk Factors

• Incidence ranges from 0.78% to 1.4% of TURP procedures 2
• Risk factors include:
  • Prolonged resection time
  • Large prostate size
  • High irrigation pressure
  • Multiple cystoscopic applications in the same session 5
  • Open prostatic sinuses/vessels during resection

Diagnosis

Early recognition is critical for successful management:

• Laboratory findings: Urgent electrolytes showing hyponatremia (sodium < 130 mmol/L) 6
• Clinical signs: Mental status changes, visual disturbances, nausea, vomiting, bradycardia, hypotension 6, 2
• Hemodynamic changes: Can be detected using monitoring tools such as transesophageal Doppler ultrasonography 4

Management

Management of TURP syndrome requires prompt intervention:

1. Immediate surgical measures:

   • Control bleeding and suspend the operation 5
   • Reduce irrigation pressure if procedure must continue

2. Hemodynamic assessment and support:

   • Perform passive leg raise test to determine fluid responsiveness 6
   • If fluid responsive, administer crystalloid bolus (500 mL) 6
   • If not fluid responsive, use vasopressors (phenylephrine for tachycardia, ephedrine for bradycardia) 6

3. Hyponatremia correction:

   • Administer hypertonic saline (3% NaCl) for severe hyponatremia 2
   • Careful correction to avoid central pontine myelinolysis

4. Respiratory support:

   • For pulmonary edema: CPAP with PEEP, supplemental oxygen 2
   • Mechanical ventilation if respiratory failure develops

5. Diuresis:

   • Administer loop diuretics (e.g., furosemide) to promote fluid excretion 2

6. Acid-base correction:

   • Sodium bicarbonate for metabolic acidosis 2

Prevention

Several strategies can reduce the risk of TURP syndrome:

• Limiting resection time to under 60 minutes
• Using bipolar resection techniques instead of monopolar
• Considering alternative surgical approaches (laser techniques) 7
• Monitoring for fluid absorption during the procedure (e.g., using ethanol-containing irrigant and measuring ethanol in exhaled breath) 3
• Maintaining low irrigation pressure

Monitoring

Vigilant monitoring is essential during and after TURP:

• Continuous vital signs monitoring
• Regular electrolyte checks during lengthy procedures
• Monitoring mental status in patients under regional anesthesia
• Hemodynamic monitoring using appropriate tools
• Be aware that TURP syndrome can present up to 24 hours postoperatively 6

Pitfalls and Caveats

• Not all post-TURP hypotension is due to hypovolemia; approximately 50% of cases require vasopressors rather than fluid administration 6
• Avoid excessive fluid administration in non-responsive patients as this may worsen TURP syndrome 6
• Standard signs of hypovolemia are not reliable predictors of fluid responsiveness in the postoperative setting 6
• The clinical presentation can be variable and easily confused with other acute disorders 3