What are the clinical features and immediate management of transurethral resection of the prostate (TURP) syndrome?

TURP Syndrome: Clinical Features and Immediate Management

Definition and Pathophysiology

TURP syndrome is a life-threatening complication caused by absorption of electrolyte-free irrigating fluid into the bloodstream during transurethral resection of the prostate, resulting in dilutional hyponatremia, hypervolemia, and potential cardiovascular and neurological collapse. 1

The syndrome occurs in less than 1% of TURP procedures but represents a unique and potentially fatal complication requiring immediate recognition and treatment. 2, 3 The pathophysiology involves four key mechanisms: circulatory distress from rapid absorption of electrolyte-free irrigating fluid, adverse effects of glycine (the irrigant), dilution of protein and electrolyte concentrations, and disturbance of renal function. 4

Clinical Features

Early Signs and Symptoms

• Cardiovascular manifestations: Bradycardia, arterial hypertension (paradoxically), and subsequent hypotension as the syndrome progresses 5
• Neurological symptoms: Confusion, dizziness, restlessness, visual disturbances, and altered mental status 2, 4
• Respiratory symptoms: Hypoxemia, dyspnea, and pulmonary edema in severe cases 5, 6
• Gastrointestinal symptoms: Nausea and vomiting 2

Laboratory Findings

• Severe hyponatremia: Sodium levels can drop precipitously, with reported cases showing levels as low as 90-120 mmol/L 5, 6, 7
• Hyperkalemia: May occur concurrently (potassium concentration up to 6.48 mmol/L) 5
• Decreased serum osmolality: Typically around 234 mOsmol/kg or lower 6
• Metabolic acidosis: pH can drop to 7.23 with associated hypoxemia (pO2 45 mmHg) 6

Severe Manifestations

In advanced cases, patients may develop cerebral edema, coma, pulmonary edema, cardiovascular collapse, convulsions, and death. 4, 6, 7

A critical caveat: Under general anesthesia, neurological symptoms are masked, making early detection more challenging and requiring heightened vigilance with hemodynamic monitoring. 7, 8 This is why neuraxial anesthesia is often preferred for TURP procedures—it allows early detection of neurological deterioration. 8

Immediate Management

Step 1: Recognize and Stop the Procedure

The first and most critical step is to immediately suspend the operation and control bleeding. 7 Early diagnosis is paramount to prevent progression to life-threatening complications. 6, 7

Step 2: Assess Severity

• Obtain immediate serum sodium, potassium, and osmolality measurements 5, 6
• Perform arterial blood gas analysis to assess pH, pO2, and pCO2 6
• Monitor vital signs continuously, including urine output and fluid balance 2

Step 3: Specific Treatment Based on Severity

For Hyponatremia:

• Administer hypertonic saline 3% solution: 150 mL intravenously for severe hyponatremia (sodium <120 mmol/L) 5, 6
• The goal is to raise sodium levels gradually to avoid osmotic demyelination syndrome 6

For Hyperkalemia:

• Nebulized levosalbutamol (or albuterol) to shift potassium intracellularly 5
• Consider additional measures if potassium >6.5 mmol/L (calcium gluconate, insulin/glucose, sodium bicarbonate)

For Pulmonary Edema/Respiratory Failure:

• Furosemide 20 mg intravenously to promote diuresis and reduce fluid overload 6
• CPAP-PSV Pro breathing through mask with +5 cmH2O PEEP, 8 cmH2O supporting pressure, and 70-100% FiO2 6
• Intubation and mechanical ventilation may be required in severe cases 6

For Metabolic Acidosis:

• 100 mL sodium bicarbonate 8.4% intravenously if pH <7.25 6

Step 4: General Supportive Care

• Provide general life support directed toward hypotension, hyponatremia, and anuria 4
• Maintain crystalloid administration at 1-4 mL/kg/hr as maintenance fluid (not boluses) 2
• Monitor hemodynamic variables continuously; transesophageal Doppler can detect acute hypervolemia in patients under general anesthesia 8

Prevention Strategies

Limit resection time to under 90 minutes to reduce irrigant absorption. 2 Use bipolar TURP when available, as it has a reduced risk of TURP syndrome compared to monopolar TURP, particularly in patients with renal impairment. 3, 9 Bipolar systems use saline irrigation rather than glycine, eliminating the risk of glycine toxicity and allowing for longer resection times. 9

Methods to monitor irrigating fluid absorption include using irrigating fluid containing tracer amounts of ethanol, which permits uptake measurement via exhaled breath ethanol concentration. 4 However, patient safety can only be guaranteed if absorption is actively monitored during the procedure. 4

Common pitfall: Multiple cystoscopic applications in the same session may facilitate development of TURP syndrome by increasing cumulative irrigant absorption. 7 Avoid prolonged or repeated procedures when possible.