Transurethral resection syndrome—it does not have to be a mystery - Home Study Program - Brief Article

AORN Journal,  Jan, 2002  by Ann Chambers

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Other transient complications include stress urinary incontinence, urge incontinence, and impotence. The urethra may become scarred, necessitating dilation of the urethral lumen. Some patients may experience a recurrence of symptoms 10 or more years later, necessitating a second TURP procedure. (12)

PHYSIOLOGY OF FLUID ABSORPTION

Fluid flows from an area of high pressure to an area of low pressure until both areas are of equal pressure. This principle can be applied to the bladder. Fluid (ie, irrigant) is used during a TURP procedure to keep the surgical field free of blood. The rate of the irrigant flowing into the patient's bladder is directly proportional to the height of the irrigating bag above the patient's bladder and whether the bladder is partially or completely empty. The higher the irrigant is hung, the higher the fluid pressure and the faster the flow. (13) This creates pressure in the urethra and bladder.

The pressure of the irrigant has a direct bearing on fluid absorption. To clearly see the surgical site, a flow of irrigation strong enough to slow the rate of bleeding and wash away blood present in the urethra is needed. This means the pressure of the irrigant must be equal to or greater than the pressure of the blood leaking from the opened vessels. If the pressure of the irrigant is greater than the patient's diastolic blood pressure, the fluid flows to the area of lower pressure and is absorbed into the patient's blood stream. On average, patients absorb 1 L to 2 L of irrigant in approximately 40 minutes during a TURP procedure. (14) This can vary, however, with the height of the bag.

Hypotonic fluid draws sodium and potassium out of intracellular spaces into extracellular spaces, thereby diluting their levels. As the electrolytes shift out of the cells, fluid shifts into the cells so that the tonicity matches that of the extracellular space. The cells swell with this extra fluid, causing cellular edema, which makes increased intravascular volume and cerebral edema of great concern.

Maintaining the patient's core temperature is an additional concern. Large quantities of fluids are flowing in and out of the bladder. The patient's temperature drops if enough cool fluids are used, so many surgeons prefer using warm irrigating solution. Some clinicians, however, use only room temperature fluids because warmth causes vasodilation and results in more bleeding. The effects of hypothermia coupled with anesthetic medications received can be more detrimental to the patient than the amount of increased bleeding resulting from warmed irrigating solutions. Lower body temperatures slow the body's metabolism and prolong the effects of anesthetic agents. Hypothermia also slows the blood's ability to clot. Prolonged bleeding may occur with a decrease in platelet activity and an increase in fibrinolysis. (15) The longer the vessels are open and bleeding, the greater the risk of fluid absorption.

IRRIGATING FLUIDS

Several types of fluids are available for use during a TURP procedure. Fluid choice is based on