TURP syndrome : a skeleton - PowerPoint Presentation

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TURP syndrome:a skeleton in the closet is still lurking!

Assoc. Prof. Tatjana Šimurina, MD PhD tsimurina@unizd.hr tatjana.simurina@mefos.hr

9th CEAAC, INTENSIVE MEDICINE DAYS

Conflicts of Interest declaration I have no

conflict of interest.

TURP ~60% of men > 60 years suffer from

BHP/LUTS (voiding problems, decreased QoL)TURP

: ~30% of urologists’ workload

Transurethral resection

techniques:m-TURP (monopolar)

b-TURP (bipolar

, TUR

in

saline)Minimally invasive surgical therapies, MIST: Laser enucleation L- TURP [HoLEP, ThuLEP, (Holmium/Thulium) laser enucleation] TUVP (transurethral evaporization)Transurethral needle ablation Plasma vaporization (”button” procedure), photoselective vaporization (PVP)TUMT (transurethral microwave therapy)WAVE (water vapor energy ablation)PUL (prostatic urethral lift)TUIP (transurethral incision prostate)

Sun

F,

Sun

X,

Shi

Q,

Zhai

Y. Medicine; 2018: 97:51(e13360)

Day-case TURP: is it feasible? Careful

selection of candidatesManagement of

patients’ expectations

Proper surgical

technique selection

Improvement

of

instruments

Hemostasis control (CTD,catheter tensioning device; TXA)Early urinary catheter removal Normal vital signs and adequate urine output Anesthetic management during and after TURPMore experience with outpatient transurethral surgeryKhan A. Urol Ann 2014; 6(4):334–9.Subrata SA, Istani YP, Kesetyaningsih TW. Int J of Urol Nurs 2018;12(1):35-46.

Ideal irrigation fluid (IF) does not exist! Isotonic

NonhemolyticNontoxic when absorbed Not metabolised

Translucent Electrically inert

Does not alter osmolality Rapidly excreted

Osmotic diuretic Simple, easy to sterilize

Inexpensive

No solution meets all of the criteria !

IFs for m-TURP, b-TURP, L-TURPHypotonic solutions (electrolyte free

): Glycine 1.2-1.5%, Mannitol 3%, Sorbitol, Cytal (2.7% sorbitol and 0.54% mannitol), Glucose 2.5-4% , Urea 1%m-TURP Monopolar diathermy

active electrode at the end of resectoscope

and external return electrode Higher risk of rapid absorption, fluid overload,

dilutional hyponatremiaDistilled water is rarely used (extreme

hypotonicity

: hemolysis, shock and renal failure)

Isotonic

solutions (electrolyte-

containing

): Normal saline, lactated Ringerb-TURP Bipolar diathermy active and return electrodes are located within the resectoscopeRisk of fluid overload and surrounding tissue edema Decreased risk of electrolyte disturbancesTURis, L-TURP (Laser TURP) = TURP with normal saline: decreased risk of TURP syndrom (but higher incidence of urethral stricture)no risk for hemolysis, improved coagulation, blood loss reductionno cardiac toxicityhyperchloremic acidosis, fluid overload - impairment in cardiac function better visibility

Pharmacology of common fluids for irrigation

Solution for irrigation (Tonicity, osmolality

mOsm /kg)Pharmacokinetics

Pharmacodynamics (adverse effects)

Normal saline

(Isotonic

, 308

)

T

½ half–

life 110 min Distribution: 25% intravascular space 75% interstitial space Rapid infusion of large amount lead to hyperchloremic acidosis Ringer‘s lactate (Isotonic, 273)T ½ 50 min Hepatic metabolism of lactate Relative excess of bicarbonate from lactate metabolism (alkalosis, hyperkalemia) Glycine 1.2% or 1.5%(Hypotonic, 175 / 220)T ½ distribution 6 min; T ½ elimination 40 min Renal excretion 5-10%

Penetration into the CNS (limited)

Hepatic metabolism to ammonia

Glycine

(

nonessential

amino

acid

)

inhibitory

neurotransmitter

in

the

CNS

and

retina

Potentiation

of

the

NMDA receptor

Glycine

toxicity

:

headache

,

nausea

,

facial

warmth

,

visual

impairment

(

blindness

),

myocardial

depression

Hyperammonemia

:

neurological

symptoms

Mannitol 3% (

Hypotonic

, 179)

Mannitol 5%

(Isotonic,

298)

T

½

distribution

10 min; T

½

elimination

100 min

Osmotic

diuresis

Rapid expansion of intravascular volume - fluid overload, pulmonary

oedema

, cardiac failure

Bradycardia, hypotension

Sorbitol

3.5%

(Hypotonic

,165)

T

½

distribution

6 min

T

½

elimination

33 min (5-10%

renal

excretion

)

Hepatic

metabolism

to

fructose

and

lactate

Unabsorbed: diuresis, laxative

Metabolite fructose: hyperglycemia, lactic acidosis

Hypoglycemia (fructose-1,6-diphosphatase deficiency)

Death ( fructose intolerance)

Complications of TURP Intraoperative

Postoperative Myocardial ischemia (25%)Myocardial

ischemia/ AMI

Acute myocardial infarction

, AMI (1-3%)

DVT

Hypothermia

Clot retention (vagal stimulation, pain) (4.9%)

Shivering

Bladder spasmPerforation of the bladder Bladder neck/urethral stricture (3-8%)Perforation of prostatic capsule Acute urinary retention (4.5%)Penile erection Retrograde ejaculation (65.4%)Lithotomy position: pulmonary compliance/ lung volumes decreased Urinary tract infection /epididiymitis (4.1%)Lithotomy position: cardiac preload increase Postoperative cognitive dysfunction TURP syndrome (1%)

Bleeding

requiring

transfusion

(2.9%)

Taylor BL, Jaffe WI. Can J

Urol

2015;22(

Suppl

1):24-9

.

Ahyai

SA,

GillingP

,

Kaplan

SA,

et

al

.

Eur

Urol

2010;58(3):384-97.

TURP syndrome: a sceleton in the closet is still lurking!

Severe TURP syndrome is a very rare complication but potentially fatal with mortality rate ~ 25% Group of clinical symptoms that occur during and post endoscopic surgical procedures as result of the rapid, high-volume absorption of the irrigation fluid into the circulation resulting in hypoosmolality, dilutional hyponatremia, and metabolic acidosis

Clinical manifestations can also occur with a serum sodium level of > 125 mmol

/l°Incidence of TURP syndome: 0.78% - 1.4%

*A large scale multicenter study of 10,654 men: 30

day mortality rate of 0.1%

Immediate morbidity of 11.1 %

†

A nation-wide, long-term analysis of 23,123 men:

Mortality for TURP at 90-days 0.7% , 1 year, 2.8%, 5 year 12.7%, 8 years 20%8-year incidence of MI 4.8%Šimurina T, Mraović B, Župčić M, et al. Liječ Vjesn 2020;142:160–9°Zepnick H, Steinbach F, Schuster F. Aktuelle Urol. 2008; 39(5):369–72*Reich O, Gratzke C, Bachmann A, et al. J Urol. 2008;180(1):246-9†Madersbacher S, Lackner J, Brössner C at al. Eur Urol 2005;47(4):499-504

Early, intermediate and late signs and

symptoms of TURP syndrome Neurologic

Cardiovascular Respiratory MetabolicRenal and

other

Headache

Dizziness

Hypertension

O

2 desaturationHyponatremia Acute renal failure Nausea, vomitingReflex bradycardia Tachypnea Hypo-osmolalityHemolysis/anemia RestlessnessTachiarrhythmias Hypoxemia Hypergycinemia Disorientation Hypotension (spinal + epidural; ac. hypoNa; periop.

bleeding

;

vasovagal

reflex

,

vasoactive

substance

from

the

op. field)Pulmonary edema

Hyperammonemia

Apprehension

Negative

inotropy

Respiratory

arrest

Metabolic

acidosis

Confusion

ECG:

widened

QRS,

ST

elevation

, T-

wave

inversion

Visual disturbances

,

transient

blideness

VEBs

,

Ventricular

arrhythmias

Somnolence

Congestive

heart

failure

Convulsions

Myocardial

infarction

Coma

,

Death

Cardiovascular

collapse

Risk factors for TURP syndrome Large prostate (>75g)

˚Prolonged resection time (>90 min):

RI, DM/HT, (renal

insufficiency, diabetes mellitus and hypertension) >40 min

HT >45 min

High inflow irrigation fluids pressure

(infusion bag higher than 100 cm)

Large irrigation fluid volume

(+

comorbidities

) CAD, Coronary artery disease, ≥20L (low salt diet, digitalis, diuretics, reduced exercise)DM, >24L (reduced total body water, electrolytes and blood volume)DM / HT ( + large gland size, prolonged resection time), > 20L CKD, Chronic kidney disease, ( + large gland size, prolonged resection time), >15LCapsular perforation, open prostatic veins and sinusesIrrigation fluid type: hypotonic fluids, high volume of plasma substitute (colloids ≥500mL)Preoperative hyponatremia Smoking (prostatic vascular damage) Acute urinary retention, distended bladder (high intravesical pressure) Continuous irrigation fluid drainage (leaking into the abdominal / extraperitoneal space) Age >80 years (23/98 , 23.5% 95% CI 14.9-32.0%)*˚Fujiwara A et al. BMC Urology 2014: 14:67 Narayanan KJ, Kannab VP. Int JRes Med Sci 2017;5(8): 3317-21*Nakahira J et al. BMC Anesthesiology 2014; 14:30

Retrospective study, N=1,502 TURPs over 15 years, spinal anesthesia, 1.5% glycine

Resection time (min): median 55 (range 40-75)Resection weight (g): median 44 (range 24-65)Volume of intraoperative IF (L): median 28 (range 24-48)Blood analysis: preoperative vs postoperative values (median)

Hct 42 vs 33 %Hb

142 vs 101 g/LNa 142 vs 121 mmol/L

TURP complications

(9 pts. were admitted to HDU; all pts

.

recovered within 48

h):

TURP syndrome in 48 patients (3.2%)EARLY signs of TURP syndrome: nausea 44/48, apprehension 37/48, visual disturbance 29/48, vomiting 28/48, bradycardia 19/48, disorientation 17/48, dyspnea 17/48)Capsular perforation in 16/48 pts. Blood transfusion in 1 patient

Regional or General Anesthesia, that is the

question !AnesthesiaREGIONALGENERAL

ADVANTAGESDetection of early signs of TURP syndrome Pts. unable to

lie supine

Earliy detection of capsular tears /bladder perforationPts.

with

consistent

cough Reduced blood loss (lower blood pressure)Incidence of myocardial ischemia is similar as for RA Peripheral vasodilatation minimizes circula­tory overloadPts. who need ventilatory and hemodynamic supportPts. with severe respiratory disease Pts. who have contraindications or refuse RA Lower incidence of deep vein thrombosis, DVT Better safety in anticoagulated patientsGood postoperative analgesia (lower incidence of postop. hypertension or tahycardia)Caudal and sacral blockade = hemodynamic stabilityDISADVANTAGES Penile erection interferes with surgery Lithotomy - VT and FRC reduced /higher the risk of aspiration

Lower safety in anticoagulated patients

Penile

erection

Postoperative

analgesics

Short term morbidity, long term outcomes and mortality are similar with both techniques.

At the present time, less emphasis is placed on RA.

Intraoperative monitoring Standard monitors according to the recommendations:

Standard ASA monitors: pulse oximeter SpO2 ; ECG; noninvasive blood pressure NIBP; and a temperature monitorWHO-WFSA International Standards for a Safe Practice of Anesthesia:

SpO2 ; intermittent monitoring of BP; confirmation of correct placement of ETT by auscultation and E

tCO2 ; WHO Safe Surgery Checklist; a system for transfer of care at the end of an anesthetic

Non-Invasive hemodynamic monitoring (

finger

cuff

: R/R, HR,CO)

Direct arterial blood pressure

Frequent blood sampling for electrolytes, blood gas analysis ABG, RBCsTransthoracic echocardiographyMonitoring of the amount of intravenous fluid administration (normal saline)Ethanol monitoring of IF absorption Gelb AW, Morriss WW, Johnson W, et al. Can J Anaesth 2018;65:698.Whitaker D, Brattebø G, Trenkler S, et al. Eur J Anaesthesiol. 2017;34(1):4-7. http://www.eba-uems.eu/resources/PDFS/safety-guidelines/EBA-Minimal-monitor.pdf Checketts MR, Alladi R, Ferguson K, et al. Anaesthesia 2016;71:85.

A prospective observational study, N = 20, ASA 1,2, TURP under spinal anesthesiaIrrigating fluid (IF) 2.7% sorbitol, 0.54% mannitol solution,1% ethanol (fluid absorption ~ ethanol in expired breath)

Pre- and postoperative blood analysis : Hb, Hct, platelet count, PT-INR, aPTT, electrolyte (Na, K, Cl, iCa), ROTEM INTEM-CT clotting time was significantly lengthened

by 14% (P=0.001)INTEM-a-angle was significantly decreased by 3% (P=0.011)

EXTEM- CFT clot formation time was significantly prolonged by 18% (P=0.008)EXTEM-MCF

maximum clot firmness was significantly decreased by 4% (P=0.010)FIBTEM-MCF was significantly decreased by 13% (P=0.015)Hb

(P<0.001),

Hct

(P<0.001),

platelet counts (P<0.001), K (P=0.024), iCa (P=0.004) were significantly decreased and PT-INR (P=0.001) significantly increased after surgeryThe amount of absorbed IF significantly correlated with the weight of resected tissue (P=0.001) and change of INTEM-CT (P<0.001)IF absorbed during TURP impaired the blood coagulation cascade by:disruption in the coagulation factor activity and lowering the coagulation factor concentration via dilutionROTEM as a point of care is helpful tool in ambulatory setting in the assessment of clotting function and early detection of a coagulopathic state

Case scenario75-year old male, history of hypertension and strokeb-TURP

in lithotomy position under general anesthesia with LMA (refused neuraxial block) with PCV 18 cm H2O , rate 16, FiO2 40% , sevoflurane 1.5 %Intraop

. monitoring: SpO2, body temp.,

ECG, non-invasive hemodynamic monitoring - NIBP (MABP), HR

The surgery time ~ 80 min, surgery was uneventful, minimal blood lossIntraop

.

normal

saline

NS1500 ml IV, warmed NS for continuous irrigation (infusion bag 70 cm above the op. table)Calculated IF deficit (difference of IF administered and volume removed by suction) ~ 2.5 LNear the end of surgery BP raised transiently from preop. 140/85 to 195/100 mmHg and HR from 85 to 105 bpm, SpO2 decreased to 88%, TV decreased, from 450 to 300 mlAuscultation: bilateral lung crepitation and wheezing.Treatment: Surgery was terminated immediately, IF and IV fluids were stopped, FiO2 increased to 100%, furosemide 40 mg IV, aminophylline IV LMA was replaced with ETT, continued mechanical ventilation with PCV with propofol sedation for 90 minutes in PACU Laboratory results: 1. ABG: hyperchloremic metabolic acidosis (pH 7.15, SaO2 88%, chloride 118 mmol/L), 2. ABG: improvement (pH 7.35, SaO2 98%, chloride 110 mmol/L), serum sodium 127 mmol/L, potassium 3.5 mmol/, Hb 89 g/LChest X-ray: obscured bilateral lower lung fields (pulmonary edema); ECG: no abnormalitiesDiscontinuation of sedation – spontaneous breathing, extubation, PACU stay ~150 minutesPatient transfer to the ward and discharged to home next morning

Take home points It is important to identify predictive factors for TURP complications, to take risk minimization measures and to provide early treatment.

TURPis (L-TURP, bTURP) techniques reduce a risk of surgical bleeding, TURP syndrome, catheterization period and there is no risk of cardiac toxicity.

Vigilance for IF toxicity and meticulous monitoring for early signs of fluid overload reduces perioperative morbidity.

Non-invasive hemodynamic

monitoring, point of care monitoring including ABG, CBC, electrolyte and ROTEM may provide early and complete insight of patient

s’

physiologic well being

.

Appropriate communication with urologist, patients and escort is crucial to avoid delayed discharge or hospital readmission.

Thank You for Your Attention

! Hvala na pozornosti!