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Sterile Water as an Irrigating Fluid for Transurethral Resection of the

Prostate: Anesthetical View of the Records of 1600 Cases

Article  in  Southern medical journal · May 2008

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 Original Article
Sterile Water as an Irrigating Fluid for
Transurethral Resection of the Prostate:
Anesthetical View of the Records of 1600 Cases
Reza Shariat Moharari, MD, Mohammad Reza Khajavi, MD,
Peyman Khademhosseini, MD, Seyed Reza Hosseini, MD, and Atabak Najafi,
Objectives: Absorption of the fluid used for bladder irrigation during
transurethral resection of prostate (TURP) may disturb the circulatory
system and lead to clinical symptoms known as the transurethral resec-
tion syndrome. The purpose of this study was to evaluate the changes
in electrolytes in patients who had undergone TURP.
Methods: For all the cases with benign prostatic hypertrophy en-
rolled in the present study, TURP was performed as recommended
in Miller’s Anesthesia, the sixth edition. Sterile water was used as an
irrigating fluid for bladder washing. Laboratory tests were performed
before and immediately after the surgery.
Results: No statistically significant changes were reported in the
serum sodium, blood urea nitrogen, creatinine, and hematocrit. The
most common complications were hypotension (8.3%), hyperten-
sion (7.8%), nausea (6.4%), and vomiting (2.8%). Hyponatremia,
decreased hematocrit, and increased blood urea nitrogen/creatinine
were rarely reported (2.5, 1.0, and 0.9%, respectively).
Conclusion: Sterile water has been shown to be a safe irrigating
fluid for TURP.
Key Words: anesthesia complications, fluid and electrolyte balance,
spinal anesthesia, transurethral resection of prostate
T ransurethral resection of prostate (TURP) is the gold stan-
dard of surgical management in benign prostatic hyper-
trophy. Although glycine 1.5% is the most popular irrigating
fluid in this surgery, it results in several complications such
as hypotension, bradycardia, confusion, and chest pain.1,2
From the Departments of Anesthesiology, Emergency Medicine, and Urol-
ogy, Sina Hospital, Medical Sciences/University of Tehran, Tehran, Iran.
Reprint requests to Reza Shariat Moharari, MD, Sina Hospital, Hassan Abad
Square, Tehran, Iran. Email: moharari@sina.tums.ac.ir
This study was conducted after the approval in ethical board committee of
our hospital.
Accepted August 20, 2007.
Copyright © 2008 by The Southern Medical Association
0038-4348/0⫺2000/10100-0373
Southern Medical Journal • Volume 101, Number 4, April 2008
MD
Since 1955, these clinical features have been known as trans-
urethral resection syndrome.3 Although the safety of water as
an irrigating solution in TURP remains controversial, this
fluid has been commonly used in our center (Sina University
Hospital) for many years. The purpose of this study was to
report the clinical and the laboratory findings in the patients
undergoing TURP by administering sterile water.
Patients and Methods
In this study, the records of 1,600 patients who had un-
dergone TURP in Sina University Hospital (Tehran, Iran)
during January 1992 to December 2004 were reviewed. The
indication for performing TURP was as follows: (1) Acute
urinary retention, (2) Recurrent/persistent urinary tract infec-
tion, (3) Significant symptoms from bladder outlet obstruc-
tion not responsive to medical treatment, (4) Recurrent gross
hematuria, (5) Pathophysiologic changes of the kidneys, ure-
thra, or bladder secondary to prostatic obstruction, and (6)
Bladder calculus secondary to obstruction.4
All the patients were in good general health. All the patients
signed an informed consent and also accepted that the results
and medical files would be reviewed for research activities.
Based on the medical condition of each patient, spinal
anesthesia was induced at the level of T8 –T10 by isobaric
Key Points
• Absorption of the fluid used during TURP may dis-
turb the circulatory system and lead to transurethral
resection syndrome.
• Using sterile water as irrigating fluid, there were no
statistically significant changes in serum sodium,
blood urea nitrogen, creatinine, and hematocrit before
and after the operation.
• Hypotension, hypertension, nausea, and vomiting were
the most common complications; hyponatremia, de-
creased hematocrit, and increased blood urea nitrogen/
creatinine were rarely reported.
373
Moharari et al • Sterile Water as an Irrigating Fluid

lidocaine 5% (100 mg) or hyperbaric bupivacaine 0.5% (10 Table 1. Changes in biochemical indicators of patients
mg). Patients who were anesthetized using other methods, throughout the operation
such as general anesthesia due to anatomic problems or the
patients’ refusal were excluded from the study. This very Paired t test
group included 4% of all of the cases. A standardized TURP Preoperation Postoperation
operation5 was performed on all of the subjects using con- Mean ⴞ SD Mean ⴞ SD t P
tinuous flow resectoscope. The operations were done by sev- Na (mEq/L) 138 ⫾ 8 137 ⫾ 9 1.100 NS
eral experienced urologists who were the academic staff of BUN (mg/dL) 14 ⫾ 6 15 ⫾ 5 1.111 NS
the hospital. Cr (mg/dL) 1.0 ⫾ 0.6 1.1 ⫾ 0.5 0.511 NS
Serum sodium (Na), blood urea nitrogen (BUN), creati- Hct (%) 38 ⫾ 8 37 ⫾ 9 0.812 NS
nine (Cr), and hematocrit (Hct) of each patient were recorded
before and immediately after the operation (maximally 1 NS, nonsignificant; Na, serum sodium; BUN, blood urea nitrogen; Cr, cre-
atinine; Hct, hematocrit; SD, standard deviation.
hour). All of the tests were carried out in a unique laboratory
(Sina University Hospital). Besides the body temperature,
pulse rate and noninvasive blood pressure, electrocardiogram not intend to show that sterile water is the best irrigating
monitoring, and pulse oximetry were observed during the fluid, but emphasize the point that it is safe and cheap.
course of operation. The reliability of the results was estab- Sterile water is a historical and traditional fluid used to
lished in a pilot study. Sterile water (37°C) localized 85 cm irrigate the bladder during TURP. It is accepted that transurethral
above the patients’ beds was administered for all of the cases. resection syndrome caused by dilutional hyponatremia results
The volume of the irrigating fluid used and reflected was secondary to the absorption of at least 3000 mL of irrigating
recorded to compute the absorbed fluid. The patients’ urine fluid.3,6 According to the present study, smaller absorbed vol-
was collected and its volume was calculated as milliliter per umes may elicit milder forms of the syndrome; as a matter of
hour. The operation time (from the induction of anesthesia fact, the amount of absorbed fluid was neglectable and hypona-
until the time the patient was transferred from the recovery tremia (Na ⬍130 mEq/dL) was rare (2.5%).
room) and also the proper weight of the resected tissues were According to the results of the present study, there were
recorded. The definition of unpleasant biochemical events no statistically significant changes in the serum Na, BUN, Cr,
and the cardiovascular evaluation are based on Miller’s An- and Hct. This finding is probably achieved due to the small
esthesia, the sixth edition.5 amount of irrigating fluid absorbed. Previous studies have
The statistical analysis was done using SPSS 10.0 soft- shown the higher amount of absorbed fluid to be accompa-
ware. Biochemical indicators were recorded as mean and stan- nied with more frequent complications and more severe
dard deviation (SD) and comparison of pre- versus postop- changes in electrolytes and Hct.2
eration variables was done with paired t test. As ␣ was set at Absorption of the fluid used for bladder irrigation during
0.05, P ⬍ 0.05 was considered significant. TURP may disturb the circulatory system and lead to clinical

Table 2. Frequency of unpleasant events and

Results complications during or immediately after TURP
The mean age of the patients (⫾SD) was 66.8 ⫾ 6.4
years with the median age of 67, ranging from 54 to 84 years. Complications Frequency Percent
The mean operation time (⫾SD) was 40 ⫾ 4 minutes (median
of 38). The mean weight of the resected tissue and the resec- Hyponatremia 40 2.5
tion rate (⫾SD) were 31 ⫾ 5 g and 16 ⫾ 2 g/min, respectively. Increased BUN/Cr 15 0.9
The mean irrigating absorption (⫾SD) was 293 ⫾ 25 mL. Oliguria 1 0.0
Table 1 shows no significant differences between pre- Decreased Hct (⬍30%) 16 1.0
and immediately postoperation quantities of biochemical in- Active bleeding 3 0.0
dicators of serum. Reported complications and unpleasant Nausea 103 6.4
events are listed in Table 2. Vomiting 45 2.8
Hypertension 125 7.8
Hypotension (includes orthostatic) 132 8.3
Discussion Bradycardia 32 2.0
The present study reports the results of a wide range of Other arrhythmias (eg, PAC, PVC, etc) 78 4.9
patients who were candidates for TURP. This study is unique Change in body temperature 22 1.4
because of the large sample size used; moreover, due to being Mortality 0 0.0
conducted in a referral academic hospital, the findings are PAC, premature atrial contraction(s); PVC, premature ventricular contrac-
independent of the surgeons’ experience. This case study does tion(s); BUN, blood urea nitrogen; Cr, creatinine; Hct, hematocrit.

374 © 2008 Southern Medical Association


symptoms, known as the transurethral resection syndrome.
The prevalence of the syndrome varies in different studies,
which might be related to factors including the type of chem-
ical fluid used for irrigation (eg, sterile water, mannitol, gly-
cine, etc), the osmotic characteristic of the irrigating fluid
(hypo-, normo-, or hyperosmolar fluids), the patient’s condi-
tion, and the amount of fluid absorbed.2,3,7,8 According to
Hagstrom3, the susceptibility of patients to develop these
symptoms varies according to their age and physical condi-
tions.
Some investigators have shown that the fluid’s temper-
ature interacts with the complications.1 The fluid bags with
the room temperature of 37°C, which were traditionally used
in our center, prevent some cardiovascular changes and hypo-
or hyperthermia.
Some authors suggested that hypertension is caused by
the fluid overload in the clinical syndrome during and after
TURP, though it maybe followed by dilutional hyponatremic
shock.1 The results of Hahn et al’s2 research showed that
hypertension occurred in approximately 20% of the patients
who underwent TURP regardless of the amount of the ab-
sorbed fluid. On the contrary, hypotension was strongly as-
sociated with the increase of absorption during and after the
procedure. The cause of hypotension is not as clear as the
cause of hypertension, but it maybe the result of acute hypo-
natremia,6 dissemination of vasoactive substances from the
operating field,9 and the circulation itself.10 Significant hem-
orrhage also increases the risk of intraoperative decreases in
the arterial pressure. In our study, hypertension was reported
in 7.8% of the cases, which maybe related to other situations
such as the prevalence of hypertension in the elderly in Iran.
Hypotension was somewhat more frequent, but it may not be
a serious problem, as many cases only had the transient form,
probably due to some amounts of bleeding. This condition
could be easily managed by serum therapy and the re-balanc-
ing of the body fluids. Also, the frequency of cardiac arrhyth-
mias maybe related to the patients’ age; the most frequent
forms were premature atrial contraction and premature ven-
tricular contraction, which are more common in the elderly
individuals. As mentioned above, body temperature was con-
trolled during the operation and the fluid of the normal body
temperature was used. This might lead to a significant reduc-
tion in the occurrence of cardiac arrhythmias. Olsson et al1
showed the symptoms of bradycardia, hypotension, and im-
paired diuresis after transurethral resection of the prostate
were associated with each other. In our study, oliguria was
seen in only one patient.
Southern Medical Journal • Volume 101, Number 4, April 2008
View publication stats
Original Article
Few cases of fever or hypothermia were reported in our
study. According to Hahn et al,2 postoperative fever was
common in those who absorbed irrigating fluid (21%) com-
pared with only 3% of the nonabsorbing patients. They sug-
gested that fluid absorption promotes bacteremia after TURP.
The nature of the prostatic hypertrophy, elective surgery, and
hygienic methods of surgery may reduce the abovementioned
events.
Conclusion
TURP with sterile water is safe and inexpensive. Signif-
icant hyponatremia and fluid absorption did not occur, and
there was no mortality.
Acknowledgments
We thank all patients who let us use their information.
Also, we thank all urologists, anesthesiologists, and their res-
idents for helping us. We gratefully acknowledge Dr. Patricia
Khashayar for reviewing this manuscript and providing help-
ful comments.
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