Brrrrvh Journulo/ Uroiog? (1985).

57,450-452
( 1985 Briti\h Journal of llrology

Hyponatraemia Following Transurethral Resection of

the Prostate

J. C. RHYMER, T. J. BELL, K. C. PERRY and J. P. WARD

Department of Urology. District General Hospital, Eastbourne

Summary-In a prospective study of 100 patients undergoing transurethral resection, changes in

serum sodium were estimated during the per-operative and post-operative periods. The weight of
prostate resected and the volume of irrigant fluid used influenced the changes in serum sodium. In
93 patients these changes were not statistically significant. I n only seven patients were significant
falls i n serum sodium recorded, in one case t o a level of 103 mmol/l. All seven exhibited the clinical
features of the transurethral syndrome and there was one post-operative death which w e attributed
to it. The TUR syndrome undoubtedly exists and its incidence in this series was 7%. Its pathogenesis
and clinical management are discussed.

A complication of transurethral resection of the
prostate (TUR) characterised by bradycardia,
hypotension and a post-operative confusional state
together with profound hyponatraemia is called the
TUR syndrome. It has been reported by Charlton
( 1 980), Reiz et al. (198 1) and Bird et al. (1982) and
can cause sudden death on the operating table or in
the post-operative period (Osborn et al., 1980).
Massive absorption of irrigant fluid causing
haemodilution has been postulated as the cause of
this syndrome. Changes in serum sodium levels can
be used as an index of the degree of dilution and a
prospective study was undertaken to investigate
these changes. The aim of the study was to recog-
nise the syndrome and to establish its incidence in a
general urology unit.
Patients and Methods
A prospective study was undertaken of 100 con-
secutive patients undergoing TUR between
October 1983 and June 1984. Their ages ranged
from 54 to 90 years with a mean of 72 (SD f 7.17).
The procedures were carried out using Storz
Iglesias continuous flow resectoscopes (25 or 28F)
and the irrigant fluid was 1.5% glycine with a pres-
Accepted for publication 13 December 1984
450
sure head of approximately 1 m above the operat-
ing table. Throughout the procedure all patients
received 1 1 Hartmann’s solution intravenously (IV)
and 1 mg Burinex (bumetanide) IV at the end.
Post-operatively, all patients received an IV in-
fusion of Hartmann’s solution alternating with 5%
dextrose 1 litre 8-hourly. This was continued until
each patient was drinking satisfactorily, usually on
the first post-operative day.
Serum sodium and other electrolytes were
measured immediately before and after resection
prior to administration of the diuretic, and on the
first post-operative day. The samples were analysed
in a multichannel analyser with an error of
f 3 m m o l serum sodium at a test level of
140mmol. The volume of glycine used for irriga-
tion and the weight of the prostate resected were
recorded.
Within the group of 100 patients, due to slightly
different operative techniques by the two consult-
ant urologists, two subgroups were defined:
(i) Those using suction drainage of glycine with an
apparatus giving a pressure of - 5 cm of water
during resection. There was no post-operative
irrigation in this group (49 patients).
(ii) Those using gravity drainage of glycine during
resection but continuous bladder irrigation
using glycine in the post-operative period (51
patients).
 HYPONATRAEMIA FOLLOWING TRANSURETHRAL RESECTION OF THE PROSTATE 45 1

Results no significant difference between them when con-

Most patients tolerated transurethral resection
extremely well with minimal changes in the serum
sodium levels. There was a mean fall of 3.65 mmol/l
during the operation and a further fall of 1 mmol
by the first post-operative day. These changes,
however, were not statistically significant. The
mean weight of prostate resected was 2 7 g and
the mean volume of irrigant 15.251 of glycine
(Table I ) .
Table 1 Changes in Serum Sodium Levels
Overall Group A
Number of patients 100 49 51
Age 72(7.2) 71.4(7.2) 72.6(7.l)
Volume ofglycine (I) 15.25 (6.58) 16.29 (6.98) 14.73 (6.03)
Weight ofprostate ( 9 ) 27.5 (15.3) 27.9 (16.3) 27.0 (13.4)
Per-operative sodium
fall (mmolll) 3.65 (5.67) 3.71 (6.07)
Post-operative sodium
fall (mmolil) 0.96 (4.63) 1.06 (4.71)
All results arc' Mean f SD
Seven patients (7%) developed significant post-
operative hypotension with hyponatraemia (Table
2). The intra-operative fall in serum sodium in
these cases was from 6 to as much as 32 mmol/l. In
100 patients there was a significant correlation
between the weight of prostate resected and the
per-operative sodium fall (P<0.05), but by the first
post-operative day this was no longer the case
because of the inverse correlation between weight
of gland and post-operative sodium fall.(P> 0.05).
There was a similar strong correlation (coefficient
of correlation 0.76 (P<0.05) between the weight of
gland resected and the volume of glycine used.
Comparing the two subgroups A and B, there was
sidering any results.
Whilst the results showed an overall fall in serum
sodium levels, there were two distinct trends.
Patients with larger glands tended to show a
greater per-operative sodium fall and a post-opera-
tive recovery of serum sodium levels. Hence in the
22 patients whose glands weighed 40 g or more, the
mean per-operative fall was 6 f 7 mmol/l compared
with 3 k 4.2 mmol/l in the remaining 78 patients
( P < 0.05); in the post-operative period a change of
+ 1-.36mmol f6. I4 mmol/l occurred, compared
with - 1.61 *4mmol/l (P>0.05). Both groups
attained similar levels on the first post-operative
Group B morning.
In none of the seven patients found to be hypo-
tensive post-operatively could the effect of anaes-
thetic agents or blood loss be found to be
contributory. Significant falls in serum sodium
levels were recorded in all of these patients and are
3.59 (4.15) shown in Table 2. Of this group, cases 3 and 6 were
0.18 (4.48) operated upon for retention of urine and the others
were elective procedures. Only in case 4 was the his-
tology malignant. Case 5 was a 79-year-old gentle-
man who underwent a 56 g resection under general
anaesthesia and post-operative catheter irrigation
was not employed ( i . ~Group
. A). He developed a
profound TUR syndrome and although intra-
venous diuretics and calcium were employed he
made little clinical recovery, although his plasma
sodium rose from 103 to 120 mmol/l, and he died
on the second post-operative day from left ven-
tricular failure and huge bilateral pleural effusions.
His dilutional picture was compounded by the
effects of blood loss, and after biochemical correc-
tion had become apparent it was thought that his
continuing hypotension could, in part, be due to
blood loss. He was accordingly transfused 2 units
of packed cells slowly and although he tolerated
these at the time, he subsequently died. We believe

Table 2 Details of 7 Patients with Post-operative Hypotension and Hyponatraemia

Serum sodium (mmol/l)
- ~~

Patient Age Wt ofgland ( g ) Vnlume ofgl-vcine ( I ) Before rewrtinn After revectinn Arrt day
~

1 77 25 16 139 120 130

2 84 70 30 141 125 136
3 71 25 18 137 125 138
4 16 18 6 I39 133 130
5* 79 56 45 I35 I03 120
6 81 20 18 137 129 133
7 71 15 12 136 Ill 125

* This patient died on the second-post operative day.

452
his death was attributable to altered capillary per-
meability and intercurrent cardiovascular disease.
At post mortem cerebral oedema was not present.
Discussion
Osborn rt al. (1980) reported three patients who
collapsed after prostatectomy and were found to be
profoundly hyponatraemic. In these cases there
was the paradoxical combination of bradycardia
and hypotension. Creevy (1947) attributed this so-
called TUR syndrome to the use of water irrigation
being infused intravenously via the prostatic
venous plexus and so causing haemolysis, but the
same has been reported with glycine and mannitol
(Logie et a/., 1980). Oester and Madsen (1969),
using radioisotopes, found the absorption of irri-
gating fluid could be up to 4 I of which the intra-
vascular component could be up to 1.8 I.
The entering of periprostatic venous spaces
during resection, permitting irrigant absorption
and bladder overdistension, is a predisposing fac-
tor. Consideration has been given to preventing the
syndrome by the reduction of irrigating pressure
during resection. The Iglesias continuous flow
resectoscope maintains an intravesical pressure of
10mmHg and should in theory achieve this.
Stephenson et al. ( 1 980), however, found no signifi-
cant difference in serum glycine (and serine, its
metabolite) estimations when comparing inter-
mittent and continuous flow and concluded that in
both techniques similar volumes may be absorbed.
Treatment of the established case is contro-
versial. Charlton ( I 980) recommended the admin-
istration of potent loop diuretics and hypertonic
saline together with positive inotropes and calcium.
By contrast, Bird et al. (1982) advised “masterly
inactivity” by withdrawing all treatment and they
felt that the use of hypertonic solutions was con-
traindicated for fear of precipitating pulmonary
oedema. The policy of our unit was to administer
10 ml of 10% calcium gluconate (IV) and a further
dose of diuretic, to restrict fluids and to await
events. Six of the seven patients diagnosed as
having the syndrome recovered within 48 h. In the
post-operative phase, the trend was for sodium
levels to increase in patients with larger glands and
in whom there had been a large post-operative fall.
Conversely, the trend was for sodium levels to de-
crease post-operatively in patients with small
glands in whom there had been a small per-opera-
tive fall. Thus, when considering the overall change
in serum sodium, we could find no statistical corre-
lation with weight resected or with the volume of
glycine used.
BRITISH J O U R N A L OF U R O L O G Y
Comparison between the two subgroups A and
B, which were statistically matched and yet were
not chosen by a randomised controlled method,
seems to suggest that neither suction drainage dur-
ing resection nor post-operative irrigation affects
the serum sodium changes.
We believe a per-operative fall in serum sodium
of I5 mmol/l or more may lead to serious conse-
quences if untreated, although lesser falls in serum
sodium may occur in patients who exhibit the
clinical features of the TUR syndrome. Careful
diagnosis and treatment of the pulmonary compli-
cations is paramount and may possibly have pre-
vented the one death in our series. Further studies
are in progress.
Acknowledgements
We thank D r J. Surtees and the technical staff of the Chemical
Pathology Laboratory for their assistance, and also our anaes-
thetic colleagues.
References
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plications of transurethral resection of the prostate. British
Journal of Urology, 54, 564-565.
Charlton, A. J . (1980). Cardiac arrest during transurethral pros-
tatectomy after absorption of 1 Sohglycine. Anaesthesia, 35,
804-806.
Creevy, C . D. (1947). Haemolytic reactions during transurethral
prostatectomy. Journal of Urology, 58, 125-I3 I .
Logie, J. R., Keenan, R. A., Whiting, P. H. and Steyn, J. H.
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The Authofs
J. C. Rhymer, MB, BS, Senior House Officer.
T. J . Bell, FRCS, Registrar.
K . C. Perry, FRCS, Consultant Urologist.
J. P. Ward, MS, FRCS. Consultant Urologist
Requests for reprints to: J. P. Ward, Department of Urology,
District General Hospital, Eastbourne, East Sussex BN21 2UD.