British Journal of Urology (1997), 79, 669–680
R E V IE W
Irrigating fluids in endoscopic surgery
R .G. HAH N
Department of Anaesthesia, South Hospital, Stockholm, Sweden
Introduction
Endoscopic operations in the genitourinary tract require
the use of an irrigating fluid to gently dilate mucosal
spaces and to remove blood and cut tissue from the
operating field. There are several di
erent irrigating
fluids available commercially and it might be dicult to
know which one to use. The choice tends to be governed
largely by tradition, although the price and properties of
the fluid (e.g. stickiness and transparency) also play a
role. The pharmacological e
ects of the fluid become
important whenever it is absorbed by the patient.
However, adverse reactions to irrigating fluids have not
been documented as they have for drugs.
Most irrigating fluids were developed when the docu-
mentation of safety was much less important than it is
today. Pharmacologists and regulatory authorities also
pay little attention to these solutions because they are
conceived as devices (like soap and detergents) rather
than drugs. Nevertheless, numerous reports of sympto-
matic and even fatal fluid absorption during TURP and
transcervical resection of the endometrium (TCRE, an
operation for alleviating menorrhagia) emphasize the
importance of using an irrigating fluid with a favourable
profile of adverse e
ects [1–6].
For many years, little comparative data were available
showing whether one irrigating fluid is more prone to
adverse e
ects than others. However, during the past
decade several studies covering this topic have been
reported. The purpose of this article is to summarize
those reports and also to review the progress that has
been made in understanding the adverse e
ects during
this period of time.
History
Sterile water was used as the irrigating fluid during the
early years of TURP. However, obscure reactions with
post-operative haemoglobinuria sometimes occurred and
severe cases even led to death. Enrichment of the blood
with salicylate [7] and glucose [8] when added to the
Accepted for publication 21 January 1997
© 1997 British Journal of Urology
sterile water made urologists realize, in 1947, that the
absorption of the irrigating fluid into the circulation
through severed prostatic veins must be the cause of the
haemolysis. As electrolytes do not allow cutting by
electrocautery, one or several non-electrolyte solutes
capable of preventing haemolysis were then added to
the irrigating fluid.
Glycine was the first suggested as suitable; this amino
acid is an endogenous substance, transparent in an iso-
osmotic (2.2%) solution and reasonably cheap [9]. The
other irrigating fluids used today, mannitol and mixtures
of sorbitol and mannitol, were introduced somewhat
later [10,11]. The only further development in the
composition of irrigating fluids since the early 1950s is
the addition of ethanol up to a concentration of 1%,
which allows fluid absorption to be monitored by expired-
breath ethanol tests [12].
Despite their non-haemolytic properties, absorption of
the new irrigating fluids continued to be associated with
adverse events which were often summarized as ‘trans-
urethral resection reactions’ (TUR syndrome). The clini-
cal descriptions of this syndrome from the mid-1950s
are still the cornerstones of our view of the risks associ-
ated with the use of irrigating fluids [13–15].
Incidence of fluid absorption
The uptake of small amounts of irrigating fluid occurs
during almost every TURP [16] and TCRE [17,18]. The
absorbed volume varies greatly and cannot be predicted
in the individual patient, although it tends to be larger
in extended and bloody operations (Fig. 1) [19]. The
uptake of 1 L of fluid, which corresponds to an acute
decrease in the serum sodium concentration of
5–8 mmol/L [12], is the volume above which the risk of
absorption-related symptoms is statistically increased [6].
Large series of patients show that the absorption of
>1 L occurs in 5% [20], 8% [19] and 10% [21] of the
TURPs performed. Even higher values have been noted
in some smaller case series, to judge from the reported
changes in serum sodium [22,23].
Absorption during TCRE is usually larger than during
TURP [18,24], which is probably due to spontaneous
669
670 R.G. HAH N

Operating time leakage through the fallopian tubes [25]. Large-scale

≤ 60 min absorption also seems to be more common during
(n = 518)
TCRE [26].

Risk estimates for symptoms

The estimates for the incidence of TUR syndrome range
between 0% [27], 1% [28], 2% [29], 7% [1] and 10%
[14,30,31]. However, the TUR syndrome is poorly
defined and many mild cases have probably been misin-
terpreted and wrongly attributed to old age, anaesthesia
and excessive blood loss. The symptoms arising might
also be di
erent depending on the choice of irrigating
fluid. Therefore, it is more useful to establish separately
the incidence of absorption and the risk of symptoms
arising for di
erent ranges of absorption of a particular
irrigating fluid. Such data for glycine 1.5% plus ethanol
1% have recently become available.
In a retrospective review, Olsson et al. [6] found a
mean of 1.3 symptoms from the circulatory and nervous
system in each TURP during which very little or no
glycine was absorbed (0–300 mL). This value increased
to 2.3 when 1–2 L of fluid was taken up, while a mean
of 5.8 symptoms occurred when >3 L was absorbed
Operating time
> 60 min [6]. The dose-dependent increase in the number of
(n = 182) symptoms arising was corroborated in a subsequent
prospective study [21]. These studies were the first to
show statistically that the risk of having symptoms
increases progressively as more glycine solution is
absorbed; most symptoms develop 30–60 min after the
completion of surgery.

Fig. 1. Fluid absorption during TURP depending on whether the
operating time exceeds 1 h. The absorption is larger in extended
operations (Mann–Whitney test P<0.001) but it may still occur
during shorter procedures. The case series is presented in detail in
[19]. Dark green, 0–150 mL. Light green, 151–500 mL. Light red,
501–1000 mL. Dark red, 1001–2000 mL. Black, >2000 mL.
Glycine 2.2%
A combination of animal experiments and clinical studies
should form the basis of any assessment of the compara-
tive risks associated with the use of an irrigating fluid.
A review of such studies suggests, for example, that a
2.2% solution of glycine, which is marketed in some
European countries, should not be used in the clinic.
Six of seven volunteers who received 1 L of glycine
2.2% by intravenous infusion over 20 min developed
symptoms of visual disturbances and nausea, which
were severe in one [32]. However, when the same
subjects received glycine 1.5% plus ethanol, they
reported only mild skin-prickling sensations, and manni-
tol solutions (5% and 3% plus ethanol) induced no
symptoms at all. Clinical studies also show a high
likelihood of symptoms developing as soon as >1 L of
glycine 2.2% is absorbed [33]. In the mouse, infusions
given by the intravenous [34] and intraperitoneal [35]
routes show that glycine 2.2% is associated with a
poorer chance of survival than the same volume of
glycine 1.5%. The increase in glycine content from 1.5%

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 I RRI GATI NG F L UI DS IN E N DOS CO PIC S UR GE RY 671

to 2.2% was originally designed to reduce the dangers glycine infusions, a finding recently corroborated in mice
associated with fluid absorption. Inasmuch as no such [48] (Fig. 2). Furthermore, degenerative changes have
benefit can be found, glycine 2.2% should be abandoned. been described in the liver and kidneys of rats [49],
albeit not in rabbits [37].
Also in patients, glycine 1.5% has been associated
Glycine 1.1%
with subacute e
ects on the myocardium. Nine of 11
This irrigant was common in the early days of TURP patients undergoing TURP and absorbing 1 L of glycine
[9,14,15]. A reduction of the glycine content from 1.5% solution showed depression or inversion of the T-wave
to 1.1% is associated with a poorer outcome in mice on the electrocardiogram 24 h after surgery [50]. In an
[34]. In the rabbit, cellular oedema was worse with epidemiological study, absorption exceeding 500 mL
glycine 1.0% plus ethanol than with other irrigating doubled the long-term risk of acute myocardial infarction
fluids [36], particularly in the liver and in the kidney [51]. The latter finding is interesting in view of the
[37]. In human subjects, no advantage of glycine 1.0% higher long-term mortality after transurethral versus
over glycine 1.5% was found experimentally [38] or open prostatectomy, which has prompted debate among
clinically [21]. It may be concluded that lowering the urologists for some years.
glycine content from 1.5% to 1.1% o
ers no benefit but These reports, implying a high acute mortality and
reduces the safety limit for haemolysis, which normally subacute myocardial damage from glycine 1.5%, are
occurs slightly below 1.0%. Therefore, glycine 1.1% and worrying. There is an urgent need for further studies on
1.0% should not be used. this topic, as the use of this irrigating fluid is very
widespread.
Sterile water
Despite the adverse experiences with sterile water in the
1940s, it is still used for TURP in some clinics in Europe
and the USA and quite frequently in developing countries
[39]. This irrigating fluid provides excellent vision during
endoscopy as the erythrocytes entering the operating
field haemolyse immediately. A retrospective review of
thousands of patients undergoing TURP shows that the
operative mortality was reduced when the non-
haemolysing solutions were introduced [40] and such a
protective e
ect is supported by results from animal
experiments [41]. When sterile water is used, hypertonic
mannitol must be given intravenously during the resec- a
tion to prevent symptoms arising [42,43]. Therefore,
sterile water should be reserved for diagnostic pro-
cedures. Those who use it alone during TURP expect no
absorption to occur, which can never be guaranteed.

Glycine 1.5%
Importantly, the most widely used irrigating fluid,
glycine 1.5%, seems to be associated with more serious
consequences than solutions containing alternative sol-
utes. The acute mortality is higher in mice [44] and
rabbits [36] given an intravenous infusion of glycine
1.5%, compared to that with mannitol and sorbitol b
solutions. Furthermore, glycine reduces the vitality and
survival of isolated cardiomyocytes [45], which is likely Fig. 2. Myocardial lesions 10 days after an intravenous infusion of
glycine 1.5% in a mouse. Dilated interstitium with proliferated
to increase the long-term risk of heart disease [46,47].
endothelial cells and fibroblasts in the vicinity of an area of
In rabbit hearts, myocardial ischaemic damage could be disrupted myofibres. Arrows point at areas of disruption (upper).
detected by special staining techniques after infusions of Foci of necrosis with mono- and polymorphonuclear leucocytic
glycine, but not after infusions of mannitol or sorbitol reaction (lower). The photographs were provided by Professor
[37]. Subendocardial necrosis also occurred after some Jovan Rajs, Karolinska Institute.

© 1997 British Journal of Urology 79, 669–680

672 R.G. HAH N
Central haemodynamics
TURP seems to depress myocardial function, particularly
when the operative duration exceeds 1 h [52]. Evans
et al. found that stroke volume and the cardiac index
were reduced but that these changes were prevented by
using irrigating fluid at body temperature [53]. In con-
trast, Lawson et al. reported that the induction of anaes-
thesia is an important cause of haemodynamic
alterations, while little happens during the surgical
procedure [54].
About 0.5% of patients develop acute myocardial
infarction during TURP [55]. However, transient myo-
cardial ischaemia has been detected during 20% of
TURPs [56] with no di
erence between spinal and
general anaesthesia [57]. It is regrettable that fluid
absorption was not considered as a possible cause of
these ischaemic events.
Intravenous infusion studies in animals yield conflict-
ing results regarding the central haemodynamic e
ect
of glycine [58,59]. In humans, the infusion of 1.2 L of
glycine reduced cardiac output and transiently increased
arterial pressure [38]. Although the haemodynamic
changes were fairly small, glycine exerted an e
ect on
the circulation not shared by alternative solutions.
However, 30 min later, mannitol and sorbitol-mannitol
were also associated with a low stroke volume and high
peripheral resistance, possibly due to the cooling of the
volunteers. Another infusion study supports the view
that glycine elevates blood pressure [32], which is also
induced by sterile water [41–43].
Dilutional hypocalcaemia has been implicated as a
source of acute cardiovascular disturbances when
glycine is absorbed [60,61]. The serum sodium and free-
calcium levels decrease to the same degree during intra-
venous infusion of irrigating fluid in volunteers [62] and
in pigs [63]. Calcium is restored more rapidly, probably
due to mobilization of calcium from bone tissue.
Arterial hypotension
The classical haemodynamic signs of the TUR syndrome
when glycine solution is used consist of a transient
arterial hypertension, that may be absent if the bleeding
is profuse, followed by more prolonged hypotension
[14,64]. The risk of post-operative hypotension is actu-
ally already increased when moderate amounts of glycine
solution are absorbed; there was a fivefold increase
in risk when 1–2 L was absorbed compared with
0–300 mL [6].
The mechanism for this hypotension is unclear. My
research group has recently performed a series of in vitro
experiments using macrophage J774.1 to study the e
ect
of glycine on the nitric-oxide system, obtaining no
evidence that local vasodilatation was the cause. Prostatic
tissue substances are released into the circulation during
fluid absorption [50,65], which might cause hypotension
[66]. Endotoxins may also be dispersed, sometimes in
association with fluid absorption [67]. A metabolic aci-
dosis might contribute to the reduction of cardiac output,
although the acidosis is usually fully compensated as long
as long as a TUR syndrome is not apparent [68].
Singer et al. measured a very low cardiac output in
one patient with the TUR syndrome which suggests that
cardiodepression or hypovolaemia is responsible for the
hypotension [69]. The onset of hypotension usually
occurs when fluid absorption has just stopped, when
blood volume is low [64]. Although irrigating fluid
absorption does increase the blood volume, the hypervo-
laemia is brief and probably changes very easily into
hypovolaemia. Other clinical [70] and experimental
[32,41,71] studies support the view that hypovolaemia
is the likely result of fluid absorption. A temporary
increase in bleeding during absorption probably
contributes to this phenomenon [64].
The results reported above relate to glycine solution,
but arterial hypotension is also a problem after absorp-
tion of sorbitol 3% [72] and of mannitol 3% and 5%
[72,73] despite the latter expanding blood volume more
than glycine 1.5% [32,38,74]. This problem is perhaps
less pronounced with sorbitol-mannitol solutions, with
which blood pressure can be normal despite a fatal
outcome [75].
Cerebral e
ects
Most patients who show a transient deterioration of
mental status after TURP have absorbed irrigating fluid
[5]. Nausea, vomiting and confusion occur between six
and nine times more often when 1–2 L of glycine
solution is absorbed than when no absorption is detected
[6]. Consciousness might be lowered when even more
glycine is absorbed [76], which has been associated with
hyperammonaemia [16].
The amount of glycine appears to make an indepen-
dent contribution to cerebral e
ects in volunteers [32]
and to mortality in mice [34]. However, the hyponatrae-
mia induced by all irrigating fluids eventually gives rise
to neurological symptoms caused by cerebral oedema.
Istre et al. detected cerebral oedema by CT that correlated
with nausea after the absorption of as little as 1 L of
glycine 1.5% in females undergoing TCRE [26]. In sheep,
the concentration of sodium and glycine changed much
less in the cerebrospinal fluid than in serum, while the
alterations of the osmolality were similar [58]. The
sodium level in the brain is also e
ectively maintained
during the absorption of sorbitol [72].
Serum osmolality usually remains normal or falls by
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 I RRI GATI NG F L UI DS IN E N DOS CO PIC S UR GE RY 673

a maximum of about 10 mosmol/kg when fluid is
absorbed. However, the change in osmolality correctly
indicates tissue oedema only when mannitol is absorbed.
As glycine and sorbitol enter the cells, these solutes will
be accompanied by water through osmosis, even when
serum osmolality is normal. When these irrigating fluids
are used, tissue oedema will therefore be greater than
indicated by the serum osmolality (Fig. 3). Thus, the
concept ‘isotonic hyponatraemia’ is not useful when
these irrigants are studied. It is particularly irrelevant
when ethanol is used to indicate fluid absorption, as this
agent increases the osmolality without redistributing
water.
The metabolic e
ects of glycine have received much
attention as a possible cause of cerebral e
ects. A corre-
lation between symptoms and the increase in the serum
level of glutamate has been reported [32,33] but, more
importantly, also between symptoms and hyperam-
monaemia after infusion of glycine 2.2% [32] and during
TURP [77]. More than 1.5 L of glycine 1.5% seems to
be required for any marked increase in the blood
ammonia level to occur [32,78,79]. Whatever the
reason, the ammonia level does not increase even when
much larger amounts of glycine 1.5% plus ethanol 1%
are absorbed [80].
Hyperammonaemia implies that the body cannot fully
metabolize the nitrogen component of glycine; the
carbon skeleton seems to be metabolized more easily.
Most of it is degraded to carbon dioxide and water by
the glycine-cleavage system [81], although some glycine
enters the citric-acid cycle and causes a moderate elev-
ation of the blood levels of the non-essential amino acids
[33,82]. Glycine is also metabolised to glycolic acid and
glyoxylic acid, which can be detected in plasma and
cerebrospinal fluid [83], but this metabolic pathway
seems to be of minor importance [81]. As glyoxylate is
a precursor of oxalate, there has been concern as to
whether glycine promotes the formation of oxalate renal
stones. However, the excretion of oxalate does not corre-
late with glycine absorption during TURP [84,85] and
does not increase after experimental infusion of glycine
[86].
Sorbitol is metabolized to fructose, with a half-life of
35 min, which may present a problem in a patient with
hypersensitivity to fructose [87]. Mannitol is eliminated
by renal excretion with a half-life of 120 min and is not
associated with metabolic problems. The elimination
becomes prolonged in patients with impaired renal
function.
Restlessness and epileptic seizures are signs of massive
absorption. They are probably caused by hyponatraemia
as these symptoms have been associated with the use of
both glycine [14] sorbitol 3% [72], sorbitol-mannitol
[75] and sterile water [42].

Glycine 1.0% plus Glycine 1.5% plus Mannitol 3% plus Sorbitol 2% plus
ethanol 1% ethanol 1% ethanol 1% mannitol 1%

Fig. 3. Distribution of irrigating fluid water 30 min (upper row) and 90 min (lower row) after a rapid intravenous infusion of 15 mL/kg
of irrigating fluids in 10 healthy male volunteers (mean values). Serum osmolality was essentially unchanged, the mean for the fluids
varying between 296 and 301 mosmol/kg, but the glycine still had a more pronounced intracellular distribution than the other fluids
(ANOVA P<0.01). The case series was presented in [38] and the calculations are explained in [101] and [103]. Dark green, Blood. Light
green, Urine. Light red, Interstitial. Dark red, Intracellular.

© 1997 British Journal of Urology 79, 669–680

674 R.G. HAH N
Visual disturbances
Blurring of vision was first reported to be a complication
of glycine absorption in 1956 [14]. The condition might
proceed to transient blindness and is sometimes the only
sign of fluid absorption [88] while it can also be part of
a severe TUR syndrome [89]. Funduscopic findings
[88,90] and intra-ocular pressure [22] remain normal,
while the pupillary reflexes may be present or absent.
Wong et al. have studied this phenomenon by measur-
ing visually evoked potentials in the dog [59] and during
TURP [91]. They found a prolongation of the time
required for impulses to travel through the visual path-
ways when glycine levels were 5–10 mmol/L, which
corresponds to the administration of 1–2 L of glycine
1.5% in an adult male [82]. Later studies of TURP
[92,93] and in the laboratory [79] show that disturb-
ances of the visual pathways may occur when much
less glycine is absorbed. After 10 volunteers received five
incremental doses of 200 mL of glycine 2.2%, visual
disturbances with changes in visually evoked potentials
occurred in five, sometimes after as little as one dose
[79]; the EEG was unchanged.
Marked visual disturbances have not been associated
with irrigating fluids other than glycine nor with water
intoxication. Therefore, a toxic e
ect of glycine on the
retina, where it acts as an inhibitory neurotransmitter,
is the likely cause. Glycine levels in the vitreous fluid
increase in parallel with those of the cerebrospinal fluid
during glycine overload, and amounts to 3–5% of those
found in plasma [94]. As with skeletal muscle [95], the
glycine concentration in the vitreous fluid remains
unchanged for several hours.
Water excretion
The excretion of urine is rapidly increased by all irrigat-
ing fluids, albeit more promptly when mannitol is given
300
250
Urinary excretion (mmol)
200
150
100
50
0
Glycine 1.0% Glycine 1.5% Mannitol 3%
+ ethanol 1% + ethanol 1% + ethanol 1%
Infusion
[38]. When 1 L of glycine 1.5% is infused, the amount
of glycine in the primary urine far exceeds the capacity
for reabsorption, which also results in osmotic diuresis
[58,82]. About 10% of a glycine load [82] and sorbitol
load [96] is eliminated in this way (Fig. 4). Osmotic
diuresis is indisputable with mannitol, as the urine is
the main route of elimination [73,96].
Two hours after an infusion of 1 L of irrigating fluid,
nearly all the fluid volume has been excreted regardless
of whether glycine, sorbitol or mannitol has been infused
[32,38,78] (Fig. 3). The situation is not the same when
larger amounts are administered. In the rabbit, the
excretion of glycine solution then becomes much less
than for sorbitol and mannitol [36]. In the sheep, 46%
of the water load was excreted 3.5 h after a glycine load,
while the corresponding value after infusions of isotonic
saline was 70% [58]. These di
erences are due to a
greater intracellular accumulation of glycine solution
[95], which results in a dose-dependent half-life [97],
and also because glycine stimulates secretion of ADH
from the neurohypophysis. This hormone aggravates the
hyponatraemia and maintains the fluid overload.
Elevated plasma levels of ADH occur when the glycine
dose exceeds 20 g in sheep [58] and in patients under-
going TURP [89,98,99].
Sodium losses
The hyponatraemia associated with the TUR syndrome
is often interpreted as the result of dilution alone.
Therefore, authors have suggested that spontaneous
[41,75] or stimulated [29,100] diuresis should be the
chief therapy. Recent studies have altered this view;
there is a loss of sodium during the osmotic diuresis
associated with irrigating fluids. Large amounts of
glycine also stimulate the release of atrial natriuretic
peptide in excess of that expected by the volume load,
which further promotes natriuresis [101].
Sodium
Potassium
Calcium
Urea
Creatinine
Amino acids
Mannitol
Sorbitol
Osmotic gap
Fig. 4. Composition of urine 90 min after
an intravenous infusion of 15 mL/kg of
irrigating fluids in 10 healthy male
volunteers (mean values). The osmotic gap
Sorbitol 2% represents negatively charged ions, which
+ mannitol 1%
were not measured. The case series is
presented in [38].
© 1997 British Journal of Urology 79, 669–680

The urinary excretion of sodium represents an absolute
loss as the irrigant contains no electrolytes. The loss
increases linearly with the volume of fluid absorbed, and
amounts to 100 mmol when 4 L of fluid has been taken
up (Fig. 5). This fluid absorption results in an acute
decrease of 30 mmol/L in the serum sodium level [12],
but the subsequent losses of sodium are sucient to
reduce it by 10 mmol/L. Hence, the natriuresis makes
spontaneous restoration of the serum sodium level
more dicult.
Operations in which there is blood loss along with
fluid absorption will also incur the entrapment of sodium
ions. Electrolytes from the interstitial fluid enter the
blood when irrigating fluid is being absorbed, while
water travels in the opposite direction [64]. Therefore,
some of the electrolytes lost from bleeding vessels and
by the excretion of urine are derived from the interstitial
fluid. The magnitude of this entrapment increases with
blood loss, but it usually does not exceed 10–15 mmol
during an operation [102].
Progressive cellular oedema
The role of the kidney and the di
erences in distribution
between lost and added solutes are important in under-
standing why irrigating fluids cause cellular and brain
oedema even when serum osmolality is marginally
changed. It is dicult for the kidneys to maintain a high
level of water excretion without losing large amounts of
osmotically active solutes [58,103]. The osmotic diuresis
100
r = 0.94
P < 0.005
80
Sodium excretion (mmol)
60
40
20
0 Fig. 6. Schematic drawing illustrating how glycine solution causes
0 1 2 3
Infused glycine solution (L)
Fig. 5. The urinary excretion of sodium during and after intra-
venous infusion of glycine solution in sheep and humans. Each
point denotes the mean value from one study with a correction for
a baseline excretion of 0.06 mmol/min. From [102], with
permission.
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I RRI GATI NG F L UI DS IN E N DOS CO PIC S UR GE RY 675
induced by all irrigating fluids is associated with loss of
extracellular ions, such as sodium, while the solutes
used in the irrigants (except mannitol) di
use intracellul-
arly and are also metabolized. Therefore, a situation
develops with a persistent slightly reduced serum osmol-
ality and a gradually increasing cellular oedema (Fig. 6).
Calculations of the fluid distribution in volunteers indi-
cate that glycine hydrates the cells more than other
irrigants (Fig. 3). Similar results have been found by
light microscopy of vital organs in animals overhydrated
with irrigating fluids [37]. There is no evidence of self-
correction of the hypo-osmolality and cellular oedema
during the first hours after overhydration corresponding
to 3 L in an adult male [58,101,103].
Retroperitoneal absorption
Irrigating fluid may be deposited in a pool in the retroperi-
toneal space if there is an instrumental perforation of the
prostatic capsule. These events occur in 1% of the patients
undergoing TURP [2,29] and may be fatal [15,75,
104,105]. The fluid probably exerts pressure on the caval
vein and di
uses, in part, through the peritoneal mem-
brane [2,106]; metabolic acidosis may be severe [105].
The pathophysiological events involved in ‘extrava-
sation’ were first studied in animals by Mahoney et al.
[107] while later studies were conducted in humans
Fluid absorption
glycine
Na Na
Na
Na
Urine
4
cellular oedema despite adequate urine flow. The glycine in the
absorbed fluid distributes outside and inside the cells while the
induced osmotic diuresis carries along sodium that is present
outside the cells only. Losses of intracellular ions are relatively
small. Glycine is primarily metabolized to water and to carbon
dioxide, which is removed by breathing. All these factors promote
intracellular distribution of the irrigant water.
676 R.G. HAH N
[108,109]. They show that electrolytes from the extra-
cellular fluid enter the pool of fluid. A reduction of the
plasma volume ensues as the solutes travelling in the
other direction, e.g. glycine or sorbitol, are metabolized
or accumulate intracellularly. Mild to moderate hypona-
traemia and hypo-osmolality develop with a delay,
the lowest value usually being recorded 2–4 h after the
operation [2,108]. Uptake of the irrigant water by the
blood occurs fairly slowly.
The number of symptoms for di
erent ranges of
absorption is the same as for absorption directly into the
vascular system, but the tendency to cause abdominal
pain, bradycardia and arterial hypotension is greater [6].
There is also a high risk of failure to diurese spon-
taneously, which is associated with the hypotension
[6,15,107]. Severe TUR syndromes have been reported
following extravasation with both glycine [2], sorbitol
[110] and sorbitol-mannitol [75].
This special form of the TUR syndrome can also occur
if the bladder is perforated. Then, irrigating fluid accumu-
lates directly in the peritoneal cavity during TURP [110]
or during transurethral resection of bladder tumours
[111].
Prevention of fluid absorption
The incidence and volume of fluid absorption can be
reduced, but no method is capable of eliminating it
completely. Stopping the resection after 1 h of surgery is
helpful, as the risk of fluid absorption is somewhat higher
in prolonged operations (Table 1). The degree of fluid
absorption is also a matter of surgical skill; consultants
usually cause less absorption than residents [20],
although this is not supported by all studies [112].
Several methods are aimed at reducing the pressure
in the operating field, from which fluid absorption occurs
at a pressure of about 2 kPa [113,114]. The height of
the irrigating fluid bag above the operating table did not
correlate with fluid absorption in 550 patients under-
going TURP [115]. Ekengren et al. found that the
maximum but not the mean pressure or the period of
excessive pressure (>2 kPa), increased when the fluid
bags were placed higher [114]. Furthermore, the
capacity of the bladder was a statistically more important
factor than the bag height in determining the intraves-
ical pressure.
Continuous-flow methods have been claimed to
decrease fluid absorption [116,117], although some
authors have found no such reduction [113,118] and
TUR syndrome still occurred [28]. Perhaps the key to
success is to check that a low pressure is actually
obtained, as outflow obstruction occurs readily.
Monitoring the intravesical pressure allows a more
consistent reduction of fluid absorption [119,120]
although TUR syndromes are still not completely
prevented [121].
Temperature
Feeling cold is a frequent complaint from patients under-
going TURP. A drop in body temperature alters the
haemodynamic situation [53] and may result in shiver-
ing [122,123], which markedly increases oxygen con-
sumption. The ability to compensate for heat loss by
increasing heat production is impaired in elderly men.
The time required to regain normal temperature after
the operation increases with the age of the patient [122].
Bladder irrigation is an important source of heat loss;
the use of irrigating fluids at room temperature results
in a decrease in body temperature of 1–2°C [123–125].
This decrease is smaller with an irrigant heated to 37°C
(‘prewarmed’) than with a fluid used at ambient tempera-
ture, but it still averages 1°C during TURP [123,124],
regardless of whether general or spinal anaesthesia is
used [122,124]. A continuously warmed irrigating
medium is needed to limit the drop in body temperature
to below 1°C [125,126].
The decrease in temperature is greater during TURP
than during transurethral resection of bladder tumours
when the irrigating fluid is prewarmed [126]. This
di
erence may be explained by fluid absorption, which
operates as a specific cooling mechanism [127]. This
contributes to the chilling and shivering which some-
times occur even when prewarmed fluid has been
absorbed [6].
Treatment
The treatment of mild adverse e
ects of irrigating fluids
consist of supportive measures only. Nasal oxygen and
an anti-emetic if nausea occurs are usually sucient.
Absorption of >2 L of fluid should be monitored for
4–6 h in the post-operative follow-up because sudden
cardiovascular disturbances may pose a problem [6].
Patients who have absorbed >3 L should be treated
overnight in the intensive care unit. There is a threat to
life and a knowledge of adequate management is there-
fore essential.
Visual disturbances need no treatment as they resolve
spontaneously within 8 h. Hypertension may develop at
the end of surgery but needs no treatment. It should
subside quickly and be reversed to hypotension, which is
more troublesome. This shock-like hypotension should be
treated without delay with judicious infusion of a colloid
combined with adrenergic drugs. Metabolic acidosis
should be compensated by the intravenous infusion of a
bu
er. Depressed consciousness is managed with mainten-
ance of a free airway and positive-pressure ventilation.
© 1997 British Journal of Urology 79, 669–680
 I RRI GATI NG F L UI DS IN E N DOS CO PIC S UR GE RY
Intravenous calcium may be used to treat acute
cardiac disturbances during surgery [60–62,69]. The
administration of hypertonic saline is indicated when
many adverse e
ects develop or the serum sodium
concentration drops below 120 mmol/L. It consists of
the intravenous infusion of 3–5% saline solution, usually
in a volume of 300–500 mL over 4 h. Both experimental
[100,128] and clinical [31,76,129] studies support the
usefulness of this treatment. There is no evidence that
hypertonic saline can result in pontine myelinolysis
when given to treat acute hyponatraemia in humans
where supplementation is started promptly and the
serum sodium concentration is increased by ≤2 mmol/L
per hour [129].
Two-thirds of the hypertonic saline restores serum
sodium and osmolality, while one third redistributes
water from the cells to the extracellular space [103],
where it becomes available to diuretic treatment with
frusemide. The latter drug is widely used in the treatment
of fluid absorption, but such use is questionable in the
absence of hypertonic saline as frusemide acts by increas-
ing sodium excretion. The e
ect may even be poor in
the hyponatraemic patient. Mannitol 15% is a better
choice, as this solution operates independently from the
serum sodium level and also increases the extracellular
osmolality [42,43,128,130]. In the absence of pulmon-
ary oedema, diuretic therapy should not be instituted
until the cardiovascular situation is stable; it is usually
sucient to start this 30–60 min after the operation.
Extravasation should be treated with the same meas-
ures applied when the irrigating fluid passes directly into
the circulation. Morbidity and mortality can also be
reduced by surgical drainage of the retroperitoneal fluid
[104], but this treatment seems to be necessary only
after massive absorption [2]. Such drainage removes
extracellular electrolytes that have moved into the fluid
pool. The magnitude of these losses is dependent on
the lapse of time between surgery and the drainage
procedure [109].
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Author
Robert G. Hahn, MD, PhD, Associate Professor of Anaesthesia
at the Karolinska Institute, Stockholm Söder Hospital, S-118
83 Stockholm, Sweden.
© 1997 British Journal of Urology 79, 669–680