TURP Syndrome
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Direct answer
TURP syndrome is the absorption of large volumes of hypotonic irrigation fluid (classically 1.5 per cent glycine) through open prostatic venous sinuses during transurethral resection, producing dilutional hyponatraemia, volume expansion and glycine toxicity. Early features are hypertension with reflex bradycardia, nausea and restlessness; later come confusion, visual disturbance or transient blindness, seizures, pulmonary oedema and coma. Treatment is to stop the resection, check serum sodium, restrict fluids, give oxygen and diuretics, and use 3 per cent hypertonic saline for symptomatic hyponatraemia or sodium below about 120 mmol/L — carefully, to avoid osmotic demyelination.
What you must remember
- Onset may be intraoperative (under spinal or general anaesthesia, where the only signs may be hypertension, bradycardia, nausea or restlessness) or delayed in recovery.
- Absorption rates of 10-50 mL of irrigant per minute are possible through the prostatic venous plexus; 1 litre of absorbed glycine drops serum sodium substantially.
- Glycine itself is toxic: an inhibitory neurotransmitter analogue causing visual blurring and transient blindness, and its metabolism to ammonia can cause encephalopathy.
- Characteristic cardiovascular sequence: hypertension and bradycardia first (volume expansion, hyponatraemia), then hypotension and arrhythmia as myocardial depression and severe hypo-osmolality set in.
- Prevention: limit resection time (traditionally under about 60 minutes), keep irrigation pressure low, limit resection in large glands, prefer bipolar resection with saline irrigation, and monitor intraoperatively.
- Bipolar TURP, HoLEP and laser vaporisation use normal saline and virtually abolish TURP syndrome — the modern preventive answer.
- Other TURP complications for the exam: retrograde ejaculation (the commonest, in roughly two-thirds to three-quarters), urethral stricture or bladder neck contracture (a few per cent), transfusion-requiring bleeding, clot retention, and urinary incontinence in under 1-2 per cent.
An intraoperative deterioration, walked through
A 70-year-old under spinal anaesthesia is 50 minutes into a TURP for a 60 g prostate when the anaesthetist notes blood pressure rising from 130/80 to 170/100 with a pulse fallen from 80 to 52; the patient complains of nausea and blurred vision and becomes restless. The disciplined sequence: stop the resection and achieve haemostasis; assume TURP syndrome; send urgent serum sodium, osmolality and ammonia if available; complete the procedure rapidly or abandon and stage it; in recovery, monitor hourly urine output and neurology.
If sodium returns at 116 mmol/L with confusion, treatment is 3 per cent hypertonic saline (commonly 100 mL boluses with repeat sodium measurement) to lift sodium by a limited initial amount and abolish seizures, alongside fluid restriction, oxygen and, if volume overloaded, furosemide. Overly rapid correction risks central pontine myelinolysis, so correction targets are conservative (a rise of no more than about 8-10 mmol/L in 24 hours in chronic settings; symptomatic seizures justify faster initial correction per current guidance). The visual disturbance needs no specific treatment — it resolves as glycine clears over hours, and that expected resolution is a favourite viva detail. Post-operative confusion in a TURP patient is TURP syndrome until sodium is proven normal.
Where students slip
The trap is treating the early hypertensive bradycardic patient for "light anaesthesia" or pain and pushing on with the resection; volume expansion with hyponatraemia is the physiology, and the correct reflex is to stop, look at the clock and check sodium. Second, candidates reach for normal saline as the resuscitation fluid — normal saline adds water retention problems and does not treat symptomatic hyponatraemia; the answer is hypertonic saline with controlled correction. Third, forgetting that the syndrome also follows transurethral resection of bladder tumours and hysteroscopic surgery with glycine distension broadens the differential when the stem is not a prostate.
Frequently asked questions
What is the mechanism of TURP syndrome?
Absorption of hypotonic glycine irrigation through open venous sinuses, causing dilutional hyponatraemia, hypo-osmolality, volume expansion and direct glycine toxicity.
Why does visual disturbance occur in TURP syndrome?
Glycine is an inhibitory neurotransmitter analogue toxic to the retina; transient blurred vision or blindness occurs and resolves as glycine is cleared, typically within hours.
How is symptomatic TURP syndrome treated?
Stop surgery, restrict free fluids, give oxygen and diurese if overloaded, and administer 3 per cent hypertonic saline for seizures or sodium under about 120 mmol/L, with monitored, limited correction.
How does bipolar TURP prevent TURP syndrome?
Bipolar systems allow isotonic saline irrigation, so systemic absorption does not produce the hyponatraemia seen with hypotonic glycine or sterile water.
What is the commonest long-term complication of TURP?
Retrograde ejaculation, occurring in roughly 65-75 per cent of sexually active men, due to destruction of the bladder neck; it is usually part of the consent conversation.