There are many potential intraoperative complications that can occur during TURP. These include significant bleeding (at times requiring transfusion), perforation of the prostatic capsule, perforation of the bladder, injury to the rectum, and development of TUR syndrome resulting from overabsorption of hypotonic fluid and its resultant dilutional hyponatremia. The most significant improvement in TURP complications over the last 10 years has been in the number of intraoperative complications. In the 1990s, bleeding requiring transfusion was the most common intraoperative complication associated with TURP, affecting more than 2% of patients who underwent the operation. This was followed closely by TUR syndrome (2%) and myocardial arrythmia (just over 1%) (3). After the development of more sophisticated equipment, shorter operative time, and better irrigant solutions, transfusion requirements and TUR syndrome now affect less than 1% of patients (21). Interestingly, in the last 10 years, myocardial arrhythmia, occurring in just over 1% of patients, has been more prevalent (3). Timely and meticulous performance of TURP, with careful attention to detail, can help prevent many of these complications.
Excessive bleeding can occur for a variety of reasons. A frequent cause is failure to control early bleeding, particularly from arteries, which subsequently impairs visualization to the extent that identification of bleeding vessels becomes increasingly difficult. Perforation of the surgical capsule, especially early in the procedure, is another common culprit. Although generally venous and not arterial, this type of bleeding can be particularly difficult to control with cauterization because of the size of the vessels. When this occurs early, especially in large prostates, some surgeons advocate completing the resection on the side of the perforation and aborting the rest of the procedure. If necessary, TURP can be completed at a later date. Late perforation of the capsule generally allows completion of the procedure; however, this complication must be recognized, thereby prompting the surgeon to finish the procedure expeditiously. In all situations, aggressive attempts at hemostasis should occur before stopping the procedure and inserting the urethral catheter. Persistent bright red blood in the urethral catheter after irrigation suggests the presence of an uncontrolled artery, mandating removal of the catheter with repeat cystoscopic examination and fulguration. Weighted averages of the risk for blood transfusion associated with TURP approx 12%; however, recent reviews of the literature suggest that the rate has decreased to less than 1% (2,21).
Perforations of the surgical prostatic capsule and bladder are not uncommon during TURP. Perforation of the surgical capsule generally results in the unroofing of periprostatic venous channels, causing bleeding that can be difficult to control. Similar results (i.e., excessive bleeding) can also be obtained by perforating or undermining the bladder neck. In contrast to the periprostatic veins, this bleeding is often arterial and amenable to cauterization using the resectoscope loop. Perforation of the bladder is generally the result of poor visualization from excessive bleeding and bladder overdistention. When this problem is recognized, the procedure should be terminated as soon as possible. Because perforation is almost always extraperitoneal, management with urethral catheterization is sufficient. In the rare instance of intraperitoneal extravasation, open surgical repair is necessary. If a rectal injury occurs during TURP, initial treatment with prolonged urinary diversion by means of a urethral or suprapubic catheter is reasonable. On the other hand, if there is persistent drainage of feculent material into the urinary tract, fecal diversion with a colostomy is the treatment of choice.
As mentioned earlier, resection deep to the surgical capsule can uncover large prostatic venous sinuses. When this occurs, irrigation (continuous or not) can result in the absorption of large volumes of relatively hypo-osmolar fluid. When sterile water was used as the irrigant, hemolysis was a potential complication that could eventuate in hemoglobinuria and acute tubular necrosis. With the advent of more isotonic solutions, the incidence of hemolysis has been dramatically reduced. Nevertheless, unopposed large infusions of these substances can still produce life-threatening dilutional hyponatremia. The constellation of symptoms associated with these occurrences is the TUR syndrome, which occurs in less than 1% of patients undergoing TURP (21). Typical symptoms and signs include mental confusion, nausea, vomiting, hypertension, bradycardia, and other arrhythmias. The neurologic symptoms are thought to be the result of cerebral edema caused by a relative hypoproteinemia. The latter decreases serum osmolality, predisposing the patient to a fluid shift into the brain. Patients typically do not become symptomatic until the serum sodium is less than 125 meq/mL. Mebust et al. also found that the risk of this complication increased with prostate size, particularly if >45 g (3). In addition, duration of surgery also correlated with development of TUR syndrome, especially when this exceeded 90 min. Another suggested cause of this syndrome is ammonia toxicity because glycine is metabolized into glycolic acid and ammonia. Although this is plausible, that the syndrome occurs even when other irrigation fluids are used would support the more accepted cause of hyponatremia.
Most patients with normal renal function are able to withstand large increases in intravascular volume by diuresis. This ability is reduced in patients with renal insufficiency (even mild) and in those with myocardial dysfunction. When excessive fluid absorption occurs, even patients with normal renal function are unable to increase diuresis enough to prevent dilutional hyponatremia. When recognized during TURP, TUR syndrome should prompt a rapid conclusion of the procedure, even if additional tissue needs to be resected. This, of course, must be preceded by establishment of an acceptable level of hemostasis. Initial treatment with intravenous diuretics (i.e., furosemide) is reasonable; however, if there is not a rapid amelioration of the symptoms of hyponatremia, 3% hypertonic saline should be administered slowly over 3-6 hr.
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