Makindo Medical Notes

Related Subjects: | Sodium Physiology | Hyponatraemia | TURP Hyponatraemia Syndrome | Hypernatraemia | Diabetes Insipidus | Benign Prostatic Hyperplasia | Prostate Cancer

💧 Transurethral Resection (TUR) Syndrome is an iatrogenic form of water intoxication. It occurs when large volumes of hypotonic irrigation fluid (e.g., glycine, sorbitol, mannitol) are absorbed during TURP. The resulting fluid overload + hyponatraemia → cerebral oedema, neurological dysfunction, and cardiorespiratory compromise. ⚠️

⚠️ TURP Hyponatraemia Syndrome (Na+ rise ≤ 8–12 mmol/L per 24h)

💦 Fluid overload → dilutional hyponatraemia + pulmonary oedema. 🧠 Rapid correction risks central pontine myelinolysis → correct sodium slowly. ⛔ Stop irrigation immediately; restrict fluids. 🩺 ABC + resuscitate. Severe symptoms when Na+ < 110 mmol/L. 💊 IV Furosemide 40–80 mg stat to promote diuresis. 🧪 Consider 3% hypertonic saline if Na+ < 120 mmol/L (50–100 ml over 2–3 hrs with close monitoring). 🚑 Seek urgent senior/ICU support; check Na+ every few hours. 💉 Seizures → IV Lorazepam 2–4 mg.

ℹ️ About

• ❗ A cause of acute hyponatraemia in surgical patients.
• Occurs when irrigation fluid absorption > 2000 ml.
• ⚡ Medical emergency – can progress rapidly intra- or post-operatively.

🧬 Aetiology

• TURP procedure: Prostatic tissue resected using monopolar diathermy.
• Irrigation solution: Maintains visibility and clears clots/tissue.
• Absorption of hypotonic fluid: Glycine (200 mOsm/L), sorbitol, mannitol → dilutional hyponatraemia.
• ⚡ Normal saline is avoided with monopolar diathermy (electrical conduction risk). Bipolar systems allow saline irrigation ✅.
• 💀 Distilled water (historical) → haemolysis, hyperkalaemia, acute renal failure.

🛡️ Prevention

• Use isotonic or near-isotonic irrigants if equipment allows (e.g. bipolar TURP with saline).
• ⏱️ Limit TURP duration to reduce absorption risk.
• 📊 Monitor fluid balance + electrolytes intra/post-op.
• 👨‍⚕️ Train surgical/anaesthesia teams to detect early warning signs.

🩺 Clinical Features

• 🌟 Early: prickling/burning face/neck, lethargy, apprehension.
• 🧠 Neurological: restlessness, headache → confusion → seizures → coma.
• ❤️ Bradycardia, hypotension, arrhythmias.
• 🌬️ Dyspnoea from pulmonary oedema.
• ⏳ Onset: during surgery or immediate post-op.

🔍 Investigations

• 🧪 Serum Na⁺: low (<120 mmol/L in severe cases).
• ⬇️ Plasma osmolality (dilutional).
• 📈 ECG: bradycardia, arrhythmias.
• 📊 Fluid balance chart: excess absorption noted.

🛠️ Management

• Immediate Actions: Stop irrigation + surgery; ABC; oxygen; restrict fluids.
• Correct Na⁺ slowly: Hypertonic saline (3%) if symptomatic/severe; rise ≤ 8–12 mmol/L per 24h.
• 💊 Diuretics: IV furosemide for fluid overload.
• ⚡ Seizure control: IV Lorazepam 2–4 mg.
• Monitoring: Na⁺ every 2–4 hrs, vitals, neuro obs.
• ICU: For severe/symptomatic cases. Involve nephrology/critical care.

📚 Review

• Stanford Urology: TUR Syndrome – Almost Gone but Not Forgotten

💡 Exam Pearl: TURP syndrome = dilutional hyponatraemia + fluid overload from hypotonic irrigation. Key distinction: raise sodium slowly to avoid osmotic demyelination. ⚠️

Cases

TURP hyponatraemia (“TURP syndrome”) case: A 72-year-old man undergoing monopolar TURP (glycine irrigation) develops restlessness → confusion, headache, visual blurring and then hypertension, bradycardia with rising airway pressures at 55 minutes; post-op bloods show Na⁺ 112 mmol/L, low serum osmolality, and mild haemolysis. Management is stop the procedure and irrigation, call senior help, ABC with oxygen, switch to isotonic fluids, insert catheter and assess fluid balance; if symptomatic/severe, give 3% hypertonic saline 100 mL over 10 min (repeat to arrest neurological symptoms), consider IV furosemide if fluid overloaded, treat seizures with benzodiazepines, and limit Na⁺ correction to ≤8–10 mmol/L in 24 h (frequent VBGs). Contributing factors include prolonged resection time, high irrigation pressure, venous sinus absorption and glycine metabolism (↑ammonia). Prevention: prefer bipolar TURP with normal saline, keep resection <60 min, use low-pressure closed irrigation, monitor input/output, and intra-op electrolytes when prolonged or unstable.