Review Article of Global Journal of Urology and Nephrology
The transurethral resection of the Prostate (TURP) syndrome and acute dilutional hyponatraemia (HN): A comprehensive literature review from first incidence in 1947 to disappearance in 2018
Ahmed N. Ghanem 1, Salma A. Ghanem2, Khalid A. Ghanem3 and Nisha Pindoria 4
No1 President Mubarak Street, Mansoura 35511, Egypt.
Introduction and objective: To report on the literature review on the TURP syndrome from its first report in 1947 to disappearance from urology in 2018
Material and methods: The literature on the TURP syndrome from 1947 to 2018 was reviewed. We summarise the evidence on its incidence, prevalence, patho-aetiology, clinical picture and management. With the introduction of normal saline as irrigating fluid for the TURP procedure, the TURP syndrome as characterised with hyponatraemia (HN) has been eradicated. We introduce the concept of volumetric overload shocks (VOS) to be prepared when another syndrome induced by saline overload strikes.
Results: The TURP syndrome is induced by massive absorption of the sodium-free irrigating fluid and is characterized with acute dilutional HN- hence it is eradicated with use of saline as irrigant. It presents with shock and multiple vital organ dysfunction and was easily mistaken for one of the recognised shocks calling for further volume expansion with isotonic solutions with disastrous consequences. Identifying the concept of VOS does not only help in the management of the TURP syndrome but also with recognizing the syndrome induced by saline overload. Hypertonic sodium therapy has proved effective in treatment.
Conclusion: The review demonstrates that VOS in clinical practice is of two types; Type 1 (VOS1) induced by sodium-free fluid and type 2 (VOS2) induced by sodium-based fluids- the later has no serum marker of HN. Both conditions present with multi-system organ dysfunction but one system may predominate. VOS2 presents as the adult respiratory distress syndrome.
Keywords: Hyponatraemia; shock; the transurethral prostatectomy syndrome (TURS); the adult respiratory distress syndrome (ARDS), Starling’s law, Capillary hydrodynamics
How to cite this article:
Ahmed N. Ghanem, Salma A. Ghanem, Khalid A. Ghanem and Nisha Pindoria. The transurethral resection of the Prostate (TURP) syndrome and acute dilutional hyponatraemia (HN): A comprehensive literature review from first incidence in 1947 to disappearance in 2018. Global Journal of Urology and Nephrology, 2018, 1:7. DOI:10.28933/gjun-2018-12-0308
1. Allen PR, Hughes RG, Goldie DJ and Kennedy RH. (1981) Absorption during TUR. Br Med Jour: 232-240.
2. Anderson RJ, Chung HM,Kluge R, Scherier RW. (1985) Hyponatraemia: a prospective analysis of its epidemiology and the pathogenic role of vasopressin. Ann Intern Med: 102: 164-8.
3. Appel PI, Shoemaker WC. (1981) Evaluation of fluid therapy in adult respiratory disease. Critical Care Medicine 1981: 9 862-9.
4. Arief AI, Llach F and Massry SG. (1976) Neurological manifestation and morbidity of hyponatraemia: correlation with brain water and electrolytes. Medicine: 55: 121-9.
5. Arief AI. (1986) Hyponatraemia , convulsion, respiratory arrest and permanent brain damage after elective surgery in healthy women. N Eng Jour Med: 314: 1529-35.
6. Arieff AI. Ayus JC. (1993) Endometrial ablation complicated by fatal hyponatraemic encephalopathy. JAMA; 270: 1230-2
7. Arieff AI. (1992) Hyponatraemia and death or permanent brain damage in healthy children. Br Med Jour; 304: 1218-22
8. Arieff AI. (1993) Management of hyponatraemia. Br Med Jour; 307: 305-8
9. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. (1967) Acute respiratory distress in adults. Lancet; ii: 319-23.
10. Ayus JC, Arieff AI. (1999) Chronic Hyponatraemic Encephalopathy in Postmenopausal Women: Association of Therapies With Morbidity and Mortality. JAMA Middle East; Volume IX No 10: 58-63. Reprint of (JAMA 1999; 281: 2299-2304)
11. Ayus JC, Arieff AI. (1997) Postoperative hyponatremia. Ann Intern Med. Jun 15; 126(12): 1005-6.
12. Ayos JC, Krothapalli RK and Arief AI. (1987) Treatment of symptomatic hyponatraemia and its relation to brain damage. N Eng Jour Med: 317; 1190-5.
13. Batuman V, Dreisbach A, Maesaka JK, Rothkopf M and Ross E. (1984) Renal and electrolyte effects of total parentral nutrition. Jour of Parentral and Entral Nutrition; 8: 546-51.
14. Bear RA and Neal GN. (1983) A clinical Approach to common electrolyte problems: 1. Hyponatraemia. Can Med Assoc J: 128: 1171-4.
15. Beirne GN, Madsen PO, Burns RO. (1965) Serum electrolyte and osmolality changes following transurethral resection of the prostate. Br Jour Uro; 93: 83-86.
16. Berg G, Fedor EJ, Fisher B. (1962) Physiologic observations related to the transurethral resection reaction. J Urol; 87: 4, 596-600.
17. Bertrand J., Gambini A, Cazalaa JB, at al. (1981) Le syndrome de resection de la prostate (TURP) syndrome, mythe oy realite? Jour d’ Urologie; 87: 1-4
18. Bird D, Slade N, Feneley RCL. (1982) Intravascular complication of transurethral prostatectomy. Br J Uro; 54: 564-5.
19. Cicarelli FE and Mantell LK. (1961) Studies on fluid and electrolyte alteration during transurethral prostatectomy. J Urol; 85: 75-82.
20. Charlton AJ. (1980) Cardiac arrest during transurethral surgery after absorption of 1.5% glycine. Anaesth.; 35: 804-7
21. Chilton CP, Morgan RJ, England HR, Paris AMI and Blandy JP. (1978) A critical evaluation of the results of transurethral resection of the prostate. Br J Urol: 50; 542-6.
22. Chung CP, Kluge R, Scherier RW and Anderson RJ. (1986) Postoperative hyponatraemia. A prospective study. Arch Intern Med: 146; 333-6.
23. Colapinto V, Armstrong DJ and Finlayson DC. (1973) Red cell mass and plasma volume changes during TURP. The Canadian Journal of Surgery: 16; 143-151.
24. Creevy CD. (1947) A fatal haemolytic reaction during transurethral prostatic resection. Surgery: 21; 56-66
25. Creevy CD. (1947) Haemolytic reactions during transurethral prostatic resection. J Urol; 58: 125.
26. Creevy CD. (1951) The mortality of transurethral resection of the prostate. J Urol: 65; 876-83.
27. Dandonna P, Fonseca V and Baron. (1985) Hypoalbuminaemic hyponatraemia: a new syndrome? Br Med Jour; 291: 1253-5.
28. Danowski TS, Winkler AW, Elkington JR. (1946) The treatment of shock due to salt depression; comparison of isotonic, of hypertonic saline and of isotonic glucose solutions. J. Clin. Invest.; 25: 130.
29. Desmond J. (1970) Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatraemia during transurethral resection. Can Jour Surg.; 13: 116-121.
30. Editorial. (1969) Dissiminated intravascular coagulation. JAMA: 210; 338-9.
31. Editorial. (1980) Second best prostatectomy. Br Med Jour : 280; 90
32. Emmett JL, Gilbough JH and McLean. (1969) Fluid absorption during transurethral resection: Comparison of mortality and morbidity after irrigation with water and non-haemolytic solutions. J Urol: 101; 884-9.
33. Evans JWH, Singer M, Chapple CR. et al. (1992) Haemodynamic evidence for cardiac stress during transurethral surgery Br Med Jour; 304: 666-71.
34. Friedman NJ, Hoag MS, Robinson AJ and Aggeler PM. (1969) Haemorrhagic syndromes following transurethral resection for benign adenoma. Arch Intern Med; 124: 341-9.
35. Gale D, Nottley RG. (1985) TURP without TURP syndrome. Br J Uro; 57: 708-10
36. Gamble JL. (1949) Chemical Anatomy, Physiology and Pathology of Extra-cellular Fluid. Cambridge, Mass., Harvard University Press.
37. Ghanem AN, Ward JP. (1988) Fluid absorption during urological surgery. Br J Uro.; 61: 168-9.
38. Ghanem AN, Ward JP. (1990) Osmotic and metabolic sequelae of volumetric overload in relation to the TURP syndrome. Br J Uro; 66: 71-78
39. Ghanem AN, Wojtlewski JA, Penney MD. (1987) Dangers in treating hyponatraemia. Br Med Jour;; 294: 837.
40. Ghanem AN. (1985) Hypoalbuminaemic hyponatraemia: a new syndrome. Br Med. Jour.; 29:1502
41. Ghanem AN. (1988) Hyponatraemia and hypo-osmolality. Lancet; ii: 572
42. Ghanem, A.N. and Ghanem, S.A. (2016) Volumetric Overload Shocks: Why Is Starling’s Law for Capillary Interstitial Fluid Transfer Wrong? The Hydrodynamics of a Porous Orifice Tube as Alternative. Surgical Science; 7: 245-249. http://dx.doi.org/10.4236/ss.2016.76035
43. Ghanem AN. (2001) Magnetic field-like fluid circulation of a porous orifice tube and its relevance to the capillary-interstitial fluid circulation: preliminary report. Medical Hypotheses; 56(3): 325-334.
44. Ghanem AN. (2000) Monitoring the critically ill patient. J R Coll Surg Edinb; 45 (2): 138-9.
45. Ghanem AN. (1987) Serum osmolality gap. Lancet; ii: 223-4
46. Ghanem AN. Wojtulewski JA, Penney MD. (1987) Dangers in treating hyponatraemia. Br Med J.; 294: 837.
47. Ghanem KA and Ghanem AN. (2017) The proof and reasons that Starling’s law for the capillary-interstitial fluid transfer is wrong, advancing the hydrodynamics of a porous orifice (G) tube as the real mechanism. Blood, Heart and Circ, Volume 1(1): 1-7. doi: 10.15761/BHC.1000102 Available online.
48. Ghanem SA, Ghanem KA, Ghanem A N. (2017) Volumetric Overload Shocks in the Patho-Etiology of the Transurethral Resection of the Prostate (TURP) Syndrome and Acute Dilution Hyponatraemia: The Clinical Evidence Based on Prospective Clinical Study of 100 Consecutive TURP Patients. Surg Med Open Access J.: 1(1);1-7
49. Ghanem KA and Ghanem AN. (2017) Volumetric overload shocks in the patho-etiology of the transurethral resection prostatectomy syndrome and acute dilution hyponatraemia: The clinical evidence based on 23 case series. Basic Research Journal of Medicine and Clinical Sciences ISSN 2315-6864 Vol. 6(4): pp. 35-43 April
50. Ghanem KG, Ghanem AN. (2017) The Physiological Proof that Starling’s Law for the Capillary-Interstitial Fluid Transfer is Wrong: Advancing the Porous Orifice (G) Tube Phenomenon as Replacement. Open Acc Res Anatomy. 1(2). OARA.000508. 2017.
51. Goodwin WE, Cason JF and Scott WW. (1951) Haemoglobinaemia and lower nephron nephrosis following transurethral prostatic surgery. J Urol: 65;1075-91.
52. Griffin M, Dobson L and Weaver JC. (1955) Volume of irrigating fluid transfer during transurethral prostatectomy, studies with radioisotopes. J Urol: 74; 646-51.
53. Guyton AC and Coleman TG. (1968) Regulation of interstitial fluid volume and pressure. Annals of Newyork Academy of Science: 150; 537-47.
54. Hagstrom RS. (1955) Studies on fluid absorption during transurethral prostatic resection. J Urol: 73; 852-9.
55. Hahn GH, Zhang W, Rajs J. (1996) Pathology of the heart after overhydration with glycine solution in the mouse. APMIS; 104: 915-20.
56. Hahn RG, Berlin T, Lewnhaupt A. (1987) Factors influencing the osmolality and the concentration of blood haemoglobin and electrolytes during transurethral resection of the prostate. Acta Anaesthiol Scan: 31: 601-7
57. Hahn RG, Nennesmo I, Rajs J, et al. (1996) Morphological and X-ray Micro-analytical Changes in Mammalian Tissue after Overhydration with Irrigating Fluids. Eur Uro; 29: 355-61
58. Hahn RG, Nilsson H, Carlstrom H, Hjelmqvist H, Zhang W, Rundergreen M. (1996) Renal function during intravenous infusion of urological irrigating fluids in the sheep. Acta Anaesthiol Scand; 40: 671-683
59. Hahn RG, Sahdfeldt L, Nymen. (1998) Double blind randomized study of symptoms associated with absorption of glycine 1.5% or mannitol 3% during transurethral resection of the prostate. J Urol; 160: 397-401.
60. Hahn RG, Stalberg HP, Carlstrom H, Hjelmqvist H, Ulman J, Rundergreen M. (1994) Plasma Atrial Natriuretic Peptide concentration and Renin Activity during Overhydration with 1.5% Glycine Solution in Conscious Sheep. The Prostate; 24: 55-61
61. Hahn RG. Ekergreen JC. (1993) Pattern of irrigating fluid absorption during transurethral resection of the prostate as indicated by ethanol. J Urol; 149: 502-6
62. Hahn RG. (1990) Fluid and electrolyte dynamics during development of the TURP syndrome. Br J Uro. Jul; 66(1):79-84.
63. Hahn RG. (1997) Irrigating fluids in endoscopic surgery. Br J Uro;: 79: 669-80
64. Hahn RG. (1996) Total fluid balance during transurethral resection of the prostate. Int Uro Nephrol.; 28 (5): 665-71
65. Halberthal M, Halperin Ml, and Bohn D. (2001) ‘Lesson of the week’: Acute hyponatraemia in children admitted to hospital: retrospective analysis of factors contributing to its development and resolution. Br Med Jour: 322; 780-782
66. Harrison III RH, Boren JS, Robinson JR. (1956) Dilutional hyponatraemic shock: another concept of the transurethral prostatic reaction. J Urol.: 75 (1); 95-110.
67. Henderson DJ and Middleton RG. (1980) Coma from hyponatraemia of the transurethral resection of prostate. Urology; XV (3): 267-271
68. Heytens L, Camu F. (1984) Pulmonary edema during caesarean section related to the use of oxytocin drugs. Acta Anaesthesiologica Belgica; 35: 155-64.
69. Hoekstra Pt, Kahnoski R, McCamish MA, Bergen W, Heetderks DR. (1983) Transurethral prostatic resection syndrome- a new perspective: Encephalopathy with associated hyperammonaemia. J Uro; 130: 704-7 [see also Editor’s comments].
70. Istre O, Bjoennes J, Naes R et al. (1994) Postoperative cerebral oedema after Transcervical Endometrial Resection and Uterine Irrigation with 1.5% Glycine. Lancet; 344: 1187-9.
71. Iverson Hansen R Iverson H and Chrstiansen B. (1978) Intravesical pressure during transurethral resection using Iglesias resectoscope with continous irrigation and suction. Scand J Urol Nephrol:12; 223-5.
72. Jacobson J. (1965) Prolonged respiratory inadequacy following Transurethral Resection of the Prostate. Anaesth.; 20: 329-33
73. Karnovesky M. J. (1967) The ultra structural basis of capillary permeability studied with peroxidase as a tracer. J Cell Biol; 35: 213–236.
74. Kay MC, Kay J, Begun F, Yeung JE. (1985) Vision loss following transurethral resection of the prostate. J Clin Neuroophthalmol. Dec;5(4):273-6.
75. Kirshenbaum MA. (1979) Sever mannitol induced hyponatraemia complicating transurethral prostatic resection J Uro; 121: 686-8
76. Lessels AM, Honan RP, Haboubi NY, Ali HH and Greene MJ. (1982) Death during prostatectomy. J Clin Path; 35: 117.
77. Logie JRC, Keenan RA, Whiting PH, Steyn JH. (1980) Fluid absorption during prostatectomy. Br J Uro; 52: 526-8.
78. Madsen PO and Naber KG. (1973) The importance of pressure in the prostatic fossa and absorption of irrigating fluid during transurethral resection of the prostate. J Urol: 109; 44652.
79. Maluf NSR, Boren JS and Brandes GE. (1956) Absorption of irrigating solution and associated changes upon transurethral resection of the prostate. J Urol: 75; 824-36.
80. Marmar JL and Allen SD. (1970) The transurethral reaction secondry ti intraperitoneal extravasation of the irrigating solution. J Urol: 104; 457-8.
81. Marx GF and Orkin LR. (1962) Complications associated with transurethral surgery. Anesthiology: 23; 802-12.
82. McLaughlin WL, Holyoke JB Bowler JP. (1947) Oliguria during transurethral resection of the prostate. J Urol: 58; 47-60.
83. Melton JE and Nattie EE. (1983) Brain and CSF water and ions during dilutional and iso-osmotic hyponatraemia in the rat. The American Physiological Society; 724-732.
84. Mitchell JP. Transurethral resection. Br Med Jour 1970: 3; 241-6.
85. Moffat , Hamilton DN and Ledingham IMcA. (1985) A history of surgical shock. Journal of the Royal College of Surgeons of Edinburgh: 30:73-9.
86. Mommsen S, Genster HG and Moller J. (1977) Changes in the serum concentration of sodium, potassium and free haemoglobin during TURP- Parts of the TUR syndrome? Urological Research: 5; 201-5.
87. Narins RG. (1986) Therapy of hyponatraemia. N Engl J Med: 314, 1573-4.
88. Nesbit RM and Glickman SI. (1948) The use of glycine as an irrigating medium during transurethral resection. J Urol: 59; 1212-7.
89. Norris HT, Aashem GM, Sherrard DJ and Tremann JA. (1973) Symptomatology, pathophysiology and treatment of the transurethral resection of the prostate syndrome. Br J Uro; 45: 420-7.
90. O’Donnel DE. (1983) Serum acid phosphatase elevation with transurethral resection syndrome. Br J Uro: XXII, 4; 388-390.
91. Oester A and Madsen PO. (1969) Determination of absorption of irrigasting fluid during transurethral resection of the prostate by means of radioisotopes. J Urol: 102; 714-9.
92. Osborn DE, Rao PN, Greene MJ, Barnard RJ. (1980) Fluid absorption during transurethral surgery. Br Med Jour.; 28: 1549-50.
93. Pichlmayr R and Kock MLS. (1979) Acute post surgical syndrome. Clinics in Gastroentrology: 2; 249-71
94. Pindoria N, Ghanem SA, Ghanem KA and Ghanem AN, (2017) Volumetric overload shocks in the patho-etiology of the transurethral resection prostatectomy syndrome and acute dilution hyponatraemia. Integr Mol Med, doi: 10.15761/IMM.1000279 Available online
95. Rao PN. (1987) Fluid absorption during urological surgery. Br J Uro.; 60: 93-9.
96. Reddick LF and Walton KN. Physiologic Changes during transurethral resection of the prostate. Anaesthesis and Analgesia 1967:46, 5; 618-23.
97. Renkin E. M. (1986) Some consequences of capillary permeability to macromolecules: Starling’s hypothesis reconsidered. Am J Physiol (Heart Circ Physiol); 250, 19: H706–H710.
98. Rhodin J. A. (1967) The ultra structure of mammalian arterioles and precapillary sphincters. J Ultrastructure Research; 18: 181–222.
99. Rhymer JC, Bell TJ, Perry KC, Ward JP. (1985) Hyponatraemia following transurethral resection of the prostate. Br J Uro; 57: 450-2.
100. Roesch R P, Stoelting R K, Lingman J E, et al. (19830 hyper ammonaemia toxicity resulting from glycine absorption during TURP. Anesthesiology 1983; 58: 577-9.
101. Rowntree LO. (1923) Water Intoxication. A.M.A . Arch. Int. Med.; 32: 157.
102. Ryder K, Olsen J, Richard O, kanoski RJ,Karen RCand Oie TO. (1984) Hyperammonaemia after transurethral resection of the prostate: A report of two cases. J Urol: 132; 995-7.
103. Sadaba1 LM , Garcia-Layana1 AI , Maldonado1 MJ and Berian2 JM . (2006) Bilateral ischemic optic neuropathy after transurethral prostatic resection: a case report. BMC Ophthalmology, 6:32 doi:10.1186/1471-2415-6-32
104. Sellevold O, Brevic H, Tveter K. (1983) Changes in oncotic pressure, osmolality and electrolytes following transurethral resection of the prostate using glycine as irrigant. Scand J Uro Nephrol; 17: 31-36.
105. Shepard RI, Crous SE, Babyan RK aand Siroky MB. (1986) The role of ammonia toxicity in the post transurethral prostatectomy syndrome. Br J Urol: 60; 149-51.
106. Spencer Hoyt H, Goebel J L, Lee HI, Schoenbrod J. (1958) Types of shock reaction during transurethral resection and relation to acute renal failure. J Uro; 79: 500-7.
107. Starling EH. Factors involved in the causation of dropsy. (1886) Lancet: ii; 1266-70, 1330-34, 1406-10.
108. Sterns RH, Riggs JE and Schochet SS. (1986) Osmotic demyelination syndrome following correction of hyponatraemia. N Eng J Med: 314; 1535-42.
109. Still JA and Modell JH. (1973) Acute water intoxication during TURP using glycine solution for irrigation. Anaesthiology: 39; 567.
110. Strom S. (1984) Cardiac enzymes after transurethral resection of the prostate. Scand J Urol Nephrol: 18; 289-92.
111. Swales JD. (1987) Dangers in treating hyponatraemia. Br Med Jour: 294; 261-2.
112. Taylor RO, Maxson ES, Carter FDH, Bethard WF and Prentiss RJ. (1958) Volumetric, gravimetric and radioisotopic determination of fluid transfer in transurethral prostatectomy. J Urol: 79; 490-9.
113. Thomas D and Hales P. (1984) Overhydration during transurethral resection of the prostate using glycine as an irrigating solution. Anaesth Inten Care: 12;366-9.
114. Tranbaugh RF and Lewis FR. (1982) Respiratory insufficiency. Symposium on trauma. Surgical clinic of North America: 62;, 1; 121-32.
115. Wakim KG. (1971) The pathophysiologic basis for the clinical manifestations and complications of transurethral prostatic resection. J Urol; 106: 719-28.
116. Watters DAK, Chamroonkul MA, Eastwood MA, et al. (1984) Changes in liver function associated with parentral nutrition. J Roy Coll Surg Edin; 29: 339-44
117. Whitfield HN, Mills VA. Percutaneous nephrolithotomy. Br J Uro; 1985: 603-4
118. Worthley LIG Thomas PD. (1986) The treatment of hyponatraemic seizure with intravenous 29.2% Saline. Br Med Jour: 292; 168-70.
119. Wright HK and Gann DS. (1962) Severe postoperative hyponatraemia without symptoms of water intoxication. Surg Gyn & Obst.; November: 553-6.
120. Zhang W. Hahn RG. (1996) ّDouble toxicityْ of glycine solution in the mouse. Br J Uro; 77: 203-6
121. Zhang W. Hahn RG. (1995) Water and solute excretion after intravenous infusion of new irrigating fluids in the rabbit. Scand J Uro Nephrol; 29: 241-7