Illusive Dynamic Nadirs and Masks of Postoperative Hyponatraemia and the TURP Syndrome: Volumetric Overload Over Time (VO/T) Concept for Resolving its Puzzle

Illusive Dynamic Nadirs and Masks of Postoperative Hyponatraemia and the TURP Syndrome: Volumetric Overload Over Time (VO/T) Concept for Resolving its Puzzle

Ahmed N. Ghanem1*, Khalid A Ghanem2, Salma A. Ghanem3, Nisha Pindoria4 and Yasmina Saad Elsayed5.
1.Mansoura University,No1 President Mubarak Street, Mansoura 35511, Egypt. 2Mansoura University Hospital, Mansoura 35511, Egypt. 3.Barts & The Royal London NHS Trust,Royal London Hospital,Whitechapel road Whitechapel,London,E1 1BB;4.North Middlesex University Hospital,Sterling Way,London ,N18 1QX; 5. Mansoura University Hospital, Mansoura 35511, Egypt

Global Journal of Urology and Nephrology

Introduction and Objective Postoperative hyponatraemia (HN) causes serious morbidity and mortality, of which the transurethral resection of the prostate (TURP) syndrome is a unique model. It is an illusive puzzle with unclear definition, unknown aetiology, difficult diagnosis and disputed therapy. Clinical presentation ranges from prodromal symptoms to severe signs of circulatory shock and multiple vital organ dysfunction/ failure (MVOD/F) or death. All severe cases were reported retrospectively and attributed to multiple toxic/ dilution hypotheses interchangeably with recognized clinical conditions. The overlooked VO/T causes dynamic HN nadirs and masks making it a complex clinical/biochemical jigsaw puzzle with false and missing pieces. The objective here is to resolve this puzzle.

Patients and Methods: Investigations based on clinical observations, critical literature analysis, physics-physiological and clinical prospective studies done over the past 32 years. Observations and deductive analysis identified VO/T insult, HN nadirs, clinical paradoxical masks of shock and MVOD/F. Documented evidence provided correct puzzle pieces and stepping-stones that led to new understanding, rejecting false and discovering missing ones. Prospective studies verified and quantified VO/T insult causing secondary, tertiary HN nadirs and osmotic gaps. Severity depends on VO over T and fluid type of sodium-free (VO1) and sodium-based (VO2) fluids and tonicity as well as patient’s variables of body weight and hormones. The results of all prospective studies on VO, HN nadirs, and clinical severity grades have contributed to resolving the puzzle that is impossible to resolve using a single prospective study.

Results: “VO over T” causes the biochemical and clinical features of HN and the TURP syndrome. Dilutional HN “shock” and “VO” concepts were reported 45 and 11 years ago but VO insult remained invisible. The puzzle was resolved after unraveling the dynamic role of T in HN nadirs, discovering missing pieces and refuting unduly incriminated dilutional and toxic hypotheses. 3.5l of VO1 (5% body weight) infused in 1h causes HN shock and MVOD/F syndrome. The immediate postoperative secondary HN nadir is proportional to VO1 and clinical severity but shock mask is confused with haemorrhage or sepsis. The late tertiary HN nadir is disproportional to both but osmotic fluid shift into cell “Missing VO” confuses VO1 cell oedema and necrosis with cerebral or cardiac infarction. Inappropriate therapeutic response with “aggressive vascular expansion” erases HN, makes shock irreversible and establishes MVOD/F.


The concept of “VO over T’ insult explains the aetiology of HN and the TURP syndrome and pathophysiology of HN nadirs unveiling its paradoxical presentation masks and refuting dilutional and toxic hypotheses. It exposes the biochemical, clinical and therapeutic illusions, resolving HN puzzle and paving the way to identify “VO shock”, “optimize” fluid therapy and precise life-saving hypertonic sodium therapy. The new capillary-interstitial hypothesis based on G tube dynamic makes resolving MVOD/F puzzle neither difficult nor distant.

Keywords: Hyponatraemia, The TURP syndrome, The multiple vital organ dysfunction/ failure syndrome, ARDS, Shock, Capillary-interstitial transfer, Haemodynamic, Fluid therapy, Volumetric overload, hypertonic sodium therapy.

Free Full-text PDF

How to cite this article:
Ahmed N. Ghanem, Khalid A Ghanem, Salma A. Ghanem, Nisha Pindoria and Yasmina Saad Elsayed. Illusive Dynamic Nadirs and Masks of Postoperative Hyponatraemia and the TURP Syndrome: Volumetric Overload Over Time (VO/T) Concept for Resolving its Puzzle Global Journal of Urology and Nephrology, 2019, 2:10

1. Rowntree LO. Water Intoxication. A.M.A . Arch. Int. Med. 1923; 32: 157.
2. Danowski TS, Winkler AW, Elkington JR. The treatment of shock due to salt depression; comparison of isotonic, of hypertonic saline and of isotonic glucose solutions. J. Clin. Invest. 1946; 25: 130.
3. Creevy CD. Haemolytic reactions during transurethral prostatic resection. J Uro. 1947; 58: 125.
4. Harrison III RH, Boren JS, Robinson JR. Dilutional hyponatraemic shock: another concept of the transurethral prostatic reaction. J Uro. 1956; 75 (1): 95-110.
5. Arieff AI. Hyponatraemia, convulsion, respiratory arrest and permanent brain damage after elective surgery in healthy women. N Engl J Med 1986; 314 (24): 1529-34.
6. Ghanem AN, Ward JP. Osmotic and metabolic sequelae of volumetric overload in relation to the TURP syndrome. Br J Uro 1990; 66: 71-78
7. Ghanem AN. Magnetic field-like fluid circulation of a porous orifice tube and its relevance to the capillary-interstitial fluid circulation: preliminary report. Medical Hypotheses 2001; 56(3): 325-334.
8. Arieff AI. Management of hyponatraemia. Br Med Jour 1993; 307: 305-8
9. Ayus JC, Arieff AI. Chronic Hyponatraemic Encephalopathy in Postmenopausal Women: Association of Therapies With Morbidity and Mortality. JAMA Middle East 1999; Volume IX No 10: 58-63. Reprint of (JAMA 1999; 281: 2299-2304)
10. Lane N, Allen K. Hyponatraemia after orthopaedic surgery. EDITORIAL. Br Med Jour 1999; 318: 1363-1364.
11. Arieff AI. Hyponatraemia and death or permanent brain damage in healthy children. Br Med Jour 1992; 304: 1218-22
12. Halberthal M, Halperin ML, Bohn D. Acute hyponatraemia in children admitted to hospital: retrospective analysis of factors contributing to its development and resolution. Br Med Jour 2001; 322: 780-782.
13. Hahn RG. Irrigating fluids in endoscopic surgery. Br J Uro; 1997: 79: 669-80
14. Gamble JL. Chemical Anatomy, Physiology and Pathology of Extra-cellular Fluid. Cambridge, Mass., Harvard University Press 1949.
15. Darrow DC, Pratt EL. Fluid Therapy. JAMA.1950; 143: 365, 143: 432.
16. Moyer CA. Fluid Balance. Chicago. Year Book Publishers. 1953.
17. Chassin JL. Postoperative electrolyte disturbances. Surg. Clin. N. Amer. 1954; 34: 323.
18. Spencer Hoyt H, Goebel J L, Lee HI, Schoenbrod J. Types of shock reaction during transurethral resection and relation to acute renal failure. J Uro 1958; 79: 500-7.
19. Logie JRC, Keenan RA, Whiting PH, Steyn JH. Fluid absorption during prostatectomy. Br J Uro 1980; 52: 526-8.
20. Bertrand J., Gambini A, Cazalaa JB, at al. Le syndrome de resection de la prostate (TURP) syndrome, mythe oy realite? Jour d’ Urologie 1981; 87: 1-4
21. Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet 1967; ii: 319-23.
22. Charlton AJ. Cardiac arrest during transurethral surgery after absorption of 1.5% glycine. Anaesth. 1980; 35: 804-7
23. Osborn DE, Rao PN, Greene MJ, Barnard RJ. Fluid absorption during transurethral surgery. Br Med Jour. 1980; 28: 1549-50.
24. Lessels AM, Honan RP, Haboubi NY, Ali HH and Greene MJ. Death during prostatectomy. J Clin Path 1982; 35: 117.
25. Jacobson J. Prolonged respiratory inadequacy following Transurethral Resection of the Prostate. Anaesth. 1965; 20: 329-33
26. Heytens L, Camu F. Pulmonary edema during caesarean section related to the use of oxytocin drugs. Acta Anaesthesiologica Belgica 1984; 35: 155-64.
27. Henderson DJ and Middleton RG. Coma from hyponatraemia of the transurethral resection of prostate. Urology 1980; XV (3): 267-271
28. Kirshenbaum MA. Sever mannitol induced hyponatraemia complicating transurethral prostatic resection J Uro 1979; 121: 686-8
29. Istre O, Bjoennes J, Naes R et al. Postoperative cerebral oedema after Transcervical Endometrial Resection and Uterine Irrigation with 1.5% Glycine. Lancet 1994; 344: 1187-9
30. Arieff AI. Ayus JC. Endometrial ablation complicated by fatal hyponatraemic encephalopathy. JAMA 1993; 270: 1230-2
31. Whitfield HN, Mills VA. Percutaneous nephrolithotomy. Br J Uro; 1985: 603-4
32. Kabalin JN. Laser surgery performed with right angle firing neodymium: YAG laser fibre at 40 watts power setting. J Uro 1993; 95-9
33. Dandonna P, Fonseca V and Baron. Hypoalbuminaemic hyponatraemia: a new syndrome? Br Med Jour 1985; 291: 1253-5.
34. Batuman V, Dreisbach A, Maesaka JK, Rothkopf M and Ross E. Renal and electrolyte effects of total parentral nutrition. Jour of Parentral and Entral Nutrition 1984; 8: 546-51.
35. Mayer CA. Acute temporary changes in renal function associated with major surgical procedures. Surgery. 1950; 24: 198.
36. Watters DAK, Chamroonkul MA, Eastwood MA, et al. Changes in liver function associated with parentral nutrition. J Roy Coll Surg Edin 1984; 29: 339-44
37. Thompson PD, Gledhill RF, Quin NP, Rossor MN, Stainly P, Coomes EN. Neurological complications associated with parentral treatment: central pontine myelinolysis and Wernicke’s encephalopathy. Br Med Jour. 1986; 292: 684-5
38. Bird D, Slade N, Feneley RCL. Intravascular complication of transurethral prostatectomy. Br J Uro 1982; 54: 564-5.
39. Friedman NJ, Hoag MS, Robinson AJ and Aggeler PM. Haemorrhagic syndromes following transurethral resection for benign adenoma. Arch Intern Med 1969; 124: 341-9.
40. Evans JWH, Singer M, Chapple CR. et al. Haemodynamic evidence for cardiac stress during transurethral surgery Br Med Jour 1992; 304: 666-71.
41. Nilsson A, Randmaa I, Hahn RG, Haemodynamic effects of irrigating fluids studied by Doppler ultrasonography in volunteers. Br J Urol 1996; 77: 541-6
42. Guyton AC. Textbook of Medical Physiology. 7th Ed.Philadelphia. An HBJ International Edition. WB Saunders Company.1986; Chapters: 36, 19, 21 and 26.
43. Wright HK and Gann DS. Severe postoperative hyponatraemia without symptoms of water intoxication. Surg Gyn & Obst. 1962; November: 553-6.
44. Berg G, Fedor EJ, Fisher B. Physiologic observations related to the transurethral resection reaction. J Uro 1962; 87: 4, 596-600.
45. Beirne GN, Madsen PO, Burns RO. Serum electrolyte and osmolality changes following transurethral resection of the prostate. Br Jour Uro 1965; 93: 83-86.
46. Desmond J. Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatraemia during transurethral resection. Can Jour Surg.1970; 13: 116-121.
47. Wakim KG. The pathophysiologic basis for the clinical manifestations and complications of transurethral prostatic resection. J Uro 1971; 106: 719-28.
48. Norris HT, Aashem GM, Sherrard DJ and Tremann JA. Symptomatology, pathophysiology and treatment of the transurethral resection of the prostate syndrome. Br J Uro 1973; 45: 420-7
49. Sellevold O, Brevic H, Tveter K. Changes in oncotic pressure, osmolality and electrolytes following transurethral resection of the prostate using glycine as irrigant. Scand J Uro Nephrol 1983; 17: 31-36.
50. Rhymer JC, Bell TJ, Perry KC, Ward JP. Hyponatraemia following transurethral resection of the prostate. Br J Uro 1985; 57: 450-2.
51. Inaba H, Hirasawa H, Mizuguchi T. Serum osmolality gap in postoperative patients in intensive care. Lancet 1987; i: 1331-5
52. 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
53. 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
54. 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.