Anesthesia and Medical Practice Journal (ISSN: 2637-9953)

Article / research article

"Association of Irrigation Fluid Used and Serum Electrolyte Changes in Trans Ureteral Resection of Prostate (Turp) at Dr. Hedgewar Rugnalaya, Aurangabad"

Kulkarni SG*

Anaesthesia Department, Dr. Hedgewar Hospital, Aurangabad, Maharashtra, India

*Corresponding author: Supriya Gajanan Kulkarni, Anaesthesia Department, Dr. Hedgewar Hospital, Aurangabad-431005, Maharashtra, India

Received Date: 11 September, 2020; Accepted Date: 16 September, 2020; Published Date: 24 September, 2021

Abstract

Introduction: Trans Urethral Resection of the Prostate as a gold standard treatment for benign prostatic hyperplasia is performed with fluid irrigation that may cause electrolyte disturbance due to excessive fluid absorption; and may lead to electrolyte imbalance crises. It can cause hemolysis and changes in hematocrit value. Here in this study we primarily focused on electrolytic disturbances only. Different types of irrigation fluid are used for Trans urethral resection of prostate (TURP) procedure worldwide. In our institute we used sterile water as an irrigation fluid. The advantage of using sterile water are – Easily available, Cheap, electrically inert, nontoxic, transparent, easy to sterile and disadvantage is it is hypotonic. Ideal irrigation fluid should be isotonic, non-hemolytic, electrically inert, nontoxic, transparent, easy to sterile and should be inexpensive.

Materials and Methods: A descriptive retrospective study was conducted at Dr. Hedgewar Hospital, Aurangabad between January to December 2017. The subjects were BPH patients who underwent TURP surgery at Dr. Hegdewar Rugnalaya. Data were retrieved from medical records. We used sterile water as an irrigation fluid in TURP procedures. We had performed pre and postoperative electrolyte level, weight of prostate, amount of irrigation fluid used.

Results: 76 subjects, the mean age was 70.77 years and the mean weight of the prostate was 47.56 grams. No significant change in levels of Sodium, Potassium and chloride noted post operatively (mean changes in electrolytes are Na+-0.51, K+-0.05, CL-- 1.03 respectively).

Conclusion: Serum electrolyte levels were not significantly changes after surgery.

Keywords

BPH; Electrolyte Disturbance; TURP; Irrigation Fluid; ASA grade.

Introduction

Trans Urethral Resection of the Prostate (TURP) is performed by cutting or resecting the prostate tissue with electrocautery through urethra and use a cystoscope to visualize the prostate area [1]. Irrigation fluid is needed to distend the operative area and maintain the visibility [2]. Electrolyte disturbances such as hypervolemic hyponatremia and hyperkalemia, because of cell lysis often occurred during the TURP procedure [1,3,4]. These disturbances should be fully corrected because it leads to increased morbidity & mortality rate. Pre & post-surgery electrolyte monitoring should be done.

Different types of irrigation fluid are used for TURP procedure worldwide e.g. 1.5% glycine, 5% Dextrose, 0.9 % normal saline & sterile water. There are some advantages and disadvantages of each irrigation fluid. 1.5% Glycine is more cardio toxic, more expensive, and chances of TURP syndrome are high with Gycine [5]. 5% dextrose causes hyperglycemia & stickness of the surgeons gloves & instruments. Monopolar cautery cannot be used along with 5% Dextrose & NS 0.9%, as it causes dispertion of high frequency current from resectocope [6].

In our institute we used sterile water as an irrigation fluid. The advantage of using sterile water are - Easily available, Cheap, electrically inert, nontoxic, transparent, easy to sterile and disadvantage is it is hypotonic. Ideal irrigation fluid should be isotonic, non-hemolytic, electrically inert, nontoxic, transparent, easy to sterile and should be inexpensive.

Objective

This study is to determine the incidence of changes in electrolyte level in TURP procedure.

Material & methods: This study was conducted at Hedgewar Hospital, Aurangabad, Maharashtra India. The subjects were benign prostatic hyperplasia (BPH) patients of ASA grade I & II who underwent TURP surgery in the period from January 2017 to December 2017. We had collected data of 76 patients. Data were retrieved from medical records, including 1) Name and Age 2) Weight of prostate 3) Serum Electrolyte level pre & post-surgery 4) Time of resection (in minutes), 5) Amount of irrigation fluid used in (liters) 6) Amount of irrigation fluid drained out (liters) 7) Difference in irrigation fluid used and drained out in liter. Electrolyte imbalance was defined as presence of any or both serum sodium < 130 or > 145 mmol/L and serum potassium <3.5 or > 5.5 mmol/L, Serum Chloride <97 or >117 mmol/L. Average age was 70.77 years, average weight of prostate 47.56 gm, average resection time 29 min, the average irrigation fluid used 8.3 liter, average irrigation fluid came out 8.22 liter. All patients had received subarachnoid block with Inj. Bupivacane 0.5 heavy. Average level of subarachnoid block was T10, average IV fluid given intraop were 1 liter of Ringer lactate.

Inclusion criteria: Patients with Benign prostate hyperplasia BPH of ASA grade I & II.

Exclusion criteria

• Patient who were having comorbidities like

• Patients of hypertension who were on diuretics,

• DM- uncontrolled requiring Inj. Insulin

• Patients having cardiac conditions like IHD, Old MI, on diuretic and antiplatelet agents like clopidogrel.

• Patients undergoing additions surgery along with TURP like cystolitholapexy, cystolithotripsy

• Patient having urinary tract infection urine pus cells >10.

• Patient having pre op electrolyte imbalance.

Materials and Methods

In our setup we used the sterile water as an irrigation fluid in all TURP procedures. We compared preoperative and postoperative electrolyte changes and difference in irrigation fluid used and drained out during TURP of the all patients. In our institution surgeon does low pressure TURP i.e. bladder is frequently evacuated and does not allow to distend. The height of irrigation fluid was constant, i.e. 70 cm.

Statistical analysis was done using Graph Pad insta program. Results and baseline characteristics were described by mean and standard deviation. One-way ANOVA was applied to determine significant changes between pre and post-surgery variables. As P value less than 0.05 considered statistically significant.

Result and Discussion

76 Male subject of BPH who required TURP, was enrolled in this study of age group 53 to 97. The P value is < 0.0001, considered extremely significant. Variation among column means is significantly greater than expected by chance. Tukey-Kramer Multiple Comparisons Test: If the value of q is greater than 3.344 then the P value is less than 0.05. Average pre-operative serum electrolyte were, average Na+ 135.81, average K+ 4.21, average Cl102.11 (Refrence T-1, T-2, T-3). And average post-operative serum electrolyte was, average Na+ 135.15, average K+ 4.27, average Cl102.4 (Refrence T-1, T-2, T-3).

Mean irrigation fluid used was 8.3 liters, mean irrigation fluid drained out 8.2 liters, mean irrigation fluid absorbed 0.07 liters (Reference T-5).

Average age in years was 70.77 years, average weight of prostate gland in grams was 47.56 gms, average resection time 29 minutes (Reference T-6).

No significant difference found in pre and post levels of Na+, K+ & Cl-. No significant difference found in the irrigation fluid used and came out of bladder. The fluid is absorbed directly into the vascular system when the tissue has been resected and venous sinus opened [7]. Fluid pressure exceeds 2 kPa (15 mm Hg) significantly increases volume absorption [8,9]. Electrolyte imbalance such as hyponatremia, hyperkalemia, and hypo/hyperchloridemia often occurred when excessive fluid was absorbed during the TURP procedure, depending upon which fluid is used for irrigation [7,8]. Preoperative electrolyte monitoring is most important before TURP. Some factors can influence the electrolyte disturbances; such as weight of resected tissue, intravenous fluids, irrigation fluids, irrigation volume, and the time spent for surgery [4].

We had done all the cases under regional anaesthesia i.e. subarachnoid block, symptoms caused due to electrolyte imbalance can be early picked up in regional anaesthesia but in case of GA general anaesthesia it can be masked and may be recognize after full blown TURP syndrome [3].

Also that duration of surgery, amount of irrigation fluid used, height of irrigation fluid are the major factors which plays role in electrolyte imbalance. Dilutional hypernatremia can causes neurological symptoms like headache, confusion, visual disturbance and convulsion etc. and hypo osmolality due to fluid absorption can causes hemolysis. K Gupta, et al. mentioned in their article that satisfactory reduction of serum Na+ level and elevation of serum K+ level was observed post operatively which was directly proportional to volume of irrigation fluid used, duration of procedure and volume of prostate gland resected [8].

Here in our study low pressure TURP were done i.e. bladder was frequently evacuated and did not allowed to distend the difference between amount of irrigation fluid used and amount which had drained out was not significant which indicate very minimal absorption of fluid through open venous sinuses. Average duration of surgery was not more than 30 minutes and volume of prostate was not more than 48 gm [9,10].

Mohrari RS, et al. also did the study in 2008 using sterile water as an irrigating fluid for TURP in 1600 cases & found no statistically significant changes in serum sodium, blood urea nitrogen, creatinine & hematocrit values. Our results are similar to their study that no significant difference found in pre & postoperative electrolytes. Mean changes in electrolyte are Na+ 0.51, K+ 0.05, Cl- 1.03.

In table 1, we were done comparison of Pre and post Na and Fluid, the mean difference of pre and post Na was -0.5066 which was insignificant. Value of Pre Na Vs Difference F and Post Na Vs Difference F were also non-significant.

In table 2, we were done comparison of Pre K Vs Post K and Fluid, the mean difference of pre and post K was -0.01539 which was insignificant. Value of Pre K Vs Difference F and Post K Vs Difference F were statistically highly insignificant.

In table 3, we were done comparison of Pre Cl Vs Post Cl and Fluid, the mean difference of pre and post Cl -1.022 which was insignificant. Value of Pre Cl Vs Difference F and Post Cl Vs Difference F Were F were statistically highly insignificant.

In table 4, average value of Na+ in pre-Op was 135.81 and in post-OP was 135.15, K+ value in pre-OP was 4.21, and in postOP was 4.27, the Cl- value of pre-OP was 102.11 and post-OP was 102.4.

Mean irrigation fluid used was 8.30 lit, Mean irrigation fluid drained out was 8.22 lit, Mean irrigation fluid absorbed was 0.07 lit.

According to tables 5 and 6 we conclude;

1. Low pressure TURP done in all cases so that less absorption of irrigation fluid ensured.

2. Height of irrigation fluid was maintained constant and as low as possible.

3. Time of resection was not more than 29 minutes.

4. Proper selection of patients for TURP having prostate gland weight less than 47.56 gm.

Conclusion

There was no significant change of electrolyte during TURP surgery. Pre and post-operative electrolyte should be monitored to prevent electrolyte imbalance & its consequences. Care and precaution were taken at many levels to avoid the electrolyte changes such as,

• Low pressure TURP done in all cases so that less absorption of irrigation fluid ensured.

• Height of irrigation fluid was maintained constant and as low as possible.

• Time of resection was not more than 29 minutes.

• Proper selection of patients for TURP having prostate gland weight less than 47.56 gm.

So, proper selection of patients, limiting the resection time and maintaining low pressure in bladder definitely prevent the electrolyte disturbances in post TURP surgeries.


Comparison

Mean   Difference

Q

P Value

Pre Na Vs Post Na

-0.5066

0.9031

              P <0.05

Pre Na Vs Difference F

134.34

239.51

P <0.001

Post Na Vs Difference F

134.85

240.42

P <0.001


Table 1: Pre Na vs post Na vs difference in fluid.

Comparison

Mean  Difference

Q

P Value

Pre K Vs Post K

-0.01539

0.1998

P <0.05

Pre K Vs Difference F

3.769

48.919

P<0.001

Post K Vs Difference F

3.785

49.119

P<0.001


Table 2: Pre K vs Post K vs difference in fluid.

Comparison

Mean Difference

Q

P Value

Pre Cl Vs Post Cl

-1.022

1.662

P <0.05

Pre Cl Vs Difference F

101.32

164.73

P<0.001

Post Cl Vs Difference F

102.34

166.39

P<0.001


Table 3: Pre Cl Vs Post Cl Vs difference in fluid.

Serum Electrolytes

Average Pre-OP value

 Average Post-Op Value

Na+

135.81

135.15

K+

4.21

4.27

Cl-

102.11

102.4


Table 4: Mean electrolytes.

Mean irrigation fluid used

8.30 Lit

Mean irrigation fluid drained out

8.22 Lit

Mean irrigation fluid absorbed

0.07 Lit


Table 5: Mean irrigation fluid used, mean irrigation fluid drained out, mean irrigation fluid absorbed.

Average Age (yrs)

70.77              

Average weight of prosate gland (gm)

47.56

Average resection time (sec)

29 min


Table 6: Average age, average weight of prostate, average resection time.

References

  1. Altaf J, Arain AH, Devrajani BR, Baloch S (2016) Serum Electrolyte Disturbances in Benign Prostate Hyperplasia after Transurethral Resection of the Prostate. J Nephrol Ther 6: 238.
  2. Patel SN, Patel ND (2014) Serum sodium and serum potassium changes during transurethral resection of the prostate gland in patients under subarachnoid block. NJMR 4: 322-325.
  3. Demirel I, Ozer A, Bayar M, Erhan O (2012) TURP syndrome and severe hyponatremia under general anaesthesia. BMJ Case Reports 16.
  4. Guo R, Yu W, Meng Y, Zhang K, Xu B, et al. Correlation of benign prostatic obstruction-related complications with clinical outcomes in patients after transurethral resection of the prostate. The Kaohsiung Journal of Medical Sciences 33: 144-151.
  5. Rassweiler J, Teber D, Kuntz R, Hofmann R (2006) Complications of Transurethral Resection of the Prostate (TURP)-Incidence, Management, and Prevention. European Urology 50: 969-979.
  6. Gupta K, Rastogi B, Jain M, Gupta P, Sharma D (2010) Electrolyte changes: An indirect method to assess irrigation fluid absorption complications during transurethral resection of prostate: A prospective study. Saudi Journal of Anaesthesia 4: 142-146.
  7. Hahn R (2006) Fluid absorption in endoscopic surgery. British Journal of Anaesthesia 96: 8-20.
  8. Yousef AA, Suliman GA (2010) A randomized comparison between three types of irrigating fluid during transurethral resection in benign prostatic hyperplagia. BMC Anesthesiol 10: 7.
  9. Krishnamurthy H, Philip S (2001) TURP syndrome current concepts in pathophysiology & management. Indian journal of urology 17: 97-102.
  10. Moharari RS, Khajvi MR, Khodemhosselni P, Hosseini SR, Najafi A (2008) Sterile water as an irrigating fluide for transurethral resection of the prostate anaesthetical view of the records of 1600 cases. South Med J 101: 373-375.

Citation: Kulkarni SG (2019) Association of Irrigation Fluid Used and Serum Electrolyte Changes in Trans Ureteral Resection of Prostate (Turp) at Dr. Hedgewar Rugnalaya, Aurangabad. Anesth Med Pract J 4: 133. DOI:10.29011/2637-9953.100133

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