Case Presentation: A 78-year-old man with a past medical history of coronary artery disease, cardiac amyloidosis, and paroxysmal atrial fibrillation presented for an elective transurethral resection of the prostate (TURP). Post-procedure, while in the recovery area, he was noted to have difficulty awakening from anesthesia, noted to have altered mental status and bradycardia. Laboratory studies revealed newly developed severe hyponatremia (Na 103 mmol/L), hyperkalemia (K 5.7 mmol/L), hyperammonemia (0.173 mmol/L), and metabolic acidosis (pH 7.27). He received a 100-mL bolus of 3% hypertonic saline in the recovery unit for hyponatremia correction. Although arousable and able to converse, he remained lethargic with worsening mentation. The patient was transferred urgently to the intensive care unit, where a second bolus of hypertonic saline was administered. Severe hyponatremia was attributed to post-TURP syndrome in the setting of large-volume bladder irrigation using 1.5% glycine; approximately 33 liters of irrigation fluid were used during the procedure. Given the combination of profound electrolyte abnormalities, hyperammonemia and neurologic symptoms, intermittent hemodialysis was initiated promptly. Over the next 24 hours, the patient’s condition gradually improved, and he was transferred out of the ICU. Urology resumed continuous bladder irrigation with normal saline until Foley catheter removal. The patient was ultimately discharged home on postoperative day 4 in his baseline state of health without further complications.
Discussion: Post-TURP syndrome is an uncommon but very serious complication following a TURP procedure that requires large volumes of irrigating fluid. Severe hyponatremia causing neurologic symptoms occurs in only 2% of all TURP cases. Normally the lower urinary tract system has selective permeability in response to osmotic gradients to help regulate and manage changes in urine concentration. This also serves as a barrier to prevent uptake of fluids or solutes into the surrounding tissues and circulation. TURP procedures, however, run the risk of severing large prostatic blood vessels intraoperatively, which then allows for rapid absorption of irrigant and a resulting dilutional hyponatremia. In this particular case, the patient had worsening neurologic symptoms given very low sodium concentrations, glycine toxicity, and the accumulation of ammonia secondary to glycine metabolism. Prevention of post-TURP syndrome focuses on minimizing total intraoperative fluid absorption if possible. Limiting the duration of surgery and monitoring the quantity of fluid absorbed are general measures to prevent such complications. There should always be a low threshold to suspect post-TURP syndrome for longer surgeries requiring large amounts of irrigation, and especially if the patient has difficulty awakening from anesthesia. Management involves expedited correction of low sodium levels with hypertonic saline, and the removal of toxic metabolites, excess volume, and osmotic derangements via hemodialysis.
Conclusions: Post-TURP syndrome is an uncommon complication of a commonly performed procedure in older males. Timely and appropriate management of toxic and electrolyte derangements are needed to prevent irreversible and even fatal outcomes for an otherwise benign urological procedure.