Transurethral resection syndrome: pathophysiology and nursing management

Transurethral Resection Syndrome

Since 1930, transurethral resection of the prostrate (TURP) has been the customary treatment for both moderate as well as severe prostatic hypertrophy. But there are many complications that can occur because of TURP. Transurethral Resection Syndrome is one such complication that occurs due to water intoxication of the body resulting in various acid-base imbalances including hyponatremia. Though the developments in TURP surgical procedures has made the occurrence of this syndrome less frequent, with the complication occurring in only about 2% of all patients undergoing these procedures but if occurs the syndrome has pretty serious consequences including cellular edema, increased intervascular volume and hyponatremia. Therefore, it becomes mandatory for the nurses to have a basic knowledge of the syndrome (including how and why), ability to identify the early signs of the syndrome and the ways to take care of the patients with this syndrome. The paper stresses on explaining all of the aforementioned points and presents steps that are to be taken by the trained nurses in such instances.

Introduction

In order to comprehend the TUR syndrome, it becomes essential to have a basic knowledge of the anatomical and physiological structures of the prostrate gland. In men, the prostrate gland surrounds the urethra at the base of the bladder. It is composed of the musculofibrous glandular tissue, which is surrounded by the fibrous capsule. And multiple follicle pouches inside the gland join to form excretory ducts that empty into urethra. The network formed by the follicles is supported by the musculofibrous tissue and is enclosed in a vascular network of capillaries, known as vascular sinus. Further, urethra and other ejaculatory ducts penetrate prostrate gland. The ejaculatory ducts carry the secretions produced by seminal vesicles and vas deferens and these secretions mix with the secretions of the prostrate gland and are secreted during ejaculation.

Usually, after approximately thirty years of age these prostrate glands in men enlarge. The primary causes for this enlargement is believed to be the increased release of testicular androgens causing proliferation of glandular tissue in the prostrate. And this enlargement of prostrate is known as Benign Prostatic Hypertrophy (BPH). It is very difficult to rectify it in the beginning and is treated only after it shows severe symptoms. The symptoms are largely dependent on the manner in which prostrate enlarges. More often than not, the growth of the tissue commences at the part of prostrate near urethra and in the advanced stages, the nodules start developing in the tissue. The growth of these nodules decides severity of symptoms, with the men in whom the development is towards urethra showing severe symptoms and the ones in whom the direction of growth is opposite showing little or no symptoms.

Nodular growth in the direction of the urethra, narrowed and obstructs the urine flow from the bladder. Moreover, with this retention of urine flow the wall becomes even more muscular with trabeculations forming in the bladder. If this condition remains untreated then the pouches between the muscles can extend beyond and form diverticula. This can lead to the elevation of the back wall of the bladder (trigone) towards abdomen, further leading to the distortion of the location openings of ureteral orifices, which are located in the proximal borders of the trigonal area. Thus, making it essential for the surgeons to locate ureteral orifices before resection and prevent inadvertent ureteral resection. This can be achieved by using varying procedures, with Transurethral Resection of Prostrate being one of the possible procedures.

Transurethral Resection of the Prostrate (TURP)

TURP was developed in 1930 to treat BPH that resulted in urinary retention. And until recently it was the only procedure that was considered to be more invasive as compared to the open prostatectomy. And today, with the development of other medical therapies and other procedures that TURP is performed only in the cases where other treatments have not been effective or in the cases where the patient experiences urinary retention. In addition, being highly effective, TURP is known for its long-term success rate. Also, it has lesser complications and short recovery period as compared to open prostatectomy. Therefore, more persistent prostatectomy is used only in the patients with extremely large prostate, whose prostate shape makes the procedure risky or with any urological abnormality that requires incision of abdomen for the access to the prostrate. The circulating nurse examines the patient's medical record and the surgical and anesthesia consents are signed and witnessed without fail. Then the phases of introduction, identity verification, NPO status determination and allergies related to patient's are carried on by the circulating nurse. The nurse then asks the patient to authenticate his understanding of the procedure. The circulating nurse and anesthesia care provider transport the patient to the cystoscopy room. After induction of anesthesia, the surgeon, anesthesia care provider, and circulating nurse place the patient in the lithotomic position and pad the patient's extremities and all bony prominences. The circulating nurses check for correct anatomical alignment to prevent nerve, muscle, and skin damage.

Transurethral Resection Syndrome

The risk is higher in some patients for developing TUR syndrome. These kinds of patients can be with history of liver disease, UTIs, significant muscular atrophy, bladder stones, or obstructive uropathy. One or two liters of fluid absorbed in forty minutes in a healthy patient usually do not result in TUR syndrome; however, extravasation of irrigant is time and pressure related. Patients who present with larger prostates that require more than forty minutes of resection time for an adequate urinary outlet to be created are at an increased risk. The surgeon's technique also can affect the length of the procedure. The incidence of TUR syndrome is most frequent in patients with a prostate gland larger than forty-five grams and when the resection time lasts longer than ninety minutes. Surgeons may chose to perform an open prostatectomy if the patient presents with a large prostate. Another option for patients with a large prostate is to perform the TURP procedure in two steps. In this situation, the surgeon performs a partial TURP and has the patient return for a second procedure to complete resection of the prostate at a later date after full recovery from the initial procedure.

Symptoms of TUR syndrome

In the early onset of TUR syndrome, a conscious patient initially complains of nausea, possibly accompanied by vomiting (Table 1). Cooperatively, the anesthesia care provider, surgeon, and circulating nurse determine whether the nausea and/or vomiting are caused by spinal anesthetic or TUR syndrome. It can be done by observing the patient for other signs of TUR syndrome and considering factors that could rule out TUR syndrome (Ex. length of surgical time, height of irrigant source, blood loss). Uneasiness and weariness also are initial indicators of TUR syndrome. The patient's crucial signs may remain stable but bradycardia and an increase in blood pressure may occur. Other early symptoms include disorientation, visual disturbances, headache, dizziness, and, in some situations, abdominal distention as fluid is absorbed through perforations in the prostatic capsule. Symptoms pile on if TUR syndrome goes unrecognized and the procedure continues. The absorptions of large quantities of glycine can cause prickling sensations of the skin in the patients. As cerebral edema sets in, the patient becomes more confused. The patient's blood pressure may drop as a result of acute hyponatremia or significant hemorrhage decreasing the arterial pressure. Neuromuscular disturbances ranging from twitches to seizures can occur. The patient may experience dyspnea with cyanosis. Ischemia can occur either in the heart or the kidney, resulting in chest pain and failed spontaneous diuresis. Sooner or later, the patient may become comatose.

Table 1: Symptoms of Transurethral Resection Syndrome

Symptoms of TUR Syndrome

Early symptoms

Apprehension

Nausea and/or vomiting

Disorientation

Dizziness

Headache

Hypertension

Bradycardia

Lethargy

Abdominal distention

Late symptoms

Neuromuscular disturbances (Ex. twitching, seizures)

Visual disturbances

Hypotension

Dyspnea

Cyanosis

Myocardial ischemia

Renal tubular necrosis and decreased urinary output

Cerebral edema

Coma

Treatment: TUR Syndrome

It is not always possible to prevent this impediment. Its better if TUR syndrome is diagnosed in its earliest stages, so that it can be resolved before the patient leaves the OR. The TURP protocol that was developed and used at WakeMed, Raleigh, NC, instructs surgical team members about TUR syndrome. Use of this protocol has greatly improved early recognition of TUR syndrome and rapid treatment response. An important preventive measure is for the surgeon to inform the circulating nurse and anesthesia care provider that the patient has a large prostate. It's the choice of anesthetic agents to provide and regulate in anticipation of a potentially longer procedure. Depending on the patient's medical history, spinal anesthesia is the anesthetic of choice, when possible. With spinal anesthesia, the patient remains awake, allowing the anesthesia care provider and circulating nurse to assess the patient's mental status and subjective symptoms. When general anesthesia must be used, knowing how TUR syndrome occurs and factors affecting its onset helps in assessing the patient. Preoperative preparation. Before leaving the cystoscopy room to complete the initial patient assessment in the preoperative holding area, the circulating nurse begins intraoperative interventions. He or she verifies that all necessary instruments, supplies, and equipment are available and in working order. Glycine is placed by nurses in the fluid warmer and presets to 131° F (41° C). The fluid flows through the warmer very quickly during TURP, so it rarely reaches this temperature. The methods to warm the patient are available for use during the procedure to prevent the onset of hypothermia and works best between 70° F. And 72° F (20.9° C. To 22° C). He or she confirms with the anesthesia care provider that blood tubes are available to draw and send blood to the laboratory for immediate blood tests (i.e., complete blood count [CBC], hemoglobin/hematocrit [H/H], electrolyte levels) in the event they are needed. The patient's medical records are verified for baseline vital signs, history and physical completed by the surgeon; signed informed consent form; notation of the patient's mental status and orientation; and laboratory results, including a CBC, H/H, and electrolyte panel.

The surgical team members have basis from which to they compare changes that may occur intraoperatively. If the patient has received anticoagulant therapy or has taken aspirin regularly or recently, a coagulation panel also should be available in the medical record. An anomalous coagulation result is a