Aim
To improve the safe management of urological irrigation fluids and prevent avoidable cases of TUR syndrome by promoting the correct selection, labelling, handover, switching and documentation of irrigation fluids across theatre, recovery, and ward settings.
Background
The problems with performing transurethral resection, particularly of prostates, are well described (1) with TUR Syndrome a recognised complication of prolonged irrigation with water & glycine. This problem can be reduced, though not totally prevented, by utilising isotonic glycine as the irrigating fluid and by using strategies such as avoiding TURP on big prostates (>80 mls) or limiting resection time to less than 1 hour when using glycine as the irrigation fluid. Alternatives that use saline for irrigation, such as bipolar TURP (2) and laser prostatectomy (HoLEP/ThuLEP or ThuFLEP) (3,4) can also be safely utilised.
There have been a number of cases recently where, despite short resection times, patients have developed TUR syndrome. The exact mechanism of these problems is not fully known but seems to be the use of “glycine” for irrigation during the post-operative period in recovery and on the ward. Some of these issues are related to the near identical bags containing saline, water and glycine. The only way to be sure which fluid is being used is to read the print on the bag with the same colour scheme and font being used for all similarly sized bags. It also does not appear to be standard practice to record in the patient’s notes the fluid irrigated in the post-op period, unlike in theatre where the amount of fluid used is routinely recorded.
Recommendations
The Victorian Perioperative Consultative Council recommends that:
- Alternatives to glycine TURP are available and should be discussed with patients & considered especially if the prostate gland is larger > 80cc or planned resection time is expected to be long.
- If glycine is used during TURP, the irrigation fluid is switched to saline before the patient leaves the operating theatre.
- All fluid used for irrigation is recorded in the patient notes.
- Manufacturers consider making the bags of irrigation fluid obviously different e.g. different colours for each fluid.
- All staff are reminded of the importance of using the correct fluids in the various situations.
References
1. Rassweiler J, Teber D, Kuntz R, Hofman R. Complications of transurethral resection of the prostate (TURP) – incidence, management and prevention. Eur Urol. 2006; 50:969-79. Doi:10.1016/j.eururo.2005.12.042.
2. Mamoulakis C, Trompetter M, de la Rosette J. Bipolar transurethral resection of the prostate: the ‘golden standard’ reclaims its leading position. Curr Opin Urol. 2009; 19:26-32. Doi:10.1097/MOU.0B013e32831e44da.
3. Vincent MW, Gilling PJ. HoLEP has come of age. World J Urol. 2015;33:487-93. Doi: 10.1007/s00345-014-1443-x.
4. Aybal HC, Yilmaz M, Barlas IS, Duvarci M, Tuncel A, Tunc L. Comparison of HoLEP, ThuLEP and ThuFLEP in the treatment of benign prostatic obstruction: a propensity score-matched analysis. World J Urol. 2024; 42:374. Doi: 10.1007/s00345-024-05082-2.