Hyponatremia following transurethral resection or hysteroscopy
- Michael Emmett, MD
Michael Emmett, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Chief of Internal Medicine
- Baylor University Medical Center
- Olav Istre, MD, PhD
Olav Istre, MD, PhD
- Professor, Deptartment of Obstetrics and Gynecology
- South Danish University
- Odense, Denmark
- Robert G Hahn, MD, PhD
Robert G Hahn, MD, PhD
- Professor of Anesthesiology
- The University of Linköping, Sweden
- Associate Professor
- Karolinska Institutet, Stockholm, Sweden
- Section Editors
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor of Medicine
- University of Rochester School of Medicine and Dentistry
- Tommaso Falcone, MD, FRCSC, FACOG
Tommaso Falcone, MD, FRCSC, FACOG
- Section Editor — Minimally Invasive Gynecologic Surgery
- Professor of Obstetrics and Gynecology
- Cleveland Clinic Lerner College of Medicine
- Deputy Editors
- John P Forman, MD, MSc
John P Forman, MD, MSc
- Deputy Editor — Nephrology
- Assistant Professor of Medicine
- Harvard Medical School
- Sandy J Falk, MD, FACOG
Sandy J Falk, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Clinical Instructor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
A variety of transurethral, hysteroscopic, and other percutaneous procedures utilize large volumes of irrigating/distension solutions. These procedures include transurethral resection of the prostate (TURP), transurethral resection of bladder tumors, hysteroscopic transcervical diagnostic and therapeutic procedures (eg, resection of submucosal leiomyomas), percutaneous removal of kidney stones, and some other percutaneous and minimally invasive procedures.
The electrosurgery devices that have traditionally been used during these procedures have a monopolar design and cannot be used with electrolyte-containing irrigation fluids (eg, isotonic saline or lactated Ringer's). Several different nonconductive (ie, non-electrolyte) solutions have been employed. The use of these non-electrolyte solutions has been associated with a number of complications including hyponatremia, a variable degree of hypoosmolality, and certain solution-specific problems described below.
Bipolar electrosurgery devices and various laser and microwave systems have been introduced, and these devices are compatible with electrolyte-containing irrigation and distension solutions [1-5]. Use of isotonic saline or Ringer's lactate solution will not generate hyponatremia. However, absorption of a large volume of saline solution will expand the extracellular fluid volume and may generate volume overload, pulmonary edema, and hypertension.
Hyponatremia following use of nonconductive (ie, non-electrolyte) irrigation solutions for transurethral resection of the prostate or bladder or for hysteroscopy will be reviewed here. General principles of diagnosis and management of hyponatremia and of TUR and hysteroscopy are discussed separately. (See "Diagnostic evaluation of adults with hyponatremia" and "Overview of the treatment of hyponatremia in adults" and "Transurethral procedures for treating benign prostatic hyperplasia" and "Clinical presentation, diagnosis, and staging of bladder cancer" and "Overview of hysteroscopy" and "Hysteroscopy: Managing fluid and gas distending media", section on 'Fluid media'.)
NONCONDUCTIVE IRRIGATION FLUIDS
Three major nonconductive (ie, non-electrolyte) fluids are used for surgical procedures:
- Zeltser I, Pearle MS, Bagley DH. Saline is our friend. Urology 2009; 74:28.
- Mohta M, Bhagchandani T, Tyagi A, et al. Haemodynamic, electrolyte and metabolic changes during percutaneous nephrolithotomy. Int Urol Nephrol 2008; 40:477.
- Issa MM. Technological advances in transurethral resection of the prostate: bipolar versus monopolar TURP. J Endourol 2008; 22:1587.
- Mamoulakis C, Skolarikos A, Schulze M, et al. Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate. BJU Int 2012; 109:240.
- Michielsen DP, Coomans D, Braeckman JG, Umbrain V. Bipolar transurethral resection in saline: the solution to avoid hyponatraemia and transurethral resection syndrome. Scand J Urol Nephrol 2010; 44:228.
- Mebust WK, Holtgrewe HL, Cockett AT, et al. Transurethral prostatectomy: immediate and postoperative complications. Cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol, 141: 243-247, 1989. J Urol 2002; 167:5.
- Aydeniz B, Gruber IV, Schauf B, et al. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol 2002; 104:160.
- Jansen FW, Vredevoogd CB, van Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96:266.
- Atici S, Zeren S, Ariboğan A. Hormonal and hemodynamic changes during percutaneous nephrolithotomy. Int Urol Nephrol 2001; 32:311.
- Istre O, Skajaa K, Schjoensby AP, Forman A. Changes in serum electrolytes after transcervical resection of endometrium and submucous fibroids with use of glycine 1.5% for uterine irrigation. Obstet Gynecol 1992; 80:218.
- Istre O, Bjoennes J, Naess R, et al. Postoperative cerebral oedema after transcervical endometrial resection and uterine irrigation with 1.5% glycine. Lancet 1994; 344:1187.
- Olsson J, Hahn RG. Ethanol monitoring of irrigating fluid absorption in transcervical resection of the endometrium. Acta Anaesthesiol Scand 1995; 39:252.
- Hahn RG, Stalberg HP, Ekengren J, Rundgren M. Effects of 1.5% glycine solution with and without 1% ethanol on the fluid balance in elderly men. Acta Anaesthesiol Scand 1991; 35:725.
- Hahn RG. Transurethral resection syndrome from extravascular absorption of irrigating fluid. Scand J Urol Nephrol 1993; 27:387.
- Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth 2006; 96:8.
- Hahn RG. Transurethral resection syndrome after transurethral resection of bladder tumours. Can J Anaesth 1995; 42:69.
- Dorotta I, Basali A, Ritchey M, et al. Transurethral resection syndrome after bladder perforation. Anesth Analg 2003; 97:1536.
- Olsson J, Berglund L, Hahn RG. Irrigating fluid absorption from the intact uterus. Br J Obstet Gynaecol 1996; 103:558.
- Paschopoulos M, Polyzos NP, Lavasidis LG, et al. Safety issues of hysteroscopic surgery. Ann N Y Acad Sci 2006; 1092:229.
- Corson SL, Brooks PG, Serden SP, et al. Effects of vasopressin administration during hysteroscopic surgery. J Reprod Med 1994; 39:419.
- Hahn RG, Ekengren JC. Patterns of irrigating fluid absorption during transurethral resection of the prostate as indicated by ethanol. J Urol 1993; 149:502.
- Goldenberg M, Cohen SB, Etchin A, et al. A randomized prospective comparative study of general versus epidural anesthesia for transcervical hysteroscopic endometrial resection. Am J Obstet Gynecol 2001; 184:273.
- Bergeron ME, Beaudet C, Bujold E, et al. Glycine absorption in operative hysteroscopy: the impact of anesthesia. Am J Obstet Gynecol 2009; 200:331.e1.
- Goldenberg M, Zolti M, Bider D, et al. The effect of intracervical vasopressin on the systemic absorption of glycine during hysteroscopic endometrial ablation. Obstet Gynecol 1996; 87:1025.
- Sharma DP, Harvey AB. Does intraprostatic vasopressin prevent the transurethral resection syndrome? BJU Int 2000; 86:223.
- Hahn RG. Smoking increases the risk of large scale fluid absorption during transurethral prostatic resection. J Urol 2001; 166:162.
- Rhymer JC, Bell TJ, Perry KC, Ward JP. Hyponatraemia following transurethral resection of the prostate. Br J Urol 1985; 57:450.
- Hahn RG. Relations between irrigant absorption rate and hyponatraemia during transurethral resection of the prostate. Acta Anaesthesiol Scand 1988; 32:53.
- Inman RD, Hussain Z, Elves AW, et al. A comparison of 1.5% glycine and 2.7% sorbitol-0.5% mannitol irrigants during transurethral prostate resection. J Urol 2001; 166:2216.
- Phillips DR, Milim SJ, Nathanson HG, et al. Preventing hyponatremic encephalopathy: comparison of serum sodium and osmolality during operative hysteroscopy with 5.0% mannitol and 1.5% glycine distention media. J Am Assoc Gynecol Laparosc 1997; 4:567.
- Gonzales R, Brensilver JM, Rovinsky JJ. Posthysteroscopic hyponatremia. Am J Kidney Dis 1994; 23:735.
- Barisic D, Wamsteker K, Strelec M, et al. The effect of sorbitol-mannitol absorption on serum sodium concentration during hysteroscopic surgery. Gynaecol Endosc 1996; 5:323.
- Olsson J, Hahn RG. Simulated intraperitoneal absorption of irrigating fluid. Acta Obstet Gynecol Scand 1995; 74:707.
- Silver SM, Kozlowski SA, Baer JE, et al. Glycine-induced hyponatremia in the rat: a model of post-prostatectomy syndrome. Kidney Int 1995; 47:262.
- Sunderrajan S, Bauer JH, Vopat RL, et al. Posttransurethral prostatic resection hyponatremic syndrome: case report and review of the literature. Am J Kidney Dis 1984; 4:80.
- Campbell HT, Fincher ME, Sklar AH. Severe hyponatremia without severe hypoosmolality following transurethral resection of the prostate (TURP) in end-stage renal disease. Am J Kidney Dis 1988; 12:152.
- Agarwal R, Emmett M. The post-transurethral resection of prostate syndrome: therapeutic proposals. Am J Kidney Dis 1994; 24:108.
- Ayus JC, Arieff AI. Glycine-induced hypo-osmolar hyponatremia. Arch Intern Med 1997; 157:223.
- Ghanem AN, Ward JP. Osmotic and metabolic sequelae of volumetric overload in relation to the TUR syndrome. Br J Urol 1990; 66:71.
- American College of Obstetricians and Gynecologists. ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy. Obstet Gynecol 2005; 106:439.
- Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic fluid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc 2000; 7:167.
- BEIRNE GJ, MADSEN PO, BURNS RO. SERUM ELECTROLYTE AND OSMOLALITY CHANGES FOLLOWING TRANSURETHRAL RESECTION OF THE PROSTATE. J Urol 1965; 93:83.
- Agraharkar M, Agraharkar A. Posthysteroscopic hyponatremia: evidence for a multifactorial cause. Am J Kidney Dis 1997; 30:717.
- Hahn RG, Rundgren M. Vasopressin responses during transurethral resection of the prostate. Br J Anaesth 1989; 63:330.
- Rundgren M, Hjelmqvist H, Gunnarsson U, Hahn RG. Intracerebroventricular infusion of glycine stimulates vasopressin release in conscious sheep. Neuroreport 1993; 4:1052.
- Issa MM, Young MR, Bullock AR, et al. Dilutional hyponatremia of TURP syndrome: a historical event in the 21st century. Urology 2004; 64:298.
- Berg A, Sandvik L, Langebrekke A, Istre O. A randomized trial comparing monopolar electrodes using glycine 1.5% with two different types of bipolar electrodes (TCRis, Versapoint) using saline, in hysteroscopic surgery. Fertil Steril 2009; 91:1273.
- Michielsen DP, Debacker T, De Boe V, et al. Bipolar transurethral resection in saline--an alternative surgical treatment for bladder outlet obstruction? J Urol 2007; 178:2035.
- Gilleran JP, Thaly RK, Chernoff AM. Rapid communication: bipolar PlasmaKinetic transurethral resection of the prostate: reliable training vehicle for today's urology residents. J Endourol 2006; 20:683.
- Hahn RG, Ekengren J. Absorption of irrigating fluid and height of fluid bag during transurethral resection of the prostate. Br J Urol 1993; 72:80.
- Nezhat CH, Fisher DT, Datta S. Investigation of often-reported ten percent hysteroscopy fluid overfill: is this accurate? J Minim Invasive Gynecol 2007; 14:489.
- Hahn RG. The volumetric fluid balance as a measure of fluid absorption during transurethral resection of the prostate. Eur J Anaesthesiol 2000; 17:559.
- Shipstone DP, Inman RD, Beacock CJ, Coppinger SW. Validation of the ethanol breath test and on-table weighing to measure irrigating fluid absorption during transurethral prostatectomy. BJU Int 2002; 90:872.
- Hahn RG. Fluid absorption and the ethanol monitoring method. Acta Anaesthesiol Scand 2015; 59:1081.
- Hahn RG. Prevention of TUR syndrome by detection of trace ethanol in the expired breath. Anaesthesia 1990; 45:577.
- Drobin D, Hjelmqvist H, Piros D, Hahn RG. Monitoring of fluid absorption with nitrous oxide during transurethral resection of the prostate. Acta Anaesthesiol Scand 2008; 52:509.
- Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection syndrome using glycine as the irrigant. J Urol 1995; 154:123.
- Shirk GJ, Gimpelson RJ. Control of intrauterine fluid pressure during operative hysteroscopy. J Am Assoc Gynecol Laparosc 1994; 1:229.
- Hasham F, Garry R, Kokri MS, Mooney P. Fluid absorption during laser ablation of the endometrium in the treatment of menorrhagia. Br J Anaesth 1992; 68:151.
- Gray RA, Lynch C, Hehir M, Worsley M. Intravesical pressure and the TUR syndrome. Anaesthesia 2001; 56:461.
- Madsen PO, Naber KG. The importance of the pressure in the prostatic fossa and absorption of irrigating fluid during transurethral resection of the prostate. J Urol 1973; 109:446.
- Hultén J. Prevention of irrigating fluid absorption during transurethral resection of the prostate. Scand J Urol Nephrol Suppl 1984; 82:1.
- Hahn RG. Intravesical pressure during irrigating fluid absorption in transurethral resection of the prostate. Scand J Urol Nephrol 2000; 34:102.
- Mizutani AR, Parker J, Katz J, Schmidt J. Visual disturbances, serum glycine levels and transurethral resection of the prostate. J Urol 1990; 144:697.
- Radziwill AJ, Vuadens P, Borruat FX, Bogousslavsky J. Visual disturbances and transurethral resection of the prostate: the TURP syndrome. Eur Neurol 1997; 38:7.
- Karci A, Erkin Y. Transient blindness following hysteroscopy. J Int Med Res 2003; 31:152.
- Hahn RG, Sandfeldt L, Nyman CR. Double-blind randomized study of symptoms associated with absorption of glycine 1.5% or mannitol 3% during transurethral resection of the prostate. J Urol 1998; 160:397.
- Witz CA, Silverberg KM, Burns WN, et al. Complications associated with the absorption of hysteroscopic fluid media. Fertil Steril 1993; 60:745.
- Wang JH, He Q, Liu YL, Hahn RG. Pulmonary edema in the transurethral resection syndrome induced with mannitol 5%. Acta Anaesthesiol Scand 2009; 53:1094.
- Bernstein GT, Loughlin KR, Gittes RF. The physiologic basis of the TUR syndrome. J Surg Res 1989; 46:135.
- Istre O, Jellum E, Skajaa K, Forman A. Changes in amino acids, ammonium, and coagulation factors after transcervical resection of the endometrium with a glycine solution used for uterine irrigation. Am J Obstet Gynecol 1995; 172:939.
- Ryder KW, Olson JF, Kahnoski RJ, et al. Hyperammonemia after transurethral resection of the prostate: a report of 2 cases. J Urol 1984; 132:995.
- Hahn RG, Sandfeldt L. Blood ammonia levels after intravenous infusion of glycine solution with and without ethanol. Scand J Urol Nephrol 1999; 33:222.
- Hahn RG. Blood ammonia concentrations resulting from absorption of irrigating fluid containing glycine and ethanol during transurethral resection of the prostate. Scand J Urol Nephrol 1991; 25:115.
- Vaney DI, Nelson JC, Pow DV. Neurotransmitter coupling through gap junctions in the retina. J Neurosci 1998; 18:10594.
- Hahn RG. Glycine 1.5% for irrigation should be abandoned. Urol Int 2013; 91:249.
- Hahn RG, Gebäck T. Fluid volume kinetics of dilutional hyponatremia; a shock syndrome revisited. Clinics (Sao Paulo) 2014; 69:120.
- Sterns RH, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol 2009; 29:282.
- Weissman JD, Weissman BM. Pontine myelinolysis and delayed encephalopathy following the rapid correction of acute hyponatremia. Arch Neurol 1989; 46:926.
- Donatucci CF, Deshon GE Jr, Wade CE, Hunt M. Furosemide-induced disturbances of renal function in patients undergoing TURP. Urology 1990; 35:295.
- Crowley K, Clarkson K, Hannon V, et al. Diuretics after transurethral prostatectomy: a double-blind controlled trial comparing frusemide and mannitol. Br J Anaesth 1990; 65:337.
- Montesinos Baillo A, Banús Gassol JM, Palou Redorta J, et al. Physiopathology and surgical treatment of extravasated peritoneal fluid after transurethral resection. Eur Urol 1984; 10:183.
- NONCONDUCTIVE IRRIGATION FLUIDS
- RISK FACTORS
- PATHOGENESIS OF HYPONATREMIA
- Volume and rate of fluid absorption
- Time course of hyponatremia
- Time course of osmolar shifts
- Avoid use of nonconductive irrigants
- Monitor fluid absorbed
- - Halt procedure at absorption thresholds
- Minimize fluid pressure
- Limit operation time
- CLINICAL MANIFESTATIONS
- Pathogenesis of neurologic symptoms
- Asymptomatic hyponatremia
- Symptomatic hyponatremia
- - Role of hypertonic saline
- - Role of hemodialysis
- - Loop diuretics
- - Possible role of surgical drainage
- SUMMARY AND RECOMMENDATIONS