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 Emeritus
- 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:
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- 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
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS