Original Article

Sterile Water as an Irrigating Fluid forTransurethral Resection of the Prostate:Anesthetical View of the Records of 1600 CasesReza Shariat Moharari, MD, Mohammad Reza Khajavi, MD,Peyman Khademhosseini, MD, Seyed Reza Hosseini, MD, and Atabak Najafi, MD

Objectives: Absorption of the fluid used for bladder irrigation duringtransurethral resection of prostate (TURP) may disturb the circulatorysystem and lead to clinical symptoms known as the transurethral resec-tion syndrome. The purpose of this study was to evaluate the changesin electrolytes in patients who had undergone TURP.

Methods: For all the cases with benign prostatic hypertrophy en-rolled in the present study, TURP was performed as recommendedin Miller’s Anesthesia, the sixth edition. Sterile water was used as anirrigating fluid for bladder washing. Laboratory tests were performedbefore and immediately after the surgery.

Results: No statistically significant changes were reported in theserum sodium, blood urea nitrogen, creatinine, and hematocrit. Themost common complications were hypotension (8.3%), hyperten-sion (7.8%), nausea (6.4%), and vomiting (2.8%). Hyponatremia,decreased hematocrit, and increased blood urea nitrogen/creatininewere rarely reported (2.5, 1.0, and 0.9%, respectively).

Conclusion: Sterile water has been shown to be a safe irrigatingfluid for TURP.

Key Words: anesthesia complications, fluid and electrolyte balance,spinal anesthesia, transurethral resection of prostate

Transurethral resection of prostate (TURP) is the gold stan-dard of surgical management in benign prostatic hyper-

trophy. Although glycine 1.5% is the most popular irrigatingfluid in this surgery, it results in several complications suchas hypotension, bradycardia, confusion, and chest pain.1,2

Since 1955, these clinical features have been known as trans-urethral resection syndrome.3 Although the safety of water asan irrigating solution in TURP remains controversial, thisfluid has been commonly used in our center (Sina UniversityHospital) for many years. The purpose of this study was toreport the clinical and the laboratory findings in the patientsundergoing TURP by administering sterile water.

Patients and MethodsIn this study, the records of 1,600 patients who had un-

dergone TURP in Sina University Hospital (Tehran, Iran)during January 1992 to December 2004 were reviewed. Theindication for performing TURP was as follows: (1) Acuteurinary retention, (2) Recurrent/persistent urinary tract infec-tion, (3) Significant symptoms from bladder outlet obstruc-tion not responsive to medical treatment, (4) Recurrent grosshematuria, (5) Pathophysiologic changes of the kidneys, ure-thra, or bladder secondary to prostatic obstruction, and (6)Bladder calculus secondary to obstruction.4

All the patients were in good general health. All the patientssigned an informed consent and also accepted that the resultsand medical files would be reviewed for research activities.

Based on the medical condition of each patient, spinalanesthesia was induced at the level of T8–T10 by isobaric

From the Departments of Anesthesiology, Emergency Medicine, and Urol-ogy, Sina Hospital, Medical Sciences/University of Tehran, Tehran, Iran.

Reprint requests to Reza Shariat Moharari, MD, Sina Hospital, Hassan AbadSquare, Tehran, Iran. Email: moharari@sina.tums.ac.ir

This study was conducted after the approval in ethical board committee ofour hospital.

Accepted August 20, 2007.

Copyright © 2008 by The Southern Medical Association

0038-4348/0�2000/10100-0001

Key Points• Absorption of the fluid used during TURP may dis-

turb the circulatory system and lead to transurethralresection syndrome.

• Using sterile water as irrigating fluid, there were nostatistically significant changes in serum sodium,blood urea nitrogen, creatinine, and hematocrit beforeand after the operation.

• Hypotension, hypertension, nausea, and vomiting werethe most common complications; hyponatremia, de-creased hematocrit, and increased blood urea nitrogen/creatinine were rarely reported.

Southern Medical Journal • Volume 101, Number 4, April 2008 1

lidocaine 5% (100 mg) or hyperbaric bupivacaine 0.5% (10mg). Patients who were anesthetized using other methods,such as general anesthesia due to anatomic problems or thepatients’ refusal were excluded from the study. This verygroup included 4% of all of the cases. A standardized TURPoperation5 was performed on all of the subjects using con-tinuous flow resectoscope. The operations were done by sev-eral experienced urologists who were the academic staff ofthe hospital.

Serum sodium (Na), blood urea nitrogen (BUN), creati-nine (Cr), and hematocrit (Hct) of each patient were recordedbefore and immediately after the operation (maximally 1hour). All of the tests were carried out in a unique laboratory(Sina University Hospital). Besides the body temperature,pulse rate and noninvasive blood pressure, electrocardiogrammonitoring, and pulse oximetry were observed during thecourse of operation. The reliability of the results was estab-lished in a pilot study. Sterile water (37°C) localized 85 cmabove the patients’ beds was administered for all of the cases.The volume of the irrigating fluid used and reflected wasrecorded to compute the absorbed fluid. The patients’ urinewas collected and its volume was calculated as milliliter perhour. The operation time (from the induction of anesthesiauntil the time the patient was transferred from the recoveryroom) and also the proper weight of the resected tissues wererecorded. The definition of unpleasant biochemical eventsand the cardiovascular evaluation are based on Miller’s An-esthesia, the sixth edition.5

The statistical analysis was done using SPSS 10.0 soft-ware. Biochemical indicators were recorded as mean and stan-dard deviation (SD) and comparison of pre- versus postop-eration variables was done with paired t test. As � was set at0.05, P � 0.05 was considered significant.

ResultsThe mean age of the patients (�SD) was 66.8 � 6.4

years with the median age of 67, ranging from 54 to 84 years.The mean operation time (�SD) was 40 � 4 minutes (medianof 38). The mean weight of the resected tissue and the resec-tion rate (�SD) were 31 � 5 g and 16 � 2 g/min, respectively.The mean irrigating absorption (�SD) was 293 � 25 mL.

Table 1 shows no significant differences between pre-and immediately postoperation quantities of biochemical in-dicators of serum. Reported complications and unpleasantevents are listed in Table 2.

DiscussionThe present study reports the results of a wide range of

patients who were candidates for TURP. This study is uniquebecause of the large sample size used; moreover, due to beingconducted in a referral academic hospital, the findings areindependent of the surgeons’ experience. This case study does

not intend to show that sterile water is the best irrigatingfluid, but emphasize the point that it is safe and cheap.

Sterile water is a historical and traditional fluid used toirrigate the bladder during TURP. It is accepted that transurethralresection syndrome caused by dilutional hyponatremia resultssecondary to the absorption of at least 3000 mL of irrigatingfluid.3,6 According to the present study, smaller absorbed vol-umes may elicit milder forms of the syndrome; as a matter offact, the amount of absorbed fluid was neglectable and hypona-tremia (Na �130 mEq/dL) was rare (2.5%).

According to the results of the present study, there wereno statistically significant changes in the serum Na, BUN, Cr,and Hct. This finding is probably achieved due to the smallamount of irrigating fluid absorbed. Previous studies haveshown the higher amount of absorbed fluid to be accompa-nied with more frequent complications and more severechanges in electrolytes and Hct.2

Absorption of the fluid used for bladder irrigation duringTURP may disturb the circulatory system and lead to clinical

Table 2. Frequency of unpleasant events andcomplications during or immediately after TURP

Complications Frequency Percent

Hyponatremia 40 2.5

Increased BUN/Cr 15 0.9

Oliguria 1 0.0

Decreased Hct (�30%) 16 1.0

Active bleeding 3 0.0

Nausea 103 6.4

Vomiting 45 2.8

Hypertension 125 7.8

Hypotension (includes orthostatic) 132 8.3

Bradycardia 32 2.0

Other arrhythmias (eg, PAC, PVC, etc) 78 4.9

Change in body temperature 22 1.4

Mortality 0 0.0

PAC, premature atrial contraction(s); PVC, premature ventricular contrac-tion(s); BUN, blood urea nitrogen; Cr, creatinine; Hct, hematocrit.

Table 1. Changes in biochemical indicators of patientsthroughout the operation

PreoperationMean � SD

PostoperationMean � SD

Paired t test

t P

Na (mEq/L) 138 � 8 137 � 9 1.100 NS

BUN (mg/dL) 14 � 6 15 � 5 1.111 NS

Cr (mg/dL) 1.0 � 0.6 1.1 � 0.5 0.511 NS

Hct (%) 38 � 8 37 � 9 0.812 NS

NS, nonsignificant; Na, serum sodium; BUN, blood urea nitrogen; Cr, cre-atinine; Hct, hematocrit; SD, standard deviation.

Moharari et al • Sterile Water as an Irrigating Fluid

2 © 2008 Southern Medical Association

symptoms, known as the transurethral resection syndrome.The prevalence of the syndrome varies in different studies,which might be related to factors including the type of chem-ical fluid used for irrigation (eg, sterile water, mannitol, gly-cine, etc), the osmotic characteristic of the irrigating fluid(hypo-, normo-, or hyperosmolar fluids), the patient’s condi-tion, and the amount of fluid absorbed.2,3,7,8 According toHagstrom3, the susceptibility of patients to develop thesesymptoms varies according to their age and physical condi-tions.

Some investigators have shown that the fluid’s temper-ature interacts with the complications.1 The fluid bags withthe room temperature of 37°C, which were traditionally usedin our center, prevent some cardiovascular changes and hypo-or hyperthermia.

Some authors suggested that hypertension is caused bythe fluid overload in the clinical syndrome during and afterTURP, though it maybe followed by dilutional hyponatremicshock.1 The results of Hahn et al’s2 research showed thathypertension occurred in approximately 20% of the patientswho underwent TURP regardless of the amount of the ab-sorbed fluid. On the contrary, hypotension was strongly as-sociated with the increase of absorption during and after theprocedure. The cause of hypotension is not as clear as thecause of hypertension, but it maybe the result of acute hypo-natremia,6 dissemination of vasoactive substances from theoperating field,9 and the circulation itself.10 Significant hem-orrhage also increases the risk of intraoperative decreases inthe arterial pressure. In our study, hypertension was reportedin 7.8% of the cases, which maybe related to other situationssuch as the prevalence of hypertension in the elderly in Iran.Hypotension was somewhat more frequent, but it may not bea serious problem, as many cases only had the transient form,probably due to some amounts of bleeding. This conditioncould be easily managed by serum therapy and the re-balanc-ing of the body fluids. Also, the frequency of cardiac arrhyth-mias maybe related to the patients’ age; the most frequentforms were premature atrial contraction and premature ven-tricular contraction, which are more common in the elderlyindividuals. As mentioned above, body temperature was con-trolled during the operation and the fluid of the normal bodytemperature was used. This might lead to a significant reduc-tion in the occurrence of cardiac arrhythmias. Olsson et al1

showed the symptoms of bradycardia, hypotension, and im-paired diuresis after transurethral resection of the prostatewere associated with each other. In our study, oliguria wasseen in only one patient.

Few cases of fever or hypothermia were reported in ourstudy. According to Hahn et al,2 postoperative fever wascommon in those who absorbed irrigating fluid (21%) com-pared with only 3% of the nonabsorbing patients. They sug-gested that fluid absorption promotes bacteremia after TURP.The nature of the prostatic hypertrophy, elective surgery, andhygienic methods of surgery may reduce the abovementionedevents.

ConclusionTURP with sterile water is safe and inexpensive. Signif-

icant hyponatremia and fluid absorption did not occur, andthere was no mortality.

AcknowledgmentsWe thank all patients who let us use their information.

Also, we thank all urologists, anesthesiologists, and their res-idents for helping us. We gratefully acknowledge Dr. PatriciaKhashayar for reviewing this manuscript and providing help-ful comments.

References1. Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection

syndrome using glycine as the irrigant. J Urol 1995;154:123–128.

2. Hahn RG, Sanfeldt L, Nyman CR. Double blind randomized study ofsymptoms associated with absorption of glycine 1.5% or monitol 3%during transurethral resection of the prostate. J Urol 1998;160:397–401.

3. Hagstrom RS. Studies on fluid absorption during transurethral prostaticresection. J Urol 1955;73:852–859.

4. Wein AJ, Kavoussi LR, Novick AC, et al. Campbell Walsh Urology.Philadelphia, Saunders Elsevier, 2007, ed 9.

5. Malhotra V, Sudheendra V, Diwan S. Anesthesia and the renal andgenitourinary system, in Miller RD (ed): Miller’s Anesthesia. Philadel-phia, Elsevier Churchill Livingstone, 2005, ed 6, pp 2189–2194.

6. Harrison RH, Boren JH, Robinson JR. Dilutional hyponatremic shock:another concept of the transurethral prostatic resection. J Urol 1956;75:95–110.

7. Shih HC, Kang HM, Yang CR, et al. Safety of distilled water as anirrigating fluid for transurethral resection of the prostate. Zhonghua YiXue Za Zhi 1999;62:503–508.

8. Hahn RG. Early detection of the transurethral resection syndrome bymarking the irrigating fluid with 1% ethanol. Acta Anaesthesiol Scand1989;33:146–151.

9. Verrili RA, Uhlman RC, Viek NF, et al. The hypotensive effect ofprostatic extract. J Urol 1962;87:184–186.

10. Hahn R, Stalberg H, Carlstrom K, et al. Plasma atrial natriuretic peptideconcentration and rennin activity during overhydration with 1.5% gly-cine solution in conscious sheep. Prostate 1994;24:55–61.

Original Article

Southern Medical Journal • Volume 101, Number 4, April 2008 3