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      Sudden occurence of hypotension and bradycardia during greenlight laser transurethral resection of prostate: case report of two cases

      case-report
      Author(s): 1 , 2 ,
      Publication date (Electronic):
      Journal: BMC Anesthesiology
      Publisher: BioMed Central
      Keywords: Parasympathetic reflex, Transurethral resection of prostate, Greenlight laser

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          Abstract

          Background

          Greenlight laser transurethral resection of prostate (TURP) is a standard surgical method used to treat patients with prostate gland enlargement, it is safe and effective.

          Case presentation

          We report two cases of sudden occurence of hypotension and bradycardia during greenlight laser TURP. Two patients with benign prostatic hypertrophy were scheduled for greenlight laser TURP under spinal anesthesia. Hypotension and bradycardia were suddenly occurred during the operation. The blood gas analysis revealed no hyponatremia (indicating TURP syndrome) or anemia (indicating hemorrhage). Operation was suspended and inotropic agents were administrated intravenous immediately, then blood pressure and heart rate increased to normal level within some minutes. The patients were discharged from hospital without any complications. We considered parasympathetic reflex was occurred during greenlight laser TURP.

          Conclusion

          Apart from TURP syndrome, hemorrhage, bladder perforation and high spinal anesthesia, the parasympathetic reflex which is caused by operative process can also induce hypotension and bradycardia during TURP.

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          Most cited references15

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          Bipolar transurethral resection in saline--an alternative surgical treatment for bladder outlet obstruction?

          Dirk Michielsen, Tibaut Debacker, Veerle De Boe … (2007)
          The transurethral resection in saline system uses bipolar energy for transurethral prostate resection, thus, avoiding the need for glycine irrigation and its associated complications. We compared the clinical efficacy and safety of bipolar transurethral resection in saline and of monopolar transurethral prostate resection for symptomatic benign prostate hyperplasia. From January 2005 to June 2006, 238 consecutive patients with symptomatic benign prostate hyperplasia were randomized into a prospective, controlled trial comparing the 2 treatment modalities. Patient demographics, operative time, hospital stay and complications were noted. Serum hemoglobin and electrolytes were determined in all patients immediately before and after the endoscopic procedure. During 18 months 120 patients were randomized to the conventional transurethral prostate resection group and 118 were randomized to the transurethral resection in saline group. Patient profiles, weight of resected prostatic tissue and duration of hospitalization were similar in the 2 groups. The decrease in serum sodium and serum chloride was statistically significantly greater in the transurethral prostate resection group than in the transurethral resection in saline group (each p = 0.05). The transurethral resection in saline procedure required significantly more time (mean 56 vs 44 minutes, p <0.01). There was 1 case (0.8%) of transurethral resection syndrome in the transurethral prostate resection group but none in the transurethral resection in saline group. Postoperative bleeding did not significantly differ between the 2 groups. Clot retention was observed in 6 (5%) and 4 patients (3%) in the transurethral prostate resection and transurethral resection in saline group, respectively. Two repeat interventions were required in the transurethral prostate resection group. The bipolar transurethral resection in saline system is as efficacious as monopolar transurethral prostate resection but it is safer than the latter because of the lesser decrease in postoperative hypernatremia and the smaller risk of transurethral resection syndrome. However, probably due to technical reasons, transurethral resection in saline operative time is significantly longer.
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            Transurethral resection syndrome in elderly patients: a retrospective observational study

            Junko Nakahira, Toshiyuki Sawai, Atsushi Fujiwara … (2014)
            Background Transurethral resection of the prostate (TURP) involves the risk of transurethral resection (TUR) syndrome owing to hyponatremia. Irrigation fluid type, duration of operation, and weight of resected mass have been evaluated as risk factors for TUR syndrome. The purpose of the present study was to identify risk factors related to TUR syndrome in the elderly. Methods After obtaining approval from the Institutional Review Board, data on all elderly males (aged 70 years and older) who underwent TURP under regional anesthesia over a 6-year period at our institution were retrospectively reviewed. TUR syndrome was defined as evidence of a central nervous system disturbance such as nausea, vomiting, restlessness, confusion, or even coma with a circulatory abnormality both intra- and post-operatively. Patients were divided into two groups, positive and negative, for the occurrence of the syndrome. Data such as previous medical history, preoperative and postoperative serum data, weight of resected mass, duration of operation, irrigation fluid drainage technique, anesthetic technique, operative infusion and transfusion volume, and neurological symptoms were collected. Only observational variables with p   45 g (OR 4.1, 95% CI 1.2–14.7) were associated with significantly increased risks for TUR syndrome (Hosmer-Lemeshow test, p = 0.94, accuracy 84.7%). Conclusions These results suggest that the use of a plasma substitute and continuous irrigation through a suprapubic cystostomy must be avoided during TURP procedures in the elderly.
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              Anatomic study of periprostatic nerve distribution: immunohistochemical differentiation of parasympathetic and sympathetic nerve fibres.

              Roman Ganzer, Jens-Uwe Stolzenburg, Wolf F Wieland … (2012)
              Many authors advocate a high anterior incision during nerve-sparing radical prostatectomy (RP) to improve potency results. Despite a growing number of studies describing autonomic nerves in the ventrolateral position of the prostate, little is known about their quality and their role in erectile function. The intention of this study was a detailed characterisation of the topographic distribution of periprostatic nerves, including immunohistochemical differentiation of proerectile parasympathetic from sympathetic nerves. A total of 228 whole-mount sections of 38 prostates (base, middle, apex) from patients following non-nerve-sparing laparoscopic RP were analysed. Immunohistochemical analysis was performed using antibodies against tyrosine hydroxylase for sympathetic and vesicular acetylcholine transporter for parasympathetic nerve fibre staining. Quantification of periprostatic parasympathetic and sympathetic nerves was performed after defining prostatic regions via a digital grid. Differences among three independent variables were tested with the nonparametric Kruskal-Wallis test. The total number of parasympathetic nerves did not decrease from the base to the apex. They were dispersed at the base and mainly located dorsolaterally at the apex, with 14.6% above the horizontal line at the base and only 1.5% at the apex. In contrast, the total number of sympathetic nerves decreased significantly from base to apex, with a constant proportion of ventrolateral nerves between 9% (base) and 6.2% (apex). This anatomic study is limited by the investigation of postprostatectomy specimens and the lack of functional results. Despite the presence of ventrolateral periprostatic nerves, only a minority of these nerves seems to have a parasympathetic proerectile quality. The arguments in favour of a high anterior incision during nerve-sparing prostatectomy might not only include preserved nerves but also other factors, such as reduced traction or improved anatomic support of the neural structures. Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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                Author and article information

                Contributors
                Zheng Guan: guanzheng1980@126.com
                Jingjie Liu: liujjxing8008@126.com
                Journal
                Journal ID (nlm-ta): BMC Anesthesiol
                Journal ID (iso-abbrev): BMC Anesthesiol
                Title: BMC Anesthesiology
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2253
                Publication date (Electronic): 30 August 2016
                Publication date PMC-release: 30 August 2016
                Publication date Collection: 2015
                Volume: 16
                Issue: 1
                Electronic Location Identifier: 70
                Affiliations
                [1 ]Department of Anesthesiology, The First Affiliated Hospital of Xi’an Jiaotong University, Yanta West Road, No.277, 710061 Xi’an, China
                [2 ]Department of Neurology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
                Article
                Publisher ID: 234
                DOI: 10.1186/s12871-016-0234-x
                PMC ID: 5006278
                PubMed ID: 27576558
                SO-VID: 4d905ee3-6c06-4347-bda5-10bb75c0608c
                Copyright © © The Author(s). 2016
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 8 January 2016
                Date accepted : 24 August 2016
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2016

                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: parasympathetic reflex,transurethral resection of prostate,greenlight laser
                Data availability:
                ScienceOpen disciplines: Anesthesiology & Pain management
                Keywords: parasympathetic reflex, transurethral resection of prostate, greenlight laser

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