Skip to main content
  1. BAUS Home
  2. Training & Trainees
  3. Urology SHO
  4. Other conditions
  5. TUR syndrome

Please note: This page is intended for healthcare professionals only. It is designed as a general educational guide and does not replace local guidance, senior clinical advice, or individual clinical judgement. Patients should not use this page as medical advice and should seek advice from an appropriate healthcare professional.

TUR Syndrome

Transurethral resection (TUR) syndrome is an iatrogenic fluid overload with secondary hyponatremia. This can occur from 15min up to 24hrs post-operatively.

Immediate priorities

  • Early identification is key - perform A-E assessment
  • Inform Urology SpR and involve ICU team early
  • Perform blood gas + bloods to measure plasma Na, Osmolality and Hb
  • Consult ITU / Medical team before Na correction

Cause

  • It is seen in a variety of endoscopic surgical procedures, although classically after transurethral resection of the prostate (TURP) and less commonly after TURBT or PCNL in long cases.
  • It occurs when irrigating fluid (particularly glycine) is absorbed in excess and produces systemic manifestations

Risk Factors

  • Monopolar resection (lower risk with Bipolar as it uses saline irrigation)
  • Long resection time > 1 hr (resection shouldn’t be longer than 90min) which also leads to larger fluid use
  • Height of bag > 70cm
  • Perforation of the prostate capsule or bladder
  • Large prostate size (>45g) → prolonged resection time + excessive bleeding
  • Significant haemorrhage
  • Patient age and comorbidity (CKD, CHF)

Presentation

CNS

Due to Glycine and Ammonia neurotoxicity and acute hypo-osmolality. Blood-brain barrier is virtually impermeable to sodium but freely permeable to water.

  • Restlessness, headache, visual disturbances, nausea / vomiting
  • Confusion, seizures, coma
Cardiovascular and respiratory
  • Hypertension, tachycardia, tachypnoea
  • Hypoxia, pulmonary oedema, hypotension, bradycardia
Metabolic and renal
  • Hyponatraemia, hyperglycaemia, hypocalcaemia
  • Intravascular haemolysis, DIC syndrome, acute renal failure
  • If Physiological Saline is used (bipolar dissection) – risk of hyperchloraemic acidosis
  • If Sorbitol-Mannitol solution used – risk of hyperglycemia and type B lactic acidosis

Management

Initial Management
  1. Early identification is key - Perform A-E assessment
  2. Inform Urology SpR and involve ICU team early
  3. Blood gas + bloods to measure plasma Sodium, Osmolality and Hb

Treatment is primarily supportive

  1. Consider fluid restriction
  2. Promote diuresis if pulmonary oedema (unless hypotensive; will worsen hyponatraemia)
    • IV Furosemide 40mg, IV 20% Mannitol 100ml
  3. Sodium correction if Na <120 or neurological symptoms
    • Always consult ITU/Medical team before correction!
    • May require IV NaCl 3% 1000ml with max rate of 100ml/hr (give over 12hrs)
    • Don't exceed rate of correction 1mmol/L/h
  4. Visual disturbances - usually self-limiting and resolves in 24hrs
    • Glycine half-life 85min
  5. Agitation, confusion, seizures - benzodiazepines (Midazolam/Diazepam) or Phenytoin. Consider Magnesium.
  6. Supplemental oxygen as required. Seldom may require airway protection with intubation
  7. Hypotension and bradycardia - discuss with ICU - may require atropine, calcium, vasopressors

References

  1. Hawary A, Mukhtar K, Sinclair A, Pearce I. Transurethral resection of the prostate syndrome: almost gone but not forgotten. J Endourol. 2009;23(12):2013-2020. doi:10.1089/end.2009.0129
  2. Arslan K., Şahin A.S. Transurethral resection of the prostate (TURP) syndrome: a review of perioperative management. Comp Med. 2024 Apr 24;16(2):123–127. doi: 10.14744/cm.2024.85570.
  3. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention. Eur Urol. 2006;50(5):969-980. doi:10.1016/j.eururo.2005.12.042