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UROSCAN
Year : 2010  |  Volume : 26  |  Issue : 3  |  Page : 466-468
 

Serum glucose as a predictor of fluid absorption during transurethral bipolar prostatic surgery


1 Department of Anesthesia, Kasturba Medical College, Manipal, India
2 Department of Urology, Kasturba Medical College, Manipal, India

Date of Web Publication1-Oct-2010

Correspondence Address:
Joseph Thomas
Department of Urology, Kasturba Medical College, Manipal
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Thomas JT, Chawla A, Thomas J. Serum glucose as a predictor of fluid absorption during transurethral bipolar prostatic surgery. Indian J Urol 2010;26:466-8

How to cite this URL:
Thomas JT, Chawla A, Thomas J. Serum glucose as a predictor of fluid absorption during transurethral bipolar prostatic surgery. Indian J Urol [serial online] 2010 [cited 2019 Jun 17];26:466-8. Available from: http://www.indianjurol.com/text.asp?2010/26/3/466/70603

Piros D, Fagerström T, Collins JW, Hahn RG. Glucose as a marker of fluid absorption in bipolar transurethral surgery. Anesth Analg 2009;109:1850-5.



   Summary Top


This study was conducted to evaluate if glucose added to the irrigant can be used as a tracer for fluid absorption during transurethral resection of prostate (TURP). The clinical part of the study investigated whether the changes in serum glucose concentration matched that of the serum sodium concentration. Monopolar TURP was performed in 250 patients with the patients randomized to receive either 1.5% glycine or 5% glucose as the irrigant. Blood samples were taken just before and 5 min after the procedure for the measurement of serum glucose and sodium concentrations. The second experimental part of the study was on 10 healthy volunteers aimed at creating a nomogram correlating the irrigating fluid volume and the increase in serum glucose. A constant infusion of acetated Ringer lactate at 20 mL/kg with 1% glucose was administered over 30 min. Blood samples were collected at different periods for various biochemical analyses, including glucose concentration.

There was no change in serum sodium or serum glucose concentrations in patients who had 1.5% glycine as irrigant when there was no absorption. However, when there was fluid absorption, there was a significant correlation between the decrease in the serum sodium and increase in the serum glucose concentration when 5% glucose in water was used as the irrigating solution. The results also showed that the absorption of the irrigating fluid containing isotonic glucose increased the serum glucose concentration in inverse linear proportion to the reduction in serum sodium concentration. The linearity included serum sodium changes from 0 to 20 mmol/L corresponding to the absorption of up to 3.5 L. This finding was used in the experimental model for identifying the potential usefulness of glucose as a tracer in bipolar transurethral surgery. The tracer was evaluated based on kinetic data derived from volunteers who received the infusion of Ringer's acetate with 1% glucose. A nomogram was constructed, which showed that regardless of the pattern of absorption in a 1-h operation, the absorption of 1 and 2 L would increase the plasma glucose concentration by 3.7 and 6.9 mmol/L followed by a decrease of 30% per 10 min. It has been shown by clinical trials that serum glucose concentration will not change due to endocrine variations during TURP if there is no fluid absorption, even in diabetics. Taking this variation into consideration, the study has shown that the existence of absorption can be detected with 95% confidence if the plasma concentration increases by more than 1.4 mmol/L.


   Comments Top


Absorption of the 1-2 L of irrigating fluid is a common problem with transurethral resection of prostate (TURP), producing minor TUR syndrome in 5-10% of patients undergoing TURPs. Life-threatening complications of TUR syndrome occurs when the absorption is in excess of 3 L. Although intraoperative ethanol or nitrous oxide monitoring can foresee and prevent major absorption during the resection, it is seldom used routinely. [1],[2] During the commonly done monopolar prostatic resection, the measurement of postoperative sodium concentration can be used to assess fluid absorption. One of the proposed advantages of bipolar TURP is that it does not cause TUR syndrome as it uses 0.9% NaCl for irrigation, [3],[4] and the serum sodium concentration will not reflect fluid absorption. Although the consequences of hyponatremia, such as cerebral edema, can be avoided with electrolyte-containing crystalloids, there can be problems due to rapid vascular overload, such as pulmonary edema. This necessitates the need for a readily available method to determine clinically relevant fluid absorption during bipolar surgery. This study confirmed the usefulness of measuring glucose to diagnose fluid absorption during transurethral procedures. It has been shown by clinical trials that serum glucose concentration will not change due to endocrine variations during TURP if there is no fluid absorption even in diabetics. [5] The use of glucose in the irrigant brings in concerns regarding the problems due to high levels of plasma glucose. However, it has been shown that the serum glucose levels have to be significantly high for the complications to develop. [6] The study has not looked at the metabolic stress response that can occur in a TURP associated with major blood loss or fluid absorption. [5] The issue of insulin resistance in the elderly, which can also increase the plasma glucose level during a clinical TURP, also has not been addressed. There was no apparent effect of diabetes mellitus on the degree of hyperglycemia. This may be because fluid absorption is more during the end of surgery allowing little time for differences in the half-life of glucose to affect the plasma glucose levels. There can be overestimation of absorbed fluid volume estimated by the nomogram if the sampling of plasma glucose is delayed at the end of the TURP. Another issue is when the surgical duration is longer than 60 min. In this study, the simulation studies carried out for 90 min showed that plasma glucose concentration increases by >1.4 mmol/L for all patterns of fluid absorption.

 
   References Top

1.Checketts MR, Duthie WH. Expired breath ethanol measurement to calculate irrigating fluid absorption during transurethral resection of the prostate: experience in a district general hospital. Br J Urol 1996;77:198-202.  Back to cited text no. 1      
2.Piros D, Drobin D, Hahn RG. Nitrous oxide for monitoring fluid absorption in volunteers. Br J Anaesth 2007;98:53-9.   Back to cited text no. 2      
3.Bhansali M, Patankar S, Dobhada S, Khaladkar S. Management of large (>60 g) prostate gland: PlasmaKinetic Superpulse (bipolar) versus conventional (monopolar) transurethral resection of the prostate. J Endourol 2009;23:141-5.  Back to cited text no. 3      
4.Chen Q, Zhang L, Liu YJ, Lu JD, Wang GM. Bipolar transurethral resection in saline system versus traditional monopolar resection system in treating large-volume benign prostatic hyperplasia. Urol Int 2009;83:55-9.   Back to cited text no. 4      
5.Hahn RG. Influence of the fluid balance on the cortisol and glucose responses to transurethral prostatic surgery. Acta Anaesthesiol Scand 1989;33:638-41.  Back to cited text no. 5      
6.Kagansky N, Levy S, Knobler H. The role of hyperglycemia in acute stroke. Arch Neurol 2001;58:1209-12.  Back to cited text no. 6      



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