- Email: [email protected]
Electrolytes Found in Irrigating Fluids During Transurethral Prostatectomy
THE JOURNAL OF UROLOGY
Vol. 85, No. 1, January 1961 Printed in U.S.A.
ELECTROLYTES FOUI\'D IN IRRIGATING FLUIDS DURING TRANSURETHRAL PROSTATECTOMY JAMES NL WHISENAND
AND
JAMES J. MOSES
From the Department of Urology, San Diego County General Hospital, San Diego, Cal.
Transurethral prostatic surgery has come a long way in the years since a grateful James Buchanan (Diamond Jim) Brady endowed a foundation because of a successful punch operation; the skilled resectionist now performs a prostatectomy that compares well with the best of enucleators. However, as the operation has improved, a few problems have become apparent. One was solved by Creevy,1 who popularized the use of isotonic irrigating fluid to prevent intravascular hemolysis. Dilutional hyponatrernfa was described by Harrison and associates,2 and Taylor and associates 3 proved that patients could absorb up to 3.5 liters of irrigating fluid. This study was undertaken to determine some of the electrolytes present in irrigants used during surgery, and to see if there was any important loss of them by the patient.
Electrolytes in prostatic fluid and semen possibly present in the irrigants were not significant in amount. Standard laboratory methods were used throughout. All determinations were done by the same technician. Values used for electrolyte calculations were taken from Gamble. 5 Irrigants used were distilled water, 1 per cent glycine, and 3.3 per cent sorbitol. RESULTS
Total amounts of various substances present in different irrigating fluids during 15 transurethral prostatectomies are listed in table 1. Electrolytes and urea nitrogen in the blood estimated lost in each case were calculated and results placed above and to the right of the laboratory values. The two minus prosphorus values are due to the correction for urinary phosphorus. JVIaximum and average electrolytes recovered from irrigants in per cent of total available 111 extracellular space are listed in table 2.
MATERIALS AND METHODS
All irrigating fluids used during the 15 transurethral prostatectomies ,vere collected separately in chen1ically clean containers. Aliquots of each were centrifuged, after hemoglobin determination, and analyzed for sodium, potassium, chlorides, calcium, phosphorus, urea and urea nitrogen. Approximate urine formation during surgery was determined from the amount of urea found in the irrigant after deducting the blood urea. All measured electrolyte values were then corrected for amounts present in the urine using the standard table of constituents from Best and Taylor. 4
DISCUSSION
Minimal electrolyte loss occurred in all but two instances. In one, 25 per cent of the average available potassium was recovered from the irrigating fluid (sorbitol). In another, 16.8 per cent of the average available phosphorus was recovered from the irrigant (distilled water). These high values could be due to cellular lysis as a slight degree of hemolysis was noted in some of the cases in which isotonic irrigants were used, and phosphorus recovery was consistently higher in those cases in which distilled water was used. Some puzzling findings were noted. In all but one case, less chloride was recovered from the irrigating fluid than was calculated present from the blood therein. An average 24.5 meq. chloride
Read at annual meeting of American Urological Association, Inc., Chicago, Ill., May 16-19, 1960. 1 Creevy, C. D.: Hemolysis and transurethral resection. Surgery, 39: 180-188, 1956. 2 Harrison, R.H. III, Boren, J. S. and Robinson, J. R.: Dilutional hyponatremic shock: Another concept of the transurethral prostatic resection reaction. J. Urol., 75: 95-110, 1956. 3 Taylor, R. 0. and associates: Volumetric, gravimetric and radioisotopic determination of fluid transfer in transurethral prostatectomy. J. Urol., 79: 490-499, 1958. 4 Best, C. H. and Taylor, N. B.: The Physiological Basis of Medical Practice, 4th ed. Baltimore: Williams & Wilkins, 1945.
5 Gamble, J. C.: Chemical Anatomy, Physiology and Pathology of Extracellular Fluid. Boston: Harvard University Press, 1949.
83
84
J. M. WHISEXAND AND J. J. MOSES TABLE
1
Na
K
Cl
Ca
p
Urea
Urea N
Blood Loss
Urine Volume
meq.
nieq.
nieq.
nig.
mg.
mg.
tng.
cc
cc
34.8 196
290
H20 20.2 25. 8
1
-
I
14.8 4. 95
I
20.8 7. 7
14.5 25. 5
I
I
8.7 23. 6
420
I
I 12. 7
------ ------1----- ------ - - - - - - - - - - - - - - ---- - - 2
21.0 29 . 2
16.7 6 .4
I I
23.6 9 .8
15.1
23.5
I
33.o
I
16.5 23 . 1
9.9 24 . 6
23.o
13.8
228
330
4. 5
460
_13.9
______ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
_]
55.2
1
3 _ 82.5 ___ 16.3 ____ 21.o ___ 31.2 ___ 84.4_ _
510 _ _ 238 _
14.6 4 I 11.6
273
10.7 2.25
15.0 3.3
10.5 76.4
6.3 14.1
I f
14.6 56. 9
II
10.7 17 .1
I
15.0 32. 0
10.5 ] 36 .4
I
6.3 36 .4
I
16.2 130
210
520
16.2 240
210
) 17. 8
651
15.8 310
190
I. I 23.4
----------,--~-------------~
5
I
39.6 108
7.9
_______ ] _ ~ I
Glycine I
1
I
14.85 57.9
.52 5.0
I I
19.6 9.2
I
10.4 119.3
5.7 -6.5
I
- - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - ! _ __
42.0 2
I
1.49
40.2
11
2.95
55.6
I
6.9
29.7
16.2
26.0
64.8
5.2
448
'I
210
540
10.0
-1------------~--------------~---------i---.
38.2
1.35
50.5
27.0
13.7
58.8
- ------i------------------------------___]____ 3
48. 6
4
20.3 10 . 2
5
44. 2
I
3. 56
8 .4
65. 3
.1 1. 41
26.8 1. 54
14.3 10 . 06
20.6
I 11.0 I 68 .4
15.65
.55
3 .3
I 1
5.6
8. 1
510
1 .8 11 . o
200
238
31.2 99
6.0
24.0
33 . 6
000
490
425
250
I
13. 5
I I
4. 1
j'
200
33 . 2
Sorbitol - - - - ~ - - ~ ,- - - - - - - - - 1 - - - - ~ - - - - - - - 1 - - - ~ - - - I- - -
1 -
4. 3 3 .1 ------
.138
II
.4
5 .15 1.1
I
2. 75 3 .1
1. 5 5. 8
6. 0
I!
75. 6
36
50
i
2.5
______ ____ _____ - - - - - - - - - - - - - - - - - · - - - ,
)
2
31. 2 46.2
1.1 8.45
41.0 20.4
22.0 42.8
12.0 16.6
420
3
4.3 15.2
.11 1.24
4.1 3.26
2.2 14.3
1.2 -31. 55
920.2
430
4
7.0 21.1
1. 7
9.25 3.5
5.0 21.0
27.0 9.2
165
77
5
21.0 79.3
18.2
14.8 50.6
7.1 5.0
768
32.4 336
.25
.74
27.8 25.6
48.0 195
400
11.2
40
36.2
90
5.3
270
26.9
4.8
6.8
ELECTROLYTES IN IRRIGATING FLUIDS TABLE
Sodium Potassium Chloride Calcium Phosphorus
2
Maximum
Average
3.4% 25.0% (sorbitol) 1.18% 7 .8% (glycine) 16.8% (dist. H,0)
1.38% 3.25% 1.18% 2.97% 4.4%
should have been recovered; only 11 meq. were found. In four of the 5 cases in which distilled
85
water was used, less potassium was found than was calculated to be present. An average 16.4 meq. potassium should have been present; only 7.5 meq. were recovered. CONCLUSIONS
Average electrolyte loss during transurethral prostatectomy appears insignificant. However, it may be possible for a given patient to lose an appreciable amount of potassium or phosphorus.
6837 La Jolla Blvd., La Jolla, Cal. (J. M. W.)
Vol. 85, No. 1, January 1961 Printed in U.S.A.
ELECTROLYTES FOUI\'D IN IRRIGATING FLUIDS DURING TRANSURETHRAL PROSTATECTOMY JAMES NL WHISENAND
AND
JAMES J. MOSES
From the Department of Urology, San Diego County General Hospital, San Diego, Cal.
Transurethral prostatic surgery has come a long way in the years since a grateful James Buchanan (Diamond Jim) Brady endowed a foundation because of a successful punch operation; the skilled resectionist now performs a prostatectomy that compares well with the best of enucleators. However, as the operation has improved, a few problems have become apparent. One was solved by Creevy,1 who popularized the use of isotonic irrigating fluid to prevent intravascular hemolysis. Dilutional hyponatrernfa was described by Harrison and associates,2 and Taylor and associates 3 proved that patients could absorb up to 3.5 liters of irrigating fluid. This study was undertaken to determine some of the electrolytes present in irrigants used during surgery, and to see if there was any important loss of them by the patient.
Electrolytes in prostatic fluid and semen possibly present in the irrigants were not significant in amount. Standard laboratory methods were used throughout. All determinations were done by the same technician. Values used for electrolyte calculations were taken from Gamble. 5 Irrigants used were distilled water, 1 per cent glycine, and 3.3 per cent sorbitol. RESULTS
Total amounts of various substances present in different irrigating fluids during 15 transurethral prostatectomies are listed in table 1. Electrolytes and urea nitrogen in the blood estimated lost in each case were calculated and results placed above and to the right of the laboratory values. The two minus prosphorus values are due to the correction for urinary phosphorus. JVIaximum and average electrolytes recovered from irrigants in per cent of total available 111 extracellular space are listed in table 2.
MATERIALS AND METHODS
All irrigating fluids used during the 15 transurethral prostatectomies ,vere collected separately in chen1ically clean containers. Aliquots of each were centrifuged, after hemoglobin determination, and analyzed for sodium, potassium, chlorides, calcium, phosphorus, urea and urea nitrogen. Approximate urine formation during surgery was determined from the amount of urea found in the irrigant after deducting the blood urea. All measured electrolyte values were then corrected for amounts present in the urine using the standard table of constituents from Best and Taylor. 4
DISCUSSION
Minimal electrolyte loss occurred in all but two instances. In one, 25 per cent of the average available potassium was recovered from the irrigating fluid (sorbitol). In another, 16.8 per cent of the average available phosphorus was recovered from the irrigant (distilled water). These high values could be due to cellular lysis as a slight degree of hemolysis was noted in some of the cases in which isotonic irrigants were used, and phosphorus recovery was consistently higher in those cases in which distilled water was used. Some puzzling findings were noted. In all but one case, less chloride was recovered from the irrigating fluid than was calculated present from the blood therein. An average 24.5 meq. chloride
Read at annual meeting of American Urological Association, Inc., Chicago, Ill., May 16-19, 1960. 1 Creevy, C. D.: Hemolysis and transurethral resection. Surgery, 39: 180-188, 1956. 2 Harrison, R.H. III, Boren, J. S. and Robinson, J. R.: Dilutional hyponatremic shock: Another concept of the transurethral prostatic resection reaction. J. Urol., 75: 95-110, 1956. 3 Taylor, R. 0. and associates: Volumetric, gravimetric and radioisotopic determination of fluid transfer in transurethral prostatectomy. J. Urol., 79: 490-499, 1958. 4 Best, C. H. and Taylor, N. B.: The Physiological Basis of Medical Practice, 4th ed. Baltimore: Williams & Wilkins, 1945.
5 Gamble, J. C.: Chemical Anatomy, Physiology and Pathology of Extracellular Fluid. Boston: Harvard University Press, 1949.
83
84
J. M. WHISEXAND AND J. J. MOSES TABLE
1
Na
K
Cl
Ca
p
Urea
Urea N
Blood Loss
Urine Volume
meq.
nieq.
nieq.
nig.
mg.
mg.
tng.
cc
cc
34.8 196
290
H20 20.2 25. 8
1
-
I
14.8 4. 95
I
20.8 7. 7
14.5 25. 5
I
I
8.7 23. 6
420
I
I 12. 7
------ ------1----- ------ - - - - - - - - - - - - - - ---- - - 2
21.0 29 . 2
16.7 6 .4
I I
23.6 9 .8
15.1
23.5
I
33.o
I
16.5 23 . 1
9.9 24 . 6
23.o
13.8
228
330
4. 5
460
_13.9
______ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
_]
55.2
1
3 _ 82.5 ___ 16.3 ____ 21.o ___ 31.2 ___ 84.4_ _
510 _ _ 238 _
14.6 4 I 11.6
273
10.7 2.25
15.0 3.3
10.5 76.4
6.3 14.1
I f
14.6 56. 9
II
10.7 17 .1
I
15.0 32. 0
10.5 ] 36 .4
I
6.3 36 .4
I
16.2 130
210
520
16.2 240
210
) 17. 8
651
15.8 310
190
I. I 23.4
----------,--~-------------~
5
I
39.6 108
7.9
_______ ] _ ~ I
Glycine I
1
I
14.85 57.9
.52 5.0
I I
19.6 9.2
I
10.4 119.3
5.7 -6.5
I
- - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - ! _ __
42.0 2
I
1.49
40.2
11
2.95
55.6
I
6.9
29.7
16.2
26.0
64.8
5.2
448
'I
210
540
10.0
-1------------~--------------~---------i---.
38.2
1.35
50.5
27.0
13.7
58.8
- ------i------------------------------___]____ 3
48. 6
4
20.3 10 . 2
5
44. 2
I
3. 56
8 .4
65. 3
.1 1. 41
26.8 1. 54
14.3 10 . 06
20.6
I 11.0 I 68 .4
15.65
.55
3 .3
I 1
5.6
8. 1
510
1 .8 11 . o
200
238
31.2 99
6.0
24.0
33 . 6
000
490
425
250
I
13. 5
I I
4. 1
j'
200
33 . 2
Sorbitol - - - - ~ - - ~ ,- - - - - - - - - 1 - - - - ~ - - - - - - - 1 - - - ~ - - - I- - -
1 -
4. 3 3 .1 ------
.138
II
.4
5 .15 1.1
I
2. 75 3 .1
1. 5 5. 8
6. 0
I!
75. 6
36
50
i
2.5
______ ____ _____ - - - - - - - - - - - - - - - - - · - - - ,
)
2
31. 2 46.2
1.1 8.45
41.0 20.4
22.0 42.8
12.0 16.6
420
3
4.3 15.2
.11 1.24
4.1 3.26
2.2 14.3
1.2 -31. 55
920.2
430
4
7.0 21.1
1. 7
9.25 3.5
5.0 21.0
27.0 9.2
165
77
5
21.0 79.3
18.2
14.8 50.6
7.1 5.0
768
32.4 336
.25
.74
27.8 25.6
48.0 195
400
11.2
40
36.2
90
5.3
270
26.9
4.8
6.8
ELECTROLYTES IN IRRIGATING FLUIDS TABLE
Sodium Potassium Chloride Calcium Phosphorus
2
Maximum
Average
3.4% 25.0% (sorbitol) 1.18% 7 .8% (glycine) 16.8% (dist. H,0)
1.38% 3.25% 1.18% 2.97% 4.4%
should have been recovered; only 11 meq. were found. In four of the 5 cases in which distilled
85
water was used, less potassium was found than was calculated to be present. An average 16.4 meq. potassium should have been present; only 7.5 meq. were recovered. CONCLUSIONS
Average electrolyte loss during transurethral prostatectomy appears insignificant. However, it may be possible for a given patient to lose an appreciable amount of potassium or phosphorus.
6837 La Jolla Blvd., La Jolla, Cal. (J. M. W.)