Background Benign prostatic hypertrophy with lower urinary tract symptoms, which include nocturia, frequency, and bladder outlet obstruction with incomplete voiding, is a common indication for prostatic... [ view full abstract ]
Background
Benign prostatic hypertrophy with lower urinary tract symptoms, which include nocturia, frequency, and bladder outlet obstruction with incomplete voiding, is a common indication for prostatic resection. The gold standard for benign prostatic hypertrophy resection is transurethral resection (TURP), but patients with large prostates are not candidates for TURP and have traditionally undergone open surgical resection. Recently, less invasive transurethral holmium laser resection of the prostate (HoLEP) with normal saline urologic irrigation has been utilized for resection of larger benign prostates. HoLEP has a steep procedural learning curve and is performed at only approximately twenty centers in the United States. We describe complications of a HoLEP procedure due to fluid absorption caused by intraoperative large volume normal saline urologic irrigation.
Case Report
Our patient is a 70 year old male with a large (140cc) prostate who underwent HoLEP for BPH causing chronic bladder outlet obstruction. His medical history was complicated by chronic hepatitis C, daily alcohol use, cirrhosis with esophageal varices, hypertension, and multiple myeloma. During the HoLEP, the patient progressively became hypothermic, and 150 minutes after procedure start developed progressive hypoxemia resistant to alveolar recruitment and with unchanged ventilation parameters or end tidal carbon dioxide levels. ABG analysis revealed a hyperchloremic non-gap metabolic acidosis and large A-a gradient. Discussion with the surgical team revealed the use of 40 liters of normal saline bladder irrigation fluid, with an estimated 90 minutes of case time remaining. The procedure was aborted and the patient was transported intubated to intensive care with lactated ringers in place of the standard normal saline bladder irrigation. Spiral CT chest was negative for pulmonary embolism, and cardiac evaluation was unremarkable. The patient returned the following week for completion of the HoLEP procedure and again developed progressive hypothermia, hypoxia and hyperchloremic non-gap metabolic acidosis necessitating post-op intubation.
Discussion
HoLEP has a steep learning curve, but provides benefits over traditional open surgical treatment in patients with large benign prostates. This case, only the 8th HoLEP procedure to be performed at UCSF, highlights potential pitfalls in this procedure. The first case report of an identical HOLEP complication presentation was published only 6 days prior to this case. We postulate that this patient’s portal hypertension may have caused a proliferation or engorgement of his prostatic venous sinuses predisposing him to increased absorption of urologic normal saline irrigation fluid. Patients on dialysis or with congestive heart failure may also be predisposed. Such patients should be identified and strategies for reducing or mitigating the effects of volume overload should be included in the HoLEP anesthetic and operative plan.
