高氯酸血症─攝護腺刮除手術不可忽視的併發症：案例報告

林奇柏、嚴孟意、石宏仁、林介山、王百孚、張進寶、黃勝賢、陳俊吉、江恆杰、張建祥、
陳柏華、陳一中、潘岳

彰化基督教醫院泌尿外科

Non-negligible complication during transurethral resection of the prostate, hyperchloremic metabolic acidosis: a case report and review of literature

Chi-Bo Lin, Meng-Yi Yan, Hung-Jen Shih, Jesun Lin, Pai-Fu Wang, Chang-Pao Chang, Sheng-Hsien Huang, Chun-Chi Chen, Herng-Jye Jiang, Jian-Xiang Zhang, Pao-Hwa Chen, Yi-Zhong Chen, Pan Yueh

Division of Urology, Department of Surgery, Changhua Christian Hospital

  In bipolar and laser transurethral resection of the prostate (TURP), normal saline can be used as the irrigation solution instead of distilled water, the electrolyte-free irrigation fluid we used in monopolar TURP. The risk of TUR syndrome and severe electrolyte disturbance is reduced when normal saline is used as the irrigation fluid. However, the use of normal saline irrigation also causes acid-base imbalance and electrolyte disturbance. In this report, we presented a case with hyperchloremic metabolic acidosis possibly caused by the absorption of normal saline during laser TURP.

  This is an 80-year-old male patient with past history of colon cancer, hypertension, type 2 DM and COPD. The pre-operation prostate sonography showed prostate volume was about 75mL. He received transurethral cystolithotripsy and laser-TURP on 2022-9-9. Near the end of the operation, low blood pressure, hypothermia and severe metabolic acidosis developed. The blood gas revealed repiratory acidosis with metabolic acidosis (pH: 7.129, BE: -11.1, pCO2: 52.4, HCO3: 17.6). The patient was transferred to the intensive care unit (ICU) after surgery with ventilator due to dyspnea and difficult weaning. Upon ICU adimssion, the chloride level was 117. The chest x ray revealed pulmonary edema and suspect RLL pneumonia. We prescribed antibiotics treatment, sodium bicarbonate supplement, lasix and hychlozide. At the time of transfer from the ICU, the acidosis had resolved. Successful weaning from mechanical ventilation was done on post-operative day 6. He was then transferred to general ward on post-operative day 7 and discharged on post-operative day 14.

  By reviewing the literature, risk factors of hyperchloremic metabolic acidosis during TURP including large irrigation volume, capsular perforation, manipulating close to the prostatic capsule, large vessel injury, height of the irrigation solution bag exceeding 60 cm, long operation time and extended tissue resection. We must pay attention to acid-base and electrolyte status when rapid absorption of excessive isotonic solution is suspected, even during bipolar and laser TURP, which use normal saline as the irrigation fluid. In the event of hyperchloremic acidosis during TUR operation, prompt intervention including diuretics with supplemental bicarbonate are necessary to prevent further complications.