Management of bladder neck bleeding. Balloon is blocked with 20 cc more than the resection weight in the bladder and put under traction to occlude venous bleeders (From Rassweiler et al. )
Retraction of resectoscope with advancement of the loop to achieve a better angle for visualization of a bleeding artery (From Rassweiler et al. )
Effective coagulation of a large vessel by sealing of the lumen using slow circumferential movements of the loop (From Rassweiler et al. )
Early recognition of an extravasation is of great importance as a delayed diagnosis will cause more severe complications such as extra- or intra-abdominal fluid retention or a TUR-Syndrome.
In case of an unnoticed perforation of the prostate capsule the palpation of a tense (lower) abdomen will be crucial. Furthermore, symptoms of a TUR-Syndrome should draw the attention to the possibly underlying causes.
Controlled, but early termination of the operation is vital to avoid unnecessary aggravation of the situation. The flow of the irrigation should be as limited as possible and normal saline should be used. Special care should be taken with the fluid balance of the patient including balancing the fluid bags. A severe and symptomatic fluid retention requires puncture and drainage.
Fortunately, the frequency of a TUR-Syndrome is rare compared to the early years due to improvements in the technique and instrumentation. However, the rareness of the occurrence also increases the risk of missing an early diagnosis. The symptoms of a TUR-Syndrome will occur mostly intra-operatively but can be also seen in the early post-operative period. Also during bipolar TUR-Prostate fluid overload of the patient can occur.
Symptoms of a TUR-Syndrome are: Nausea and Vomiting, Hypertension, Bradycardia, Tachypnea, Pulmonary Oedema, Vision Disorders, Confusion and Agitation.
Intensive Monitoring and fluid balance is required. The flow of the irrigation (normal saline) should be as low as possible. Electrolyte imbalances need to be treated carefully.
Urine analysis prior to surgery and appropriate antibiotic treatment in case of an urinary tract infection is recommended. However, peri-operative urinary tract infection will still occur in this inhomogeneous patient collective with predisposing factors such as residual urine, retention and indwelling catheters.