606
there are many who continue to wear some protection despite succssful control of the prolapse. The second consideration is that constipation and failure of rectal evacuation is a source of morbidity in at least 60% of patients after rectopexy; although some of these patients had needed to strain or were constipated beforehand, most had had no difficulty. If colonic transit is defective preoperatively partial colonic resection is now advised at the time of rectopexy, the extent of the resection depending on the degree and site of the stasis. Abdominal rectopexy commonly impairs rectal motility, either because
rectal dissection causes denervation, or because there is a redundant sigmoid colon above the fixed rectum which causes a functional obstruction. Thus many surgeons now confine rectal mobilisation to the posterior plane, and resect the redundant sigmoid to form an anastomosis between the descending colon and the upper rectum after sutured rectopexy.This procedure is potentially more hazardous than rectopexy and requires longer anaesthesia. Moreover, the addition of a total pelvic floor repair for incontinence necessitates an extensive operation with an abdominal and a perineal dissection that may be inappropriate in frail elderly people. What are the alternatives? Most of them-eg, an encircling perianal suture of ’Teflon’, wire, or silastic,3-S the Delorme operation,6--8 perineal rectopexy, and rectosigmoidectomy alones-give very poor results with a high frequency of recurrent prolapse. Nevertheless, the perianal approach causes little or no morbidity: patients are mobilised the day after operation and can be discharged within 4-5 days. A perineal operation that successfully controlled the prolapse and corrected the physiological abnormality, would be worth exploring.9 In this respect perineal rectosigmoidectomy combined with perineal rectopexy and total pelvic floor repair with coloanal anastomosis has some appeal. There is no wound because the operation merely amputates the prolapse while the remaining additions are done through the exposure. The procedure takes less than an hour, general anaesthesia is not necessary and, although there is an anastomosis, it is so low that it can easily be protected by a rectal catheter placed above it. Stapling techniques should increase the safety of this approachIt remains to be seen whether this perineal operation both controls the prolapse and overcomes the functional complications that have been so troublesome to patients undergoing abdominal rectopexy. So what will be the options in 10 years’ time? Perineal procedures are probably here to stay, especially when the technique of laparoscopic colectomy and mobilisation of the rectum to the pelvic floor has been fully developed. When these methods have been mastered and instrumentation has improved, it will be possible to design operative procedures for benign disease that allow partial and complete colectomy through the everted rectum.
These resections could even be combined with stapled construction of complex reservoirs with rectal or anal anastomoses.
Keighley MRB, Fielding JWL, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consective patients. Br J Surg 1983; 70: 229-32. 2. Prykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969; 2: 1225-30. 3. Gabriel WB. Thiersch’s operation for anal incontinence. Proc R Soc Med 1.
1948; 42: 467-68. TM, Fraser IA, Maybury NK. Treatment of rectal prolapse by sphincteric support using silastic rods. Br J Surg 1985; 72: 491-92. 5. Vongsangnak V, Varma JS, Smith AN. Reappraisal of Thiersch’s operation for complete rectal prolapse. J R Coll Surg Edin 1985; 30:
4. Hunt
185-87. 6. Christiansen
J, Kirkegaard P. Delorme’s operation for complete rectal prolapse. Br J Surg 1987; 68: 537-38. 7. Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme’s operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986; 68: 143-46. 8. Uhlig B, Sullivan E. The modified Delorme operation. Dis Colon Rectum
1979; 22: 513-21. Finlay IG, Aitchison M. Perineal excision of the rectum for prolapse in the elderly. Br J Surg 1991; 78: 687-89. 10. Vormeulen FB, Nivatvongs S, Franze DT, Balcos EG, Goldberg SM. A technique for perineal rectosigmoidectomy using autosuture devices. Surg Gynecol Obstet 1983; 156: 84-86. 9.
Monitoring TURP Transurethral resection of the prostate (TURP) remains under close scrutiny after the publication of a study 2 years ago1 which suggested that long-term mortality from this procedure is higher than with open prostatectomy or other forms of surgery. An earlier editorial2 likened the effects of this article to a boulder rolling into the urological millpond. So far, the study has withstood critical analysis, and waves continue to spread in the mare urologica. Absorption of irrigating solution during the procedure is an important difference between TURP and open prostatectomy and the consequences remain understood. incompletely Despite modem techniques, nearly 1 litre of irrigating solution is absorbed on average during a routine TURP procedure.3,4 In addition to volume effects (hypervolaemia and dilutional hyponatraemia), metabolic complications such as hyperammonaemia may develop and patients may become hypothermic if unheated irrigant is used.Irrigating solution is forced into the retroperitoneum when the prostatic capsule is perforated. When the large valveless veins within the prostate are opened, irrigant is injected directly into the circulation because of the pressure difference between the venous circulation and the height of the irrigant above the patient. These routes of absorption-one slow and the other much more rapid-give rise to different clinical manifestations. There is little doubt that absorption of large amounts of irrigant (3 litres or more) can result in acute distress, sometimes leading to death. The proposition that there is a continuum of effects and that smaller degrees of absorption may be stressful has lately been revived.6
607
In view of these adverse effects it is surprising that no routine method for measuring fluid absorption during TURP has been devised. Because blood is mixed with the irrigant, assessment of haemorrhage is also complex. Thus, assessment of fluid balance and haemorrhage has been a matter of estimation, based on clinical skills and experience. Colour-blind anaesthetists may be at a considerable disadvantage in this respect. Methods that have been advanced for monitoring fluid balance during TURP include weighing the patient, measuring the amount of "lost" irrigating solution, and estimating concentrations of substances added to the irrigant.7-9 Radioisotopes have been used to estimate the amounts absorbed, and changes in serum sodium have been releated to absorption.8--10 None of these methods has found favour in urological practice: in some instances the techniques are unreliable or clearly impracticable for routine use and in others the assays are time consuming and laborious. Although changes in serum sodium are widely thought to reflect absorption, homoeostatic mechanisms render them inaccurate after the first few minutes of absorption." A new method for detecting rapid absorption proposed by Hulten and his colleagues12 seems to overcome many of these disadvantages. This makes use of the well-known principle that technique the body burden of ethanol can be estimated from a breath sample. A known concentration of ethanol is added to the irrigating solution and the amount entering the patients circulation is estimated with an alcometer. The technique has been refined and described in several reports from this group.12-18 Ethanol-containing solutions have been assessed in healthy young volunteers with no adverse effects (although intravenous infusion of both glycine and mannitol solutions were harmful). Initially 2% ethanol was used, with one patient becoming euphoric after absorption of about 1-5 litres of irrigant during TURP. Subsequently, 1% ethanol was evaluated, although it is considerably less sensitive. In the early studies patients were awake and breathed spontaneously into the alcometer; now the method has been applied to unconscious patients. This technique is not perfect. Although it warns of significant intravascular absorption (1litre or more), it does not give early warning of absorption into the retroperitoneal space. It relies on the use of a crude formula (given the multiple compartments potentially involved) to correct for the effects of metabolism, excretion, and diffusion from one compartment to another, making quantification of the total amount of irrigant absorbed questionable. Absorption of about 1 litre in 10 minutes is proposed as the trigger for action. However, lesser degrees of absorption may be of clinical significance and this method does not address blood loss or the cumulative effects of intravenous fluids. Nevertheless, the system has advantages in terms of speed and practicality. If absorption is detected efforts can be made to reduce it or the
be curtailed and treatment instituted. There is little doubt that this method would warn of the infrequently observed but often catastrophic TUR syndrome, a loosely defined constellation of signs and symptoms resulting from massive
operation
can
absorption of irrigating fluid. Monitoring of fluid balance seems a logical and positive means of reducing potential stresses during TURP and improving the overall standard of care. It could be relevant to other procedures in which absorption may occur, including percutaneous nephrolithotomy and transcervical endometrial resection. This method of monitoring irrigating fluid absorption is timely in view of the concerns that have been raised about endoscopic prostatectomy. Systems for monitoring blood loss automatically during TURP have been described and also deserve consideration, since blood loss during TURP is variable and may be clinically important. Other methods of monitoring fund balance during TURP are being developed; these will need to be compared with Hulten’s approach.
1. Roos NP, Wennberg JE, Malenka DJ, et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med 1989; 320: 1120-24. 2. Editorial. TU or not TU. Lancet 1989; i: 1361-62. 3. Rao PN. Fluid absorption during urological endoscopy. Br J Urol 1987; 60: 93-99. 4. Hahn R, Berlin T, Lewenhaupt A. Rapid massive irrigating fluid absorption during transurethral resection of the prostate. Acta Chir Scand 1986; 530: 63-65. 5. Rabke HB, Jenicek JA, Khouri E. Hypothermia associated with transurethral resection of the prostate. J Urol 1962; 87: 447-49. 6. Coppinger SWV, Hudd C. Risk factor for myocardial infarction in transurethral resection of the prostate? Lancet 1989; ii 7: 859. 7. Hagstrom RA. Studies on fluid absorption during transurethral resection. J Urol 1955; 73: 852-59. 8. Oester A, Madsen PO. Determination of absorption of irrigating fluid during transurethral resection of the prostate by means of radioisotopes. J Urol 1969; 102: 714-19. 9. Norlen H. Isotonic solutions of mannitol, sorbitol, and glycine and distilled water as irrigating fluids during transurethral resection of the prostate and circulation of irrigating fluid index. Scand J Urol Nephrol 1986; 96 (suppl). 10. Watkins-Pitchford JM, Payne SR, Rennie CD, Riddle PR. Hyponatraemia during transurethral resection-its practical prevention. Br J Urol 1984; 56: 676-78. 11. Hahn RG. Relations between irrigant absorption rate and hyponatraemia during transurethral resection of the prostate. Acta Anaesthesiol Scand
1988; 32: 53-60. 12. Hulten J, Sarma VJ, Hjertberg H, Palmquist B.
Monitoring of irrigating fluid absorption during transurethral prostatectomy. Anaesthesia 1991; 46: 349-53. 13. Hulten JO, Jorfeldt LS, Wictorsson YM. Monitoring fluid absorption during TURP by marking the irrigating solution with ethanol. Scand J Urol Nephrol 1986; 20: 245-51. 14. Hahn R, Berlin T, Lewenhaupt A. Irrigating fluid absorption and blood loss during transurethral resection of the prostate studied with a regular interval monitoring (RIM) method. Scand J Urol Nephrol 1988; 22: 23-30. 15. Hulten JO, Hahn RG. Monitoring irrigating fluid absorption during transurethral resection of the prostate (TURP); a comparison between 1 and 2% ethanol as a tracer. Scand J Urol Nephrol 1989; 23: 103-08. 16. Hahn RG, Stalberg HP, Gustafsson SA. Intravenous infusion of irrigating fluids containing glycine or mannitol with and without ethanol. J Urol 1989; 142: 1102-05. 17. Hahn RG. Early detection of the TUR syndrome by marking the irrigating fluid with 1% ethanol. Acta Anaesthesiol Scand 1989; 33: 146-51. 18. Hahn RG. Prevention of TUR syndrome by detection of trace ethanol in expired breath. Anaesthesia 1990; 45: 577-81.
there are many who continue to wear some protection despite succssful control of the prolapse. The second consideration is that constipation and failure of rectal evacuation is a source of morbidity in at least 60% of patients after rectopexy; although some of these patients had needed to strain or were constipated beforehand, most had had no difficulty. If colonic transit is defective preoperatively partial colonic resection is now advised at the time of rectopexy, the extent of the resection depending on the degree and site of the stasis. Abdominal rectopexy commonly impairs rectal motility, either because
rectal dissection causes denervation, or because there is a redundant sigmoid colon above the fixed rectum which causes a functional obstruction. Thus many surgeons now confine rectal mobilisation to the posterior plane, and resect the redundant sigmoid to form an anastomosis between the descending colon and the upper rectum after sutured rectopexy.This procedure is potentially more hazardous than rectopexy and requires longer anaesthesia. Moreover, the addition of a total pelvic floor repair for incontinence necessitates an extensive operation with an abdominal and a perineal dissection that may be inappropriate in frail elderly people. What are the alternatives? Most of them-eg, an encircling perianal suture of ’Teflon’, wire, or silastic,3-S the Delorme operation,6--8 perineal rectopexy, and rectosigmoidectomy alones-give very poor results with a high frequency of recurrent prolapse. Nevertheless, the perianal approach causes little or no morbidity: patients are mobilised the day after operation and can be discharged within 4-5 days. A perineal operation that successfully controlled the prolapse and corrected the physiological abnormality, would be worth exploring.9 In this respect perineal rectosigmoidectomy combined with perineal rectopexy and total pelvic floor repair with coloanal anastomosis has some appeal. There is no wound because the operation merely amputates the prolapse while the remaining additions are done through the exposure. The procedure takes less than an hour, general anaesthesia is not necessary and, although there is an anastomosis, it is so low that it can easily be protected by a rectal catheter placed above it. Stapling techniques should increase the safety of this approachIt remains to be seen whether this perineal operation both controls the prolapse and overcomes the functional complications that have been so troublesome to patients undergoing abdominal rectopexy. So what will be the options in 10 years’ time? Perineal procedures are probably here to stay, especially when the technique of laparoscopic colectomy and mobilisation of the rectum to the pelvic floor has been fully developed. When these methods have been mastered and instrumentation has improved, it will be possible to design operative procedures for benign disease that allow partial and complete colectomy through the everted rectum.
These resections could even be combined with stapled construction of complex reservoirs with rectal or anal anastomoses.
Keighley MRB, Fielding JWL, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consective patients. Br J Surg 1983; 70: 229-32. 2. Prykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969; 2: 1225-30. 3. Gabriel WB. Thiersch’s operation for anal incontinence. Proc R Soc Med 1.
1948; 42: 467-68. TM, Fraser IA, Maybury NK. Treatment of rectal prolapse by sphincteric support using silastic rods. Br J Surg 1985; 72: 491-92. 5. Vongsangnak V, Varma JS, Smith AN. Reappraisal of Thiersch’s operation for complete rectal prolapse. J R Coll Surg Edin 1985; 30:
4. Hunt
185-87. 6. Christiansen
J, Kirkegaard P. Delorme’s operation for complete rectal prolapse. Br J Surg 1987; 68: 537-38. 7. Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme’s operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986; 68: 143-46. 8. Uhlig B, Sullivan E. The modified Delorme operation. Dis Colon Rectum
1979; 22: 513-21. Finlay IG, Aitchison M. Perineal excision of the rectum for prolapse in the elderly. Br J Surg 1991; 78: 687-89. 10. Vormeulen FB, Nivatvongs S, Franze DT, Balcos EG, Goldberg SM. A technique for perineal rectosigmoidectomy using autosuture devices. Surg Gynecol Obstet 1983; 156: 84-86. 9.
Monitoring TURP Transurethral resection of the prostate (TURP) remains under close scrutiny after the publication of a study 2 years ago1 which suggested that long-term mortality from this procedure is higher than with open prostatectomy or other forms of surgery. An earlier editorial2 likened the effects of this article to a boulder rolling into the urological millpond. So far, the study has withstood critical analysis, and waves continue to spread in the mare urologica. Absorption of irrigating solution during the procedure is an important difference between TURP and open prostatectomy and the consequences remain understood. incompletely Despite modem techniques, nearly 1 litre of irrigating solution is absorbed on average during a routine TURP procedure.3,4 In addition to volume effects (hypervolaemia and dilutional hyponatraemia), metabolic complications such as hyperammonaemia may develop and patients may become hypothermic if unheated irrigant is used.Irrigating solution is forced into the retroperitoneum when the prostatic capsule is perforated. When the large valveless veins within the prostate are opened, irrigant is injected directly into the circulation because of the pressure difference between the venous circulation and the height of the irrigant above the patient. These routes of absorption-one slow and the other much more rapid-give rise to different clinical manifestations. There is little doubt that absorption of large amounts of irrigant (3 litres or more) can result in acute distress, sometimes leading to death. The proposition that there is a continuum of effects and that smaller degrees of absorption may be stressful has lately been revived.6
607
In view of these adverse effects it is surprising that no routine method for measuring fluid absorption during TURP has been devised. Because blood is mixed with the irrigant, assessment of haemorrhage is also complex. Thus, assessment of fluid balance and haemorrhage has been a matter of estimation, based on clinical skills and experience. Colour-blind anaesthetists may be at a considerable disadvantage in this respect. Methods that have been advanced for monitoring fluid balance during TURP include weighing the patient, measuring the amount of "lost" irrigating solution, and estimating concentrations of substances added to the irrigant.7-9 Radioisotopes have been used to estimate the amounts absorbed, and changes in serum sodium have been releated to absorption.8--10 None of these methods has found favour in urological practice: in some instances the techniques are unreliable or clearly impracticable for routine use and in others the assays are time consuming and laborious. Although changes in serum sodium are widely thought to reflect absorption, homoeostatic mechanisms render them inaccurate after the first few minutes of absorption." A new method for detecting rapid absorption proposed by Hulten and his colleagues12 seems to overcome many of these disadvantages. This makes use of the well-known principle that technique the body burden of ethanol can be estimated from a breath sample. A known concentration of ethanol is added to the irrigating solution and the amount entering the patients circulation is estimated with an alcometer. The technique has been refined and described in several reports from this group.12-18 Ethanol-containing solutions have been assessed in healthy young volunteers with no adverse effects (although intravenous infusion of both glycine and mannitol solutions were harmful). Initially 2% ethanol was used, with one patient becoming euphoric after absorption of about 1-5 litres of irrigant during TURP. Subsequently, 1% ethanol was evaluated, although it is considerably less sensitive. In the early studies patients were awake and breathed spontaneously into the alcometer; now the method has been applied to unconscious patients. This technique is not perfect. Although it warns of significant intravascular absorption (1litre or more), it does not give early warning of absorption into the retroperitoneal space. It relies on the use of a crude formula (given the multiple compartments potentially involved) to correct for the effects of metabolism, excretion, and diffusion from one compartment to another, making quantification of the total amount of irrigant absorbed questionable. Absorption of about 1 litre in 10 minutes is proposed as the trigger for action. However, lesser degrees of absorption may be of clinical significance and this method does not address blood loss or the cumulative effects of intravenous fluids. Nevertheless, the system has advantages in terms of speed and practicality. If absorption is detected efforts can be made to reduce it or the
be curtailed and treatment instituted. There is little doubt that this method would warn of the infrequently observed but often catastrophic TUR syndrome, a loosely defined constellation of signs and symptoms resulting from massive
operation
can
absorption of irrigating fluid. Monitoring of fluid balance seems a logical and positive means of reducing potential stresses during TURP and improving the overall standard of care. It could be relevant to other procedures in which absorption may occur, including percutaneous nephrolithotomy and transcervical endometrial resection. This method of monitoring irrigating fluid absorption is timely in view of the concerns that have been raised about endoscopic prostatectomy. Systems for monitoring blood loss automatically during TURP have been described and also deserve consideration, since blood loss during TURP is variable and may be clinically important. Other methods of monitoring fund balance during TURP are being developed; these will need to be compared with Hulten’s approach.
1. Roos NP, Wennberg JE, Malenka DJ, et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med 1989; 320: 1120-24. 2. Editorial. TU or not TU. Lancet 1989; i: 1361-62. 3. Rao PN. Fluid absorption during urological endoscopy. Br J Urol 1987; 60: 93-99. 4. Hahn R, Berlin T, Lewenhaupt A. Rapid massive irrigating fluid absorption during transurethral resection of the prostate. Acta Chir Scand 1986; 530: 63-65. 5. Rabke HB, Jenicek JA, Khouri E. Hypothermia associated with transurethral resection of the prostate. J Urol 1962; 87: 447-49. 6. Coppinger SWV, Hudd C. Risk factor for myocardial infarction in transurethral resection of the prostate? Lancet 1989; ii 7: 859. 7. Hagstrom RA. Studies on fluid absorption during transurethral resection. J Urol 1955; 73: 852-59. 8. Oester A, Madsen PO. Determination of absorption of irrigating fluid during transurethral resection of the prostate by means of radioisotopes. J Urol 1969; 102: 714-19. 9. Norlen H. Isotonic solutions of mannitol, sorbitol, and glycine and distilled water as irrigating fluids during transurethral resection of the prostate and circulation of irrigating fluid index. Scand J Urol Nephrol 1986; 96 (suppl). 10. Watkins-Pitchford JM, Payne SR, Rennie CD, Riddle PR. Hyponatraemia during transurethral resection-its practical prevention. Br J Urol 1984; 56: 676-78. 11. Hahn RG. Relations between irrigant absorption rate and hyponatraemia during transurethral resection of the prostate. Acta Anaesthesiol Scand
1988; 32: 53-60. 12. Hulten J, Sarma VJ, Hjertberg H, Palmquist B.
Monitoring of irrigating fluid absorption during transurethral prostatectomy. Anaesthesia 1991; 46: 349-53. 13. Hulten JO, Jorfeldt LS, Wictorsson YM. Monitoring fluid absorption during TURP by marking the irrigating solution with ethanol. Scand J Urol Nephrol 1986; 20: 245-51. 14. Hahn R, Berlin T, Lewenhaupt A. Irrigating fluid absorption and blood loss during transurethral resection of the prostate studied with a regular interval monitoring (RIM) method. Scand J Urol Nephrol 1988; 22: 23-30. 15. Hulten JO, Hahn RG. Monitoring irrigating fluid absorption during transurethral resection of the prostate (TURP); a comparison between 1 and 2% ethanol as a tracer. Scand J Urol Nephrol 1989; 23: 103-08. 16. Hahn RG, Stalberg HP, Gustafsson SA. Intravenous infusion of irrigating fluids containing glycine or mannitol with and without ethanol. J Urol 1989; 142: 1102-05. 17. Hahn RG. Early detection of the TUR syndrome by marking the irrigating fluid with 1% ethanol. Acta Anaesthesiol Scand 1989; 33: 146-51. 18. Hahn RG. Prevention of TUR syndrome by detection of trace ethanol in expired breath. Anaesthesia 1990; 45: 577-81.
