To the Editor: In the articles, “Absorption of Irrigating Fluid During Transurethral Prostatic Resection as Measured by Ethanol Radioisotopes, and Regular-Interval Monitoring,” and “Use of Ethanol as Marker Substance to Increase Patient Safety During Transurethral Prostatic Resection,” by Hans Hjertberg, et al., published in the November issue (vol. 38, pages 417 and 423, 1991, respectively), and letter to the editor on “Absorption of Irrigating Fluid During TURP,” by Richards P Lyons, in the April issue (vol. 39, page 396, 1992) of UROLOGY the authors have continued to emphasize the need to detect this condition. This is a condition that is often unrecognized although it may have far wider consequences than is currently realized. The combination of various indicators of fluid absorption, instead of relying on one, may be a way to monitor water overload more accurately Ethanol detection in breath and blood as well as direct weighing of the patient with a sensitive scale are sound methods. They would require the addition of a specified amount of ethanol in each bag of irrigating fluid and the use of a sensitive scale. A further problem with direct weighing of the patient is the diuresis that added fluid causes; so weighing of the inflow and outflow irrigating fluid for the TURP and intravenous fluids given also would have to be made. The use of glycine and sorbitol for TURP has been established so long ago that these isotonic, nonhemolytic, nonconductive, crystal-clear, irrigating fluids have become the de facto standard. These fluids are, however, not without their drawbacks: hyper-ammonemia sometimes, many times the toxic levels in glycine overload, and water intoxication in sorbitol absorption. Mannitol is less popular because of its strong diuretic effect and resultant hyponatremia. Water alone as irrigating fluid for TURP has been pretty much rejected because of its hemolytic effect. Long-term effects of hyper-ammonemia at very high levels are not clearly known. Various neurologic effects have been reported, most of them reversible. Similarly, long-term effects of rapid highdose sorbitol infusion are not clear. Various reports revealing the toxic effects of intracellular sorbitol in diabetics (essentially acceleration of the aging process) makes one wonder what the effect may be with its rapid and large absorption in TURF? If there is any possibility of long-term untoward effects of


i JULY1992


TURP vis-a-vis open prostatectomy, perhaps the irrigating fluid used should be examined closely. One solution to the problem may be the use of isotonic dextrose solution, readily available as intravenous infusion fluid. This would have the advantage of easy monitoring of fluid overload as indicated by the rise in blood glucose level. In the not too distant future noninvasive monitoring of blood glucose may be available, which would further facilitate detection of fluid absorption when dextrose solution is used. Dextrose is a more basic natural substance than sorbitol or glycine to be overdosed in and perhaps less toxic and more readily correctable. It would have to be used with extra care in diabetics. Another alternative may be a less “aggressive and radical” TURP Conceivably it may be better to do staged TURPs than one aggressive, complete TURP which may result in large (unrecognized massive?) fluid absorption, for the bigger prostate. Perhaps a case can be made for a better irrigating fluid or a less aggressive TURP? L. Tan, M.D. 4294 Fifth Avenue Marianna, Florida 32446





To the Editor: The sutures attached to the distal end of the Double-J ureteral stents have, in theory, allowed for removal of the stents without cystoscopic intervention. It has been my dilemma and that expressed by several colleagues that the “loop” of suture is often inadvertently manipulated to cause premature displacement of the stent. The following technique may obviate stent displacement. Technique With the stent in position in the upper urinary tract, and the suture “loop” exiting the urethra, I cut the loop at its most distal aspect, then place a surgeon’s knot with the two ends of the suture and tie the knot just inside the meatus. Complete the knot with a second and third throw, This leaves two separate strands of suture exiting from the meatus. In a very small series (7 patients), this technique has avoided displacement of the stent. Patrick W. Kronmiller, M.D. Mountain View Hospital Payson, Utah 84651


Ureteral stent removal sutures.

LETTERS TO THE EDITOR ABSORPTION OF IRRIGATING DURING TURP FLUID To the Editor: In the articles, “Absorption of Irrigating Fluid During Transurethra...
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