Through the capsule

Ask the room

You are doing this case. Where is the danger, and what is your first move if it happens?

Take answers before advancing. The point of the debrief is what they say now, not what the next slide says.

• Resecting past the circular fibres of the surgical capsule opens venous sinuses and the perivesical or retroperitoneal space, the route by which hypotonic irrigant enters the circulation.

resectoscope view

1. Pass the resectoscope and perform a full check cystoscopy, identifying both ureteric orifices, the bladder neck, and the verumontanum.
2. Set the irrigant running and hang the fluid no higher than needed; excess height raises intravesical pressure and absorption.
3. Resect the median lobe first to create an open channel to the bladder neck.
4. Take the lateral lobes systematically, working in even passes from bladder neck towards the verumontanum.
5. Resect to the level of the circular capsular fibres - the smooth, often paler surface - and stop at that plane.
6. Achieve haemostasis as you go, coagulating arterial bleeders and noting any opened venous sinus.
7. Stay proximal to the verumontanum at the apex and clear the apical tissue under direct vision.
8. Evacuate chips, confirm haemostasis at low pressure, and place a three-way catheter on irrigation.

• The surgical capsule is the floor of the resection, and at the apex it is thin.
• Beyond it lie the venous plexus and the periprostatic space.
• Two failures share one plane.
• Resection through the capsule can open venous sinuses and the periprostatic space, creating a route for irrigant absorption.
• With monopolar glycine irrigation, absorption can produce hyponatraemia and volume overload.
• Glycine and its metabolites can contribute to symptoms, and clinical severity does not always match the serum sodium value.
• Assess symptoms, serum sodium, osmolality and fluid balance together.
• Bipolar resection in saline removes the hypotonic irrigant and largely removes the syndrome.

• Resection time over 90 minutes
• Large gland, over 45 g
• Irrigant bag hung too high (raised intravesical pressure)
• Capsular perforation or widely opened venous sinuses
• Monopolar diathermy with hypotonic glycine irrigant

1. Stop resecting and stop irrigant inflow. Alert the anaesthetist immediately; do not deepen the cavity chasing tissue.
2. Assess airway, breathing and circulation while securing haemostasis and planning a controlled end to the procedure.
3. Send urgent serum sodium and osmolality; assess conscious level, cardiorespiratory status and fluid balance.
4. Distinguish hypotonic hyponatraemia from other causes of deterioration, including effects of absorbed glycine. Guide fluid management by clinical assessment and the local emergency protocol.
5. Severe or moderately severe symptoms attributed to hyponatraemia require urgent senior anaesthetic and critical-care input. Treat in a monitored setting with hypertonic saline when indicated; do not wait for a sodium threshold. escalation trigger
6. Track sodium and urine output closely. Actively manage an excessive rise with specialist advice; symptom relief does not remove the need to prevent overcorrection.
7. Document the perforation site, the opened sinuses, irrigant type and resection time, the sodium trend, and the management and correction plan in the op note.

Three questions

1. Why does bipolar resection in saline prevent TUR syndrome?
2. How do you balance urgent treatment and safe sodium correction?
3. Where is the capsule most vulnerable and why?

Answers are on the card under the viva section. Hold them back until everyone has tried.

• The strong answer assesses symptoms and tonicity, escalates promptly, and explains how sodium and urine output guide treatment.
• It recognises both the capsular breach and the systemic effects of irrigant absorption, without using a sodium threshold as a substitute for clinical assessment.