European Society of Anaesthesiology.

Transurethral resection of the prostate (TURP) syndrome is a rare but potentially fatal syndrome with multifactorial pathophysiology that is now better understood. Unfortunately, despite this improved understanding, it is not yet obsolete and still remains a risk. Many reviews of TURP syndrome have been presented from an anesthetic perspective; this review reflects more the urologic perspective with emphasis on the importance of multidisciplinary management of this complex syndrome. We present a review of TURP syndrome that specifically assesses advances in the understanding of risk factors, pathophysiology, and techniques used to prevent this syndrome. The databases Medline, Embase, Cochrane Controlled Trial Register, and Database of Abstracts of Reviews of Effects were systematically reviewed from inception to April 2009 for the keywords TUR (P), TUR (P) syndrome, and transurethral resection of prostate. There was no language restriction for our search. Randomized controlled trials, review articles and case series were included in our search. Our review showed a declining trend in the incidence of TURP syndrome despite TURP remaining the gold standard for the management of benign prostatic obstruction. Technologic advances using an array of laser techniques, the use of bipolar circuitry, together with advances in training techniques have helped minimize the risk of development of this syndrome. This review demonstrates the complexity of TURP syndrome. Even with a greater understanding of the pathophysiology, it highlights the unpredictability of the syndrome from presenting symptoms, preventative measures, and management. TURP syndrome cannot be protocol driven and the need for vigilance, a high index of suspicion, intensive monitoring, and a multidisciplinary approach is vital.

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We conducted this study to evaluate the efficacy of a transversus abdominis plane block in reducing morphine requirements in the first 24 h after renal transplant surgery. We performed transversus abdominis plane injections under ultrasound guidance in 54 patients with either 20 ml levobupivacaine 0.5% (n = 27) or 20 ml saline 0.9% (n = 27). All patients received regular paracetamol and patient-controlled analgesia postoperatively. Three participants were not studied owing to protocol violations. In the remaining 51 patients, median (IQR [range]) morphine consumption in the first 24 h was similar in both the transversus abdominis plane group (19.4 (11.7À28.6 [0.5À49.8]) mg) and the control group (16.4 (12.0À31.0 [0.0À61.7]) mg), p = 0.94. We found that use of ultrasound-guided transversus abdominis plane block for renal transplantation did not reduce 24-h morphine requirements.

Editor-Dr Chin makes a valid point and we thank him for his letter in response to our study. 1 The author comments that our conclusions may not be justified because even the low volume (5 ml) group had a 45% risk of phrenic palsy. Our results would then be meaningless if the magnitude of decrease in spirometry values were the same in all patients who developed phrenic palsy. Table 1 displays the characteristics of group I (all low volume), group Ia (low volume, no palsy), group Ib (low volume, palsy), and group II (high volume, all of whom developed phrenic palsy). Differences between group Ib (low volume, palsy) and group II (high volume) have been compared using t-tests. Significance is assumed at P,0.05. Reassuringly it appears that even patients who get phrenic nerve palsy in the low-volume group have significantly better preservation of lung function than the highvolume group (Fig. 1). This adds further weight to our conclusion that low volume (5 ml) ultrasound-guided interscalene block provides equivalent analgesia, but causes significantly less respiratory compromise compared with high-volume (20 ml) block.