Excessive Isotonic Irrigation Fluid Absorption Mimicking Bladder Perforation during Holmium Laser Enucleation of the...

Holmium laser enucleation of the prostate (HoLEP) is an effective surgical method for the treatment of benign prostatic obstruction. Although transurethral resection syndrome is classically associated with hypotonic irrigation fluids, complications due to fluid absorption can also occur during HoLEP when isotonic saline is used.

We present 3 patients with large-volume benign prostatic hyperplasia (prostate volumes 113-191 mL) who developed a clinical picture mimicking bladder perforation after HoLEP. All patients developed intraoperative abdominal distension, respiratory distress, and hypoxemia. Cystoscopic and radiological evaluations excluded bladder perforation. Blood gas analysis showed hyperchloremic metabolic acidosis in all cases (pH 7.01-7.22; Cl 117-122 mmol/L). Operative times ranged from 130 to 262 min and irrigation volumes from 48 to 56 L. After supportive treatment with diuretics and ventilatory support, clinical and biochemical stabilization was achieved within 6 h. Hospital stay ranged from 5 to 10 days; no mortality occurred.

Despite the use of isotonic saline, prolonged HoLEP procedures with high irrigation volumes can cause significant fluid absorption leading to hyperchloremic metabolic acidosis, abdominal distension, and pulmonary edema that can mimic bladder perforation. Awareness of this complication is essential for both surgeons and anesthesiologists managing patients undergoing high-volume HoLEP.