# Refractory metabolic acidosis and acute abdominal compartment syndrome following Holmium Laser Enucleation of Prostate (HoLEP)

## TL;DR

A patient developed severe acidosis and abdominal complications after a prostate surgery using large amounts of saline.

## Contribution

First reported case linking HoLEP with refractory metabolic acidosis and acute abdominal compartment syndrome.

## Key findings

- Excessive normal saline absorption during HoLEP led to severe hyperchloremic metabolic acidosis.
- Acute abdominal compartment syndrome developed, requiring emergency dialysis and ICU management.
- The case highlights risks of prolonged HoLEP and capsular perforation.

## Abstract

Holmium Laser Enucleation of the Prostate (HoLEP) is a widely used minimally invasive surgical technique for benign prostatic hyperplasia (BPH), offering advantages such as reduced bleeding, shorter hospitalization, and elimination of TURP syndrome. However, complications related to fluid absorption and capsular perforation can still occur. We report a rare case of severe refractory metabolic acidosis and acute abdominal compartment syndrome (ACS) following HoLEP.

A 74-year-old male with diabetes and hypertension underwent HoLEP for a 180-ml prostate, during which 106 liters of normal saline irrigation were used over three hours. Intraoperatively, the patient developed sudden respiratory distress and hypotension, with arterial blood gas analysis revealing severe metabolic acidosis (pH 7.141, HCO3 11 mEq/L, Cl 115 mEq/L), primarily due to excessive saline absorption and hyperchloremia. The patient required intubation, vasopressor support, and emergency dialysis due to worsening hemodynamic instability. Postoperative imaging revealed intra-abdominal fluid collection, which was drained percutaneously. After two days of intensive ICU management, the acidosis resolved, and the patient was successfully extubated.

This is the first case highlighting the potential risks of normal saline absorption and the effect of capsular perforation, which caused ACS and refractory acidosis, and required CRRT due to the prolonged duration of HoLEP.