Excessive Isotonic Irrigation Fluid Absorption Mimicking Bladder Perforation During HoLEP: A Case Series and Diagnostic Challenge.

INTRODUCTION: 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, fluid absorption-related complications may also arise during HoLEP when isotonic saline is used. CASE PRESENTATIONS: We present three patients with large-volume benign prostatic hyperplasia (prostate volumes 113-191 mL) who developed a clinical picture mimicking bladder perforation following HoLEP. All patients developed intraoperative abdominal distension, respiratory distress, and hypoxemia. Cystoscopic and radiological evaluations excluded bladder perforation. Blood gas analysis demonstrated hyperchloremic metabolic acidosis (pH 7.01-7.22; Cl 117-122 mmol/L) in all cases. Operative times ranged from 130 to 262 minutes, with irrigation volumes of 48-56 L. Following supportive management with diuretics and ventilatory support, clinical and biochemical stabilization was achieved within 6 hours. Hospital stay ranged from 5 to 10 days; no mortality was observed. CONCLUSION: Despite the use of isotonic saline, prolonged HoLEP procedures with high irrigation volumes may result in significant fluid absorption causing 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 large-volume HoLEP.