Transurethral resection of the prostate, bladder explosion and hyponatremic encephalopathy: a rare case report of malpractice

We present an original case report of a bladder explosion during a TURP intervention for benign pros- tatic hypertrophy, that was brought on by the absorption of about 5 liters of glycine 1.5% and then onset of a severe hyponatremia. The quick and inappropriate correction of this electrolyte imbalance led the onset of encephalopa- thy and the death of the patient. The authors discuss the pathogenesis of these uncommon diseases and, consider- ing the most recent Italian Legislation, they highlight the importance to respect good clinical practice standards and guidelines to ensure the most appropriate treatments for the patient and remove any assumptions of medical liability.