When Your Surgeon Can't Get the Irrigation Solution They Need

If your upcoming surgery requires Mannitol/Sorbitol irrigation solution and your facility can't get it, you're probably wondering: what now? The good news is that your surgeon has several alternatives to choose from, and in many cases, these alternatives work just as well — or even better — depending on the equipment available.

In this guide, we'll explain what Mannitol/Sorbitol is, how it works, and walk through the most common alternatives so you can have an informed conversation with your surgical team.

For background on the current shortage, see: Why is Mannitol/Sorbitol so hard to find?

What Is Mannitol/Sorbitol?

Mannitol/Sorbitol irrigation solution is a sterile fluid used during certain surgical procedures to keep the surgical area clear and visible. It's a combination of two sugar alcohols — Sorbitol (2.7%) and Mannitol (0.54%) — mixed in sterile water.

The solution comes in 3,000 mL bags and is manufactured by ICU Medical, the only company producing this specific combination product in the United States.

It's used primarily during:

• TURP (transurethral resection of the prostate)
• Other transurethral urologic procedures
• Hysteroscopic surgeries

For a complete overview, see: What is Mannitol/Sorbitol? Uses, dosage, and what you need to know.

How Does Mannitol/Sorbitol Work?

During transurethral surgery, the surgeon inserts instruments through the urethra to reach the prostate or uterus. They need a continuous flow of fluid to:

• Keep the surgical field visible by washing away blood and tissue debris
• Distend (expand) the cavity so the surgeon can see and work

The key requirement is that the irrigation fluid must be nonelectrolytic — meaning it doesn't conduct electricity. This is essential when using monopolar electrosurgical instruments, which use electrical current to cut tissue and control bleeding. If the irrigation fluid conducted electricity, the current could travel unpredictably and cause serious injury.

Mannitol/Sorbitol is ideal because it's nonconductive, provides enough osmolality (178 mOsmol/L) to minimize the risk of red blood cell destruction (hemolysis) if absorbed into the bloodstream, and Mannitol acts as an osmotic diuretic to help the body excrete any fluid that is absorbed during surgery.

For more detail, read: How does Mannitol/Sorbitol work? Mechanism of action explained.

Alternative 1: Glycine 1.5% Irrigation Solution

Glycine 1.5% is the most widely used alternative to Mannitol/Sorbitol for monopolar transurethral procedures. It's been used for decades and is well-established in urologic surgery.

How It Compares

• Compatibility: Like Mannitol/Sorbitol, Glycine is nonelectrolytic and safe to use with monopolar instruments
• Availability: Generally more widely available, with multiple manufacturers
• Cost: Comparable pricing to Mannitol/Sorbitol

Key Differences

Research has shown that Glycine 1.5% carries a higher risk of neurological side effects compared to Mannitol/Sorbitol when significant volumes are absorbed. A clinical study found the risk of neurological symptoms (like nausea and visual disturbances) was 4.8 times higher with Glycine compared to Mannitol-based solutions. In rare cases, Glycine absorption has been associated with temporary blindness.

That said, Glycine 1.5% has a long safety track record when used properly, and most procedures are completed without significant absorption-related complications.

Alternative 2: Normal Saline (0.9% Sodium Chloride)

Normal saline is the safest irrigation option from a biochemical standpoint — it's isotonic, widely available, and eliminates the risk of dilutional hyponatremia (dangerously low sodium levels) that comes with nonelectrolytic solutions.

The Catch

Normal saline conducts electricity, so it cannot be used with monopolar electrosurgical instruments. It can only be used with bipolar resectoscopes, which are designed to work in a conductive fluid environment.

When It Works

If your surgical facility has bipolar equipment, normal saline may actually be the best option — shortage or not. Many urologists are increasingly moving toward bipolar TURP specifically because it allows safe use of saline and avoids the risks associated with nonelectrolytic irrigation fluids.

Ask your surgeon: "Do you have bipolar resectoscope equipment available?" If the answer is yes, the Mannitol/Sorbitol shortage may not affect your procedure at all.

Alternative 3: Sterile Water for Irrigation

Sterile water is the simplest and least expensive irrigation option. It's nonelectrolytic and compatible with monopolar instruments.

The Risk

Plain sterile water is severely hypotonic, which means that if significant amounts are absorbed into the bloodstream during surgery, it can cause intravascular hemolysis — the destruction of red blood cells. This makes it the highest-risk option among the commonly available irrigation fluids.

When It's Used

Sterile water is sometimes used for shorter procedures where the expected fluid absorption is minimal. However, most surgeons prefer other options for longer procedures like TURP due to the hemolysis risk.

Alternative 4: 5% Dextrose in Water (D5W)

D5W is another nonelectrolytic irrigating fluid that has been used as an alternative in some settings. It provides osmolality that helps protect against hemolysis.

Considerations

• Hyperglycemia risk: Because D5W contains glucose, significant absorption can cause blood sugar spikes, which is a particular concern for patients with diabetes
• Less commonly used: D5W is not as well-established as Glycine or Mannitol/Sorbitol for urologic irrigation
• Availability: D5W has also been affected by the broader IV fluid shortage

Which Alternative Is Best for You?

The right choice depends on several factors that only your surgical team can evaluate:

• What equipment is available — Bipolar vs. monopolar resectoscope
• Expected length of surgery — Longer procedures = more fluid absorption risk
• Your health conditions — Diabetes, heart disease, and kidney problems all factor in
• What's in stock — The shortage affects different products at different facilities

Here's a quick comparison:

• Glycine 1.5%: Best alternative for monopolar procedures. Higher neurological risk than Mannitol/Sorbitol but widely available.
• Normal Saline: Safest overall, but requires bipolar equipment.
• Sterile Water: Cheapest and most available, but highest risk of hemolysis.
• D5W: Nonelectrolytic option, but risk of hyperglycemia and limited track record.

Final Thoughts

The Mannitol/Sorbitol shortage is real, but it doesn't have to mean your surgery gets canceled. There are proven alternatives, and your surgical team has dealt with supply challenges before. The most important thing you can do is have an open conversation with your surgeon about which irrigation solution is safest and most available for your specific procedure.

If you're still looking for Mannitol/Sorbitol, use Medfinder to check availability near you. And for tips on locating this product, read our guide: How to find Mannitol/Sorbitol in stock near you.

For information about potential side effects of irrigation solutions, see: Mannitol/Sorbitol side effects: What to expect.