Comparison of Urinary Symptoms in Patients with Benign Prostatic Hyperplasia (BPH) that Had Been Prostatectomy for Prostate Weight More and Less than 50 Grams
ABSTRACT
BACKGROUND: Nowdays prostatic HyperplasiaI is the most common benign neoplasm in Aging male . It was estimated that 200.000 medicare patients had a prostatectomy that year.
The main pur pose of this study is comparison if urinary symptoms after prostatectomy in the Benign hyperplasic patients with prostatic weight >50&<50gr in Urological center of Moradi Hospital in Rafsanjan city from march 1993 to august 2001
Material and methods: This study was a analytic- descriptive study that assessed 200 Benign hyperplastic patients after prostatectomy admitted in urological center of Moradi Hospital within 8years. The method of study was simple non probabilitical. Data Werecollected by questionnaire data analyze was performed by EP16 and chi square test paired T test .
Results: from 200 cases 28 patients death 12 patients not available from 160 residual cases 89 patients had prostate weight > 50gr and71 patients had prostatic weight <50gr . the mean scores of urinary symptoms in the patients with prostatic weight >50gr (=5/85) lesser than of the mean scores of urinary symptoms in the patients with prostatic weight <50gr(=7/44)but no significant difference was been seen. (PV=0/1616)
Frequency distribution of urinary symptoms in the patients with prostatic weight more than 50gr(13/5%)lesser than of patients with prostatic weight less than 50gr(19/7%)but not significant PV: (0/3973) and frequency distribution of urinary symptoms in the total patients was 16/3% the sensation of incomplete empting in the patients with prostatic weight <50gr {mean=0/47 frequency 7% )was lesser than of patients group>50gr(mean=0/74 frequency=12%) but not significant. The six symptoms (nocturia, frequency , urgency hesitency ,intermittency ,weak urinary stream) in the patients groups>50gr were lesser than of patients groups<50gr but only two symptoms hesitency and weak urinary stream were significant.
Conclusion: since not significant statistic defference between two groups >50gr&<50gr open prostatectomy can use in the patients with prostatic weght less than 50gr.
Declaration of interest: None
Key words: open prostatectomy, prostatic weight
Introduction:
Benign prostatic hyperplasia (BPH) is the most common benign tumor in men and its incidence is age dependent and in autopsy studies the incidence rate in men over 80 years to reach 90% (1)
Barry and colleagues Studies in Boston of America on 210 patients with benign prostatic hyperplasia were the mean AUA, decrease from 17/6 to 7/1 postoperative (P <0/001). (2)
Other study in Finland on 401 BPH patients who underwent prostatectomy by transurethral retrograde prostatectomy (TURP) technique was done, it found that after 6/5 years follow up 92% of patients were improved. (3)
In a study on 856 men to assess the association of prostate weight with resolve of sexual function after radical prostatectomy was shown that prostate size is not associated with recovery urinary outcome.(4)
In a study on 729 patients was shown that laparoscopic radical prostatectomy despite preoperative differences increasing prostatic size is not related to retarded or worse postoperative urinary health related quality of life. (5)
In a study on 1024 men underwent radical retropubic prostatectomy was showed that no clinically relevant risks were related to increasing body weight.(6)
In a study found that the predictor variable of prostate weight is significantly inversely related to the outcomes of high-grade disease, positive surgical margins, extracapsular extension and biochemical progression (comparing prostate weight < 20 v ≥ 100 g). Similar relationships were seen between preoperative transrectal ultrasound–measured prostate volume and high-grade disease, positive surgical margins, extracapsular extension ,seminal vesicle invasion , and biochemical progression .(7)
Urinary incontinence after prostatectomy can effect health related
quality of life in men resolved with prostatectomy for prostate cancer.
Currently no consensus exists on which patients are at risk for impaired health
related quality of life secondary to post-prostatectomy urinary incontinence.(8)
In a study , It was found that age may be considered both a direct and indirect (BPH-related) prognostic factor for sexual activity. Suprapubic prostatectomy recovery obstructive symptoms, and maintains sexual desire, overall sexual satisfaction and an improvement in quality of life. However, irritative symptoms, erection, orgasm and sexual intercourse satisfaction are not significantly altered.(9)
The evaluation of urinary complaints is helpful before pre-operation for predicting the outcome (10).
In a study was shown that body weight has not significantly related to operative time intraoperative complications , perioperative complications . The prostate volume has significantly and inversely related to the positive surgical margin rate .The prostate volume was not significantly related to the operative time, intraoperative complications , perioperative complications , postoperative complications , postoperative continence .(11)
Materials and Methods:
In this cross sectional study, in-patients with benign prostatic hyperplasia that had been prostatectomy and hospitalized at the Urology ward of Moradi hospital (Rafsanjan, Iran), has been studied with simple non randomized method in 3 months. Two hundred patients were selected. Exclusion criteria was, CNS disease (e.g. spinal cord injuries and Parkinson) other prostate diseases such as, prostate cancer, chronic prostate or bladder diseases such as bladder stones, bladder cancer, patients with urinary tract infection, and diabetic patients.
A questionnaire was used to collect data containing: demographic characteristics, weight of prostate before and after surgery، seven urinary symptoms include, 1.Feeling of not complete urine drainage, 2. frequency, 3. intermittency, 4. Weak stream urination, 5. urgency, 6. straining for urination, 7. nocturia. These variables scored from zero to five. The patients according to their prostate weight divided into two groups. Group A , less than 50 grams and Group B, more than 50 grams.
This study was approved by scientific and ethics committee of Rafsanjan University of Medical Sciences and all of patients signed Informed consent form.
Data was analyzed by Spss-16 software via Chi square test and T-test. P<0.05 was statistically significant.
Results and Discussion
Out of 200 patients, 40 patients left the study and 160 patients divided to two groups (Group-A 89 and Group-B 71).
The mean weight of prostate for group A before and after prostatectomy were 29.77±1.56 and 5.58±6.59 (P= 0.0001) and group B 29.63±1.91 and 7.44±7.7 (P=0.0001) respectively.
Table 1 shows the mean scores for two groups according to patients symptoms.
The frequency of urinary symptoms in a group (13,5 %) lower than the frequency of urinary symptoms in B group (19.7 %) but statistically not significant (PV = 0/3973) and distribution of urinary symptoms in the total samples was 16.3 %.
Feeling of incomplete voiding symptoms in patients with A group ,frequency of 12 percent and mean = 0.74 was more than of patients B group ( 7%) and mean =0.47 but it was not statistically significant.
Six signs of intermittency and frequency, weak steam of rurination, urgency, straining to initiate urination, nocturia in patients A group was less than patients B group, that the only symptom of weak urination, straining to begin urination statistically were significant.
In a study , in Finland in 1993 determined that 92 % of patients undergoing prostatectomy (TURP) were satisfied with their urinary condition (12)
In other research that was conducted in 1986 in America, it was shown that 84% of patients who assessed one year after surgery were improved While in the third year, 75% of patients were improved (1)
A surgical approach, when indicated, may reduce urinary and sexual symptoms, thus restoring a good quality of life.
During the recent half century TURP has been the standard method for treatment of BPH.(13)
In another study conducted in America in 1986, 90% of patients who followed up were improved completely. In this study, two procedure of TURP surgery and TVP(Transvesical Prostatectomy) had been achieved for the patients, research showed there are very little clinical difference between two groups regard to the postoperative results. (13)
In another study in Italy in 1993 found that 95% of patients were completely recovered (14)
As was observed, according to the results of this research , recovery rate after operation were variable in the 70 to 96% and this study is consistent with the overall improvement of 83%.
According to the table 1 also scores a total average urinary symptoms in patients with preoperative prostate about 50gr ,(Mean=5.85), the mean total scores of urinary symptoms in patients with preoperative in B group (Mean=7.44)The mean total clinical symptoms between A group and B group is not significant. (P-value=0.1616)
In both groups of patients there were recovery and satisfaction. Although clinically patients in A group , recovered and satisfied better, But considering that this difference is not statistically significant This is not a specific recommendation about the timing of surgical intervention based on prostate weight for the Urologist . whether patients in B group in the absence of TURP surgery according to legitimate reasons, open prostatectomy can be used ? Regard to the high percentage recovery of 80% of these patients despite lack of statistical difference between the two groups of patients, yes it is.
One of the indications for enlarged prostate is open prostatectomy and TURP should be done for small Prostate, for the surgeon is a subjective concept. Experience and the surgeon’s skill and other factors can be effective for the determine of surgeon’s approach.
According to Table 2 ,average scores were used in urinary symptoms preoperation in A group (Mean=29.775) and post operation (mean=5.85). The difference is statistically significant (P<0.00001) represents the efficacy of surgery in these patients is high and also in patients in B group , urinary symptom scores before surgery Mean= 29.63 and after surgery ( Mean=7.44) that it is statistically significant. (p<0.0001)
In a survey in 1992 in Boston , was determined that the mean scores of urinary symptoms assessed using the AUA Symptom Score Index ranged 17.6 to 7.1 that postoperative prostatectomy was reduced {P<0.001)(15)
According table 1 , incomplete voiding feeling of the complaint scores were used in B group (Mean =0.47) lower scores feeling incomplete evacuation in patients in a group (mean=0.74) and we expected , the patients with lower weight of prostate would had a higher mean urinary score than another group and it is exactly opposite with our anticipation.(P- value=0.2147)
According to table 3 ,the frequency of complaints, feeling of incomplete emptying of the samples in A group was 74% and the frequency distribution of complaints, incomplete emptying feeling of the samples with prostate weight in b group was 12 percent and totally , 10% in both groups is the frequency distribution of patients with prostate weight below 50gr was less than patients in A group , but it is not statistically significant. (P-Value=0.3961)
According to the table 1 , Mean frequency scores in patients with prostate weight below 50 gr were more than another group but the difference was not statistically significant.(P-Value =04173)
According the table 4 , distribution of frequency in patients with prostate weight below 50 gr was 15 % and in another group was 12% , this difference is not statistically significant.(p-value=0.7333)according to the table 1 mean urinary frequency scores in prostate weight 50gr> 88/0 = mean were more than in patients with prostate weight 50gr <78/0 = mean This difference is not statistically significant (4433. 0 = PV) Also based on Table 5 Frequency distribution of urinary frequency in the samples studied With prostate weight more than 50 gr (18%) and in the samples in b group (12%) and at all is 15% in both groups that frequency distribution in the B group is more than of A group but it isn’t significant statistically (Pv=0.097). According to table 1 the mean scores of weak urinary flow in the b groups is more .This clinical difference is quite significant statistically (Pv=0.0179). Also according to Table 6 frequency distribution of weak urinary flow in the B group (23%) and in the B group 9% and at all is 15%. The difference of between two groups is statistically significant. (Pv=0.0178 A)According to Table 1the average scores of urgency in the B group (Mean =1.21) is more than of A group ( Mean=( 0.95) that this is not statistically significant (Pv=0.3671). Also according to the Table 7 frequency distribution of urgency in the B group (27%) and in the A group (21%) and in both groups is 24% that in the B group is more than A group but it isn’t statistically significant.(Pv=0.5403) According to the Table 1 the mean score of Straining to begin urination in the B group (mean=0.6) is more than A group.(Mean= 0.1) and this difference is statistically significant.(Pv=0.0048) .Also according to the Table 8 frequency distribution of straining to begin urination in the B group (10%) and in the A group (1%) and at all is 5%. This is clear that frequency distribution of straining to begin urination in the B group is more and this is statistically significant.(Pv=0.0224) .According to the Table 1 the mean score of nocturia in the B group (Mean=2.12) is more than A group (Mean =1.85). This difference is not statistically significant (Pv=0.3671). Also according to the table 9 frequency distribution of nocturia in the B group (41%) and in the A group (30%) and at all is 35%, this difference isn’t statistically significant too .
In a survey in US in 1986, during a period of five years , the nocturia was remained in more than of 50% of patients who were undergoing TVP operation(14) that these findings are more than of our survey
At all from 7 urinary complaints only was the incomplete voiding feeling in the A group that it isn’t significant statistically. The remained of 6 urinary complaints in the A group was less than compare to B group that among this 6 complaints only the two complaints of weak urinary flow and straining to begin urination were statistically significant, perhaps the reason was that this two complaints are more specific obstructive complaints for BPH .
| P-Value | (Mean±SD) | Groups | |
| 0.214 | 0.47 ± 1.14 | Group A | Feeling of not complete urine drainage |
| 0.74 ± 1.51 | Group B | ||
| 0.417 | 0.95 ± 1.49 | Group A | Frequency |
| 0.76± 1.44 | Group B | ||
| 0.658 | 0.88 ± 1.62 | Group A | Intermittency |
| 078 ± 1.23 | Group B | ||
| 0.017 | 1.21 ± 1.64 | Group A | Weak stream urination |
| 0.64 ± 1.36 | Group B | ||
| 0.367 | 1.21 ± 1.92 | Group A | Urgency |
| 0.95 ± 1.7 | Group B | ||
| 0.004 | 1.6 ± 1.5 | Group A | Straining for urination |
| 0.1 ± 0.6 | Group B | ||
| 0.367 | 2.12 ± 1.6 | Group A | Nocturia |
| 1.85 ± 1.42 | Group B | ||
| 0.161 | 7.44 ± 7.7 | Group A | Total Urinary Symptoms |
| 5.85 ± 6.59 | Group B |
Table 1: Comparison of mean scores for two groups according to patients urinary symptoms(T-test applied)
| Group A+B
n (%) N=160 |
Group B
n (%) N=99 |
Group A
n (%) N= 71 |
Presence of Urinary symptoms |
Urinary symptoms |
| 16 (10) | 11 (12) | 5 (7) | Yes
|
Feeling of not complete urine drainage |
| 144 (90) | 78 (88) | 66(93) | No
|
|
| 22 (13) | 11 (12) | 11(15) | Yes
|
Frequency |
| 138 (87) | 78 (88) | 60(85) | No
|
|
| 25 (15) | 11 (12) | 13(18) | Yes
|
Intermittency |
| 135 (85) | 78 (88) | 58(82) | No
|
|
| 25 (15) | 8 (9) | 17(23) | Yes
|
Weak stream urination |
| 135 (85) | 81 (91) | 54(77) | No
|
|
| 38 (24) | 19 (21) | 19(27) | Yes
|
Urgency |
| 122 (76) | 70 (79) | 52(73) | No
|
|
| 8 (5) | 1 (1) | 7(10) | Yes
|
Straining for urination |
| 152 (95) | 88 (99) | 64(90) | No
|
|
| 56 (35) | 27 (30) | 29(41) | Yes
|
Nocturia |
| 104 (65) | 62 (70) | 42(59) | No
|
|
| 26 (16.3) | 12 (13.5) | 14(19.7) | Yes
|
Total Urinary Symptoms |
| 134 (83.7) | 77 (86.5) | 57(80.3) | No
|
Table 2: Frequency of urinary symptoms in groups A and B.
Conclusion
As the comparison of two group of with weight below and above 50 gr that were been under open prostatectomy showed no significant difference , therefore it possible that use open prostatectomy for patients with prostate weight below 50 gr.
Suggestions
Relationship between divers prostat weights before operation should be reviewed.
In spite of The AUA Symptom Score, URODYNAMIC studies used to evaluate postoperative patients too.
The mortality rate of open prostatectomy in these patients should be assessed
The results of open prostatectomy are compared to with TURP surgery
The incidence of complications after open prostatectomy should review
ACKNOWLEDGEMENTS
We thank the staff of Urology service in Moradi hospital of Rafsanjan and Mrs. Batoul Badieh Neshin for kind participation.
References
1. Garraway WM, Collins GN, Lee RJ. High prevalence of benign prostatic hypertrophy in the community. Lancet, 1991; 338: 469.
2.Ala – opasmy – Aitola PT- Evaluation of mmediate and late results of transurethral resection of the prostate- scand gurol nephrol – 1993:27(2):235-9
3.Montorsi F – Long Term clinical reliability of transurethral and open prostatectomy for Benign Prostatic obstraction – Eur – Urol 1993:23(2):262-6
4.Nicholas T. Ward, J. Kellogg Parsons, Adam W. Levinson, Herman S. Bagga, Lynda Z. Mettee, Li-Ming Su, and Christian P. Pavlovich. Prostate Cancer: Radical Prostatectomy Prostate Size Is Not Associated With Recovery of Sexual Function After Minimally Invasive Radical Prostatectomy.
5.Adam W. Levinson, Herman S. Bagga, Christian P. Pavlovich, Lynda Z. Mettee, Nicholas T. Ward. Richard E. Link and Li-Ming SuThe Impact of Prostate Size on Urinary Quality of Life Indexes Following Laparoscopic Radical Prostatectomy. THE JOURNAL OF UROLOGY. 2008:179, 1818-1822.
6. ELIAS I. HSU, EUGENE K. HONG, HERBERT LEPOR INFLUENCE OF BODY WEIGHT AND PROSTATE VOLUME ON INTRAOPERATIVE, PERIOPERATIVE, AND POSTOPERATIVE OUTCOMES AFTER RADICAL RETROPUBIC PROSTATECTOMY. UROLOGY 61 (3), 2003.601-6.
7. Stephen J. Freedland, William B. Isaacs, Elizabeth A. Platz,
Martha K. Terris,William J. Aronson, Christopher L. Amling, Joseph C. Presti Jr and
Christopher J. Kane. Prostate Size and Risk of High-Grade, Advanced Prostate Cancer and Biochemical Progression After Radical Prostatectomy: A Search Database Study. Journal of Clinical Oncology.
8. Christopher B. Anderson, Melissa R. Kaufman, Mary S. Dietrich,
Daniel A. Barocas, Sam S. Chang, Michael S. Cookson , Joseph A. Smith, Jr.,
Peter E. Clark , S. Duke Herrell. Recovery of Urinary Function After Radical Prostatectomy:
Identification of Trajectory Cluster Groups. 1346-51. THE JOURNAL OF UROLOGY. 2012 .187, 1346-1351.
9. M. Gacci, R. Bartoletti,S. Figlioli,E. Sarti,B. Eisner ,V. Boddi,M. Rizzo
Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study . 2003. 91(3) ; 196–200.
10.Elias I Hsu , Eugene K Hong , Herbert Lepor . Influence of body weight and prostate volume on intraoperative, perioperative, and postoperative outcomes after radical retropubic prostatectomy. Urology. 2003;61(3)601–606.
11. ELIAS I. HSU, EUGENE K. HONG, HERBERT LEPOR .INFLUENCE OF BODY WEIGHT AND PROSTATE VOLUME ON INTRAOPERATIVE, PERIOPERATIVE, AND POSTOPERATIVE OUTCOMES AFTER RADICAL RETROPUBIC PROSTATECTOMY. UROLOGY , 2003;61 (3) .601-5.
12. M. Gacci, R. Bartoletti,S. Figlioli,E. Sarti,B. Eisner ,V. Boddi,M. Rizzo
Urinary symptoms, quality of life and sexual function in patients with benign prostatic hypertrophy before and after prostatectomy: a prospective study . 2003. 91(3) ; 196–200.
13. Donovan JL, Frankel SJ, Nanchahal K et al. Prostatectomy for benign prostatic hyperplasia. In StevensA, RafteryJ eds, Health Care Needs Assessment. Vol. 2. Oxford: Radcliffe Medical Press, 1994: 140 – 201.
14. Steiner MS, Morton RA, and Walsh PC: Impact of anatomicalradical prostatectomy on urinary continence. J Urol 145: 512–515, 1991.
Posted By:
- Masoud Radman
Assistant professor of Otolaryngology. Rafsanjan University of Medical Sciences. Rafsanjan, Iran.
- Ali Panahi
Assistant professor of Urology. Rafsanjan University of Medical Sciences. Rafsanjan, Iran
- Omid rezahosseini
MD. Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Hamid Mirhoseini
Msc of Anesthesiology. Shahid Sadoughi of Yazd University of Medical Sciences, Yazd, Iran
- Reza Bidaki
Assis prof of Psychiatry Rafsanjan University of Medical Sciences. Rafsanjan, Iran. (Corresponding’s author)
- Mohammad Jamali Paghale
Assis prof of Urology Rafsanjan University of Medical Sciences. Rafsanjan, Iran
