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

    

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