Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms (LUTS) in men, especially the elderly men. Although BPH is not considered as a life-threatening disease, its impact on patient’s quality of life should not be underestimated. [5]
The incidence of both DM and BPH increases with age. As also noted in our study, the majority of patients were in their early 7th decade of life. Deferent studies found that The prevalence of diabetes in BPH patients candidates for surgery varies from 5–17%. [6, 7]
Although there has been discussion of a potential link between diabetes and BPH in several research, it is unknown if diabetes might impact the therapeutic advantages of surgery for BPH patients. [8] To examine the many facets of postoperative outcomes, we thus carried out a prospective trial with long-term follow-up.
There have been reports that diabetics exhibit a much higher yearly prostatic development rate and significantly more severe symptoms when compared to healthy controls. Numerous explanations have been proposed to explain this relationship. Diabetes for an extended period of time can result in bladder dysfunction, which is characterized by autonomic neuropathy that denervates the detrusor muscles in a parasympathetic and perhaps sympathetic manner. [9]
Ischemia brought on by atherosclerosis may impair detrusor function and cause fibrosis, atrophy of the smooth muscles, and noncompliance with bladder functions. Diabetes can impact the bladder's dynamic and static components by slowing down the detrusor muscle and speeding up the development of the prostate gland, respectively. [10] Reduced NOS/NO in the prostate and bladder due to diabetes and hyperinsulinemia causes muscle cell proliferation and structural alterations in the prostate, while concurrently increasing contraction impacts bladder compliance and outlet resistance. [11] In our study, all patients were complaining from sever obstructive urinary symptoms and candidate for surgical intervention.
Many studies suggest that the increased growth factor levels that the prostate stroma is exposed to over time as a result of chronic hypoxia may be the cause of the higher prostatic growth rate in diabetic patients [12]. However, other studies that show a decreased perfusion of the prostate's transitional zone have not demonstrated any differences in the mean prostate volume between BPH patients with diabetes and those without it. To bolster this assertion, Burke et al. demonstrated that while there was a gradual drop in Q max and a development in the intensity of symptoms, diabetes was not substantially linked to the yearly percentage of changes in prostate. These data suggest that the presence of diabetes may be less directly linked with the prostate growth and more closely related to the dynamic components of the lower urinary tract function. [13]
In this study, we selected 40 patients who were uncontrolled diabetic with sever obstructive symptoms candidate for surgical intervention. Preoperative and postoperative (after bipolar TURP) assessments were done by urodynamic study, IPSS, Q max and PVRU to study the changes.
Even though the symptoms of diabetic neuropathy in the urine are similar to those of BPH, our diabetic patients' significant improvement in IPSS following surgery (61.49% after a 12-month follow-up) indicates that a significant obstructive component was present and that they were carefully chosen for surgery. As a result, the long-term diabetes did not compromise the positive outcomes of the procedure for these patients.
We found significant postoperative improvement of all parameters. There was significant postoperative reduction in IPSS score (61.49% after 12 months follow up), improvement of QOL (52.46% after 12 months), Q max (194.61% after 12 months) and PVRU (81.46% after 12 months). We found also significant decrease in mean detrusor pressure at Q max one month after TURP(The mean ± SD Pdet@Qmax at pre-treatment and one month after TURP was (81.78 ± 17.9 vs. 41.3 ± 7.8) (P < 0.0001). This significant improvement in detrusor pressure delineates the relief of obstruction in most of cases.
In our study, the combination of increased IPSS and PVR may indicate a good result prognosis in such patients with no need for the pressure flow as an invasive technique.
Mane D.A et al., found significant improvement of IPSS, QOL index, and Qmax postoperatively in diabetic patients. [14] De Lima and Netto also found significant improvement of IPSS and Qmax in urodynamically diagnosed obstructed patients. [15] Min et al., found reduction of 61.5 ml PVR postoperatively in obstructed group which was less than the volume in our study. [16] In the study done by Min et al. 2013, they had divided BPH patients into different groups, according to degree of obstruction seen in urodynamics, where they found greater results in obstructed group as compared to equivocal and unobstructed group. [16] Han et al. 2008 explained the effect of TURP in patients without BOO and weak detrusor contractility, by suggesting that the BPH patients with weak detrusor contractility during UDS may not be diagnosed as obstruction because of insufficient rise in detrusor pressure. They reported that TURP can treat the obstruction undiagnosed in UDS to improve LUTS. [17]
Another study by Venrooij et al. 2003 compared the outcome of TURP in obstructed, unobstructed, or equivocal men. They showed that there is a reduction in urethral resistance factor to about 70% in obstructed group and 40% in unobstructed group post‑TURP, suggesting that the reduction in urethral resistance postoperatively can increase the flow rate in patients without BOO. This could be the possible reason for improvement in flow rate and thus QOL postoperatively beyond expectation in patients who had obstruction and diabetic cystopathy in the present study. [18]
In our study, all selected patients had uncontrolled DM and sever obstructive symptoms with poor QOL. Many other studies found significant association between the diabetes and the severity of obstructive urinary symptoms. (Sarma AV et al., 2008) (Michel MC et al., 2000). [4, 19] These studies found that BPH with DM had more severe symptom score and poor QOL as compared to non-diabetic BPH patients.
In our study, we tried to find relation between diabetic preoperative parameters and postoperative results to can predict the postoperative improvement. We found significant negative correlation between age, FBS, duration of DM, HbA1c, PVR, infected urine, IPSS and bladder capacity from one side and postoperative improvement from the other side. There was significant positive correlation between the improvement and preoperative Q max and BCI.
On the same line, Loli et al, found significant relation between preoperative HbA1c and postoperative improvement after TURP. They recommend optimising diabetes control prior to TURP reduces risk of reoperation. [20]
Although all our patients improved postoperatively, but these studied factors can predict the degree of postoperative improvement and the benefit from TURP in uncontrolled diabetic patients.
Although we have promising results, we need to study these factors in larger number of patients with longer follow up.