Evaluation of quality of life in patients undergoing surgery for benign prostatic hyperplasia

Abstract

Introduction: Benign prostatic hyperplasia (BPH) is one of the most common diseases in the world and also one of the most common causes of urinary complaints that occur with increasing age. Thus, BPH should be addressed with surgical procedures. To contribute to the relevant literature, the present study aims to investigate the effects of surgical therapies for BPH on the patients quality of life.

Materials and methods: This study included 120 patients who underwent surgery for BPH at a Training and Research Hospital. The short-form health survey (SF-36) was administered to the patients before the surgery and at three months after the surgery. Eight parameters of the SF-36 and mental (MCS) and physical (PCS) component summary scores were calculated. The Student’s t-test, Wilcoxon, and chi-square test were used in the statistical analysis.

Results: When the eight parameters within the SF-36 health questionnaire were examined separately, the findings showed that patients quality of life increased significantly with respect to physical functioning, social functioning, and role limitations because of emotional problems , vitality, bodily pain, general health perceptions, and mental health domains three months after surgery (p < .001). The PCS and MCS significantly increased after surgery (p < .001).

Conclusion: The SF-36 questionnaire results showed that a significant improvement in the patients quality of life was observed in patients who underwent surgery for BPH. Our findings suggest that SF-36 could be considered a reliable evaluation test to be used in the patients with BPH after surgery.

Keywords:

• BPH surgery
• SF-36
• quality of life

Introduction

Benign prostatic hyperplasia (BPH) is the most common condition behind urinary complaints, which occur with increasing age in males and result in a bladder outlet obstruction. BPH is one of the most common causes of morbidity in the world [1,2], occur in 15 to 60% of males aged above 40 y and is rising to as high as 80% in men aged above 70 y. In the US, approximately 25% of males have undergone surgery for BPH [3,4].

BPH produces many symptoms that affect the quality of life of patients that could be divided into two groups: irritative and obstructive symptoms. Irritative symptoms include frequent urination, dysuria, and urgency, whereas obstructive symptoms include hesitancy (i.e. trouble in starting to urinate), decreases in the caliber and speed of the urine stream, feelings of residual urine after urinating, dribbling after urination, and intermittency.

Due to the increasing number of patients in recent years, therapeutic options for BPH have increased substantially with the development of new medical agents by pharmaceutical companies and the introduction of less invasive interventional therapies by technology companies. Meanwhile, treatment guidelines have gained currency and have led to the development of treatment standards. There is a consensus regarding the challenges of treatment when patients develop complications, such as urinary tract infections, impairment in renal function, and resistant hematuria, this has led to efforts to evaluate symptoms and plan treatments according to the severity of the symptoms in uncomplicated patients [5,6].

Postoperative complications and their effects on the patients quality of life are other vital concerns, considering the burden of symptoms that affect patients with BPH and the increasing popularity of surgical therapies for BPH in the world. In this regard, the surgical treatment of BPH has become the most broadly studied area of research in the world, and the effects of surgery have been widely discussed [7].

The present study aims to investigate the effects of surgical therapies for BPH on the patients quality of life. Thus, an short form-36 (SF-36) health survey, which has been validated in many countries, including Turkey, was administered to the patients before surgery and at three months after surgery.

Materials and methods

This study was conducted at a Training and Research Hospital after obtaining Ethics Committee approval, reference number 358, dated November 17 2015. This study included 120 patients who underwent prostatic surgery for BPH between April 2015 and June 2016. Patients with acute prostatitis, patients who received five alpha-reductase inhibitor affecting prostate specific antigen (PSA) levels, patients with urethral stenosis, patients who underwent a biopsy, and patients with a neurogenic bladder or a history of surgery to the lower urinary tract were excluded from the study. In the present study, the transurethral resection of the prostate (TURP), which has been used as the gold standard treatment in the surgical management of BPH and the open prostatectomy, which is commonly preferred particularly in patients with large prostates, despite the introduction of different treatment methods, were performed. Patients underwent a routine rectal examination, urinary ultrasonography, PSA measurement, uroflowmetry, post-void residual volume measurement, and measurement of prostate volume to evaluate lower urinary tract symptoms before surgery. A complete urine analysis and urine culture were obtained routinely to rule out possible infections and the international prostate symptom score (I-PSS) was used to evaluate the patients symptoms. Based on this scoring system, the patients were divided into three groups as none-mild (0–7), moderate (8–19), and severe (20–35). This groups included 10, 70, and 40 patients, respectively.

The SF-36 questionnaire was administered to the patients who underwent surgical treatment before the surgery and at three months after surgery to evaluate the quality of life, which allowed the changes in physical and psychological components of the quality of life to be evaluated post-surgery. The results were then compared with normative data on SF-36 reference values in the Turkish population.

The SPSS 15.0 (SPSS for Windows, 15.0, SPSS Chicago, IL) software package was used for the statistical analysis. In the analysis of quantitative data, variables with normal distribution were analyzed using a paired sample Student’s t-test and variables without a normal distribution were analyzed with a Wilcoxon test. A Chi-square test was used for the analysis of qualitative data. A p value less than .05 was considered statistically significant.

The SF-36 is a 36-item questionnaire for evaluating the quality of life. According to the responses given to the questions, quality of life is assessed in eight domains (physical functioning, social role functioning, physical role functioning, emotional role functioning, mental health, vitality, bodily pain, and general health perceptions) and as a summary of these domains, physical component (PCS) and mental component (MCS) summary scores are calculated [8,9]. These parameters were evaluated in our patients.

Results

Demographic data are shown in Table 1. The SF-36 questionnaire was administered to the study patients before surgery and at three months after surgery and the eight scales of the SF-36 questionnaire were evaluated separately, along with two summary parameters.

Table 1. Demographic data of the patients.

Parameters n =120	Number
Age (mean ± SD)	63.95 ± 7.7
Presence of MS	32 (26.7%)
BMI (kg/m^2 ± SD)	27.2 ± 4.4
Hypertension (%)	38 (31.7%)
Diabetes mellitus (%)	29 (24.2%)

The mean score on the physical functioning scale before and after surgery was 64.8 ± 13.6 and 77 ± 17.4 respectively, with a statistically significant difference (p < .001). The mean score on physical role functioning scale was 62.2 ± 36.8 before surgery and 80.3 ± 21.1 after surgery, with a statistically significant difference (p < .001). The mean score in the general health perceptions scale before and after surgery was 63.1 ± 17 and 75.5 ± 17.4, respectively and there was a statistically significant difference (p < .001). The mean score on the vitality scale was 58.8 ± 19.7 before surgery and 72.6 ± 14.5 after surgery with a statistically significant difference (p < .001). The mean score on the social role functioning scale was 67.6 ± 26.8 before surgery and 79.9 ± 20 after surgery and there was a statistically significant difference (p < .001). The mean score on the emotional role functioning scale was 61.1 ± 35.3 before surgery and 84.1 ± 18.9 after surgery and there was a statistically significant difference (p < .001). The mean score on the mental health scale was 70.2 ± 18.5 before surgery and 80.2 ± 12.4 after surgery with a statistically significant difference (p < .001). The mean score on the bodily pain scale was 64.9 ± 24.5 before surgery and 81.7 ± 17.2 after surgery and there was a statistically significant difference (p < .001). The mean score on the physical component summary (PCS) was 42.7 ± 7.5 before surgery and 48.5 ± 5.8 after surgery and there was a statistically significant difference (p < .001). The mean score on the mental component summary (MCS) was 42.7 ± 7.5 before surgery and 48.5 ± 5.8 after surgery and there was a statistically significant difference (p < .001). We also examined the IPSS score in three groups and in all the groups there was a statistically significant difference before and after surgery (p < .001).

Statistically significant differences were identified in all scales of the SF-36 questionnaire and quality of life improved after surgery. In other words, patients who underwent surgery for BPH witness a significant increase in life quality. Data about the SF-36 parameters are provided in detail in Table 2.

Table 2. SF-36 parameters of the patients.

SF-36 parameters	Mean preoperativevalues	Meanpostoperativevalues	p value
Physical functioning (PF)	64.8 ± 13.6	77 ± 17.4	.0001
Physical role functioning (PRF)	62.2 ± 36.8	80.3 ± 21.1	.0001
General health perceptions (GHP)	63.1 ± 17	75.5 ± 17.4	.0001
Vitality (V)	58.8 ± 19.7	72.6 ± 16.6	.0001
Social role functioning (SRF)	67.6 ± 26.8	79.9 ± 20	.0001
Emotional role functioning (ERF)	61.1 ± 35.3	84.1 ± 18.9	.0001
Mental health (MH)	70.2 ± 18.5	80.2 ± 12.4	.0001
Bodily pain	64.9 ± 24.5	81.7 ± 17.2
Physical component summary (PCS)	42.7 ± 7.5	48.5 ± 5.8	.0001
Mental component summary (MCS)	45.9 ± 8.9	51.5 ± 6.0	.0001

Graphic illustration of SF-36 parameters are shown in the Figures 1 and 2.

Figure 1. Illustration of SF-36 parameters before and after surgery.

Figure 2. Summary of SF-36 parameters.

Discussion

Quality of life is one of the most popular topics in studies conducted over the last two decades all around the world, including Turkey. Various assessment methods have been used in these studies in which the effects of disease or treatment on the patients quality of life were evaluated. SF-36 is the most popular method among the tools for evaluating the quality of life, with many studies conducted around the world making use of it. The Turkish version of SF-36 has been validated in many studies of a vast number of patients for its use in the Turkish population and there are also studies reporting the normative values of the Turkish population [10–12]. The present study has also made use of the SF-36 health survey. The most important studies in which the reliability of the Turkish version of SF-36 has been validated include Koçyiğit et al. [10] and Pınar et al. [11] Koçyiğit et al. [10] evaluated the reliability of SF-36 questionnaire in a study of 50 patients with osteoarthritis and 50 patients with chronic lumbar pain. In these patients, Cronbach alpha coefficients reflecting the reliability were found to be between 0.7324 and 0.7612 [10].

In the study conducted by Pınar et al. [11] the reliability of SF-36 was evaluated in a study of 419 patients with cancer and the Cronbach alpha coefficient was found to be 0.70 in these patients. These two pioneering studies and the study by Demiral et al. [12] show that the Turkish version of SF-36 could be used reliably for the evaluation of patients’ quality of life.

Similar to the present study, Yoshimura et al. [13] conducted a study using the SF-36 questionnaire, but unlike the present study, they evaluated patients who underwent a transurethral resection due to a bladder tumor. The patients were compared with the normative values of the Japanese population and the findings showed that both the physical and mental components of the SF-36 parameters after the first TURP procedure were negatively affected by cancer perception when compared to the preoperative values. The study also identified an improvement in these components in subsequent TURP procedures, which was attributed to the patients adjusting to the idea of living with cancer. The difference in this study is that patients had severe symptoms associated with BPH and the reevaluation was performed after relieving the symptoms.

Similar to the present study, Büker et al. [14] evaluated the quality of life in 25 patients with BPH undergoing TURP and reported an improvement in all quality of life parameters of the SF-36 questionnaire, with all parameters showing statistically significant changes (p values below .05). Different from the present study, Lee et al. [15] prospectively evaluated 397 patients who underwent holmium laser enucleation of the prostate (HOLEP) and saw significant improvements in the quality of life parameters and lower urinary tract symptoms. Rigatti et al. [16] and Peter et al. [17] evaluated two groups of patients who underwent HOLEP or TURP. They reported improvements in the life qualities of both groups and compared the two groups regarding the complications. Kuntz et al. [18] compared HOLEP with the open prostatectomy procedure and reported an improvement in the quality of life with both techniques after surgery. Different from the present study, Abigar-Pedraza et al. [19] compared the effects of bipolar transurethral resection and thermotherapy on the quality of life and evaluated the superiority of one technique over the other. They found out that both methods increased the quality of life compared to the preoperative values, with a bipolar resection being found to be superior to laser thermotherapy. There are different studies about HOLEP and quality of life [20,21].

The present study found out that patients who exhibit symptoms of BPH scored lower in the SF-36 than the normative values of the Turkish population. The present study in particular compared patients aged 45 years and older with the normative data of the matching 45 patients in the study by Demiral et al. [12] and found out that BPH affects the quality of life of patients. Furthermore, patients undergoing surgery for BPH showed a significant improvement in SF-36 parameters after surgery when compared to the preoperative values and when the parameters were evaluated individually, significant improvements were found in all parameters of SF-36 compared to the preoperative values (p < .0001). This result suggests that patients who undergo surgery for BPH experienced a significant improvement in the quality of life in both the physical and mental components of the scale. At the same time, eight of the 120 patients showed a decrease in quality of life and an evaluation of these eight patients showed that all developed postoperative urethral stenosis, meaning that the postoperative uroflowmetry values and symptoms of these eight patients were negatively affected, which led to the decrease in the quality of life. These patients underwent additional therapy for urethral stenosis, which provided symptom relief.

This study has several limitations. Some patients included had trouble in understanding some of the complex questions and so the option that best corresponded to their response was considered the correct answer. The small number of patients in the statistical analysis must also be considered, although we highlight that the improvement in postoperative SF-36 parameters and overall life quality is a remarkable finding. Finally, the results cannot be generalized for males from different geographical regions, since the data included only Turkish men.

Conclusion

In conclusion, our findings suggest that SF-36 is an appropriate tool for evaluating the quality of life in patients with BPH undergoing surgery. The SF-36 questionnaire was used to evaluate the quality of life before and after surgery in the present study, which revealed that a significant improvement in the patients quality of life was seen after surgery. Properly designed, prospective, and randomized studies on larger cohorts of patients are required to confirm the results of the present study.

Disclosure statement

There is no conflict of interests between authors.