| [Background]Benign prostatic hyperplasia (BPH) is common disease among elderly men. At the age of 60, more than half of them have got BPH, by the age of 80, almost all of them will suffer from BPH, which always cause dysuria, urinary frequency, urgency and nocturia, which also call lower urinary tract syndrome (LUTS), influencing health and life quality of elderly men. While this illness is very common, but its pathogenesis has not been well understood yet. It is generally believed that aging and testosterone are two indispensable factors in the pathogenesis of BPH, as well as some other mechanism theory, but its pathogenesis is still not very sure. In recent years, some studies have indicated that BPH may be related to the metabolic syndrome. Hammarsten’s search team first proposed that MS might be one of the pathogenesis of BPH in 1998, and even regared BPH as one part of MS. After searching 158 patients with LUTS, they found some components of MS were risk factor for the development of BPH, such as non-insulin dependent diabetes mellitus, hypertension, low levels of HDL and high level of insulin. Since then, more and more studies focused on the relationship between BPH and MS. These studies mainly focused on two aspects, the first aspect was relationship MS and the occurrence as well as development of BPH, the second aspect was the relationship between MS and LUTS. Despite it had been supported by many evidences in epidemiology and pathogenesis, whether MS is the pathogenesis of BPH/LUTS or not is still controversial. This paper discussed these two aspects through presenting a literature review and meta analysis.With the progress of medical technology, the surgical treatment toward BPH changed with each passing day. From open to minimally invasive technique, form conventional monopolar TURP to bipolar TURP, from electrocision to laser technique, huge changes have taken place in the BPH surgical field. Suprapubic cystostomy was commonly used in monopolar transurethral resection of prostate. But its benefit for the bipolar transurethral resection of prostate is still not clear. The controversial monopolar transurethral resection of prostate (monopolar TURP) is the gold standard of surgical treatment for BPH, but the irrigation liquid used in monopolar TURP is nonionic and insulative, excessive absortion of this nonionic liquid may cause transurethral resection syndrome (TURS) which is mainly characterized by hyponatremia and hypervolemia, and is a serious threat to patient’s safety. Intraoperatively combined with suprapubic cystostomy can prevent the TURS by reducing the absorption of irrigation liquid while making a monopolar TURP. As one method of "low pressure irrigation technique", many reports in domestic literature had pronounced that making a suprapubic cystoseomy in monopolar TURP had many advantages, such as shortening the operation time, reducing intraoperative blood loss, decreasing the incidence of TURS and making it more safety to high-risk patients. But its benefit and necessity in bipolar TURP (especially for prostate under 80 gram) has not been fully discussed and reported. Compared with monopolar TURP, bipolar TURP has lower incidence of TURS and other complications, weakening the position of controversial monopolar TURP. Thus, it is necessary to investigate that does suprapubic cystostomy still have obvious benefits and necessity to bipolar TURP especially those for BPH under 80 gram just like it to monopolar TURP? This paper investigated the benefit and necessity of suprapubic cystostomy to bipolar TURP by retrospectively analyzing the date of patients whom had been treated with an B-TURP for BPH under 80 gram in our hospital, in order to provide some reference for doctors when making bipolar TURP to treat BPH under 80 gram.With the aging, patients with BPH will become more and more popular. It is necessary to explore the pathogenesis of BPH and reappraise the benefit of some commonly used surgical technique in the new context of technology. The aim of this article is to explore the relationship between BPH and its possible pathogenesis, metabolic syndrome(MS) and to investigate the value of suprapubic cystostomy to TURP for BPH under 80 gram while the bipolar plasma cutting system has been widely used.[Objective]1. Reviewed the related literatures home and abroad about the relationship between MS and BPH/LUTS, made a brief and comprehensive overview of these subject. Focused on the impact of MS on the volume of the prostate and the symptoms of the lower urinary tract. And introduced the topics related to the basic concepts, clinical evidence and biological mechanism, also provided the necessary background knowledge for the second part:a meta analysis on relationship between MS and BPH/LUTS.2. Fully incorporated the relevant research literatures. Quantitatively analysised the the impact of MS on prostate volume and lower urinary tract symptoms by making a meta analysis, as well as expanded the samples of studies. In order to make the conclusions on relationship between MS and BPH/LUTS more convinced.3. Evaluated the benefit of suprapubic cystostomy to bipolar TURP treating BPH under 80 gram, in order to provide some reference for doctors whether a suprapubic cystostomy should be made or not when making bipolar TURP to treat BPH under 80 gram.[Methods]1. Respectively used the following terms:prostate, hyperplasia, hypertrophy of the prostate, lower urinary tract symptoms, combined with metabolic syndrome (in Chinese) as key words to make a searching on the following Chinese database: Chinese biomedical literature service (SinoMed), China national knowledge internet (CNKI), Wanfang and VIP Chinese database. In addition, used the following key words:benign prostatic hyperplasia, benign prostatic enlargement, BPH, BPE and lower urinary tract symptoms, LUTS combined with metabolic syndrome to make a search on several English databases including Pubmed, Embase, Web of Science. After browsing through the literature titles and abstract, completely collected the literatures published from past to May of 2015 which studied the relationship between MS and BPH/LUTS. Focus on two aspects:1. The effect of MS on prostate volume; 2.The effect of MS on lower urinary tract symptoms, meanwhile sorted out the related concepts of the subject of "the relationship between MS and BPH/LUTS", research progress, biological mechanisms and studies prospects.2. Furtherly extracted the related researches from the literatures which were collected from the above chapter, used the meta analysis as a method to analysis the impact of metabolic syndrome on prostate volume and the severity of lower urinary tract. And this meta analysis was made by Stata 12.0 software (a data software by which a meta analysis can be made).Weight mean difference (WMD) was taken as the effect index. The I2 value was taken to evaluate the heterogeneity between studies. When the I2 value is smaller than or equal to 50%, the heterogeneity was considered small, and the fixed effect model was used to make this meta analysis; when the I2 value is bigger than 50%, the heterogeneity was considered very obvious, in this case, a meta regression analysis would be used to find out the factors that impacts the heterogeneity, and then a subgroups analysis would be made according to this factors under the random effect model. Otherwise, a sensitivity analysis would be used to test the stability of the conclusion. Finally the Egger Method was use to evaluate the publications bias. If it is showed that there is some sort of publication bias, the trim and fill method would be further used to identify and correct the publication bias in order to assess the reliability of conclusion from meta analysis.3. Data collected from patients whom were made a bipolar TURP to treat their BPH under 80 gram from January 2012 to October 2015 at Nanfang Hospital were retrospectively analyzed. According to whether a suprapubic cystostomy was made or not in the bipolar TURP, the patients were divided into two groups, the cystostomy group and non-cystostomy group. Four kinds of outcomes were compared between groups, including outcomes of operative safety (intraoperative transfusion volume, decrease in blood sodium, decrease proportion in HCT, and decrease in HGB); outcomes of operation efficiency (operation time, prostate resected weight); outcomes of morbidity (blood transfusion rate, postoperative fever rate, catheter blocking rate); and outcomes of nursing care (bladder washing time, catheter indwelling time, postoperative hospitalization time), in order to comprehensively assess the benefits of suprapublic cystostomy to bipolar TURP treating the BPH under 80 gram.[Results]1. Totally 213 literatures were collected altogether. Throughout the literature we can know:(1) Most of the research showed that MS can promote the benign prostatic hyperplasia (BPH), embodied in men with MS tend to have larger prostate volume and faster prostate volume of annual growth rate; and a part of the studies found these phenomenon only in the male such as under 60 years old; part of the researches argued that it was the components of MS but not MS itself that promoted BPH; in addition, part of the studies did not find there was correlation between MS and BPH. (2) A large number of studies have indicated that MS can aggravate the severity of LUTS; some studies were able to find the phenomenon only in men under the age of 60; some studies found that MS had no significant association with the severity of LUTS.(3) The related clinical studies and animal experiments showed that MS promote the progress of BPH/LUTS mainly through the following several ways, which included insulin resistance, sex hormone change, pelvic atherosclerosis, inflammation, vascular endothelial injury and so on. (4) Some studies showed that MS seem to have a negative impact on both drug effect and operation effect of patients with BPH/LUTS. Improving the MS status may benefit patients with BPH/LUTS in some degree. But there is still a lack of prospective randomized controlled trials with large number sample to confirm this view.2. A total of 15 studies were included,13 of which had focused on relationship between MS and prostate volume,11 of which studied in the relationship between MS and lower urinary tract symptoms. All these studies included a total of 8690 cases of male subjects, with a total of 2465 cases with and 6225 cases without MS.(1 Relationship between MS and prostate volume:A total of 13 research papers with 7532 subjects were included in the statistics, the MS group and non MS group respectively contained 2259 and 5273 subjects. There were obvious heterogeneity between the studies (I2=85.9%). From the first part of this paper, we can know that age may be one of the factors that affect the relationship of MS-BPH, so stratified subgroup analysis was played according to the mean age of subjects and diagnosis standard of MS in each included study. The overall WMD value of meta analysis is 4.53, which 95%CI is 3.03-6.04. According to the WMD value of each subgroup, it showed that men with metabolic syndrome had greater prostate volume than those without metabolic syndrome. This difference in prostate volume can be seen at each age subgroup and MS diagnostic criteria subgroup.(2)Relationship between MS and lower urinary tract symptoms:A total of 11 research papers with 5270 subjects were included in this statistics, the MS group and non MS group respectively contained 1575 and 3695 subjects. There was obvious heterogeneity between the studies (I2=88.6%), thus the meta analysis was performed using a random effects mode. From the first part of the survey, we can know that age may be one of the factors that affect the relationship between MS and LUTS, so this study based on the average age of the study (to 60 years old as the grouping boundaries) for subgroup analysis. The overall WMD value was 0.83, which 95%CI was-0.23～1.89, meaning that the differences of IPSS score between male with and without metabolic syndrome did not have any statistical significances. From the results of the WMD of each subgroup, regardless of any age group, we can know that the severity of lower urinary tract syndrome of men with MS was equivalent to those of men without MS, that is to say no obvious difference was showed between the IPSS score of MS group and non MS group. All in all, metabolic syndrome had no obvious impact on LUTS. Ulteriorly the use of sensitivity analysis indicated that the conclusion was stable.3.585 subjects were enrolled into the study, with 366 in cystostomy group and 219 in non-cystostomy group. Declines in the serum sodium, haematocrict and blood haemoglobin concentration for cystostomy and non-cystostomy group were 0.06 and 0.54 mmol/L (P>0.05),2.44 and 2.89%(P>0.05),9.62 and 10.42 g/L, respectively (P>0.05). Resection weight were 42.50 and 43.76g, respectively (P>0.05), while the cystostomy group had longer operation time (90.75 vs 76.28min, P<0.05). There were no difference in the rate of blood transfusion, postoperative fever and catheter blocking. Meanwhile, compared with the non-cystostomy group, cystostomy group had longer time for bladder washing (3.15 vs 2.57d, P<0.05), catheter indwelling(5.19 vs 4.15d, P<0.05) and hospitalization after operation(7.36 vs 5.65d, P<0.05).[Conclusion]1. There was a lack of unified conclusion that whether there is a link between MS and BPH/LUTS. The underlying biological mechanisms that linked between the MS and BPH/LUTS mainly refered to the following aspects:Insulin resistance, sex hormone change, pelvic atherosclerosis, inflammation, vascular endothelial injury and so on. Some studies showed that MS seem to have a negative impact on both drug effect and operation effect of patients with BPH/LUTS. Improving the MS status may benefit patients with BPH/LUTS in some degree. But there was still a lack of prospective randomized controlled trials with large number sample to confirm this view.2. MS is a risk factor for the increase of prostate volume, but it is not sure that it is related to the severity of LUTS.3. To the prostate under 80 gram, no obvious value was showed in B-TURP combined with suprapubic cystostomy, and it lead to longer time for operation and bladder washing, catheter indwelling and hospitalization after operation. |
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