The impact of central obesity on storage LUTS and urinary incontinence after prostatic surgery: Beyond the Abstract

Central obesity can be considered as an early step in the development of Metabolic Syndrome (MetS), a complex disorder, collecting a cluster of medical conditions including dyslipidemia (high triglycerides and low HDL cholesterol), hyperglycemia and arterial hypertension, in addition to central (abdominal) obesity.

Considering that the excess of bodyweight has progressively increased in the last decades, central obesity has rapidly become a worldwide epidemic disorder with a remarkable socioeconomic impact, due to its association with increased morbidity and mortality. Moreover, the progressive aging of male population increased the possibilities of coexisting morbidities associated with obesity such as lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) or to prostate cancer (PCa) needing primary treatment, including radical prostatectomy (RP), which can further adversely affect the quality of life.

Simple/endoscopic and radical prostatectomy are the most common surgical procedures in urologic unit all over the world for BPE and PCa, respectively. After both interventions, patients can present bothering storage LUTS that can worsen all the other clinical outcomes. Our study will review the role of central obesity as a risk factor for storage LUTS or urinary incontinence, after prostatic surgery for BPE or PCa.

An extensive literature search, limited to the English language was performed in PubMed and Scopus, without the adoption of temporary limits.  The  following search terms were included in the search: “LUTS”, “incontinence”, “BPH”, “BPE”, “Prostate cancer”,“MetS”, “obesity”, “central obesity”, “waist circumference”, “prostate surgery”, “TURP”, “prostectomy”, “simple prostatectomy” “radical prostatectomy”. IPSS, IPSS storage sub-score and IPSS QoL (International Prostate Symptom Score), AUA (American Urological Association) Symptom Score were the main validated efficacy outcomes.

A recent prospective trial by Sener et al. evaluated the impact of MetS and its components on the outcomes of  transurethral resection of the prostate (TURP) in 50 patients with and 50 without MetS. The Authors reported a significantly better IPSS and Qmax improvement in the group without MetS: 6 months postoperatively, IPSS was found to be 11.2 ± 0.87 vs. 12.9 ± 0 .88 and Qmax 18.2 ±0.81 vs. 13.9 ±1.12. In addition, there was a statistically significant improvement in terms of quality of life (QoL) in both groups after TURP, but patients without MetS presented a more remarkable improvement of their QoL as compared to those with MetS (p=0.034). Interestingly, after multivariate analyses, among MetS factors, abdominal obesity retained a significant and negative correlation with QoL (OR=7.286,p=0.043). In addition, in a multicenter prospective study by Gacci et al. on 378 men treated with surgery (OP or TURP) for large BPE, a waist circumference of ≥102 cm was associated with a higher risk of an incomplete recovery of both total IPSS (OR 0.343, P = 0.001) and storage IPSS (OR 0.208, P < 0.001). 

The prevalence of post prostatectomy LUTS, including storage LUTS and urinary incontinence, can be influenced by several items, comprising preoperative patient characteristics, surgeon experience, surgical technique, and methods used to collect and report data. In a single institution cohort study on 252 men who underwent open radical prostatectomy,  Van Roermund et al. reported a significant difference in term of occurrence of urinary incontinence, between obese (BMI >30) and non-obese (BMI <or=30) men: 25.8 vs. 8.7%, respectively, p < 0.05. Moreover, in a recent longitudinal trial assessing the changes in LUTS after robotic RP in 127 men evaluated preoperatively and at 3, 6, and 12 months after RP Kim et al. demonstrated that higher BMI was associated with a worsening of LUTS at 3 months postoperatively (OR:1.148, p=0.048). At postoperative 12 months a higher BMI was negatively associated with improvement in storage symptoms (OR:0.856, p=0.033). 

In conclusion, visceral obesity can be considered as one of the main preoperative risk factor of post-prostatic surgery storage LUTS and urinary incontinence, regardless of open, laparoscopic or robotic techniques used. Further studies are needed before introducing the measurement of central obesity in daily  clinical practice during preoperative counseling and postoperative follow up.

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Written by: Mauro Gacci1, Arcangelo Sebastianelli1, Matteo Salvi1, Cosimo De Nunzio2, Andrea Tubaro2,  Stavros Gravas3, Ignacio Moncada4, Sergio Serni1, Mario Maggi5, Linda Vignozzi5

1: Department of Urology, University of Florence, Careggi Hospital, Florence, Italy 

2: Department of Urology, Sant’Andrea Hospital, University ‘La Sapienza’, Rome, Italy

3: Department of Urology, University Hospital of Larissa, Larissa, Greece

4: Department of Urology, Hospital La Zarzuela, Madrid, Spain

5: Department of Clinical Physiopathology, University of Florence, Florence, Italy