After obtaining ethics approval from the local ethics committee (approval no:72/1167), we retrospectively identified the prospectively maintained database records of 558 patients diagnosed with bladder calculi concomitant BPO between 2014 January – 2021 January at two tertial referred center. Patients who underwent simultaneous prostate and bladder stone surgery were excluded from the study. Patients with neurogenic bladder, a history of bladder calculi removal or surgery for BPO, history of renal or ureteral stone, renal impairment, urinary tract dilatation, underactive detrusor, and urethral stricture were excluded from the study. Patients who received previous medical therapy for BPO or, not received medical therapy after calculi removal and who had recurrent urinary retention or indwelling foley catheter were also excluded. Figure 1 shows the flowchart of the study.
A total of 117 patients were included in the study. These patients preferred bladder removal only, although combined surgery was recommended Before bladder calculi removal, patients’ data such as age, Charlson Comorbidity Index (CCI) score, American Society of Anaesthesiologists (ASA) score, International Prostate Symptom Score (IPSS), prostate specific-antigen (PSA), prostate volume, post-voiding residual (PVR) urine volume, uroflowmetry, and cystoscopy findings were recorded as baseline values. IPSS with the quality-of-life (QoL) index, ranging from zero (delighted) to six (terrible), was used as the QoL surrogate indicator. The stone size was calculated by ultrasonography using the maximum diameters of the largest calculi. Transabdomial ultrasonography was performed in all patients to measure the total prostate volume and intravesical prostatic protrusion (IPP). The degree of IPP was classified as grade 1 (≤ 5 mm), grade 2 (> 5–10 mm), and grade 3 (> 10 mm) . All patients were administered alpha-blocker and 5-alpha reductase inhibitors after bladder calculi removal. Patients were reassessed at 1, 6, and 12 months and then annually after surgery by IPSS, uroflowmetry, and PVR urine volume. Deterioration in QoL index and lower urinary tract symptoms, presence of residual urine over 100 ml, an increase in IPSS score were considered as medical treatment failure. During follow-up, patients who benefited from medical treatment after bladder calculi surgery were determined as group 1 (control group), and patients who underwent surgery for BPO due to medical treatment failure or any indication were determined as group 2. Preoperative baseline variables between the two groups and their effects on future prostate surgery were investigated. Patients who had undergone prostate surgery at the time of evaluation were excluded from the further analysis. Transurethral resection of the prostate (TUR-P) or holmium laser prostate enucleation (HoLEP) was performed in all patients as the prostate surgical method. The presence of postoperative residual stone was evaluated according to abdominal ultrasonography as well as viewing with direct vision at the end of the surgical process. Residual stones of 4 mm and below were noted as stone-free.
Descriptive statistics of data are given as mean, standard deviation, median, minimum-maximum, frequency, and percentage. Pearson chi-square or Fisher’s exact test were performed for categorical variables. Normality assumptions were checked with the Shapiro-Wilk test. The differences between the two groups were evaluated using the Student’s t-test for normally distributed data or Mann-Whitney U test for non-normally distributed data. Cox regression proportional hazard regression was used to identify independent preoperative factors that could predict the requirements for prostate surgery during follow-up. Statistical analysis was performed using IBM SPSS Statistics for Windows version 22.0 (IBM Corp., Armonk, NY). P < 0.05 was considered statistically significant.