Hypothesis / aims of study
BPH is a common condition that affects men over the age of 50 and can cause lower urinary tract symptoms, with nocturia being particularly troublesome as it can negatively impact health and quality of life by disrupting sleep. Nocturia has been linked to various conditions, including cardiac disease, type 2 diabetes mellitus, and metabolic syndrome. Recent research has identified sleep disturbances as significant risk factors for type 2 diabetes mellitus, with difficulty initiating sleep increasing the risk by 55% and difficulty maintaining sleep increasing the risk by 74%. Lower urinary tract symptoms have also been found to be strongly correlated with testosterone deficiency (TD), which is prevalent in approximately one-third of men with obesity, type 2 diabetes mellitus, or metabolic syndrome. The causal relationship between testosterone deficiencies and type 2 diabetes mellitus is still unclear, but previous studies have shown that testosterone replacement therapy can improve blood sugar control and reduce insulin resistance. Surgical interventions, such as anatomical endoscopic enucleation of prostate (AEEP) [1], have been found to effectively improve nocturia and LUTS [2], which may have implications for type 2 diabetes mellitus.
Study design, materials and methods
We retrospectively evaluated patients with type 2 DM who underwent AEEP between January 2019 to December 2020 at our hospital. Baseline patient demographics including testosterone level, HbA1c, nocturia, and postoperative data, with HbA1c every 6 months for 1.5 years, testosterone level and times of nocturia were collected. Paired sample T test and Wilcoxon signed rank test were used to compare preoperative and postoperative data.
Interpretation of results
The current study investigated the trend of HbA1c levels and its association with TD following AEEP in patients with type 2 diabetes. Our findings demonstrated that HbA1c levels in men with hypotestosteronemia and type 2 diabetes improved significantly after undergoing AEEP during the follow-up period. Although we did not find a significant association between changes in testosterone levels and HbA1c levels after AEEP in men with type 2 diabetes, our study is the first to report that AEEP can improve HbA1c status in hypotestosteronemic men with type 2 DM.
Sleep disorders are common in patients with type 2 diabetes, and nocturia is a prevalent symptom. A literature review conducted in 2021 concluded that correcting sleep disorders could prevent the progression of diabetes and improve health and quality of life. Keskin et al. (2015) also reported that sleep disorders are common in patients with diabetes and can negatively affect blood sugar control. In our study, we found that the frequency of nocturia episodes in hypotestosteronemic patients with type 2 diabetes decreased significantly after receiving AEEP. This improvement in nocturia may lead to better sleep quality, which could further correct HbA1c levels.
Previous studies have demonstrated that TRT can improve metabolic status and HbA1c levels in diabetic men with TD. However, there are conflicting results regarding whether TRT can improve glycemic status in hypogonadal men. It's worth noting that the TRT mentioned in the above studies refers to exogenous testosterone. Recently, Y-R Li et al. (2022) reported that endoscopic enucleation of the prostate could increase testosterone levels in hypotestosteronemic patients, using a research method similar to ours. There is also a study that demonstrated no association between elevated endogenous testosterone levels and significant clinical morbidity. K. Khodamoradi et al. (2021) compared exogenous TRT with raising endogenous testosterone levels and concluded that exogenous TRT still has unignorable long-term consequences of continued use, such as gynecomastia, sleep apnea, and potential risks of heart attack. Further study for endogenous TRT is still necessary.
Our study is limited by its small sample size and the lack of information regarding diet and lifestyle habits. Nonetheless, our study is the first to demonstrate that AEEP can improve HbA1c status in hypotestosteronemic men with type 2 DM. This finding has important clinical implications and suggests that surgical intervention, in addition to medication and lifestyle modifications, can be a viable approach for controlling DM. Further larger-scale studies and data collection are necessary to validate our results.
Metabolic syndrome, including dyslipidemia, is known to play a role in the development and progression of BPH and LUTS. In our study, we collected lipid panel data, including HDL/LDL, TG, and total cholesterol; however, we did not observe any significant improvement in these measures. The lack of significant findings may be due to the fact that lipids are heavily influenced by diet, and the small sample size of our study may have impacted the test results.