Benign Prostatic Hyperplasia (BPH) is a common urological condition affecting older men, characterized by the non-cancerous enlargement of the prostate gland.[1] This enlargement occurs predominantly in the transition zone of the prostate and often results in obstruction of the urethra, leading to bothersome lower urinary tract symptoms (LUTS).[1,2] These symptoms, including urinary frequency, urgency, nocturia, weak stream, and incomplete bladder emptying, significantly affect the quality of life in men over the age of 50. The global prevalence of BPH continues to rise due to increasing life expectancy, making effective management of the condition a critical focus in urological care.[3,4]

One of the most widely used and effective treatments for BPH is Transurethral Resection of the Prostate (TURP). [5,6] TURP is a minimally invasive surgical procedure that involves the removal of excess prostate tissue through the urethra, relieving the obstruction caused by BPH. Despite the availability of various medical therapies and minimally invasive alternatives, TURP remains the gold standard for patients with moderate to severe symptoms, particularly when medical management fails to provide adequate relief.[3,4]

The severity and impact of LUTS due to BPH are commonly evaluated using the International Prostate Symptom Score (IPSS), a validated questionnaire that quantifies the patient’s urinary symptoms and the associated distress. The IPSS consists of seven questions regarding urinary symptoms and one question assessing the patient’s overall quality of life. The score ranges from 0 to 35, with higher scores indicating more severe symptoms. It provides a standardized method for clinicians to assess the impact of BPH on patients’ daily lives and to monitor the outcomes of various treatments, including TURP.[3,7,8]

Preoperative assessment of patients undergoing TURP typically involves the use of the IPSS to establish a baseline understanding of the severity of the patient's symptoms. This baseline score is crucial for evaluating the effectiveness of the surgery. Postoperatively, the IPSS is used again to gauge improvements in symptoms and to determine the overall success of the procedure. By comparing preoperative and postoperative IPSS scores, clinicians can quantitatively assess how much the surgery has alleviated the patient's symptoms and improved their quality of life. The difference between the preoperative and postoperative scores can also serve as an indicator of the patient's satisfaction and functional recovery.[1,2,4,7]

While TURP is generally successful in relieving urinary symptoms, the outcomes can vary depending on factors such as the patient’s age, prostate size, and the presence of other comorbidities. Understanding the changes in IPSS before and after surgery allows for a more precise evaluation of the procedure's efficacy, especially in terms of symptom relief and quality of life improvement. Postoperative improvements in IPSS are typically significant, with most patients experiencing a marked reduction in urinary symptoms and an enhancement in their overall well-being. However, some patients may encounter complications or experience persistent symptoms, which can be detected through a follow-up assessment using the IPSS.

The study was conducted in the Department of General Surgery at Dr. D. Y. Patil Medical College, Hospital and Research Institute, Kolhapur over a period of 23 months, from April 2023 to February 2025 after receiving approval from the Institutional Ethics Committee, of Dr. D. Y. Patil Medical College, Hospital and Research Institute, Kolhapur.63 participants were included in the study.

Inclusion Criteria

Male patients aged over 50 years presenting with Lower Urinary Tract Symptoms (LUTS) suggestive of BPH, diagnosed clinically and radiologically with BPH and scheduled for TURP and willing to provide written informed consent and comply with follow-up protocols.

Exclusion Criteria

Patients with a history of previous transurethral resection of the prostate, who had undergone surgical interventions for urethral or vesical calculi, individuals with LUTS due to causes other than BPH, including neurogenic bladder or urethral strictures, with uncontrolled diabetes mellitus (particularly with PSA > 4 ng/ml) and those unfit for surgery due to comorbid conditions or deranged renal function tests.

All patients underwent a clinical assessment and were subjected to a standardized diagnostic and pre-operative evaluation protocol such as Clinical History and Physical Examination, Digital Rectal Examination(DRE), laboratory Investigation, Radiological Assessment, Uroflowmetry and Urodynamic studies (when indicated).

Patients with complications were stabilized and optimized before surgery.

Patients underwent TURP under spinal anesthesia as per standard protocols. The surgeries were performed using monopolar resectoscopes, and hospital stay duration was recorded from the day of the procedure. Post-operative care included monitoring for complications such as bleeding, UTI, retention, incontinence, and bladder spasms. The primary outcome measure was the change in IPSS scores, assessed at three time points: pre-operative, 1month post-operative, and 3-months post-operative. Complication rates were also recorded and analyzed.

All data were entered into a Microsoft Excel master sheet. Descriptive statistics were used for analysis.

Table 1: Pre-Operative IPSS Summary Statistics

Data from 63 individuals were analyzed, with a mean IPSS of 23.54 and a standard deviation of 7.26, indicating a moderate degree of variability in symptom severity. The scores ranged from a minimum of 8.00 to a maximum of 34.00. The 25th percentile was recorded at 20.00, the median (50th percentile) at 23.00, and the 75^th percentile at 30.00. These statistics suggest that a majority of patients experienced moderate to severe lower urinary tract symptoms prior to surgery.

Table 2: IPSS Classification (Pre-Operative) Count and Percentage

The pre-operative IPSS classification data reveals that a significant majority of the participants, 50 out of 63 (79.37%), were categorized as having severe symptoms. In contrast, 13 individuals (20.63%) experienced moderate symptoms. This distribution indicates that most patients presented with advanced lower urinary tract symptoms before undergoing surgical intervention.

Table 3: Pre-Operative Symptom Summary Statistics

Among the pre-operative symptom scores across five domains of lower urinary tract symptoms, incomplete emptying had the highest mean score of 2.70 with a median of 3.00 and a standard deviation of 1.19, indicating it was the most prominent symptom reported by patients. This was closely followed by intermittency (mean 2.68, median 3.00, SD 1.01) and urgency (mean 2.65, median 3.00, SD 1.02), suggesting that these were also common and consistently experienced symptoms. Weak stream had a comparable mean of 2.63 and median of 3.00 but with slightly higher variability (SD 1.25). Frequency was the least severe symptom with the lowest mean of 2.41 and median of 2.00. Overall, most symptoms had median scores around 3, indicating moderate to severe severity across the board in the pre-operative period.

Table 4: Post-Operative IPSS (1 Month) Summary Statistics

Based on data from 63 participants, the mean post-operative IPSS was 13.89, showing a notable reduction compared to the pre-operative values. The standard deviation was 4.60, indicating moderate variability in patient responses. Scores ranged from a minimum of 6.00 to a maximum of 23.00. The 25th percentile was 10.00, the median (50th percentile) was 13.00, and the 75th percentile reached 18.00. These findings reflect an overall improvement in urinary symptoms following surgical intervention, with most patients experiencing mild to moderate symptoms one month post-operatively.

Table 5: IPSS Classification (1 Month Post-Operative) Count and Percentage

The majority of patients, 48 out of 63 (76.19%), fell into the moderate symptom category, suggesting a substantial reduction in symptom severity compared to pre-operative levels. Severe symptoms persisted in 11 patients (17.46%), while 4 individuals (6.35%) achieved a mild symptom classification. These findings indicate that the surgical intervention had a positive impact on most patients, with a significant number transitioning from severe to moderate or mild symptom levels within one month post-operatively.

Table 6: Post-Operative IPSS (3 Months) Summary Statistics

Among the 63 participants, the mean IPSS score decreased to 9.38, with a standard deviation of 4.69, indicating both a significant reduction in symptom severity and moderate variability. The minimum score recorded was 1.00, while the maximum was 18.00. The 25th percentile value was 5.50, the median (50th percentile) was 9.00, and the 75th percentile was 13.00. These results suggest that most patients experienced mild to moderate symptoms by the three-month mark, highlighting the sustained effectiveness of the treatment.

Table 7: IPSS Classification (3 Months Post-Operative) Count and Percentage

Table 8: Comparison of IPSS Classification Counts and Percentages

Initially, the majority of patients (79.37%) had severe symptoms, with 20.63% classified as moderate and none as mild. One month after surgery, there was a substantial shift, with severe cases dropping to 17.46%, moderate cases rising to 76.19%, and mild cases emerging at 6.35%. By three months post-operatively, no patients remained in the severe category, while 58.73% were classified as moderate and 41.27% as mild. The highly significant chi-squared test p-value of 0.0000 confirms that these changes in IPSS classification over time are statistically significant.

Table 9: Complication Summary Table

The most common complication was urinary tract infection (UTI), reported in 10 patients, accounting for 15.87% of the cohort. This was followed by bleeding, which occurred in 8 patients (12.70%), and bladder spasms, reported in 6 cases (9.52%). Urinary retention was noted in 5 patients (7.94%), while incontinence was the least frequent complication, affecting only 2 patients (3.17%). Overall, the incidence of complications was relatively low, with most being mild and manageable in nature.

IPSS

In above study, the mean pre-operative International Prostate Symptom Score (IPSS) was 23.54, indicating that most patients experienced moderate to severe lower urinary tract symptoms (LUTS). This observation is consistent with previous research. Parth et al.[9] reported a nearly identical mean pre-operative IPSS of 23.61, suggesting similar patient symptom burdens. Sudeep Raj KC et al.[10] recorded a higher mean IPSS of 28.92, likely reflecting more advanced disease due to delayed presentation. Alam et al.[11] documented a mean pre-operative IPSS of 25.18, again supporting the presence of moderate to severe LUTS. Although Baek et al.[12] did not report direct IPSS values, their study population consisted of symptomatic patients undergoing bipolar TURP, indirectly confirming severe baseline symptoms. Banoth et al.[13] also indicated severe symptomatology, albeit without specific IPSS data, while Masumori et al.[14], in a long-term study, confirmed substantial symptom scores at baseline. Collectively, these studies corroborate that the IPSS values observed in the study are consistent with global data and reinforce that TURP is typically indicated in patients with moderate to severe

LUTS.

In cohort, 79.37% of patients were classified as having severe LUTS pre-operatively, and 20.63% had moderate symptoms. This distribution aligns with other reports. KC et al.[10] similarly noted a high prevalence of severe symptoms, reflected by a mean IPSS of 28.92. Alam et al.[11] and Parth et al.[9] also reported mean scores above 23, placing most patients within the severe category. Chahal et al.[15] found that larger prostate volumes correlated with significantly higher IPSS scores, often classifying patients as severe.

Symptoms

In above study, the severity of individual lower urinary tract symptoms (LUTS) was analyzed using domain-specific scores within the International Prostate Symptom Score (IPSS) framework. Among the five primary domains assessed, incomplete emptying had the highest mean score of 2.70, followed closely by intermittency (2.68), urgency (2.65), and weak stream (2.63). Frequency was reported as the least severe symptom with a mean of 2.41. These values indicate that most patients experienced moderate to severe obstructive symptoms, which are hallmark clinical features of benign prostatic hyperplasia (BPH) in individuals undergoing transurethral resection of the prostate (TURP).

The findings of the study are consistent with previously published literature. Alam et al.[11] reported urgency and frequency as the dominant complaints among BPH patients scheduled for TURP. Their cohort exhibited median scores approximating 3.00 across most symptom domains, indicating a similarly high burden of LUTS. This pattern supports the concept that the majority of patients undergoing surgery present at an advanced stage of symptomatology, often after prolonged conservative management or delayed healthcare access.

Parth et al.[9] also highlighted incomplete emptying and weak stream as the leading symptoms contributing to patient discomfort and poor quality of life, particularly in cases with elevated total IPSS values. Their observations resonate closely with the current findings, where incomplete emptying and weak stream were consistently among the most severe domains reported.

The high severity scores in obstructive domains are further supported by physiological studies. Ugraiah et al.[16] demonstrated a strong correlation between the patient-reported symptom of incomplete emptying and a reduction in maximum urinary flow rate (Qmax) on uroflowmetry testing. This relationship has clinical implications, as incomplete emptying is not only a subjective symptom but also reflects underlying pathophysiology related to bladder outlet obstruction. Consequently, incomplete emptying can be considered a reliable marker of symptom severity and a predictive indicator for the need for surgical intervention. The correlation between subjective and objective findings reinforces the validity of the IPSS as a valuable diagnostic and monitoring tool.

In contrast to the obstructive symptoms, frequency was found to be the least severe in the present cohort, with a mean score of 2.41. While still indicative of patient discomfort, this symptom typically correlates with bladder irritability and detrusor overactivity, which are secondary manifestations of prolonged bladder outlet obstruction. This finding suggests that in the current population, obstructive features dominated the clinical picture, with irritative symptoms being present but less pronounced.

Furthermore, the predominance of obstructive over irritative symptoms in the study supports TURP’s indication as a highly effective surgical approach specifically targeting bladder outlet obstruction. By resecting obstructive prostatic tissue, TURP directly addresses the anatomical cause of the most distressing symptoms reported by patients. As such, the study’s domain analysis provides strong baseline data for comparison with post-operative outcomes, where a significant reduction in these obstructive symptoms is anticipated.

Post-Operative IPSS scorings [ 1 month, 3 month and 6-month]

In above study, the mean IPSS one month post-operatively was 13.89, reflecting a significant improvement from the pre-operative score of 23.54. This early reduction in symptom burden is consistent with findings in similar studies. KC et al. [10] reported a reduction in mean IPSS from 28.92 to 5.38 at one month, demonstrating a more pronounced decline, likely due to variation in baseline severity and healthcare setting. Alam et al.[11] also found an early post-operative drop in IPSS from 25.18 to 15.00 within one month, similar in trajectory to the present study. Parth et al. [9], although they assessed outcomes at 12 weeks, showed a comparable trend of significant reduction from a pre-op mean of 23.61 to 15.71, suggesting that the steepest symptom decline occurs in the first month. Thus, the above study’s one-month IPSS results align closely with multi-centre evidence, confirming TURP’s rapid and effective symptomatic benefit.

In the above study, one month after TURP, 76.19% of patients were classified as having moderate symptoms, 17.46% as severe, and 6.35% as mild. This represents a significant shift from the pre-operative profile, where nearly 80% had severe symptoms. Similar improvements have been reported in other studies. KC et al. documented an even more dramatic change, with most patients moving into the mild category within a month and only a few retaining moderate symptoms. Alam et al.[11] also observed a marked reduction in severity, where most patients transitioned from severe to moderate symptom levels at one month. Banoth et al.[13] and Ugraiah et al.[16] described symptom category improvements as well, though they focused on mean score reduction and qualitative improvements rather than explicit IPSS categories.

In above study, the mean IPSS at three months post-TURP was 9.38, indicating continued improvement from the one-month post-op mean of 13.89 and a significant decline from the pre-operative score of 23.54. This trajectory of sustained symptom relief is echoed in other studies. Parth et al. reported a three-month post-op IPSS of 15.71 at 12 weeks, slightly higher than the present study’s value, though still reflecting meaningful improvement from their baseline of 23.61. KC et al.[10] found an even greater improvement, with IPSS dropping to 5.38 at one month, suggesting either earlier symptom control or differences in symptom interpretation and follow-up intervals. Alam et al.[11] recorded a three-month IPSS of 8.14, very similar to the current study, further validating the consistent benefits of TURP in symptom relief over time.

At three months post-operatively, the study reported 58.73% of patients with moderate symptoms and 41.27% with mild symptoms, with no patients remaining in the severe category. This shift marks a substantial improvement from the pre-operative classification, where nearly 80% were in the severe category. Similar outcomes were observed in other studies. KC et al.[10] found that the majority of patients achieved mild symptom levels within one month post-TURP, and this benefit was sustained over time, indicating even better outcomes than the current study. Alam et al. reported that IPSS and QoL scores significantly improved by three months, with many patients transitioning to milder symptom categories.[11] Parth et al.[9] although using a 12-week endpoint, demonstrated a consistent pattern where most patients moved out of the severe group postoperatively, showing that three months is a sufficient interval for substantial recovery. Chahal et al.[15] and Ugraiah et al.[16] also observed this transition, even in patients with large prostates, suggesting that IPSS improvements are not strictly limited by gland size. Collectively, the shift in IPSS classification in this study is in strong agreement with the broader literature, validating TURP as an effective intervention for symptom resolution within three months.

IPSS Pre Vs Post-operative

The study observed a clear and progressive improvement in symptom severity following TURP, as shown through IPSS classifications over time. Pre-operatively, 79.37% of patients had severe symptoms, which dropped to 17.46% at one month and 0% by three months. Simultaneously, the proportion of mild cases increased from 0% pre-operatively to 6.35% at one month and 41.27% at three months. These shifts were statistically significant (p-value = 0.0000), mirroring trends found in multiple other studies. KC et al.[10] also documented a steep reduction in symptom severity, with a majority of their patients classified as mild within one month of surgery. Alam et al.[11] showed a similar trajectory, where patients transitioned from severe to moderate and mild categories by three months. Parth et al.[9] highlighted a similar distribution shift at 12 weeks, supporting the consistent post-TURP symptom relief timeline.

Complications:

In the above study, the incidence of post-operative complications following transurethral resection of the prostate (TURP) was relatively low, confirming the overall safety of the procedure. The most common complication was urinary tract infection (UTI), observed in 15.87% of patients. This was followed by bleeding in 12.70%, bladder spasms in 9.52%, urinary retention in 7.94%, and urinary incontinence in 3.17% of the cohort. These results are consistent with complication rates reported across multiple similar studies evaluating TURP outcomes.

Sudeep Raj KC et al.[10] reported similar findings in their study, where UTI and post-operative bleeding were the most frequent complications encountered. Their experience, like that of the current study, suggests that these events are often transient and can be managed effectively with conservative measures. Alam et al.[11] also observed UTIs and bleeding as the predominant post-TURP complications, with all cases successfully treated without the need for re-intervention.

TURP proved to be a safe procedure, with a manageable complication profile; the most frequent post-op issue was UTI (15.87%). No major surgical re-interventions were needed, and complications were resolved with conservative treatment. The progressive reduction in IPSS scores at 1 month and 3 months shows that TURP provides both immediate and mid-term symptom control. The study reinforces that IPSS is a reliable tool for quantifying LUTS and monitoring post-surgical improvement in patients undergoing TURP.

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