Archivio Italiano di Urologia e Andrologia 2016; 88, 4258

ORIGINAL PAPER

Effects of obesity surgery (laparoscopic sleeve
gastrectomy technique) on lower urinary tract symptoms,
depression and quality of life of males: Prospective study

Fatih Uruç 1, Serkan Akan 1, Bekir Aras 2, Çağlar Yıldırım 1, Aytaç Şahin 1, Ozgur Haki Yuksel 1, 
Mehmet Timuçin Aydın 3, Ayhan Verit 1

1 Department of Urology, Fatih Sultan Mehmet Research and Training Hospital, Istanbul, Turkey;
2 Department of Urology, Dumlupınar University, Evliya Çelebi Research and Training Hospital, Kütahya, Turkey;
3 Department of General Surgery, Fatih Sultan Mehmet Research and Training Hospital, Istanbul, Turkey. 

Purpose: Technically, obesity weakens the
pelvic base muscles by causing an increase

in the intraabdominal pressure and intravesical pressure due
to increasing fat and it triggers the occurrence of lower uri-
nary tract symptoms. However it is believed that weight loss
will cause recovery of these symptoms. Our purpose in this
study is to research about the effects of the weight loss
achieved by using especially the Laparoscopic Sleeve
Gastrectomy (LSG) technique of bariatric surgery which is
being more and more widely used today.
Materials and Methods: Out of all patients who had LSG sur-
gery due to obesity earlier in our center during the period
between April 2014 and March 2015, 22 applicable male
patients were considered after a brief exclusion criteria appli-
cation. Age, height, weight, and body mass index (BMI) data
of these patients were recorded before the operation.
International Prostate Symptom Score (IPSS), International
Consultation on Incontinence Questionnaire - short from)
(ICIQ-SF), Beck depression inventory (BECK) and  Short form
- 36 (SF-36) were filled for the patients and the data were
recorded. Also, the weight loss amounts and BMI decreases of
the patients after the operation were recorded.
Results: After the procedure, the decrease in the averages of
BECK depression inventory, IPSS, ICIQ-SF and the increase
in the Mental and Physical subgroup scores of SF-36 were
found statistically coherent.
Conclusion: The adverse effect of obesity, which is observed
more and more often in today's world, on lower urinary tract
symptoms and on the quality of life is undeniable. In our
study, we think that the bariatric surgery made by using the
LSG technique, not only causes serious amount of weight loss,
but also reduces urinary dysfunction and enhances the quality
of life among males.

KEY WORDS: Obesity; Lower urinary system; Bariatric surgery;
Sleeve gastrectomy; Quality of life.

Submitted 12 April 2016; Accepted 22 May 2016

Summary

No conflict of interest declared.

According to the data of World Health Organization
(WHO), it is detected that 1.6 billion adults are over-
weight. And among these individuals, approximately
300 million females are obese (1, 2). While 67% of the
population of United States of America (USA) are classi-
fied either as obese or overweight, in many European
countries, this ratio is around 40-50% (3). According to
the data of 2011, over 40 million of children under 5
years old are overweight (1, 2). It is known that there are
approximately 500 million obese adults and that this
number is on the rise. Approximately 2,8 people a year
dies as a result of being overweight or obesity(4).
Obesity prevalence was found to be 22.3% in the
Obesity Prevalence Study (TURDEP) in Turkey, in 1997
(5). In the TURDEP II study that was conducted in 2010,
the obesity rate in Turkey was found to have increased to
32%. This striking fast increase is alarming (6).
While weight loss can be achieved with non-surgical meth-
ods, it was observed that 66% of these patients reached
their former weight in a time period as short as 24 months.
The compatibility that the patient will have with the diet
during the medical treatment application might form an
idea about the patient’s compatibility with post-operational
treatment. Surgical treatment of morbid obesity stands out
due to its possibility of causing deaths as a results of addi-
tional diseases and becoming epidemic (7). Today,
bariatric surgery is the most effective treatment modality
that causes 15% or more weight loss than the normal pro-
cedure (8). Taking mortality, morbidity, cost, patient satis-
faction and most importantly the expected weight loss rate
into consideration, laparoscopic sleeve gastrectomy (LSG)
is one of the most preferred surgical procedures today (9,
10). More than 220.000 bariatric surgical procedures are
applied in a year in USA (11). Technically, obesity weak-
ens the pelvic base muscles by causing increase in the
intra-abdominal pressure and intravesical pressure due to
fattening increase and triggers the lower urinary tract
symptoms (LUTS). It is believed that weight loss will cause
recovery of these symptoms (12-14).
Our purpose in this study is to research about the effects
of the weight loss achieved by using especially the
Laparoscopic Sleeve Gastrectomy (LSG) technique of

DOI: 10.4081/aiua.2016.4.258

INTRODUCTION
Obesity is one of the most important health problems in
both developing and developed countries today because
of the diseases it brings with it. The number of people
with obesity has nearly doubled since the year 1980.

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259Archivio Italiano di Urologia e Andrologia 2016; 88, 4

Effects of obesity surgery on lower urinary symptoms

bariatric surgery which is being more and more widely
used today, on the LUTS and quality of life of males.

MATERIAL AND METHOD
Twenty-two male patients who has LSG surgery due to
obesity between April 2014 and March 2015 were taken
into study. The patients who met the exclusion criteria
below, were excluded from the study.
Exclusion criteria’s were: (I) the patient being unwilling,
(II) the patient having a known mental or psychiatric dis-
ease, (III) the patient having had any surgical or unsur-
gical weight loss treatment earlier, (IV) the patient hav-
ing had any surgical procedures for incontinence or any
medical treatment due to LUTS earlier, (V) the patient
being under the age of 18, (VI) the patient having any
respiratory system diseases (COPD) or any neurological
diseases that can be related to urinary symptoms.
Twenty-two male patients who met the criteria above were
taken under study and the data were evaluated in pre-
operational and post-operational periods. Age, height,
weight, and body mass index (BMI) data of these patients
were recorded pre-operation International Prostate
Symptom Score (IPSS), International Consultation on
Incontinence Questionnaire - short from) (ICIQ-SF), Beck
depression inventory (BECK) and Short form - 36 (SF-36)
were filled for the patients and the data were recorded.
Also, the weight loss amounts and BMI decreases of the
patients post-operation were recorded.
IPSS: It is a scoring system originally named as American
urology association symptom score and it consists of 8
questions. 0-7 points means mildly symptomatic, 8-19
points mean average symptomatic and 20-35 points means
severely symptomatic condition. Severity and progression
on a certain period of time of symptoms are compared.
ICIQ-SF: It enables measuring of the severity of inconti-
nence symptoms and its effects on quality of life. The scor-
ing system that consists of 4 questions, is evaluated
between 0-21 points. BECK Depression inventory: It is a
21 multiple choice question self-evaluating inventory that
is applied to children and adults to measure the severity of
anxiety. 0-21 points is evaluated as mild anxiety, 22-356
points is evaluated as average anxiety, 36-63 points is eval-
uated as severe anxiety.
SF-36: It is a reliable, valid and very often used standard
in evaluating the quality of life. Scale consists of 36 sub-
jects and these ensures the measurement of 8 dimen-
sions. These are; vitality (energy), physical function,
pain, general health physical, emotional and social role
restrictions, mental health. Scoring is summed up in 2
topics that are PCS: physical component summary and
MCS: Mental component summary.

Surgery technique
The patients were operated using LSG technique.
Operations were conducted by general surgeons. Sleeve
gastretomy (SG) first started to be applied as the restric-
tive component of the Duodenal Switch operation first.
This method was taken into practical use as a risk reduc-
ing method in the patients who are at high risk and who
may not be able to tolerate long term procedures (15).
LSG became a more often used, safe and efficient pri-

mary bariatric surgical method that is highly popular
among the surgeons and the patients (16). After the large
curvature is freed from 2-3 cm proximal of pylorus up to
the angle of HIS (incisura cardiaca), stomach resection is
practiced. Posterior dissection is applied by making
angle of HIS visible so as not to leave a large fundus
pouch. Bending of the stomach from incisura angularis is
prevented by fixating the sleeve tube by stitching the
omentum or gastrocolic fat. LSG has become a very often
preferred method alone or alongside the other methods
in treatment of morbid obesity (17).
Statistical Analysis: The study was planned as a prospec-
tive study. While evaluating the findings obtained during
the studyi IBM SPSS Statistics 22 (IBM SPSS, Turkey) pro-
gram was used fort he statistical analyses. The compatibil-
ity of the parameters to the normal range was evaluated
with Shapiro Wilks test during the evaluation of the study
data. Along with the definitive statistical methods (aver-
age, standard deviation) while evaluating the study data,
student t test was used in comparisons between two
groups of parameters that Show normal distribution in the
comparison of quantitative data, Mann Whitney U test
was used in comparison between two groups of parame-
ters that don’t Show normal distribution. Pairedsample t
test was used in the same group comparison of parameters
that Show normal distribution and Wilcoxon sign test was
used in the same group comparison of parameters that
don’t Show normal distribution. Pearson correlation
analysis was used in analyzing the relations between
parameters that are compatible with normal distribution.
Coherence was evaluated at p < 0.05 level.

RESULTS
The study was conducted with 22 male cases that had LSG
between the dates April 2014 and March 2015. The ages
of the cases vary between 24 and 51 years and the average
of the ages is 34.59 ± 8.07 years. Statistically meaningful
decrease is detected in the average post-operative BMI val-
ues, body weight, scores of IPSS and BECK depression
inventory in comparison with the post-operative values
(for all of them p = 0.001; p < 0.01). Statistically mean-
ingful increases are observed in the PCS and MCS’ of the
individuals when pre-operative values are compared to
the post-operative ones (for all p = 0.001; p < 0.01).
Statistically meaningful decrease was detected in ICIQ-SF
between pre-operation and post-operation averages (p =
0.002; p < 0.01) (Table 1). There is positive correlation at
62.8% level observed between post-operative BMI change
ratio and post-operative IPSS change ratio when com-
pared with the pre-operative values (p = 0.002; p < 0.01).
No statistically meaningful correlation was shown
between post-operative BMI change ratio and post-opera-
tive BECK depression inventory and ICIQ-SF parameters
change ratio when compared with the pre-operative val-
ues (for all p > 0.05). There is no meaningful correlation
between pre-operative and post-operative BMI change
amount and age (p > 0.05) (Table 2).

DISCUSSION
According to the data of NHNES (National Health and

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260

Nutrition Examination Survey) it is noted that 35.5% of
the males above the age of 20 are obese (BMI ≥ 30 kg/m2)
and 73.9% of them are either overweight or obese (BMI
≥ 25 kg/m2) . Metabolic syndrome (MS) is a disease that
has a multifactorial component that causes insulin resist-
ance whereas its mechanisms are not completely known
(18). While MS incident is 42% among individuals at 70
years of age and above, it is 6,7% among the individuals
of younger ages between 20-29 years (19). 
Epidemiological and clinical data show that obesity,
physical activity and nutrition are changeable risk factors
for benign prostate hyperplasia (BPH) and LUTS (20).
Although the pathophysiological mechanisms that cause
LUTS in obesity are not completely known, many
hypotheses were claimed. In many studies, it was shown
that obese males have larger prostates that can cause
obstruction and consequently LUTS (21). An important
correlation was found between metabolic syndrome and
yearly prostate volume increase (22). Adipose tissue releas-
es the aromatase enzymes that cause androgens turn into
estrogens. It is claimed that prostate growth is lead by the
hyperplasia in the prostatic tissue associated with the
increase of estrogen/testosterone that originates from the
testosterone turning into estrogens in the adipose tissue in
obese males (23). Adipocytes cause cytokine release. Some
researchers think that, as a consequence of the occurrence
of systemic inflammation or oxidative stress in metabolic
syndrome, cytokines are released to cause LUTS (24). 

In another study, it is argued that in obesity with the
increased sympathetic nervous system activation,
increased irritative LUTS are caused by contraction of the
prostatic muscle component (25).
However in an experimental animal study, it is shown
that apoptosis occurs in the neural cells that are exposed
to hyperglycemia for a long time causing an increase in
LUTS as a result of autonomic hyperactivity with respect
to the parasympathetic system (26).
As seen above, many hypotheses were put forward about
the relation between obesity and LUTS and many studies
were conducted on this relationship in the recent years.
The results of a 10 year study of 5926 patients, conducted
in USA, show that severe LUTS could be prevented at the
rate of 20% in males who preserved their normal weight
(27). Again, Mondul et al. indicated that the total and
abdominal fattening increase is a serious risk factor to
develop or increase LUTS severity in males and that it is an
important target in prevention and treatment of LUTS (28).
In a study of 7318 patients, Penson et al. indicated that
decreasing physical activity causes an increase in LUTS
severity in males that are in normal weight, without taking
race into account (29). Again, in a study on the effect of
obesity on urine storage symptoms, which was conducted
in 2013 with 6000 participants, it was reported that a
strong relation exists between obesity and frequency of
micturition in males (30). Antithetically to the studies
above, Demir et al. and Yee at al. declared that they did not
find any relation between LUTS and abdominal obesity
(31). However they detected that weight loss causes recov-
ery in LUTS (32). Luke et al. evaluated LUTS of the patients
using IPSS demonstrating that there is improvement in
LUTS after weight loss, although this was not correlated
with the degree of the weight loss or the duration of the
weight loss (33).
Pre-operation IPSS average was found to be 4.5 ± 2.22 in
our study in which the average age is 34.59 ± 8.07; 19 of
our total 22 male patients were mildly symptomatic (0-7
points) pre-operation, 3 of them were in the average
symptomatic group with 8-19 points. Post-operation
IPSS average was evaluated as 1.91 ± 1.48 and this
decrease was found to be statistically significant. When
compared with the pre-operation values, a positive cor-
relation at 62.8% level is observed in post-operation BMI
change rates and post-operation IPSS change rates. In
our study, in order to measure the severity and the effects
of incontinence symptoms on the quality of life, the
patients were evaluated with ICIQ-SF form pre-operation
and post-operation. Incontinence was not observed in 14
patients out of 22 patients (63%) in the pre-operation
evaluation. In our study, while it was observed that both
pre-operation and post-operation incontinence rates are
relatively low, the post-operation decrease observed in
ICIQ-SF average was found to be statistically significant.
Effects of obesity on depression and quality of life for male
patients was also evaluated in our study with BECK depres-
sion inventory and SF-36 form. Average score of BECK
depression inventory was evaluated as low anxiety pre-
operation with 15.36 ± 2.4 point; it has shown improve-
ment by decreasing in the post-operation period. In the
study that was conducted in Turkey in 2010, on the effect
of the rheumatoid arthritis disease on the patient’s overall

Table 1. 
Evaluating post-operation data compared to the 
pre-operation data of the study parameters in males.

Pre-operation Post-operation
Avg ± SD (median) Avg ± SD (median)

BMI 49.57 ± 6.21 38.98 ± 5.51 10.001**
Weight 149.73 ± 21.34 118.23 ± 19.13 10.001**
IPSS 4.5 ± 2.22 (5) 1.91 ± 1.48 (2) 20.001**
ICIQ-SF 1.82 ± 2.15 (1) 0.32 ± 0.95 (0) 20.002**
BECK 15.36 ± 2.4 (15.5) 9.55 ± 2.09 (9) 20.001**
PCS 34.5 ± 8.13 42.95 ± 4.95 10.001**
MCS 40.92 ± 6.48 46.71 ± 6.48 10.001**
1Paired  Samples Test; 2Wilcoxon Sign Test; **p < 0.01.

Table 2. 
Post-operation BMI change in comparison with pre-
operation and evaluation of the relations between
changes in parameters.

Fif.1 - Overall quality of life of Males.
[IPSS: !nternational Prostate Symptom Score – ICIQ-SF: !nternational
consultation on incontinence questionnaire short form – BECK: Beck
depression scale – PCS: Physical summary scores – MCS: Mental summary
scores. Series 1: Pre-Gastrectomy – Series 2: Post-Gastrectomy]

Post-operation changes BMI percentage change
in comparison with pre-operation r p
Age -0.076 0.736
IPSS 0.628 0.002**
ICIQ-SF 0.324 0.142
BECK 0.232 0.298
1Paired Samples Test; 2Wilcoxon Sign Test; **p < 0.01.

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Effects of obesity surgery on lower urinary symptoms

quality of life average PCS in the control group was found
51.28 and MCS was found 41.43 (34). However in our
study the average post-operation PCS in the obese patients
was measured as 34.5 and MCS as 40.92 that were lower
than the population average. Post-operation PCS and MCS
scores significantly increased to 42.9 and 46.7.

CONCLUSION
The negative effect of gradually increasing obesity on
LUTS and the quality of life is undeniable in today’s
World. We think that while bariatric surgery helps weight
loss in serious amounts, it also decreases the urinary
 dysfunction in males and increases their quality of life.

REFERENCES
1. WHO Factsheet N°311.

2. Çıtak Akbulut G, Özmen MM, Besler HT. Obesity the disease of the
era. TUBITAK Science and Technical Magazine March 2007: 1.

3. World Health Organization. WHO global database on body mass
index. 

4. World Health Organization. Obesity and Overweight. Available at
http://www.who.int/mediacentre/factsheets/fs311/en/ [accessed 28
Sept 2012]

5. Satman I, Yilmaz T, Sengul A, et al. Population-based study of dia-
betes and risk characteristics in Turkey: results of the Turkish diabetes
epidemiology study (TURDEP). Diabetes care. 2002; 25:1551-6.

6. Satman I, Omer B, Tutuncu Y, et al. Twelve year trends in the
prevalence and risk factors of diabetes and pre diabetes in Turkish
adults. Eur J Epidemiol. 2013; 28:169.

7. Sjostrom L, Narbro K, Sjostrom D, et al. Effects of bariatric surgery
on mortality in Swedish obese subjects. N Engl J Med. 2007; 357:741. 

8. Colquit JL, Picot J, Loveman E, et al. Surgery for obesity. Cochrane
Database Syst Rev. 2009; 2:CD003641.

9. Dixon JB, le Roux CW, Rubino F, Zimmet P. Bariatric surgery for
type 2 diabetes. Lancet. 2012; 379:2300. 

10. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide
2011. Obes Surg. 2013; 23:427. 

11. Taylor K. Bariatric surgery fact sheet. American Society for
Metabolic and Bariatric Surgery web site. Available at
http//www.asbs.org/Newsite07/media/asmbs_fs_surgery.pdf.
[accessed February 23, 2011]

12. Bai SW, Kang JY, Rha KH, et al. Relationship of urodynamic
parameters and obesity in women with stress urinary incontinence. J
Reprod Med. 2002; 47:559.  

13. Han MO, Lee NY, Park HS. Abdominal obesity is associated with
stress urinary incontinence in Korean women. Int Urogynecol J Pelvic
Floor Dysfunct. 2005; 17:35.

14. Wasserberg N, Haney M, Petrone P, et al. Morbid obesity adverse-
ly impacts pelvic floor function in females seeking attention for weight
loss surgery. Dis Colon Rectum. 2007; 50:2096.

15. Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve
gastrectomy as staging and primary bariatric procedure. Surg Obes
Relat Dis. 2009; 5:469. 

16. Brethauer SA. Sleeve gastrectomy. Surg Clin N Am. 2011;
91:1265.

17. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am.
1967; 47:1345-51.

18. Hammarsten J, Hogstedt B. Hyperinsulinaemia as a risk fact or for
developing benign prostatic hyperplasia. Eur Urol. 2001; 39:151.

19. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syn-
drome among US adults: findings from the third National Health and
Nutrition Examination Survey. JAMA 2002; 287:356.

20. Raheem OA, Parsons JK. Associations of obesity, physical activity
and diet with benign prostatic hyperplasia and lower urinary tract
symptoms. Curr Opin Urol. 2014; 24:10.

21. Muller RL, Gerber L, Moreira DM, et al. Obesity is associated with
increased prostate growth and attenuated prostate volume reduction by
dutasteride. Eur Urol. 2013; 63:1115. 

22. Glynn RJ, Campion EW, Bouchard GR, Silbert JE. The develop-
ment of benign prostatic hyperplasia among volunteers in the
Normative Aging Study. Am J Epidemiol. 1985; 121:78.

23. Parsons JK, Sarma AV, McVary K, Wei JT. Obesity and benign
prostatic hyperplasia: clinical connections, emerging etiological para-
digms and future directions. J Urol. 2009; 182:27.

24. Furukawa S, Fujita T, Shimabukuro M, et al. Increased oxidative
stress in obesity and its impact on metabolic syndrome. J Clin Invest.
2004; 114:1752.

25. Giovannucci E, Rimm EB, Chute CG, et al. Obesity and benign
prostatic hyperplasia. Am J Epidemiol. 1994; 140:989.

26. Cellek S, Rodrigo J, Lobos E, et al. Selective nitrergic neuron degen-
eration in diabetes mellitus a nitric oxide-dependent phenomenon. Br J
Pharmacol. 1999; 128:1804.

27. Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and
trends in the distribution of body mass index among US adults 1999-
2010. JAMA. 2012; 307:491. 

28. Mondul AM, Giovannucci E, Platz EA. A prospective study of obe-
sity, and the incidence and progression of lower urinary tract symp-
toms. J Urol. 2014; 191:715.

29. Penson DF, Munro HM, Signorello LB, et al. Urologic Diseases in
America Project. Obesity, physical activity and lower urinary tract
symptoms: results from the Southern Community Cohort Study. J Urol.
2011; 186:2316. 

30. Vaughan CP, Auvinen A, Cartwright R, et al. Impact of obesity on
urinary storage symptoms: results from the FINNO study. J Urol.
2013; 189:1377.

31. Demir O, Akgul K, Akar Z, et al. Association between severity of
lower urinary tract symptoms, erectile dysfunction and metabolic syn-
drome. Aging Male. 2009; 12:29.

32. Yee CH, So WY, Yip SK, et al. Effect of weight reduction on the
severity of lower urinary tract symptoms in obese male patients with
benign prostatic hyperplasia: a randomized controlled trial. Korean J
Urol. 2015; 56:240-6; discussion 246.

33. Luke S, Addison B, Broughton K, et al. Effects of bariatric surgery
on untreated lower urinary tract symptoms: a prospective multicentre
cohort study. BJU Int. 2015; 115:466.

34. Kırgız C, Senel Ö, Sever O, Arslanoglu E. Observing the quality of
life of the training personnel that are working in physical education and
sports departments. Kafkas Educational Research Magazine 1(1),
April 2014.

Correspondence
Fatih Uruç, MD (Corresponding Author) - urucmd@gmail.com
Fatih Sultan Mehmet Research and Training Hospital, Department of Urology
Içerenkoy/Atasehir, Tr- 34752 Istanbul, Turkey
Serkan Akan - drserkanakan@gmail.com
Bekir Aras - bekiraras1@gmail.com
Çağlar Yıldırım - C_yildirim_87@hotmail.com
Aytaç Şahin - draytacsahin@gmail.com
Ozgur Haki Yuksel - Yuksel:ozgurhaki@gmail.com
Mehmet Timuçin Aydın - mtimucina@gmail.com 
Ayhan Verit - veritayhan@yahoo.com

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