OBJECTIVE To critically evaluate the use of uroflowmetry (UF) in a large urethral stricture disease cohort as a means to monitor for stricture recurrence. MATERIALS AND METHODS This study included men that underwent anterior urethroplasty and completed a study-specific follow-up protocol. Pre- and postoperative UF studies of men found to have cystoscopic recurrence were compared to UF studies from successful repairs. UF components of interest included maximum flow rate (Qm), average flow rate (Qa), and voided volume, in addition to the novel post-UF calculated value of Qm minus Qa (Qm-Qa). Area under the receiver operating characteristic curves (AUC) of individual UF parameters was compared. RESULTS Qm-Qa had the highest AUC (0.8295) followed by Qm (0.8241). UF performed significantly better in men ≤40 with an AUC of 0.9324 and 0.9224 for Qm-Qa and Qm respectively, as compared to 0.7484 and 0.7661 in men >40. Importantly, of men found to have anatomic recurrences, only 41% had a Qm of ≤15 mL/s at time of diagnostic cystoscopy, whereas over 83% were found to have a Qm-Qa of ≤10 mL/s. CONCLUSION Qm rate alone may not be sensitive enough to replace cystoscopy when screening for stricture recurrence in all patients, especially in younger men where baseline flow rates are higher. Qm-Qa is a novel calculated UF measure that appears to be more sensitive than Qm when using UF to screen for recurrence, as it may be a better numerical representation of the shape of the voiding curve.

OBJECTIVE To validate the use of the International Prostate Symptom Score (IPSS) as a stand-alone tool to detect urethral stricture recurrence following urethroplasty. MATERIALS AND METHODS This study included 393 men who had undergone anterior urethroplasty and were enrolled in a multi-institutional outcomes study. Data analyzed included pre- and post-operative answers to the IPSS in addition to findings from a same- day cystoscopy. IPSS from men found to have cystoscopic recurrence were then compared to scores from those with successful repairs, and receiver operating characteristic curves were plotted to illustrate the predictive ability of these questions to screen for cystoscopic recurrence. RESULTS Mean postoperative scores were lower (fewer symptoms) in successful repairs; IPSS improved from preoperative values regardless of recurrence. Successful repairs had significantly better degree of improvement in question #5 (assessing weak stream) compared to recurrences. Receiver operating characteristic curves demonstrated the highest area under the curve for the IPSS quality of life question (0.66) that alone outperformed the complete IPSS questionnaire (0.56). CONCLUSION The IPSS had inadequate sensitivity and specificity to be used as a stand-alone screening tool for stricture recurrence in this large cohort of men, highlighting the need to continue development of a disease-specific, validated patient-reported outcome measure.

Purpose Subjective measures of success after urethroplasty have become increasingly valuable in postoperative monitoring. We examined patient reported satisfaction following anterior urethroplasty using objective measures as a proxy for success. Materials and Methods Men 18 years old or older with urethral strictures undergoing urethroplasty were prospectively enrolled in a longitudinal, multi-institutional urethroplasty outcomes database. Preoperative and postoperative assessment included questionnaires to assess lower urinary tract symptoms, pain, satisfaction and sexual health. Analyses controlling for stricture recurrence (defined as the inability to traverse the reconstructed urethra with a flexible cystoscope) were performed to determine independent predictors of dissatisfaction. Results At a mean followup of 14 months we found a high 89.4% rate of overall postoperative satisfaction in 433 patients and a high 82.8% rate in those who would have chosen the operation again. Men with cystoscopic recurrence were more likely to report dissatisfaction (OR 4.96, 95% CI 2.07–11.90) and men reporting dissatisfaction had significantly worse uroflowmetry measures (each p <0.02). When controlling for recurrence, multivariate analysis revealed that urethra and bladder pain (OR 1.71, 95% CI 1.05–2.77 and OR 2.74, 95% CI 1.12–6.69, respectively), a postoperative decrease in sexual activity (OR 4.36, 95% CI 2.07–11.90) and persistent lower urinary tract symptoms (eg straining to urinate OR 3.23, 1.74-6.01) were independent predictors of dissatisfaction. Conclusions Overall satisfaction after anterior urethroplasty is high and traditional measures of surgical success strongly correlate with satisfaction. However, independently of the anatomical appearance of the reconstructed urethra, postoperative pain, sexual dysfunction and persistent lower urinary tract symptoms were predictors of patient dissatisfaction.

Objective To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. Materials/Methods We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes versus time since fellowship and case number. Results A total of 613 consecutive cases from six surgeons were analyzed, with a functional success rate of 87.3%. The success for bulbar urethroplasties was higher than for penile urethroplasties (88.2% vs 78.3%, p = 0.0116). The success of anastomotic repairs was higher than for substitution repairs (95.0% vs 82.4%, p = 0.0001). There was a statistically significant trend towards improved outcomes with increasing number of cases (p = 0.0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (> 90% success), was approximately 100 cases for all types of reconstruction were considered and 70 cases for bulbar urethroplasties. There were statistical differences in success rates among the participating surgeons (p = 0.0014). Complications decreased with time (p = 0.0053). Conclusions This study shows success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.

Purpose Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral stricture disease. In this study we determine systemic comorbidities associated with lichen sclerosus in men. Materials and Methods We analyzed data from 1,151 men who were enrolled in a multi-institutional prospective urethroplasty outcomes database. Individuals were grouped by stricture etiology, and baseline demographics, medical histories and patient reported outcome measures were retrospectively compared across groups. Results Of the 1,151 men in the database 81 (7.0%) were noted to have lichen sclerosus related urethral stricture disease. Average patient age was 46.06 ± 16.52 years, with those with lichen sclerosus being significantly older than those without lichen sclerosus (51.26 ± 13.84 vs 45.68 ± 16.64, p = 0.0011). Men with lichen sclerosus were more likely to have hypertension, hyperlipidemia and diabetes, and to use tobacco products. Controlling for age, men with lichen sclerosus related urethral stricture disease had a higher body mass index (aOR 1.089, 95% CI 1.050–1.130), and were more likely to have hypertension (aOR 2.028, 1.21–3.41) and be active tobacco users (aOR 2.0, 1.36–3.40). Mean preoperative patient reported outcome measures scores for urinary and sexual function were similar. Controlling for stricture length and location, the adjusted odds of surgical failure were higher for lichen sclerosus related urethral stricture disease (aOR 1.9, 95% CI 0.9–4.2). Conclusions Lichen sclerosus related urethral stricture disease is associated with chronic systemic diseases. This association may implicate a systemic inflammatory and/or autoimmune pathophysiology. A 2-hit mechanism implicating local and systemic factors for lichen sclerosus related urethral stricture disease development and progression is hypothesized.