^*With the Trauma and Urologic Reconstructive Network of Surgeons.

There is not consensus on how to define a successful urethroplasty. The goal of academic, reconstructive urologists is to be objective and data-driven in our approach to urethral stricture disease. However, this push for more objectivity may be contrary to patient-centered care. In the past, urethroplasty had been considered a success if a patient never needed retreatment of their stricture.¹ The limitations of this definition include (1) not accounting for patients who cannot afford further care or seek follow-up care elsewhere, and (2) surgeons having different thresholds to reoperate. Due to a desire to increase the academic rigor of our definition of success after urethroplasty, there has been a move toward using alternative, objective definitions of success. These include the presence of a strong force of stream, lack of recurrence on cystoscopy, and lack of voiding symptoms on validated questionnaires.² Unfortunately, this variety of outcomes reported in the literature makes it challenging to compare success rates across studies.

Therefore, we need to come to universal agreement regarding which outcomes to use to define success after urethroplasty. Until we do, we will struggle to progress the field of stricture management. In our study, we sought to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort. Using the Trauma and Urologic Reconstructive Network of Surgeons multi-institutional database, we evaluated success based on 5 separate definitions of urethroplasty failure. These included: (1) receipt of stricture retreatment, (2) anatomical recurrence on flexible cystoscopy, (3) uroflow maximum flow rate <15 mL/s, (4) symptomatic recurrence using validated questionnaires, and (5) failure by any of the above definitions. These groups are referred to as “retreatment,” “cystoscopy,” “uroflow,” “questionnaire,” and “any failure.” We included 712 men in our analysis who had undergone a first-time, single-stage, anterior urethroplasty and completed all recommended follow-up. We found that success after urethroplasty changed drastically simply by changing the way success is defined. Specifically, the 1- and 5-year estimated probabilities of success, from highest to lowest, were 94% and 75% for retreatment, 88% and 71% for cystoscopy, 84% and 58% for uroflow, 67% and 37% for questionnaire, and 57% and 23% for any failure (P < .001; see Figure).

Our data show marked variability in success rates based on the outcome measure used, and this represents the problem we face in comparing outcomes across studies in the literature. This begs the question of whether there is merit to developing a research-based definition of success after urethroplasty. This could be likened to the American Society for Radiation Oncology definition for biochemical recurrence after radiotherapy for prostate cancer, which is not intended to be a threshold value for initiation of treatment. Rather, it is meant as a research definition to standardize clinical trials.³ Similarly, a research-based definition of urethroplasty success may be different than clinical success but is essential for clinical trials and multi-institutional comparisons.

Using the “retreatment” definition after urethroplasty would be a patient-centered outcome because it requires no invasive tests or burdensome follow-up. However, this definition’s limitations (as previously stated) and lack of objectivity make it a less-than-ideal outcome measure as a research-based definition of success. Conversely, “cystoscopy” is an excellent option for an objective, reproducible, research-based definition of success. However, it is not a good tool for measuring clinical success because it is costly, invasive, and only 50%-65% of men comply with postoperative cystoscopy.^4,5 Further, cystoscopy tends to overestimate failures since 35%-42% of men with an anatomical recurrence on cystoscopy are asymptomatic.^4,6,7 As such, cystoscopy may not be ideal for a clinical or research-based definition of success. “Uroflow” is fast, cheap, and noninvasive while also providing objective data postoperatively. This test can, however, be confounded by bladder dysfunction, prostatic enlargement, urethral inflammation, and bladder volume.^8,9 Lastly, “questionnaires” represent the most patient-centered measure to define a successful urethroplasty. However, as previously mentioned, men can develop an asymptomatic recurrence that would go undetected using symptom-based questionnaires. In addition, men may report weak stream not attributable to a stricture recurrence, which is suggested by our data showing success rates by questionnaires were lower than cystoscopy at both 1 and 5 years.

This study was not intended to dictate what the definition of success after urethroplasty should be. Our goal was to provide a fair comparison of success rates in a single group of men using currently available definitions. As a group, urologists could choose 1 or several of these outcomes to be the universal clinical and/or research-based definition of successful urethroplasty moving forward. This common language would surely foster multi-institutional comparisons and meta-analyses with the goal of optimizing urethral stricture management.

Acknowledgements

The original versions of this study and the included Figure were published in their original version in The Journal of Urology^®.¹⁰