Urethral stricture disease is a relatively common occurrence, affecting approximately 1% of the US male population.¹ Despite the known overall poor long-term efficacy, endoscopic management remains the mainstay of care for men with strictures both as primary treatment, as well as for recurrent disease.^2-4 Urethroplasty techniques, while highly successful overall, remain relatively centralized to providers at tertiary referral centers, which can serve as an obstacle to accessibility to care for many patients.⁵ While provider- and hospital-level barriers are clear, what has traditionally been less clear is how the journey of reaching definitive therapy is experienced by patients and what patient-level factors are at play. Furthermore, the impact that delayed definitive therapy and multiple endoscopic procedures prior to urethroplasty have on patients is not well understood. As such, we sought to explore this qualitatively by interviewing patients who had undergone multiple endoscopic procedures prior to urethroplasty to better understand their experiences and to better illustrate internal and external factors that contribute to determining their care.⁶

Qualitative research is not a well-known methodology for most urologists. While quantitative methods are often used to test hypotheses via statistical analysis, qualitative methods provide a structured analytical way of describing phenomena or experiences that are often complex and not adequately expressed numerically. Qualitative research methods give investigators the opportunity to understand the social world in which we live to better explain how individuals are affected by experiences and situations around them. While often discarded as a “pseudoscience,” well-done qualitative research involves stringent methodologies that utilize systematic data collection, organization, and analysis.⁷ Furthermore, in contrast to quantitative analysis in which the data are in the form of numbers, qualitative data take the form of textual information taken from interviews or observations. These data give rich insight into the subjects’ experiences to understand how various phenomena impact their lives.

To better understand how multiple endoscopic procedures for urethral stricture prior to urethroplasty impacted the lives of patients involved, we purposively selected 20 individuals who had such an experience to interview utilizing a semistructured questionnaire, specifically inquiring about the experience of undergoing multiple endoscopic procedures, how treatment options were discussed, what driving forces pushed them to seek urethroplasty, and what factors affected their ultimate decision for urethroplasty.⁶ As opposed to sampling techniques utilized in quantitative analysis, where samples are chosen with the goal of being representative of the population, “purposive” sampling is a form of nonprobability sampling that selectively chooses patients for a study based on their exposures and experiences. This type of sampling allows researchers to garner insight and perspective on a particular patient experience, often supplemented by representative quotations taken directly from the study subjects.

Analysis of our interview data provided rich insight into the experience of this patient cohort, with multiple primary themes elicited from the data (Figure). Patients who underwent multiple endoscopic procedures had unmet treatment expectations. They described only temporary relief of their symptoms, frustration with the need for frequent trips to the operating room, and disappointment with subsequent failures of their procedures. They also noted dissatisfaction with quality of life due to the multiple procedures. There was a constant fear of being unable to urinate, a loss of freedom to do the things they enjoy, and embarrassment by their urinary habits.

There were significant financial and logistical factors that ultimately played a role in their decisions to proceed with urethroplasty as well, both positive and negative. Time required off work and need to travel to reach a specialist to undergo urethroplasty were significant negative factors. However, many stated that if they had been aware of options for more definitive care, cost and travel to centers where urethroplasty could have been performed would not have been significant barriers. Ultimately, those who underwent urethroplasty reported significant improvement in quality of life, not just in improvement of urinary function, but also in their ability to regain and restore their social relationships.

While a number of prior studies have examined the utilization and success of endoscopic management for recurrent urethral stricture disease, this was the first study that explored the complex biopsychosocial interplay of factors affecting a patient’s experience with multiple endoscopic surgeries, as well as the internal and external factors impacting treatment-seeking behaviors. These data provide valuable insight into better understanding the processes of care for patients with urethral stricture disease and provide complementary information to help providers counsel patients. From prior work we have statistical information as to the likelihood of success of repeat endoscopic procedures, while this study helps us to better understand the impact of these procedures on quality of life. While novel to many urologists, qualitative methodologies can be incredibly valuable in allowing us to better analyze the patient experience and tailor our counseling and recommendations accordingly.