Psychometric validation of the Spanish version of the USS-PROM questionnaire for patients who undergo anterior urethral surgery

Analysis of prognostic factors of failure in perineal urethrostomy

PURPOSE

To identify prognostic factors of failure in patients undergoing perineal urethrostomy (PU) with Blandy technique, with inverted U-shaped perineal flap.

METHODS

This is a retrospective study of PU of non-oncological causes (2001-2017). Data of age, BMI, history of diabetes mellitus, etiology of urethral stricture, type of stricture, previous surgeries, dilatation and suprapubic catheter were collected. Failure was defined as the need for any instrumentation after surgery. Variables were analyzed by Cox regression and Kaplan-Meier curves were used for survival analysis.

RESULTS

A total of 115 PU were performed. Median age was 61 years (IQR 53-68) and BMI 27.9 (IQR 25-30.9). The most frequent etiologies were: lichen sclerosus (30.4%), iatrogenic (27%), and idiopathic (25.7%). 62.6% had panurethral stricture. There were no complications in 73%. Clavien I complications occurred in 25.2%, Clavien II in 0.9% and Clavien IVa in 0.9%. The overall success rate was 51.3% with a median follow-up of 71 months. In the last 8 years, it was 75%. In the multivariate analysis, we found that age (p = 0.01), BMI (p = 0.01), date of surgery (p = 0.01), and suprapubic catheter (p = 0.003) were predictive variables. The voiding satisfaction rate was 88.7%.

CONCLUSIONS

PU with Blandy technique is a surgery with low morbidity. During the entire study period, it had a failure rate of 48.7% but the failure rate decreased to 25% over the last 8 years. Age, BMI, date of surgery and suprapubic catheter are the most important prognostic factor of failure.

Evaluation of non-invasive tests as diagnostic tools in assessment of bladder outlet obstruction severity in men with anterior urethral stricture

Introduction

The aim of this article was to evaluate non-invasive tests, which were typically used in preoperative diagnosis of male patients with anterior urethral strictures in the assessment of the urethral resistance caused by urethral occlusion.

Material and methods

A total of 63 adult males with confirmed urethral stricture and aged below 55 years old were enrolled in the study. Data obtained from non-invasive tests such as uroflowmetry (UF), ultrasound examination (USG), and questionnaires such as from The International Prostatic Symptom Score (IPSS), and The Patient-Reported Outcome Measure for Urethral Stricture Surgery (USS-PROM) were analyzed.

Results

Among all analyzed non-invasive tests, bladder wall thickness (BWT) showed the highest correlation with the degree of urethral occlusion described as percentage of preserved urethral lumen (r = -0.70; p <0.0001). UF variables presented medium degree of correlation, with maximum flow rate (Qmax) as the best parameter (p = 0.45; p = 0.0005). Results from both questionnaires did not show any correlation with the severity of the urethral stricture. Multiple linear regression analysis showed that only BWT was an independent predictor in detection degree of urethral occlusion.

Conclusions

UF and USG seem to be useful additional diagnostic tools in assessment severity of urethral occlusion in men suffering from anterior urethral stricture. Among them, USG had the highest correlation with degree of urethral occlusion.

Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT

BACKGROUND

Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men.

DESIGN

Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed.

SETTING

UK NHS with recruitment from 38 hospital sites.

PARTICIPANTS

A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture.

INTERVENTIONS

A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group).

MAIN OUTCOME MEASURES

The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence.

RESULTS

The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective.

LIMITATIONS

We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis.

CONCLUSIONS

The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective.

FUTURE WORK

Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98009168.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.

A Comprehensive Review Emphasizing Anatomy, Etiology, Diagnosis, and Treatment of Male Urethral Stricture Disease

To date, urethral stricture disease in men, though relatively common, represents an often poorly managed condition. Therefore, this article is dedicated to encompassing the currently existing data upon anatomy, etiology, symptoms, diagnosis, and treatment of the disease, based on more than 40 years of experience at a tertiary referral center and a PubMed literature review enclosing publications until September 2018.

Turkish validation of the urethral stricture surgery specific patient-reported outcome measure (USS-PROM) with supplemental assessment of erectile function and morbidity due to oral graft harvesting

AIMS

We validated a Turkish language version of the urethral stricture surgery specific patient-reported outcome measure (USS-PROM) in men undergoing anterior urethroplasty. We also investigated changes in erectile function (EF) and quality of life (QoL) due to oral mucosa graft (OMG) harvesting.

METHODS

The USS-PROM captures lower urinary tract symptoms (LUTS), health related QoL (HRQoL) with EQ-5D visual analogue scale (EQ-VAS). To evaluate EF and OMG morbidity, we used International Index of Erectile Function (IIEF-5) and a self-completed questionnaire, respectively. Psychometric assessment of USS-PROM included test-retest reliability, internal consistency, criterion validity, and responsiveness. Objective evidence for urethroplasty success was demonstrated with fluoroscopic imaging and urethral calibration at post-operative six months.

RESULTS

Among the 101 men included during study period, 42 had complete pre- and postoperative 6th month data for analysis. The test-retest intraclass correlation was 0.79. Cronbach's α for internal consistency of the LUTS construct was 0.79. There was a significant negative correlation between total LUTS scores and peak flow rates, both preoperatively (r = -0.478) and postoperatively (r = -0.508). Mean baseline EQ-VAS increased from 70 to 84 postoperatively (P < 0.001), indicating improved HRQoL. IIEF scores did not change significantly after urethroplasty. Early and late-term QoL impairment rates due to OMG harvesting were 28.9 and 13.1%, respectively. Three (7.1%) men required endoscopic intervention for recurrence within 6 months.

CONCLUSIONS

Turkish version of USS-PROM showed comparable psychometric properties with the original version. Complementation of this instrument with additional measures that address sexual function and OMG morbidity provides better QoL assessment for urethral reconstruction.