In the published literature, there are several definitions of success in the treatment of strictures. Some define success as a flow rate of 15ml/second or greater. However, this is not a very high flow rate as a normal flow is often greater than 35ml/sec and it is very possible for a patient to have significant narrowing of the urethra with a flow rate of 15 ml/sec. In general, flow rate tests are used in older papers reporting the success of dilations and incisions. In addition, dilations and incisions were considered successful if the patient did not require treatment. However, it is very possible that the patient had a recurrent stricture after a third failed procedure and simply chose not to have the procedure repeated again. In other papers, procedures are declared successful if open surgery can be avoided, even if periodic catheterization is required.
Last year, a patient was referred to our Center by his local urologist. He was contacted by Dr. Gelman, and scheduled a consultation but then cancelled and elected to seek care closer to his home. When he was contacted months later to confirm he received proper care, he indicated that he found a Reconstructive Urologist whose practice is predominantly Female Urology but included male stricture surgery. He underwent urethral reconstruction for a short bulbar stricture with excision and primary anastomosis. The patient reported that he was given the impression that the surgery was a complete success, but he also stated he was required to return for periodic catheter insertions, and that these procedures were associated with significant bleeding. The patient then elected to come to our Center for evaluation and a RUG was performed that revealed a 9 cm recurrent narrow caliber stricture.
Those who specialize in male urethral stricture surgery and present and publish their results, as we do, generally confirm wide patency of the repair months after the surgery as a measure of technical success, and consider the surgery a failure if any catheterization or dilation is subsequently required. By our definition, this patient did not have a successful outcome. He had an early failure of his surgery and a recurrent stricture significantly more complex than when he was originally referred to our institution.
At the Center for Reconstructive Urology, it is our protocol to perform urethroscopy 4 months after surgery to assess the patency of the urethra. We always use a camera connected to a high-resolution monitor so that our patients can see their stricture before surgery, and then see the area of repair after surgery. The reason we wait 4 months is that we want to allow the urethra to completely heal, and then confirm that no narrowing developed during the healing process. We stress the importance of this follow-up and when patients travel from out-of-state for care, we confirm prior to surgery that they will be willing to return for this 4-month follow-up. This is how we confirm technical success.
In addition, we stress the importance of annual follow-up for life with symptom assessment using a standardized questionnaire, urinalysis, measurement of flow rate and residual urine volume (PVR). If there is any concern of recurrence, urethroscopy is advised to directly assess the caliber of the urethra. Our long-term success is defined as life long wide patency of the urethra without recurrence or a need for dilation or catheterization.
However, for us or anyone to truly know the long-term success, indefinite follow-up is necessary. Most of our patients are referred by their local urologists, and many patients travel from out-of-town for care. We never wish to interfere with the relationship between our patients and their local doctors and therefore, subsequent to the 4-month visit, we encourage our patients to return to their referring urologists for this care, although we are happy to provide this follow-up. Unfortunately, many patients do not make these appointments. Moreover, patients move and do not provide us with forwarding contact information. When this happens, patients become “lost to follow-up”. This is a problem for all academic physicians who present and publish outcome data, and can lead to an overestimation of success.
For example, a publication states that the success rate of a certain stricture surgery is 100% with an average follow-up of 5 years, and no patient developed a recurrence. That may mean that every patient had a perfect result, or the paper is just saying how long ago on average the surgery was performed. Perhaps some patients developed a recurrence and pursued care elsewhere. We are not immune to this problem. Although some of our own patients have been “lost to follow-up”, we make a major effort to maintain contact with our patients as we want our outcome data to truly and accurately reflect our results. At the Center for Reconstructive Urology, we maintain a detailed database that contains many fields of data entry, and this allows us to assess Our Results and for any given procedure at any given time. We constantly update our database, and make a major effort to maintain contact with our patients.
Overall, our technical success rate exceeds 95%. We are happy to provide you with more detailed information regarding Our Results for a specific surgery upon request based on our most recent data.