Patient-Reported Outcome Measures in Urethral Reconstruction

  • Nima Baradaran
  • Lindsay A. Hampson
  • Todd C. Edwards
  • Bryan B. Voelzke
  • Benjamin N. Breyer
Surgery (J Simhan, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Surgery


Purpose of Review

Treatment of anterior urethral stricture disease (USD) has shifted from endoscopic approaches to urethroplasty with significantly higher success rates among reconstructive urologists. This academic stance has led to a critical evaluation of “success” and developing disease-specific instruments to assess surgical outcomes focusing on patients’ satisfaction rather than the historical goal of avoiding secondary procedures.

Recent Findings

Many disease non-specific and/or non-validated patient-reported outcome measures (PROMs) have been utilized to evaluate the voiding symptoms and sexual of function of patients after urethroplasty in the literature. Urethral Stricture Surgery PROM (USS PROM) is the first validated, disease-specific PROM for anterior USD which has been designed in 2001. Urethral Stricture Symptoms and Impact Measure (USSIM) is a comprehensive PROM and is currently being validated at multiple institutions.


This article reviews the tools used to assess success after urethroplasty and elaborates the need to develop a comprehensive USD-specific PROM.


Urethral stricture Patient-reported outcome measures Treatment outcome Sexual dysfunction Urination disorders 


Compliance with Ethical Standards

Conflict of Interest

Nima Baradaran, Lindsay A. Hampson, Todd C. Edwards, Bryan B. Voelzke, and Benjamin N. Breyer each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Alwaal A, Blaschko SD, McAninch JW, Breyer BN. Epidemiology of urethral strictures. Transl Androl Urol. 2014;3(2):209–13. PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Santucci RA, Joyce GF, Wise M. Male urethral stricture disease. J Urol. 2007;177(5):1667–74. Scholar
  3. 3.
    Meeks JJ, Erickson BA, Granieri MA, Gonzalez CM. Stricture recurrence after urethroplasty: a systematic review. J Urol. 2009;182(4 SUPPL):1266–70. Scholar
  4. 4.
    Heyns CF, Steenkamp JW, De Kock MLS, Whitaker P. Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? J Urol. 1998;160(2):356–8. Scholar
  5. 5.
    Alwaal A, Sanford TH, Harris CR, Osterberg EC, McAninch JW, Breyer BN. Urethral stricture score is associated with anterior urethroplasty complexity and outcome. J Urol. 2016;195(6):1817–21. Scholar
  6. 6.
    Liu JS, Hofer MD, Oberlin DT, Milose J, Flury SC, Morey AF, et al. Practice patterns in the treatment of urethral stricture among American urologists: a paradigm change? Urology. 2015;86(4):830–4. Scholar
  7. 7.
    Kessler TM, Fisch M, Heitz M, Olianas R, Schreiter F. Patient satisfaction with the outcome of surgery for urethral stricture. J Urol. 2002;167(6):2507–11. Scholar
  8. 8.
    Erickson BA, Ghareeb GM. Definition of successful treatment and optimal follow-up after urethral reconstruction for urethral stricture disease. Urol Clin North Am. 2017;44(1):1–9. Scholar
  9. 9.
    Erickson BA, Breyer BN, McAninch JW. The use of uroflowmetry to diagnose recurrent stricture after urethral reconstructive surgery. Int Braz J Urol. 2010;36(5):639–40. Scholar
  10. 10.
    Morey AF, McAninch JW, Duckett CP, Rogers RS. American urological association symptom index in the assessment of urethroplasty outcomes. J Urol. 1998;159(4):1192–4. Scholar
  11. 11.
    Heyns CF, Marais DC. Prospective evaluation of the American Urological Association symptom index and peak urinary flow rate for the followup of men with known urethral stricture disease. J Urol. 2002;168(5):2051–4. Scholar
  12. 12.
    Tam CA, Voelzke BB, Elliott SP, Myers JB, McClung C, Vanni AJ, et al. Critical analysis of the use of uroflowmetry for urethral stricture disease surveillance. Urology. 2016;91:197–201. Scholar
  13. 13.
    • Erickson BA, Elliott SP, Voelzke BB, Myers JB, Broghammer JA, Smith TG 3rd, et al. Multi-institutional 1-year bulbar urethroplasty outcomes using a standardized prospective cystoscopic follow-up protocol. Urology. 2014;84(1):213–6. Multi-institution report on bulbar urethroplasty with large sample size and close follow-up. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Bertrand LA, Voelzke BB, Elliott SP, Myers JB, Breyer BN, Vanni AJ, et al. Measuring and predicting patient dissatisfaction after anterior urethroplasty using patient reported outcomes measures. J Urol. 2016;196(2):453–61. Scholar
  15. 15.
    Black N, Jenkinson C. Measuring patients’ experiences and outcomes. BMJ. 2009;339(b2495):b2495. Scholar
  16. 16.
    Devlin NJ, Appleby J. Getting the most out of PROMs: putting health outcomes at the heart of NHS decision-making. Health Econ 2010:1–92.
  17. 17.
    •• Jackson MJ, Sciberras J, Mangera A, Brett A, Watkin N, N'Dow JMO, et al. Defining a patient-reported outcome measure for urethral stricture surgery. Eur Urol. 2011;60(1):60–8. First attempt at developing a urethral stricture-specific instrument. This instrument is validated with excellent psychometric values and is widely used by reconstrucive urologists and includes a quality of life component. CrossRefPubMedGoogle Scholar
  18. 18.
    Terwee CB, Bot SDM, de Boer MR, van der Windt DAWM, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34–42. Scholar
  19. 19.
    •• Breyer BN, Edwards TC, Patrick DL, Voelzke BB. Comprehensive qualitative assessment of urethral stricture disease: toward the development of a patient centered outcome measure. J Urol. 2017;198(5):1113–8. This is the preliminary publication of the process to develop the most comprehensive urethral stricture-specific PROM to date. The instrument is being validated at several centers in the USA. CrossRefPubMedGoogle Scholar
  20. 20.
    Barry MJ, Fowler FJ Jr, O’Leary MP, Bruskewitz RC, Holtgrewe HL, Mebust WKCA. The American Urological Association symptom index for benign prostatic hyperplasia. Measure Commit Am Urol Assoc J Urol. 1992;148(5):1549–57.Google Scholar
  21. 21.
    Homma Y, Yoshida M, Yamanishi T, Gotoh M. Core lower urinary tract symptom score (CLSS) questionnaire: a reliable tool in the overall assessment of lower urinary tract symptoms. Int J Urol. 2008;15(9):816–20. Scholar
  22. 22.
    Wei JT, Dunn RL, Hoag L, Faerber G, Dorr R, McGuire EJ. The incontinence symptom index (ISI): a novel and practical symptom score for the evaluation of urinary incontinence severity. J Urol. 2003;169(4):S33 abstract 128.Google Scholar
  23. 23.
    Kaplan SA, Olsson CA, Te AE. The American Urological Association symptom score in the evaluation of men with lower urinary tract symptoms: at 2 years of followup, does it work? J Urol. 1996;155(6):1971–4. CrossRefPubMedGoogle Scholar
  24. 24.
    Chai TC, Belville WD, McGuire EJ, Nyquist L. Specificity of the American Urological Association voiding symptom index: comparison of unselected and selected samples of both sexes. J Urol. 1993;150(5 Pt 2):1710–3. CrossRefPubMedGoogle Scholar
  25. 25.
    Nuss GR, Granieri MA, Zhao LC, Thum DJ, Gonzalez CM. Presenting symptoms of anterior urethral stricture disease: a disease specific, patient reported questionnaire to measure outcomes. J Urol. 2012;187(2):559–62. Scholar
  26. 26.
    Johnson EK, Latini JM. The impact of urethroplasty on voiding symptoms and sexual function. Urology. 2011;78(1):198–201. Scholar
  27. 27.
    Nunnally J, Bernstein I. Psychometric theory. 3rd ed. New York: McGraw Hill; 1994.Google Scholar
  28. 28.
    Jackson MJ, Chaudhury I, Mangera A, Brett A, Watkin N, Chapple CR, et al. A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure. Eur Urol. 2013;64(5):777–82. Scholar
  29. 29.
    • Voelzke BB. Critical review of existing patient reported outcome measures after male anterior urethroplasty. J Urol. 2013;189(1):182–8. Excellent review of existing validated instruments for urethral stricture. CrossRefPubMedGoogle Scholar
  30. 30.
    Coursey JW, Morey AF, McAninch JW, et al. Erectile function after anterior urethroplasty. J Urol. 2001;166(6):2273–6. Scholar
  31. 31.
    Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term followup of bulbar end-to-end anastomosis: a retrospective analysis of 153 patients in a single center experience. J Urol. 2007;178(6):2470–3. Scholar
  32. 32.
    Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49(6):822–30. Scholar
  33. 33.
    O’Leary MP, Fowler FJ, Lenderking WR, et al. A brief male sexual function inventory for urology. Urology. 1995;46(5):697–706. Scholar
  34. 34.
    Rosen RC, Catania J, Pollack L, Althof S, O’Leary M, Seftel AD. Male Sexual Health Questionnaire (MSHQ): scale development and psychometric validation. Urology. 2004;64(4):777–82. Scholar
  35. 35.
    Glina S, Sommers WJ, McCullough AR, Lue TF, Zeineh SJ, Scmidt RA, et al. Neuroanatomy of penile erection: its relevance to iatrogenic impotence. J Sex Med. 2011;8(2):337–40. CrossRefPubMedGoogle Scholar
  36. 36.
    Mundy AR. Results and complications of urethroplasty and its future. Br J Urol. 1993;71(3):322–5. Scholar
  37. 37.
    Blaschko SD, Sanford MT, Cinman NM, McAninch JW, Breyer BN. De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis. BJU Int. 2013;112(5):655–63. Scholar
  38. 38.
    Anger JT, Sherman ND, Webster GD. The effect of bulbar urethroplasty on erectile function. J Urol. 2007;178(3):1009–11. Scholar
  39. 39.
    • Erickson BA, Granieri MA, Meeks JJ, Mcvary KT, Gonzalez CM. Prospective analysis of ejaculatory function after anterior urethral reconstruction. J Urol. 2010;184(1):238–42. Comprehensive and prospective evaluation of sexual dysfunction after anterior urethroplasty using validated instruments.
  40. 40.
    Xie H, Xu Y-M, Xu X-L, Sa Y-L, Wu D-L, Zhang X-C. Evaluation of erectile function after urethral reconstruction: a prospective study. Asian J Androl. 2009;11(2):209–14. Scholar
  41. 41.
    Sharma V, Kumar S, Mandal AK, Singh SK. A study on sexual function of men with anterior urethral stricture before and after treatment. Urol Int. 2011;87(3):341–5. Scholar
  42. 42.
    Erickson BA, Wysock JS, McVary KT, Gonzalez CM. Erectile function, sexual drive, and ejaculatory function after reconstructive surgery for anterior urethral stricture disease. BJU Int. 2007;99(3):607–11. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Nima Baradaran
    • 1
  • Lindsay A. Hampson
    • 1
  • Todd C. Edwards
    • 2
  • Bryan B. Voelzke
    • 3
  • Benjamin N. Breyer
    • 1
    • 4
  1. 1.Department of UrologyUniversity of California - San FranciscoSan FranciscoUSA
  2. 2.Department of Health Services, Seattle Quality of Life GroupUniversity of WashingtonSeattleUSA
  3. 3.Department of UrologyUniversity of Washington - Harborview Medical CenterSeattleUSA
  4. 4.Zuckerberg San Francisco General Hospital and Trauma CenterUniversity of California – San FranciscoSan FranciscoUSA

Personalised recommendations