الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
It is well known that USD affects patient’s QoL significantly. Various treatment approaches for management of USD exist, however open urethroplasty is considered as the mainstay technique being a highly effective and durable approach for managing stricture disease[103]. The optimal follow-up post-urethroplasty must allow for evaluation of both anatomic and subjective outcomes, also prevent patients from undergoing unnecessary invasive testing that leads to increased cost and risk for patient’s discomfort and anxiety[42]. The definition of “success” after urethroplasty is a point of controversy in the literature and up till now there is lack of use of a standardized method for defining a successful urethroplasty[42]. Previously a successful urethroplasty was considered when there was no need for a secondary procedure regardless of urinary symptoms or the appearance of the reconstructed urethra. In fact, this definition is outdated and incomplete, and the proper one should include both objective and subjective outcomes measures[42]. As a result, there has been a move toward using alternative definitions of success in the last decade. These include strong force of stream and lack of voiding symptoms, or recurrence on urethrocystoscopy/RUG. Unfortunately, this variety of outcomes reported in the literature makes it difficult to compare success rates across studies [140]. A more objective definition of success is the “anatomic success”, defined as “normal urethral lumen during RUG or cystoscopy, regardless of patient symptoms”. Anatomical failure is considered when a (16-17 Fr) flexible urethroscopy found to be impassable [61, 164]. RUG has a few advantages compared with cystoscopy in that it can visualize the entire urethra simultaneously, may be able to more easily diagnose diverticula and fistulas, and is easier to compare to preoperative to postoperative objective findings. However, it is logistically difficult to perform in a standardized fashion and thus its interpretation can be considered subjective.[42] Hence, a flexible urethrocystoscopy remains the most reliable way to compare the anatomy of a reconstructed urethra among patients and between centers. Over the last ten years, the evaluation of urethral surgery outcomes has shifted towards a “patient-reported definition of success”. Even if the surgeon reconstructed a wide and patent urethra, if patients experience pain, sexual dysfunction or perceive their urinary function as not improved, they will not rate their outcome as successful[42]. Regardless of anatomic success after urethroplasty, post-operative pain, sexual dysfunction and persistent LUTS were independent predictors of patient dissatisfaction [165]. Due to this evident discrepancy between surgeon’s assessment and patient assessment, PROMs such as USS-PROM have been developed for the follow-up after urethroplasty as it allows a detailed and standardized analysis of success, morbidity and QoL from patient’s perspective, and should therefore be consistently utilized in outcome reporting of urethroplasty [10]. Given how important, though often discordant, both the anatomic findings and patient-reported outcomes are in determining success after urethroplasty, the authors strongly believe that these parameters should be reported simultaneously but separately for all urethroplasty outcomes studies. This modification in success rates reporting will make it easier to compare surgical outcomes between different surgeries, different surgeons, and different types of strictures[42]. The present study aimed to assess the outcomes of urethral surgeries used in treatment of anterior USD from patient perspective and comparing it with the objective tools used for assessment. We demonstrated an anatomical success rate of 90%. Meanwhile a significant improvement of USS-PROM, IPSS and QoL scores with satisfaction rate of 80% was detected. Hence, the importance of taking patient’s satisfaction in consideration is crucial for assessing success of surgery and it should not be neglected. Among the anatomically recurrent cases, 12.5% achieved a subjective success. On the other hand, 50% of patients who showed dissatisfaction by using the USS-PROM, anatomical success confirmed by flexible urethrocystoscopy has been present. The main reasons behind dissatisfaction in the current series were sexual dysfunction, recurrence or persistence of obstructive LUTS, recurrent UTI with bothersome LUTS or bothersome post-voiding dribbling and/or genitourinary pain. One of the essential drawbacks of the USS-PROM questionnaire is the lacking of questions addressing the cosmetic changes of the genitalia and the effect of urethral surgery on sexual life and relationships in addition to lacking reporting morbidity related to the site of graft intake. In conclusion, the present study demonstrated that using a combined methods of assessment for urethral stricture reconstructive surgery was better for both patient and surgeon evaluation of the post-operative outcomes. We have shown with both patient-reported outcomes and objective measures a significant improvement in symptoms, QoL scores, Q-max and endoscopic view after urethral reconstruction. USS-PROM allows a detailed and standardized analysis of QoL, success and morbidity, and should therefore be consistently utilized in outcome reporting. Harmonization of surveillance protocols is obviously needed as a method to more effectively compare the outcomes between different urethral reconstruction procedures and institutions. The use of a tool specifically designed to assess urethral stricture disease is a great advance in this field and should be encouraged as an attempt to minimize costs and to incorporate the patient’s perspective in this process.