About the Audit

Treatment of a stricture which is causing troublesome symptoms is always surgical. Initial surgery is usually optical urethrotomy (a telescopic procedure under anaesthetic) or dilatation (stretching) of the urethra.

If a stricture recurs after this initial surgery, surgeon & patient may then consider a reconstructive procedure, called urethroplasty. The type of urethroplasty needed is determined by a special X-ray of the water pipe (called a urethrogram). This shows whether surgery needs to be performed near to the bladder (proximal urethroplasty) or near to the tip of the penis (distal urethroplasty). The urethrogram also helps to decide whether the surgery can be undertaken in one or more stages, with or without the use of graft material, and whether the narrowed area needs to be removed or just made wider.

In practice, urethroplasty is only undertaken by a small group of surgeons with a sub-specialist interest in reconstructive surgery. BAUS has been collecting urethroplasty data since 2010, to try and develop a better understanding of the presentation of urethral stricture disease and to enable surgeons to share information regarding investigation, surgical management and surgeon-perceived outcome from their interventions. In future,we hope to be able to present more patient-reported outcomes information. Analysis of the data is helping reconstructive surgeons (and the urologists who refer patients to them) gain a better understanding of the risks and expected complications of the procedures. Now that data has been collected for 5 years, it was felt appropriate to share some of this information about urethral reconstruction with potential patients and the wider public.

In this audit, we have presented:

• information about the quality of the urethroplasy data coming from individual surgeons and units in the UK,
• the total number of urethroplasties for each surgeon as an indication of the scope of their practice and
• outcome measures for bulbar (proximal) urethroplasty, the most commonly-performed urethral reconstructive procedure, where sufficient data has been collected for the figures to be meaningful.  Information is presented about the length of the patient's hospital stay, complication rates during, and up to 30 days after, their operation, and their urine flow rate (as an indication of the improvement in the most common presenting symptom).  

The data presented are surgeon-reported, by entry into the BAUS Data & Audit System , and are very much dependent upon the detailed information surgeons generate about their patients.  There is no reliable method for validating the data entered other than by comparing this to Hospital Episode Statistics (HES) .  HES data are routinely collected by hospitals in England at the time of a patient's discharge from hospital.  Variations in the procedure coding that is recorded may mean that HES activity is not a totally reliable indicator of urethroplasty practice.  We are currently investigating how to make this coding more accurate.

It must be emphasized that there are no financial incentives (or penalties) for surgeons, hospitals or Trusts to support collection of urethroplasty data, and this may also impact on the quality of data from individual centres.

The data publication period covers 2013 and 2014 only.  BAUS is very much aware that there are gaps in the data presented, and that incomplete data entry may result in apparent variations in clinical outcomes. This is, however, the first step in a process and we are clear that, whilst flawed, it will deliver valuable informaton for improving care in the future.  We understand that assiduous, or incomplete, data gathering may result in some surgeons appearing to have more complications than their colleagues; we have sought explanations from these clinicians and this, too, is presented in their individual results. We hope that improvements in the uniformity of recording might make it easier for patients to compare individual surgeons' technical outcomes in the future.

We hope that, in future, objective information will give a better indication of the outcome and side-effects of urethroplasty using, for example:

• patient-reported outcome measures - PROMs ⁽¹⁾
• the sexual health inventory for men - SHIM ⁽²⁾
• a urine flow rate before & after surgery

Using the widely-accepted Clavien Dindo classification of post-operative complications will also allow meaningful discussions with our patients about the potential for adverse events as a result of this surgery.

Cumulative data from previous years will appear when it becomes available on the Data & Audit pages of the Professionals section.

References

1. A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure.  Jackson MJ, Chaudhury I, Mangera A, Brett A, Watkin N, Chapple CR et al.  Eur Urol 2013 Nov; 64(5): 777 - 782.  (Read the abstract in a new window ).
2. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience.  Cappelleri JC and Rosen RC.  Int J Impot Res 2005 Jul-Aug; 17(4): 307 - 319.  (Read the abstract in a new window ).