Prospective evaluation of a new visual prostate symptom score, the international prostate symptom score and uroflowmetry before and after treatment in men with urethral stricture disease

INTRODUCTION AND OBJECTIVES: Despite reports that voiding symptoms have a high sensitivity (87%), specificity (88%), and negative predictive value (95%) for stricture recurrence after urethroplasty, follow up-protocols after urethroplasty have been implemented uniformly for all patients, regardless of the type of urethral reconstruction performed (J Urol. 2010;184:1386-1390). We propose a risk stratified follow-up protocol for use after urethroplasty and explore potential cost savings. METHODS: Decision analysis was performed between two follow-up protocols: (a) a symptom based, risk stratified protocol in which excision and primary anastomosis (EPA) urethroplasty patients had less testing (Figure) and (b) a standard protocol in which all urethroplasty patients had the same standard risk follow-up. Protocol development was based on published follow-up practices and stricture recurrence rates after urethroplasty. EPA was assumed to have a 94% success rate. We assumed that all patients with failure underwent urethrotomy and patients with recurrence in the symptom-based surveillance had a delayed diagnosis and required suprapubic tube. The Nationwide Inpatient Sample from 2010 was queried to identify the number of urethoplasties performed per year in the United States. Decision analysis was performed using TreeAge Pro Healthcare software (Williamstown, MA). RESULTS: The 5-year cost of a symptom based, risk-stratified follow up protocol is $429.69 per patient versus $2827.39 per patient using standard follow-up practice. There were an estimated 7761 urethroplasties performed in the US in 2010. Assuming that 60% were EPA, then over 5 years of follow-up, the risk stratified protocol translates to an estimated savings of $11,165,130. Sensitivity analysis showed that the symptom based, risk-stratified follow up protocol was far more cost-effective than standard follow up in all settings. Less than 1% of patients would be expected to have an asymptomatic recurrence using the risk-stratified follow up protocol. CONCLUSIONS: A risk-stratified, symptom-based approach to EPA urethroplasty follow-up would produce a significant reduction of health care costs, while decreasing the patient burden associated with follow-up visits, invasive testing, and radiation exposure.