(Published 2016; Amended 2023)

To cite this guideline:
Wessells H, Morey A, Vanni A, Rahimi L, Souter L. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71.

The Practice Guidelines Committee would like to acknowledge the contributions of Dr. Allen Morey, MD and Dr. Lesley Souter, Ph.D. to the 2023 Guideline Amendment.

Unabridged version of this Guideline [pdf]

Urethral Stricture Guideline Amendment [pdf]

Hunter Wessells, MD; Kenneth W. Angermeier, MD; Sean P. Elliott, MD; Christopher M. Gonzalez, MD; Ron T. Kodama, MD; Andrew C. Peterson, MD; James Reston, PhD; Keith Rourke, MD; John T. Stoffel, MD; Alex Vanni, MD; Bryan Voelzke, MD; Lee Zhao, MD; Richard A. Santucci, MD

SUMMARY

Purpose

The clinical guideline on urethral stricture provides a clinical framework for the diagnosis of urethral stricture and includes discussion of initial management, urethroplasty, reconstruction, contracture, stenosis, special circumstances, and post-operative follow-up care.

Methodology

A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1990 to 12/1/2015) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of urethral stricture in men. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria.  The search for the 2023 Amendment used the Ovid, MEDLINE, Embase, and ClinicalTrials.gov databases and was modified to included females and males (search dates 12/2015 – 10/2022 for males; 01/1990 – 10/2022 for females) and one new Key Question on sexual dysfunction outcomes in men with bulbar urethral strictures was added (search dates: 01/1990 – 10/2022).  All searches yielded 11,752 citations; after inclusion and exclusion criteria were applied, 81 studies were added to the existing evidence base. These publications were used to create the guideline statements. If sufficient evidence existed, then the body of evidence for a particular treatment was assigned a rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty) and evidence-based statements of Strong, Moderate, or Conditional Recommendation based on risks and benefits were developed. Additional information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed.

GUIDELINE STATEMENTS

Diagnosis/Initial Management

1. Clinicians should include urethral stricture in the differential diagnosis of patients who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection, and after rising post-void residual. (Moderate Recommendation; Evidence Level: Grade C)
2. After performing a history, physical examination, and urinalysis, clinicians may use a combination of patient reported measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected urethral stricture. (Clinical Principle)
3. Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethrography to make a diagnosis of urethral stricture. (Moderate Recommendation; Evidence Level: Grade C)
4. Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture. (Expert Opinion)
5. Surgeons may utilize urethral endoscopic management (e.g., urethral dilation, direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management of urethral stricture, such as discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure. (Expert Opinion)
6. Surgeons may place a suprapubic cystostomy to promote “urethral rest” prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. (Conditional Recommendation; Evidence Level: Grade C)

Dilation/Internal Urethrotomy/Urethroplasty

7. Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty for the initial treatment of a short (<2cm) bulbar urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
8. Surgeons may perform either dilation or direct visual internal urethrotomy when performing endoscopic treatment of a urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)
9. Surgeons may safely remove the urethral catheter within 72 hours following uncomplicated dilation or direct visual internal urethrotomy. (Conditional Recommendation; Evidence Level: Grade C)
10. In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct visual internal urethrotomy to maintain urethral patency. (Conditional Recommendation; Evidence Level: Grade C)
11. a. Surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy. (Moderate Recommendation; Evidence Level: Grade C)
    b. Surgeons may offer urethral dilation or direct visual internal urethrotomy, combined with drug-coated balloons, for recurrent bulbar urethral strictures <3cm in length. (Conditional Recommendation; Evidence Level: Grade B)
12. Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise. (Expert Opinion)

Anterior Urethral Reconstruction

13. Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical Principle)
14. Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate Recommendation; Evidence Level: Grade C)
15. Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence rates with endoscopic treatments. (Moderate Recommendation; Evidence Level: Grade C)
16. Surgeons should offer urethroplasty as the initial treatment for patients with long (≥2cm) bulbar urethral strictures, given the low success rate of direct visual internal urethrotomy or dilation. (Moderate Recommendation; Evidence Level: Grade C)
17. Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)
18. a. Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional Recommendation; Evidence Level: Grade C)
    b. Surgeons should offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty in patient populations at high risk for failure of urethral reconstruction. (Expert Opinion)
19. a. Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion)
    b. Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong Recommendation; Evidence Level: Grade A)
20. Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols. (Expert Opinion)
21. Surgeons should not perform a single stage tubularized graft urethroplasty. (Expert Opinion)
22. Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle)

Pelvic Fracture Urethral Injury

23. Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. (Moderate Recommendation; Evidence Level: Grade C)
24. Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion)
25. Definitive urethral reconstruction for pelvic fracture urethral injury should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion) 

Female Urethral Reconstruction

26. Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)

Bladder Neck Contracture/Vesicourethral Stenosis

27. Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure. (Expert Opinion)
28. Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)
29. Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)

Special Circumstances

30. In men who require chronic self-catheterization (e.g., neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion)

Lichen Sclerosus

31. Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. (Clinical Principle)
32. In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong Recommendation; Evidence Level: Grade B)

Post-operative Follow-up

33. Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct visual internal urethrotomy, or urethroplasty. (Expert Opinion)

INTRODUCTION

Purpose

Urethral stricture is chronic fibrosis and narrowing of the urethral lumen caused by acute injury, inflammatory conditions, and iatrogenic interventions including urethral instrumentation, surgery, and prostate cancer treatment. The symptoms of urethral stricture are non-specific and may overlap with other common conditions that confound timely diagnosis, including lower urinary tract symptoms (LUTS) and urinary tract infections (UTI). Urologists play a key role in the initial evaluation of urethral stricture and currently provide all accepted treatments. Thus, urologists must be familiar with the evaluation and diagnostic tests for urethral stricture as well as endoscopic and open surgical treatments. This guideline provides evidence-based guidance to clinicians and patients regarding how to recognize symptoms and signs of a urethral stricture/stenosis, carry out appropriate testing to determine the location and severity of the stricture, and recommend the best options for treatment. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment. As the science relevant to urethral stricture evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Methodology

2016 Guideline

A systematic review for the 2016 guideline was conducted to identify published articles relevant to the diagnosis and treatment of urethral stricture in men. Literature searches were performed on English-language publications using the Pubmed, Embase, and Cochrane databases from 1/1/1990 to 12/1/2015 by the ECRI Institute and were included in a systematic review evidence report. Preclinical studies (e.g., animal models), commentary, editorials, non-English language publications, and meeting abstracts were excluded. Additional exclusion criteria were as follows: studies of females; studies of stricture prevention; patients with epispadias, congenital strictures, and duplicated urethra; trauma already covered under trauma guidelines including diagnosis and management of acute pelvic fracture urethral injury (PFUI) or pelvic fracture urethral disruption; urethral cancer not related to stricture; or voiding symptoms not related to stricture. Studies with less than 10 patients were generally excluded from further evaluation and thus data extraction given the unreliability of the statistical estimates and conclusions that could be derived from them. In rare instances, we have included studies with less than 10 patients or studies preceding the literature search date if no other evidence was identified. For certain key questions that had little or no evidence from comparative studies, we included case series with 50 or more patients. Review article references were checked to ensure inclusion of all possible relevant studies. Multiple reports on the same patient group were carefully examined to ensure inclusion of only non-redundant information. The systematic review yielded a total of 250 publications relevant to preparation of the guideline.

Quality of Individual Studies and Determination of Evidence Strength

The quality of individual studies that were either randomized controlled trials (RCTs) or clinical controlled trials  was assessed using the Cochrane Risk of Bias tool.¹ Observational cohort studies with a comparison of interest were evaluated with the Drug Effectiveness Review Project instrument.² Conventional diagnostic cohort studies, diagnostic case-control studies, or diagnostic case series that presented data on diagnostic test characteristics were evaluated using the QUADAS 2 tool, which evaluates the quality of diagnostic accuracy studies.³

The categorization of evidence strength is conceptually distinct from the quality of individual studies. Evidence strength refers to the body of evidence available for a particular question and includes not only individual study quality but also consideration of study design, consistency of findings across studies, adequacy of sample sizes, and generalizability of samples, settings, and treatments for the purposes of the guideline. The American Urological Association (AUA) categorizes the level  of a body of evidence as Grade A (well-conducted and highly-generalizable RCTs or exceptionally strong observational studies with consistent findings); Grade B (RCTs with some weaknesses of procedure or generalizability or moderately strong observational studies with consistent findings); or Grade C (RCTs with serious deficiencies of procedure, generalizability, or extremely small sample sizes or observational studies that are inconsistent, have small sample sizes, or have other problems that potentially confound interpretation of data). By definition, Grade A evidence is evidence about which the Panel has a high level of certainty, Grade B evidence is evidence about which the Panel has a moderate level of certainty, and Grade C evidence is evidence about which the Panel has a low level of certainty.⁴

2023 Amendment

The 2016 guideline search strategy was modified to include females in addition to males and was used to systematically search Ovid, MEDLINE, Embase, and ClinicalTrials.gov databases for new evidence published between December 2015 and October 2022.  A second search was designed to only identify female urethral stricture studies published between January 1990 and December 2015, the timeframe covered in the original guideline for male patients.  Finally, a third search (January 1990 – October 2022) was developed to address a new Key Question comparing sexual dysfunction outcomes in men with bulbar urethral strictures receiving either non-transecting anastomotic urethroplasty procedures or transecting procedures.  Titles and abstracts of studies identified by all searches were reviewed in a two-stage process.  During the first stage, studies were reviewed to determine if they assessed urethral stricture in males or females, and if they met the study selection criteria of prespecified study type, minimum allowable sample size, and if published in English.  Allowable study types included systematic reviews, RCTs, diagnostic accuracy studies, cohort studies with and without comparison group, case-control studies, and case series.  All other study types were excluded.  Only studies that enrolled at least 10 patients were considered for inclusion in the evidence base.  During the second stage of title and abstract review, abstracts were compared to the PICO criteria (Appendix 1).  Additionally, studies were assessed to determine if they either directly informed the Key Questions or if they presented data that could reaffirm or refute the original guideline statements. 

In the original ECRI evidence report that underpinned the male urethral stricture guideline,⁵ single-arm observational studies that evaluated urethroplasty or bulbar urethral strictures were excluded, and the evidence base was comprised of RCTs and comparative cohort studies.  This exclusion criterion was retained in the amendment when evaluating studies that enrolled male or both male and female populations.  However, based on a paucity of data, single-arm studies that enrolled a solely female population were retained.  Following study selection, 81 studies were included in the amendment evidence base (Appendix 2). 

Individual Study Quality and Potential for Bias

Quality assessment for all retained studies was conducted.  Using this method, studies deemed to be of low quality would not be excluded from the systematic review, but would be retained, and their methodological strengths and weaknesses discussed where relevant.  To define an overall study quality rating for each included study, risk of bias as determined by validated study-type specific tools was paired with additional important quality features.  AMSTAR-2  was used for assessment of systematic review with and without meta-analyses.⁶  To evaluate the risk of bias within the identified RCTs, the Cochrane Risk of Bias Tool⁷ was employed, while for observational studies, a Risk of Bias in Non-Randomized Studies – of Intervention (ROBINS-I) tool⁸ was used.  Additional important quality features, such as study design, comparison type, power of statistical analysis, and sources of funding were extracted for each study.    

Certainty of Evidence by GRADE

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to determine the aggregate evidence quality for each recommendation statement.⁹  GRADE defines a body of evidence in relation to how confident guideline developers can be that the estimate of effects as reported by that body of evidence is correct.  Evidence is categorized as high, moderate, low, and very low, and assessment is based on the aggregate risk of bias for the evidence base, plus limitations introduced as a consequence of inconsistency, indirectness, imprecision and publication bias across the studies.¹⁰  Upgrading of evidence is possible if the body of evidence indicates a large effect or if confounding would suggest either spurious effects or would reduce the demonstrated effect. 

The AUA employs a 3-tiered strength of evidence system to underpin evidence-based guideline statements. Table 1 summarizes the GRADE categories, definitions, and how these categories translate to the AUA strength of evidence categories. In short, high certainty by GRADE translates to AUA A-category strength of evidence, moderate to B, and both low and very low to C.

AUA Nomenclature: Linking Statement Type to Evidence Level 

The AUA nomenclature system explicitly links statement type to body of evidence level, degree of certainty, magnitude of benefit or risk/burdens, and the Panel's judgment regarding the balance between benefits and risks/burdens (Table 2). Strong Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is substantial. Moderate Recommendations are directive statements that an action should (benefits outweigh risks/burdens) or should not (risks/burdens outweigh benefits) be undertaken because net benefit or net harm is moderate. Conditional Recommendations are non-directive statements used when the evidence indicates that there is no apparent net benefit or harm or when the balance between benefits and risks/burden is unclear. All three statement types may be supported by any body of evidence grade. Grade A evidence in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances and that future research is unlikely to change confidence. Grade B evidence in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but that better evidence could change confidence.  Grade C evidence in support of a Strong or Moderate Recommendation indicates that the statement can be applied to most patients in most circumstances, but that better evidence is likely to change confidence. Grade C evidence is only rarely used in support of a Strong Recommendation. Conditional Recommendations also can be supported by Grade A, B, or C evidence. When Grade A is used, the statement indicates that benefits and risks/burdens appear balanced, the best action depends on patient circumstances, and future research is unlikely to change confidence. When Grade B evidence is used, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances and better evidence could change confidence. When Grade C evidence is used, there is uncertainty regarding the balance between benefits and risks/burdens, alternative strategies may be equally reasonable, and better evidence is likely to change confidence.

For some clinical issues, particularly diagnosis, there was little or no evidence from which to construct evidence-based statements. Where gaps in the evidence existed, the Panel provides guidance in the form of Clinical Principles or Expert Opinion with consensus achieved using a modified Delphi technique if differences of opinion emerged.¹¹ A Clinical Principle is a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature. Expert Opinion refers to a statement, achieved by consensus of the Panel, that is based on members' clinical training, experience, knowledge, and judgment for which there is no evidence.

Table 1: Strength of Evidence Definitions

Table 2: AUA Nomenclature Linking Statement Type to Level of Certainty, Magnitude of Benefit or Risk/Burden, and Body of Evidence Strength

Process 

The Urethral Stricture Panel was created in 2013 by the American Urological Association Education and Research, Inc. The Practice Guidelines Committee (PGC) of the AUA selected the Panel Co-Chairs who in turn appointed the additional panel members with specific expertise in this area. The AUA conducted a thorough peer review process. The draft guidelines document was distributed to 90 peer reviewers. The panel reviewed and discussed all submitted comments and revised the draft as needed. Once finalized, the guideline was submitted for approval to the PGC and the AUA Science and Quality Council. Then it was submitted to the AUA Board of Directors for final approval. Funding of the panel was provided by the AUA; panel members received no remuneration for their work.

The Urethral Stricture Amendment Panel was created in 2020 by the AUA. The Chair of the original guideline was appointed Chair of the amendment panel.  The balance of the panel was composed of one member of the original panel and one content expert who was not a member of the original guideline panel. The outside expert was approved by the PGC Chairs. The AUA conducted a thorough peer review process and the draft guideline document was distributed to 50 peer reviewers, 21 of whom submitted a total of 67 comments. The Amendment Panel reviewed and discussed all submitted comments and revised the draft as needed. Once finalized, the guideline was submitted for approval to the PGC and Science and Quality Council. It was then submitted to AUA Board of Directors for final approval. Panel members received no renumeration for their work. 

Background

The urethra extends from the bladder neck, which is composed of smooth muscle circular fibers, to the meatus, with varying histological features and stromal support based on anatomical location. The components of the posterior urethra are lined with transitional epithelium, whereas the male anterior urethra is lined with pseudostratified columnar epithelium that changes to stratified squamous epithelium in the fossa navicularis. The posterior urethra includes both the prostatic and membranous urethra in men whereas in women it consists solely of the membranous urethra. The prostatic urethra extends from the distal bladder neck to the distal end of the veru montanum. The distal external sphincter mechanism surrounds the membranous urethra and is comprised of both intrinsic smooth muscle and rhabdosphincter. The anterior urethra includes the bulbar urethra, penile urethra, and fossa navicularis. This portion of the urethra is surrounded by the corpus spongiosum, which in the bulbar urethra is surrounded by the bulbocavernosus muscle. The fossa navicularis is located entirely within the glans penis.

Urethral stricture is the preferred term for any abnormal narrowing of the anterior urethra, which runs from the bulbar urethra to the meatus and is surrounded by the corpus spongiosum. Urethral strictures are associated with varying degrees of spongiofibrosis. Narrowing of the posterior urethra, which lacks surrounding spongiosum, is thus referred to as a "stenosis." PFUI typically creates a distraction defect with resulting obstruction or obliteration.¹²

Urethral strictures or stenoses are treated endoscopically or with urethroplasty. Endoscopic management is performed by either urethral dilation or direct vision internal urethrotomy (DVIU). There are a multitude of different urethroplasty techniques that can be generally divided into tissue transfer-involved procedures and non-tissue transfer-involved procedures. Anastomotic urethroplasty does not involve tissue transfer and can be performed in both a transecting and non-transecting manner. Excision and primary anastomosis urethroplasty involve transection and removal of the narrowed segment of urethra and corresponding spongiofibrosis with anastomosis of the two healthy ends of the urethra and corpus spongiosum. Non-transecting anastomotic urethroplasty preserves the corpus spongiosum, thus allowing the strictured urethra to be excised and reanastomosed or incised longitudinally through the narrowed segment of the urethra and closed in a Heineke-Mikulicz fashion.

Techniques that involve tissue transfer can be categorized into single-stage and multi-stage procedures. In single-stage procedures, the urethra is augmented in caliber by transferring tissue in the form of a graft or flap. Multi-stage procedures use a graft as a urethral substitute for future tubularization.

Epidemiology

Geographic setting, socioeconomic factors, and access to healthcare can affect stricture etiology. In high income countries, the most common etiology of urethral stricture is idiopathic (41%) followed by iatrogenic (35%). Late failure of hypospadias surgery and stricture resultant from endoscopic manipulation (e.g., transurethral resection) are common iatrogenic reasons. In comparison, trauma (36%) is the most common cause in low- and middle-income countries, reflecting higher rates of road traffic injuries, less developed trauma systems, inadequate roadway systems, and conceivably socioeconomic factors leading to a higher prevalence of trauma-related strictures.^13-15

Strictures in the bulbar urethra are more common than other anatomic locations in males; however, certain etiologies are closely associated with an anatomic segment of the urethra.¹³ For example, strictures related to hypospadias and lichen sclerosus ([LS]; previously termed balanitis xerotica obliterans) are generally located in the penile urethra, while traumatic strictures and stenoses tend to be located in the bulbar and posterior urethra.

Preoperative Assessment

Presentation

Patients with urethral stricture most commonly present with decreased urinary stream and incomplete bladder emptying but may also demonstrate UTI, epididymitis, rising post-void residual (PVR), or decreased force of ejaculation. Additionally, patients may present with urinary spraying or dysuria.¹⁶

Patient Reported Outcomes Measures

Patient reported measures (PRMs) help elucidate the presence and severity of patient symptoms and bother and thus may serve as an important component of urethral stricture diagnosis and management. While the American Urological Association Symptom Index (AUASI) includes items assessing decreased urinary stream and incomplete bladder emptying, it does not identify other symptoms seen in patients with a urethral stricture, such as urinary spraying and dysuria.¹⁶ Therefore, there is a need for development of a standardized urethral stricture PRM that can be used to assess symptoms, degree of bother, and quality of life (QoL) impact. A more disease specific standardized PRM will also allow for comparison of patient outcomes across research studies. Several have been developed in more recent years.^{17, 18}

Diagnosis

All patients being evaluated for LUTS should have a complete history and physical examination and urinalysis at a minimum. Decreased urinary stream, incomplete emptying, and other findings such as UTI should alert clinicians to include urethral stricture in the differential diagnosis. In the initial assessment of patients suspected of having a urethral stricture, a combination of PRMs to assess symptoms, uroflowmetry to determine severity of obstruction, and ultrasound PVR volume to identify urinary retention may be used. Patients with symptomatic urethral stricture typically have a reduced peak flow rate.^{19, 20} Confirmation of a urethral stricture diagnosis is made with urethroscopy, retrograde urethrography (RUG), or ultrasound urethrography. In women, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG).^{21, 22} Urethroscopy readily identifies a urethral stricture but does not delineate the location and length of strictures. RUG, with or without VCUG, allows for identification of stricture location in the urethra, length of the stricture, and degree of lumen narrowing.^{23, 24}  All of these stricture characteristics are important for subsequent treatment planning. Ultrasound urethrography can be used to identify the location, length, and severity of male urethral stricture.²⁵ While ultrasound urethrography is a promising technique, further studies are needed to validate its value in clinical practice.

Preoperative assessment for definitive reconstruction should elicit details of the etiology, diagnostic information about length and location of the stricture, and prior treatments. In the case of PFUI, a detailed history should document all associated injuries and angiographic embolization of any pelvic vessels. The history should assess preoperative sexual function and urinary continence. Physical examination should include an abdominal and genital exam, digital rectal exam, and assessment of lower extremity mobility for operative positioning.

Patient Selection

Patient selection and proper surgical procedure choice are paramount to maximize the chance of successful outcome in the treatment of urethral stricture. The main factors to consider in decision making include stricture etiology, location, and severity; prior treatment; comorbidity; and patient preference. As with any operation, surgeons should consider a patient's goals, preferences, comorbidities, and fitness for surgery prior to performing urethroplasty.²⁶

Operative Considerations

Before proceeding with surgical management of a urethral stricture, the physician should provide an appropriate antibiotic to reduce surgical site infections. Preoperative urine cultures are recommended to guide antibiotic choice, and active UTIs must be treated before urethral stricture intervention. Prophylactic antibiotic choice and duration should follow AUA Best Practice Policy Statement.²⁷ To avoid bacterial resistance, antibiotics should be discontinued after a single dose or within 24 hours. Antibiotics can be extended in the setting of an active UTI or if there is an existing indwelling catheter.²⁷ In the setting of endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins.²⁷ Antimicrobial prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors.²⁷

Positioning of the extremities should be careful to avoid pressure on the calf muscles, peroneal nerve, and ulnar nerve when using the lithotomy position. Use of sequential compression devices is recommended to reduce deep venous thromboembolism and nerve compression injuries. Perioperative parenteral deep venous thromboembolism prophylaxis is a consideration in select circumstances for open reconstruction.

Postoperative Care

A urinary catheter should be placed following urethral stricture intervention to divert urine from the site of intervention and prevent urinary extravasation. Either urethral catheter or suprapubic (SP) cystostomy is a viable option; a urethral catheter is thought to be optimal as it may serve as a stent around which the site of urethra intervention can heal. The length of urinary catheterization is widely variable, with a shorter recommended time for endoscopic interventions than open urethral reconstruction.²⁸

Urethrography or voiding cystography is typically performed two to three weeks following open urethral reconstruction to assess for complete urethral healing. Replacement of the urinary catheter is recommended in the setting of a persistent urethral leak to avoid tissue inflammation, urinoma, abscess, and/or urethrocutaneous fistula. A urethral leak will heal in almost all circumstances with a longer duration of catheter drainage.^{29, 30}

Complications

Erectile dysfunction (ED), as measured by the International Index of Erectile Function (IIEF) may occur transiently after male urethroplasty with resolution of nearly all reported symptoms approximately six months postoperatively.^31-35 Meta-analysis has demonstrated the risk of new onset ED following anterior urethroplasty to be ~1%.³⁶  Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of surgery. ED in this cohort may be related to the initial pelvic trauma rather that the subsequent urethral reconstruction.³⁷

Ejaculatory dysfunction manifested as pooling of semen, decreased ejaculatory force, ejaculatory discomfort, and decreased semen volume has been reported by up to 21% of men following bulbar urethroplasty.³⁸ Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction but the exact etiology remains uncertain.^39-41 Conversely, some patients, as measured by the Men's Sexual Health Questionnaire, will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.³⁸ Data on ejaculatory function in men undergoing penile urethroplasty or urethroplasty for PFUI is limited.

Follow Up

Successful treatment for urethral stricture (endoscopic or surgical) is most commonly defined as no further need for surgical intervention or instrumentation.^42-54 Some studies use the absence of postoperative or post-procedural patient reported obstructive voiding symptoms and/or peak uroflow >15m/sec as a benchmark for successful treatment.^55-60 Additional measures of success that have been used alone or in combination include urethral patency assessed by urethro-cystoscopy, absence of recurrent stricture on urethrography, PVR urine <100mL, "unobstructed" flow curve shape on uroflowmetry, absence of UTI, ability to pass a urethral catheter, and patient-reported improvement in LUTS.^61-65 Consensus has not been reached on the optimal postoperative surveillance protocol to identify stricture recurrence following urethral stricture treatment.

GUIDELINE STATEMENTS

Clinicians should include urethral stricture in the differential diagnosis of patients who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection, and rising post-void residual. (Moderate Recommendation; Evidence Level: Grade C)

After performing a history, physical examination, and urinalysis, clinicians may use a combination of patient reported measures, uroflowmetry, and ultrasound post-void residual assessment in the initial evaluation of suspected urethral stricture. (Clinical Principle)

Clinicians should use urethro-cystoscopy, retrograde urethrography, voiding cystourethrography, or ultrasound urethography to make a diagnosis of urethral stricture. (Moderate Recommendation; Evidence Level: Grade C)

Clinicians planning non-urgent intervention for a known stricture should determine the length and location of the urethral stricture. (Expert Opinion)

Surgeons may utilize urethral endoscopic management (e.g., urethral dilation or direct visual internal urethrotomy) or immediate suprapubic cystostomy for urgent management of urethral stricture, such as discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure. (Expert Opinion)

Surgeons may place a suprapubic cystostomy to promote “urethral rest” prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. (Conditional Recommendation; Evidence Level: Grade C)

Surgeons may offer urethral dilation, direct visual internal urethrotomy, or urethroplasty for the initial treatment of a short (<2cm) bulbar urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)

Surgeons may perform either dilation or direct visual internal urethrotomy when performing endoscopic treatment of a urethral stricture. (Conditional Recommendation; Evidence Level: Grade C)

Surgeons may safely remove the urethral catheter within 72 hours following uncomplicated dilation or direct visual internal urethrotomy. (Conditional Recommendation; Evidence Level: Grade C)

In patients who are not candidates for urethroplasty, clinicians may recommend self-catheterization after direct visual internal urethrotomy to maintain temporary urethral patency. (Conditional Recommendation; Evidence Level: Grade C)

11a.  Surgeons should offer urethroplasty, instead of repeated endoscopic management for recurrent anterior urethral strictures following failed dilation or direct visual internal urethrotomy. (Moderate Recommendation; Evidence Level: Grade C)

11b. Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated balloons, for recurrent bulbar urethral strictures <3cm in length. (Conditional Recommendation; Evidence Level: Grade B)

Surgeons who do not perform urethroplasty should refer patients to surgeons with expertise. (Expert Opinion)

Surgeons may initially treat meatal or fossa navicularis strictures with either dilation or meatotomy. (Clinical Principle)

Surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures. (Moderate Recommendation; Evidence Level: Grade C)

Surgeons should offer urethroplasty to patients with penile urethral strictures given the expected high recurrence rates with endoscopic treatments. (Moderate Recommendation; Evidence Level: Grade C)

Surgeons should offer urethroplasty as the initial treatment for patients with long (≥2cm) bulbar urethral strictures given the low success rate of direct visual internal urethrotomy or dilation. (Moderate Recommendation; Evidence Level: Grade C)

Surgeons may reconstruct long multi-segment strictures with one-stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)

18a. Surgeons may offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty. (Conditional Recommendation; Evidence Level: Grade C)

18b. Surgeons should offer perineal urethrostomy as a long-term treatment option to patients as an alternative to urethroplasty in patient populations at high risk for failure of urethral reconstruction. (Expert Opinion)

19a. Surgeons should use oral mucosa as the first choice when using grafts for urethroplasty. (Expert Opinion)

19b. Surgeons may use either buccal or lingual mucosal grafts as equivalent alternatives. (Strong Recommendation; Evidence Level: Grade A)

Surgeons should not perform substitution urethroplasty with allograft, xenograft, or synthetic materials except under experimental protocols. (Expert Opinion)

Surgeons should not perform a single-stage tubularized graft urethroplasty. (Expert Opinion)

Surgeons should not use hair-bearing skin for substitution urethroplasty. (Clinical Principle)

Clinicians should use retrograde urethrography with voiding cystourethrogram and/or retrograde + antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. (Moderate Recommendation; Evidence Level: Grade C)

Surgeons should perform delayed urethroplasty instead of delayed endoscopic procedures after urethral obstruction/obliteration due to pelvic fracture urethral injury. (Expert Opinion)

Definitive urethral reconstruction for pelvic fracture urethral injury should be planned only after major injuries stabilize and patients can be safely positioned for urethroplasty. (Expert Opinion)

Surgeons may reconstruct female urethral strictures using oral mucosal grafts, vaginal flaps, or a combination of these techniques. (Moderate Recommendation; Evidence Level: Grade C)

Surgeons may perform a dilation, bladder neck incision, or transurethral resection for bladder neck contracture after endoscopic prostate procedure. (Expert Opinion)

Surgeons may perform a dilation, vesicourethral incision, or transurethral resection for post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)

Surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. (Conditional Recommendation; Evidence Level: Grade C)

In men who require chronic self-catheterization (e.g., neurogenic bladder), surgeons may offer urethroplasty as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization. (Expert Opinion)

Clinicians may perform biopsy for suspected lichen sclerosus and must perform biopsy if urethral cancer is suspected. (Clinical Principle)

In lichen sclerosus-proven urethral stricture, surgeons should not use genital skin for reconstruction. (Strong Recommendation; Evidence Level: Grade B)

Clinicians should monitor urethral stricture patients to identify symptomatic recurrence following dilation, direct visual internal urethrotomy or urethroplasty. (Expert Opinion)

FUTURE DIRECTIONS

Much of the literature on the topic urethral strictures consists of single surgeon or single institution case series with inconsistent definitions of stricture length, location, and etiology; success of treatment; and follow up. These inconsistencies make comparisons between studies difficult, while also providing ample opportunities for future research. To improve the quality of research, the Panel recommends the following:

• Standardize research terms to allow comparison between centers; specifically, the International Consultation on Urological Diseases nomenclature should be used. For example, the term "urethral stricture" should be applied to a narrowing of the anterior urethra that restrict the flow of urine.
• Utilization of an urethral stricture classification system that organizes the disease process, allows for improved patient counseling on expected outcomes, and better facilitates comparison of similar strictures across research studies.^{237, 238} Future urethroplasty research should include classification systems to better evaluate and compare uniform strictures.
• In studies of the treatment of urethral strictures, multiple criteria for success should be reported.  When data is available, studies should report success based on several criteria: PRMs, symptoms, uroflowmetry, radiography, cystoscopy, and need for subsequent procedures. This would facilitate comparison between multiple studies. A consensus primary outcome measure should be considered for future RCT and registry studies.
• The duration of follow-up based on time of last clinic visit, telephone contact, or absence of known treatment for recurrence should be reported in all studies of urethral stricture treatment. Time-to-event analysis (Kaplan-Meier curves) should be reported.
• Multi-institutional collaboration should be formed to evaluate management of uncommon diagnoses such as PFUI, hypospadias, panurethral strictures, and LS.
• Urethral stricture remains a subject of active investigation. The Panel suggests the following issues in future investigations:
• Basic science and epidemiological research into the etiology of urethral strictures.
• Continued evaluation of robotic techniques to treat posterior urethral strictures and those extending into the proximal bulbar urethra.
• Prevention of catheter associated urethral injury and traumatic strictures through educational efforts on proper technique of catheter insertion and management after insertion.
• Studies on the effectiveness of early diagnosis and treatment of LS toward prevention of disease progression and urethral stricture formation.
• Basic science and animal studies using novel graft materials for urethral reconstruction (i.e., stem cells, tissue-engineered scaffolds).
• Long-term follow-up for adults in patients who have been treated as children, such as urethral stricture in adults after hypospadias repair.
• Further evaluation of alternative sources of autologous graft material.
• The efficacy of injection or balloon-coated anti-proliferative or other pharmacological agents at time of endoscopic treatment for penile urethral stricture, previous failed urethroplasty, posterior urethral stenosis, and bladder neck contracture.
• The relationship between of urethroplasty and ED.
• Role of urethral transection in urethroplasty regarding morbidity and outcomes.
• Dissemination and implementation of optimal perioperative antibiotic strategies for urethrotomy and urethroplasty.^{239, 240}
• Determination of the ideal tissue for substitution urethroplasty.
• The optimal tissue and urethroplasty technique for urethral stricture following phalloplasty.

ABBREVIATIONS

REFERENCES

1. Higgins JPT SJ, Page MJ, Elbers RG, Sterne JAC: Chapter 8: Assessing risk of bias in a randomized trial. Cochrane Handbook for Systematic Reviews of Interventions version 6.2 (updated February 2021): Cochrane 2022.

2. Appendix b: Quality assessment methods for durg class reviews for the drug effectiveness review project. . Oregon Health & Science University 2005;

3. Whiting PF, Rutjes AW, Westwood ME et al: Quadas-2: A revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011; 155: 529.

4. Faraday M, Hubbard H, Kosiak B et al: Staying at the cutting edge: A review and analysis of evidence reporting and grading; the recommendations of the american urological association. BJU Int 2009; 104: 294.

5. Wessells H, Angermeier KW, Elliott S et al: Male urethral stricture: American urological association guideline. J Urol 2017; 197: 182.

6. Shea BJ, Reeves BC, Wells G et al: Amstar 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Bmj 2017; 358: j4008.

7. Higgins JP, Altman DG, Gotzsche PC et al: The cochrane collaboration's tool for assessing risk of bias in randomised trials. Bmj 2011; 343: d5928.

8. Sterne JA, Hernan MA, Reeves BC et al: Robins-i: A tool for assessing risk of bias in non-randomised studies of interventions. Bmj 2016; 355: i4919.

9. Guyatt G, Oxman AD, Akl EA et al: Grade guidelines: 1. Introduction-grade evidence profiles and summary of findings tables. J Clin Epidemiol 2011; 64: 383.

10. Balshem H, Helfand M, Schunemann HJ et al: Grade guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011; 64: 401.

11. Hsu C, Sandford, BA: The delphi technique: Making sense of consensus. Practical Assessment, Research, and Evaluation 2019; 12: 1.

12. Latini JM, McAninch JW, Brandes SB et al: Siu/icud consultation on urethral strictures: Epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries. Urology 2014; 83: S1.

13. Stein DM, Thum DJ, Barbagli G et al: A geographic analysis of male urethral stricture aetiology and location. BJU Int 2013; 112: 830.

14. Fenton AS, Morey AF, Aviles R et al: Anterior urethral strictures: Etiology and characteristics. Urology 2005; 65: 1055.

15. Lumen N, Hoebeke P, Willemsen P et al: Etiology of urethral stricture disease in the 21st century. J Urol 2009; 182: 983.

16. Nuss GR, Granieri MA, Zhao LC et al: Presenting symptoms of anterior urethral stricture disease: A disease specific, patient reported questionnaire to measure outcomes. J Urol 2012; 187: 559.

17. Jackson MJ, Chaudhury I, Mangera A et al: A prospective patient-centred evaluation of urethroplasty for anterior urethral stricture using a validated patient-reported outcome measure. Eur Urol 2013; 64: 777.

18. Breyer BN, Edwards TC, Patrick DL et al: Comprehensive qualitative assessment of urethral stricture disease: Toward the development of a patient centered outcome measure. J Urol 2017; 198: 1113.

19. Erickson BA, Breyer BN and McAninch JW: Changes in uroflowmetry maximum flow rates after urethral reconstructive surgery as a means to predict for stricture recurrence. J Urol 2011; 186: 1934.

20. Erickson BA, Breyer BN and McAninch JW: The use of uroflowmetry to diagnose recurrent stricture after urethral reconstructive surgery. J Urol 2010; 184: 1386.

21. Blaivas JG and Groutz A: Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology. Neurourol Urodyn 2000; 19: 553.

22. Defreitas GA, Zimmern PE, Lemack GE et al: Refining diagnosis of anatomic female bladder outlet obstruction: Comparison of pressure-flow study parameters in clinically obstructed women with those of normal controls. Urology 2004; 64: 675.

23. Mahmud SM, El KS, Rana AM et al: Is ascending urethrogram mandatory for all urethral strictures? J Pak Med Assoc 2008; 58: 429.

24. Andersen J, Aagaard J and Jaszczak P: Retrograde urethrography in the postoperative control of urethral strictures treated with visual internal urethrotomy. Urol Int 1987; 42: 390.

25. McAninch JW, Laing FC and Jeffrey RB, Jr.: Sonourethrography in the evaluation of urethral strictures: A preliminary report. J Urol 1988; 139: 294.

26. Santucci RA, McAninch JW, Mario LA et al: Urethroplasty in patients older than 65 years: Indications, results, outcomes and suggested treatment modifications. J Urol 2004; 172: 201.

27. Wolf JS, Jr., Bennett CJ, Dmochowski RR et al: Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008; 179: 1379.

28. Al-Qudah HS, Cavalcanti AG and Santucci RA: Early catheter removal after anterior anastomotic (3 days) and ventral buccal mucosal onlay (7 days) urethroplasty. Int Braz J Urol 2005; 31: 459.

29. Palminteri E, Berdondini E, Shokeir AA et al: Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: Urinary and sexual outcomes of a new technique. J Urol 2011; 185: 1766.

30. El-Kassaby AW, El-Zayat TM, Azazy S et al: One-stage repair of long bulbar urethral strictures using augmented russell dorsal strip anastomosis: Outcome of 234 cases. Eur Urol 2008; 53: 420.

31. Anger JT, Sherman ND and Webster GD: The effect of bulbar urethroplasty on erectile function. J Urol 2007; 178: 1009.

32. Dogra PN, Saini AK and Seth A: Erectile dysfunction after anterior urethroplasty: A prospective analysis of incidence and probability of recovery--single-center experience. Urology 2011; 78: 78.

33. Erickson BA, Granieri MA, Meeks JJ et al: Prospective analysis of erectile dysfunction after anterior urethroplasty: Incidence and recovery of function. J Urol 2010; 183: 657.

34. Erickson BA, Wysock JS, McVary KT et al: Erectile function, sexual drive, and ejaculatory function after reconstructive surgery for anterior urethral stricture disease. BJU Int 2007; 99: 607.

35. Johnson EK and Latini JM: The impact of urethroplasty on voiding symptoms and sexual function. Urology 2011; 78: 198.

36. Blaschko SD, Sanford MT, Cinman NM et al: De novo erectile dysfunction after anterior urethroplasty: A systematic review and meta-analysis. BJU Int 2013; 112: 655.

37. Feng C, Xu YM, Barbagli G et al: The relationship between erectile dysfunction and open urethroplasty: A systematic review and meta-analysis. J Sex Med 2013; 10: 2060.

38. Erickson BA, Granieri MA, Meeks JJ et al: Prospective analysis of ejaculatory function after anterior urethral reconstruction. J Urol 2010; 184: 238.

39. Andrich DE, Leach CJ and Mundy AR: The barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU Int 2001; 88: 385.

40. Dubey D, Kumar A, Bansal P et al: Substitution urethroplasty for anterior urethral strictures: A critical appraisal of various techniques. BJU Int 2003; 91: 215.

41. Palminteri E, Berdondini E, De Nunzio C et al: The impact of ventral oral graft bulbar urethroplasty on sexual life. Urology 2013; 81: 891.

42. Ahmad H, Mahmood A, Niaz WA et al: Bulbar uretheral stricture repair with buccal mucosa graft urethroplasty. J Pak Med Assoc 2011; 61: 440.

43. Barbagli G, Palminteri E, Guazzoni G et al: Bulbar urethroplasty using buccal mucosa grafts placed on the ventral, dorsal or lateral surface of the urethra: Are results affected by the surgical technique? J Urol 2005; 174: 955.

44. Barbagli G, Palminteri E, Lazzeri M et al: Interim outcomes of dorsal skin graft bulbar urethroplasty. J Urol 2004; 172: 1365.

45. Erickson BA, Breyer BN and McAninch JW: Single-stage segmental urethral replacement using combined ventral onlay fasciocutaneous flap with dorsal onlay buccal grafting for long segment strictures. BJU Int 2012; 109: 1392.

46. Fu Q, Zhang J, Sa YL et al: Transperineal bulboprostatic anastomosis in patients with simple traumatic posterior urethral strictures: A retrospective study from a referral urethral center. Urology 2009; 74: 1132.

47. Kulkarni SB, Joshi PM and Venkatesan K: Management of panurethral stricture disease in india. J Urol 2012; 188: 824.

48. Liu Y, Zhuang L, Ye W et al: One-stage dorsal inlay oral mucosa graft urethroplasty for anterior urethral stricture. BMC Urol 2014; 14: 35.

49. Morey AF, Lin HC, DeRosa CA et al: Fossa navicularis reconstruction: Impact of stricture length on outcomes and assessment of extended meatotomy (first stage johanson) maneuver. J Urol 2007; 177: 184.

50. Santucci RA, Mario LA and McAninch JW: Anastomotic urethroplasty for bulbar urethral stricture: Analysis of 168 patients. J Urol 2002; 167: 1715.

51. Singh A, Panda SS, Bajpai M et al: Our experience, technique and long-term outcomes in the management of posterior urethral strictures. J Pediatr Urol 2014; 10: 40.

52. Wang P, Fan M, Zhang Y et al: Modified urethral pull-through operation for posterior urethral stricture and long-term outcome. J Urol 2008; 180: 2479.

53. Xu YM, Fu Q, Sa YL et al: Outcome of small intestinal submucosa graft for repair of anterior urethral strictures. Int J Urol 2013; 20: 622.

54. Zhou FJ, Xiong YH, Zhang XP et al: Transperineal end-to-end anastomotic urethroplasty for traumatic posterior urethral disruption and strictures in children. Asian J Surg 2002; 25: 134.

55. Goel A, Goel A and Jain A: Buccal mucosal graft urethroplasty for penile stricture: Only dorsal or combined dorsal and ventral graft placement? Urology 2011; 77: 1482.

56. Raber M, Naspro R, Scapaticci E et al: Dorsal onlay graft urethroplasty using penile skin or buccal mucosa for repair of bulbar urethral stricture: Results of a prospective single center study. Eur Urol 2005; 48: 1013.

57. Rourke KF, McCammon KA, Sumfest JM et al: Open reconstruction of pediatric and adolescent urethral strictures: Long-term followup. J Urol 2003; 169: 1818.

58. Sa YL, Xu YM, Qian Y et al: A comparative study of buccal mucosa graft and penile pedical flap for reconstruction of anterior urethral strictures. Chin Med J (Engl) 2010; 123: 365.

59. Sharma AK, Chandrashekar R, Keshavamurthy R et al: Lingual versus buccal mucosa graft urethroplasty for anterior urethral stricture: A prospective comparative analysis. Int J Urol 2013; 20: 1199.

60. Soliman MG, Abo Farha M, El Abd AS et al: Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: A prospective randomized study. Scand J Urol 2014; 48: 466.

61. Cecen K, Karadag MA, Demir A et al: Plasmakinetic™ versus cold knife internal urethrotomy in terms of recurrence rates: A prospective randomized study. Urol Int 2014; 93: 460.

62. Heinke T, Gerharz EW, Bonfig R et al: Ventral onlay urethroplasty using buccal mucosa for complex stricture repair. Urology 2003; 61: 1004.

63. Hudak SJ, Lubahn JD, Kulkarni S et al: Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts. BJU Int 2012; 110: 592.

64. Qu Y, Zhang W, Sun N et al: Immediate or delayed repair of pelvic fracture urethral disruption defects in young boys: Twenty years of comparative experience. Chin Med J (Engl) 2014; 127: 3418.

65. Xu YM, Feng C, Sa YL et al: Outcome of 1-stage urethroplasty using oral mucosal grafts for the treatment of urethral strictures associated with genital lichen sclerosus. Urology 2014; 83: 232.

66. Seo IY, Lee JW, Park SC et al: Long-term outcome of primary endoscopic realignment for bulbous urethral injuries: Risk factors of urethral stricture. Int Neurourol J 2012; 16: 196.

67. Erickson BA, Elliott SP, Voelzke BB et al: Multi-institutional 1-year bulbar urethroplasty outcomes using a standardized prospective cystoscopic follow-up protocol. Urology 2014; 84: 213.

68. Gormley EA: Vaginal flap urethroplasty for female urethral stricture disease. Neurourol Urodyn 2010; 29 Suppl 1: S42.

69. Nitti VW, Tu LM and Gitlin J: Diagnosing bladder outlet obstruction in women. J Urol 1999; 161: 1535.

70. Hajebrahimi S, Maroufi H, Mostafaei H et al: Reconstruction of the urethra with an anterior vaginal mucosal flap in female urethral stricture. Int Urogynecol J 2019; 30: 2055.

71. Sarin I, Narain TA, Panwar VK et al: Deciphering the enigma of female urethral strictures: A systematic review and meta-analysis of management modalities. Neurourology & Urodynamics 2021; 40: 65.

72. Khawaja AR, Dar YA, Bashir F et al: Outcome of dorsal buccal graft urethroplasty in female urethral stricture disease (fusd); our institutional experience. International Urogynecology Journal 2021; 18: 18.

73. Onol FF, Antar B, Kose O et al: Techniques and results of urethroplasty for female urethral strictures: Our experience with 17 patients. Urology 2011; 77: 1318.

74. Kore RN and Martins FE: Dorsal onlay urethroplasty using buccal mucosal graft and vaginal wall graft for female urethral stricture - outcome of two-institution study. Indian Journal of Urology 2022; 38: 140.

75. Petrou SP, Rogers AE, Parker AS et al: Dorsal vaginal graft urethroplasty for female urethral stricture disease. BJU Int 2012; 110: E1090.

76. Sahin C and Yesildal C: Female urethral stricture: Which one is stronger? Labial vs buccal graft. International Urogynecology Journal 2022; 18: 18.

77. Lane GI, Gracely A, Uberoi P et al: Changes in patient reported outcome measures after treatment for female urethral stricture. Neurourol Urodyn 2021; 40: 986.

78. Babnik Peskar D and Visnar Perovic A: Comparison of radiographic and sonographic urethrography for assessing urethral strictures. Eur Radiol 2004; 14: 137.

79. Bach P and Rourke K: Independently interpreted retrograde urethrography does not accurately diagnose and stage anterior urethral stricture: The importance of urologist-performed urethrography. Urology 2014; 83: 1190.

80. Angermeier KW, Rourke KF, Dubey D et al: Siu/icud consultation on urethral strictures: Evaluation and follow-up. Urology 2014; 83: S8.

81. Sussman RD, Kozirovsky M, Telegrafi S et al: Gel-infused translabial ultrasound in the evaluation of female urethral stricture. Female Pelvic Med Reconstr Surg 2020; 26: 737.

82. Akano AO: Evaluation of male anterior urethral strictures by ultrasonography compared with retrograde urethrography. West Afr J Med 2007; 26: 102.

83. Chiou RK, Anderson JC, Tran T et al: Evaluation of urethral strictures and associated abnormalities using high-resolution and color doppler ultrasound. Urology 1996; 47: 102.

84. Choudhary S, Singh P, Sundar E et al: A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral strictures. Clin Radiol 2004; 59: 736.

85. Gong EM, Arellano CM, Chow JS et al: Sonourethrogram to manage adolescent anterior urethral stricture. J Urol 2010; 184: 1699.

86. Gupta N, Dubey D, Mandhani A et al: Urethral stricture assessment: A prospective study evaluating urethral ultrasonography and conventional radiological studies. BJU Int 2006; 98: 149.

87. Gupta S, Majumdar B, Tiwari A et al: Sonourethrography in the evaluation of anterior urethral strictures: Correlation with radiographic urethrography. J Clin Ultrasound 1993; 21: 231.

88. Heidenreich A, Derschum W, Bonfig R et al: Ultrasound in the evaluation of urethral stricture disease: A prospective study in 175 patients. Br J Urol 1994; 74: 93.

89. Kochakarn W, Muangman V, Viseshsindh V et al: Stricture of the male urethra: 29 years experience of 323 cases. J Med Assoc Thai 2001; 84: 6.

90. Mitterberger M, Christian G, Pinggera GM et al: Gray scale and color doppler sonography with extended field of view technique for the diagnostic evaluation of anterior urethral strictures. J Urol 2007; 177: 992.

91. Morey AF and McAninch JW: Role of preoperative sonourethrography in bulbar urethral reconstruction. J Urol 1997; 158: 1376.

92. Nash PA, McAninch JW, Bruce JE et al: Sono-urethrography in the evaluation of anterior urethral strictures. J Urol 1995; 154: 72.

93. D'Elia A, Grossi FS, Barnaba D et al: Ultrasound in the study of male urethral strictures. Acta Urol Ital 1996; 10

94. Pushkarna R, Bhargava SK and Jain M: Ultrasonographic evaluation of abnormalities of the male anterior urethra. Indian J Radiol Imaging 2000; 10: 89.

95. Samaiyar SS, Shukla RC, Dwivedi US et al: Role of sonourethrography in anterior urethral stricture. Ind J Urol 1999; 15: 146.

96. Morey AF and McAninch JW: Sonographic staging of anterior urethral strictures. J Urol 2000; 163: 1070.

97. Terlecki RP, Steele MC, Valadez C et al: Urethral rest: Role and rationale in preparation for anterior urethroplasty. Urology 2011; 77: 1477.

98. Viers BR, Pagliara TJ, Shakir NA et al: Delayed reconstruction of bulbar urethral strictures is associated with multiple interventions, longer strictures and more complex repairs. Journal of Urology 2018; 199: 515.

99. Moncrief T, Gor R, Goldfarb RA et al: Urethral rest with suprapubic cystostomy for obliterative or nearly obliterative urethral strictures: Urethrographic changes and implications for management. J Urol 2018; 199: 1289.

100. Heyns CF, Steenkamp JW, De Kock ML et al: Treatment of male urethral strictures: Is repeated dilation or internal urethrotomy useful? J Urol 1998; 160: 356.

101. Launonen E, Sairanen J, Ruutu M et al: Role of visual internal urethrotomy in pediatric urethral strictures. J Pediatr Urol 2014; 10: 545.

102. Steenkamp JW, Heyns CF and de Kock ML: Internal urethrotomy versus dilation as treatment for male urethral strictures: A prospective, randomized comparison. J Urol 1997; 157: 98.

103. Hafez AT, El-Assmy A, Dawaba MS et al: Long-term outcome of visual internal urethrotomy for the management of pediatric urethral strictures. J Urol 2005; 173: 595.

104. Kumar S, Kapoor A, Ganesamoni R et al: Efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture. Korean J Urol 2012; 53: 614.

105. Zehri AA, Ather MH and Afshan Q: Predictors of recurrence of urethral stricture disease following optical urethrotomy. Int J Surg 2009; 7: 361.

106. Nilsen OJ, Holm HV, Ekerhult TO et al: To transect or not transect: Results from the scandinavian urethroplasty study, a multicentre randomised study of bulbar urethroplasty comparing excision and primary anastomosis versus buccal mucosal grafting. European Urology 2022; 07: 07.

107. Haines T and Rourke KF: The effect of urethral transection on erectile function after anterior urethroplasty. World journal of urology 2017; 35: 839.

108. Ekerhult TO, Lindqvist K, Peeker R et al: Low risk of sexual dysfunction after transection and nontransection urethroplasty for bulbar urethral stricture. Journal of Urology 2013; 190: 635.

109. Furr JR, Wisenbaugh ES and Gelman J: Urinary and sexual outcomes following bulbar urethroplasty-an analysis of 2 common approaches. Urology 2019; 130: 162.

110. Atak M, Tokgoz H, Akduman B et al: Low-power holmium:Yag laser urethrotomy for urethral stricture disease: Comparison of outcomes with the cold-knife technique. Kaohsiung J Med Sci 2011; 27: 503.

111. Vicente J, Salvador J and Caffaratti J: Endoscopic urethrotomy versus urethrotomy plus nd-yag laser in the treatment of urethral stricture. Eur Urol 1990; 18: 166.

112. Mazdak H, Izadpanahi MH, Ghalamkari A et al: Internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures. Int Urol Nephrol 2010; 42: 565.

113. Zhang K, Qi E, Zhang Y et al: Efficacy and safety of local steroids for urethra strictures: A systematic review and meta-analysis. J Endourol 2014; 28: 962.

114. Mazdak H, Meshki I and Ghassami F: Effect of mitomycin c on anterior urethral stricture recurrence after internal urethrotomy. Eur Urol 2007; 51: 1089.

115. Giannakopoulos X, Grammeniatis E, Gartzios A et al: Sachse urethrotomy versus endoscopic urethrotomy plus transurethral resection of the fibrous callus (guillemin's technique) in the treatment of urethral stricture. Urology 1997; 49: 243.

116. Khan S, Khan RA, Ullah A et al: Role of clean intermittent self catheterisation (cisc) in the prevention of recurrent urethral strictures after internal optical urethrotomy. J Ayub Med Coll Abbottabad 2011; 23: 22.

117. Pansadoro V and Emiliozzi P: Internal urethrotomy in the management of anterior urethral strictures: Long-term followup. J Urol 1996; 156: 73.

118. Srivastava A, Dutta A and Jain DK: Initial experience with lingual mucosal graft urethroplasty for anterior urethral strictures. Med J Armed Forces India 2013; 69: 16.

119. Steenkamp JW, Heyns CF and de Kock ML: Outpatient treatment for male urethral strictures--dilatation versus internal urethrotomy. S Afr J Surg 1997; 35: 125.

120. Bodker A, Ostri P, Rye-Andersen J et al: Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: A controlled study of a new therapy. J Urol 1992; 148: 308.

121. Kjaergaard B, Walter S, Bartholin J et al: Prevention of urethral stricture recurrence using clean intermittent self-catheterization. Br J Urol 1994; 73: 692.

122. Matanhelia SS, Salaman R, John A et al: A prospective randomized study of self-dilatation in the management of urethral strictures. J R Coll Surg Edinb 1995; 40: 295.

123. Afridi NG, Khan M, Nazeem S et al: Intermittent urethral self dilatation for prevention of recurrent stricture. J Postgrad Med Inst 2010; 24: 239.

124. Tammela TL, Permi J, Ruutu M et al: Clean intermittent self-catheterization after urethrotomy for recurrent urethral strictures. Ann Chir Gynaecol Suppl 1993; 206: 80.

125. Murthy PV, Gurunadha Rao TH, Srivastava A et al: Self-dilatation in urethral stricture recurrence. Indian J Urol 1997; 14: 33.

126. Husmann DA and Rathbun SR: Long-term followup of visual internal urethrotomy for management of short (less than 1 cm) penile urethral strictures following hypospadias repair. J Urol 2006; 176: 1738.

127. Gallegos MA and Santucci RA: Advances in urethral stricture management. F1000Res 2016; 5: 2913.

128. Jordan GH, Wessells H, Secrest C et al: Effect of a temporary thermo-expandable stent on urethral patency after dilation or internal urethrotomy for recurrent bulbar urethral stricture: Results from a 1-year randomized trial. J Urol 2013; 190: 130.

129. Hudak SJ, Atkinson TH and Morey AF: Repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease duration. J Urol 2012; 187: 1691.

130. Goulao B, Carnell S, Shen J et al: Surgical treatment for recurrent bulbar urethral stricture: A randomised open-label superiority trial of open urethroplasty versus endoscopic urethrotomy (the open trial). European Urology 2020; 78: 572.

131. Elliott SP, Coutinho K, Robertson KJ et al: One-year results for the robust iii randomized controlled trial evaluating the optilume((r)) drug-coated balloon for anterior urethral strictures. J Urol 2022; 207: 866.

132. Pickard R, Goulao B, Carnell S et al: Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: The open rct. Health Technology Assessment 2020; 24: 1.

133. Virasoro R, Delong JM, Estrella RE et al: A drug-coated balloon treatment for urethral stricture disease: Three-year results from the robust i study. Research and Reports in Urology 2022; 14: 177.

134. Helmy TE, Sarhan O, Hafez AT et al: Perineal anastomotic urethroplasty in a pediatric cohort with posterior urethral strictures: Critical analysis of outcomes in a contemporary series. Urology 2014; 83: 1145.

135. Meeks JJ, Barbagli G, Mehdiratta N et al: Distal urethroplasty for isolated fossa navicularis and meatal strictures. BJU Int 2012; 109: 616.

136. Tausch TJ and Peterson AC: Early aggressive treatment of lichen sclerosus may prevent disease progression. J Urol 2012; 187: 2101.

137. Stormont TJ, Suman VJ and Oesterling JE: Newly diagnosed bulbar urethral strictures: Etiology and outcome of various treatments. J Urol 1993; 150: 1725.

138. Santucci R and Eisenberg L: Urethrotomy has a much lower success rate than previously reported. J Urol 2010; 183: 1859.

139. Chowdhury PS, Nayak P, Mallick S et al: Single stage ventral onlay buccal mucosal graft urethroplasty for navicular fossa strictures. Indian J Urol 2014; 30: 17.

140. Onol SY, Onol FF, Gumus E et al: Reconstruction of distal urethral strictures confined to the glans with circular buccal mucosa graft. Urology 2012; 79: 1158.

141. Virasoro R, Eltahawy EA and Jordan GH: Long-term follow-up for reconstruction of strictures of the fossa navicularis with a single technique. BJU Int 2007; 100: 1143.

142. Broadwin M and Vanni AJ: Outcomes of a urethroplasty algorithm for fossa navicularis strictures. Canadian Journal of Urology 2018; 25: 9591.

143. Venn SN and Mundy AR: Urethroplasty for balanitis xerotica obliterans. Br J Urol 1998; 81: 735.

144. Goel A, Goel A, Dalela D et al: Meatoplasty using double buccal mucosal graft technique. Int Urol Nephrol 2009; 41: 885.

145. Al-Ali M and Al-Hajaj R: Johanson's staged urethroplasty revisited in the salvage treatment of 68 complex urethral stricture patients: Presentation of total urethroplasty. Eur Urol 2001; 39: 268.

146. Kozinn SI, Harty NJ, Zinman L et al: Management of complex anterior urethral strictures with multistage buccal mucosa graft reconstruction. Urology 2013; 82: 718.

147. Meeks JJ, Erickson BA and Gonzalez CM: Staged reconstruction of long segment urethral strictures in men with previous pediatric hypospadias repair. J Urol 2009; 181: 685.

148. Myers JB, McAninch JW, Erickson BA et al: Treatment of adults with complications from previous hypospadias surgery. J Urol 2012; 188: 459.

149. Noll F and Schreiter F: Meshgraft urethroplasty using split-thickness skin graft. Urol Int 1990; 45: 44.

150. Greenwell TJ, Venn SN and Mundy AR: Changing practice in anterior urethroplasty. BJU Int 1999; 83: 631.

151. Onol SY, Onol FF, Onur S et al: Reconstruction of strictures of the fossa navicularis and meatus with transverse island fasciocutaneous penile flap. J Urol 2008; 179: 1437.

152. Armenakas NA, Morey AF and McAninch JW: Reconstruction of resistant strictures of the fossa navicularis and meatus. J Urol 1998; 160: 359.

153. Aldaqadossi H, El Gamal S, El-Nadey M et al: Dorsal onlay (barbagli technique) versus dorsal inlay (asopa technique) buccal mucosal graft urethroplasty for anterior urethral stricture: A prospective randomized study. Int J Urol 2014; 21: 185.

154. Barbagli G, Kulkarni SB, Fossati N et al: Long-term followup and deterioration rate of anterior substitution urethroplasty. J Urol 2014; 192: 808.

155. Hosseini J, Kaviani A, Hosseini M et al: Dorsal versus ventral oral mucosal graft urethroplasty. Urol J 2011; 8: 48.

156. Hussein MM, Moursy E, Gamal W et al: The use of penile skin graft versus penile skin flap in the repair of long bulbo-penile urethral stricture: A prospective randomized study. Urology 2011; 77: 1232.

157. Mathur RK, Nagar M, Mathur R et al: Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: Evaluation and determinants of success. BJU Int 2014; 113: 120.

158. Mangera A and Chapple C: Management of anterior urethral stricture: An evidence-based approach. Curr Opin Urol 2010; 20: 453.

159. Mangera A, Patterson JM and Chapple CR: A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol 2011; 59: 797.

160. Levine LA, Strom KH and Lux MM: Buccal mucosa graft urethroplasty for anterior urethral stricture repair: Evaluation of the impact of stricture location and lichen sclerosus on surgical outcome. J Urol 2007; 178: 2011.

161. Pahwa M, Gupta S, Pahwa M et al: A comparative study of dorsal buccal mucosa graft substitution urethroplasty by dorsal urethrotomy approach versus ventral sagittal urethrotomy approach. Adv Urol 2013; 2013: 124836.

162. Breyer BN, McAninch JW, Whitson JM et al: Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol 2010; 183: 613.

163. Kinnaird AS, Levine MA, Ambati D et al: Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: A multivariate analysis of 604 urethroplasties. Can Urol Assoc J 2014; 8: E296.

164. Mathur RK and Sharma A: Tunica albuginea urethroplasty for panurethral strictures. Urol J 2010; 7: 120.

165. Sharma G, Sharma S and Parmar K: Buccal mucosa or penile skin for substitution urethroplasty: A systematic review and meta-analysis. Indian Journal of Urology 2020; 36: 81.

166. Gelman J and Siegel JA: Ventral and dorsal buccal grafting for 1-stage repair of complex anterior urethral strictures. Urology 2014; 83: 1418.

167. Palminteri E, Manzoni G, Berdondini E et al: Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Eur Urol 2008; 53: 81.

168. Jiang J, Zhu Y, Jiang L et al: Combined dorsal plus ventral double-graft urethroplasty in anterior urethral reconstruction. Indian J Surg 2015; 77: 996.

169. Talab SS, Cambareri GM and Hanna MK: Outcome of surgical management of urethral stricture following hypospadias repair. Journal of Pediatric Urology 2019; 15: 354.e1.

170. Fuchs JS, Shakir N, McKibben MJ et al: Changing trends in reconstruction of complex anterior urethral strictures: From skin flap to perineal urethrostomy. Urology 2018; 122: 169.

171. Murphy GP, Fergus KB, Gaither TW et al: Urinary and sexual function after perineal urethrostomy for urethral stricture disease: An analysis from the turns. Journal of Urology 2019; 201: 956.

172. Barbagli G, De Angelis M, Romano G et al: Clinical outcome and quality of life assessment in patients treated with perineal urethrostomy for anterior urethral stricture disease. J Urol 2009; 182: 548.

173. Peterson AC, Palminteri E, Lazzeri M et al: Heroic measures may not always be justified in extensive urethral stricture due to lichen sclerosus (balanitis xerotica obliterans). Urology 2004; 64: 565.

174. Patel CK, Buckley JC, Zinman LN et al: Outcomes for management of lichen sclerosus urethral strictures by 3 different techniques. Urology 2016; 91: 215.

175. Kamp S, Knoll T, Osman M et al: Donor-site morbidity in buccal mucosa urethroplasty: Lower lip or inner cheek? BJU Int 2005; 96: 619.

176. Wang A, Chua M, Talla V et al: Lingual versus buccal mucosal graft for augmentation urethroplasty: A meta-analysis of surgical outcomes and patient-reported donor site morbidity. International Urology & Nephrology 2021; 53: 907.

177. Rourke K, McKinny S and St Martin B: Effect of wound closure on buccal mucosal graft harvest site morbidity: Results of a randomized prospective trial. Urology 2012; 79: 443.

178. Hwang EC, de Fazio A, Hamilton K et al: A systematic review of randomized controlled trials comparing buccal mucosal graft harvest site non-closure versus closure in patients undergoing urethral reconstruction. The World Journal of Mens Health 2022; 40: 116.

179. Farahat YA, Elbahnasy AM, El-Gamal OM et al: Endoscopic urethroplasty using small intestinal submucosal patch in cases of recurrent urethral stricture: A preliminary study. J Endourol 2009; 23: 2001.

180. Gargollo PC, Cai AW, Borer JG et al: Management of recurrent urethral strictures after hypospadias repair: Is there a role for repeat dilation or endoscopic incision? J Pediatr Urol 2011; 7: 34.

181. Palminteri E, Berdondini E, Colombo F et al: Small intestinal submucosa (sis) graft urethroplasty: Short-term results. Eur Urol 2007; 51: 1695.

182. Koraitim MM: The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol 1995; 153: 63.

183. Srivastava A, Vashishtha S, Singh UP et al: Preputial/penile skin flap, as a dorsal onlay or tubularized flap: A versatile substitute for complex anterior urethral stricture. BJU Int 2012; 110: E1101.

184. McAninch JW and Morey AF: Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol 1998; 159: 1209.

185. Barbagli G, De Angelis M, Palminteri E et al: Failed hypospadias repair presenting in adults. Eur Urol 2006; 49: 887.

186. Scarberry K, Bonomo J and Gomez RG: Delayed posterior urethroplasty following pelvic fracture urethral injury: Do we have to wait 3 months? Urology 2018; 116: 193.

187. Hampson LA, Myers JB, Vanni AJ et al: Dorsal buccal graft urethroplasty in female urethral stricture disease: A multi-center experience. Transl Androl Urol 2019; 8: S6.

188. Kumaraswamy S, Mandal S, Das MK et al: Long-term follow-up and success rate of ventral inlay buccal mucosal graft urethroplasty for female urethral stricture disease. Urology 2022; 166: 146.

189. Manasa T, Khattar N, Tripathi M et al: Dorsal onlay graft urethroplasty for female urethral stricture improves sexual function: Short-term results of a prospective study using vaginal graft. Indian Journal of Urology 2019; 35: 267.

190. Mukhtar BMB, Spilotros M, Malde S et al: Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women. BJU Int 2017; 120: 710.

191. Katiyar VK, Sood R, Sharma U et al: Critical analysis of outcome between ventral and dorsal onlay urethroplasty in female urethral stricture. Urology 2021; 23: 23.

192. Borboroglu PG, Sands JP, Roberts JL et al: Risk factors for vesicourethral anastomotic stricture after radical prostatectomy. Urology 2000; 56: 96.

193. Brede C, Angermeier K and Wood H: Continence outcomes after treatment of recalcitrant postprostatectomy bladder neck contracture and review of the literature. Urology 2014; 83: 648.

194. Pfalzgraf D, Beuke M, Isbarn H et al: Open retropubic reanastomosis for highly recurrent and complex bladder neck stenosis. J Urol 2011; 186: 1944.

195. Ramchandani P, Banner MP, Berlin JW et al: Vesicourethral anastomotic strictures after radical prostatectomy: Efficacy of transurethral balloon dilation. Radiology 1994; 193: 345.

196. Surya BV, Provet J, Johanson KE et al: Anastomotic strictures following radical prostatectomy: Risk factors and management. J Urol 1990; 143: 755.

197. Redshaw JD, Broghammer JA, Smith TG, 3rd et al: Intralesional injection of mitomycin c at transurethral incision of bladder neck contracture may offer limited benefit: Turns study group. J Urol 2015; 193: 587.

198. Vanni AJ, Zinman LN and Buckley JC: Radial urethrotomy and intralesional mitomycin c for the management of recurrent bladder neck contractures. J Urol 2011; 186: 156.

199. Kirshenbaum EJ, Zhao LC, Myers JB et al: Patency and incontinence rates after robotic bladder neck reconstruction for vesicourethral anastomotic stenosis and recalcitrant bladder neck contractures: The trauma and urologic reconstructive network of surgeons experience. Urology 2018; 118: 227.

200. Shakir NA, Alsikafi NF, Buesser JF et al: Durable treatment of refractory vesicourethral anastomotic stenosis via robotic-assisted reconstruction: A trauma and urologic reconstructive network of surgeons study. European Urology 2021; 11: 11.

201. Giudice CR, Lodi PE, Olivares AM et al: Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy. Int Braz J Urol 2019; 45: 253.

202. Vitarelli A, Vulpi M, Divenuto L et al: Prerectal-transperineal approach for treatment of recurrent vesico-urethral anastomotic stenosis after radical prostatectomy. Asian Journal of Urology. 2022;

203. Shamout S, Yao HHI, Mossa AH et al: Persistent storage symptoms following y-v plasty reconstruction for the treatment of refractory bladder neck contracture. Neurourology & Urodynamics 2022; 41: 1082.

204. Casey JT, Erickson BA, Navai N et al: Urethral reconstruction in patients with neurogenic bladder dysfunction. J Urol 2008; 180: 197.

205. Secrest CL, Madjar S, Sharma AK et al: Urethral reconstruction in spinal cord injury patients. J Urol 2003; 170: 1217.

206. Christmann-Schmid C, Hediger M, Groger S et al: Vulvar lichen sclerosus in women is associated with lower urinary tract symptoms. Int Urogynecol J 2018; 29: 217.

207. Pugliese JM, Morey AF and Peterson AC: Lichen sclerosus: Review of the literature and current recommendations for management. J Urol 2007; 178: 2268.

208. Barbagli G, Palminteri E, Mirri F et al: Penile carcinoma in patients with genital lichen sclerosus: A multicenter survey. J Urol 2006; 175: 1359.

209. Liaw A, Rickborn L and McClung C: Incidence of urethral stricture in patients with adult acquired buried penis. Adv Urol 2017; 2017: 7056173.

210. Fuller TW, Pekala K, Theisen KM et al: Prevalence and surgical management of concurrent adult acquired buried penis and urethral stricture disease. World J Urol 2019; 37: 1409.

211. Pariser JJ, Soto-Aviles OE, Miller B et al: A simplified adult acquired buried penis repair classification system with an analysis of perioperative complications and urethral stricture disease. Urology 2018; 120: 248.

212. Erickson BA, Elliott SP, Myers JB et al: Understanding the relationship between chronic systemic disease and lichen sclerosus urethral strictures. J Urol 2016; 195: 363.

213. Hofer MD, Zhao LC, Morey AF et al: Outcomes after urethroplasty for radiotherapy induced bulbomembranous urethral stricture disease. J Urol 2014; 191: 1307.

214. Blaschko SD, Harris CR, Zaid UB et al: Trends, utilization, and immediate perioperative complications of urethroplasty in the united states: Data from the national inpatient sample 2000-2010. Urology 2015; 85: 1190.

215. Das S and Tunuguntla HS: Balanitis xerotica obliterans--a review. World J Urol 2000; 18: 382.

216. Depasquale I, Park AJ and Bracka A: The treatment of balanitis xerotica obliterans. BJU Int 2000; 86: 459.

217. Nasca MR, Innocenzi D and Micali G: Penile cancer among patients with genital lichen sclerosus. J Am Acad Dermatol 1999; 41: 911.

218. Powell J, Robson A, Cranston D et al: High incidence of lichen sclerosus in patients with squamous cell carcinoma of the penis. Br J Dermatol 2001; 145: 85.

219. Trivedi S, Kumar A, Goyal NK et al: Urethral reconstruction in balanitis xerotica obliterans. Urol Int 2008; 81: 285.

220. Kulkarni S, Barbagli G, Kirpekar D et al: Lichen sclerosus of the male genitalia and urethra: Surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009; 55: 945.

221. Blaschko SD, McAninch JW, Myers JB et al: Repeat urethroplasty after failed urethral reconstruction: Outcome analysis of 130 patients. J Urol 2012; 188: 2260.

222. Barbagli G, Guazzoni G and Lazzeri M: One-stage bulbar urethroplasty: Retrospective analysis of the results in 375 patients. Eur Urol 2008; 53: 828.

223. Barbagli G, Morgia G and Lazzeri M: Dorsal onlay skin graft bulbar urethroplasty: Long-term follow-up. Eur Urol 2008; 53: 628.

224. Figler BD, Malaeb BS, Dy GW et al: Impact of graft position on failure of single-stage bulbar urethroplasties with buccal mucosa graft. Urology 2013; 82: 1166.

225. Gimbernat H, Arance I, Redondo C et al: Analysis of the factors involved in the failure of urethroplasty in men. Actas Urol Esp 2014; 38: 96.

226. Hwang JH, Kang MH, Lee YT et al: Clinical factors that predict successful posterior urethral anastomosis with a gracilis muscle flap. Korean J Urol 2013; 54: 710.

227. Kessler TM, Schreiter F, Kralidis G et al: Long-term results of surgery for urethral stricture: A statistical analysis. J Urol 2003; 170: 840.

228. Singh BP, Andankar MG, Swain SK et al: Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology 2010; 75: 179.

229. Whitson JM, McAninch JW, Elliott SP et al: Long-term efficacy of distal penile circular fasciocutaneous flaps for single stage reconstruction of complex anterior urethral stricture disease. J Urol 2008; 179: 2259.

230. Bircan MK, Sahin H and Korkmaz K: Diagnosis of urethral strictures: Is retrograde urethrography still necessary? Int Urol Nephrol 1996; 28: 801.

231. Kostakopoulos A, Makrychoritis K, Deliveliotis C et al: Contribution of transcutaneous ultrasonography to the evaluation of urethral strictures. Int Urol Nephrol 1998; 30: 85.

232. Badlani GH, Press SM, Defalco A et al: Urolume endourethral prosthesis for the treatment of urethral stricture disease: Long-term results of the north american multicenter urolume trial. Urology 1995; 45: 846.

233. Hussain M, Greenwell TJ, Shah J et al: Long-term results of a self-expanding wallstent in the treatment of urethral stricture. BJU Int 2004; 94: 1037.

234. Milroy E and Allen A: Long-term results of urolume urethral stent for recurrent urethral strictures. J Urol 1996; 155: 904.

235. Ashken MH, Coulange C, Milroy EJ et al: European experience with the urethral wallstent for urethral strictures. Eur Urol 1991; 19: 181.

236. Sertcelik N, Sagnak L, Imamoglu A et al: The use of self-expanding metallic urethral stents in the treatment of recurrent bulbar urethral strictures: Long-term results. BJU Int 2000; 86: 686.

237. Erickson BA, Flynn KJ, Hahn AE et al: Development and validation of a male anterior urethral stricture classification system. Urology 2020; 143: 241.

238. Kurtzman JT, Kosber R, Kerr P et al: Evaluating tools for characterizing anterior urethral stricture disease: A comparison of the lse system and the urethral stricture score. J Urol 2022; 208: 1083.

239. Kim S, Cheng KC, Alsikafi NF et al: Minimizing antibiotic use in urethral reconstruction. J Urol 2022; 208: 128.

240. Kim S, Cheng KC, Patell S et al: Antibiotic stewardship and postoperative infections in urethroplasties. Urology 2021; 152: 142.

This document was written by the Male Urethral Stricture Guideline Panel of the American Urological Association Education and Research, Inc., which was created in 2015. The Practice Guidelines Committee (PGC) of the AUA selected the committee chair. Panel members were selected by the chair. Membership of the panel included specialists in urology with specific expertise on this disorder. The mission of the panel was to develop recommendations that are analysis-based or consensus-based, depending on panel processes and available data, for optimal clinical practices in the treatment of male urethral strictures. Funding of the panel was provided by the AUA. Panel members received no remuneration for their work. Each member of the panel provides an ongoing conflict of interest disclosure to the AUA. While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend and to encourage compliance by practitioners with current best practices related to the condition being treated. As medical knowledge expands and technology advances, the guidelines will change. Today these evidence-based guidelines statements represent not absolute mandates but provisional proposals for treatment under the specific conditions described in each document. For all these reasons, the guidelines do not pre-empt physician judgment in individual cases. Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences. Conformance with any clinical guideline does not guarantee a successful outcome. The guideline text may include information or recommendations about certain drug uses ('off label') that are not approved by the Food and Drug Administration (FDA), or about medications or substances not subject to the FDA approval process. AUA urges strict compliance with all government regulations and protocols for prescription and use of these substances. The physician is encouraged to carefully follow all available prescribing information about indications, contraindications, precautions and warnings. These guidelines and best practice statements are not in-tended to provide legal advice about use and misuse of these substances. Although guidelines are intended to encourage best practices and potentially encompass available technologies with sufficient data as of close of the literature review, they are necessarily time-limited. Guidelines cannot include evaluation of all data on emerging technologies or management, including those that are FDA-approved, which may immediately come to represent accepted clinical practices. For this reason, the AUA does not regard technologies or management which are too new to be addressed by this guideline as necessarily experimental or investigational.