To cite this guideline:
Wessells H, Angermeier KW, Elliott S et al: Male urethral stricture: American Urological Association guideline. J Urol 2017; 197: 182.

Published 2016

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

Unabridged version of this Guideline [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

Purpose

The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of urethral stricture.

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. The review yielded an evidence base of 250 articles after application of inclusion/exclusion criteria. 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 strength 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 men who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection (UTI), and after rising post void residual. (Moderate Recommendation; Evidence Strength 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 Strength 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 or direct visual internal urethrotomy [DVIU]) 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 (SP) cystostomy prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. (Expert Opinion)

Dilation/Internal Urethrotomy/Urethroplasty

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

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

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

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

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

12. Surgeons who do not perform urethroplasty should offer patients referral 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 Strength 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 Strength 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 (DVIU) or dilation. (Moderate Recommendation; Evidence Strength 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 Strength Grade C)

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

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

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 (PFUI). (Moderate Recommendation; Evidence Strength Grade C)

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

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

Bladder Neck Contracture/Vesicourethral Stenosis

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

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

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

Special Circumstances

29. 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)

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

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

Post-operative Follow-up

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

Purpose

Urethral stricture is chronic fibrosis and narrowing of the urethral lumen caused by acute injury, inflammatory conditions, and iatrogenic interventions including urethral instrumentation or surgery and prostate cancer treatment. The symptoms of urethral stricture are non-specific and may overlap with other common conditions including lower urinary tract symptoms (LUTS) and urinary tract infections (UTI) to confound timely diagnosis. 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 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

Systematic review. A systematic review was conducted to identify published articles relevant to the diagnosis and treatment of urethral stricture. Literature searches were performed on English-language publications using the Pubmed, Embase, and Cochrane databases from 1/1/1990 to 12/1/2015. Data from studies published after the literature search cut-off will be incorporated into the next version of this guideline. 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 disruption (PFUD); 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 RCTs or CCTs 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 Because there is no widely-agreed upon quality assessment tool for single cohort observational intervention studies, the quality of these studies was not assessed.

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 AUA categorizes the strength 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

AUA Nomenclature: Linking Statement Type to Evidence Strength. The AUA nomenclature system explicitly links statement type to body of evidence strength, level of certainty, magnitude of benefit or risk/burdens, and the Panel's judgment regarding the balance between benefits and risks/burdens (see Table 1). 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 strength grade. Body of evidence strength Grade A 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. Body of evidence strength Grade B 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. Body of evidence strength Grade C 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. Body of evidence strength Grade C is only rarely used in support of a Strong Recommendation. Conditional Recommendations also can be supported by any body of evidence strength. When body of evidence strength is Grade A, 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 body of evidence strength Grade B is used, benefits and risks/burdens appear balanced, the best action also depends on individual patient circumstances and better evidence could change confidence. When body of evidence strength Grade C 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.⁵ 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.

Process. The Urethral Stricture Panel was created in 2013 by the American Urological Association Education and Research, Inc. (AUA). 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.

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 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. 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 urethra is completely 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." Pelvic fracture urethral injury typically creates a distraction defect with resulting obstruction or obliteration.⁶

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 (EPA) urethroplasty involves transection and removal of the narrowed segment of urethra and corresponding spongiofibrosis with anastomosis of the two healthy ends of the urethra. 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 developed 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 developing 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.^7-9

Strictures in the bulbar urethra predominate over other anatomic locations; however, certain etiologies are closely associated with an anatomic segment of the urethra.⁷ 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.

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 urine volume or decreased force of ejaculation. Additionally, patients may present with urinary spraying or dysuria.¹⁰

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.¹⁰ 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 impact. A more disease specific standardized PRM will also allow for comparison of patient outcomes across research studies.

Diagnosis

All men being evaluated for lower urinary tract symptoms should have a complete history and physical examination and urinalysis at a minimum. Decreased urinary stream, incomplete emptying and other findings such as urinary tract infection 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 post-void residual volume to identify urinary retention may be used. Patients with symptomatic urethral stricture typically have a reduced peak flow rate.^11,12 Confirmation of a urethral stricture diagnosis is made with urethroscopy, retrograde urethrography, or ultrasound urethrography. Urethroscopy readily identifies a urethral stricture, but does not delineate the location and length of strictures. Retrograde urethrography (RUG) with or without voiding cystourethrography (VCUG) allows for identification of stricture location in the urethra, length of the stricture, and degree of lumen narrowing.^13,14 All of these stricture characteristics are important for subsequent treatment planning. Ultrasound urethrography can be used to identify the location, length and severity of the stricture.¹⁵ 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 pelvic fracture urethral injury, a detailed history should document all associated injuries and angiographic embolization of any pelvic vessels. The history should assess pre- operative erectile 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.¹⁶

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 urinary tract infections must be treated before urethral stricture intervention. Prophylactic antibiotic choice and duration should follow AUA Best Practice Policy Statement.¹⁷ 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 urinary tract infection or if there is an existing indwelling catheter.¹⁷ In the setting of endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins leading the AUA Antimicrobial Prophylaxis panel to support their use.¹⁷ Antimicrobial prophylaxis is recommended at the time of urethral catheter removal in patients with certain risk factors.¹⁷

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 (VTE) and nerve compression injuries. Perioperative parenteral VTE 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 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.¹⁸

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.^19,20

Complications

Erectile dysfunction, as measured by the International Index of Erectile Function (IIEF) may occur transiently after urethroplasty with resolution of nearly all reported symptoms approximately six months postoperatively.^21-25 Meta-analysis has demonstrated the risk of new onset erectile dysfunction following anterior urethroplasty to be ~1%.²⁶ Type of urethroplasty, specifically anastomotic urethroplasty, as a causative risk factor for sexual dysfunction remains unclear. Erectile function following urethroplasty for PFUI does not appear to significantly change as a result of surgery. Erectile dysfunction in this cohort may be related to the initial pelvic trauma rather that the subsequent urethral reconstruction.²⁷

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.²⁸ Urethroplasty technique may play a role in the occurrence of ejaculatory dysfunction but the exact etiology remains uncertain.^29-31 Conversely, some patients, as measured by the Men's Sexual Health Questionnaire (MSHQ), will notice an improvement in ejaculatory function following bulbar urethroplasty, particularly those with pre-operative ejaculatory dysfunction related to obstruction caused by the stricture.²⁸ 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.^32-44 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.^45-50 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, post-void residual urine <100mL, "unobstructed" flow curve shape on uroflowmetry, absence of urinary tract infection, ability to pass a urethral catheter, and patient reported improvement in lower urinary tract symptoms.^51-55 Consensus has not been reached on the optimal postoperative surveillance protocol to identify stricture recurrence following urethral stricture treatment.

Clinicians should include urethral stricture in the differential diagnosis of men who present with decreased urinary stream, incomplete emptying, dysuria, urinary tract infection (UTI), and rising post void residual. Moderate Recommendation; Evidence Strength 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 Strength 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 [DVIU]) 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 (SP) cystostomy prior to definitive urethroplasty in patients dependent on an indwelling urethral catheter or intermittent self-dilation. Expert Opinion

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

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

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

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

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

Surgeons who do not perform urethroplasty should offer patients referral 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 Strength Grade C

Surgeons should offer urethroplasty to patients with penile urethral strictures, because of the expected high recurrence rates with endoscopic treatments. Moderate Recommendation; Evidence Strength 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 (DVIU) or dilation. Moderate Recommendation; Evidence Strength 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 Strength Grade C

Surgeons may offer perineal urethrostomy as a long term treatment option to patients as an alternative to urethroplasty. Conditional Recommendation; Evidence Strength Grade C

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

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

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 Strength Grade C)

Surgeons may perform open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis. Conditional Recommendation; Evidence Strength 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 (LS), and must perform biopsy if urethral cancer is suspected. Clinical Principle

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

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

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

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

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

Much of the literature on the topic urethral strictures consists of single surgeon or single institution case series with inconsistent definitions of disease process, success of treatment, and follow up. These inconsistencies resulted in difficulty in comparison between studies. These inadequacies in the literature means there is ample opportunities for future research. To improve the quality of research, the Panel recommends the following:

• Research terms should be standardized to allow comparison between centers—the International Consultation on Urological Diseases⁶ 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.
• In studies of the treatment of urethral strictures, multiple criteria for success should be reported. When data is available, studies should report success based several criteria: patient reported outcome measures, symptoms, uroflowmetry, radiography, cystoscopy, and need for subsequent procedures. Reporting success based on multiple criteria would facilitate comparison between multiple studies.
• The duration and type of follow up should be reported in all studies of urethral stricture treatment, follow up based on time of last clinic visit, telephone contact, or absence of known treatment for recurrence. Time-to-event analysis (Kaplan-Meier) should be reported.
• Multi-institutional collaboration should be formed to evaluate management of uncommon diagnoses such as pelvic fracture urethral injury, hypospadias, panurethral strictures, and LS.
• Multi-centered randomized clinical trials, pragmatic trials, or registries should be created for evaluation of techniques, such as injection of antiproliferative agents during DVIU, dorsal versus ventral onlay buccal mucosa graft urethroplasty, and skin flap versus oral mucosa graft urethroplasty.
• Multiple measures have been used to determine and report success after treatment for urethral stricture. Currently there is no universally accepted definition of success following treatment for urethral stricture. Multi-center randomized trials are necessary to standardize follow-up protocols to accurately and efficiently define successful treatment, and enable comparative effectiveness research across centers.

Urethral stricture remains a subject of active investigation. The Panel suggests the following issues in future investigations:

• Both basic science and epidemiological research into the etiology of urethral strictures.
• Prevention of traumatic strictures through educational efforts on proper technique of catheter 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—stem cells, tissue-engineered scaffolds, etc.
• 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 of anti-proliferative or other pharmacological agents at time of endoscopic incision for urethral stricture and bladder neck contracture.
• The relationship between of urethroplasty and erectile dysfunction.
• Role of urethral transection in urethroplasty regarding morbidity and outcomes.
• The optimal timing and duration of perioperative antibiotics given at the time of urethrotomy and urethroplasty.
• Determination of the ideal tissue for substitution urethroplasty.

AUSAI American Urological Association Symptom Index

1. Assessing risk of bias in included studies. In: Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [database online]. Hoboken (NJ): John Wiley & Sons, Ltd.; 2011 Mar 20 [accessed 2012 Dec 04].
2. Appendix B: quality assessment methods for drug class reviews for the drug effectiveness review project. [internet]. Portland (OR): Oregon Health & Science University; 2005 Jan 01 [accessed 2010 May 28]. [5 p].
3. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011 Oct 18;155(8): 529-36.
4. Faraday M, Hubbard H, Kosiak B, Dmochowski R. Staying at the cutting edge: a review and analysis of evidence reporting and grading; the recommendations of the American Urological Association. BJU Int. 2009 Aug; 104(3): 294-7.
5. Hsu C and Sandford BA. The Delphi Technique: making sense of consensus. Practical Assessment, Research & Evaluation. 2007 Aug; 12(10): 1-8.
6. Latini JM, McAninch JW, Brandes SB, Chung JY, Rosenstein D. SIU/ICUD Consultation On Urethral Strictures: Epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries. Urology. 2014 Mar;83(3 Suppl):S1-7. doi: 10.1016/j.urology.2013.09.009. Epub 2013 Nov 8. Review.
7. Stein DM, Thum DJ, Barbagli G, Kulkarni S, Sansalone S, Pardeshi A, Gonzalez CM. A geographic analysis of male urethral stricture aetiology and location. BJU Int. 2013 Oct;112(6): 830-4.
8. Fenton AS, Morey AF, Aviles R, Garcia CR. Anterior urethral strictures: etiology and characteristics. Urology. 2005 Jun;65(6): 1055-8.
9. Lumen N, Hoebeke P, Willemsen P, De Troyer B, Pieters R, Oosterlinck W. Etiology of urethral stricture disease in the 21st century. J Urol. 2009 Sep;182(3): 983-7.
10. Nuss GR, Granieri MA, Zhao LC, Thum DJ, Gonzalez CM. Presenting symptoms of anterior urethral stricture disease: A disease specific, patient reported questionnaire to measure outcomes. J Urol. 2012 Feb;187(2): 559-62.
11. Erickson BA, Breyer BN, McAninch JW. Changes in uroflowmetry maximum flow rates after urethral reconstructive surgery as a means to predict for stricture recurrence. J Urol. 2011 Nov;186(5): 1934-7.
12. Erickson BA, Breyer BN, McAninch JW. The use of uroflowmetry to diagnose recurrent stricture after urethral reconstructive surgery. J Urol. 2010 Oct;184(4): 1386-90.
13. Mahmud SM, El KS, Rana AM, Zaidi Z. Is ascending urethrogram mandatory for all urethral strictures? J Pak Med Assoc. 2008 Aug;58(8): 429-31.
14. Andersen J, Aagaard J, Jaszczak P. Retrograde urethrography in the postoperative control of urethral strictures treated with visual internal urethrotomy. Urol Int. 1987;42(5): 390-1.
15. McAninch JW, Laing FC, Jeffrey RB Jr. Sonourethrography in the evaluation of urethral strictures: a preliminary report. J Urol. 1988 Feb;139(2): 294-7.
16. Santucci RA, McAninch JW, Mario LA, Rajpurkar A, Chopra AK, Miller KS, Armenakas NA, Tieng EB, Morey AF. Urethroplasty in patients older than 65 years: indications, results, outcomes and suggested treatment modifications. J Urol. 2004 Jul;172(1): 201-3.
17. American Urological Association. Best practice policy statement on urologic surgery antimicrobial prophylaxis. Linthicum (MD): American Urological Association Education and Research, Inc.; 2008 [updated 2014 Jan]. 48 p.
18. Al Qudah HS, Cavalcanti AG, Santucci RA. Early catheter removal after anterior anastomotic (3 days) and ventral buccal mucosal onlay (7 days) urethroplasty. Int Braz J Urol. 2005 Sep-Oct;31(5): 459-64.
19. Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A. Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: Urinary and sexual outcomes of a new technique. J Urol. 2011 May;185(5): 1766-71.
20. El Kassaby AW, El Zayat TM, Azazy S, Osman T. One-stage repair of long bulbar urethral strictures using augmented Russell dorsal strip anastomosis: outcome of 234 cases. Eur Urol. 2008 Feb;53(2): 420-4.
21. Anger JT, Sherman ND, Webster GD. The effect of bulbar urethroplasty on erectile function. J Urol. 2007 Sep;178(3): 1009-11.
22. Johnson EK, Latini JM. The impact of urethroplasty on voiding symptoms and sexual function. Urology. 2011 Jul;78(1):198-201. Also available: http://dx.doi.org/10.1016/j.urology.2011.01.045.
23. Dogra PN, Saini AK, Seth A. Erectile dysfunction after anterior urethroplasty: A prospective analysis of incidence and probability of recovery-single-center experience. Urology. 2011 Jul;78(1): 78-81.
24. Erickson BA, Granieri MA, Meeks JJ, Cashy JP, Gonzalez CM. Prospective analysis of erectile dysfunction after anterior urethroplasty: incidence and recovery of function. J Urol. 2010 Feb;183(2): 657-61.
25. Erickson BA, Wysock JS, McVary KT, Gonzalez CM. Erectile function, sexual drive, and ejaculatory function after reconstructive surgery for anterior urethral stricture disease. BJU Int. 2007 Mar;99(3): 607-11.
26. Blaschko SD, Sanford MT, Cinman NM, McAninch JW, Breyer BN. De novo erectile dysfunction after anterior urethroplasty: A systematic review and meta-analysis. BJU Int. 2013 Sep;112(5): 655-63.
27. Feng C, Xu YM, Barbagli G, Lazzeri M, Tang CY, Fu Q, Sa YL. The relationship between erectile dysfunction and open urethroplasty: a systematic review and meta-analysis. J Sex Med. 2013 Aug;10(8): 2060-8.
28. Erickson BA, Granieri MA, Meeks JJ, McVary KT, Gonzalez CM. Prospective analysis of ejaculatory function after anterior urethral reconstruction. J Urol. 2010 Jul;184(1): 238-42.
29. Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives the best results for patch urethroplasty of the bulbar urethra. BJU Int. 2001;88(4): 385-9.
30. Palminteri E, Berdondini E, De Nunzio C, Bozzini G, Maruccia S, Scoffone C, Carmignani L. The impact of ventral oral graft bulbar urethroplasty on sexual life. Urology. 2013 Apr;81(4): 891-8.
31. Dubey D, Kumar A, Bansal P, Srivastava A, Kapoor R, Mandhani A, Bhandari M. Substitution urethroplasty for anterior urethral strictures: A critical appraisal of various techniques. BJU Int. 2003 Feb;91(3): 215-8.
32. Wang P, Fan M, Zhang Y, Huang C, Feng J, Xiao Y. Modified urethral pull-through operation for posterior urethral stricture and long-term outcome. J Urol. 2008 Dec;180(6): 2479-85.
33. Liu Y, Zhuang L, Ye W, Ping P, Wu M. One-stage dorsal inlay oral mucosa graft urethroplasty for anterior urethral stricture. BMC Urol. 2014;14(1): 35.
34. Singh A, Panda SS, Bajpai M, Jana M, Baidya DK. Our experience, technique and long-term outcomes in the management of posterior urethral strictures. J Pediatr Urol. 2014 Feb;10(1): 40-4.
35. Kulkarni SB, Joshi PM, Venkatesan K. Management of panurethral stricture disease in India. J Urol. 2012 Sep;188(3):824-30. Also available: http://dx.doi.org/10.1016/j.juro.2012.05.020. PMID: 22818345
36. Ahmad H, Mahmood A, Niaz WA, Akmal M, Murtaza B, Nadim A. Bulbar uretheral sricture repair with buccal mucosa graft urethroplasty. J Pak Med Assoc. 2011 May;61(5):440-2. PMID: 22204174
37. Xu YM, Fu Q, Sa YL, Zhang J, Song LJ, Feng C. Outcome of small intestinal submucosa graft for repair of anterior urethral strictures. Int J Urol. 2013 Jun;20(6): 622-9. Also available: http://dx.doi.org/10.1111/j.1442-2042.2012.03230.x. PMID: 23131085
38. Fu Q, Zhang J, Sa YL, Jin Sb, Xu Ym. Transperineal bulboprostatic anastomosis in patients with simple traumatic posterior urethral strictures: A retrospective study from a referral urethral center. Urology. 2009 Nov;74(5):1132-6. Also available: http://dx.doi.org/10.1016/j.urology.2009.05.078. PMID: 19716593
39. Morey AF, Lin HC, DeRosa CA, Griffith BC. Fossa navicularis reconstruction: impact of stricture length on outcomes and assessment of extended meatotomy (first stage Johanson) maneuver. J Urol. 2007 Jan;177(1):184-7. Also available: http://dx.doi.org/10.1016/j.juro.2006.08.062. PMID: 17162036
40. Zhou FJ, Xiong YH, Zhang XP, Shen PF. Transperineal end-to-end anastomotic urethroplasty for traumatic posterior urethral disruption and strictures in children. Asian J Surg. 2002;25(2):134-8. PMID: 12376233
41. Barbagli G, Palminteri E, Guazzoni G, Montorsi F, Turini D, Lazzeri M. 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 Sep;174(3):955-7. Also available: http://dx.doi.org/10.1097/01.ju.0000169422.46721.d7.
42. Barbagli G, Palminteri E, Lazzeri M, Turini D. Interim outcomes of dorsal skin graft bulbar urethroplasty. J Urol. 2004 Oct;172(4):1365-7. Also available: http://dx.doi.org/10.1097/01.ju.0000139727.70523.30. PMID: 15371845
43. Santucci RA, Mario LA, McAninch JW. Anastomotic urethroplasty for bulbar urethral stricture: Analysis of 168 patients. J Urol. 2002;167(4):1715-9. PMID: 11912394
44. Erickson BA, Breyer BN, 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 May;109(9):1392-6. Also available: http://dx.doi.org/10.1111/j.1464-410X.2011.10483.x. PMID: 21880103
45. Soliman MG, Abo Farha M, El Abd AS, Abdel Hameed H, El Gamal S. 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 Oct;48(5):466-73. Epub 2014 Mar 3. Also available: http://dx.doi.org/10.3109/21681805.2014.888474. PMID: 24579804
46. Lingual versus buccal mucosa graft urethroplasty for anterior urethral stricture: a prospective comparative analysis. Int J Urol. 2013 Dec;20(12):1199-203. Also available: http://dx.doi.org/10.1111/iju.12158. PMID: 23601029
47. Goel A, Goel A, Jain A. Buccal mucosal graft urethroplasty for penile stricture: Only dorsal or combined dorsal and ventral graft placement? Urology. 2011 Jun;77(6):1482-6. Also available: http://dx.doi.org/10.1016/j.urology.2010.12.058. PMID: 21354596
48. Sa YL, Xu YM, Qian Y, Jin SB, Fu Q, Zhang XR, Zhang J, Gu BJ. A comparative study of buccal mucosa graft and penile pedical flap for reconstruction of anterior urethral strictures. Chin Med J. 2010 Feb 5;123(3):365-8. Also available: http://dx.doi.org/10.3760/cma.j.issn.0366-6999.2010.03.020. PMID: 20193261
49. Raber M, Naspro R, Scapaticci E, Salonia A, Scattoni V, Mazzoccoli B, Guazzoni G, Rigatti P, Montorsi F. 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 Dec;48(6):1013-7. Also available: http://dx.doi.org/10.1016/j.eururo.2005.05.003. PMID: 15970374
50. Rourke KF, McCammon KA, Sumfest JM, Jordan GH. Open reconstruction of pediatric and adolescent urethral strictures: Long-term followup. J Urol. 2003 May 1;169(5):1818-21. Also available: http://dx.doi.org/10.1097/01.ju.0000056035.37591.9f. PMID: 12686852
51. Xu YM, Feng C, Sa YL, Fu Q, Zhang J, Xie H. Outcome of 1-stage urethroplasty using oral mucosal grafts for the treatment of urethral strictures associated with genital lichen sclerosus. Urology. 2014 Jan;83(1):232-6. Also available: http://dx.doi.org/10.1016/j.urology.2013.08.035. PMID: 24200196
52. Hudak SJ, Lubahn JD, Kulkarni S, Morey AF. Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts. BJU Int. 2012 Aug;110(4):592-6. Also available: http://dx.doi.org/10.1111/j.1464-410X.2011.10787.x. PMID: 22192812
53. Heinke T, Gerharz EW, Bonfig R, Riedmiller H. Ventral onlay urethroplasty using buccal mucosa for complex stricture repair. Urology. 2003 May 1;61(5):1004-7. Also available: http://dx.doi.org/10.1016/S0090-4295(02)02523-2. PMID: 12736024
54. Cecen K, Karadag MA, Demir A, Kocaaslan R. PlasmaKinetic versus cold knife internal urethrotomy in terms of recurrence rates: A prospective randomized study. Urol Int. 2014 Aug 14;:Epub ahead of print. Also available: http://dx.doi.org/10.1159/000363249.
55. Qu YC, Zhang WP, Sun N, Huang CR, Tian J, Li ML, Song HC, Li N. Immediate or delayed repair of pelvic fracture urethral disruption defects in young boys: Twenty years of comparative experience. Chin Med J. 2014;127(19):3418-22. Also available: http://dx.doi.org/10.3760/cma.j.issn.0366-6999.20141205.
56. Seo IY, Lee JW, Park SC, Rim JS. Long-Term outcome of primary endoscopic realignment for bulbous urethral injuries: Risk factors of urethral stricture. Int Neurourol J. 2012 Dec;16(4):196-200. Also available: http://dx.doi.org/10.5213/inj.2012.16.4.196.
57. Erickson BA, Elliott SP, Voelzke BB, Myers JB, Broghammer JA, Smith III TG, McClung CD, Alsikafi NF, Brant WO. Multi-institutional 1-Year bulbar urethroplasty outcomes using a standardized prospective cystoscopic follow-up protocol. Urology. 2014 Jul;84(1):213-6. Epub 2014 May 14. Also available: http://dx.doi.org/10.1016/j.urology.2014.01.054. PMID: 24837453
58. Peskar DB, Perovic AV. Comparison of radiographic and sonographic urethrography for assessing urethral strictures. Eur Radiol. 2004 Jan;14(1):137-44.
59. Bach P, Rourke K. Independently interpreted retrograde urethrography does not accurately diagnose and stage anterior urethral stricture: The importance of urologist-performed urethrography. Urology. 2014 May;83(5):1190-3. Also available: http://dx.doi.org/10.1016/j.urology.2013.12.063.
60. Gupta S, Majumdar B, Tiwari A, Gupta RK, Kumar A, Gujral RB. Sonourethrography in the evaluation of anterior urethral strictures: Correlation with radiographic urethrography. J Clin Ultrasound. 1993;21(4):231-9. PMID: 8478455
61. Akano AO. Evaluation of male anterior urethral strictures by ultrasonography compared with retrograde urethrography. West Afr J Med. 2007 Apr-Jun;26(2):102-5. PMID: 17939309
62. Gong EM, Arellano CMR, Chow JS, Lee RS. Sonourethrogram to manage adolescent anterior urethral stricture. J Urol. 2010 Oct;184(4):1699-702. Also available: http://dx.doi.org/10.1016/j.juro.2010.03.074. PMID: 20728141
63. Mitterberger M, Christian G, Pinggera GM, Bartsch G, Strasser H, Pallwein L, Frauscher F. Gray scale and color Doppler sonography with extended field of view technique for the diagnostic evaluation of anterior urethral strictures. J Urol. 2007 Mar;177(3):992-7. Also available: http://dx.doi.org/10.1016/j.juro.2006.10.026. PMID: 17296394
64. Choudhary S, Singh P, Sundar E, Kumar S, Sahai A. A comparison of sonourethrography and retrograde urethrography in evaluation of anterior urethral strictures. Clin Radiol. 2004 Aug 1;59(8):736-42. Also available: http://dx.doi.org/10.1016/j.crad.2004.01.014. PMID: 15262549
65. Kochakarn W, Muangman V, Viseshsindh V, Ratana-Olarn K, Gojaseni P. Stricture of the male urethra: 29 years experience of 323 cases. J Med Assoc Thai. 2001 Jan;84(1):6-11. PMID: 11281501
66. Heidenreich A, Derschum W, Bonfig R, Wilbert DM. Ultrasound in the evaluation of urethral stricture disease: A prospective study in 175 patients. Br J Urol. 1994;74(1):93-8. PMID: 8044532
67. D'Elia A, Grossi FS, Barnaba D, Larocca L, Sallustio G, De Palma M, Raguso G. Ultrasound in the study of male urethral strictures. Acta Urol Ital. 1996;10(4):275-7.
68. Gupta N, Dubey D, Mandhani A, Srivastava A, Kapoor R, Kumar A. Urethral stricture assessment: A prospective study evaluating urethral ultrasonography and conventional radiological studies. BJU Int. 2006 Jul;98(1):149-53. Also available: http://dx.doi.org/10.1111/j.1464-410X.2006.06234.x. PMID: 16831160
69. Pushkarna R, Bhargava SK, Jain M. Ultrasonographic evaluation of abnormalities of the male anterior urethra. Indian J Radiol Imaging. 2000;10(2):89-91.
70. Samaiyar SS, Shukla RC, Dwivedi US, Singh PB. Role of sonourethrography in anterior urethral stricture. Ind J Urol. 1999;15(2):146-51.
71. Morey AF, McAninch JW. Role of preoperative sonourethrography in bulbar urethral reconstruction. J Urol. 1997 Oct;158(4):1376-9. Also available: http://dx.doi.org/10.1016/S0022-5347(01)64219-8. PMID: 9302124
72. Chiou RK, Anderson JC, Tran T, Patterson RH, Wobig R, Taylor RJ, McAninch JW. Evaluation of urethral strictures and associated abnormalities using high- resolution and color Doppler ultrasound. Urology. 1996;47(1):102-7. Also available: http://dx.doi.org/10.1016/S0090-4295(99)80391-4. PMID: 8560640
73. Nash PA, McAninch JW, Bruce JE, Hanks DK. Sono-urethrography in the evaluation of anterior urethral strictures. J Urol. 1995;154(1):72-6. Also available: http://dx.doi.org/10.1016/S0022-5347(01)67231-8. PMID: 7776459
74. Morey AF, McAninch JW. Sonographic staging of anterior urethral strictures. J Urol. 2000 Apr;163(4):1070-5. Review. PubMed PMID: 10737469.
75. Terlecki RP, Steele MC, Valadez C, Morey AF. Urethral rest: role and rationale in preparation for anterior urethroplasty. Urology. 2011 Jun;77(6):1477-81. doi: 10.1016/j.urology.2011.01.042. Epub 2011 Apr 21. PubMed PMID: 21513968.
76. Steenkamp JW, Heyns CF, De Kock ML. Internal urethrotomy versus dilation as treatment for male urethral strictures: A prospective, randomized comparison. J Urol. 1997 Jan;157(1):98-101. PMID: 8976225
77. Heyns CF, Steenkamp JW, De Kock ML, Whitaker P. Treatment of male urethral strictures: Is repeated dilation or internal urethrotomy useful? J Urol. 1998 Aug;160(2):356-8. Also available: http://dx.doi.org/10.1016/S0022-5347(01)62894-5. PMID: 9679876
78. Launonen E, Sairanen J, Ruutu M, Taskinen S. Role of visual internal urethrotomy in pediatric urethral strictures. J Pediatr Urol. 2014 Jun;10(3):545-9. Also available: http://dx.doi.org/10.1016/j.jpurol.2013.11.018. PMID: 24388665
79. Hafez AT, ElAssmy A, Dawaba MS, Sarhan O, Bazeed M. Long-term outcome of visual internal urethrotomy for the management of pediatric urethral strictures. J Urol. 2005 Feb;173(2):595-7. Also available: http://dx.doi.org/10.1097/01.ju.0000151339.42841.6e. PMID: 15643267
80. Kumar S, Kapoor A, Ganesamoni R, Nanjappa B, Sharma V, Mete UK. Efficacy of holmium laser urethrotomy in combination with intralesional triamcinolone in the treatment of anterior urethral stricture. Korean J Urol. 2012 Sep;53(9):614-8. PMID: 23060998
81. Zehri AA, Ather MH, Afshan Q. Predictors of recurrence of urethral stricture disease following optical urethrotomy. Int J Surg. 2009;7(4):361-4. Also available: http://dx.doi.org/10.1016/j.ijsu.2009.05.010. PMID: 19500695
82. Atak M, Tokgoz H, Akduman B, Erol B, Donmez I, Hanc V, Turksoy O, Mungan NA. Low-power holmium:YAG laser urethrotomy for urethral stricture disease: comparison of outcomes with the cold-knife technique. Kaohsiung J Med Sci. 2011 Nov;27(11):503-7. Also available: http://dx.doi.org/10.1016/j.kjms.2011.06.013. PMID: 22005159
83. Vicente J, Salvador J, Caffaratti J. Endoscopic urethrotomy versus urethrotomy plus Nd-YAG laser in the treatment of urethral stricture. Eur Urol. 1990;18(3):166-8. PMID: 2261927
84. Mazdak H, Izadpanahi MH, Ghalamkari A, Kabiri M, Khorrami MH, Nouri-Mahdavi K, Alizadeh F, Zargham M, Tadayyon F, Mohammadi A, Yazdani M. Internal urethrotomy and intraurethral submucosal injection of triamcinolone in short bulbar urethral strictures. Int Urol Nephrol. 2010 Sep;42(3):565-8. Also available: http://dx.doi.org/10.1007/s11255-009-9663-5. PMID: 19949861
85. Zhang K, Qi E, Zhang Y, Sa Y, Fu Q. Efficacy and safety of local steroids for urethra strictures: a systematic review and meta-analysis. J Endourol. 2014 Aug;28(8):962-8. Epub 2014 Jun 3. Also available: http://dx.doi.org/10.1089/end.2014.0090. PMID: 24745607
86. Mazdak H, Meshki I, Ghassami F. Effect of mitomycin C on anterior urethral stricture recurrence after internal urethrotomy. Eur Urol. 2007 Apr;51(4):1089-92; discussion 1092. Epub 2006 Nov 27. PubMed PMID: 17157434.
87. Srivastava A, Dutta A, Jain DK. Initial experience with lingual mucosal graft urethroplasty for anterior urethral strictures. Med J Armed Forces India. 2013;69(1):16-20. Also available: http://dx.doi.org/10.1016/j.mjafi.2012.05.006. PMID: 24532928
88. Khan S, Khan RA, Ullah A, ul Haq F, ur Rahman A, Durrani SN, Khan MK. Role of clean intermittent self catheterisation (CISC) in the prevention of recurrent urethral strictures after internal optical urethrotomy. J Ayub Med Coll Abbottabad. 2011 Apr-Jun;23(2):22-5. PMID: 24800335
89. Giannakopoulos X, Grammeniatis E, Gartzios A, Tsoumanis P, Kammenos A. Sachse urethrotomy versus endoscopic urethrotomy plus transurethral resection of the fibrous callus (Guillemin's technique) in the treatment of urethral stricture. Urology. 1997 Feb;49(2):243-7. Also available: http://dx.doi.org/10.1016/S0090-4295(96)00450-5. PMID: 9037288
90. Steenkamp JW, Heyns CF, de Kock ML. Outpatient treatment for male urethral strictures--dilatation versus internal urethrotomy. S Afr J Surg. 1997 Aug;35(3):125-30. PMID: 9429329
91. Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: Long-term followup. J Urol. 1996 Jul;156(1):73-5. Also available: http://dx.doi.org/10.1016/S0022-5347(01)65942-1. PMID: 8648841
92. Afridi NG, Khan M, Nazeem S, Hussain A, Ahmad S, Aman Z. Intermittent urethral self dilatation for prevention of recurrent stricture. J Postgrad Med Inst. 2010 Jul-Sep;24(3):239-43
93. Matanhelia SS, Salaman R, John A, Matthews PN. A prospective randomized study of self-dilatation in the management of urethral strictures. J R Coll Surg Edinb. 1995;40(5):295-7. PMID: 8523302
94. Kjaergaard B, Walter S, Bartholin J, Andersen JT, Nohr S, Beck H, Jensen BN, Lokdam A, Glavind K. Prevention of urethral stricture recurrence using clean intermittent self-catheterization. Br J Urol. 1994;73(6):692-5. PMID: 8032838
95. Bodker A, Ostri P, Rye-Andersen J, Edvardsen L, Struckmann J. Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: A controlled study of a new therapy. J Urol. 1992;148(2):308-10. PMID: 1635124
96. Murthy PV, Gurunadha Rao TH, Srivastava A, Sitha Ramaiah K, Ramamurthy N, Sasidharan K. Self-dilatation in urethral stricture recurrence. Indian J Urol. 1997;14(1):33-5.
97. Tammela TL, Permi J, Ruutu M, Talja M. Clean intermittent self-catheterization after urethrotomy for recurrent urethral strictures. Ann Chir Gynaecol. 1993;82:80-3. PMID: 8291876
98. Husmann DA, Rathbun SR. Long-term followup of visual internal urethrotomy for management of short (less than 1 mm) penile urethral strictures following hypospadias repair. J Urol. 2006 Oct;176(4):1738-41. Also available: http://dx.doi.org/10.1016/S0022-5347(06)00617-3. PMID: 1694563799.
99. Jordan GH, Wessells H, Secrest C, Squadrito Jr JF, McAninch JW, Levine L, Van Der Burght M. 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 Jul;190(1):130-6. Also available: http://dx.doi.org/10.1016/j.juro.2013.01.014. PMID: 23313208
100. Hudak SJ, Atkinson TH, Morey AF. Repeat transurethral manipulation of bulbar urethral strictures is associated with increased stricture complexity and prolonged disease duration. J Urol. 2012 May;187(5):1691-5. Also available: http://dx.doi.org/10.1016/j.juro.2011.12.074.
101. Helmy TE, Sarhan O, Hafez AT, Dawaba M, Ghoneim MA. Perineal anastomotic urethroplasty in a pediatric cohort with posterior urethral strictures: critical analysis of outcomes in a contemporary series. Urology. 2014 May;83(5):1145-8. Also available: http://dx.doi.org/10.1016/j.urology.2013.11.028. PMID: 4485997
102. Fall B, Sow Y, Diallo Y, Sarr A, Ze ondo C, Thiam A, Sikpa KH, Diao B, Fall PA, Ndoye AK, Ba M, Diagne BA. Urethroplasty for male urethral strictures: Experience from a national teaching hospital in Senegal. Afr J Urol. 2014 Jun;20(2):76-81. Also available: http://dx.doi.org/10.1016/j.afju.2014.02.003
103. Meeks JJ, Barbagli G, Mehdiratta N, Granieri MA, Gonzalez CM. Distal urethroplasty for isolated fossa navicularis and meatal strictures. BJU Int. 2012 Feb;109(4):616-9. Also available: http://dx.doi.org/10.1111/j.1464-410X.2011.10248.x. PMID: 21615852
104. Tausch TJ, Peterson AC. Early aggressive treatment of lichen sclerosus may prevent disease progression. J Urol. 2012 Jun;187(6):2101-5. Also available: http://dx.doi.org/10.1016/j.juro.2012.01.071.
105. Stormont TJ, Suman VJ, Oesterling JE. Newly diagnosed bulbar urethral strictures: Etiology and outcome of various treatments. J Urol. 1993;150(5):1725-8. PMID: 8411459
106. Santucci R, Eisenberg L. Urethrotomy has a much lower success rate than previously reported. J Urol. 2010 May;183(5):1859-62. Also available: http://dx.doi.org/10.1016/j.juro.2010.01.020. PMID: 20303110
107. Chowdhury PS, Nayak P, Mallick S, Gurumurthy S, David D, Mossadeq A. Single stage ventral onlay buccal mucosal graft urethroplasty for navicular fossa strictures. Indian J Urol. 2014 Jan;30(1):17-22. doi: 10.4103/0970-1591.124200. PubMed PMID: 24497676; PubMed Central PMCID: PMC3897046.
108. Onol SY, Onol FF, Gumus E, Topaktas R, Erdem MR. Reconstruction of distal urethral strictures confined to the glans with circular buccal mucosa graft. Urology. 2012 May;79(5):1158-62. Also available: http://dx.doi.org/10.1016/j.urology.2012.01.046. PMID: 22449449
109. Virasoro R, Eltahawy EA, Jordan GH. Long-term follow-up for reconstruction of strictures of the fossa navicularis with a single technique. BJU Int. 2007 Nov;100(5):1143-5. Also available: http://dx.doi.org/10.1111/j.1464-410X.2007.07078.x. PMID: 17627782
110. Onol SY, Onol FF, Onur S, Inal H, Akbaş A, Köse O. Reconstruction of strictures of the fossa navicularis and meatus with transverse island fasciocutaneous penile flap. J Urol. 2008 Apr;179(4):1437-40. doi: 10.1016/j.juro.2007.11.055. Epub 2008 Mar 4. PubMed PMID: 18295281.
111. Armenakas NA, Morey AF, McAninch JW. Reconstruction of resistant strictures of the fossa navicularis and meatus. J Urol. 1998 Aug;160(2):359-63. Also available: http://dx.doi.org/10.1016/S0022-5347(01)62895-7. PMID: 9679877
112. Venn SN, Mundy AR. Urethroplasty for balanitis xerotica obliterans. Br J Urol. 1998;81(5):735-7. Also available: http://dx.doi.org/10.1046/j.1464-410X.1998.00634.x. PMID: 9634051
113. Goel A, Goel A, Dalela D, Sankhwar SN. Meatoplasty using double buccal mucosal graft technique. Int Urol Nephrol. 2009;41(4):885-7. Also available: http://dx.doi.org/10.1007/s11255-009-9555-8. PMID: 19350407
114. Kozinn SI, Harty NJ, Zinman L, Buckley JC. Management of complex anterior urethral strictures with multistage buccal mucosa graft reconstruction. Urology. 2013 Sep;82(3):718-22. Also available: http://dx.doi.org/10.1016/j.urology.2013.03.081. PMID: 23876581
115. Al Ali M, 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(3):268-71. Also available: http://dx.doi.org/10.1159/000052451. PMID: 11275717
116. Meeks JJ, Erickson BA, Gonzalez CM. Staged reconstruction of long segment urethral strictures in men with previous pediatric hypospadias repair. J Urol. 2009 Feb;181(2):685-9. Also available: http://dx.doi.org/10.1016/j.juro.2008.10.013. PMID: 19091342
117. Noll F, Schreiter F. Meshgraft urethroplasty using split-thickness skin graft. Urol Int. 1990;45(1):44-9. PMID: 2305495
118. Myers JB, McAninch JW, Erickson BA, Breyer BN. Treatment of adults with complications from previous hypospadias surgery. J Urol. 2012 Aug;188(2):459-63. Also available: http://dx.doi.org/10.1016/j.juro.2012.04.007.
119. Greenwell TJ, Venn SN, Mundy AR. Changing practice in anterior urethroplasty. BJU Int. 1999;83(6):631-5. Also available: http://dx.doi.org/10.1046/j.1464-410X.1999.00010.x.
120. Aldaqadossi H, El Gamal S, ElNadey M, El Gamal O, Radwan M, Gaber M. 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 Feb;21(2):185-8. Also available: http://dx.doi.org/10.1111/iju.12235. PMID: 23931150
121. Hussein MM, Moursy E, Gamal W, Zaki M, Rashed A, Abozaid A. 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 May;77(5):1232-7. Also available: http://dx.doi.org/10.1016/j.urology.2010.08.064. PMID: 21208648
122. Barbagli G, Kulkarni SB, Fossati N, Larcher A, Sansalone S, Guazzoni G, Romano G, Pankaj JM, DellAcqua V, Lazzeri M. Long-term followup and deterioration rate of anterior substitution urethroplasty. J Urol. 2014 Sep;192(3):808-13. Also available: http://dx.doi.org/10.1016/j.juro.2014.02.038. PMID: 24533999
123. Mathur RK, Nagar M, Mathur R, Khan F, Deshmukh C, Guru N. Single-stage preputial skin flap urethroplasty for long-segment urethral strictures: Evaluation and determinants of success. BJU Int. 2014 Jan;113(1):120-6. Also available: http://dx.doi.org/10.1111/bju.12361. PMID: 24053413
124. Hosseini J, Kaviani A, Hosseini M, Mazloomfard MM, Razi A. Dorsal versus ventral oral mucosal graft urethroplasty. Urol J. 2011;8(1):48-53. PMID: 21404203
125. Mangera A, Chapple C. Management of anterior urethral stricture: An evidence-based approach. Curr Opin Urol. 2010 Nov;20(6):453-8. Also available: http://dx.doi.org/10.1097/MOU.0b013e32833ee8d5. PMID: 20827208
126. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011 May;59(5):797-814. doi: 10.1016/j.eururo.2011.02.010. Epub 2011 Feb 24. Review. PubMed PMID: 21353379.
127. Levine LA, Strom KH, 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 Nov;178(5):2011-5. Also available: http://dx.doi.org/10.1016/j.juro.2007.07.034. PMID: 17869301
128. Pahwa M, Gupta S, Pahwa M, Jain BD, Gupta M. A comparative study of dorsal buccal mucosa graft substitution urethroplasty by dorsal urethrotomy approach versus ventral sagittal urethrotomy approach. Adv Urol. 2013;2013:124836. Also available: http://dx.doi.org/10.1155/2013/124836. PMID: 24194754
129. Kinnaird AS, Levine MA, Ambati D, Zorn JD, Rourke KF. Stricture length and etiology as preoperative independent predictors of recurrence after urethroplasty: A multivariate analysis of 604 urethroplasties. Can Urol Assoc J. 2014 May;8(5-6):E296-300. doi: 10.5489/cuaj.1661. PubMed PMID: 24940453; PubMed Central PMCID: PMC4039590.
130. Breyer BN, McAninch JW, Whitson JM, Eisenberg ML, Mehdizadeh JF, Myers JB, Voelzke BB. Multivariate analysis of risk factors for long-term urethroplasty outcome. J Urol. 2010 Feb;183(2):613-7. Also available: http://dx.doi.org/10.1016/j.juro.2009.10.018. PMID: 20018318
131. Mathur RK, Sharma A. Tunica albuginea urethroplasty for panurethral strictures. Urol J. 2010 Spring;7(2):120-4. PMID: 20535700
132. Gelman J, Siegel JA. Ventral and dorsal buccal grafting for 1-stage repair of complex anterior urethral strictures. Urology. 2014 Jun;83(6):1418-22. Also available: http://dx.doi.org/10.1016/j.urology.2014.01.024. PMID: 24745799
133. Palminteri E, Manzoni G, Berdondini E, Di Fiore F, Testa G, Poluzzi M, Molon A. Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Eur Urol. 2008 Jan;53(1):81-90. Also available: http://dx.doi.org/10.1016/j.eururo.2007.05.033. PMID: 17583417
134. Peterson AC, Palminteri E, Lazzeri M, Guanzoni G, Barbagli G, Webster GD. Heroic measures may not always be justified in extensive urethral stricture due to lichen sclerosus (balanitis xerotica obliterans). Urology. 2004 Sep;64(3):565-8. Also available: http://dx.doi.org/10.1016/j.urology.2004.04.035. PMID: 15351594
135. Barbagli G, De Angelis M, Romano G, Lazzeri M. Clinical outcome and quality of life assessment in patients treated with perineal urethrostomy for anterior urethral stricture disease. J Urol. 2009 Aug;182(2):548-57. Also available: http://dx.doi.org/10.1016/j.juro.2009.04.012. PMID: 19524945
136. Dubey D, Vijjan V, Kapoor R, Srivastava A, Mandhani A, Kumar A, Ansari MS. Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial. J Urol. 2007 Dec;178(6):2466-9. Also available: http://dx.doi.org/10.1016/j.juro.2007.08.010. PMID: 17937943
137. Kamp S, Knoll T, Osman M, Hacker A, Michel MS, Alken P. Donor-site morbidity in buccal mucosa urethroplasty: lower lip or inner cheek?. BJU Int. 2005 Sep;96(4):619-23. Also available: http://dx.doi.org/10.1111/j.1464-410X.2005.05695.x. PMID: 16104921
138. Trivedi S, Kumar A, Goyal NK, Dwivedi US, Singh PB. Urethral reconstruction in balanitis xerotica obliterans. Urol Int. 2008 Oct;81(3):285-9. Also available: http://dx.doi.org/10.1159/000151405. PMID: 18931544
139. Rourke K, McKinny S, St Martin B. Effect of wound closure on buccal mucosal graft harvest site morbidity: results of a randomized prospective trial. Urology. 2012 Feb;79(2):443-7. doi: 10.1016/j.urology.2011.08.073. Epub 2011 Nov 25. PubMed PMID: 22119261.
140. Palminteri E, Berdondini E, Colombo F, Austoni E. Small intestinal submucosa (SIS) graft urethroplasty: short-term results. Eur Urol. 2007 Jun;51(6):1695-701. Also available: http://dx.doi.org/10.1016/j.eururo.2006.12.016. PMID: 17207913
141. Farahat YA, Elbahnasy AM, El Gamal OM, Ramadan AR, El Abd SA, Taha MR. Endoscopic urethroplasty using small intestinal submucosal patch in cases of recurrent urethral stricture: A preliminary study. J Endourol. 2009 Dec 1;23(12):2001-5. Also available: http://dx.doi.org/10.1089/end.2009.0074. PMID: 19839728
142. Gargollo PC, Cai AW, Borer JG, Retik AB. Management of recurrent urethral strictures after hypospadias repair: Is there a role for repeat dilation or endoscopic incision? J Pediatr Urol. 2011 Feb;7(1):34-8. Also available: http://dx.doi.org/10.1016/j.jpurol.2010.03.007. PMID: 20462798
143. Koraitim MM. The lessons of 145 posttraumatic posterior urethral strictures treated in 17 years. J Urol. 1995;153(1):63-66. Also available: http://dx.doi.org/10.1097/00005392-199501000-00024. PMID: 7966793
144. Kapoor R, Srivastava A, Vashishtha S, Singh UP, Srivastava A, Ansari MS, Kapoor R, Pradhan MR. Preputial/penile skin flap, as a dorsal onlay or tubularized flap: A versatile substitute for complex anterior urethral stricture. BJU Int. 2012 Dec;110(11 Pt C):E1101-8. Also available: http://dx.doi.org/10.1111/j.1464-410X.2012.11296.x. PMID: 22863081
145. McAninch JW, Morey AF. Penile circular fasciocutaneous skin flap in 1-stage reconstruction of complex anterior urethral strictures. J Urol. 1998 Apr;159(4):1209-13. Also available: http://dx.doi.org/10.1016/S0022-5347(01)63558-4. PMID: 9507836
146. Barbagli G, De Angelis M, Palminteri E, Lazzeri M. Failed hypospadias repair presenting in adults. Eur Urol. 2006 May;49(5):887-95. Also available: http://dx.doi.org/10.1016/j.eururo.2006.01.027.
147. Borboroglu PG, Sands JP, Roberts JL, Amling CL. Risk factors for vesicourethral anastomotic stricture after radical prostatectomy. Urology. 2000 Jul;56(1):96-100. PubMed PMID: 10869633.
148. Surya BV, Provet J, Johanson KE, Brown J. Anastomotic strictures following radical prostatectomy: risk factors and management. J Urol. 1990 Apr;143(4):755-8. PMID: 2313800
149. Brede C, Angermeier K, Wood H. Continence outcomes after treatment of recalcitrant postprostatectomy bladder neck contracture and review of the literature. Urology. 2014;83(3):648-52. Also available: http://dx.doi.org/10.1016/j.urology.2013.10.042. PMID: 24365088
150. Pfalzgraf D, Beuke M, Isbarn H, Reiss CP, Meyer-Moldenhauer WH, Dahlem R, Fisch M. Open retropubic reanastomosis for highly recurrent and complex bladder neck stenosis. J Urol. 2011 Nov;186(5):1944-7. Also available: http://dx.doi.org/10.1016/j.juro.2011.07.040. PMID: 21944115
151. Ramchandani P, Banner MP, Berlin JW, Dannenbaum MS, Wein AJ. Vesicourethral anastomotic strictures after radical prostatectomy: Efficacy of transurethral balloon dilation. Radiology. 1994 Nov;193(2):345-9. PMID: 7972741
152. Vanni AJ, Zinman LN, Buckley JC. Radial urethrotomy and intralesional mitomycin C for the management of recurrent bladder neck contractures. J Urol. 2011 Jul;186(1):156-60. doi: 10.1016/j.juro.2011.03.019. Epub 2011 May 14. PubMed PMID: 21575962.
153. Redshaw JD, Broghammer JA, Smith TG 3rd, Voelzke BB, Erickson BA, McClung CD, Elliott SP, Alsikafi NF, Presson AP, Aberger ME, Craig JR, Brant WO, Myers JB. Intralesional injection of mitomycin C at transurethral incision of bladder neck contracture may offer limited benefit: TURNS Study Group. J Urol. 2015 Feb;193(2):587-92. doi: 10.1016/j.juro.2014.08.104. Epub 2014 Sep 6. PubMed PMID: 25200807; PubMed Central PMCID: PMC4307389.
154. Nikolavsky D, Blakely SA, Hadley DA, Knoll P, Windsperger AP, Terlecki RP, Flynn BJ. Open reconstruction of recurrent vesicourethral anastomotic stricture after radical prostatectomy. Int Urol Nephrol. 2014 Oct 25;46(11):2147-52. Also available: http://dx.doi.org/10.1007/s11255-014-0816-9.
155. Elliott SP, McAninch JW, Chi T, Doyle SM, Master VA. Management of severe urethral complications of prostate cancer therapy. J Urol. 2006 Dec;176(6 Pt 1):2508-13. PubMed PMID: 17085144.
156. Secrest CL, Madjar S, Sharma AK, Covington-Nichols C. Urethral reconstruction in spinal cord injury patients. J Urol. 2003 Oct;170(4 Pt 1):1217-21; discussion 1221. PubMed PMID: 14501728.
157. Casey JT, Erickson BA, Navai N, Zhao LC, Meeks JJ, Gonzalez CM. Urethral reconstruction in patients with neurogenic bladder dysfunction. J Urol. 2008 Jul;180(1):197-200. doi: 10.1016/j.juro.2008.03.056. Epub 2008 May 21. PubMed PMID: 18499188.
158. Das S, Tunuguntla HS. Balanitis xerotica obliterans--a review. World J Urol. 2000 Dec;18(6):382-7. Review. PubMed PMID: 11204255.
159. Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus: review of the literature and current recommendations for management. J Urol. 2007 Dec;178(6):2268-76. Also available: http://dx.doi.org/10.1016/j.juro.2007.08.024. PMID: 17936829
160. Depasquale I, Park AJ, Bracka A. The treatment of balanitis xerotica obliterans. BJU Int. 2000 Sep;86(4):459-65. Review. PubMed PMID: 10971272.
161. Barbagli G, Palminteri E, Mirri F, Guazzoni G, Turini D, Lazzeri M. Penile carcinoma in patients with genital lichen sclerosus: a multicenter survey. J Urol. 2006 Apr;175(4):1359-63. PubMed PMID: 16515998.
162. Nasca MR, Innocenzi D, Micali G. Penile cancer among patients with genital lichen sclerosus. J Am Acad Dermatol. 1999 Dec;41(6):911-4. PubMed PMID: 10570372.
163. Powell J, Robson A, Cranston D, Wojnarowska F, Turner R. High incidence of lichen sclerosus in patients with squamous cell carcinoma of the penis. Br J Dermatol. 2001 Jul;145(1):85-9. PubMed PMID: 11453912.
164. Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M. Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol. 2009 Apr;55(4):945-56.
165. Blaschko SD, McAninch JW, Myers JB, Schlomer BJ, Breyer BN. Repeat urethroplasty after failed urethral reconstruction: Outcome analysis of 130 patients. J Urol. 2012 Dec;188(6):2260-4. Also available: http://dx.doi.org/10.1016/j.juro.2012.07.101. PMID: 23083654
166. Singh BP, Andankar MG, Swain SK, Das K, Dassi V, Kaswan HK, Agrawal V, Pathak HR. Impact of prior urethral manipulation on outcome of anastomotic urethroplasty for post-traumatic urethral stricture. Urology. 2010 Jan;75(1):179-82. Also available: http://dx.doi.org/10.1016/j.urology.2009.06.081. PMID: 19854488
167. Figler BD, Malaeb BS, Dy GW, Voelzke BB, Wessells H. Impact of graft position on failure of single-stage bulbar urethroplasties with buccal mucosa graft. Urology. 2013 Nov;82(5):1166-70. Also available: http://dx.doi.org/10.1016/j.urology.2013.07.013.
168. Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethroplasty: retrospective analysis of the results in 375 patients. Eur Urol. 2008 Apr;53(4):828-33. Also available: http://dx.doi.org/10.1016/j.eururo.2008.01.041. PMID: 18243497
169. Barbagli G, Morgia G, Lazzeri M. Dorsal onlay skin graft bulbar urethroplasty: long-term follow-up. Eur Urol. 2008 Mar;53(3):628-34. Also available: http://dx.doi.org/10.1016/j.eururo.2007.08.019. PMID: 17728049
170. Gimbernat H, Arance I, Redondo C, Meilán E, Ramón de Fata F, Angulo JC. Analysis of the factors involved in the failure of urethroplasty in men. Actas Urol Esp. 2014 Mar;38(2):96-102. Also available: http://dx.doi.org/10.1016/j.acuro.2013.07.003. PMID: 24051326
171. Hwang JH, Kang MH, Lee YT, Park DS, Lee SR. Clinical factors that predict successful posterior urethral anastomosis with a gracilis muscle flap. Korean J Urol. 2013 Oct;54(10):710-4. Also available: http://dx.doi.org/10.4111/kju.2013.54.10.710. PMID: 24175047
172. Whitson JM, McAninch JW, Elliott SP, Alsikafi NF. Long-term efficacy of distal penile circular fasciocutaneous flaps for single stage reconstruction of complex anterior urethral stricture disease. J Urol. 2008 Jun;179(6):2259-64. Also available: http://dx.doi.org/10.1016/j.juro.2008.01.087. PMID: 18423682
173. Kessler TM, Schreiter F, Kralidis G, Heitz M, Olianas R, Fisch M. Long-term results of surgery for urethral stricture: A statistical analysis. J Urol. 2003 Sep 1;170(3):840-4. Also available: http://dx.doi.org/10.1097/01.ju.0000080842.99332.94. PMID: 12913712
174. Kostakopoulos A, Makrychoritis K, Deliveliotis Ch, Nazlidou I, Picramenos D. Contribution of transcutaneous ultrasonography to the evaluation of urethral strictures. Int Urol Nephrol. 1998;30(1):85-9. PMID: 9569118
175. Bircan MK, Sahin H, Korkmaz K. Diagnosis of urethral strictures: Is retrograde urethrography still necessary? Int Urol Nephrol. 1996;28(6):801-4. PMID: 9089050
176. Badlani GH, Press SM, Defalco A, Oesterling JE, Smith AD. Urolume endourethral prosthesis for the treatment of urethral stricture disease: Long-term results of the North American Multicenter Urolume trial. Urology. 1995;45(5):846-56. Also available: http://dx.doi.org/10.1016/S0090-4295(99)80093-4. PMID: 7747374
177. Milroy E, Allen A. Long-term results of urolume urethral stent for recurrent urethral strictures. J Urol. 1996 Mar;155(3):904-8. Also available: http://dx.doi.org/10.1016/S0022-5347(01)66342-0. PMID: 8583603
178. Hussain M, Greenwell TJ, Shah J, Mundy A. Long-term results of a self-expanding wallstent in the treatment of urethral stricture. BJU Int. 2004 Nov;94(7):1037-9. Also available: http://dx.doi.org/10.1111/j.1464-410X.2004.05100.x. PMID: 15541123
179. Sertcelik N, Sagnak L, Imamoglu A, Temel M, Tuygun C. The use of self-expanding metallic urethral stents in the treatment of recurrent bulbar urethral strictures: Long-term results. BJU Int. 2000;86(6):686-9. Also available: http://dx.doi.org/10.1046/j.1464-410X.2000.00891.x. PMID: 11069377
180. Ashken MH, Coulange C, Milroy EJ, Sarramon JP. European experience with the urethral Wallstent for urethral strictures. Eur Urol. 1991;19(3):181-5. PMID: 1855523

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.