Editing AUA: Urethral Stricture Disease (2023) (section)

===Preoperative Assessment===
*'''<span style="color:#ff0000">Important stricture characteristics for subsequent treatment planning (4):</span>'''
*#'''<span style="color:#ff0000">Stricture location in the urethra</span>'''
*#'''<span style="color:#ff0000">Length of the stricture</span>'''
*#'''<span style="color:#ff0000">Degree of lumen narrowing</span>'''
*#'''<span style="color:#ff0000">Prior treatments</span>'''
*'''<span style="color:#ff0000">If planning non-urgent intervention for a known stricture, determine the length and location of the urethral stricture by (4):</span>'''
#'''<span style="color:#ff0000">Retrograde urethrography</span>'''
#*See [https://radiopaedia.org/cases/urethral-stricture-post-radiation Figures] of retrograde urethrogram demonstrating post-radiation stricture
#'''<span style="color:#ff0000">Voiding cystourethrography</span>'''
#'''<span style="color:#ff0000">Cystourethroscopy</span>'''
#'''<span style="color:#ff0000">Ultrasound urethography</span>'''

* '''<span style="color:#ff0000">Males with a urethral stricture who have been managed with either an indwelling urethral catheter or self-dilation should generally undergo suprapubic cystostomy placement prior to imaging</span>'''
** This allows the full length of the stricture to develop to determine the true severity of the stricture including its degree of narrowing, and accurate determination of definitive treatment options
**'''A period of “urethral rest” between 4-6 weeks allows the stricture to mature prior to evaluation and management'''.
***A similar period of observation is recommended before reassessing a stricture after failure or dilation or DVIU.
**If a patient can forgo  clean intermittent catheterization (CIC) without acute urinary retention, a SP tube may be omitted during urethral rest.

==== Retrograde urethrogram, with or without voiding cystourethrography ====
*'''<span style="color:#ff0000">Remains the study of choice for delineation of stricture length, location, and severity in men'''
*'''Advantages'''
**'''Can be used to evaluate stricture'''
**#'''Location in the urethra'''
**#'''Length'''
**#'''Degree of lumen narrowing'''
*'''Disadvantages'''
**'''Complete or near complete occlusion of the urethra may make the assessment of the urethra proximal to the stricture difficult.''' 
***In this instance, RUG may be combined with antegrade VCUG or other methods to define the extent of the stricture.
**Image quality and accuracy of RUG is operator-dependent; surgical planning should be based on high quality images generated by experienced practitioners or the surgeon him/herself
*Adverse Events
**Patient discomfort
**UTI (rare)
**Hematuria
**Contrast extravasation (very rare)
**Contrast reaction, should there be an allergy
***Risk is very low in the absence of inadvertent extravasation and may be mitigated by pre-medication with oral corticosteroids and histamine blockers

==== Voiding Cystourethrography ====
*Technique
**Performed by passing a small catheter proximal to the stricture, by retrograde filling of the bladder during RUG, or by antegrade filling via a SP tube
*When used in conjunction with urodynamics to asses complex voiding dysfunction, elevated detrusor voiding pressures and urethral narrowing on VCUG indicate a clinically significant urethral stricture or other obstructive process.
**In females, videourodynamic studies can be used to diagnose urethral strictures by demonstrating elevated detrusor voiding pressures and urethral obstruction on voiding cystourethrography (VCUG)
*'''Advantage'''
**'''Allows visualization of the urethra'''
*'''Disadvantage'''
**'''Not always sufficient to completely delineate the distal extent of an urethral stricture'''

==== Urethroscopy ====
*'''Advantage'''
**'''Identifies and localizes urethral stricture and allows evaluation of the distal caliber'''
*'''Disadvantage'''
**'''Length of the stricture and the urethra proximal to the urethral stricture cannot be assessed in most cases'''
***When flexible cystoscopy does not allow visual assessment proximal to the urethral stricture, small caliber cystoscopy with a ureteroscope or flexible hysteroscope can be useful adjuncts.

==== Ultrasound Urethrography ====
*'''Can be used to evaluate stricture'''
*#'''Location in the urethra'''
*#'''Length'''
*#'''Degree of lumen narrowing'''
*High sensitivity and specificity in the male anterior urethra
*Adverse events
**Patient discomfort
*Dependent on a skilled ultrasonographer
*Further studies are needed to validate its value in clinical practice.