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

====Selecting Approach====
*'''<span style="color:#ff0000">Initial treatment based on location of stricture</span>'''
=====Meatal or Fossa navicularis=====
*'''<span style="color:#ff0000">Initial treatment of uncomplicated urethral stricture confined to the meatus or fossa navicularis: simple dilation or meatotomy,</span>''' with or without guidewire placement
*'''<span style="color:#ff0000">Completely obliterated strictures or associated with previous hypospadias repair, prior failed endoscopic manipulation, previous urethroplasty, or LS: urethroplasty'''
**Meatal and fossa navicularis strictures refractory to endoscopic procedures are unlikely to respond to further endoscopic treatments.
**Some patients may opt for repeat endoscopic treatments or intermittent self-dilation in lieu of more definitive treatment such as urethroplasty.
*Options for the surgical treatment of meatal and fossa strictures
**Meatoplasty
**Extended meatotomy
**Variations of urethroplasty
*Important to consider both aesthetic and functional outcomes when reconstructing strictures involving the glanular urethra.
=====Penile urethra=====
*'''<span style="color:#ff0000">Initial treatment: urethroplasty</span>'''
**'''High recurrence rates are expected with endoscopic treatments,''' except in select cases of previously untreated short strictures.
*'''Penile urethral strictures are more likely to'''
**'''Be related to hypospadias, LS, or iatrogenic etiologies when compared to strictures of the bulbar urethra'''
**'''Require tissue transfer and/or a staged approach''' '''compared to bulbar urethral strictures'''
=====Bulbar urethra=====
*'''<span style="color:#ff0000">Initial treatment of stricture < 2cm: endoscopic management or urethroplasty</span>'''
**'''<span style="color:#ff0000">Surgeons may offer urethral dilation, or direct visual internal urethrotomy, combined with drug-coated (e.g. paclitaxel) balloons, for recurrent bulbar urethral strictures <3cm in length.'''
***'''<span style="color:#ff00ff">ROBUST III'''
****Patients with recurrent anterior urethral strictures <3cm in length
****Randomized to endoscopic treatment of the stricture combined with paclitaxel-coated urethral balloon versus DVIU/dilation
****Primary outcome: urethral patency at 6 months
****Secondary outcome: freedom from retreatment at 1 year
****Results
*****Drug-coated balloon had improved freedom from intervention at 1 year compared to DVIU/dilation alone (83.2% versus 21.7%)
****[https://pubmed.ncbi.nlm.nih.gov/34854748/ Elliott, Sean P., et al. "One-year results for the ROBUST III randomized controlled trial evaluating the Optilume® drug-coated balloon for anterior urethral strictures." ''The Journal of urology'' 207.4 (2022): 866-875.]
***Men receiving paclitaxel-coated urethral balloon should use contraception through 6 months posttreatment if their partner has child-bearing potential
****Significant levels of paclitaxel were measured in semen
*'''<span style="color:#ff0000">Initial treatment of stricture ≥2cm: urethroplasty</span>'''
**Longer strictures are less responsive to endoscopic treatment
**Urethroplasty may be performed using a variety of techniques based on the experience of the surgeon, most often through substitution or augmentation of the narrowed segment of the urethra.
*'''Urethroplasty should be offered following failed endoscopic management of anterior urethral strictures'''
**Urethral strictures that have been previously treated with dilation or DVIU are unlikely to be successfully treated with another endoscopic procedure with failure rates of >80%.
**'''Repeated endoscopic treatment may''' 
***'''Cause longer strictures'''
***'''Increase the complexity of subsequent urethroplasty'''
**In patients who are unable to undergo, or who prefer to avoid urethroplasty, repeated endoscopic procedures, or intermittent self-catheterization may be considered as palliative measures.