Editing AUA: Male Urethral Stricture (2016) (section)

==Management==
*'''Options for urgent management (discovery of symptomatic urinary retention or need for catheterization prior to another surgical procedure):'''
*#'''Endoscopic (e.g. urethral dilation or direct visual internal urethrotomy [DVIU])'''
*#'''Immediate suprapubic cystostomy'''
*'''Options for delayed management:'''
*# '''Endoscopic''' '''(e.g. urethral dilation or direct visual internal urethrotomy [DVIU])'''
*#'''Urethroplasty'''
*#*'''Generally divided into tissue transfer vs. non-tissue transfer techniques'''
*#**'''Non-tissue transfer: anastomotic urethroplasty is a non-tissue transfer procedure''' '''and can be performed in both a transecting (removing spongiosum) and non-transecting manner.'''*#***Excision and primary anastomosis urethroplasty involves transection and removal of the narrowed segment of the urethra and corresponding spongiofibrosis with anastamosis 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 reanastamosed, or incised longitudinally through the narrowed segment of the urethra and closed in a Heineke-Mikulicz fashion.
*#**'''Tissue transfer procedures can be categorized into single stage and multi-stage procedures.'''
*'''Initial treatment based on location of stricture'''
**'''Fossa navicularis'''***'''Initial treatment of uncomplicated urethral stricture confined to the meatus or fossa navicularis: simple dilation or meatotomy,''' with or without guidewire placement
***'''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. Furthermore, urethroplasty is the best option for completely obliterated strictures or strictures associated with previous hypospadias repair or LS.
**'''Penile urethra'''***'''Initial treatment: urethroplasty'''
****'''High recurrence rates are expected with endoscopic treatments.'''
*** '''Penile urethral strictures are more likely to require tissue transfer and/or a staged approach''' '''compared to bulbar urethral strictures'''
**'''Bulbar urethra'''
***'''Initial treatment of stricture < 2cm: endoscopic management or urethroplasty'''
****'''Dilation and DVIU have similar success and complication rates and can be used interchangeably'''.
*****Few studies exist that compare different methods of performing DVIU, but cold knife and laser incision of the stricture scar appear to have similar success rates and may be used interchangeably.
****'''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, and may 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.
***'''Initial treatment of stricture ≥2cm: urethroplasty'''
****Longer strictures are less responsive to endoscopic treatment
*Long multi-segment strictures (panurethral) may be reconstructed with one stage or multi-stage techniques using oral mucosal grafts, penile fasciocutaneous flaps or a combination of these techniques.
** '''Oral mucosa should be used as the first choice when using grafts for urethroplasty.'''
***'''Oral mucosa may be harvested from the inner cheeks,''' which provide the largest graft area, '''the undersurface of the tongue, or the inner lower lip.'''
****'''Harvest of buccal mucosa from the inner cheek results in fewer complications and better outcomes as compared to a lower lip donor site.'''
****When harvesting buccal mucosa from the inner cheek, the donor site may safely be left open to heal by secondary intention or closed primarily.
*** Hair-bearing skin should not be used for substitution urethroplasty.
***Substitution urethroplasty should not be performed with allograft, xenograft, or synthetic materials except under experimental protocols.
**'''A single-stage tubularized graft urethroplasty should not be performed'''.
***Tubularized urethroplasty consists of a technique in which a graft or flap is rolled into a tube over a catheter to completely replace a segment of urethra. This approach, when attempted in a single stage, has a high risk of restenosis and should be avoided.
***When no alternative exists, a tubularized flap can be performed with '''results that are inferior to onlay flaps.'''
**'''In LS proven urethral stricture, surgeons should not use genital skin for reconstruction'''.
***Treatment of genital skin LS reduces symptoms, such as skin itching and bleeding, and may serve to prevent meatus stenosis and progression to extensive stricture of the penile urethra. '''Current therapies rely heavily on topical moderate- to high-potency steroid creams, such as clobetasol or mometasone creams.'''
*** The use of genital skin flaps and grafts should be avoided due to very high long-term failure rates.
*'''Perineal urethrostomy'''
**'''May be offered as a long term treatment option to patients as an alternative to urethroplasty.'''
**'''Indications (6):'''
**#'''Recurrent or primary complex anterior stricture'''
**#'''Numerous failed attempts at urethroplasty'''
**#'''Extensive LS'''
**#'''Advanced age'''
**#'''Medical co-morbidities precluding extended operative time'''
**# '''Patient choice'''
*Urethroplasty may be offered as a treatment option for urethral stricture causing difficulty with intermittent self-catheterization (e.g. neurogenic bladder)
*'''Operative Considerations'''
** '''Antibiotic prophylaxis'''
***'''Should be given to all patients before proceeding with surgical management of a urethral stricture to reduce surgical site infections.'''
****'''Different than 2015 CUA Antibiotics Prophylaxis guidelines which recommend considering prophylaxis in patients at high risk of infectious complications'''
****'''Preoperative urine cultures are recommended to guide antibiotics, and active urinary tract infections must be treated before intervention.'''
****'''With endoscopic urethral stricture management, oral fluoroquinolones are more cost effective than intravenous cephalosporins'''