Context: There is no clear evidence that determines which type of urethroplasty to perform under which particular circumstance.
Objective: To review the options for urethroplasty at different sites in the urethra and for different types of stricture indicating which procedure should be used in which circumstances according to the best available evidence.
Evidence acquisition: Recent publications have been reviewed and supplemented with the authors' personal experience.
Evidence synthesis: Currently, in the developed world, the most common types of stricture are relatively short and are situated in the bulbar urethra. There is good evidence that these are best treated by excision and end-to-end anastomosis if they are short enough or by patch urethroplasty using a buccal mucosal graft if they are longer. Distal penile urethral strictures are the next most common type of stricture, but the evidence base is weaker, although there is agreement that penile strictures due to lichen sclerosus often require a staged approach to reconstruction, again using buccal mucosal grafts. Urethroplasty for pelvic fracture urethral injury is an altogether different type of technique for an altogether different type of pathology. There is good evidence that this is best treated by bulbo-prostatic anastomotic urethroplasty. Other types of strictures and salvage surgery have no good evidence base and are specialised areas where experience and judgement are necessary.
Conclusions: The evidence base for urethral surgery has been developed for the more common types of urethral strictures in the last 20 yr, but it is still as much an art as it is a science.