A new staging system for anterior urethral strictures

Introduction: Currently there is no widely accepted staging system for anterior urethral strictures. We developed and evaluated the reliability of an easy to use classification system for anterior urethral strictures in men. Methods: We devised a staging system based on cystoscopic findings of no stricture (stage 0), wide caliber stricture (stage 1), stricture requires gentle dilation with a 16Fr flexible cystoscope (stage 2), stricture cannot be dilated (stage 3) and no visible lumen (stage 4). Content validity was established by a panel of 5 urologists. On 2 separate occasions 3 urologists independently viewed videos obtained during cystoscopy and staged the tightest visible stricture. If multiple strictures were present, the stricture with the smallest visible lumen was used for the purpose of this study. All men who had undergone cystoscopy at our institution between 2011 and 2012 were included in the study. Exclusion criteria were poor video quality and not visualizing the entire urethra during cystoscopy. Results: A total of 101 videos of consecutive cystoscopies were reviewed. Intra-observer agreement was 76% to 94% (Cohen κ 0.65-0.90) and interobserver agreement was 73% to 82% (Cohen κ 0.51-1.00, 0.69 overall, p<0.001). The intra-observer and interobserver agreement increased for each stage, with 3 and 4 almost unanimously identified by all 3 observers (Cohen κ 0.93 and 1.00, p <0.001). Conclusions: This new staging system is simple and easy to use, and has excellent intra-observer and good interobserver reliability. The staging system provides a simple lexicon for describing the appearance of anterior urethral strictures.