Identification of stricture subtypes may be a first step in better clarifying the role and extent of anatomical obstruction for the development of symptoms in stricture disease. The use of this staging system may help better elucidate the natural history of urethral strictures. For example, it is not clear to us the likelihood of stage 1 strictures progressing to stage 3 or 4 strictures. Clinicians are often confronted with incidentally discovered wide caliber (ie stage 1) primary strictures and may have difficulty counseling C59 wnt research buy these patients as to the need for followup or the likelihood of problems developing. The

classification scheme presents a framework for research charting the progression of these strictures and could define whether there is a pattern as well as the time to such progression. It would be informative for physicians and crucial for patients to be able to determine whether symptoms worsen even when a stricture does not progress to a higher stage. The staging system described is reliable and the results of its validation make sense intuitively, as reliability was lower in identifying low grade strictures because these are somewhat ambiguous

and likely clinically similar. Specifically, stage 1 and 2 strictures were less accurately classified than stage 3 and 4 strictures. We believe the reason for this discrepancy is that we used videos of cystoscopies rather than live, witnessed LY294002 mw cystoscopies, and thus cystoscopic haptic feedback is difficult if not impossible watching videos. The reliability of stage 0 to 2 strictures would likely be higher with real-time cystoscopy. The stages that describe strictures that typically require treatment did in fact have exceptional

reliability. All 3 observers, including the generalist, scored fairly high using this classification system. Therefore, physicians who do not typically specialize in strictures would know that a stage 3 or 4 stricture should be referred to a specialist. An additional weakness of our study is Sodium butyrate that we used a Stryker flexible cystoscope. Although technology may change and others may use different equipment, we do not expect such changes would be enough to preclude the relevance of the rough estimation of stricture caliber provided by cystoscopy. The staging system is not applicable when a rigid cystoscope is used. It primarily focuses on lumenal narrowing, does not assess the extent of spongiofibrosis, the amount of which may better determine stricture progression, and does not yet incorporate voiding symptoms or flow rates. The staging system does not evaluate multiple stage 3 or 4 strictures but only the first stage 3 stricture encountered (ie the most distal) is identified.