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de Toledo et al. Plast Aesthet Res 2022;9:5 https://dx.doi.org/10.20517/2347-9264.2021.103 Page 9 of 11

Future directions
Although there have been some important advances in the understanding and management of FUS, there is
still room for improvement. Data available is scarce and with an overall poor level of evidence. Published
studies consist mostly of descriptive, retrospective series or technique papers with a small number of
patients. Most of these are single-center with the exception of two multicenter studies [25,44] . There is a need
for long-term randomized, controlled trials comparing different treatments. We also advocate the idea of
the creation of an international registry to collect data prospectively for more robust and long-term
[32]
evidence suggested by Chakraborty et al. . The recent publication of the European Association of Urology
guidelines for the management of female urethral strictures provides a framework for decision making in
[8]
these cases .
In the future, new technology might play a role in managing FUS disease. Both tissue engineering and drug-
coated balloons may be options that will increase our armamentarium. Although more robust data in tissue
engineering is found for male patients, there are some ongoing preclinical and clinical studies open on FUS,
which hopefully will show good preliminary results in this innovative field . Drug-coated balloons for the
[47]
treatment of urethral stricture also showed promising results in male patients with 70% success at 12-month
follow-up and is yet to be determined with future studies if it could demonstrate similar efficacy in female
patients .
[48]
CONCLUSION
For many years, FUS disease has been a mostly anecdotal field. However, we have seen an increasing
interest in the reconstructive urology community. Although rare, the true incidence of FUS is probably
underestimated. Its vague presenting symptoms make it mandatory to have a high index of clinical
suspicion to diagnose and treat the patient appropriately. A thorough clinical history is advised with
emphasis on prior surgical or radiation history. In institutions without expertise in this area, referral to an
experienced center is recommended. As a first-line treatment, the patient can be offered UD, but we
discourage serial dilations in case of initial failure in patients who are surgical candidates. Augmentation
urethroplasty, using either flaps or grafts, is the gold standard treatment in FUS. Unfortunately, there is
insufficient high-quality data to recommend one approach or technique over the other. Current literature
suggests acceptable success with low complication rates for flaps and grafts, independent of a specific
approach. Since the available literature consists mainly of retrospective cases with a small number of
patients, long-term randomized controlled trials comparing different treatment outcomes would be helpful
to improve the available level of evidence. Finally, the promising field of tissue engineering may play a role
in female urethroplasty, given promising preliminary results. If implemented, tissue-engineered grafts could
shorten operative time and diminish donor site morbidity.

DECLARATIONS
Authors’ contributions
Contributed equally to this work in writing and proofing: de Toledo IA, DeLong J
Performed the literature search: de Toledo IA
Edited the manuscript: DeLong J

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.