There are significant levels of concern about both the safety assessment and financial evaluation of the whole hydropower system, especially at early project stages. In addition, there is a variety of reliable and accurate methods for analysis, design, and optimization of steel pressure liners in hydropower plants. Several countries have developed specific regulations and codes for the design, installation, and safety evaluation of under-pressure piping, as well as estimates of the potential risks associated with failure. This paper reviews the current methodologies and codes available for design and safety assessment of either unstiffened or stiffened pressure steel liners in hydropower plants. After examining the main guidelines and practical conclusions drawn from recent research in the field of liners subjected to either internal or external pressure, this article then discusses the relevant regulations and codes. The scope of this work is to summarize the advantages, disadvantages, and main characteristics of the existing design criteria, analysis methods, and other issues related to steel liners. Afterwards, this paper compares the main reliable formulations and modelling techniques, even the most recent or sophisticated ones. Lastly, we draw some conclusions regarding their accuracy and scope of applicability.