Multiple surveys have documented practice patterns for male anterior urethral stricture management in various countries, highlighting concerns about the overuse of endoscopic treatments. However, no comprehensive data exists for Japan. We conducted the first nationwide survey to evaluate current practice patterns among Japanese urologists. 

Based on previous surveys conducted in various countries, including the United States, we modified a 16-item questionnaire suitable for Japanese urologists by translating it into Japanese. The Japanese Urological Association (JUA) officially conducted this online survey to all members between December 2023 and March 2024. Logistic regression analysis was used to identify factors associated with supporting the "reconstructive ladder" approach.

Of 9,898 JUA members contacted, 1,028 (10.4%) responded. Most respondents (81.2%) treated ≤5 urethral stricture cases annually, with 86.4% having performed ≤5 urethroplasties in their careers. While 91.1% and 94.2% had experience with direct vision internal urethrotomy (DVIU) and urethral dilation, respectively, only 30.0% had performed excision and primary anastomosis, and <10% had conducted oral mucosa graft urethroplasty (OMGU). Most respondents (65.1%) considered DVIU appropriate for strictures <1cm, with only 5.5% considering it for strictures >3cm. For a 34-year-old male with a 3.5cm idiopathic bulbar urethral stricture, 68.8% would refer to a reconstructive urologist, 15.6% would choose endoscopic management, and 12.9% would perform urethroplasty. The most common time for catheter removal after DVIU was one week, followed by two weeks. 75.1% of respondents left the catheter for more than 3 days after DVIU. Uroflowmetry was the most frequently performed examination for regular follow-up after urethroplasty, followed by urethroscopy and retrograde urethrography. The "reconstructive ladder" approach was supported by 24.7% of respondents. On multivariable analysis, those under 50 years of age, Board-certified instructors, and those who reported limiting DVIU to short bulbar strictures were less likely to support the "reconstructive ladder" approach (p =0.0000007, p <0.0000001 and p <0.0000001, respectively). 

While more than 90% of Japanese urologists are experienced with endoscopic treatments, urethroplasty, particularly OMGU, remains uncommon. Most prefer referring to reconstructive specialists, though some still favor endoscopic management even when not indicated. Most left the urethral catheter in place more than 3 days after DVIU. These findings highlight the need for enhanced training in reconstructive techniques, theoretical education, and more precise treatment algorithms.