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 prior performed surveys in China, Germany, Türkiye, Italy, the Netherlands, the USA and ESGURS members, members of our working group modified a 16-items questionnaire suitable for Japanese urologists by translating from the original questionnaire to Japanese. This survey using either single-choice nor multiple-choice questions queried respondents about their own characteristics, surgery-related experience, medical judgments, pre- and post-operative evaluations, and perioperative management. We received permission from the JUA that there were no ethical problems and started this study. A presentation of the project along with invitation letters were sent by e-mail from JUA section to all JUA members. The questionnaires were distributed and collected using Microsoft Forms, (Microsoft corporation, Redmond, Washington, USA). One reminder was sent to all JUA members. This study was conducted from December 19, 2023, to March 20, 2024.

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).

We were able to confirm the current status and perspectives of JUA members regarding anterior urethral stricture. While over 90% of urologists have experience with DVIU and urethral dilation, the number of cases of urethral stricture experience is lower compared to overseas, and urethroplasty, particularly graft-based procedures, is not widely practiced. Compared to previous reports, a majority of respondents indicated that they would perform urethroplasty initially when necessary. This approach was significantly more common among urologists who are under 50 years old, instructors, and those who limit DVIU indications to strictures up to 1 cm. Most members preferred to refer patients to specialists rather than treating them themselves, which supports the centralization of patients to specialized hospitals. On the other hand, there were many members who chose transurethral treatments over urethroplasty as an initial treatment, showing a divergence from the evidence. A significant number of responses indicated a preference for leaving the urethral catheter in place for an extended period after DVIU, suggesting that many members may not fully understand the pros and cons of transurethral procedures for urethral stricture.

While there is increasing recognition that urethroplasty should be conducted by specialists, there remains a significant preference for transurethral treatments. These findings highlight the need for enhanced training in reconstructive techniques, theoretical education, and more precise treatment algorithms in Japan.