Understanding global practice patterns in bulbar urethral reconstruction to inform urethroplasty training

To characterize global variation in operative decision-making for bulbar urethral strictures and identify surgeon-level factors associated with technique selection and intra-surgeon concordance.

A cross-sectional survey was distributed to members of two large international reconstructive urological societies. Participants selected preferred techniques for standardized short (1 cm) and long (3-4 cm) bulbar strictures presented as written scenarios and corresponding retrograde urethrograms (RUGs). Concordance was defined as consistent technique selection across formats for the same stricture. Associations between preferences, concordance, and surgeon characteristics were analyzed.

A total of 167 surgeons from 38 countries responded; 40.7% completed formal reconstructive fellowship training. Technique selection for short strictures varied significantly by both training region (p < 0.001) and practice region (p < 0.001), whereas preferences for long strictures were consistent, with a majority favoring dorsal onlay buccal grafting. Years in practice and case volume were not associated with technique choice. Overall concordance was low, particularly for short strictures (33.5% vs. 50.9% for long, p < 0.01). Concordance was higher among U.S.-trained, fellowship-trained, and U.S.-practicing surgeons for both long and short strictures. For long strictures, concordance was 65.1% vs. 42.3% (p < 0.01) by training region, 66.2% vs. 40.4% (p < 0.01) by fellowship status, and 63.6% vs. 44.6% (p = 0.03) by practice region. For short strictures, concordance was 44.4% vs. 26.9% (p = 0.03) by training region, 48.5% vs. 23.2% (p < 0.01) by fellowship status, and 50.9% vs. 25.0% (p < 0.01) by practice region.

Substantial global variability exists in the management of bulbar urethral strictures, especially for short strictures. Surgeon experience and volume do not predict technique selection or decision consistency, whereas training background does. Low intra-surgeon concordance suggests that even individual surgeons do not apply a consistent decision-making process to similar presentations, a gap that structured curricula, standardized imaging interpretation, and consensus-driven frameworks could directly address.