A urethral stricture presents a critical choice for surgeons: attempt complex reconstruction that restores normal anatomy, or create a permanent opening that sidesteps the blockage entirely. This decision carries profound implications for patient quality of life, sexual function, and long-term urinary health. Analysis of nearly 3,100 cases from the American College of Surgeons database reveals how urologists nationwide make this consequential choice. The data shows a stark 19-to-1 preference for urethroplasty, the reconstructive gold standard, over perineal urethrostomy, which creates a permanent opening between the urethra and perineum. However, patients with diabetes, hypertension, or chronic obstructive pulmonary disease face significantly higher odds of receiving the simpler urethrostomy procedure. The pattern suggests surgeons systematically reserve the more complex reconstruction for healthier patients while offering the permanent diversion to those deemed higher surgical risks. This risk-stratified approach reflects practical surgical decision-making, where comorbidities influence both operative complexity and healing capacity. Yet the analysis raises important questions about whether medical optimization might expand reconstructive options for some patients currently directed toward permanent urinary diversion. The findings illuminate a largely unstudied aspect of urological practice patterns, where patient factors beyond stricture anatomy drive treatment selection. For men facing urethral stricture repair, understanding these selection criteria becomes crucial for informed decision-making and potentially seeking second opinions when reconstruction remains a viable goal.