We determined whether endoscopic realignment or cystostomy would provide the best immediate management of pelvic fracture urethral injury. We retrospectively reviewed the records of 590 patients with pelvic fracture urethral injury. Of the patients 522 were included in analysis due to strict criteria, including 129 in the endoscopic realignment group and 393 in the cystostomy group. Data on stricture formation and length, intervention technique and long-term functional outcomes were analyzed. In the endoscopic realignment group stricture developed in 111 patients (83%) at a mean of 23.5 months, which is longer than the 7.6 months reported in the cystostomy group (p <0.05). Mean stricture length was 3.2 cm in the realignment group and 3.7 cm in the cystostomy group (p <0.05). Internal urethrotomy was performed in 21 patients (19%) treated with realignment vs 18 (5%) treated with cystostomy (p <0.05). Further repair was accomplished via simple perineal anastomosis in 57 patients (51%) with realignment and 138 (35%) with cystostomy (p <0.05). Ancillary procedures such as corporeal splitting, inferior pubectomy and crural rerouting were necessary in 14 (13%), 14 (13%) and 5 patients (4%) in the endoscopic realignment group, and in 94 (24%), 100 (25%) and 43 (11%), respectively, in the cystostomy group (all p <0.05). The rates of impotence and incontinence did not statistically differ between the endoscopy and cystostomy groups (14.3% vs 16.2% and 1.6% vs 2.1%, respectively, p >0.05). Endoscopic realignment may reduce stricture formation and length, and facilitate urethroplasty. However, endoscopic realignment is also associated with a prolonged clinical course for recurrence.