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ANTA Urethroplasty (Augmented Non-Transected Anastomotic)

The ANTA urethroplasty (Augmented Non-Transected Anastomotic) was described by Welk and Kodama in 2012 as the first non-transecting version of augmented anastomotic urethroplasty. It applies the vessel-sparing principle to bulbar strictures that are too long for pure anastomosis but contain an obliterative core: the spongiosum is mobilized but never transected, the strictured mucosa is excised through the spongiosum (mucosectomy), the healthy mucosal edges are anastomosed, and the remaining strictured but non-obliterated segments are augmented with a dorsal onlay BMG.[1]

For the broader non-transecting family, see Non-Transecting Bulbar Urethroplasty, MsANTA / Joshi Step, MANTA, and ntAAU. For the transecting alternative, see Augmented Anastomotic Urethroplasty. For graft material, see Buccal Mucosa Graft.

Concept and Rationale​

Traditional augmented anastomotic urethroplasty (AAU; Guralnick and Webster, 2001) transects the urethra and spongiosum to excise a focal dense segment within a longer bulbar stricture. One urethral wall is re-anastomosed as a roof or floor strip, and the opposite defect receives a ventral or dorsal onlay; the original series used 22 grafts and 7 pedicled skin flaps.[2] In selected defects with viable residual spongiosum, ANTA leaves the spongiosum and its major arterial supply in continuity.[1][3] Mucosectomy still interrupts communicating vessels between the spongiosum and urethral mucosa.[7]

ANTA was the first technique to address the AAU indication without spongiosal transection. For the foundational evidence base on non-transecting urethroplasty (Chapman 2019 sexual-dysfunction signal,[4] Oszczudlowski 2023 meta-analysis,[6] Scandinavian RCT), see the umbrella article on Non-Transecting Bulbar Urethroplasty. Redmond / Rourke 2020 compared transecting AAU with non-transecting dorsal onlay in 507 men. Redmond / Rourke's adjusted analysis associated transecting AAU with failure versus dorsal onlay (HR 4.8, p = 0.002).[5]

Indications​

  • Bulbar strictures too long for pure anastomosis (typically >2 cm) with a dense obliterative or near-obliterative core surrounded by a longer segment of narrowing.[1]
  • Patients in whom preservation of the corpus spongiosum is prioritized; a specific ANTA sexual-function benefit remains unproven.[3][4]
  • A useful alternative when the surgeon wishes to use a smaller graft than would be required for pure dorsal onlay over the entire strictured segment.[1]

Contraindications / limitations​

  • Obliterative segment too long for safe excision through a non-transected spongiosum
  • Lichen sclerosus requires assessment of the full diseased segment and an oral-mucosa reconstruction plan; it is not an automatic contraindication to single-stage oral grafting. Genital skin is avoided in LS; EAU makes a strong recommendation against it in augmentation penile urethroplasty.[10]
  • Strictures suitable for pure dorsal onlay BMG (where the excisional component is unnecessary)

Surgical Technique​

Step 1. Approach. Expose the bulbar urethra through a midline perineal incision and mobilize it dorsally off the corporal tunica. Leave the bulb attached to the perineal body to preserve the main bulbar arteries; do not transect the spongiosum.[12]

Step 2. Dorsal urethrotomy and focal excision. Open the urethra dorsally through the stricture to healthy mucosa. Excise the scarred mucosa and superficial spongiofibrosis at the narrowest segment while leaving the vascularized underlying spongiosum and its ventral continuity intact.[12]

Step 3. Mucosal anastomosis at the obliterative core. The healthy mucosal edges at the site of excision are spatulated and anastomosed in a tension-free, mucosa-to-mucosa fashion, the "anastomotic" component of the technique.

Step 4. Dorsal onlay BMG augmentation. A buccal mucosal graft is then placed as a dorsal onlay to augment the remaining narrowed but non-obliterated segments of the urethra, the "augmentation" component. The graft is sutured to the urethral plate edges and quilted to the underlying tunica albuginea of the corpora cavernosa.

Step 5. Closure. The dorsal graft lies against the corporal tunica; secure the urethral margins to the graft and close the remaining tissues without constriction. Bulbospongiosus and perineal tissues are approximated. Catheter duration depends on repair complexity and healing; 2–3 weeks is common after graft reconstruction. Assess for extravasation by urethrography before removal.[11]

The result is reconstruction of the bulbar urethra without spongiosal transection; the spongy tissue and its bulbar artery supply remain in continuity throughout the repair.[1]

Distinction from Transecting AAU​

FeatureTransecting AAU[2]ANTA[1]
SpongiosumCompletely transectedPreserved (in continuity)
Bulbar arteriesDisruptedPreserved
Obliterative segmentExcisedExcised (mucosectomy through spongiosum)
AnastomosisSpatulated end-to-end (full thickness)Mucosa-to-mucosa only
GraftOnlay over the anastomotic siteDorsal onlay over remaining narrowed segments
Comparative evidenceRetrospective association with more recurrence than dorsal onlay[5]Small separate cohort[1]

Outcomes — Welk / Kodama 2012​

The original Welk / Kodama 2012 series compared 21 ANTA patients with 23 dorsal onlay patients:[1]

ParameterANTADorsal onlay
n2123
No additional stricture treatment20/21 (95.2%)21/23 (91.3%)
Median buccal graft length4.5 cm5.0 cm (p = 0.047)
Median follow-up (whole cohort)2.3 years2.3 years

The 93% success rate was for all 44 patients combined, with one ANTA and two dorsal-onlay patients requiring additional treatment.[1] The ANTA graft was modestly shorter, but donor-site complications did not differ significantly; only 59% responded to the cross-sectional outcomes survey.[1] In a separate series of augmented non-transecting bulbar repairs, post-micturition dribble was reported in 5/16 patients; the authors reported no significant bother among patients with dribble.[12] The mean 13-month follow-up was for the full 65-patient non-transecting cohort.[12]

Selecting the augmented component​

EAU 2026 weakly recommends augmented non-transecting anastomotic repair during bulbar free graft urethroplasty for short, nearly obliterative critical segments; its level 3 evidence summary describes overall bulbar strictures over 2 cm with a critical area under 1 cm.[10] Adequate healthy spongiosum must remain; a full-thickness traumatic obliteration may require a different reconstruction.[10]

ANTA in the Non-Transecting Family​

FeatureVS-EPA / ntEPA[3]ANTA[1]MsANTA[7]MANTA[8]ntAAU[9]
Initial reportVS-EPA 2007 / ntEPA 20122012202220232025
SpongiosumPreservedPreservedPreservedPreservedPreserved
MucosaExcisedExcised (mucosectomy)Preserved (incised)Dorsal scar superficially excisedExcised
ApproachDorsal or ventralDorsalDorsal or ventralVentralDorsal
GraftNoneDorsal onlay BMGOnlay BMGVentral onlay BMGDorsal onlay BMG
Ideal strictureSelected short bulbar stricture (Jordan's original cohort: 0.5–2.5 cm)>2 cm with obliterative coreNarrowed but viable mucosa≥2 cm with obliterative ≤1.5 cmLong bulbar narrowing with a short critical segment

ANTA was described as the first non-transecting augmented anastomotic technique. MsANTA, MANTA and ntAAU were described later as variants.

Named variants overlap; their small cohorts, endpoints and follow-up differ and do not establish a ranking of procedures.

Key Takeaways​

  • ANTA was the first non-transecting AAU, described by Welk and Kodama in 2012.[1]
  • The corpus spongiosum is mobilized but never transected; the strictured mucosa is excised through the preserved spongiosum.
  • Dorsal onlay BMG augments the remaining narrowed segments, with a shorter median buccal graft harvested than in the dorsal onlay comparison group (4.5 versus 5.0 cm, p = 0.047).[1]
  • 20/21 ANTA patients required no further treatment at median cohort follow-up of 2.3 years; the often-quoted 93% was the combined ANTA and onlay cohort.[1]
  • MsANTA (2022), MANTA (2023) and ntAAU (2025) were described later as variants of the non-transecting augmented approach.

Videos​

ANTA Urethroplasty
Operative technique

References​

  1. Welk BK, Kodama RT. The augmented nontransected anastomotic urethroplasty for the treatment of bulbar urethral strictures. Urology. 2012;79(4):917-21. doi:10.1016/j.urology.2011.12.008.

  2. Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol. 2001;165(5):1496-501. doi:10.1016/s0022-5347(05)66335-5

  3. Jordan GH, Eltahawy EA, Virasoro R. The technique of vessel sparing excision and primary anastomosis for proximal bulbous urethral reconstruction. J Urol. 2007;177(5):1799-802. doi:10.1016/j.juro.2007.01.036.

  4. Chapman DW, Cotter K, Johnsen NV, et al. Nontransecting techniques reduce sexual dysfunction after anastomotic bulbar urethroplasty: results of a multi-institutional comparative analysis. J Urol. 2019;201(2):364-370. doi:10.1016/j.juro.2018.09.051.

  5. Redmond EJ, Hoare DT, Rourke KF. Augmented anastomotic urethroplasty is independently associated with failure after reconstruction for long bulbar urethral strictures. J Urol. 2020;204(5):989-995. doi:10.1097/JU.0000000000001177.

  6. Oszczudlowski M, Yepes C, Dobruch J, Martins FE. Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis. BJU Int. 2023;132(3):252-261. doi:10.1111/bju.16108.

  7. Joshi P, Bandini M, Kulkarni SB. Mucosal-sparing augmented non-transected anastomotic (MsANTA) urethroplasty: a step forward in ANTA urethroplasty. BJU Int. 2022;130(1):133-136. doi:10.1111/bju.15734.

  8. Marks P, Dahlem R, Janisch F, et al. Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures. BJU Int. 2023;132(4):444-451. doi:10.1111/bju.16112.

  9. Baudry A, Schirmann A, Guillot-Tantay C, et al. Non-transecting anastomotic augmented urethroplasty with dorsal onlay buccal graft for the treatment of bulbous urethral strictures: results and complications. World J Urol. 2025;43(1):238. doi:10.1007/s00345-025-05633-1.

  10. European Association of Urology. EAU Guidelines on Urethral Strictures: disease management in males. 2026. Current guideline.

  11. European Association of Urology. EAU Guidelines on Urethral Strictures: perioperative care of urethral surgery. 2026. Current guideline.

  12. Bugeja S, Andrich DE, Mundy AR. "Non-transecting bulbar urethroplasty." Transl Androl Urol. 2015;4(1):41-50. doi:10.3978/j.issn.2223-4683.2015.01.07