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MsANTA / Joshi Step Urethroplasty (Mucosal-Sparing Augmented Non-Transected Anastomotic)

The MsANTA urethroplasty (Mucosal-Sparing Augmented Non-Transected Anastomotic) is a non-transecting bulbar urethroplasty described by Joshi, Bandini, and Kulkarni in 2022 as a "step forward" from ANTA. It preserves both the corpus spongiosum and the native urethral mucosa (the mucosa is incised and reconfigured but never resected) and augments the reconstructed plate with a buccal mucosal onlay.[1]

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

Concept and Rationale​

The non-transecting principle progressively spares more tissue with each iteration:[1][2][3]

TechniqueSpongiosumMucosa
Transecting EPA / AAUTransectedExcised
VS-EPA / ntEPAPreservedExcised
ANTAPreservedExcised (mucosectomy)
MsANTA / Joshi StepPreservedPreserved (incised, not excised)

The authors present MsANTA as a "step forward" because the intrinsic mucosal blood supply and communicant vessels from the corpus spongiosum to the urethral mucosa are kept in continuity; neither the spongiosum nor the mucosa is resected.[1]

Indications​

  • In the original series, eligible patients had non-traumatic bulbar strictures with a viable near-obliterative segment (<7 Fr) no longer than 1.5 cm; the authors describe traumatic strictures with severe spongiosal and submucosal fibrosis as unsuitable for MsANTA.[1]
  • The original 24-patient series treated non-traumatic strictures with bulbar narrowing (median total length 4 cm; median narrowest segment 1 cm); six strictures also extended into the penile urethra.[1]
  • Patients with viable narrowed mucosa when tissue preservation is an operative goal.[1][2] The 2026 EAU guideline gives a weak recommendation for augmented non-transecting anastomotic repair during bulbar free-graft urethroplasty for short, nearly obliterative segments; the recommendation applies to the technique family.[8]
  • Fogaing and Aubé-Peterkin describe a tension-free Joshi step as usually feasible when the narrowest segment is under 1.5 cm with dorsal onlay and under 1 cm with ventral onlay, and recommend 5-0 monofilament polydioxanone with bites through both mucosa and spongiosum to reduce mucosal tearing.[10]

Contraindications / limitations​

  • Completely obliterated or nonviable mucosa cannot be preserved. [8]
  • 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. Avoid genital skin in LS. [8]
  • Strictures suitable for pure dorsal onlay BMG (where reconstruction of the plate is unnecessary)

Surgical Technique​

Step 1. Approach. Bulbar urethra exposed via perineal midline incision. The corpus spongiosum is mobilized but not transected. Either a ventral or dorsal urethrotomy approach is used.

Step 2. Mucosal-preserving urethrotomy. Unlike ANTA, where the strictured mucosa is excised (mucosectomy), in MsANTA the native urethral mucosa is preserved. The original dorsal approach marks the narrowed ventral plate and transposes healthy proximal and distal mucosal edges without excising the intervening mucosa; ventral onlay uses the same step on the dorsal plate.[1]

Step 3. Mucosa-to-mucosa anastomosis. Approximate the healthy mucosal edges without tension to widen the native urethral plate. In the original report, dorsal approximation was possible at about 1 cm (maximum 1.5 cm); a longer gap could cause tension and spongiosal bulging, and the authors avoided this step with ventral onlay when the narrow segment exceeded 1 cm.[1] In the original dorsal approach, each 5-0 polydioxanone bite passes through mucosa and spongiosum on one edge, then spongiosum and mucosa on the opposing edge; the authors aim to retain the mucosal communicant vessels.[1]

Step 4. Onlay BMG augmentation. An onlay graft augments the reconstructed plate, usually with buccal mucosa; two patients with penile extension in the original 24-patient series received preputial skin grafts.[1] The graft is sutured to the urethrotomy edges with absorbable suture. The original report used 5-0 polydioxanone for the mucosal anastomosis and a dorsal onlay graft as described by Barbagli in 21 of 24 patients.[1]

Step 5. Closure. Closure follows the graft orientation: ventral grafts may be covered with spongiosum; dorsal grafts are supported on the corporal tunica. Approximate the perineal tissues without constricting the repair. Catheter duration depends on repair complexity and healing; 2–3 weeks is common after graft reconstruction. Assess for extravasation by urethrography before removal. [9]

Distinction from ANTA​

The intended anatomic distinction from the original Welk / Kodama 2012 ANTA technique is the complete sparing of the communicant vessels from the corpus spongiosum to the urethral mucosa.[1][3]

FeatureANTA[3]MsANTA[1]
SpongiosumPreservedPreserved
MucosaExcised (mucosectomy)Preserved (incised, not excised)
Communicant vesselsDisrupted at the mucosaPreserved
AnastomosisMucosal edges after mucosectomyDirect mucosa-to-mucosa after incision
Ideal strictureBulbar stricture treated by complete excision plus onlayNarrowed but viable mucosa

By preserving the mucosa as well as the spongiosum, MsANTA aims to minimize ischemic injury to the urethral plate and reduce the risk of restricture at the reconstructed site.[1]

Outcomes​

The original Joshi, Bandini and Kulkarni 2022 cohort was preliminary: 24 patients, median follow-up 11.5 months (IQR 3.8–19.2), and success in 87.5%.[1] Failure was defined as obstructive symptoms or Qmax <10 mL/s, with or without instrumentation.[1] No Clavien-Dindo grade ≥III complication occurred within 30 days. Five patients had urinary infections (grade II) and six had penile hematomas managed conservatively.[1] The authors describe the technique as easy and reproducible. A 2026 single-center conference abstract reported composite success in 132/139 (95.0%) primary, non-traumatic bulbar cases at a mean 22 months; eligibility required a near-obliterative segment <7 Fr and ≤1.5 cm, and success required Qmax ≥10 mL/s, no obstructive symptoms, and no further intervention.[11] Comparative and long-term MsANTA outcomes remain unavailable.

The non-transecting evidence base (Chapman 2019 sexual-dysfunction signal,[4] Oszczudlowski 2023 meta-analysis,[5] Scandinavian RCT of transecting EPA versus buccal mucosal grafting[12]) is housed in the umbrella Non-Transecting Bulbar Urethroplasty article and supports the rationale for tissue preservation.

MsANTA in the Non-Transecting Family​

FeatureVS-EPA / ntEPA[2]ANTA[3]MsANTA[1]MANTA[6]ntAAU[7]
Initial reportVS-EPA 2007 / ntEPA 20122012202220232025
SpongiosumPreservedPreservedPreservedPreservedPreserved
MucosaExcisedExcisedPreserved (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)Bulbar stricture treated by complete excision plus onlayNarrowed but viable mucosa≥2 cm with obliterative ≤1.5 cmLong bulbar narrowing with a short critical segment

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

Key Takeaways​

  • MsANTA / Joshi Step aims to preserve both the spongiosum and the native mucosa.[1]
  • The technique modifies ANTA (2012) by preserving the narrowest segment's mucosa and bringing healthy proximal and distal mucosal edges together instead of excising the stricture mucosa.[1]
  • The technique suits bulbar strictures with a narrowed but viable mucosa. Nonviable mucosa or complete obliteration calls for a different reconstruction, chosen according to the full defect.
  • The technique preserves the communicant vessels from spongiosum to mucosa, which the authors expect to limit ischemic injury to the urethral plate.[1]
  • The original 2022 cohort was small (24 patients, 87.5% success at a median 11.5 months) and has no comparative or long-term follow-up.[1]

Videos​

MsANTA / Joshi Step Urethroplasty
Mucosal-sparing augmented non-transected anastomotic technique

References​

  1. 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.

  2. 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.

  3. 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.

  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. 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.

  6. 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.

  7. 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.

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

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

  10. Fogaing C, Aubé-Peterkin M. The Joshi Step. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:95-97.

  11. Barot PV, Navarro J, Thakkar S, et al. "IP39-02 The largest single-centre cohort of mucosal-sparing augmented non-transected anastomotic (MsANTA) urethroplasty: mid-term success and patient-reported outcome measures (PROMs)." J Urol. 2026;215(5S):e805. doi:10.1097/01.JU.0001191512.50502.2b.02

  12. Nilsen OJ, Holm HV, Ekerhult TO, et al. "To Transect or Not Transect: Results from the Scandinavian Urethroplasty Study, A Multicentre Randomised Study of Bulbar Urethroplasty Comparing Excision and Primary Anastomosis Versus Buccal Mucosal Grafting." Eur Urol. 2022;81(4):375-382. doi:10.1016/j.eururo.2021.12.017