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MANTA Urethroplasty (Mucomucosal Anastomotic Non-Transecting Augmentation)

The MANTA urethroplasty (Mucomucosal Anastomotic Non-Transecting Augmentation) is a non-transecting bulbar urethroplasty described by Marks, Dahlem, and Janisch in 2023 (Hamburg) for bulbar strictures ≥2 cm with a focal obliterative segment ≤1.5 cm. It combines a dorsal mucomucosal anastomosis at the obliterative core with a ventral onlay BMG, all approached ventrally and preserving the corpus spongiosum.[1]

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

Concept and Rationale​

MANTA was developed for a specific anatomic problem: the bulbar stricture that contains a short obliterative core (≤1.5 cm) within a longer overall stricture (≥2 cm).[1]

  • Pure EPA / VS-EPA would not span the longer surrounding narrowing.
  • Pure dorsal onlay BMG may be inadequate when the focal dorsal bed is <0.5 cm wide; MANTA selection in the original series was based on intraoperative assessment.[1]
  • Transecting AAU was associated with more recurrence than pure dorsal onlay in a retrospective cohort (adjusted HR 4.8); MANTA was not a comparator.[2]
  • MANTA anastomoses the dorsal mucosa across the obliterative segment without transecting the spongiosum, then augments the entire strictured length with a ventral onlay graft.[1]

This preserves spongiosal continuity. MANTA excises dorsal scar and mucosa, while MsANTA preserves native mucosa.[1][7]

The EAU 2026 guideline makes a weak recommendation to perform augmented non-transecting anastomotic repair during bulbar free graft urethroplasty in short, nearly obliterative segments (level of evidence 3).[9]

Indications​

  • Bulbar strictures ≥2 cm total length with a focal obliterative segment ≤1.5 cm, a dorsal bed <0.5 cm wide, and scar confined to the mucosa without severe spongiofibrosis; confirm these findings intraoperatively.[1]
  • Penobulbar strictures were 30% of the original Marks 2023 cohort.[1]
  • Redo cases were 26% of the Marks 2023 cohort.[1]
  • Patients in whom preserving spongiosal continuity is a technical goal based on non-transecting rationale.[3][5] A MANTA-specific reduction in sexual dysfunction has not been established.[1]

Contraindications / limitations​

  • Obliterative segment >1.5 cm lies outside the original study criteria. Tension and viable tissue determine feasibility.
  • 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. [9]
  • Strictures suitable for pure dorsal onlay BMG (where transection / anastomosis is not needed)

Surgical Technique​

Step 1. Ventral approach. Stricture approached ventrally to avoid extensive dorsal mobilization. A perineal midline incision is made; the corpus spongiosum is exposed without transection.

Step 2. Ventral urethrotomy. Make a ventral midline urethrotomy distal to the stricture to open the lumen for direct visualization, then extend it under blunt-probe guidance until healthy tissue is reached proximally and distally. Measure total stricture length, obliterative length, and the narrowest dorsal-bed width intraoperatively before selecting MANTA.[1]

Step 3. Dorsal scar excision (superficial). At the level of the obliterative core, the dorsal scar is superficially excised while the spongiosum is left intact (non-transecting). Viable dorsolateral mucosal edges bordering the excised dorsal scar are exposed for mucomucosal reapproximation.[1]

Step 4. Dorsal mucomucosal anastomosis. The healthy dorsolateral mucosal edges are joined in a dorsal mucomucosal anastomosis, the "anastomotic" half of the technique, with interrupted 5-0 monofilament absorbable sutures to widen the dorsal bed; for very proximal bulbar strictures, the authors advise bottom-up J-shaped sutures at 11, 12, and 1 o'clock to reach the dorsoproximal mucosa.[1] Confirm viable edges and a tension-free repair.

Step 5. Ventral onlay BMG. A buccal mucosal graft is placed as a ventral onlay to augment the entire strictured segment (including the just-anastomosed dorsal core), the "augmentation" half of the technique. The graft is sutured to the ventral urethrotomy edges with absorbable sutures (5-0 / 6-0 PDS or Vicryl).

Step 6. Closure. The corpus spongiosum is closed over the graft (spongioplasty); bulbospongiosus muscle and perineal tissues approximated. Catheter duration depends on repair complexity and healing; after urethroplasty, an indwelling catheter is commonly left in place for 2–3 weeks.[10] In the original MANTA series, men without previous open reconstruction received a transurethral catheter for 10 days plus a suprapubic catheter for 21 days, while redo cases received a transurethral catheter alone for 21 days.[1] Assess for extravasation by urethrography before removal. [10]

The dorsal mucosal anastomosis widens the urethral bed before ventral graft augmentation, without spongiosal transection.[1]

Outcomes — Marks 2023 Hamburg Series​

ParameterResult
Number of patients54
Median follow-up41 months
Stricture inclusion criteria≥2 cm with obliterative segment ≤1.5 cm
Penobulbar location30%
Redo cases26%
Functional success (no symptomatic retreatment)50/54 (93%); four patients were lost before 3 months, and routine late anatomic surveillance was incomplete
LUTS score (pre → post)13 → 3.5 (p < 0.001)
IIEF-EF (pre → post)27 → 24 (NS, p ≥ 0.4)
Reported satisfaction45/45 respondents satisfied (12/45) or very satisfied (33/45); 9/54 had no satisfaction response
[1]

MANTA vs. Other Non-Transecting Variants​

FeatureVS-EPA / ntEPA[3]ANTA[6]MsANTA[7]MANTA[1]ntAAU[8]
Initial reportVS-EPA 2007 / ntEPA 20122012202220232025
SpongiosumPreservedPreservedPreservedPreservedPreserved
MucosaExcisedExcisedPreserved (incised, not excised)Dorsal scar superficially excisedExcised
ApproachDorsal or ventralDorsalDorsal or ventralVentralDorsal
GraftNoneDorsal onlay BMGOnlay BMGVentral onlay BMGDorsal onlay BMG
AnastomosisMucosa-to-mucosaMucosalMucosalDorsal mucomucosal at obliterative coreMucosal
Ideal strictureSelected short bulbar stricture (Jordan's original cohort: 0.5–2.5 cm)Bulbar stricture treated by complete excision plus onlayNontraumatic bulbar with focal <7 Fr portion ≤1.5 cm (≤1 cm for ventral onlay)≥2 cm with obliterative ≤1.5 cmLong bulbar narrowing with a short critical segment

Why MANTA Matters​

In the retrospective Redmond / Rourke 2020 comparison (n = 507), transecting augmented anastomotic urethroplasty (AAU) was independently associated with stricture recurrence (HR 4.8, p = 0.002) compared to pure non-transecting dorsal onlay.[2] MANTA has reported 93% functional success in a separate cohort of 54 patients.[1] For the broader non-transecting evidence base (Chapman 2019 sexual-dysfunction signal,[5] Oszczudlowski 2023 meta-analysis,[4] Scandinavian RCT), see the umbrella Non-Transecting Bulbar Urethroplasty article.

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

Key Takeaways​

  • MANTA was described in 2023 for bulbar strictures ≥2 cm with an obliterative segment ≤1.5 cm.[1]
  • MANTA combines a ventral approach, a dorsal mucomucosal anastomosis and a ventral onlay BMG, without spongiosal transection.[1]
  • 93% functional success in 54 patients at median 41 months; no significant change in IIEF-EF; all reported respondents satisfied or very satisfied.[1]
  • The original cohort included 26% redo cases and 30% penobulbar strictures.[1]
  • MANTA is one of the augmented non-transecting variants, with ANTA, MsANTA and ntAAU. Palminteri et al. also described a ventral approach with dorsal mucosal anastomosis and a ventral oral graft in 68 men with tight bulbar strictures averaging 1 cm, compared with MANTA's ≥2 cm eligibility.[1][11]

Videos​

Non-Transecting Anastomotic Bulbar Urethroplasty
Philippine Urological Association

References​

  1. 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.

  2. 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.

  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. 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.

  5. 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.

  6. 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.

  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. 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.

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

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

  11. Palminteri E, Preto M, Mari A, et al. "Non-transecting dorsal mucosal anastomosis plus ventral oral graft for the treatment of urethral bulbar strictures: single surgeon experience." Int Urol Nephrol. 2022;54(12):3171–3177. doi:10.1007/s11255-022-03257-7