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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 cannot reconstruct the obliterative core.
  • Transecting AAU carries the Redmond / Rourke 2020 HR 4.8 recurrence signal compared with pure dorsal onlay.[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. Because dorsal scar and mucosa are excised, it should not be described as preserving every mucosal communicant vessel; mucosal preservation is the distinguishing aim of MsANTA.[1][7]

Indications​

  • Bulbar strictures ≥2 cm total length with a focal obliterative segment ≤1.5 cm[1]
  • Penobulbar location is feasible (30% of the original Marks 2023 cohort)
  • Redo cases (26% of the Marks 2023 cohort)
  • Patients in whom preservation of the spongiosum is prioritized to reduce sexual dysfunction[3][5]

Contraindications / limitations​

  • Obliterative segment >1.5 cm lies outside the original study criteria; do not extrapolate its results to longer cores. 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. A ventral midline urethrotomy is performed through the strictured segment, opening the lumen for direct visualization.

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). Healthy dorsal mucosal edges are exposed proximal and distal to the obliterative segment.

Step 4 — Dorsal mucomucosal anastomosis. The healthy dorsal mucosal edges are brought together in a dorsal mucomucosal anastomosis — the "anastomotic" half of the technique. A short segment alone does not guarantee feasibility: 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; 2–3 weeks is common after graft reconstruction. Assess for extravasation by urethrography before removal. [10]

The result is a neourethra of triangular cross-section — dorsal mucomucosal anastomosis + ventral graft — 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 retreatment)93%
LUTS score (pre → post)13 → 3.5 (p < 0.001)
IIEF-EF (pre → post)27 → 24 (NS, p ≥ 0.4)
Reported satisfactionAll reported respondents satisfied/very satisfied; interpret within this single cohort
[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 strictureShort ≤2 cm>2 cm with obliterative coreNarrowed but non-obliterated≥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. It was not tested against AAU in that study, so superiority and a causal effect of avoiding transection are unproven.[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 is a 2023 described modification for the specific scenario of bulbar strictures ≥2 cm with an obliterative segment ≤1.5 cm.
  • Ventral approach with dorsal mucomucosal anastomosis + ventral onlay BMG — circumferential reconstruction without spongiosal transection.
  • 93% functional success in 54 patients at median 41 months; no significant change in IIEF-EF; all reported respondents satisfied or very satisfied.[1]
  • Versatile — successfully used in 26% redo cases and 30% penobulbar strictures.
  • Sits alongside ANTA, MsANTA, and ntAAU as variants of the augmented non-transecting concept; differentiated by ventral approach + dorsal mucomucosal anastomosis configuration.

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.