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Non-Transecting Bulbar Urethroplasty

Non-transecting bulbar urethroplasty (ntBU) is a vessel-sparing modification of traditional excision and primary anastomosis (EPA) that achieves equivalent stricture-free rates (90–98%) while significantly reducing penile complications and likely reducing erectile dysfunction compared to transecting techniques.[1][2][3] Rather than fully dividing the corpus spongiosum, ntBU preserves the outer spongiosal shell and its dual arterial supply, removes only the mucosal scar tissue from within the intact spongiosa, and reconstructs a tension-free mucosa-to-mucosa anastomosis — yielding durable stricture-free rates without the vascular injury that drives penile shortening and glans ischemia after transecting repair.

Historical Development and Rationale​

The concept of spongiosa-preserving anastomotic urethroplasty was introduced by Jordan et al. in 2007 and formalized by Andrich and Mundy in 2012, who published the first dedicated series of non-transecting anastomotic bulbar urethroplasty.[4] The physiologic rationale rests on a recognized over-engineering of traditional EPA: complete-thickness corpus spongiosum transection is not required to remove the fibrotic mucosal segment causing obstruction.[3][5] Transection disrupts the bilateral bulbar arteries, which supply both the urethra and, via retrograde flow through the spongiosum, the glans penis. Glans ischemia produces the characteristic post-EPA triad of reduced glans tumescence, penile shortening, and diminished erectile capacity.

By preserving the corpus spongiosum and its vasculature, ntBU aims to:

  • Maintain bulbar artery blood flow and minimize glans ischemia
  • Reduce de novo erectile dysfunction
  • Preserve a well-vascularized tissue bed for future redo surgery with grafts
  • Reduce penile shortening and chordee[3][5]

Indications​

  • Short bulbar urethral strictures, typically <2 cm, though selected series extend to 5 cm with augmentation
  • Posterior urethral strictures (88.5% success in one series of 26 patients)[5]
  • Both primary and recurrent strictures
  • Can be combined with buccal mucosal grafts for longer strictures (ANTA, MANTA, and ntAAU variants — see below)[11][12][13]

Surgical Technique​

The procedure is performed through a perineal incision in lithotomy position. Two main approaches exist — dorsal and ventral — sharing the core principle of spongiosal preservation.

Dorsal Approach (Jordan / Bugeja Technique)​

This is the most widely described technique.[3][5]

  1. Exposure: Midline perineal incision; bulbospongiosus muscle divided in the midline; corpus spongiosum fully mobilized from the corpora cavernosa.
  2. Dorsal urethrotomy: The corpus spongiosum is rotated 180° to expose the dorsal surface. A dorsal midline urethrotomy is made through the strictured segment, extending into healthy urethra proximally and distally. The spongiosum is not transected.
  3. Mucosectomy: Fibrotic mucosal tissue is excised from within the intact spongiosa. The outer spongiosal shell and its blood supply are preserved throughout.
  4. Spatulation: Healthy mucosal edges are spatulated on opposite sides to widen the lumen.
  5. Anastomosis: A tension-free, mucosa-to-mucosa anastomosis is performed using 5-0 absorbable sutures (interrupted or running). The dorsal urethrotomy is then closed.
  6. Spongioplasty: The corpus spongiosum is re-approximated over the anastomosis with 4-0 absorbable sutures.
  7. Catheter: A 16–18 Fr urethral catheter is left in place for 9–14 days — typically shorter than the 14–21 days used after transecting EPA.[3][5]

Ventral Approach​

Described independently by Morán et al. and Bogdanov et al. as an alternative that avoids extensive dorsal mobilization of the corpus spongiosum.[6][7]

  1. A ventral midline urethrotomy is made through the stricture.
  2. Mucosal scar tissue is excised (mucosectomy) while preserving the dorsal spongiosum.
  3. Healthy mucosal edges are approximated without tension.
  4. Mucosal closure is performed in a Heineke–Mikulicz fashion using 5-0 absorbable monofilament; spongioplasty with 4-0 absorbable suture.

The ventral approach avoids circumferential spongiosa mobilization, which may be advantageous in patients with prior ventral dissection or anatomic constraints.

Augmented Non-Transecting Techniques​

For strictures >2 cm or those with an obliterative component, the non-transecting principle has been extended by combining internal mucosectomy with buccal mucosal graft augmentation.

VariantDescriptionKey Outcome Data
ANTA (augmented non-transected anastomotic urethroplasty)Mucosectomy + dorsal onlay BMG; smaller graft than pure onlay BMG93% success; smaller graft required (4.5 cm vs. 5.0 cm, p = 0.047)[11]
MANTA (mucomucosal anastomotic non-transecting augmentation)For strictures ≥2 cm with obliterative segment <1.5 cm; ventral modification93% functional success at median 41 months; IIEF-EF 27 → 24 (p ≥ 0.4); 100% patient satisfaction[12]
ntAAU (non-transecting augmented anastomotic urethroplasty with dorsal onlay BMG)42 patients; dorsal onlay technique90.5% anatomical success at median 18 months; median IIEF-5 of 22 postoperatively[13]

An important caveat for augmented repairs: in long bulbar strictures, transecting augmented anastomotic urethroplasty was independently associated with failure compared to non-transecting dorsal onlay (HR 4.8, p = 0.002), reinforcing the preferential role of the non-transecting approach whenever grafts are added to the anastomotic repair.[14]

Outcomes​

Stricture-Free Rates​

Multiple meta-analyses and comparative studies consistently demonstrate no significant difference in stricture recurrence between transecting and non-transecting approaches:

  • Multi-institutional comparative analysis (352 patients): 97.9% vs. 93.8% success (p = 0.18)[1]
  • Meta-analysis of 19 studies (Oszczudlowski et al.): pooled RR 1.06 (95% CI 0.82–1.36) — no difference[2]
  • Meta-analysis of 13 studies, 1,683 patients (Zhao et al.): no significant difference in success rate, Qmax, or overall complications[8]

Sexual Function and Penile Outcomes​

This is the primary domain of benefit for ntBU:

  • Multi-institutional analysis (Chapman et al., 352 patients): De novo sexual dysfunction 4.3% vs. 14.3% (p = 0.008). On multivariate analysis, only the transecting technique was independently associated with sexual dysfunction (p = 0.01); age, stricture length, etiology, and surgeon were not.[1]
  • Meta-analysis (Zhao et al., 1,683 patients): ntBU had a significantly lower incidence of erectile dysfunction compared to transecting bulbar urethroplasty (tBU); no differences in other perioperative outcomes.[8]
  • Meta-analysis (Oszczudlowski et al., 19 studies): ED risk ratio 0.73 (95% CI 0.49–1.08) — trending toward benefit but not statistically significant. Penile complications were significantly lower: RR 0.47 (95% CI 0.28–0.76, p < 0.05).[2]
  • Scandinavian Urethroplasty Study (Nilsen et al.) — the only RCT (151 patients): Compared transecting EPA to non-transecting BMG. tEPA had significantly more penile complications (p = 0.02), particularly reduced glans filling (p = 0.03) and shortened penis (p = 0.001). No difference in IIEF-5 scores. Recurrence rates were equivalent (12.9% in both groups).[9]
  • Lumen et al. (75 patients): De novo ED in 21.9% at 3 months, largely transient. Post-void dribbling in only 4.7%.[10]
  • Frankiewicz et al. multicenter IIEF analysis: Preoperative erectile function and younger age were the strongest predictors of erectile function preservation; diabetes was associated with worse short-term outcomes.[15]

Other Perioperative Outcomes​

OutcomeNon-TransectingTransectingNotes
Operative time~87 min~98 minComparable or shorter
Catheterization time~9 days~14 daysShorter for ntBU
Overall complications4.3%8.1%Not statistically significant (p = 0.25)[1]
Learning curveNone observed—No effect across 75-pt tertile analysis[10]

Predictors of Outcomes​

  • Preoperative erectile function and younger age are the strongest predictors of postoperative erectile function preservation[15]
  • Diabetes is associated with worse short-term erectile function outcomes[15]
  • Complex strictures involving both penile and bulbar regions adversely affect long-term patency[15]
  • Stricture length ≥5 cm is associated with lower patency rates when augmented techniques are applied[16]
  • No substantial learning curve effect has been demonstrated in dedicated single-center series[10]

Non-transecting techniques are increasingly favored within the reconstructive urology community. Among Society of Genitourinary Reconstructive Surgeons (GURS) members surveyed in 2024, dorsal graft placement was preferred (66%) over ventral (34%) for bulbar urethroplasty with BMG, and anastomotic urethroplasty remained preferred over BMG for short bulbomembranous strictures (63% vs. 37%).[17] The trend toward non-transecting approaches reflects accumulating evidence that vascular preservation reduces penile complications without compromising stricture-free rates — and that when augmentation is required for longer strictures, the non-transecting dorsal onlay approach outperforms transecting augmented anastomotic repair.[2][8][14]

References​

1. 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

2. 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

3. Virasoro R, DeLong JM. "Non-transecting bulbar urethroplasty is favored over transecting techniques." World J Urol. 2020;38(12):3013–3018. doi:10.1007/s00345-019-02867-8

4. Andrich DE, Mundy AR. "Non-transecting anastomotic bulbar urethroplasty: a preliminary report." BJU Int. 2012;109(7):1090–1094. doi:10.1111/j.1464-410X.2011.10508.x

5. Verla W, Oosterlinck W, Waterloos M, Lumen N. "Vessel-sparing excision and primary anastomosis." J Vis Exp. 2019;(143). doi:10.3791/58214

6. Morán E, Sáez Moreno I, Bonillo MA, et al. "Ventral approach for the non-transecting bulbar urethroplasty." Urology. 2021;152:197–198. doi:10.1016/j.urology.2021.02.003

7. Bogdanov AB, Veliev EI, Sokolov EA, et al. "Nontransecting anastomotic urethroplasty via ventral approach without full mobilization of the corpus spongiosum dorsal semicircumference." Urology. 2021;152:136–141. doi:10.1016/j.urology.2020.10.074

8. Zhao X, Xing Y, Zhang X, et al. "Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis." J Sex Med. 2023;21(1):11–19. doi:10.1093/jsxmed/qdad141

9. 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

10. Lumen N, Poelaert F, Oosterlinck W, et al. "Nontransecting anastomotic repair in urethral reconstruction: surgical and functional outcomes." J Urol. 2016;196(6):1679–1684. doi:10.1016/j.juro.2016.06.016

11. Welk BK, Kodama RT. "The augmented nontransected anastomotic urethroplasty for the treatment of bulbar urethral strictures." Urology. 2012;79(4):917–921. doi:10.1016/j.urology.2011.12.008

12. 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

13. 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

14. 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

15. Frankiewicz M, Białek Ł, Rydzińska M, et al. "Impact of urethroplasty on erectile function: a multicenter analysis of the International Index of Erectile Function score changes across different etiologies of urethral stricture." J Clin Med. 2025;14(9):2936. doi:10.3390/jcm14092936

16. Hoy NY, Kinnaird A, Rourke KF. "Expanded use of a dorsal onlay augmented anastomotic urethroplasty with buccal mucosa for long segment bulbar urethral strictures: analysis of outcomes and complications." Urology. 2013;81(6):1357–1361. doi:10.1016/j.urology.2013.02.012

17. Berg C, Singh A, Hu P, et al. "Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons." Urology. 2024;191:139–143. doi:10.1016/j.urology.2024.06.019