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ntAAU Urethroplasty (Non-Transecting Augmented Anastomotic)

The ntAAU urethroplasty — Non-Transecting Augmented Anastomotic — is a variant of non-transecting bulbar urethroplasty described by Baudry, Schirmann, and Guillot-Tantay in 2025. It applies the vessel-sparing principle specifically to the traditional augmented anastomotic urethroplasty with dorsal onlay buccal graft: the obliterative segment is excised through the spongiosum without transecting it, and the remaining strictured urethra is augmented with a dorsal onlay BMG.[1]

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

Concept and Rationale​

ntAAU and ANTA (Welk / Kodama 2012) share the same conceptual framework — non-transecting excision of an obliterative segment combined with dorsal onlay BMG augmentation. The retrospective Baudry 2025 series reports short- to intermediate-term outcomes in selected long bulbar strictures with a critical segment, where pure EPA cannot bridge the defect but the surgeon wishes to avoid full spongiosal transection.[1][2]

The clinical importance of avoiding spongiosal transection — the Chapman 2019 sexual-dysfunction signal,[3] the Oszczudlowski 2023 meta-analysis,[5] and the Scandinavian RCT — is housed in the umbrella Non-Transecting Bulbar Urethroplasty article. The signal most directly relevant to ntAAU is Redmond / Rourke 2020 (n = 507): transecting AAU was independently associated with stricture recurrence (HR 4.8, p = 0.002) vs pure non-transecting dorsal onlay.[4] Redmond did not include a separate ntAAU arm; that association cannot prove that transection caused recurrence or that ntAAU prevents it.

Indications​

  • Longer bulbar strictures with a short, nearly obliterative critical segment that can be excised and reapproximated without tension while preserving viable spongiosum. Do not interpret total stricture length >2 cm as permission to excise a >2 cm obliterative core. [10]
  • The surgeon wishes to avoid full spongiosal transection with the aim of preserving vascularity; a sexual-function benefit for this specific variant is unproven.[3]
  • Adequate native urethral plate exists for the dorsal onlay graft to engraft against.[1]

Contraindications / limitations​

  • 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. [10]
  • Strictures suitable for pure dorsal onlay BMG (where the excisional component is unnecessary)
  • Strictures where the obliterative segment is too long for safe excision through a non-transected spongiosum

Surgical Technique​

The technique combines the principles of non-transecting excision with dorsal onlay buccal graft augmentation.[1]

Step 1 — Approach. Bulbar urethra exposed via a perineal midline incision. The corpus spongiosum is mobilized but not transected.

Step 2 — Mucosectomy of the obliterative segment. The obliterative segment is excised through the spongiosum (similar to ANTA), removing the fibrotic mucosal core while the outer spongy tissue remains in continuity.

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.

Step 4 — Dorsal onlay BMG augmentation. A buccal mucosal graft is placed as a dorsal onlay to augment the remaining strictured 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 spongiosum remains in continuity throughout — preserving the bulbar arteries and the dorsal vascular supply to the urethral mucosa.[1][6]

Outcomes — Baudry 2025​

The Baudry / Schirmann / Guillot-Tantay 2025 series:[1]

ParameterResult
Number of patients42
Median follow-up18 months
DesignRetrospective single-center cohort; no randomized comparator
Anatomical success (16.5 Fr flexible cystoscope passage)90.5%
Functional success (Qmax >15 mL/s)83.3%
Complication rate14.2% (infections, abscess, bleeding)
Postoperative median IIEF-522 among 31 questionnaire respondents
Salvage of failuresRedo urethroplasty

A postoperative IIEF-5 score of 22 does not establish preservation without a paired baseline comparison. Anatomical and functional success use different definitions and should not be interchanged.[1]

ntAAU vs. ANTA​

ntAAU and ANTA are conceptually similar — both excise an obliterative segment without transecting the spongiosum and augment with dorsal onlay BMG. The differences are largely a matter of contemporary descriptive nomenclature and patient selection focus.

FeatureANTA[7]ntAAU[1]
Year20122025
SpongiosumPreservedPreserved
MucosaExcised (mucosectomy)Excised (mucosectomy)
ApproachDorsalDorsal
GraftDorsal onlay BMGDorsal onlay BMG
Series indicationObliterative core within longer narrowingLong bulbar stricture with a critical segment
Original n2142
Success20/21 without retreatment; median cohort follow-up 2.3 years90.5% anatomical / 83.3% functional at 18 months

The Baudry 2025 series provides larger contemporary outcome data for the indication that ANTA originally targeted, with postoperative IIEF-5 documentation but no proof of an erectile-function advantage.

ntAAU in the Non-Transecting Family​

FeatureVS-EPA / ntEPA[6]ANTA[7]MsANTA[8]MANTA[9]ntAAU[1]
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 strictureShort ≤2 cm>2 cm with obliterative coreNarrowed 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​

  • ntAAU is a 2025 reported non-transecting augmented anastomotic technique — Baudry 2025.[1]
  • Conceptually similar to ANTA (2012) — non-transecting excision + dorsal onlay BMG — with selection based on total stricture length, the short critical segment and viable residual spongiosum.
  • 90.5% anatomical success / 83.3% functional success in 42 patients at 18-month median follow-up.[1]
  • Median postoperative IIEF-5 was 22 in 31 respondents; preserved function or superiority over transecting AAU cannot be inferred.
  • No direct comparative advantage over transecting AAU can be inferred from the separate Redmond cohort.[4]
  • Failures managed with redo urethroplasty; complication rate 14.2%.

Videos​

Non-Transecting Augmented Bulbar Urethroplasty
AINU Surgical Videos (2025)

References​

  1. 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.

  2. Coddington N, Higgins M, Mian A, Flynn B. Non-transecting urethroplasty for bulbar urethral strictures — narrative review and treatment algorithm. J Clin Med. 2022;11(23):7033. doi:10.3390/jcm11237033.

  3. 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.

  4. 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.

  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. 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.

  7. 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.

  8. 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.

  9. 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.

  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.