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Transmeatal OMG Ventral Inlay (Nikolavsky)

The transmeatal oral mucosal graft (OMG) ventral inlay urethroplasty, developed by Dmitriy Nikolavsky and colleagues, reconstructs selected distal strictures through the meatus without splitting the glans or a separate penile or perineal incision. In Sterling’s series, 42/44 were patent without additional intervention at mean 36 months[1]; in Daneshvar’s 68-man multicenter cohort, 54/57 men with at least 12 months of follow-up remained stricture-free at median 17 months.[2]

For graft material, see Buccal Mucosa Graft. For the dorsal-inlay variant in fossa navicularis, see Sliding-T Dorsal Inlay. For the broader Asopa principle, see Asopa Dorsal Inlay OMG. For minced-BMG / endoscopic delivery concepts, see Liquid / Minced Buccal Mucosal Graft.

Concept and Rationale​

Some open reconstructions for fossa navicularis and distal strictures use glans splitting, circumferential urethral mobilization, or perineal or penile incisions. The Nikolavsky technique performs the entire reconstruction transurethrally through the meatus, using the natural access point of the distal urethra to avoid those incisions.[1][2]

The ventral wall of the fossa navicularis and distal urethra is accessible through the meatus, and a ventral urethrotomy can be performed under direct vision to excise scar tissue and create a graft bed, all without external incisions. The BMG is then delivered through the meatus using a suture-based "pull-through" technique and quilted in place.[1]

Nikolavsky and colleagues first reported the technique in 2016: transurethral ventral wedge resection of the stenosed segment, then transurethral delivery and spread fixation of a buccal mucosal graft inlay into the resulting urethrotomy. The initial series included three men with fossa navicularis or distal strictures (mean length 2.1 cm, range 1–4) and at least two previous failed procedures; at a mean 18 months (range 12–24) there were no recurrences or fistulas, mean preoperative and postoperative uroflow values were 4.3 and 19, and no chordee or change in sexual function was noted.[11]

Step-by-Step Technique​

The procedure is accomplished in four steps as described by Sterling, Daneshvar, and Nikolavsky (2023).[1]

Exposure and scar excision​

  • Patient supine; meatus retracted with stay sutures or a small self-retaining retractor.
  • Under direct vision through the meatus, place a guidewire into the bladder and inject methylene blue into the urethra to distinguish healthy mucosa. Make lateral meatal incisions at 3 and 9 o’clock for atraumatic retraction, excise the cicatrice via a transurethral ventral urethrotomy, and inspect the proximal urethra endoscopically.[1]
  • The ventral urethrotomy is carried through the strictured segment to a patent proximal lumen, and scar is excised until the lumen is at least 24 Fr, creating a ventral trough that exposes the underlying corpus spongiosum.[1]

When no suprapubic tract is available to help gauge the proximal extent of a longer stricture, an alternative described in the surgical atlas literature passes a guidewire retrogradely through the meatus, advances a lubricated 5-6 Fr Fogarty catheter to patent bulbar urethra, inflates its balloon to 20-26 Fr, and withdraws it until resistance marks the proximal edge of the stenosis for external marking.[10]

Graft delivery (the "pull-through")​

  • A buccal mucosal graft is harvested from the inner cheek using standard technique and defatted.
  • The graft is trimmed to a triangular shape, wider at the meatal end and tapering proximally to match the geometry of the ventral urethrotomy defect. One described sizing approach cuts the graft about 1-1.5 cm longer than the measured defect and 2.5-3 cm at its widest point.[10]
  • A double-armed 6-0 polydioxanone (PDS) suture is placed through the proximal (narrow) end of the triangular BMG.
  • The suture needles are passed transurethrally to the proximal extent of the urethrotomy and brought out through the ventral penile skin externally.
  • By pulling on the suture externally, the graft is delivered through the meatus and advanced to the proximal extent of the urethrotomy (the "pull-through" maneuver).
  • The suture is secured externally over a bolster on the ventral penile skin, anchoring the proximal graft in position.

Graft fixation and quilting​

  • The distal (wide) end of the graft is secured to the meatal edges with 5-0 polyglactin (Vicryl).
  • Additional 6-0 double-armed PDS quilting sutures are placed through the graft and underlying tissue for spread fixation, serving two functions: prevent graft contracture by maintaining the graft in a spread, flat configuration, and eliminate dead space between the graft and underlying bed (promoting imbibition and inosculation).
  • The graft sits on the ventral corpus spongiosum, the vascularized graft bed.

Catheter placement and closure​

  • A 16 Fr silicone urethral catheter is placed through the reconstructed urethra, serving as a stent to maintain patency and compress the graft against its bed during healing; one described approach inflates its balloon to about 10 cc and secures the catheter to avoid excessive ventral pressure on the graft.[10]
  • No external incisions are closed. The entire procedure is performed through the meatus.
  • The originating center planned same-day discharge; 40/44 patients went home on the day of surgery and four stayed overnight.[1]

Postoperative protocol​

  • Same-day discharge.[1][2]
  • Catheter removal and void trial at 1 week in the originating center’s protocol; individualize timing according to reconstruction and healing. Before removal after urethroplasty, assess for extravasation with validated urethrography ; maintain drainage and repeat assessment after one week if a significant leak persists.[1][12]
  • Follow-up with uroflowmetry, PVR, IPSS, SHIM.
  • In Sterling's protocol, cystoscopy was offered for Qmax <13 mL/s, worsening IPSS, or subjective complaints; routine visits used examination, uroflowmetry, PVR, and questionnaires.[1]

Clinical Outcomes​

StudyDesignnMedian stricture lengthEtiologyMedian OR / EBLSuccessFollow-up
Daneshvar 2020 (multi-institutional, 12 centers)[2]Retrospective68 (57 with ≥12 mo FU)2 cm (IQR 2–3)LS 34%; iatrogenic 32%; traumatic 15%; prior hypospadias repair 9%[10]72 min / 20 mL95% (54/57)median 17 mo (IQR 13–22)
Sterling 2023 (single-center, originating institution)[1]Retrospective44FN / distalmixed120 min (median)95% (42/44)mean 36 mo (IQR 22–50 as reported)
Tolbert 2025 — TraMUS extension to penile[3]Retrospective13 (11 with one-year outcome data)—iatrogenic 46%; hypospadias 23%; LS 15%—91% primary success (10/11)median 14 mo (range 11–28)

Multi-institutional validation (Daneshvar 2020)​

Daneshvar’s retrospective 12-institution cohort supports technical reproducibility. Outcomes were available for 57/68 men at at least 12 months, which limits generalization to all treated patients.[2]

  • Qmax improved from 5 to 18 mL/s (p < 0.001).[2]
  • Three of the 57 evaluable patients did not remain stricture-free.[1][2] The separate Sterling series reported two recurrences with more proximal disease.[1][2]
  • In Sterling’s series, both recurrences were treated successfully with dorsal onlay BMG urethroplasty.[1]
  • Significant improvements in Qmax, PVR, IPSS, and QOL scores.
  • No difference in postoperative sexual function scores (SHIM unchanged, p = 0.85).

TraMUS — extension to penile urethral strictures (Tolbert 2025)​

In 2025, Tolbert et al. at the Mayo Clinic described an extension of the Nikolavsky technique to penile urethral strictures, termed TraMUS (Transmeatal Urethral Surgery).[3]

  • Same transmeatal ventral inlay principle, with longer grafts (avg 6.5 cm, range 3–15 cm).
  • The cohort included 2 men with lichen sclerosus and 3 with hypospadias-related strictures; it did not compare transmeatal repair with staged reconstruction.[3]
  • Success was 91% at 1 year (10/11 evaluable); the single failure occurred at 3 months.[3]
  • One patient developed de novo incontinence (reported as 9%; 11 of 13 treated men had one-year outcome data).[3]
  • No other procedure-related complications.
  • Further studies needed to confirm long-term efficacy and compare to traditional open penile urethroplasty.

Advantages​

  1. No external incision. Entire procedure performed through the meatus; avoids a separate external access wound; graft, oral-donor and catheter complications remain possible.[1][2]
  2. Glans-sparing. Avoids glans splitting.
  3. No circumferential urethral mobilization. Limits urethral mobilization.
  4. Same-day discharge.[1][2]
  5. One-week catheter protocol. Patients in the originating-center series returned for a void trial after one week.[1]
  6. Sexual-function assessment. In Daneshvar's cohort, median SHIM was 22 before and 21 after repair (p = 0.85).[2] In Sterling's 44-patient series, four men had a postoperative SHIM decrease greater than three points.[1]
  7. Multicenter experience. The retrospective cohort included 68 men at 12 institutions; 54/57 men with at least 12 months of follow-up remained stricture-free at a median of 17 months.[2]
  8. Complications. Daneshvar reported no fistula, glanular dehiscence, graft necrosis or chordee.[2] In Sterling’s 44-patient series, no graft loss, fistula or glans dehiscence was reported, but seven men reported de novo urinary stream spraying; among 16 with preoperative splitting or spraying, six reported resolution and ten no change.[1]
  9. Short operative time. Median 72 min in the multi-institutional series.[2]

Comparison with Other Distal-Urethral Techniques​

TechniqueApproachnSuccessFollow-upDischargeKey AdvantageKey Limitation
Nikolavsky transmeatal ventral inlay[1][2]Transmeatal ventral urethrotomy; no external penile access incision44 (single); 68 (multi, 57 with ≥12 mo FU)95% without additional intervention (42/44, single); 95% stricture-free (54/57, multi)mean 36 mo (single); median 17 mo (multi)40/44 same day in single-center seriesNo external penile access incision; 1-wk catheter protocolMeatus-origin distal strictures in original series
TraMUS — penile extension[3]Transmeatal13 (11 with one-year outcome data)91% primary success (10/11)median 14 mo—Extends Nikolavsky to penile stricturesVery early data; 1 de novo incontinence case (reported as 9%)
Sliding-T dorsal inlay (Rourke)[4]Open (ventral urethrotomy)2725/27 (about 93%) passed 16-Fr cystoscopemean 29.6 mo—Simultaneous meatal reconstructionSingle-center; open approach; 19/27 (70.4%) had LS
Transurethral dorsal inlay (Farrell)[5]Transurethral1693.8% anatomic; 100% functional28.8 mo—Glans-sparing; transurethralShorter strictures (1.7 cm); small series
Dorsal inlay BMG (Zumstein / Hamburg)[6]Open3269%42 mo—Longest follow-up for dorsal inlay50% hypospadias; lower success
Meatotomy (Meeks / Barbagli)[7]Meatotomy7387%61 mo (all 93 men)—Simplest approachNo graft; limited to short strictures

Graft Biology — Why Ventral Inlay Works​

  • Graft bed. The graft is placed as an inlay into the defect created by the ventral urethrotomy and sits on the ventral corpus spongiosum, which is vascularized for imbibition and neovascularization.[1][2]
  • Triangular graft shape. The triangle is intended to match the geometry of the fossa navicularis and to avoid redundant tissue that could cause sacculation or diverticulum formation.[1]
  • Quilting sutures. Spread fixation is intended to limit graft contracture and to eliminate dead space, where hematoma or seroma could lead to graft failure.[1]

Patient Selection​

Ideal candidates (original indication)[1][2]​

  • Fossa navicularis or distal penile strictures beginning at the meatus. Sterling reported a mean length of 2 cm (range 1–5 cm) in the 44-patient series.[1]
  • Recurrent meatal / distal strictures that have failed endoscopic management
  • Lichen sclerosus-related distal strictures. LS accounted for 34% of the multicenter cohort.[2] In Sterling’s series, 9/44 had LS etiology and both recurrences had biopsy-confirmed LS.[1]
  • Patients desiring minimally invasive, same-day surgery with rapid recovery

Expanded indications (TraMUS)[3]​

  • Penile urethral strictures (graft lengths up to 15 cm)
  • Iatrogenic, LS, and hypospadias-related penile strictures
  • Patients who wish to avoid open penile urethroplasty

Contraindications / limitations​

  • Obliterative strictures where the ventral urethral plate is completely destroyed: the technique requires a viable ventral graft bed. Before reconstructive surgery, the 2026 EAU guideline recommends RUG to define stricture location and length and combined RUG/VCUG for nearly obliterative disease .[14]
  • Long or proximal strictures. TraMUS has used grafts up to 15 cm, but proximal visualization and suture reach limit transmeatal access; long-term outcome data remain limited.[3][13]
  • Unrecognized proximal extension. The two recurrences in Sterling's series had more proximal disease than initially appreciated; define the full stricture extent before choosing transmeatal repair.[1]

Guideline Context​

The AUA Urethral Stricture Disease Guideline Amendment (2023) recommends offering urethroplasty to patients with recurrent meatal or fossa navicularis strictures , and notes that LS-related fossa navicularis strictures are less likely to be reconstructed successfully using genital skin transfer; oral mucosal graft success has been reported in this setting.[8] The multi-institutional retrospective data are consistent with offering the Nikolavsky technique within this recommendation. The 2026 EAU guideline recommends offering open meatoplasty or distal urethroplasty for meatal or fossa navicularis/distal strictures .[15] For LS-related penile strictures, it recommends avoiding genital-skin augmentation and single-stage oral mucosa graft urethroplasty when local conditions permit .[15]

Limitations and Future Directions​

  • No randomized controlled trials. All evidence is from retrospective case series. A randomized comparison with open dorsal inlay or staged urethroplasty has not been done.
  • Intermediate-term follow-up. Sterling reported mean follow-up of 36 months. Given that stricture recurrence can occur years after urethroplasty (particularly in LS), longer follow-up is needed to confirm durability.[1]
  • TraMUS extension is very early. Of 13 treated patients, 11 had one-year outcome data after two were lost at 4 and 8 months; median reported follow-up was 14 months, and one patient developed de novo incontinence (reported as 9%). Complex etiologies warrant cautious interpretation.[3]
  • Surgeon learning curve. The technique requires comfort with transurethral suturing and graft manipulation; the 12-institution cohort of 68 men reported pooled outcomes (54/57 men with at least 12 months of follow-up were stricture-free at a median of 17 months).[2]
  • Adjacent endoscopic-suturing approaches. Ungerer 2023 described a fully endoscopic urethroplasty using the RD 180 suturing device for membranous strictures, a conceptually related but technically distinct approach extending minimally invasive urethroplasty to the posterior urethra.[9]

Practical Role​

Transmeatal ventral inlay is an option for selected distal strictures in experienced hands. Counseling covers the observational evidence, oral-graft morbidity, recurrence and the possible need for open revision.[1][2][3]

Videos​

Transmeatal OMG Ventral Inlay
Operative technique
Transmeatal OMG Ventral Inlay
Operative technique

References​

  1. Sterling J, Daneshvar M, Nikolavsky D. Transurethral ventral inlay buccal mucosa graft urethroplasty: technique and intermediate outcomes. BJU Int. 2023;132(1):109-111. doi:10.1111/bju.16007.

  2. Daneshvar M, Simhan J, Blakely S, et al. Transurethral ventral buccal mucosa graft inlay for treatment of distal urethral strictures: international multi-institutional experience. World J Urol. 2020;38(10):2601-2607. doi:10.1007/s00345-019-03061-6.

  3. Tolbert SN, Findlay BL, Ungerer GN, et al. Transmeatal urethral surgery (TraMUS): technique and one-year outcomes in the management of penile urethral strictures. World J Urol. 2025;43(1):338. doi:10.1007/s00345-025-05718-x.

  4. Hoare D, Fersovich JH, Saavedra A, Rourke KF. Single-stage reconstruction of fossa navicularis strictures using a "sliding-T" dorsal inlay urethroplasty with buccal mucosal graft. Urology. 2021;152:201-202. doi:10.1016/j.urology.2020.12.031.

  5. Farrell MR, Campbell JG, Zhang L, Nowicki S, Vanni AJ. Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty. World J Urol. 2022;40(6):1523-1528. doi:10.1007/s00345-022-03994-5.

  6. Zumstein V, Dahlem R, Maurer V, et al. Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options. World J Urol. 2020;38(10):2609-2620. doi:10.1007/s00345-019-03035-8.

  7. Meeks JJ, Barbagli G, Mehdiratta N, Granieri MA, Gonzalez CM. Distal urethroplasty for isolated fossa navicularis and meatal strictures. BJU Int. 2012;109(4):616-9. doi:10.1111/j.1464-410X.2011.10248.x.

  8. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.

  9. Ungerer G, Kemble J, Sischka M, Balzano FL, Warner JN. Endoscopic urethroplasty using buccal graft for male membranous urethral stricture. Urology. 2023;181:e200-e203. doi:10.1016/j.urology.2023.05.059.

  10. Bearrick E, Cedars B, Nikolavsky D. Transurethral Ventral BMG Inlay Urethroplasty for Fossa Navicularis and Distal Urethral Strictures. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:351-355. doi:10.1007/978-981-97-5196-9_35

  11. Nikolavsky D, Abouelleil M, Daneshvar M. "Transurethral Ventral Buccal Mucosa Graft Inlay Urethroplasty for Reconstruction of Fossa Navicularis and Distal Urethral Strictures: Surgical Technique and Preliminary Results." Int Urol Nephrol. 2016;48(11):1823-1829. doi:10.1007/s11255-016-1381-1

  12. European Association of Urology. "Perioperative Care of Urethral Surgery." EAU Guidelines on Urethral Strictures. 2026. Official guideline.

  13. Cedars B, Nikolavsky D. "Transurethral ventral buccal mucosal inlay grafting: a narrative review." Transl Androl Urol. 2025;14(8):2391-2397. doi:10.21037/tau-24-615

  14. European Association of Urology. "Diagnostic Evaluation." EAU Guidelines on Urethral Strictures. 2026. Official guideline.

  15. European Association of Urology. "Disease Management in Males." EAU Guidelines on Urethral Strictures. 2026. Official guideline.