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ANTA Urethroplasty (Augmented Non-Transected Anastomotic)

The ANTA urethroplasty — Augmented Non-Transected Anastomotic — was described by Welk and Kodama in 2012 as the first non-transecting version of augmented anastomotic urethroplasty. It applies the vessel-sparing principle to bulbar strictures that are too long for pure anastomosis but contain an obliterative core: the spongiosum is mobilized but never transected, the strictured mucosa is excised through the spongiosum (mucosectomy), the healthy mucosal edges are anastomosed, and the remaining strictured but non-obliterated segments are augmented with a dorsal onlay BMG.[1]

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

Concept and Rationale​

The traditional augmented anastomotic urethroplasty (AAU; Guralnick / Webster 2001) addresses bulbar strictures with a focal obliterative core within a longer narrowing: the urethra and spongiosum are completely transected, the obliterative segment is excised, and a graft bridges the remaining defect.[2] In selected defects with viable residual spongiosum, ANTA applies the non-transecting principle — the corpus spongiosum remains in continuity throughout, preserving the bulbar arteries and dorsal vascular supply.[1][3]

ANTA was the first technique to address the AAU indication without spongiosal transection. For the foundational evidence base on non-transecting urethroplasty (Chapman 2019 sexual-dysfunction signal,[4] Oszczudlowski 2023 meta-analysis,[6] Scandinavian RCT), see the umbrella article on Non-Transecting Bulbar Urethroplasty. Redmond / Rourke 2020 compared transecting AAU with non-transecting dorsal onlay in 507 men; it did not test ANTA. Its adjusted recurrence association (HR 4.8, p = 0.002) should not be interpreted as a causal estimate for spongiosal transection or excision alone.[5]

Indications​

  • Bulbar strictures too long for pure anastomosis (typically >2 cm) with a dense obliterative or near-obliterative core surrounded by a longer segment of narrowing.[1]
  • Patients in whom preservation of the corpus spongiosum is prioritized; a specific ANTA sexual-function benefit remains unproven.[3][4]
  • A useful alternative when the surgeon wishes to use a smaller graft than would be required for pure dorsal onlay over the entire strictured segment.[1]

Contraindications / limitations​

  • Obliterative segment too long for safe excision through a non-transected spongiosum
  • 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)

Surgical Technique​

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

Step 2 — Mucosectomy of the strictured segment. The strictured urethral mucosa is excised through the spongiosum — the fibrotic mucosal segment is removed while the outer spongy tissue and its vasculature remain 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 of the technique.

Step 4 — Dorsal onlay BMG augmentation. A buccal mucosal graft is then placed as a dorsal onlay to augment the remaining narrowed but non-obliterated segments of the 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 result is reconstruction of the bulbar urethra without spongiosal transection — the spongy tissue and its bulbar artery supply remain in continuity throughout the repair.[1]

Distinction from Transecting AAU​

FeatureTransecting AAU[2]ANTA[1]
SpongiosumCompletely transectedPreserved (in continuity)
Bulbar arteriesDisruptedPreserved
Obliterative segmentExcisedExcised (mucosectomy through spongiosum)
AnastomosisSpatulated end-to-end (full thickness)Mucosa-to-mucosa only
GraftOnlay over the anastomotic siteDorsal onlay over remaining narrowed segments
Comparative evidenceRetrospective association with more recurrence than dorsal onlay[5]Small separate cohort; not included in the Redmond comparison[1]

Outcomes — Welk / Kodama 2012​

The original Welk / Kodama 2012 series compared 21 ANTA patients with 23 dorsal onlay patients:[1]

ParameterANTADorsal onlay
n2123
No additional stricture treatment20/21 (95.2%)21/23 (91.3%)
Median buccal graft length4.5 cm5.0 cm (p = 0.047)
Median follow-up (whole cohort)2.3 years2.3 years

The 93% success rate was for all 44 patients combined, with one ANTA and two dorsal-onlay patients requiring additional treatment. The ANTA graft was modestly shorter, but donor-site complications did not differ significantly; only 59% completed the oral-morbidity survey. This small retrospective comparison did not establish equivalence or lower donor morbidity.[1]

Selecting the augmented component​

EAU supports augmented non-transecting repair for a short, nearly obliterative focus within a longer bulbar stricture. Adequate healthy spongiosum must remain; a full-thickness traumatic obliteration may require a different reconstruction. [10] The Redmond comparison was an institutional, retrospective change from transecting AAU to dorsal onlay, with no ANTA arm; it cannot identify excision as an independent mechanism of failure.[5]

ANTA in the Non-Transecting Family​

FeatureVS-EPA / ntEPA[3]ANTA[1]MsANTA[7]MANTA[8]ntAAU[9]
Initial reportVS-EPA 2007 / ntEPA 20122012202220232025
SpongiosumPreservedPreservedPreservedPreservedPreserved
MucosaExcisedExcised (mucosectomy)Preserved (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

ANTA was the first non-transecting augmented anastomotic technique and established the conceptual framework that MsANTA, MANTA, and ntAAU subsequently refined.

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

Key Takeaways​

  • ANTA was the first non-transecting AAU — described by Welk and Kodama in 2012.[1]
  • The corpus spongiosum is mobilized but never transected; the strictured mucosa is excised through the preserved spongiosum.
  • Dorsal onlay BMG augments the remaining narrowed segments, with a smaller graft than would be needed for pure dorsal onlay (4.5 vs 5.0 cm, p = 0.047).[1]
  • 20/21 ANTA patients required no further treatment at median cohort follow-up of 2.3 years; the often-quoted 93% was the combined ANTA/onlay cohort.
  • The Redmond association concerns transecting AAU versus dorsal onlay, not the entire augmented non-transecting family.[5]
  • ANTA established the conceptual framework for the entire non-transecting augmented family (MsANTA 2022, MANTA 2023, ntAAU 2025).

Videos​

ANTA Urethroplasty
Operative technique

References​

  1. 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.

  2. Guralnick ML, Webster GD. The augmented anastomotic urethroplasty: indications and outcome in 29 patients. J Urol. 2001;165(5):1496-501.

  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. 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.

  5. 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.

  6. 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.

  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. 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.

  9. 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.

  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.