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Augmented Anastomotic Urethroplasty

Augmented anastomotic urethroplasty (AAU) is a hybrid technique that combines excision of the most fibrotic / obliterative segment of a stricture with an onlay graft to reconstruct longer bulbar urethral strictures that are too long for simple excision and primary anastomosis (EPA) alone. Originally described by Guralnick and Webster in 2001, it achieves success rates of 90–97% depending on series and technique, though recent large-scale data suggest the transecting variant may be independently associated with higher recurrence than pure non-transecting dorsal onlay.[1][2][3]

For the buccal graft itself, see Buccal Mucosa Graft. For vessel-sparing variants, see Non-Transecting Bulbar Urethroplasty and Jordan Vessel-Sparing EPA.

Definition and Concept​

The core principle of AAU is to address strictures that contain a focal segment of dense fibrosis or obliteration within a longer area of narrowing. Rather than excising the entire stricture (excessive tension) or relying solely on a graft over heavily scarred tissue (poor graft take), AAU excises the worst 1–2 cm segment, performs a partial anastomosis (roof or floor strip), and augments the remaining defect with an onlay graft.[1][4]

As Guralnick and Webster originally described it: a short bulbar stricture ≤1 cm is best managed by EPA, but when total stricture length is too great for excision and anastomosis, the surgeon can perform "stricture excision with roof or floor strip anastomosis augmented by an onlay."[1]

Indications​

  • Bulbar urethral strictures >2 cm with a focal obliterative or densely fibrotic segment not amenable to EPA alone[1][6]
  • Strictures where the obliterative segment is 1–2 cm within a longer area of narrowing (total length typically 2–5+ cm)[1][6]
  • Recurrent strictures after prior endoscopic treatment or urethroplasty[4]
  • Strictures where a pure onlay graft would otherwise be placed over heavily scarred, poorly vascularized tissue (the anastomotic component removes that segment)[4]
  • The AUA Urethral Stricture Disease Guideline (2023) recommends urethroplasty as initial treatment for bulbar strictures ≥2 cm, with substitution or augmentation of the narrowed segment[7]

Surgical Technique​

Two main configurations exist, defined by which urethral wall is preserved for the anastomosis and which side receives the graft.

Configuration 1 — Roof Strip (Dorsal) Anastomosis + Ventral Onlay​

  1. The strictured segment is exposed via a perineal approach.
  2. The corpus spongiosum is fully transected through the most fibrotic segment.
  3. The most diseased portion is excised.
  4. The dorsal (roof) urethral plate is preserved and anastomosed end-to-end, creating a "roof strip" anastomosis.
  5. This leaves an oval ventral defect that is augmented with an onlay graft (buccal mucosa or pedicled skin flap).
  6. The graft is sutured to the edges of the ventral defect.[1][6]

Configuration 2 — Floor Strip (Ventral) Anastomosis + Dorsal Onlay​

  1. Same exposure and excision of the most fibrotic segment.
  2. The ventral (floor) urethral wall is preserved and anastomosed.
  3. The resulting dorsal defect is augmented with a dorsal onlay graft (typically buccal mucosa placed on the tunica albuginea of the corpora cavernosa, per the Barbagli technique).
  4. This configuration is more commonly used in contemporary practice.[1][3]

In the original Guralnick / Webster series, 20 of 29 patients received a floor strip anastomosis with dorsal onlay, and 9 received a roof strip anastomosis with ventral onlay. Mean excised length was 1.2 cm and mean onlay length was 4.5 cm.[1]

The Augmented Russell Technique (El-Kassaby)​

A specific variant in 234 patients with long bulbar strictures (mean 4.2 cm): excision of most of the diseased segment (mean 2.8 cm) with dorsal strip anastomosis, augmented by a ventral buccal mucosal patch (mean 4.7 cm). Success rate was 93.7% at mean 36 months.[6]

Key Outcomes by Series​

StudynTechniqueMean Stricture LengthSuccessFollow-up
Guralnick / Webster 2001[1]29Transecting AAU (dorsal or ventral onlay)1.5 cm (RUG)93%28 mo
Abouassaly / Angermeier 2007[4]69Transecting AAU—90%34 mo
El-Kassaby 2008[6]234Augmented Russell (dorsal strip + ventral BMG)4.2 cm93.7%36 mo
Hoy / Rourke 2013[3]163Dorsal onlay augmented anastomotic + BMGlong segment96.9%31 mo
Welk / Kodama 2012 (ANTA)[8]21Non-transecting ANTA + BMG—20/21 without further treatment (95.2%)2.3 yr (whole cohort median)
Redmond / Rourke 2020[2]221 (AAU) vs 286 (DO)Transecting AAU vs non-transecting DO4.4 cm93.9% overall78.9 mo
Baudry 2025 (ntAAU)[5]42Non-transecting AAU + dorsal BMGlong bulbar stricture with a critical segment90.5% anatomical18 mo
Marks 2023 (MANTA)[9]54Ventral non-transecting + dorsal mucomucosal anastomosis≥2 cm (obliterative ≤1.5 cm)93% functional41 mo

The Critical Controversy — AAU vs. Pure Dorsal Onlay​

The landmark study by Redmond and Rourke (2020) — a large retrospective comparison (507 patients, mean follow-up 78.9 months) — fundamentally challenged the role of transecting AAU:[2]

  • Transecting AAU was independently associated with stricture recurrence on multivariate analysis (HR 4.8, p = 0.002)
  • Other independent predictors of failure: increasing stricture length (HR 1.2, p = 0.002) and iatrogenic etiology (HR 3.2, p = 0.03)
  • No difference in Clavien ≥2 complications (3.6% vs 4.2%, p = 0.74) or de novo ED (5.9% vs 5.6%, p = 0.89)
  • The institution shifted from routinely performing transecting AAU to non-transecting dorsal onlay around 2011, reflecting the evolving evidence

The institutional shift around 2011 creates potential era and selection confounding. This study supports careful selection of the excisional component; it does not prove that transection itself causes failure, and it did not compare ANTA, MANTA or ntAAU with AAU.

Complications​

Complication rates must remain attached to the operation and cohort studied. In Guralnick/Webster’s 29 AAU repairs, postvoid dribbling occurred in 13 patients, pseudodiverticulum in two, subjective shortening in five and new erectile dysfunction in one.[1] In Hoy’s 163-patient dorsal-onlay augmented anastomotic series, the reported rates were 41.7% dribbling, 3.7% UTI, 3.1% ED, 10.4% orchalgia and 4.3% donor-site morbidity; these are not rates for pure dorsal onlay.[3]

The direct Redmond comparison reported Clavien ≥2 events in 3.6% versus 4.2% and de novo ED at six months in 5.9% versus 5.6% (AAU versus dorsal onlay), without significant differences.[2] Avoid using these separate series to claim a universal complication-rate advantage.

Evolution — Non-Transecting Augmented Techniques​

Recognition that transecting AAU may be inferior to non-transecting approaches has driven several vessel-sparing augmented modifications.

1. ANTA (Augmented Non-Transected Anastomotic) — Welk / Kodama 2012. The first non-transecting augmented technique. Complete stricture excision (mucosectomy) without transecting the spongiosum, combined with dorsal onlay BMG. In the ANTA subgroup, 20/21 required no further treatment (95.2%; 93% was the combined 44-patient ANTA/onlay cohort). The median buccal graft was modestly shorter (4.5 cm vs 5.0 cm, p = 0.047).[8]

2. MsANTA (Mucosal-Sparing ANTA) — Kulkarni 2022. A refinement where the native urethral mucosa is neither transected nor resected but reconstructed with a direct mucosa-to-mucosa anastomosis, preserving the communicant vessels from the corpus spongiosum to the urethral mucosa.[10]

3. MANTA (Mucomucosal Anastomotic Non-Transecting Augmentation) — Marks 2023. A ventral approach for strictures ≥2 cm with an obliterative segment ≤1.5 cm. The scar is superficially excised dorsally while the spongiosum is left intact. Dorsal mucomucosal anastomosis is complemented by a ventral onlay graft. In 54 patients at median 41 months: 93% functional success, no change in erectile function (IIEF-EF 27 → 24, p ≥ 0.4), and 100% patient satisfaction.[9]

4. ntAAU (Non-Transecting Augmented Anastomotic) — Baudry 2025. Non-transecting AAU with dorsal onlay BMG for selected long bulbar strictures with a short critical segment. In 42 patients: 90.5% anatomical success, 83.3% functional success at median 18 months. Complication rate 14.2%. Median postoperative IIEF-5 was 22 in 31 respondents; a postoperative score alone does not establish preserved erectile function.[5]

Graft Placement — Dorsal vs. Ventral Onlay​

A 2025 meta-analysis of 8 studies and 655 patients comparing dorsal vs ventral onlay BMG urethroplasty found:[11]

  • Success rates — no significant difference (RR 1.00, 95% CI 0.94–1.06, p = 0.97)
  • Qmax — comparable at 3 and 12 months
  • Transient ED — significantly lower with ventral technique (RR 0.24, 95% CI 0.08–0.67, p = 0.006)
  • Permanent ED — no difference (RR 0.57, p = 0.72)

Among GURS members, dorsal graft placement is preferred (66%) over ventral (34%) for bulbar urethroplasty with BMG.[12] Choose the graft position according to anatomy, tissue quality and surgeon experience. [13]

The meta-analysis concerns graft position, not the benefit of adding an anastomotic component. The permanent-ED estimate was imprecise (95% CI 0.03–12.20); absence of a significant difference is not proof of equal risk.[11]

Predictors of Failure​

  • Transecting AAU versus dorsal onlay in the Redmond cohort (adjusted HR 4.8, p = 0.002; association, not a causal effect of all transection)[2]
  • Increasing stricture length (HR 1.2, p = 0.002); strictures ≥5 cm are particularly prone to recurrence (p = 0.010)[2][3]
  • Iatrogenic etiology (HR 3.2, p = 0.03)[2]
  • Older age (mean 52 vs 39 yr in failures vs successes, p = 0.02)[4]
  • Postoperative UTI (28% in failures vs 3.2% in successes, p = 0.05)[4]
  • Lichen sclerosus requires a specific oral-mucosa reconstruction plan; one-stage repair is not uniformly contraindicated, and a single series should not define its expected failure rate. [13]

Choosing the Reconstruction​

Stricture patternReconstruction to consider
Short, traumatic bulbar stricture with nearly complete obliteration and full-thickness fibrosisTransecting EPA
Short bulbar stricture without straddle injuryNon-transecting EPA or a free graft
Longer bulbar narrowing with a viable plateFree-graft augmentation; dorsal, dorsolateral or ventral according to anatomy
Longer narrowing with a short nearly obliterative focusSelected augmented non-transecting repair if viable tissue and a tension-free partial anastomosis are achievable
Extensive obliteration or adverse local tissuesIndividualized complex or staged reconstruction; do not choose a named variant from length alone

These selections follow the EAU framework. The augmented non-transecting recommendation is weak, reflecting limited comparative evidence. Total stricture length and length of the obliterative core are different measurements. [13]

Key Takeaways​

  • AAU bridges the gap between EPA (short strictures) and pure onlay grafting (longer strictures) by addressing the focal obliterative component that limits graft take.
  • Traditional transecting AAU achieves 90–94% success but is independently associated with higher recurrence (HR 4.8) compared to pure non-transecting dorsal onlay in the largest comparative study.[2]
  • The field has shifted toward non-transecting augmented techniques (ANTA, MsANTA, MANTA, ntAAU) that preserve the corpus spongiosum while combining mucosectomy / anastomosis with onlay grafting, with encouraging small-cohort outcomes; these are not comparative proof of superior patency or sexual function.
  • Discuss dribbling, sexual and penile symptoms as well as patency; rates depend on technique, baseline symptoms and measurement method.
  • For longer strictures without a focal obliterative segment, a pure non-transecting dorsal onlay is now preferred over transecting AAU.
  • Longer strictures were associated with recurrence in the cited AAU cohorts; a universal 5 cm threshold across techniques is not established.

Videos​

Augmented Anastomotic Urethroplasty
Operative technique

References​

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

  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. 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):1357-61. doi:10.1016/j.urology.2013.02.012.

  4. Abouassaly R, Angermeier KW. Augmented anastomotic urethroplasty. J Urol. 2007;177(6):2211-5; discussion 2215-6. doi:10.1016/j.juro.2007.01.140.

  5. 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.

  6. El-Kassaby AW, El-Zayat TM, Azazy S, Osman T. One-stage repair of long bulbar urethral strictures using augmented Russell dorsal strip anastomosis: outcome of 234 cases. Eur Urol. 2008;53(2):420-4. doi:10.1016/j.eururo.2007.06.002.

  7. 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.

  8. 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.

  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. 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.

  11. Hassan AA, Soliman AM, Shouman HA, et al. Dorsal- vs ventral-onlay buccal mucosal graft urethroplasty for urethral strictures: a meta-analysis. BJU Int. 2025. doi:10.1111/bju.16811.

  12. 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.

  13. European Association of Urology. EAU Guidelines on Urethral Strictures: disease management in males. 2026. Current guideline.