MsANTA / Joshi Step Urethroplasty (Mucosal-Sparing Augmented Non-Transected Anastomotic)
The MsANTA urethroplasty — Mucosal-Sparing Augmented Non-Transected Anastomotic — is a non-transecting bulbar urethroplasty described by Joshi, Bandini, and Kulkarni in 2022 as a "step forward" from ANTA. It preserves both the corpus spongiosum and the native urethral mucosa — the mucosa is incised and reconfigured but never resected — and augments the reconstructed plate with a buccal mucosal onlay.[1]
For the broader non-transecting family, see Non-Transecting Bulbar Urethroplasty, ANTA, MANTA, and ntAAU. For the transecting alternative, see Augmented Anastomotic Urethroplasty. For graft material, see Buccal Mucosa Graft.
Concept and Rationale
The non-transecting principle progressively spares more tissue with each iteration:[1][2][3]
| Technique | Spongiosum | Mucosa |
|---|---|---|
| Transecting EPA / AAU | Transected | Excised |
| VS-EPA / ntEPA | Preserved | Excised |
| ANTA | Preserved | Excised (mucosectomy) |
| MsANTA / Joshi Step | Preserved | Preserved (incised, not excised) |
MsANTA represents a "step forward" because the intrinsic mucosal blood supply and communicant vessels from the corpus spongiosum to the urethral mucosa are kept in continuity — neither the spongiosum nor the mucosa is resected.[1]
Indications
- Bulbar strictures with a narrowed but not completely obliterated lumen, where the mucosa — though diseased — retains some viability and vascular connections to the underlying spongiosum.[1]
- Patients in whom maximum tissue sparing is prioritized to preserve sexual and ejaculatory function.[2][4]
Contraindications / limitations
- Completely obliterated or nonviable mucosa cannot be preserved; reconstruction depends on the extent of fibrosis, not an automatic assignment to another named variant. [8]
- 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. [8]
- Strictures suitable for pure dorsal onlay BMG (where reconstruction of the plate is unnecessary)
Surgical Technique
Step 1 — Approach. Bulbar urethra exposed via perineal midline incision. The corpus spongiosum is mobilized but not transected. Either a ventral or dorsal urethrotomy approach is used.
Step 2 — Mucosal-preserving urethrotomy. Unlike ANTA — where the strictured mucosa is excised (mucosectomy) — in MsANTA the native urethral mucosa is preserved. The fibrotic / scarred mucosa is incised along the long axis but not removed.
Step 3 — Mucosa-to-mucosa anastomosis. The mucosal edges are reconfigured with a direct mucosa-to-mucosa anastomosis, effectively enlarging the native urethral plate at the level of the stricture. The intrinsic mucosal blood supply (communicant vessels from the spongiosum to the mucosa) is preserved throughout.
Step 4 — Onlay BMG augmentation. A buccal mucosal graft is placed as a dorsal or ventral onlay to augment the reconstructed urethral plate. The graft is sutured to the urethrotomy edges with absorbable sutures (5-0 / 6-0 PDS or Vicryl).
Step 5 — Closure. Closure follows the graft orientation: ventral grafts may be covered with spongiosum; dorsal grafts are supported on the corporal tunica. Approximate the perineal tissues without constricting the repair. Catheter duration depends on repair complexity and healing; 2–3 weeks is common after graft reconstruction. Assess for extravasation by urethrography before removal. [9]
Distinction from ANTA
The intended anatomic distinction from the original Welk / Kodama 2012 ANTA technique is the complete sparing of the communicant vessels from the corpus spongiosum to the urethral mucosa.[1][3]
| Feature | ANTA[3] | MsANTA[1] |
|---|---|---|
| Spongiosum | Preserved | Preserved |
| Mucosa | Excised (mucosectomy) | Preserved (incised, not excised) |
| Communicant vessels | Disrupted at the mucosa | Preserved |
| Anastomosis | Mucosal edges after mucosectomy | Direct mucosa-to-mucosa after incision |
| Ideal stricture | Obliterative core | Narrowed but viable mucosa |
By preserving the mucosa as well as the spongiosum, MsANTA aims to minimize ischemic injury to the urethral plate and reduce the risk of restricture at the reconstructed site.[1]
Outcomes
The original Joshi / Bandini / Kulkarni 2022 cohort is small and described as preliminary. Outcomes were reported as promising, with the technique characterized as easy and reproducible.[1] Larger comparative series and long-term follow-up are needed.
The broader evidence does not directly establish MsANTA-specific functional benefit. The non-transecting evidence base — Chapman 2019 sexual-dysfunction signal,[4] Oszczudlowski 2023 meta-analysis,[5] Scandinavian RCT — is housed in the umbrella Non-Transecting Bulbar Urethroplasty article and supports the rationale for tissue preservation.
MsANTA in the Non-Transecting Family
| Feature | VS-EPA / ntEPA[2] | ANTA[3] | MsANTA[1] | MANTA[6] | ntAAU[7] |
|---|---|---|---|---|---|
| Initial report | VS-EPA 2007 / ntEPA 2012 | 2012 | 2022 | 2023 | 2025 |
| Spongiosum | Preserved | Preserved | Preserved | Preserved | Preserved |
| Mucosa | Excised | Excised | Preserved (incised) | Dorsal scar superficially excised | Excised |
| Approach | Dorsal or ventral | Dorsal | Dorsal or ventral | Ventral | Dorsal |
| Graft | None | Dorsal onlay BMG | Onlay BMG | Ventral onlay BMG | Dorsal onlay BMG |
| Ideal stricture | Short ≤2 cm | Obliterative core | Narrowed but viable mucosa | ≥2 cm with obliterative ≤1.5 cm | Long 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
- MsANTA / Joshi Step aims to spare mucosa in addition to spongiosum — preserving both the spongiosum and the native mucosa.[1]
- The technique evolved from ANTA (2012) by adding mucosal preservation: the strictured mucosa is incised and reconfigured rather than resected.
- Best suited for bulbar strictures with a narrowed but viable mucosa — not for nonviable mucosa or complete obliteration; choose the reconstruction according to the full defect.
- Preserves the communicant vessels from spongiosum to mucosa, theoretically minimizing ischemic injury to the urethral plate.
- Original 2022 cohort is small — described as easy and reproducible with promising preliminary outcomes; larger comparative series are needed.
Videos
References
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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European Association of Urology. EAU Guidelines on Urethral Strictures: disease management in males. 2026. Current guideline.
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European Association of Urology. EAU Guidelines on Urethral Strictures: perioperative care of urethral surgery. 2026. Current guideline.