MANTA Urethroplasty (Mucomucosal Anastomotic Non-Transecting Augmentation)
The MANTA urethroplasty — Mucomucosal Anastomotic Non-Transecting Augmentation — is a non-transecting bulbar urethroplasty described by Marks, Dahlem, and Janisch in 2023 (Hamburg) for bulbar strictures ≥2 cm with a focal obliterative segment ≤1.5 cm. It combines a dorsal mucomucosal anastomosis at the obliterative core with a ventral onlay BMG, all approached ventrally and preserving the corpus spongiosum.[1]
For the broader non-transecting family, see Non-Transecting Bulbar Urethroplasty, ANTA, MsANTA / Joshi Step, and ntAAU. For the transecting alternative, see Augmented Anastomotic Urethroplasty. For graft material, see Buccal Mucosa Graft.
Concept and Rationale
MANTA was developed for a specific anatomic problem: the bulbar stricture that contains a short obliterative core (≤1.5 cm) within a longer overall stricture (≥2 cm).[1]
- Pure EPA / VS-EPA would not span the longer surrounding narrowing.
- Pure dorsal onlay BMG cannot reconstruct the obliterative core.
- Transecting AAU carries the Redmond / Rourke 2020 HR 4.8 recurrence signal compared with pure dorsal onlay.[2]
- MANTA anastomoses the dorsal mucosa across the obliterative segment without transecting the spongiosum, then augments the entire strictured length with a ventral onlay graft.[1]
The result — circumferential reconstruction without spongiosal transection, preserving the bulbar arteries and communicant vessels.[3][4]
Indications
- Bulbar strictures ≥2 cm total length with a focal obliterative segment ≤1.5 cm[1]
- Penobulbar location is feasible (30% of the original Marks 2023 cohort)
- Redo cases (26% of the Marks 2023 cohort)
- Patients in whom preservation of the spongiosum is prioritized to reduce sexual dysfunction[3][5]
Contraindications / limitations
- Obliterative segment >1.5 cm — too long for safe dorsal mucomucosal anastomosis
- Lichen sclerosus
- Strictures suitable for pure dorsal onlay BMG (where transection / anastomosis is not needed)
Surgical Technique
Step 1 — Ventral approach. Stricture approached ventrally to avoid extensive dorsal mobilization. A perineal midline incision is made; the corpus spongiosum is exposed without transection.
Step 2 — Ventral urethrotomy. A ventral midline urethrotomy is performed through the strictured segment, opening the lumen for direct visualization.
Step 3 — Dorsal scar excision (superficial). At the level of the obliterative core, the dorsal scar is superficially excised while the spongiosum is left intact (non-transecting). Healthy dorsal mucosal edges are exposed proximal and distal to the obliterative segment.
Step 4 — Dorsal mucomucosal anastomosis. The healthy dorsal mucosal edges are brought together in a dorsal mucomucosal anastomosis — the "anastomotic" half of the technique. This is feasible because the obliterative segment is ≤1.5 cm.
Step 5 — Ventral onlay BMG. A buccal mucosal graft is placed as a ventral onlay to augment the entire strictured segment (including the just-anastomosed dorsal core) — the "augmentation" half of the technique. The graft is sutured to the ventral urethrotomy edges with absorbable sutures (5-0 / 6-0 PDS or Vicryl).
Step 6 — Closure. The corpus spongiosum is closed over the graft (spongioplasty); bulbospongiosus muscle and perineal tissues approximated. 16–18 Fr urethral catheter placed for 2–3 weeks.
The result is a neourethra of triangular cross-section — dorsal mucomucosal anastomosis + ventral graft — without spongiosal transection.[1]
Outcomes — Marks 2023 Hamburg Series
| Parameter | Result |
|---|---|
| Number of patients | 54 |
| Median follow-up | 41 months |
| Stricture inclusion criteria | ≥2 cm with obliterative segment ≤1.5 cm |
| Penobulbar location | 30% |
| Redo cases | 26% |
| Functional success | 93% |
| LUTS score (pre → post) | 13 → 3.5 (p < 0.001) |
| IIEF-EF (pre → post) | 27 → 24 (NS, p ≥ 0.4) |
| Patient satisfaction | 100% |
MANTA vs. Other Non-Transecting Variants
| Feature | VS-EPA / ntEPA[3] | ANTA[6] | MsANTA[7] | MANTA[1] | ntAAU[8] |
|---|---|---|---|---|---|
| Year | 2007 | 2012 | 2022 | 2023 | 2025 |
| Spongiosum | Preserved | Preserved | Preserved | Preserved | Preserved |
| Mucosa | Excised | Excised | Preserved (incised, not excised) | 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 |
| Anastomosis | Mucosa-to-mucosa | Mucosal | Mucosal | Dorsal mucomucosal at obliterative core | Mucosal |
| Ideal stricture | Short ≤2 cm | >2 cm with obliterative core | Narrowed but non-obliterated | ≥2 cm with obliterative ≤1.5 cm | Obliterative >2 cm |
| Success | 90–98% | 93% | preliminary (small cohort) | 93% | 90.5% |
Why MANTA Matters
Redmond / Rourke 2020 (n = 507) demonstrated that transecting augmented anastomotic urethroplasty (AAU) was independently associated with stricture recurrence (HR 4.8, p = 0.002) compared to pure non-transecting dorsal onlay.[2] MANTA addresses the same anatomic indication as transecting AAU — but without transection — and demonstrates 93% functional success at intermediate follow-up.[1] For the broader non-transecting evidence base (Chapman 2019 sexual-dysfunction signal,[5] Oszczudlowski 2023 meta-analysis,[4] Scandinavian RCT), see the umbrella Non-Transecting Bulbar Urethroplasty article.
Key Takeaways
- MANTA is the most recently described niche technique for the specific scenario of bulbar strictures ≥2 cm with an obliterative segment ≤1.5 cm.
- Ventral approach with dorsal mucomucosal anastomosis + ventral onlay BMG — circumferential reconstruction without spongiosal transection.
- 93% functional success in 54 patients at median 41 months; no significant change in IIEF-EF; 100% patient satisfaction.[1]
- Versatile — successfully used in 26% redo cases and 30% penobulbar strictures.
- Sits alongside ANTA, MsANTA, and ntAAU as variants of the augmented non-transecting concept; differentiated by ventral approach + dorsal mucomucosal anastomosis configuration.
Videos
References
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.