Skip to main content

Non-Transecting Bulbar Urethroplasty

Non-transecting bulbar urethroplasty comprises repairs that preserve spongiosal continuity while reconstructing the narrowed urethra. Comparative evidence suggests fewer penile complications, with no detected difference in recurrence; an erectile-function benefit is less consistent. The operation can involve mucosal excision, a limited stricturoplasty or graft augmentation according to the defect. These approaches should not be treated as one identical procedure.[1][2][3]

Heineke-Mikulicz geometry: Generic luminal repair, conceptual sequence

A longitudinal incision across a short narrowing is closed transversely, widening the local lumen while shortening the segment. The closure axis rotates; the organ itself is not rotated. Tissue mobility, vascularity and appropriate defect selection limit this geometric principle. Related: Heineke-Mikulicz principle. (Original WARWIKI schematic; see the figure source record and review limits.)

Historical Development and Rationale​

The concept of spongiosa-preserving anastomotic urethroplasty was introduced by Jordan et al. in 2007 and formalized by Andrich and Mundy in 2012, who published the first dedicated series of non-transecting anastomotic bulbar urethroplasty.[4] Preserving viable spongiosum avoids unnecessary disruption of urethral blood supply. This is particularly relevant in non-traumatic strictures with superficial fibrosis. It is not a universal substitute for transection: nearly obliterative short straddle-injury strictures with full-thickness fibrosis are an established indication for tEPA. [18] Penile shortening and reduced glans filling are reported outcomes; a single ischemic mechanism has not been proven to explain all postoperative sexual symptoms.

By preserving the corpus spongiosum and its vasculature, ntBU aims to:

  • Maintain bulbar artery blood flow and minimize glans ischemia
  • Reduce de novo erectile dysfunction
  • Preserve a well-vascularized tissue bed for future redo surgery with grafts
  • Reduce penile shortening and chordee[3][5]

Indications​

  • Short bulbar strictures, usually around 2 cm or less, without full-thickness traumatic obliteration; longer defects may need a graft [18]
  • Posterior urethral strictures (88.5% success in one series of 26 patients)[5]
  • Both primary and recurrent strictures
  • Can be combined with buccal mucosal grafts for longer strictures (ANTA, MANTA, and ntAAU variants — see below)[11][12][13]

Surgical Technique​

The procedure is performed through a perineal incision in lithotomy position. Two main approaches exist — dorsal and ventral — sharing the core principle of spongiosal preservation.

Dorsal Non-Transecting Anastomotic Approach​

Jordan’s vessel-sparing repair and subsequent non-transecting modifications share a vascular-preservation aim but differ in dissection. The following summarizes the dorsal approach; scar depth and tissue viability determine how much spongiosum can be preserved.[3][5]

  1. Exposure: Midline perineal incision; bulbospongiosus muscle divided in the midline; corpus spongiosum fully mobilized from the corpora cavernosa.
  2. Dorsal urethrotomy: Expose the dorsal surface without excessive torsion of the preserved attachments. A dorsal midline urethrotomy is made through the strictured segment, extending into healthy urethra proximally and distally. The spongiosum is not transected.
  3. Mucosectomy: Fibrotic mucosal tissue is excised from within the intact spongiosa. The outer spongiosal shell and its blood supply are preserved throughout.
  4. Spatulation: Healthy mucosal edges are spatulated on opposite sides to widen the lumen.
  5. Anastomosis: A tension-free, mucosa-to-mucosa anastomosis is performed using 5-0 absorbable sutures (interrupted or running). The dorsal urethrotomy is then closed.
  6. Spongioplasty: The corpus spongiosum is re-approximated over the anastomosis with 4-0 absorbable sutures.
  7. Catheter: Catheter size and duration are tailored to the repair; selected uncomplicated short repairs may allow early removal. Urethrography should assess extravasation before removal. [19]

Ventral Approach​

Described independently by Morán et al. and Bogdanov et al. as an alternative that avoids extensive dorsal mobilization of the corpus spongiosum.[6][7]

  1. A ventral midline urethrotomy is made through the stricture.
  2. Mucosal scar tissue is excised (mucosectomy) while preserving the dorsal spongiosum.
  3. Healthy mucosal edges are approximated without tension.
  4. Mucosal closure is performed in a Heineke–Mikulicz fashion using 5-0 absorbable monofilament; spongioplasty with 4-0 absorbable suture.

The ventral approach avoids circumferential spongiosa mobilization, which may be advantageous in patients with prior ventral dissection or anatomic constraints.

Augmented Non-Transecting Techniques​

For strictures >2 cm or those with an obliterative component, the non-transecting principle has been extended by combining internal mucosectomy with buccal mucosal graft augmentation.

VariantDescriptionKey Outcome Data
ANTA (augmented non-transected anastomotic urethroplasty)Mucosectomy + dorsal onlay BMG; smaller graft than pure onlay BMG20/21 without further treatment; 93% was the combined 44-patient ANTA/onlay cohort. Median graft 4.5 versus 5 cm (p = 0.047)[11]
MANTA (mucomucosal anastomotic non-transecting augmentation)For strictures ≥2 cm with obliterative segment ≤1.5 cm; ventral modification93% functional success at median 41 months; IIEF-EF 27 → 24 (p ≥ 0.4); 100% patient satisfaction[12]
ntAAU (non-transecting augmented anastomotic urethroplasty with dorsal onlay BMG)42 patients; dorsal onlay technique90.5% anatomical success at median 18 months; median IIEF-5 of 22 postoperatively[13]

An important caveat for augmented repairs: in long bulbar strictures, transecting augmented anastomotic urethroplasty was independently associated with failure compared to non-transecting dorsal onlay (HR 4.8, p = 0.002), in a retrospective institutional comparison with an era change. It did not compare the named non-transecting augmented variants, and cannot establish transection as the cause of failure.[14]

Outcomes​

Stricture-Free Rates​

Multiple meta-analyses and comparative studies consistently demonstrate no significant difference in stricture recurrence between transecting and non-transecting approaches:

  • Multi-institutional comparative analysis (352 patients): 97.9% vs. 93.8% success (p = 0.18)[1]
  • Meta-analysis of 19 studies (Oszczudlowski et al.): pooled RR 1.06 (95% CI 0.82–1.36) — no difference[2]
  • Meta-analysis of 13 studies, 1,683 patients (Zhao et al.): no significant difference in success rate, Qmax, or overall complications[8]

Sexual Function and Penile Outcomes​

This is the primary domain of benefit for ntBU:

  • Multi-institutional analysis (Chapman et al., 352 patients): De novo sexual dysfunction 4.3% vs. 14.3% (p = 0.008). On multivariate analysis, only the transecting technique was independently associated with sexual dysfunction (p = 0.01); age, stricture length, etiology, and surgeon were not.[1]
  • Meta-analysis (Zhao et al., 1,683 patients): ntBU had a significantly lower incidence of erectile dysfunction compared to transecting bulbar urethroplasty (tBU); no differences in other perioperative outcomes.[8]
  • Meta-analysis (Oszczudlowski et al., 19 studies): ED risk ratio 0.73 (95% CI 0.49–1.08) — trending toward benefit but not statistically significant. Penile complications were significantly lower: RR 0.47 (95% CI 0.28–0.76, p < 0.05).[2]
  • Scandinavian Urethroplasty Study (Nilsen et al.) — randomized trial (151 patients): Compared transecting EPA to non-transecting BMG. tEPA had significantly more penile complications (p = 0.02), particularly reduced glans filling (p = 0.03) and shortened penis (p = 0.001). No difference in IIEF-5 scores. Recurrence was 12.9% in both groups, but the study was not powered to demonstrate equivalent recurrence risk.[9]
  • Lumen et al. (75 patients): De novo ED in 21.9% at 3 months, largely transient. Post-void dribbling in only 4.7%.[10]
  • Frankiewicz et al. multicenter IIEF analysis: Preoperative erectile function and younger age were the strongest predictors of erectile function preservation; diabetes was associated with worse short-term outcomes.[15]

2026 long-term randomized follow-up: Holm and colleagues again report more penile shortening and reduced glans filling after tEPA than BMG, with similar recurrence. This extends the original trial; it is not a randomized comparison of ntEPA, ANTA or MANTA. [20]

Other Perioperative Outcomes​

OutcomeNon-TransectingTransectingNotes
Overall complications4.3%8.1%Not statistically significant (p = 0.25)[1]
Learning curveNo association detected in one series—This does not establish absence of a learning curve; 75-pt tertile analysis[10]

Predictors of Outcomes​

  • Preoperative erectile function and younger age are the strongest predictors of postoperative erectile function preservation[15]
  • Diabetes is associated with worse short-term erectile function outcomes[15]
  • Complex strictures involving both penile and bulbar regions adversely affect long-term patency[15]
  • Stricture length ≥5 cm is associated with lower patency rates when augmented techniques are applied[16]
  • A small single-center analysis did not detect a learning-curve effect; this does not imply the operation needs no supervised learning[10]

Non-transecting techniques are increasingly favored within the reconstructive urology community. Among Society of Genitourinary Reconstructive Surgeons (GURS) members surveyed in 2024, dorsal graft placement was preferred (66%) over ventral (34%) for bulbar urethroplasty with BMG, and anastomotic urethroplasty remained preferred over BMG for short bulbomembranous strictures (63% vs. 37%).[17] The trend toward non-transecting approaches reflects accumulating evidence that vascular preservation reduces penile complications without compromising stricture-free rates — and that when augmentation is required for longer strictures, a retrospective comparison favored dorsal onlay over transecting augmented anastomotic repair, subject to selection and era confounding.[2][8][14]

Videos​

Non-Transecting Bulbar Urethroplasty
Operative technique

References​

  1. 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

  2. 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

  3. Virasoro R, DeLong JM. "Non-transecting bulbar urethroplasty is favored over transecting techniques." World J Urol. 2020;38(12):3013–3018. doi:10.1007/s00345-019-02867-8

  4. Andrich DE, Mundy AR. "Non-transecting anastomotic bulbar urethroplasty: a preliminary report." BJU Int. 2012;109(7):1090–1094. doi:10.1111/j.1464-410X.2011.10508.x

  5. Verla W, Oosterlinck W, Waterloos M, Lumen N. "Vessel-sparing excision and primary anastomosis." J Vis Exp. 2019;(143). doi:10.3791/58214

  6. Morán E, Sáez Moreno I, Bonillo MA, et al. "Ventral approach for the non-transecting bulbar urethroplasty." Urology. 2021;152:197–198. doi:10.1016/j.urology.2021.02.003

  7. Bogdanov AB, Veliev EI, Sokolov EA, et al. "Nontransecting anastomotic urethroplasty via ventral approach without full mobilization of the corpus spongiosum dorsal semicircumference." Urology. 2021;152:136–141. doi:10.1016/j.urology.2020.10.074

  8. Zhao X, Xing Y, Zhang X, et al. "Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis." J Sex Med. 2023;21(1):11–19. doi:10.1093/jsxmed/qdad141

  9. Nilsen OJ, Holm HV, Ekerhult TO, et al. "To transect or not transect: results from the Scandinavian Urethroplasty Study, a multicentre randomised study of bulbar urethroplasty comparing excision and primary anastomosis versus buccal mucosal grafting." Eur Urol. 2022;81(4):375–382. doi:10.1016/j.eururo.2021.12.017

  10. Lumen N, Poelaert F, Oosterlinck W, et al. "Nontransecting anastomotic repair in urethral reconstruction: surgical and functional outcomes." J Urol. 2016;196(6):1679–1684. doi:10.1016/j.juro.2016.06.016

  11. Welk BK, Kodama RT. "The augmented nontransected anastomotic urethroplasty for the treatment of bulbar urethral strictures." Urology. 2012;79(4):917–921. doi:10.1016/j.urology.2011.12.008

  12. 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

  13. 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

  14. 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

  15. Frankiewicz M, Białek Ł, Rydzińska M, et al. "Impact of urethroplasty on erectile function: a multicenter analysis of the International Index of Erectile Function score changes across different etiologies of urethral stricture." J Clin Med. 2025;14(9):2936. doi:10.3390/jcm14092936

  16. 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):1357–1361. doi:10.1016/j.urology.2013.02.012

  17. 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

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

  19. European Association of Urology. EAU Guidelines on Urethral Strictures: perioperative care of urethral surgery. 2026. Current guideline.

  20. Holm HV, Ohnesorge SS, Nilsen OJ. Long-term outcomes of transecting versus nontransecting bulbar urethroplasty: results from the Scandinavian Urethroplasty Study. Eur Urol Focus. 2026;12(3):316–318. doi:10.1016/j.euf.2026.05.007.