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Transmeatal OMG Ventral Inlay (Nikolavsky)

The transmeatal oral mucosal graft (OMG) ventral inlay urethroplasty, developed by Dmitriy Nikolavsky at SUNY Upstate Medical University, is a minimally invasive, single-stage, glans-sparing technique that delivers a buccal mucosal graft entirely through the urethral meatus — without any perineal or penile incision. It achieves 95% success at 36 months (single-center, 44 patients) and 95% at 17 months in a 12-institution multi-institutional validation (68 patients), with same-day discharge and no fistula, glanular dehiscence, graft necrosis, or chordee reported in any series.[1][2]

For graft material, see Buccal Mucosa Graft. For the dorsal-inlay variant in fossa navicularis, see Sliding-T Dorsal Inlay. For the broader Asopa principle, see Asopa Dorsal Inlay OMG. For minced-BMG / endoscopic delivery concepts, see Liquid / Minced Buccal Mucosal Graft.

Concept and Rationale​

Traditional urethroplasty for fossa navicularis and distal urethral strictures requires either glans splitting, circumferential urethral mobilization, or perineal / penile incisions — each carrying risks of cosmetic deformity, sexual dysfunction, and prolonged recovery. The Nikolavsky technique addresses these limitations by performing the entire reconstruction transurethrally through the meatus, leveraging the natural access point of the distal urethra.[1][2]

The key insight: the ventral wall of the fossa navicularis and distal urethra is accessible through the meatus, and a ventral urethrotomy can be performed under direct vision to excise scar tissue and create a graft bed — all without external incisions. The BMG is then delivered through the meatus using a suture-based "pull-through" technique and quilted in place.[1]

Step-by-Step Technique​

The procedure is accomplished in four steps as described by Sterling, Daneshvar, and Nikolavsky (2023).[1]

Exposure and scar excision​

  • Patient supine; meatus retracted with stay sutures or a small self-retaining retractor.
  • Under direct vision through the meatus, the cicatrice is excised via a transurethral ventral urethrotomy.
  • The ventral urethrotomy is carried through the strictured segment until the urethral lumen is at least 24 Fr (confirming adequate scar excision), creating a ventral trough exposing the underlying corpus spongiosum.

Graft delivery (the "pull-through")​

  • A buccal mucosal graft is harvested from the inner cheek using standard technique and defatted.
  • The graft is trimmed to a triangular shape — wider at the meatal end and tapering proximally to match the geometry of the ventral urethrotomy defect.
  • A double-armed 6-0 polydioxanone (PDS) suture is placed through the proximal (narrow) end of the triangular BMG.
  • The suture needles are passed transurethrally to the proximal extent of the urethrotomy and brought out through the ventral penile skin externally.
  • By pulling on the suture externally, the graft is delivered through the meatus and advanced to the proximal extent of the urethrotomy (the "pull-through" maneuver).
  • The suture is secured externally over a bolster on the ventral penile skin, anchoring the proximal graft in position.

Graft fixation and quilting​

  • The distal (wide) end of the graft is secured to the meatal edges with 5-0 polyglactin (Vicryl).
  • Additional 6-0 double-armed PDS quilting sutures are placed through the graft and underlying tissue for spread fixation, serving two functions: prevent graft contracture by maintaining the graft in a spread, flat configuration, and eliminate dead space between the graft and underlying bed (promoting imbibition and inosculation).
  • The graft sits on the ventral corpus spongiosum, the vascularized graft bed.

Catheter placement and closure​

  • A 16 Fr silicone urethral catheter is placed through the reconstructed urethra, serving as a stent to maintain patency and compress the graft against its bed during healing.
  • No external incisions are closed — the entire procedure is performed through the meatus.
  • Patients are discharged the same day.

Postoperative protocol​

  • Same-day discharge.[1][2]
  • Catheter removal and void trial at 1 week — significantly shorter than the 2–3 wk catheterization typical of open urethroplasty.[1]
  • Follow-up with uroflowmetry, PVR, IPSS, SHIM.
  • Cystoscopy for surveillance of graft take and stricture recurrence.

Clinical Outcomes​

StudyDesignnMedian stricture lengthEtiologyMedian OR / EBLSuccessFollow-up
Daneshvar 2020 (multi-institutional, 12 centers)[2]Retrospective68 (57 with ≥12 mo FU)2 cm (IQR 2–3)LS 34%; iatrogenic 28%; idiopathic 22%; other 16%72 min / 20 mL95% (54/57)median 17 mo (IQR 13–22)
Sterling 2023 (single-center, originating institution)[1]Retrospective44FN / distalmixed120 min (median)95% (42/44)median 36 mo (IQR 22–50)
Tolbert 2025 — TraMUS extension to penile[3]Retrospective13 (11 with ≥12 mo FU)avg graft 6.5 cm (range 3–15)iatrogenic 46%; hypospadias 23%; LS 15%—91% (10/11)median 14 mo (range 11–28)

Multi-institutional validation (Daneshvar 2020)​

The most important study validating the generalizability of the Nikolavsky technique — the procedure was successfully reproduced across 12 different institutions with varying levels of experience.[2]

  • Qmax improved from 5 to 18 mL/s (p < 0.001).
  • The 2 recurrences were found to have urethral stenosis that extended more proximally than the original repair — failures attributable to underestimation of stricture length rather than graft failure.
  • Both recurrences were successfully treated with dorsal onlay buccal urethroplasty (open technique).
  • Significant improvements in Qmax, PVR, IPSS, and QOL scores.
  • No difference in postoperative sexual function scores (SHIM unchanged, p = 0.85).

TraMUS — extension to penile urethral strictures (Tolbert 2025)​

In 2025, Tolbert et al. at the Mayo Clinic described an extension of the Nikolavsky technique to penile urethral strictures, termed TraMUS (Transmeatal Urethral Surgery).[3]

  • Same transmeatal ventral inlay principle, with longer grafts (avg 6.5 cm, range 3–15 cm).
  • Includes patients with lichen sclerosus and hypospadias — traditionally considered indications for staged urethroplasty.
  • 91% success at 1 yr (10/11 evaluable); the single failure occurred at 3 mo.
  • 1 patient (9%) developed de novo incontinence — a complication not seen in the fossa navicularis series, possibly related to more proximal extent.
  • No other procedure-related complications.
  • Further studies needed to confirm long-term efficacy and compare to traditional open penile urethroplasty.

Advantages​

  1. No external incision — entire procedure performed through the meatus; eliminates wound complications, preserves penile skin, no visible scarring.[1][2]
  2. Glans-sparing — glans never split, preserving cosmesis, sensation, and vascularity.
  3. No circumferential urethral mobilization — preserves urethral blood supply, reduces ischemic complications.
  4. Same-day discharge.[1][2]
  5. Short catheterization (1 wk) — vs 2–3 wk for most open urethroplasty.[1]
  6. Preserved sexual function — SHIM unchanged in both single-center and multi-institutional series (p = 0.85).[2]
  7. Generalizable — multi-institutional study across 12 centers confirmed reproducibility.[2]
  8. Low complication rate — zero fistula, zero glanular dehiscence, zero graft necrosis, zero chordee across all series.[1][2]
  9. Short operative time — median 72 min in the multi-institutional series.[2]

Comparison with Other Distal-Urethral Techniques​

TechniqueApproachnSuccessFollow-upDischargeKey AdvantageKey Limitation
Nikolavsky transmeatal ventral inlay[1][2]Transmeatal (no incision)44 (single); 68 (multi)95%36 mo; 17 moSame dayNo incision; same-day discharge; 1-wk catheterLimited to distal / FN strictures (original)
TraMUS — penile extension[3]Transmeatal1391%14 moSame dayExtends Nikolavsky to penile stricturesVery early data; 1 incontinence case
Sliding-T dorsal inlay (Rourke)[4]Open (ventral urethrotomy)2792.4%29.6 moOvernightSimultaneous meatal reconstruction; high LS successSingle-center; open approach
Transurethral dorsal inlay (Vanni)[5]Transurethral1693.8%28.8 mo—Glans-sparing; transurethralShorter strictures (1.7 cm); small series
Dorsal inlay BMG (Zumstein / Hamburg)[6]Open3269%42 moOvernightLongest follow-up for dorsal inlay50% hypospadias; lower success
Meatotomy (Meeks / Barbagli)[7]Open7387%61 moSame daySimplest approachNo graft; limited to short strictures

Graft Biology — Why Ventral Inlay Works​

  • Graft bed — placed as an inlay into the defect created by the ventral urethrotomy, sitting on the ventral corpus spongiosum (well-vascularized for imbibition and neovascularization).[1][2]
  • Triangular graft shape — matches the natural geometry of the fossa navicularis and prevents redundant tissue that could cause sacculation or diverticulum formation.[1]
  • Quilting sutures — spread fixation prevents graft contracture (recurrence) and eliminates dead space (hematoma / seroma → graft failure).[1]
  • No sacculation risk — unlike traditional ventral onlay in the bulbar urethra (associated with pseudodiverticulum formation in up to 26% of cases), the ventral inlay in the distal urethra does not appear to carry this risk — zero sacculations across all series.[2][8]

Patient Selection​

Ideal candidates (original indication)[1][2]​

  • Fossa navicularis strictures (1–3 cm)
  • Recurrent meatal / distal strictures that have failed endoscopic management
  • Lichen sclerosus-related distal strictures (34% of multi-institutional cohort)
  • Patients desiring minimally invasive, same-day surgery with rapid recovery

Expanded indications (TraMUS)[3]​

  • Penile urethral strictures (graft lengths up to 15 cm)
  • Iatrogenic, LS, and hypospadias-related penile strictures
  • Patients who wish to avoid open penile urethroplasty

Contraindications / limitations​

  • Obliterative strictures where the ventral urethral plate is completely destroyed — the technique requires a viable ventral graft bed.
  • Very long panurethral strictures — TraMUS has used grafts up to 15 cm but long-term data are lacking.
  • Strictures extending into the bulbar urethra — the 2 recurrences in the Sterling series were found to have more proximal disease than initially appreciated; accurate preoperative stricture length assessment is critical.[1]

Guideline Context​

The AUA Urethral Stricture Disease Guideline Amendment (2023) recommends offering urethroplasty to patients with recurrent meatal or fossa navicularis strictures (Moderate Recommendation, Grade C), noting that LS-related strictures are more likely to be reconstructed successfully using oral mucosal grafts.[9] The multi-institutional validation data support the Nikolavsky technique within this recommendation framework.

Limitations and Future Directions​

  • No randomized controlled trials — all evidence is from retrospective case series. A prospective RCT comparing the Nikolavsky technique to open dorsal inlay or staged urethroplasty would be valuable.
  • Intermediate-term follow-up — longest follow-up is 36 months. Given that stricture recurrence can occur years after urethroplasty (particularly in LS), longer follow-up is needed to confirm durability.[1]
  • TraMUS extension is very early — 13 patients with 14-month follow-up; the 9% incontinence rate and inclusion of complex etiologies warrant cautious interpretation.[3]
  • Surgeon learning curve — the multi-institutional study demonstrated generalizability, but the technique requires comfort with transurethral suturing and graft manipulation.
  • Adjacent endoscopic-suturing approaches — Ungerer 2023 described a fully endoscopic urethroplasty using the RD 180 suturing device for membranous strictures — a conceptually related but technically distinct approach extending minimally invasive urethroplasty to the posterior urethra.[10]

Key Takeaways​

The Nikolavsky transmeatal ventral inlay BMG urethroplasty represents a paradigm shift in management of fossa navicularis and distal urethral strictures — achieving 95% success rates comparable to open urethroplasty while offering no external incision, same-day discharge, 1-week catheterization, and preserved sexual function.[1][2] The multi-institutional validation across 12 centers confirms generalizability, and the recent TraMUS extension to penile urethral strictures (91% at 1 yr) suggests applicability may expand further.[3] It is currently the most extensively validated minimally invasive urethroplasty technique in the literature.

Videos​

Transmeatal OMG Ventral Inlay
Operative technique
Transmeatal OMG Ventral Inlay
Operative technique

References​

  1. Sterling J, Daneshvar M, Nikolavsky D. Transurethral ventral inlay buccal mucosa graft urethroplasty: technique and intermediate outcomes. BJU Int. 2023;132(1):109-111. doi:10.1111/bju.16007.
  2. Daneshvar M, Simhan J, Blakely S, et al. Transurethral ventral buccal mucosa graft inlay for treatment of distal urethral strictures: international multi-institutional experience. World J Urol. 2020;38(10):2601-2607. doi:10.1007/s00345-019-03061-6.
  3. Tolbert SN, Findlay BL, Ungerer GN, et al. Transmeatal urethral surgery (TraMUS): technique and one-year outcomes in the management of penile urethral strictures. World J Urol. 2025;43(1):338. doi:10.1007/s00345-025-05718-x.
  4. Hoare D, Fersovich JH, Saavedra A, Rourke KF. Single-stage reconstruction of fossa navicularis strictures using a "sliding-T" dorsal inlay urethroplasty with buccal mucosal graft. Urology. 2021;152:201-202. doi:10.1016/j.urology.2020.12.031.
  5. Farrell MR, Campbell JG, Zhang L, Nowicki S, Vanni AJ. Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty. World J Urol. 2022;40(6):1523-1528. doi:10.1007/s00345-022-03994-5.
  6. Zumstein V, Dahlem R, Maurer V, et al. Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options. World J Urol. 2020;38(10):2609-2620. doi:10.1007/s00345-019-03035-8.
  7. Meeks JJ, Barbagli G, Mehdiratta N, Granieri MA, Gonzalez CM. Distal urethroplasty for isolated fossa navicularis and meatal strictures. BJU Int. 2012;109(4):616-9. doi:10.1111/j.1464-410X.2011.10248.x.
  8. Dubey D, Kumar A, Bansal P, et al. Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques. BJU Int. 2003;91(3):215-8. doi:10.1046/j.1464-410x.2003.03064.x.
  9. 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.
  10. Ungerer G, Kemble J, Sischka M, Balzano FL, Warner JN. Endoscopic urethroplasty using buccal graft for male membranous urethral stricture. Urology. 2023;181:e200-e203. doi:10.1016/j.urology.2023.05.059.