Mucosal‐sparing augmented non‐transected anastomotic (MsANTA) urethroplasty: a step forward in ANTA urethroplasty

Abstract

The surgical advancement of urethral reconstruction is a rapidly moving field. In the last decade, the technique for bulbar urethroplasty has evolved towards less invasive approaches with minimal transection and more tissue sparing in order to increase the patency rate. In this study, we provide a step forward in the augmented non‐transected anastomotic (ANTA) urethroplasty proposed in 2012, with a true mucosa‐sparing modification of the technique. In detail, the bulbar urethral lumen is approached with either a ventral or dorsal urethrotomy. Differently from previous techniques, the native urethral mucosa is neither transected nor resected but is reconstructed with a direct mucosa‐to‐mucosa anastomosis. This allows a complete sparing of communicant vessels that come from the corpus spongiosum to the urethral mucosa. The technique aims to preserve the native vascularity of the urethral mucosa by enlarging the native urethral plate with a direct anastomosis at the level of the stricture, and without the need for resection. In our hands the technique was easy and reproducible, and it carried promising results in the preliminary cohort where it was applied.

Mucomucosal anastomotic non‐transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures

“…A MANTA is not necessarily dependent on stricture length, as our patients' graft length ranged from 2 to 10 cm. In line with one previous report of ventral resection and dorsal augmentation [28], we observed that the crucial part of the procedure, the dorsal resection of the narrowest, scarred mucosal segment, can be sufficiently performed in obliterative segments up to 1.5 cm, still allowing for generating a sufficient dorsal urethral plate and a tension-free anastomosis.…”

“…For AAU, most surgeons rely on dorsal grafting, albeit no difference in efficacy has been shown in a series comparing dorsal vs ventral positions [27]. The same holds true for ntAAU, only one recent very small series has mentioned ventral grafting as an option and performed a ventral ntAAU in three patients [28]. Pending results from the DoVe trial (NCT04551417), the comparative effectiveness of different grafting positions is not known and has not been undergirded by high-level evidence [1,4].…”

“…The six-item LUTS score, as derived from the USS PROM, significantly improved from a baseline median (IQR) score of 13 (8)(9)(10)(11)(12)(13)(14) to postoperative median (IQR) score of 3.5 (1-8) (P < 0.001). In sexually active patients, there were no differences in the median baseline vs postoperative IIEF-EF scores (median [IQR] 27 [17][18][19][20][21][22][23][24][25][26][27][28][29][30] vs 24 [14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]; P = 0.4). Similarly, no differences were found in the median ICIQ-UI sum scores (median [IQR] 0 [0-8] vs 0 [0-7]; P = 0.5).…”

Controversies of mucosa and spongiosum preservation in non‐transecting augmented anastomotic repair

“…This choice is due to the more acute penobulbar angle observed on the dorsal aspect, making it more intuitive to place an onlay on the shallower ventral site. However, in instances where the dorsal urethral bed exceeds 0.5 cm, we frequently employ the technique outlined by Joshi et al [5], known as the mucosal-sparing approach (MsANTA). This method involves gathering the lateral mucosal edges to expand the width of the dorsal bed without the need of disrupting mucosal integrity.…”

Future directions in urethroplasty: emphasising mucosal preservation and reducing graft dependency

“…Our belief in preserving mucosal vessels for effective healing reinforces the importance of retaining mucosa at any cost. Additionally, as described in our own publication [4], reconstructing the dorsal urethral plate is more complex in ventral approaches due to the limited dorsal mobility of the urethra, making the joining of urethral mucosa with sutures more challenging. Therefore, when planning this reconstruction, we advocate for a dorsal approach.…”