The Mucosal‐sparing Augmented Non‐Transected Anastomosis ( <scp>MsANTA)</scp> principle for tubular organs

In the field of reconstructive surgery, innovations often begin at the operating table. We would like to share an observation that has become a frequent step in our daily practice. In 2020 Dr Pankaj was performing an augmented urethroplasty with a dorsal onlay technique. I was standing behind him and noticed he was giving a couple of extra sutures to the urethral plate. That manoeuvre was out of our standard protocol. I was curious and asked him: ‘What are you doing there Pankaj?’. He replied: ‘I am just aligning the mucosal edges to widen the narrowest segment; it takes one more minute before closing the urethra’. I answered: ‘Keep doing it’. What Dr Pankaj was doing, follows a worldwide applied principle: the Heineke–Mikulicz stricturoplasty [1] but based on the augmented non-transecting anastomosis for bulbar strictures during dorsal approach [2]. From clinical observation, patients with near-obliterative strictures often develop high voiding pressures in the proximal urethra. With time, this constant pressure usually causes dilatation of the urethra, proximal to the stricture. We use this dilated urethral mucosa to anastomose it to the distal healthy urethra, folding down or burying the nearly obliterative point. In this way, the narrowest part becomes the widest, with a mucosa-sparing technique: the Mucosal-sparing Augmented non-Transected Anastomosis (MsANTA) (Fig. 1). The preserved mucosa re-epithelializes, and with the augmentation, the result is a good calibre urethra. Slowly, MsANTA became common in our daily practice, and after proving good outcomes we published our experience [3]. In urethral reconstruction, we kept performing MsANTA not only in the ventral wall during dorsal augmentation of the bulbar urethra, but also in the dorsal wall during ventral approach, lateral walls during Asopa inlay, complex hypospadias, and even in revision of anastomosis between urethral mucosa and tubularised flaps. Moreover, during reconstruction of ureteric strictures by robot or laparoscopy, we usually augment the stricture site with buccal mucosa graft. It was not until 2 years ago that we realised MsANTA can be applied at the narrowest point in the ureter too, obtaining promising outcomes [4]. We believe that MsANTA might represent a general principle of reconstruction. By keeping our minds open to discussion and creativity, we may recognise more areas of application: urethra, ureter, fallopian tubes, vagina, oesophagus, bowel, rectum, arteries, veins, lymphatics, ducts. Born from experience in the operating room, the extrapolation of MsANTA across specialties could provide colleagues from all over the world with a reproducible, low-cost, and time-saving tool for the reconstruction of any tubular organ in the human body. Nothing is declared.