Male Stress Urinary Incontinence (Post Prostatectomy Incontinence)
Laparoscopic robot-assisted implantation of artificial urinary sphincter (AUS) for stress urinary incontinence (SUI) is a procedure that combines the advantages of both a modern minimally-invasive approach and those of a proximal placement of the AUS cuff that is expected to decrease the risk of erosion in the long-term, to avoid the cuff compression leading to incontinence episodes when sitting and to avoid the risk of urethral lesions with catheterization [1,2]. The robotic AUS positioning at the level of the bladder neck in males with neurogenic SUI has been already reported . Herein, we aimed to report the case of a patient with post-transurethral resection of prostate (TURP) SUI in whom an AUS was placed in a periprostatic position using a transperitoneal robot-assisted approach.
A 78-year old men with severe post-TURP SUI was candidate for AUS implantation. He presented with gravitational incontinence (1800 g/24 hour at pad test) requiring a permanent condom catheter and due to urethral sphincter deficiency with normal detrusor function, capacity and compliance at urodynamics. He had a transobturator sling implanted five months before without any benefit. A minimally-invasive robotic approach was proposed, using a trans-peritoneal classical four-arm da Vinci Xi (Intuitive Surgical Inc., Sunnyvale, CA, USA) setting with two assistant port (12mm and 5mm) and 0° lens. A surgeon with expertise in both robotic prostatic surgery and male incontinence surgery (E.S.) performed the procedure. With patient in 27° Trendelenburg position and a urethral 12Ch Foley catheter inserted, an initial posterior approach to the recto-prostatic space from Douglas’ pouch was used, according to the Montsouris technique for radical prostatectomy . Dissection was performed behind the seminal vesicles and Denonvilliers fascia plane. After opening the Retzius’ space, the antero-lateral surface of the prostate was freed and the endopelvic fascia incised bilaterally so as to reach the space already dissected by the posterior pathway. The measuring tape was introduced through the 12mm port and the prostatic circumference assessed with the help of cystoscopic vision. A 10cm AMS800TM (Boston Scientific, Boston, MA, USA) cuff was introduced and placed around the prostate. A reservoir (61–70 cmH2O) was introduced by a small right iliac fossa incision and placed in the Retzius’ space. After cuff pressurization under cystoscopic control to account for the extravolume needed to fill the cuff and to confirm the appropriate urethral closure, all AUS components were extraperitonealized and the reservoir filled with 22 ml of saline solution. Finally, the pump was placed in a scrotal pouch, the AUS parts were connected and the system deactivated.
Total operative time was 185 min, with neglectable blood loss. The urethral catheter was removed on day three and the patient was discharged in the fourth postoperative day. The AUS was activated 6 weeks after surgery. At 6 months follow-up the patient was completely continent (no pad use), and no complications occurred.
In experienced centers, the laparoscopic robot-assisted placing of an AUS in a periprostatic position for post-TURP SUI appears to be a safe, minimally-invasive and effective procedure that offers the advantages of both the robotic approach and proximal position of the AUS. The Montsouris technique allows a direct and straightforward approach to the recto-prostatic space. This promising early experience warrants larger studies with long-term follow-up to draw definite conclusions on safety and efficacy of this approach in the post-TURP patients setting.