Since the first robotic AUS implantation in 2014, many urologists have reported their experiences with this operation. We aimed to investigate the effectiveness and safety of robot-assisted artificial urinary sphincter (AUS) implantation surgery for female patients with severe stress urinary incontinences (SUI).

The study complied with the Cochrane Methods Group for the Systematic Review and Meta-analysis, and referred to Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). There was no need for IRB approval because all data were derived from open-sourced studies. A comprehensive search was carried out across multiple databases, including PubMed, EMBASE, Web of Science Clarivate, Cochrane library, Medicine and clinicaltrials.gov between inception to March 2022. Studies were included if they met the inclusion criteria and were evaluated by different quality evaluation methods according to study types. P value and 95% confidence intervals (CI) of outcome measures mainly including continence rates, intraoperative and postoperative complication rates were pooled to present the efficacy and safety.

A total of 9 studies with 157 participants were finally included. Eight retrospective and one prospective study met the inclusion criteria with moderate and high evidence levels. The pooled results showed that patients with robot-assisted AUS implantation treatment, presented great continence rate (P=0.83, 95%CI:0.76-0.89) but high complication rate (Intraoperation: 0.21 95%CI:0.11-0.34; Postoperation: 0.20 95%CI: 0.12-0.29). In addition, compared with the posterior approach, the classical surgical approach had better efficacy and safety.

The results of this study indicate that robot-assisted AUS implantation surgery is effective for patients, but the incidence of complications is at a high level. Previous studies have reported that compared with traditional open access, endoscopic technology has better vision and less abdominal injury. Compared with laparoscopic technology, the robotic benefits of magnified vision and endowrist instrumentation could improve the surgical ease of the procedure.
The high incidence of complications may result from the following reasons. First, as a new technology, robot-assisted AUS implantation surgery is still in an exploratory stage, and its best surgical approach and surgical method are still under continuous experiment. There are slight differences in surgical approaches and methods reported in various included literature. For example, Gondran Tellier attempted to enter from the posterior approach, Peyronnet used fingers to assist in the separation of bladder and vagina. Secondly, the operator experience of robotic surgery is also the critical factor affecting the occurrence of intraoperative complications. In the separation of vagina and bladder, the doctor's surgical technology, experience, and the surgical team's cooperation directly affect the incidence of bladder and vaginal injury. Several articles also mentioned that the complication rates decreased significantly with the change of learning curve. Moreover, many patients with robot-assisted AUS implantation surgery have a history of pelvic surgery, so the pelvic adhesion is severe during the operation, which affects the surgical exposure and the anatomy of important structures, resulting in more intraoperative injury.

The results of this study indicated that robot-assisted AUS implantation surgery improved SUI patients’ urinary continence ability, but the complication rates were at a high level, which mainly included intraoperative vaginal and bladder injury and postoperative acute urinary retention. We also look forward to more large sample studies to provide guidance and preference for clinical practice.

Lucas MG, Bosch RJ, Burkhard FC, et al. EAU guidelines on surgical treatment of urinary incontinence. Actas urologicas espanolas. Sep 2013;37(8):459-7doi:10.1016/j.acuro.2013.02.002
Biardeau X, Rizk J, Marcelli F, Flamand V. Robot-assisted laparoscopic approach for artificial urinary sphincter implantation in 1women with urinary stress incontinence: surgical technique and initial experience. European urology. May 2015;67(5):937-4doi:10.1016/j.eururo.2014.12.041