One of the potential advantages of the robot-assisted approach for artificial urinary sphincter (AUS) implantation in female patients would be to allow direct vision throughout the dissection of the bladder neck. However, this was not the case in the technique initially described (Fournier, Urology 2014) in which the posterior aspect of the bladder neck was dissected blindly. The objective of this video was to describe a change modified robotic anterior AUS implantation in female patients with constant direct vision during bladder neck dissection.

We present the case of a 57-year-old female patient with a history of TOT in 2017 referred recurrence of stress urinary incontinence. She was wearing 4 pads per day, with a 24h pad weight test of 350g. The cystoscopy did not show any sling extrusion. On physical examination, she had a positive cough stress test with a fixed urethra, no pelvic organ prolaps. On preoperative urodynamics, the maximum urethral closure pressure was 16 cmH2O, there was no detrusor overactivity but a poor bladder contractility (PdetQmax=14 cm H2O, Q max=13 ml/s), post-void residual=10 ml. She was offered four therapeutic options: pubovaginal sling, Bulkamid periurethral injections, Adjustable Continence therapy periurethral balloons or robotic AUS implantation and elected this later option.

The patient is placed in 23° Tredelenburg at 23° position with side-docking of the Da Vinci Xi Robot . A transperitoneal approach is used. After bladder filling, the Retzius space is dissected to reach the endopelvic fascia on bothside of the bladder neck. The lateral aspects of the bladder are dissected extensively on both sides. Dissection of the vaginal fornix helped by the assistant finger placed in the vagina is more extensive than in the initial technique, aiming to free the fingertip widely. This will allow a large mobilization of the bladder neck during the dissection granting a direct vision during the dissection of the posterior aspect of the bladder neck using the medial prograsp as a retractor to move the bladder neck medially and upwards.

We describe here a modified anterior technique of robotic AUS implantation in female patients that allows continuous direct vision during the bladder neck dissection and may reduce the risk of intraoperative bladder neck and vaginal injury

Continence 2S2 (2022) 100488
DOI: 10.1016/j.cont.2022.100488