Here we present the management of a bladder neck cuff artificial urinary sphincter revision by way of a robot-assisted laparoscopic approach in a spinal cord injured patient. We describe in detail our surgical approach and demonstrate key points of the procedure to aid other surgeons undertaking this procedure.

A 67-year-old gentleman with T4 spinal cord injury following a motorbike accident underwent a robot-assisted laparoscopic revision of a bladder neck AUS. He had a significant background of prior sphincterotomy after urodynamic studies had identified a high pressure bladder with low compliance, which resulted in poor quality of life secondary to mixed urinary incontinence.  

Subsequent to sphincterotomy, our patientHe had  underwent a urethral sling insertion, suprapubic catheter insertion, and intravesical botulinum toxin. Despite urgency urinary incontinence being well controlled with intravesical botulinum toxin injection, stress urinary incontinence persisted. As a result, the patient was referred to our service leading to a robot-assisted insertion of an AUS. Whilst this intervention allowed for good initial control, 3-years post insertion the patient had worsening stress urinary incontinence and decision was made for revision of the AUS cuff size.

Dissection of the anterior pelvic peritoneum was commenced on the left-side (location of balloon reservoir) using a fenestrated bipolar and curved monopolar mayo scissor to open the space of Retzius (Figure 1). This dissection was then completed on the right-side of the pelvis. The bladder was not dissected completely free from the anterior pelvic wall such has been reported in other case series (1). The AUS tubing was identified and dissected to locate the balloon reservoir followed by the bladder neck cuff (Figure 2). The cuff was uncoupled using mayo scissors and removed via a small incision in the left lower quadrant. A tape measure was inserted and slung around the bladder neck, measuring a circumference of 5.5cm. An appropriately sized AMS 800 artificial urinary sphincter (Boston Scientific) was inserted and tied intracorporeally to the measuring tape, which then acted as a guide to place the cuff into an appropriate position around the bladder neck. The cuff was then coupled and secured. New tubing from the cuff was connected to old tubing of the balloon reservoir extracorporeally via the left lower quadrant incision using the AMS Quick Connect system (Boston Scientific) before being re-inserted into the left retropubic space. A flexible cystoscopy was performed via the exisiting SPC tract demonstrating appropriate bladder neck coaptation on device cycling. Washout of the left lower quadrant wound was performed using a gentamicin solution. Peritoneum was closed using a 3-0 V-Loc suture. The robot was undocked, wounds closed, and procedure concluded. 

The patient was given 24-hours of IV Cefazolin as prophylactic cover followed by a 5-day oral course of cephalexin 500mg BD. After a 4-night stay the patient was discharged home on simple analgesia. The AUS was activated intra-operatively given this was a continence preserving device rather than intended for voluntary voiding. The patient was reviewed routinely 6-weeks post-operatively with no complications identified and no further stress urinary incontinence.

Here we present our step-by-step approach to a robot-assisted laparoscopic revision of a bladder neck AUS in the hands of experienced functional and robotic urologists. We demonstrate the feasibility of this approach and guide readers as to the technical elements and key steps of a novel surgery. Given the increased utilisation of robot-assisted surgery, this article is designed to assist surgeons in the principals of robot-assisted AUS revision, as this is likely to become a more common operation in future.

Yates D, Phé V, Rouprêt M, et al. Robot-assisted laparoscopic artificial urinary sphincter insertion in men with neurogenic stress urinary incontinence. BJUI. 2013. https://doi.org/10.1111/bju.12072