Neurogenic Stress Urinary Incontinence (NSUI) is often attributed to sphincter underactivity, and/or pelvic floor weakness with or without a concomitant open bladder neck [1,2]. Most patients achieve continence and quality of life (QoL) throught clean intermittent catheterization (CIC), however further treatment is needed sometimes. Despite the several options to manage SUI in the neurogenic adult population, consensus regarding the optimal treatment is still lacking. The simultaneous presence of severe storage neurological lower urinary tract dysfunction (N-LUTD) such as neurogenic detrusor overactivity (NDO) and lower compliance often complicates treatment decisions. Furthermore, the distortion of the urethral anatomy caused by neurogenic SUI surgery may result in difficulty in CIC and increased rate of complications [3].
Among the current treatment options are the artificial urinary sphincter (AUS), autologous/synthetic slings, adjustable continence therapy and bulking agents.
This work describes the technique of laparoscopic artificial urinary sphincter implantation by transperitoneal approach.

We present a 22 years-old paraplegic patient due to T10 spinal cord injury as consequence of car accident. He had severe urinary incontinence despite performing CIC 7-8 times per day. 
The pre-operative urodynamic study showed a good bladder compliance, a bladder hyposensitivity, without neurogenic detrusor overactivity and with an incompetent sphincter. He was proposed for a periprostatic AUS implantation after multidisciplinary discussion.

The patient is positioned in lithotomy with slight Trendelenburg. A transperitoneal approach was chosen and six ports were placed: one 11mm at the umbilicus; one11mm in the right pararectal line laterally to the umbilicus; another 11mm half-way between the umbilicus and the pubic symphysis, and further 3 ports of 5mm, two internal to the left and right anterior superior iliac spines and one in right pararectal line. 
Initially a posterior peritoneal incision at the rectovesical pouch is performed followed the dissection of the vas deferens and posterior bladder neck. Then, after opening the Retzius space and releasing the bladder, the endopelvic fascia is exposed bilaterally and  lateral prostate dissection is undertaken to identify the location of the bladder neck. The use of diathermy is reduced to attempt maximum nerve-sparing. After bladder neck dissection is completed with the aid of a right-angled dissector, the cuff size measure is taken (8cm bladder neck). A 9cm cuff is chosen due to the patient’s young age and small prostate size (<25cc).
Once the cuff is adequately situated, the measuring tape is removed and the two ends of the AUS cuff are ‘snapped’ together. The balloon is inserted empty thought a right inguinal incision and filled with 24cc of saline (pressure 71-80cmH2O). The tubing of the cuff and balloon are exteriorized via the same incision. A right-side subdartos scrotal tunnel is created for the pump placement. The AUS tubings are connected and the cuff is pressurized. The anterior and posterior peritoneum are re-apposed with running barbed suture to extra-peritonealize the cuff and the ballon. The device is deactivated at the end of the procedure. Operative time was 120 minutes. Bladder catheter was removed at day 1 post-operative and the patient was discharged at day 5 without reported complications.
The cuff was activated 6 weeks after surgery. No immediate post-operative complications were reported.

Laparoscopic assisted implantation of AUS is a feasible procedure in experienced hands with very few rates of immediate pos-operative complications. The minimally invasive approach provides better cosmesis and pain management with less blood loss. The AUS is the preferred treatment option in the neurological population with NSUI. Although it has a high surgical revision rate, it provides the best treatment modality to achieve continence.

Musco S, Ecclestone H, ’t Hoen L, Blok BFM, Padilla-Fernández B, Del Popolo G, et al. Efficacy and safety of surgical treatments for neurogenic stress urinary incontinence in adults: A Systematic Review. Eur Urol Focus. 2022;8: 1090–1102.
Farag F, Koens M, Sievert K-D, De Ridder D, Feitz W, Heesakkers J. Surgical treatment of neurogenic stress urinary incontinence: A systematic review of quality assessment and surgical outcomes. Neurourol Urodyn. 2016;35: 21–25.
Chartier-Kastler E, Guillot-Tantay C, Ruggiero M, Cancrini F, Vaessen C, Phé V. Outcomes of robot-assisted urinary sphincter implantation for male neurogenic urinary incontinence. BJU Int. 2022;129: 243–248.