Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine on exertion, sneezing, or coughing and affects between 10% and 40% of women, with significant implications for social functioning and mental health (1,3). The most commonly accepted surgical treatment for female SUI has been mid-urethral slings, which, despite high success rates, may lead to complications such as pelvic pain, dyspareunia, and mesh-related discomfort, and may be unsuitable for patients with intrinsic sphincter deficiency or recurrent incontinence (2). As noted in recent literature, there is a growing need for innovative approaches when standard therapies fail. Artificial urinary sphincters, while traditionally reserved for male patients, are increasingly being considered for complex female cases. Here, we present a novel subclitoral approach for AUS implantation in a female patient with severe stress-predominant UI.

A 51-year-old female with a BMI of 39 and a history of Kelly plication, anterior/posterior colporrhaphy, perineoplasty, and thyroidectomy presented with stress-dominant mixed urinary incontinence unresponsive to antimuscarinic therapy. Her comorbidities included asthma, hypertension, diabetes mellitus, and hypothyroidism. Physical exam revealed positive stress test in both standing and lithotomy positions. She was selected for AUS implantation via a subclitoral approach using the ContiClassic® Artificial Urinary Sphincter.

Under general anesthesia, a periurethral incision was made over and around the urethral meatus. Subclitoral dissection allowed safe mobilization of the urethra. The cuff was placed circumferentially around the bladder neck. A tunneling needle was used to guide the tubing into the retropubic space, where the pressure-regulating balloon was placed through a separate suprapubic incision. The control pump was positioned within the major labia. Urethral integrity was meticulously preserved throughout the procedure.

The early postoperative course was uneventful. No intraoperative or immediate postoperative complications occurred. At one-month follow-up, the patient reported a marked reduction in pad use and improved quality of life. There was no evidence of erosion, infection, or device malfunction.

The surgical management of female SUI remains a challenge in patients with complex comorbidities or recurrent disease following conventional therapies. In this context, subclitoral implantation of the ContiClassic® AUS represents a promising approach that has not yet been widely implemented. Although not minimally invasive, the technique is technically feasible and offers favorable short-term outcomes in terms of continence, safety, and patient satisfaction when performed with careful dissection and anatomical expertise. As concerns over synthetic sling complications grow, this approach may provide a viable alternative for individualized treatment. Further studies with larger cohorts and longer-term follow-up are necessary to validate its efficacy and safety.

Capobianco G, Madonia M, Morelli S, Dessole F, De Vita D, Cherchi PL, Dessole S. Management of female stress urinary incontinence: A care pathway and update. Maturitas. 2018 Mar;109:32-38. doi: 10.1016/j.maturitas.2017.12.008. Epub 2017 Dec 9. PMID: 29452779.
Fusco F, Abdel-Fattah M, Chapple CR, Creta M, La Falce S, Waltregny D, Novara G. Updated Systematic Review and Meta-analysis of the Comparative Data on Colposuspensions, Pubovaginal Slings, and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence. Eur Urol. 2017 Oct;72(4):567-591. doi: 10.1016/j.eururo.2017.04.026. Epub 2017 May 4. PMID: 28479203.
Hunskaar S, Burgio K, Diokno A, Herzog AR, Hjälmås K, Lapitan MC. Epidemiology and natural history of urinary incontinence in women. Urology. 2003 Oct;62(4 Suppl 1):16-23. doi: 10.1016/s0090-4295(03)00755-6. PMID: 14550833.