Artificial urinary sphincter (AUS) implantation remains the gold standard for the treatment of severe male stress urinary incontinence. However, patients with fragile urethras present a major surgical challenge. The risk of urethral erosion, infection, and device failure is significantly higher. Several urethral reinforcement strategies have been proposed, including transcorporal cuff placement. We describe a novel urethral protective technique combining bilateral corpora cavernosa flaps with an interposed abdominal aponeurosis graft to provide multilayer reinforcement during AUS cuff placement in fragile urethras.

This is a video showing the operative steps and outcomes of a new urethral reinforcement technique. The procedure was performed in patients considered high risk for urethral complications undergoing primary or revision AUS implantation.
After standard perineal exposure of the bulbar urethra, the corpora cavernosa are identified and square shape incisions are made bilaterally to create two vascularized corpora cavernosa flaps. These flaps are mobilized medially and a rectangular aponeurosis graft is harvested from the anterior abdominal wall through a small suprapubic incision. The graft is tailored and placed ventrally under the urethra, creating a protective interface between the urethra and the cuff. The two corpora cavernosa flaps are then rotated medially and sutured over the graft, forming a multilayer protective “sandwich” composed of urethra, aponeurosis, and vascularized corporal tissue. The AUS cuff is subsequently positioned around this reinforced segment in standard fashion, and the device is completed per routine technique. Dorsally, the corpora cavernosa was closed with the remaining flap of aponeurosis
Primary endpoints included perioperative safety ando one year continence outcomes.

Four patients with fragile urethras underwent AUS implantation using this technique. All patients had significant risk factors for urethral complications, as shown on the vídeo.
The procedure was successfully completed in all cases without intraoperative complications. No urethral injuries occurred during dissection or cuff placement. Postoperative recovery was uneventful in all patients, and no early infections, erosions, or device explantations were observed during follow-up.
After device activation, all patients achieved good continence outcomes, defined as social continence (0–1 safety pad per day). No cases of early urethral atrophy or mechanical malfunction were identified during short-term follow-up.

Fragile urethras remain one of the most challenging scenarios in AUS surgery due to the high risk of erosion and device failure. The described technique combines vascularized corpora cavernosa flaps with an interposed abdominal aponeurosis graft to provide a complete urethral protection during cuff placement. In this preliminary series, the technique was feasible, safe, and associated with encouraging early continence outcomes and absence of early erosions.