Hypothesis / aims of study
For women with moderate to severe stress urinary incontinence (SUI), synthetic or autologous urethral slings are the gold standard worldwide. Sling failure rate is ~10-15% but can be much higher for SUI related to intrinsic sphincter deficiency (ISD) as opposed to hypermobility. While the AUS is standard of care for men with moderate-to-severe SUI, it is an emerging approach in women especially for ISD who have failed prior continence surgeries. Adoption of the robotic technique in women has been influenced by countries’ regulatory authorities and variable international guidelines. This procedure is uncommonly performed in the United States due to FDA restrictions. We report the initial experience in Australia and New Zealand of implementing robotic AUS for women with SUI.
Study design, materials and methods
A multi-institution series of 20 women who underwent AUS for SUI was collected prospectively, March 2022 to March 2026. The series included five surgeons, five institutions and two countries (Australia and New Zealand). Perioperative, complication and early continence outcomes were collected.
Results
Mean age was 63yo, 19 patients had non-neurogenic and one had neurogenic SUI. Mean pre-operative pads per day was 7, mean abdominal leak point pressure on urodynamics was 51cmH2O. 19 patients had prior incontinence surgeries; 15 had a combination of both sling(s) and bulking agent, one bulking only, two sling only, one had a prior AUS insertion. The patient with neurogenic SUI did not have prior SUI procedures.
The majority had an anterior approach to surgical dissection (n=18) and two patients had a combined anterior and posterior approach. There were six patients with intraoperative injuries (30%); five vaginal, one bladder and vaginal injury, however all proceeded to AUS implantation. Mean operative time was 308 minutes factoring in complex dissection after multiple prior surgeries. Median cuff size was 7.5cm.
Median catheterisation time was 2 days, mean length of hospital stay was 2.5 days. There were 6 minor Clavien complications (4 cases of retention requiring catheterisation, 1 case of prolonged catheterisation for bladder injury, 1 UTI/thrush). There were no major complications (Clavien III-V). There were 4 revision surgeries (20%) and 2 explants (10%) in 5 patients. Revisions include 1 pump moved to the other side, one cuff exposed in the vagina requiring closure with Martius flap, 1 vaginal flap performed as cuff felt during intercourse, 1 cuff downsized. Explantations include one in a patient who had a subsequent spinal surgery with prolonged catheter and continence regressed, she went on to have a bladder neck closure and SPC. Second explantation occurred in a patient who went on to have a cystectomy for refractory overactivity, AUS was functional at the time of explantation.
Two patients have received adjunct procedures: One intradetrusor botox injections for detrusor overactivity and one SNM for detrusor underactivity.
At last follow up 65% (13/20) of patients were completely dry and 30% (6/20) had improved continence. One patient was dry initially but regressed after a prolonged catheterisation following spinal surgery. Mean follow up was 11.3 months [1-34mths].
Interpretation of results
Robotic AUS in women has been safely introduced in Australia and New Zealand with comparable perioperative and continence outcomes to international literature.