Stress urinary incontinence (SUI) is a common complication after radical cystectomy (RC) and ileal neobladder in both male and female patients. Because the cuff can be easily implanted around the bulbar urethra, the artificial urinary sphincter (AUS) is commonly used to treat post-RC SUI in male patients. Because there is no native bladder neck left to place the cuff and due to the technical challenge of the implantation, the use of AUS in female patients with post RC SUI and ileal neobladder has never been reported The objective of this video was to present a case of robot-assisted AMS 800 AUS implantation in a female patient with an history of radical cystectomy and ileal neobladder

We present the case of a 60-year-old female patient with an history of robot-assisted RC and intracorporeal ileal neobladder for a muscle invasive bladder cancer. She experienced severe SUI postoperatively. Despite pelvic floor muscle training, she was still needing six pads per day 12 months after the RC. SUI was demonstrated on cough stress test with no urethral hypermobility.There was no unhibited contraction of the neobladder on urodynamics and the maximum urethral closure pressure was 16 cmH2O.  She was offered two surgical options: pubovaginal sling or robotic bladder AUS implantation with clear information on the possible risks of AUS in her situation. She opted for the later option

The standard robotic AUS “anterior” implantation technique was used. The procedure was done transperitoneally. The neobladder was filled with saline right from the beginning to identify clearly its boundaries. There were some adhesions between the neobladder and the pubic bone which were freed carefully. The endoplevic fascia was reached on both sides of the bladder neck. The lateral aspects of the bladder were widely dissected. The right vaginal fornix wha dissected to find the vesicovaginal “bold” plane as previously described. Interestingly possibly due to the use a robotic intracoporea approach for the RC, there were no adhesions between the neobladder and the vagina. The same step wass performed on the left side. The neobladder neck was easily dissected under direct vision from one side to another, sized with the measuring tape and the cuff is inserted. The cuff size was 75 mm and a 51-60 cmH2O pressure regulating balloon was used. The operative time was 110 minutes and the patient was discharged on postoperative day 3 after removal of the catheter. There was no perioperative complications. The sphincter was activated after 6 weeks and a reoperation was needed at 3 months to relocate the pump. The patient had an improved continence still requiring two pads per day at 6 months follow-up

Robot assisted AUS implantation in female patients appears safe effective and feasible even in complex cases including women with an history of RC and ileal neobladder. The dissection of the neobladder neck was relatively easy. After 6 months of follow-up, the contact of the AUS cuff with the ileum did not cause adverse events.