Female stress urinary incontinence (SUI) is highly prevalent. Artificial urinary sphincter is an option for severe or complex female SUI cases. In case of bladder neck cuff extrusion, AUS explantation is required and further SUI treatment (AUS reimplantation or others) can be challenging. In the present video, we report and describe a new surgical technique aiming both to treat AUS bladder neck extrusion and to prevent recurrence of SUI.

We present the case of a 43-year-old female patient with a history of urethrovaginal fistula after the excision of a paraurethral leiomyoma. After   urethrovaginal fistula repair with a Martius flap interposition she reported severe SUI. After failure of two TVT slings, she still reported SUI with 350 g on 24h pad weigh test, massive leakage on cough stress test with a fixed urethra. She underwent robotic AUS implantation with complete resolution of SUI postoperatively. Six months after the implantation, she presented a recurrence of the SUI and urethral pain. Bladder neck extrusion of the AUS cuff was diagnosed on flexible cystoscopy. A robotic AUS explantation was planned. We offered to place a fascial sling at the bladder neck during the explantation to minimize the risk of SUI and urethrovaginal fistula recurrence

Five ports are placed. The Da Vinci Xi robot is docked on the left side of the patient (side docking).   The bladder is dropped down from the abdominal wall. The AUS pressure regulating balloon is found, dissected and explanted.  Opening the fibrotic tissue surrounding the bladder neck, the cuff is found, dissected and opened. 
The anterior aspect of the bladder is opened longitudinally to repair the bladder neck defect transvesically. The edges of the bladder incision are sutured on each side to the abdominal wall to improve the transvesical bladder neck exposure. The inflammatory/necrotic tissues surrounding the extrusion orifice are excised. The orifice is then closed transversally (to avoid bladderneck stenosis) in two layers (detrusor and mucosa individually) using interrupted 4/0 Vicryl sutures
To harvest rectus fascia sling, a 7 cm suprapubic incision is made and carried down to the rectus fascia. A 10x1.5 cm rectus fascial sling is harvested. The fascia is then closed using two running sutures. The fascial sling is inserted through the 12 mm assistant port and placed around the bladder neck in the dissected space of the explanted AUS cuff. 
The sling is pulled towards the rectus fascia using two permanent 2/0 monofilament stitches inserted into the abdomen with a Reverdun needle and placed at each end of the sling. We tightened the sling above the rectus fascia moderately on the assistant finger 
The bladder and all the cutaneous incision are closed. 

The operative time was 280 minutes with minimal blood loss. There was no postoperative complications. The patient was discharged on postoperative day 2. The urethral catheter was removed at day 15 and the patient resumed spontaneous voiding with post-void residual of 70 ml. At 1 month, she is socially continent, wearing 1 pad per day.

Robotic artificial urinary sphincter explantation and concomitant fascial sing insertion in case of bladder neck cuff extrusion appears feasible and may be an interesting salvage option to prevent SUI recurrence and avoid further anti-incontinence surgical procedures likely to be highly challenging.

Continence 2S2 (2022) 100483
DOI: 10.1016/j.cont.2022.100483