In recent years, laparoscopic and robotic techniques for Artificial Urinary Sphincter (AUS) implantation in female patients have shown promising outcomes, particularly in cases of recurrent stress urinary incontinence (SUI) following previous anti-incontinence procedures, as well as in neurogenic and non-neurogenic intrinsic sphincter deficiency. The aim of this video is to compare the laparoscopic and robotic-assisted approaches for AUS implantation through a vesicovaginal approach.

This study presents detailed case reports of two female patients who underwent AUS implantation using different surgical techniques. The first patient, aged 78 years, underwent the laparoscopic approach, while the second patient, aged 57 years, underwent the robotic-assisted approach. 
Both patients were positioned in a 30-degree Trendelenburg position to optimize surgical exposure. The laparoscopic procedure utilized a transperitoneal approach with the placement of four trocars, whereas the robotic procedure involved the use of five trocars. 

The surgical steps followed are the same for both approaches:
It starts with carefully dissecting the vesicovaginal space, using a vaginal valve to find the front vaginal wall precisely.

After opening the peritoneum, blunt dissection is extended distally until neck's dorsal is identified. 
Then, both laterovesical spaces are dissected until we reach the endopelvic fascia. This frees up the posterior part of the bladder neck.

Next up, we handle the front side of the bladder neck delicately to keep the pubovesical ligament as long as possible. We measure the bladder neck's size with a cuff sizer, double-checking with a cystoscopy to avoid any bladder damage during dissection. 

To make cuff placement easier, we stitch the cuff's end to the cuff sizer.

We make a small suprapubic incision for inserting the balloon in the retroperitoneal space. The final steps involve externalizing the balloon and cuff tubes, creating a path from the incision to the labia majora for the pump placement, inflating the balloon with saline, and connecting everything with the Quick Connect tool.

We close the peritoneum with a barbed suture and don't leave any drains in place.

The operative time for the laparoscopic approach was 180 minutes, while it was 155 minutes for the robotic-assisted approach. No complications were encountered during the laparoscopic procedure. However, a bladder perforation occurred during the robotic approach, necessitating repair with continuous suture.

The AUS is left deactivated and will be activated six weeks after surgery

AUS implantation is an effective option for treating female patients with refractory SUI, with reported continence rates ranging from 60% to 100% in recent studies. Minimally invasive techniques, such as laparoscopic and robotic approaches, offer advantages such as shorter hospital stays, reduced postoperative pain, and fewer intraoperative complications compared to open surgery. Additionally, both laparoscopic and robotic approaches provide benefits in terms of dissection precision, particularly in the area between the posterior bladder neck and the anterior vaginal wall.

The video demonstrates that AUS implantation can be performed with comparable technical proficiency using both laparoscopic and robotic techniques. While robotics offer enhanced accuracy and visibility, experienced laparoscopic surgeons can achieve similar advantages. Overall, the choice between laparoscopic and robotic approaches should consider factors such as surgeon expertise, patient characteristics, and institutional resources.

Continence 12S (2024) 101524
DOI: 10.1016/j.cont.2024.101524