Robot-assisted female AMS-800 Artificial Urinary Sphincter (AUS) implantation is a challenge surgery that needs to be trained well. The lack of procedure-based simulation model except cadaver led us to use porcine model for training purposes. Our aim is to describe and evaluate a standardized technique of robotic bladder neck AUS implantation in female pigs to maintain stepwise surgical procedure on porcine model as a first European experience in robotic surgical training course.

Two consecutive female AUS implantation was planned on porcine model. Following appropriate anesthetic preparation, under 30 degrees, Trendelenburg position, an incision was made 1 cm above the umbilicus and Veress needle was inserted into the peritoneal cavity. Following having a 8 mmHg pressure, an 8 mm robotic port was inserted for camera. On both lateral sides of this port (with a distance of 8 cm) two additional robotic ports were inserted for robotic instruments. On the left side (2 cm above the line connecting camera port and left robotic port), a 12 mm Airseal port was inserted for assistance & CO2 insufflation.  The four-arm Da Vinci XI robot was placed in a caudal-side docking position. Three robotic instruments were used for procedure: a bipolar Prograsp, Maryland forceps and scissor. AMS-800 device was used. Identification Stepwise Surgery 
Surgical anatomic landmarks were identified as bladder neck, anterior surface of vagina, bilateral ureters, median umblical ligament, epigastric vessels, paravaginal fascia, pubic bone, iliac vessels. A 8 Fr urethral catheter was inserted, the bladder is filled with 100 ml of saline to identify its boundaries. The bladder was dropped down from the abdominal wall, and the Retzius space was dissected until the bladder neck and the paravaginal fascia are individualized. The bladder neck was identified with saline instilled in the bladder, and vesicourethral junction was very transparent seen on porcine model to insert the AUS cuff at this site. Pre-para vesical, bladder neck and urethral dissection were performed to expose vesico-vaginal space. We placed one catheter to manipulate vaginal wall while doing dissection between bladder neck and anterior vaginal wall. The assistant catheter was placed in one of the lateral fornix in order to push it upward and laterally, toward the ipsilateral shoulder. It allowed start of the dissection of the vesicovaginal plane “on” the tip of the assistant catheter, laterally, away from the bladder neck, minimizing the risk of bladder neck injury. Once the plane had been developed sufficiently, dissection was pursued behind the bladder neck using the Prograsp forceps, “sliding” on the assistant catheter while gently opening the blades to the bladder neck and vaginal walls to separate them. The bladder neck circumference was measured using a measuring tape introduced through the 12-mm port. The cuff was then introduced through the same 12-mm port and positioned around the bladder neck. The regulating balloon was implanted in the prevesical space. All connections of cuff- balloon and pump were performed at the site of 12 mm assistant port. The system was activated and de-activated as live surgery. All parts of real surgery were completed in success.

Console time was 185 min and 4.5 cuff size was used. No intraoperative complication occurred including bladder neck, vaginal, bladder or vascular injury on female porcine model. Having a porcine intra-abdominal pelvic anatomy video tutorial before the course significantly increased understanding pelvic anatomy. Both trainees completed all steps of the procedure successfully.

Training on porcine for robotic AUS implantation is considered appropriate for the development of technical and non-technical skills. Porcine anatomy provided a realistic surgical section. It is cost effective, alternative to cadaveric model, sufficient for improving manual skills and learning the female AUS technique.