The classical technique of laparoscopic artificial urinary sphincter (AUS) implantation in not widely spread because of its complexity. There is a blind dissection of the dorsal side of the bladder neck, which increase the risk of erosion and cuff migration. We propose to start surgery with vesicovaginal space dissection, which allows to place the cuff around the bladder neck under direct view.

We describe the technique of AUS implantation with the vesicovaginal approach in a 75-y.o woman who underwent a sling implantation in 2010.  She did not recover complete continence, showed incontinence with minimum movements, and a negative Ulmsten test. Cystoscopy revealed no sling extrusion and videourodynamics suggested intrinsic sphincter deficiency.
The patient is placed in a 30⁰ Trendelenburg position and surgery is performed using a transperitoneal approach. First, the vesicovaginal space is created.  A vaginal valve is essential in order to identify the anterior vaginal wall. Dissection is extended distally until the dorsal side of the bladder neck is identified.  Now, the peritoneum is opened in its anterior part and the dissection is extended at both lateral sides of the bladder till the endopelvic fascia is reached. At this moment, we are able to perform the main step of the procedure, which is connecting the vesicovaginal space to the laterovesical spaces. Then, the anterior side of the bladder neck is dissected trying to preserve the maximum length of pubovesical ligament.The bladder neck diameter is measured and a cystoscopy is performed to check that the bladder neck was not injured. The cuff is placed and the pressure-regulating balloon is inserted. A 2 cm left suprapubic incision is made and a 5 mm port is placed through it. Then, the balloon and the cuff tubes are externalised. A subcutaneous passage is created from the suprapubic incision to the ipsilateral labia majora where the pump is placed. The balloon is inflated with 23 cc of saline and the components are connected. Finally, peritoneum is closed with a barbed suture. No drain is left in place. AUS is left deactivated and will be activated at 6 weeks after surgery.

Operative time was 140 minutes. No intraoperative complications occurred. Bladder catheter was removed 72 hours after surgery. The patient had a post-void residual volume of 100 cc, which was managed conservatively. Hospital stay was 72 hours. After six months the patient is pad-free and satisfaction with the procedure was 9/10.

Laparoscopy provides a magnified view, which allows a better dissection of the urethrovaginal space and the bladder neck. And most importantly, the dissection of the dorsal side of the bladder neck similarly to laparoscopic sacrocolpopexy, allows a non-blind implantation of the cuff which could avoid potential complications. This might allow the AUS implantation technique to become more reproducible.