Orthotopic neobladder is the preferred urinary diversion following radical cystectomy in fit patients without contraindications. However, there is a high risk of urinary incontinence after this procedure, especially in women, since there may be damage to the anatomical structures that support the urethra.

We report a novel approach to stress urinary incontinence in women previously submitted to radical cystectomy with construction of a neobladder. We describe the case of a 55 years old female patient, diagnosed with bladder urothelial carcinoma pT2N0M0 in 2019. The patient was submitted to anterior pelvic exenteration with preservation of the urethra, followed by a Studer orthotopic neobladder. Follow-up revealed no sign of recurrence at 3 years post-op. The patient was on clean intermittent catheterization (CIC) 5-6 times per 24h but described urinary incontinence between catheterizations. She voided on average 280 mL of urine (range 100-450 mL), as reported in the bladder diary, and used 2 diapers per day and 1 during the night. On physical examination, a cough-stress test revealed urethral hypermobility with urinary leak. We proposed a sub-urethral autologous sling placement, and the patient signed the informed consent after explanation of risks and potential benefits. The patient was under general anesthesia and in lithotomy position. A 14 Fr Foley catheter was inserted in the neobladder and a suprapubic median incision was performed, on the site of the previous laparotomy incision. After exposure of the anterior rectus fascia, a graft of 8x2 cm was harvested. The fascia was closed with 0 absorbable polyglactin suture, subcutaneous tissue and skin were sutured. The graft was prepared for placement by removal of adherent fat tissue, marking of the midline, and 2-0 absorbable barbed suture strings were tied on each end of the graft. A 2 cm midline incision was made on the anterior vaginal wall after hydrodissection with saline. Blunt dissection was performed bilaterally, avoiding perforation of urethra and neobladder. The obturator membrane was perforated and the strings of the autologous fascia were brought out bilaterally through the obturator foramen using a trocar, in an “in-out” movement, with exteriorization on the crease between labia majora and thigh. The sling was positioned in the midline with a slight tension. Urethrocystoscopy revealed no perforation of the neobladder nor the urethra. Vaginal incision was closed using 2-0 absorbable polyglactin suture. The Foley catheter was removed and the patient restarted CIC and was discharged on the 2nd post-operative day.

In a post-op evaluation at 3 weeks, patient was fully continent, and a cough-stress test revealed no leak. Up to date, 8 months after surgery, no complications have been reported and the patient remains continent, doing CIC 5 times per day.

Autologous slings are classically placed in a retropubic position. However, the presence of a neobladder and the obvious derangement of pelvic anatomy may rise the risks of such a procedure, namely perforation of the neobladder. The passage of the sling via transobturator reduces, in our view, this risk. The placement of a synthetic sling, while potentially reducing risks and complexity of the procedure, would have to be weighted against the possibility of sling erosion in a patient doing CIC. Finally, we found the use of a barbed suture as a string very helpful, as this enabled a higher tension on the sling. The risk of urinary retention was not a concern, since the patient was doing CIC. In conclusion, we present a video of a new surgical approach to stress urinary incontinence in women doing CIC after orthotopic urinary diversion.

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Continence 7S1 (2023) 101021
DOI: 10.1016/j.cont.2023.101021