Implantation of an artificial urinary sphincter is the surgical treatment of last resort for stress urinary incontinence (SUI) due to sphincter inccompetence. 
In some patients who have undergone multiple abdominal surgeries, the placement of this material by the transperitoneal approach can be complex and with an increased risk of complications due to intestinal adhesiolysis.

We present the case of Mrs H, 47 years old. She has a closed spina bifida with a neurological bladder that required a supra-trigonal cystectomy and enlargement enteroplasty by laparotomy in 1996. She does exclusive self-catheterization. She has already undergone numerous abdominal operations, with a history of ileal fistula secondary to an ovariectomy for a benign lesion. She had stress urinary incontinence which had been worsening for many years, initially treated with a Goebell Stoekel aponevrotic sling in 2003. Her urodynamic showed a well-controlled bladder, with a closure pressure of 23 cmH2O. 
We proposed her the implantation of an artificial urinary sphincter. She is well aware of the risks inherent to this procedure in her situation. 
Due to the patient's history, an extraperitoneal implantation is proposed.

The patient is placed in the Tredelenburg position with her legs spread. 
The ports are positioned. The umbilical port is placed first without penetrating the peritoneal cavity. A finger dissection allows the pre-peritoneal space to be freed. 
Three other 8 mm ports are positioned on the finger in the right and left pararectal line and left flank. A 12 mm assist port is placed in the right flank. The Da Vinci Xi robot is docked on the right side of the patient (side docking). 


The preperitoneal space is dissected, and the neobladder completely freed from the abdominal wall, until the endo-pelvic fascia is reached. 
The bladder neck is located, and it is separated from the vaginal wall on a finger placed in the vagina. Dissection is made difficult by the Goebell Stoekel strip, which is cut. 
Finally, the bladder neck is separated from the vaginal wall. 
The cuff measuring device is placed in the dissection plane. An 8 mm cuff is measured. The cuff is placed.

A 4 cm supra pubic incision is made and the balloon is inserted into the preperitoneal cavity. 
The sphincter connectors are made in the infra pubic incision, and the pump housing is made in the left large lip. 

Incisions are closed. 

The operative time was 170 minutes, with minimal blood loss. There was no post operative complications.

The implantation of an artificial urinary sphincter by the extra peritoneal approach is an interesting option in case of material implantation for patients who have already undergone multiple surgeries, by allowing the placement of the material without passing through the abdominal cavity.

Continence 7S1 (2023) 100792
DOI: 10.1016/j.cont.2023.100792