One of the potential disadvantages of the robot-assisted approach for artificial urinary sphincter (AUS) implantation in female patients is that it does not allow the lead surgeon to have direct sensations of the width of vaginal wall left during the bladder neck dissection. One of the main limitations of robotic female AUS is that the surgeon relies on the vaginal assistance of his/her bedside assistance. The objective of this video was to describe a modified robotic anterior AUS implantation in female patients with minimal vaginal assistance.

We present the case of a 61-year-old female patient with a history of Bucrh colposuspension  in 2002 referred for recurrence of stress urinary incontinence. She is wearing 3 pads per day, with a 24h pad weight test of 300g. The cystoscopy did not show any stitch extrusion. On physical examination, she had a positive cough stress test with a fixed urethra, no pelvic organ prolapse. On preoperative urodynamics, the maximum urethral closure pressure was 18 cmH2O, there was no detrusor overactivity. She was offered four therapeutic options: pubovaginal sling, Bulkamid periurethral injections, Adjustable Continence therapy periurethral balloons or robotic AUS implantation and elected this latter option.

The patient is placed in 23° Tredelenburg at 23° position with side-docking of the Da Vinci Xi Robot . A transperitoneal approach is used. After bladder filling, the Retzius space is dissected to reach the endopelvic fascia on bothside of the bladder neck. The lateral aspects of the bladder are dissected extensively on both sides. The edge of the bladder neck is identified on both sides and the bladder neck is separated from the vaginal all  by gently spreading the blades of the prograsp forceps. Once the dissection has been sufficiently intiiade on each side, the assistant places a finger in the vagina on each side of the bladder neck to enlarge the opening in the endoplevic fascia and dissect under constant direct vision the posterior aspect of the bladder neck. The assistant remove her finger from the vagina  and the bladder neck dissection is completed

We describe here a modified anterior technique of robotic AUS implantation in female patients that allows continuous direct vision during the bladder neck dissection and require only minimal vaginal assistance which may reduce the risk of intraoperative bladder neck and vaginal injury and faciltate reproducibility.

Continence 7S1 (2023) 100794
DOI: 10.1016/j.cont.2023.100794