One of the potential advantages of the robot-assisted approach for artificial urinary sphincter (AUS) implantation in female patients would be to minimize the risk of intraoperative vaginal or bladder neck injury. However, vaginal injury does occur during robotic female AUS implantation. While the old dogma of stopping the procedure when it happens has been abandoned, the best technique of repair of the vaginal injury has yet tobe determined. The objective of this video was to present a technique of peritoneal flap interposition to repair vaginal injury during robotic female AUS implantation in order to minimize the risk of cuff erosion or infection.

We present the case of a 72-year-old female patient with a history of Burch colposuspension, TVT in 2017 and transvaginal mesh repair for POP who presented with recurrence of stress urinary incontinence. She was wearing 5 pads per day. The cystoscopy did not show any sling 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 29 cmH2O, there was no detrusor overactivity. She was consted for a robotic AUS implantation

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. Dissection of the vesicovaginal plane is helped by dissecting the TVT and freeing from both the vaginal and urethral walls. When a vaginal injury occur, the first step is to find back the right plane and to try to create a passage around the bladder neck for the future cuff.Then the vagina is closed in multiple layers. Finally a peritoneal V flaps is created and interposed between the vagina and the future cuff, throughout the dissected space around the bladder neck. Out of 101 robotic female AUS, there was 9 vaginal injury. Five were repaired without tissue interposition and four with peritoneal flap interposition. Only two explantation for vaginal exposure were needed, and none in the tissue interposition group (p=0.44)

We describe here a technique of peritoneal flap interposition in case of vaginal injury during robotic female AUS implantation which may minimize the risk of explantation for AUS erosion or infection.

Continence 12S (2024) 101525
DOI: 10.1016/j.cont.2024.101525