Artificial urinary sphincter (AUS) is the most effective surgical treatment for male stress urinary incontinence (SUI). One of the biggest challenge to overcome is AUS implantation in male with frail urethra due to history of radiotherapy or previous erosion or urethral stricture. AUS implantation preserving the bulbospongiosus muscle has recently been described as a possible technique to minimize the risk of erosion in this patients’ population 
The aim of the video was to present a technique of bulbospongiosus muscle preservation during male AUS implanation

We present the case of Mr G, 77 year-old. He has an history of radical prostatectomy for prostate cancer pT3N1R1 with postoperative SUI, leading to the insertion of an Advance XP sling in 2018. Recurrence of prostate cancer required radiotherapy in 2020, exacerbating the incontinence. A first artificial urinary sphincter (AUS) implantation in 2022 resulted in urethral cuff extrusion within a month after activation, with to Fournier gangrene. Consequently, the AUS was explanted. He was referred to our center to proceed with a new AUS implantation.

The patient was placed in the lithotomy position. A longitudinal perineal incision was made, extending until reaching the bulbospongiosus muscle. The urethra was carefully dissected while preserving the muscle attachment to the urethra. Clear visualization allowed the isolation of the urethra from the corpus cavernosum, circumnavigating both the urethra and the muscle.
Measurement of the urethra and muscle, averaging 50-55 mm, indicated an appropriate size. Considering the patient's medical history, a 55 mm cuff was chosen to minimize pressure on the urethra, thereby reducing the risk of urethral erosion. The cuff was placed, and an inguinal incision was made for the placement of the balloon. Finally, the pump was positioned in the left scrotum.
The operation lasted 90 minutes with minimal blood loss. The patient was discharged on the first day but was readmitted for an additional three days due to a significant hematoma. The AUS was activated six weeks post-surgery. At 4 months the patient in socially continent (one pad per day) without erosion or infection of the device.

AUS cuff implantation around the bulbospongiosus muscle is safe and feasible, even in complex cases. This technique may be of help to minimize the risk of erosion in patients with frail urethra.

Continence 12S (2024) 101645
DOI: 10.1016/j.cont.2024.101645