V06-06: Robotic artificial urinary sphincter explantation and concomitant fascial sing insertion in case of bladder neck cuff extrusion for female patients

Camille HAUDEBERT*, Juliette Hascoet, Lucas Freton, Claire Richard, Karim Bensalah, Gregory Verhoest, Zine Eddine Khene, Romain Mathieu, Andrea Manunta, Benoit Peyronnet, Rennes, France

Introduction: Female stress urinary incontinence (SUI) is highly prevalent. Artificial urinary sphincter is an option for severe or complex female SUI cases. In case of bladder neck cuff extrusion, AUS explantation is required and further SUI treatment can be challenging. In the present video, we report and describe a new surgical technique aiming both to treat AUS bladder neck extrusion and to prevent recurrence of SUI.

Methods: We present the case of a 43-year-old female patient with a history of urethrovaginal fistula. After the repair with a Martius flap interposition she reported severe SUI. She reported SUI with 350 g on 24h pad weigh test, massive leakage on cough stress test with a fixed urethra. She underwent robotic AUS implantation with complete resolution of SUI. Six months after, she had a recurrence of the SUI and urethral pain. Bladder neck extrusion of the AUS cuff was diagnosed on cystoscopy. A robotic AUS explantation was planned. We offered to place a fascial sling at the bladder neck during the explantation to minimize the risk of SUI and urethrovaginal fistula recurrence.

Results: Five ports are placed. The bladder is dropped down from the abdominal wall.Opening the fibrotic tissue surrounding the bladder neck, the cuff is found, dissected and opened.
The anterior aspect of the bladder is opened longitudinally to repair the bladder neck defect transvesically. The edges of the bladder incision are sutured on each side to the abdominal wall to improve the transvesical bladder neck exposure. The inflammatory/necrotic tissues surrounding the extrusion orifice are excised. The orifice is then closed transversally in two layers (detrusor and mucosa individually) using interrupted 4/0 Vicryl sutures

We harvest a 10x1.5 cm rectus fascial sling. The fascial sling is inserted in the abdomen and placed around the bladder neck.
The sling is pulled towards the rectus fascia using two permanent 2/0 monofilament stitches inserted into the abdomen with a Reverdun needle and placed at each end of the sling. We tightened the sling above the rectus fascia moderately.
The operative time was 280 minutes. There was no postoperative complications. The urethral catheter was removed at day 15 and the patient resumed spontaneous voiding.

Conclusions: Robotic artificial urinary sphincter explantation and concomitant fascial sing insertion in case of bladder neck cuff extrusion appears feasible and may be an interesting salvage option to prevent SUI recurrence and avoid further anti-incontinence surgical procedures likely to be highly challenging.

Source of Funding: None