Robotic Implantation of Artificial Urinary Sphincter in female patient

Procedure Steps:

• Patient's positioning, ports placement and robot docking

• Access to the bladder neck

• Vesicovaginal dissection

• Cuff and balloon placement

• Pump placement and connexions

Technique Description:

The procedure is performed by two surgeons: a surgeon at the console and another surgeon (or a surgeon in training in some cases) to provide assistance on the surgical field.

Patient's positioning, ports placement and robot docking The patient is placed in a 23 ° Trendelenburg position. The procedure is performed using a transperitoneal approach with a 0° lens. Five ports are placed (figure 1): one 12-mm camera port at the umbilicus, three 8-mm robotic ports (one in the right flank and two at the lateral edge of right and left rectus abdominis muscles) and an additional 12-mm port in the left flank for the assistant. A minimum 7 cm space is maintained between each port. The four-arm Da Vinci Si robot is placed in a right side-docking position (figure 2). Only three robotic instruments are used for the whole procedure: a bipolar prograsp forceps in the left robotic arm, scissors in the internal right robotic arm and a regular prograsp forceps in the external right robotic arm.

Access to the bladder neck A 14 Fr urethral catheter is inserted and the bladder is filled with 100 to 300 ml of saline to identify its boundaries. The bladder is dropped down from the abdominal wall and the Retzius space is dissected until the bladder neck and the endopelvic fascia are individualized. Before starting the dissection of the vesicovaginal space, it is paramount to locate accurately the bladder neck as in this technique the AUS cuff will be inserted around the bladder neck and not at the level of the urethra. The bladder neck is larger than the urethra and its wall is thicker allowing the use of a larger cuff, minimizing the risk of erosion. The bladder neck contours are identified thanks to the saline instilled in the bladder and if needed the catheter balloon can also be gently moved back and forth by the assistant.

Vesicovaginal dissection Once the space of Retizus has been dissected down to the endopelvic fascia the assistant surgeon places one finger in the vagina (figure 3). This is a key point of this technique. The assistant finger is placed in one of the lateral fornix in order to push it upward and laterally, towards the ispilateral shoulder. It allows to start the dissection of the vesicovaginal plane "on" the tip of the assistant’s finger, laterally, away from the bladder neck minimizing the risk of bladder neck injury. The additional benefit of pushing the vaginal fornix laterally is that, after the dissection has been sufficiently initiated, it enables direct vision of the vesicovaginal space posterior to the bladder neck. The plane is initiated with cold scissors. In our early cases we incised the endopelvic fascia to open it but we realized that if the fascia is sufficiently stretched by the assistant finger, it can be opened simply by gently spreading it with the edge of the scissors. This allows to perform a purely blunt dissection of the bladder neck (i.e. no incision by electrocautery is used at any point during this step) to minimize the risk of bladder neck or vaginal injury. While performing these subtle moves with the scissors, the perivesical fascia is entered and the vaginal wall appears progressively as a shiny white plane (called in France the bald plane as it looks like a bald head). This is the plane where the dissection around the bladder neck has to be carried out. The breach in the endopelvic fascia is extended cranially and caudally, by cutting with the scissors parallel to the vaginal wall, to avoid traction on the bladder neck and vaginal wall during the dissection and to allow the assistant finger pushing more thoroughly. Using the edge of the scissors, all the small fibers of the endopelvic and perivesical fascia are reclined medially, carrying on the dissection of the white shiny vaginal wall (the ″bald″ plane). Once the plane has been sufficiently developed dissection is pursued behind the bladder neck using the prograsp forceps, ″sliding″ on the assistant finger while gently opening the blades tangentially to the bladder neck and vaginal walls to separate them (figure 4). Once the median line has been reached the same maneuvers are performed on the other side of the bladder neck. The two dissected spaces are thus joined, with often a remaining ″veil″ of perivesical fascia to be opened on the tip of the Prograsp forceps after the assistant surgeon has ensured with his/her finger that the vaginal wall is intact and has not been pinched by the tip of the Prograsp forceps (figure 5). At the end of the dissection the bladder is filled with methylene blue to verify the integrity of the bladder neck. The bladder dome is intentionally opened only in a few cases when the vesicovaginal dissection is felt very challenging, to allow monitoring of the dissection from inside the bladder, in order to minimize the risk of bladder neck injury.

Cuff and balloon placement The bladder neck circumference is measured using a measuring tape introduced through the 12mm port. The cuff is then introduced through the same 12 mm port and positioned around the bladder neck. The device is manipulated cautiously to avoid any damage. The 61-70 cmH2O pressure regulating balloon is implanted in the prevesical space via a 3-cm suprapubic incision and filled with saline. The peritoneum is then closed with barbed suture.

Pump placement and connexions The pump is implanted in one of the labia majora by creating a subcutaneous passage starting from the short suprapubic incision used to introduce the balloon and using a long instrument (e.g. scissors or Kelly clamp). The connexions are made through the suprapubic incision. The incisions are closed. At the end of the procedure the device is deactivated.

Learning Points:

• Key role of the assistant surgeon, putting tension in the vaginal fornices and exposing the vesicovaginal plane

• Create the space for the cuff at the level of the bladder neck, not at the level of the urethra

• Always favor blunt dissection

• Never forget antibiotic prophylaxis (sterile urine+augmentin or cefoxitine)

• Keep the bladder partially filled during the dissection to identify the bladder neck boundaries and diagnose right away a bladder neck injury if any

• Always open the endopelvic fascia and start the vesicovaginal plane dissection very laterally to avoid bladder neck injury

• Use fenestrated prograsp forceps to dissect the posterior part of the bladder neck

• If vaginal or bladder neck injury happen, OK to implant if you can create a space for the cuff away from the injury and if you can repair the injury nicely, doing multiple layers suture (1 explantation out of 12 patients in such scenario in our multicenter experience)

• When sizing the bladder neck, do remember that the patient is in Tredelenburg position which thins the tissue. Always go for a cuff larger than smaller to avoid post-operative urinary retention

• Insert the cuff through the 12 mm port, the balloon and the cuff through a 3 cm subinguinal incision