- To describe for the first time the technique of robot-assisted artificial urinary sphincter (R-AUS) insertion in male patients with neurogenic incontinence.
artificial urinary sphincter
The indications for artificial urinary sphincter (AUS) insertion can be classified as congenital neurogenic (e.g. spina bifida), acquired neurogenic (e.g. spinal cord injury), congenital non-neurogenic (e.g. exstrophy–epispadias complex) and acquired non-neurogenic (e.g. post-prostatectomy) [1, 2]. A rare important indication is in male patients with neurogenic stress urinary incontinence secondary to spinal cord injury. Our institution has extensive experience in AUS insertion with open and pure laparoscopic approaches, as previously reported [3, 4]. In the present study, we decribe for the first time the technique of da Vinci® (Intuitive Surgical, Sunnyvale, CA, USA) robot-assisted AUS (R-AUS) insertion in male patients with neurogenic incontinence.
Since January 2011, six men with neurogenic sphincter weakness incontinence have undergone bladder neck R-AUS (AMS 800, American Medical Systems, Inc., Minnetonka, MN, USA) placement in our department. The indication for AUS insertion was refractory troublesome stress urinary incontinence in all patients. A body mass index >30 kg/m2 was an exclusion criterion.
A single robotic surgeon (C.V.) with experience of >500 robotic procedures in the area of urological surgery was the primary surgeon. He was assisted by another surgeon (E.C.K.) with vast experience of open AUS implantation. The robotic procedure was performed in accordance with the key principle steps of open AUS insertion (Figs 1-8) and replicated the laparoscopic technique we described recently .
Under general anaesthesia and broad-spectrum i.v. antibiosis (co-amoxiclav 1.2 g), surgical skin preparation with povidone-iodine solution was performed and a 12-F Foley urethral catheter inserted. To implant the AUS device robotically, we used a transperitoneal approach and a three-arm standard da Vinci® robot, with five ports (×2 8 mm, ×2 12 mm, ×1 5 mm) as would be used for robot-assisted radical prostatectomy. In a 30° reverse Trendelenburg position, the procedure commences with a posterior peritoneal incision directly down on to the seminal vesicles/vas deferens and posterior bladder neck.
Subsequently, after opening Retzius' space anteriorly and releasing the bladder, lateral prostate dissection is performed to identify clearly the precise location of the bladder neck on both sides. The cuff tape measure is introduced via a bedside assistant with a stitch secured to one end. Using bipolar forceps in the right instrument arm and after clean dissection of the posterior bladder neck, it is possible to introduce the forceps from the midline posteriorly out to the left side of the prostate/bladder neck. Grasping the suture of the tape measure, the surgeon can then pull the tape measure through into the midline posteriorly. Now, leaving the tape measure resting in the midline, the bipolar forceps are introduced into the previously dissected right bladder neck plane and passed through in to the midline posteriorly to re-grasp the suture. This can then be pulled through so that the tape measure appears to the right of the bladder neck. It is then possible to complete the circumferential assessment of the bladder neck by approximating the two ends of the tape measure in the midline anteriorly.
Once the size of cuff is determined, the actual AUS cuff is introduced and sutured intracorporeally to one end of the tape measure that is currently situated exactly around the bladder neck. Once the AUS cuff is secured, it can be pulled the full circumference around the bladder neck by withdrawing the tape measure, taking great care to ensure that no twist in the cuff develops.
Once the cuff is adequately situated, the tape can be cut from the cuff and removed, and the two ends of the AUS cuff are definitively ‘snapped’ together. The tubing for the pump and reservoir are exteriorized via a small right iliac fossa incision and the reservoir is left intra-abdominally in a lateral vesicular space. The anterior and posterior peritoneum are re-apposed so as to completely extra-peritonealize the cuff, reservoir and tubing. The AMS800 parts are connected, cuff pressurized, and the pump is placed in a classic scrotal position via the iliac fossa incision. The device is de-activated at the end of the procedure.
Postoperatively, patients receive 2 days of prophylactic oral antibiotics (co-amoxiclav 625 mg thrice daily), have their urethral catheter removed on day 2 and are discharged on day 3 with the cuff de-activated. The cuff is activated 4 weeks after surgery. Postoperative complications were defined according to the Clavien grading system as recommended .
The median age of the six patients was 51.5 years. Table 1 shows the key patient characteristics. The median operating time was 195 (175–250) min. The sizes (cm) of the cuff were 7.5 cm (n = 3) and 8 cm (n = 3). The median (range) length of hospital stay was 4 (4–6) days. We detected two minor complications (Clavien I): one patient developed epididymitis and one patient retained the bladder catheter for 2 more days because of a blood clot. Table 2 shows the relevant pre-, peri- and postoperative data. At a median follow-up of 13 months, all six patients had a functioning device with complete continence. To date, we have observed no incidence of early erosion, device infection or malfunction.
|Patient 1||Patient 2||Patient 3||Patient 4||Patient 5||Patient 6||Overall|
|Mean body mass index||23.5||25||24.6||21.6||20.4||20.2||23.02|
|Previous incontinence surgery||No||ACT||ACT||ACT||No||No||50%|
|Patient 1||Patient 2||Patient 3||Patient 4||Patient 5||Patient 6|
|Operation time, min||250||230||190||180||175||200|
|Estimated blood loss, mL||50||150||100||80||65||890|
|Cuff size, cm||8||7.5||7.5||7.5||8||8|
|Conversion to open||No||No||No||No||No||No|
|Complications (Clavien grade)|
|Other||No||Epididymitis (I)||No||No||Clot in bladder catheter (I)||No|
|Length catheterization, days||2||2||2||2||4||2|
|Hospital stay, days||4||6||5||4||4||5|
|Time to device activation, weeks||4||4||4||4||4||4|
In the present study, we describe the technique of robotically inserting an AMS800 AUS at the bladder neck in male patients. Bladder neck cuff placement is necessary in men with neurogenic stress urinary incontinence owing to: (i) the frequent need for intermittent self-catheterization that increases the incidence of cuff erosion if the cuff is bulbar; (ii) pressure applied to bulbar urethra in wheelchair-bound patients; (iii) open bladder neck with sacral cord lesions with urine-filled prostatic urethra which is a potential source of infection with a bulbar cuff; and (iv) future endoscopic treatment risks erosion of a bulbar cuff .
Although robot-assisted urological surgery was initially focused on radical prostatectomy, the surgical platform is versatile and appropriate for a wide range of urological procedures. In terms of AUS insertion, a pure laparoscopic approach is technically challenging and the dissection of Retzius' space, particularly in patients with previous incontinence surgery, is difficult. The inherent attributes of robot-assisted surgery (precise dissection, three-dimensional high-definition vision, manoeuvrability in tight spaces and suturing) substantially decrease the complexity of minimally invasive AUS insertion. This is particularly pertinent in light of the knowledge that open AUS outcomes are directly correlated with surgeon experience .