Robot-assisted laparoscopic artificial urinary sphincter insertion in women with stress urinary incontinence: a pilot single-centre study

A robot-assisted laparoscopic revision of an artificial urinary sphincter in a patient with spinal cord injury

This step-by-step article demonstrates our approach to robot-assisted laparoscopic revision of a bladder neck sited artificial urinary sphincter (AUS) for a spinal cord injured patient. The bladder neck location of an AUS in the spinal cord injured demographic is ideal to minimise urethral complications and urinary tract infections, whilst the transabdominal approach reduces the risk of wound breakdown that can occur via the typical perineal incision for AUS insertion. The accompanying video will guide viewers as to our minimally invasive technique for cuff revision in the event of secondary surgery for recurrent urinary incontinence.

Robot-assisted Periprostatic Artificial Urinary Sphincter Implantation in Men with Neurogenic Stress Urinary Incontinence: Description of the Surgical Technique and Comparison of Long-term Functional Outcomes with the Open Approach

BACKGROUND

Periprostatic artificial urinary sphincter implantation (pAUSi) is a rare yet relevant indication for male neurogenic stress urinary incontinence (SUI).

OBJECTIVE

To describe the surgical technique of robot-assisted pAUSi (RApAUSi) and compare the long-term functional results with the open pAUSi (OpAUSi).

DESIGN, SETTING, AND PARTICIPANTS

Data of 65 consecutive men with neurogenic SUI undergoing pAUSi between 2000 and 2022 in a tertiary centre were collected retrospectively.

SURGICAL PROCEDURE

Thirty-three patients underwent OpAUSi and 32 underwent RApAUSi. OpAUSi cases were performed by a single surgeon, experienced in functional urology and prosthetic surgery. RApAUSi cases were performed by the same surgeon together with a second surgeon, experienced in robotic surgery.

MEASUREMENTS

Outcome measures were achievement of complete urinary continence, intra- and postoperative complications, and surgical revision-free survival (SRFS).

RESULTS AND LIMITATIONS

RApAUSi showed superior results to OpAUSi in terms of median (interquartile range) operative time (RApAUSi: 170 [150-210] min vs OpAUSi: 245 [228-300] min; p < 0.001), estimated blood loss (RApAUSi: 20 [0-50] ml vs OpAUSi: 500 [350-700] ml; p < 0.001), and median length of hospital stay (LOS; RApAUSi: 5 [4-6] d vs OpAUSi: 11 [10-14] d; p < 0.001). Clavien-Dindo grade ≥3a complications occurred more frequently after OpAUSi (RApAUSi: 1/32 [3%] vs OpAUSi: 10/33 [30%]; p = 0.014). Achievement of complete urinary continence (zero pads) was comparable between the groups (RApAUSi: 24/32 [75%] vs OpAUSi: 24/33 [73%]; p = 0.500). The median follow-up periods were 118 (50-183) and 56 (25-84) mo for OpAUSi and RApAUSi, respectively (p < 0.001). A tendency towards longer SRFS was observed in the RApAUSi group (p = 0.076). The main study limitation was its retrospective nature.

CONCLUSIONS

RApAUSi is an efficient alternative to OpAUSi, resulting in shorter operative times, less blood loss, fewer severe complications, and a shorter LOS with similar functional results and need for revision surgery.

PATIENT SUMMARY

Compared with open periprostatic artificial urinary sphincter implantation (pAUSi), robot-assisted pAUSi leads to faster recovery and similar functional results, with fewer postoperative complications.

Stress Urinary Incontinence: An Unsolved Clinical Challenge

Stress urinary incontinence is still a frequent problem for women and men, which leads to pronounced impairment of the quality of life and withdrawal from the social environment. Modern diagnostics and therapy improved the situation for individuals affected. But there are still limits, including the correct diagnosis of incontinence and its pathophysiology, as well as the therapeutic algorithms. In most cases, patients are treated with a first-line regimen of drugs, possibly in combination with specific exercises and electrophysiological stimulation. When conservative options are exhausted, minimally invasive surgical therapies are indicated. However, standard surgeries, especially the application of implants, do not pursue any causal therapy. Non-absorbable meshes and ligaments have fallen into disrepute due to complications. In numerous countries, classic techniques such as colposuspension have been revived to avoid implants. Except for tapes in the treatment of stress urinary incontinence in women, the literature on randomized controlled studies is insufficient. This review provides an update on pharmacological and surgical treatment options for stress urinary incontinence; it highlights limitations and formulates wishes for the future from a clinical perspective.

Robotic-assisted artificial urinary sphincter revisions for women suffering from non-neurogenic stress incontinence: a single center experience

PURPOSE

Patients with artificial urinary eventually need surgical revision. Unfortunately, in women, this requires another invasive abdominal intervention. Robotic-assisted revision may provide a less invasive and more acceptable approach for sphincter revision in women. We wanted to determinate the continence status after robotic-assisted artificial urinary sphincter revision among women with stress incontinence. We also examined postoperative complications and the safety of the procedure.

METHODS

The chart of the 31 women with stress urinary incontinence who underwent robotic-assisted AUS revision at our referral center from January 2015 to January 2022 were reviewed retrospectively. All patients underwent a robotic-assisted artificial urinary sphincter revision by one of our two expert surgeons. The primary outcome was to determinate the continence rate after revision and the secondary outcome aimed to evaluate the safety and feasibility of the procedure.

RESULTS

Mean patients age was 65 years old, and the mean time between the sphincter revision and previous implantation was 98 months. After a mean follow-up of 35 months, 75% of the patients were fully continent (0-pad). Moreover, 71% of the women were back to the same continence status as with the previously functional sphincter, while 14% even have an improved continence status. Clavien-Dindo grade [Formula: see text] 3 and overall complications occurred in 9% and 20.5% of our patients, respectively. This study is mainly limited by its retrospective design.

CONCLUSION

Robotic-assisted AUS revision carries satisfying outcome in terms of continence and safety.

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology

The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were 'robotic assisted', 'ureteric reimplantation', 'cystoplasty', 'ileal conduit', 'neobladder', 'sacrocolpopexy', 'colposuspension', 'artificial urinary sphincter', 'genitourinary fistula' and 'posterior urethral stenoses'. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the long-term efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training.

Efficacy and Safety of Robot-assisted AUS Implantation Surgery in Treating Severe Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the effectiveness and safety of robot-assisted artificial urinary sphincter (AUS) implantation surgery for female patients with severe stress urinary incontinences (SUI) by performing a systematic literature review.

METHODS

A comprehensive search was carried out across multiple databases, including PubMed, EMBASE, Web of Science Clarivate, Cochrane library, Medicine and clinicaltrials.gov between inception to March 2022. Studies were included if they met the inclusion criteria and were evaluated by different quality evaluation methods according to study types. P value and 95% confidence intervals (CI) of outcome measures mainly including continence rates, intraoperative and postoperative complication rates were pooled to present the efficacy and safety.

RESULTS

A total of 9 studies with 157 participants were finally included. Eight retrospective and 1 prospective study met the inclusion criteria with moderate and high evidence levels. The pooled results showed that patients with robot-assisted AUS implantation treatment, presented great continence rate (P = .83, 95%CI:0.76-0.89) but high complication rate (Intraoperation: 0.21 95%CI:0.11-0.34; Postoperation: 0.20 95%CI: 0.12-0.29). In addition, subgroup analysis of 2 approaches showed that compared with the posterior approach, the traditional surgical approach had better efficacy and safety.

CONCLUSION

The results of this study indicated that robot-assisted AUS implantation surgery improved SUI patients' urinary continence, but the complication rates were high, which mainly included intraoperative vaginal and bladder injury and postoperative acute urinary retention. More evidence from prospective studies is needed to provide guidance for clinical practice.

Long-term device survival after a first implantation of AMS800™ for stress urinary incontinence: Comparison between men and women

PURPOSE

The artificial urinary sphincter is the reference treatment for stress urinary incontinence in men, but it remains rarely used in women. This study aimed to compare long-term device survival between women and men, after the first implantation of an AMS800™ artificial urinary sphincter (Boston Scientific) for the treatment of a non-neurogenic stress urinary incontinence.

MATERIALS AND METHODS

This retrospective cohort study included all patients with nonneurogenic stress urinary incontinence who underwent surgery in a large-volume university hospital between 2000 and 2013. The primary outcome was the overall survival of the device, defined as the absence of any repeated surgery (revision or explantation) during follow-up. Men and women were matched 3:1 according to age and year of implantation. Differences were analyzed using a Cox model accounting for matching and applying time intervals because hazards were not proportional over time. Sensitivity analyzes were performed, excluding firstly a population with a history of radiotherapy and secondly a population with more than one previous surgery for urinary incontinence.

RESULTS

A total of 107 women were matched to 316 men. Median follow-up was 6.0 years (Q1-Q3 1.8-9.4): 7.0 years (Q1-Q3 3.1-10.3) for women and 5.1 years (Q1-Q3 1.3-9.1) for men. During the follow-up, 56 patients had an explantation of the device: 44 men (13.9%) and 12 women (11.2%), and 113 had a revision: 85 men (26.9%) and 28 women (26.1%). Men have a significantly higher risk of explantation or revision than women between 6 months and 8 years after implantation (hazard ratio 2.12 [1.29-3.48]). Before 6 months and after 8 years, there were no significant differences. Both sensitivity analyses found consistent results.

CONCLUSIONS

This study suggests that device survival seems better in women after the first 6 months.

Outcomes of robot-assisted urinary sphincter implantation for male neurogenic urinary incontinence

OBJECTIVES

To report the functional outcomes of robot-assisted laparoscopic artificial urinary sphincter implantation (R-AUS) in men with neurogenic stress urinary incontinence (SUI).

PATIENTS AND METHODS

A monocentric retrospective study included all consecutive adult male neuro-urological patients who underwent R-AUS for SUI between January 2011 and August 2018. The AUS was implanted via a transperitoneal robot-assisted laparoscopic approach. Intraoperative and early postoperative complications were reported (Clavien-Dindo classification). Continence was defined as no pad usage. Revision and explantation rates were also evaluated.

RESULTS

Overall, 19 men with a median (interquartile range [IQR]) age of 45 (37-54) years were included. No conversion to laparotomy was needed. Three minor (Clavien-Dindo Grade I-II) early postoperative complications occurring in three (15.8%) patients were reported. The median (IQR) follow-up was 58 (36-70) months. At the end of the follow-up, the continence rate was 89.5%. The AUS revision and explantation rates were 5.3% and 0%, respectively.

CONCLUSION

A R-AUS is a safe and efficient procedure for AUS implantation in adult male neuro-urological patients, referring to the challenging open technique.

New technique of robot-assisted laparoscopic artificial urinary sphincter implantation in female by a posterior approach with intraoperative cystoscopic monitoring

PURPOSE

To report the early experience of a modified technique of robot-assisted artificial urinary sphincter (AUS) implantation in female, with a posterior approach to the bladder neck and intraoperative real-time cystoscopic monitoring.

METHODS

Retrospective monocentric study included all consecutive female who underwent a primary robot-assisted AUS implantation between 2017 and 2019. Real-time intraoperative cystoscopic monitoring was carried out to check the correct level of the dissection and to avoid any injury during bladder neck dissection. Perioperative and intraoperative data, functional outcomes and complications were assessed. Continence was defined as 0 to 1 pad per day.

RESULTS

Twenty-four patients were included, the median age was 66 years, 23/24 (96%) had previous SUI or prolapse surgery. Two conversions to open surgery and 2 modifications of the surgical technique with anterior dissection of the bladder neck were required due to major vesicovaginal adhesions. Overall, 20 patients underwent the robotic posterior approach. Eleven intraoperative complications in 10 patients (50%) occurred, including 7 bladder injuries 4 vaginal injuries, without the need to stop the procedure. The median hospital stay was 3 days (2-7). One AUS was removed at 1 year due to vaginal erosion. At last follow-up (median 26 months (22-36)), 95% of the devices were in place and activated and the continence rate was 84%.

CONCLUSIONS

Early functional results of robot-assisted AUS implantation with a posterior approach to the bladder neck and intraoperative cystoscopic monitoring are promising despite the high rate of intraoperative complications due to previous surgeries. Further evaluation of this technique is required.

[Incontinence surgery-quality criteria and structured follow-up]

The following article summarizes the current evidence including postoperative success rates and complications for various surgical options in the treatment of urinary incontinence. Due to different inclusion criteria and inconsistent definitions of study endpoints, the analysis of available studies is difficult. Thus, comparative studies with new devices for established treatment options should be planned. Structured processes used in certified continence centers improve the quality of care. Furthermore by documenting relevant complications, comparisons of treatment results thus become possible and provide evidence for the use of different surgical options in the treatment of urinary incontinence.

Outcomes of laparoscopic artificial urinary sphincter in women with stress urinary incontinence: mid-term evaluation

PURPOSE

Although artificial urinary sphincter (AUS) has become an established treatment for moderate to severe stress urinary incontinence (SUI), implantation can be challenging. This study aimed to review the outcomes of laparoscopic AUS (LAUS) implantation and revision in women presenting with SUI.

METHODS

We reviewed the files of female patients presenting with moderate to severe SUI treated with LAUS implantation from October 2007 to July 2017. Surgeries were performed by one surgeon experienced in open AUS implantation and starting LAUS implantation. The primary endpoint was postoperative urinary continence, which was divided into three categories: complete continence, improved continence, and unchanged incontinence. The secondary outcomes were complications, explantation-free and revision-free time.

RESULTS

A total of 49 women (mean age 64 years, range 40-80) had LAUS implantation. Among the 42 patients (85.7%) with an AUS in place at the last follow-up, 25 (59.5%) were fully continent, 16 (38.1%) had improved continence, and 1 (2.4%) had unchanged incontinence. At the last follow-up, 29 (59.2%) patients had their initial AUS and 13 (26.5%) had at least one reintervention. There were 9 (18.4%) intraoperative complications and 25 (51%) postoperative complications, of which 9 (18.4%) were Clavien⩾3. After a median follow-up of 4 years, 9 (18.4%) explantations and 11 (22.5%) revisions occurred. The average period without explantation or revision was 3.7 and 3.1 years, respectively.

CONCLUSION

Our study shows that the laparoscopic approach for AUS implantation is an efficient treatment option for women with moderate to severe SUI.

Robot-assisted artificial urinary sphincter implantation

PURPOSE OF REVIEW

The aim of the present manuscript was to provide an overview on the current state of robotic artificial urinary sphincter (AUS) implantation in male and female patients.

RECENT FINDINGS

Over the past few years, several series have been reported, with promising outcomes for the most part. This has contributed to expand the use of bladder neck AUS, especially in female patients, which was, until then, hampered by its perioperative morbidity.

SUMMARY

Robotic AUS has been developed to overcome the technical challenge of bladder neck implantation in female patients and in specific male subgroups, especially self-catheterizing neurological patients. All the series of robotic AUS implantation published in the past few years reported much lower rates of cuff erosion and AUS explantation than the historical open cohorts suggesting that the robotic approach might become the standard for female AUS implantation. This less morbid approach along with technological improvement of the AUS device may contribute to make it a more popular option in the treatment of female stress urinary incontinence due to intrinsic sphincter deficiency. There are much less data available on robotic bladder neck AUS implantation in male patients.