Step by step illustrative video of laparoscopic artificial urinary sphincter implantation in a woman with recurrent stress urinary uncontinence
Agostinho Cordeiro1, João P. Torres1-2, Vitor H. Nogueira1, Estevão Lima1-2
1Dept. of CUF Urology and Service of Urology, Braga, Portugal
2Surgical Sciences Research Domain, Life and Health Sciences Research Institute - University of Minho, Portugal
Citation: Cordeiro A, Torres J P, Nogueira V H, Lima E Step by step illustrative video of laparoscopic artificial urinary sphincter implantation in a woman with recurrent stress urinary uncontinence.
Key Words: laparoscopy • artificial urinary sphincter • stress urinary incontinence • implantation

Introduction. Urinary stress incontinence (SUI) is the most common subtype of incontinence and is defined as the perception of urine loss with effort (1-3). In most cases, it is due to insufficient support of the bladder neck, conditioning urethral hypermobility , and in a minority, intrinsic sphincter deficiency (ISD) (2-5). Sometimes both pathophysiological mechanisms occur simultaneously (4). The initial treatment of SUI consists of lifestyle changes, pelvic floor rehabilitation and medication (1,2). If medical failure occurs, surgical treatments for urinary incontinence are considered.

Surgery correction of urinary stress incontinence (SUI) has a failure rate ranging from 5% to 80% (1-5). Many procedures have been described to treat SUI, however there is currently no consensus on the superiority of any technique (6). What seems to be consensus is that most of these techniques have their efficacy diminished when applied secondary to another surgical treatment, and there is still no consensus for its indication as a treatment for recurrent female urinary incontinence (UI). While the AUS has become the gold standard for the treatment of male sphincter deficiency (1), the experience in women continues to be limited, namely laparoscopically. However, some authors have shown that it is useful when ISD is presente, with or without urethral hypermobility, with reported cases with excellent long-term continence rates (6,7).

Description. In this illustrative video, ten surgical steps of a laparoscopic AUS implantation are described. In this case, a 55 year-old woman was submitted to two previous surgical procedures for UI without success.
Step 1. Pre-vesical space or extra-peritoneal approach and placement of the trocars.
Step 2. Isolation of the proximal urethra.
Step 3. Bilateral peri-urethral space dissection.
Step 4. Urethral and vaginal integrity confirmation with diluted methylene blue injection.
Step 5. Measurement of the urethral circumference and placement of the cuff.
Step 6. Placement of the reservoir balloon in pre-vesical location.
Step 7. Sub-dermal space approach.
Step 8. Placement of the pump.
Step 9. Adjustment of the whole system in a closed circuit and filling with saline solution.
Step 10. Confirmation of proper system functioning and subsequent sphincter deactivation.

Conclusions. The laparoscopic approach of AUS implantation, appears to provide a better image, facilitating dissection, especially in the area of ​​the bladder where it is technically demanding, and in women who have undergone previous pelvic surgery. AUS laparoscopic implantation in women appears to be a good alternative to the classic surgical technique and an excellent option in complicated and refractory cases of urinary incontinence.

  1. Lucas MG, Bosch RJ, Burkhard FC, Cruz F, Madden TB, Nambiar AK, , et al. EAU guidelines on urinary incontinence. Actas Urol Esp. 2013;37:459-72.
  2. Rouprêt M, Misraï V, Vaessen C, Cardot V, Cour F, Richard F,  et al. Laparoscopic approach for urinary sphincter implantation in women with intrinsic sphincter deficiency incontinence: a single-centre preliminary experience. Eur Urol. 2010;57:499–505.
  3. Poinas G, Droupy S, Ben Naoum K, Boukaram M, Wagner L, Soustelle L, et al. Treatment of women urinary incontinence by artificial urinary sphincter: efficacy, complications and survival. Prog Urol. 2013;23:415-24.
  4. Chartier-Kastler E, Van Kerrebroeck P, Olianas R, Cosson M, Man-Dron E, Delorme E, et al. Artificial urinary sphincter (AMS 800) implantation for women with intrinsic sphincter deficiency: a technique for insiders? BJU Int. 2011;107:1618-26..
  5. Chung E, Cartmill RA. 25-year experience in the outcome of artificial urinary sphincter in the treatment of female urinary incontinence. BJU Int. 2010;106:1664-76.
  6. Phé V, Benadiba S, Rouprêt M, Granger B, Richard F, Chartier-Kastler E. Long-term functional outcomes after artificial urinary sphincter implantation in women with stress urinary incontinence. BJU Int. 2014;113:961-77.
  7. Chung E, Navaratnam A, Cartmill RA. Can artificial urinarysphincter be an effective salvage option in women following failed anti-incontinence surgery? Int Urogynecol J. 2011;22:363-8.
Article history
Submitted: 26 December, 2018
Accepted: 12 February, 2019
Published online: 12 February, 2019
doi: 10.5173/ceju.2019.1839
Corresponding author
Agostinho Cordeiro
Conflicts of interest:  The authors declare no conflicts of interest.
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