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Robotic three-incision approach to bladder neck artificial urinary sphincter insertion
Erin R. McNamara, MD, MPH, Carlos R. Estrada, Jr., MD, MBA, Michael P. Kurtz, MD, MPH.
Boston Children's Hospital, Boston, MA, USA.

BACKGROUND: We report the second case of bladder neck artificial urinary sphincter (AUS) insertion in a child. Such a technique may have advantages in avoiding an open pelvic approach, improved visualization for patients with spina bifida and compact lower abdominal anatomy, and in decreased blood loss.
METHODS: A 7-year-old girl with lipomyelomeningocele presented with refractory gravitational incontinence. She had bladder-sphincter synergy, complete emptying on a uroflow, and was refractory to anticholinergics, botulinum toxin injection, biofeedback, a trial of pseudoephedrine, and even intermittent catheterization.
RESULTS: We performed a bladder neck AUS insertion robotically through a single camera port and one incision for each robotic arm. The important lessons from the case are that an anterior-only approach to the bladder neck works nicely robotically, and the traditional posterior and anterior approach may not be necessary or helpful. We performed all tubing connections through a port site; we removed the cannula, introduced the reservoir into the abdomen (it is too large to pass through a port), plugged the larger fascial incision with a 12mm traditional laparoscopic trochar, and placed the robotic cannula through the 12mm port. Lastly, whereas pump and tubing connections have previously been performed through a dedicated inguinal incision with the pump placed antegrade through this, we found it straightforward to place the pump in the manner of a laparoscopic orchidopexy, from the abdomen into the labia. The patient has continence except for extreme pelvic pressure (balance beam activities).
CONCLUSIONS: A robotic approach to AUS insertion works well, and only three incisions may be necessary. Antegrade, trans-pelvic pump placement through a port is simple, and a posterior approach may be avoided in some cases. <!--EndFragment-->


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