The artificial urinary sphincter (AUS) can be a solution for patients who have urinary incontinence due to compromised bladder outlet resistance, most commonly patients with neurogenic bladder dysfunction. This device includes a cuff that wraps around the bladder neck or urethra, a fluid reservoir that is placed in the pelvis and a pump that is implanted in the patient’s scrotum or labia. When pumped, the cuff deflates, allowing patients to void or catheterize. Initially used in men who experience chronic incontinence following treatment for prostate cancer, the AUS is now available for use in women and children as well. Stuart Bauer, MD, at Boston Children’s Hospital, was the first pediatric urologist to use the AUS in children.
Despite their potential effectiveness, the AUS is still not widely used in pediatrics, due in part to the challenges associated with surgically implanting them. “It can be difficult to accurately visualize the correct anatomical planes and safely place the device around the child’s bladder neck,” explains urologist Carlos Estrada Jr., MD, MBA, director of the Spina Bifida and Spinal Cord Conditions Center. “We try to reserve the procedure for children who have severe incontinence in whom medical management has failed.”
A game-changing innovation
As the use of robotics has increased in urology, it has allowed for improved precision, helping transform open surgeries to minimally invasive procedures. However, it had never been used to complete a full pediatric AUS implantation. Last December, as she prepared for an AUS implantation in a 7-year-old female patient, urologist Erin McNamara, MD, MPH — who has trained in robotic complex pelvic reconstructive techniques — wondered if this procedure could benefit from robotic technology.
“We do a lot of robotic surgery at Boston Children’s, but never for this particular procedure,” she says. “Based on my previous experience using this technique in adults, I thought this could be a good opportunity to apply it to younger patients.”
After explaining the approach to the patient’s parents and getting their approval, McNamara collaborated with Estrada and their colleague Michael Kurtz, MD, MPH, a pediatric urologist who specializes in robotic surgery, to form a plan. Initially, they expected to use the robot for as much of the procedure as possible, switching to standard surgery when necessary. But as the operation progressed, the team was encouraged by their success. “We just kept going,” says McNamara.
New option for eligible patients
The result was the first completely robotic pediatric AUS implantation in the world using only three small laparoscopic port incisions. The technique allowed the team to more accurately visualize the child’s anatomy, allowing for safer and more precise placement of the AUS. The minimally invasive approach can also result in fewer and smaller scars and a faster recovery.
Today, the patient is doing well and is completely dry, thanks to her ability to close her bladder neck with the AUS. Based on the success of this first case, the team plans to offer the robot-assisted approach to more eligible patients undergoing AUS placement surgery.
“I have placed many of these devices via open surgery, and I can clearly see that the incredible visualization the robotic approach offers results in a safer dissection around the bladder neck,” says Estrada. “I really think this approach will allow us to offer this procedure to more patients and families.”
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