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Background Artificial urinary sphincter (AUS) implantation is recommended for women suffering urinary stress incontinence. Robot-assisted laparoscopy allows improved dexterity and visibility compared to traditional laparoscopy, potentially providing significant advantages for deep pelvic surgery. Objective To report our surgical technique and initial experience in transperitoneal robot-assisted laparoscopic AUS implantation in women with urinary stress incontinence. Design, setting, and participants Eleven eligible patients with AUS implantation or revision using robot-assisted laparoscopy for urinary stress incontinence were included between January 2012 and February 2014 at Department of Urology, Lille University Hospital. Surgical technique Procedures were performed with the assistance of a four-arm da Vinci robot. The urethrovaginal space was dissected after transperitoneal access to the Retzius space. An 11-mm port placed in the right iliac fossa allowed introduction of the AUS device. The cuff and balloon tubes were externalised via a 5-mm suprapubic incision. The peritoneum was finally sutured. Measurements Clinical data were prospectively collected before, during, and after the procedure. Results were classified as complete continence (no leakage and no pad usage), social continence (leakage and/or pad usage with no impact on social life), or failure (leakage and/or pad usage impacting social life). Results and limitations After mean follow-up of 17.6 mo (interquartile range 10.8–26 mo), eight patients (72.7%) had a successful AUS implantation, of whom seven (87.5%) reported complete continence and one had social continence. Two vaginal injuries and two bladder injuries occurred intraoperatively . Two patients experienced early minor postoperative complications and two had a major postoperative complication. Conclusions Robot-assisted laparoscopic AUS implantation is a feasible procedure. Further studies will better assess the place of robot-assisted laparoscopy in AUS implantation. Patient summary We investigated the treatment of 11 patients with stress urinary incontinence using robot-assisted implantation of an artificial urinary sphincter (AUS). The results show that the procedure is feasible procedure, and future studies will to help assess the place of robot-assisted laparoscopy in AUS implantation.

We thank Phe et al for their insightful comments regarding our article on robot-assisted laparoscopic artificial urinary sphincter (AUS) implantation in women with stress urinary incontinence [1]. Their knowledge on AUS implantation, derived from leading experience in this field, is of great interest. With the aim of promoting this underdeveloped approach, we would like to address some of the issues they raised. As stated by the commentators, AUS implantation is challenging in women, especially after multiple antiincontinence surgeries, and we agree that careful selection of candidates to undergo this procedure is a necessity. However, we question the validity of a Marshall or submidurethral test in this specific population, especially since data on evaluation of intrinsic sphincter deficiency and/or urethral hypermobility after multiple anti-incontinence surgeries are scarce in the literature. Because of our high intraoperative complication rate, we agree that technical aspects of the procedure should be revised. Step-by-step improvement is inherent to all novel surgical approaches, and in our case will probably lead to a decrease in overall morbidity and description of a more standardized and simplified technique. Now that our own experience with this procedure has grown, we believe that the magnified vision offered by the robotassisted approach initially prompted us to perform a dissection that was too close and medial, and was probably responsible for our initial high rate of intraoperative complications. We now assume that the dissection should be initiated more laterally, distant to the medial anatomic structures. Unpublished results for our most