INTRODUCTION
Urologists should be proficient in the evaluation and management of lower urinary tract disorders. Functional and reconstructive urology (FRU) is a rapidly expanding subspecialty within urology. Some view FRU as a rebranding effort, whereas others regard it as a framework that unifies established domains, including female urology, neurourology, urodynamics, benign prostatic hyperplasia (BPH), men’s health, and reconstructive urology. Regardless of terminology, the overarching goal of this subspecialty is to improve care for patients with urinary tract disorders. By encompassing male and female patients and neurogenic and non-neurogenic conditions, FRU seeks to support effective urine storage and voiding and, in turn, improve quality of life.
Robotic surgery was first introduced in 1985 for neurosurgical biopsies [1] and advanced substantially with the development of the da Vinci robotic system. Robotic platforms offer improved visualization and enhanced dexterity, which can be advantageous in complex anatomy and reoperative fields. Clinical scenarios such as prior exploratory laparotomy, gunshot wounds, abdominal stomas, prior radiation therapy, and recent surgery are no longer considered absolute contraindications to robotic approaches. In addition, near-infrared fluorescence (NIRF) imaging can strengthen intraoperative decision-making by enabling assessment of tissue perfusion and improving identification of structures that may be difficult to distinguish under white light alone. The use of indocyanine green (ICG) fluorescence in combination with ureteroscopy (white light) and cystoscopic visualization via TilePro is also pivotal for optimizing visualization during reconstructive procedures. Moreover, compared with laparoscopy, robotic platforms generally facilitate intracorporeal suturing, which has contributed to broader adoption of reconstructive robotic techniques [2, 3].
These advantages have increasingly been applied to FRU procedures over time, with favorable outcomes reported across multiple settings. In FRU, robotic technology has the potential to refine established techniques, facilitate more anatomically precise dissection and reconstruction, and broaden procedural options across multiple domains. This review focuses on less widely adopted robotic approaches in FRU and considers how evolving technology may further advance the field.
METHODOLOGY
The PubMed and Web of Science databases were searched for articles published between 1985 and 2024, primarily in English, using the search terms “bladder neck reconstruction,” “vesicourethral anastomotic stricture reconstruction,” “upper urinary tract reconstruction,” “sacrocolpopexy,” “simple prostatectomy,” and “female artificial urinary sphincter.” This review was conducted as a narrative review, and all studies were assessed by a single reviewer. Both abstracts and peer-reviewed publications were cited in this manuscript to provide a comprehensive overview of the current state and future potential of robotic techniques in FRU.
BLADDER NECK RECONSTRUCTION
Background
Bladder neck contracture (BNC) is a common complication after BPH surgery and results from fibrosis and narrowing of the bladder neck [4]. This condition can cause bladder outlet obstruction (BOO) and substantially impair quality of life [5, 6]. Reported incidence rates of BNC after transurethral resection of the prostate (TURP), holmium laser enucleation of the prostate (HoLEP), and thulium laser enucleation of the prostate are 0.3%–9.2%, 2%, and 2.2%, respectively [7, 8]. Based on these rates, it is estimated that nearly 2,500 new cases of BNC occur annually in the United States.
BNC is often straightforward to manage and typically does not involve the external urethral sphincter (EUS), thereby posing minimal risk of incontinence. In addition, it is described as unrelated to radiation therapy and may respond well to advanced treatment modalities when initial dilation or incision fails, with reported success rates of 90%–100% [9].
Surgical Technique
In the restoration of BNC initially described by Young in 1953, robot-assisted Y–V plasty has become one of the most well-known and established treatment modalities [10]. Typically, Y–V plasty is performed for strictures measuring 10F or larger, whereas complete excision and anastomosis are reserved for strictures measuring less than 10F, with modifications based on patient anatomy and surgical history [11].
Using a transperitoneal approach, the procedure begins with dissection of the space of Retzius and proceeds to the level of the BNC. A 0° lens is commonly used for visualization. To precisely localize the stricture, retrograde flexible cystoscopy is performed with Firefly mode enabled, with visualization facilitated using the TilePro system (Fig. 1A). Under cystoscopic guidance, the stricture is incised longitudinally using robotic monopolar scissors until adequate patency is achieved. Dense fibrotic tissue is then excised circumferentially, followed by bladder neck reconstruction using double-armed barbed sutures to maintain repair integrity (Fig. 1B).
To create the bladder flap, a reversed “Y” is marked on the anterior bladder wall using monopolar electrocautery. The tip of the V-shaped flap is advanced and anastomosed to the distal end of the stricture incision, and the bladder neck is widened using barbed sutures. A 22F Foley catheter is inserted to maintain urethral patency. A common technical error is creating an overly narrow flap (Fig. 1C). To avoid this, the “Y” should be designed with a sufficiently wide base. After flap creation, intravenous ICG is administered to identify and excise poorly vascularized areas. After completion of the Y–V anastomosis (Fig. 1D), a filling test is performed to confirm repair integrity. Finally, the upper peritoneum is sutured to close the space of Retzius.
Considerations
Several studies of BNC reconstruction report an average prostate volume of approximately 30 mL [12, 13]. This finding suggests that smaller prostates may be more susceptible to BNC. It also underscores the need for caution when considering BPH surgery in patients with smaller prostates and highlights the importance of avoiding excessive bladder neck resection [13]. In addition, potential complications of Y–V plasty, including persistent voiding dysfunction, should be considered carefully in patients with detrusor underactivity (DU) [14].
VESICOURETHRAL ANASTOMOTIC STRICTURE RECONSTRUCTION
Background
Radical prostatectomy (RP) is one of the most commonly performed robotic procedures in urology. Although functional outcomes are generally favorable for most patients [15, 16], vesicourethral anastomotic stricture (VUAS) can occur as a result of scar formation and may substantially affect quality of life.
Recent reports indicate that the prevalence of symptomatic VUAS is approximately 1.3%–2.4% after robot-assisted RP, compared with 7.1%–19.8% after open RP [17-20]. However, prevalence increases 1–3 years after radiation therapy, with an estimated incidence of 2.7%–10% in patients undergoing both RP and external beam radiation therapy [21].
Etiology
The causes of VUAS can be grouped into 2 broad categories. First are technical factors during RP, including inadequate mucosa-to-mucosa anastomosis, insufficient tension control, extravasation, or the influence of foreign bodies such as staples or clips [22]. Second are radiation-related effects before or after RP. Obliterative endarteritis and apoptosis of tissue progenitor cells are described as key mechanisms, and free radicals and reactive oxygen species are implicated in progressive fibrosis [23].
Surgical Technique (Why VUAS Is Challenging)
Scar formation in VUAS is associated with the postoperative inflammatory phase and can lead to dense fibrotic narrowing at the vesicourethral anastomosis [24]. Management strategies often begin with chronic catheter-based approaches such as clean intermittent catheterization (CIC), a suprapubic tube, or an indwelling Foley catheter. Endoscopic treatments—including balloon dilation and direct vision internal urethrotomy with or without injection—are commonly pursued next, with abdominal and/or perineal reconstruction reserved as a final option. One study reported that only 58% of patients responded to a single endoscopic treatment [25]. The natural history of untreated refractory VUAS can involve lifelong repeated catheterizations and multiple endoscopic procedures and may progress to urinary diversion [26].
Refractory VUAS after RP presents challenges distinct from BNC. It can be technically demanding because of its proximity to the sphincter mechanism and is also challenging in terms of access, visualization, and assessment of tissue viability. Open reconstruction carries risks of injury to the rectum, urethral sphincter, and cavernous nerves. In addition, reanastomosis via a perineal approach can be particularly difficult and may require abdominoperineal dissection or pubectomy [27]. Excision and primary anastomosis (EPA) is reported to achieve success rates of 60%–87% [28, 29]. However, even when patency is achieved after open reconstruction, de novo stress urinary incontinence (SUI) is reported to be nearly universal (93%–100%) [30, 31]. Patients with prior perineal incisions—particularly those with a history of pelvic radiation therapy—also have an increased risk of erosion with artificial urinary sphincter (AUS) cuffs.
Robotic reconstruction of VUAS provides the advantage of antegrade access to the genitourinary diaphragm. An abdominal approach may reduce incontinence risk and can facilitate localization of VUAS using white-light cystoscopy and NIRF. Combining intravenous ICG with NIRF can also be useful for evaluating tissue perfusion.
Robotic VUAS Reconstruction Algorithm (Fig. 2)
Endoscopic evaluation, including assessment of stricture caliber and its relationship to the EUS, is central to decision-making. During cystoscopy, the stricture caliber and its relationship to the EUS should be determined, and radionecrosis should be assessed. If radionecrosis is evident, reconstruction is generally not recommended. Magnetic resonance imaging is also recommended to assess proximity to the pubic bone and evaluate for osteomyelitis. When the proximal extent of the stricture is unclear, a retrograde urethrogram can be useful for determining VUAS length.
In the subsequent algorithm, EUS involvement is a key determinant. If the EUS is not involved and the residual lumen measures 10F or larger, a nontransecting bladder flap (Y–V plasty) may be an appropriate option. If the lumen caliber is less than 10F, EPA is often preferred. When EPA is challenging, an anterior bladder flap technique with minimal radiation influence, such as the Tanagho flap [32], may be considered as an alternative.
If the stricture extends past the EUS, regardless of lumen caliber, perineal dissection followed by a urethral pull-through procedure can be performed to achieve a tension-free anastomosis [33].
UPPER URINARY TRACT RECONSTRUCTION
Background
Depending on the stricture location, a wide range of reconstructive options are available (Fig. 3). Because the ureter connects the kidney to the bladder, upper urinary tract reconstruction requires substantial instrument mobility, making laparoscopic and robotic approaches well suited to these procedures. Because the surgical plan may change intraoperatively based on the location and extent of the ureteral stricture—and because suturing constitutes a substantial component of many reconstructions—robotic approaches may be preferable [34].
Simple Ureteral Reimplantation
The choice between a transvesical and an extravesical approach, as well as the decision to use a refluxing or nonrefluxing technique, often depends on the surgeon’s preference. Advantages of this technique include easier length management than end-to-end ureteroureterostomy and high success rates attributable to the robust bladder blood supply. However, this approach is generally limited to short-segment strictures, and approach-specific risks should be considered [35].
Psoas Hitch
When the defect length extends beyond a few centimeters, simple ureteral reimplantation may become infeasible, making a psoas hitch a more practical option. One advantage of this technique is that extensive dissection of the stricture segment is not required. In addition, bladder hitching can reduce tension at the anastomosis during storage and voiding cycles. The procedure involves suturing the bladder dome to the psoas minor tendon or the psoas major muscle. In female patients, the psoas minor tendon can be difficult to identify, and inadvertent incorporation of the genitofemoral nerve is a concern. In such cases, it may be safer to suture the psoas major muscle, using absorbable sutures placed vertically and not too deeply. This technique can cover up to 8 cm from the ureterovesical junction (UVJ). However, it is not suitable for patients with a contracted bladder or bilateral strictures [36].
Boari Flap
For longer defects, a Boari flap is commonly used and can typically provide sufficient length up to the L5 level [37]. It is generally performed in conjunction with a psoas hitch, using a rectangular flap approximately 3–4 cm wide. A sufficiently wide pedicle is essential to support neoureteral patency and maintain adequate vascular supply. A Boari flap can cover up to 12 cm from the UVJ; however, it is not suitable for patients with a contracted bladder. High success rates for robot-assisted Boari flap procedures have been reported in multiple studies [38, 39]. In patients with adequate bladder capacity, a flap up to 10–15 cm long can be created with careful construction. To reduce ischemia risk, the base of the flap is recommended to be at least 5 cm wide. After the initial anastomosis between the ureter and bladder flap is completed, alignment is confirmed, and ICG is injected to verify adequate perfusion of both the ureter and flap [40].
Ureteroplasty Using Buccal Mucosa Graft
Two main approaches are used for buccal mucosa graft (BMG) ureteroplasty: patch grafting and tubularized reconstruction. However, patch grafting after ureterotomy is most commonly performed [41]. For strictures with preserved luminal patency, an onlay technique is used, in which a longitudinal incision is made along the stricture and the graft is sutured over the resulting ureteral defect. In contrast, for obliterative strictures or cases in which the ureteral mucosa is nonviable, an augmented anastomotic technique is used. This involves resecting the diseased segment, performing anterior spatulation at both ends, anastomosing a posterior ureteral plate, and suturing the graft over the resulting defect [42].
A notable feature is the need for omental wrapping to support graft vascularity. Multiple approaches to omental placement have been described; however, provided that adequate graft contact is maintained, several methods are acceptable. Use of BMG for urinary tract stricture repair, including ureteral and urethral strictures, has increased. A key advantage is preservation of the ureteral plate, which supports vascular supply [34]. A limitation is the inability to bypass the diseased ureteral segment, which necessitates meticulous dissection of the affected area. BMG ureteroplasty is generally appropriate for upper- or mid-ureter strictures up to approximately 5 cm. It is also important for the patient to have no conditions affecting the oral mucosa.
Ileal Ureter Replacement
Ileal ureter replacement is often considered a last-resort option for both upper and lower ureteral reconstruction [43]. For upper ureteral reconstruction, it is indicated in long-segment strictures (>6 cm) when BMG is unsuitable, in the presence of multiple strictures, or when contralateral ureteral strictures are present. For lower ureteral reconstruction, additional indications include reduced bladder compliance in the setting of contralateral ureteral strictures [44]. Conversely, this technique is not suitable for patients with active inflammatory bowel disease, a history of extensive bowel surgery, renal insufficiency, or short bowel syndrome. On the right side, the ascending colon can be mobilized to facilitate anastomosis. However, on the left side, mobilization is limited by the sigmoid colon; therefore, a mesenteric window is created to pass part or all of the ileal segment before reconstruction proceeds [45].
ROBOTIC SACROCOLPOPEXY
Background
Minimally invasive sacrocolpopexy has become increasingly popular compared with vaginal approaches for the treatment of pelvic organ prolapse (POP) [46]. It is commonly considered the gold standard for prolapse repair because it provides higher anatomic success rates than vaginal apical repairs using native tissue [47].
The procedure was first described in 1957 by Arthur and Savage, who performed hysteropexy by suturing the uterine fundus to the anterior longitudinal ligament [48]. In 1962, Lane introduced sacrocolpopexy, describing suspension of the vaginal apex to the anterior longitudinal ligament of the sacrum [49]. Several modifications have since been introduced. The fixation point shifted from the promontory to the S1–2 region, reducing the risk of injury to vascular structures and the hypogastric plexus. Initially, mesh fixation was limited to the vaginal apex; later, mesh arms were extended to the anterior and posterior vaginal walls. Another major evolution has been the widespread use of type I polypropylene macropore mesh, although some surgeons continue to use biologic grafts.
Surgical technique - Is Sacrocolpopexy Effective?
Severe POP is a common and challenging surgical condition. Historically, reconstructive procedures were performed via vaginal approaches; however, advances in minimally invasive techniques have made graft-based sacrocolpopexy an effective option for apical prolapse (Fig. 4). This approach differs from vaginal colpopexy in both the types and rates of complications. Accordingly, risks and benefits should be weighed for each patient, and contemporary evidence should be incorporated to support surgical decision-making.
Mesh-based sacrocolpopexy is highly effective for the treatment of moderate to severe apical POP. Success is often defined using strict criteria: no prolapse below the hymen; Pelvic Organ Prolapse Quantification point C not descending beyond one-third of the total vaginal length; a “No” response to question 3 on the Pelvic Floor Disability Index-20 questionnaire; and no need for repeat prolapse surgery or pessary use postoperatively. Using these criteria, the 5-year success rate is approximately 90%. In contrast, the success rate for native tissue repair under the same criteria is substantially lower, at approximately 30%–40% [50].
However, sacrocolpopexy effectively addresses upper and midvaginal prolapse but may not fully resolve distal vaginal problems, including distal prolapse, bladder neck hypermobility, SUI, distal rectocele, outlet constipation, and perineal body deficiency. Moreover, despite overall symptom improvement and quality-of-life gains after minimally invasive sacrocolpopexy (MIS-SCC), postoperative dissatisfaction is often related to constipation, perceived prolapse recurrence, or issues associated with concomitant SUI procedures [51].
Recent studies report no significant difference in anatomic correction of anterior-apical POP between MIS-SCC and transvaginal anterior mesh surgery. However, MIS-SCC demonstrated better outcomes in correcting posterior vaginal wall defects and preserving overall vaginal length [52]. In addition, among normal-weight, overweight, and obese women, robot-assisted or laparoscopic sacrocolpopexy performed by experienced surgeons appears to have similar intraoperative complication rates. Given the advantages of minimally invasive approaches in obese patients, minimally invasive surgery is recommended as a treatment option for vault prolapse in overweight or obese women [53].
ROBOT-ASSISTED SIMPLE PROSTATECTOMY
Background
Open simple prostatectomy is performed less frequently because endoscopic approaches for BPH are widely used. Nevertheless, enucleation remains important for large adenomas, and minimally invasive approaches may offer advantages, including reduced blood loss, lower morbidity, and faster recovery. Since Sotelo et al. first reported robotic-assisted simple prostatectomy (RASP) in 2008, the procedure has gained increasing use, particularly from the early 2010s onward, and has been reported as safe and effective [54-56].
Simple prostatectomy may be performed via transperitoneal or extraperitoneal access, either through the bladder (transvesical) or using the Millin technique. The dexterity and degrees of freedom provided by robotic assistance can facilitate enucleation in large glands. One major reason HoLEP is not widely adopted is its steep learning curve, reportedly requiring 25–50 cases. In contrast, RASP can reportedly be learned by surgeons with robotic experience in approximately 10–12 cases [57, 58].
Indications
The primary determinant for selecting simple prostatectomy over other bladder outlet reduction procedures is prostate volume. The American Urological Association guideline on surgical management of BPH recommends considering simple prostatectomy in patients with large prostates. Although the definition of a “large” prostate is subjective, discussion of simple prostatectomy is typically warranted for prostate volumes ≥85 mL [59]. Larger glands are associated with longer TURP resection times, increased complications, and reduced efficiency.
A major advantage of RASP is avoidance of transurethral surgery. In addition, RASP may be considered in patients with prior hypospadias repair, those with a penile prosthesis that makes endoscopic access challenging, or those with orthopedic conditions (e.g., ankylosis of the hip) that complicate lithotomy positioning.
Surgical Technique
Two main approaches are used to expose and remove the adenoma. In the transvesical approach, the bladder is opened to access the adenoma. By identifying the plane between the anterior fibromuscular stroma and the adenoma, the adenoma can be removed while minimizing sphincter injury. Both intra- and extraperitoneal approaches are possible. With the extraperitoneal approach, a Trendelenburg angle of only 10°–15° is often sufficient to limit bowel interference. In the transcapsular approach, an incision is made on the anterior surface of the prostatic capsule. Bleeding may occur from the dorsal vein complex, and if it cannot be controlled with electrocautery, continuous suturing is used for hemostasis. If the median lobe is not prominent, a urethral-sparing technique (Madigan technique) can be performed (Fig. 5). This technique may increase ejaculation preservation compared with conventional methods, with reported rates of 65%–86.6% [60-63].
Considerations
Open simple prostatectomy, HoLEP, and RASP share similar surgical principles. Compared with conventional TURP, these approaches allow closer dissection near the sphincter, which can improve efficacy by enabling a larger resection volume. However, endoscopic approaches are associated with a higher risk of transient postoperative SUI [64, 65]. A comparison of perioperative parameters is summarized in Table 1.
The anterior aspect of the prostatic apex (between 10 and 2 o’clock) contains bulky sphincter tissue, which can make the anterior apex challenging to manage during HoLEP. In addition, the apex lacks a true capsule and consists of a long band of fibromuscular stroma tissue [66]. During RASP, the adenoma and fibromuscular stroma are more readily distinguishable. By leaving a portion of fibromuscular stroma intact while resecting the adenoma, sphincter injury may be avoided. This interpretation is consistent with continence outcomes reported in recent studies, in which SUI rates were mostly below 5% [67, 68].
Another important benefit of RASP is avoidance of transurethral surgery, particularly in patients with urethral strictures. Even when only minimal fibrotic bands are observed on cystoscopy, transurethral surgery for large adenomas can exacerbate stricture formation and may not achieve the primary goal of relieving BOO (Fig. 6). Primary endoscopic treatment in such cases has a relatively low success rate of approximately 50% [69]. By avoiding transurethral instrumentation, RASP may offer an advantage in this setting.
ARTIFICIAL URINARY SPHINCTER
Male Robotic AUS
AUS in nonneurogenic male urinary incontinence
For male urinary incontinence due to intrinsic sphincter deficiency (ISD), the AUS has been established over the past decades as the most effective and standard treatment option [70]. In particular, in nonneurogenic male SUI after RP, much of the lissosphincter surrounding the bladder neck and proximal urethra is removed during surgery, resulting in loss of the passive continence mechanism. To reduce the likelihood of postoperative incontinence, an approximately ≥1.5-cm urethral length—including the remaining rhabdosphincter—should be preserved; when this length is insufficient, persistent incontinence is more likely [71, 72]. AUS implantation allows most patients to achieve social continence (0–1 pad/day), with reported rates of approximately 90% [73]. Patient-reported satisfaction is also high, exceeding 80% in most series. Complications such as infection and urethral erosion are relatively infrequent in nonneurogenic patients, with reported infection rates of approximately 13% and urethral erosion rates of 5%–10% [74-76]. Mechanical durability is favorable, with long-term follow-up studies reporting device survival free of mechanical failure of 50%–79% at 5 years and approximately 64% at 10 years. Owing to these outcomes, AUS remains widely regarded as a first-line option for post-prostatectomy incontinence [73].
AUS in neurogenic male urinary incontinence
In patients with neurogenic bladder due to conditions such as spinal cord injury or spina bifida, AUS is also a major treatment option when sphincter insufficiency leads to urinary incontinence. However, outcomes in neurogenic male urinary incontinence are generally less favorable than those in nonneurogenic cases. Reported social continence rates after AUS implantation in neurogenic patients range from approximately 50% to 80%, compared with ~90% in nonneurogenic populations. In addition, these patients have higher rates of device-related complications and a greater need for revision surgery. In the study by Elliott et al. [77], more than half of patients with an AUS required revision within 5 years, and across series, device explantation rates are approximately 20%, which is similar to or slightly higher than rates in nonneurogenic cohorts. Infection and urethral erosion are also more common in neurogenic patients, with reported infection rates of 5%–15% and urethral erosion rates of up to 20% [74, 76]. This increased erosion risk is particularly pronounced when the cuff is placed around the bulbar urethra, largely because multiple risk factors are present in neurogenic patients undergoing bulbar cuff placement.
The disadvantages of bulbar urethral cuff placement in neurogenic bladder can be summarized as follows [78]:
(1) CIC: Many neurogenic bladder patients rely on CIC for bladder emptying. When a cuff is placed at the bulbar urethra, repeated catheter passage through the cuff segment can cause chronic urethral trauma and increase the risk of cuff erosion.
(2) Perineal pressure in wheelchair users: Patients with paraplegia who are wheelchair-bound for prolonged periods experience continuous perineal pressure while sitting. This imposes additional mechanical stress on a bulbar cuff, potentially leading to local ischemia and a higher erosion risk.
(3) Open bladder neck: In patients with sacral cord lesions and an open bladder neck, urine can pool within the prostatic urethra. In the presence of a bulbar cuff, stagnant urine can promote bacterial colonization, thereby increasing the risk of infection and cuff erosion.
(4) Subsequent endoscopic procedures: Bladder stones and other conditions requiring urethral or bladder endoscopic procedures are relatively common in neurogenic bladder. With a bulbar cuff in place, passage of endoscopic instruments can increase friction at the cuff segment, which may markedly increase the risk of cuff erosion.
For these reasons, in male patients with neurogenic urinary incontinence, cuff placement at the bladder neck is generally recommended when feasible. Multiple retrospective studies have reported lower urethral erosion rates with periprostatic (bladder neck) cuffs than with bulbar cuffs. For example, in the systematic review by Farag et al. [79], erosion rates with bladder neck cuffs were approximately 5%–10%, lower than the ~20% reported with bulbar cuffs. Reported social continence and infection rates are generally similar between bladder neck and bulbar cuff placement, with ranges of approximately 70%–90% and 5%–15%, respectively. However, device longevity is described as favoring bladder neck placement. In a French multicenter study, after a mean follow-up of 7 years, 74% of patients still had a functioning AUS (i.e., continence maintained) [70], and bladder neck cuff placement showed a trend toward longer device survival without explantation than bulbar cuff placement (median device survival 24.5 years vs. 18.5 years). It should be noted, however, that cuff location itself is not considered an independent prognostic factor; rather, the need for intermittent catheterization has been identified as the most important risk factor for device failure [80, 81].
Technique of bladder neck cuff placement and robot‑assisted approaches
Although bladder neck AUS cuff placement has the advantages described above, it is technically demanding. In the open approach, the surgeon enters the retropubic (space of Retzius), performs meticulous dissection around the bladder-prostate junction, and circumferentially mobilizes the bladder neck to accommodate the cuff, which requires advanced anatomic knowledge and surgical expertise [82]. To address these challenges, robot-assisted bladder neck cuff implantation has been introduced. In 2013, Yates et al. [82] reported the first series of 6 male patients with neurogenic urinary incontinence who underwent robot-assisted laparoscopic AUS implantation at the bladder neck, with favorable short-term outcomes. Subsequently, additional experience—particularly from the group at Pitié-Salpêtrière Hospital in Paris—has accumulated. In a study of 19 patients who underwent robot-assisted bladder neck AUS implantation between 2011 and 2018, 89.5% achieved improvement sufficient to require only 0–1 pad/day at a median follow-up of 58 months. In the same cohort, the AUS revision rate was 5.3%, and the permanent explantation rate was 0%, suggesting favorable complication profiles compared with historical open series.
These early data suggest that enhanced visualization and precise dissection around the bladder neck with robotic assistance may improve outcomes for this technically challenging procedure and may reduce complications in neurogenic patients. Prospective studies comparing long-term outcomes of robot-assisted and open AUS implantation are needed. If safety and effectiveness are confirmed in larger series, robot-assisted bladder neck cuff placement may become a standard approach for neurogenic male urinary incontinence.
Female AUS
Background
Despite the 2011 U.S. Food and Drug Administration (FDA) warning on vaginal mesh, midurethral slings (MUS) remain the standard treatment for SUI worldwide. The short-term success rate of MUS exceeds 90%, and common SUI risk factors such as obesity, age, and vaginal delivery have minimal impact on short-term outcomes [83]. However, the probability of requiring reoperation for recurrent SUI increases to 5% at 10 years and has been reported to be as high as 10% in some studies [84, 85]. Prior studies have shown that patients with reduced urethral mobility or low maximal urethral closure pressure (MUCP) have long-term recurrence rates of 68%–75% [86, 87]. Lo et al. reported that the success rate of repeat MUS in patients with poor urethral mobility is only approximately 25% [88].
Male SUI most commonly occurs after RP, and AUS is well established as the standard treatment for SUI caused by ISD in male patients. Less widely recognized is that AUS, developed by American Medical Systems, was originally designed primarily for women [89]. The first clinical use of AUS dates to the early 1970s, before the widespread adoption of RP and when male SUI prevalence was relatively low [90]. In the mid-1990s, the female AUS did not receive FDA approval in the United States. Over the past 2 decades, it has been used primarily in Europe, particularly in specialized tertiary centers in France, through open surgical approaches. More recently, robotic approaches have been developed to address the technical complexity of AUS implantation and reduce morbidity [91, 92]. This paper aims to introduce indications for female AUS implantation when initial MUS has failed.
Indication
ISD with urethral hypomobility: Failure of MUS can generally be attributed to 2 categories of factors. The first is patient-related factors, in which the underlying cause of SUI does not align with the mechanism of MUS, which is based on urethral support. The second is surgeon-related factors, such as suboptimal tension adjustment or positioning, which are closely associated with surgical experience and volume. These factors are interrelated. MUS achieves optimal efficacy when positioned at the mid-urethra with appropriate tension adjustment. Studies have shown that success rates decrease when the proximal distance between the tape and the bladder neck during Valsalva is too short. In addition, success rates drop substantially when the tape-to-urethra distance exceeds 5 mm [93, 94]. Wlaźlak et al. [94] reported outcomes for 109 patients with ISD who underwent tension-free vaginal tape with 6 months of follow-up. The overall success rate was 82%, and ISD severity did not significantly impact outcomes. However, reduced urethral mobility was associated with lower success rates, with patients with a hypomobile urethra having a success rate of approximately 67%.
Thus, MUS success in ISD patients decreases substantially when urethral mobility is poor, making tension adjustment more challenging and highlighting why surgeon and patient factors are difficult to separate. This underscores the importance of surgeon experience in repeat procedures. For example, in cases of index MUS failure, high-volume surgeons were reported to reduce failure risk by 25% compared with low-volume surgeons [95]. When ISD is the predominant contributor, even high-volume surgeons may have difficulty improving MUS outcomes. In pure ISD cases, as noted above, repeat MUS success rates fall below 25%. Although comparative data between female AUS and other options are limited, female AUS can be an effective surgical option for severe ISD with urethral hypomobility, alongside fascial slings (Fig. 7).
ISD with urethral hypomobility and DU: A second indication is when DU is also present. AUS is the only anti-incontinence procedure that can support both storage and voiding by increasing outflow resistance at rest when the cuff is closed, while maintaining low outflow resistance during voiding when the cuff is open [92]. The relatively low urinary retention rates reported in AUS series support the hypothesis that AUS generates minimal BOO [96].
During robotic AUS surgery, placing the patient in a deep Trendelenburg position can improve exposure by reducing tissue bulk in the operative field. In addition, because the cuff is positioned at the bladder neck, excessive tightness is typically unnecessary, potentially maximizing its “nonobstructive” profile. Alternative options after failed MUS include fascial slings or Burch colposuspension. In a 2007 randomized controlled trial, fascial slings demonstrated higher success rates for SUI, whereas adverse events—including voiding dysfunction requiring revision and urinary tract infection—were more favorable with the Burch procedure [97]. A study with 2 years of follow-up showed that both procedures increased the BOO index, with a larger increase observed among sling patients (Burch +6.27, Sling +20.12) [96]. These findings suggest that both procedures act by increasing bladder outlet resistance. However, neither these procedures nor bulking agent injections substantially affected MUCP [98, 99]. Therefore, AUS may be a more suitable option for patients with ISD, urethral hypomobility, and DU.
Neurogenic SUI: In women with neurogenic SUI, provided that CIC is feasible, the treatment of choice is a pubovaginal sling (PVS) [100, 101]. More recently, studies have reported the safety and efficacy of synthetic slings, emphasizing their convenience and suggesting that vaginal erosion risk is not substantially higher than the 2%–3% observed in the general population [102]. However, cure rates with synthetic slings are lower than those with PVS, and erosion risk increases with prolonged CIC use [79].
For neurogenic SUI, AUS is reported to achieve higher success rates than PVS [103]. Persistent leakage despite AUS may occur because the bladder neck cuff is positioned within the abdominal pressure zone, which can reduce leakage during increases in abdominal pressure. A distinct advantage of AUS, compared with slings, is its ability to maintain a consistent bladder-pressure threshold for leakage, which may provide protection for renal function.
Pure ISD: A fourth indication is pure ISD. In patients with failed MUS, thorough history-taking is essential. One important example is ectopic ureter, in which abnormal development of the ureterotrigonal connection can result in pure ISD [104]. In such cases, the mesh can be removed, and robotic AUS implantation can be performed. Special attention is required to ensure that the ectopic ureter insertion site is managed appropriately during surgery. When the cuff is placed more distally, outcomes are less favorable, with a reported erosion rate of 22%, failing to leverage the advantages associated with bladder neck cuff placement [105].
Surgical technique
One major challenge in female AUS implantation is dissection at the bladder neck [90]. This is attributed to the absence of a well-defined plane between the urethra and vagina and to the deep location of the bladder neck within the pelvis. Morbidity associated with open approaches has historically limited broader adoption of female AUS. Current guidelines recommend its use in carefully selected patients [106]. In France, female AUS has been recommended as a first-line option for ISD, in part because repeated surgeries tend to increase morbidity.
Female AUS is reported to have a high success rate of approximately 90%, accompanied by a relatively high revision rate of 30% [107]. Minimizing injury to the vagina and urethra is essential; therefore, vaginal manipulation by an assistant is an important component of the procedure. The technique involves 2 key steps. First, the vesicovaginal plane (“bald plane”) is developed between the endopelvic fascia with the assistant’s finger serving as a guide. Second, under direct vision, a prograsp forceps is used to dissect posteriorly around the bladder neck, completing the urethrovaginal plane distally, again guided by the assistant’s finger [91]. Peyronnet et al. [91] published the largest single-center study on female AUS in 2019, involving 10 surgeons with limited experience. Among included patients, 85.7% had previously undergone MUS, and an anterior approach was used. Only 1 device removal occurred, with 82% achieving complete continence and 94% reporting improvement. A subsequent multicenter study expanded to 14 centers across Europe reported similar outcomes [108]. Ongoing high-quality studies and continued advances in robotic surgery are expected to further establish AUS as an important treatment option for female SUI, nearly 50 years after its introduction.
CONCLUSIONS
Over the past decade, robotic technology has advanced surgical management options in FRU. However, complex procedures—particularly those involving bowel manipulation or reoperation in challenging pelvic environments—require substantial technical expertise and experience. Surgeons should avoid attempting unfamiliar procedures solely because robotic platforms are available; traditional surgical principles remain essential. Robotic proficiency alone is insufficient; comprehensive FRU training, including disease evaluation, surgical management, and postoperative care, remains necessary. Robotic surgery outcomes appear promising, yet prospective studies comparing safety, efficacy, and cost-effectiveness with open or laparoscopic approaches are still needed.
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