The artificial urinary sphincter (AUS) is the gold standard for treatment of post prostatectomy stress urinary incontinence (SUI). A subset of patients who have an AUS placed will subsequently require transurethral intervention with a resectoscope for treatment of a variety of conditions including bladder neck contracture (BNC) with or without associated dystrophic calcifications, bladder tumor, or intravesical clot burden. With improved survivorship after treatment of prostate cancer in the modern era, more patients with an indwelling AUS will likely require such procedures utilizing a resectoscope.  

Passage of large instruments, such as standard resectoscopes (which are usually 24-28Fr in circumference) through the AUS cuff for endoscopic treatment is not possible for cuffs < 5 cm.  Furthermore, even with successful navigation in cuffs > 5 cm, such instrumentation risks cuff trauma with subsequent cuff erosion, device damage, and/or infection.  

Current options for resectoscope placement in such situations include a suprapubic approach using a percutaneously placed access sheath as well as “unbuckling” of the existing AUS cuff.  Suprapubic access is invasive and potentially morbid due to risk of bowel injury and other complications. Alternatively, deactivating AUS and unbuckling the cuff through a perineal incision before instrumentation, followed by rebuckling the device postoperatively has been suggested. However, unbuckling the AUS cuff adds considerable time for the procedure, procedural complexity, as well as risk of wound complications and device infection [1].

As an alternative, we have repurposed and utilized a smaller diameter gynecological resectoscope to address this clinical problem. The “Princess”® is a 21Fr resectoscope (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL, USA) primarily used for gynecologic intrauterine procedures (hysteroscopic myomectomy, polypectomy, endometrial ablation). It is compatible with bipolar cautery to minimize risk of thermal injury to AUS implant. It has continuous flow irrigation capability and a working channel that accommodates instruments up to 7Fr. We have utilized this device transurethrally for several cases successfully without the need for unbuckling of the AUS cuff.

In this video, we demonstrate the novel use of the Princess resectoscope as an off-label solution for transurethral resection of calcifications at the bladder neck in a patient with an AUS. 

This patient is an 81-year-old with a history of TURP for bladder outlet obstruction, previously treated with a metallic mesh urethral stent for recurrent BNC which had been incompletely excised. Thereafter, an AUS with a 4cm cuff was placed for SUI. He subsequently developed calcifications along the remaining portion of the stent, requiring multiple endoscopic treatments with laser lithotripsy. He presented for transurethral resection of recurrent dystrophic urethral calcifications.   This video demonstrates successful atraumatic navigation of the AUS cuff with removal of the abnormal tissue.  After the conclusion of the procedure, the patient’s AUS was reactivated prior to discharge home.

This procedure demonstrated no short-term post-operative visual or functional damage to a 4 cm AUS cuff after passage of the gynecological resectoscope for successful treatment of bladder neck calcifications. A total of 6 patients with a variety of conditions requiring a resectoscope have been similarly treated at our institution.

Repurposing of this gynecological resectoscope represents a promising, novel solution to address a clinically unmet need for effective transurethral resection in patients with indwelling AUS, while protecting the AUS cuff from excessive compression and manipulation. Prospective efficacy and safety data collection is needed to formally validate this device’s clinical safety and efficacy for use in the male lower urinary tract following AUS implantation.

Ivan SJ, Cohn JA, Loh-Doyle JC, Lentz AC, Simhan J. Cuff Conundrums: Best Practice Recommendations for Urethral Instrumentation With an Artificial Urinary Sphincter in Place. J Urol. 2025;213(3):271-273. doi:10.1097/JU.0000000000004312

Continence 19S (2026) 102730
DOI: 10.1016/j.cont.2026.102730