Fig. 1
Being radiopaque the position of the Argus System can be easily verified with a simple XRay after surgery
As with all new products, some aspects of the Argus system design had changed over time, improving the original model:
The width of the pad was increased to keep it from rotating and widen the compression surface.
Washers with a large diameter were added under smaller ones used for adjustment. They help protect the supporting fascia and muscle tissues.
The columns were reinforced with a stronger silicone material to prevent spontaneous breakage (a situation that occurred with the original model and was corrected promptly) (Fig. 2).
Fig. 2
The design of the needles, wider pad, and the big washer
A number of surgical instruments were specially designed for the procedure:
Needles with a 90° curve for the suprapubic implant, spiral needles for the transobturator approach, with a hook or crochet for allowing it to catch and drag the columns.
The interchangeable handle allows it to reposition once the sharp point has passed through the wall, releasing the hook to catch the columns (Fig. 3).
Fig. 3
Needles can be interchangeable
An instrument called “pusher” catches the small washer, making it easier to move it throughout the column of cones during adjustment by lifting or lowering the washers (Fig. 4).
Fig. 4
The pusher
The Surgical Technique
Suprapubic Approach
As Schaffer described, under spinal or general anesthesia, a 16 French Foley catheter is passed and the patient is placed in the dorsolithotomy position [1]. The suprapubic and perineal area have to be shaved and scrubbed with povidone-iodine soap. The anal canal is carefully isolated with drapes. A 5–7 cm transverse suprapubic incision is made until the aponeurosis is clearly seen. A 7-cm vertical perineal incision, centered in the inferior border of the pubic bone, is made, and then the dissection is carried down to bulbocavernosus muscle that is left in place undisturbed. The superficial perineal aponeurosis is clearly seen, the space between the bulbocavernosus and ischiocavernosus muscles is developed with both blunt and sharp dissection. With the specially designed 90° angle crochet needle, the perineal membrane is perforated anteriorly while the urethra is protected and displaced contralaterally with the other hand. The needle is introduced “shaving” the isciopubic ramus 2 cm. downward from the inferior border of the pubic bone.
Once the perineal membrane is perforated, the needle tip is directed to the suprapubic incision, behind the pubic bone, toward the ipsilateral shoulder. The needle is brought outside the rectus fascia. The same procedure is repeated on the contralateral side. With the needles in place, a cystoscopy is done to confirm the integrity of the urethra and the bladder. If a perforation is seen, the needle is then repositioned; usually more laterally. The handles are changed at the suprapubic needle tips so the crochet tip in the perineum allows the columns to be snapped and moved upward to the abdominal area (Fig. 5).
Fig. 5
Anatomy and point of extraction of the Argus T needle
As this point the big washer, first, and the smaller one afterward are transferred and positioned against the rectus fascia, but these are not yet tightened. The silicone pad must remain in the middle of the bulbar urethra.
Next the cystoscope is reinserted and the saline bag is set at a level of 35–40 cm above the pubic symphysis. The adjustment of the sling is made moving the washers with a “pusher” downward to tighten or upward to loosen the sling. The main objective is to achieve the urethral wall cooptation and to observe the stoppage of saline dripping in the chamber indicating that a retrograde leak point pressure (RLPP) of 35–40 cm has been achieved (Fig. 6). An indwelling 16-french Foley catheter is placed, and after a generous irrigation using a solution of saline plus gentamycin, the wound is closed in several layers. Antibiotic prophylaxis with intravenous 1 g of cephalothin during the surgical procedure and gentamicin every 12 h until the Foley catheter is removed. The Foley catheter is removed within 24–48 h after surgery and a voiding test is performed. A plain X-ray of the pelvis is taken to assess the final position of the sling and can be used for comparison during the follow-up (Fig. 1).
Fig. 6
Taking the retrograde leak point pressure. The column of water to address its mark with an arrow
Transobturator Approach
When the transobturator approach is preferred, the procedure begins with a perineal incision exactly as described for the suprapubic approach. A 2–3 cm inguinal incision is made 2 cm below the adductor longus tendon insertion in the pubis and over the inguinal fold. The fat is separated until the fascia, covering the muscles of the obturator foramen, is clearly seen. The spiral needles are passed from the outside to the inside, receiving the crochet point with the index finger of the other hand, which at the same time protects the urethra by pushing it away from the needle tip. The columns are transferred bilaterally and positioning of the washers is done (Fig. 6). Then the adjustment is carried out and regulated by the retrograde leak point pressure (RLPP) [3], until 35–40 cm of water pressure is reached. We use an intravenous infusion water line inserted 5–7 cm in the anterior urethra and manually compressing the penis with the other hand (Fig. 7).
