Ureteral Anastomosis Pyeloplasty and Prostatectomy

Oxidized cellulose, gelatin, collagen, and gelatin matrix/thrombin combination are not considered sealants or adhesives and should not be used to close any part of the collecting system. Therefore, only fibrin sealant should be employed for controlling urinary leakage after planned or traumatic disruption (42) of the collecting system.

Several investigators have utilized porcine models to attempt closure of the urinary tract with fibrin sealant. After performing laparoscopic ureteral transection in five pigs, McKay et al. approximated the ureter with two transmural sutures and sealed the anastomosis with fibrin sealant. Outcomes were compared to those of conventional ureteral anastomosis. Although renal pelvis perfusion tests were higher (12.6 cm H2O vs. 3 cm H,O) in the fibrin-sealant group at eight weeks, the values were within normal range for the porcine model. The authors concluded that laparoscopic ureteral anastomosis using fibrin preparations was feasible (43).

Wolf et al., using a porcine model to compare the efficacy of fibrin sealant for closure of five linear ureterotomies with laser-assisted anastomosis, mechanical suturing

Performing ureteral anastomoses with fibrin glue alone and no stay sutures is not recommended.

Experimental and clinical data indicate that the sole use of fibrin sealant for ureteral anastomosis is unsafe. However, fibrin sealant applied with a limited number of approximating sutures may achieve results comparable to those of sutured anastomosis while decreasing operative time.

Laparoscopic prostatectomy is another field of application for hemostatic agents even if the magnified visualization and the insufflation pressures already facilitate the control of the oozing frequently seen during open prostatectomy.

device, and conventional laparoscopic suturing, concluded that fibrin sealant yielded more favorable radiographic findings, flow characteristics, and histology (44).

Anidjar et al. attempted to approximate porcine ureters using only fibrin sealant after laparoscopic segmental ureterectomy. The ureteral ends were held together for five minutes after the sealant was applied. No immediate anastomotic disruption occurred, and patency of all 10 anastomoses with no leakage in eight and minimal leakage in two was documented with fluoroscopy. Two pigs representing the chronic arm of the study died because of massive urinoma on postoperative days 6 and 8, respectively. Histologic examination revealed no significant coaptation of the ureteral ends.

Performing ureteral anastomoses with fibrin glue alone and no stay sutures is not recommended (45).

In another series, the combination of fibrin sealant and sutures applied in three patients with traumatic ureteral injuries was successful (42). To our knowledge, no other human studies of fibrin sealant for ureteral anastomosis are available.

Experimental and clinical data indicate that the sole use of fibrin sealant for ureteral anastomosis is unsafe. However, fibrin sealant applied with a limited number of approximating sutures may achieve results comparable to those of sutured anastomosis while decreasing operative time.

To determine the efficacy of fibrin-sealant-assisted ureteral anastomosis, additional clinical trials, with a larger number of patients, are awaited.

Fibrin sealant has been also used to complete the ureteropelvic anastomosis during a laparoscopic ureteropelvic junction obstruction repair (1). Eden et al. successfully performed eight retroperitoneal laparoscopic dismembered pyeloplasties by first approximating the ureteropelvic anastomosis with stay sutures, and subsequently sealing the anastomosis with fibrin glue. Patients were followed up with diuretic renography performed at three months and yearly thereafter. At one to two years follow-up, all patients had satisfactory upper-tract drainage. However, further clinical studies with larger numbers of patients are necessary to evaluate this technique.

We do not rely on the fibrin sealant for closure of the ureteropelvic anastomosis during laparoscopic junction obstruction repair. Rather, we perform running or interrupted suturing of the anastomosis and occasionally apply fibrin glue to suture lines. Although suturing is more time consuming than simply applying fibrin sealant, we still believe that the water-tightness of the anastomosis is better achieved with traditional closure.

Laparoscopic prostatectomy is another field of application for hemostatic agents even if the magnified visualization and the insufflation pressures already facilitate the control of the oozing frequently seen during open prostatectomy.

We do not routinely use any of the hemostatic agents and would likely use fibrin sealant if needed because of its potential to help seal the urethral anastomosis. To date, there are no reports describing the routine application of any of the hemostatic agents to laparoscopic prostatectomy, and we are unaware of any clinical trails upon which to base the efficacy of any of these agents in this particular setting.

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