V10-04: Robotic pyeloplasty using barbed suture: technique, controversies and considerations

Video

Introductions and Objectives
Despite use of barbed suture during robot-assisted radical prostatectomy or partial nephrectomy, concerns have been raised about a high early failure rate when used during minimally-invasive pyeloplasty (MIP). In this video, we present our technique of robotic pyeloplasty using barbed suture, review the literature on barbed suture for MIP and discuss the controversies, tips, and tricks.

Methods
We present a case of a 55 year old man with right-sided uretero-pelvic junction obstruction (UPJO). The patient was placed in the modified flank position. Port placement was a 12 mm camera port, two 8 mm robotic ports, and a 5 mm assistant port. The robot was docked at a 30-degree angle to the flank. A robotic cautery hook was used to aid with fine hemostatic dissection. The renal pelvis and upper ureter were mobilized to reveal a crossing vessel. Round tip scissors were used to perform dismemberment and spatulation (Anderson-Hynes technique). The ureter was transposed over the crossing vessel and anastomosis was performed using a unidirectional barbed suture (3-0 Stratafix^™; Ethicon, Somerville, NJ, USA) in a running fashion. Following completion of the posterior layer, an antegrade ureteral stent was placed followed by closing the anterior layer in a similar fashion.

Results
Strategies for successful robotic pyeloplasty using barbed suture include: (1) selection of appropriate barbed suture – suture composition, absorbability, distribution of barbs and needle type vary between manufacturers (2) minimizing tension during suture placement to avoid tissue necrosis (3) use of round tip scissors to avoid spiral spatulation of the ureter (4) use of the obstructing UPJ tissue as a handle-hold for manipulation (5) avoid use of 12 mm assistant port for needle entry by utilizing needle placement via a robotic port. Advantages of barbed suture include no loss of tension as seen in non-barbed monofilament suture with possibility of suture loosening, and use of a “continuous interrupted” method; the barbs allow the anastomotic tension to be evenly spread to avoid gaps and mimic interrupted suture. Of 18 patients who have undergone laparoscopic or robotic pyeloplasty using barbed suture at our institution, the success rate was 17/18 (94%).

Conclusions
Barbed suture for MIP provides a watertight anastomosis that is technically easier to perform. A key principle is to know your barbed suture as incorrect suture selection may compromise success. Our results demonstrate excellent success rates when using the barbed suture for MIP.

Funding: none