LAPAROSCOPIC UROLOGY
Comparison of Standard Absorbable Sutures with Self-Retaining Sutures
in Retroperitoneoscopic Partial Nephrectomy: A Retrospective Study of 68
Patients
Weifeng Xu, Hanzhong Li,* Yushi Zhang, Xuebin Zhang, Zhigang Ji
Purpose: Although laparoscopic partial nephrectomy (LPN) has been increasingly adopted in the treatment of small
localized renal tumor, technical changes remain nowadays. The current study aimed to evaluate the safety and effica-
cy of the novel QUILLTM Self-Retaining System (SRS) for renorrhaphy during LPN.
Materials and Methods: Sixty-eight patients with kidney neoplasm that accepted LPN at the Peking Union Medical
College Hospital from July 2010 to March 2013 were retrospectively analyzed. Thirty-five patients who received
renal sutures with QUILLTM SRS constituted group 1. The control group (group 2) composed of 33 patients who
received standard absorbable Vicryl sutures by the same surgeon. Renorrhaphy was performed in both groups using
two layers, with a closure of the deep vessels and collecting system, followed by a running closure of the renal cap-
sule. The demographic and perioperative parameters [gender, laterality of the tumor, body mass index (BMI), tumor
size, standardized nephrometry scoring system (R.E.N.A.L. Nephrometry Score)], estimated blood loss and warm
ischemic time (WIT)) were compared between the groups. Risk factors of WIT and blood loss were analyzed using
logistic regression analysis.
Results: Renorrhaphy was successfully completed in both groups. The baseline data of two groups did not differ
significantly. Logistic regression analysis showed WIT decreased when the QUILLTM SRS was used (21.8 ± 3.5 min
vs. 25.6 ± 4.0 min; β = -4.109, P < .001). Suture methods were an independent predictor of WIT rather than blood
loss (115.7 ± 57.9 mL vs. 137.9 ± 68.5 mL; P = .329).
Conclusion: QUILLTM SRS can be effectively and safely used for renorrhaphy during LPN with the potential advan-
tage of shortening WIT.
Keywords: suture techniques; laparoscopy; kidney neoplasms; nephrectomy; methods; feasibility studies; sutures;
treatment outcome.
INTRODUCTION
Laparoscopic partial nephrectomy (LPN) is effective in tumor control and renal function preservation.(1-3) LPN achieves comparable effects on T1a-stage
kidney neoplasms to open partial nephrectomy.(4,5) LPN
results in satisfactory effects on T1b-stage kidney neo-
plasms.(2) Laparoscopic surgery has been adopted by an
increasing number of urologists over traditional open sur-
gery due to the following advantages: minimal invasive-
ness, more aesthetic wounds, less severe postoperative
pain and faster recovery.(6) However, LPN remains tech-
nically challenging. During LPN, intraoperative warm
ischemia of the affected kidney is often necessary. This
treatment benefits the visualization of the tumor extent
as well as complete tumor resection. In addition, it facil-
itates the closure of the parenchyma. However, ischemia
reperfusion can lead to damage to renal function, and the
severity of the damage is positively associated with warm
ischemia time (WIT); to better preserve renal function,
WIT should be shortened as much as possible.(7,8) Renal
suturing and knotting are the most time-consuming and
challenging steps during LPN. Simplifying these com-
plex procedures can reduce WIT and better preserve renal
function. Continuing innovation has led to the reduction
of the WIT through various technical modifications, such
as sliding clip renorrhaphy, early hilar unclamping and
unclamped partial nephrectomy.(9-11)
The QUILLTM self-retaining suture (QUILLTM SRS) (An-
giotech, Vancouver, Canada) is a barbed suture materi-
al (Figure 1). The barbs change direction mid-suture,
prevent slippage through tissue, and eliminate the need
to maintain continuous tension while suturing and tying
knots. QUILLTM SRS is used primarily for wound clo-
sure during plastic surgery procedures. Its potential ap-
plication in urological surgery was assessed in an animal
model of vesicourethral and ureteropelvic anastomoses
and found to be a reliable knotless method of performing
watertight anastomoses.(12,13) Although the applicability
of the self-retaining barbed suture V-Loc™ 180 for the
renal collecting system and parenchyma sutures in LPN
has been reported,(14,15) to the best of our knowledge stud-
Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.
* Correspondence: Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China.
Tel: +86 139 11095525; Fax: +86 010 69156035. E-mail: lihanzhongcn@163.com.
Laparoscopic Urology 1878
ies on the safety and efficacy of QUILLTM SRS have not
been found in literature. Here, we evaluated the safety of
QUILLTM SRS for use in renal suturing in LPN. Further-
more, we compared it with a standard suture for effective-
ness on renal WIT.
MATERIALS AND METHODS
Study Subjects
From July 2010 to March 2013, sixty-eight patients
with kidney neoplasm who received LPN at the Peking
Union Medical College Hospital were retrospectively
analyzed. Thirty-five of them subjected to renal sutures
with QUILLTM SRS between February 2012 and March
2013 constituted group 1. The remaining 33 of them sub-
jected to standard absorbable Vicryl (Vicryl™, Ethicon,
Johnson & Johnson, Somerville, NJ, USA) sutures by the
same surgeon between July 2010 and December 2011
comprised group 2. Group 1 included 22 males and 13
females. The patients’ ages ranged from 42 to 75 years
with a median age of 58.1 ± 8.1 years. Group 2 included
21 males and 12 females. The patients’ ages ranged from
38 to 72 years (median, 57.4 ± 8.7 years).
The inclusion criteria included single tumor with a clini-
cal stage between cT1a and cT1b. The exclusion criteria
included abnormalities in platelet or clotting time before
operation, recurrent renal tumor, other simultaneous sur-
gery and a history of surgery in the same operative region.
For each patient, body mass index (BMI), tumor size,
laterality, WIT, estimated blood loss during surgery,
and postoperative complications were recorded. The
standardized nephrometry scoring system (R.E.N.A.L.
Nephrometry Score) was used to evaluate the complexity
of the surgery.(16)
The R.E.N.A.L. Nephrometry Score consists of (R)adius
(tumor size as maximal diameter), (E)xophytic/endophyt-
ic properties of the tumor, (N)earness of tumor deepest
portion to the collecting system or sinus, (A)nterior (a)/
posterior (p) descriptor and the (L)ocation relative to the
polar line. WIT was calculated from the obstruction of
the renal artery with the bulldog clip to the loosening of
the clip. The final data were then compared between the
groups. All the operations were performed by the same
surgeon. The surgeon was experienced in retroperitoneo-
scopic surgery, who had performed LPN for hundreds of
patients before this study.
This study was conducted in accordance with the Dec-
laration of Helsinki and with the approval of the institu-
tional ethics committee of Peking Union Medical College
Hospital. Informed consent was obtained from all partic-
ipants.
Surgical Techniques
The subjects in both groups underwent operations through
Patient Characteristics QUILLTM SRS Absorbable Suture P Value
Group (n = 35) Group (n = 33)
Age (years)a 58.1 ± 8.1 57.4 ± 8.7 .713
Sex (Male/Female) 22/13 21/12 .947
BMI (kg/m2) 25.1 ± 1.6 24.7 ± 1.9 .337
Side, Left/Right 18/17 19/14 .611
Maximum tumour size (cm) 2.8 ± 0.6 2.9 ± 0.5 .513
R.E.N.A.L. score 6.3 ± 1.2 6.2 ± 1.0 .625
Blood Loss (mL) 115.7 ± 57.9 137.9 ± 68.5 .153
WIT (min) 21.8 ± 3.5 25.6 ± 4.0 < .001
Postoperative complications,b 1/35 1/33 1.0
Pulmonary infection (I) 1 0
Bleeding (III) 0 1
Postoperative pathology
Clear cell carcinoma 33 32
Papillary cell carcinoma 2 1
Abbreviation: QUILLTM SRS, QUILLTM Self-Retaining System.
* Data are presented as means ± standard error of the means ( sx ± ).
a The mean ± standard deviation of the mean.
b Clavien-Dindo grade.
Table 1. Baseline data and perioperative outcomes of patients in the study groups.
Figure 1. QUILLTM Self-Retaining System.
Figure 2. Photograph of a QUILLTM Self-Retaining System
used during an operation.
Self-Retaining Sutures in Laparoscopic Partial Nephrectomy-Xu et al
Vol 11. No 05 Sept-Oct 2014 1879
a retroperitoneal approach. A 10 mm trocar was placed 2
cm above the iliac crest at the middle axillary line into a
30° inspection glass; another 10 mm trocar was placed
under the costal margin along the posterior axillary line
as the major operating channel. A 5 mm trocar was placed
under the costal margin along the anterior axillary line as
the accessory channel. The renal pedicle was blocked by
blocking the renal artery alone with a bulldog clip after
isolation. In cases where an accessory renal artery was
present on preoperative computed tomographic angiog-
raphy, the artery was also blocked using a bulldog clip
after being set free. The renal parenchyma was cut 0.5 cm
away from the tumor margin by opening the renal capsule
using an electric hook and then cutting off the entire tu-
mor and a portion of the renal tissue using sharp scissors.
Electrical coagulation was used to stanch the bleeding if
the blood vessels were clearly observed. Methods for re-
nal suture and renorrhaphy in group 1. Group 1 received
a QUILLTM SRS. The suture was tightened unidirection-
ally and did not backslide because of the immobilization
of the multiple barbs within the tissue. A series of 3-0
QUILLTM SRS were used to repair the impaired collect-
ing system. A HEM-O-LOK clip was placed at the end
of a 15 cm long suture inserted from outside the kidney,
and the inner layer was sutured and closed the collecting
system. The needle was withdrawn from outside the renal
capsule, and knotting was unnecessary because of fixa-
tion of the suture to the barbs. Additional 0 size QUILLTM
SRS sutures were used to suture the second layer of the
renal parenchyma. A HEM-O-LOK clip was also placed
at the end of the sutures, and each suture was pulled tight-
ly after the stitching. The sutures did not backslide due to
the anchoring of the unidirectional barbs on the suture.
Renorrhaphy was completed using the same approach
(Figure 2).
Methods for renal suture and renorrhaphy in group 2.
Group 2 received standard absorbable sutures. The sutur-
ing and knotting involved in the repair of the open col-
lecting system were performed using 1 or more 15 cm
long 4-0 absorbable sutures. The suturing and ligation to
the broken ends and bleeding points on the wound surface
were completed. All of the knots were placed within the
wound surface. The renal parenchyma was sutured con-
tinuously using 25 cm long 0 size absorbable sutures (the
actual length used in LPN can be 15-25 cm long, which
varies according to the tumor size and wound area, based
on our experience), and a HEM-O-LOK clip was placed
at the end of the sutures. The needle was inserted from
outside the renal capsule and then withdrawn through the
opposite capsule. After each stitch, the suture was pulled
tightly, and a HEM-O-LOK clip was placed on the side
on which the needle was withdrawn to avoid backsliding
of the suture (Figure 3). After completing the renorrha-
phy, the suture was cut, the Bulldog clip was loosened to
restore the renal blood flow, and the restoration of normal
renal blood supply was confirmed.
Statistical Analysis
Statistical analyses were performed with the Statistical
Package for the Social Science (SPSS Inc, Chicago, Illi-
nois, USA) version 16.0. Measures of central tendency in
continuous data were presented as means ± standard er-
ror of the means ( sx ± ).The differences in continuous
variables between two groups were compared using in-
dependent t-tests and the associations of categorical vari-
ables were analyzed using chi-square tests. Multivariate
linear regression analysis was performed to determine the
independent predictors of WIT and blood loss. All statis-
tics were tested using the two-tailed method. P < .05 was
considered statistically significant.
RESULTS
Baseline and Perioperative Data
The baseline and perioperative data of the two groups
are summarized in Table 1. No significant differences
in the baseline data were observed between the groups.
Renorrhaphy was successfully completed without any
conversions to an open procedure or nephrectomy in both
groups. The two groups did not show significant differ-
ences in the perioperative outcomes except for the WIT
Dependent Variable: WIT Dependent Variable: Blood Loss
Parameters
β P Value β P Value
Maximum tumour size -1.152 .501 96.238 .000
R.E.N.A.L. Score 1.506 .085 -8.756 .421
Suture method -4.109 .000 -11.395 .329
BMI 0.151 .552 -2.620 .412
Table 2. Multiple linear regression analysis: Predictors of warm ischemia time and blood loss.
Abbreviations: WIT, warm ischemia time; BMI, body mass index.
Figure 3. Photograph of an absorbable suture in a patient in
group 2.
Self-Retaining Sutures in Laparoscopic Partial Nephrectomy-Xu et al
Laparoscopic Urology 1880
(21.8 ± 3.5 min vs. 25.6 ± 4.0 min, P < .001). For post-
operative complications, one patient suffered pulmonary
infection in group 1. After antibacterial treatment, the pa-
tient recovered. In group 2, there was 1 case of postoper-
ative bleeding, which was cured by performing interven-
tional angiography of the renal artery and super-selective
embolization.
Multiple Linear Regression Analysis
The associations between possible risk factors and WIT/
blood loss in patients subjected to LPN were analyzed
using logistic regression analysis, which included max-
imum tumor size, R.E.N.A.L. score, suture method and
BMI. The results are summarized in Table 2.
As shown in Table 2, the WIT decreased when the
QUILLTM SRS was performed
(β = -4.109, P < .05) and suture methods were an inde-
pendent predictor of WIT. However, they were not pre-
dictive for blood loss (P = .329).
DISCUSSION
There have only been a few reports on the use of QUILLTM
sutures in urological surgery, laparoscopic pyeloureteral
anastomosis, and vesicourethral anastomosis.(12) No study
has been conducted to evaluate the use of these sutures in
partial nephrectomy until now; this is the first report on
the use of QUILLTM sutures in renal tissue suturing and
repair during LPN.
This study evaluated the safety and efficacy of QUILL-
TM SRS for renorrhaphy during LPN. In group 1, one pa-
tient presented with pulmonary infection after operation,
which was proved unrelated to the new suture method.
This finding indicates that QUILLTM SRS sutures are safe
for use as renal sutures. Furthermore, logistic regression
analysis showed that suture methods, rather than other
factors, were an independent predictor of WIT. This find-
ing suggests that QUILLTM SRS may benefit renal func-
tion protection by reducing the renal WIT during LPN.
Moreover, patients with abnormalities in platelets or clot-
ting time before operation were excluded from this study,
which successfully avoided the possibility of bleeding
caused by the hematological system. In addition, all the
operations in this study were performed by the same sur-
geon, which greatly reduced the risk of bleeding caused
by human factors. The regression analysis evidenced
that suture methods were not associated with blood loss.
Therefore, QUILLTM SRS is safe for renorrhaphy during
LPN.
Partial nephrectomy is the standard treatment for local-
ized renal tumors, achieving the same outcome as radical
nephrectomy with respect to the tumor control rate;(17) this
approach benefits the patients by preserving the function
of the affected kidney.(17-20) Laparoscopic partial nephrec-
tomy has achieved the same efficacy as open surgery in
terms of tumor treatment and renal function preservation,
while offering the following advantages: less invasive-
ness, more aesthetic wounds, less severe postoperative
pain, and faster recovery.(21) However, because this ap-
proach is technically difficult and risk its widespread
use is limited because it requires performing renal tumor
resection and renal suture, repair and knotting within a
short period of time to reduce the renal WIT and pre-
serve the residual renal function. This procedure presents
a significant challenge for beginners and even experi-
enced laparoscopic surgeons, as the process of suturing
and knotting under laparoscopic guidance is difficult
and time-consuming. Gill and colleagues reported that
in 1800 cases of open and laparoscopic partial nephrec-
tomy performed over the same period, despite the more
complex conditions in the open surgery cases, the WIT
in the patients who underwent laparoscopy was 10 min
longer than that of patients who underwent open surgery.
(21) The renal WIT can be reduced by simplifying the re-
nal suturing and knotting process, thereby improving the
surgical safety. Although hemostatic colloids are appli-
cable for capillary hemorrhage from the wound surface
after partial nephrectomy, suturing hemostasis is a better
choice for noticeable hemorrhage or hemorrhage from the
broken ends of small arteries. Furthermore, suturing can
directly close the collective system, thereby reducing the
incidence of postoperative urine leakage. During tradi-
tional laparoscopy, absorbable sutures are used to suture
and close the renal collecting system and repair the renal
parenchyma, either intermittently or continually. Because
it is easy for the sutures to backslide, it is usually neces-
sary for the surgeon to pull the sutures tightly with one
hand, leaving the other hand to stitch. This strategy leads
to inapposite sutures and an increased risk of postopera-
tive bleeding and urinary fistula. Most surgeons adopt a
modified suture method to reduce the technical difficul-
ty and increase safety. Suture retraction was avoided by
applying a HEM-O-LOK clip to fix the suture after each
stitch; the number of knots was also reduced. Although
this approach effectively simplifies the operation and im-
proves the safety, repeatedly changing the needle carriers
and HEM-O-LOK pliers increases the WIT. Moreover,
the cost of surgery is increased due to the need for addi-
tional HEM-O-LOK clips.
QUILLTM is a knotless, self-retaining barbed suture
(SRBS). There is one needle at each end of the suture,
and a group of barbs is placed every 1 cm on the suture;
these barbs change direction at the midpoint of the su-
tures. QUILLTM was first used for wound closure in plas-
tic surgery and gynecology and obstetrics.(22,23) The initial
application of SRBS in urological surgery was in pyelo-
ureteroplasty and vesicourethral anastomosis, achieving
good results in both in vitro and animal experiments.(12,13)
Sergey Shikanov and colleagues reported that in pigs, the
same effect was achieved during partial nephrectomy to
close the collecting system and repair the renal parenchy-
ma, indicating that this novel suture is safe and reliable
in renorrhaphy.(24) Olweny and colleagues reported the
use of another barbed suture, the V-LOC suture, during
laparoscopic renorrhaphy and collecting system closure
and compared it with traditional absorbable sutures; the
former approach significantly reduced the intraopera-
tive renal WIT. They also believed that barbed sutures
would likely reduce the incidence of serious intraoper-
ative bleeding.(25) Sammon and colleagues reported that
during robot-assisted laparoscopic partial nephrectomy,
the use of V-LOC sutures to suture and repair the kidneys
and collecting systems improved the efficiency of the su-
tures, shortened the renal WIT, and was safe and reliable.
(26) Jeon and colleagues reported that the use of V-LOC for
kidney suturing in transperitoneal LPN noticeably short-
ens the WIT of the kidneys.(14) The same result was also
Self-Retaining Sutures in Laparoscopic Partial Nephrectomy-Xu et al
Vol 11. No 05 Sept-Oct 2014 1881
reported by Selcuk and colleagues.(15) Our results were
consistent with those in literatures. However, none of
the released studies focused on retroperitoneal partial ne-
phrectomy. QUILLTM sutures solve the problem of knot-
ting under laparoscopic guidance, thereby improving the
efficiency of suturing. Because its own barbs can exert
a unidirectional anchoring effect within the renal tissue,
there is no backsliding after pulling the suture tightly,
which facilitates two-handed suturing by the operator.
The strain is evenly distributed to multiple barbs along
the length of the suture, which allows the suture to exert a
greater stretching force at the wound margin and satisfies
the wound margin apposition. No complications were ob-
served regarding the suture material being incompatible
with the renal tissue, suggesting good histocompatibility.
Additionally, there was no secondary bleeding or urinary
fistula in group 1, indicating the safety of this approach.
Because there was no need to produce knots under laparo-
scopic guidance or to change the HEM-O-LOK clips, the
renorrhaphy time and WIT were significantly reduced,
and improved renal function preservation was achieved.
This study had limitations. First, the results of this study
were based on only one surgeon’s experience. Therefore,
the WIT and intraoperative hemorrhage volume values
have limited generalizability. Second, because this study
was retrospective in nature, the two groups were not se-
lected through match-pair. Third, the sample size was
small, and more cases remain to be analyzed in the future.
CONCLUSION
The novel QUILLTM SRS is as effective, efficient, and
safe as a conventional technique in laparoscopic partial
nephrectomy. Compared with the standard absorbable
suture, QUILLTM SRS greatly shortened the renal WIT.
Further studies are needed to corroborate these findings,
but the present results indicate a promising development
in reducing WIT during minimally invasive partial ne-
phrectomy.
CONFLICT OF INTEREST
None declared.
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