What suture is preferred for Pelvic Collecting System (PCS) repair after partial nephrectomy?

Preferred Suture for Pelvic Collecting System Repair After Partial Nephrectomy

For pelvic collecting system (PCS) repair after partial nephrectomy, use 2-0 polyglactin (Vicryl) suture on a CT-1 needle in a running continuous technique. 1

Standard Technique for PCS Repair

The established approach for collecting system repair during partial nephrectomy involves:

• Suture type: 2-0 polyglactin (Vicryl) absorbable suture 1
• Needle: CT-1 needle for optimal tissue handling 1
• Technique: Running continuous suture pattern to achieve watertight closure 1, 2

This technique is consistently described across multiple large surgical series and represents the time-tested standard for laparoscopic and open partial nephrectomy procedures. 1

Rationale for Polyglactin Selection

Polyglactin suture is preferred because:

• Absorbable synthetic material eliminates need for suture removal in deep collecting system 1
• Appropriate tensile strength maintains watertight closure during healing phase 1
• 2-0 caliber provides sufficient strength for collecting system tissue without excessive bulk 1
• CT-1 needle offers optimal curve and size for intracorporeal suturing in confined renal spaces 1

Complete Reconstruction Algorithm

After tumor excision with collecting system entry:

1. Achieve hemostasis: Cauterize cut surface with argon beam coagulator and ligate visible vessels 3
2. Repair collecting system: Close any caliceal entry with running 2-0 polyglactin suture on CT-1 needle 1
3. Reconstruct parenchyma: Use 0 polyglactin suture on CT-X needle with pledgeted clip technique for parenchymal closure 1
4. Place perirenal drain: Mandatory when collecting system repair performed 1

Alternative Suture Considerations

Barbed suture (V-Loc 180) represents a newer option that may reduce warm ischemia time:

• Reduces mean warm ischemia time from 32.8 minutes to 26.4 minutes compared to conventional polyglactin 4
• Allows knotless closure with self-retaining properties 5, 4
• May reduce clinically significant bleeding (18.4% vs 3.4%, p=0.06) 4
• Successfully used for both collecting system and parenchymal layers 5

However, polyglactin remains the established standard with extensive safety data across thousands of procedures. 1

Critical Technical Points

Collecting system repair requires:

• Watertight closure to prevent postoperative urinary leak/fistula 3, 2
• Running continuous technique rather than interrupted sutures for efficiency during warm ischemia 1, 2
• Longer warm ischemia time: Expect 30.2 minutes vs 19.4 minutes when collecting system repair needed (p<0.0001) 2
• Extended operative time: Mean 238 minutes vs 207 minutes without collecting system repair (p=0.03) 6

Postoperative Management

When collecting system repair performed:

• Place perirenal drain in all cases 1
• Remove ureteral catheter and Foley together on postoperative day 2 1
• Maintain drain for minimum 5 days 1
• Remove drain when output <50cc daily for 3 consecutive days 1

Common Pitfalls to Avoid

• Inadequate closure: Urinary leak occurs in 1.9% of cases with collecting system repair; ensure complete watertight closure 6
• Excessive warm ischemia: Collecting system repair adds approximately 10 minutes to warm ischemia time; work efficiently 2
• Premature drain removal: Maintain drain minimum 5 days even if output appears low initially 1
• Using inappropriate suture size: 2-0 caliber is specifically chosen for collecting system; larger sutures create excessive tissue trauma, smaller sutures lack adequate strength 1