Suture choice for cystotomy

Re: Suture choice for cystotomy

John Flynn — Tue, 01 Oct 2013 19:18:42 GMT

[quote user="jenny overton"]I thought that monocryl broke down more easily if there was any bladder infection and didn't hold its tensile strength, so i switched to using tow inverting simple continuous layers of pds.[/quote]

I'm sure I read somewhere (though it may not have been accurate...) that PDS maintained tensile strength for a full 3 days in acidic sterile urine? (given the number of folks who use this, I'm guessing that is time aplenty to regain sufficent tissue strength then?)

I think there was a study somewher that showed catgut was the only one that seriously retained any strength in the presence of proteus infection?

Re: Suture choice for cystotomy

jenny overton — Tue, 01 Oct 2013 11:08:59 GMT

I thought that monocryl broke down more easily if there was any bladder infection and didn't hold its tensile strength, so i switched to using tow inverting simple continuous layers of pds.

Re: Suture choice for cystotomy

Michael Woodhouse — Mon, 30 Sep 2013 23:36:40 GMT

I have used Cushings inverting for closing bladder - under the implication that you were supposed to use them for hollow organ closure.

Re: Suture choice for cystotomy

Kate Richardson — Sat, 28 Sep 2013 18:35:21 GMT

[quote user="John Flynn"]

But possibly don't get as tidy mucosal apposition.

I wonder if the resulting rougher mucosal internal environment would be just as likely a nidus for urolith environment (or even more so) than some dissolvable suture penetrating the lumen?

[/quote]

Possibly in theory, but I have followed these cases with ultrasound and have not seen any problems such as repeat uroliths/ chronic bladder wall thickening. (These cases will have therapies such as dietary modifications as well). My thinking is that the bladder wall is very elastic and the constant stretching and relaxing helps return it to normal over time?? Only a theory though!

Re: Suture choice for cystotomy

John Flynn — Sat, 28 Sep 2013 12:53:58 GMT

[quote user="Kate Richardson"]That way I avoid penetrating the lumen with any suture material. [/quote]

I think I know what you mean - like a cow caesar

But possibly don't get as tidy mucosal apposition.

I wonder if the resulting rougher mucosal internal environment would be just as likely a nidus for urolith environment (or even more so) than some dissolvable suture penetrating the lumen?

Re: Suture choice for cystotomy

Kate Richardson — Sat, 28 Sep 2013 12:44:41 GMT

I have always used an continuous inverting suture pattern, (am hopeless with the names of patterns, poss cushings?) where I take bites of tissue of partial thickness with each bite being parallel to the incision. Does that make sense??!!! That way I avoid penetrating the lumen with any suture material. Just a single layer and tack some omentum over the bladder if necessary, but usually gently expand the bladder with saline once sutured to test the suture line. Touch wood haven't had any problems so far

Re: Suture choice for cystotomy

John Flynn — Sat, 28 Sep 2013 12:31:22 GMT

So with 26 votes cast, we have 5 contenders, and I guess the simple answer might be that any of them if fine and no clear reason to favour one over the other.

Still, here's where I'm at:

I can see the advantage of a swaged on needle
I can see the theoretical advantage of a monofilament
I can see the advantage of a suture that disintegrates quickly so no nidus for urolith formation remaining

Some unknowns (to me):

How long do I need to maintain tensile strength for? 3days? Anyone ever had cystotomies breakdown due to suture losing tensile strength before wound has gained sufficient tissue strength? I guess if going to happen then would be the blocked cat that re-blocked and therefore had huge pressure building up?

Given the indication being discussed, I'm assuming acidic, sterile urine.

I'm maybe starting to see a theoretical advantage to closing in 2 layers as Martin describes (assuming thick bladder etc) as could leave a suture in the urine environment (assuming can't avoid lumen penetration) that would dissolve as rapdily as possible and then something else in serosa?

Re: Suture choice for cystotomy

Martin Atkinson — Sat, 28 Sep 2013 11:15:26 GMT

I suture the mucosa with a single continuous layer of PDS (don't know how you avoid penetrating and never had a problem from having done so!) and a separate layer in the muscularis, same material if any left over, otherwise would use Vicryl for that.

Re: Suture choice for cystotomy

John Flynn — Sat, 28 Sep 2013 10:30:05 GMT

[quote user="Braden Collins"]p.s. Don't penetrate the lumen as suture material in the lumen can be a cause of new stone formation.[/quote]

Any tips on avoiding penetrating lumen?

Re: Suture choice for cystotomy

Braden Collins — Sat, 28 Sep 2013 09:42:29 GMT

p.s. Don't penetrate the lumen as suture material in the lumen can be a cause of new stone formation.

Re: Suture choice for cystotomy

Braden Collins — Sat, 28 Sep 2013 09:41:19 GMT

Monocryl is my preferred choice as it is a monofilament and is rapidly degraded, both of which are what you want for bladders as they heal quickly so you don't need something long lasting, and monofilament is less likely to create a nidus for infection.