Assessment of alternative tissue approximation techniques for laparoscopy

Objective To investigate the feasibility and results of applying alternative techniques of tissue approximation for experimental urothelial re-anastomosis in an open and laparoscopic setting. Materials and methods The study was carried out in two phases; in phase 1, an open porcine ureteric re-anastomosis was performed using gelatin/resorcin/formaldehyde (GRF) glue, fibrin glue or potassium-titanyl-phosphate laser tissue-welding with a fluorescein-doped human albumin solder. The anastomoses were assessed both immediately, by leak pressure, and by the operating time, upper tract urodynamic studies and light and scanning electron microscopy, 6 weeks after surgery. In phase 2, the best technique from phase 1 was compared with sutured controls for porcine retroperitoneoscopic dismembered pyeloplasty, using the same assessment criteria. Results In phase 1, GRF glue produced adhesion which was insufficiently flexible to withstand rotation of the anastomosis and this technique was therefore abandoned. Fibrin-glued anastomoses withstood leak pressures equal to those from laser-welding (P=0.91) and gave similar changes in maximum pressure with a Whitaker test at 6 weeks (P=0.30), but were superior in requiring a shorter operating time (P=0.02) and in their electron and light microscopic appearances. In phase 2, fibrin glue gave similar changes in maximum pressure with a Whitaker test to those from polyglactin 910 sutures (P=0.51) but withstood higher leak pressures (P=0.01), had a shorter operating time (P=0.01) and had superior electron and light microscopic appearances. Conclusion Fibrin glue produced effective experimental laparoscopic pelvi-ureteric anastomoses within less operating time than did sutured controls. Such anastomoses withstood supra-physiological pressures, with no evidence of functional obstruction and with a more favourable histological result after 6 weeks. Laparoscopic evaluation of this modality in a clinical setting is now justified.