International Urology and Nephrology 10 (2), pp. 117--124 (1978)

The Use of Tissue Adhesive "Chirurcoll-Polfa" in Surgical Fixation of the Kidney J. DAREWICZ, W. GRUSZECKI, B. CYLWIK, J. SZPIGANOWICZ, A. PACHMAN Institute of Surgery, and Department of Pathological Anatomy, Bia|ystok Medical School, Poland (Received January 31, 1977)

Experimental and clinical investigations were carried out on the application of tissue adhesive "Chirurcoll-Polfa" in surgical fixation of the kidney. It was found that the adhesive gives firm tissue adhesion without causing an inflammatory reaction, and can be safely used in operations for fixation of the kidneys.

Fixation of the kidneys is frequently carried out during urological operations, not only when it is the operation of choice as in the case of nepbroptosis, but also when the kidney is moved during other types of operations. Until recently the kidney was usually fixed by means of sutures, but since the tissue adhesives have been introduced into urology [2-6, 8, 11-14], the possibility of performing kidrey fixation without using the techniques previously employed has arisen. The aim of our investigations was to study the possibility of fixing the kidney by means of tissue adhesive under experimental and clinical conditions.

Material

and methods

Experimental For the experiments, 5 mongrel dogs weighing 10-12 kg were used. The operations were performed in an identical way on each animal; premedication - an intramuscular injection of dolantine with atropine - was administered half an hour before the operation. The operation was carried out with the animals anaesthetized by intravenous injection of tlziopental in doses of 5 mg/kg body weigkt. After disinfection of the animal's skin, the abdominal cavity was opened urAer sterile conditions by means of an incision parallel to the right costal arc. The kidney was separated from t~e surrounding tissue leaving the fibrous capsule intact and tl~e fat was removed from the surface of the iliopsoas muscle where the kidney was to be fixed. After the other organs of the abdominal cavity had been carefully isolated from tl'.e prepared site by means of gauze, the tissue adhesive was sprayed onto the posterior surface of the kidney within its upper pole for 1-2 sec from a distance of 15-20 cm and the kidney was pressed to the muscle for 30 sec. International Urology and Nephrology 10, 1978

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16or the experiments "Chirurcoll-Polfa" adhesive spray produced by Tarchomin Pharmaceutical Laboratories "Polfa" was used. The chemical composition of the adhesive is 2-cyanoacrylic acid n-butyl ester. It was found that the posterior surface of the kidney was firmly fixed to the muscle after 30 sec. There were no changes on its anterior surface. After fixation of the kidney, the abdominal cavity was sealed. No drainage, hydration or antibiotics were applied. The postoperative period was without complications. Two months after the operation, experimental ureteropyelography was performed on the anaesthetized animals, the catheter being introduced through the open bladder. The animals were then killed by narcosis and an autopsy was performed. The kidneys were removed together with the surrounding tissues for histopathological examination.

Fig. 1. Ureteropyelography. Normal position of kidney International Urology and Nephrology 10, 1978

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Results

Ureteropyelography carried out two months after the operation on the side in which the kidney was fixed showed that the kidney had a normal position in all the animals and that the anatomical structures in the pyelo-calyx system were unchanged (Fig. 1). During autopsy it was found that the posterior surface of

Fig. 2. Photomicrograph. Structure of kidney with thickened fibrous capsule, connective tissue layer with resorptive granulomas and structure of transverse striated muscle. Haematoxylin-eosin, • 80

the kidney fibrous capsule was very firmly fixed to the iliopsoas muscle by means of a band of connective tissue. The renal parenchyma had a normal coloration without any optically discernible inflammatory characteristics and was easily separated from the capsule. There were no signs of inflammation in the tissues surrounding the kidney. Histological examinations revealed concretion of the kidney with the transversely striated muscles by a layer consisting of fibrous connective tissue containing numerous collagen fibres, capillaries and sporadically cellular elements of the lymphocyte and fibroblast types (Fig. 2). In this layer near the thickened renal capsule a band of granulation consisting of numerous resorptive cells and multinuclear foreign body giant cells occurred. In the neighbourhood of these cells, several spaces containing amorphous weakly acidophilic substances were seen International Urology and Nephrology 10, 1978

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which corresponded to the remains of the adhesive (Fig. 3). No histological changes were observed in the structure of the kidneys or the transversely striated muscles.

Fig. 3. Photomicrograph. Thickened renal fibrous capsule with numerous collagen fibres. In the centre, a band of resorptive granulomas and a light area containing the remains of the adhesive. Haematoxylin-eosin, • 180

Clinical observations Fixation of the kidney was carried out in 6 patients (4 women and 2 men). Patient G. J., aged 37, and patient M. M., aged 35, were suffering from sinistral nephroptosis (Fig. 4). The operation was made with a lumbar extraperitoneal incision. After separating the kidney from the surrounding loose tissue, its posterior surface within the upper pole was fixed with "Chirurcoll-Polfa" adhesive spray to the m. iliopsoas exactly as in the experiments on animals. There were no postoperative complications in these two cases. The patients were allowed to get up and walk on the third day after the operation and on the 10th day they were discharged from hospital. On discharge their general condition was very good and there were no complaints as regards the kidneys. Urography made 10 days after the operation revealed that the kidneys were normally positioned at the physiological site (Fig. 5). Fixation of the kidney was performed in a third patient, M. H., aged 69, after plastic surgery for hydronephrosis during which it was necessary to separate International Urology and Nephrology 10, 1978

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the kidney from the surrounding tissues. There were no postoperative complications and the patient could move about on the third day. The fourth patient, C. A., aged 22, was operated on for lithiasis of the upper kidney. This was a case of a double L-shaped kidney situated on the right side. Because of the difficulty in finding the concretion in the superior calyx of the upper kidney and the complicated anatomical relations (vascular anomalies)

Fig. 4. Urography. Ptosis of right kidney

it was necessary to separate the kidney from its surroundings. After removal of the concretion through the pelvis, the kidney was fixed to the iliopsoas muscle as in the previous cases by means of "Chirurcoll-Polfa" adhesive. There were no postoperative complications. During operation on the fifth patient, J. J., aged 55, the tissue adhesive was applied twice. Because of nephrolithiasis and cystoid lesions in the upper pole of the kidney, this pole was resected and its surface covered with adhesive. The International Urology and Nephrology 10, 1978

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kidney was then removed and fixed to the iliopsoas muscle with adhesive. In order to ensure a dry surface of the pole before applying the adhesive, the renal artery was temporarily clamped.

Fig. 5. Urography. Condition after kidney fixation. Normal anatomical relations

The last patient, S. A., aged 55, was operated on for horseshoe kidney stones. After removal of the stone from the right kidney, the kidney isthmus was excised after which both poles of the kidney were pulled apart and stuck to the muscles. The results of the operation were good. Discussion

The main object of the experiments on animals was to determine whether the aerosol adhesive of Polish production, "Chirurcoll-Polfa", gives a sufficiently firm adhesion of the organs and whether any inflammatory reaction occurs in the International Urology and Nephrology 10, 1978

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renal parenchyma at the site of polymerization. Such a reaction might be expected since some authors reported the occurrence of inflammatory lesions when methyl dicyanoacrylate was used [10]. Bertetti and Quiroli [1] and Pelc Ill] noted a slight damage to the parenchyma adjacent to the surface of the wound repaired with adhesive. An inflammatory lesion at the site of fixation of the kidney to the surrounding tissues could cause disturbances in renal function and undesirable adhesions within the renal pelvis and ureter. If, on the other hand, the tissues fixed with an adhesive proved to be too weak, detachment of the kidney could occur. That this is a real risk has been shown by the reports of some authors who found that the polymer membrane was fragile and tended to crack [15]. The results of our experiments on animals revealed that 2 months after the operation during which the kidney was fixed by the tissue adhesive there were no inflammatory reactions at the site of fixation. These findings are in agreement with those of other authors [7, 9]. No such reactions were found in either the iliopsoas muscle or in the renal parenchyma. The changes induced by polymerization involved only the renal fibrous capsule and the surface layer of the iliopsoas muscle. No disturbances in the dynamics of the renal excretory system were observed. Since the animals could move about within a few hours after the operation and the autopsy findings were completely satisfactory it was considered that the adhesion provided by the aerosol tissue adhesive "Chirurcoll-Polfa" was firm enough to permit its application in this type of operation. The excellent results of the kidney fixation surgery carried out on animals, together with the reports of other authors warranted the use of the adhesive in such operations in clinical practice. The beneficial properties of the adhesive in the 6 cases requiring kidney fixation had been completely confirmed. It is particularly significant that in none of these cases were any inflammatory reactions noted in either the kidney or the surrounding tissues which healed by first intention. The patients did not complain of tugging or soreness which is frequently noted in cases of nephropexy performed with sutures. There were no disturbances in renal function of patients in whom the adhesive was used. The use of the aerosol adhesive "Chirurcoll-Polfa" makes it possible to eliminate the traditional sutures which not infrequently caused infection of the organ. Apart from the classical cases of fixation of floating kidney, the adhesive proved particularly useful in operations where the kidney had to be separated from its surrounding tissues. It should also be emphasized that fixation of the kidney by the capsule without uncovering the kidney parenchyma is an additional protection against an inflammatory process. The speed with which the kidney could be fixed to the muscle (30 sec) meant that the duration of surgery was considerably reduced. Because there was no danger of the traditionally applied stitches' breaking, in cases where the kidney fixation procedure had been applied without any other operations, the patients were able to move about freely on the 2nd or 3rd day 4

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after the o p e r a t i o n . T h e r a p i d a n d u n c o m p l i c a t e d healing o f the w o u n d also m e a n t t h a t the p a t i e n t ' s stay in h o s p i t a l was c o n s i d e r a b l y shorter. T h e following conclusions were d r a w n f r o m the u n d o u b t e d l y g o o d results o f k i d n e y fixation in b o t h e x p e r i m e n t a l a n i m a l s a n d clinical cases: 1. T h e tissue a d h e s i o n given b y the a e r o s o l is p e r m a n e n t . 2. N o i n f l a m m a t o r y r e a c t i o n was o b s e r v e d a t the site o f adhesion. 3. T h e use o f the adhesive s h o r t e n s the o p e r a t i o n a n d the p a t i e n t ' s stay in h o s p i t a l . 4. The Polish a e r o s o l adhesive " C h i r u r c o l l - P o l f a " is suitable for k i d n e y fixation surgery.

References 1. Bertetti, C., Quiroli, A.: Microvascular reconstructive processes in experimental partial nephrectomy repaired with catgut and a modern adhesive. Microangiographic study. Omnia Med., 45, 799 (1967). 2. Fein, R. L., Matsumoto, T., Solway, H. B.: Renal injury suture versus n-butyl-cyanoacrylate tissue adhesive spray repair. Invest. Urol., 8, 12 (1970). 3. Fox, M., Henry, L., Lomax, H., Rees, R. W. : The effect of isobutyl-cyanoacrylate monomer adhesive on closure of nephrectomy and partial nephrectomy incisions. Brit. J. Urol., 41, 539 (1969). 4. Freese, P., Heinrich, P., Hinze, M. : Die Verwendung yon Klebstoffen in der organerhaltenden Nierenchirurgie (Tierexperimentelle Studie). Der Chirur#, 37, 56 (1966). 5. Hayashi, Y., Shimizu, S., Takizawa, H.: The experimental study of cyanoacrylateadhesive to nephrotomic incision. Jap. J. Urol., 56, 331 (1965). 6. Just-Viera, J. O., Puron del Aquila, R., Yeager, G. H.: Experimental control of renal hemorrhage with the use of rapidly polymerizing adhesives. Surgery, 55, 531 (1964). 7. Kazofi, M., Rachwa~-Sochacka, L., Kurnatowski, W.: Zastosowanie kleju "ChirurcollPolfa" w chirurgii nerek. Polimery w medycynie. Suppl. 153 (1976). 8. Mastalerski, J." Ocena angiograficzna nerek ps6w po cz~ciowej resekcji i zaopatrzeniu klejem tkankowym. Pol. Prze#. Radiol. Med. Nukl., 6, 779 (1971). 9. Nee(, H., Preusser, K. P., Pieper, S.: Histomorphologische Befunde nach Nierenkleben. Zbl. Chir., 94, 1629 (1969). 10. Noszczyk, W., Kulicki, M., Wierzbicka, E., Kurnatowski, W.: Do~wiadczalne zaopatrzehie ran narz~d6w mi~szowych pochodnymi kwasu 2-cyanoakrylowego. Pol. Przeg. Chir., 6, 999 (1972). 11. Pelt, T. : Badania do~wiadczalne nad zaopatrzeniem ran mi~szu nerkowego przy u~yciu polskiego kleju. Problemy lekarskie, 12, 737 (1973). 12. Rathert, P., Siemmensen, H., Thiel, K. H. : Experimental and clinical use of cyanoacrylate and amniotic tissue in partial nephrectomy. J. Urol., 100, 427 (1968). 13. Tniel, K. H., Rathert, P., Siemmensen, H.: Methyl-2-cyanoacrylat bei Eingriffen am Nierenparenchym. Chirur#, 37, 54 (1966). 14. Truss, F.: Die Nierengewebsvertr/iglichkeit des Klebstoffs Methyl-2-cyanoacrylat. Urolovie (A), 8, 355 (1969). 15. Zag6rski, W. : Do~wiadczalne zaopatrywanie ran nerek z zastosowaniem cyanoakrylowego kleju chirurgicznego i g~bki kolagenowej Pam. XLVI Zjazdu Chirurg6w Polskich. Lublin II, 638 (1972).

International Urology and Nephrology 10, 1978

The use of tissue adhesive "Chirurcoll-Polfa" in surgical fixation of the kidney.

International Urology and Nephrology 10 (2), pp. 117--124 (1978) The Use of Tissue Adhesive "Chirurcoll-Polfa" in Surgical Fixation of the Kidney J...
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