LETTERS TO THE EDITOR USE OF FIBRIN NEPHRECTOMY
GLUE
FOR PARTIAL
References 1. Scott R, et al: First clinical report of a new biodegradable membrane for use in urological surgery. Br J Ural 68: 421 (1991). 2. Scott R, ef al: The evolution of a biodegradable membrane for use in urological surgery, Br J Urol 62: 26-31 (1988).
To the Editor: We read with interest the article, “Fibrin Glue for Partial Nephrectomy.” by A. K. Levinson, D. A. Swanson, D. E. Johnson, F. J. Greskovich, R. A. Stephenson, and B. Lichtiger published in the October issue (vol. 38, pages 314 316, 1991) of UROLOGY. In it they quite rightly alluded to the place of surgical suture for transected vessels and used the glue to apply topical hemostasis to the raw surface. A number of points arise from this study. Most striking is the composition of the fibrin glue. With public concern over the transmission of animal viral disease, such as bovine spongioform encephalopathy, the use of bovine thrombin in the glue is an obvious risk. Is the thrombin derived from diseasefree and accredited herds? Secondly, it seems a somewhat laborious process to prepare the fibrin glue which, in the context of acute hemorrhage from a raw renal surface would seem inappropriate. Thirdly, the fibrin glue, though seemingly effective as a hemostat, did not provide an adequate seal against urinary leakage as evidenced by the 1 patient requiring insertion of a ureteric stent to seal the urinary leak. We have recently reported our own surgical management of partial nephrectomy in which suturing of a biodegradable membrane, a composite of collagen film and polyglactin 910 (Vicryl) mesh, over the cut surface of the kidney achieved both hemostasis and a urinary seal.’ The material is easy to handle and can be applied quickly. The collagen film is prepared from cow hide obtained from accredited disease-free herds in Australia. The collagen Vicryl mesh has been shown in in vivo studies to be leakproof to urine.2 The collagen has hemostatic properties by activation of the intrinsic clotting pathway and by platelet adherence. Animal studies have demonstrated the composite material to be replaced in seventy days by host fibrous tissue resembling renal capsule without associated renal parenchymal damage.2 Such a material offers advantages over the fibrin glue in terms of ease of application, as a seal against urinary leakage, and safety in so far as animal viral disease transmission. We would be interested in the authors’ comments.
Reply
Douglas
M.D.
R. Scott, J.F!, M.D.. F.R.C.S. R. N. Meddings. F.R.C.S. J. l? Buckley. F.R.C.S. Glasgow Royal Infirmary Glasgow, Scotland
UROLOGY
I JUNE 1992
1 VOLUME XXXIX,
NUMBER
by Authors:
Doctors Scott, Meddings, and Buckley have raised important issues. First, we would like to assure them that the bovine materials used in the thrombin are received from U.S.D.A.-licensed establishments that hold veterinary certification documenting that the bovine source materials are derived only from normal, healthy cattle. Furthermore, no cases of spongiform encephalopathy in cattle have ever been found in the United States. Second, the authors are wrong in their impression that preparing the fibrin glue is a laborious process. The mixture of thrombin and autologous cryoprecipitate is easily and quickly prepared by the operating-room nurse or technician. Autologous cryoprecipitate is a routine preparation of blood products and is obtained preoperatively at the time the patient gives autologous blood. Finally, although fibrin glue did not provide an adequate seal against urinary leakage in one of our patients, it should be noted that Scott et al. * reported postsurgical problems in 4 of their patients after using their biodegradable membrane: a urinoma developed in 1 patient whose ureter they wrapped with the membrane after ureterolithotomy; in 2 of 3 patients in whom they used their product at the time of vesicovaginal fistula, recurrent fistulas developed within two weeks; and 1 of 2 patients whose urethrovaginal fistulas they closed with the membrane later required a secondary procedure. Although the authors’ preliminary results are encouraging, the availability of fibrin glue in the United States and the ease of administration using the DuoFlo Topical Delivery Applicator make fibrin glue a valuable addition to our current surgical repertoire. E. Johnson, M.D., et al. Department of Urology University of Texas Anderson Cancer Center Houstoll. Texas 77030
*Scott R, et al: First clinical report of a new biodegradable membrane for use in urological surgery, Br J Ural 68: 421 (1991).
6
GLUE
FOR PARTIAL
References 1. Scott R, et al: First clinical report of a new biodegradable membrane for use in urological surgery. Br J Ural 68: 421 (1991). 2. Scott R, ef al: The evolution of a biodegradable membrane for use in urological surgery, Br J Urol 62: 26-31 (1988).
To the Editor: We read with interest the article, “Fibrin Glue for Partial Nephrectomy.” by A. K. Levinson, D. A. Swanson, D. E. Johnson, F. J. Greskovich, R. A. Stephenson, and B. Lichtiger published in the October issue (vol. 38, pages 314 316, 1991) of UROLOGY. In it they quite rightly alluded to the place of surgical suture for transected vessels and used the glue to apply topical hemostasis to the raw surface. A number of points arise from this study. Most striking is the composition of the fibrin glue. With public concern over the transmission of animal viral disease, such as bovine spongioform encephalopathy, the use of bovine thrombin in the glue is an obvious risk. Is the thrombin derived from diseasefree and accredited herds? Secondly, it seems a somewhat laborious process to prepare the fibrin glue which, in the context of acute hemorrhage from a raw renal surface would seem inappropriate. Thirdly, the fibrin glue, though seemingly effective as a hemostat, did not provide an adequate seal against urinary leakage as evidenced by the 1 patient requiring insertion of a ureteric stent to seal the urinary leak. We have recently reported our own surgical management of partial nephrectomy in which suturing of a biodegradable membrane, a composite of collagen film and polyglactin 910 (Vicryl) mesh, over the cut surface of the kidney achieved both hemostasis and a urinary seal.’ The material is easy to handle and can be applied quickly. The collagen film is prepared from cow hide obtained from accredited disease-free herds in Australia. The collagen Vicryl mesh has been shown in in vivo studies to be leakproof to urine.2 The collagen has hemostatic properties by activation of the intrinsic clotting pathway and by platelet adherence. Animal studies have demonstrated the composite material to be replaced in seventy days by host fibrous tissue resembling renal capsule without associated renal parenchymal damage.2 Such a material offers advantages over the fibrin glue in terms of ease of application, as a seal against urinary leakage, and safety in so far as animal viral disease transmission. We would be interested in the authors’ comments.
Reply
Douglas
M.D.
R. Scott, J.F!, M.D.. F.R.C.S. R. N. Meddings. F.R.C.S. J. l? Buckley. F.R.C.S. Glasgow Royal Infirmary Glasgow, Scotland
UROLOGY
I JUNE 1992
1 VOLUME XXXIX,
NUMBER
by Authors:
Doctors Scott, Meddings, and Buckley have raised important issues. First, we would like to assure them that the bovine materials used in the thrombin are received from U.S.D.A.-licensed establishments that hold veterinary certification documenting that the bovine source materials are derived only from normal, healthy cattle. Furthermore, no cases of spongiform encephalopathy in cattle have ever been found in the United States. Second, the authors are wrong in their impression that preparing the fibrin glue is a laborious process. The mixture of thrombin and autologous cryoprecipitate is easily and quickly prepared by the operating-room nurse or technician. Autologous cryoprecipitate is a routine preparation of blood products and is obtained preoperatively at the time the patient gives autologous blood. Finally, although fibrin glue did not provide an adequate seal against urinary leakage in one of our patients, it should be noted that Scott et al. * reported postsurgical problems in 4 of their patients after using their biodegradable membrane: a urinoma developed in 1 patient whose ureter they wrapped with the membrane after ureterolithotomy; in 2 of 3 patients in whom they used their product at the time of vesicovaginal fistula, recurrent fistulas developed within two weeks; and 1 of 2 patients whose urethrovaginal fistulas they closed with the membrane later required a secondary procedure. Although the authors’ preliminary results are encouraging, the availability of fibrin glue in the United States and the ease of administration using the DuoFlo Topical Delivery Applicator make fibrin glue a valuable addition to our current surgical repertoire. E. Johnson, M.D., et al. Department of Urology University of Texas Anderson Cancer Center Houstoll. Texas 77030
*Scott R, et al: First clinical report of a new biodegradable membrane for use in urological surgery, Br J Ural 68: 421 (1991).
6
