0022-534 7/79/1216-0836$02. 00/0
Vol. 121, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
STONE FORMATION ON POLYPROPYLENE SUTURE G. BRUCE HEALEY
AND
MICHAEL M. WARREN*
From the Department of Surgery, Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, Texas
ABSTRACT
Polypropylene is a relatively new suture material with many advantages, which has been demonstrated in experimental studies to be a safe material for urologic operations. However, recently, 2 patients had polypropylene suture at the matrix of urinary calculi. Symptoms from the calculi developed in both patients in the late postoperative period and both had large amounts of fibrosis around the sutured urothelium. Polypropylene has been shown under experimental conditions to be a suitable suture material for use in urologic operations. 1 However, it must be added now to the list of potential nidi for the development of urinary tract calculi (cotton, silk and even chromic catgut have been implicated most often). 2 Herein we report on 2 patients treated for urinary calculi on polypropylene suture. CASE REPORTS
Case 1. A 29-year-old man was treated for urinary calculi on polypropylene suture in 1976. He was hospitalized initially in 1975 for complaints of dysuria, nocturia, left flank pain, and occasional nausea and vomiting. History revealed a right nephrectomy when the patient was 2 years old for a congenital malformed kidney. He stated that he had had no problems with hematuria nor stone disease during the intervening years. The patient had a solitary left kidney with a congenital ureteropelvic junction obstruction. A left Foley Y-V-plasty was done using 4-zero polypropylene suture. Postoperatively, he did well for approximately 6 months with negative urine cultures and normal creatinine clearance determinations. In 1976, approximately 8 months after the pyeloplasty, severe left flank pain, nausea, vomiting and hematuria occurred. Physical examination revealed a temperature of 39C, pulse 90 and regular, and blood pressure 130/70 mm. Hg. He was in severe pain. On examination of the abdomen well healed bilateral flank incisions were observed as well as mild tenderness to palpation on the right side. The results of laboratory studies included a hematocrit of 40 per cent, hemoglobin 13.7 gm./100 ml. and white blood count 900 cc/cu. ml. Serum electrolyte concentrations were within the normal range. Urinalysis revealed red blood cells too numerous to count and 4 to 5 white blood cells with few bacteria per high power field. Urine culture yielded Proteus mirabilis, which was sensitive to all commonly used urinary antibiotics. An excretory urogram (IVP) demonstrated calculi at the ureteropelvic junction (fig. 1). A left pyeloplasty revealed a stone attached to a polypropylene suture. All exposed sutures were removed from the old operative site and convalescence was uneventful. The patient was lost to followup but 5 months postoperatively he returned to the hospital with left flank pain, chills, fever and hematuria. An IVP demonstrated 2 large calculi at the ureteropelvic junction and severe hydronephrosis (fig. 2). He was rehospitalized and given intravenous fluids and parenteral antibiotics. Surgical exploration of the left renal pelvis revealed a great deal of fibrosis around the ureteropelvic junction. Within the pelvis 2 large calculi were attached to the urothelium by additional polypropylene suture material (fig. Accepted for publication September 29, 1978. * Requests for reprints: Division of Urology, ME-805 John Sealy Hospital, Galveston, Texas 77550.
3). Consequently, the pyeloplasty was taken down and reduced, with meticulous care to resect all of the suture material. The patient is well and has been free of stones and infection. Case 2. A 26-year-old man had urinary calculi on polypropylene suture 4 years after a right ureterolithotomy elsewhere to remove a ureteral calculus. Subsequently, he remained asymptomatic for 2 years. At that time right flank pain radiating into the scrotum, occasional chills, fever and nausea developed. The symptoms persisted for 2 years, at which time an IVP revealed a right ureteral calculus. The patient was referred to us and an IVP demonstrated a right ureteral calculus approximately 1 cm. in diameter, with pronounced obstructive changes in the proximal portions of the upper urinary tracts. Temperature was 37C, pulse 90 and
Fm. 1. IVP in case 1 approximately 6 months after first pyeloplasty shows 2 small calculi at ureteropelvic junction.
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STONE FORMATION ON POLYPROPYLENE SUTURE
Fm. 2. Case 1. A, film of kidneys, ureters and bladder approximately 5 months after small stones were removed. B, IVP 5 months after lithotomy shows larger stones at ureteropelvic junction.
cated by prolonged flank drainage, which abated without further operative treatment. The patient has been asymptomatic and the urine has remained sterile for 18 months. DISCUSSION
Fm. 3. Photograph of stones removed in case 1. Note polypropylene suture within matrix of right stone.
regular, and blood pressure 130/75 mm. Hg. Physical examination revealed a well healed right flank incision and mild tenderness to palpation at the right costovertebral angle. Urinalysis showed red blood cells too numerous to count and 25 to 30 white blood cells per high power field. Urine culture yielded Pseudomonas aeruginosa (10 4). Serum electrolyte concentrations were all within the normal range. The patient was given intravenous fluids and antibiotics for 2 days followed by a right ureterolithotomy. At operation a large amount of fibrous tissue was seen around the ureter. When the stone was removed a non-absorbable suture was incorporated within its matrix. Consequently, the ureter was explored further and 2 other sutures were removed from the previous surgical site. The postoperative course was compli-
Polypropylene is a relatively new suture material. Its advantages are superior strength, non-reactivity and notable ease of handling along with resistance to absorption. Also, since it is a monofilament it has no capillary action and less surface area for crystalline deposition. It has been shown in experimental studies to develop an epithelial cover rapidly and to be no more likely to form stones than chromic catgut. 3 • 4 Previously, any stones that formed on polypropylene suture were believed to develop in the early postoperative period. 2 • 3 However, in both of our patients, stones formed on the suture material at the end of the postoperative period. Also, both stones were associated with infected urine. Our patients had large amounts of fibrosis around the sutured urothelium, which does not bear out the descriptions in the literature that polypropylene is an inert material. Thus, the use of polypropylene suture in an operation on the urinary epithelium appears to place the patient at risk of stone formation. Consequently, until more knowledge is gathered the physician should be wary of its use in urinary tract operations. REFERENCES
1. Bartone, F. F. and Stinson, W.: Reaction of the urinary tract to
polypropylene sutures. Invest. Urol., 14: 44, 1976. 2. Higgins, C. C. and Straffon, R. A.: Urolithiasis. In: Urology, 2nd ed. Edited by M. F. Campbell. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 16, p. 681, 1963. 3. Hepperlen, T. W., Stinson, W., Hutson, J. and Bartone, F. F.: Epithelialization after cystotomy. Invest. Urol., 12: 269, 1975. 4. Yudofsky, S. C. and Scott, F. B.: Urolithiasis on suture materials: its importance, pathogenesis and prophylaxis: an introduction to the monofilament Teflon suture. J. Urol., 102: 745, 1969.
Vol. 121, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
STONE FORMATION ON POLYPROPYLENE SUTURE G. BRUCE HEALEY
AND
MICHAEL M. WARREN*
From the Department of Surgery, Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, Texas
ABSTRACT
Polypropylene is a relatively new suture material with many advantages, which has been demonstrated in experimental studies to be a safe material for urologic operations. However, recently, 2 patients had polypropylene suture at the matrix of urinary calculi. Symptoms from the calculi developed in both patients in the late postoperative period and both had large amounts of fibrosis around the sutured urothelium. Polypropylene has been shown under experimental conditions to be a suitable suture material for use in urologic operations. 1 However, it must be added now to the list of potential nidi for the development of urinary tract calculi (cotton, silk and even chromic catgut have been implicated most often). 2 Herein we report on 2 patients treated for urinary calculi on polypropylene suture. CASE REPORTS
Case 1. A 29-year-old man was treated for urinary calculi on polypropylene suture in 1976. He was hospitalized initially in 1975 for complaints of dysuria, nocturia, left flank pain, and occasional nausea and vomiting. History revealed a right nephrectomy when the patient was 2 years old for a congenital malformed kidney. He stated that he had had no problems with hematuria nor stone disease during the intervening years. The patient had a solitary left kidney with a congenital ureteropelvic junction obstruction. A left Foley Y-V-plasty was done using 4-zero polypropylene suture. Postoperatively, he did well for approximately 6 months with negative urine cultures and normal creatinine clearance determinations. In 1976, approximately 8 months after the pyeloplasty, severe left flank pain, nausea, vomiting and hematuria occurred. Physical examination revealed a temperature of 39C, pulse 90 and regular, and blood pressure 130/70 mm. Hg. He was in severe pain. On examination of the abdomen well healed bilateral flank incisions were observed as well as mild tenderness to palpation on the right side. The results of laboratory studies included a hematocrit of 40 per cent, hemoglobin 13.7 gm./100 ml. and white blood count 900 cc/cu. ml. Serum electrolyte concentrations were within the normal range. Urinalysis revealed red blood cells too numerous to count and 4 to 5 white blood cells with few bacteria per high power field. Urine culture yielded Proteus mirabilis, which was sensitive to all commonly used urinary antibiotics. An excretory urogram (IVP) demonstrated calculi at the ureteropelvic junction (fig. 1). A left pyeloplasty revealed a stone attached to a polypropylene suture. All exposed sutures were removed from the old operative site and convalescence was uneventful. The patient was lost to followup but 5 months postoperatively he returned to the hospital with left flank pain, chills, fever and hematuria. An IVP demonstrated 2 large calculi at the ureteropelvic junction and severe hydronephrosis (fig. 2). He was rehospitalized and given intravenous fluids and parenteral antibiotics. Surgical exploration of the left renal pelvis revealed a great deal of fibrosis around the ureteropelvic junction. Within the pelvis 2 large calculi were attached to the urothelium by additional polypropylene suture material (fig. Accepted for publication September 29, 1978. * Requests for reprints: Division of Urology, ME-805 John Sealy Hospital, Galveston, Texas 77550.
3). Consequently, the pyeloplasty was taken down and reduced, with meticulous care to resect all of the suture material. The patient is well and has been free of stones and infection. Case 2. A 26-year-old man had urinary calculi on polypropylene suture 4 years after a right ureterolithotomy elsewhere to remove a ureteral calculus. Subsequently, he remained asymptomatic for 2 years. At that time right flank pain radiating into the scrotum, occasional chills, fever and nausea developed. The symptoms persisted for 2 years, at which time an IVP revealed a right ureteral calculus. The patient was referred to us and an IVP demonstrated a right ureteral calculus approximately 1 cm. in diameter, with pronounced obstructive changes in the proximal portions of the upper urinary tracts. Temperature was 37C, pulse 90 and
Fm. 1. IVP in case 1 approximately 6 months after first pyeloplasty shows 2 small calculi at ureteropelvic junction.
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837
STONE FORMATION ON POLYPROPYLENE SUTURE
Fm. 2. Case 1. A, film of kidneys, ureters and bladder approximately 5 months after small stones were removed. B, IVP 5 months after lithotomy shows larger stones at ureteropelvic junction.
cated by prolonged flank drainage, which abated without further operative treatment. The patient has been asymptomatic and the urine has remained sterile for 18 months. DISCUSSION
Fm. 3. Photograph of stones removed in case 1. Note polypropylene suture within matrix of right stone.
regular, and blood pressure 130/75 mm. Hg. Physical examination revealed a well healed right flank incision and mild tenderness to palpation at the right costovertebral angle. Urinalysis showed red blood cells too numerous to count and 25 to 30 white blood cells per high power field. Urine culture yielded Pseudomonas aeruginosa (10 4). Serum electrolyte concentrations were all within the normal range. The patient was given intravenous fluids and antibiotics for 2 days followed by a right ureterolithotomy. At operation a large amount of fibrous tissue was seen around the ureter. When the stone was removed a non-absorbable suture was incorporated within its matrix. Consequently, the ureter was explored further and 2 other sutures were removed from the previous surgical site. The postoperative course was compli-
Polypropylene is a relatively new suture material. Its advantages are superior strength, non-reactivity and notable ease of handling along with resistance to absorption. Also, since it is a monofilament it has no capillary action and less surface area for crystalline deposition. It has been shown in experimental studies to develop an epithelial cover rapidly and to be no more likely to form stones than chromic catgut. 3 • 4 Previously, any stones that formed on polypropylene suture were believed to develop in the early postoperative period. 2 • 3 However, in both of our patients, stones formed on the suture material at the end of the postoperative period. Also, both stones were associated with infected urine. Our patients had large amounts of fibrosis around the sutured urothelium, which does not bear out the descriptions in the literature that polypropylene is an inert material. Thus, the use of polypropylene suture in an operation on the urinary epithelium appears to place the patient at risk of stone formation. Consequently, until more knowledge is gathered the physician should be wary of its use in urinary tract operations. REFERENCES
1. Bartone, F. F. and Stinson, W.: Reaction of the urinary tract to
polypropylene sutures. Invest. Urol., 14: 44, 1976. 2. Higgins, C. C. and Straffon, R. A.: Urolithiasis. In: Urology, 2nd ed. Edited by M. F. Campbell. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 16, p. 681, 1963. 3. Hepperlen, T. W., Stinson, W., Hutson, J. and Bartone, F. F.: Epithelialization after cystotomy. Invest. Urol., 12: 269, 1975. 4. Yudofsky, S. C. and Scott, F. B.: Urolithiasis on suture materials: its importance, pathogenesis and prophylaxis: an introduction to the monofilament Teflon suture. J. Urol., 102: 745, 1969.
