Sutures
Suture selection in urologic reconstruction is rarely taught systematically and almost always learned by imitation. The reality is that every substitution urethroplasty, vesicourethral anastomosis, ureteral reimplant, and augmentation cystoplasty involves 6–10 distinct suture-and-needle decisions, and the defaults vary by fellowship tree. This article consolidates the evidence and lays out what the reconstructive urologist actually picks up off the Mayo stand and why.
See also: Barbed Sutures, Incisions & Closure, Bowel Anastomosis, Needles, Wound Healing.
The Five Properties of the Ideal Suture
Surgical sutures are rated on five axes:[1][2]
- Predictable tensile strength over the wound-healing window.
- Good handling characteristics — pliability, memory, feel at the needle.
- Secure knot with a predictable number of throws.
- Minimal tissue reactivity.
- Resistance to infection and bacterial colonization.
No suture achieves all five. The selection decision trades them off against the biology of the tissue being repaired and the time the repair has to heal.
Classification
Sutures are classified on three axes:
- Absorbability: absorbable (loses strength and is degraded) vs non-absorbable (retains strength indefinitely).
- Structure: monofilament (single strand) vs multifilament / braided (many strands).
- Origin: natural (silk, catgut) vs synthetic (polymers).
The dominant clinical divide for the reconstructive urologist is monofilament vs multifilament — it predicts infection risk, tissue drag, and knot behavior more than any other property.
Absorbable Sutures
Fast Absorbable (Loses Strength Within 30 Days)
| Suture | Structure | Trade name | Strength retention | Urologic use |
|---|---|---|---|---|
| Polyglactin 910 | Multifilament, braided | Vicryl | 25% at 4 wk; absorbed 8–10 wk | Bladder mucosa, ureteral reimplant, vaginal cuff |
| Polyglycolic acid (PGA) | Multifilament (or monofilament) | Dexon | Similar to Vicryl | Largely displaced by Vicryl |
| Poliglecaprone 25 | Monofilament | Monocryl | 50–75% at 1 wk; 20–30% at 2 wk | Subcuticular skin, vesicourethral anastomosis, bladder neck reconstruction |
| Chromic catgut | Natural monofilament | Chromic | Enzymatic degradation, variable | Largely historical; some pediatric skin |
Slow Absorbable (Strength Retained >30 Days)
| Suture | Structure | Trade name | Strength retention | Urologic use |
|---|---|---|---|---|
| Polydioxanone | Monofilament | PDS II | >50% at 6 wk; absorbed 6–8 mo | Urethroplasty, fascial closure (STITCH), high-tension anastomosis |
| Polyglyconate | Monofilament | Maxon | Similar to PDS | Equivalent alternative to PDS |
| Polyglactin 910 extended | Multifilament | Vicryl Plus | Extended via triclosan coating | Contaminated-field closure |
PDS has the highest sustained tensile strength among routine sutures tested and is the reference material for fascial closure and long-healing-window urologic anastomoses.[4][5]
Degradation Mechanism
- Natural sutures (catgut, silk) degrade by enzymatic proteolysis — highly variable and tissue-reactive.
- Synthetic absorbables (Vicryl, Monocryl, PDS) degrade by hydrolysis — predictable, weakly reactive. This is why synthetic displaced natural almost universally.
Non-Absorbable Sutures
| Material | Structure | Trade name | Strength | Urologic use |
|---|---|---|---|---|
| Polypropylene | Monofilament | Prolene | Retains >60 d; near-permanent | Sling suspensory arms, mesh fixation, AUS capsular repair, permanent bladder-neck reinforcement |
| Nylon | Mono- or multifilament | Ethilon, Nurolon | Long-term | Skin closure, tendon |
| Silk | Multifilament, natural | Silk | Loses strength over months in vivo | Historical; highest tissue reactivity and microbial adherence[6][7] |
| Polyester | Multifilament, coated | Ethibond, Ti-Cron | Very high tensile strength | AUS cuff fixation, sling arms |
| PTFE / Gore-Tex | Monofilament | CV-series | Most stable over time[4] | Vascular / IVC reconstruction |
| Stainless steel | Monofilament | — | Maximum strength | Sternal closure (not urologic) |
Monofilament vs Multifilament — the Decision That Matters Most
| Property | Monofilament | Multifilament |
|---|---|---|
| Tissue drag | Low | High |
| Tensile strength for a given size | Lower | Higher |
| Knot security | Lower (more throws required) | Higher |
| Handling / pliability | Stiffer; more memory | Better; more pliable |
| Bacterial adherence | Low | High (bacteria harbor between filaments) |
| Infection risk | Low | Higher |
| Tissue reactivity | Low | Higher |
| Suture sinus risk | Low | Higher |
For the urologist: use monofilament in any contaminated or potentially contaminated field, any permanent-implant (mesh, AUS, IPP) case, and any long-healing anastomosis. Multifilament (Vicryl) is acceptable for short-healing mucosal approximation where handling matters (bladder mucosa, vaginal cuff).
Size — USP Gauge
USP sizes run from 10-0 (finest, microsurgical) through 0, 1, 2, up to 5 (thickest, sternal). Increasing number of zeros = smaller diameter. 6-0 is smaller than 4-0.[11]
Principle: use the smallest size that accomplishes the purpose.[1]
Larger diameter (3-0 vs 5-0) produces higher tear-through force — relevant in tissue that is friable or under tension.[12] Suture size does not materially affect knot security.[8]
Typical Sizes by Urologic Task
| Task | Suture | Size |
|---|---|---|
| Urethroplasty — spongiosum / ventral onlay | Vicryl or Monocryl | 5-0 or 6-0 |
| Urethroplasty — graft fixation | PDS or Monocryl | 6-0 |
| Vesicourethral anastomosis (RARP) | Monocryl or V-Loc | 3-0 |
| Ureteral reimplant mucosa-to-mucosa | Vicryl or Monocryl | 4-0 or 5-0 |
| Ureteroureterostomy | Monocryl or PDS | 4-0 or 5-0 |
| Bladder mucosa | Vicryl | 3-0 |
| Bladder detrusor / seromuscular | Vicryl | 2-0 or 3-0 |
| Augmentation cystoplasty — bowel to bladder | Vicryl or PDS | 3-0 |
| Pyeloplasty (open or robotic) | Monocryl or Vicryl | 4-0 or 5-0 |
| AUS cuff capsular closure / IPP corporotomy | PDS or Vicryl | 2-0 |
| Sling arm fixation / mesh anchor | Prolene | 0 or 1 |
| Fascia — midline laparotomy | PDS (monofilament slow-absorb) | 2-0 (STITCH small-bites) |
| Subcuticular skin | Monocryl | 4-0 |
Knot Security — Material and Throws
Number of throws required for a secure knot depends on material and knot type:[8][9][16]
| Suture type | Square knot | Surgeon's knot |
|---|---|---|
| Multifilament (Vicryl, silk) | 4–5 throws | 4 throws |
| Monofilament (PDS, Prolene, Monocryl) | 6 throws | 4 throws |
Beyond 5 throws there is no additional security — more throws just means more foreign material and more bulk.[8] The optimal surgeon's knot uses 3–5 initial twists; benefit plateaus beyond 5.[17]
Monofilament requires more throws because of low friction between layers — the knot can slip. Vicryl's braided structure grabs itself and holds earlier.
Triclosan-Coated (Antibacterial) Sutures
Vicryl Plus (polyglactin + triclosan) and PDS Plus are coated with triclosan, an antibacterial agent, to reduce bacterial colonization of the suture and consequent surgical site infection.
Evidence is conflicting:
- A 2023 meta-analysis of 29 RCTs showed a 24% reduction in SSI (RR 0.76) with triclosan-coated sutures.[18]
- A 2025 JAMA Network Open meta-analysis confirmed consistent SSI reduction (RR 0.79).[20]
- WHO 2016 and NICE recommend triclosan-coated sutures conditionally.[19]
- A high-quality 2022 Lancet Infectious Diseases meta-analysis restricted to the best-conducted RCTs (5 trials, 8,619 patients) found no significant SSI difference (16.8% vs 18.4%) and argued for removing the routine-use recommendation.[21]
Practical stance: reasonable to use in contaminated-field urologic cases (cystectomy with bowel diversion, fistula repair, infected cases) where the absolute SSI rate is high and the incremental cost is justifiable. Less compelling for clean cases with low baseline SSI.
Barbed Sutures — Knotless Running Closure
The full product biomechanics (V-Loc 90/180, Quill SRS, Stratafix, MONOFIX), per-indication evidence, the upper-tract pyeloplasty controversy (Liatsikos 83% failure, Radford 40% pediatric failure, Anand 2022 meta), the overtightening-to-avoid technique, SBO risk from exposed tails (Clapp 2020), and the where-to-use-and-where-to-avoid clinical decision framework live at Barbed sutures. The overview below is the summary; the dedicated article is the reference.
Barbed sutures are self-anchoring monofilament sutures with helically arranged barbs cut into the suture surface. The barbs grip tissue as the suture is passed, eliminating the need for knot tying and distributing tension along the closure instead of concentrating it at knots.[13][22][23] The reconstructive value is practical: in deep pelvic, laparoscopic, and robotic fields, a running closure can be tensioned without an assistant constantly following the suture.
For the reconstructive urologist and urogynecologist, the highest-yield uses are:
- Robot-assisted vesicourethral anastomosis — the classic GU application
- Robotic pyeloplasty — faster running pelvis-to-ureter closure
- Renorrhaphy — holds compression during sliding-clip parenchymal closure
- Cystotomy / bladder closure — especially in robotic cystectomy, partial cystectomy, or fistula repair
- Sacrocolpopexy mesh attachment and vaginal cuff closure — knotless running pelvic closure
Types
| Type | Mechanism | Examples | Practical issue |
|---|---|---|---|
| Unidirectional | Barbs face one direction; terminal loop anchors first pass | V-Loc, Stratafix Spiral | Easy robotic workflow; extrusion/dehiscence signal is most prominent in body-wall and subcutaneous use |
| Bidirectional | Barbs face away from the midpoint; closure proceeds from center outward | Quill | More even tension distribution; no terminal loop |
Mechanism and handling
| Principle | Effect |
|---|---|
| Self-anchoring | Barbs grip tissue on passage; no knot required |
| No assistant needed to hold tension | Useful in robotic VUA, pyeloplasty, renorrhaphy, and deep pelvic closure |
| Slippage prevention | Running closure maintains approximation without repeated retensioning[24] |
| Uniform tensile distribution | Avoids the focal ischemia created by bulky knots or constricting loops[23] |
| Not easily backed out | Tension must be set deliberately; over-tightening is harder to correct |
Biomechanical studies show that barbed closures may have lower ultimate tensile strength than layered conventional closure in skin models, but still exceed clinical wound tension requirements; tissue reaction is generally mild and comparable to conventional monofilament sutures.[25][26] In urinary-tract reconstruction, the key question is less raw tensile strength and more whether a continuous mucosa-to-mucosa closure remains watertight without focal strangulation.
Urologic and reconstructive evidence
| Application | Evidence signal | Reconstructive interpretation |
|---|---|---|
| Vesicourethral anastomosis | Zorn RCT: anastomosis time 13.1 vs 20.8 min; less need to readjust tension; equivalent early continence[24]. Meta-analysis confirms shorter anastomosis time without higher leak or stenosis.[27] | Best-established GU indication; now a normal robotic default. |
| Pyeloplasty | Biomechanical and clinical series show shorter suture time, reduced suture-line shortening, and comparable redo rates.[28][29][30] | Helpful when intracorporeal knot tying is the time-limiting step. |
| Partial nephrectomy renorrhaphy | Robotic series reported warm ischemia reduction from 24.7 to 18.5 min with no slippage or tearing.[31] | Useful for compression and clip-sliding workflow; not a reconstructive anastomosis but a key urologic use case. |
| Gynecologic / urogynecologic closure | Systematic reviews report shorter cuff-closure time and operative time, with no consistent increase in cuff dehiscence.[14][32] | Reasonable for vaginal cuff and sacrocolpopexy mesh attachment when the surgeon is comfortable with running closure. |
| Fascial closure | Meta-analysis suggests shorter closure time and lower SSI without higher incisional hernia in abdominal closure series.[33] | Consider in selected abdominal closure; PDS small-bites remains the default evidence anchor for midline fascia. |
Complications and precautions
The safety signal is context-dependent. In broad surgical meta-analysis, barbed sutures shorten closure time without a consistent increase in major complications.[13] In plastic/body-contouring literature, unidirectional barbed sutures show higher wound-dehiscence and suture-extrusion odds, especially in subcutaneous or superficial closure.[15][34]
Practical precautions:
- Avoid skin and superficial subcutaneous closure when extrusion would be clinically obvious or difficult to manage.
- Trim tails flush and bury free ends where possible.
- Avoid free intraperitoneal barbed loops; early case reports linked exposed tails to small-bowel obstruction, although large cohort data do not support a frequent causal relationship.[35][36]
- Do not over-tighten mucosa-to-mucosa anastomoses; barbs hold tension, so ischemic narrowing is easy to create if each bite is cinched too aggressively.
- Single-layer running closure is often preferable to stacked barbed layers in soft tissue; two-layer barbed closure has been associated with higher wound separation in some body-contouring data.[34]
Product examples
| Product | Direction | Material pattern | Common reconstructive use |
|---|---|---|---|
| V-Loc 90 / 180 | Unidirectional | Absorbable | Robotic VUA, cystotomy closure, pyeloplasty |
| Stratafix Spiral | Unidirectional | PDO / Monocryl-family variants | Running closure in robotic or laparoscopic fields |
| Quill | Bidirectional | Absorbable or non-absorbable variants | Center-outward closure, body-wall and pelvic closure |
Bottom line: barbed sutures are a suture-material decision, not a separate named operation. They are most useful when knot tying and tension maintenance are the bottleneck; they are least attractive in superficial closure, friable ischemic tissue, or any field where exposed barbs could catch bowel or extrude.
Practical Selection by GU Reconstructive Procedure
| Operation | Mucosa / inner layer | Muscular / outer layer | Fascia | Skin |
|---|---|---|---|---|
| Urethroplasty (bulbar BMG) | 5-0 Vicryl or Monocryl (graft/mucosa) | 4-0 Vicryl (spongiosum) | 2-0 Vicryl (Colles') | 4-0 Monocryl subcuticular |
| Radical prostatectomy (open) | 3-0 Monocryl (VUA) | 3-0 Vicryl (bladder neck) | 0 PDS loop | staples or 4-0 Monocryl |
| RARP (robotic) | 3-0 V-Loc 180 (VUA) | — | 0 PDS loop | 4-0 Monocryl |
| Ureteral reimplant | 4-0 Monocryl (mucosa) | 3-0 Vicryl (detrusor) | 0 PDS | 4-0 Monocryl |
| Pyeloplasty | 4-0 or 5-0 Monocryl (pelvis to ureter) | — | 0 PDS | 4-0 Monocryl |
| Augmentation cystoplasty | 3-0 Vicryl or PDS (bowel-to-bladder) | 3-0 Vicryl (serosa reinforcement) | 0 PDS loop | 4-0 Monocryl |
| VVF repair | 3-0 Vicryl (bladder) | 3-0 Vicryl (interposition) | 0 PDS | 4-0 Monocryl |
| AUS implant | 2-0 PDS (corporotomy) | 2-0 Vicryl (tunica) | 0 PDS | 4-0 Monocryl |
| Pubovaginal sling | 0 or 1 Prolene (fascia arms) | 2-0 Vicryl (anterior vaginal wall) | 0 PDS if abdominal | 4-0 Monocryl |
| Cystectomy + ileal conduit | 3-0 Vicryl (bowel) + 3-0 Monocryl (ureter-to-conduit) | 3-0 Vicryl | 1 PDS loop or 2-0 small-bites | staples |
These are typical defaults, not a rigid protocol — fellowship tree, surgeon preference, and case-specific anatomy drive local variation.
Alternatives to Sutures
| Option | Urologic use | Trade-off |
|---|---|---|
| Skin staples | Midline laparotomy, cystectomy skin, lateral nephrectomy skin | Fast, low reaction; removal discomfort |
| Tissue adhesive (2-octylcyanoacrylate / Dermabond) | Pediatric skin, low-tension incisions | No removal; not for high-tension or infected wounds |
| Surgical tape (Steri-Strips) | Adjunct after sutures/staples removed | Limited tension tolerance |
No difference in SSI vs sutures in most comparisons.[10]
Complications — Suture-Attributable
- Suture sinus / extrusion — more common with non-absorbable (OR 2.18) and multifilament sutures.[1][3]
- Stitch abscess — multifilament higher risk than monofilament.
- Tissue reactivity — silk and catgut > polyester > nylon > Vicryl > PDS / Monocryl > Prolene.
- Encrustation / calculi — a urologic-specific complication: permanent suture in the urinary tract becomes a calculus nidus. Never use non-absorbable suture full-thickness through urothelium.
- Mesh erosion — Prolene through urothelium erodes over time and is the feared complication of transvaginal synthetic mesh.
References
1. Byrne M, Aly A. "The Surgical Suture." Aesthet Surg J. 2019;39(Suppl_2):S67–S72. doi:10.1093/asj/sjz036
2. Li Y, Meng Q, Chen S, et al. "Advances, Challenges, and Prospects for Surgical Suture Materials." Acta Biomater. 2023;168:78–112. doi:10.1016/j.actbio.2023.07.041
3. Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. "Closure Methods for Laparotomy Incisions for Preventing Incisional Hernias and Other Wound Complications." Cochrane Database Syst Rev. 2017;11:CD005661. doi:10.1002/14651858.CD005661.pub2
4. Taysi AE, Ercal P, Sismanoglu S. "Comparison Between Tensile Characteristics of Various Suture Materials With Two Suture Techniques: An In Vitro Study." Clin Oral Investig. 2021;25(11):6393–6401. doi:10.1007/s00784-021-03943-3
5. Elgohary DH, Saad MA, Salem MM, Sherazy EH, Khalifa TF. "Assessment the Properties of Various Surgical Sutures." Sci Rep. 2025;15(1):33330. doi:10.1038/s41598-025-20311-3
6. Dragovic M, Pejovic M, Stepic J, et al. "Comparison of Four Different Suture Materials in Respect to Oral Wound Healing, Microbial Colonization, Tissue Reaction and Clinical Features — Randomized Clinical Study." Clin Oral Investig. 2020;24(4):1527–1541. doi:10.1007/s00784-019-03034-4
7. Yaman D, Paksoy T, Ustaoğlu G, Demirci M. "Evaluation of Bacterial Colonization and Clinical Properties of Different Suture Materials in Dentoalveolar Surgery." J Oral Maxillofac Surg. 2022;80(2):313–326. doi:10.1016/j.joms.2021.09.014
8. Silver E, Wu R, Grady J, Song L. "Knot Security — How Is It Affected by Suture Technique, Material, Size, and Number of Throws?" J Oral Maxillofac Surg. 2016;74(7):1304–12. doi:10.1016/j.joms.2016.02.004
9. Romeo A, Fujimoto C, Cipullo I, et al. "Effect of Diameter and Type of Suture on Knot and Loop Security." J Clin Med. 2023;12(19):6418. doi:10.3390/jcm12196418
10. Provenzano DA, Hanes M, Hunt C, et al. "ASRA Pain Medicine Consensus Practice Infection Control Guidelines for Regional Anesthesia and Pain Medicine." Reg Anesth Pain Med. 2025. doi:10.1136/rapm-2024-105651
11. Byrne M, Aly A. "The Surgical Needle." Aesthet Surg J. 2019;39(Suppl_2):S73–S77. doi:10.1093/asj/sjz035
12. Potter CT, Maloney ME, Riopelle AM, Fudem GM, Schanbacher CF. "Impact of Needle Design and Suture Gauge on Tissue Tearing During Skin Suturing: A Comparative Analysis." Dermatol Surg. 2025;51(2):148–151. doi:10.1097/DSS.0000000000004389
13. Lin Y, Lai S, Huang J, Du L. "The Efficacy and Safety of Knotless Barbed Sutures in the Surgical Field: A Systematic Review and Meta-Analysis of RCTs." Sci Rep. 2016;6:23425. doi:10.1038/srep23425
14. Hafermann J, Silas U, Saunders R. "Efficacy and Safety of V-Loc™ Barbed Sutures Versus Conventional Suture Techniques in Gynecological Surgery." Arch Gynecol Obstet. 2024;309(4):1249–1265. doi:10.1007/s00404-023-07291-3
15. Su X, Lin Y, Wu Y, et al. "Effectiveness and Safety of Knotless Barbed Sutures in Cosmetic Surgery: A Systematic Review and Meta-Analysis." J Plast Reconstr Aesthet Surg. 2023;87:416–429. doi:10.1016/j.bjps.2023.10.084
16. Zimmer CA, Thacker JG, Powell DM, et al. "Influence of Knot Configuration and Tying Technique on the Mechanical Performance of Sutures." J Emerg Med. 1991;9(3):107–13. doi:10.1016/0736-4679(91)90313-5
17. Modiri O, Ebriani J, Sauvageau A, Davis J. "A New Twist on the Surgeon's Knot: Quantifying Suture Security." Dermatol Surg. 2025;51(4):375–378. doi:10.1097/DSS.0000000000004493
18. Otto-Lambertz C, Decker L, Adams A, Yagdiran A, Eysel P. "Can Triclosan-Coated Sutures Reduce the Postoperative Rate of Wound Infection? Data From a Systematic Review and Meta-Analysis." Surgery. 2023;174(3):638–646. doi:10.1016/j.surg.2023.04.015
19. Allegranzi B, Zayed B, Bischoff P, et al. "New WHO Recommendations on Intraoperative and Postoperative Measures for Surgical Site Infection Prevention: An Evidence-Based Global Perspective." Lancet Infect Dis. 2016;16(12):e288–e303. doi:10.1016/S1473-3099(16)30402-9
20. Jalalzadeh H, Timmer AS, Buis DR, et al. "Triclosan-Containing Sutures for the Prevention of Surgical Site Infection: A Systematic Review and Meta-Analysis." JAMA Netw Open. 2025;8(3):e250306. doi:10.1001/jamanetworkopen.2025.0306
21. NIHR Global Surgery Unit. "Alcoholic Chlorhexidine Skin Preparation or Triclosan-Coated Sutures to Reduce Surgical Site Infection: A Systematic Review and Meta-Analysis of High-Quality RCTs." Lancet Infect Dis. 2022;22(8):1242–1251. doi:10.1016/S1473-3099(22)00133-5
22. Moya AP. "Barbed Sutures in Body Surgery." Aesthet Surg J. 2013;33(3 Suppl):57S–71S. doi:10.1177/1090820X13499577
23. Ruff GL. "The History of Barbed Sutures." Aesthet Surg J. 2013;33(3 Suppl):12S–16S. doi:10.1177/1090820X13498505
24. Zorn KC, Trinh QD, Jeldres C, et al. "Prospective Randomized Trial of Barbed Polyglyconate Suture to Facilitate Vesico-Urethral Anastomosis During Robot-Assisted Radical Prostatectomy: Time Reduction and Cost Benefit." BJU Int. 2012;109(10):1526–1532. doi:10.1111/j.1464-410X.2011.10763.x
25. Mabey JG, Kammien AJ, Mookerjee VG, Thomson JG. "A Biomechanical Analysis of Barbed and Monofilament Suture in an Ex Vivo Skin Closure Model." Aesthetic Plast Surg. 2025. doi:10.1007/s00266-025-04947-0
26. Zaruby J, Gingras K, Taylor J, Maul D. "An In Vivo Comparison of Barbed Suture Devices and Conventional Monofilament Sutures for Cosmetic Skin Closure: Biomechanical Wound Strength and Histology." Aesthet Surg J. 2011;31(2):232–240. doi:10.1177/1090820X10395010
27. Li H, Liu C, Zhang H, et al. "The Use of Unidirectional Barbed Suture for Urethrovesical Anastomosis During Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis of Efficacy and Safety." PLoS One. 2015;10(7):e0131167. doi:10.1371/journal.pone.0131167
28. Amend B, Muller O, Bedke J, et al. "Biomechanical Proof of Barbed Sutures for the Efficacy of Laparoscopic Pyeloplasty." J Endourol. 2012;26(5):540–544. doi:10.1089/end.2011.0037
29. Sorokin I, O'Malley RL, McCandless BK, Kaufman RP. "Successful Outcomes in Robot-Assisted Laparoscopic Pyeloplasty Using a Unidirectional Barbed Suture." J Endourol. 2016;30(6):660–664. doi:10.1089/end.2016.0040
30. Anand S, Jukic M, Krishnan N, Pogorelic Z. "Barbed Versus Non-Barbed Suture for Pyeloplasty Via the Minimally Invasive Approach: A Systematic Review and Meta-Analysis." J Laparoendosc Adv Surg Tech A. 2022;32(10):1056–1063. doi:10.1089/lap.2021.0868
31. Sammon J, Petros F, Sukumar S, et al. "Barbed Suture for Renorrhaphy During Robot-Assisted Partial Nephrectomy." J Endourol. 2011;25(3):529–533. doi:10.1089/end.2010.0455
32. Planella LV, Garcia IR, Camps SF, Barri-Soldevila PN, Diaz SC. "Optimizing Vaginal Cuff Closure: A Systematic Review and Meta-Analysis of Barbed Versus Conventional Sutures in Total Laparoscopic and Robotic-Assisted Hysterectomies." J Minim Invasive Gynecol. 2025. doi:10.1016/j.jmig.2025.06.023
33. Matsuda A, Yamada T, Uehara K, et al. "Comparison Between Barbed and Non-Barbed Sutures for Fascial Closure in Abdominal Surgery: A Systematic Review and Meta-Analysis." Surg Today. 2025. doi:10.1007/s00595-025-03118-7
34. Cortez R, Lazcano E, Miller T, et al. "Barbed Sutures and Wound Complications in Plastic Surgery: An Analysis of Outcomes." Aesthet Surg J. 2015;35(2):178–188. doi:10.1093/asj/sju012
35. Clapp B, Klingsporn W, Lodeiro C, et al. "Small Bowel Obstructions Following the Use of Barbed Suture: A Review of the Literature and Analysis of the MAUDE Database." Surg Endosc. 2020;34(3):1261–1269. doi:10.1007/s00464-019-06890-z
36. Sassun R, Cerkauskaite D, Sileo A, et al. "Use of Barbed Suture in Surgery and the Risk of Intestinal Obstruction: Analysis of a Large Institutional Cohort." Surg Endosc. 2026. doi:10.1007/s00464-026-12580-4