The manner in which hemostasis and tissue adhesion is achieved intraoperatively is critical to improving the outcomes of urologic surgery. Innovation in other surgical specialties has led to the development of a variety of topical biologic agents that locally enhance the clotting cascade to achieve either hemostasis, tissue adhesion, or both. Although many are routinely being used in a variety of surgical subspecialties, the benefits of hemostatic agents are rarely demonstrated due to the lack of well-designed clinical trials.

The ideal hemostatic agent must achieve instant closure of blood vessels without damage to surrounding tissues, is immunologically inert, and must maintain the tissue seal until vascular obliteration and tissue healing occurs. The utility of hemostatic agents, therefore, extends from any type of elective surgery to emergency surgical procedures.

The agents used can be broadly classified into topical hemostatic agents, tissue sealants, and tissue adhesives. There are several published review articles that specifically look at the different types and indications of these agents; here, we present a summary with a particular focus on their utility in urologic surgery (Table 1).

Topical Hemostatic Agents

Topical hemostatic agents are designed to achieve hemostasis by promoting clot formation through the activation of the clotting cascade. They come in a variety of forms, ranging from sponge-type materials to liquids. The liquid forms are suitable in cases of limited blood loss, in which the agent will remain in one place. If blood loss is large, solid agents can be applied to the bleeding surface, with or without pressure to enhance the clotting of the surrounding tissue and vessels.

One such group is fibrin sealants, which contain fibrinogen and thrombin (these have approval for use as topical hemostatic agents, tissue sealants, and tissue adhesives). The concentration of fibrinogen determines the clot strength, and the concentration of thrombin determines the rate of clot formation.¹ Unlike other hemostatic agents, fibrin sealants do not rely on the presence of blood or serum for clot formation.

Tissue Sealants

Sealants are agents that can prevent the leakage of fluids by providing a physical barrier, which also aids in hemostasis. One example is polyethylene glycol (PEG) polymer, which is used for vascular sealing and sealing of the dura. Albumin with glutaraldehyde has a role in sealing of large vessel anastomoses.

Adhesives

Adhesives are agents that glue tissues together, such as cyanoacrylate, which is used for topical external use (eg, skin lacerations). Fibrin sealants have been approved for use in the attachment of skin grafts to underlying tissue in the place of staples. Albumin with glutaraldehyde has been approved as an adhesive for the different arterial wall layers in aortic surgery.²

Renal Surgery: Nephron-sparing Surgery and Nephrectomy

Current data suggest that, due to advances in detection, approximately 60% of renal tumors are detected at stage T1N0M0. This trend has led to an increase in the number of patients undergoing nephron-sparing surgery.³ A partial nephrectomy is a common urologic procedure performed for small renal tumors in patients with preexisting renal failure or solitary kidney, when preservation of nephrons is paramount. Reducing the ischemia time arising from clamping of the renal hilum is an important aim during surgery, as longer ischemia times are thought to be associated with longer renal function recovery times.⁴ In conventional open partial nephrectomy, application of ice to the kidney reduces the parenchymal temperature, which has an effect of extending the threshold of ischemia time.⁵ A combination of sutures, bolsters, electrocautery, and argon laser is available to achieve reliable hemostasis, assisting an early exit from ischemia. The routine use of ice and other agents is often limited in laparoscopic or robotic partial nephrectomies.

Topical hemostatic agents are feasible alternatives to traditional methods of hemostasis, as they can easily be applied through laparoscopic port sites. One of the first case series of laparoscopic partial nephrectomy utilized hemostatic glue consisting of gelatin, resorcinol, and formaldehyde, in combination with other hemostatic devices, and concluded that use of biologic glue enhanced the process of hemostasis.⁶ Another case series reported the safety of a two-component gelatin matrix hemostatic agent (Floseal^® Hemostatic Matrix; Baxter Healthcare, Deerfield, IL) as the sole hemostatic agent in cases of open or laparoscopic partial nephrectomy after hilar clamping.⁷ The authors reported that Floseal provided an immediate and durable effect in controlling bleeding with no significant perirenal hematoma formation in all 25 patients studied. Using a similar gelatin matrix hemostatic agent and technique, Bak and colleagues⁸ showed satisfactory and rapid hemostasis after 1 to 2 minutes in all 6 cases, with a warm ischemia time ranging between 10 and 14 minutes. Similar results were shown in a larger cohort by Gill and colleagues⁹; they found the Floseal-treated group had significantly fewer complications. In a study on 12 pigs, Ploussard and associates¹⁰ concluded that the use of Floseal with concurrent TISSEEL^® (Baxter Healthcare) sealant was sufficient to control major medullary vascular injuries and replace conventional sutures without compromising operative outcomes in deep one-third partial nephrectomy.

Hemostatic agents often contain nonhuman components which must be shown to be immunologically inert to minimize the risks of secondary hemorrhage, infection, inflammation, and nephron loss. Immunologic response to hemostatic agents has been studied by Park and associates¹¹ who investigated the long-term consequences of PEG-based hydrogel tissue sealant in a porcine model, showing no detectable humoral or cell-mediated immune response after 2 weeks without deleterious effects to renal tubules.

Repair of collecting system injuries during partial nephrectomy using tissue sealants has also been described.¹² Tissue sealants have the effect of rapidly sealing two edges of tissue, in addition to hemostatic effects. Although unsuitable in arterial bleeding, in which the sealant can be washed away, effective sealing of the collecting system prevents urinoma formation and reduces the need for suturing, which may increase the warm ischemia time.

Johnston and colleagues¹³ compared the efficacy of TISSEEL in achieving hemostasis and collecting system repair against standard sutured bolsters prospectively in 100 cases of nonrandom consecutive laparoscopic partial nephrectomy. TISSEEL was used in group 1 (n = 75), and sutured bolsters were used in group 2, in which injury to the collecting system or renal sinus was confirmed intraoperatively (n = 25). Overall, postoperative hemorrhage or urine leakage occurred in 9% and 2% of patients, respectively. Moreover, in patients with known collecting system injury, 7 of 17 patients in group 1 (41%) had hemorrhage or leakage, in contrast to 2 of 18 patients in group 2 (11%; P = .04). Although the use of sutured surgical bolster is recommended by the authors in laparoscopic partial nephrectomy when intraoperative injury to renal sinus or collecting system is known, the study is confounded by the differences in tumor size and use of other adjuncts.

In a study designed to explore whether fibrin sealants impact negatively on outcomes in robot-assisted partial nephrectomy, Cohen and colleagues¹⁴ assessed 114 consecutive patients. EVICEL^® Fibrin Sealant (Ethicon, Somerville, NJ) fibrin sealant was used in the first 74 patients during renorrhaphy, and the other 40 patients had renorrhaphy without the use of a hemostatic agent. Multivariable logistic regression showed no significant predictive value of omission of hemostatic agents for perioperative outcomes (P > .05). In another study, Arnoux and coworkers¹⁵ compared perioperative outcomes in a hemostatic agents group (91 cases; 69.5%) with a conventional surgical hemostasis group (40 cases). The authors found no difference between the two groups with regard to surgical complications, transfusions, conversion to radical nephrectomy, or hospital stay.

Hemostatic agents may be used to avoid clamping of the renal pedicle and therefore avoid ischemia altogether. Triaca and coworkers¹⁶ achieved effective control of parenchymal bleeding using a combination of Floseal and suture ligation without any vascular clamping in 37 of 43 open partial nephrectomy cases. Similarly, Finley and colleagues¹⁷ avoided hilar clamping in 14 of 15 patients undergoing laparoscopic wedge resection of nonhilar small renal lesions using a combination of a TISSEEL, harmonic scalpel, argon laser beam, and oxidized cellulose. Although the study was small and the role of TISSEEL is confounded by the use of other hemostatic devices, it demonstrates that, in a well-selected patient cohort, and with a range of laparoscopically delivered hemostatic devices available during surgery, it is possible to avoid hilar clamping during laparoscopic partial nephrectomy. Mele and associates¹⁸ undertook a prospective analysis of the use of TachoSil^® (Baxter Healthcare) in 3 pediatric patients with Wilms tumor (synchronous bilateral tumor in one) undergoing nephron-sparing surgery.¹⁸ All procedures were performed without hilar clamping, drainage, or stent placement, and none of the patients required blood transfusion. Small perirenal fluid collections were documented postoperatively, and all spontaneously resolved within 4 weeks of surgery. The authors concluded that, in children undergoing nephron-sparing surgery, TachoSil is effective and safe for controlling mild to moderate bleeding, and also facilitates sealing and wound dressing.

The safety of hemostatic sealants in laparoscopic nephrectomy without hilar clamping was further substantiated in another case series of small peripheral tumors in which clamp-free tumor excision was achieved in 44% (20/44) of cases. In all successful cases, Floseal was the sole hemostatic agent aside from the harmonic scalpel used for dissection. Two patients had postoperative hemorrhage requiring intervention, and two cases required prolonged stent insertion for urinary extravasation. The authors, however, emphasized the reproducibility of this technique, as the outcomes were not significantly different among three experienced surgeons.¹⁹

Intraoperative blood pressure is an important factor that may influence postoperative outcome. Johnston and associates²⁰ compared the efficacy of different hemostatic agents in 70 porcine partial nephrectomies at an elevated systolic blood pressure. Most agents were found to be effective for small resections at a systolic blood pressure of 100 mm Hg. However, only the combination of sutured bolster and Floseal was consistently effective with an elevated systolic blood pressure of 200 mm Hg. Rouach and colleagues²¹ also conducted a similar but randomized study in hypertensive pigs to compare different hemostatic agents with conventional suturing in achieving hemostasis and collecting system repair. The authors found that thrombin/gelatin granules decreased warm ischemia time and controlled bleeding as effectively as sutures, but suturing was most effective in closing an opened collecting system.

Interestingly, the area of tissue necrosis around the wound was found to be smaller when no suturing was performed.²¹ A study comparing two nonrandomized cohorts of 32 patients with standard suture closure and 24 patients with closure using tissue sealants (BioGlue^® Surgical Adhesive; CryoLife, Kennesaw, GA and COSEAL Surgical Sealant; Baxter Healthcare) found a significantly better postoperative renal function using tissue sealant, with average renal function loss of 11.49%, compared with 20.36% when suturing was used (P = .02).²²

The popularity of hemostatic agents in laparoscopic partial nephrectomy is shown in recent multi-institutional surveys across the United States and Europe.^23,24 This showed routine use of a heterogeneous range of hemostatic agents, and overall transfusion (2.7%) and urinary leakage (1.9%) rates were low. More recently, Minervini and colleagues²⁵ describe how, in a multicenter study, they found that topical hemostatic agents were used in over 92% (n = 943) of open or laparoscopic nephron-sparing surgical cases.

Naitoh and associates²⁶ recently described a surgical glue derived from food additives which offers an advantage over biologic agents due to reduced infection risk, superior self-degradability, and lower cost. Using animal partial nephrectomy models, they showed a significant reduction in blood loss when compared with fibrin glue. Demonstration of the true advantage of hemostatic agents and sealants in partial nephrectomy, however, requires a randomized-controlled study to investigate postsurgical outcomes.

Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy (PCNL) differs from other surgical procedures of the kidney in that hemostatic adjuncts are not routinely applied to the kidney. Control of bleeding relies on tamponade achieved intraoperatively through insertion of serial dilators and postoperatively through a wide-bore nephrostomy tube.²⁷ Although risks of complications requiring intervention are small, patients require hospital admission for postoperative observation after removal of the nephrostomy tube.

A pioneering study conducted by Pfab and coworkers²⁸ explored the feasibility of using collagen-fibrin adhesive sealant to achieve hemostasis along the renal parenchymal tract, enabling the insertion of smaller nephrostomy tubes. The authors concluded that the fibrin glue was useful in reducing hemorrhage from the tract and obviated the use of large-bore nephrostomy tubes postoperatively.

More recent studies have assessed the safety of completely tubeless PCNLs using hemostatic agents that are applied inside the parenchymal tract. An observational study compared the outcomes between patients with primary closure of tract using fibrin glue (TISSEEL; n = 20) and a control group receiving the nephrostomy tube (n = 23).²⁹ Results showed no significant difference in postoperative hematocrit, pain, infection, or urinary leakage rates. The authors concluded that the use of fibrin glue is safe in tubeless PCNL. Another observational study compared outcomes between 17 TISSEEL-sealed tubeless PCNL cases and 25 PCNL cases with nephrostomy.³⁰ There was no difference in bleeding or urine leakage rates, and the patients who received tubeless PCNL had shorter hospital stays and required less postoperative analgesia. Nagele and colleagues³¹ reported the tract-sealing time of Floseal ranged from 2 to 5 minutes (n = 11). Another randomized control trial compared a group that underwent TachoSil sealed tubeless PCNL (n = 49) with a control group that received nephrostomy tubes (n = 47).³² It showed a significant reduction in the urinary leakage rate and hospital stay, with no difference in analgesic requirement or pain scores. A large retrospective case series of 107 patients who underwent tubeless PCNL with hemostatic agents also found it to be associated with reduced hospital stay, though the authors acknowledged the limitations of this study.³³

Outcomes in the above studies are mirrored in a systematic review and meta-analysis of randomized studies comparing tubeless PCNL versus PCNL with nephrostomy, with the exclusion of studies using sealants.³⁴ The study found the tubeless procedure to be associated with reduced hospital stay and urinary leakage rates, with no detectable difference in postoperative hematocrit or transfusion rates. Postoperative pain was reduced in 5 of 6 studies, although heterogeneity prevented a meta-analysis. These findings suggested that the lack of nephrostomy tube alone is sufficient to explain the improved outcomes post PCNL.

Further studies, however, explored the role of hemostatic agents in tubeless PCNL. A prospective, randomized controlled trial comparing TISSEEL application (n = 32) to no TISSEEL (n = 31) in tubeless PCNL revealed that the use of sealant reduced postoperative pain and urinary extravasation rates, although difference in hospital stay and blood loss did not reach significance.³⁵ Another randomized controlled trial of tubeless PCNL with or without the use of SPONGOSTAN^™ Absorbable Haemostatic Gelatin Sponge (Ethicon), a gelatin tissue hemostatic agent, showed that application of sealant resulted in less postoperative pain and lower urinary extravasation rates, and also shorter hospital stay, without a detectable difference in blood loss.³⁶

Not all studies share the same trend, however, as another randomized study of 20 patients undergoing PCNL with or without Surgicel^® absorbable hemostat (oxidized regenerated cellulose) (Ethicon) showed no significant difference in urinary extravasation rates.³⁷ A recent randomized trial of patients undergoing PCNL compared three methods: tubeless PCNL with Floseal (n = 10), tubeless PCNL with a fascial stitch technique (n = 10), or PCNL with a Cope loop nephrostomy tube (n = 11).³⁸ The only significant outcome was the 1-week postoperative pain evaluated by the visual analogue scale, which was highest in the Floseal group, although as the authors suggest, the numbers in each group were too small to draw any accurate conclusion.

One major concern remaining in the use of hemostatic agents and sealants in PCNL is the risk of urinary obstruction due to inadvertent sealing of the upper tracts. The safety of these agents in relation to the collecting system can be obtained from the experiments using different sealants in the porcine urinary collecting system. Hemostatic agents, when injected into the collecting system or ureter, caused significant obstruction, which did not resolve over a period of 5 days.³⁹ The authors recommended the use of an occlusion balloon catheter to prevent spillage of such agents into the collecting system when used for tract sealing. Ways to maintain the patency of the upper urinary tract include the use of an occlusion balloon during sealant injection,⁴⁰ or insertion of an antegrade stent,³¹ although the problem of sealant colic does not appear as a reported complication in any published trial.

Pyeloplasty

Although tissue sealants may be useful during pyeloplasty for pelviureteric anastomosis, few studies have addressed this potential in the clinical setting. One study investigated the preclinical efficacy of tissue glues in a porcine pyeloplasty model, comparing three different methods of tissue sealing.⁴¹ Fibrin glue was found to be superior to gelatin/resorcinol/formaldehyde glue and laser tissue welding when leak pressures and operating times were evaluated, and even withstood higher leak pressures than the conventional suturing techniques. The authors subsequently applied the technique in nine patients undergoing retroperitoneal laparoscopic dismembered pyeloplasty.⁴² Although stay sutures were used to oppose the urothelium and therefore the procedure was not totally suture-free, results showed shorter operative time and postoperative hospital stay, and less analgesia requirement than historical sutured control subjects, and showed satisfactory upper tract drainage as assessed by diuretic renography after 3 months. The efficacy of fibrin glue was further investigated in a larger porcine study comparing fibrin glued, laser-welded, or sutured anastomosis in pyeloplasty.⁴³ Their findings, however, did not support the previous benefits of glued anastomosis, showing urinoma formation in 4, and ureteric obstruction in 2 of 7 animals, and overall showed no benefit over sutured pyeloplasty. Borges and associates⁴⁴ describe the use of a fibrin sealant in a coagulum pyelolithotomy, which can be used in the classic or robotic laparoscopic transperitoneal dismembered ureteropyeloplasty. They noted that the procedure results in reduced incidence of incomplete stone removal.⁴⁴ Despite some encouraging results in a small case series, no subsequent studies have investigated the efficacy of tissue sealants in pyeloplasty in the clinical setting.

Renal Trauma

The use of hemostatic agents in renal trauma may improve outcomes by minimizing blood loss, preventing nephrectomy, or replacing coagulating hemostatic devices such as diathermy, which can damage surrounding parenchymal tissue. A porcine randomized study of artificially inflicted grade 4 renal injuries showed intraoperative repair using gelatin matrix (Floseal) to be superior over sutured gelatin sponge bolsters in reducing intraoperative blood loss and time to achieve hemostasis.⁴⁵ A similar randomized porcine renal injury study comparing four different methods of repair showed repair by fibrin sealants to be superior over capsular suturing in reducing blood loss and time to hemostasis.⁴⁶ No clinical studies have examined the role of hemostatic agents in renal trauma, mainly due to the emergency nature of these cases.

Other Applications of Tissue Sealants in Urology

Diverse use of tissue glues has been reported in simple retropubic prostatectomy,⁴⁷ radical retropubic prostatectomy,⁴⁸ surgery for Fournier gangrene,⁴⁹ and for closure of urinary fistulas of different etiologies.⁵⁰ Promising initial experience has been reported in patients with complex urethral stricture disease who underwent penile urethral reconstruction.⁵¹ The fibrin sealant group (n = 18) enabled earlier catheter removal and wound healing compared with historic control subjects (n = 25). Michael and colleagues⁵² described the successful treatment of unremitting gross hematuria following laparoscopic radical nephrectomy, with instillation of a fibrin sealant. In a single case review, Omar and associates⁵³ reported the successful endoscopic delivery of cyanoacrylate and lipidol sealant in the treatment of urethrocutaneous fistula, with spontaneous healing of the opening on the skin a week later. Finally, in another single case study, Chao and coworkers⁵⁴ described the successful use of TISSEEL fibrin sealant for the management of unremitting gross hematuria due to renal arteriopelvic fistula following PCNL. The authors suggest that fibrin sealants may be used as an adjunct to renal angiography and embolization when the source of bleeding cannot be accurately identified using traditional imaging modalities.

Conclusions

Choosing the optimal method of hemostasis for each surgical technique may minimize perioperative blood loss, improve tissue viability, and prevent complications. Hemostatic agents and tissue sealants are one of many options to achieve effective hemostasis and tissue sealing in urologic surgery.

One major problem is the heterogeneity in the previous studies, using a variety of surgical techniques and hemostatic agents, which poses a challenge in performing a combined analysis. There is also a paucity of large well-designed randomized controlled studies in the field, without which firm conclusions cannot be drawn. Success stories, however, have been reported in a small case series, and for the majority of cases, it remains for this hypothesis to be examined in larger studies. Although no robust grade 1A evidence yet exists to support the routine use of hemostatic agents in any urologic surgery, the message is clear that this will be achieved sooner than later. 

References

1. Carless PA, Henry DA, Anthony DM. Fibrin sealant use for minimizing peri-operative allogeneic blood transfusion. Cochrane Database Syst Rev. 2003;(2):CD004171.
2. Spotnitz WD, Burks S. State-of-the-art review: hemostats, sealants, and adhesives II: update as well as how and when to use the components of the surgical toolbox. Clin Appl Thromb Hemost. 2010;16:497-514.
3. Jemal A, Bray F, Center MM. et al. Global cancer statistics. CA Cancer J Clin. 2011;61:69-90.
4. Novick AC. Renal hypothermia: in vivo and ex vivo. Urol Clin North Am. 1983;10:637-644.
5. Tyritzis SI, Zachariades M, Evangelou K, et al. Effects of prolonged warm and cold ischemia in a solitary kidney animal model after partial nephrectomy: an ultrastructural investigation. Ultrastruct Pathol. 2011;35:60-65.
6. Hoznek A, Salomon L, Antiphon P, et al. Partial nephrectomy with retroperitoneal laparoscopy. J Urol. 1999;162:1922-1926.
7. Richter F, Schnorr D, Deger S, et al. Improvement of hemostasis in open and laparoscopically performed partial nephrectomy using a gelatin matrix-thrombin tissue sealant (FloSeal). Urology. 2003;61:73-77.
8. Bak, JB, Singh A, Shekarriz B. Use of gelatin matrix thrombin tissue sealant as an effective hemostatic agent during laparoscopic partial nephrectomy. J Urol. 2004;171(2 Pt 1):780-782.
9. Gill IS, Ramani AP, Spaliviero M, et al. Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant. Urology. 2005;65:463-466.
10. Ploussard G, Haddad R, Loutochin O, et al. A combination of hemostatic agents may safely replace deep medullary suture during laparoscopic partial nephrectomy in a pig model. J Urol. 2015;193:318-324.
11. Park EL, Ulreich JB, Scott KM, et al. Evaluation of polyethylene glycol based hydrogel for tissue sealing after laparoscopic partial nephrectomy in a porcine model. J Urol. 2004;172(6 Pt 1):2446-2550.
12. Pruthi, RS, Chun J, Richman M. The use of a fibrin tissue sealant during laparoscopic partial nephrectomy. BJU Int. 2004;93:813-817.
13. Johnston WK 3rd, Montgomery JS, Seifman BD, et al. Fibrin glue v sutured bolster: lessons learned during 100 laparoscopic partial nephrectomies. J Urol. 2005;174:47-52.
14. Cohen J, Jayram G, Mullins JK, et al. Do fibrin sealants impact negative outcomes after robot-assisted partial nephrectomy? J Endourol. 2013;27:1236-1239.
15. Arnoux V, Descotes JL, Fiard G, et al. The use of haemostatic agent: impact on perioperative outcomes of partial nephrectomy [Article in French]. Prog Urol. 2013;23:317-322.
16. Triaca V, Zagha RM, Libertino JA. Does thrombin sealant allow nephron-sparing surgery with no renal artery occlusion? A description of technique and initial results. BJU Int. 2005;95:1273-1275.
17. Finley DS, Lee DI, Eichel L, et al. Fibrin glue-oxidized cellulose sandwich for laparoscopic wedge resection of small renal lesions. J Urol. 2005;173:1477-1481.
18. Mele E, Ceccanti S, Schiavetti A, et al. The use of Tachosil as hemostatic sealant in nephron sparing surgery for Wilms tumor: preliminary observations. J Pediatr Surg. 2013;48:689-694.
19. Wille AH, Tüllmann M, Roigas J, et al. Laparoscopic partial nephrectomy in renal cell cancer- results and reproducibility by different surgeons in a high volume laparoscopic center. Eur Urol. 2006;49: 337-342.
20. Johnston WK 3rd, Kelel KM, Hollenbeck BK, et al. Acute integrity of closure for partial nephrectomy: comparison of 7 agents in a hypertensive porcine model. J Urol. 2006;175:2307-2311.
21. Rouach Y, Delongchamps NB, Patey N, et al. Suture or hemostatic agent during laparoscopic partial nephrectomy? A randomized study using a hypertensive porcine model. Urology. 2009;73:172-177.
22. Hidas G, Lupinsky L, Kastin A, et al. Functional significance of using tissue adhesive substance in nephron-sparing surgery: assessment by quantitative SPECT of 99m Tc-Dimercaptosuccinic acid scintigraphy. Eur Urol. 2007;52:785-789.
23. Breda A, Stepanian SV, Lam JS, et al. Use of haemostatic agents and glues during laparoscopic partial nephrectomy: a multi-institutional survey from the United States and Europe of 1347 cases. Eur Urol. 2007;52:798-803.
24. Celia A, Zeccolini G, Guazzoni G, et al. Laparoscopic nephron sparing surgery: a multi-institutional European survey of 592 cases. Arch Ital Urol Androl. 2008;80:85-91.
25. Minervini A, Siena G, Carini M. Hemostatics for nephron-sparing surgery. Expert Rev Med Devices. 2013;10:153-155.
26. Naitoh Y, Kawauchi A, Kamoi K, et al. Hemostatic effect of new surgical glue in animal partial nephrectomy models. Urology. 2013;81:1095-1100.
27. Srinivasan AK, Herati A, Okeke Z, Smith AD. Renal drainage after percutaneous nephrolithotomy. J Endourol. 2009;23:1743-1749.
28. Pfab R, Ascherl R, Blümel G, Hartung R. Local hemostasis of nephrostomy tract with fibrin adhesive sealing in percutaneous nephrolithotomy. Eur Urol. 1987;13:118-121.
29. Mikhail AA, Kaptein JS, Bellman GC. Use of fibrin glue in percutaneous nephrolithotomy. Urology. 2003;61:910-914.
30. Shah HN, Kausik V, Hedge S, et al. Initial experience with hemostatic fibrin glue as adjuvant during tubeless percutaneous nephrolithotomy. J Endourol. 2006;20:194-198.
31. Nagele U, Schilling D, Anastasiadis AG, et al. Closing the tract of mini-percutaneous nephrolithotomy with gelatin matrix hemostatic sealant can replace nephrostomy tube placement. Urology. 2006;68: 489-493.
32. Cormio L, Perrone A, Di Fino G, et al. TachoSil^® sealed tubeless percutaneous nephrolithotomy to reduce urine leakage and bleeding: outcome of a randomized controlled trial. J Urol. 2012;188: 145-150.
33. Gudeman SR, Stroup SP, Durbin JM, et al. Percutaneous stone surgery using a tubeless technique with fibrin sealant: report of our first 107 cases. BJU Int. 2012;110(11 Pt C):E1048-E1052.
34. Borges CF, Fregonesi A, Silva DC, Sasse AD. Systematic review and meta-analysis of nephrostomy placement versus tubeless percutaneous nephrolithotomy. J Endourol. 2010;24:1739-1746.
35. Shah HN, Hegde S, Shah JN, et al. A prospective, randomized trial evaluating the safety and efficacy of fibrin sealant in tubeless percutaneous nephrolithotomy. J Urol. 2006;176(6 Pt 1):2488-2492.
36. Singh I, Saran RN, Jain M. Does sealing of the tract with absorbable gelatin (Spongostan) facilitate tubeless PCNL? A prospective study. J Endourol. 2008;22:2485-2493.
37. Aghamir SM, Khazaeli MH, Meisami A. Use of Surgicel for sealing nephrostomy tract after totally tubeless percutaneous nephrolithotomy. J Endourol. 2006;20:293-295.
38. Li R, Louie MK, Lee HJ, et al. Prospective randomized trial of three different methods of nephrostomy tract closure after percutaneous nephrolithotripsy. BJU Int. 2011;107:1660-1665.
39. Kim IY, Eichel L, Edwards R, et al. Effects of commonly used hemostatic agents on the porcine collecting system. J Endourol. 2007;21:652-654.
40. Lee DI, Uribe C, Eichel L, et al. Sealing percutaneous nephrolithotomy tracts with gelatin matrix hemostatic sealant: initial clinical use. J Urol. 2004;171 (2 Pt 1):575-578.
41. Eden CG, Coptcoat MJ. Assessment of alternative tissue approximation techniques for laparoscopy. Br J Urol. 1996;78:234-242.
42. Eden CG, Sultana SR, Murray KH, Carruthers RK. Extraperitoneal laparoscopic dismembered fibrin-glued pyeloplasty: medium-term results. Br J Urol. 1997;80:382-389.
43. Barrieras D, Reddy PP, McLorie GA, et al. Lessons learned from laser tissue soldering and fibrin glue pyeloplasty in an in vivo porcine model. J Urol. 2000;164(3 Pt 2):1106-1110.
44. Borges R, Azinhais P, Retroz E, et al. Coagulum pyelolithotomy “revisited” by laparoscopy: technique modification. Urology. 2012;6:1412. e5-1412.e8.
45. Hick EJ, Morey AF, Harris RA, Morris MS. Gelatin matrix treatment of complex renal injuries in a porcine model. J Urol. 2005;173:1801-1804.
46. Griffith BC, Morey AF, Rozanski TA, et al. Central renal stab wounds: treatment with augmented fibrin sealant in a porcine model. J Urol. 2004;171: 445-447.
47. Morey AF, McDonough RC 3rd, Kizer WS, Foley JP. Drain-free simple retropubic prostatectomy with fibrin sealant. J Urol. 2002;168:627-629.
48. Diner, EK, Patel SV, Kwart AM. Does fibrin sealant decrease immediate urinary leakage following radical retropubic prostatectomy? J Urol. 2005;173: 1147-1149.
49. DeCastro BJ, Morey AF. Fibrin sealant for the reconstruction of Fournier’s gangrene sequelae. J Urol. 2002;167:1774-1776.
50. Muto G, D’Urso L, Castelli E, et al. Cyanoacrylic glue: a minimally invasive nonsurgical first line approach for the treatment of some urinary fistulas. J Urol. 2005;174:2239-2243.
51. Hick EJ, Morey AF. Initial experience with fibrin sealant in pendulous urethral reconstruction. Is early catheter removal possible? J Urol. 2004;171:1547-1549.
52. Michael A, Sheridan-Jonah A, Kovac JR, et al. A novel endoscopic treatment for ureteric remnant hemorrhage post laparoscopic radical nephrectomy. Scand J Urol. 2013;47:244-247.
53. Omar M, Abdulwahab-Ahmed A, El Mahdey Ael D. Endoscopic management of a chronic ureterocutaneous fistula using cyanoacrylic glue. Cent European J Urol. 2014;67:430-432.
54. Chao D, Abdulla AN, Kim S, et al. A novel endoscopic treatment for renal arteriopelvic fistula post-percutaneous nephrolithotomy (PCNL). Int Braz J Urol. 2014;40:568-573.