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Barbed Sutures — Dedicated Article

Barbed sutures have reshaped robotic GU reconstruction. The same self-anchoring property that eliminates knot-tying is also the mechanism that makes them dangerous in small-caliber tubular anastomoses — the literature is sharply divided between VUA (success story), renorrhaphy (success story), and pyeloplasty (highly contested, with series reporting 83% and 40% failure rates). This article is the dedicated deep-dive: product biomechanics, indication-by-indication evidence, the upper-tract controversy, technique to avoid overtightening, and a clinical decision framework. For the broader suture-materials framework see Sutures.

Products Available to the Urologist​

ProductManufacturerDirectionMaterialAbsorptionAnchorKey property
V-Loc 90Medtronic (Covidien)UnidirectionalPolyglyconate (PGA/PCL copolymer)~90 dPreformed loop at tailFaster absorption; lower long-term strength
V-Loc 180Medtronic (Covidien)UnidirectionalPolyglyconate~180 dPreformed loop at tailLonger strength retention; most-studied in VUA[1][7]
Quill SRSAngiotech / Surgical SpecialtiesBidirectionalPolydioxanone (PDO)~180 dBarbs reverse at midpoint (no loop)Higher stiffness (172.8 N/mm²); associated with 83% pyeloplasty failure in one series[2][3]
StratafixEthicon (J&J)Uni- or bidirectionalPolyglactin 910 or PDO90–180 dWelded loop or bidirectional barbsComparable holding strength to V-Loc[4]
MONOFIXSamyangUnidirectionalAbsorbable monofilament~180 dTriangular stopper (no loop)Equivalent tensile strength and histology to V-Loc / Stratafix in porcine model[5]

V-Loc 180 vs Quill PDO (Gingras 2012 porcine): V-Loc 180 had significantly stronger wound holding at days 3 and 7 (p = 0.002 and p = 0.001) — the critical early healing window.[7] This biomechanical differential may partially explain the divergent upper-tract outcomes.

Biomechanics — Three Differences That Drive Technique​

Barbed sutures differ from conventional in three clinically important ways:[6]

PropertyBarbed (Quill 4-0)Conventional (PDS 4-0)Clinical implication
Breaking strength11.57 N18.41 N~ 37% weaker — upsize one gauge (3-0 barbed ≈ 4-0 PDS strength)
Stiffness172.8 N/mm²128.9 N/mm²~ 34% stiffer — less compliant; maintains approximation but may cut delicate tissue
Suture-line shortening26.6%40.7%Less purse-stringing — advantageous for tubular closure, but still matters in small-caliber anastomoses

Holding strength with Hem-o-lok / Lapra-Ty clips for renorrhaphy (Paka 2017):[8]

  • 2-0 V-Loc: 15.9 N (superior)
  • 2-0 Stratafix: 13.8 N
  • 2-0 Vicryl: 5.7 N (significantly worse; p < 0.05)

Stratafix renorrhaphy — the Gupta 2016 critical finding​

Stratafix PGA-PCL + Lapra-Ty clips at 3 weeks

Gupta 2016 functional-duration study of renorrhaphy closure systems at 4 N tension:[30]

  • Stratafix PGA-PCL with Lapra-Ty/Hem-o-lok: 82% failure at 3 weeks
  • V-Loc 180 with Lapra-Ty/Hem-o-lok: 24% failure at 3 weeks (p < 0.0001)

The combination of Stratafix's faster-absorbing PGA-PCL material and the Lapra-Ty clip backstop produces unreliable long-term tissue holding — the Lapra-Ty absorbs on a similar timeline to the suture, and the bidirectional barb architecture does not compensate for the rapid strength loss.

Practical implication: prefer V-Loc 180 over Stratafix PGA-PCL for renorrhaphy with sliding-clip technique. If Stratafix must be used, pair it with a knot or Hem-o-lok (not Lapra-Ty) and use lower closure tension.[30]

Stratafix architecture — PDO vs PGA-PCL​

Stratafix ships in two bidirectional barbed configurations that matter for application:

FormulationMaterialAbsorptionPairs conceptually with
Stratafix Spiral PDOPolydioxanone~180 daysQuill SRS (same PDO bidirectional architecture — caution in upper tract, see Liatsikos)
Stratafix Spiral PGA-PCLPolyglycolic acid + polycaprolactone~90 daysFaster-absorbing variant — the renorrhaphy-with-Lapra-Ty liability in Gupta 2016[30]

For VUA, a prospective comparison of bidirectional double-armed barbed suture vs Monocryl with posterior rhabdosphincter reconstruction (Cakici & Canda 2018, n = 100) showed significantly shorter VUA time (16.8 vs 21.2 min) and significantly higher immediate continence at catheter removal: 76% vs 40% (p = 0.002) in the bidirectional-barbed arm.[31] A single non-randomized study, but the mechanistic reading (bidirectional barbs distribute tension more evenly than unidirectional anchor-and-loop) is plausible.

1. The Upper-Tract Controversy — Pyeloplasty​

This is the most contested application of barbed suture in urology. The evidence is sharply divided — series have reported both excellent outcomes and catastrophic failure rates.

The alarm signals​

SourcePopulationSutureFinding
Liatsikos 2013 multi-center6 adults, laparoscopic pyeloplastyQuill SRS5 / 6 (83%) recurrent stricture requiring further intervention. Authors: "barbed suture should not be recommended for upper urinary tract reconstruction" until the cause is understood.[2]
Radford 2018 pediatric10 children, robotic pyeloplastyV-Loc for pelvic closure4 / 10 (40%) worsening hydronephrosis requiring restenting (n=1) or redo-pyeloplasty (n=3). All 4 were asymptomatic — failures detected only on imaging. Histology: "plaque-like" inflammatory reaction at the suture line. Vicryl group: 1 / 15 (6.7%) redo[3]

The counter-evidence​

SourcePopulationSutureFinding
Sorokin 201613 adults, robotic pyeloplasty4-0 V-Loc92% success — equivalent to 4-0 non-barbed (10 / 11 unobstructed on postoperative DRG in both arms)[9]
Anand 2022 meta5 studies—OR time shorter with barbed (p = 0.01); redo-pyeloplasty trend higher but not significant — RR 6.00 (95% CI 0.78–46.14; p = 0.09); no difference in total complications; significant heterogeneity[10]

Interpretation. The wide CI on the redo-pyeloplasty point estimate (0.78–46.14) means the pooled data neither confirm nor refute a 6-fold risk. Product matters — Quill SRS was involved in the 83% failure series; V-Loc has produced mixed results. Whether this reflects the bidirectional-vs-unidirectional mechanism, the PDO-vs-polyglyconate material, or the learning curve is not resolved.

Why upper-tract failure may occur​

MechanismWhy it matters in UPJ / ureter
Suture-line shortening (26.6%)Even modest shortening critically narrows a ~ 1-cm-diameter UPJ anastomosis
Tissue cutting by barbsMicro-lacerations in delicate tissue; amplified by 34% higher stiffness → fibrosis → stricture
Plaque-like inflammatory reactionSeen on Radford histology; not a feature of conventional suture[3]
Stone formation on exposed barbsYalcin 2018 rabbit bladder: 4 / 7 on V-Loc vs 1 / 7 on Vicryl at 6 wk (p = 0.039)[11]
Suture migration3 / 7 on V-Loc at 6 wk (p = 0.050)[11]
Irreversible overtighteningBarbs prevent loosening — once too tight, cannot be corrected → ischemic stricture
Learning curveLiatsikos noted failures occurred "at least in the initial cases of each surgeon"[2]

The fibrosis paradox​

Barbed suture produces less inflammation and fibrosis histologically than Vicryl or Monocryl (p = 0.010 at 3 wk; p = 0.002 at 6 wk in rabbit bladder).[11] Yet clinical outcomes in the upper tract suggest more fibrotic stricture. The resolution is probably that mechanical effects (shortening, cutting, migration) matter more than the inflammatory response in small-caliber tubular structures.

2. VUA During Robotic Prostatectomy — The Success Story​

In contrast to the upper tract, VUA is supported by consistent, robust evidence. Three RCTs and two meta-analyses:

StudyDesignnFinding
Zorn 2012RCT70Barbed: faster (13.1 vs 20.8 min; p < 0.01); less tension readjustment (6% vs 24%; p = 0.03); cheaper ($48 vs $70); equivalent continence[12]
Williams 2010RCT81Barbed: more cystogram leak initially (20% vs 2.8%; p = 0.019). After technique modification to avoid overtightening, leak dropped to 6.3%[13]
Sammon 2011RCT64Barbed: 26% reduction in total anastomosis time; equivalent 6-wk functional outcomes[14]
Li 2015 meta9 studies786↓ anastomosis time (WMD −3.98 min), ↓ operative time (WMD −10.06 min); no difference in leak, continence, catheterization[15]
Bai 2015 meta10 studies747↓ operative time (MD −10.54 min); equivalent complications[16]

The overtightening problem — and its solution​

The Williams 2010 RCT is the most instructive study on barbed-suture technique. Initial cystogram extravasation was 20% vs 2.8% (p = 0.019). After recognizing that the self-anchoring mechanism was causing inadvertent overtightening, the team modified technique — deliberately leaving slight laxity in each pass — and the leak rate dropped to 6.3%.[13]

Technique to avoid overtightening
  • Do not pull the suture taut after each bite — let the barbs maintain gentle approximation
  • Leave a small gap between tissue edges that will close naturally as barbs engage
  • Parachute — place several bites before approximating the tissues
  • Avoid excessive tension when cinching the final suture

Run the line loose. If it looks snug, it is already too tight. The barbs prevent any self-correction.

The tissue-damage signal​

Haga 2018 prospective cohort (n = 88, MRI at 9 mo post-RARP):[17]

  • Grade 2/3 urethral damage: adjusted RR 2.98 (barbed vs non-barbed)
  • Grade 2/3 periurethral damage: adjusted RR 3.85
  • Worse QoL index at 1, 9, 12 mo (p = 0.023, 0.025, 0.011)
  • More urinary incontinence at 3 mo (p = 0.041)

Subclinical tissue injury compensated for in most patients — but may contribute to worse outcomes in a subset. Long-term continence is equivalent in the big meta-analyses, but the MRI signal is worth knowing.

3. Renorrhaphy — The Other Success Story​

Bertolo 2019 systematic review (67 studies qualitative, 19 quantitative):[18]

  • Running suture (including barbed): shorter OR time, shorter WIT, lower complication and transfusion rates vs interrupted
  • Barbed specifically: lower OR time, lower WIT, less blood loss vs non-barbed
  • Single-layer vs double-layer: single-layer shorter OR and WIT
StudyDesignnWIT (barbed vs conventional)Finding
Olweny 2012Retrospective7826.4 vs 32.8 min (p = 0.001)Bleeding requiring intervention: 3.4% vs 18.4% (p = 0.06)[19]
Erdem 2013Matched-pair6619 vs 28 min (p = 0.037)Inner-layer renorrhaphy time 350 vs 505 sec (p = 0.004)[20]
Liu 2015PADUA-matched8220.7 vs 27.5 min (p < 0.05)GFR reduction 20.8% vs 29% (p < 0.05) — better renal preservation[21]
Hu 2025RCT5011.76 vs 14.56 min (p < 0.05)Better 3-mo GFR preservation; no conversions[22]
Di Franco 2025Prospective5522.5 min (mean)Novel R-BEP technique with elongated PTFE pledgets; 100% hemostasis; 69% RENAL ≥ 7[23]

Why renorrhaphy works where pyeloplasty fails: the renal parenchyma is thick, compressible tissue that tolerates the mechanical effects of barbs far better than the thin-walled, small-caliber UPJ. Renorrhaphy is not a tubular anastomosis with luminal narrowing concerns — it is a parenchymal compression closure where self-anchoring is purely advantageous.

4. Bladder Closure — Mixed Evidence​

Advantages:

  • Gözen 2012 pig bladder model: running barbed had highest leak pressure (419.7 mL) vs running Vicryl (353.8 mL) vs interrupted Vicryl (276.2 mL) (p < 0.05)[24]
  • Yalcin 2018 — less inflammation and fibrosis histologically than Vicryl or Monocryl[11]

Concerns (rabbit bladder model, Yalcin 2018):[11]

  • Stone formation: 4 / 7 on V-Loc vs 1 / 7 on Vicryl at 6 wk (p = 0.039)
  • Suture migration: 3 / 7 on V-Loc at 6 wk (p = 0.050)

Not systematically studied in humans for bladder closure, but the animal signal is legitimate enough to use barbed suture cautiously in any location with prolonged urine contact.

5. Intracorporeal Urinary Diversion — Limited Data​

Weld 2006 (earliest preclinical porcine evaluation) tested a prototype self-anchoring suture for pyeloplasty and bladder-neck anastomosis:[25]

  • In-vitro failure force: no difference (13.2 ± 2.6 N vs 14.1 ± 3.1 N; p = 0.22)
  • OR time: no difference
  • Radiographic integrity: no extravasation at 1 wk in any animal
  • Early fibrosis signal

    Histopathology revealed significantly more fibrotic reaction with barbed-suture bladder-neck anastomosis (p < 0.05)[25]

6. Small Bowel Obstruction — A Unique Complication​

Clapp 2020 review of literature + MAUDE database identified 18 published cases and 14 MAUDE reports of SBO secondary to barbed suture:[26]

FeatureData
MechanismExposed barbs on suture tail or cut end snag adjacent bowel → internal hernia or volvulus
Mean time to presentation26.3 days postop (range 1–196 d)
PresentationAbdominal pain 88.9%; vomiting 33.3%; distension 27.8%
CT findingsMesenteric volvulus 5 cases; strangulation 2
ManagementAll required operative exploration — laparoscopy successful in most

Prevention (particularly relevant in cystectomy + diversion, where bowel is in close proximity to the suture line):

  • Bury the suture tail beneath tissue
  • Cut the suture flush — no exposed barb ends in the peritoneum
  • Prefer suture designs with preformed loop / triangular stopper that eliminate exposed barb tails

7. Cross-Field Safety Meta-Analysis​

Lin 2016 meta (17 RCTs, n = 1,992, across all surgical specialties):[27]

  • Suture time ↓ (SMD −0.95; p = 0.0001)
  • Operative time ↓ (SMD −0.28; p = 0.003)
  • Blood loss — no difference
  • Postoperative complications ↑ (OR 1.43; 95% CI 1.05–1.96; p = 0.03)

Su 2023 cosmetic-surgery meta (14 studies, n = 2,259):[28]

  • Wound dehiscence ↑ (OR 1.60; p = 0.02)
  • Suture extrusion ↑ (OR 3.97; p = 0.0001) — particularly with unidirectional barbed
  • Infection, delayed healing, hematoma — no difference

The overall safety profile is favorable for running GU-tract closures but carries real risks outside the carefully validated indications.

Clinical Decision Framework — Where to Use, Where to Avoid​

ApplicationRecommendationEvidenceRationale
VUA (robotic prostatectomy)✅ Recommended — standard of careHigh (3 RCTs + 2 metas)Consistent time savings; equivalent continence/stricture; avoid overtightening[12][15]
Renorrhaphy (partial nephrectomy)✅ RecommendedModerate (SR + comparative)WIT ↓ 6–9 min; better renal-function preservation[18][21]
Posterior (Rocco) reconstruction✅ RecommendedModerateSelf-anchoring eliminates need for assistant tension
Pyeloplasty (adults)⚠️ Use with caution — V-Loc over Quill; experienced surgeons onlyLow–moderate, conflictingMeta: shorter OR but 6× higher redo trend (p = 0.09); Quill SRS 83% failure series[2][10]
Pyeloplasty (children)❌ Avoid for pelvic closureSingle series40% worsening hydronephrosis — asymptomatic, imaging-detected; plaque-like inflammatory reaction[3]
Ureteroileal anastomosis❌ AvoidExpert opinionSmall-caliber tubular; stricture risk from shortening/cutting; stone risk
Ureteral repair / reimplant❌ AvoidExpert + preclinicalDelicate tissue; cutting/migration risk; ACS guidelines specify interrupted absorbable[29]
Bladder closure⚠️ Use with cautionAnimal data onlyHigher leak pressure but significant stone-formation and migration signal[11]
Bowel anastomosis (ileoileostomy)✅ AcceptableModerateStandard use; bury suture tails to prevent SBO[26]

Practical Pearls​

  • Use it for VUA and renorrhaphy. These are the consistently supported indications — time-saving, equivalent-to-better functional outcomes, manageable tissue trade-off.[12][15][18]
  • Avoid it in the small-caliber tubular urinary tract — ureter, UPJ, ureteroileal anastomosis. The 26.6% suture-line-shortening and stiffer body cut or narrow delicate lumens. Radford's 40% pediatric-pyeloplasty failure rate with V-Loc is the defining cautionary data.[3]
  • If using barbed in pyeloplasty, pick V-Loc over Quill. The Liatsikos 83% failure series used Quill SRS (bidirectional, PDO); V-Loc has produced a more mixed signal. Gingras' biomechanical data show V-Loc 180 has significantly stronger early wound-holding than Quill PDO.[2][7]
  • The overtightening pitfall is the single most common error. Run the line loose. Williams dropped VUA leak rate from 20% to 6.3% with a deliberate-laxity modification.[13]
  • Upsize one gauge. 4-0 barbed is ~ 37% weaker than 4-0 PDS; 3-0 barbed approximates 4-0 PDS strength.[6]
  • Stones on barbs are a real signal. Rabbit model showed 4 / 7 on V-Loc vs 1 / 7 on Vicryl at 6 wk. Take this seriously in any closure with prolonged urine contact.[11]
  • Bury tails or use loop/stopper designs — Clapp 2020 catalogued 18 + 14 MAUDE cases of barbed-suture-induced SBO, mean presentation day 26. Particular concern after cystectomy with diversion.[26]
  • Subclinical urethral tissue damage (Haga MRI) is worth knowing even if it does not show up in meta-analysis continence data.[17]

References​

1. Medtronic. V-Loc wound closure device — product information. Accessed 2026.

2. Liatsikos E, Knoll T, Kyriazis I, et al. "Unfavorable outcomes of laparoscopic pyeloplasty using barbed sutures: a multi-center experience." World J Urol. 2013;31(6):1441–1444. doi:10.1007/s00345-012-1019-6

3. Radford A, Turner A, Ashraf J, Subramaniam R. "Robotic pyeloplasty in children: a 'barbed' shortcut." J Laparoendosc Adv Surg Tech A. 2018;28(4):486–489. doi:10.1089/lap.2017.0494

4. Ethicon. Stratafix — product information. Accessed 2026.

5. Kim J, Eom HJ, Shin H, et al. "In vivo comparison of MONOFIX, a novel barbed suture with a triangular stopper, with pre-existing products in a porcine model." J Minim Invasive Gynecol. 2020;27(2):473–481. doi:10.1016/j.jmig.2019.04.005

6. Amend B, Müller 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

7. Gingras K, Zaruby J, Maul D. "Comparison of V-Loc 180 wound closure device and Quill PDO knotless tissue-closure device for intradermal closure in a porcine in vivo model: evaluation of biomechanical wound strength." J Biomed Mater Res B Appl Biomater. 2012;100(4):1053–1058. doi:10.1002/jbm.b.32670

8. Paka B, Bossemeyer R, Tourojman M, Gupta R, Lane BR. "Holding strength of a Hem-o-lok/Lapra-Ty clip combination on sutures used during partial nephrectomy." Urology. 2017;107:138–143. doi:10.1016/j.urology.2017.06.024

9. 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

10. Anand S, Jukić M, Krishnan N, Pogorelić 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

11. Yalcin S, Kibar Y, Tokas T, et al. "In vivo comparison of 'V-Loc 90 wound closure device' with 'Vicryl' and 'Monocryl' in regard to tissue reaction in a rabbit bladder model." Urology. 2018;116:231.e1–231.e5. doi:10.1016/j.urology.2018.02.027

12. 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

13. Williams SB, Alemozaffar M, Lei Y, et al. "Randomized controlled trial of barbed polyglyconate versus polyglactin suture for robot-assisted laparoscopic prostatectomy anastomosis: technique and outcomes." Eur Urol. 2010;58(6):875–881. doi:10.1016/j.eururo.2010.07.021

14. Sammon J, Kim TK, Trinh QD, et al. "Anastomosis during robot-assisted radical prostatectomy: randomized controlled trial comparing barbed and standard monofilament suture." Urology. 2011;78(3):572–579. doi:10.1016/j.urology.2011.03.069

15. 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

16. Bai Y, Pu C, Yuan H, et al. "Assessing the impact of barbed suture on vesicourethral anastomosis during minimally invasive radical prostatectomy: a systematic review and meta-analysis." Urology. 2015;85(6):1368–1375. doi:10.1016/j.urology.2015.02.033

17. Haga N, Kurita N, Yanagida T, et al. "Effects of barbed suture during robot-assisted radical prostatectomy on postoperative tissue damage and longitudinal changes in lower urinary tract outcome." Surg Endosc. 2018;32(1):145–153. doi:10.1007/s00464-017-5649-z

18. Bertolo R, Campi R, Klatte T, et al. "Suture techniques during laparoscopic and robot-assisted partial nephrectomy: a systematic review and quantitative synthesis of peri-operative outcomes." BJU Int. 2019;123(6):923–946. doi:10.1111/bju.14537

19. Olweny EO, Park SK, Seideman CA, Best SL, Cadeddu JA. "Self-retaining barbed suture for parenchymal repair during laparoscopic partial nephrectomy; initial clinical experience." BJU Int. 2012;109(6):906–909. doi:10.1111/j.1464-410X.2011.10547.x

20. Erdem S, Tefik T, Mammadov A, et al. "The use of self-retaining barbed suture for inner layer renorrhaphy significantly reduces warm ischemia time in laparoscopic partial nephrectomy: outcomes of a matched-pair analysis." J Endourol. 2013;27(4):452–458. doi:10.1089/end.2012.0574

21. Liu W, Chen M, Zu X, et al. "The use of self-retaining barbed suture preserves superior renal function during laparoscopic partial nephrectomy: a PADUA score matched comparison." J Laparoendosc Adv Surg Tech A. 2015;25(2):130–134. doi:10.1089/lap.2014.0302

22. Hu X, Miao J, Xie K, et al. "Efficacy and safety of self-retaining double-needle barb suture in transabdominal path robot-assisted laparoscopic partial nephrectomy for T1 renal cancer." BMC Cancer. 2025;25(1):429. doi:10.1186/s12885-025-13825-6

23. Di Franco G, Furbetta N, Guadagni S, et al. "A new renorrhaphy technique using barbed sutures and elongated pledgets for robotic partial nephrectomy." Ann Surg Oncol. 2025. doi:10.1245/s10434-025-18090-2

24. Gözen AS, Arslan M, Schulze M, Rassweiler J. "Comparison of laparoscopic closure of the bladder with barbed polyglyconate versus polyglactin suture material in the pig bladder model: an experimental in vitro study." J Endourol. 2012;26(6):732–736. doi:10.1089/end.2011.0194

25. Weld KJ, Ames CD, Hruby G, Humphrey PA, Landman J. "Evaluation of a novel knotless self-anchoring suture material for urinary tract reconstruction." Urology. 2006;67(6):1133–1137. doi:10.1016/j.urology.2005.12.022

26. 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

27. 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 randomized controlled trials." Sci Rep. 2016;6:23425. doi:10.1038/srep23425

28. 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

29. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.

30. Gupta R, Sunny N, Noyes SL, et al. "Functional duration of closure systems used in partial nephrectomy." J Urol. 2016;196(5):1560–1565. doi:10.1016/j.juro.2016.06.093

31. Cakici OU, Canda AE. "Bidirectional barbed only vs poliglecaprone suture with rhabdosphincter reconstruction for urethrovesical anastomosis during robotic radical prostatectomy: does it make any difference?" J Endourol. 2018;32(10):944–949. doi:10.1089/end.2018.0386