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Sutures

Sutures are the materials used to approximate and support tissue in urologic reconstruction. Suture selection is rarely taught systematically and is mostly learned by imitation. A substitution urethroplasty, vesicourethral anastomosis, ureteral reimplant or augmentation cystoplasty involves 6–10 separate suture-and-needle decisions, and defaults vary between training lineages. This article summarizes the properties of common materials, the evidence for specific choices and typical selections by procedure.

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]

  1. Predictable tensile strength over the wound-healing window.
  2. Good handling characteristics. Pliability, memory, feel at the needle.
  3. Secure knot with a predictable number of throws.
  4. Minimal tissue reactivity.
  5. 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) versus non-absorbable (not designed to be absorbed; long-term strength still varies by material).
  • Structure: monofilament (single strand) versus multifilament / braided (many strands).
  • Origin: natural (silk, catgut) versus synthetic (polymers).

The main practical divide is monofilament versus multifilament, which affects tissue drag, knot behavior and bacterial adherence.

Absorbable Sutures​

Fast Absorbable (Loses Strength Within 30 Days)​

SutureStructureTrade nameStrength retentionUrologic use
Polyglactin 910Braided (monofilament in sizes 9-0 and 10-0)Vicryl25% at 4 wk for sizes 6-0 and larger; absorbed in 56–70 days[40]Bladder mucosa, ureteral reimplant, vaginal cuff
Polyglycolic acid (PGA)Braided multifilament in the classic Dexon productDexonProduct-dependent; broadly short-absorbableLargely displaced by newer absorbables
Poliglecaprone 25MonofilamentMonocrylUndyed: 50–60% at 1 wk, 20–30% at 2 wk; dyed: 60–70% at 1 wk, 30–40% at 2 wk (manufacturer data)[41]; absorption complete between days 91 and 119[59]Subcuticular skin, vesicourethral anastomosis, bladder neck reconstruction
Chromic catgutNatural monofilamentChromicEnzymatic degradation, variableLargely historical; some pediatric skin

Slow Absorbable (Strength Retained >30 Days)​

SutureStructureTrade nameStrength retentionUrologic use
PolydioxanoneMonofilamentPDS IILong strength retention; absorbed approximately 182–238 days (product-specific)Urethroplasty, fascial closure (STITCH), selected long-healing anastomoses
PolyglyconateMonofilamentMaxonLong-absorbable; check product-specific profileAlternative slow-absorbable material

PDS II is a commonly selected slow-absorbable monofilament for fascial closure and repairs needing support over weeks; the cited in-vitro comparison is specific to its tested materials and conditions.[4][35] Vicryl Plus is not a slow-absorbable formulation: it is triclosan-coated polyglactin 910 with the manufacturer's listed absorption of 56–70 days, like the corresponding standard coated Vicryl product.[36]

Degradation Mechanism​

  • Natural sutures (catgut, silk) degrade by enzymatic proteolysis; degradation is highly variable and tissue-reactive.
  • Synthetic absorbables (Vicryl, Monocryl, PDS) degrade by hydrolysis, which is predictable and weakly reactive. Natural and synthetic absorbables remain suture options with different degradation mechanisms.[1][2]

Sutures in Urine​

A 1987 review of genitourinary suture choice reported that the bladder regains 100% of the strength of unwounded tissue in 14 to 21 days and that braided synthetic absorbables keep their tensile strength for about 21 days.[53] The incidence of suture urolithiasis rises with the time suture stays in the urinary tract, and nonabsorbable sutures or staples predictably promote stones; the review recommended absorbable suture for urinary-tract closure. Infected urine, especially with Proteus species, degrades synthetic absorbables faster than gut, and the review recommended gut suture for closure in the presence of infection.[53] Catgut was banned in Europe by 2013.[55]

StudyModelFindings
el-Mahrouky 1987[54]PDS, polyglycolic acid and chromic catgut immersed for up to 10 days in plasma, sterile urine or infected urinePlasma: no significant change. Sterile urine: PDS lost all breaking strength by day 3; polyglycolic acid lost 64% by day 10; catgut kept its strength. E. coli urine: PDS lost all strength by day 6; polyglycolic acid lost 71% and catgut 8% by day 10. Proteus urine: PDS and polyglycolic acid lost all strength after 1 day; catgut lost 5.8% by day 10.
Kerstein 2013[55]6-0 Vicryl, Vicryl Rapide, Monocryl and PDS stored in human urine or saline for up to 27 daysUrine reduced the strength of all four. PDS was the most resilient; Vicryl Rapide degraded completely by day 6; Vicryl and Monocryl had similar degradation profiles, with Vicryl retaining strength longer. The authors favored Vicryl for hypospadias urethroplasty.
Schiller 1993[64]PDS, polyglycolic acid, polyglactin 910, polyglyconate and chromic gut incubated for 28 days in sterile or infected canine urineSterile urine: PDS and chromic gut kept more than 90% of their strength at 28 days; polyglyconate kept 24%; polyglycolic acid and polyglactin 910 kept less than 30% at 21 days (7% in E. coli urine). Proteus urine: polyglycolic acid and polyglactin 910 lost all strength after 24 hours and PDS after 7 days. All materials lost more strength in alkaline than in neutral or acidic urine.
Greenberg 2004[65]PDS, poliglecaprone 25, polyglyconate and glycomer 631 immersed for up to 28 days in sterile (acidic, neutral, basic) or infected canine urineAll four lost tensile strength in every medium. PDS kept the greatest strength throughout. All four disintegrated before day 7 in Proteus urine. The authors judged poliglecaprone 25 strength possibly inadequate by 14 to 21 days, the critical bladder-healing period.
Stewart 1990[56]120 rat bladders closed with PDS, polyglactin or chromic catgutNo suture predisposed to infection. PDS caused more inflammation early, with all three similar by 6 months. PDS absorbed more slowly than chromic and at a rate similar to polyglactin. Calculogenic potential did not differ over 6 months.
Case 1976[66]Dog cystotomy closed with polyglactin 910, polyglycolic acid or chromic catgut; examined at 5 to 30 daysTissue reaction to polyglactin 910 and polyglycolic acid was similar, with early separation and cellular invasion of the suture fibers; early reaction to catgut was benign.
Bartone 1977[67]Guinea-pig cystotomy (polyglactin 910, silk or chromic controls) and dog ureteral anastomosis (polyglactin 910 or chromic)Small epithelial bladder cysts appeared at 3 months with polyglactin 910 and grew over time; ureteral cystic diverticula appeared at 8 months.
Morris 1986[68]Rabbit cystostomy closed with 5-0 chromic, PDS or polypropylene; examined at 15 to 90 daysCalculi formed on all three sutures; how long calculi persisted followed how long the suture material lasted.
Wainstein 1997[57]Rabbit pyeloureterotomy closed with interrupted 7-0 chromic catgut, polyglactic acid, PDS or polytrimethylene carbonateChromic caused the most inflammation and foreign-body reaction at 10 days and 5 weeks. Polyglactic acid was fully reabsorbed by 5 weeks. At 12 weeks suture persisted in 50% of PDS and 100% of polytrimethylene carbonate renal units. No calculi formed.
DiSandro 1996[58]117 boys after hypospadias repair; urethral anastomosis with PDS (1987–1990) versus chromic or polyglycolic acidStricture 23.6% with PDS versus 6.8% (43.8% versus 9.5% with pedicled tube flaps); single-operation correction 50.9% versus 76.1%; fistula rates did not differ. PDS remained unabsorbed in the urethra up to 7 months. The authors advised against interrupted PDS in small-caliber urethral anastomoses.

Non-Absorbable Sutures​

MaterialStructureTrade nameStrengthUrologic use
PolypropyleneMonofilamentProleneNon-absorbable; long-lastingSling suspensory arms, selected mesh fixation and permanent support outside urinary lumen
NylonMono- or multifilamentEthilon, NurolonLong-termSkin closure, tendon
SilkMultifilament, naturalSilkLoses strength over months in vivoHistorical; highest tissue reactivity and microbial adherence[5][6]
PolyesterMultifilament, coatedEthibond, Ti-CronDurable non-absorbable supportSelected permanent fascia/sling fixation outside the urinary lumen; not a routine AUS cuff suture
PTFE / Gore-TexMonofilamentCV-seriesMost stable tensile strength in one 14-day artificial-saliva comparison of eight 3-0 materials[4]Vascular / IVC reconstruction
Stainless steelMonofilament—Maximum strengthSternal closure (not urologic)

Monofilament vs Multifilament — the Decision That Matters Most​

PropertyMonofilamentMultifilament
Tissue dragLowHigh
Tensile strength for a given sizeVaries by polymer and test condition[4]Varies by polymer and test condition
Knot securityLower (more throws required)Higher
Handling / pliabilityStiffer; more memoryBetter; more pliable
Bacterial adherenceOften lower in comparative modelsOften higher in comparative models (filament interstices can retain bacteria)
Infection riskDepends on material, site and procedureDepends on material, site and procedure
Tissue reactivityLowHigher
Suture sinus riskLowHigher

For the urologist: monofilament is often preferred where bacterial wicking, permanent exposure or prolonged tissue support is a concern. Device instructions, tissue, exposure and local infection-control practice govern the particular repair. Multifilament Vicryl remains a useful option for short-healing mucosal approximation where handling matters (for example, bladder mucosa or vaginal cuff).

Size — USP Gauge​

USP size designations include 11-0 and 10-0 for microsurgery, then 6-0, 4-0, 0, 1, 2 and 5. More zeros indicate a smaller diameter: 6-0 is finer than 4-0. Available sizes depend on the material and product.[1][52]

Principle: use the smallest size that accomplishes the purpose.[1]

In a bench skin-suturing model, larger diameter (3-0 versus 5-0 nylon) produced higher tear-through force, which is relevant in friable tissue or tissue under tension.[10] In one oral-surgery bench test, suture size did not change the knot-slippage endpoint; laparoscopic tests found larger monofilaments less predictable with some knot sequences.[7][8]

Sizes in GU Reconstruction​

The table lists the sizes reported for each layer in the cited series and technique descriptions. These series used polyglactin 910, polyglecaprone 25 or polydioxanone; barbed suture was used in one vesicourethral anastomosis trial and one bladder closure.

Layer or anastomosisSizes reported
Urethral mucosa and graft edges (dorsal onlay and ventral inlay urethroplasty)5-0 to 6-0[62][63]
Bulbar excision and primary anastomosis3-0 to 4-0, eight interrupted sutures[60][61]
Vesicourethral anastomosis (robot-assisted radical prostatectomy)3-0 barbed or 4-0 polyglecaprone 25[22]
Graft to corpora (dorsal onlay)3-0[62]
Ureter: reimplant mucosa, pyeloplasty, ureter to Boari flap4-0 to 5-0[69][71][72]
Vesicovaginal fistula, bladder and vaginal layers3-0 to 4-0[73][74]
Bladder wall: detrusor tunnel, cystorrhaphy, Boari tube and bladder defect2-0 to 3-0[71][72]
Bladder to psoas tendon2-0[71][72]
Ileal neobladder reservoir3-0[70]
Midline fascia (small bites)2-0[47]

In a 559-patient randomized trial of elective midline laparotomy, 2-0 PDS small bites (5 mm from the edge and 5 mm apart) reduced estimated 13-year cumulative incisional hernia versus looped PDS large bites (10 mm by 10 mm): 34% versus 49%, with median follow-up of 8 years.[47]

Knot Security — Material and Throws​

Number of throws required for a secure knot depends on the specific material, knot sequence, loading and test conditions.[7][8][14] Throws by suture and size, position in the suture line, sliding-knot configuration and tying technique are on Knot Security. A 2016 oral-surgery bench study found that square and surgeon's knots generally needed four throws and sliding knots five in its tested materials; an additional throw after five did not improve that study's outcome.[7] In contrast, a 2023 laparoscopic bench study found that tested monofilament half-knot/half-hitch sequences needed six throws with blocking hitches, whereas tested polyfilament sequences were secure with four or five.[8] The number of initial twists in a surgeon's knot and the subsequent locking sequence also changed knot security.[15]

For the practical maneuver that improves run-down and reduces glove perforation with monofilament and UHMWPE braids, see Glove Wetting for Knot Tying. For why running sutures through bacitracin ointment or petroleum jelly is a tradition with measurable mechanical and safety costs, see Suture Lubrication.

Triclosan-Coated (Antibacterial) Sutures​

Vicryl Plus (polyglactin 910) and PDS Plus are triclosan-coated sutures intended to inhibit bacterial growth on the suture. Their effect on surgical site infection varies by operative setting and by which trials are included in the analysis.[18][19]

Evidence is conflicting:

  • A 2023 meta-analysis of 29 RCTs reported a 24% reduction in SSI (RR 0.76, 95% CI 0.67–0.87), with a significant effect only in the abdominal-surgery subgroup.[16]
  • A 2025 JAMA Network Open meta-analysis of 31 RCTs (17,968 participants) found fewer SSIs (RR 0.75, 95% CI 0.65–0.86; moderate-certainty evidence).[18]
  • WHO 2016 made a conditional recommendation for triclosan-coated sutures, and NICE recommends considering them, especially for paediatric surgery.[17][45]
  • A high-quality 2022 Lancet Infectious Diseases meta-analysis restricted to the best-conducted RCTs in clean-contaminated, contaminated, or dirty surgery (5 trials, 8,619 analyzed patients; clean procedures excluded) found no significant SSI difference (16.8% vs 18.4%) and concluded that guideline recommendations for routine use should be reconsidered.[19]

Practical stance. A 2025 Surgical Infection Society guideline recommends triclosan-coated suture for abdominal incision closure to reduce SSI (Grade 1A), while the 2022 restricted high-quality-trial analysis and 2025 broader analysis reach different pooled conclusions.[37][19][18]

Barbed Sutures — Knotless Running Closure​

Dedicated deep-dive article. The full product biomechanics (V-Loc 90/180, Quill SRS, Stratafix, MONOFIX), per-indication evidence, the upper-tract pyeloplasty controversy (Liatsikos 5/6 stricture recurrences with Quill in early cases[38], Radford: 4/10 children remained asymptomatic despite worsening hydronephrosis and MAG-3 drainage after stent removal following V-Loc closure of the renal pelvis[39], Anand 2022 meta[28]), 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.[11][20][21] 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.

The main reconstructive uses are:

  • Robot-assisted vesicourethral anastomosis. The classic GU application
  • Selected robotic pyeloplasty. May shorten suturing, but upper-tract failure signals require material- and technique-specific caution
  • Renorrhaphy. Holds compression during sliding-clip parenchymal closure
  • Cystotomy or bladder closure. Especially in robotic cystectomy, partial cystectomy, or fistula repair
  • Sacrocolpopexy mesh attachment and vaginal cuff closure. Knotless running pelvic closure. For mesh attachment, check the selected product and regional instructions: the cited V-Loc 90 and 180 technical sheets exclude synthetic-graft fixation.[42][43]

Types​

TypeMechanismExamplesPractical issue
UnidirectionalBarbs face one direction; terminal loop anchors first passV-Loc, Stratafix SpiralEasy robotic workflow; extrusion/dehiscence signal is most prominent in body-wall and subcutaneous use
BidirectionalBarbs face away from the midpoint; closure proceeds from center outwardQuillMore even tension distribution; no terminal loop

Mechanism and handling​

PrincipleEffect
Self-anchoringBarbs grip tissue on passage; no knot required
No assistant needed to hold tensionUseful in robotic VUA, pyeloplasty, renorrhaphy, and deep pelvic closure
Slippage preventionRunning closure maintains approximation without repeated retensioning[22]
Distributed tensionMay reduce focal knot bulk[21]
Not easily backed outTension 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.[23][24] In urinary-tract reconstruction, the main question is less raw tensile strength and more whether a continuous mucosa-to-mucosa closure remains watertight without focal strangulation.

Urologic and reconstructive evidence​

ApplicationEvidence signalReconstructive interpretation
Vesicourethral anastomosisIn Zorn's 70-patient RCT, anastomosis time was 13.1 vs 20.8 min, with less tension readjustment; no statistically significant pad-free continence difference was detected through 6 months (mean follow-up 6.2 months).[22] A meta-analysis of 3 randomized and 6 observational studies (786 cases) found about 4 min shorter anastomosis time without a detected difference in leak or continence.[25]A well-studied GU application for shortening suturing time.
PyeloplastyEx vivo porcine testing found shorter suture time, and nonrandomized clinical comparisons reported shorter overall operative time.[26][27] In an early adult series using Quill for the ureteropelvic anastomosis, 5/6 developed recurrent stricture.[38] In ten children whose renal pelvis was closed with V-Loc, 4/10 had worsening hydronephrosis and MAG-3 drainage after stent removal while asymptomatic; three underwent redo pyeloplasty.[39] A five-study 2022 meta-analysis estimated higher redo risk with barbed suture (RR 6.00, 95% CI 0.78–46.14; not statistically significant).[28]Not proven equivalent for redo risk.
Partial nephrectomy renorrhaphyIn a single-surgeon consecutive series (15 conventional, then 15 V-Loc repairs), mean warm ischemia time was 24.7 versus 18.5 minutes; no V-Loc slippage or tearing was reported.[29]Useful for compression and clip-sliding workflow.
Gynecologic / urogynecologic closureSystematic reviews report shorter cuff-closure time and operative time, with no consistent increase in cuff dehiscence.[12][30]Barbed suture can be considered for vaginal-cuff closure. For sacrocolpopexy mesh attachment, check the chosen product's regional instructions: the cited V-Loc 90 and 180 technical sheets exclude synthetic-graft fixation.[42][43]
Fascial closureA meta-analysis of 7 studies (12,278 patients, mostly non-randomized) found barbed sutures were associated with lower SSI (OR 0.41, 95% CI 0.31–0.53) but did not detect a statistically significant difference in fascial complications.[31]Consider only a product whose instructions support the intended fascial use: Medtronic's US information says fascial-closure safety and effectiveness for V-Loc 90 and 180 have not been established.[46]

Complications and precautions​

The safety signal is context-dependent. A meta-analysis of 17 randomized trials found shorter suture and operative times with barbed sutures and more postoperative complications overall (OR 1.43, 95% CI 1.05–1.96), with results varying by subgroup; the authors judged the safety evidence insufficient.[11] In plastic or body-contouring literature, unidirectional barbed sutures show higher wound-dehiscence and suture-extrusion odds, especially in subcutaneous or superficial closure.[13][32]

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.[33][34]
  • 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.[32]

Product examples​

ProductDirectionMaterial patternCommon reconstructive use
V-Loc 90 / 180UnidirectionalAbsorbable; listed tensile-strength interval 14 days for 90 versus 21 days for 180, with absorption in 90–110 versus 180 days[42][43]Robotic VUA[44], cystotomy closure, selected pyeloplasty[44]; match the variant to the repair
Stratafix SpiralUnidirectionalPDO / Monocryl-family variantsRunning closure in robotic or laparoscopic fields
QuillUni- or bidirectional, by variant[50]Absorbable or non-absorbable variantsCenter-outward closure with the bidirectional version; body-wall and pelvic closure depend on the chosen product

Summary. A barbed suture is a material choice within an operation. It is 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.

Alternatives to Sutures​

OptionUrologic useTrade-off
Skin staplesMidline laparotomy, cystectomy skin, lateral nephrectomy skinFast, low reaction; removal discomfort
Tissue adhesive (2-octylcyanoacrylate / Dermabond)Pediatric skin, low-tension incisionsNo removal; not for high-tension or infected wounds
Surgical tape (Steri-Strips)Adjunct after sutures/staples removedLimited tension tolerance

For selected surgical skin incisions, a Cochrane review found no clear infection difference between tissue adhesive and sutures, but more wound dehiscence with adhesive (RR 3.35, 95% CI 1.53–7.33; low-quality evidence). This does not support adhesive for high-tension, infected or deeper reconstructive closures.[9]

Complications — Suture-Attributable​

  • Suture sinus or extrusion. In laparotomy closure, sinus or fistula-tract formation was less frequent with absorbable than non-absorbable sutures (RR 0.49, 95% CI 0.26–0.94; low-quality evidence).[3] Multifilament sutures are also associated with more sinus formation than monofilament.[1]
  • Stitch abscess. Multifilament higher risk than monofilament.
  • Tissue reactivity. In a rabbit reproductive-tract microsuture study, tissue reaction varied by suture material, caliber, and time after placement.[51]
  • Encrustation or calculi. Any suture exposed to urine can become a calculus nidus, especially with prolonged exposure; calculi have also been reported after Vicryl pyeloplasty. Avoid non-absorbable full-thickness passes through urothelium and minimize exposed suture and knots.[48][49][53]
  • Erosion. Polypropylene mesh, and permanent suture placed through the wall of the urinary tract or vagina, can erode into the lumen over time.

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. 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

6. 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

7. 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

8. 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

9. Dumville JC, Coulthard P, Worthington HV, et al. "Tissue Adhesives for Closure of Surgical Incisions." Cochrane Database Syst Rev. 2014;(11):CD004287. doi:10.1002/14651858.CD004287.pub4

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Moya AP. "Barbed Sutures in Body Surgery." Aesthet Surg J. 2013;33(3 Suppl):57S–71S. doi:10.1177/1090820X13499577

21. Ruff GL. "The History of Barbed Sutures." Aesthet Surg J. 2013;33(3 Suppl):12S–16S. doi:10.1177/1090820X13498505

22. 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

23. 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

24. 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

25. 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

26. 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

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