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Shah M, Medina LG, Azhar RA, La Riva A, Ortega D, Sotelo R. Urine leak after robotic radical prostatectomy: not all urine leaks come from the anastomosis. J Robot Surg 2021; 16:247-255. [PMID: 33895942 DOI: 10.1007/s11701-021-01242-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/14/2021] [Indexed: 11/27/2022]
Abstract
Radical prostatectomy is the gold standard in patients that are surgical candidates with localized prostate cancer. While most postoperative urine leaks are from vesico-urethral anastomosis, urologists must be aware that a small percentage of patients may have a urine leak from other sites that may have been inadvertently injured during the procedure. We propose a systematic workup to evaluate the source of the urinary leak as well as appropriate management of such injuries. The mid-ureter can be injured during lymph node dissection. The distal ureter is at risk of injury when performing the Montsouris approach. The posterior bladder neck dissection can at times be challenging. If not careful, one can easily cause an injury to the trigone and/or ureteral orifices. The most common site of leak is at the vesico-urethral anastomosis due to a non-watertight closure. The management of intraoperatively detected ureteral injuries require placement of a ureteral stent. The location, severity and type of injury determine the reconstruction required to fix it. Postoperatively urine leak can be frequently detected when assessing the pelvic drain, and imaging such as CT Urogram with a cystogram phase may be helpful in the diagnosis. Urine leak after robotic-assisted laparoscopic radical prostatectomy remains a rare complication, sometimes the diagnosis can be challenging, and management varies depending on the site and severity of injury.
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Affiliation(s)
- Mihir Shah
- Christiana Care Urology, Wilmington, Delaware, USA
| | - Luis G Medina
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA
| | - Raed A Azhar
- Department of Urology, King Abdul Aziz University, Jeddah, Saudi Arabia
| | - Anibal La Riva
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA
| | - David Ortega
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA
| | - Rene Sotelo
- USC Institute of Urology, University of Southern California, 1441 Eastlake Ave., Suite 7416, Los Angeles, CA, 90089-9178, USA.
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Dal Moro F, Goffo F, Ferraioli G, Zaborra C, Valotto C. How to manage a partial detachment of the ureter during robotic radical prostatectomy? Minerva Urol Nephrol 2020; 73:672-673. [PMID: 32003206 DOI: 10.23736/s2724-6051.19.03628-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The management of a ureteral orifice injury occurring during robotic radical prostatectomy (RARP) represents a challenge for urologists. Several techniques have been proposed to treat an intraoperative injury, but intraoperative positioning of a DJ stent represents the most common treatment in cases of a partial injury of the ureteral orifice. We present a technique to ensure the successful outcome in cases of a partial detachment of the ureter during RARP. When the orifice is identified after the incision of the bladder neck and it appears very close to the anastomosis line setting up a partial detachment of the ureter, before implanting a DJ stent, one tip could be to perform a small incision of the anterior wall of the orifice to spatulate it and then proceeding to a short slip of the ureter: the eversion of the mucosa - thus creating a sort of "folded shirt cuff" - allows the fixation of the ureter to the bladder wall. We successfully performed this technique in two cases of RARP.
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Affiliation(s)
- Fabrizio Dal Moro
- Department of Medicine, Udine University Hospital, Udine, Italy - .,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy -
| | - Federico Goffo
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Giordana Ferraioli
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Carlotta Zaborra
- Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - Claudio Valotto
- Department of Medicine, Udine University Hospital, Udine, Italy
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Akdere H, Aktoz T, Arıkan MG, Atakan İH, Veneziano D, Gözen AS. Embarking with laparoscopic radical prostatectomy and dealing with the complications and collateral problems: A single-center experience. Turk J Urol 2019; 46:37-43. [PMID: 31657697 DOI: 10.5152/tud.2019.19008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/28/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of the present study was to report our single-center initial experience in laparoscopic radical prostatectomy (LRP) with special emphasis on the complications and collateral problems and their management. MATERIAL AND METHODS A total of 48 patients (mean age 64 years) underwent LRP in our institution between August 2014 and July 2018. Two surgeons completed a fellowship training program for LRP before. Mentored operations started after the first 10 cases. The patients were divided in two groups of 30 (group I) and 18 (group II) patients. Demographic, preoperative, peroperative, and postoperative data were collected prospectively. Anesthesiology and nurses' team performances, as well as problems and their management, were reviewed. RESULTS The demographic data for both groups (group I vs. group II) were similar. Estimated blood loss (695.5±139.23 vs. 398±339.39 mL) and intraoperative complication rates (36.66% vs. 5.55%) were significantly (p<0.05) higher in group I. Conversion to open surgery occurred in 7 (20%) patients in group I and in 1 (5.55%) patient in group II. Continence rates at 12 (83%) months were similar in both groups. Positive surgical margins were 8.33% for pT2 and 27.1% for pT3 stages. CONCLUSION A validated fellowship program before starting LRP and performing the first cases under mentorship are helpful. The complication and conversion rates decrease after 30 cases in addition to the improved experience also with improved cooperation with the anesthesiologist and scrub nurse.
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Affiliation(s)
- Hakan Akdere
- Department of Urology, Trakya University School of Medicine, Edirne, Turkey
| | - Tevfik Aktoz
- Department of Urology, Trakya University School of Medicine, Edirne, Turkey
| | | | | | - Domenico Veneziano
- Grande Ospedale Metropolitano, Department of Urology and Kidney Transplant, Reggio Calabria, Italy
| | - Ali Serdar Gözen
- SLK-Kliniken Urology Department, Heidelberg University, Heilbronn, Germany
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Bedir F, Keske M, Demirdogen SO, Kocaturk H, Atmaca AF, Canda AE. Diagnosis and Conservative Management of Ureteral Orifice Injury During Robotic Prostatectomy for a Large Prostate with a Prominent Median Lobe. J Endourol Case Rep 2019; 5:39-41. [PMID: 31179382 PMCID: PMC6555169 DOI: 10.1089/cren.2018.0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Robot-assisted laparoscopic radical prostatectomy (RALRP) is now considered the standard treatment for localized prostate cancer. However, challenges may arise when dealing with large prostates with a prominent median lobe because the ureteral orifices may not always be visible during dissection and maybe injured in the process. We describe our experience on the diagnosis and conservative management of ureteral orifice injury in this situation. Case: A Gleason score 3 + 3 prostatic adenocarcinoma was detected during 12-quadrant prostate biopsy performed after measurement of a serum prostate specific antigen value of 8.1 ng/mL in a 65-year-old man presenting with lower urinary tract symptoms. The left ureter orifice was observed to have been injured by scissors at dissection of the neck of the bladder and enlarged median lobe at RALRP. An online video call was made to more experienced robotic surgeons for advice. Diagnosis and management of the ureteral injury are presented. Conclusion: Ureteral orifice injury during an RALRP may be managed conservatively with intraoperative ureteral stenting without the need for reimplantation nor conversion to open surgical techniques. Online video call with experienced robotic surgeons is helpful in the decision process.
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Affiliation(s)
- Fevzi Bedir
- Department of Urology, University of Health Sciences, affiliated with the Erzurum Training and Research Hospital, Erzurum, Turkey
| | - Murat Keske
- Department of Urology, University of Health Sciences, affiliated with the Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Saban Oguz Demirdogen
- Department of Urology, University of Health Sciences, affiliated with the Erzurum Training and Research Hospital, Erzurum, Turkey
| | - Huseyin Kocaturk
- Department of Urology, University of Health Sciences, affiliated with the Erzurum Training and Research Hospital, Erzurum, Turkey
| | - Ali Fuat Atmaca
- Department of Urology, Ankara Yildirim Beyazit University, School of Medicine, affiliated with Ankara Ataturk Training and Research Hospital, Ankara, Turkey
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Cohen RJ, Li J, Shannon T. Prediction of bladder neck invasion and tumor extension to bladder neck margin by prostatic adenocarcinoma: a nomogram using biopsy data including transition zone tumor morphology. Hum Pathol 2016; 57:85-90. [PMID: 27473268 DOI: 10.1016/j.humpath.2016.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/21/2016] [Accepted: 07/06/2016] [Indexed: 11/25/2022]
Abstract
Transition zone (TZ) prostatic adenocarcinoma can be identified on needle core biopsy based on tumor morphology, provided that the sample is preserved in a glutaraldehyde-based tissue fixative. TZ tumors have a propensity to grow larger than their peripheral counterparts without extraprostatic extension and finally to escape the gland by invading the bladder neck. We investigated the value of biopsy-determined parameters including TZ origin to predict the risk of isolated bladder neck invasion at radical prostatectomy. If reliable, this will enable urologists to expand their bladder neck dissection and avoid an isolated positive bladder neck margin. The study cohort consisted of 3942 patients with detailed pre operative biopsy information who underwent curative-intent radical prostatectomy between January 2010 and December 2015 in Western Australia. Multivariate logistic regression models were developed to predict isolated bladder neck invasion or isolated positive bladder neck margin. A predictive preoperative nomogram is presented. The predictive accuracy is shown in the calibration plot (the area under the curve: 0.777). The accuracy of the nomogram is dependent on the biopsy identification of transition zone cancer features, parameters only reliably interpretable after glutaraldehyde tissue fixation.
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Affiliation(s)
- Ronald J Cohen
- Uropath Pty Ltd, West Leederville, WA, 6007, Australia; School of Pathology and Laboratory Medicine, Faculty of Medicine and Dentistry, University of Western Australia, Crawley, WA, 6009, Australia.
| | - Jian Li
- Uropath Pty Ltd, West Leederville, WA, 6007, Australia
| | - Thomas Shannon
- Hollywood Specialist Centre, Nedlands, WA, 6009, Australia
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Sotelo RJ, Haese A, Machuca V, Medina L, Nuñez L, Santinelli F, Hernandez A, Kural AR, Mottrie A, Giedelman C, Mirandolino M, Palmer K, Abaza R, Ghavamian R, Shalhav A, Moinzadeh A, Patel V, Stifelman M, Tuerk I, Canes D. Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery. Eur Urol 2015; 69:334-44. [PMID: 26385157 DOI: 10.1016/j.eururo.2015.08.060] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. OBJECTIVE We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. DESIGN, SETTING, AND PARTICIPANTS Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. SURGICAL PROCEDURE Surgical footage was available for a variety of complications during RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined. RESULTS AND LIMITATIONS As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. CONCLUSIONS Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. PATIENT SUMMARY Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.
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Affiliation(s)
- René J Sotelo
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela; University of Southern California, Los Angeles, CA, USA.
| | - Alexander Haese
- Martini Clinic Prostate Cancer Center, University Clinic Eppendorf, Hamburg, Germany
| | - Victor Machuca
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | - Luis Medina
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | - Luciano Nuñez
- Center of Robotics and Minimally Invasive Surgery, Instituto Médico La Floresta, Caracas, Venezuela
| | | | | | | | | | | | | | | | - Ronney Abaza
- Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Arieh Shalhav
- Duchossois Center for Advanced Medicine, Chicago, IL, USA
| | - Alireza Moinzadeh
- Lahey Hospital and Medical Center Institute of Urology, Burlington, MA, USA
| | - Vipul Patel
- Global Robotics Institute, Celebration, FL, USA
| | | | - Ingolf Tuerk
- St. Elizabeth's Medical Center, Brighton, MA, USA
| | - David Canes
- Lahey Hospital and Medical Center Institute of Urology, Burlington, MA, USA
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Montes SFP, Rodríguez IG, Ugarteburu RG, Villamil LR, Mendez BD, Gil PS, Madera JM. Intraoperative laparoscopic complications for urological cancer procedures. World J Clin Cases 2015; 3:450-456. [PMID: 25984519 PMCID: PMC4419108 DOI: 10.12998/wjcc.v3.i5.450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/30/2015] [Accepted: 04/09/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution.
METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications.
RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy).
CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.
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Saar M, Ohlmann CH, Janssen M, Stöckle M, Siemer S. [Radical prostatectomy. Detection and management of intra- and postoperative complications]. Urologe A 2014; 53:976-83. [PMID: 25023234 DOI: 10.1007/s00120-014-3500-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Radical prostatectomy is the most common treatment for organ-confined prostate cancer. Performed without complications and limitations, surgery will allow complete removal of the tumor and, therefore, cure the patient. Operative techniques have been improved during the last few decades to reduce invasiveness of the procedure. Furthermore, optimized perioperative management has shortened hospital stay. To ensure rapid recovery of each patient, early detection of complications is highly relevant. Herein, different scenarios for peri- and postoperative complications are described, and recommendations for best practice solutions are reviewed.
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Affiliation(s)
- M Saar
- Klink für Urologie und Kinderurologie, Universitätsklinikum des Saarlandes, Kirrberger Straße 1, Geb. 6, 66421, Homburg/Saar, Deutschland,
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Gözen AS, Akin Y, Akgul M, Yazici C, Klein J, Rassweiler J. A Novel Practical Trocar Placement Technique for Extraperitoneal Laparoscopic and Robotic-Assisted Laparoscopic Radical Prostatectomy in Patients with Lower Midline Abdominal Incisions. J Laparoendosc Adv Surg Tech A 2014; 24:417-21. [DOI: 10.1089/lap.2013.0569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ali Serdar Gözen
- Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany
| | - Yigit Akin
- Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany
| | - Murat Akgul
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | - Cenk Yazici
- Department of Urology, Namik Kemal University School of Medicine, Tekirdag, Turkey
| | - Jan Klein
- Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany
| | - Jens Rassweiler
- Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany
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Jhaveri JK, Penna FJ, Diaz-Insua M, Jeong W, Menon M, Peabody JO. Ureteral injuries sustained during robot-assisted radical prostatectomy. J Endourol 2013; 28:318-24. [PMID: 24147874 DOI: 10.1089/end.2013.0564] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE During the last decade, the annual volume of robot-assisted prostatectomies performed in the United States has risen steadily. Refinements in surgical technique, understanding of anatomy, and experience have led to more complex patients being offered surgery for management of organ-confined prostate cancer. Complication rates of robot-assisted prostatectomy have been reported in several articles; however, a paucity of data exists when evaluating ureteral injuries sustained during robot-assisted prostatectomy. No standardized universal criteria for reporting and grading of complications exists; therefore, the Martin-Donat criteria with Clavien-Dindo classification system were used to evaluate ureteral injuries in our series. PATIENTS AND METHODS From January 2001 to June 2013, 6442 consecutive patients were treated with robot-assisted prostatectomy at the same institution by one of five surgeons. All complications were documented through a prospectively maintained prostate cancer database with supplementation from electronic medical records, operative and nursing notes, claims data, discharge summaries, outpatient and emergency visits, institutional morbidity and mortality data, as well as National Surgical Quality Improvement Program data. The Martin-Donat criteria were used to facilitate the accurate and comprehensive reporting of surgical complications while complication severity was assigned following the Clavien-Dindo classification system. RESULTS Three patients sustained ureteral injuries (ureteral transection) in our series. Both surgeons were beyond their learning curve (greater than 1000 cases) when the injuries occurred; one patient needed readmission, and all patients had risk factors predisposing them to ureteral injury. Each patient was managed with robot-assisted ureteroneocystostomy (1), open transureteroureterostomy (1) and robot-assisted ureteroureterostomy (1) respectively. CONCLUSIONS Ureteral injuries are uncommon; however, thorough preoperative evaluation and surgical planning could identify patients at high risk for sustaining ureteral injury during prostatectomy. Measures can be taken preoperatively or intraoperatively to reduce the probability of ureteral injury, eliminating the necessity for additional procedures postoperatively.
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Affiliation(s)
- Jay K Jhaveri
- Vattikuti Urology Institute, Henry Ford Health System , Detroit, Michigan
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Fu WJ, Xu YD, Wang ZX, Li G, Shi JG, Cui FZ, Zhang Y, Zhang X. New ureteral scaffold constructed with composite poly(L-lactic acid)-collagen and urothelial cells by new centrifugal seeding system. J Biomed Mater Res A 2012; 100:1725-33. [PMID: 22447771 DOI: 10.1002/jbm.a.34134] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 02/19/2012] [Accepted: 02/21/2012] [Indexed: 11/07/2022]
Abstract
A tissue-engineered ureteral scaffold was constructed with composited poly L-lactic acid (PLLA)-collagen endoluminal stent and uroepithelial cells (UECs) using a new seeding system. The electrospun PLLA-collagen nanofibrous mesh was seeded efficiently with human ureteral epithelial cells using a modified centrifugal seeding device. The cellular nanofibrous mesh was then wound around a spiral endoluminal stent to form a cellular composited PLLA-collagen ureteral scaffold. The cellular ureteral scaffold was subcutaneously implanted into nude mice. Cell attachment, distribution, and viability in vitro were investigated along with the cell fate in vivo. (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay showed that scaffolds seeded with centrifugal method had higher cellular activity than scaffolds seeded with static method (p < 0.05), and the metabolic activity per cell had no significant differences between the two methods (p > 0.05). Histologic analysis showed that the entrapped UECs remained in the scaffolds after 2 wk of implantation. The results of the study indicated that the composited PLLA-collagen endoluminal stent could serve as alternative cell carrier for tissue engineering ureter. In addition, the new modified centrifugal seeding system allowed rapid homogeneous distribution of cells onto the nanofibrous mesh, which will be useful to ureteral reconstruction.
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Affiliation(s)
- Wei-Jun Fu
- Department of Urology, Chinese People's Liberation Army General Hospital, Military Postgraduate Medical College, Haidian District, Beijing 100853, People's Republic of China.
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