Adult stem cell therapy of female stress urinary incontinence

Cell Therapy by Mesenchymal Stromal Cells Versus Myoblasts in a Pig Model of Urinary Incontinence

The leading cause of stress urinary incontinence (SUI) in women is the urethral sphincter muscle deficiency caused by mechanical stress during pregnancy and vaginal delivery. In men, prostate cancer surgery and injury of local nerves and muscles are associated with incontinence. Current treatment often fails to satisfy the patient's needs. Cell therapy may improve the situation. We therefore investigated the regeneration potential of cells in ameliorating sphincter muscle deficiency and UI in a large animal model. Urethral sphincter deficiency was induced surgically in gilts by electrocautery and balloon dilatation. Adipose tissue-derived stromal cells (ADSCs) and myoblasts from Musculus semitendinosus were isolated from male littermates, expanded, characterized in depth for expression of marker genes and in vitro differentiation, and labeled. The cells were injected into the deficient sphincter complex of the incontinent female littermates. Incontinent gilts receiving no cell therapy served as controls. Sphincter deficiency and functional regeneration were recorded by monitoring the urethral wall pressure during follow-up by two independent methods. Cells injected were detected in vivo during follow-up by transurethral fluorimetry, ex vivo by fluorescence imaging, and in cryosections of tissues targeted by immunofluorescence and by polymerase chain reaction of the sex-determining region Y (SRY) gene. Partial spontaneous regeneration of sphincter muscle function was recorded in control gilts, but the sphincter function remained significantly below levels measured before induction of incontinence (67.03% ± 14.00%, n = 6, p < 0.05). Injection of myoblasts yielded an improved sphincter regeneration within 5 weeks of follow-up but did not reach significance compared to control gilts (81.54% ± 25.40%, n = 5). A significant and full recovery of the urethral sphincter function was observed upon injection of ADSCs within 5 weeks of follow-up (100.4% ± 23.13%, n = 6, p < 0.05). Injection of stromal cells provoked slightly stronger infiltration of CD45pos leukocytes compared to myoblasts injections and controls. The data of this exploratory study indicate that ADSCs inherit a significant potential to regenerate the function of the urethral sphincter muscle.

The effect of skeletal muscle-derived cells implantation on stress urinary incontinence and functional urethral properties in female patients

OBJECTIVE

To evaluate improvement of stress urinary incontinence (SUI) and functional status of the urethra after autologous skeletal-muscle derived cell (aSMDC) implantation.

METHODS

Phase I-II, open, non-randomized, single-center study of ultrasound guided aSMDC implantation (dosed at 0.2 × 10⁶  cells/2 mL) into the external urethral sphincter to treat SUI.

RESULTS

A total of 38 patients were treated and followed for 2 years. SUI measured by Incontinence Episode Frequency score, short pad test, quality of life, patient's and clinician's perception significantly improved and remained improved after 2 years. However, urodynamic urethral properties in general did not improve at 1-year after treatment. Subgroup analysis revealed that addition of an adjuvant functional electrical stimulation therapy discontinued 4 weeks after injection in the compliant group, gave better urodynamic values and maintained the long-term SUI improvement at 2 years.

CONCLUSION

The aSMDC injection was safe and well-tolerated by patients. The status of SUI improved and with it the quality of life of patients, even if this was not necessarily reflected in the urodynamic urethral properties. Electrical stimulation, as an adjuvant therapy, could have an essential role in the success of the therapy.

CLINICAL REGISTRATION

Clinical study was registered under Eudra-CT number: 2010-021867-34 at European Clinical Trial Database (EudraCT), accessible at: EudraCT (europa.eu).

A systematic review of stem cell therapy treatment for women suffering from stress urinary incontinence

BACKGROUND

Stem cell therapy (SCT) is used for regeneration of injured tissues. This seems a novel promising strategy for restoring urethral sphincter function in patients with stress urinary incontinence (SUI).

OBJECTIVE

To summarize the clinical trials available to date on SCT for treatment of SUI in women.

SEARCH STRATEGY

PubMed, Cochrane Library, Scopus and Embase.

SELECTION CRITERIA

Prospective interventional case series, randomized prospective interventional study and prospective cohort study assessing women aged 18 years and over diagnosed with SUI and treated by SCT were included. The quality of studies was finally assessed using the JBI Critical Appraisal Checklists according to the PRISMA guidelines.

DATA COLLECTION AND ANALYSIS

Nineteen studies (n = 773 patients) were selected for final analysis. These were conducted worldwide between the years 2005 and 2016. Although different cell types were used, general processing steps were similar. The follow-up period ranged between 6 weeks and 6 years and included common subjective and objective evaluation tools.

RESULTS

Overall, the studies imply that SCT for treatment of SUI is a safe and effective treatment.

CONCLUSION

In our opinion, the initial results of SCT for the treatment of SUI seem promising. Standardization and validation of this treatment modality is required before it can be recommended for routine use.

Injection of Porcine Adipose Tissue-Derived Stromal Cells by a Novel Waterjet Technology

Previously, we developed a novel, needle-free waterjet (WJ) technology capable of injecting viable cells by visual guided cystoscopy in the urethral sphincter. In the present study, we aimed to investigate the effect of WJ technology on cell viability, surface markers, differentiation and attachment capabilities, and biomechanical features. Porcine adipose tissue-derived stromal cells (pADSCs) were isolated, expanded, and injected by WJ technology. Cell attachment assays were employed to investigate cell-matrix interactions. Cell surface molecules were analyzed by flow cytometry. Cells injected by Williams Needle (WN), normal cannula, or not injected cells served as controls. Biomechanical properties were assessed by atomic force microscopy (AFM). pADSCs injected by the WJ were viable (85.9%), proliferated well, and maintained their in vitro adipogenic and osteogenic differentiation capacities. The attachment of pADSCs was not affected by WJ injection and no major changes were noted for cell surface markers. AFM measurements yielded a significant reduction of cellular stiffness after WJ injections (p < 0.001). WJ cell delivery satisfies several key considerations required in a clinical context, including the fast, simple, and reproducible delivery of viable cells. However, the optimization of the WJ device may be necessary to further reduce the effects on the biomechanical properties of cells.

Treatment of Stress Urinary Incontinence with Muscle Stem Cells and Stem Cell Components: Chances, Challenges and Future Prospects

Urinary incontinence (UI) is a major problem in health care and more than 400 million people worldwide suffer from involuntary loss of urine. With an increase in the aging population, UI is likely to become even more prominent over the next decades and the economic burden is substantial. Among the different subtypes of UI, stress urinary incontinence (SUI) is the most prevalent and focus of this review. The main underlying causes for SUI are pregnancy and childbirth, accidents with direct trauma to the pelvis or medical treatments that affect the pelvic floor, such as surgery or irradiation. Conservative approaches for the treatment of SUI are pelvic physiotherapy, behavioral and lifestyle changes, and the use of pessaries. Current surgical treatment options include slings, colposuspensions, bulking agents and artificial urinary sphincters. These treatments have limitations with effectiveness and bear the risk of long-term side effects. Furthermore, surgical options do not treat the underlying pathophysiological causes of SUI. Thus, there is an urgent need for alternative treatments, which are effective, minimally invasive and have only a limited risk for adverse effects. Regenerative medicine is an emerging field, focusing on the repair, replacement or regeneration of human tissues and organs using precursor cells and their components. This article critically reviews recent advances in the therapeutic strategies for the management of SUI and outlines future possibilities and challenges.

Cervical elongation caused by big cervical fibroid resembling malignant cervical prolapse? Management via vaginal surgery

INTRODUCTION

Cervical elongation could lead to cervical elongation thus worsen the descent of uterine prolapse. In certain cases, this hypertrophic and hyperplastic mass could have fragile surface with some bleeding and necrotic, resembling cervical cancer. As case of cervical elongation due to cervical fibroid is quite rare, such cases are valuable to be reported. We present two cases of cervical fibroid with cervical elongation resembling cervical malignancy.

PRESENTATION OF CASE

First case was A 59-year-old lady with intractable vaginal mass since one day before admission. Bleeding from the mass was positive. We found a bulky vaginal mass exceeding hymenal ring, 14 × 7 × 6 cm sized, with some necrotic and discharge, foul smelling, and some bleeding area. Ultrasound evaluation revealed a cervical fibroid with differential diagnosis cervical malignancy. The second case was Mrs 53-year-old with vaginal mass since last year. For the last 7 months the mass has been bigger and could not be inserted into vagina, with some bleeding. We found globular vaginal mass 12 × 9 × 6 cm exceeding hymenal ring, with some necrotic and reddish surface, foul smelling, discharge, and some blood. Ultrasound evaluation revealed cervical mass on anterior lip with elongated cervices. Both cases have been menopaused. As the clinical presentation resembling malignancy, we did biopsy. The biopsy results were no evidence of malignancy, then we did Manchester fothergill, and colporaphy as needed.

DISCUSSION

Length between internal to external cervical ostium ≥ 5 cm correlated to cervical elongation. Growing cervical mass could drag the cervix, predisposing to cervical elongation and prolapse. Cervical fibroids protruded through vagina was usually pedunculated. But in our cases, the fibroids were not pedunculated but manifested as a bulky mass on the cervical tissue with some bleeding and necrotics, mimicking cervical malignancy. The most important initial management besides ultrasound evaluation was mass biopsy.

CONCLUSION

In such cervical fibroids with cervical elongation resembling cervical malignancy, biopsy is compulsory to determine the diagnosis and to lead the management.

Regenerated Cell Therapy for Stress Urinary Incontinence: A Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of regenerated cell therapy for stress urinary incontinence (UI) in humans.

METHODS

We searched articles from PubMed, Embase, and the Cochrane Library database published before February 24, 2020. Of 396 records identified, 23 articles on human clinical research met our criteria, including a total of 890 patients. Stata/SE12.0 software was used to analyze cure, efficiency (cure rate plus improvement rate), and complication rates.

RESULTS

No significant differences in cure rates and effective rates were observed for any cell type in males. However, in females, the myocytes with fibroblasts subgroup (82%) and nucleated cells with platelets subgroup (89%) exhibited significantly higher cure rates compared with the other two subgroups (25% and 36%). Pooled effective rates of myocytes and fibroblasts (92%) and nucleated cells with platelets (97%) were also higher compared with the other two subgroups (72% and 60%). Pooled complication rates were 23% and 26% in males and females, respectively, and there were some differences among subgroups. Although some studies reported postoperative complications, no serious complications were reported and most recovered within 1-2 weeks.

CONCLUSIONS

Limited studies have indicated the safety and effectiveness of regenerated cells for treating stress UI in the follow-up period, which may be an ideal method to treat stress UI in the future. Moreover, nucleated cells with platelets and myocytes with fibroblasts were markedly effective, but whether cell injection therapies elicit superior effects need further confirmation.

Biomedical applications of muscle-derived stem cells: from bench to bedside

INTRODUCTION

Skeletal muscle-derived stem cells (Sk-MDSCs) are considered promising sources of adult stem cell therapy. Skeletal muscle comprises approximately 40-50% of the total body mass with marked potential for postnatal adaptive response, such as muscle hypertrophy, hyperplasia, atrophy, and regenerative capacity. This strongly suggests that skeletal muscle contains various stem/progenitor cells related to muscle-nerve-vascular tissues, which would support the above postnatal events even in adulthood.

AREA COVERED

The focus of this review is the therapeutic potential of the Sk-MDSCs as an adult stem cell autograft. For this purpose, the validity of cell isolation and purification, tissue reconstitution capacity in vivo after transplantation, comparison of the results of basic mouse and preclinical human studies, potential problematic and beneficial aspects, and effective usage have been discussed following the history of clinical applications.

EXPERT OPINION

Although the clinical application of Sk-MDSCs began as a therapy for the systemic disease of Duchenne muscular dystrophy, here, through the unique local injection method, therapy for severely damaged peripheral nerves, particularly the long-gap nerve transection, has been introduced. The beneficial aspects of the use of Sk-MDSCs as the source of local tissue transplantation therapy have also been discussed.

Status, challenges, and future prospects of stem cell therapy in pelvic floor disorders

Pelvic floor disorders (PFDs) represent a group of common and frequently-occurring diseases that seriously affect the life quality of women, generally including stress urinary incontinence and pelvic organ prolapse. Surgery has been used as a treatment for PFD, but almost 30% of patients require subsequent surgery due to a high incidence of postoperative complications and high recurrence rates. Therefore, investigations of new therapeutic strategies are urgently needed. Stem cells possess strong multi-differentiation, self-renewal, immunomodulation, and angiogenesis abilities and they are able to differentiate into various cell types of pelvic floor tissues and thus provide a potential therapeutic approach for PFD. Recently, various studies using different autologous stem cells have achieved promising results by improving the pelvic ligament and muscle regeneration and conferring the tissue elasticity and strength to the damaged tissue in PFD, as well as reduced inflammatory reactions, collagen deposition, and foreign body reaction. However, with relatively high rates of complications such as bladder stone formation and wound infections, further studies are necessary to investigate the role of stem cells as maintainers of tissue homeostasis and modulators in early interventions including therapies using new stem cell sources, exosomes, and tissue-engineering combined with stem cell-based implants, among others. This review describes the types of stem cells and the possible interaction mechanisms in PFD treatment, with the hope of providing more promising stem cell treatment strategies for PFD in the future.

A novel waterjet technology for transurethral cystoscopic injection of viable cells in the urethral sphincter complex

AIMS

In a recent preclinical study, we noticed that injection of cells in the urethral sphincter by needle through a cystoscope under visual control frequently yielded in misplacement or loss of cells. We, therefore, investigated if a needle-free waterjet device delivers viable cells under defined settings, including injection volume and pressure, fluid velocity and transportation media, precisely through the urothelium and connective tissue close to the sphincter muscle without full penetration of the sphincter apparatus.

METHODS

Mesenchymal stromal cells (MSCs) were prepared for needle-free waterjet injections. Upon injections into liquids cell viability and yield were investigated by trypan blue dye exclusion. Upon injection into cadaveric urethral tissue samples, cells were isolated from the urethrae and expanded to prove that this novel method delivered viable cells into the tissue. MSC injections by William's needle served as controls.

RESULTS

Waterjet injections of MSCs into isotonic cell culture medium resulted in equal or better yields of viable cells when compared with needle injections. Upon injection in urethral tissue samples, the waterjet technology facilitated fast and precise injections of viable cells through urothelial, mucosal and submucosal layers to reach the sphincter muscle. By controlling the injection pressure, loss of cells due to insufficient thrust or unintended full penetration was avoided.

CONCLUSIONS

Needle-free waterjet injections deliver cells in the urethra faster and more precisely when compared with needle injections without compromising their viability. This is the first proof-of-concept study providing evidence that a waterjet transports viable cells precisely into the targeted tissue.

Agreement between simple catheter method and 3D transperineal ultrasound for assessing urethral length measurement before stress urinary incontinence treatment

AIMS

Optimal placement of periurethral material has an important role in treatment efficacy with stress urinary incontinence (SUI). The validity of methods for determining urethral length and the precise location of the mid-urethral complex for SUI treatment have been sparsely studied. The aim of this study was to investigate the agreement between urethral lengths measured with a catheter and by transperineal ultrasound.

METHODS

Fifty-seven women with SUI or mixed urinary incontinence (MUI) with predominant stress symptoms were recruited. The urethral length was assessed with 3D transperineal ultrasound and measurements were taken offline from the postero-inferior margin of the pubic symphysis to the bladder neck. Then, it was measured with a foley catheter by another evaluator, blinded to the ultrasound data. The distance between the inflated balloon and the urethral meatus was considered.

RESULTS

Thirty-three women (58%) had SUI and 24 (42%) had MUI. The mean urethral length evaluated with ultrasound and the catheter were 3.03 ± 0.34 cm and 3.02 ± 0.41 cm (P = 0.857), respectively. Agreement between the two methods as assessed by the intra-class correlation coefficient was 0.90 (CI0.82-0.94, P ≤ 0.001). Limits of agreement (Bland-Altman) were +0.46 to -0.45 cm, with a mean difference of -0.01 ± 0.23 cm.

CONCLUSIONS

Findings of this study, reveal an excellent agreement between a simple catheter technique and ultrasound assessment for measuring urethral length, with a small mean bias and clinically acceptable limits of agreement. This provides relevant information in clinical practice for determining optimal placement of periurethral material or mid-urethral tape for SUI treatment.

Cell-based therapy for the treatment of female stress urinary incontinence: an early cost-effectiveness analysis

AIM

To perform an early cost-effectiveness analysis of in vitro expanded myoblasts (IVM) and minced myofibers versus midurethral slings (MUS) for surgical treatment of female stress urinary incontinence.

METHODS

Cost-effectiveness and sensitivity analyses were performed using a decision tree comprising previously published data and expert opinions.

RESULTS & CONCLUSION

In the base case scenario, MUS was the cost-effective strategy with a negative incremental cost-effectiveness ratio compared with IVM and a positive incremental cost-effectiveness ratio compared with minced myofibers. However, the sensitivity analysis indicates that IVM may become an alternative providing greater effect at a higher cost. With the possibility of becoming more effective, IVM treatment would be advantageous over MUS given its reduced invasiveness and lower risks of complications.

Development of an in vitro potency assay for human skeletal muscle derived cells

BACKGROUND

Potency is a quantitative measure of the desired biological function of an advanced therapy medicinal product (ATMP) and is a prerequisite for market approval application (MAA). To assess the potency of human skeletal muscle-derived cells (SMDCs), which are currently investigated in clinical trials for the regeneration of skeletal muscle defects, we evaluated acetylcholinesterase (AChE), which is expressed in skeletal muscle and nervous tissue of all mammals.

METHODS

CD56+ SMDCs were separated from CD56- SMDCs by magnetic activated cell sorting (MACS) and both differentiated in skeletal muscle differentiation medium. AChE activity of in vitro differentiated SMDCs was correlated with CD56 expression, fusion index, cell number, cell doubling numbers, differentiation markers and compared to the clinical efficacy in patients treated with SMDCs against fecal incontinence.

RESULTS

CD56- SMDCs did not form multinucleated myotubes and remained low in AChE activity during differentiation. CD56+ SMDCs generated myotubes and increased in AChE activity during differentiation. AChE activity was found to accurately reflect the number of CD56+ SMDCs in culture, their fusion competence, and cell doubling number. In patients with fecal incontinence responding to SMDCs treatment, the improvement of clinical symptoms was positively linked with the AChE activity of the SMDCs injected.

DISCUSSION

AChE activity was found to truly reflect the in vitro differentiation status of SMDCs and to be superior to the mere use of surface markers as it reflects not only the number of myogenic SMDCs in culture but also their fusion competence and population doubling number, thus combining cell quality and quantification of the expected mode of action (MoA) of SMDCs. Moreover, the successful in vitro validation of the assay proves its suitability for routine use. Most convincingly, our results demonstrate a link between clinical efficacy and the AChE activity of the SMDCs preparations used for the treatment of fecal incontinence. Thus, we recommend using AChE activity of in vitro differentiated SMDCs as a potency measure in end stage (phase III) clinical trials using SMDCs for skeletal muscle regeneration and subsequent market approval application (MAA).

Limited accuracy of transurethral and periurethral intrasphincteric injections of cellular suspension

AIMS

The efficacy of cell therapy in patients with stress urinary incontinence (SUI) is lower than expected. The aim of this study was to determine the injection accuracy rate both with transurethral and periurethral route.

METHODS

Autologous intraurethral cell transplantation was performed in female goats. The cells were injected either periurethrally (PERI group, two depots/animal, n = 8) or transurethrally (TRANS group, eight depots/animal, n = 11). Transurethral injections were performed under endoscopic guidance. The number and distribution of cell depots in urethras were analyzed in the three-step protocol: 1) screening of whole explants by in vivo imaging system; 2) systematic microscopic analysis of raw 10 μm cross-sections; 3) immunohistochemistry. As control, four urethras collected 1 day after transurethral transplantation were used. Episodes of cell suspension leakages after needle withdrawal were noted.

RESULTS

In all experimental animals depots were identified in the urethral wall 28 days after transplantation. The mean percentage of depots located in the urethral wall in relation to all performed injections amounted to 68.7% and 67.0% for PERI and TRANS groups, respectively. The mean proportions of depots which were identified in external urethral sphincter (EUS) amounted 18.8% and 17.1%, respectively. Suspension leakage was observed in 19% of transurethral injections.

CONCLUSIONS

Although majority of cell depots were administrated accurately into the urethral wall, the precise delivery of cells into EUS is limited regardless of injection method. The insufficient accuracy of cell delivery into EUS and cell suspension leakage can contribute to the low efficacy of cell therapy in human patients with SUI.

Autologous and heterotopic transplantation of adipose stromal vascular fraction ameliorates stress urinary incontinence in rats with simulated childbirth trauma

Introduction

Autologous transplantation of adipose stromal vascular fraction (SVF) is a cost-effective and technically accessible option for cell therapy. Clinical study of SVF transplantation for male stress urinary incontinence (SUI) is underway, but the effectiveness remains unknown for female SUI, majority of which is caused by childbirth trauma.

Methods

Vaginal Distension (VD) rats were generated as in vivo model for female SUI. To quantitate the severity of SUI, leak point pressure (LPP) was measured by placing a bladder catheter. There was a characteristic waveform of LPP with two-peaks, and we counted the second peak as an LPP value. Adipose SVF was separated from inguinal fat and delivered into external urethral sphincter (EUS) through transperineal injection. LPP was measured 7 or 14 days after SVF transplantation. Tissue damage and collagen synthesis around the EUS were visualized by Masson's trichrome and eosin staining. Antibody against α-smooth muscle actin (α-SMA) was used to stain smooth muscle or activated stromal cells. Donor SVF cells were distinguished from recipient EUS tissue by tracking with GFP transgene.

Results

VD procedure decreased the frequency at which the normal LPP waveform appeared and lowered the LPP value. SVF injection normalized the waveform as well as the level of LPP. VD disrupted histological structure of EUS and SVF failed to differentiate into striatal muscles. Instead, SVF increased α-SMA positive cells and collagen synthesis but the phenomena depended on VD stimulus. GFP tracking indicated that the transplanted SVF cells persisted for four weeks and synthesized α-SMA protein simultaneously.

Conclusions

Autologous transplantation of adipose SVF displayed bulking effects through collagen synthesis. However, such heterotopic activation was dependent on tissue damage.

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VD rat is a reproducible in vivo model for female SUI.

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LPP waveform is a good indicator of normal EUS function.

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Transplantation of adipose SVF normalizes LPP decline caused by VD.

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Heterotopic SVF synthesizes collagen, depending on tissue damage.

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Heterotopic SVF does not display voiding obstruction.

In vivo imaging system for explants analysis-A new approach for assessment of cell transplantation effects in large animal models

Introduction

Despite spectacular progress in cellular transplantology, there are still many concerns about the fate of transplanted cells. More preclinical studies are needed, especially on large animal models, to bridge the translational gap between basic research and the clinic. Herein, we propose a novel approach in analysis of cell transplantation effects in large animals explants using in vivo imaging system (IVIS®) or similar equipment.

Material and methods

In the in vitro experiment cells labeled with fluorescent membrane dyes: DID (far red) or PKH26 (orange) were visualized with IVIS®. The correlation between the fluorescence signal and cell number with or without addition of minced muscle tissue was calculated. In the ex vivo study urethras obtained from goats after intraurethral cells (n = 9) or PBS (n = 4) injections were divided into 0.5 cm cross-slices and analyzed by using IVIS®. Automatic algorithm followed or not by manual setup was used to separate specific dye signal from tissue autofluorescence. The results were verified by systematic microscopic analysis of standard 10 μm specimens prepared from slices before and after immunohistochemical staining. Comparison of obtained data was performed using diagnostic test function.

Results

Fluorescence signal strength in IVIS® was directly proportional to the number of cells regardless of the dye used and detectable for minimum 0.25x10⁶ of cells. DID-derived signal was much less affected by the background signal in comparison to PKH26 in in vitro test. Using the IVIS® to scan explants in defined arrangement resulted in precise localization of DID but not PKH26 positive spots. Microscopic analysis of histological specimens confirmed the specificity (89%) and sensitivity (80%) of IVIS® assessment relative to DID dye. The procedure enabled successful immunohistochemical staining of specimens derived from analyzed slices.

Conclusions

The IVIS® system under appropriate conditions of visualization and analysis can be used as a method for ex vivo evaluation of cell transplantation effects. Presented protocol allows for evaluation of cell delivery precision rate, enables semi-quantitative assessment of signal, preselects material for further analysis without interfering with the tissue properties. Far red dyes are appropriate fluorophores to cell labeling for this application.

Cell therapy for stress urinary incontinence: Present-day frontiers

Stress urinary incontinence (SUI) significantly diminishes the quality of patients' lives. Currently available surgical and nonsurgical therapies remain far from ideal. At present, advances in cellular technologies have stirred growing interest in the use of autologous cell treatments aimed to regain urinary control. The objective was to conduct a review of the literature and analyse preclinical and clinical studies dedicated to various cell therapies for SUI, assessing their effectiveness, safety, and future prospects. A systematic literature search in PubMed was conducted using the following key terms: "stem," "cell," "stress," "urinary," and "incontinence." A total of 32 preclinical studies and 15 clinical studies published between 1946 and December 2014 were included in the review. Most preclinical trials have used muscle-derived stem cells and adipose-derived stem cells. However, at present, the application of other types of cells, such as human amniotic fluid stem muscle-derived progenitor cells and bone marrow mesenchymal stromal cells, is becoming more extensive. While the evidence shows that these therapies are effective and safe, further work is required to standardize surgical techniques, as well as to identify indications for their use, doses and number of doses. Future research will have to focus on clinical applications of cell therapies; namely, it will have to determine indications for their use, doses of cells, optimal surgical techniques and methods, attractive cell sources, as well as to develop clinically relevant animal models and make inroads into understanding the mechanisms of SUI improvement by cell therapies.

Stem Cell Therapy: Current Applications and Potential for Urology

Stem cell therapy holds the potential to revolutionize the treatment of a number of chronic conditions. Stem cells ability to home in on injured sites of the body, stimulate angiogenesis, tissue regeneration, immunomodulation, anti-inflammatory, and anti-fibrotic factors have attracted their use in the treatment of many conditions. Urology has registered one of the highest experimental successes using stem cell therapy. However, the rate of clinical applications is comparatively lower. This review takes a look at our efforts so far and what needs to be done in order to maximize the clinical benefit we can derive from stem cells.

Women's views on autologous cell-based therapy for post-obstetric incontinence

AIM

Fecal and urinary incontinence are devastating consequences of obstetric-related perineal injury. The aim of the present study is to determine acceptability to parous women of autologous cell-based therapy for fecal and urinary incontinence that arises due to pelvic diaphragm tearing during vaginal childbirth.

MATERIALS & METHODS

A multiple choice questionnaire survey was offered to 76 parous women at the Maternity Unit, University College Hospital, London, UK. Seventy completed questionnaires - response rate: 92%.

RESULTS

In total, 84% of women indicated a willingness to accept autologous cell-based therapy for obstetric injury-induced incontinence rather than surgery.

CONCLUSION

These observational data provide an indication of likely acceptance of autologous cell-based therapies for birth injury incontinence and will help with designing new therapeutic approaches.

Targeted therapy for stress urinary incontinence: a systematic review based on clinical trials

INTRODUCTION

Controversy exists regarding the therapeutic benefit of cell-based therapy in the treatment of stress urinary incontinence (SUI).

AREAS COVERED

The aim of this systematic review was to evaluate evidence regarding the therapeutic effect and safety of cell-based therapy in the treatment of SUI and to propose a new approach to SUI treatment utilizing tissue engineering methodologies. We have thoroughly reviewed the literature using PubMed in order to identify only original, clinical studies involving cell therapy for SUI.

EXPERT OPINION

Cell-based therapy, as practiced today, is a safe but ineffective method for SUI treatment. The key to an optimal therapeutic outcome in SUI is accurate diagnosis combined with targeted therapy. Targeted therapy in SUI should be based on cell implantation to restore and regenerate the damaged urethral sphincter and/or the construction of a neo-pubourethral ligament utilizing tissue engineering methodologies.

New strategies to improve results of mesh surgeries for vaginal prolapses repair--an update

The use of meshes has become the first option for the treatment of soft tissue disorders as hernias and stress urinary incontinence and widely used in vaginal prolapse's treatment. However, complications related to mesh issues cannot be neglected. Various strategies have been used to improve tissue integration of prosthetic meshes and reduce related complications. The aim of this review is to present the state of art of mesh innovations, presenting the whole arsenal which has been studied worldwide since composite meshes, coated meshes, collagen's derived meshes and tissue engineered prostheses, with focus on its biocompatibility and technical innovations, especially for vaginal prolapse surgery.

Stem cell applications for pathologies of the urinary bladder

New stem cell based therapies are undergoing intense research and are widely investigated in clinical fields including the urinary system. The urinary bladder performs critical complex functions that rely on its highly coordinated anatomical composition and multiplex of regulatory mechanisms. Bladder pathologies resulting in severe dysfunction are common clinical encounter and often cause significant impairment of patient’s quality of life. Current surgical and medical interventions to correct urinary dysfunction or to replace an absent or defective bladder are sub-optimal and are associated with notable complications. As a result, stem cell based therapies for the urinary bladder are hoped to offer new venues that could make up for limitations of existing therapies. In this article, we review research efforts that describe the use of different types of stem cells in bladder reconstruction, urinary incontinence and retention disorders. In particular, stress urinary incontinence has been a popular target for stem cell based therapies in reported clinical trials. Furthermore, we discuss the relevance of the cancer stem cell hypothesis to the development of bladder cancer. A key subject that should not be overlooked is the safety and quality of stem cell based therapies introduced to human subjects either in a research or a clinical context.

Prospects of stem cell treatment in benign urological diseases

Stem cells (SCs) are undifferentiated cells that are capable of self-renewal and differentiation and that therefore contribute to the renewal and repair of tissues. Their capacity for division, differentiation, and tissue regeneration is highly dependent on the surrounding environment. Several preclinical and clinical studies have utilized SCs in urological disorders. In this article, we review the current status of SC use in benign urological diseases (erectile dysfunction, Peyronie disease, infertility, and urinary incontinence), and we summarize the results of the preclinical and clinical trials that have been conducted.

Stress urinary incontinence animal models as a tool to study cell-based regenerative therapies targeting the urethral sphincter

Urinary incontinence (UI) is a major health problem causing a significant social and economic impact affecting more than 200million people (women and men) worldwide. Over the past few years researchers have been investigating cell therapy as a promising approach for the treatment of stress urinary incontinence (SUI) since such an approach may improve the function of a weakened sphincter. Currently, a diverse collection of SUI animal models is available. We describe the features of the different models of SUI/urethral dysfunction and the pros and cons of these animal models in regard to cell therapy applications. We also discuss different cell therapy approaches and cell types tested in preclinical animal models. Finally, we propose new research approaches and perspectives to ensure the use of cellular therapy becomes a real treatment option for SUI.

In vivo imaging of adipose-derived mesenchymal stem cells in female nude mice after simulated childbirth injury

The aim of the present study was to track in vivo the distribution and survival of adipose-derived mesenchymal stem cells (ASCs) transplanted into female BALB/c nude mice following simulated childbirth injury, using green fluorescent protein and luciferase dual labeling, bioluminescent imaging (BLI) and histological evaluation. The results demonstrated that the dually labeled ASCs could be detected for up to eight weeks in vivo. The number of implanted cells decreased during the first three weeks, and then stabilized until the end of the experiment. According to the linear regression plot, ~27,621 implanted cells survived until eight weeks after implantation. Transplanted ASCs predominantly existed at the inoculation site of the vagina, with little or no spread to other organs. Histological analysis confirmed the survival of the engrafted ASCs. The study provided basic evidence that BLI techniques can be used to monitor ASCs in vivo in real time and in the long term. Through local administration, ASCs could survive in the long term to facilitate repair following pelvic-floor injury.

Autologous adipose stem cells in treatment of female stress urinary incontinence: results of a pilot study

The purpose of our study was to find out whether transurethral injections of autologous adipose stem cells (ASCs) are an effective and a safe treatment for female stress urinary incontinence (SUI). We treated five SUI patients with ASCs combined with bovine collagen gel and saline. Prior to the treatment, the ASCs were isolated from subcutaneous fat and expanded for 3 weeks in a good manufacturing practice-level laboratory. The mixture of ASCs and collagen was injected transurethrally via cystoscope. Additionally, viability, multipotency, and surface marker profile of ASCs were analyzed in vitro. We followed up with patients 3, 6, and 12 months after the injections. The primary endpoint was a cough test to measure objectively the effect of the treatment. Validated questionnaires were used to determine the subjective cure rate. After 6 months, 1 of 5 patients displayed a negative cough test with full bladder filled with 500 ml of saline. At 1 year, the cough test was negative with three patients; two of them were satisfied with the treatment and did not wish further treatment for SUI. Validated questionnaires showed some subjective improvement in all five patients. This is the first study describing the use of autologous ASCs in combination with collagen gel for female SUI treatments. Thus far, the treatment with autologous ASCs has proven safe and well tolerated. However, the feasibility and efficacy of the treatment were not optimal; therefore, additional research is needed to develop SUI injection therapies.

Implantation of autologous adipose-derived cells reconstructs functional urethral sphincters in rabbit cryoinjured urethra

We investigated the ability of autologous adipose-derived cells injected into cryoinjured rabbit urethras to improve urinary continence and explored the possible mechanisms by which it occurred. Adipose tissue was harvested from the perivesical region of nine 10-week-old female New Zealand White rabbits and cultured for 7 days. Immediately after harvesting the tissue, we injured the internal urethral orifice by spraying liquid nitrogen for 20 s. The cultured cells expressed the mesenchymal cell marker STRO1, but not muscle cell markers myoglobin or smooth muscle actin (SMA). Just before implantation, the adipose-derived cells were labeled with the PKH26 fluorescent cell linker. Autologous 2.0×10(6) adipose-derived cells (five rabbits) or a cell-free control solution (four rabbits) was injected around the cryoinjured urethras at 7 days after injury. Fourteen days later, the leak point pressure (LPP) was measured, and the urethras were harvested for immunohistochemical analyses. At 14 days after implantation, LPP of the cell-implanted group was significantly higher compared with the cell-free control group (p<0.05). In immunohistochemical examination, the reconstructed skeletal and smooth muscle areas in the cell-implanted regions were significantly more developed than those in controls (p<0.01). Implanted PKH26-labeled adipose-derived cells were immunohistochemically positive for myoglobin, SMA, and Pax7 antibodies, which are markers for skeletal muscles, smooth muscles, and myoblast progenitor cells, respectively. In addition, these implanted cells were positive for the nerve cell markers, tubulin β3, S100, and the vascular endothelial cell marker, von Willebrand factor. Furthermore, some of the implanted cells were positive for the transforming growth factor β1, nerve growth factor, and vascular endothelial growth factor. In conclusion, implantation of autologous adipose-derived cells into the cryoinjured rabbit urethras promoted the recovery of urethral function by myogenic differentiation, neuroregeneration, and neoangiogenesis of the implanted cells and/or the surrounding tissues as well as by bulking effects. Thus, treatment of human radical prostatectomy-related stress urinary incontinence by adipose-derived cell implantation could have significant therapeutic effects.

Emerging nanostructured materials for musculoskeletal tissue engineering

This review summarizes the recent developments in the preparation and applications of nanostructured materials for musculoskeletal tissue engineering.

Stem cell homing factor, CCL7, expression in mouse models of stress urinary incontinence

OBJECTIVES

Animal models of vaginal distention (VD) have demonstrated increased expression of chemokine (C-C motif) ligand 7 (CCL7) In this study, we investigated the expression of CCL7 in mice models of simulated birth trauma-induced urinary incontinence using VD and pudendal nerve transection (PNT).

METHODS

Forty-nine mice were divided into 6 groups: VD, sham VD, PNT, sham PNT, anesthesia, and age-matched controls. The urethra, vagina, and rectum were harvested for the expression of CCL7 immediately or 24 hours after assigned procedure. Venous sampling for quantification of serum CCL7 was also performed. An analysis of variance model was used to compare the relative expression of CCL7 in each group.

RESULTS

Urethral CCL7 expression in the VD group was significantly higher than control group after 24 hours (P < 0.01). There was no difference in the urethral CCL7 expression in PNT, sham PNT, sham VD, or anesthesia groups compared with the controls. No statistically significant difference was noted in the vaginal and rectal expression of CCL7 between any of the groups except for sham PNT. Statistically significant differences were noted in the serum CCL7 expression in the VD, PNT, and sham PNT (P < 0.01 in all) groups after 24 hours compared with the control group.

CONCLUSIONS

This study demonstrates overexpression of urethral CCL7 after VD but not PNT. This suggests that nerve injury does not contribute to the CCL7 overexpression. The overexpression of CCL7 in the serum of mice after VD suggests a translational potential where CCL7 measurement could be used as a surrogate for injury after delivery.

Regenerative medicine based applications to combat stress urinary incontinence

Stress urinary incontinence (SUI), as an isolated symptom, is not a life threatening condition. However, the fear of unexpected urine leakage contributes to a significant decline in quality of life parameters for afflicted patients. Compared to other forms of incontinence, SUI cannot be easily treated with pharmacotherapy since it is inherently an anatomic problem. Treatment options include the use of bio-injectable materials to enhance closing pressures, and the placement of slings to bolster fascial support to the urethra. However, histologic findings of degeneration in the incontinent urethral sphincter invite the use of tissues engineering strategies to regenerate structures that aid in promoting continence. In this review, we will assess the role of stem cells in restoring multiple anatomic and physiological aspects of the sphincter. In particular, mesenchymal stem cells and CD34⁺ cells have shown great promise to differentiate into muscular and vascular components, respectively. Evidence supporting the use of cytokines and growth factors such as hypoxia-inducible factor 1-alpha, vascular endothelial growth factor, basic fibroblast growth factor, hepatocyte growth factor and insulin-like growth factor further enhance the viability and direction of differentiation. Bridging the benefits of stem cells and growth factors involves the use of synthetic scaffolds like poly (1,8-octanediol-co-citrate) (POC) thin films. POC scaffolds are synthetic, elastomeric polymers that serve as substrates for cell growth, and upon degradation, release growth factors to the microenvironment in a controlled, predictable fashion. The combination of cellular, cytokine and scaffold elements aims to address the pathologic deficits to urinary incontinence, with a goal to improve patient symptoms and overall quality of life.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

PURPOSE

To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.

METHODS

Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT.

OUTCOMES

adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.

RESULTS

Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.

CONCLUSION

Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Stem cell therapy in bladder dysfunction: where are we? And where do we have to go?

To date, stem cell therapy for the bladder has been conducted mainly on an experimental basis in the areas of bladder dysfunction. The therapeutic efficacy of stem cells was originally thought to be derived from their ability to differentiate into various cell types. Studies about stem cell therapy for bladder dysfunction have been limited to an experimental basis and have been less focused than bladder regeneration. Bladder dysfunction was listed in MESH as "urinary bladder neck obstruction", "urinary bladder, overactive", and "urinary bladder, neurogenic". Using those keywords, several articles were searched and studied. The bladder dysfunction model includes bladder outlet obstruction, cryoinjured, diabetes, ischemia, and spinal cord injury. Adipose derived stem cells (ADSCs), bone marrow stem cells (BMSCs), and skeletal muscle derived stem cells (SkMSCs) are used for transplantation to treat bladder dysfunction. The main mechanisms of stem cells to reconstitute or restore bladder dysfunction are migration, differentiation, and paracrine effects. The aim of this study is to review the stem cell therapy for bladder dysfunction and to provide the status of stem cell therapy for bladder dysfunction.

The effect of urine-derived stem cells expressing VEGF loaded in collagen hydrogels on myogenesis and innervation following after subcutaneous implantation in nude mice

Impairment of sphincter muscles or their neural and vascular support leads to stress urinary incontinence. The aim of this study was to determine the role of urine-derived stem cells (USCs) over-expressing vascular endothelial growth factor (VEGF) in collagen-I gel on angiogenesis, cell survival, cell growth, myogenic phenotype differentiation of the implanted cells and innervations following implantation in vivo. USCs were infected with adenovirus containing the human VEGF165 and green fluorescent protein genes. A total of 5 × 10(6) cells, USCs alone, or plus endothelial cells or human skeletal myoblasts (as control) suspended in collagen-I gel were subcutaneously implanted into nude mice. Extensive vascularization and more implanted cells was noted in VEGF-expressing USCs groups compared to the non-VEGF groups in vivo. Numbers of the cells displaying endothelial markers (CD 31 and von Willebrand's factor) and myogenic markers (myf-5, MyoD and desmin), and regenerated nerve fibers displaying neural markers (S-100, GFAP and neurofilament) significantly increased in the grafts of VEGF-expressing USCs. Improved angiogenesis by VEGF-expressing USCs enhanced grafted cell survival, recruited the resident cells and promoted myogenic phenotype differentiation of USCs and innervation. This approach has important clinical implications for the development of cell therapies for the correction of stress urinary incontinence.

Regenerative medicine as a new therapeutic strategy for lower urinary tract dysfunction

The use of regenerative medicine for the treatment of organic and functional disorders intractable to conventional treatment has increased worldwide. This innovative medical field might particularly hold promise for the treatment of life-threatening diseases or healing of irreplaceable organs, such as the heart, liver and brain. Dysfunction of the urogenital tract and associated organs other than the kidney might not have immediate life-threatening implications; furthermore, the effectiveness of alternative therapy, such as enterocystoplasty for bladder cancer, has been shown. Therefore, most physicians or scientists do not give much importance to these disorders. However, urological disease has increased in developed societies in recent years. Furthermore, medical costs have also escalated. Disorders of the lower urinary tract, such as urinary disturbance or incontinence, can lead to other complications, impairing quality of life and ultimately increasing short- and long-term medical expenses. Regenerative medicine might hold potential solutions to these problems. Recent advances in urogenital regenerative medicine are reviewed in the present article, with particular reference to lower urinary tract reconstruction. The potential of regenerative medicine for the treatment of intractable lower urinary tract dysfunction compared with conventional treatment is also discussed.

Skeletal myogenic differentiation of urine-derived stem cells and angiogenesis using microbeads loaded with growth factors

To provide site-specific delivery and targeted release of growth factors to implanted urine-derived stem cells (USCs), we prepared microbeads of alginate containing growth factors. The growth factors included VEGF, IGF-1, FGF-1, PDGF, HGF and NGF. Radiolabeled growth factors were loaded separately and used to access the in vitro release from the microbeads with a gamma counter over 4 weeks. In vitro endothelial differentiation of USCs by the released VEGF from the microbeads in a separate experiment confirmed that the released growth factors from the microbeads were bioactive. USCs and microbeads were mixed with the collagen gel type 1 (2 mg/ml) and used for in vivo studies through subcutaneous injection into nude mice. Four weeks after subcutaneous injection, we found that grafted cell survival was improved and more cells expressed myogenic and endothelial cell transcripts and markers compared to controls. More vessel formation and innervations were observed in USCs combined with six growth factors cocktail incorporated in microbeads compared to controls. In conclusion, a combination of growth factors released locally from the alginate microbeads induced USCs to differentiate into a myogenic lineage, enhanced revascularization and innervation, and stimulated resident cell growth in vivo. This approach could potentially be used for cell therapy in the treatment of stress urinary incontinence.

Activation of VEGF and ERK1/2 and improvement of urethral function by adipose-derived stem cells in a rat stress urinary incontinence model

OBJECTIVE

To investigate the injected autologous adipose-derived stem cells (ADSCs) in improving stress urinary incontinence in a rodent model of parturition-related stress incontinence and the possible mechanism.

METHODS

The 40 rats were developed stress urinary incontinence models by postpartum balloon dilation of the vagina for 4 hours followed by bilateral ovariectomy. ADSCs were isolated from the peri-ovarian fat and labeled with thymidine analog 5-ethynyl-2-deoxyuridine (EdU). Twenty stress urinary incontinence rats received peri-urethral injection of phosphate-buffered saline as the negative controls and the other 20 stress urinary incontinence rats received peri-urethral injection of EdU-labeled ADSCc. Twenty control rats underwent sham ovariectomy without balloon dilation and served as positive controls. Four weeks later, voiding function was assessed by cystometry. Urethral histologic examination (Masson trichrome stain, picrosirius red stain, Hart elastin stain, Gordon and Sweet stain, and immunohistochemical stain) and Western blot were performed on urethral tissues.

RESULTS

Both leak point pressure and bladder capacity were significantly increased in ADSC-treated rats, compared to the balloon-injured ovariectomized rats. Histologic examination revealed normalized appearance of the fibromuscular structure of the urethra as well as increased peri-urethral blood vessel density in ADSC-treated rats. On Western blot, vascular endothelial growth factor and P-extracellular signal-regulated kinases (ERKs)1/2 protein was expressed at a higher rate in tissues from ADSC-treated rats compared to phosphate-buffered saline-treated rats.

CONCLUSION

Peri-urethral injection of ADSCs is associated with more normal urinary function and urethral structure in rats with parturition-related incontinence. The activation of vascular endothelial growth factor and ERK1/2 may be responsible for the paracrine effects from ADSCs.

Muscle-derived cells for treatment of iatrogenic sphincter damage and urinary incontinence in men

Introduction. Aim of this study was to assess the safety and efficacy of injection of autologous muscle-derived cells into the urinary sphincter for treatment of postprostatectomy urinary incontinence in men and to characterize the injected cells prior to transplantation. Methods. 222 male patients with stress urinary incontinence and sphincter damage after uroloical procedures were treated with transurethral injection of autologous muscle-derived cells. The transplanted cells were investigated after cultivation and prior to application by immunocytochemistry using different markers of myogenic differentiation. Feasibility and functionality assessment was achieved with a follow-up of at least 12 months. Results. Follow-up was at least 12 months. Of the 222 treated patients, 120 responded to therapy of whom 26 patients (12%) were continent, and 94 patients (42%) showed improvement. In 102 (46%) patients, the therapy was ineffective. Clinical improvement was observed on average 4.7 months after transplantation and continued in all improved patients. The cells injected into the sphincter were at least ~50% of myogenic origin and representative for early stages of muscle cell differentiation. Conclusions. Transurethral injection of muscle-derived cells into the damaged urethral sphincter of male patients is a safe procedure. Transplanted cells represent different phases of myogenic differentiation.

Beneficial effects of non-matched allogeneic cord blood mononuclear cells upon patients with idiopathic osteoporosis

Background

Immunological arguments and historical examples have shown that treatment with cord blood for non-hematopoietic activities, such as growth factor production and stimulation of angiogenesis, may not require matching or immune suppression.

Methods

To study the benefit of blood mononuclear cell therapy, 8 patients with idiopathic osteoporosis were given intermittent treatments with non-matched allogeneic cord blood mononuclear cells for 3 months. Morning fasting samples were collected for measuring urine N telopeptide of type-1 collagen, serum bone-specific alkaline phosphatase, and insulin-like growth factor 1 during one-year study.

Results

Clinical response was striking. Serum insulin-like growth factor 1 significantly increased in all patients at 3 months compared with baseline values, from 264.1 ± 107.0 to 384.4 ± 63.1 ng/mL (P = 0.002), with a tendency to return to baseline values at 12 months (312.9 ± 75.5 ng/mL, P = 0.083). In contrast, differences in serum bone-specific alkaline phosphatase and urine N telopeptide of type-1 collagen were not significant at 3 (P = 0.765, P = 0.057) or 12 months (P = 0.889, P = 0.122). A beneficial effect on bone density was observed in all patients at the lumbar spine. The mean bone mineral density calculated during therapy (0.6811 ± 0.1442 g/cm²) tended higher than baseline values (0.6239 ± 0.1362 g/cm², P < 0), and percentage change (median) varied from 8.85% at 3 months to 7.85% at one year. All patients are now well after one year.

Conclusions

The findings indicate that for these patients with idiopathic osteoporosis, treatment with cord blood mononuclear cells led to a significant increase in insulin-like growth factor 1 levels, which favors the increase in bone mineral density.

Intrasphincteric autologous myoblast injections with electrical stimulation for stress urinary incontinence

OBJECTIVE

To assess the feasibility and safety of ultrasound-guided autologous myoblast injections into the external urethral sphincter followed by electrical stimulation (ES) as a possible 2-step treatment for stress urinary incontinence (SUI).

METHODS

Autologous myoblasts isolated from a biceps muscle sample were injected under transurethral ultrasound guidance into the external urethral sphincter of 38 female patients. The patients also underwent ES postoperatively to enhance cell integration. Treatment feasibility, as well as possible intraoperative and postoperative complications, was assessed 6weeks after the injections. Additionally, the effects of the myoblast injections followed by an ES cycle were compared to those of a preoperative ES cycle undergone by the same patients.

RESULTS

No serious adverse events or complications were noted and the procedure was well tolerated. Compared with the objective and subjective measurements collected after the preoperative ES cycle, the corresponding measurements obtained 6weeks postoperatively, after the completion of a second ES cycle, indicated considerable improvement. The results to the stress test were negative for 29 (78.4%) of the patients, 5 (13.5%) considered their SUI cured, and 29 (78.4%) reported improvement.

CONCLUSION

Intrasphincteric autologous myoblast injections followed by ES is minimally invasive and feasible, and safely produced promising initial results. EU Clinical Trials EudraCT No. 2009-012389-30 ClinicalTrials.gov identifier: NCT01355133.

Protective effect of sodium ascorbate on efficacy of intramuscular transplantation of autologous muscle-derived cells

INTRODUCTION

The possible reason for elimination of myogenic cells after transplantation is inflammation at the injection site associated with oxidative stress. The aim of this study was to determine whether preconditioning of muscle-derived cells with an antioxidant, sodium ascorbate, can influence the fate of transplanted cells.

METHODS

Autologous transplantation of muscle-derived cells was performed in rabbits. Isolated cells were identified, lipofected with β-galactosidase, preincubated or not with sodium ascorbate, and injected intramuscularly.

RESULTS

Two weeks after autologous transplantation in the edge of a previous muscle defect, donor cells formed multinucleated young myotubes. Pretreatment of cells with sodium ascorbate before injection resulted in a significant increase of donor cells at the injection site 2 weeks after transfer.

CONCLUSIONS

These results show that: (1) preincubation with antioxidant can increase the efficacy of myogenic cell transplantation; and (2) oxidative stress may play a role in elimination of cells after autologous transplantation.

Stem cell therapy for stress urinary incontinence: a critical review

Stress urinary incontinence (SUI) is a prevailing health problem that severely impacts quality of life. Because SUI is mainly due to urethral sphincter deficiency, several preclinical and clinical trials have investigated whether transplantation of patient's own skeletal muscle-derived cells (SkMDCs) can restore the sphincter musculature. The specific cell type of SkMDCs has been described as myoblasts, satellite cells, muscle progenitor cells, or muscle-derived stem cells, and thus may vary from study to study. In more recent years, other stem cell (SC) types have also been tested, including those from the bone marrow, umbilical cord blood, and adipose tissue. These studies were mostly preclinical and utilized rat SUI models that were established predominantly by pudendal or sciatic nerve injury. Less frequently used animal models were sphincter injury and vaginal distension. While transurethral injection of SCs was employed almost exclusively in clinical trials, periurethral injection was used in all preclinical trials. Intravenous injection was also used in one preclinical study. Functional assessment of therapeutic efficacy in preclinical studies has relied almost exclusively on leak point pressure measurement. Histological assessment examined the sphincter muscle content, existence of transplanted SCs, and possible differentiation of these SCs. While all of these studies reported favorable functional and histological outcomes, there are questions about the validity of the animal model and claims of multilineage differentiation. In any event, SC transplantation appears to be a promising treatment for SUI.

Recurrent stress urinary incontinence after synthetic mid-urethral sling procedures

PURPOSE OF REVIEW

Synthetic mid-urethral slings (MUSs) have been widely adopted for female stress urinary incontinence (SUI). Practitioners are encountering increasing numbers of women with recurrent SUI after a failed MUS. Several studies over the past 18 months have reported outcomes for secondary continence procedures in this context and form the basis of this review.

RECENT FINDINGS

Expert consensus supports a trial of conservative therapy for recurrent SUI, although a sound evidence base is lacking. As regards repeat surgical intervention, retrospective studies on repeat synthetic MUSs have demonstrated medium-term cure rates of 60-70%, which is lower than that achieved with primary surgery. Secondary transobturator tape appears inferior to secondary retropubic tape in women with intrinsic sphincteric deficiency. Promising early results have been reported with spiral slings and the adjustable continence procedures, although these interventions are technically more challenging and longer-term follow-up is warranted. Artificial urinary sphincters show high efficacy rates for severe, refractory SUI, although complication rates are higher in women with prior failed MUS.

SUMMARY

Repeat synthetic MUSs are likely to form the mainstay of secondary continence procedures presently. Longer-term follow-up of promising newer modalities, including adjustable continence therapies, is required. Above all, there is an urgent need for good quality, prospective data to guide practitioners in this growing clinical challenge.

The potential of stem cells in the treatment of skeletal muscle injury and disease

Tissue engineering is a pioneering field with huge advances in recent times. These advances are not only in the understanding of how cells can be manipulated but also in potential clinical applications. Thus, tissue engineering, when applied to skeletal muscle cells, is an area of huge prospective benefit to patients with muscle disease/damage. This could include damage to muscle from trauma and include genetic abnormalities, for example, muscular dystrophies. Much of this research thus far has been focused on satellite cells, however, mesenchymal stem cells have more recently come to the fore. In particular, results of trials and further research into their use in heart failure, stress incontinence, and muscular dystrophies are eagerly awaited. Although no doubt, stem cells will have much to offer in the future, the results of further research still limit their use.

Safety, efficacy and health related quality of life of autologous myoblast transplantation for treatment of urinary incontinence in children with bladder exstrophy-epispadias complex

PURPOSE

Children with bladder exstrophy-epispadias complex undergoing endourethral autologous myoblast transplantation to treat urinary incontinence were evaluated at 4 years of followup regarding the safety, efficacy and durability of the procedure, and health related quality of life.

MATERIALS AND METHODS

Seven boys underwent autologous myoblast transplantation between May and December 2006. All patients had persistent urinary incontinence after bladder neck reconstruction and bulking agent injection. Patients were followed for 4 years after autologous myoblast transplantation regarding clinical outcomes and cystometric, urodynamic, uroflowmetric and urethrocystoscopic evaluations. Health related quality of life was also measured before treatment and at final followup.

RESULTS

No evidence of urinary obstruction was observed. Five children (71%) were completely continent and 2 (29%) were socially dry with complete daytime dryness at final followup. Health related quality of life was improved significantly. Urodynamic studies revealed a progressive increase in bladder capacity (p <0.001). Mean detrusor leak point pressure showed a 27 cm H(2)O (158%) increase during 4-year followup. Uroflowmetry parameters of voided volume and average maximum flow rate were improved significantly (p <0.001).

CONCLUSIONS

The 4-year outcomes demonstrate that autologous myoblast transplantation for urinary incontinence in children with bladder exstrophy-epispadias complex is relatively reliable, reproducible, safe and effective with minimal morbidity. This novel treatment represents a promising therapeutic approach in patients with urinary incontinence. Further randomized trials with larger numbers of patients and longer followup are needed.