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Seifalian A, Digesu A, Khullar V. The use of animal models in preclinical investigations for the development of a surgical mesh for pelvic organ prolapse. Int Urogynecol J 2024; 35:741-758. [PMID: 38358519 PMCID: PMC11052796 DOI: 10.1007/s00192-024-05741-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/20/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Polypropylene (PP) mesh for the treatment of pelvic organ prolapse (POP) has raised substantial concerns over long-term complications, leading to its ban in multiple countries. In response, emerging materials are being explored as alternatives for prolapse surgery. Preclinical animal models have historically played a pivotal role in validating medical devices, prior to clinical trials. Successful translation of these materials necessitates the identification of suitable animal models that replicate the female human pelvis and its biomechanical properties. Preclinical in vivo testing assesses the safety of surgical mesh and treatment efficacy in preventing POP recurrence. METHODS The research critically reviews animal models used for preclinical pelvic mesh testing over the last decade and proposes a promising model for future preclinical studies. RESULTS Rats were the most common mammal used for toxicity and biocompatibility investigations through abdominal implantation. Although non-human primates serve as a gold standard for efficacy testing, ethical considerations limit their use owing to their close biological and cognitive resemblance to humans. Consequently, sheep were the most preferred large animal model owing to their reproductive system similarities and propensity for spontaneous POP following parity. CONCLUSION The study contributes valuable insights into the selection of appropriate animal models for preclinical pelvic mesh testing, offering guidance that is crucial for enhancing the safety and efficacy of novel surgical interventions in the treatment of POP.
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Affiliation(s)
- Amelia Seifalian
- Department of Urogynaecology, Imperial College London, London, UK.
| | - Alex Digesu
- Department of Urogynaecology, Imperial College London, London, UK
| | - Vikram Khullar
- Department of Urogynaecology, Imperial College London, London, UK
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2
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Miller B, Wolfe W, Gentry JL, Grewal MG, Highley CB, De Vita R, Vaughan MH, Caliari SR. Supramolecular Fibrous Hydrogel Augmentation of Uterosacral Ligament Suspension for Treatment of Pelvic Organ Prolapse. Adv Healthc Mater 2023; 12:e2300086. [PMID: 37220996 DOI: 10.1002/adhm.202300086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 05/11/2023] [Indexed: 05/25/2023]
Abstract
Uterosacral ligament suspension (USLS) is a common surgical treatment for pelvic organ prolapse (POP). However, the relatively high failure rate of up to 40% underscores a strong clinical need for complementary treatment strategies, such as biomaterial augmentation. Herein, the first hydrogel biomaterial augmentation of USLS in a recently established rat model is described using an injectable fibrous hydrogel composite. Supramolecularly-assembled hyaluronic acid (HA) hydrogel nanofibers encapsulated in a matrix metalloproteinase (MMP)-degradable HA hydrogel create an injectable scaffold showing excellent biocompatibility and hemocompatibility. The hydrogel can be successfully delivered and localized to the suture sites of the USLS procedure, where it gradually degrades over six weeks. In situ mechanical testing 24 weeks post-operative in the multiparous USLS rat model shows the ultimate load (load at failure) to be 1.70 ± 0.36 N for the intact uterosacral ligament (USL), 0.89 ± 0.28 N for the USLS repair, and 1.37 ± 0.31 N for the USLS + hydrogel (USLS+H) repair (n = 8). These results indicate that the hydrogel composite significantly improves load required for tissue failure compared to the standard USLS, even after the hydrogel degrades, and that this hydrogel-based approach can potentially reduce the high failure rate associated with USLS procedures.
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Affiliation(s)
- Beverly Miller
- Department of Chemical Engineering, University of Virginia, Charlottesville, VA, 22903, USA
| | - Wiley Wolfe
- Scripps Institution of Oceanography, University of California, San Diego, La Jolla, CA, 92 093, USA
| | - James L Gentry
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, 22 903, USA
| | - M Gregory Grewal
- Department of Chemical Engineering, University of Virginia, Charlottesville, VA, 22903, USA
| | - Christopher B Highley
- Department of Chemical Engineering, University of Virginia, Charlottesville, VA, 22903, USA
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, 22 903, USA
| | - Raffaella De Vita
- Stretch Lab, Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, 24 061, USA
| | - Monique H Vaughan
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, 22 903, USA
| | - Steven R Caliari
- Department of Chemical Engineering, University of Virginia, Charlottesville, VA, 22903, USA
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, 22 903, USA
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3
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Polypropylene Pelvic Mesh: What Went Wrong and What Will Be of the Future? Biomedicines 2023; 11:biomedicines11030741. [PMID: 36979721 PMCID: PMC10045074 DOI: 10.3390/biomedicines11030741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023] Open
Abstract
Background: Polypropylene (PP) pelvic mesh is a synthetic mesh made of PP polymer used to treat pelvic organ prolapse (POP). Its use has become highly controversial due to reports of serious complications. This research critically reviews the current management options for POP and PP mesh as a viable clinical application for the treatment of POP. The safety and suitability of PP material were rigorously studied and critically evaluated, with consideration to the mechanical and chemical properties of PP. We proposed the ideal properties of the ‘perfect’ synthetic pelvic mesh with emerging advanced materials. Methods: We performed a literature review using PubMed/Medline, Embase, Cochrane Library (Wiley) databases, and ClinicalTrials.gov databases, including the relevant keywords: pelvic organ prolapse (POP), polypropylene mesh, synthetic mesh, and mesh complications. Results: The results of this review found that although PP is nontoxic, its physical properties demonstrate a significant mismatch between its viscoelastic properties compared to the surrounding tissue, which is a likely cause of complications. In addition, a lack of integration of PP mesh into surrounding tissue over longer periods of follow up is another risk factor for irreversible complications. Conclusions: PP mesh has caused a rise in reports of complications involving chronic pain and mesh exposure. This is due to the mechanical and physicochemical properties of PP mesh. As a result, PP mesh for the treatment of POP has been banned in multiple countries, currently with no alternative available. We propose the development of a pelvic mesh using advanced materials including emerging graphene-based nanocomposite materials.
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MacCraith E, Joyce M, do Amaral RJFC, O'Brien FJ, Davis NF. Development and in vitro investigation of a biodegradable mesh for the treatment of stress urinary incontinence. Int Urogynecol J 2022; 33:2177-2184. [PMID: 35312806 PMCID: PMC9343266 DOI: 10.1007/s00192-022-05160-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/22/2022] [Indexed: 11/18/2022]
Abstract
Introduction and hypothesis The use of polypropylene (PP) mesh for stress urinary incontinence (SUI) surgery has declined because of safety concerns. The aim of this study is to evaluate a biodegradable polycaprolactone (PCL) mesh and a PCL composite mesh tissue engineered with human uterine fibroblasts (HUFs) for SUI surgery by comparing mechanical properties and in vitro biocompatibility to commercially available PP and porcine dermis (PD). Methods The mechanical properties of four scaffold materials were evaluated: PCL, PCL-collagen-hyaluronic acid composite, acellular porcine dermal collagen (PD) (Pelvicol™) and polypropylene (Gynecare TVT™ Exact®). HUFs were seeded on separate scaffolds. After 7 and 14 days scaffolds were assessed for metabolic activity and cell proliferation using Alamar Blue, Live/Dead and PicoGreen assays. Soluble collagen production was evaluated using a Sircol assay. Results PCL and the composite scaffold reached ultimate tensile strength (UTS) values closest to healthy pelvic floor tissue (PCL = 1.19 MPa; composite = 1.13 MPa; pelvic floor = 0.79 MPa; Lei et al. Int Urogynecol J Pelvic Floor Dysfunct. 18(6):603-7, 2007). Cells on PCL showed significantly greater cell viability than PP at day 7 (p < 0.0001). At D14 the composite scaffold showed significantly greater cell viability than PP (p = 0.0006). PCL was the best performing scaffold for soluble collagen production at day 14 (106.1 μg versus 13.04 μg for PP, p = 0.0173). Conclusions We have designed a biodegradable PCL mesh and a composite mesh which demonstrate better biocompatibility than PP and mechanical properties closer to that of healthy pelvic floor tissue. This in vitro study provides promising evidence that these two implants should be evaluated in animal and human trials.
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Affiliation(s)
- E MacCraith
- Tissue Engineering Research Group & AMBER Centre, Department of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland. .,Department of Urology, Blackrock Clinic, Dublin, Ireland.
| | - M Joyce
- Tissue Engineering Research Group & AMBER Centre, Department of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - R J F C do Amaral
- Tissue Engineering Research Group & AMBER Centre, Department of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - F J O'Brien
- Tissue Engineering Research Group & AMBER Centre, Department of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - N F Davis
- Tissue Engineering Research Group & AMBER Centre, Department of Anatomy & Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Urology, Blackrock Clinic, Dublin, Ireland
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5
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Diedrich CM, Guler Z, Hympanova L, Vodegel E, Zündel M, Mazza E, Deprest J, Roovers JP. Evaluation of the short-term host response and biomechanics of an absorbable poly-4-hydroxybutyrate scaffold in a sheep model following vaginal implantation. BJOG 2021; 129:1039-1049. [PMID: 34865300 PMCID: PMC9303173 DOI: 10.1111/1471-0528.17040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/19/2021] [Accepted: 11/30/2021] [Indexed: 12/01/2022]
Abstract
Objective To evaluate the host‐ and biomechanical response to a fully absorbable poly‐4‐hydroxybutyrate (P4HB) scaffold in comparison with the response to polypropylene (PP) mesh. Design In vivo animal experiment. Setting KU Leuven Center for Surgical Technologies. Population Fourteen parous female Mule sheep. Methods P4HB scaffolds were surgically implanted in the posterior vaginal wall of sheep. The comparative PP mesh data were obtained from an identical study protocol performed previously. Main outcome measures Gross necropsy, host response and biomechanical evaluation of explants, and the in vivo P4HB scaffold degradation were evaluated at 60‐ and 180‐days post‐implantation. Data are reported as mean ± standard deviation (SD) or standard error of the mean (SEM). Results Gross necropsy revealed no implant‐related adverse events using P4HB scaffolds. The tensile stiffness of the P4HB explants increased at 180‐days (12.498 ± 2.66 N/mm SEM [p =0.019]) as compared to 60‐days (4.585 ± 1.57 N/mm) post‐implantation, while P4HB degraded gradually. P4HB scaffolds exhibited excellent tissue integration with dense connective tissue and a moderate initial host response. P4HB scaffolds induced a significantly higher M2/M1 ratio (1.70 ± 0.67 SD, score 0–4), as compared to PP mesh(0.99 ± 0.78 SD, score 0–4) at 180‐days. Conclusions P4HB scaffold facilitated a gradual load transfer to vaginal tissue over time. The fully absorbable P4HB scaffold, in comparison to PP mesh, has a favorable host response with comparable load‐bearing capacity. If these results are also observed at longer follow‐up in‐vivo, a clinical study using P4HB for vaginal POP surgery may be warranted to demonstrate efficacy. Tweetable Abstract Degradable vaginal P4HB implant might be a solution for treatment of POP. Degradable vaginal P4HB implant might be a solution for treatment of POP.
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Affiliation(s)
- Chantal M Diedrich
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Zeliha Guler
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lucie Hympanova
- Centre for Surgical Technologies, Biomedical Sciences Group, KU Leuven, Leuven, Belgium.,Third Faculty of Medicine, Institute for the Care of Mother and Child, Charles University, Prague, Czech Republic
| | - Eva Vodegel
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manuel Zündel
- Institute of Mechanical Systems, ETH Zurich, Zurich, Switzerland.,Swiss Federal Laboratories for Materials Science and Technology, EMPA, Dübendorf, Switzerland
| | - Edoardo Mazza
- Institute of Mechanical Systems, ETH Zurich, Zurich, Switzerland.,Swiss Federal Laboratories for Materials Science and Technology, EMPA, Dübendorf, Switzerland
| | - Jan Deprest
- Centre for Surgical Technologies, Biomedical Sciences Group, KU Leuven, Leuven, Belgium
| | - Jan Paul Roovers
- Department of Obstetrics and Gynaecology, Center for Reproductive Medicine (AMC), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Morch A, Doucède G, Lecomte-Grosbras P, Brieu M, Rubod C, Cosson M. Pelvic organ prolapse meshes: Can they preserve the physiological behavior? J Mech Behav Biomed Mater 2021; 120:104569. [PMID: 34058600 DOI: 10.1016/j.jmbbm.2021.104569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/24/2020] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
Implants for the cure of female genital prolapse still show numerous complications cases that sometimes have dramatic consequences. These implants must be improved to provide physiological support and restore the normal functionalities of the pelvic area. Besides the trend towards lighter meshes, a better understanding of the in vivo role and impact of the mesh implantation is required. This work investigates the mechanical impact of meshes after implantation with regards to the behavior of the native tissues. Three meshes were studied to assess their mechanical and biological impact on the native tissues. An animal study was conducted on rats. Four groups (n = 17/group) underwent surgery. Rats were implanted on the abdominal wall with one of the three polypropylene knitted mesh (one mesh/group). The last group served as control and underwent the same surgery without any mesh implantation. Post-operative complications, contraction, mechanical rigidities, and residual deformation after cyclic loading were collected. Non-parametric statistical comparisons were performed (Kruskal-Wallis) to observe potential differences between implanted and control groups. Mechanical characterization showed that one of the three meshes did not alter the mechanical behavior of the native tissues. On the contrary, the two others drastically increased the rigidities and were also associated with clinical complications. All of the meshes seem to reduce the geometrical lengthening of the biological tissues that comes with repetitive loads. Mechanical aspects might play a key role in the compatibility of the mesh in vivo. One of the three materials that were implanted during an animal study seems to provide better support and adapt more properly to the physiological behavior of the native tissues.
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Affiliation(s)
- Annie Morch
- Univ. Lille, CNRS, Centrale Lille, UMR 9013- LaMcube - Laboratoire de Mécanique, Multiphysique, Multi-échelle, F-59000, Lille, France
| | - Guillaume Doucède
- Service de Chirurgie gynécologique - CHU Lille, F-59000, Lille, France; Université de Lille - Faculté de Lille, F-59000, Lille, France
| | - Pauline Lecomte-Grosbras
- Univ. Lille, CNRS, Centrale Lille, UMR 9013- LaMcube - Laboratoire de Mécanique, Multiphysique, Multi-échelle, F-59000, Lille, France
| | - Mathias Brieu
- Univ. Lille, CNRS, Centrale Lille, UMR 9013- LaMcube - Laboratoire de Mécanique, Multiphysique, Multi-échelle, F-59000, Lille, France; California State University - Los Angeles, College Engineering - Computer Science, and Technology, Dept. Mechanical Engineering, United States
| | - Chrystèle Rubod
- Univ. Lille, CNRS, Centrale Lille, UMR 9013- LaMcube - Laboratoire de Mécanique, Multiphysique, Multi-échelle, F-59000, Lille, France; Service de Chirurgie gynécologique - CHU Lille, F-59000, Lille, France; Université de Lille - Faculté de Lille, F-59000, Lille, France
| | - Michel Cosson
- Univ. Lille, CNRS, Centrale Lille, UMR 9013- LaMcube - Laboratoire de Mécanique, Multiphysique, Multi-échelle, F-59000, Lille, France; Service de Chirurgie gynécologique - CHU Lille, F-59000, Lille, France; Université de Lille - Faculté de Lille, F-59000, Lille, France.
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7
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Peró M, Casani L, Castells-Sala C, Pérez ML, Moga Naranjo E, Juan-Babot O, Alserawan De Lamo L, López-Chicón P, Vilarrodona Serrat A, Badimon L, Porta Roda O. Rabbit as an animal model for the study of biological grafts in pelvic floor dysfunctions. Sci Rep 2021; 11:10545. [PMID: 34006889 PMCID: PMC8131625 DOI: 10.1038/s41598-021-89698-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 04/22/2021] [Indexed: 11/28/2022] Open
Abstract
The aims of this study were to evaluate the feasibility of the New Zealand White (NZW) rabbit for studying implanted biomaterials in pelvic reconstructive surgery; and to compare the occurrence of graft-related complications of a commercial polypropylene (PP) mesh and new developed human dermal matrix implanted at vaginal and abdominal level. 20 white female NZW rabbits were randomized into two groups, experimental group (human acellular dermal matrices-hADM-graft) and control group (commercial PP graft). In each animal, grafts were surgically implanted subcutaneously in the abdominal wall and in the vaginal submucosa layer for 180 days. The graft segments were then removed and the surgical and clinical results were analyzed. The main surgical challenges during graft implantation were: (a) an adequate vaginal exposure while maintaining the integrity of the vaginal mucosa layer; (b) to keep aseptic conditions; (c) to locate and dissect the breast vein abdominal surgery; and (d) to withdraw blood samples from the ear artery. The most abnormal findings during the explant surgery were found in the PP group (33% of vaginal mesh extrusion) in comparison with the hADM group (0% of vaginal graft extrusion), p = 0.015. Interestingly, macroscopic observation showed that the integration of the vaginal grafts was more common in the hADM group (40%) than in the PP group, in which the vaginal mesh was identified in 100% of the animals (p = 0.014). The NZW rabbit is a good model for assessing materials to be used as grafts for pelvic reconstructive surgery and vaginal surgery. Animals are easily managed during the procedures, including surgical intervention and vaginal mucosa approach. Additionally, hADM is associated with fewer clinical complications, as well as better macroscopic tissue integration, compared to PP mesh.
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Affiliation(s)
- Marta Peró
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Carrer Sant Quintí, 89, 08041, Barcelona, Spain.
| | - Laura Casani
- Research Institute of the Hospital de Sant Pau-IIB Sant Pau, Barcelona, Spain
| | - Cristina Castells-Sala
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Maria Luisa Pérez
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Esther Moga Naranjo
- Department of Immunology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Juan-Babot
- Research Institute of the Hospital de Sant Pau-IIB Sant Pau, Barcelona, Spain
| | - Leticia Alserawan De Lamo
- Department of Immunology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Patricia López-Chicón
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Anna Vilarrodona Serrat
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Lina Badimon
- Research Institute of the Hospital de Sant Pau-IIB Sant Pau, Barcelona, Spain
| | - Oriol Porta Roda
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Carrer Sant Quintí, 89, 08041, Barcelona, Spain
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8
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Hu Q, Zhang R, Zhang H, Yang D, Liu S, Song Z, Gu Y, Ramalingam M. Topological Structure Design and Fabrication of Biocompatible PLA/TPU/ADM Mesh with Appropriate Elasticity for Hernia Repair. Macromol Biosci 2021; 21:e2000423. [PMID: 33870647 DOI: 10.1002/mabi.202000423] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/21/2021] [Indexed: 11/06/2022]
Abstract
The meshes for hernia repair result in many problems that are related to complications including chronic pain and limited movement due to inadequate mechanical strength, non-absorbability, or low elasticity. In this study, degradable polylactic acid (PLA), synthetic thermoplastic polyurethane (TPU), and acellular dermal matrix (ADM) powders are combined to prepare a novel PLA/TPU/ADM mesh with three different topological structures (square, circular, and diamond) by 3D printing. The physicochemical properties and structural characteristics of mesh are studied, the results show that the diamond structure mesh with the pore size of 3 mm has sufficient elasticity and tensile strength, which provides the efficient mechanical strength required for hernia repair (16 N cm-1 ) and the value more than polypropylene(PP) mesh. Besides, in vitro and in vivo experiments demonstrate human umbilical vein endothelial cells could successfully proliferate on the PLA/TPU/ADM mesh whose biocompatibility with the host is shown using a rat model of abdominal wall defect. In conclusion, the results of this study demonstrate that the PLA/TPU/ADM mesh may be considered a good choice for hernia repair as its potential to overcome the elastic and strength challenges associated with a highly flexible abdominal wall, as well as its good biocompatibility.
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Affiliation(s)
- Qingxi Hu
- Rapid Manufacturing Engineering Center, Shanghai University, Shanghai, 200444, China.,Shanghai Key Laboratory of Intelligent Manufacturing and Robotics, Shanghai University, Shanghai, 200072, China
| | - Rennan Zhang
- Rapid Manufacturing Engineering Center, Shanghai University, Shanghai, 200444, China
| | - Haiguang Zhang
- Rapid Manufacturing Engineering Center, Shanghai University, Shanghai, 200444, China.,Shanghai Key Laboratory of Intelligent Manufacturing and Robotics, Shanghai University, Shanghai, 200072, China
| | - Dongchao Yang
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200011, China
| | - Suihong Liu
- Rapid Manufacturing Engineering Center, Shanghai University, Shanghai, 200444, China
| | - Zhicheng Song
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200011, China
| | - Yan Gu
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200011, China
| | - Murugan Ramalingam
- Biomaterials and Organ Engineering Group, Centre for Biomaterials, Cellular and Molecular Theranostics, School of Mechanical Engineering, Vellore Institute of Technology, Vellore, 632014, India
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9
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Besseling PJ, Mes T, Bosman AW, Peeters JW, Janssen HM, Bakker MH, Fledderus JO, Teraa M, Verhaar MC, Gremmels H, Dankers PYW. The in‐vitro biocompatibility of ureido‐pyrimidinone compounds and polymer degradation products. JOURNAL OF POLYMER SCIENCE 2021. [DOI: 10.1002/pol.20210072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paul J. Besseling
- Department of Nephrology and Hypertension University Medical Center Utrecht Utrecht The Netherlands
| | | | | | | | - Henk M. Janssen
- SyMO‐Chem BV Den Dolech 2 Eindhoven The Netherlands
- Department of Biomedical Engineering, Laboratory of Chemical Biology Eindhoven University of Technology Eindhoven The Netherlands
| | - Maarten H. Bakker
- Institute for Complex Molecular Systems Eindhoven University of Technology Eindhoven The Netherlands
| | - Joost O. Fledderus
- Department of Nephrology and Hypertension University Medical Center Utrecht Utrecht The Netherlands
| | - Martin Teraa
- Department of Nephrology and Hypertension University Medical Center Utrecht Utrecht The Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension University Medical Center Utrecht Utrecht The Netherlands
| | - Hendrik Gremmels
- Department of Nephrology and Hypertension University Medical Center Utrecht Utrecht The Netherlands
| | - Patricia Y. W. Dankers
- Department of Biomedical Engineering, Laboratory of Chemical Biology Eindhoven University of Technology Eindhoven The Netherlands
- Institute for Complex Molecular Systems Eindhoven University of Technology Eindhoven The Netherlands
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10
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Biodegradable materials for surgical management of stress urinary incontinence: A narrative review. Eur J Obstet Gynecol Reprod Biol 2021; 259:153-160. [PMID: 33676124 DOI: 10.1016/j.ejogrb.2021.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/18/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022]
Abstract
Stress urinary incontinence (SUI) was managed with techniques such as colposuspension, autologous fascia sling and urethral bulking agents. The introduction of the mid-urethral polypropylene (PP) sling in the 1990s led to a significant and rapid global change in SUI surgery. The synthetic non-degradable PP sling had superior results to traditional SUI procedures but its use has now declined due to significant complications such as pain and mesh erosion. These complications are attributed to its poor biocompatibility and integration into vaginal tissues. The efficacy of PP was extrapolated from studies on abdominal wall repair and it is now clear that integration of implanted materials in the pelvic floor differs from the abdominal wall. With PP prohibited in some jurisdictions, female patients with SUI have few management options. In the present review we summarise recent advances in SUI surgery and evaluate potential alternatives to PP slings with a particular focus on degradable materials. Allograft and xenograft materials demonstrate good biocompatibility but have yielded suboptimal cure rates. Tissue engineered synthetic degradable materials outperform unmodified synthetic degradable materials in terms of biomechanics and cell support. Synthetic tissue engineered degradable materials show promising results from in vitro studies and future research should focus on animal and human trials in this field.
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11
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Fully absorbable poly-4-hydroxybutyrate implants exhibit more favorable cell-matrix interactions than polypropylene. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 120:111702. [PMID: 33545861 DOI: 10.1016/j.msec.2020.111702] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/22/2020] [Accepted: 11/02/2020] [Indexed: 12/18/2022]
Abstract
Pelvic organ prolapse (POP) is a multifactorial condition characterized by the descent of the pelvic organs due to the loss of supportive tissue strength. This is presumably caused by the decreased fibroblast function and the subsequent change in the quality of the extracellular matrix. The correction of POP using an implant intends to provide mechanical support to the pelvic organs and to stimulate a moderate host response. Synthetic polypropylene (PP) implants were commonly used for the correction of prolapse. Although they were successful in providing support, these implants have been associated with clinical complications in the long term due to substantial foreign body response and inappropriate tissue integration. The complications can be avoided or minimized by engineering a biocompatible and fully absorbable implant with optimized mechanical and structural characteristics that favor more appropriate cellular interactions with the implant. Therefore, in this study, we evaluated implants comprised of poly-4-hydroxybutyrate (P4HB), a fully absorbable material with high mechanical strength, as an alternative to PP. The P4HB implants were knitted in four unique designs with different pore shapes ranging from a more rectangular geometry- as it is in PP implant- to a rounded geometry, to determine the effect of the implant structure on the textural and mechanical properties and subsequent cell-matrix interaction. The cellular response was investigated by seeding primary vaginal fibroblasts isolated from patients with POP. P4HB favored cellular functions more than PP, as indicated by greater cell attachment and proliferation (P < 0.01), and significantly more collagen deposition (P4HB vs PP, 11.19 μg vs 6.67 μg) at 28 days culture (P < 0.05). All P4HB implants had higher strength and lower stiffness than the PP scaffold. The material and the design of the implant also influenced the behavior of vaginal fibroblasts. The aspect ratio of the vaginal POP fibroblasts cultured on the PP implant (1.61 ± 0.75) was significantly (P < 0.005) smaller than those cultured on P4HB implants (average 2.31 ± 0.09). The P4HB structure with rounded pores showed the lowest stiffness and highest fibroblast attachment and proliferation (P < 0.01). Overall, P4HB induces more matrix deposition compared to PP and knit design can further optimize cell behavior.
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Farmer ZL, Domínguez-Robles J, Mancinelli C, Larrañeta E, Lamprou DA. Urogynecological surgical mesh implants: New trends in materials, manufacturing and therapeutic approaches. Int J Pharm 2020; 585:119512. [PMID: 32526332 DOI: 10.1016/j.ijpharm.2020.119512] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/14/2023]
Abstract
Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI) are two prevalent disorders affecting 30-40% of women worldwide. Current strategies to repair or improve these medical conditions are non-surgical options such as physiotherapy, or surgical options such as the use of vaginal meshes. The synthetic material polypropylene (PP), which has long been used for manufacturing these vaginal meshes, is associated with severe complications such as chronic pain, infection or mesh erosion. As a result of a widespread reporting and unacceptably high rates of complications, these issues have become a public health concern. Regulatory bodies have recently deemed the transvaginal placement of PP mesh in the pelvic floor (PF) no longer a suitable treatment method for PF repair, leading to the need for a novel approach to the manufacture and selection of materials for urogynecological meshes. Medical devices, such as vaginal meshes can be manufactured using a variety of techniques including injection moulding, electrospinning, hot-melt extrusion (HME) or more recently 3D printing. Over the past decade, the use of 3D printing within the medical device industry has expanded and offers a promising approach to manufacture patient-specific surgical mesh when combined with imaging tools. This review will summarise the current strategies to treat POP and SUI, the issues and use of current meshes for the treatment of these pelvic floor disorders (PFDs), and the future directions for the manufacture of more suitable urogynecological meshes, as well as their potential materials.
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Affiliation(s)
- Zara-Louise Farmer
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Juan Domínguez-Robles
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Caterina Mancinelli
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Eneko Larrañeta
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
| | - Dimitrios A Lamprou
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK.
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Mori da Cunha MGM, Arts B, Hympanova L, Rynkevic R, Mackova K, Bosman AW, Dankers PY, Deprest J. Functional supramolecular bioactivated electrospun mesh improves tissue ingrowth in experimental abdominal wall reconstruction in rats. Acta Biomater 2020; 106:82-91. [PMID: 32006652 DOI: 10.1016/j.actbio.2020.01.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/24/2020] [Accepted: 01/24/2020] [Indexed: 12/18/2022]
Abstract
Development of biomaterials for hernia and pelvic organ prolapse (POP) repair is encouraged because of high local complication rates with current materials. Therefore, we aimed to develop a functionalized electrospun mesh that promotes tissue ingrowth and provides adequate mechanical strength and compliance during degradation. We describe the in vivo function of a new supramolecular bioactivated polycarbonate (PC) material based on fourfold hydrogen bonding ureidopyrimidinone (UPy) units (UPy-PC). The UPy-PC material was functionalized with UPy-modified cyclic arginine-glycine-aspartic acid (cRGD) peptide additives. Morphometric analysis of the musculofascial content during wound healing showed that cRGD functionalization promotes myogenesis with inhibition of collagen deposition at 14 days. It also prevents muscle atrophy at 90 days and exerts an immunomodulatory effect on infiltrating macrophages at 14 days and foreign body giant cell formation at 14 and 90 days. Additionally, the bioactivated material promotes neovascularization and connective tissue ingrowth. Supramolecular cRGD-bioactivation of UPy-PC-meshes promotes integration of the implant, accelerates tissue ingrowth and reduces scar formation, resulting in physiological neotissue formation when used for abdominal wall reconstruction in the rat hernia model. Moreover, cRGD-bioactivation prevents muscle atrophy and modulates the inflammatory response. Our results provide a promising outlook towards a new type of biomaterial for the treatment of hernia and POP. STATEMENT OF SIGNIFICANCE: Development of biomaterials for hernia and pelvic organ prolapse (POP) repair is encouraged because of high local complication rates with current materials. Ureidopyrimidinone-polycarbonate is a elastomeric and biodegradable electrospun mesh, which could mimic physiological compliance. The UPy-PC material was functionalized with UPy-modified cyclic arginine-glycine-aspartic acid (cRGD) peptide additives. Supramolecular cRGD-bioactivation of UPy-PC-meshes promotes integration of the implant, accelerates tissue ingrowth and reduces scar formation, resulting in physiological neotissue formation when used for abdominal wall reconstruction in rat hernia model. Moreover, cRGD-bioactivation prevents muscle atrophy and modulates the inflammatory response. These data provide a promising outlook towards a new type of biomaterial for the treatment of hernia and POP.
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The importance of developing relevant animal models to assess existing and new materials. Curr Opin Urol 2020; 29:400-406. [PMID: 31008781 DOI: 10.1097/mou.0000000000000625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW We summarize the recent literature on the use of different animal models for testing existing and new materials for treatment of pelvic organ prolapse. RECENT FINDINGS A wide spectrum of animal models is being used in urogynecology, both for the study of physiologic and pathophysiologic processes, training in surgical procedures, yet mainly to study the host response to implant materials. The quality of studies is variable, and procedures, read-outs, and reporting are not standardized. This makes comparison very difficult. The research community is experimenting with different knitting patterns, novel polymers, bioactivation, as well as resorbable rather than durable implants. Outcomes of the experiments are dependent on the location of implantation. Lighter polypropylene constructs seem to induce a less vigorous host response than elder heavier products. Modification of the surface yields contradictory findings. Resorbable acellular collagen matrices may be reintroduced as prophylactically inserted support structures. SUMMARY Although animal experimentation with novel candidate implants is advocated, there is a lack of standardization in reporting. The concept of resorbable construct is being revived, as durable materials have caused clinical graft-related complications. Large animal experiments seem to provide interesting and more comprehensive information, yet their use may be contested.
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Hympánová L, Rynkevic R, Román S, Mori da Cunha MG, Mazza E, Zündel M, Urbánková I, Gallego MR, Vange J, Callewaert G, Chapple C, MacNeil S, Deprest J. Assessment of Electrospun and Ultra-lightweight Polypropylene Meshes in the Sheep Model for Vaginal Surgery. Eur Urol Focus 2020; 6:190-198. [DOI: 10.1016/j.euf.2018.07.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/21/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
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Bonito V, de Kort BJ, Bouten CV, Smits AI. Cyclic Strain Affects Macrophage Cytokine Secretion and Extracellular Matrix Turnover in Electrospun Scaffolds. Tissue Eng Part A 2019; 25:1310-1325. [DOI: 10.1089/ten.tea.2018.0306] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Valentina Bonito
- Soft Tissue Engineering & Mechanobiology Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Bente J. de Kort
- Soft Tissue Engineering & Mechanobiology Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carlijn V.C. Bouten
- Soft Tissue Engineering & Mechanobiology Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Anthal I.P.M. Smits
- Soft Tissue Engineering & Mechanobiology Group, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
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Abstract
Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are conditions which result in significant physical, mental and social consequences for women worldwide. The high rates of recurrence reported with primary repair for POP led to the use of synthetic mesh to augment repairs in both primary and secondary cases following failed previous POP repair. The widely reported, unacceptably high rates of complications associated with the use of synthetic, transvaginal mesh in pelvic floor repair have severely limited the treatment options that surgeons can offer. This article summarises the recent advances in pelvic floor repair, such as improved quantification and modelling of the biomechanics of the pelvic floor and the developing technology within the field of tissue engineering for treatment of SUI/POP, including biomaterials and cell-based therapies. Finally, we will discuss the issues surrounding the commercial introduction of synthetic mesh for use within the pelvic floor and what lessons can be learned for the future as well as the current guidance surrounding treatment for SUI/POP.
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Affiliation(s)
- Emma Mironska
- Department of Materials Science and Engineering, Kroto Research Institute, University of Sheffield, Red Hill, Sheffield, S37HQ, UK
| | - Christopher Chapple
- Urology Department, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Sheila MacNeil
- Department of Materials Science and Engineering, Kroto Research Institute, University of Sheffield, Red Hill, Sheffield, S37HQ, UK
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Mori da Cunha MGMC, Hympanova L, Rynkevic R, Mes T, Bosman AW, Deprest J. Biomechanical Behaviour and Biocompatibility of Ureidopyrimidinone-Polycarbonate Electrospun and Polypropylene Meshes in a Hernia Repair in Rabbits. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E1174. [PMID: 30974868 PMCID: PMC6480159 DOI: 10.3390/ma12071174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 12/29/2022]
Abstract
Although mesh use has significantly improved the outcomes of hernia and pelvic organ prolapse repair, long-term recurrence rates remain unacceptably high. We aim to determine the in vivo degradation and functional outcome of reconstructed abdominal wall defects, using slowly degradable electrospun ureidopyrimidinone moieties incorporated into a polycarbonate backbone (UPy-PC) implant compared to an ultra-lightweight polypropylene (PP) textile mesh with high pore stability. Twenty four New-Zealand rabbits were implanted with UPy-PC or PP to either reinforce a primary fascial defect repair or to cover (referred to as gap bridging) a full-thickness abdominal wall defect. Explants were harvested at 30, 90 and 180 days. The primary outcome measure was uniaxial tensiometry. Secondary outcomes were the recurrence of herniation, morphometry for musculofascial tissue characteristics, inflammatory response and neovascularization. PP explants compromised physiological abdominal wall compliance from 90 days onwards and UPy-PC from 180 days. UPy-PC meshes induced a more vigorous inflammatory response than PP at all time points. We observed progressively more signs of muscle atrophy and intramuscular fatty infiltration in the entire explant area for both mesh types. UPy-PC implants are replaced by a connective tissue stiff enough to prevent abdominal wall herniation in two-thirds of the gap-bridged full-thickness abdominal wall defects. However, in one-third there was sub-clinical herniation. The novel electrospun material did slightly better than the textile PP yet outcomes were still suboptimal. Further research should investigate what drives muscular atrophy, and whether novel polymers would eventually generate a physiological neotissue and can prevent failure and/or avoid collateral damage.
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Affiliation(s)
| | - Lucie Hympanova
- (A.W.B.).
- Department of Development and Regeneration, Woman and Child, Group Biomedical Sciences, KU Leuven, 3000 Leuven, Belgium.
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, 14700 Prague, Czech Republic.
| | - Rita Rynkevic
- (A.W.B.).
- Department of Development and Regeneration, Woman and Child, Group Biomedical Sciences, KU Leuven, 3000 Leuven, Belgium.
- INEGI, Faculdade de Engenharia da Universidade do Porto, Universidade do Porto, 4099-002 Porto, Portugal.
| | - Tristan Mes
- SupraPolix BV, 5611 Eindhoven, The Netherlands.
| | | | - Jan Deprest
- (A.W.B.).
- Department of Development and Regeneration, Woman and Child, Group Biomedical Sciences, KU Leuven, 3000 Leuven, Belgium.
- Pelvic Floor Unit, University Hospitals KU Leuven, 3000 Leuven, Belgium.
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Entrenamiento de fuerza y resistencia en hipoxia: efecto en la hipertrofia muscular. BIOMEDICA 2019; 39:212-220. [PMID: 31021559 DOI: 10.7705/biomedica.v39i1.4084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Indexed: 02/07/2023]
Abstract
El entrenamiento en altitud y el entrenamiento en hipoxia simulada producen adaptaciones fisiológicas y bioquímicas en el músculo esquelético como la capacidad oxidativa, así como modificaciones de la actividad mitocondrial, en el metabolismo aerobio y en el contenido de mioglobina.El propósito de esta revisión fue analizar las adaptaciones del músculo esquelético en respuesta a la exposición temporal a la hipoxia combinada con ejercicios de fuerza y resistencia. Según los hallazgos de numerosos autores, las adaptaciones estructurales del músculo son similares en la hipoxia y en la ‘normoxia’, con excepción de un aumento en el volumen muscular y en el área de la sección transversal de la fibra muscular, que son mayores en la hipoxia.En conclusión, la sinergia del entrenamiento de fuerza y resistencia y la hipoxia normobárica produce mejores y mayores adaptaciones, ganancias y cambios fisiológicos beneficiosos en el tejido muscular, lo cual genera cambios fenotípicos favorables, como la hipertrofia del músculo esquelético.
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Hympanova L, Mori da Cunha MGMC, Rynkevic R, Wach RA, Olejnik AK, Dankers PY, Arts B, Mes T, Bosman AW, Albersen M, Deprest J. Experimental reconstruction of an abdominal wall defect with electrospun polycaprolactone-ureidopyrimidinone mesh conserves compliance yet may have insufficient strength. J Mech Behav Biomed Mater 2018; 88:431-441. [DOI: 10.1016/j.jmbbm.2018.08.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/17/2018] [Accepted: 08/19/2018] [Indexed: 01/18/2023]
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Roman S, Mangir N, Hympanova L, Chapple CR, Deprest J, MacNeil S. Use of a simple in vitro fatigue test to assess materials used in the surgical treatment of stress urinary incontinence and pelvic organ prolapse. Neurourol Urodyn 2018; 38:107-115. [DOI: 10.1002/nau.23823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/27/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Sabiniano Roman
- Department of Materials Science and Engineering, Kroto Research Institute; University of Sheffield; Sheffield United Kingdom
| | - Naside Mangir
- Department of Materials Science and Engineering, Kroto Research Institute; University of Sheffield; Sheffield United Kingdom
- Royal Hallamshire Hospital; Sheffield United Kingdom
| | - Lucie Hympanova
- Department of Development and Regeneration, KU Leuven; University of Leuven; Leuven Belgium
- Third Faculty of Medicine, Institute for the Care of the Mother and Child; Charles University; Prague Czech Republic
| | | | - Jan Deprest
- Department of Development and Regeneration, KU Leuven; University of Leuven; Leuven Belgium
| | - Sheila MacNeil
- Department of Materials Science and Engineering, Kroto Research Institute; University of Sheffield; Sheffield United Kingdom
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Smits AI, Bouten CV. Tissue engineering meets immunoengineering: Prospective on personalized in situ tissue engineering strategies. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2018. [DOI: 10.1016/j.cobme.2018.02.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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