Electrospun Matrices for Pelvic Floor Repair: Effect of Fiber Diameter on Mechanical Properties and Cell Behavior

The Effect of Growth Factors on Vaginal Wound Healing: A Systematic Review and Meta-analysis

Surgical outcomes of pelvic organ prolapse (POP) surgery are poor, resulting in a 20% recurrence risk. Following the hypothesis that impaired wound healing is the main determinant of recurrent POP, growth factors have the potential to promote wound healing and may improve surgical outcomes. In this study, we systematically reviewed the effect of growth factors on vaginal wound healing in both in vitro and animal studies. For each independent comparison, the standardized mean difference and 95% CI were calculated using the Hedges' g correction. Of the 3858 retrieved studies, seven studies were included, of which six were included in meta-analysis (three in vitro studies and four in vivo studies). In vitro, basic fibroblast growth factor (bFGF) promotes proliferation, differentiation, and collagen types I and III production. Epidermal growth factor stimulates proliferation and connective tissue growth factor promotes Tenascin-C expression. These effects, however, are less pronounced in vivo; only bFGF slightly promotes collagen production. The review shows that growth factors, particularly bFGF, are able to promote vaginal wound healing in vitro. The uncertain in vivo findings suggest that preclinical models should be improved. The ultimate goal is to develop effective growth factor-supplemented therapies that improve surgical outcomes for POP.

Solvent system effects on the physical and mechanical properties of electrospun Poly(ε-caprolactone) scaffolds for in vitro lung models

Mechanical properties are among the key considerations for the design and fabrication of complex tissue models and implants. In addition to the choice of material and the processing technique, the solvent system can significantly influence the mechanical properties of scaffolds. Poly(ε-caprolactone) (PCL) has been abundantly used to develop constructs, fibrous in particular, for pharmaceutical and biomedical research due to the flexibility offered by PCL-based fibrous matrices. The effect of solvent type on the morphological features of electrospun fibres has been extensively studied. Nevertheless, comprehensive studies on the impact of the solvent system on the mechanical properties of electrospun PCL fibres are lacking. This study elucidates the relationship between topographical, physical and mechanical properties of electrospun PCL fibrous meshes upon using various solvent systems. The results of the mechanical investigation highlight the significance of inter-fibre bonds on the mechanical properties of the bulk membranes and that the option of altering the solvent system composition could be considered for tuning the mechanical properties of the PCL scaffolds to serve specific biomedical application requirements. The applicability of the developed membranes as artificial ECM (Extracellular matrix) in the lung will then be investigated and compared to the commercial Polycarbonate (PC) membranes that are often used for in vitro lung models.

Absorbable Electrospun Poly-4-hydroxybutyrate Scaffolds as a Potential Solution for Pelvic Organ Prolapse Surgery

Women with pelvic organ prolapse (POP) have bothersome complaints that significantly affect their quality of life. While native tissue repair is associated with high recurrence rates, polypropylene knitted implants have caused specific implant-related adverse events that have detrimental, often irreversible, effects. We hypothesize that surgical outcome can be improved with a tissue-engineered solution using an absorbable implant that mimics the natural extracellular matrix (ECM) structure, releases estrogen, and activates collagen metabolism by fibroblasts as the main regulators of wound healing. To this aim, we produced electrospun poly-4-hydroxybutyrate (P4HB) scaffolds and biofunctionalized them with estradiol (E2). The cell-implant interactions relevant for POP repair were assessed by seeding primary POP vaginal fibroblasts isolated from patients on electrospun P4HB scaffolds with 1%, 2%, or 5% E2 and without E2. To test our hypothesis on whether ECM mimicking structures should improve regeneration, electrospun P4HB was compared to knitted P4HB implants. We evaluated vaginal fibroblast proliferation, ECM deposition, and metabolism by quantification of collagen, elastin, and matrix metalloproteinases and by gene expression analysis for 28 days. We established effective E2 drug loading with a steady release over time. Significantly higher cell proliferation, collagen-, and elastin deposition were observed on electrospun P4HB scaffolds as compared to knitted P4HB. For this study, physical properties of the scaffolds were more determinant on the cell response than the release of E2. These results indicate that making these electrospun P4HB scaffolds E2-releasing appears to be technically feasible. In addition, electrospun P4HB scaffolds promote the cellular response of vaginal fibroblasts and further studies are merited to assess if their use results in improved surgical outcomes in case of POP repair.

Tissue-engineered repair material for pelvic floor dysfunction

Pelvic floor dysfunction (PFD) is a highly prevalent urogynecology disorder affecting many women worldwide, with symptoms including pelvic organ prolapse (POP), stress urinary incontinence (SUI), fecal incontinence, and overactive bladder syndrome (OAB). At present, the clinical treatments of PFD are still conservative and symptom-based, including non-surgical treatment and surgery. Surgical repair is an effective and durable treatment for PFD, and synthetic and biological materials can be used to enforce or reinforce the diseased tissue. However, synthetic materials such as polypropylene patches caused a series of complications such as mesh erosion, exposure, pain, and inflammation. The poor mechanical properties and high degradation speed of the biomaterial meshes resulted in poor anatomical reduction effect and limitation to clinical application. Therefore, the current treatment options are suboptimal. Recently, tissue-engineered repair material (TERM) has been applied to repair PFD and could markedly improve the prognosis of POP and SUI repair surgery in animal models. We review the directions and progression of TERM in POP and SUI repair. Adipose-derived stem cells (ADSCs) and endometrial mesenchymal stem cells (eMSCs) appear to be suitable cell types for scaffold seeding and clinical implantation. The multidisciplinary therapy approach to tissue engineering is a promising direction for tissue repair. More and longer follow-up studies are needed before determining cell types and materials for PFD repair.

Development of 3D Printed Biodegradable Mesh with Antimicrobial Properties for Pelvic Organ Prolapse

To address the increasing demand for safe and effective treatment options for pelvic organ prolapse (POP) due to the worldwide ban of the traditional polypropylene meshes, this study introduced degradable polycaprolactone (PCL)/polyethylene glycol (PEG) composite meshes fabricated with melt-electrowriting (MEW). Two PCL/PEG mesh groups: 90:10 and 75:25 (PCL:PEG, wt%) were fabricated and characterized for their degradation rate and mechanical properties, with PCL meshes used as a control. The PCL/PEG composites showed controllable degradation rates by adjusting the PEG content and produced mechanical properties, such as maximal forces, that were higher than PCL alone. The antibacterial properties of the meshes were elicited by coating them with a commonly used antibiotic: azithromycin. Two dosage levels were used for the coating: 0.5 mg and 1 mg per mesh, and both dosage levels were found to be effective in suppressing the growth of S. aureus bacteria. The biocompatibility of the meshes was assessed using human immortalized adipose derived mesenchymal stem cells (hMSC). In vitro assays were used to assess the cell viability (LIVE/DEAD assay), cell metabolic activity (alamarBlue assay) and cell morphology on the meshes (fluorescent and electron microscopy). The cell attachment was found to decrease with increased PEG content. The freshly drug-coated meshes showed signs of cytotoxicity during the cell study process. However, when pre-released for 14 days in phosphate buffered saline, the initial delay in cell attachment on the drug-coated mesh groups showed full recovery at the 14-day cell culture time point. These results indicated that the PCL/PEG meshes with antibiotics coating will be an effective anti-infectious device when first implanted into the patients, and, after about 2 weeks of drug release, the mesh will be supporting cell attachment and proliferation. These meshes demonstrated a potential effective treatment option for POP that may circumvent the issues related to the traditional polypropylene meshes.

Role of Fibroblasts and Myofibroblasts on the Pathogenesis and Treatment of Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is a multifactorial connective tissue disorder caused by damage to the supportive structures of the pelvic floor, leading to the descent of pelvic organs in the vagina. In women with POP, fibroblast function is disturbed or altered, which causes impaired collagen metabolism that affects the mechanical properties of the tissue. Ideal surgical repair, either native tissue repair or POP surgery using an implant, aims to create a functional pelvic floor that is load-bearing, activating fibroblasts to regulate collagen metabolism without creating fibrotic tissue. Fibroblast function plays a crucial role in the pathophysiology of POP by directly affecting the connective tissue quality. On the other hand, fibroblasts determine the success of the POP treatment, as the fibroblast-to-(myo)fibroblast transition is the key event during wound healing and tissue repair. In this review, we aim to resolve the question of “cause and result” for the fibroblasts in the development and treatment of POP. This review may contribute to preventing the development and progress of anatomical abnormalities involved in POP and to optimizing surgical outcomes.

Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction

Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...

Mesopore Controls the Responses of Blood Clot-Immune Complex via Modulating Fibrin Network

Formation of blood clots, particularly the fibrin network and fibrin network-mediated early inflammatory responses, plays a critical role in determining the eventual tissue repair or regeneration following an injury. Owing to the potential role of fibrin network in mediating clot-immune responses, it is of great importance to determine whether clot-immune responses can be regulated via modulating the parameters of fibrin network. Since the diameter of D-terminal of a fibrinogen molecule is 9 nm, four different pore sizes (2, 8, 14, and 20 nm) are rationally selected to design mesoporous silica to control the fibrinogen adsorption and modulate the subsequent fibrin formation process. The fiber becomes thinner and the contact area with macrophages decreases when the pore diameters of mesoporous silica are greater than 9 nm. Importantly, these thinner fibers grown in pores with diameters larger than 9 nm inhibit the M1-polorazation of macrophages and reduce the productions of pro-inflammatory cytokines and chemokines by macrophages. These thinner fibers reduce inflammation of macrophages through a potential signaling pathway of cell adhesion-cytoskeleton assembly-inflammatory responses. Thus, the successful regulation of the clot-immune responses via tuning of the mesoporous pore sizes indicates the feasibility of developing advanced clot-immune regulatory materials.

Understanding Fibroblast Behavior in 3D Biomaterials

Traditional monolayer culture fails to fully recapitulate the in vivo environment of connective tissue cells such as the fibroblast. When cultured on stiff two-dimensional (2D) plastic, fibroblasts become highly proliferative forming broad lamellipodia and stress fibers. Conversely, in different three-dimensional (3D) culture systems, fibroblasts have displayed a diverse array of features; from an "activated" phenotype like that observed in 2D cultures and by myofibroblasts, to a quiescent state that likely better represents in vivo fibroblasts at rest. Today, a plethora of microfabrication techniques have made 3D culture commonplace, for both tissue engineering purposes and in the study of basic biological interactions. However, establishing the in vivo mimetic credentials of different biomimetic materials is not always straightforward, particularly in the context of fibroblast responses. Fibroblast behavior is governed by the complex interplay of biological features such as integrin binding sites, material mechanical properties that influence cellular mechanotransduction, and microarchitectural features like pore and fiber size, as well as chemical cues. Furthermore, fibroblasts are a heterogeneous group of cells with specific phenotypic traits dependent on their tissue of origin. These features have made understanding the influence of biomaterials on fibroblast behavior a challenging task. In this study, we present a review of the strategies used to investigate fibroblast behavior with a focus on the material properties that influence fibroblast activation, a process that becomes pathological in fibrotic diseases and certain cancers.

Tissue engineering to treat pelvic organ prolapse

Pelvic organ prolapse (POP) is a frequent chronic illness, which seriously affects women's living quality. In recent years, tissue engineering has made superior progress in POP treatment, and biological scaffolds have received considerable attention. Nevertheless, pelvic floor reconstruction still faces severe challenges, including the construction of ideal scaffolds, the selection of optimal seed cells, and growth factors. This paper summarizes the recent progress of pelvic floor reconstruction in tissue engineering, and discusses the problems that need to be further considered and solved to provide references for the further development of this field.

Biodegradable materials for surgical management of stress urinary incontinence: A narrative review

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.

Fully absorbable poly-4-hydroxybutyrate implants exhibit more favorable cell-matrix interactions than polypropylene

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.

Construction and application of textile-based tissue engineering scaffolds: a review

Tissue engineering (TE) provides a practicable method for tissue and organ repair or substitution. As the most important component of TE, a scaffold plays a critical role in providing a growing environment for cell proliferation and functional differentiation as well as good mechanical support. And the restorative effects are greatly dependent upon the nature of the scaffold including the composition, morphology, structure, and mechanical performance. Medical textiles have been widely employed in the clinic for a long time and are being extensively investigated as TE scaffolds. However, unfortunately, the advantages of textile technology cannot be fully exploited in tissue regeneration due to the ignoring of the diversity of fabric structures. Therefore, this review focuses on textile-based scaffolds, emphasizing the significance of the fabric design and the resultant characteristics of cell behavior and extracellular matrix reconstruction. The structure and mechanical behavior of the fabrics constructed by various textile techniques for different tissue repairs are summarized. Furthermore, the prospect of structural design in the TE scaffold preparation was anticipated, including profiled fibers and some unique and complex textile structures. Hopefully, the readers of this review would appreciate the importance of structural design of the scaffold and the usefulness of textile-based TE scaffolds in tissue regeneration.

Emerging Nano/Micro-Structured Degradable Polymeric Meshes for Pelvic Floor Reconstruction

Pelvic organ prolapse (POP) is a hidden women's health disorder that impacts 1 in 4 women across all age groups. Surgical intervention has been the only treatment option, often involving non-degradable meshes, with variable results. However, recent reports have highlighted the adverse effects of meshes in the long term, which involve unacceptable rates of erosion, chronic infection and severe pain related to mesh shrinkage. Therefore, there is an urgent unmet need to fabricate of new class of biocompatible meshes for the treatment of POP. This review focuses on the causes for the downfall of commercial meshes, and discusses the use of emerging technologies such as electrospinning and 3D printing to design new meshes. Furthermore, we discuss the impact and advantage of nano-/microstructured alternative meshes over commercial meshes with respect to their tissue integration performance. Considering the key challenges of current meshes, we discuss the potential of cell-based tissue engineering strategies to augment the new class of meshes to improve biocompatibility and immunomodulation. Finally, this review highlights the future direction in designing the new class of mesh to overcome the hurdles of foreign body rejection faced by the traditional meshes, in order to have safe and effective treatment for women in the long term.

Recent advances in pelvic floor repair

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.

Gentle cyclic straining of human fibroblasts on electrospun scaffolds enhances their regenerative potential

The extracellular matrix of fascia-like tissues is a resilient network of collagenous fibers that withstand the forces of daily life. When overstretched, the matrix may tear, with serious consequences like pelvic organ prolapse (POP). Synthetic implants can provide mechanical support and evoke a host response that induces new matrix production, thus reinforcing the fascia. However, there is considerable risk of scar formation and tissue contraction which result in severe complications. Matrix producing fibroblasts are both mechanosensitive and contractile; their behavior depends on the implant's surface texture and mechanical straining. Here we investigate the effect of both in a newly-designed experimental setting. Electrospun scaffolds of Nylon and PLGA/PCL and a non-porous PLGA/PCL film were clamped like a drumhead and seeded with fibroblasts of POP patients. Upon confluency, scaffolds were cyclically strained for 24 or 72 h at 10% and 0.2 Hz, mimicking gentle breathing. Non-loading condition was control. Strained fibroblasts loosened their actin-fibers, thereby preventing myofibroblastic differentiation. Mechanical loading upregulated genes involved in matrix synthesis (collagen I, III, V and elastin), matrix remodeling (α-SMA, TGF-β1, MMP-2) and inflammation (COX-2, TNF-α, IL8, IL1-β). Collagen genes were expressed earlier under mechanical loading and the ratio of I/III collagen increased. Matrix synthesis and remodeling were stronger on the electrospun scaffolds, while inflammation was more prominent on the non-porous film. Our findings indicate that mechanical straining enhances the regenerative potential of fibroblasts for the regeneration of fascia-type tissues and limit the risk of scar tissue formation. These effects are stronger on an electrospun texture. STATEMENT OF SIGNIFICANCE: Pelvic organ prolapsed is a dysfunctional disease in female pelvic floor that can reduce the quality of life women. Currently, trans-vaginal knitted meshes are used to anatomically correct the dysfunctional tissues. However, the meshes can create sever adverse complications in some patients (e.g. chronic pain) in longer-term. As an alternative, we developed nanofibrous matrices by electrospinning based on different materials. We designed an in-vitro culture system and subjected cell-seeded matrices to cyclic mechanical loading. Results revealed that gentle straining of POP-cells on electrospun matrices, advances their regenerative potential at morphological and gene expression levels. Our findings, provide a proof-of-concept for using electrospun matrices as an alternative implant for pelvic floor repair, given that the parameters are designed efficiently and safely.

Mesenchymal stem cell cultivation in electrospun scaffolds: mechanistic modeling for tissue engineering

Tissue engineering is a multidisciplinary field of research in which the cells, biomaterials, and processes can be optimized to develop a tissue substitute. Three-dimensional (3D) architectural features from electrospun scaffolds, such as porosity, tortuosity, fiber diameter, pore size, and interconnectivity have a great impact on cell behavior. Regarding tissue development in vitro, culture conditions such as pH, osmolality, temperature, nutrient, and metabolite concentrations dictate cell viability inside the constructs. The effect of different electrospun scaffold properties, bioreactor designs, mesenchymal stem cell culture parameters, and seeding techniques on cell behavior can be studied individually or combined with phenomenological modeling techniques. This work reviews the main culture and scaffold factors that affect tissue development in vitro regarding the culture of cells inside 3D matrices. The mathematical modeling of the relationship between these factors and cell behavior inside 3D constructs has also been critically reviewed, focusing on mesenchymal stem cell culture in electrospun scaffolds.

Thermally induced self-agglomeration 3D scaffolds with BMP-2-loaded core-shell fibers for enhanced osteogenic differentiation of rat adipose-derived stem cells

Introduction

Scaffold structure plays a vital role in cell behaviors. Compared with two-dimensional structure, 3D scaffolds can mimic natural extracellular matrix (ECM) and promote cell–cell and cell–matrix interactions. The combination of osteoconductive scaffolds and osteoinductive growth factors is considered to have synergistic effects on bone regeneration.

Materials and methods

In this study, core–shell poly(lactide-co-glycolide) (PLGA)/polycaprolactone (PCL)–BMP-2 (PP–B) fibrous scaffolds were prepared through coaxial electrospinning. Next, we fabricated 3D scaffolds based on PP–B fibers with thermally induced self-agglomeration (TISA) method and compared with conventional PLGA/PCL scaffolds in terms of scaffold morphology and BMP-2 release behaviors. Then, rat adipose-derived stem cells (rADSCs) were seeded on the scaffolds, and the effects on cell proliferation, cell morphology, and osteogenic differentiation of rADSCs were detected.

Results

The results demonstrated that 3D scaffold incorporated with BMP-2 significantly increased proliferation and osteogenic differentiation of rADSCs, followed by PP–B group.

Conclusion

Our findings indicate that scaffolds with 3D structure and osteoinductive growth factors have great potential in bone tissue engineering.

Biomimetic implants for pelvic floor repair

BACKGROUND

Polypropylene implants are used for the reconstructive surgery of urogynaecological disorders like pelvic organ prolapse, but severe complications associated with their use have been reported. There is evidence that surface properties and a difference in mechanical stiffness between the implant and the host tissue contribute to these adverse events. Electrospinning is an innovative engineering alternative that provides a biomimetic microstructure for implants, resulting in a different mechano-biological performance.

AIM

The main objective of this review is to inform about the potential of electrospun matrices as an alternative modality for pelvic floor repair.

METHODS

Publications with the following studies of electrospun matrices were reviewed: (i) the technique; (ii) in vitro use for soft tissue engineering; (iii) in vivo use for reconstruction of soft tissues in animals; and (iv) clinical use in humans.

RESULTS

Electrospun matrices provide a synthetic mimic of natural extracellular matrix (ECM), favoring cellular attachment, proliferation and matrix deposition, through which a proper, low-inflammatory tissue-implant interaction can be established. Electrospun sheets can also be created with sufficient mechanical strength and stiffness for usage in prolapse surgery.

CONCLUSION

Electrospun matrices mimic the structural topography of the extracellular matrix and can be functionalized for better biological performance. As such, they have great potential for the next generation of urogynecological implants. However, their long-term safety and efficacy must still be established in vivo.