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957Coating with type a collagen, fibronectin, or pronectin does not improve adherence of human urothelial cells seeded on small intestine submucosa
0~: FUTUREASPEC~OFRECONSTRUCtiVEOROLO6Y Saturday, 19 March,14:00-15:30,Room4.3/Hall4
957
958
COATING WITH TYPE A COLLAGEN, FIBRONECTIN, OR P R O N E C T I N DOES N O T I M P R O V E A D H E R E N C E OF H U M A N U R O T H E L I A L CELLS SEEDED ON S M A L L INTESTINE S U B M U C O S A
OFF-SHELF C O M M E R C I A L L Y AVAILABLE A C E L L U L A R C O L L A G E N MATRIX SIS® BY C O O K F O R U R E T H R A L R E C O N S T R U C T I O N
Fell G., Christ-Adler M., Maurer S., Krug J., Corvin S., Sievert K.D., Stenzl A.
Sievert K.D. a, Nagele U. 1, Brinkmann 0. 2, Wuelfing C. 2, Praetorius M. 1, Seibold J?, Stenzl A. 1, Hertle L. 2
Eberhard-Karls University Tuebingen, Department of Urology, Tuebingen, Germany
1University of Tuebingen, Department of Urology, Tuebingen, Germany, 2University of Muenster, Department of Urology, Muenster, Germany
I N T R O D U C T I O N & OBJECTIVES: Small intestine submucosa (SIS®, Cook) is a biomatrix for urinary bladder repair device because of its rapid degradation and elimination via the urine. However, small intestine submucosa does not have the same regenerative potential with regard to the urothelium, The aim of the study was to test adherence and viability of human urotheliaI cells (HUC) seeded on SIS® membranes coated with different adhesion molecules.
I N T R O D U C T I O N & OBJECTIVES: Although the buccal mucosa patch is the golden standard for urethral reconstruction, new materials need to be clinically evaluated to minimize surgical necessity and to shorten operating room (OR) time. During recent years, acellular tissue such as SIS by Cook, became commercially available. We explored the use of single layer SIS® as a urethral patch in patients undergoing urethral repair.
M A T E R I A L & M E T H O D S : After obtaining informed consent ureter samples were isolated from radical nephrectomy specimens. A sample was incubated in a solution containing EDTA and aprotinin. Urothelium was then isolated and digested with type IV collagenase. The urothelial cell suspension obtained was cultivated in complete keratinocyte serum-free medium (KSFMc) at 37 °C in a humidified atmosphere of 5 % CO2. Subeonfluent monolayers were detached with tIypsirdEDTA and then seeded on SIS® membranes at a concentration of 5x 10/'4 HUC/mL and cultivated in KSFMc (37 °C, 5 % CO2). SIS® specimens have been coated with type A collagen, fibronectin, or pronectin. Control SIS® was preincubated with KSFMc. Proliferation and viability of HUC cells was analyzed with the photometric WST-I test after 1, 3, and 9 days. Growth of HUC on SIS® was studied by phase contrast microscopy. To demonstrate HUC attached on SIS® the specimens were examined histologically.
MATERIAL & M E T H O D S : Thirteen approved patients (ten adult male (32 - 56 years) with urethral stricture and 3 boys (5.8 and 16 years) with hypospadia) underwent a urethral reconstruction with SIS® as an on-lay patch anastomosed to the corporal tissue with interrupted absorbable sutures. The adults received a patch of 4 - 10 cm length x 1 cm wide in relation to the length of their s~cmre. The hypospadia repair required a patch of 3 x 0.5 cm. The current mean follow-up is 12 months.
RESULTS: In general, WST-1 tests for HUC seeded either to coated SIS® or to native SIS® demonstrated high toxic effects to the urothelial cells. Proliferation and viability of HUC were significantly reduced after 1 day compared to the controls (p<0.0001). Histology of SIS® seeded with HUC showed no evident differences between preincubated and coated conditions, resp. However, native, i.e. uncoated and unseeded SIS® specimens revealed multiple porcine nuclei residues in histology. CONCLUSIONS: Viability and adherence of HUC to SIS® could not be improved by adhesion molecules coated on SIS®. Since SIS® seems to diminish the viability of seeded HUC and because SIS® contains porcine DNA residues we conclude that SIS® may not be well suitable for construction of cell-matrix implants for tissue engineering of the lower urinary tract.
RESULTS: Operating time for the urethral reconstruction was reduced compared to controls that had native tissue harvest. All patients had a successful urethroplasty and showed adequate healing. In the follow-up of 12 months, the three boys demonstrated a satisfying surgical outcome with normal voiding. In the mean of six months post-operative, four of 10 males with urethroplasty demonstrated re-strictures in the proxinaal area of the patch. Additionally, one of the four patients developed a fistula and requested further surgical treatment. The remaining three were treated with urethrotomy. At the 12 month follow-up, the other six adult patients still had a satisfactory urine flow (16 - 26 ml/sec) without a sign of re-stricture. CONCLUSIONS: Using an off-shelf acellular matrix appears to be beneficial in selected eases. With regard to the literature, a 60% success rate for patients with a urethral stricture that had multiple prior surgeries is acceptable. For those who underwent the hypospadia reconstruction, the outcome was very satisfactory. Additionally, we were able to avoid the harvesting of a buccal mucosa flap and shorten the OR time. A larger number of patients with a continued long-term follow-up are needed to evaluate the final outcome.
959 SMALL-INTESTINE-SUBMUCOSA IN U R E T H R A L STRICTURE REPAIR
960 THE BULBOURETHRAL COMPOSITE SUSPENSION ALTERNATIVE TO THE A R T I F I C I A L S P H I N C T E R
IS
AN
Hanser S., Bastian P., Mueller S. John H., Blick N., Hauri D. University Hospital, Department of Urology, Bonn, Germany Zurich University Hospital, Department of Urology, Zurich, Switzerland INTRODUCTION & OBJECTIVES: The purpose was to define the feasibility and outcome of porcine small-intestine-submucosa (SIS) used as xenograft in urethral stricture repair as an alternative to autologous tissues. SIS is the acellular connective tissue of the intestine, commercially available and approved for the use in humans. MATERIAL & METHODS: 5 Pts. underwent open surgery for urethral stricture repair using SIS. We used a 4 layer SIS graft for the repair (Surgisis ES,Wilson-Cook Medical). 2/5 had a bulbar stricture 3/5 suffered from a combined penile-bulbar stricture. The median stricture length was 9 cm (3.5-10 cm). All pts. had previous internal urethrotomy (ut) (3/5:1 ut, 1/5:2 ut; 1/5:3 ut). The etiology was in 3 pts. related to previous heart surgery, in 1 pt. due to urethral catheter and in one pt. following TUR-E The urethral stricture repair was performed as an onlay urethroplasty, SIS was used to augment the urethral caliber at the stricture site. A Foley catheter and a percutaneous cystostomy for drainage were placed. The Foley catheter was removed ten days after surgery. Three weeks after the operation a voiding cystourethrography and a retrograde urethrography were performed. RESULTS: Flow studies were available in 3 pts. preoperatively, in 1 pt. voiding was
not possible due to urinary retention and in 1 pt. the flow study was not performed. The mean value of the maximal-flow was 4.2 ml/s (n=3), mean value of the mean flow was 2.6 ml/s (n-3). Postoperatively lpt. had an extravasation treated by prolonged suprapubic drainage. 1 pt. had a severe urethritis after surgery, 1 pt. a urinary tract infection and 1 pt. had a bilateral compartment syndrom of the lower leg. Three pts. had a stricture recurrence after a mean time of 7.2 month (3.7-12.4 month), two of these pts. had an open repair using buccal mucosa, one pts. refused repeated surgery. The maximum flow of this pt. is 4.7 ml/s after surgery (3.Sml/s before surgery). The difference of the maximum flow was 10.3 ml/s for mean values and 4.8 ml/s for the mean flow. CONCLUSIONS: In three of five pts. the operation was not successfull, two of them needed an open revision. The experimental data were promising but SIS could not fulfil our expectations. The advantage using a xenograft is the shortening of the operation time because there is no need of graft harvesting and the comfort for the patient is better without an additional wound. The graft is expensive but this may be compensated by the reduced operation time. Usually we do not have such high recurrence and reoperation rates when we are using autologous tissue for urethral repair. We only used SIS in 5 pts. but we stopped the series due to poor results.
European Urology Supplements 4 (2005) No. 3, pp. 242
INTRODUCTION & OBJECTIVES: Recently a new bulbourethral sling procedure was proposed for patients with severe post-prostatectomy incontinence (J.Urol.171, 1866-70, 2004). This study reports the ongoing experience in this technique. MATERIAL & METHODS: Bulbourethral composite suspension was performed in 33 consecutive stress incontinent patients aged 66 (42-83) years. They had undergone radical prostatectomy (n-30) or transurethral resection (11-3) 30(8-248) months before. 7/33(21%) of the patients were severe stress incontinent and depended on diapers or condom catheter. Urinary stress incontinence and quality of life were assessed preoperatively by a validated questionnaire and a modified pad-test. Urethrocystoscopy excluded urethral stricture. The procedure was performed with a longitudinal perineal and a transverse suprapubic incision in regional or general anaesthesia placing a 4x2cm collagen implant (Pelvicol®, Bard) for urethral protection and a polypropylene retropubic sling (Uretex®, Bard) that was tied suprapubically. Tension was adjusted under patient's coughing and with retrograde urethral closure pressure monitoring at 60cm H20. Statistical analyses included the chi-squam test and the Mann-Whitney test, with p<0.05 being the accepted significance level. RESULTS: Bladder perforation occurred in 10/33(30%) patients. One patient had open revision of injured extem iliac artery and 1 patient had transient femoral nerve irritation. The Foley catheters were removed after 3 days. All patients had primary wound healing. Patients reported only minimal postoperative pain. Three patients had urinary retention and underwent sling tension release. No urethral or vesical erosion occurred. Clinical follow-up was performed at median 14(range 1-42) months postoperatively. 24/33(73%) of the patients were completely dry or wore one protection per day. 9/33(27%) of the patients had no benefit, where of 5 underwent artificial sphincter procedure with good functional outcome. The number of pads decreased from 5(2-12) preoperatively to 0(0-10) postoperatively, p<0.001. Quality of life improved from 5(4-6) to 1(0-6), p<0.001. Cumulative material costs for all patients were 26.400 Euro, while saved pad-costs within the follow-up period amounted to 49.800 Euro. CONCLUSIONS: The bulbourethral composite suspension is a new efficient and cost effective operative treatment option in patients with severe post-prostatectomy urinary incontinence. This technique may become an alternative to the artificial urinary sphincter. Although encouraging early functional postoperative results, long term durability, urethral tolerabifity and detrusor flmction have to be carefully observed.
957
958
COATING WITH TYPE A COLLAGEN, FIBRONECTIN, OR P R O N E C T I N DOES N O T I M P R O V E A D H E R E N C E OF H U M A N U R O T H E L I A L CELLS SEEDED ON S M A L L INTESTINE S U B M U C O S A
OFF-SHELF C O M M E R C I A L L Y AVAILABLE A C E L L U L A R C O L L A G E N MATRIX SIS® BY C O O K F O R U R E T H R A L R E C O N S T R U C T I O N
Fell G., Christ-Adler M., Maurer S., Krug J., Corvin S., Sievert K.D., Stenzl A.
Sievert K.D. a, Nagele U. 1, Brinkmann 0. 2, Wuelfing C. 2, Praetorius M. 1, Seibold J?, Stenzl A. 1, Hertle L. 2
Eberhard-Karls University Tuebingen, Department of Urology, Tuebingen, Germany
1University of Tuebingen, Department of Urology, Tuebingen, Germany, 2University of Muenster, Department of Urology, Muenster, Germany
I N T R O D U C T I O N & OBJECTIVES: Small intestine submucosa (SIS®, Cook) is a biomatrix for urinary bladder repair device because of its rapid degradation and elimination via the urine. However, small intestine submucosa does not have the same regenerative potential with regard to the urothelium, The aim of the study was to test adherence and viability of human urotheliaI cells (HUC) seeded on SIS® membranes coated with different adhesion molecules.
I N T R O D U C T I O N & OBJECTIVES: Although the buccal mucosa patch is the golden standard for urethral reconstruction, new materials need to be clinically evaluated to minimize surgical necessity and to shorten operating room (OR) time. During recent years, acellular tissue such as SIS by Cook, became commercially available. We explored the use of single layer SIS® as a urethral patch in patients undergoing urethral repair.
M A T E R I A L & M E T H O D S : After obtaining informed consent ureter samples were isolated from radical nephrectomy specimens. A sample was incubated in a solution containing EDTA and aprotinin. Urothelium was then isolated and digested with type IV collagenase. The urothelial cell suspension obtained was cultivated in complete keratinocyte serum-free medium (KSFMc) at 37 °C in a humidified atmosphere of 5 % CO2. Subeonfluent monolayers were detached with tIypsirdEDTA and then seeded on SIS® membranes at a concentration of 5x 10/'4 HUC/mL and cultivated in KSFMc (37 °C, 5 % CO2). SIS® specimens have been coated with type A collagen, fibronectin, or pronectin. Control SIS® was preincubated with KSFMc. Proliferation and viability of HUC cells was analyzed with the photometric WST-I test after 1, 3, and 9 days. Growth of HUC on SIS® was studied by phase contrast microscopy. To demonstrate HUC attached on SIS® the specimens were examined histologically.
MATERIAL & M E T H O D S : Thirteen approved patients (ten adult male (32 - 56 years) with urethral stricture and 3 boys (5.8 and 16 years) with hypospadia) underwent a urethral reconstruction with SIS® as an on-lay patch anastomosed to the corporal tissue with interrupted absorbable sutures. The adults received a patch of 4 - 10 cm length x 1 cm wide in relation to the length of their s~cmre. The hypospadia repair required a patch of 3 x 0.5 cm. The current mean follow-up is 12 months.
RESULTS: In general, WST-1 tests for HUC seeded either to coated SIS® or to native SIS® demonstrated high toxic effects to the urothelial cells. Proliferation and viability of HUC were significantly reduced after 1 day compared to the controls (p<0.0001). Histology of SIS® seeded with HUC showed no evident differences between preincubated and coated conditions, resp. However, native, i.e. uncoated and unseeded SIS® specimens revealed multiple porcine nuclei residues in histology. CONCLUSIONS: Viability and adherence of HUC to SIS® could not be improved by adhesion molecules coated on SIS®. Since SIS® seems to diminish the viability of seeded HUC and because SIS® contains porcine DNA residues we conclude that SIS® may not be well suitable for construction of cell-matrix implants for tissue engineering of the lower urinary tract.
RESULTS: Operating time for the urethral reconstruction was reduced compared to controls that had native tissue harvest. All patients had a successful urethroplasty and showed adequate healing. In the follow-up of 12 months, the three boys demonstrated a satisfying surgical outcome with normal voiding. In the mean of six months post-operative, four of 10 males with urethroplasty demonstrated re-strictures in the proxinaal area of the patch. Additionally, one of the four patients developed a fistula and requested further surgical treatment. The remaining three were treated with urethrotomy. At the 12 month follow-up, the other six adult patients still had a satisfactory urine flow (16 - 26 ml/sec) without a sign of re-stricture. CONCLUSIONS: Using an off-shelf acellular matrix appears to be beneficial in selected eases. With regard to the literature, a 60% success rate for patients with a urethral stricture that had multiple prior surgeries is acceptable. For those who underwent the hypospadia reconstruction, the outcome was very satisfactory. Additionally, we were able to avoid the harvesting of a buccal mucosa flap and shorten the OR time. A larger number of patients with a continued long-term follow-up are needed to evaluate the final outcome.
959 SMALL-INTESTINE-SUBMUCOSA IN U R E T H R A L STRICTURE REPAIR
960 THE BULBOURETHRAL COMPOSITE SUSPENSION ALTERNATIVE TO THE A R T I F I C I A L S P H I N C T E R
IS
AN
Hanser S., Bastian P., Mueller S. John H., Blick N., Hauri D. University Hospital, Department of Urology, Bonn, Germany Zurich University Hospital, Department of Urology, Zurich, Switzerland INTRODUCTION & OBJECTIVES: The purpose was to define the feasibility and outcome of porcine small-intestine-submucosa (SIS) used as xenograft in urethral stricture repair as an alternative to autologous tissues. SIS is the acellular connective tissue of the intestine, commercially available and approved for the use in humans. MATERIAL & METHODS: 5 Pts. underwent open surgery for urethral stricture repair using SIS. We used a 4 layer SIS graft for the repair (Surgisis ES,Wilson-Cook Medical). 2/5 had a bulbar stricture 3/5 suffered from a combined penile-bulbar stricture. The median stricture length was 9 cm (3.5-10 cm). All pts. had previous internal urethrotomy (ut) (3/5:1 ut, 1/5:2 ut; 1/5:3 ut). The etiology was in 3 pts. related to previous heart surgery, in 1 pt. due to urethral catheter and in one pt. following TUR-E The urethral stricture repair was performed as an onlay urethroplasty, SIS was used to augment the urethral caliber at the stricture site. A Foley catheter and a percutaneous cystostomy for drainage were placed. The Foley catheter was removed ten days after surgery. Three weeks after the operation a voiding cystourethrography and a retrograde urethrography were performed. RESULTS: Flow studies were available in 3 pts. preoperatively, in 1 pt. voiding was
not possible due to urinary retention and in 1 pt. the flow study was not performed. The mean value of the maximal-flow was 4.2 ml/s (n=3), mean value of the mean flow was 2.6 ml/s (n-3). Postoperatively lpt. had an extravasation treated by prolonged suprapubic drainage. 1 pt. had a severe urethritis after surgery, 1 pt. a urinary tract infection and 1 pt. had a bilateral compartment syndrom of the lower leg. Three pts. had a stricture recurrence after a mean time of 7.2 month (3.7-12.4 month), two of these pts. had an open repair using buccal mucosa, one pts. refused repeated surgery. The maximum flow of this pt. is 4.7 ml/s after surgery (3.Sml/s before surgery). The difference of the maximum flow was 10.3 ml/s for mean values and 4.8 ml/s for the mean flow. CONCLUSIONS: In three of five pts. the operation was not successfull, two of them needed an open revision. The experimental data were promising but SIS could not fulfil our expectations. The advantage using a xenograft is the shortening of the operation time because there is no need of graft harvesting and the comfort for the patient is better without an additional wound. The graft is expensive but this may be compensated by the reduced operation time. Usually we do not have such high recurrence and reoperation rates when we are using autologous tissue for urethral repair. We only used SIS in 5 pts. but we stopped the series due to poor results.
European Urology Supplements 4 (2005) No. 3, pp. 242
INTRODUCTION & OBJECTIVES: Recently a new bulbourethral sling procedure was proposed for patients with severe post-prostatectomy incontinence (J.Urol.171, 1866-70, 2004). This study reports the ongoing experience in this technique. MATERIAL & METHODS: Bulbourethral composite suspension was performed in 33 consecutive stress incontinent patients aged 66 (42-83) years. They had undergone radical prostatectomy (n-30) or transurethral resection (11-3) 30(8-248) months before. 7/33(21%) of the patients were severe stress incontinent and depended on diapers or condom catheter. Urinary stress incontinence and quality of life were assessed preoperatively by a validated questionnaire and a modified pad-test. Urethrocystoscopy excluded urethral stricture. The procedure was performed with a longitudinal perineal and a transverse suprapubic incision in regional or general anaesthesia placing a 4x2cm collagen implant (Pelvicol®, Bard) for urethral protection and a polypropylene retropubic sling (Uretex®, Bard) that was tied suprapubically. Tension was adjusted under patient's coughing and with retrograde urethral closure pressure monitoring at 60cm H20. Statistical analyses included the chi-squam test and the Mann-Whitney test, with p<0.05 being the accepted significance level. RESULTS: Bladder perforation occurred in 10/33(30%) patients. One patient had open revision of injured extem iliac artery and 1 patient had transient femoral nerve irritation. The Foley catheters were removed after 3 days. All patients had primary wound healing. Patients reported only minimal postoperative pain. Three patients had urinary retention and underwent sling tension release. No urethral or vesical erosion occurred. Clinical follow-up was performed at median 14(range 1-42) months postoperatively. 24/33(73%) of the patients were completely dry or wore one protection per day. 9/33(27%) of the patients had no benefit, where of 5 underwent artificial sphincter procedure with good functional outcome. The number of pads decreased from 5(2-12) preoperatively to 0(0-10) postoperatively, p<0.001. Quality of life improved from 5(4-6) to 1(0-6), p<0.001. Cumulative material costs for all patients were 26.400 Euro, while saved pad-costs within the follow-up period amounted to 49.800 Euro. CONCLUSIONS: The bulbourethral composite suspension is a new efficient and cost effective operative treatment option in patients with severe post-prostatectomy urinary incontinence. This technique may become an alternative to the artificial urinary sphincter. Although encouraging early functional postoperative results, long term durability, urethral tolerabifity and detrusor flmction have to be carefully observed.