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MP24-18 DETRUSOR BIOENGINEERING USING COMPRESSED COLLAGEN, ADIPOSE-DERIVED STEM CELLS AND SMOOTH MUSCLE CELLS
THE JOURNAL OF UROLOGYâ
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Vol. 197, No. 4S, Supplement, Saturday, May 13, 2017
haematological and microbiological findings suggest that the fundamental problem is the urine leak and direct fistulation into (and sometimes through) the pubic symphysis. The more extensive the leak the worse the pain. The urinary and tissue microbiology did not correlate with each other or with the symptoms. The correct terminology for this condition, we believe, is Urosymphyseal Fistulae. Source of Funding: none
MP24-17 NATURAL HISTORY, PREVALENCE, PREDICTORS & OUTCOMES OF PARASTOMAL HERNIA AFTER ROBOTASSISTED RADICAL CYSTECTOMY Youssef Ahmed*, Ahmed Hussein, Paul May, Basim Ahmad, Taimoor Ali, Khurshid Guru, Buffalo, NY INTRODUCTION AND OBJECTIVES: Parastomal hernia (PH) is a frequent complication of urinary diversion after radical cystectomy. We investigated the prevalence, predictors and outcomes of PH. Clinical and radiologic evidence of PH was also investigated. METHODS: Retrospective review of 446 patients who underwent RARC at our institution from 2005 was conducted. Data was reviewed for demographics, clinical findings, imaging results and other perioperative outcomes. Radiologic PH was defined as protrusion of abdominal content through the stoma defect in the abdominal wall. PH was further described in terms of symptoms and their management. Kaplan Meier method was used to depict time to developing PH and logistic regression to evaluate predictors of PH. RESULTS: 384 patients who underwent RARC and IC were included in the analysis. Mean age was 70 years with median follow up of 18 months (IQR 6.8-34-.7). 74 (19%) patients had radiological evidence of PH, 24 (32%) were symptomatic and 8 (11%) underwent treatment. Median time to develop PH was 13 months (IQR 8.8-22). PH occurred at a rate of 10%, 33% and 36% at 1, 3 and 5 years respectively (Fig 1). Median time to symptoms was 24 months after RARC (IQR 7-39.6) and (8 months after radiological diagnosis. Patients with PH had significantly higher BMI (30 vs 28, p¼0.009), longer overall operative time (347 vs 388 min, p¼0.01), urinary diversion time (128 vs 108 p¼0.03) and higher blood loss (400 vs 250, p¼0.01). The incidence of PH was studied based on incorporation of intra-corporeal diversion in the program (Fig 2). On Multivariable analysis operative time was the only variable associated with higher incidence of PH (OR 1.25, 95% CI 1.02-1.04, p<0.001). CONCLUSIONS: PH is a common complication following RARC (20%). Approximately one-third will develop symptoms and 10% will require surgical treatment. Risk for developing PH plateaus after the 3rd year. Longer operative time was associated with higher incidence of PH.
Source of Funding: Roswell Park Alliance Foundation
MP24-18 DETRUSOR BIOENGINEERING USING COMPRESSED COLLAGEN, ADIPOSE-DERIVED STEM CELLS AND SMOOTH MUSCLE CELLS Jakub Smolar*, Schlieren, Switzerland; Maya Horst, Daniel Eberli, Zurich, Switzerland INTRODUCTION AND OBJECTIVES: Conditions impairing bladder function in children and adults often need urinary diversion or augmentation cystoplasty as when untreated they may cause severe bladder dysfunction and kidney failure. Currently, the gold standard therapy of end-stage bladder disease refractory to conservative management is enterocystoplasty, which despite providing functional improvement is associated with significant long-term complications. Therefore, there is a strong clinical need for alternative therapies for these reconstructive procedures. The aim of this study is to develop functional smooth muscle tissue for the detrusor muscle repair combining various cell types in hydrogel scaffolds. METHODS: Rat bladder smooth muscle (SMC) and adiposederived stem cells (ADSC) were isolated, expanded and characterized using flow cytometry. ADSC were pre-differentiated into SMC-like cells (pADSC). Cells were combined in ratios 1:1, 1:2 and 1:3 (SMC:pADSC) and embedded in compressed collagen (CC). After 1, 2 and 3 weeks, cells in CC scaffolds, direct and indirect 2D co-cultures were analyzed for viability, proliferation, morphology, SMC-marker expression and functionality. RESULTS: Cell growth conditions have been optimized and cells have shown high viability and good proliferation in the CC scaffolds. Interconnected microtissues and cell layers have developed all over the CC already after 1 week of co-culture. At 1 and 2 week timepoints cells in CC showed strong expression of the SMC markers calponin, MyH11 and smoothelin. Direct cell co-culture resulted in significantly increased cellular proliferation. Microtissues consisted of a SMC-core surrounded by pADSC. Indirect co-culture resulted in an increased pADSC survival and ratio-dependent increase in SMC-proliferation. pADSC proliferation rate also improved, but remained unaffected by the cell ratio, with 1:1 showing the most consistent results. SMC-marker expression normalized between the different ratios after 2 weeks of co-culture and reached almost the SMC monoculture expression levels. The 1:1 co-culture contracted significantly better than the other ratios after 24h. CONCLUSIONS: We have shown that a SMCepADSC co-culture results in an improved cell survival, proliferation, microtissue and cell layer formation without any significant changes in phenotype
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Saturday, May 13, 2017
and functionality. The combination of SMC and pADSC with CC may help to engineer functional detrusor muscle tissue by solving the major issues of tissue engineering, namely poor cell survival, proliferation, phenotype instability and functionality. Source of Funding: Fromm Fellowship Helmut Horten Foundation
MP24-19 TRANSVESICAL VENTRAL BUCCAL MUCOSA GRAFT INLAY CYSTOPLASTY FOR RECONSTRUCTION OF REFRACTORY BLADDER NECK CONTRACTURES AFTER BENIGN PROSTATIC HYPERPLASIA SURGERY: SURGICAL TECHNIQUE AND PRELIMINARY RESULTS Rodrigo Donalisio da Silva*, Jeffrey M. Marks, Fernando J. Kim, Brian J. Flynn, Denver, CO INTRODUCTION AND OBJECTIVES: The treatment of bladder neck contracture (BNC) after BPH surgery is challenging and may even require open reconstructive surgery in patients that whish to avoid chronic catheterization or suprapubic urinary diversion. The aim of this study is to introduce a novel surgical technique for the reconstruction of refractory BNC using buccal mucosal graft (BMG) inlay through a transvesical approach. METHODS: We performed a retrospective analysis of patients that underwent open reconstructive surgery for refractory BNC after BPH surgery from 2010-2016 by a single surgeon (BJF). Steps of the procedure: transvesical ventral wedge resection of the fibrotic bladder neck contracture and spread fixation of appropriately sized BMG inlay. The patients were followed for post-operative complications and stricture recurrence with uroflowemtry, PVR, cystoscopy and outcome questionnaires. Outcome measures included length of follow-up, surgical technique, operative time, hospital stay, complications, and subsequent need for catheterization RESULTS: A total of 13 patients presented refractory BNC of which 11 were suitable for reconstruction and 2 required urinary diversion. Eleven patients underwent reconstruction underwent transvesical ventral buccal mucosa graft inlay cystoplasty. Prior BPH surgery included transurethral resection of the prostate (64%), plasma vaporization of prostate (27%), and open prostatectomy (9.1%). Urinary retention (82%) was the most common presenting symptom and 73% of patients were using a catheter (Foley, suprapubic, self-catheterization) pre-operatively. An average of 2.3 endoscopic procedures were performed before BNC reconstruction. Overall, BNC diameter was 9.1 Fr. The average BMG size was 11.3 cm2, operative time was 298 minutes, and hospital stay was 3.3 days. Post-operatively, four patients had transient urinary retention and two had epididymorchytis. At a mean follow-up of 1.2 (0-5.1) years, only one patient had chronic retention and was considered a failure and remains dependent on selfcatheterization. CONCLUSIONS: BNC after BPH surgery is challenging surgical issue. Transvesical ventral BMG inlay cystoplasty is a feasible option that effectively treats refractory BNC. This graft augmentation technique using buccal mucosa graft provide good outcomes with low morbidity for patients that failed multiple endoscopic treatments Source of Funding: None
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MP24-20 EARLY AMBULATION DECREASES HOSPITAL LENGTH OF STAY IN RENAL TRAUMA: A RANDOMIZED, PROSPECTIVE STUDY Ilija Aleksic*, Igor Sorokin, Himanshu Aggarwal, Adam Walker, Paul Feustel, Ronald Kaufman, Albany, NY INTRODUCTION AND OBJECTIVES: Non-operative management (NOM) is the standard of care for blunt renal trauma. Observation for blunt renal trauma has been widely adopted with practitioner dependent duration of bed rest. A paucity of data exists regarding the effect of bed rest on outcomes and on hospital length of stay (LOS). Urologists commonly offer either bed rest for four to five days or until the resolution of gross hematuria. Given the system-wide emphasis on reducing LOS, we sought to prospectively determine if early ambulation leads to shorter hospital stays and its safety for patients with grade 2-4 blunt renal trauma. METHODS: After obtaining IRB approval and consent from patients with Grade 2-4 renal laceration, patients were randomized to either four days of strict bed rest or strict bed rest until resolution of hematuria. Primary end-point was hospital LOS while intervention performed, complications, and rate of re-bleed was also collected. The study was closed due to failure to accrue. RESULTS: From Aug 2012 - Sep 2015, 12 patients were randomized into one of the two groups. The bed rest group consisted of four patients while the early ambulation group consisted of eight. Median age overall was 23.5, with 22.99 in the bed rest and 25.61 in the early ambulation group (p¼0.8). Overall, 3 were female (25%) and 9 were male (75%). The cohort consisted of one Grade 2 (8.3%), eight Grade 3 (66.7%), and three Grade 4 (25.0%) renal lacerations. Median time to ambulation was 2 days, with 5 and 1.5 days for bed rest and early groups, respectively (p<0.01). Median LOS was 4.0 days with 6.0 days and 3.0 days for the bed rest and early groups, respectively (p<0.05).No re-bleeds were documented in either group and no interventions were required for the early ambulation group. Two patients in the bed rest arm required angiography without other intervention and one required a blood transfusion. One patient acquired a catheter associated urinary tract infection. CONCLUSIONS: Strict bed rest protocols are associated with higher morbidity due to prolonged immobilization and the subsequent increase in LOS exposure iatrogenic morbidity and cost. Albiet a small sample size, our data illustrate Level 1 evidence that early ambulation yields decreased hospital LOS without causing adverse side effects.
Source of Funding: none
e308
Vol. 197, No. 4S, Supplement, Saturday, May 13, 2017
haematological and microbiological findings suggest that the fundamental problem is the urine leak and direct fistulation into (and sometimes through) the pubic symphysis. The more extensive the leak the worse the pain. The urinary and tissue microbiology did not correlate with each other or with the symptoms. The correct terminology for this condition, we believe, is Urosymphyseal Fistulae. Source of Funding: none
MP24-17 NATURAL HISTORY, PREVALENCE, PREDICTORS & OUTCOMES OF PARASTOMAL HERNIA AFTER ROBOTASSISTED RADICAL CYSTECTOMY Youssef Ahmed*, Ahmed Hussein, Paul May, Basim Ahmad, Taimoor Ali, Khurshid Guru, Buffalo, NY INTRODUCTION AND OBJECTIVES: Parastomal hernia (PH) is a frequent complication of urinary diversion after radical cystectomy. We investigated the prevalence, predictors and outcomes of PH. Clinical and radiologic evidence of PH was also investigated. METHODS: Retrospective review of 446 patients who underwent RARC at our institution from 2005 was conducted. Data was reviewed for demographics, clinical findings, imaging results and other perioperative outcomes. Radiologic PH was defined as protrusion of abdominal content through the stoma defect in the abdominal wall. PH was further described in terms of symptoms and their management. Kaplan Meier method was used to depict time to developing PH and logistic regression to evaluate predictors of PH. RESULTS: 384 patients who underwent RARC and IC were included in the analysis. Mean age was 70 years with median follow up of 18 months (IQR 6.8-34-.7). 74 (19%) patients had radiological evidence of PH, 24 (32%) were symptomatic and 8 (11%) underwent treatment. Median time to develop PH was 13 months (IQR 8.8-22). PH occurred at a rate of 10%, 33% and 36% at 1, 3 and 5 years respectively (Fig 1). Median time to symptoms was 24 months after RARC (IQR 7-39.6) and (8 months after radiological diagnosis. Patients with PH had significantly higher BMI (30 vs 28, p¼0.009), longer overall operative time (347 vs 388 min, p¼0.01), urinary diversion time (128 vs 108 p¼0.03) and higher blood loss (400 vs 250, p¼0.01). The incidence of PH was studied based on incorporation of intra-corporeal diversion in the program (Fig 2). On Multivariable analysis operative time was the only variable associated with higher incidence of PH (OR 1.25, 95% CI 1.02-1.04, p<0.001). CONCLUSIONS: PH is a common complication following RARC (20%). Approximately one-third will develop symptoms and 10% will require surgical treatment. Risk for developing PH plateaus after the 3rd year. Longer operative time was associated with higher incidence of PH.
Source of Funding: Roswell Park Alliance Foundation
MP24-18 DETRUSOR BIOENGINEERING USING COMPRESSED COLLAGEN, ADIPOSE-DERIVED STEM CELLS AND SMOOTH MUSCLE CELLS Jakub Smolar*, Schlieren, Switzerland; Maya Horst, Daniel Eberli, Zurich, Switzerland INTRODUCTION AND OBJECTIVES: Conditions impairing bladder function in children and adults often need urinary diversion or augmentation cystoplasty as when untreated they may cause severe bladder dysfunction and kidney failure. Currently, the gold standard therapy of end-stage bladder disease refractory to conservative management is enterocystoplasty, which despite providing functional improvement is associated with significant long-term complications. Therefore, there is a strong clinical need for alternative therapies for these reconstructive procedures. The aim of this study is to develop functional smooth muscle tissue for the detrusor muscle repair combining various cell types in hydrogel scaffolds. METHODS: Rat bladder smooth muscle (SMC) and adiposederived stem cells (ADSC) were isolated, expanded and characterized using flow cytometry. ADSC were pre-differentiated into SMC-like cells (pADSC). Cells were combined in ratios 1:1, 1:2 and 1:3 (SMC:pADSC) and embedded in compressed collagen (CC). After 1, 2 and 3 weeks, cells in CC scaffolds, direct and indirect 2D co-cultures were analyzed for viability, proliferation, morphology, SMC-marker expression and functionality. RESULTS: Cell growth conditions have been optimized and cells have shown high viability and good proliferation in the CC scaffolds. Interconnected microtissues and cell layers have developed all over the CC already after 1 week of co-culture. At 1 and 2 week timepoints cells in CC showed strong expression of the SMC markers calponin, MyH11 and smoothelin. Direct cell co-culture resulted in significantly increased cellular proliferation. Microtissues consisted of a SMC-core surrounded by pADSC. Indirect co-culture resulted in an increased pADSC survival and ratio-dependent increase in SMC-proliferation. pADSC proliferation rate also improved, but remained unaffected by the cell ratio, with 1:1 showing the most consistent results. SMC-marker expression normalized between the different ratios after 2 weeks of co-culture and reached almost the SMC monoculture expression levels. The 1:1 co-culture contracted significantly better than the other ratios after 24h. CONCLUSIONS: We have shown that a SMCepADSC co-culture results in an improved cell survival, proliferation, microtissue and cell layer formation without any significant changes in phenotype
THE JOURNAL OF UROLOGYâ
Vol. 197, No. 4S, Supplement, Saturday, May 13, 2017
and functionality. The combination of SMC and pADSC with CC may help to engineer functional detrusor muscle tissue by solving the major issues of tissue engineering, namely poor cell survival, proliferation, phenotype instability and functionality. Source of Funding: Fromm Fellowship Helmut Horten Foundation
MP24-19 TRANSVESICAL VENTRAL BUCCAL MUCOSA GRAFT INLAY CYSTOPLASTY FOR RECONSTRUCTION OF REFRACTORY BLADDER NECK CONTRACTURES AFTER BENIGN PROSTATIC HYPERPLASIA SURGERY: SURGICAL TECHNIQUE AND PRELIMINARY RESULTS Rodrigo Donalisio da Silva*, Jeffrey M. Marks, Fernando J. Kim, Brian J. Flynn, Denver, CO INTRODUCTION AND OBJECTIVES: The treatment of bladder neck contracture (BNC) after BPH surgery is challenging and may even require open reconstructive surgery in patients that whish to avoid chronic catheterization or suprapubic urinary diversion. The aim of this study is to introduce a novel surgical technique for the reconstruction of refractory BNC using buccal mucosal graft (BMG) inlay through a transvesical approach. METHODS: We performed a retrospective analysis of patients that underwent open reconstructive surgery for refractory BNC after BPH surgery from 2010-2016 by a single surgeon (BJF). Steps of the procedure: transvesical ventral wedge resection of the fibrotic bladder neck contracture and spread fixation of appropriately sized BMG inlay. The patients were followed for post-operative complications and stricture recurrence with uroflowemtry, PVR, cystoscopy and outcome questionnaires. Outcome measures included length of follow-up, surgical technique, operative time, hospital stay, complications, and subsequent need for catheterization RESULTS: A total of 13 patients presented refractory BNC of which 11 were suitable for reconstruction and 2 required urinary diversion. Eleven patients underwent reconstruction underwent transvesical ventral buccal mucosa graft inlay cystoplasty. Prior BPH surgery included transurethral resection of the prostate (64%), plasma vaporization of prostate (27%), and open prostatectomy (9.1%). Urinary retention (82%) was the most common presenting symptom and 73% of patients were using a catheter (Foley, suprapubic, self-catheterization) pre-operatively. An average of 2.3 endoscopic procedures were performed before BNC reconstruction. Overall, BNC diameter was 9.1 Fr. The average BMG size was 11.3 cm2, operative time was 298 minutes, and hospital stay was 3.3 days. Post-operatively, four patients had transient urinary retention and two had epididymorchytis. At a mean follow-up of 1.2 (0-5.1) years, only one patient had chronic retention and was considered a failure and remains dependent on selfcatheterization. CONCLUSIONS: BNC after BPH surgery is challenging surgical issue. Transvesical ventral BMG inlay cystoplasty is a feasible option that effectively treats refractory BNC. This graft augmentation technique using buccal mucosa graft provide good outcomes with low morbidity for patients that failed multiple endoscopic treatments Source of Funding: None
e309
MP24-20 EARLY AMBULATION DECREASES HOSPITAL LENGTH OF STAY IN RENAL TRAUMA: A RANDOMIZED, PROSPECTIVE STUDY Ilija Aleksic*, Igor Sorokin, Himanshu Aggarwal, Adam Walker, Paul Feustel, Ronald Kaufman, Albany, NY INTRODUCTION AND OBJECTIVES: Non-operative management (NOM) is the standard of care for blunt renal trauma. Observation for blunt renal trauma has been widely adopted with practitioner dependent duration of bed rest. A paucity of data exists regarding the effect of bed rest on outcomes and on hospital length of stay (LOS). Urologists commonly offer either bed rest for four to five days or until the resolution of gross hematuria. Given the system-wide emphasis on reducing LOS, we sought to prospectively determine if early ambulation leads to shorter hospital stays and its safety for patients with grade 2-4 blunt renal trauma. METHODS: After obtaining IRB approval and consent from patients with Grade 2-4 renal laceration, patients were randomized to either four days of strict bed rest or strict bed rest until resolution of hematuria. Primary end-point was hospital LOS while intervention performed, complications, and rate of re-bleed was also collected. The study was closed due to failure to accrue. RESULTS: From Aug 2012 - Sep 2015, 12 patients were randomized into one of the two groups. The bed rest group consisted of four patients while the early ambulation group consisted of eight. Median age overall was 23.5, with 22.99 in the bed rest and 25.61 in the early ambulation group (p¼0.8). Overall, 3 were female (25%) and 9 were male (75%). The cohort consisted of one Grade 2 (8.3%), eight Grade 3 (66.7%), and three Grade 4 (25.0%) renal lacerations. Median time to ambulation was 2 days, with 5 and 1.5 days for bed rest and early groups, respectively (p<0.01). Median LOS was 4.0 days with 6.0 days and 3.0 days for the bed rest and early groups, respectively (p<0.05).No re-bleeds were documented in either group and no interventions were required for the early ambulation group. Two patients in the bed rest arm required angiography without other intervention and one required a blood transfusion. One patient acquired a catheter associated urinary tract infection. CONCLUSIONS: Strict bed rest protocols are associated with higher morbidity due to prolonged immobilization and the subsequent increase in LOS exposure iatrogenic morbidity and cost. Albiet a small sample size, our data illustrate Level 1 evidence that early ambulation yields decreased hospital LOS without causing adverse side effects.
Source of Funding: none