Tissue-engineered autologous bladders for patients needing cystoplasty
by
Drs. Anthony Atala , Stuart B Bauer, Shay Soker , James J Yoo  and Alan B Retik

Background: Patients with end-stage bladder disease can be treated with cystoplasty using gastrointestinal segments. The presence of such segments in the urinary tract has been associated with many complications. We explored an alternative approach using autologous engineered bladder tissues for reconstruction.

Methods: Seven patients with myelomeningocele, aged 4–19 years, with high-pressure or poorly compliant bladders, were identified as candidates for cystoplasty. A bladder biopsy was obtained from each patient. Urothelial and muscle cells were grown in culture, and seeded on a biodegradable bladder-shaped scaffold made of collagen, or a composite of collagen and polyglycolic acid. About 7 weeks after the biopsy, the autologous engineered bladder constructs were used for reconstruction and implanted either with or without an omental wrap. Serial urodynamics, cystograms, ultrasounds, bladder biopsies, and serum analyses were done.

Results: Follow-up range was 22–61 months (mean 46 months). Post-operatively, the mean bladder leak point pressure decrease at capacity, and the volume and compliance increase was greatest in the composite engineered bladders with an omental wrap (56%, 1·58-fold, and 2·79-fold, respectively). Bowel function returned promptly after surgery. No metabolic consequences were noted, urinary calculi did not form, mucus production was normal, and renal function was preserved. The engineered bladder biopsies showed an adequate structural architecture and phenotype.

Conclusions: Engineered bladder tissues, created with autologous cells seeded on collagen-polyglycolic acid scaffolds, and wrapped in omentum after implantation, can be used in patients who need cystoplasty.

Excerpt from article published online April 4, 2006 in the Lancet. Go to www.thelancet.com for complete article.

Introduction: Dr. Peter G. Chait is a Paediatric Interventional Radiologist at the Hospital for Sick Children in Toronto, Canada. Dr. Chait has developed a new, minimally invasive treatment for children with bowel/fecal incontinence. He, together with Dr. Barry Shandling, has pioneered a new antegrade colonic enema technique involving the insertion of a cecostomy (catheter into the cecum) using image guidance. To date, Dr. Chait has performed over 150 cecostomy insertions in children ranging from 2-20 years of age. Dr. Chait can be contacted at (416) 813-6814 Web site: www.cecostomy.com

What is a Cecostomy Catheter (C-Tube)?
A cecostomy is a catheter that is inserted into the cecum, which is the first part of the large bowel and is usually located within the right lower quadrant of the abdomen. The natural passage of food is into the mouth, through the stomach and small intestines into the cecum, then through the rest of the large bowel into the rectum, and out the anus. Since a cecostomy is inserted into this first part of large bowel, patients with fecal incontinence or their caregivers can use the cecostomy to administer a small-volume phosphate enema followed by a saline enema to quickly and completely evacuate and cleanse the large intestine, emptying through the anal opening.

In this way, potentially embarrassing accidents are avoided, and the patient often gains greater independence and freedom to pursue activities previously prevented by fear of incontinent episodes. The C-tube remains in the colon and provides a comfortable, convenient way to fully cleanse the bowel with an enema. Emptying the colon in this regular, predictable way can prevent unexpected leakage. After their C-tube insertion, some patients are able to give their own enemas for the first time.

Placement of a cecostomy tube is a minimally invasive procedure involving insertion of a temporary cecostomy catheter (C-tube) into the patient's cecum through a single puncture into the skin. Approximately six weeks later, the patient returns for a short, simple outpatient procedure to replace the temporary catheter with a tiny more permanent tube.

Benefits of a Cecostomy:
We have had a tremendous response from our patients and their families, telling us how the cecostomy has changed their lives. They find the antegrade colonic enema cecostomy technique is much more effective than other techniques, significantly improving resolution of incontinence, resulting in fewer accidents and many patients no longer wearing diapers. Our patients have reported increased independence and mobility, and have responded with an increased self-esteem and better grades.

It should be emphasized that this procedure is one management approach to a complex problem. Ideally, fecal incontinence should be evaluated and treated by the multidisciplinary spina bifida team and treatment decisions should be made by patients and their families.

Resources:
Children's National Medical Center
Washington, D.C.
Dr. Steven Lossef,
Director, Interventional Radiology
(202) 884-2485

Johns Hopkins Hospital
Baltimore, Maryland
Dr. Sally Mitchell,
Associate Prof. Radiology
(410) 614-2233