Stem cells for the treatment of urinary incontinence

A systematic review of stem cell therapy treatment for women suffering from stress urinary incontinence

BACKGROUND

Stem cell therapy (SCT) is used for regeneration of injured tissues. This seems a novel promising strategy for restoring urethral sphincter function in patients with stress urinary incontinence (SUI).

OBJECTIVE

To summarize the clinical trials available to date on SCT for treatment of SUI in women.

SEARCH STRATEGY

PubMed, Cochrane Library, Scopus and Embase.

SELECTION CRITERIA

Prospective interventional case series, randomized prospective interventional study and prospective cohort study assessing women aged 18 years and over diagnosed with SUI and treated by SCT were included. The quality of studies was finally assessed using the JBI Critical Appraisal Checklists according to the PRISMA guidelines.

DATA COLLECTION AND ANALYSIS

Nineteen studies (n = 773 patients) were selected for final analysis. These were conducted worldwide between the years 2005 and 2016. Although different cell types were used, general processing steps were similar. The follow-up period ranged between 6 weeks and 6 years and included common subjective and objective evaluation tools.

RESULTS

Overall, the studies imply that SCT for treatment of SUI is a safe and effective treatment.

CONCLUSION

In our opinion, the initial results of SCT for the treatment of SUI seem promising. Standardization and validation of this treatment modality is required before it can be recommended for routine use.

Two phase I/II clinical trials for the treatment of urinary incontinence with autologous mesenchymal stem cells

We evaluated the safety and feasibility of adipose‐derived mesenchymal stem cells to treat endoscopically urinary incontinence after radical prostatectomy in men or female stress urinary. We designed two prospective, nonrandomized phase I‐IIa clinical trials of urinary incontinence involving 9 men (8 treated) and 10 women to test the feasibility and safety of autologous mesenchymal stem cells for this use. Cells were obtained from liposuction containing 150 to 200 g of fat performed on every patient. After 4 to 6 weeks and under sedation, endoscopic intraurethral injection of the cells was performed. On each visit (baseline, 1, 3, 6, and 12 months), clinical parameters were measured, and blood samples, urine culture, and uroflowmetry were performed. Every patient underwent an urethrocystoscopy and urodynamic studies on the first and last visit. Data from pad test, quality‐of‐life and incontinence questionnaires, and pads used per day were collected at every visit. Statistical analysis was done by Wilcoxon signed‐rank test. No adverse effects were observed. Three men (37.5%) and five women (50%) showed an objective improvement of >50% (P < .05) and a subjective improvement of 70% to 80% from baseline. In conclusion, intraurethral application of stem cells derived from adipose tissue is a safe and feasible procedure to treat urinary incontinence after radical prostatectomy or in female stress urinary incontinence. A statistically significant difference was obtained for pad‐test improvement in 3/8 men and 5/10 women. Our results encourage studies to confirm safety and to analyze efficacy.

Anti-inflammatory effect of adipose-derived stem cells in the treatment of pelvic organ prolapse

Objective

This study investigated the effect of recombinant human connective tissue growth factor (hCTGF) on rat adipose-derived stem cells (ADSCs) and explored the feasibility of using ADSCs to treat pelvic organ prolapse.

Methods

ADSCs were isolated from rat inguinal adipose tissue and characterized by flow cytometry and for osteogenic and adipogenic differentiation. ADSCs were treated with recombinant hCTGF and qRT-PCR was performed to detect collagen I and III expression on post-treatment days 7, 14, and 28. Osteogenic and adipogenic differentiation of ADSCs was performed to evaluate the effect of hCTGF. ADSCs were seeded in biological grafting materials, acellular porcine pericardium (APP) and acellular bovine pericardium (ABP), then implanted in the rat vagina. Histology was performed to observe inflammation among different groups.

Results

Collagen I and III expression in ADSCs was significantly increased, and the ability to differentiate into osteogenic and adipogenic lineages was diminished after hCTGF treatment. APP and ABP seeded with ADSCs significantly decreased inflammation and protected from degradation in vivo compared with APP and ABP only; ABP seeded with ADSCs had the lowest inflammation.

Conclusion

hCTGF regulates collagen I and III expression and induces ADSC differentiation in vitro. ADSCs decrease inflammation associated with APP and ABP in vivo.

Urethral Sphincter Mechanism Incompetence in Dogs: An Update

Urethral sphincter mechanism incompetence (USMI) is the most common cause of acquired urinary incontinence in dogs. The pathogenesis of USMI is multifactorial and complex. Studies have shown variable results regarding the effects and timing of sterilization on the incidence of USMI. Diagnosis of USMI is often based on history, physical examination, and elimination of other differentials. Treatment options for USMI include medications, such as α-adrenergic agents and estrogen products, minimally-invasive urethral bulking procedures, surgical procedures (e.g., indwelling urethral occluders), or combination therapy. The overall prognosis for USMI is typically fair to good with long-term therapy.

Stem Cell Therapy for Male Urinary Incontinence

INTRODUCTION

Among the medical and surgical options which have been proposed in the last years for the management of male stress urinary incontinence (SUI), stem cell therapy represents a new frontier treatment. The aim of this paper is to update the current status of stem cell therapy in animal and human studies for the management of iatrogenic male SUI.

MATERIAL AND METHODS

A PubMed review of the literature on stem cell therapy for the treatment of male SUI was performed.

RESULTS

Regarding animal studies, bone marrow-, muscle- and adipose-derived stem cells have been widely studied, showing regeneration of the urethral sphincter and recovery of the damaged pelvic nerves. With regard to human studies, only four papers are available in the literature using muscle- and adipose-derived stem cells which reported a significant improvement in sphincteric function and incontinence with no severe side effects.

CONCLUSIONS

In spite of these promising results, further studies are needed with longer follow-ups and larger numbers of patients in order to clarify the potential role of stem cell therapy for the treatment of male SUI.

Regeneration of degenerated urinary sphincter muscles: improved stem cell-based therapies and novel imaging technologies

Stress urinary incontinence (SUI) is a largely ousted but significant medical, social, and economic problem. Surveys suggest that nowadays approximately 10% of the male and 15% of the female population suffer from urinary incontinence at some stage in their lifetime. In women, two major etiologies contribute to SUI: degeneration of the urethral sphincter muscle controlling the closing mechanism of the bladder outflow and changes in lower pelvic organ position associated with degeneration of connective tissue or with mechanical stress, including obesity and load and tissue injury during pregnancy and delivery. In males, the reduction of the sphincter muscle function is sometimes due to surgical interventions as a consequence of prostate cancer treatment, benign prostate hyperplasia, or of neuropathical origin. Accordingly, for women and men different therapies were developed. In some cases, SUI can be treated by physical exercise, electrophysiological stimulation, and pharmacological interventions. If this fails to improve the situation, surgical interventions are required. In standard procedures, endoprostheses for mechanical support of the weakened tissue or mechanical valves for a bladder outflow control are implanted. In 20% of cases treated, repeat procedures are required as implants yield all sorts of side effects in time. Based on preclinical studies, the application of an advanced therapy medicinal product (ATMP) such as implantation of autologous cells may be a curative and long-lasting therapy for SUI. Cellular therapy could also be an option for men suffering from incontinence caused by injury of the nerves controlling the muscular sphincter system. Here we briefly report on human progenitor cells, especially on mesenchymal stromal cells (MSCs), their expansion and differentiation to smooth muscle or striated muscle cells in vitro, labeling of cells for in vivo imaging, concepts of improved, precise, yet gentle application of cells in muscle tissue, and monitoring of injected cells in situ.

Stress urinary incontinence in women and cell therapy: What can we expect from the future?

Stress urinary incontinence (SUI) is a common disorder that affects a large number of women and their quality of life. The aim of SUI therapy is to restore the existing urethral function via physical therapy, biofeedback, pelvic floor rehabilitation, pharmacological therapy, bulking agents and surgical approaches. Currently, the gold standard for the management of SUI is the tension-free vaginal sling, which provides structural support to the female urethra. However, even minimally invasive surgical procedure such as “slings” carries risks for the patients, lost efficacy over the time and has long-term complications. For this reason, new therapeutic modalities are needed. Cell therapy has been emerged as an alternative to be used on the treatment of different diseases. The use of stem cells as a therapeutic option for SUI is an attractive alternative because, theoretically, injected cells could restore functional muscle cells and aid in sphincter closure in women with sphincter-associated incontinence. This study aims to review the current literature regarding evidences for using stem cell therapy on stress urinary incontinence in women.

Combined injection of three different lineages of early-differentiating human amniotic fluid-derived cells restores urethral sphincter function in urinary incontinence

OBJECTIVE

To investigate whether a triple combination of early-differentiated cells derived from human amniotic fluid stem cells (hAFSCs) would show synergistic effects in urethral sphincter regeneration.

MATERIALS AND METHODS

We early-differentiated hAFSCs into muscle, neuron and endothelial progenitor cells and then injected them into the urethral sphincter region of pudendal neurectomized ICR mice, as single-cell, double-cell or triple-cell combinations. Urodynamic studies and histological, immunohistochemical and molecular analyses were performed.

RESULTS

Urodynamic study showed significantly improved leak point pressure in the triple-cell-combination group compared with the single-cell- or double-cell-combination groups. These functional results were confirmed by histological and immunohistochemical analyses, as evidenced by the formation of new striated muscle fibres and neuromuscular junctions at the cell injection site. Molecular analysis showed higher target marker expression in the retrieved urethral tissue of the triple-cell-combination group. The injection of early-differentiated hAFSCs suppressed in vivo host CD8 lymphocyte aggregations and did not form teratoma. The nanoparticle-labelled early-differentiated hAFSCs could be tracked in vivo with optical imaging for up to 14 days after injection.

CONCLUSION

Our novel concept of triple-combined early-differentiated cell therapy for the damaged sphincter may provide a viable option for incontinence treatment.

Towards a Treatment of Stress Urinary Incontinence: Application of Mesenchymal Stromal Cells for Regeneration of the Sphincter Muscle

Stress urinary incontinence is a significant social, medical, and economic problem. It is caused, at least in part, by degeneration of the sphincter muscle controlling the tightness of the urinary bladder. This muscular degeneration is characterized by a loss of muscle cells and a surplus of a fibrous connective tissue. In Western countries approximately 15% of all females and 10% of males are affected. The incidence is significantly higher among senior citizens, and more than 25% of the elderly suffer from incontinence. When other therapies, such as physical exercise, pharmacological intervention, or electrophysiological stimulation of the sphincter fail to improve the patient’s conditions, a cell-based therapy may improve the function of the sphincter muscle. Here, we briefly summarize current knowledge on stem cells suitable for therapy of urinary incontinence: mesenchymal stromal cells, urine-derived stem cells, and muscle-derived satellite cells. In addition, we report on ways to improve techniques for surgical navigation, injection of cells in the sphincter muscle, sensors for evaluation of post-treatment therapeutic outcome, and perspectives derived from recent pre-clinical studies.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

PURPOSE

To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.

METHODS

Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT.

OUTCOMES

adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.

RESULTS

Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.

CONCLUSION

Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Biological activity and magnetic resonance imaging of superparamagnetic iron oxide nanoparticles-labeled adipose-derived stem cells

Introduction

No comparative study of adipose-derived stem cells (ADSCs) and bone marrow mesenchymal stem cells (BMSCs) by using superparamagnetic iron oxide nanoparticles (SPIOs)-labeling and magnetic resonance imaging (MRI) has been performed.

Methods

We studied the biological activity and MRI of ADSCs by labeling them with SPIOs and comparing them with BMSCs. After incubating the cells in culture medium with different levels of SPIOs (control group: 0 μg/ml; Groups 1 to 3: 25, 50, and 100 μg/ml) for 24 hours, we compared ADSCs with BMSCs in terms of intracellular iron content, labeling efficiency, and cell viability. Stem cells in the culture medium containing 50 μg/ml SPIOs were induced into osteoblasts and fat cells. Adipogenic and osteogenic differentiation potentials were compared. R₂* values of MRI in vitro were compared.

Results

The results showed that labeling efficiency was highest in Group 2. Intracellular iron content and R₂* values increased with increasing concentrations of SPIOs, whereas cell viability decreased with increasing concentrations of SPIOs, and adipogenic and osteogenic differentiation potentials decreased. However, we found no significant difference between the two kinds of cells for any of these indexes.

Conclusions

ADSCs can be labeled and traced as easily as BMSCs in vitro. Given their abundance and higher proliferative capacity, as was previously shown, ADSCs may be better suited to stem cell therapy than are BMSCs.

Reprogramming of fibroblasts from older women with pelvic floor disorders alters cellular behavior associated with donor age

We aimed to derive induced pluripotent stem cell (iPSC) lines from vaginal fibroblasts from older women with pelvic organ prolapse. We examined the effect of donor age on iPSCs and on the cells redifferentiated from these iPSCs. Vaginal fibroblasts were isolated from younger and older subjects for reprogramming. iPSCs were generated simultaneously using an excisable polycistronic lentiviral vector expressing Oct4, Klf4, Sox2, and cMyc. The pluripotent markers of iPSCs were confirmed by immunocytochemistry and quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Spectral karyotyping was performed. The ability of the iPSCs to differentiate into three germ layers was confirmed by embryoid body and teratoma formation. Senescence marker (p21, p53, and Bax) expressions were determined by qRT-PCR and Western blot. The iPSCs were redifferentiated to fibroblasts and were evaluated with senescence-associated β-galactosidase (SA) activity and mitotic index using time-lapse dark-field microscopy. iPSCs derived from both the younger and older subjects expressed pluripotency markers and showed normal karyotype and positive teratoma assays. There was no significant difference in expression of senescence and apoptosis markers (p21, p53, and Bax) in iPSCs derived from the younger subject compared with the older subject. Furthermore, fibroblasts redifferentiated from these iPSCs did not differ in SA activity or mitotic index. We report successful derivation of iPSCs from women with pelvic organ prolapse. Older age did not interfere with successful reprogramming. Donor age differences were not observed in these iPSCs using standard senescence markers, and donor age did not appear to affect cell mitotic activity in fibroblasts redifferentiated from iPSCs.

Development of stem cell therapy for stress urinary incontinence

PURPOSE OF REVIEW

In recent years, stem cell therapy has been investigated as a promising approach for the treatment of stress urinary incontinence (SUI). This article reviews the biology of stem cells and their applications as a cell-based treatment for SUI. The current status and future direction of this forefront research in urinary incontinence are also examined.

RECENT FINDINGS

During the past decade, adult stem cells have been studied as a potential cell-based approach for the treatment of SUI. The results of current preclinical and clinical studies are presented. These studies demonstrated the improvement in histologic and functional outcomes with stem cell therapies for SUI. Adult stem cells may augment sphincter regeneration and also release trophic factors, promoting vessel and nerve integration into the generated tissues. So far, the findings of the clinical trials are less impressive than the results obtained with animal studies.

SUMMARY

Although stem cell therapy holds much promise for SUI, the clinical applications in patients have been slow to materialize. This challenge, together with the currently limited data on basic science studies and clinical trials, will undoubtedly stimulate new investigations in the near future.

Reawakening atlas: chemical approaches to repair or replace dysfunctional musculature

Muscle diseases are major health concerns. For example, ischemic heart disease is the third most common cause of death. Cell therapy is an attractive approach for treating muscle diseases, although this is hampered by the need to generate large numbers of functional muscle cells. Small molecules have become established as attractive tools for modulating cell behavior and, in this review, we discuss the recent, rapid research advances made in the development of small molecule methods to facilitate the production of functional cardiac, skeletal, and smooth muscle cells. We also describe how new developments in small molecule strategies for muscle disease aim to induce repair and remodelling of the damaged tissues in situ. Recent progress has been made in developing small molecule cocktails that induce skeletal muscle regeneration, and these are discussed in a broader context, because a similar phenomenon occurs in the early stages of salamander appendage regeneration. Although formidable technical hurdles still remain, these new advances in small molecule-based methodologies should provide hope that cell therapies for patients suffering from muscle disease can be developed in the near future.

Intrasphincteric autologous myoblast injections with electrical stimulation for stress urinary incontinence

OBJECTIVE

To assess the feasibility and safety of ultrasound-guided autologous myoblast injections into the external urethral sphincter followed by electrical stimulation (ES) as a possible 2-step treatment for stress urinary incontinence (SUI).

METHODS

Autologous myoblasts isolated from a biceps muscle sample were injected under transurethral ultrasound guidance into the external urethral sphincter of 38 female patients. The patients also underwent ES postoperatively to enhance cell integration. Treatment feasibility, as well as possible intraoperative and postoperative complications, was assessed 6weeks after the injections. Additionally, the effects of the myoblast injections followed by an ES cycle were compared to those of a preoperative ES cycle undergone by the same patients.

RESULTS

No serious adverse events or complications were noted and the procedure was well tolerated. Compared with the objective and subjective measurements collected after the preoperative ES cycle, the corresponding measurements obtained 6weeks postoperatively, after the completion of a second ES cycle, indicated considerable improvement. The results to the stress test were negative for 29 (78.4%) of the patients, 5 (13.5%) considered their SUI cured, and 29 (78.4%) reported improvement.

CONCLUSION

Intrasphincteric autologous myoblast injections followed by ES is minimally invasive and feasible, and safely produced promising initial results. EU Clinical Trials EudraCT No. 2009-012389-30 ClinicalTrials.gov identifier: NCT01355133.

Recurrent stress urinary incontinence after synthetic mid-urethral sling procedures

PURPOSE OF REVIEW

Synthetic mid-urethral slings (MUSs) have been widely adopted for female stress urinary incontinence (SUI). Practitioners are encountering increasing numbers of women with recurrent SUI after a failed MUS. Several studies over the past 18 months have reported outcomes for secondary continence procedures in this context and form the basis of this review.

RECENT FINDINGS

Expert consensus supports a trial of conservative therapy for recurrent SUI, although a sound evidence base is lacking. As regards repeat surgical intervention, retrospective studies on repeat synthetic MUSs have demonstrated medium-term cure rates of 60-70%, which is lower than that achieved with primary surgery. Secondary transobturator tape appears inferior to secondary retropubic tape in women with intrinsic sphincteric deficiency. Promising early results have been reported with spiral slings and the adjustable continence procedures, although these interventions are technically more challenging and longer-term follow-up is warranted. Artificial urinary sphincters show high efficacy rates for severe, refractory SUI, although complication rates are higher in women with prior failed MUS.

SUMMARY

Repeat synthetic MUSs are likely to form the mainstay of secondary continence procedures presently. Longer-term follow-up of promising newer modalities, including adjustable continence therapies, is required. Above all, there is an urgent need for good quality, prospective data to guide practitioners in this growing clinical challenge.

Stem cell therapy for incontinence: where are we now? What is the realistic potential?

A significant number of women experience stress urinary incontinence (SUI), which greatly affects their quality of life. Recent research investigating utilization of stem cells and their derivatives for the prevention and treatment of SUI has been performed to test the effect of cell source and method of administration in several animal models of SUI. The type of stem cell, timing of optimal dose or doses after injury, mechanism of action of stem cells, and route of administration must be investigated both preclinically and clinically before stem cell therapy becomes a possible treatment for SUI, although the future of this therapy looks promising. This article reviews the progress in stem cell research for incontinence and describes areas of future work as suggested by research in other fields.

Pelvic organ distribution of mesenchymal stem cells injected intravenously after simulated childbirth injury in female rats. Obstet Gynecol Int. 2012;2012:612946. [PMID: 21941558 PMCID: PMC3177359 DOI: 10.1155/2012/612946]

The local route of stem cell administration utilized presently in clinical trials for stress incontinence may not take full advantage of the capabilities of these cells. The goal of this study was to evaluate if intravenously injected mesenchymal stem cells (MSCs) home to pelvic organs after simulated childbirth injury in a rat model. Female rats underwent either vaginal distension (VD) or sham VD. All rats received 2 million GFP-labeled MSCs intravenously 1 hour after injury. Four or 10 days later pelvic organs and muscles were imaged for visualization of GFP-positive cells. Significantly more MSCs home to the urethra, vagina, rectum, and levator ani muscle 4 days after VD than after sham VD. MSCs were present 10 days after injection but GFP intensity had decreased. This study provides basic science evidence that intravenous administration of MSCs could provide an effective route for cell-based therapy to facilitate repair after injury and treat stress incontinence.

The clinical relevance of cell-based therapy for the treatment of stress urinary incontinence

Stress urinary incontinence is a common disorder affecting the quality of life for millions of women worldwide. Effective surgical procedures involving synthetic permanent meshes exist, but significant short- and long-term complications occur. Cell-based therapy using autologous stem cells or progenitor cells presents an alternative approach, which aims at repairing the anatomical components of the urethral continence mechanism. In vitro expanded progenitor cells isolated from muscle biopsies have been most intensely investigated, and both preclinical trials and a few clinical trials have provided proof of concept for the idea. An initial enthusiasm caused by positive results from early clinical trials has been dampened by the recognition of scientific irregularities. At the same time, the safety issue for cell-based therapy has been highlighted by the appearance of new and comprehensive regulatory demands. The influence on the cost effectiveness, the clinical relevance and the future perspectives of the present clinical approach are discussed.