Autologous cell engineered bladder augmentation

Lead Research Organisation: University College London
Department Name: Institute of Child Health

Abstract

Some 3 million people in the UK experience incontinence and the cost of management is over £500 million per annum to the NHS. It can be caused by both congenital anomalies, such as a failure of the bladder in the foetus to form (bladder exstrophy), and acquired conditions such as a lost of the compliance of the bladder (neuropathic bladder) or bladder cancer. For end-stage bladder disease, the most commonly performed surgical procedure to augment or replace the bladder involves incorporating a vascularised, reconfigured segment of bowel (enterocystoplasty). Although this procedure can provide continence and enhance quality of life, it is commonly associated with serious complications, including infections, mucus production and stone formation, and long-term risk of cancer. These complications are primarily due to the fact that bowel mucosa is structurally and physiologically incompatible with the long-term exposure to urine. A number of bladder engineering strategies have been proposed and typically, these rely upon the incorporation of a natural or synthetic biomaterial into the bladder, which may or not be pre-cultured with cells derived from the patient (autologous). Despite some high profile reports, there is little evidence that bladder tissue engineering can yet achieve a functional outcome equivalent to current surgical techniques, and there remains an unmet clinical need.
The aim of this programme is to deliver functional bladder reconstruction to patients through an autologous cell engineering strategy. This project will bring together expertise in stem cells and urology (ICH, GOSH and UCLH) with urothelial cell biology and bladder tissue engineering (York) with the purpose of developing a novel technique for bladder reconstruction that will be applicable in the first instance to patients with bladder exstrophy, but eventually extended to all patients requiring bladder augmentation. The stages of the project will be firstly to develop methods to identify nd isolate the most appropriate source of autologous epithelial cells in the case of bladder exstrophy. To meet this aim, cells derived from normal and diseased bladder and from biopsies of buccal mucosa will be isolated, and characterized. Expansion of the epithelial cells will be conducted using "Good Manufacturing Practices" techniques, a standard methodology used for pharmaceutical products, to provide a ready route for translation to the clinic. Human cells will be xenogeneic transplanted in 24 pigs for bladder augmentation and functional and histological data will be obtained at 3 and 6 months after transplantation. Principal outcome measures will be: safety as measured by survival; efficacy as measured by capacity and compliance of the neo-bladder. Secondary measures for this phase will include: surgical morbidity, post-mortem immunohistological analysis of both the augmented and native mucosa, and also 'reverse translational' outcome measures, where observations of cellular behaviour are used to develop hypotheses about stem cell/cell functional engraftment in these settings in vivo.

Technical Summary

1. Sourcing of autologous cells. Bladder mucosa will be harvested from exstrophy babies undergoing primary repair according to ethical approval. Buccal mucosa epithelium will be obtained from discarded tissue during hypospadias repair. Cells will be isolated and expanded using established techniques and tested for their capacity to express differentiation-associated markers and for functional barrier properties by measuring trans-epithelial electrical resistance and permeability to urea and water. The harvest of differentiated sheets and suitable carrier for transport and delivery will be also refined.
2. Refine the procedures to allow completion of GMP standard operating. Appropriate standard operating procedures and batch manufacturing records will be based on cell culture optimization to define a robust and reproducible process able to be tested in a pre-GMP setting. All critical reagents will be identified, sourced and, if necessary, validated for GMP compliance. Human urothelial, exstrophy and buccal epithelial GMP-compliant cells will be produced/banked for transplantation into pigs.
3. Establish the porcine experimental surgical model of composite cystoplasty. A vascularised, de-epithelialized, seromuscular colonic segment will be developed in a total of 24 immunosuppressed pigs. After isolation, the patch will receive the tissue-engineered epithelial sheet in complex with the carrier (e.g. Vicryl mesh) to facilitate epithelial attachment. The pigs will be divided into 3 groups (8 animals each): one set will receive a bladder augment with a patch built with tissue derived from healthy urothelium; the second set from exstrophy-derived urothelium, and finally the third set will undergo augmentation using tissue from buccal mucosa epithelium. The animals will be sacrificed at 3 and 6 months post-augment. The assessment will include voiding behaviour records and post-mortem immunohistological analysis of both the augmented and native mucosa.

Planned Impact

The aim of this programme is to deliver a functional bladder reconstruction, through a cell/tissue engineering strategy, to children affected by bladder augmentation, who require increased bladder capacity. Bladder exstrophy is a major congenital anomaly that affects the growth and function of the bladder. Despite improvement of the surgical techniques, the need for bladder augmentation in bladder exstrophy patients, in order to achieve an adequate bladder capacity is reported in up to 70% of children. In general, the incidence of neonates born with bladder exstrophy or other congenital malformations is increasing and the results of the operations currently used for their correction are often disappointing, leaving these children with profound disabilities and poor quality of life. This has significant deleterious effects on both the family and the community.
While we focus the work of this project on the bladder exstrophy, the use of a surrogate epithelium such as the buccal mucosa here proposed may have an impact also for other indications where bladder augmentation is required but autologous urothelium cannot be used, such as for bladder cancer patients. The evidence suggests an increasing trend in the incidence of this malignancy in recent years. In 2000, worldwide, 336,000 patients were diagnosed with bladder cancer. Bladder augmentation is part of the armoury of the urologist / paediatric urologist in the treatment of urinary incontinence. Urinary incontinence is associated with tremendous costs and with a significant decrement in health-related quality of life; it is proven that in addition to high economic costs, incontinence results in medical and psychological morbidity and adverse effects on quality of life. In general, urinary incontinence, secondary to congenital and acquired diseases, is experienced by some 3 million people in the UK and the cost of management is over £500 million per annum to the NHS.
At the moment, although bladder augmentation cn provide continence and enhance quality of life, it is commonly associated with serious complications, such as mucus production, formation of stones, recurrent urinary infection, metabolic imbalance and for some, in the long term, malignant change. Management of these complications can require additional medication, bladder washouts and occasionally hospitalisation treatment.
The aim of this project is to provide a safe alternative to bowel segments for augment the bladder that will improve clinical outcomes and the quality of life for these patients and their families by reducing their risk of sequelae. This in turn will reduce the cost burden for the NHS of lifelong management of such complex patients and their complications. Once validated, the proposed surgical approach to composite cystoplasty will be easily and quickly translated into clinical application. We also envisage that this research may have, in the long term, a wider economic impact. This is based on the fact that our results could be of interest not only for the cure of congenital anomalies, but also for the treatment of acquired diseases in children as well as in adults of all ages. Moreover tissue engineering is linked to advances in technology and is likely to generate commercial interests. If our approach would prove to be correct, possible patents could be generated for commercially exploitable results. It is not our primary interest to develop a patent, but we believe that this could help acquiring future grants and fostering of future research.

Publications


10 25 50
 
Description MRC Regenerative Medicine Research Committee
Amount £249,064 (GBP)
Funding ID MR/N028414/1 
Organisation Medical Research Council (MRC) 
Department MRC Research Grant
Sector Public
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start 05/2016 
End 10/2017
 
Description Proof od concept award
Amount £100,000 (GBP)
Organisation University of Leeds 
Department Medical Technologies IKC
Sector Academic/University
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start  
 
Description B Braun-Synthetic Mesh 
Organisation B.Braun Melsungen AG
Country Germany, Federal Republic of 
Sector Private 
PI Contribution We have been testing mesh products to identify the most suitable mesh for the growth of epithelial cells for tissue engineering.
Collaborator Contribution They have provided different samples of meshes to test
Impact Collaboration has recently started, analysis of the data is not yet available
Start Year 2017
 
Description J& J Improvement on cell lifting with synthetic mesh 
Organisation Johnson & Johnson
Country United States of America 
Sector Private 
PI Contribution We have been testing various materials for identifying the most suitable mesh
Collaborator Contribution They have provided different samples of meshes to test
Impact Collaboration has recently started, analysis of the data is not yet available
Start Year 2016
 
Description 27th ESPU Congress Harrogate 2016 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited to give a lecture.
Year(s) Of Engagement Activity 2016
 
Description European Paediatric Surgeons' Association (EUPSA) conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We performed a oral presentation in which we reported aims and preliminary results of our project. This was presented at one of the largest conference for pediatric Surgeons and Urologist and lead to discussions, questions and comments from many colleagues and experts
Year(s) Of Engagement Activity 2016
 
Description European Society for Pediatric Urology (ESPU) conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We presented our project thorough a poster and an oral presentation with the aim to circulated to the scientific community our ideas and results and obtain feedback and suggestions from colleagues and international experts
Year(s) Of Engagement Activity 2016
 
Description Plenary speaker 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact presentation to a national multidisciplinary network for incontinence research working to showcase the difficulties of dealing with this condition as a way of drawing together scientific experts, facilitating new research collaborations and inspiring novel ideas for next generation treatments.
Year(s) Of Engagement Activity 2016
 
Description Presentation to ESPU Conference 2016 (Harrogate) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We presented part of the results achieved during the awarded grant in an international medical conference (European Society for Paediatric Urologist)
Year(s) Of Engagement Activity 2016
URL https://www.espu.org/events/calendar/eventdetail/6/-/
 
Description Presentation to EUPSA Conference 2016 (Milan) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We presented part of results achieved during the awarded grant to an international conference (European Pediatric Surgery Association)
Year(s) Of Engagement Activity 2016
 
Description Talk to Surgical Sixty Club 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Talk to Surgical Sixty Club
Year(s) Of Engagement Activity 2016
 
Description Tissue Engineering Congress, London, 8 - 10th September 2015 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We presented the initial results of our project. This was presented at the annual conference of tissue engineering hosted in London where we had the chance to discuss about the project with international experts and to collect comments and suggestions from them
Year(s) Of Engagement Activity 2015
 
Description Workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Workshop on basic science to a trainee clinical audience at the European Society for Paediatric Urology, Harrogate.
Year(s) Of Engagement Activity 2016
 
Description public engagement 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Civic visit to the laboratory by Lord Mayor of York and Sheriff plus their partners, with reporter.
Year(s) Of Engagement Activity 2016
 
Description public engagement talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Talk to York Vikings Rotary Club
Year(s) Of Engagement Activity 2016