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Brief Communication

Improved symptoms and signs of refractory interstitial cystitis in women after intravesical Nanofat plus platelet-rich plasma grafting: A pilot study

Hung, Man-Junga,b,*; Tsai, Ching-Peic; Ying, Tsung-Hoa,b; Chen, Gin-Dena,b; Su, Hong-Lind; Tseng, Chih-Jena,b

Author Information
Journal of the Chinese Medical Association: June 2022 - Volume 85 - Issue 6 - p 730-735
doi: 10.1097/JCMA.0000000000000735
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Abstract

1. INTRODUCTION

Painful bladder sensation accompanied by irritative urinary symptoms is the main complaints of patients with interstitial cystitis/bladder pain syndrome (IC/BPS). Further typical cystoscopic and histological features are needed for the diagnosis and subclassification of IC/BPS.1 The treatment of IC/BPS is problematic because the causes are not fully understood.2

Currently, the most accepted postulate for the pathogenesis of IC/BPS is a dysfunctional urothelium from bladder insults and the penetration of urine toxins and pathogens leads to inflammation, immunogenic responses, and neural sensitization in these patients.3 Intravesical glycosaminoglycan replenishment therapy had been used to restore the barrier function of urothelium and provide symptomatic relief in these patients. However, the therapy faces major limitations of a high proportion (~30%-40%) of nonresponders.4–6 Clinical trials of repeated intravesical Botulinum toxin A injections in patients with refractory IC/BPS have shown positive therapeutic effects because of sensory inhibitory and anti-inflammatory effects in addition to motor effects. However, postoperative urinary tract infections and voiding difficulty raised concerns.4,7,8

Recently, the potential applications of regenerative medicine, such as platelet-rich plasma (PRP) and stem cells, have been shown to be beneficial to treatment of IC/BPS in some preclinical and few clinical studies.9–12 PRP, which contains several growth factors and signal proteins released by actively degranulated platelets, acts on available cells to begin the tissue repair and regeneration processes.9,10 Nanofat, which is a stromal vascular fraction (SVF) obtained from mechanical emulsification and filtration of adipose tissue and contains a heterogeneous population of stem/progenitor cells and extracellular matrix, is a therapeutic paradigm in regenerative medicine.13–15 In plastic surgery, Nanofat is an injectable viscous extract that primarily induces tissue remodeling after grafting. In contrast, Macro- and Microfat grafts, which contain mainly small lobules of adipose tissue and viable adipocytes, are used as a filling material for soft-tissue defects.16 Combined Nanofat and PRP grafting, which was thought to work better than either alone because of a biocellular synergistic effect, has been used in skin rejuvenation, treatment of scars and infected ulcers, etc.17–21

We hypothesized that a bladder injection therapy using Nanofat and PRP combination might contribute to an in vivo tissue engineering process at the recipient sites and result in symptomatic and morphological improvement in patients with IC/BPS. In this pilot study, we aimed to evaluate the impact of this novel intravesical therapy using biocellular regenerative medicine on our patients with refractory IC/BPS.

2. METHODS

Between February and September 2019, a total of seven women with refractory IC/BPS were enrolled consecutively for this study. Informed consent was obtained. The Institutional Review Board and Ethics Committee approved this clinical trial (CSMUH No: CS1-20188).

One patient (14.3%) was excluded due to inadequate fat harvest from liposuction. Six patients, who completed a standard protocol of four consecutive bladder injection therapies at 3-month intervals, were followed up. Pain Visual Analog Scale (pain-VAS), Interstitial Cystitis Symptom and Problem Index (ICSI and ICPI), and a scaled Global Response Assessment (GRA) were used for assessing outcomes. Cystoscopic hydrodistention was performed before injections to localize various bladder mucosal lesions for a lesion-targeted treatment and to evaluate morphological responses from prior treatments.

The preparation of Nanofat grafts was conducted according to the methods described by Tonnard et al13 with some modifications using industry-manufactured specific devices (Tulip Medical Products; San Diego, CA, USA). For the preparation of PRP, a commercial device (Tropocells PRP systems; Estar Medical, Holon, Israel) was used. Approximately, 12-mL Nanofat and 8-mL PRP were obtained from 60-mL lipoaspirate and 20-mL whole blood, respectively. The mixture (~20 mL) was used for a lesion-targeted bladder injection at 10 sites (2 mL at each site). After grafting, PRP was converted into fibrin matrix by the infusion of a 10% calcium chloride solution in a 1:10 ratio to the recipient sites to facilitate the submucosal retention of the grafts22 (Fig. 1).

F1
Fig. 1:
Submucosal retention of the injected biocellular regenerative medicine containing Nanofat and platelet-rich fibrin after the infusion of a 10% calcium chloride solution at the bladder recipient site

3. RESULTS

Patient characteristics are shown in Table 1. Our patients were characterized by having unsatisfactory results to multiple lines of standard treatments at a mean duration of 24.7 ± 13.6 months (range, 12-46 months).

Table 1 - Patient characteristics
Patient Age (y) BMI (kg/m2) Body fat % Duration (mo) a ESSIC typing b Treatment
1 47 21.0 28.1 26 2 BoNT-A X 1
2 43 21.6 30.9 35 2 BoNT-A X 3
3 54 23.6 34.5 14 2 HA only
4 47 24.7 35.3 46 2 BoNT-A X 4
5 47 21.4 35.8 15 3 Electrofulguration X 3
6 40 27.7 38.7 12 2 BoNT-A X 2
Average 46.3 ± 4.7 23.3 ± 2.6 33.9 ± 3.8 24.7 ± 13.6
BoNT-A = Botulinum toxin A; ESSIC = European Society for the Study of Interstitial Cystitis; HA = hyaluronic acid; IC/BPS = interstitial cystitis/bladder pain syndrome.
aOne (16.7%) patient (No. 5) was diagnosed with ESSIC type 3 (ulcerative) IC/BPS.
bPrior treatments included monthly HA instillation in six (100%), repeated (1-4) sessions of BoNT-A bladder injection every 6 months in four (66.7%), and repeated (3) sessions of electrofulgurations of Hunner’s lesions in one (16.7%) patient, respectively.

Six months postoperatively, all patients (100%) reported marked (+3; +3 ~ −3) improvement in their overall bladder conditions on the GRA. Statistically significant (p < 0.01) improvement was also found from the changes of various pain-VAS, ICSI, and ICPI scores before and after treatments (Table 2). There were no significant adverse events except for subcutaneous ecchymosis from liposuction.

Table 2 - Treatment outcomes
Patient GRAPostoperative ICSI ICPI Pain-VAS Cystoscopic capacity (mL)
Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative
1 +3 18 3 16 1 5 1 980 1000
2 +3 19 6 16 4 6 2 950 750
3 +3 16 0 14 0 8 0 870 970
4 +3 20 11 15 7 10 3 870 980
5 +3 19 5 16 4 10 1 530 600
6 +3 19 9 12 7 10 3 625 750
Average +3 18.5 ± 1.4 5.7 ± 4.0 14.8 ± 1.6 3.8 ± 2.9 8.2 ± 2.2 1.7 ± 1.2 804.2 ± 183.4 841.7 ± 164.9
p <0.001 <0.001 <0.001 0.49
GRA = global response assessment (+3 ~ −3); ICPI = interstitial cystitis problem index (+16 ~ 0); ICSI = interstitial cystitis symptom index (20~0); Pain-VAS = pain visual analog scale (+10 ~ 0).

Progressive remission of various bladder mucosal lesions during treatments and at 6 months postoperatively was noted in all six patients (100%) (Figs. 2 and 3). The cell yield of Nanofat samples from our six patients is shown in Table 3. Mesenchymal stem cells (MSCs) cultured from Nanofat samples of the six patients were characterized in vitro via standard operating procedures according to an official recommendation23,24 (Fig. 4).

Table 3 - Analysis of the cell yield of Nanofat samples from six patients with refractory IC/BPS
Patient Mass of tested Nanofat (mL) Yield a total nucleated cells /mL Nanofat (×105) Yield b adherent cells/mL Nanofat (×105) Adherent cells/total nucleated cells (%)
1 12.0 1.6 0.11 6.9%
2 1.0 1.0 0.06 6.0%
3 2.0 4.7 0.19 4.0%
4 2.0 3.4 0.14 4.1%
5 1.5 5.2 0.19 3.7%
6 2.0 2.9 0.12 4.1%
Average 3.42 ± 4.2 3.13 ± 1.7 0.135 ± 0.05 4.3 ± 1%
IC/BPS = interstitial cystitis/bladder pain syndrome; SVF = stromal vascular fraction.
aTotal nucleated cells: the SVF cells.
bAdherent cells: the putative mesenchymal stem cells.

F2
Fig. 2:
Bladder morphological outcomes during treatments and at 6 mo postoperatively. Progressive normalization (from left to right) of bladder mucosal morphology was noted in all six (100%) patients
F3
Fig. 3:
The remission of various bladder mucosal lesions, ie, glomerulations (A-H), mucosal disruption (I, J) and fissures (K, L), after lesion-targeted bladder injection therapy with Nanofat plus platelet-rich plasma grafting
F4
Fig. 4:
In vitro characterization of cultured mesenchymal stem cells from Nanofat samples of six patients who underwent the novel bladder injection therapy. A, The growth kinetics by cumulative population doublings. B, Senescence assay by beta-galactosidase staining of cultured mesenchymal stem cells. P: passage. Arrow: senescent cells (blue). C, Microscopic cell morphology. Original magnification ×100. D, Trilineage differentiation potential by cytochemical staining with Oil Red-O (adipogenic), Alizarin Red S (osteogenic), and by immunofluorescent staining to α-smooth muscle actin (smooth muscle differentiation). Original magnification ×100. E, Detection of cell surface antigen by flow cytometry

4. DISCUSSION

Until now, there have been few clinical trials using regenerative medicine for treating IC/BPS. Lander et al12 assessed the impact of combined intravenous and local injection of autologous SVF stem cells on 109 patients with IC/BPS and found the treatment was safe and effective. However, there was no objective outcome measurement and no reporting whether repeated treatments were necessary. Jiang et al10 performed repeated bladder injection therapy using autologous PRP followed by immediate cystoscopic hydrodistention at monthly intervals in 40 patients with refractory IC/BPS and found improved symptoms and altered urinary functional proteins after treatment. However, no morphological results were reported.

In this study, the normalization of bladder mucosal morphology with consecutive treatments indicated a tissue repair and regeneration therapeutic effect. This finding also supported our hypothesis that the novel intravesical therapy might contribute to an in vivo tissue engineering process since the grafts contained fundamental elements, ie, stem cells, growth factors, and extracellular matrix, required for the activity. In the future, further studies are necessary to determine whether the clinical observations can be correlated with histologic analysis before and after treatment.

Additionally, we performed laboratory analysis of Nanofat samples from our six patients. The estimated yield of SVF cells and MSCs per milliliter of Nanofat was 310 (±170) × 103 and 14 (±5) × 103, respectively. Our yield of SVF cells was higher than that reported by Gentile et al.25 In their study, a yield of 20 ~ 200 (±3-15) × 103 SVF cells per milliliter of Nanofat obtained from four different methods was found. Besides, a positive correlation between the SVF cell yield and clinical outcomes was noted when using Nanofat grafts for treatment of scars.25 Accordingly, the relatively high SVF cell yield of our Nanofat might, therefore, contribute to the promising results in this study.

The weakness of this study was the small sample size and a lack of control study. The strength of this study was the sequential follow-up of morphological responses from consecutive treatments.

In conclusion, our preliminary results suggested autologous Nanofat plus PRP grafting is safe and effective for IC/BPS. Morphological outcomes supported our hypothesis that surgical effectiveness might be attributed to an in vivo tissue engineering process.

ACKNOWLEDGMENTS

This study was supported by grants from Chung Shan Medical University Hospital (Grant No. CSH-2021-C-042) and RONG SING Medical Foundation (Grant No. RSMF-1100191).

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Keywords:

Interstitial cystitis/bladder pain syndrome (IC/BPS); Intravesical therapy; Mesenchymal stem cells; Nanofat; Platelet-rich plasma; Stromal vascular fraction

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