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Thread: Dr. Wise; Laboratory Grown Bladder

  1. #11
    Dr. Wise; Thanks for the response. I understand what you are saying. I have used an indwelling foley for 24 years. I am at the point of needing an augmentation because of the increased risk of cancer and erosion of the uretha if I don't do something.

    After reading the article the following things sounded like reasons the laboratory grown bladder would be a better type of augmentation.

    "But because the intestine is designed to absorb nutrients and a bladder is designed to excrete, patients who have the procedure are prone to such problems as osteoporosis, increased risk of cancer and kidney stone formation."

    "The engineered bladders were sutured to patients’ original bladders during surgery. The scaffold was designed to degrade as the bladder tissue integrated with the body. Testing showed that the engineered bladders functioned as well as bladders that are repaired with intestine tissue, but with none of the ill effects."

    After reading the following do you interpret it to mean the laboratory grown bladder would not contract causing spasms like our bladder does now?

    "The main goal of the surgery was to reduce pressures inside the bladder to preserve the kidneys. In addition, urinary incontinence, which was a problem before the surgery, improved in all patients."

    I am attaching the video clip of Dr. Oz speaking with Dr. Atala.

    http://www.oprah.com/media/20090305b...generate-video
    Renee

  2. #12
    Quote Originally Posted by sreneet View Post
    Dr. Wise; Thanks for the response. I understand what you are saying. I have used an indwelling foley for 24 years. I am at the point of needing an augmentation because of the increased risk of cancer and erosion of the uretha if I don't do something.

    After reading the article the following things sounded like reasons the laboratory grown bladder would be a better type of augmentation.

    "But because the intestine is designed to absorb nutrients and a bladder is designed to excrete, patients who have the procedure are prone to such problems as osteoporosis, increased risk of cancer and kidney stone formation."

    "The engineered bladders were sutured to patients’ original bladders during surgery. The scaffold was designed to degrade as the bladder tissue integrated with the body. Testing showed that the engineered bladders functioned as well as bladders that are repaired with intestine tissue, but with none of the ill effects."

    After reading the following do you interpret it to mean the laboratory grown bladder would not contract causing spasms like our bladder does now?

    "The main goal of the surgery was to reduce pressures inside the bladder to preserve the kidneys. In addition, urinary incontinence, which was a problem before the surgery, improved in all patients."

    I am attaching the video clip of Dr. Oz speaking with Dr. Atala.

    http://www.oprah.com/media/20090305b...generate-video
    sreneet,

    I looked up the risk of bladder cancer after enteric augmentation of the bladder. Husmann, et al. (2008) reported an incidence of 4.5% in 153 patients over >10 year period. Austin (2008) likewise suggested that bladder cancer is relatively common amongst patients who had received the operation as young children. The cancers may develop in the intestinal patch (Elphick, et al. 2008) or the gastric patch (Vemulakonda, et al., 2008; Castellan, et al., 2007). In my opinion, this risk is high and, if the laboratory grown bladder has a lower risk, it would be worthwhile.

    Wise.



    References

    1. Husmann DA and Rathbun SR (2008). Long-term follow up of enteric bladder augmentations: the risk for malignancy. J Pediatr Urol. 4: 381-5; discussion 386. Department of Urology, Mayo Clinic, Rochester MN 55905, USA. OBJECTIVE: To determine the risk of bladder cancer following enteric bladder augmentation. MATERIALS AND METHODS: Patients followed for care after an enteric bladder augmentation have been entered into a registry; individuals followed for a minimum of 10 years were evaluated. RESULTS: The study criteria were met by 153 patients. Indications for bladder augmentation were neurogenic bladder in 97, exstrophy in 38 and posterior urethral valves in 18. There was a median follow-up interval of 27 years (range 10-53). A total of seven cases of malignancy developed. Median time to tumor development following augmentation was 32 years (range 22-52). Two patients with neurogenic bladder developed transitional cell carcinoma; both were heavy smokers (>50 pack per year history). Two patients with a history of posterior urethral valves and renal transplantation developed adenocarcinoma of the enteric augment. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the augmented bladder. Two patients remain alive, 5 and 6 years following radical cystoprostatectomy; five died of cancer-specific causes. CONCLUSIONS: Malignancy following enteric bladder augmentation arose in 4.5% (7/153) of our patients and was associated with coexisting carcinogenic stimuli (prolonged tobacco/chronic immunosuppressive exposure), or alternatively with the inherent risk of malignancy existing with bladder exstrophy.

    2. Austin JC (2008). Long-term risks of bladder augmentation in pediatric patients. Curr Opin Urol. 18: 408-12. Department of Urology, University of Iowa, Iowa City 52242-1089, USA. chris-austin@uiowa.edu. PURPOSE OF REVIEW: Bladder augmentation is still a commonly performed reconstructive procedure for pediatric patients with severe bladder dysfunction. Recent developments in the long-term risks associated with this procedure are reviewed. RECENT FINDINGS: There are metabolic changes in these patients after incorporation of bowel into the urinary tract. Linear growth and bone mineral density are more affected by the primary disorder rather than bladder augmentation. There is a high rate of reoperation in patients after bladder augmentation for perforation, bladder stones, and bowel obstruction. Bladder cancer has been reported in patients after bladder augmentation but also in patients without augmentation. SUMMARY: Bladder augmentation is associated with a number of potential long-term risks, including a high risk of needing further surgery and development of serious complications such as bowel obstruction or bladder perforation. Bladder stones continue to be common in patients after bladder augmentation. Multiple cases of bladder cancer have been reported recently in young adults with a history of bladder augmentation in childhood and reinforce the need for lifelong follow up for these patients. Future studies will hopefully define the benefits and role of cancer surveillance for these patients.

    3. Elphick DA, Tophill PR, Suvarna SK and Riley SA (2008). Flat adenomas in a colonic bladder augmentation patch: cystoscopic removal using an endoscopic mucosal resection technique. Urology. 72: 230 e1-3. Department of Gastroenterology, Northern General Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom. david.elphick@sth.nhs.uk. Bladder augmentation using colonic patches is being increasingly performed and a substantial risk of neoplasia in such patches has been reported. We present the case of a 62-year-old man who developed a large flat adenoma in the colonic mucosa of an augmented bladder. The adenoma was indigo-carmine dye sprayed and completely resected via a cystoscope using an endoscopic mucosal resection technique. We discuss how methods used at colonoscopy to detect and remove early neoplastic lesions may readily be employed during colonic patch surveillance at cystoscopy.

    4. Vemulakonda VM, Lendvay TS, Shnorhavorian M, Joyner BD, Kaplan H, Mitchell ME and Grady RW (2008). Metastatic adenocarcinoma after augmentation gastrocystoplasty. J Urol. 179: 1094-6; discussion 1097. Department of Urology, University of Washington School of Medicine and Division of Pediatric Urology, Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA. vijaya.vemulakonda@seattlechildrens.org. PURPOSE: Augmentation gastrocystoplasty has been proposed as an alternative to enterocystoplasty because of potential benefits, including decreased risk of mucus production, stone formation and urinary tract infections. Although cancer has rarely been reported in this patient population, it is a well recognized potential risk of all augmentation cystoplasties. To define better the risk of malignancy associated with gastric augmentation and the appropriate surveillance protocol for these patients, we describe our experience in 2 patients with metastatic adenocarcinoma following gastrocystoplasty. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who had undergone augmentation gastrocystoplasty between 1990 and 1994. Of the 72 patients identified 2 were diagnosed with a primary malignancy arising from the augmented bladder. Charts were reviewed for medical history, clinical outcomes and pathology. RESULTS: Two patients were identified with a primary bladder malignancy after gastrocystoplasty. Both patients had metastatic disease at initial presentation. Neither patient had a history of gross hematuria, recurrent urinary tract infections or pain before initial presentation. Mean patient age at augmentation was 5.5 years. Mean age at diagnosis of malignancy was 19.5 years, with a mean time from augmentation of 14 years. CONCLUSIONS: Although the risk of bladder cancer is low after gastric augmentation, the effects may be life threatening. Therefore, we advocate routine annual surveillance with cystoscopy, bladder biopsy and upper tract imaging in all patients who have undergone augmentation gastrocystoplasty.

    5. Castellan M, Gosalbez R, Perez-Brayfield M, Healey P, McDonald R, Labbie A and Lendvay T (2007). Tumor in bladder reservoir after gastrocystoplasty. J Urol. 178: 1771-4; discussion 1774. Division of Pediatric Urology, Miami Children's Hospital, Miami, Florida, USA. PURPOSE: To our knowledge the risk of malignancy in patients with previous bladder augmentation with stomach is unknown. We report 3 cases of gastric adenocarcinoma and 1 of transitional cell carcinoma after augmentation cystoplasty with stomach with long-term followup. MATERIALS AND METHODS: Between August 1989 and August 2002, 119 patients underwent augmentation cystoplasty with stomach at our 2 institutions (University of Miami School of Medicine, and Seattle Children's Hospital and Regional Medical Center). Medical records, urodynamic studies, radiographic imaging and laboratory evaluations were reviewed retrospectively and cases of malignancy were analyzed in detail. RESULTS: Four male patients had carcinoma after augmentation gastrocystoplasty. Preoperative diagnosis was neurogenic bladder in 3 patients and posterior urethral valve in 1. Three patients had gastric adenocarcinoma, while the other had poorly differentiated transitional cell carcinoma. Each case progressed to malignancy more than 10 years after augmentation (11, 12, 14 and 14 years, respectively). CONCLUSIONS: Patients who undergo bladder augmentation with a gastric remnant are at increased risk for malignancy, probably similar to that in patients with enterocystoplasty. Therefore, they require close long-term followup. Patients should be followed annually with ultrasound, and cystoscopy should be performed annually starting 10 years after gastrocystoplasty unless they have abnormal ultrasound, hematuria or another cancer risk factor. Any suspicious lesions should be biopsied, especially at the gastrovesical anastomotic site.

  3. #13
    Dr. Wise; Thanks for the reply. I was thinking the same thing about the laboratory grown bladder.
    Renee

  4. #14
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    So what does this mean when they find a repair/cure 4 sci, we still going to have to have catheters/super pubic ways to void? Or will we be able to retrain the bladder & it will learn to expand and be able to hold more? Or is this just way too early to ask this question? Because no one knows how much function or what we will get back in the future.
    keiffer66

  5. #15
    Senior Member KIM's Avatar
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    You said it. It is to early , wait for the cure and then we will see.

  6. #16
    Quote Originally Posted by Keith View Post
    So what does this mean when they find a repair/cure 4 sci, we still going to have to have catheters/super pubic ways to void? Or will we be able to retrain the bladder & it will learn to expand and be able to hold more? Or is this just way too early to ask this question? Because no one knows how much function or what we will get back in the future.
    Keith,

    Let me explain. I think that the title of the thread and the article gave the misleading impression that they have developed something that could replace the bladder. I posted to indicate that I did not think so. This simply makes a biological tissue that can be used as a substitute bladder wall and surgeons can use this for augmentation procedures.

    People who have had an augmentation of the bladder can no longer contract the bladder and therefore will not be able to micturate (pee) on their own. In theory, augmentation surgery may be reversible but it will probably be difficult or possibly impossible. However, for many people with spinal cord injury, particularly women with tetraplegia, it is the only solution that is available now to improve their quality of life. Regarding Mitrofanoff procedure and augmentation, I hope that I have not given the impression that it is always done in conjunction with augmentation.

    Most tetraplegic women do not have the manual dexterity to catheterize by themselves. They must take some clothes off and recline in order to insert the catheter. They cannot do this without help. For this reason, a suprapubic catheter is often used in people with tetraplegia but is not a particularly good long-term solution for somebody who is active. So, many women opt for a Mitrofanoff procedure which uses the appendix to create a tunnel between the belly button and the bladder, allowing a woman to catheterize without having to take her pants off and reclining.

    However, due to bladder spasticity, the bladder is often contracted and it takes much time and effort to increase bladder capacity. Increasing bladder pressure is also needed to expand the bladder capacity and this might put the kidney at risk. An "augmentation" uses a piece of intestine (enteric) or stomach (gastric) to patch the bladder. Since the "patch" cannot contract, it immediately increases the bladder capacity and reduces the ability of the bladder to contract. This reduces the pressure increases in the bladder associated with bladder spasticity. Such pressure increases pushes urine up the ureters to the kidney and can cause kidney infections and damage.

    Mitrofanoff has been used in many children and people over the last 25 years. If the bladder is flaccid, there is no need for augmentation. However, in people with spastic bladders, augmentation will increase bladder capacity and avoid the risk of high bladder pressures needed to expand bladder capacity. So, increasing numbers of people have gotten a Mitrofanoff plus augmentation. However, recent studies have indicated that there is an increased risk of cancer associated with augmentation with intestine or gastric patch. The cancer apparently occurs in the patch. My review of the literature suggest that the risk of cancer occurring in the patch may be as high as 4.5% over a 10-20 year period. There may be other complications.

    If the new artificially grown bladder walls turn out to be more resistant to cancer, they would be desirable. However, I am not sure that this data is available yet because relatively few patients have received this treatment and I think that studies were done only 5-6 years ago and long-term followup is necessary to determine cancer risk.

    This discussion is actually stimulating some new ideas. If augmentation is being done to increase bladder capacity, there must be other ways of increasing bladder capacity without augmentation. With further thought, I realize that there are indeed some other possible approaches.
    • Botox. This is now being used to reduce bladder contractions. Botox is toxic to the nerve fibers that innervate the bladder. Because the nerves grow back over a period of several months, this is not a permanent solution, it does increase the bladder capacity temporarily, during which it may be possible to maintain the bladder capacity by catheterizing intermittently so that urine will accumulate in the bladder and use of bladder antispasticity drugs such as ditropan.
    • Capsiacin. Several studies have shown that capsaicin (the essence of pepper) and various synthetic drugs that have similar effects, will cause prolonged relaxation of the bladder. This would have a similar effect as Botox and similar methods can be used to maintain the increased bladder capacity.
    • Direct expansion. I have been wondering whether it is possible to put a balloon into the bladder and simply expand the balloon to stretch the bladder wall. This might have to be done several times over a period of weeks but it would allow the expansion of the bladder without damaging the nerve supply to the bladder and without increasing the risk of cancer, as an augmentation seems to do.

    By the way, while the discussion is not about the "cure" for spinal cord injury, it is pertinent to the "cure" of bladder spasticity. It is not trivial because bladder infections were the number one cause of death of people with spinal cord injury. Improved bladder care was the main reason that most people with spinal cord injury today die of heart disease and cancer.

    Wise.
    Last edited by Wise Young; 04-15-2009 at 09:02 AM.

  7. #17
    An "augmentation" uses a piece of intestine (enteric) or stomach (gastric) to patch the bladder. Since the "patch" cannot contract, it immediately increases the bladder capacity and reduces the ability of the bladder to contract. This reduces the pressure increases in the bladder associated with bladder spasticity. Such pressure increases pushes urine up the ureters to the kidney and can cause kidney infections and damage.


    Recent studies have indicated that there is an increased risk of cancer associated with augmentation with intestine or gastric patch. The cancer apparently occurs in the patch. My review of the literature suggest that the risk of cancer occurring in the patch may be as high as 4.5% over a 10-20 year period. There may be other complications.

    So, I agreed that if the new artificially grown bladder walls turn out to be more resistant to cancer, they would be desirable.
    I'm scheduled to have this done using the intestine later this year to reduce pressures and so I can continue cathing and avoid a sphincterotomy.
    I don't want my intestines cut, scares the hell out of me, and I'm uneasy about the cancer risks.
    I really wish this grown bladder technology was an option for me, regretably it seems I will miss out.

    Here's hoping this technology gets offered to people asap!

  8. #18
    Quote Originally Posted by brython2 View Post
    I'm scheduled to have this done using the intestine later this year to reduce pressures and so I can continue cathing and avoid a sphincterotomy.
    I don't want my intestines cut, scares the hell out of me, and I'm uneasy about the cancer risks.
    I really wish this grown bladder technology was an option for me, regretably it seems I will miss out.

    Here's hoping this technology gets offered to people asap!
    Brython2,

    I understand what you are feeling and also agree with your choice. In my opinion, the risk of dying from nephritis in people with uncorrected bladder spasticity is probably greater than 50%, much higher than the 5% risk of getting cancer after augmentation. A sphincterotomy is not easily reversible and requires a full-time condom catheter to keep from leaking. So, the choices are not great.

    The risk can be reduced significantly by having regular cystoscopies to look for any evidence of abnormal growth. I also understand that smoking markedly increases bladder cancer and should be stopped. Finally, you may want to consider getting botox therapy of your bladder to reduce the spasticity. At the present, it is only a conjecture that the new laboratory grown bladder walls will be more resistant to cancer formation. That has yet to be shown.

    Wise.

  9. #19
    Senior Member Max's Avatar
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    Quote Originally Posted by Rollin Rick View Post
    So what happens to all of us Foley catheter users in the future, those of us that can only hold 100-200 CC in our tiny bladders?
    I might miss something here, as usuallol

    But why not to go suprapubic>?

  10. #20
    Senior Member Rollin Rick's Avatar
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    Quote Originally Posted by Max View Post
    I might miss something here, as usuallol

    But why not to go suprapubic>?
    Hey Max,

    I actually do have a suprapubic catheter, I have always called it a Foley. I understand that most people that have the catheter going up not so Mr. Happy is called a Foley catheter, or so called Urethra.

    Basically I was asking the same question that Keith just mentioned.

    Dr. Young, how about clamping off the catheter a couple of times a week to expand the bladder somewhat, but not over do it to a point where you're getting bad A.D.? Would this be feasible for someone with low spasticity/pressures? I actually tried this this morning and was able to hold approximately 300 CC, I didn't think that was bad for having a suprapubic for almost 8 years, what's your opinion?

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