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JU INSIGHT Robotic Bladder Autotransplant: Preclinical Studies Preparing for First-in-human Bladder Transplant
By: Nima Nassiri, MD, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles; Giovanni Cacciamani, MD, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles; Inderbir S. Gill, MD, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles | Posted on: 25 Oct 2023
Nassiri N, Cacciamani G, Gill IS. Robotic bladder autotransplantation: preclinical studies in preparation for first-in-human bladder transplant. J Urol. 2023;210(4):600-610.
Study Need and Importance
Patients with terminal bladder pathology currently have only 1 option for urinary reconstruction using a vascularized segment of intestine, which can expose them to various potential complications. These include infections, stones, progressive kidney dysfunction, weight loss, and metabolic issues. Furthermore, the risks of short- and long-term complications, including reoperation, can be substantial. If bladder transplantation were possible, it could provide patients with a more normal bladder substitute, circumventing some of these issues. Herein, careful patient selection would have to be paramount, since immunosuppression and possible intermittent catheterization would have to be deemed acceptable trade-offs, medically and logistically. To date, human vascularized bladder transplantation has not been successfully performed.
What We Found
We developed bladder transplantation in 3 incremental, stepwise, preclinical, vascularized models: porcine, pulsatile-perfused cadavers, and finally heart-beating brain-dead human research donors. We describe the technique for bladder transplantation, including robotic recovery of the vascularized composite bladder allograft, back-table vascular reconstruction, and robotic autotransplantation (see Figure). We demonstrate technical success, defined as adequate perfusion of the allograft as confirmed by direct visualization, real-time intraoperative immunofluorescence, and cystoscopy, with sustained allograft perfusion documented for up to 12 hours posttransplantation.
Limitations
Several questions remain as regards emptying characteristics and long-term compliance of the transplanted bladder, immunogenicity of the transplanted bladder, characteristics of bladder transplant rejection, and patient acceptance of this potential approach compared to standard treatment options.
Interpretation for Patient Care
We report the first known description of preclinical bladder autotransplantation in brain-dead but heart-beating human research donors and describe the robotic technique for bladder transplantation. This is in preparation for a first-in-human trial under a UNOS (United Network for Organ Sharing)−approved genitourinary vascularized composite bladder allotransplantation program (NCT 05462561). If successful, bladder transplantation could offer highly selected patients with terminal benign bladder pathology an alternative treatment option that circumvents the known complications of traditional urinary diversion.
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