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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 1  |  Page : 135-138
Is amniotic membrane a suitable biomaterial for reconstruction of long ureteral defects?

1 Department of Urology, Shiraz University of Medical Science, Shiraz, Iran
2 Department of Pathology, Shiraz University of Medical Science, Shiraz, Iran
3 Stem Cell and Transgenic Technology Research Center, Shiraz University of Medical Science, Shiraz, Iran

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Date of Web Publication22-Jan-2013

How to cite this article:
Salehipour M, Mohammadian R, Jahanbini S, Emadmarvasti V, Geramizadeh B, Tanideh N. Is amniotic membrane a suitable biomaterial for reconstruction of long ureteral defects?. Saudi J Kidney Dis Transpl 2013;24:135-8

How to cite this URL:
Salehipour M, Mohammadian R, Jahanbini S, Emadmarvasti V, Geramizadeh B, Tanideh N. Is amniotic membrane a suitable biomaterial for reconstruction of long ureteral defects?. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2022 Aug 12];24:135-8. Available from: https://www.sjkdt.org/text.asp?2013/24/1/135/106311
To the Editor,

Extensive damage to the ureter is still a challenge for all urologists. Different procedures have been introduced to bridge ureteral defects, including ureteral substitutions with intestinal segments, transuretero-ureterostomy, bladder flaps and renal autotransplantation. [1] There are also reports for the application of artificial biomaterials in ureteral replacement; however, the results were sometimes not satisfactory. [2] Amniotic membrane (AM), which has been a qualified biomaterial in reconstructive surgeries in the field of ophthalmology, [3] promised to be a good candidate for reconstruction operation in urology practices. The AM has some properties, such as facilitation of epithelial cells migration, reinforcement of basal cellular adhesion and induction of epithelial differentiation. Its anti-inflammatory ability makes it a good choice for urologic reconstructive surgeries. [4] We evaluated the use of human AM for the reconstruction of ureteral defects in a canine model in this study. This experimental study was carried out on seven mixed breed adult male dogs weighing about 15 kg. The graft was derived from human placenta right after delivery. The specimens with meconioum contamination or chorioamnionitis were discarded. After receiving the amniotic membrane in the laboratory, the following procedure was applied on all of the amniotic membranes: The chorion was separated from the amnion; This was washed two to three times in phosphate buffer solution (PBS) and antibiotic until no RBC was remaining (clearing); membranes were cut in desirable sizes (3 cm x 1 cm); membranes were attached on the nitrocellulose membrane and soaked in 4% DMSO for 10 min, 8% DMSO for 10 min and 12% DMSO for 10 min (DMSO contains both antibiotics and anti-fungal agents); membranes were frozen in 12% DMSO in -70 o, and they were brought out of the freezer before being used for any procedures. Intramuscular ceftriaxone (25 mg/ kg) was injected 15 min before starting the operation; all the interventions were performed under anesthesia in a standard operating room. A complete, circumferential incision was made over the ureter and a 3 cm segment of the mid part of the ureter was removed. A 3 cm × 1 cm patch of AM was tabularized over a 6 French feeding tube and the margins were sutured. The new tube was used to bridge the defect by suturing the proximal and distal ends of the ureter by watertight interrupted sutures over a 5 Fr Double-J stent. Antibiotic therapy with Ampicilin (300 mg q 6h) was continued for one week after the procedure. After six weeks, the animals were sacrificed and the right kidney and ureter of each animal were removed and sent for pathological study. Two dogs died in the first week after the operation and the autopsy revealed urinary leakage from the site of anastomosis with subsequent urinary ascites. In another animal, the autopsy results showed a severely hydronephrotic kidney with a thin cortex (a bag of water) and dilation in the upper part of the ureter. The lumen of the reconstructed segment of the ureter was obstructed and the catheter was not detected in its place, migrating to the urinary bladder. The wall of the reconstructed segment was thick, hard and whitish. Histopathologic studies of the reconstructed segment containing AM revealed infiltration of the inflammatory cells and macrophages, causing severe acute and chronic inflammation with formation of granulation tissue [Figure 1]. Areas of calcification and ossification in the outer wall were observed [Figure 2]. In the four remaining animals, gross pathologic evaluation revealed mild pelvocaliectasis. The catheter was in the lumen, which was stenotic. The wall of the reconstructed segment was thick, hard and whitish. In microscopic evaluation, lymphocytic and polymorphonuclear cell infiltration were detected in the renal parenchyma without glomerular or tubular damages. In the grafted segment, non-keratinizing stratified squamous metaplasia was detected along the ureter without any transitional epithelium [Figure 3]. Lymphocytic and granulocytic infiltration associated with fibrosis was observed in the wall, but no specific ureteral layer (muscle layer and adventitia) was formed. The AM has several features that make it a source of stem cells. [5] Amniotic epithelial cells (AECs) do not express HLA-A, HLA-B and HLA-DR on their surfaces. [6] They harbor HLA-G, which causes an immune tolerance by inhibition of natural killer cells and macrophages. [7] These findings may explain the reason as to why the AM is immunologically neutral, a characteristic that reduces the risk of rejection of the AM, while it is used as a biomedical scaffold. Some reports suggest that the AM can reduce inflammation. The stromal matrix of AM significantly suppresses the production of inflammatory cytokines. AM also contains natural inhibitors that can inhibit the matrix metalloproteinases produced by inflammatory cells. [8],[9] The AM consists of an epithelial monolayer, a basement membrane and a stroma. The stroma is avascular and has several layers, each of which contain large amounts of glycoproteins, peptidoglycans and collagen types I, III, IV and V. These large molecules play an important role in the attachment and migration of the host cells to the AM, which makes it a favorable substance to be used as a scaffold. [10]
Figure 1: Intramural inflammation and ulceration with abscess formation.

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Figure 2: Areas of calcification and ossification in the outer wall of ureter.

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Figure 3: Non-keratinizing stratified squamous metaplasia.

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AM has been used as a biological matrix in the urinary tract in different studies. AM was used as a scaffold in the urinary tract, [11] and as a favorable biological matrix for urothelial cell growth and proliferation. [12] In addition, AM can act as a favorable substance for induction of epithelialization. [13] Few studies have evaluated the results of the application of AM as a scaffold in the ureteral defects. In our study, in 57% of the cases, the non-keratinized stratified squamous epithelium was observed and in none of the cases, a normal ureteric wall tissue was formed. In the histopathological study, the signs of acute and chronic inflammations were detected in the implanted segments, which might be subsequent to the healing process and also due to the toxic effects of urine. Urine is a noxious stimulus and the formation of stratified squamous epithelium is a defense mechanism to protect the tissue against the urine. Long-term urinary catheter may be responsible for the development of squamous metaplasia in the urothelium. Although the AM is expected to be immunologically neutral, its rejection repression property may be applicable within the same species, but not across the species as in the present study (human AM to canine ureter); therefore, the inflammation observed in the reconstructed segments can also be considered as a rejection phenomenon. We observed that AM did not act as a favorable scaffold when it was used as a bridge in long circumferential ureteral defects, a finding which was similar to the results of the study performed by Osman et al. [14] Koziac et al introduced the application of AM as an encouraging method to repair long ureteral defects while being used as a patch graft. [15] Although the patency of the ureter was confirmed by radiological imaging, the histopathological changes in the used AM were not evaluated in the Koziac study. Infiltration of the inflammatory cells with fibrous tissue formation and lack of any specific layer of the ureter in the implanted segments imply that the AM was not a favorable biomaterial in the reconstruction of long circumferential ureteral defects in our study. Further studies are necessary to evaluate the efficacy of AM as a patch graft versus full circumferential graft in the reconstruction of ureteral defects.

   References Top

1.Schoeneich G, Winter P, Albers P, Fröhlich G, Müller SC. Management of complete ureteral replacement. Experiences and review of the literature. Scand J Urol Nephrol 1997;31:383-8.   Back to cited text no. 1
2.Baltaci S, Ozer G, Ozer E, Soygür T, Bes,alti O, Anafarta K. Failure of ureteral replacement with Gore-Tex tube grafts. Urology 1998;51: 400-3.  Back to cited text no. 2
3.Chandra A, Maurya OP, Reddy B, Kumar G, Pandey K, Bhaduri G. Amniotic membrane transplantation in ocular surface disorders. J Indian Med Assoc 2005;103:364-6, 68.   Back to cited text no. 3
4.Shimmura S, Shimazaki J, Ohashi Y, Tsubota K. Antiinflammatory effects of amniotic membrane transplantation in ocular surface disorders. Cornea 2001;20:408-13.  Back to cited text no. 4
5.Miki T, Lehmann T, Cai H, Stolz DB, Strom SC. Stem cell characteristics of amniotic epithelial cells. Stem Cells 2005;23:1549-59.   Back to cited text no. 5
6.Sakuragawa N, Tohyama J, Yamamoto H. Immunostaining of human amniotic epithelial cells: Possible use as a transgene carrier in gene therapy for inborn errors of metabolism. Cell Transplant 1995;4:343-6.   Back to cited text no. 6
7.Kubo M, Sonoda Y, Muramatsu R, Usui M. Immunogenicity of human amniotic membrane in experimental xenotransplantation. Invest Ophthalmol Vis Sci 2001;42:1539-46.   Back to cited text no. 7
8.Kim JS, Kim JC, Na BK, Jeong JM, Song CY. Amniotic membrane patching promotes healing and inhibits proteinase activity on wound healing following acute corneal alkali burn. Exp Eye Res 2000;70:329-37.   Back to cited text no. 8
9.Solomon A, Rosenblatt M, Monroy D, Ji Z, Pflugfelder SC, Tseng SC. Suppression of interleukin 1alpha and interleukin 1beta in human limbal epithelial cells cultured on the amniotic membrane stromal matrix. Br J Ophthalmol 2001;85:444-9.   Back to cited text no. 9
10.Walgenbach KJ, Voigt M, Riabikhin AW, et al. Tissue engineering in plastic reconstructive surgery. Anat Rec 2001;263:372-8.   Back to cited text no. 10
11.Iijima K, Igawa Y, Imamura T, et al. Transplantation of preserved human amniotic membrane for bladder augmentation in rats. Tissue Eng 2007;13:513-24.   Back to cited text no. 11
12.Sharifiaghdas F, Hamzehiesfahani N, Moghadasali R, Ghaemimanesh F, Baharvand H. Human amniotic membrane as a suitable matrix for growth of mouse urothelial cells in comparison with human peritoneal and omentum membranes. Urol J 2007;4:71-8.   Back to cited text no. 12
13.Shakeri S, Haghpanah A, Khezri A, et al. Application of amniotic membrane as xenograft for urethroplasty in rabbit. Int Urol Nephrol 2009;41:895-901.   Back to cited text no. 13
14.Osman Y, Shokeir A, Gabr M, El-Tabey N, Mohsen T, El-Baz M. Canine ureteral replacement with long acellular matrix tube: Is it clinically applicable? J Urol 2004;172:1151-4.  Back to cited text no. 14
15.Koziak A, Salagierski M, Marcheluk A, Szcze?niewski R, Sosnowski M. Early experience in reconstruction of long ureteral strictures with allogenic amniotic membrane. Int J Urol 2007;14:607-10.  Back to cited text no. 15

Correspondence Address:
Mehdi Salehipour
Department of Urology, Shiraz University of Medical Science, Shiraz
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.106311

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  [Figure 1], [Figure 2], [Figure 3]

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