RU2727751C1 - Method for prolongation of recurrence-free period of interstitial cystitis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to urology, and can be used for prolonging recurrence-free period of interstitial cystitis. Preliminary preparation of autologous plasma enriched with thrombocytes is performed, and its activation by means of 10 % solution of CaCl, puncturing of bladder walls. Plasma prepared from 100 ml of whole blood is prepared with triple increase of thrombocyte concentration. Freezing at temperature t -80 °C with subsequent defrosting on water bath t +40 °C. After activating with 10 % CaClsolution at ratio of 1:10, respectively, electric coagulation of the zone of ulcerous involvement of the bladder wall is performed, and immediately after that, the area is punctured every 2.0–3.0 mm, depth 2.0–3.0 mm, 1 prick – 1 ml, with the condition of introducing plasma and along the healthy edges of crater at 2–3 mm from its edge. Every 14 days, injections are repeated 4 times in the same mode. That is followed by 1, 3, 6, 12 months of clinical follow-up of the disease and a pinch biopsy of the zone of the urinary bladder wall ulcer with histologic and immunohistochemical examinations to evaluate the therapeutic results.EFFECT: method enables reducing pain syndrome, reducing frequency of urination, increasing reservoir capacity of urinary bladder, reducing frequency of recurrences, reduce the length of treatment, expand the scope of application by using autologous plasma enriched with thrombocytes, in interstitial cystitis with Hunner's involvement.1 cl, 2 dwg, 2 ex

Description

The alleged invention relates to medicine, namely urology, and can be used in the treatment of interstitial cystitis.

Interstitial cystitis is a disease characterized by persistent or recurrent pain localized in the bladder region and accompanied by at least one of the following symptoms: increased pain during filling of the bladder, increased frequency of daytime and / or nighttime urination in the absence of signs of infectious or other obvious urinary lesions bladder (Laurent O.B., Zaitsev A.V., Lipsky BC Diagnostics and treatment of interstitial cystitis in women // Saratov: Privolzhskoe book publishing house. 2001).

The prevalence of the disease is quite variable, ranging from 4.5 to 50 women per 100,000 (Nordling J. et al. (Ed.) Bladder pain: a guide for physicians. Springer Science & Business Media, 2012; Fall M. et al. EAU guidelines on chronic pelvic pain // European urology. 2010. V. 57. No. 1. P. 35-48).

The pathology under consideration is a serious social problem, leads to severe moral and physical suffering of the patient, maladjust it in the surrounding society (Wein AJ, Hanno PM, Gillenwater JY Interstitial cystitis: an introduction to the problem // Interstitial cystitis. Springer, London, 1990. P. 3-15).

The pathogenetic theory of the development of interstitial cystitis declares that due to vascular changes and trophic disturbances in the wall of the bladder, a complex of dystrophic, necrobiotic and sclerotic processes develops, involving all layers of the bladder wall (pancystitis). Atresia and vascular atrophy occurs, trophic disorders, ulcers and their complications (bleeding) occur. The developed fibrosis and sclerosis of the muscles of the bladder, as a rule, leads to its wrinkling and dysfunction (Fall M. et al. EAU guidelines on chronic pelvic pain // European urology. 2004. V. 46. No. 6. P. 681- 689).

The problem of treating patients with interstitial cystitis is extremely urgent. This is due to both the high prevalence of these conditions and the low efficiency of the existing treatment methods. It is important to emphasize that it is symptomatic treatment methods that are ineffective, and pathogenetic treatment is absent at all.

et al. The early histological effects of intravesical instillation of platelet-rich plasma in cystitis models // International neurourology journal. 2016. V. 20. №. 3. P. 188. http://dx.doi.org/10.5213/inj.1632548.274).In recent years, a huge number of studies aimed at the introduction of autologous platelet-rich plasma (ATOP) have been observed in such branches of medicine as orthopedics, surgery and cosmetology, sports medicine have positive treatment results, aimed at healing, tissue repair and anti-inflammatory effect. Taking into account the pathogenesis of the disease, a technique of local interstitial application of autologous platelet-rich plasma (APOT) was proposed. Platelet-rich plasma contains α-granules from which, after activation, multiple growth factors such as platelet-derived growth factor, transforming growth factor β, vascular endothelial growth factor and epidermal growth factor (

et al. The early histological effects of intravesical instillation of platelet-rich plasma in cystitis models // International neurourology journal. 2016. V. 20. No. 3.P. 188.http: //dx.doi.org/10.5213/inj.1632548.274).

For the closest analogue, the method studied by Taiwanese urologists "Effective and safe intravesical administration of platelet-rich plasma in the treatment of interstitial cystitis in patients refractory to traditional methods of treatment (prospective clinical study)" (Jhang JF, Lin TY, Kuo N.S. Intravesical injections of platelet-rich plasma is effective and safe in treatment of interstitial cystitis refractory to conventional treatment - A prospective clinical trial // Neurourology and urodynamics.2019. V. 38. - No. 2. - P. 703-709. PMID: 30576011 DOI : 10.1002 / nau.23898).

The study included 40 patients with interstitial cystitis, who took their own blood in a volume of 50 ml, which was subsequently centrifuged twice, received autologous platelet-rich plasma, activated it using a 10% CaCl ₂ solution in a ratio of 1:10, respectively. then plasma in a volume of 10 ml was injected into the wall of the bladder. One injection of 0.5 ml, an injection needle was inserted approximately 1 mm into the submucosa on the posterior and lateral walls of the bladder. In total, 20 injections were performed in 1 session. The number of sessions is 4-1 times a week for 1 month.

According to the authors, the persistent clinical effect is due to the fact that platelets act as mediators of inflammation and regeneration in tissues. After the initiation of the introduction of platelet-rich plasma with each subsequent injection, the pain syndrome (decrease) decreased (according to the questionnaires of the visual analogue scale), the urgency and nocturia according to the urination diaries decreased, and the bladder capacity increased according to cystoscopy data. This method was proposed by the authors as an alternative method for the therapeutic treatment of interstitial cystitis.

This work has the following disadvantages:

1. This method cannot be used in the treatment of interstitial cystitis with Hunner's lesion of the bladder wall.

2. In view of the persistence of the ulcer, the likelihood of recurrence of the clinic of cystitis in the early and delayed period is very high.

3. The interval between the introduction of 7 days is small, since the full cycle of action of the factors is 7-10 days.

Tasks:

1. Reduction of pain syndrome.

2. Decreased frequency of urination.

3. Increase in the reservoir capacity of the bladder.

4. Reducing the duration of treatment and the frequency of relapses of the disease.

5. Increasing the effect of treatment through the use of autologous platelet-rich plasma in interstitial cystitis with Hunner's lesion.

The essence of the invention is that the plasma obtained from 100 ml of whole blood is prepared with a threefold increase in the concentration of platelets, frozen at a temperature of -80 ° C, followed by thawing in a water bath at t + 40 ° C and after activation with 10% CaCl ₂ solution in a ratio of 1:10 respectively; electrocoagulation of the zone of ulcerative lesion of the bladder wall is carried out and immediately after that the zone is injected every 2.0-3.0 mm, 2.0-3.0 mm deep, 1 injection - 1 ml, with the condition of plasma injection and along the healthy edges of the crater 2-3 mm from its edge, and every 14 days, 4 times injections are repeated in the same mode, clinical monitoring of the course of the disease and a pinch biopsy of the ulcerative lesion zone of the bladder wall with histological examination are performed after 1, 3, 6, 12 months. and immunohistochemistry to assess treatment outcomes.

EFFECT: method of prolonging the relapse-free period of interstitial cystitis allows: to reduce pain syndrome, to reduce the frequency of urination, to increase the reservoir capacity of the bladder, to reduce the frequency of relapses, to shorten the treatment period, to expand the scope of application through the use of autologous platelet-rich plasma in interstitial cystitis with Hunner's lesion.

Platelet-rich autoplasm is a derivative of the patient's own blood, which makes it possible to obtain a large amount of autologous material in a short period of time with absolute biocompatibility, which makes the use of this method safe for the patient.

The clinical effect of autologous platelet-rich plasma is due to the content of many platelets, upon activation of which a large number of growth factors are secreted.

Epidermal growth factor (EGF) - stimulation of proliferation of epithelial, mesenchymal cells and fibroblasts; stimulation of migration and proliferation of endothelial cells and angiogenesis, regulation of collagenase production.

Transforming growth factor beta (TGF-b, b1 and b2) - regulation of morphogenetic factors, participation in chemotaxis, immune reactions, increased synthesis of extracellular matrix proteins, stimulation of collagen production.

Platelet growth factor (PDGFA + B) - activation of fibroblasts and myocytes of smooth muscle tissue, cell growth, stimulation of the synthesis of collagen and glycosaminoglycans, increased formation of granulation tissue, the formation of collagen matrix, activation of morphogenetic proteins, stimulation of angiogenesis, activation of migration of monocytes, macrophages; activation of macrophages.

Insulin-like growth factors (IGF - I, II) - activation of angiogenesis, stimulation of muscle tissue healing.

Vascular endothelial growth factor (VEGF, ECGF) - stimulation of endothelial cell proliferation and angiogenesis, stimulation of lymphangiogenesis, increased permeability of the vascular wall.

The main fibroblast growth factor (FGF) - stimulation of the growth of endothelial cells; stimulation of angiogenesis, stimulation of vascular stabilization growth.

Platelet-rich autoplasm is an easy-to-prepare and easy-to-use, inexpensive and minimally invasive method of producing high concentrations of autologous growth factors.

The process of obtaining platelet-rich plasma includes the following phases:

1. Taking blood from the patient.

2. Centrifugation.

3. Laboratory control.

4. Additional centrifugation.

5. Activation of autologous platelet-rich plasma. The preparation of autologous platelet-rich plasma is carried out using a manual method. The manual method of preparation is based on the step-by-step centrifugation of the patient's own plasma, which leads to the separation of blood cells in the test tube, while platelets occupy an overlying position due to their lighter molecular weight.

To obtain a platelet concentration that exceeds the baseline level by 3 times, it is sufficient to centrifuge twice at a speed of 3000 bpm for 10-15 minutes. It should be remembered that rapid centrifugation can cause mechanical destruction of plasma elements, an increase in temperature, thereby causing changes in the structure of platelets, which can trigger partial activation, degranulation of cells, with the subsequent loss of a-granules.

The activation of autologous platelet-rich plasma is a process of destruction of the platelet membrane, as a result of which α-granules are released from platelets and a significant amount of the above-described growth factors is secreted. In this regard, to activate autologous plasma, it was proposed to add a 10% calcium chloride solution (at a rate of 1:10 to the plasma volume), and cryopreservation of the prepared plasma is aimed at using the product in a delayed period.

Analyzing the mechanism of action of autologous platelet-rich plasma, evaluating the high potential of the regenerative function of this product, the possibility of stimulating angiogenesis and, as a consequence, improving tissue trophism, it can be argued that wound healing is accelerated, the safety of plasma use has been proven, based on the success of this method in treatment of diseases associated with tissue trophism disorders with reduced potential for wound healing, high efficiency of the proposed method in the treatment of interstitial cystitis as a factor stimulating tissue regeneration was revealed.

The method is carried out as follows in patients with verified interstitial cystitis, their own whole blood is taken in a volume of 100 ml. The volume of blood for the preparation of platelet-rich autoplasma should be five times the volume of plasma obtained. The whole blood is centrifuged at 3000 rpm for 15 minutes. Be sure to carry out laboratory control of the resulting platelet concentration. Additional centrifugation is carried out at 1500 rpm for 5 minutes to bring a threefold increase in platelet concentration. On average, 20 ml of autologous platelet-rich plasma is used for one therapy session. The resulting product is frozen at a temperature of -80C °, then the plasma is thawed, followed by the addition of a 10% CaCl ₂ solution in a ratio of 1:10 to the resulting plasma, respectively. Further, in sterile conditions, a pinch biopsy of the Gunner's lesion area is performed and sent for histological and immunohistochemical examination in order to determine the number of vessels in the tissue section, the prevalence of fibrosis, the presence of mast cells, and stratified squamous epithelium. Then, under sterile conditions, electrocoagulation of ulcers of the bladder wall is performed, then with the help of an endoscope through a needle, the Gunner's lesion zone is injected: they are injected every 2-3 mm: 1 injection - 1 ml, 2.0-3.0 mm deep, with the condition the introduction of plasma and along the healthy edges of the crater 2.0-3.0 mm from its edge, and every 14 days, 4 times injections are repeated in the same mode. After 1, 3, 6, 12 months after the completion of treatment with platelet-rich autoplasma, clinical monitoring of the course of the disease is performed using questionnaires (visual analogue scale of pain, urination diaries, scale of symptoms of pelvic pain, urgency and frequent urination, scale for assessing the severity of urgency) and a pinch biopsy of the edge of the ulcerative lesion zone of the bladder wall with histological and immunohistochemical examination to assess the results of treatment.

Example 1: Patient C, 73 years old, was admitted to the urology department with a verified diagnosis: Interstitial cystitis 3C. On admission she complained of pain in the lower abdomen, aggravated by filling the bladder, painful urination in small portions up to 40 times a day.

From the anamnesis it is known: Has been sick for 7 years, when the above complaints began to bother, was treated for a long time by a urologist at the place of residence, with varying success (urinating up to 20-30 times a day, small portions during urination up to 10-20 ml, in case of violation of the diet especially after ingestion of salty food, herring - the condition worsens, a history of endometriosis, for a long time treated by a urologist for a urinary tract infection, during cystoscopy, the bladder volume is 120 ml, examined for tbs - excluded, on intravenous urograms - vesicoptosis, due to severe pain Syndrome, the patient quit her job.

The patient was referred for a consultation with the KKDP urologist. After follow-up examination, she was hospitalized in the urology department for follow-up examination and surgical treatment.

From 07/08/2018 to 07/20/2018, she was inpatient treatment in the urology department No. 2 of the Regional Clinical Hospital No. 1. 07/09/2018, the patient performed - "Cystoscopy, test with potassium". The potassium test is sharply positive.

After carrying out preoperative preparation on July 13, 2018, the patient underwent spinal anesthesia under the operation - "Cystoscopy, hydro-stimulation of the bladder, transurethral resection of the bladder." According to the data of histological examination, the morphological picture corresponds to the interstitial cystitis of the ulcerative form.

During her outpatient treatment, the patient underwent bladder installations, anesthetic therapy, tricyclic antidepressants, and the interval between urination increased to 1.5 hours. The volume of urination is from 50 to 100 ml. After 1 month of therapy, the patient began to worry about pain in the lower abdomen, aggravated by filling the bladder, painful urination in small portions up to 40 times a day. Hospitalized in the urology department for further examination and further treatment. Objectively:

• laboratory data: UAC - no features. Initial parameters: platelets 289 × 10 ⁹ / l, leukocytes 7.64 × 10 ⁹ / l, erythrocytes 4.5 × 10 ¹² / l. OAM - leukocyturia, erythrocyturia, bacteriuria were not detected. Bacteriological urine culture - no microflora growth was detected.

• According to survey and intravenous urography, no shadows suspicious of calculi were found. Renal function is timely, no dilatation of the pelvicellular system was found. The ureters are traced by cystoids. The bladder is small, with cystography standing - vesicoptosis.

• When cystoscopy - the urethra is freely passable for the endoscope, the neck is not changed, the volume of the bladder is 100 ml. The mouths of the ureters are symmetrical, slit-like, urine is excreted from them in portions. The vascular pattern is pronounced. In the region of the second segment along the posterior wall, a Gunner's lesion takes place. When filling, petechial eruptions appeared with a volume of 200 ml.

Indications for treatment with autologous platelet-enriched plasma with the aim of improving trophism and tissue regeneration, increasing the reservoir capacity of the bladder, reducing pain syndrome, reducing the frequency of urination, reducing the frequency of relapses, and shortening the duration of treatment have been determined.

At the first stage, informed voluntary consent was taken from the patient for therapy, all possible risks and complications were described. Whole blood sample was taken from the patient in a volume of 100 ml. The first centrifugation of blood was performed at 3000 rpm for 15 minutes, the overlying plasma layer was taken manually from the test tube, laboratory control of the platelet concentration was performed, then repeated centrifugation was performed at 1500 rpm for 5 minutes. The overlying plasma layer with a high platelet content was taken. Repetition of laboratory control. Laboratory characteristics of the obtained plasma: platelets 872 × 10 ⁹ / l, leukocytes 0.8 × 10 ⁹ / l, erythrocytes 0.04 × 10 ¹² / l. The resulting product was frozen at t -80 ° C. The resulting autoplasma was activated by defrosting in a water bath at t + 40 ° C and adding a 10% CaCl ₂ solution in a ratio of 1:10, respectively.

Under sterile conditions, during cystoscopy, a pinched biopsy of the Gunner lesion zone is performed and sent for histological and immunohistochemical examination in order to determine the number of vessels in the tissue section, the prevalence of fibrosis, the presence of mast cells, and stratified squamous epithelium.

According to the data of pathological-histological and immunohistochemical studies: in the preparation there are fragments of the cicatricial-altered bladder wall, the integumentary epithelium is sharply thinned to 1-2 rows. Single vessels in sections. Mast Cell Tryptase, CloneAA1 The reaction is positive in mast cells: 160-170 cells in the field of view (x400). (Fig. 1 - histological picture of the wall of the bladder before treatment with autoplasma, platelet-rich x400, staining with Harris's hematoxylin).

Next, electrocoagulation of ulcers of the bladder wall was carried out, then with the help of an endoscope through a needle, the zone of Gunner's lesion was injected: 1 injection of 1 ml of plasma into the zone of the coagulation bottom, along the healthy edges of the crater, every 2 mm, the depth of injection is 2 mm, in total 22 injections. Subsequently, 4 more sessions of therapy were performed with a time interval of 1 time per 14 days according to the above method. One month after completion of therapy with autologous platelet-rich plasma, a repeated pinch biopsy of the bladder wall from the area of the Gunner lesion was performed. According to the data of pathological, histological and immunohistochemical studies: a fragment of the bladder wall with uneven epithelization of the superficial sections, without signs of ulcerative lesions. The integumentary epithelium - 4-5 rows of urothelial cells, focally - the urothelium up to 5-6 rows, single areas of urothelial proliferation, a pronounced number of arterioles are determined. Expression of mast cells (mast-cell) - 10-15 per field of view (x 400). (Fig. 2 - histological picture of the bladder wall after treatment with platelet-rich autoplasma x400, staining with Harris's hematoxylin).

Dysuric phenomena (frequency and intensity), pain syndrome began to decrease after the 1st session, the tendency persisted throughout the entire course of therapy. After the end of treatment, a decrease in symptoms persisted for 3-6 months with a gradual strengthening of the clinic, thus the period of relapse-free course was 6 months. 1, 3, 6, 12 months after completion of therapy with autologous platelet-rich plasma, a control pinch biopsy of the bladder wall from the area of the Gunner's lesion was performed for morphological assessment of intravesical platelet-rich plasma therapy.

The method of prolonging the recurrence-free period of interstitial cystitis made it possible to: reduce pain syndrome (reduce pain on a visual analogue scale from 7 to 3 points, reduce the frequency of urination (the average amount of urination before the start of treatment per day 40 times, after the end of the course of therapy 10-12 times, increase reservoir capacity of the bladder (from 100 ml to 350 ml), to reduce the frequency of relapses (relapse-free period of 6 months), to shorten the treatment period (the period of stay of the patient is 3 bed-days).

Example 2: Patient L, 39 years old, was admitted to the urology department with a diagnosis of Interstitial cystitis.

She complained of pain in the lower abdomen, aggravated by filling the bladder, painful urination in small portions up to 10-20 ml, pallakiuria up to 40-50 times a day.

From the anamnesis it is known: She has been ill for 4 years, when the above complaints began to bother her, she was treated for a long time by a urologist at the place of residence, cystitis was treated - against the background of antibacterial therapy, a slight decrease in clinical symptoms. But after a violation of the diet, hypothermia, the symptoms intensified.

The patient was referred for a consultation with the KKDP urologist. Examined, performed cystoscopy with biopsy of the bladder wall. The diagnosis was confirmed morphologically. After additional examination, she was hospitalized in the urology department for further treatment. Objectively:

• laboratory data: UAC - no features. Initial parameters: platelets 345 × 10 ⁹ / l, leukocytes 7.2 × 10 ⁹ / l, erythrocytes 5.2 × 10 ¹² / l. OAM - leukocyturia, turiocyturia, bacteriuria were not detected. Bacteriological urine culture - no microflora growth was detected.

• According to the survey and intravenous urography, no shadows of suspicious calculi were found. Renal function is timely, no dilatation of the pelvicellular system was found. The ureters are traced by cystoids. The bladder is small.

• When cystoscopy - the urethra is freely passable for the endoscope, the neck is not changed, the volume of the bladder is 150 ml. The mouths of the ureters are symmetrical, slit-like, urine is excreted from them in portions. The vascular pattern is pronounced. In the area of the second segment along the posterior wall and along the left lateral wall, there is a Gunner's lesion. When filling, petechial eruptions appeared with a volume of 200 ml.

An informed voluntary consent was taken from the patient for therapy and subsequent surgical treatment, all possible risks and complications were described.

1. The first step was to collect the patient's whole blood in a volume of 100 ml.

2. Completed the preparation of platelet-rich autoplasma according to the above technology. Laboratory characteristics of the obtained plasma: platelets 1050 × 10 ⁹ / l, leukocytes 0.4 × 10 ⁹ / l, erythrocytes 0.05 × 10 ¹² / l.

3. The resulting plasma was frozen at t -80 ° C.

4. Defrosting platelet-rich autoplasma in a water bath at t + 40 ° C and adding a 10% CaCl ₂ solution in a ratio of 1:10, respectively.

5. Under sterile conditions during cystoscopy, a pinch biopsy of the Gunner's lesion area is performed.

6. Next, electrocoagulation of ulcers of the bladder wall was carried out, then with the help of an endoscope through a needle, the zone of Gunner's lesion was injected: 1 injection of 1 ml of plasma into the zone of the coagulation bottom, along the healthy edges of the crater, every 3 mm, the depth of injection is 3 mm, total number of 22 injections. Subsequently, 4 more sessions of therapy were performed with a time interval of 1 time per 14 days according to the above method. 1, 3, 6, 12 months after the completion of therapy with autologous platelet-rich plasma, a control pinched biopsy of the bladder wall from the area of the Gunner's lesion was performed to morphologically evaluate the effectiveness of treatment with platelet-rich plasma.

Dysuric phenomena (frequency and intensity), pain syndrome began to decrease after the 1st session, the tendency persisted throughout the entire course of therapy. After the end of treatment, a decrease in symptoms persisted for 6 months and a relapse-free pattern was observed up to 12 months from the end of the course of therapy with a gradual strengthening of the clinic, thus the period of relapse-free course was 12 months.

The method of prolonging the recurrence-free period of interstitial cystitis made it possible to: reduce pain syndrome (reduce pain on a visual analogue scale from 8 to 3 points, reduce the frequency of urination (the average amount of urination before the start of treatment per day up to 40-50 times, after the end of the course of therapy 12-15 times, to increase the reservoir capacity of the bladder (from 150 to 300 ml), to reduce the frequency of relapses (relapse-free period of 12 months), to shorten the duration of treatment (the period of stay of the patient is 3 bed-days).

Claims (1)

A method of prolonging the recurrence-free period of interstitial cystitis, including preliminary preparation of autologous platelet-rich plasma and its activation with a 10% CaCl ₂ solution, chipping off the walls of the bladder, characterized in that the plasma obtained from 100 ml of whole blood is prepared with a threefold increase in the concentration of platelets, frozen at a temperature of -80 ° C, followed by defrosting in a water bath at t + 40 ° C and after activation with 10% CaCl ₂ solution in a ratio of 1:10, respectively; electrocoagulation of the zone of ulcerative lesion of the bladder wall is carried out and immediately after that the zone is injected every 2.0-3.0 mm, 2.0-3.0 mm deep, 1 injection - 1 ml, with the condition of plasma injection and along the healthy edges of the crater 2-3 mm from its edge, and every 14 days 4 times the injections are repeated in the same mode, clinical monitoring of the course of the disease and a pinch biopsy of the ulcerative lesion zone of the bladder wall with histological and immunohistochemical studies to assess the results of treatment.

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