Expert Reviews
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GENERAL GYNECOLOGY
Stem cells in gynecology
Felicia L. Lane, MD; Stephanie Jacobs, MD
D ating back to ancient times, the
Greeks recognized the human body’s
potential for regeneration. Their term for
the liver, hepar, was derived from the word
hepaomai, “to repair oneself.” Further-
more, Aristotle published observations of
animals that possessed the ability to regrow
body parts including: the salamander’s
ability to regrow its tail and of deer to re-
grow antlers.1 Attempts to more actively
partake in and control this regenerative ca-
pacity on a cellular level can be traced to the
early 1900s. In 1912, Alexis Carrel devel-
oped an “immortal” cell line from a chick
embryo, and continued to culture this cell
line for years to follow. In 1963, Ernest A.
McCulloch and James E. Till solidified the
concept of stem cells in their landmark Na-
ture publication.1 They transplanted bone
marrow cells into irradiated mice and
demonstrated that these same cells devel-
oped into colonies within the spleen. Gail
Martin and Martin Evans, in 1981, devel-
oped a line of mouse cells with the capacity
to become any tissue in the adult mouse.
From this cellular line, the term embryonic
stem cells was coined. James Thomson sub-
sequently developed the first line of human
embryonic stem cells in 1998.1 Exciting in-
vestigations of medical applications have
since exploded and brought us into the
realm of research and therapeutic poten-
tials existing today.
The study and use of stem cells has
made strides across many fields of med-
icine. This has included work in hema-
From the Division of Female Pelvic Medicine
and Reconstructive Surgery, Department of
Obstetrics and Gynecology, University of
California Irvine, Orange, CA.
Received Nov.13, 2011; revised Jan. 12, 2012;
accepted Jan. 31, 2012.
The authors report no conflict of interest.
Reprints: Felicia L. Lane, MD, 101 The City Dr.,
Bldg. 56, Orange, CA 92868. fgeas@uci.edu.
0002-9378/$36.00
Published by Mosby, Inc.
doi: 10.1016/j.ajog.2012.01.045
www. AJOG.
Stem cell based therapies hold promise for the obstetrician and gynecologist. This article
reviews the history of stem cells and some of their current applications in gynecology. Currently,
mesenchymal and muscle-derived stem cells are being explored for the treatment of urinary
and anal incontinence. Potential stem cell treatments include fistula repair, vaginal tissue
engineering, and graft material enhancement. Published animal and human pilot studies dem-
onstrate improved histologic and functional outcomes in those receiving stem cells. Trans-
planted cells may improve function by local engraftment, trophic factors, or modulation of
inflammation. Further clinical and safety studies are needed before clinical application.
Key words: gynecology, incontinence, mesenchymal, sphincter, stem cells
tology, ophthalmology, spinal cord in- termined high purity cell types.3 This
jury, burn therapy, cardiac ischemia, process is technically rigorous but neces-
and, more recently, in pelvic floor dys- sary to improve engraftment and decrease
function. In this review, we will focus on tumorigenicity.4 In addition, most readers
treatment potentials for urinary and anal are unaware that immune rejection can oc-
incontinence. Much of the existing stem cur after hESC transplantation. These cell
cell research in gynecology has focused lines acquire human leukocyte antigens
on these aspects. Results are promising, (HLA) as they mature and therefore recip-
but largely limited to animal studies. ients may need life-long immumosuppres-
Clinical, human application remains an sion.5 These special requirements and the
exciting goal, but one whose routine, ethical debates, surrounding embryonic
widespread use is premature. stem cell limit their current applications in
gynecology. Nonembryonic stem cells on
Stem cell sources the other hand, can be readily derived from
Stem cells are defined by their regenera- sources such as bone marrow, umbilical
tive capacity and their ability to differen- cord blood, and adipose tissue (multi-
tiate into 1 or more cell types. Hence, dif- potent cells), or from muscle (multi- and
ferent stem cell types possess different unipotent populations). The majority of
abilities. Toti or pluripotent stem cells, these cell types can be autologously derived
typically embryonic or fetal in source, from the gynecologic patient. Adult stem
can differentiate into any cell type or cells can be identified by a variety of mark-
germ cell layer. Multipotent, including ers including CD45, CD34, Pax7, and
mesenchymal stem cells (from blood, MyoD. In preparation, cells are selected
bone marrow, placenta, or adipose tis- from biopsied tissue (ie, bone marrow, ad-
sue), are capable of differentiating into ipose, or muscle), expanded in culture, and
multiple, but not all, cell types. Unipo- passaged to achieve confluency until de-
tent stem cells, of skin and muscle origin, sired cell transplant numbers are achieved.
are the most limited, capable of regener- Within animal studies, an identifying
ation within only 1 cell type (Figure 1).2 marker (ie, green fluorescent protein
Overall, stem cells can be derived from [GFP], BrdU, or PKH-26) is typically
embryonic and nonembyronic tissue. transduced to cells to assess for survival
Human embryonic stem cells (hESC) are and/or integration.
obtained from the inner cell mass of blas-
tocysts, are highly plastic and proliferate Origins of stem cell use in gynecology
rapidly. They are theoretically totipotent Stem cell therapy for the treatment of
and capable of differentiating into any urinary and anal incontinence is based
germ cell layer. However, hESC require on principles of skeletal muscle regener-
directed differentiation into specific de- ation. The urethral and external anal
SEPTEMBER 2012 American Journal of Obstetrics & Gynecology 149
Expert Reviews
FIGURE 1
Variation in potency of stem cell types
Lane. Stem cells. Am J Obstet Gynecol 2012.
sphincters both contain skeletal muscle
that contributes to effective continence.
However, age-related changes, injury,
and trauma can all lead to compromise
in function. Skeletal muscle possesses the
ability of inherent regeneration based on
the presence of satellite cells. Satellite
cells exist below the basal lamina in a
dormant state, and on injury are acti-
vated and act as native reparative cells.
Activated satellite cells produce myo-
blasts— unipotent muscle progenitor
stem cells (Figure 2). Myoblasts fuse to
form myotubes, and myotubes are pack-
aged into sarcomeres and align to form
myofibers. This process ultimately leads
to muscle regeneration. Unfortunately,
in the native state, the portion of satellite
cells within skeletal muscle is quite
small— unable to compensate for large
or chronic injuries alone.6
FIGURE 2
Native satellite cells produce myoblasts upon injury/activation
In the natural state, satellite cells reside below the basal lamina of skeletal muscle. At times of injury,
these cells are activated and produce unipotent myoblast cells which act as stem cells and aid in
muscular regeneration.
Lane. Stem cells. Am J Obstet Gynecol 2012.
150 American Journal of Obstetrics & Gynecology SEPTEMBER 2012
General Gynecology
Some of the earliest research using
myoblasts was in the field of Duchenne
Muscular Dystrophy. The concept of
muscle biopsy, in vitro culture, and sub-
sequent myoblast transplant to treat this
degenerative disorder was proposed in
1978. Multiple animal studies ensued
through the 1980s, and in 1990 the first
human myoblast transplant occurred.
Unfortunately, success was limited, pos-
sibly because of the nature of this sys-
temic degenerative disorder and large
burden of muscular dysfunction. In ad-
dition, transplanted cells presented an
overwhelming challenge of rapid cell
death and migration.6 Incontinence
models built on this concept, and possi-
bly because they involve a smaller muscle
burden, have demonstrated greater prom-
ise. Proof of concept of myoblast trans-
plantation in a rat stress incontinence
www.AJOG.org
model was published in 2000.7 Chancellor
et al7 demonstrated histologic evidence of
cell survival and fusion of myoblasts to
myotubes after periurethral injection.
Translation to anal incontinence models
ensued. Kang et al8 and Lorenzi et al9 pub-
lished some of the earliest work transplant-
ing stem cells into injured rat anal sphinc-
ters. Improved function was demonstrated.
Potential benefits of stem
cell use in gynecology
Use of stem cells for the treatment of uri-
nary and anal incontinence holds great
promise especially when considering
that existing options for both remain
limited. Stress urinary incontinence
(SUI) can be attributed to either loss of
urethral support and resulting hypermo-
bility, intrinsic deficiency within the ure-
thral sphincter (ISD), or a combination
of both. To date SUI can be effectively
treated with surgical placement of a
midurethral sling. Treatment of sphinc-
teric dysfunction presents a greater chal-
lenge. Urethral bulking can help to re-
store coaptation, but long-term efficacy
is lacking and local tissue reaction can
occur.10 Effective treatment options for
anal incontinence are even more sparse.
Physical therapy can provide modest ben-
efit. Sphincteroplasty, bulking agents,
and/or artificial sphincters have poor long-
term outcomes and can pose significant
risks of infection.11
As both SUI and anal incontinence
(AI) can result from loss of muscular in-
tegrity and function, rebuilding muscle
from a cellular level represents an ideal
treatment concept. Numerous animal,
along with a few human studies, have, in
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fact, demonstrated functional measures
of success. As stem cell research has ex-
panded, theories accounting for the
mechanism of action have expanded as
well. Initially, the theory was that trans-
planted cells would engraft, differentiate,
and directly lead to functional regenera-
tion. Potential explanations now in-
clude: (1) direct stem cell engraftment
and muscle regeneration; (2) localized
bulking impact; (3) trophic effect be-
cause of stem cell growth factor secre-
tion; and (4) immune modulation af-
fording improved tissue healing. These
will be addressed in further detail below.
SUI
Stem cell research for the treatment of
SUI is rapidly expanding with overall en-
couraging results.10,12-25 Bone marrow
(BMSC) and adipose-derived mesen-
chymal stem cells (ADSC) are the most
common cell populations used in mu-
rine transplants, although muscle-de-
rived stem cells (MDSC) (cultured from
patient thigh or deltoid biopsies) have
typically been used in human stud-
ies.21,23 The ideal cell population has yet
to be determined.
Transplantation method of cells has
also varied, and has included intraure-
thral, periurethral, and intravenous (IV)
routes. Localized injections make inher-
ent sense, IV injection methods, on the
other hand, less so. The method of IV
transplantation is based on stem cell
homing ability. For example, after simu-
lated injury with pelvic floor distention,
IV injected stem cells were found to mi-
grate and ultimately accumulate within
the injured pelvis.13 Benefits of IV ad-
ministration could include: a less inva-
sive route when compared with multiple
direct tissue injections, and/or could po-
tentially maximize cell delivery to the lo-
cation of greatest impact if they are con-
sistently found to, in fact, home to the
site of injury. This has yet to be clarified
in the literature. In addition, studies have
reported successful immune modulation
with IV injected mesenchymal cells. Sev-
eral clinical trials are examining IV mes-
enchymal infusions to treat a wide range
of autoimmune disorders.26 Although
incontinence research has not specifi-
General Gynecology
cally studied immune modulation, de-
creases in inflammation could improve
tissue healing.
Another point of variation among SUI
studies is the method of injury used to create
animal models of urinary incontinence. This
includes pudendal or sciatic nerve transec-
tion, crush nerve injury, urethral cyro- or
chemoinjury, and vaginal distention. Precise
comparisons are difficult; still, studies have
shown definite trends toward improved out-
come measures.
For this review, we attempt to evaluate
studies with similar methodologies in
conjunction. To begin, 2 studies, Xu et al
in 201014 and Kim et al in 2011,12 dem-
onstrated full restoration of leak point
pressures (LPP) in a rat model after ure-
thral injections of BMSC postpudendal
nerve transection. Kinebuchi et al24 fur-
ther demonstrated a trend toward LPP
restoration when BMSC were injected
into rat urethras after urethrolysis and
localized toxic injection. Although re-
sults did not reach significance, it is im-
portant to note that this last model of
injury was extensive and may represent a
more severe presentation of inconti-
nence. Furthermore on histologic evalu-
ation, Kinebuchi et al24 did demonstrate
significantly more striated muscle in the
transplantation group than in controls.
Three recent studies that used ADSC for
transplant have also shown benefit. In the
first,20ratsweretransplantedafterpudendal
crush injury. Follow-up measures demon-
strated increased LPP, closure pressure, and
functional urethral lengths compared with
controls.16 Lin et al19 demonstrated that ro-
dents receiving stem cell transplants had re-
duced voiding dysfunction (33% vs 80% in
controls)aftervaginaldistension.Zhaoetal20
found that inclusion of encapsulated nerve
growth factor (NGF) with ADSC transplant
successfully increased cell survival, differenti-
ation, and neuronal density.
Other researchers have begun to bridge
the gap to human studies. In the earliest
publication, 8 women received autologous
MDSCs (thigh muscle biopsy) in up to 4 cir-
cumferential periurethral injections. Of the 5
women available for follow up, all had im-
provement (although 2 eventually under-
went midurethral sling placement), and 1 re-
ported total continence.21 Lee et al22
demonstrated ⬎50% subjective improve-
SEPTEMBER 2012 American Journal of Obstetrics & Gynecology
Expert Reviews
ment in 26 of 39 women with SUI who were
injected transurethrally at 4 and 8 o’clock
with human umbilical cord stem cells. And,
most recently, 12 women with severe SUI
andafixedurethrareceivedinjectionofmus-
cle progenitor cells derived from autologous
deltoid biopsy. Cells were transplanted via
single injection under endoscopic guidance.
Three women were dry at 12 months based
on self-reported diary and pad test measures.
Seven women had improved pad tests, but
not improved diary measures. Two women
demonstrated slight worsening of inconti-
nence.23 There were no adverse events en-
countered in any human study. Limitations
of human and animal studies include small
sample sizes and/or lack of control groups
and randomization (Table 1).
As mentioned, multiple theories exist for
how stem cells function to improve stress in-
continence.Again,possibilitiesincludedirect
cell integration and muscular regeneration,
bulking effect, trophic impact, and/or im-
mune modulation. Murine studies have typ-
icallyusedlabeledcelltransplantations(most
commonlyGFP).Themajorityhavesuccess-
fully demonstrated labeled cell presence on
histologic examination.12-17 Such findings
supported initial theories of direct cell inte-
gration, differentiation and muscle regener-
ation. Still, on closer examination, some of
thesesamestudiesfoundasignificantdecline
in cell presence over time—as rapidly as 10
days.13 In Lim et al’s work,18 labeled human
umbilical cord blood cells were present at 2
weeks, but absent at 4—interestingly, this
was in direct contrast to the time frame of
histologic improvement. In addition, Lin et
al19 found labeled ADSC 4 weeks after trans-
plantation. However, they found lack of cell
differentiation, and thereby determined cells
did not successfully engraft. Benefit in func-
tion, Lim et al18 and Lin et al19 concluded,
was likely because of trophic factors rather
than direct stem cell muscle regeneration.
Other studies have supported efficacy via
bulking effect. Kim et al12 and Xu et al14 re-
ported evidence of “muscular masses” and
increased muscle thickness in rat urethras af-
ter transplantation. This could provide more
of an obstructive rather than functional
method of improved continence. Questions
remainregardingtheexactmechanismofac-
tion, but overall a trend toward benefit exists.
151
Expert Reviews General Gynecology www.AJOG.org

TABLE 1
Summary stem cell research in stress urinary incontinence
Author Cell source Methods Results/conclusions Complications
12
Kim et al Rat BMSC Rat population Restoration LPP/CP in transplant None
Injury: bilateral pudendal group Presence “muscle
nerve transection Muscle masses noted in urethra masses” noted
Injection: periurethral Conclude efficacy could be due
4 wk outcome measures to improved contraction ⫾
bulking effect
................................................................................................................................................................................................................................................................................................................................................................................
Cruz et al13 Rat BMSC labeled with GFP Rat population 4 d: GFP in urethra, vagina, None
Injury: vaginal distension rectum, and levator
Injection: IV 10 d: increased GFP in urethra
4 and 10 d outcome IV BMSC able to home to sites of
measure injury
................................................................................................................................................................................................................................................................................................................................................................................
Xu et al14 Rat MDSC labeled w Rat population Transplant: LPP increased with None
GFP ⫾ Fibrin Glue Injury: bilateral pudendal and without fibrin glue vs injury Transplant group: ⫹
transection without transplant increased thickness of
Injection: periurethral No significant difference in muscle with variable fiber
1, 4 wk functional function with fibrin glue, but ⫹ orientation
evaluation increased cell survival and
4 wk histology microvessel density
................................................................................................................................................................................................................................................................................................................................................................................
Corcos et al15 Rat BMSC Rat population Resolution of LPP to baseline in None
Injury: bilateral pudendal Transplant group
transection
Injection: intrasphincteric
4 wk postevaluation
................................................................................................................................................................................................................................................................................................................................................................................
Wu et al16 Rat ADSC Rat population Transplantation group: increased None
Injury: pudendal nerve LPP, CP, FUL, vs no transplant
(crush) Urethra: structural resolution to
Injection: periurethral, 3 baseline with transplantation
sites
Sacrifice at 3, 7, 14 d
posttransplantation
................................................................................................................................................................................................................................................................................................................................................................................
Lim et al18 HUCB with fluorescent label Rat population Transplants: LPP and histologic None
Injury: periurethral improvement vs control
electrocautery BUT no labeled cells found at
Injection: 2 sites, lateral 4 wk
wall midurethra Impact attributed to paracrine
Evaluation 2, 4 wk effect of cytokines and growth
factors
................................................................................................................................................................................................................................................................................................................................................................................
19
Lin et al Rat ADSC, labeled Rat population Significant improvement in LPP None
Injury: vaginal distension with either transplantation
and bilateral oopherectomy method
Injection: intraurethral or IV ⫹ Detection cells at 4 wk
Evaluation at 4 wk ⫹ Homing demonstrated in IV
transplantation
................................................................................................................................................................................................................................................................................................................................................................................
Zhao et al20 Rat ADSC rat ⫾ nerve Rat population Significant improvement LPP and None
growth factor (NGF) ⫾ Injury: bilateral pudendal muscle proportion and neuronal
encapsulated polylactic- transection density when ADSC ⫹ NGF ⫹
coglycolic acid Injection: periurethral Capsule
Evaluation at 8 wk Other ADSC groups improved but
did not return to baseline
................................................................................................................................................................................................................................................................................................................................................................................
Kinebuchi et al24 Rat BMSC Rat population LPP increased in transplant None
Also injected 1 group with Injury: urethrolysis and group, but not significant vs CFM
CFM injection toxin injection
Injection: periurethral ⫹GFP showed fusion
13 wk evaluation Less striated muscle in CFM vs
MSC or control group
Some contribution growth
factors/cytokines from medium
alone seen
................................................................................................................................................................................................................................................................................................................................................................................
Lane. Stem cells. Am J Obstet Gynecol 2012. (continued )

152 American Journal of Obstetrics & Gynecology SEPTEMBER 2012

www.AJOG.org General Gynecology Expert Reviews

TABLE 1
Summary stem cell research in stress urinary incontinence (continued)
Author Cell source Methods Results/conclusions Complications
10
Imamura et al Rabbit BMSC Rabbit population LPP higher in transplant vs None
Injury: cryoinjury control at 2 wk
Injection: intraurethral
Evaluation at 1, 2 wk
................................................................................................................................................................................................................................................................................................................................................................................
25
Fu et al Rat ADSC Rat population Max bladder capacity, LPP, and None
Injury: vaginal distention muscle thickness increased in
Injection: posterior urethra transplant group
at bladder neck
Follow-up 1, 3 mo
................................................................................................................................................................................................................................................................................................................................................................................
Carr et al 21
Autologous MDSC Human: 8 women SUI 5 women ⫹ improvement None
Injection: up to 4 1 woman ⫽ total continence
circumferential urethral 2 of the improved still proceeded
injections with midurethral sling
12 mo data 3 did not continue follow-up
................................................................................................................................................................................................................................................................................................................................................................................
22
Lee et al Human cord blood Human: 39 women w/SUI 12 months: 26 women (72.2%) None
Injection: transurethral had ⬎50% improvement
1, 3, 12 mo follow-up In selection of 10 women, MUCP
increased ⬎30 cm H2O
................................................................................................................................................................................................................................................................................................................................................................................
23
Sebe et al Autologous muscle Human: 12 women 3 patients dry: subjective diary None
progenitor cells persistent, severe SUI w and pad test
fixed urethra s/p prior failed 7 decreased with pad test, but
surgery no change after incontinence
Injection: intrasphincteric episodes 2 some worsening
Follow-up to 12 mo
................................................................................................................................................................................................................................................................................................................................................................................
ADSC, adipose derived mesenchymal stem cells; BMSC, bone marrow-derived mesenchymal stem cells; CFM, cell free medium; CP, closure pressure (urethral); FUL, functional urethral length; GFP,
green fluorescent protein; HUCB, human umbilical cord blood; LPP, leak point pressure; MDSC, muscle derived stem cells; NGF, nerve growth factor; SUI, stress urinary incontinence.
Lane. Stem cells. Am J Obstet Gynecol 2012.

AI and MDSC for the treatment of AI and 2 tude was higher in the MDSC group but not
AI is not uncommon. It is estimated to studies on MSCs.8,9,31-35 Our laboratory significantly.8 White et al,32 demonstrated
affect 2-15% of the general popula- published proof of concept that transplanted improved twitch tension, maximal titanic
tion.27,28 In women AI is often the result MDSC labeled with GFP can survive and contraction, and maximal contractile force
of an injury to the anal sphincter sus- fuse with host anal sphincter muscle (Figure in response to electrical field stimulation in
tained during childbirth. Approximately 3). In addition, 3 animal studies have looked rodents treated with myogenic stem cells vs
0.7-19.3% of vaginal deliveries can result at in vitro function of transplanted muscle controls. Work by Kajbafzadeh33 and
in anal sphincter laceration.29 Despite after euthanasia. Lorenzi et al9 divided 24 Aghaee-Afshar34 looked at the use of stem
postpartum identification and repair the WistarFurthratsinto3experimentalgroups. cells transplantation in a chronic sphincter
imaging supplement to the Childbirth and Group A underwent a sham operation, injury model. Animals in these studies un-
Pelvic Symptoms (CAPS) study demon- group B had sphincterotomy and repair of derwent sphincterotomy without subse-
strates greater than 50% of sphincter de- both anal sphincters plus saline injections,
quent repair. Stem cell transplantation was
fects will persist.30 and group C underwent sphincterotomy
performed 2-3 weeks status postinjury. Ani-
The mechanism of sphincter injury may and repair, followed by intrasphincteric in-
malswereeuthanizedatvaryingintervalsand
be due to muscle rupture, prolonged hyp- jection of bone-marrow-derived mesenchy-
histology and functional studies performed.
oxia and denervation, faulty repair, or a mal stem cells. All animals were euthanized
Histology revealed decreased fibrosis in the
combination of factors. Unfortunately, on day 30, histology and in vitro contractility
long-term success rates for primary or sec- assessed. Study results demonstrated that transplanted animals and improved mean
ondary sphincteroplasty are dismal with bone-marrow-derived mesenchymal stem anal resting pressures as well as improved
only 30% of patients demonstrating conti- cell transplants led to greater sphincter mus- anal sphincter electrical activity. No adverse
nence 5 years after surgery.30 cle area and improved contractility of muscle outcomes were described; however, 6 ani-
Myoblasts, MDSCs, and mesenchymal fibers in vitro.9 Kang et al,8 created a cryoin- mals died perioperatively in the Aghaee-Af-
stem cells (MSC) are promising potential jurywithintheanalsphincter,followedbyin- shar study. The authors commented that
therapies for AI. Since 2008, 5 peer-reviewed jection of MDSC and in vitro contractility these deaths appeared unrelated to the stem
articles have been published on myoblasts testing postmortem. The contraction ampli- cell transplants.33,34 Currently, there are no

SEPTEMBER 2012 American Journal of Obstetrics & Gynecology 153

Expert Reviews
FIGURE 3
GFP-labeled myoblasts within EAS, 10x magnification
Transplanted muscle derived stem cells labeled with GFP can survive and fuse with host anal tissue.
Reprinted, with permission, from the Department of Anatomy and Neurobiology Reeve-Irvine Research Center University of California-
Irvine.
EAS, external anal sphincter; GFP, green florescent protein.
Lane. Stem cells. Am J Obstet Gynecol 2012.
published safety or migration studies in ani-
mal models of anal incontinence.
One human study has been published
using MDSC to treat AI to obstetric
trauma.35 Ten women refractory to con-
servative therapy were provided in-
formed consent and followed for 1 year
in this pilot study. The primary outcome
measures were safety and feasibility.
Functional endpoints included Wexner
incontinence scale, anal squeeze pres-
sures and quality of life measures at 12
months. Autologous myoblasts were
harvested from a pectoralis muscle bi-
opsy, cultured, and injected into the ex-
ternal anal sphincter defect using direct
ultrasound guidance. Overall, the proce-
dure was well tolerated and no adverse
events were observed. At 12 months, the
Wexner incontinence score had de-
creased by a mean of 13.7 units (95%
confidence interval, ⫺16.3 to ⫺11.2),
anal squeeze pressures were unchanged,
and overall quality of life scores improved
by a median of 30 points (95% confidence
interval, 25– 42). Anal squeeze pressures
did rise significantly at 1 month and 6
months postinjection (P ⫽ .03) but had
decreased by 12 months. The authors con-
cluded that injection of autologous myo-
154 American Journal of Obstetrics & Gynecology SEPTEMBER 2012
General Gynecology
EAS Florescence
blasts is safe, well tolerated, and signifi-
cantly improves symptoms of AI because
of obstetric anal sphincter lacerations and
that further large scale trials with longer
follow-up are needed.35 Unfortunately, no
control group was used in this pilot study
and long-term safety follow-up has yet to
be published. Overall, these animal and
human publications demonstrate encour-
aging results with primarily improved out-
come measures (Table 2).
Safety
To date, significant adverse events have not
been reported in urinary or AI stem cell
literature. This does not hold true for stem
cell literature as a whole. To obtain ade-
quate cell numbers for transplantation,
stem cells are cultured in vitro with multi-
ple passages of growth. Although the cells
maintain their potency, they do age with
each passage. Bonab et al36 demonstrated
that when cultured in vitro, MSC from
healthy donors (2.5-63 years), showed ev-
idence of aging, as represented by de-
creased telomere length, after even 1 pas-
sage of cells. With cellular aging comes an
increased risk of acquired chromosomal
abnormalities, malignant transformation
and viral contamination. This was further
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addressed in work by Rosland et al.37 Al-
though murine MSC have previously been
noted to possess instability and potential
for malignant transformation, human
sources of MSC have typically been
thought to be more stable. In evaluation of
this theory, Rosland et al37 found that dur-
ing the long-term (up to 106 weeks) in
vitro culture of human MSC, 45.8% of cul-
tures (11 of 24) demonstrated evidence of
spontaneous malignant transformation.
When these transformed cells were then
injected IV into immunodeficient mice,
rapid tumor formation in lungs was dem-
onstrated. 36,37
Ideal route of transplantation remains
another unknown, and therefore an addi-
tional safety concern. Localized intramus-
cular (IM) injections appear less problem-
atic when compared with IV trans-
plantation. Some IM transplants have led
to benign appearing muscular mass for-
mations as described previously.12 These
masses did not appear to have malignant
features, although in-depth analysis was
not reported. IV injections of MSC, on the
other hand, have resulted in cell sequestra-
tion in both the liver and lung, resulting in
microvasculature blockage, thrombus,
and tumor formation.37-39
Likely, the safety profile of stem cell
use for SUI and AI will prove accept-
able. Adverse outcomes do not pervade
the literature. Still, the majority of re-
search has been in animal populations,
follow-up time frames have been rela-
tively short, signification methodo-
logic variations exist, and subject num-
bers for animal, and especially for
human studies, are small. More work is
needed to address guidelines for select-
ing appropriate cell source, dosage,
and method of transplantation.
Potential directions
Stem cells applications in gynecology are
not limited to incontinence therapies
alone. Preliminary work is underway in
the following areas; vaginal tissue engi-
neering, fistula repair, and graft material
enhancement.40-44 Successful develop-
ment of a neovagina and tissue recovery after
partialvaginectomywasdemonstratedinan-
imal models implanted with stem cell seeded
grafts.40,42 Stem cell transplant has also
shown efficacy in repair of recurrent recto-
www.AJOG.org General Gynecology Expert Reviews

TABLE 2
Summary stem cell research in anal incontinence
Author Cell Source Methods Results/conclusions Complications
31
Craig et al Rat myoblast No injury Evidence of fusion cells None
3 injections: 3 and 9 o’clock in all animals
................................................................................................................................................................................................................................................................................................................................................................................
8
Kang et al MDSC Cryoinjury Contractility cryoinjured None
3 injections into right ⬍ control (P ⬍ .05)
hemisphere anal sphincter Contractility MDSC
improved vs cryoinjured
(not significant)
................................................................................................................................................................................................................................................................................................................................................................................
9
Lorenzi et al Rat MSC Sphincterotomy with repair MSC improved muscle None
2 injections into either end regeneration and
sphincter increased contractile
function after sphincter
injury and repair
................................................................................................................................................................................................................................................................................................................................................................................
32
White et al Rat myoblast Sphincterotomy with repair Stem cell injection with None
bilateral sphincter injections repair improved function
at D 7 and 90 vs control
Unrepaired w/transplant:
no improvement
................................................................................................................................................................................................................................................................................................................................................................................
33
Kajbafzadeh et al Rabbit myoblast Sphincterotomy without repair Myoblasts accelerated None
Injection to injury site 3 wk repair and improved Noted regenerating
postop mean resting pressures muscle at 4 wks with
fibers in variable
orientation
................................................................................................................................................................................................................................................................................................................................................................................
35
Frudinger et al Human myoblast Chronic injury Squeeze pressures None
12-14 injections into external increased at 1 and 6 mo
sphincter but returned to baseline
at 12 mo.
Improved Wexner and
QOL
................................................................................................................................................................................................................................................................................................................................................................................
34
Aghaee-Afshar et al HUCM and rabbit MSC Sphincterotomy without repair 4/7 MSC and 2/7 in 6 rabbits died
Injection to injury site 2 wk HUCM with competent Reported complications
postop EAS unlikely due to stem
EMG frequency improved cell injections
in MSC group
................................................................................................................................................................................................................................................................................................................................................................................
HUCM, human umbilical cord matrix; MDSC, muscle-derived stem cells; MSC, mesenchymal stem cells; QOL, quality of life measures.
Lane. Stem cells. Am J Obstet Gynecol 2012.

vaginal fistula in a small group of women.43 ment options for affected individuals is ders. Before clinical application, further
Furthermore, researchers have proposed use of paramount importance. functional and safety studies are needed.
of seeded grafts to repair pelvic organ pro- Stem cell therapy holds a great deal of Priorities are as follows: (1) optimization
lapse. Perhaps stem cells and scaffolds could promise, excitement, and in some cases, of the stem cell source; (2) creation of a
allowsurgeonstomoveawayfrommeshand controversy. This review of the literature standardized cell harvest and culture
complications related to permanent materi- demonstrates that stem cells used in uri- protocol safe for human use; (3) deter-
als. These and perhaps other gynecologic nary and AI likely possess the ability to: (1) mination of maximum and minimum
conditions could benefit from stem cell engraft following transplantation; (2) im- therapeutic dosages; and (4) establish-
augmentation. prove function through bulking effect; (3) ment of a best practice transplantation
Comment elicit trophic effects on the host; and (4) route and technique. Once researchers
Pelvic floor disorders (pelvic organ pro- modulate inflammation. These properties overcome these hurdles, stem cell thera-
lapse, urinary and anal incontinence) result in beneficial histologic, functional, peutics may become a clinical reality. f
can affect up to 23% of the population.29 and clinical outcomes. However, the exact
The prevalence of these conditions in- mechanisms of repair are complex and not
REFERENCES
creases with age and parity. As our soci- yet fully elucidated.
1. Polykandriotis E, Popescu LM, Horch RE.
ety ages these conditions are poised to Existing animal and pilot human data Regenerative medicine: then and now—an up-
create great social and economic bur- support stem cell transplantation as po- date of recent history into future possibilities.
dens. Therefore, establishing new treat- tential treatments for pelvic floor disor- J Cell Mol Med 2010;14:2350-8.

SEPTEMBER 2012 American Journal of Obstetrics & Gynecology 155

Expert Reviews General Gynecology
2. Collins CA, Partridge TA. Self-renewal of the
adult skeletal muscle satellite cell. Cell Cycle
2005;4:1338-41.
3. Sharp J, Hatch M, Nistor G, Keirstead H.
Derivation of oligodendrocyte progenitor cells
from human embryonic stem cells. Methods
Mol Biol 2011;767:399-409.
4. Przyborski SA. Differentiation of human em-
bryonic stem cells after transplantation in im-
mune-deficient mice. Stem Cells 2005;23:
1242-50.
5. Deuse T, Seifert M, Phillips N, et al. Human
leukocyte antigen I knockdown human embry-
onic stem cells induce host ignorance and
achieve prolonged xenogeneic survival. Circu-
lation 2011;124:S3-9.
6. Law PK. Myoblast transfer: gene therapy for
muscular dystrophy. Austin, TX: R.G. Landes
Company; 1994.
7. Chancellor MB, Yokoyama T, Tirney S, et al.
Preliminary results of myoblast injection into the
urethra and bladder wall: a possible method for
the treatment of stress urinary incontinence and
impaired detrusor contractility. Neurourol Uro-
dyn 2000;19:279-87.
8. Kang SB, Lee HN, Lee JY, Park JS, Lee HS.
Sphincter contractility after muscle-derived
stem cells autograft into the cryoinjured anal
sphincters of rats. Disease Colon Rectum
2008;51:1367-73.
9. Lorenzi B, Pessina F, Lorenzoni P, et al.
Treatment of experimental injury of anal sphinc-
ters with primary surgical repair and injection of
bone marrow-derived mesenchymal stem cells.
Disease Colon Rectum 2008;51:411-20.
10. Imamura T, Ishizuka O, Kinebuchi Y, et al.
Implantation of autologous bone-marrow-de-
rived cells reconstructs functional urethral
sphincters in rabbits. Tissue Eng Part A 2011;
17:1069-81.
11. Feki A, Faltin DL, Lei T, Dubuisson JB, Ja-
cob S, Irion O. Sphincter incontinence: is regen-
erative medicine the best alternative to restore uri-
nary or anal sphincter function? Int J Biochem Cell
Biol 2007;39:678-84.
12. Kim SO, Na HS, Kwon D, Joo SY, Kim HS,
Ahn Y. Bone-marrow-derived mesenchymal
stem cell transplantation enhances closing
pressure and leak point pressure in a female
urinary incontinence rat model. Urol Int
2011;86:110-6.
13. Cruz M, Dissaranan C, Cotleur A, Kied-
rowski M, Penn M, Damaser M. Pelvic organ
distribution of mesenchymal stem cells injected
intravenously after simulated childbirth injury in
female rats. Obstet Gynecol Int 2012;2012:
612946.
14. Xu Y, Song YF, Lin ZX. Transplantation of
muscle-derived stem cells plus biodegradable
fibrin glue restores the urethral sphincter in a
pudendal nerve-transected rat model. Braz
J Med Biol Res 2010;43:1076-83.
15. Corcos J, Loutochin O, Campeau L, et al.
Bone marrow mesenchymal stromal cell ther-
apy for external urethral sphincter restoration in
a rat model of stress urinary incontinence. Neur-
ourol Urodyn 2011;30:447-55.
156 American Journal of Obstetrics & Gynecology SEPTEMBER 2012
16. Wu G, Song Y, Zheng X, Jiang Z. Adipose-
derived stromal cell transplantation for treat-
ment of stress urinary incontinence. Tissue Cell
2011;43:246-53.
17. Chermansky CJ, Tarin T, Kwon DD, et al.
Intraurethral muscle-derived cell injections in-
crease leak point pressure in a rat model of
intrinsic sphincter deficiency. Urology 2004;63:
780-5.
18. Lim JJ, Jang JB, Kim JY, Moon SH, Lee
CN, Lee KJ. Human umbilical cord blood
mononuclear cell transplantation in rats with in-
trinsic sphincter deficiency. J Korean Med Sci
2010;25:663-70.
19. Lin G, Wang G, Banie L, et al. Treatment of
stress urinary incontinence with adipose tissue-
derived stem cells. Cytotherapy 2010;12:88-95.
20. Zhao W, Zhang C, Jin C, et al. Periurethral
injection of autologous adipose-derived stem
cells with controlled-release nerve growth fac-
tor for the treatment of stress urinary inconti-
nence in a rat model. Eur Urol 2011;59:155-63.
21. Carr LK, Steele D, Steele S, et al. One-year
follow-up of autologous muscle-derived stem
cell injection pilot study to treat stress urinary
incontinence. Int Urogynecol J Pelvic Floor Dys-
funct 2008;19:881-3.
22. Lee CN, Jang JB, Kim JY, Koh C, Baek JY,
Lee KJ. Human cord blood stem cell therapy for
treatment of stress urinary incontinence. J Ko-
rean Med Sci 2010;25:813-6.
23. Sebe P, Doucet C, Cornu JN, et al. Intras-
phincteric injections of autologous muscular
cells in women with refractory stress urinary in-
continence: a prospective study. Int Urogynecol
J 2011;22:183-9.
24. Kinebuchi Y, Aizawa N, Imamura T, Ishizuka
O, Igawa Y, Nishizawa O. Autologous bone-
marrow-derived mesenchymal stem cell trans-
plantation into injured rat urethral sphincter. Int
J Urol 2010;17:359-68.
25. Fu Q, Song XF, Liao GL, Deng CL, Cui L.
Myoblasts differentiated from adipose-derived
stem cells to treat stress urinary incontinence.
Urology 2010;75:718-23.
26. Wang S, Yu H, Liu J, Liu B. Exploring the
methodology and application of clinical path-
way in evidence-based Chinese medicine.
Front Med 2011;5:157-62.
27. Dudding TC, Vaizey CJ, Kamm MA. Obstet-
ric anal sphincter injury: incidence, risk factors,
and management. Ann Surg 2008;247:224-37.
28. Kepenekci I, Keskinkilic B, Akinsu F, et al.
Prevalence of pelvic floor disorders in the female
population and the impact of age, mode of de-
livery, and parity. Disease Colon Rectum 2011;
54:85-94.
29. Nygaard I, Barber MD, Burgio KL, et al.
Prevalence of symptomatic pelvic floor disor-
ders in US women. JAMA 2008;300:1311-6.
30. Richter HE, Fielding JR, Bradley CS, et al.
Endoanal ultrasound findings and fecal inconti-
nence symptoms in women with and without
recognized anal sphincter tears. Obstet Gyne-
col 2006;108:1394-401.
31. Craig JB LF, Nistor G, Motakef S, Pham Q,
Keirstead H. Allogenic myoblast transplantation
www.AJOG.org
in the rat anal sphincter. Female Pelvic Med
Reconstr Surg 2010;16:205-8.
32. White AB, Keller PW, Acevedo JF, Word RA,
Wai CY. Effect of myogenic stem cells on contrac-
tile properties of the repaired and unrepaired tran-
sected external anal sphincter in an animal model.
Obstet Gynecol 2010;115:815-23.
33. Kajbafzadeh AM, Elmi A, Talab SS, Esfahani
SA, Tourchi A. Functional external anal
sphincter reconstruction for treatment of anal
incontinence using muscle progenitor cell
auto grafting. Disease Colon Rectum 2010;
53:1415-21.
34. Aghaee-Afshar M, Rezazadehkermani M,
Asadi A, Malekpour-Afshar R, Shahesmaeili A,
Nematollahi-mahani SN. Potential of human
umbilical cord matrix and rabbit bone marrow-
derived mesenchymal stem cells in repair of sur-
gically incised rabbit external anal sphincter.
Disease Colon Rectum 2009;52:1753-61.
35. Frudinger A, Kolle D, Schwaiger W, Pfeifer
J, Paede J, Halligan S. Muscle-derived cell in-
jection to treat anal incontinence due to obstet-
ric trauma: pilot study with 1 year follow-up. Gut
2010;59:55-61.
36. Bonab MM, Alimoghaddam K, Talebian F,
Ghaffari SH, Ghavamzadeh A, Nikbin B. Aging
of mesenchymal stem cell in vitro. BMC Cell Biol
2006;7:14.
37. Rosland GV, Svendsen A, Torsvik A, et al.
Long-term cultures of bone marrow-derived
human mesenchymal stem cells frequently un-
dergo spontaneous malignant transformation.
Cancer Res 2009;69:5331-9.
38. Tolar J, Nauta AJ, Osborn MJ, et al. Sar-
coma derived from cultured mesenchymal stem
cells. Stem Cell 2007;25:371-9.
39. Furlani D, Ugurlucan M, Ong L, et al. Is the
intravascular administration of mesenchymal
stem cells safe? Mesenchymal stem cells and
intravital microscopy. Microvascular Res 2009;
77:370-6.
40. Dorin RP, Atala A, Defilippo RE. Bioengi-
neering a vaginal replacement using a small bi-
opsy of autologous tissue. Semin Reprod Med
2011;29:38-44.
41. Ochoa I, Pena E, Andreu EJ, et al. Mechan-
ical properties of cross-linked collagen meshes
after human adipose derived stromal cells
seeding. J Biomed Mater Res A 2011;96:
341-8.
42. Ho MH, Heydarkhan S, Vernet D, et al.
Stimulating vaginal repair in rats through skele-
tal muscle-derived stem cells seeded on small
intestinal submucosal scaffolds. Obstet Gyne-
col 2009;114:300-9.
43. Garcia-Olmo D, Herreros D, De-La-Quin-
tana P, et al. Adipose-derived stem cells in
Crohn’s rectovaginal fistula. Case Report Med
2010;2010:961758.
44. Zou XH, Zhi YL, Chen X, et al. Mesenchymal
stem cell seeded knitted silk sling for the treat-
ment of stress urinary incontinence. Biomateri-
als 2010;31:4872-9.