Autologous Muscle Derived Cells for Treatment of Stress Urinary Incontinence in Women

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1 Autologous Muscle Derived Cells for Treatment of Stress Urinary Incontinence in Women Kenneth M. Peters,* Roger R. Dmochowski, Lesley K. Carr, Magali Robert, Melissa R. Kaufman, Larry T. Sirls,k Sender Herschorn,{ Colin Birch, Patricia L. Kultgen and Michael B. Chancellor** From Beaumont Health System, Royal Oak, Michigan (KMP, LTS, MBC); Vanderbilt Medical Center, Nashville, Tennessee (RRD, MRK); Sunnybrook Health Sciences Centre, Toronto, Ontario (LKC, SH), and Foothills Medical Centre, Calgary, Alberta (MR, CB), Canada; and MED Institute, Inc., West Lafayette, Indiana (PLK) Purpose: We assess the 12-month safety and potential efficacy of autologous muscle derived cells for urinary sphincter repair (Cook MyoSite Incorporated, Pittsburgh, Pennsylvania) in women with stress urinary incontinence. Materials and Methods: Pooled data from 2 phase I/II studies with identical patient selection criteria and outcome measures were analyzed. Enrolled patients had stress urinary incontinence refractory to prior treatment and no symptom improvement during the last 6 months. Patients received intrasphincter injection of 10 (16), 50 (16), 100 (24) or (24) autologous muscle derived cells for urinary sphincter repair, derived from biopsies of each patient s quadriceps femoris. The primary outcome measure was safety, determined by incidence and severity of adverse events. Potential efficacy was measured by changes in 3-day voiding diaries, 24-hour pad tests, and UDI-6 and IIQ-7 scores. Results: A total of 80 patients underwent injection of autologous muscle derived cells for urinary sphincter repair, and 72 completed diaries and pad tests at 12-month followup. No adverse events attributed to autologous muscle derived cells for urinary sphincter repair were reported. Higher dose groups tended to have greater percentages of patients with at least a 50% reduction in stress leaks and pad weight at 12-month followup. All dose groups had statistically significant improvement in UDI-6 and IIQ-7 scores at 12-month followup compared to baseline. Conclusions: Autologous muscle derived cells for urinary sphincter repair at doses of 10, 50, 100 and cells appears safe. Efficacy data suggest a potential dose response with a greater percentage of patients responsive to higher doses. Key Words: transplantation, autologous; urinary incontinence, stress; myoblasts, skeletal; muscle cells Abbreviations and Acronyms AMDC-USR ¼ autologous muscle derived cells for urinary sphincter repair IIQ-7 ¼ Incontinence Impact Questionnaire short form SUI ¼ stress urinary incontinence UDI-6 ¼ Urogenital Distress Inventory short form Accepted for publication February 17, Study received ethics board approval. Supported by Cook MyoSite Incorporated, Pittsburgh, Pennsylvania. * Financial interest and/or other relationship with Taris Biomedical, Medtronic Inc., Trillium Therapeutics and Uroplasty. Financial interest and/or other relationship with Allergan and Medtronic. Financial interest and/or other relationship with Cook MyoSite. Financial interest and/or other relationship with Cook MyoSite, Astellas and Allergan. k Financial interest and/or other relationship with J & J and AMS. { Financial interest and/or other relationship with Cook, Allergan, Astellas, Lilly and Pfizer. ** Financial interest and/or other relationship with Cook. See Editorial on page 301. STRESS urinary incontinence, the involuntary leakage of urine during activities that increase abdominal pressure (eg coughing, sneezing, physical exercise), affects up to 35% of adult women. 1 This condition is caused by pelvic floor weakness, urethral hypermobility and/or sphincter deficiency. Interventional therapies may be necessary when first line conservative management such as pelvic floor muscle training fails to provide adequate symptom relief. Sling procedures and bladder /14/ /0 THE JOURNAL OF UROLOGY 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Vol. 192, , August 2014 Printed in U.S.A. j 469

2 470 AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE neck suspensions can be effective. However, complications of urinary retention, worsening urgency symptoms and erosion/extrusion of mesh have been reported. 2 Injection of urethral bulking agents is less invasive, but lacks durability and has been associated with degradation/reabsorption, migration, bladder outlet obstruction and hypersensitivity reactions. 3 A potential alternate therapy is the use of autologous muscle progenitor cells, which are isolated from skeletal muscle biopsies and expanded ex vivo before injection into the urethral sphincter. This approach may benefit patients with SUI by augmenting sphincter function. Two previous studies assessed AMDC-USR in women with SUI. 4,5 A pilot study tested 18 to AMDC-USR in 8 patients and another assessed doses ranging from 1 to AMDC-USR in 38 patients. In both studies the patients could opt to receive a second treatment of AMDC-USR and the use of AMDC- USR appeared safe. Additionally, the dose ranging study results suggested greater efficacy for patients who received 2 AMDC-USR treatments of at least cells. 5 In this report we describe pooled data from 2 open label studies conducted concurrently that were designed to collectively assess the 12-month safety and potential efficacy of 4 doses of AMDC-USR for the treatment of SUI in 80 women. METHODS Two phase I/II studies were conducted to assess the 12-month safety and potential efficacy of AMDC-USR for the treatment of SUI in women. Both studies were performed in accordance with the Declaration of Helsinki. Study protocols were approved by the ethics board at each site before study initiation and written informed consent was obtained from all patients. Both studies were conducted concurrently and intended to be evaluated together. Each protocol specified the same patient selection criteria and outcome measures. Study 1 was a dose escalation study conducted between October 2008 and November 2011 at 3 investigative sites in the United States and Canada (ClinicalTrials.gov Identifier: NCT ). The study protocol, designed to test 10, 50 and AMDC-USR in 48 patients (16 patients per group), was approved by the FDA (Food and Drug Administration) and Health Canada. In an amendment approved by the FDA, study 1 was expanded to include 16 additional patients to receive 100 or AMDC-USR (8 patients per group) at 2 U.S. investigative sites. A separate protocol to test AMDC-USR in 16 patients was approved by Health Canada and was conducted at 2 Canadian investigative sites from June 2010 to September 2012 (study 2, ClinicalTrials.gov Identifier: NCT ). Inclusion criteria were women age 18 years or older with SUI refractory to prior treatment with no improvement of SUI symptoms for at least 6 months before enrollment (see Appendix). Each patient underwent a needle biopsy of the quadriceps femoris under local anesthesia during an outpatient office procedure. The biopsy tissue was placed in a hypothermic solution and shipped at 2 to 8C to a central cell processing facility at Cook MyoSite Incorporated. Manufacturing and testing were conducted using proprietary procedures based on global standards for aseptic biological product manufacturing. A subpopulation of muscle derived cells was expanded in culture. Products were formulated to the cell number dose in a total volume of 2 ml with biopreservation media and cryopreserved at 80C. Before release all products underwent complete quality control testing and inspection. The percentage of myogenic cells in the product, as identified through skeletal muscle marker expression, was 86% 14%. The other cells were primarily fibroblasts. Frozen AMDC-USR product was supplied to the investigator. The product was thawed and diluted to a total volume of 4 ml with 2 ml of 0.9% saline. Each patient received a single treatment of AMDC-USR during an outpatient office procedure. Local anesthetics were generally used. Intrasphincter injections (at least 8 injections of about 0.5 ml each) were made into the mid urethral complex, with needle lengths allowing cell injection into the region of the external striated sphincter. Techniques used included cystoscope guided transurethral injection (modified Williams Cystoscopic Injection Needle, Cook Medical, Bloomington, Indiana), cystoscope guided periurethral injection (22 gauge needle, brand not specified) and transurethral injection with the SUI Injection Needle (Cook Medical), a device containing 3 simultaneously deployed needles. The primary objective of the studies was to assess safety by the incidence and severity of adverse events. Secondary objectives were to assess efficacy via 3-day voiding diaries, 24-hour pad tests, and the validated patient questionnaires UDI-6 and IIQ-7. 6 Diaries and pad tests were completed at baseline and at 1, 3, 6 and 12 months after treatment. UDI-6 and IIQ-7 were completed at baseline and at 6 and 12 months after treatment. The percentage of patients with at least a 50% reduction from baseline stress leaks as measured by 3-day diary, the percentage with at least a 50% reduction from baseline pad weight, the percentage reporting no stress leaks over 3 days and the percentage with negative pad tests (less than 1.3 gm pad weight) were determined from 12-month data. If no outcome data were available for a patient at a given point, the patient was excluded from the calculation for that particular outcome measure and point. Patients reporting no stress leaks during 3 days at baseline were excluded from the analysis of stress leak data since no improvement could be detected by diary reported stress leaks. Stress leak and pad test data were also assessed for the subset of patients with at least 3 diary reported stress leaks during 3 days and at least a 3 gm 24-hour pad weight at baseline. Data were analyzed using SASÒ version 9.3. Continuous variables were summarized as mean standard error (range), ordinal variables were summarized as median (range) and categorical variables were summarized

3 Table 1. Baseline patient demographics and characteristics Overall AMDC-USR Dose Demographics: Mean SE pt age (range) 55 1 (35e80) 56 3 (35e73) 52 2 (44e72) 54 2 (38e80) 58 2 (42e78) 0.18 % Caucasian (No.) 96 (77) 100 (16) 100 (16) 88 (21) 100 (24) 0.32 % Black (No.) 1 (1) e e 4 (1) e % Asian (No.) 3 (2) e e 8 (2) e Mean kg/m 2 SE body mass index (range) (20.6e43.9) (22.1e38.8) (21.8e38.6) (20.6e35.7) (20.7e43.9) 0.98 % Postmenopausal (No.) 56 (45) 56 (9) 31 (5) 46 (11) 83 (20) <0.01* Urinary signs þ symptoms: % Urgency (No.) 65 (52) 75 (12) 75 (12) 58 (14) 58 (14) 0.54 % Urge incontinence (No.) 50 (40) 63 (10) 50 (8) 38 (9) 54 (13) 0.48 Median stress leaks over 3 days (range) 7 (0e65) 8.5 (1e29) 5 (0e40) 6.5 (0e33) 10 (2e65) 0.31 Mean gm 24-hour pad wt SE (range) (1.8e710.0) (3.5e69.2) (2.2e289.8) (1.8e501.8) (2.6e710.0) 0.32 Mean SE UDI-6 (range) (20.8e91.7) (29.2e91.7) (25.0e91.7) (20.8e75.0) (20.8e91.7) 0.09 Mean SE IIQ-7 (range) (9.5e100.0) (9.5e76.2) (9.5e85.7) (9.5e90.5) (9.5e100.0) 0.77 % Prior incontinence therapies (No.): Pelvic floor muscle exercises 84 (67) 88 (14) 100 (16) 83 (20) 71 (17) 0.09 Medication 31 (25) 38 (6) 38 (6) 29 (7) 25 (6) 0.77 Urethral suspension or other surgery 29 (23) 31 (5) 13 (2) 21 (5) 46 (11) 0.11 Urethral inserts/incontinence pessaries 11 (9) 6 (1) 6 (1) 13 (3) 17 (4) 0.77 Bladder training 10 (8) 13 (2) 0 (0) 13 (3) 13 (3) 0.63 Bulking injections 8 (6) 0 (0) 0 (0) 13 (3) 13 (3) 0.36 Biofeedback 6 (5) 0 (0) 13 (2) 8 (2) 4 (1) 0.67 Comparisons among dose groups were made by Fisher s exact test, nonparametric Wilcoxon rank sum or F-test, as appropriate. * Statistically significant difference among dose groups. p Value AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE 471

4 472 AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE as percentage (count). Comparisons across dose groups were made by Fisher s exact test, the Wilcoxon rank sum test or F-test. Comparisons between baseline and followup points were made by the Wilcoxon rank sum test or paired t-test. RESULTS Overall 80 patients received intrasphincter injection of AMDC-USR. Injections were delivered by a transurethral (70%, 56 of 80) or periurethral (30%, 24 of 80) approach. In study 1, 66 patients underwent biopsy and 64 patients were treated with AMDC-USR. One patient who underwent biopsy elected to not receive treatment and for 1 patient the product could not be produced. In study 2, 16 patients underwent biopsy and were treated with AMDC-USR. Overall 16 patients received AMDC-USR, 16 received AMDC-USR, 24 received AMDC-USR and 24 received AMDC-USR. A total of 100 biopsy procedures were conducted in 82 patients (67 underwent a single procedure, 12 underwent 2 procedures and 3 underwent 3 procedures). Mean biopsy mass was mg. Products that met all specifications were produced for 96% (79 of 82) of patients who underwent biopsy. AMDC-USR could not be produced for 1 patient who underwent 2 separate biopsies. Additionally, 2 patients in the AMDC-USR group received product that contained a lower percentage of myogenic cells than stipulated in product specifications. Treated patients had a mean age of 55 1 years (table 1). Demographics were similar among dose groups except for postmenopausal status, which ranged from 31% to 83% (p <0.01). No significant differences in baseline urinary incontinence measures of severity were observed among the dose groups. Sixty-six (83%) patients had at least 3 stress leaks over 3 days and at least 3 gm 24-hour pad tests at baseline. Three patients had no diary reported stress leaks over 3 days at baseline (2 patients in the dose group and 1 in the dose group). However, each of these patients did have a positive provocative stress test during screening. In addition, 65% (52 of 80) of patients reported urgency and 50% (40 of 80) reported urge incontinence (table 1). A total of 74 (93%) patients completed 12-month followup (table 2). Two patients completed validated patient questionnaires at 12-month followup but did not complete diaries or pad tests. One patient was lost to followup and 5 withdrew from the study after treatment (2 were unwilling to travel to office visits, 2 did not report improvement in symptoms and 1 had surgical treatment for incontinence). Table 2. Followup status of treated patients AMDC-USR Dose Study 1 Study Total No. No. baseline No. 6 mos No. 12 mos * * Of 74 patients 72 completed diaries and pad tests at 12-month followup. No adverse events attributed to AMDC-USR product were reported. Biopsy related adverse events occurred in 4 patients, and included wound hematoma (2 cases), procedural dizziness and associated responses (2 cases), postoperative bleeding requiring sutures (1 case) and joint swelling (1 case) (table 3). Injection procedure related adverse events occurred in 18% (14 of 80), and included dysuria (7 cases), pelvic or abdominal pain (4 cases), vulvovaginal pruritus (3 cases), urinary urgency (2 cases) and transient hematuria (2 cases). All injection procedure related events occurred after transurethral injection (25%, 14 of 56). All biopsy and injection procedure related events were easily treated or self-resolved. All dose groups had significantly fewer diary reported stress leaks at 12 months (p <0.05, table 4). This reduction was detected within 1 to 3 months of AMDC-USR treatment. Only patients who received AMDC-USR had a statistically significant reduction in mean pad weight. Similar stress leak and pad test results were observed with periurethral and transurethral injection (data not shown). Higher dose groups tended to have greater percentages of patients with at least a 50% reduction in stress leaks and pad weight at 12-month followup (fig. 1, A). While only 53% of the dose group had at least a 50% reduction in stress leaks, 69% of Table 3. Biopsy and injection procedure related adverse events Rate/Procedure Biopsy procedure*: Wound hematoma 2.0 Procedural dizziness þ associated responses 2.0 Postop bleeding 1.0 Joint swelling 1.0 Injection procedure : Dysuria 8.8 Pelvic/abdominal pain 5.0 Vulvovaginal pruritus 3.8 Urinary urgency 2.5 Hematuria 2.5 Vulvovaginal burning sensation 1.3 Sensation of foreign body within urethra 1.3 Urinary frequency 1.3 Urinary tract infection 1.3 * Events related to the biopsy procedure were defined as systemic responses to the biopsy procedure or injury at the biopsy site. Events related to the injection procedure were defined as systemic responses to the injection procedure and genitourinary events occurring within 30 days of the injection that could be attributed to cystoscopy or catheterization.

5 AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE 473 Table 4. Improvement in diary reported stress leaks and 24-hour pad tests over time AMDC-USR Dose Median stress leaks over 3 days (No., range): Baseline 8.5 (16, 1e29) 5 (14, 1e40) 7 (23, 1e33) 10 (24, 2e65) 1 Mo 2 (16, 0e32)* 3 (12, 0e51) 4 (23, 0e29)* 2.5 (24, 0e30) 3 Mos 3 (15, 0e13) 2.5 (14, 0e29)* 3 (22, 0e24) 2.5 (24, 0e27)* 6 Mos 2 (15, 0e22)* 1.5 (14, 0e50) 3 (21, 0e19) 5 (23, 0e30)* 12 Mos 3 (15, 0e17)* 1 (13, 0e55) 1.5 (20, 0e14) 1 (22, 0e27) Mean gm SE pad wt (No., range): Baseline (16, 3.5e69.2) (16, 2.2e289.8) (24, 1.8e501.8) (24, 2.6e710.0) 1 Mo (16, 0.0e89.6) (14, 0.0e347.2) (23, 0.0e201.7) (24, 0.0e475.0) 3 Mos (15, 0.3e84.6) (14, 0.0e174.8) (23, 0.0e312.3) (24, 0.0e505.0)* 6 Mos (14, 0.0e81.9) (14, 0.60e227.8) (22, 0.0e95.0) (24, 0.0e400.0)* 12 Mos (15, 0.6e79.6) (14, 0.0e183.7) (21, 0.0e230.0) (22, 0.0e545.0)* Three patients who reported no stress leaks over 3 days at baseline were excluded from the stress leak analysis. Comparisons of stress leaks at baseline and followup points were made by nonparametric Wilcoxon rank sum test. Comparison of pad weight at baseline and followup points made by paired t-test. Statistically significant changes from baseline are indicated as *dp <0.05, dp <0.01 and dp < the dose group, 85% of the dose group and 77% of the dose group met this end point. Similarly the percentage of patients with at least a 50% improvement in 24-hour pad test increased with increasing AMDC-USR dose at 12-month followup, and ranged from 20% (3 of 15) in the dose group to 64% (14 of 22) in the dose group. Similar results were observed for the subgroup of patients with at least 3 diary reported stress leaks during 3 days and at least a 3 gm 24-hour pad weight at baseline (fig. 1, B). Compared to baseline, all dose groups had statistically significant improvement in UDI-6 scores at 6 and 12-month followup, and in IIQ-7 scores at 12-month followup (fig. 2). DISCUSSION Intrasphincter injection of AMDC-USR at doses of 10, 50, 100 and cells appears safe with no serious procedure or treatment related adverse events reported. No adverse events were attributed A Percentage of patients at 12 months 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1/15 4/14 5/21 7/22 3/15 5/13 6/20 7/22 3/15 6/14 11/21 14/2217/22 8/15 9/13 17/20 10 x 10^6 50 x 10^6 100 x 10^6 200 x 10^6 AMDC-USR dose B months 12 at patients of Percentage 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Negative pad test Zero stress leaks over 3 days 50% improvement in pad test 50% reduction in stress leaks 0/13 3/10 5/18 6/18 3/13 2/10 4/18 5/18 2/13 4/10 11/1815/18 12/1814/18 7/13 6/10 10 x 10^6 50 x 10^6 100 x 10^6 200 x 10^6 AMDC-USR dose Figure 1. Improvement in stress leak frequency and amount of urine leakage at 12-month followup as gauged by percentages of patients with negative pad tests, zero stress leaks during 3 days, at least 50% improvement in pad tests and at least 50% reduction in stress leaks. Ratio at base of each bar is number of patients meeting specified outcome/total number of patients with available data. A, all patients. Patients who reported no stress leaks during 3 days at baseline were excluded from stress leak analyses since no improvement could be detected by diary reported stress leaks. B, patients with at least 3 stress leaks during 3 days and at least 3 gm 24-hour pad weight at baseline.

6 474 AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE A 70 Baseline 6 Months 12 Months B 60 Baseline 6 Months 12 Months Mean UDI-6 score * * * * * * * * Mean IIQ-7 score * * * * * * * x 10^6 50 x 10^6 100 x 10^6 200 x 10^6 AMDC-USR dose x 10^6 50 x 10^6 100 x 10^6 200 x 10^6 AMDC-USR dose Figure 2. Patient reported incontinence symptom distress and life impact. A, mean UDI-6 scores. B, mean IIQ-7 scores. UDI-6 and IIQ-7 are scored 0 to 100 with lower scores indicating higher quality of life. Error bars represent standard error of mean. Asterisk indicates statistically significant change from baseline as determined by paired t-test. Number of patients who completed questionnaire at each point is indicated at base of each bar. to AMDC-USR, and reported biopsy and injection procedure related events were consistent with the known risks of skeletal muscle biopsy and intrasphincter injection. A higher percentage of patients experienced injection procedure related events with the transurethral approach than the periurethral approach (25% [14 of 56] vs 0% [0 of 24]), but these events were minor and self-resolved or were easily treated. These safety data are consistent with other clinical studies of autologous muscle progenitor cells for the treatment of SUI and provide further support for the safety of this potential therapy. 4,5,7e13 The efficacy data suggest that a single treatment of AMDC-USR improves SUI and patient quality of life. All dose groups experienced a statistically significant reduction in stress leaks within 1 to 3 months of treatment that was maintained through the 12-month followup. Although the studies were not statistically powered to assess differences in efficacy across dose groups, data trends for the percentage of patients with at least a 50% reduction in diary reported stress leaks and at least 50% improvement in 24-hour pad tests suggest a potential dose response. In the range of tested doses a greater percentage of patients appear to be responsive to higher doses of AMDC-USR than lower doses. Similar results were observed for the subgroup of patients with at least 3 diary reported stress leaks over 3 days and at least a 3 gm 24-hour pad weight at baseline. Only patients receiving AMDC-USR had a statistically significant reduction in pad weight. Unlike the diary, which was designed to distinguish between stress leaks and urge leaks, the 24-hour pad test results may be confounded by the presence of urge incontinence, which was reported by 50% of patients. Injection approach did not appear to affect efficacy outcomes. Improvements in UDI-6 and IIQ-7 scores did not appear to be dose related. Previous results of an AMDC-USR dose ranging study in 38 women also suggested that the efficacy of AMDC-USR may be related to cell dose. 5 Patients who received 2 treatments of 32, 62 or AMDC-USR appeared to have better efficacy outcomes than those who received 2 treatments of lower doses. Other clinical studies of autologous muscle progenitor cells for SUI treatment have not examined or have not identified an effect of cell dose on safety or efficacy outcomes. 7e11,13 Self-repair mediated by autologous cell therapies is an attractive treatment modality. However, due to the individualized nature of the products, there are challenges to commercialization. AMDC- USR are produced under tightly controlled manufacturing processes that include product specifications for safety, cell dose, cell composition and myodifferentiation potential. Due to the inherent variability in cell growth across patient samples, it may not be possible to generate products for all patients or meet all nonsafety specifications for each individualized product. Furthermore, product specifications set at the start of clinical development for an autologous cell therapy are determined based on nonclinical data and may not reflect product

7 AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE 475 characteristics for optimal clinical efficacy. In this report, products that met all specifications were produced for 96% (79 of 82) of patients who underwent biopsy. Other studies of autologous muscle progenitor cells for SUI treatment have required that patients undergo open muscle biopsies. 8,9,11,12 In our studies the patients underwent less invasive needle muscle biopsies. However, repeat biopsy was necessary in 15 patients due to inadequate biopsy samples or manufacturing failures. Ongoing studies of AMDC- USR include modifications to improve biopsy procedures and stricter controls to ensure the integrity of future biopsy samples. A number of study limitations exist. The pooled sample size was not powered to demonstrate safety or efficacy by individual dose, and blinding of physicians or patients to dose was not part of the study design. Without a placebo control group the efficacy data should be interpreted with caution. These limitations are addressed by 2 double-blind, placebo controlled studies of AMDC-USR in women with moderate to severe SUI that are currently under way in North America, Europe and Asia (ClinicalTrials.gov Identifiers: NCT and NCT ). CONCLUSIONS Intrasphincter injection of AMDC-USR at doses of 10, 50, 100 and cells appears safe for the treatment of women with SUI. Efficacy data suggest that AMDC-USR treatment reduces stress leak frequency and the amount of urine leakage. In addition, efficacy data suggest a potential dose response, providing critical information for phase III trials. ACKNOWLEDGMENTS Magnus Murphy (Foothills Medical Centre), Melissa Fischer (Beaumont Health System), Pradeep Nagaraju (Beaumont Health System), Daniel Biller (Vanderbilt Medical Center), Harriette Miles Scarpero (Vanderbilt Medical Center), Renee Ward (Vanderbilt Medical Center) and Priya Padmanabhan (Vanderbilt Medical Center) served as study investigators. Alan Saunders (MED Institute, Inc., a contract research organization and Cook Group Company) served as study statistician, Jennifer Rodenberg (MED Institute, Inc.) served as clinical project manager, and Sean Werner (Cook Incorporated), Ryan Pruchnic (Cook MyoSite Incorporated) and Ron Jankowski (Cook MyoSite Incorporated) provided review of the manuscript. APPENDIX Selected inclusion and exclusion criteria Inclusion criteria Patient has provided written informed consent. Patient is at least 18 years of age. Patient has SUI with normal detrusor activity confirmed with urodynamics. Patient has bladder capacity greater than 200 ml. Patient s incontinence has not shown any improvement for at least 6 months. Patient has failed prior treatments (eg behavior modification, bladder exercises, biofeedback, electrical stimulation, bulking injections, urethral suspensions, and/or drug therapy). Patient has a viable mucosal lining along the urinary tract and in the bladder. Exclusion criteria Patient has known vesicoureteral reflux, vaginal prolapse beyond the introitus, or other significant pelvic floor abnormalities with high pressure instability. Patient cannot be maintained on a stable dose of any medication known to affect lower urinary tract function, including but not limited to anticholinergics, tricyclic antidepressants, or alpha-adrenergic blockers, throughout the treatment and followup period. Patient has urinary incontinence of neurogenic etiology. Patient has fibrosis of the tissue at the likely injection sites. Patient has any condition which could lead to significant postoperative complications, including current infection, or elevated residual urine from bladder outlet obstruction (ie repeated post-void residual volume greater than 150 ml). Patient is morbidly obese (defined as 100 pounds over their ideal body weight, or body mass index 40 or greater) and not expected to benefit from treatment. Patient has current or acute conditions involving cystitis or urethritis. Patient is actively immunosuppressed or has known allergy or hypersensitivity to bovine proteins or allergens, gentamicin sulfate, or ampicillin. REFERENCES 1. Luber KM: The definition, prevalence, and risk factors for stress urinary incontinence. Rev Urol, suppl., 2004; 6: S3. 2. Dmochowski RR, Blaivas JM, Gormley EA et al: Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol 2010; 183: Kotb AF, Campeau L and Corcos J: Urethral bulking agents: techniques and outcomes. Curr Urol Rep 2009; 10: Carr LK, Steele D, Steele S et al: 1-Year followup of autologous muscle-derived stem cell injection pilot study to treat stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: Carr LK, Robert M, Kultgen PL et al: Autologous muscle derived cell therapy for stress urinary incontinence: a prospective, dose ranging study. J Urol 2013; 189: Uebersax JS, Wyman JF, Shumaker SA et al: Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the

8 476 AUTOLOGOUS CELL THERAPY FOR STRESS URINARY INCONTINENCE Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995; 14: Blaganje M and Lukanovic A: Intrasphincteric autologous myoblast injections with electrical stimulation for stress urinary incontinence. Int J Gynaecol Obstet 2012; 117: Blaganje M and Lukanovic A: Ultrasound-guided autologous myoblast injections into the extrinsic urethral sphincter: tissue engineering for the treatment of stress urinary incontinence. Int Urogynecol J 2013; 24: Sebe P, Doucet C, Cornu JN et al: Intrasphincteric injections of autologous muscular cells in women with refractory stress urinary incontinence: a prospective study. Int Urogynecol J 2011; 22: Elmi A, Kajbafzadeh AM, Tourchi A et al: Safety, efficacy and health related quality of life of autologous myoblast transplantation for treatment of urinary incontinence in children with bladder exstrophy-epispadias complex. J Urol 2011; 186: Kajbafzadeh AM, Elmi A, Payabvash S et al: Transurethral autologous myoblast injection for treatment of urinary incontinence in children with classic bladder exstrophy. J Urol 2008; 180: Stangel-Wojcikiewicz K, Jarocha D, Piwowar M et al: Autologous muscle-derived cells for the treatment of female stress urinary incontinence: a 2-year follow-up of a Polish investigation. Neurourol Urodyn 2014; 33: Gerullis H, Eimer C, Georgas E et al: Musclederived cells for treatment of iatrogenic sphincter damage and urinary incontinence in men. ScientificWorldJournal 2012; 2012: