Vascularized Composite Bladder Allograft Transplantation

NCT ID: NCT05462561

Last Updated: 2026-01-20

Basic Information

• Recruitment Status: RECRUITING
• Clinical Phase: NA
• Total Enrollment: 5 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2023-05-01
• Study Completion Date: 2028-10-03

Brief Summary

This phase 0 trial tests the feasibility, functionality, and sustainability of vascularized composite bladder allograft transplantation in treating patients with terminal bladder pathology. A vascularized bladder allograft transplantation may provide a more durable and better-tolerated alternative to standard urinary diversion, which employs bowel. A robotic surgical approach will be employed.

Detailed Description

PRIMARY OBJECTIVE:

I. To perform a feasibility study of vascularized composite bladder allograft (VCBA) transplantation and demonstrate successful transplantation of a vascularized composite deceased-donor bladder allograft.

SECONDARY OBJECTIVES:

I. To describe the adverse events associated with VCBA transplantation.

II. To describe the immunosuppression regimen for patients undergoing VCBA transplantation.

III. To evaluate allografted bladder functionality (storage and emptying) after transplantation.

OUTLINE:

This study will be the first to report on the feasibility of human bladder transplantation. In the appropriately selected candidate, a vascularized bladder allograft transplantation may provide a more durable and better-tolerated alternative to urinary diversion using the bowel. The objective of this study is to perform successful, safe robotic genitourinary bladder allotransplantation and define the optimal surgical techniques in up to 5 genitourinary patients using standard triple-therapy immunosuppression. A multi-institutional, multidisciplinary Genitourinary Vascularized Composite Bladder Allograft Transplantation Team has been established to address this aim.

Brain dead donors who have met the criteria for Determination of Death will be selected by the Genitourinary transplant team in conjunction with the organ procurement organization (OPO) for the University of Southern California, OneLegacy. The mandatory requirements are family consent for donation. These criteria are standard and are not part of the research question at hand.

A robotic vascularized composite bladder allograft transplantation will be performed, after which patients will be monitored closely as both an inpatient and at serial timepoints after surgery in the outpatient setting.

This is the critical period when most of the surgical complications leading to allografts loss can take place. During this period, VCBA recipients will remain at the Keck USC Urology Step-down Unit for 7 days following the surgery, from where they will be moved to the regular floor. Daily examinations and post-operative ultrasound evaluation will be performed by the urology service to monitor for signs of rejection. The patient will have protocol biopsies as detailed below and during any rejection episodes. Once drug levels are stable and therapeutic and the patient is without complications, the process of discharge with close follow-up will be initiated.

Immediately after surgery, discharge will typically occur 1-3 weeks following transplantation. A detailed explanation of postoperative discharge instructions will be provided by the discharge nurse, social worker, and transplant coordinator and will include: medication dosages and associated adverse effect profiles (the patient will be instructed to record the time of all medications taken); schedule of required laboratory draws; timing of physician follow-up visits; wound care; assessment of urine output; diet; monitoring of blood pressure and temperature; hygiene; dental care; opportunistic infection prevention; use of gloves and masks; activity and exercise; maintaining a nonsmoking environment; driving; child immunization; caring for house pets; and other special instructions. The endpoint is the success of the transplant, measured by adequate blood flow and no signs of complications.

Evaluation of bladder integrity, including urine output, will be an essential component of transplant surveillance. In addition, graft biopsies will be routinely performed at one month after surgery and every 3 months through cystoscopy during the first year, plus whenever clinically indicated. Biopsies are taken from the bladder dome during in-office cystoscopy. Hemostasis is achieved through Bugby electrocautery. This is a common urologic procedure performed in outpatient surgery centers and urology clinics nationwide. The clinical care needs of each patient will likely be individually different after genitourinary transplantation and will thus be adjusted specifically per patient. Daily monitoring of the quality and quantity of urine output is considered clinically particularly relevant for monitoring graft rejection. Briefly, allograft recipients need to visit the transplant clinic staff once a week for the 1st post-operative month, then once every other week for 1 month, then once monthly for 6 months, and thereafter once every 3 months for the management of immunosuppression and assessment of rejection.

Conditions

Neurogenic Bladder; Bladder Dysfunction; Immunosuppression

Study Design

• Allocation Method: NA
• Intervention Model: SINGLE_GROUP
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

Treatment (VCBA)

Patients undergo robotic VCBA transplantation.

Group Type: EXPERIMENTAL

Quality-of-Life Assessment

Intervention Type: OTHER

Ancillary studies

Robotic Vascularized Composite Bladder Allograft Transplantation

Intervention Type: PROCEDURE

Undergo robotic VCBA transplantation.

Interventions

Quality-of-Life Assessment

Ancillary studies

Intervention Type: OTHER

Robotic Vascularized Composite Bladder Allograft Transplantation

Undergo robotic VCBA transplantation.

Intervention Type: PROCEDURE

Other Intervention Names

Quality of Life Assessment

Eligibility Criteria

Inclusion Criteria

• Age 18-80 years.
• Positive history of one of the following:

• Bladder pathology resulting in poor compliance, recurrent infections, and/or resultant upper tract (kidney and ureteral) pathology, demonstrated by hydronephrosis with resultant kidney disease.
• Localized, non-metastatic, muscle-invasive or lesser urothelial cell carcinoma of the bladder that requires therapeutic radical cystectomy will be considered only if the patient is already on pre-existing immunosuppression or who are expected candidates for immunosuppression in the near future, and then on a case-by-case basis after thorough evaluation and presentation to institutional tumor board committee. A minority of accrued patients are expected to have bladder cancer as the etiology of their cystectomy.
• Patients that are on pre-existing immunosuppression will be included in this study.
• Patient agrees to comply with the protocol and states a dedication to the immunomodulatory treatment regime.
• Patients must demonstrate appropriate manual dexterity or sufficient assistance at home to perform clean intermittent catheterizations as needed. The patient (or assistant) must demonstrate proficiency in performing clean intermittent catheterization during pre-transplant workup.

Exclusion Criteria

• No active co-existing psychosocial problems (i.e., alcoholism, drug abuse).
• Negative crossmatch with donor.
• DONOR: Any potential brain dead donor considered for solid organ transplant.
• DONOR: Age 18-65 years.
• DONOR: Stable, meaning no requirement of excessive vasopressors for maintaining blood pressure.
• DONOR: ABO compatibility.
• DONOR: Negative cross-match with recipient.

• Positive history of one of the following medical co-morbidities:

• Human immunodeficiency virus [HIV] (active or seropositive), active hepatitis B or C, viral encephalitis, untreated sepsis, active tuberculosis, viral encephalitis, toxoplasmosis, varicella zoster virus.
• Conditions that may impact the success of the surgical procedure or increase the risk of postoperative complications including inherited coagulopathies like hemophilia, Von-Willebrand's disease, protein C and S deficiency, thrombocythemia, thallassemia, sickle cell disease.
• Mixed connective tissue diseases and collagen disorders (can result in poor wound healing after surgery), including:

• Mixed connective tissue disorder
• Severe deforming rheumatoid arthritis
• Infectious, post-infectious, or inflammatory (axonal or demyelinating) neuropathy
• Ehler-Danlos syndrome
• Lipopolysaccharidosis or amyloidosis (effects nerve regeneration).
• Impaired liver function as evaluate by liver function panel, including the presence of hyperbilirubinemia, elevated aspartate aminotransferase/ alanine aminotransferase (AST/ALT), and the presence of secondary coagulopathy, measured by prothrombin, international normalized ratio, and partial thromboplastin time.
• Severe anemia (hemoglobin < 7 g/dL), leukopenia (WBC < 3 x 10 ^ 9 cell/L), or thrombocytopenia (platelets < 20 x10 ^ 9 cells/L).
• Oncology patient specific:

• History of any non-urothelial malignancy within the past 5 years, with the exception of non-melanomatous skin cancer and very-low to low risk prostate cancer on active surveillance.
• History of metastasic malignancy within the past 5 years.
• History of urothelial carcinoma in patients without pre-existing conditions that require immunosuppression and/or without the expected need for immunosuppression in the future.
• Sensitized recipients; panel reactive antibody (PRA) < 80%, with negative crossmatch to donor and no evidence of donor-specific antibody at time of transplant.
• Patients unable to receive adequate follow-up care and/or unable to receive immunosuppression due to geographic, financial or other reasons.
• Patients with a smoking history who cannot demonstrate smoking cessation for a period of 6 months prior to listing and a desire to abstain from post-operative smoking will be excluded.
• Records of poor medical compliance, documented psychological disorder(s), substance abuse or incomplete psychological clearance.
• Particular attention will be paid to the candidate's compliance and their desire to undergo the offered procedure. While there is no "score" on any particular evaluation that would rule out a patient, certain factors can aid in the identification of patients who for example may not have the ability to comply with the medical directives necessary to care for a genitourinary transplant, or psychologically are not prepared for transplant, or who have unrealistic expectations about the transplant. The decision on eligibility is a team decision. All members of the team will discuss each candidate in a multidisciplinary meeting and reasons for concern over eligibility will be discussed at a Selection Committee Meeting (per University of Southern California Transplant Center Policy). In circumstances where the candidate is considered to be less suitable, they could be given an opportunity to address these issues either through individual counseling or further education and then be reconsidered as a potential candidate. Every effort to prevent a request for allograft removal will be made. Towards these ends, a two-part initial psychiatric consultation will be rendered in addition to psychosocial evaluations already accounted for in the social work and transplantation evaluation prior to listing. The first visit focuses on background history and standard contraindications to transplantation, while the second visit is a more thorough discussion of the challenges ahead for the potential recipient and how these challenges relate to their strengths and vulnerabilities. If at this phase, or any subsequent one, significant psychological need emerges, the patient will be referred to another mental health professional for ongoing treatment with frequent communication between that provider and the transplant psychiatrist. The same psychiatrist responsible for listing and taking part in the protocol will not provide this treatment, given the potentially conflicting obligations involved and the disincentive present for the patient to be completely honest. If a greater than 6 month period of time elapses between listing and transplantation, a follow-up visit with psychiatry and social work will be arranged.
• DONOR: Unresolved sepsis.
• DONOR: Known history of urothelial or prostate cancer/malignancy.
• DONOR: Known history of bladder or prostate surgery.
• DONOR: Abnormal bladder capacity.
• DONOR: Active sexually transmitted disease.
• DONOR: Active cytomegalovirus (CMV), Epstein-Barr virus (EBV), or tuberculosis (TB) infections.
• DONOR: Hepatitis B virus (HBV) core antibody, surface antigen, or DANN positive.
• DONOR: Hepatitis C virus (HCV) antibody or viral load+.
• DONOR: Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).

• Minimum Eligible Age: 18 Years
• Maximum Eligible Age: 80 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

National Cancer Institute (NCI)

NIH

Sponsor Role: collaborator

University of Southern California

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Inderbir Gill

Role: PRINCIPAL_INVESTIGATOR

University of Southern California

Locations

USC / Norris Comprehensive Cancer Center

Los Angeles, California, United States

Site Status: RECRUITING

Countries

United States

Central Contacts

Ileana Aldana

Role: CONTACT

Ileana.aldana@med.usc.edu

323-865-0702

Facility Contacts

Ileana Aldana

Role: primary

Ileana.aldana@med.usc.edu

323-865-3000

Other Identifiers

NCI-2022-00076

Identifier Type: REGISTRY

Identifier Source: secondary_id

4B-21-5

Identifier Type: OTHER

Identifier Source: secondary_id

P30CA014089

Identifier Type: NIH

Identifier Source: secondary_id

View Link

4B-21-5

Identifier Type: -

Identifier Source: org_study_id