Regeneration of the ureter using a scaffold-free live-cell structure created with the bio-three-dimensional printing technique

Ureteral strictures, which can be caused by ureteral injury, radiation therapy, ureterolithiasis, urinary tract infections, and ureteral endometriosis, typically require ureteral reconstruction. Although tissue engineering, autologous alternative tissue transplantation, and surgical techniques applying various flaps have been carried out for ureteral regeneration, all with some success, each method has its advantages and disadvantages. As an alternative, we created the first artificial ureter structures using only live cells and grafted them into healthy rat ureters. Spheroids were created using normal human dermal fibroblasts and human umbilical vein endothelial cells and subsequently laminated using a bio-three-dimensional printer. After molding the laminated spheroids into tubular structures, the artificial ureters were transplanted into live rats. After 2-12 weeks, the animals were sacrificed and their gross and pathological features were examined. In the artificial ureteral lumen of rats with Grade 0-1 hydronephrosis, regeneration of the ureteral epithelium was observed, the thickness of which increased over the course of the experiment. Regeneration of the muscular layer was also observed, extending from the normal ureteral side toward the artificial ureter structure over time. However, complete regeneration was not observed at the end of 12 weeks. Although ureteral peristalsis was noted in all cases, it was weaker than expected. Therefore, we achieved short-segment ureteral regeneration using a cell-only structure. This finding suggests that by applying alternative strategies to this method, such as changing the cell type and composition, regeneration over the entire length of the ureter may be possible in the future. STATEMENT OF SIGNIFICANCE: Until now, ureteral regeneration techniques have been dominated by the use of high-molecular-weight compounds and autologous tissues, and there have been no reports of regeneration using structures made entirely of cells. This is the first report of ureteral regeneration using a tubular structure made from stacked spheroids. Although this study only attained short-segment ureteral regeneration, regeneration of the ureter over a much longer proportion of its length can be achieved in the future by applying other strategies, such as changing the cell type. This study provides a foundation to achieve the future goal of complete regeneration.