The search for an optimal tissue-engineered urethra model for clinical application based on preclinical trials in male animals: A systematic review and meta-analysis

Tissue engineering has emerged as a promising avenue for reconstructive urology, though only a limited number of tissue-engineered urethral constructs have advanced to clinical testing. Presently, there exists a dearth of agreement regarding the most promising constructs deserving of implementation in clinical practice. The objective of this review was to provide a comprehensive analysis of preclinical trials findings of a tissue-engineered urethra and to identify the most promising constructs for future translation into clinical practice. A systematic search of the Pubmed, Scopus, and PMC databases was conducted in accordance with the PRISMA statement. Manuscripts published in English between 2015 and 2022, reporting on the methodology for creating a tissue-engineered urethra, assessing the regenerative potential of the scaffold in a male animal model, and evaluating the clinical and histological outcomes of treatment, were included. A total of 48 manuscripts met the inclusion criteria, with 12 being eligible for meta-analysis. Meta-analysis revealed no significant benefit of any matrix type in terms of complication rates. However, acellular matrices demonstrated significant advantage over cellular matrices in case of no postoperative stricture formation (odds ratio = 0.06 [95% CI 0.01; 0.23], p < 0.01). Among all subgroups (animal models and scaffold types), the usage of acellular matrices resulted in advantageous effects. The meta-regression analysis did not show a significant impact of defect length (beta 1 = -0.02 [-0.28; 0.23], p = 0.86). We found that decellularized materials may carry less relevance for urethral reconstruction due to unfavorable preclinical outcomes. Natural polymers, used independently or with synthetic materials, resulted in better postoperative outcomes in animals compared to purely synthetic constructs. Acellular scaffolds showed promising outcomes, matching or exceeding cellular constructs. However, more studies are needed to confirm their clinical effectiveness.