46, XY female with cloacal exstrophy and masculinization at puberty.

Cloacal exstrophy of the bladder is a rare complex disorder occurring 1 in 400,000 live births and associated with cryptorchidism, vesicoureteral reflux, severe phallic inadequacy, omphalocele with short-gut syndrome, exstrophied bladder separated by exstrophied ileocecal segment, and pubic symphyseal diastasis. The association of undescended and ectopic testis with cloacal exstrophy is not uncommon, but the presence of an unexpected persistent ectopic testis at the time of puberty is quite unusual. We report the case of a 17-year-old girl with a history of 46, XY cloacal exstrophy and gender reassignment presenting with an ectopic testis of unclear location. We then review controversial literature surrounding gender assignment in these patients.

Bladder neck sling for treatment of neurogenic incontinence in children with augmentation cystoplasty: long-term followup.

PURPOSE: We retrospectively reviewed the outcome and long-term followup (mean 4.16 years) of bladder neck slings for the treatment of neurogenic urinary incontinence in 58 patients (15 males) who also underwent bladder augmentation. MATERIALS AND METHODS: A total of 58 patients with neurogenic bladder (43 females and 15 males, median age 11.4 years) underwent a rectus fascial sling procedure as part of the reconstructive efforts for continence between July 1991 and July 2003. Criteria for enhancement of bladder outlet resistance included a detrusor leak point pressure of less than 45 cm H2O, an open bladder neck during bladder filling at low detrusor pressures and clinical evidence of stress incontinence. RESULTS: Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). A total of 51 patients (88%) obtained good continence results. Five females and 2 males remained incontinent following the sling procedure. Four females underwent a secondary open bladder neck procedure at a mean of 18 months after the initial procedure (artificial urinary sphincter in 2, bladder neck closure in 2). Two male patients (5 and 17 years old) had daily underwear staining or dampness with exercise or transfer. CONCLUSIONS: We consider bladder neck slings the procedure of choice for the enhancement of bladder outlet resistance in the majority of patients with neurogenic bladder who need augmentation cystoplasty and whom we do not expect will be capable of voiding spontaneously. In males and females satisfactory long-term continence can be expected with the use of the rectus fascial sling.

Mesenchymal-epithelial interactions in bladder smooth muscle development: effects of the local tissue environment.

PURPOSE: We have previously shown that mesenchymal-epithelial interactions are necessary for the development of bladder smooth muscle. Specifically without fetal or adult urothelium embryonic rat bladder mesenchyma does not differentiate into smooth muscle. The mechanism responsible for this interaction is not known, although it is postulated that diffusable growth factors have a role. Our hypothesis is that diffusable factors within adult rat bladders influence smooth muscle differentiation. MATERIALS AND METHODS: Chimeric bladders were created by surgically implanting 14-day embryonic rat bladder mesenchyma before smooth muscle differentiation into the detrusor space of adult syngeneic hosts to test whether the host urothelium would induce smooth muscle differentiation without being in direct contact with fetal bladder mesenchymal tissue. Sub-detrusor pockets were created between the serosa and smooth muscle layer, between the smooth muscle layer and lamina propria, and between the lamina propria and urothelium in direct contact with urothelium. Controls consisted of intact 14-day embryonic rat bladders with the urothelium not removed, and 14-day embryonic bladder mesenchyma recombined with urothelium (direct contact) placed within the sub-detrusor space of the bladder and under the renal capsule. RESULTS: Immunohistochemical staining with antibodies directed against smooth muscle alpha-actin and urothelium (cytokeratin 7) revealed smooth muscle differentiation in intact embryonic bladders and bladder mesenchyma plus urothelium recombinants in contrast to bladder mesenchyma alone, which had no alpha-actin staining (morphometric smooth muscle analysis p = 0). There was no alpha-actin staining in chimeric bladders even when bladder mesenchymal grafts were placed directly in contact with host urothelium. In addition, bladder mesenchyma plus urothelial recombinants within the host bladder had less alpha-actin staining than their counterparts placed under the renal capsule (p = 0.001). CONCLUSIONS: A diffusable factor most likely exists within adult rat bladders that inhibits smooth muscle differentiation.

Mesenchymal-epithelial interactions in bladder smooth muscle development: epithelial specificity.

PURPOSE: We previously showed that mesenchymal-epithelial interactions are necessary for the development of bladder smooth muscle. Specifically without bladder epithelium embryonic bladder mesenchyme does not differentiate into smooth muscle. We determine whether this process is specific to bladder epithelium or whether epithelial cells from other organ systems induce bladder mesenchyme to differentiate into smooth muscle, as well as whether epithelial age is an important variable. MATERIALS AND METHODS: We recombined 14-day bladder mesenchyme before smooth muscle differentiation with rat epithelium from 14-day, 19-day, newborn and adult bladder, ureter, colon, ileum, stomach, cornea and epidermis. In addition, bladder epithelium was recombined with 14-day embryonic small intestinal, 14-day embryonic gastric and newborn seminal vesicle mesenchyme. All tissue recombinants were grafted under the renal capsule of an adult rat syngeneic host for 3 weeks. RESULTS: Immunohistochemical analysis with antibodies directed against smooth muscle alpha-actin revealed that all epithelial types studied induced bladder mesenchyme to differentiate into smooth muscle, although to different degrees. Induction of smooth muscle was independent of urothelial age. In addition, bladder epithelium induced intestinal, gastric and seminal vesicle mesenchyme to differentiate into smooth muscle and express an overall morphological pattern indicative of the bladder fibromuscular wall. CONCLUSIONS: The mechanism whereby urothelium induces bladder mesenchyme to differentiate into smooth muscle is not specific to embryonic urothelium. Older urothelium and heterotypic epithelium also induce smooth muscle differentiation. With the common use of bowel, stomach and ureteral segments for bladder augmentation it is important to understand the interaction of different types of epithelium with the native bladder.

Neonatal management. Role for early intervention.

Although performing pyeloplasty on an infant with a relatively healthy kidney prior to the onset of renal damage is not as well-accepted as "aggressive observation," the authors argue that early intervention is the more "conservative" or safe method of treatment for infants with ureteropelvic junction (UPJ) obstruction. Using experimental and clinical data, the authors demonstrate that prolonged partial UPJ obstruction in the developing kidney causes significant renal morbidity with time.

Cellular signaling in the bladder.

Embryologically, the urinary bladder is formed from endodermally derived epithelial cells and mesenchymal cells from the urogenital sinus and allantois. Experimentally, we have shown that bladder mesenchyme differentiates into bladder smooth muscle via an unknown signaling mechanism that originates from the urothelium. It is hypothesized that this signaling between the cellular types, occurs via growth factors. Evidence supporting this hypothesis is that a number of known growth factors, such as TGF beta 2 and 3, KGF and TGF alpha, as well as their receptors are regulated as a function of bladder development and are also modulated during experimental bladder outlet obstruction. Furthermore, growth factors most likely affect extracellular matrix degradative proteins which play a role in bladder remodeling during development, as well as in partial outlet obstruction. There is certainly impressive cellular communication that occurs during development and also occurs postnatally; such as during bladder injury. We have recently shown that KGF is directly responsible for the proliferation of urothelium during bladder injury. This normally quiescent cell, which in humans turns over once every six months to a year when injured, has the incredible ability to immediately proliferate covering the exposed areas of bladder muscle and submucosa. This proliferation is due to the direct effects of KGF, a classic paracrine growth factor which is secreted by the stromal compartment of the bladder and acts directly on the urothelium which harbors the receptor. The bladder also has an uncanny ability to regenerate. In a model to study the basic science behind bladder regeneration, a partial cystectomy was performed and an acellular tissue matrix devoid of all cellular elements was sutured to the defect. Within four days, the urothelium completely covered the acellular matrix, and within two weeks native smooth muscle was seen streaming into the acellular matrix in association with a new epithelium. It is hypothesized that cellular interactions between the epithelium and the mesenchyme, as we have shown in bladder differentiation, are encouraging the new growth of smooth muscle. For the bladder to be a safe and effective storage chamber the ideal cellular lining should be urothelium. Cells from the gastrointestinal are not optimal for this purpose since they either secrete or absorb electrolytes. We believe that the cellular interactions that occur between the urothelium and the foreign intestinal stroma will in time change the phenotype of the urothelium. Newer strategies for bladder replacement which take into account cellular signaling are critical for our young patients with neurogenic bladder disorders.

Development and regenerative ability of bladder in the transgenic epidermal growth factor receptor gene knockout mouse.

PURPOSE: During embryogenesis we have previously shown that urothelium is essential for normal bladder growth and development. Urothelial growth may be mediated by peptides of the epidermal growth factor family, since the epidermal growth factor receptor is expressed in bladder urothelium and epidermal growth factor has been shown to induce deoxyribonucleic acid synthesis and migration of urothelial cells in vitro. Bladders from transgenic mice in which the epidermal growth factor receptor gene has been knocked out were used to examine the possible role of epidermal growth factor in bladder growth and development, detrusor neoformation and bladder regeneration. MATERIALS AND METHODS: Whole bladders from transgenic knockout mice 0 to 10 days old were surgically implanted into the "subdetrusor" space of adult athymic nude rat hosts. After 10 days the dome of the host rat bladder was resected with the distal half of the transplanted knockout mouse bladder. Augmentation cystoplasty was then performed on the host rat bladder using acellular tissue matrix with a portion of the acellular matrix sutured directly to the transplanted knockout mouse bladder. The animals were sacrificed 2 or 3 weeks postoperatively. To test the ability of knockout bladder tissue to regenerate into the transplanted matrix species specific Hoechst dye was used to determine whether the cells within the acellular matrix were of host (rat) or transplant (knockout mouse) origin. Immunocytochemical analysis was used to assess muscle neoformation. Controls consisted of wild-type mouse bladders from the same litter. Since epidermal growth factor receptor knockout mice usually die in the neonatal period, the role of the epidermal growth factor receptor signaling pathway in long-term muscle development was evaluated by transplanting knockout and wild-type control bladders under the renal capsule of athymic nude mouse hosts. These mice were sacrificed 30 days later and muscle development was assessed using immunocytochemical analysis. RESULTS: Histologically the transplanted acellular tissue matrix in the experimental and control animals appeared the same, containing well differentiated urothelial and smooth muscle cells that had migrated into the transplanted matrix. Staining with species specific Hoechst dye revealed that urothelial and smooth muscle cells transplanted from the knockout and wild-type mouse bladders invaded and regenerated in the transplanted matrix. There was no apparent difference in the amount of knockout or control mouse tissue in the transplanted matrix. Also, the long-term renal capsule transplants revealed no difference in the amount of smooth muscle in the epidermal growth factor receptor knockout and wild-type bladders. CONCLUSIONS: Signaling through the epidermal growth factor receptor pathway is not necessary for normal bladder development or bladder regeneration after injury.

The effect of testosterone on androgen receptors and human penile growth.

PURPOSE: Recent rat studies suggest that early exposure to exogenous testosterone accelerates the loss of androgen receptors and compromises eventual penile length. In humans we hypothesize that down regulation of the androgen receptor is not the mechanism that stops penile growth. To test this hypothesis we investigated the effects of androgen deprivation and supplementation on the developing human penis. MATERIALS AND METHODS: A total of 15 normal human fetal penises at 7 to 19 weeks of gestation (mean plus or minus standard deviation 12 +/- 4.5) was divided in half sagittally. Specimens were grafted beneath the renal capsule of male athymic nude mice or nude rats. Three groups of host animals were prepared, including 10 with no testosterone that were castrated at grafting, 15 with testosterone and 5 with super testosterone in which 50 mg. testosterone propionate pellets were implanted subcutaneously at grafting. Each fetal penile specimen was its own control, since half was implanted into an intact animal and the other into a castrated or super testosterone host. Six weeks after grafting the specimens were analyzed for gross size (length), histology and expression of androgen receptors. RESULTS: All human fetal penile specimens grew from the nadir size and appeared as white exophytic growths on the surface of the host kidneys. Normal grafts were larger than castrate specimens (mean 6.9 +/- 2.1 versus 3.9 +/- 2.1 mm., p = 0.014). Mean length of the super testosterone specimens (7.3 +/- 2.3 mm.) was not significantly greater than that of normal specimens (p = 0.797). Histological analysis revealed that all specimens were composed of viable penile tissue. Cellular density of the castrate penises was approximately 2 times greater than that of the normal and super testosterone specimens (40.6 +/- 5.9 versus 25.1 +/- 2.8 cells per cm.2, p > 0.001), as calculated on enlarged micrographs. Supraphysiological doses of testosterone did not change the histology compared to controls. Immunohistochemical localization revealed androgen receptors expressed throughout the corporeal bodies, surrounding stroma and penile skin with intracellular localization to nucleus. The mean proportion of cells expressing androgen receptors was higher in the castrate (29.4 +/- 5.2 cells per cm.2) than in the normal (24.0 +/- 3.7) and super testosterone (24.7 +/- 4.5) grafts (p = 0.005). However, in regard to growth there was no change in the proportion of androgen receptor positive cells among the groups. CONCLUSIONS: Testosterone influences penile growth, possibly as a result of extracellular stromal expansion. The number of androgen receptor positive cells in the human fetal penis did not change among the castrate, normal and super testosterone hosts. These experiments support the hypothesis that penile growth cessation is mediated by mechanisms other than down regulation of the androgen receptor. Furthermore, these data support the hypothesis that early administration of androgen to prepubertal male individuals does not result in a shorter phallus in adulthood.

Growth factors in bladder wound healing.

INTRODUCTION: Surgical and traumatic injuries to the bladder initiate a complex series of biological processes that result in wound healing. This process involves cellular proliferation, migration and differentiation; removal of damaged tissue; and production of extracellular matrix all of which may be controlled by growth factors. In skin, keratinocyte growth factor (KGF) is induced following incisional injury. We hypothesize that in bladder wound healing KGF and other growth factors are induced to modulate tissue repair. METHODS: We have created a model of surgical bladder injury in the rodent. At 12, 24 and 48 hrs and 5 and 7 days after injury, the bladder was bisected and total RNA extracted from the anterior or wounded half and posterior or non-wounded half. Histological analysis of the bladder wound was performed with Mason's Trichrome and immunohistochemistry against smooth muscle alpha actin. RNase protection assays were performed to examine the expression of KGF, transforming growth factor (TGF)alpha and TGF beta 2 and 3 as well as the receptors for KGF and epidermal growth factor (EGF). Lastly, the effects of the exogenous administration of KGF on the bladder was tested on neonatal mice by daily injections of 5 micrograms KGF per gram body weight for 5 days. RESULTS: At 12 hours after injury KGF mRNA expression in the anterior wounded bladder half and posterior non-wounded bladder half was 8 and 6 times higher respectively, compared to unoperated control bladders. A similar response was seen for TGF alpha, where the 12 hour mRNA expression was 4.5 times higher in the anterior wounded bladder half and 3.5 times higher in the posterior non-wounded bladder half compared to unoperated control bladders. The nadir mRNA expression for both KGF and TGF alpha occurred at 7 days after bladder injury and was the same as in unoperated control bladders. EGFR mRNA expression was approximately 2 times higher in both the anterior wounded and posterior non-wounded bladder halves compared to the nadir levels which occurred at 24 hours after injury. TGF beta 2 and beta 3 mRNA levels did not significantly change in either the anterior wounded or posterior non-wounded bladder halves. Exogenous KGF stimulation resulted in a marked urothelial proliferation when compared to age matched control animals. CONCLUSION: During the early phases of bladder wound healing (12-24 hours post injury), mRNA for KGF and TGF alpha increased, whereas TGF beta 2 and beta 3 and the KGFR and EGFR remain unchanged. Additionally, exogenous KGF has a direct effect on urothelial proliferation. KGF and TGF alpha warrant further study as potential mediators of bladder wound healing.

Stricture incidence related to suture material in hypospadias surgery.

PURPOSE: To report the complication rates after hypospadias surgery, with stratification according to the type of suture used for the urethral anastomosis (rapid/intermediate absorbable v prolonged absorbable.) MATERIAL AND METHODS: During a 7-year period (1986 to 1992), 117 boys aged 5 to 124 months (mean, 14) underwent surgical correction of hypospadias. The urethral anastomoses were performed with chromic sutures before 1987 (n = 15), with polydioxanone (PDS) between 1987 and 1990 (n = 46), and with polyglycolic acid (PgA) after 1990 (n = 56). The patients were separated into two groups: those whose operations were performed before 1987 and after 1990 (using chromic or PgA sutures), and those whose surgery occurred in the intervening 3 years (using PDS). A successful result was defined as good cosmesis without urethral stricture or urethrocutaneous fistula on long-term follow up (mean follow-up period, 15.9 months). RESULTS: Of the cases that had PgA or chromic sutures, 76.1% were corrected in a single operation, as opposed to 50.9% when PDS was used (P = .002). In the chromic/PgA group, 6.8% had strictures, compared with 23.6% of the PDS group (P < .02). This contrast was most evident in cases with pedicled tube flaps; strictures occurred in 43.8% of the PDS group but in only 9.5% of the chromic/ PgA group (P < .02). There was no significant difference in the incidence of postoperative fistulas between the two groups. In some patients, the PDS sutures remained present in the urethra, without absorption, up to 7 months after the initial repair. CONCLUSION: Sutures with rapid or intermediate absorption rates provide the best results for hypospadias surgery. The extreme delay in in vivo absorption of polydioxanone should preclude its use as an interrupted suture in small-caliber urethral anastomoses.

Mesenchymal-epithelial interactions in the bladder.

During bladder development, undifferentiated mesenchymal and epithelial cells undergo an orderly sequence of differentiation defined by the expression of smooth-muscle (alpha-actin, myosin, vinculin, desmin, vimentin, and laminin) and epithelial (cytokeratins 5, 7, 8, 14, 18 and 19) protein markers. This process requires mesenchymal-epithelial interactions with bladder epithelium (urothelium) necessary for the differentiation of bladder smooth muscle. Peptide growth factors such as keratinocyte growth factor (KGF) and transforming growth factors (TGF) alpha and beta are likely candidates as mediators of these mesenchymal-epithelial interactions. Transcripts for KGF, TGF alpha, and TGF beta are regulated during bladder development and during smooth-muscle hypertrophy secondary to bladder-outlet obstruction. Finally, two experimental bladder models--(1) partial outlet obstruction and (2) regeneration of bladder smooth muscle into an acellular tissue matrix--are described in the context of mesenchymal-epithelial interactions in the bladder.

Diuretic enhanced duplex Doppler sonography in 33 children presenting with hydronephrosis: a study of test sensitivity, specificity and precision.

PURPOSE: We assessed the value of diuretic enhanced Doppler sonography in the diagnosis of pediatric renal obstruction as well as its reproducibility, sensitivity and specificity. MATERIALS AND METHODS: We studied 33 children (68 kidneys) by standard diagnostic techniques and diuretic Doppler sonography. A total of 20 obstructed kidneys was compared to 48 without obstruction and we performed surgery on 13. An average of 2.3 resistive index measurements were made per test and 436 total resistive index values were assessed by Student's t distribution and chi-square analysis before and after surgical repair. The assessor was blinded to the clinical diagnosis. RESULTS: The obstructed mean resistive index before (0.71) and after (0.74) furosemide administration differed significantly from the nonobstructed mean resistive index (0.65, p < 0.02). Postoperative mean resistive index (0.68) was not affected by the diuretic and did not differ from the mean resistive index of nonobstructed kidneys. Resistive index test sensitivity was 76% and specificity was 88%. The precision for 3 values per test was +/- 0.11. CONCLUSIONS: When at least 3 values are obtained per test, diuretic Doppler sonography predicts the actual resistive index average with 98% confidence limits 90% of the time.