Alexandra Rehfuss

Loss of expression of protein phosphatase magnesium-dependent 1A during kidney injury promotes fibrotic maladaptive repair.

Protein phosphatase magnesium‐dependent‐1A (PPM1A) dephosphorylates SMAD2/3, which suppresses TGF‐β signaling in keratinocytes and during Xenopus development; however, potential involvement of PPM1A in chronic kidney disease is unknown. PPM1A expression was dramatically decreased in the tubulointerstitium in obstructive and aristolochic acid nephropathy, which correlates with progression of fibrotic disease. Stable silencing of PPM1A in human kidney‐2 human renal epithelial cells increased SMAD3 phosphorylation, stimulated expression of fibrotic genes, induced dedifferentiation, and orchestrated epithelial cell‐cycle arrest via SMAD3‐mediated connective tissue growth factor and plasminogen activator inhibitor‐1 up‐regulation. PPM1A stable suppression in normal rat kidney‐49 renal fibroblasts, in contrast, promoted a SMAD3dependent connective tissue growth factor and plasminogen activator inhibitor‐1–induced proliferative response. Paracrine factors secreted by PPM1A‐depleted epithelial cells augmented fibroblast proliferation (>50%) compared with controls. PPM1A suppression in renal cells further enhanced TGF‐b1–induced SMAD3 phosphorylation and fibrotic gene expression, whereas PPM1A overexpression inhibited both responses. Moreover, phosphate tensin homolog on chromosome 10 depletion in human kidney‐2 cells resulted in loss of expression and decreased nuclear levels of PPM1A, which enhanced SMAD3‐mediated fibrotic gene induction and growth arrest that were reversed by ectopic PPM1A expression. Thus, phosphate tensin homolog on chromosome 10 is an upstream regulator of renal PPM1A deregulation. These findings establish PPM1A as a novel repressor of the SMAD3 pathway in renal fibrosis and as a new therapeutic target in patients with chronic kidney disease.—Samarakoon, R., Rehfuss, A., Khakoo, N.S., Falke, L. L., Dobberfuhl, A.D., Helo, S., Overstreet, J.M., Goldschmeding, R., Higgins, P. J. Loss of expression of protein phosphatase magnesium‐dependent 1A during kidney injury promotes fibrotic maladaptive repair. FASEBJ. 30, 3308–3320 (2016). www.fasebj.org

Use of Nonprostate Ultrasound in Urology Practice

Introduction: Ultrasound imaging is necessary for the care of urology patients, and urology residents are encouraged to learn ultrasound technique and interpretation. However, there is limited mandated education in this field. Currently the only ultrasound procedure considered an index case is transrectal ultrasound for prostate biopsy. We investigated the current use of nonprostate ultrasound in urological practice. Methods: We reviewed ABU (American Board of Urology) certification and recertification logs of practicing urologists from 2012 to 2014. We obtained data for the codes 76700–76776 (kidney), 76870 (scrotal), 76999 (unlisted) and 93975–93981 (Doppler including penile). Codes 51798 (post‐void residual) and 76950 (ultrasound for interstitial radiotherapy) were excluded from the study. We analyzed the results based on self‐identified demographic information provided by the urologists. Results: The practices of 2,427 urologists were reviewed and of these, 43% billed for at least 1 renal, scrotal or penile ultrasound. General and subspecialist urologists perform similar percentages of ultrasound studies, except for pediatrics (0% penile) and andrology (40% penile). Of those who reported on practice type (2,067) 82% self‐identify as in private practice and performed more ultrasound studies than academic urologists, including renal 42% vs 23%, scrotal 33% vs 15% and penile 8% vs 6%, respectively. Men performed more nonprostate ultrasounds than women (44% vs 36%, p <0.001). Conclusions: In addition to prostate ultrasound, renal and scrotal ultrasound is relevant to all urologists regardless of practice model or subspecialty. Graduating residents can expect to perform ultrasound examinations in their practices and, therefore, in addition to prostate ultrasound we should train residents in renal and scrotal ultrasound.

Surgical Anatomy for the Reconstructive Surgeon

Pelvic floor anatomy is based on a complex, dynamic interplay of organs and their support structures. The surgeon’s goal is to restore normal vaginal support while preserving its size, depth, axis and elastic properties, aiming to rehabilitate urinary, anorectal and sexual functions. In order to accomplish this, the surgeon needs a working understanding of the anatomy and structural supports for an anatomic repair.

Phenazopyridine: A Preoperative Way to Identify Ureteral Orifices

OBJECTIVE To identify difficult to see ureteral orifices (UOs), urologists need a method to stain the urine. Phenazopyridine, a urinary analgesic which discolors the urine orange, can be administered orally preoperatively. We evaluated the usefulness of phenazopyridine in identifying the UOs and optimal timing of administration. METHODS Adult patients undergoing endoscopic procedures at the Stratton VA were prospectively enrolled. Preoperative metabolic panels were reviewed. Exclusion criteria were renal insufficiency (creatinine clearance <50 mL/min), severe hepatitis or severe liver disease, glucose-6-phosphate dehydrogenase deficiency, previous hypersensitivity to phenazopyridine, or pregnancy. In phase 1, patients undergoing office flexible cystoscopy were administered 200 mg phenazopyridine the morning of the procedure. Because of the robust orange color of the urine, phase 2 was implemented. In phase 2, patients undergoing rigid cystoscopy in the operating room took 200 mg phenazopyridine at 7 PM the night before surgery. Upon entry into the bladder, UOs were identified and urine color was graded (0 = no dye, 1 = weak, 2 = moderate, and 3 = strong). Patients were assessed postoperatively for side effects. RESULTS Five patients were included in phase 1. The mean time from medication to cystoscopy was 153 minutes (range 17-304 minutes). One-third of patients had excretion of grade 3 orange urine that obscured inspection of the bladder mucosa. The study design was adjusted and we transitioned to phase 2. Twenty-three patients were enrolled in phase 2. The mean time from phenazopyridine dose to cystoscopy was 14 hours (range 13-17 hours). Seventy-three percent of patients had grade 2 efflux from the UOs. CONCLUSION Phenazopyridine can successfully identify UOs and can be administered as early as the evening before the procedure.

FRII-06 BOSTON, MA: THE HOME OF DR. JOSEPH E. MURRAY AND THE FIRST ORGAN TRANSPLANT

abysmal well into the 20th century. Operative mortality decreased after 1932, but <25% remained alive for 2 years. The cure rate jumped to 47% in the 1940s, an improvement attributed to early vessel ligation and post-operative radiation. Survival dramatically increased again with the advent of chemotherapy for Wilms, first reported in 1960. In America (1969) and Europe (1971), multi-center research groups formed to elucidate the best treatments. The groups diverged on the timing of surgery and chemotherapy. Now in an era with improved survival, treatment goals include minimizing morbidity and following long term sequelae. CONCLUSIONS: Max Wilms, a man of diverse interests who died a hero, happened upon a biologically fascinating tumor. Its treatment, well-described for over a century, continues to evolve as we identify ways of maximizing survival with the least morbidity.

MP05-17 USE OF ULTRASOUND IN UROLOGY PRACTICE

INTRODUCTION AND OBJECTIVES: To study the mechanism of the urine stream during micturition, we developed a noninvasive magnetic resonance image (MRI) protocol that simulates computational fluid dynamic (CFD) of male voiding. METHODS: MRI uroflowgraphic assessment was done during urinary voiding in the lateral position. To visualize the entire pelvis and urethra, a sagittal plane image was obtained such that a line connecting the coccyx and pubic symphysis could be observed during micturition. In addition, 2 more images were collected, bilaterally, 1 cm from the midplane. Three coronal planar imaging, at the midplane including centerline of urethra, and 1cm back side and front side were performed (figure 1A). We were collected the intermitted images until the end of voiding. Using the total 6 planar MRI digital imaging and communications in medicine (DICOM) files, we created a multiple 3D models during voiding. We created 7 models, to span the duration from initiation to terminal voiding (figure 1B). Those multiple intermitted models were converted to a serial dynamic model with special software. Pressure and velocity of the 3 different sites in the bladder simulation model were measured by CFD software. Those CFD results were compared with simple model. This simple model was artificially made in a shape resembling a balloon. RESULTS: Deformation of the bladder neck appeared to be very complicated. FCD result showed real-time changes in stream, pressure, and velocity. The intravesical pressure differed depending on the measuring site (figure 2A). The actual 3D dynamic model created from MRI data showed highly intricate urine flow (figure 2B) compare with simple model. CONCLUSIONS: A dynamic 3D model can be created from MRI data using CAD software. This new method is noninvasive and involves no radiation exposure. This dynamic model can be used for computational fluid dynamics simulation. This new method is useful in improving our understanding of the mechanism of urinary voiding. Source of Funding: This work was supported by JSPS KAKENHI grant number 15K15587