Christopher Dru

Inflammation and Pyroptosis Mediate Muscle Expansion in an Interleukin-1β (IL-1β)-dependent Manner

Background: Hyperplasia is a common phenomenon in inflamed muscle. Results: IL-1β secreted associated with pyroptotic cell death mediate IGF1-dependent detrusor expansion. Conclusion: Bladder muscle hyperplasia resulting from NLRP3 inflammatory cascade can be attenuated by neutralization of IL-1β and IGF1. Significance: Antagonizing IL-1β can have a therapeutic benefit for subjects with muscle hyperplasia resulting from chronic inflammatory diseases. Muscle inflammation is often associated with its expansion. Bladder smooth muscle inflammation-induced cell death is accompanied by hyperplasia and hypertrophy as the primary cause for poor bladder function. In mice, DNA damage initiated by chemotherapeutic drug cyclophosphamide activated caspase 1 through the formation of the NLRP3 complex resulting in detrusor hyperplasia. A cyclophosphamide metabolite, acrolein, caused global DNA methylation and accumulation of DNA damage in a mouse model of bladder inflammation and in cultured bladder muscle cells. In correlation, global DNA methylation and NLRP3 expression was up-regulated in human chronic bladder inflammatory tissues. The epigenetic silencing of DNA damage repair gene, Ogg1, could be reversed by the use of demethylating agents. In mice, demethylating agents reversed cyclophosphamide-induced bladder inflammation and detrusor expansion. The transgenic knock-out of Ogg1 in as few as 10% of the detrusor cells tripled the proliferation of the remaining wild type counterparts in an in vitro co-culture titration experiment. Antagonizing IL-1β with Anakinra, a rheumatoid arthritis therapeutic, prevented detrusor proliferation in conditioned media experiments as well as in a mouse model of bladder inflammation. Radiation treatment validated the role of DNA damage in the NLRP3-associated caspase 1-mediated IL-1β secretory phenotype. A protein array analysis identified IGF1 to be downstream of IL-1β signaling. IL-1β-induced detrusor proliferation and hypertrophy could be reversed with the use of Anakinra as well as an IGF1 neutralizing antibody. IL-1β antagonists in current clinical practice can exploit the revealed mechanism for DNA damage-mediated muscular expansion.

Histone deacetylase inhibitors mediate DNA damage repair in ameliorating hemorrhagic cystitis

Hemorrhagic cystitis is an inflammatory and ulcerative bladder condition associated with systemic chemotherapeutics, like cyclophosphomide. Earlier, we reported reactive oxygen species resulting from cyclophosphamide metabolite, acrolein, causes global methylation followed by silencing of DNA damage repair genes. Ogg1 (8-oxoguanine DNA glycosylase) is one such silenced base excision repair enzyme that can restore DNA integrity. The accumulation of DNA damage results in subsequent inflammation associated with pyroptotic death of bladder smooth muscle cells. We hypothesized that reversing inflammasome-induced imprinting in the bladder smooth muscle could prevent the inflammatory phenotype. Elevated recruitment of Dnmt1 and Dnmt3b to the Ogg1 promoter in acrolein treated bladder muscle cells was validated by the pattern of CpG methylation revealed by bisulfite sequencing. Knockout of Ogg1 in detrusor cells resulted in accumulation of reactive oxygen mediated 8-Oxo-dG and spontaneous pyroptotic signaling. Histone deacetylase (HDAC) inhibitor, suberoylanilide hydroxamic acid (SAHA), restored Ogg1 expression in cells treated with acrolein and mice treated with cyclophosphamide superior to the standard of care, mesna or nicotinamide-induced DNA demethylation. SAHA restored cyclophosphamide-induced bladder pathology to that of untreated control mice. The observed epigenetic imprinting induced by inflammation suggests a new therapeutic target for the treatment of hemorrhagic cystitis.

Bochdalek-type Diaphragmatic Hernia Leading to High-grade Kidney Obstruction

A 94-year-old female presented with sharp right flank pain. Imaging demonstrated herniation of the right renal pelvis and proximal ureter into a large diaphragmatic hernia. She underwent ureteral stent placement with resolution of her symptoms. Congenital diaphragmatic hernias can cause a variety of pulmonary, cardiac, and gastrointestinal symptoms. This is 1 of only 3 cases in the literature of unilateral kidney obstruction due to herniation of the renal pelvis and proximal ureter into a Bochdalek-type diaphragmatic hernia. Ureteral stenting is a good option to decompress the kidney. Hernia reduction and primary diaphragm repair remain the definitive treatment.

Robotic-Assisted Ureteral Reimplantation

Ureteral injuries are a rare complication of pelvic and abdominal surgery. In many cases, the injury is not recognized intraoperatively, and patients will present several days later with flank pain, fever, chills, nausea, and vomiting. Imaging may demonstrate a ureteral obstruction or a ureteral rupture. The initial management involves urinary drainage with a ureteral stent or a percutaneous nephrostomy tube. A complete transection of the ureter can be repaired primarily within the first week after the injury. Definitive or delayed surgical repair, however, is usually performed several weeks to months later. Given advancements in laparoscopic and robotic-assisted surgery, ureteral injuries can now be repaired in a minimally invasive fashion without laparotomy incisions. Robotic-assisted laparoscopic ureteral reimplantation is quickly becoming the gold standard for repair. In this chapter, the anatomy, etiology, and treatment of ureteral injuries will be discussed. The surgical techniques for ureteral reimplant with a psoas hitch or Boari flap are described.

MP06-01 EVALUATION OF THE RELATIONSHIP BETWEEN THE DONOR AND RECIPIENT DURING KIDNEY TRANSPLANT

INTRODUCTION AND OBJECTIVES: In 2014, approximately 6,100 people in the United States underwent living donor nephrectomy. Unlike other types of organ donation, this patient population has a longer-than-average life expectancy due to strict selection criteria. Greater than 99% of patients that donated a kidney at Cedars-Sinai Medical Center donated to an immediate family member, relative, or close friend. Our study seeks to qualify and quantify functional changes in the relationship between the donor and the recipient before and after surgery as well as to identify perioperative complications and stress to determine if patients are content with their decision to donate. METHODS: From 2002-2012, 532 patients underwent donor nephrectomy for kidney transplant at Cedars-Sinai Medical Center. After IRB approval, a randomized subset of these patients were administered a standardized questionnaire regarding his or her experience. We assessed if each patient would undergo the donation process again, now having more intimate knowledge and appreciation of the preand post-operative surgical and medical course. RESULTS: Of the fifty patients who participated in our survey, 92% stated that their relationship with the recipient improved after surgery. Of the 8% that noted a deterioration in the relationship, there was a distribution of dissatisfaction with relation to the sexual relationship (n1⁄41), recipient personality changes (n1⁄41), or divorce (n1⁄42). Approximately 10% of patients experienced a complication related to surgery, all of which were clavian grade I-II. Examples of these included incisional hernia (n1⁄43, upper midline incision, BMI>30 kg/m2) and urinary tract infection (n1⁄42). Overall, 98% of patients were extremely satisfied with the donation process and would not hesitate to participate again. Only one patient stated that he would not donate again, as he developed an unanticipated glomerulonephropathy not related to surgery that required hemodialysis. CONCLUSIONS: Our research demonstrates that the act of donating a kidney overwhelmingly enhances the bond between the donor and recipient. Even donors who noted a decline in their relationship with the recipient all stated that they would still donate if faced with the same decision again. This suggests that the relationship with the recipient is of highest importance and a crucial component of pre-operative counseling that should be emphasized. Our urology group has started to incorporate this practice in our management with great success.

PD12-07 HISTONE DEACETYLASE INHIBITOR SUBEROYLANILIDE HYDROXAMIC ACID AMELIORATES HEMORRHAGIC CYSTITIS VIA DNA DAMAGE REPAIR GENE PATHWAYS

INTRODUCTION AND OBJECTIVES: Hemorrhagic cystitis is a highly-morbid inflammatory bladder disease associated with nitrogen mustard alkylating agents, most notably cyclophosphamide. Acrolein, a reactive oxygen species metabolite of cyclophosphamide, has been shown to silence DNA damage repair genes via global methylation pathways. 8-oxoguanine DNA glycosylase (Ogg1) is one such silenced base excision repair enzyme that can restore DNA integrity. Subsequent inflammation from the accumulation of DNA damage results in bladder smooth muscle pyroptotic cell death. We hypothesized that reversing inflammasome-induced imprinting and gene silencing in the bladder smooth muscle could prevent hemorrhagic cystitis. METHODS: Experiments were carried out using cultured detrusor fibroblasts, B6 wild-type mice, and Ogg1 knockout mice. Hemorrhagic cystitis was induced with either cyclophosphamide or acrolein. Mesna, the current standard of care treatment to prevent hemorrhagic cystitis; Nicotinamide, a vitamin B-3 analog shown to ameliroate bladder inflammation; and suberoylanilide hydroxamic acid, a histone deacetylase (HDAC) inhibitor with anti-inflamatory properties, were added to treatment groups. Harvested tissues and cells were subjected to bisulfite sequencing and chromatin immunoprecipitation analysis to evaluate DNA methylation patterns and epigenetic imprinting. RESULTS: There was enhanced recruitment of Dnmt1 and Dnmt3b to the Ogg1 promoter in acrolein treated bladder fibroblasts as demonstrated by the pattern of CpG-island methylation and resultant bisulfite sequencing. Accumulation of reactive oxygen species with spontaneous pyroptotic signaling was found in Ogg1 knockout detrusor cells. Suberoylanilide hydroxamic acid restored Ogg1 expression to physiologic levels moreso than either nicotinamide or Mesna in all hemorrhagic cystitis models. Additionally, suberoylanilide hydroxamic acid restored histologically-visible cyclophosphamide-induced bladder damage to that of normal untreated control mice. CONCLUSIONS: The pattern of epigenetic imprinting induced by inflammation suggests a novel therapeutic target for the treatment of hemorrhagic cystitis. HDAC inhibitors can reactivate Ogg1 expression by altering DNA methylation through Dnmt3B regulation. More broadly, the data suggest that re-programming epigenetic imprinting could limit the inflammatory process induced by not only cyclophosphamide but by a multitude of other toxic insults as well.

Other Oral Agents for Chronic Pelvic Pain

There are numerous medications used to treat the wide range of symptoms associated with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and interstitial cystitis/painful bladder syndrome (IC/PBS). Some of these therapies are targeted against the painful pelvic symptoms, while others help alleviate the emotional and cognitive components associated with pelvic pain. The oral medications discussed in this chapter will include bladder anesthetics, alpha-1 receptor antagonists, nonsteroidal anti-inflammatory medications, cholinergic antagonists, and pentosan polysulfate sodium. These therapies are typically used as an adjunct in patients with refractory symptoms who are already being treated with a multimodal therapeutic regimen.

Managing mild, symptomatic pelvic organ prolapse.

The best course of action may be to delay any treatment for prolapse until symptoms become bothersome