Sarah M. Lambert

Apoptosis induced by vitamin A signaling is crucial for connecting the ureters to the bladder.

Removal of toxic substances from the blood depends on patent connections between the kidney, ureters and bladder that are established when the ureter is transposed from its original insertion site in the male genital tract to the bladder. This transposition is thought to occur as the trigone forms from the common nephric duct and incorporates into the bladder. Here we re-examine this model in the context of normal and abnormal development. We show that the common nephric duct does not differentiate into the trigone but instead undergoes apoptosis, a crucial step for ureter transposition controlled by vitamin A–induced signals from the primitive bladder. Ureter abnormalities occur in 1–2% of the human population and can cause obstruction and end-stage renal disease. These studies provide an explanation for ureter defects underlying some forms of obstruction in humans and redefine the current model of ureter maturation.

The development of the bladder trigone, the center of the anti-reflux mechanism

The urinary tract is an outflow system that conducts urine from the kidneys to the bladder via the ureters that propel urine to the bladder via peristalsis. Once in the bladder, the ureteral valve, a mechanism that is not well understood, prevents backflow of urine to the kidney that can cause severe damage and induce end-stage renal disease. The upper and lower urinary tract compartments form independently, connecting at mid-gestation when the ureters move from their primary insertion site in the Wolffian ducts to the trigone, a muscular structure comprising the bladder floor just above the urethra. Precise connections between the ureters and the trigone are crucial for proper function of the ureteral valve mechanism; however, the developmental events underlying these connections and trigone formation are not well understood. According to established models, the trigone develops independently of the bladder, from the ureters, Wolffian ducts or a combination of both; however, these models have not been tested experimentally. Using the Cre-lox recombination system in lineage studies in mice, we find, unexpectedly, that the trigone is formed mostly from bladder smooth muscle with a more minor contribution from the ureter, and that trigone formation depends at least in part on intercalation of ureteral and bladder muscle. These studies suggest that urinary tract development occurs differently than previously thought, providing new insights into the mechanisms underlying normal and abnormal development.

Management of ejaculatory duct obstruction: etiology, diagnosis, and treatment

Abnormalities of the distal ejaculatory ducts related to infertility have been well-documented. Although there are no specific findings associated with ejaculatory duct obstruction, several clinical findings are highly suggestive. A diagnosis of ejaculatory duct obstruction is suggested in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on TRUS. Other causes of infertility may be concomitantly present and need to be evaluated and treated. Trans urethral resection of ejaculatory ducts (TURED) has resulted in marked improvement in semen parameters, and pregnancies have been achieved. Proper patient selection and surgical experience are necessary to obtain optimal results. In case of testicular dysfunction, chances of success are minimal. Extended follow-up periods are needed after TURED to examine the long-term effects of this procedure. Better understanding of the anatomy and pathology of the ejaculatory ducts will continue to refine diagnostic and therapeutic procedures for this disorder.

Transitional care in pediatric urology

The transition from childhood to adolescence and into adulthood occurs as a natural component of human development. As children progress through school and gain independence, health care practitioners must facilitate a parallel transition from pediatric to adult providers. Modern medicine has succeeded in extending the life expectancy for many children with complex conditions, and adult providers are participating in their medical care through adulthood. Transitioning pediatric urology care to adult urology care is unique to every individual and his or her underlying condition, while the transition process is universal. The objectives of all pediatric urologists include preservation of the kidneys and lower urinary tracts, safe urine storage, safe urine drainage, urinary continence, fertility, sexual function, and genital cosmesis. For some children, these objectives can be attained during childhood, while other children require lifelong maintenance and management. Children with posterior urethral valves, exstrophy-epispadias complex, cloaca, vesicoureteral reflux, neurogenic bladder, disorders of sex development, cancer, hypospadias, nephrolithiasis, undescended testes, varicoceles, ureteropelvic junction obstruction, solitary kidney, and upper tract anomalies all require long-term evaluation and management. The obstacles of altering a patient and caregiver paradigm, locating adult urologists with special expertise, coordinating care with other adult specialties such as nephrology, and navigating the adult health care environment can impede the transition process.

An assessment of urologists' training and knowledge of energy-based surgical devices

To assess surgeons’ training and current understanding of existing energy‐based surgical instrumentation (ESI), we disseminated an online questionnaire to urology residents, fellows and attending urologists.

MP66-19 THE DECLINING RATE OF PEDIATRIC VARICOCELECTOMY IN NEW YORK STATE

INTRODUCTION AND OBJECTIVES: Bilateral Vanishing Testis Syndrome is one of the most challenging problems of pediatric and adolescent urology. There are at least two major problems for patients with congenital or acquired anorchia: Long-life androgen replacement therapy and possible hepatic cancer occurrence as well as fertility issue. The purpose of present study was to describe a method to produce human sized decellularized testis scaffold as a primitive step for testis tissue engineering in such complex situation. METHODS: A total of 32 sheep testes were classified in 8 groups of 4. Seven decellularization protocols were proposed which were tested on groups 1-7, respectively and group 8 was left intact as the control group. The protocols consisted of 0.5%, 1%, 2% solution of sodium dodecyl sulfate (SDS), Trypsin-EDTA 0.5%, 1%, Triton X-100 1% and 2%, respectively. Then, using the best protocol obtained in phase I, the optimal timing was evaluated; ovine testes were decellularized by arterial perfusion and specimen were collected for evaluation at 4-6-8-10-12 hours after initiation of the procedure, respectively. To evaluate the efficacy of the protocol, histological examinations, scanning electron microscopy (SEM), magnetic resonance imaging (MRI) biochemical assays and evaluation of mechanical properties were performed. The patency of vascular network of the decellularized scaffold was examined by angiography. The cytotoxicity analyses of samples was performed by tetrazolium salt MTT (3-[4,5dimethylthiazol2-yl]-2,5-diphenyltetrazolium bromide) assay. RESULTS: Histological exams depict that treating the tissues with SDS 1% for 6-8 hours was found to be the best protocol for cell removal and preserving the extracellular matrix (ECM) components. The microstructure, ultrastructure and vascular integrity of the decellularized testis scaffold were well-preserved and confirmed by scaffold angiography, SEM and MRI. Moreover, MTT assay showed that the decellularized testis was not cytotoxic to cells and it is ready for recellularization. CONCLUSIONS: The SDS 1% with 6-8 hours perfusion based protocol is the best, effective, minimally invasive technique for creation of whole testis bioscaffold with well-preserved extra-cellular matrix structure and vascular network integrity. To the best of our knowledge the whole large size testis decellularization by this novel protocol has not been reported previously. This preliminary step may pave the road for slowing these problems in future.

MP52-02 DOES PNEUMOPERITONEUM CAUSE TRANSIENT RENAL INJURY IN CHILDREN?

INTRODUCTION AND OBJECTIVES: A piezo actuator-driven pulsed water jet (ADPJ) system is novel surgical device that is not only able to preserve fine blood vessels without thermal coagulation, but also dissect at constant depth and decreases in water volume compared to conventional continuous water jet systems. The aim of this study was to clarify long term renal damages after off-clamp partial nephrectomy (PN) using the ADPJ system in animal experiments. METHODS: Sprague-Dawley rats were divided into 4 groups and subjected to sham operation, off-clamp PN by the ADPJ system, radio knife and soft coagulation. Urine and blood samples were collected, and residual kidney were harvested at 1, 7, 14, 30, and 90 days postoperatively. Renal function was evaluated by serum blood urea nitrogen (BUN). Morphological features and the extent of renal ischemia of resection surfaces were evaluated by Hematoxylin-eosin (HE) staining and by immunostaining using antibodies to 1-methyladenosine (m1A), respectively. Urinary and serum kidney injury molecule-1 (KIM-1) level, which might be elevated in the presence of renal injury, were measured by ELISA. In addition, the expression of KIM-1 RNA extracted from each resection surface were analyzed by quantitative real time reverse transcription polymerase chain reaction. RESULTS: Serum BUN level of the ADPJ group was significantly lower than soft coagulation group in 1 and 90 days (p<0.01). Although the HE staining of the ADPJ group revealed the crush injury and internal hemorrhage of the resection site in the early phase, the state was gradually recovered with the long-term course after surgery. On the other hands, broader necrosis due to coagulation was shown in radio knife and soft coagulation groups (thermal coagulation groups). The extent of m1A immunostaining were significantly smaller in the ADPJ group than thermal coagulation groups. Urinary KIM-1 level of the ADPJ group was significantly lower than those of soft coagulation group in all evaluation points. Furthermore, serum KIM-1 level of the ADPJ groups was significantly lower than those of soft coagulation groups after the 7 days (p<0.01). The expression of KIM-1 was also significantly lower in the ADPJ group than soft coagulation group in 7 and 90 days (p<0.05). CONCLUSIONS: Renal damages after off-clamp PN using the ADPJ system were significantly less compared with commercialized thermal coagulation devices, contributing to improvement of outcomes after PN.

2258 UNILATERAL HYPERCALCIURIA: A STEALTH CULPRIT IN UNILATERAL STONE FORMATION

patients were Type B (BAT1 homo), and 5 patients were Type AB (rBAT/BAT1 hetero). However, 44 patients were unclassified in these categories. Under a new classification system, Type a (rBAT hetero) and Type b (BAT1 hetero) are added, and among the 44 previously unclassified patients, 5 patients were classified as Type a and 39 patients were classified as Type b. As a phenotype, the 3 highest average cystine concentration groups were Type B (1998.7 nmol/mg Cre), Type AB (1678.5 nmol/mg Cre), and Type b (1335.0 nmol/mg Cre). When compared on the basis of genotype, the highest cystine concentration was observed in the P482L homozygous mutation (2074.6 nmol/mgCre). CONCLUSIONS: Cystinuria has been recognized as an autosomal recessive disorder; however, in cases with a P482L mutation, half of the patients were heterozygous. Because their genotype is quite different from that of patients in western countries, a new classification may be needed for Japanese patients with cystinuria.

1193 ADULTS WITH HISTORY OF WITH CONTINENT URINARY DIVERSIONS IN CHILDHOOD: HOW DO WE TRANSITION?

INTRODUCTION AND OBJECTIVES: Pediatric urologists frequently perform continent urinary diversion with ileal or sigmoid segments in children. This study assesses the progress of children with continent urinary diversions during the transition into adulthood. Our hypothesis is that these children do not successfully transition into the adult healthcare environment as they age. METHODS: We conducted a retrospective review of the records of 170 patients now over age 18 who underwent continent urinary diversion from 1952 to 1993. We mailed questionnaires detailing demographics and medical history to those with verifiable addresses. RESULTS: 170 children underwent continent urinary diversion from 1952 to 1993. 110 had verifiable addresses. There were 46 women and 64 men. Four were gender-reassigned. The primary diagnoses include 58 exstrophy, 43 spina bifida, 3 imperforate anus/cloaca, 2 nonneurogenic neurogenic bladders, 1 Klippel Trenaunay Weber, 1 radiation cystitis, 1 spinal cord tumor, and 1 unknown. Continent urinary diversions included 86 augmentation cystoplasties, 9 ureterosigmoidostomies, 6 ileal conduits, 6 neobladders, and 3 ureterosigmoidostomies that were later converted to neobladders. Median age is 35 years (range 59–19). Median age at the last visit at the Division of Pediatric Urology is 23 years (range 43–11). We evaluated 36% in our Division within the past 2 years and 55% within the past 5 years. We mailed 110 questionnaires to potential participants. 74 never responded. 17 declined to participate. This left 19 adults who completed the questionnaires. The completed questionnaires included 9 men and 10 women. Diagnoses include 11 exstrophy and 8 spina bifida. Median age is 29 years (range 20–44). Median age at the last visit at the Division of Pediatric urology is 25 years (range 43–15). All participants have seen an urologist within the past 3 years. 60% have a yearly renal ultrasound. 53% had a cystoscopy and urodynamic evaluation. 74% are followed by an internist. Less than 26% were evaluated by neurosurgery, orthopedics, or nephrology in the past 3 years. 70% of the female participants have been evaluated by gynecology in the past 3 years. CONCLUSIONS: Pediatric urologists follow many children with continent urinary diversions into their mid twenties. After that, the adults discontinue follow up in many cases. Our follow up for patients into their thirties and forties is limited. The 17% questionnaire response rate highlights this difficulty. To ensure the safety of our adult patients, we need to work hard to strengthen and secure an orderly transfer of care to adult providers.

51 – Fertility and Aging Men: An Introduction to the Male Biological Clock

Data obtained in the past decade suggested a worldwide decline in male fertility. The increase in paternal age is both a personal problem for couples and a public health problem because of the simple fact that male fertility declines with age. Journal articles by Kidd and Ford demonstrate that men over the age of 35 are twice as likely to be infertile as men younger than 25. In addition, a study of couples undergoing fertility treatments found that the amount of time it takes for a man to achieve a pregnancy rises significantly with age.