Vascular response of the rabbit bladder to short term partial outlet obstruction

Relationship between post-void residual urine volume, preoperative pyuria and intravesical recurrence after transurethral resection of bladder carcinoma

OBJECTIVES

To evaluate the relationship between residual urine volume, pyuria and bladder carcinoma recurrence.

METHODS

The clinical data of 305 patients who had post-void residual urine volume measured and preoperative pyuria were retrospectively collected. The patients were classified into three risk groups based on the presence of residual urine and pyuria: good (negative residual urine and pyuria), intermediate (positive residual urine or pyuria) and poor (positive residual urine and pyuria). Predictive factors for intravesical recurrence-free survival were statistically analyzed using Cox proportional hazard models and Kaplan-Meier methods. The propensity score matching method was used to adjust the patients' backgrounds.

RESULTS

The median follow-up period for all patients was 44 months. The presence of residual urine (P = 0.0164) and pyuria (P = 0.0233) were two independent prognostic factors for recurrence. After patients were classified into risk groups, the poor-risk group showed significantly shorter recurrence-free survival compared with that of the good- (P = 0.0002) and intermediate-risk groups (P = 0.0090). Even after matching, the presence of residual urine was related to short recurrence-free survival in male patients (P = 0.0012). When stratified by European Organization for Research and Treatment of Cancer risk groups, the presence of pyuria was related to short recurrence-free survival, especially for intermediate-risk patients without bacillus Calmette-Guérin treatment.

CONCLUSIONS

Post-void residual urine and preoperative pyuria are two risks for recurrence-free survival in non-muscle-invasive bladder cancer.

Impact of post-void residual urine volume on intravesical recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVE

To examine the impact of post-void residual urine volume on the risk of postoperative recurrence of intravesical carcinoma in patients with upper urinary tract urothelial carcinoma undergoing nephroureterectomy.

METHODS

We retrospectively reviewed the data of 81 patients who were admitted to Chiba University Graduate School of Medicine Hospital and underwent nephroureterectomy for upper urinary tract urothelial carcinoma without bladder carcinoma. We assessed the predictive factors for intravesical recurrence after nephroureterectomy in all patients. Next, we compared patients with and without a residual urine volume using propensity score-matching analysis. The presence of a residual urine volume was defined as ≥30 mL.

RESULTS

The median follow-up period among all patients was 48 months. The presence of pyuria and a residual urine volume were associated with bladder recurrence in the multivariate analysis. A total of 19 patients each were selected after matching, and we confirmed a significant difference between the presence and absence of a residual urine volume (P = 0.0291). The 2-year postoperative recurrence-free rate of patients with and without a residual urine volume was 32% and 82%, respectively.

CONCLUSIONS

This is the first study to evaluate the post-void residual urine volume and intravesical recurrence rate after nephroureterectomy for upper urinary tract urothelial carcinoma. The presence of residual urine might be a risk factor for postoperative recurrence of intravesical carcinoma.

Mast Cell Accumulation and Degranulation in Rat Bladder with Partial Outlet Obstruction

INTRODUCTION

Benign prostatic hyperplasia causes partial bladder outlet obstruction (pBOO), and many patients with pBOO are affected by not only voiding symptoms but also storage symptoms. We previously suggested that enhancement of 5-hydroxytryptamine (5-HT)-induced bladder contraction in the pBOO bladder may be one cause of storage symptoms. However, little is known about the presence of 5-HT in rat bladders. In this study, we hypothesized that mast cells are a source of 5-HT and investigated the distribution of mast cells and 5-HT in the bladders of rats with pBOO.

METHODS

The bladders of female Sprague-Dawley rats were subjected to pBOO and sham operations for 1 week, were isolated, and were fixed for light or electron microscopy. Mast cells and 5-HT in the bladders were detected by toluidine blue staining and immunohistochemical staining, respectively. The mast cells were counted under a light microscope. Degranulated mast cells were observed under an electron microscope and counted under a light microscope.

RESULTS

Mast cells were present in the mucosa/submucosa region in sham rat bladders. Their number was increased in the detrusor muscle/subserosa/serosa region, especially the subserosal layer, in pBOO rat bladders. The localization of mast cells almost matched that of 5-HT-positive cells in consecutive sections. Degranulated mast cells were present in sham and pBOO rat bladders, but the proportion of degranulated mast cells was significantly increased in every region in pBOO rat bladders compared with that in sham rat bladders.

CONCLUSION

These results suggest that mast cells contain 5-HT and are more abundant locally in the subserosal layer of pBOO rat bladders. 5-HT released from mast cells could stimulate 5-HT2 receptors on the detrusor muscle, and this may underlie storage symptoms.

FUNDING

Asahi Kasei Pharma Corp.

In vivo measurement of bladder wall oxygen saturation using optical spectroscopy

Current diagnosis, follow-up and treatment of patients suffering from bladder dysfunction are mainly symptom-targeted. A recently recognized cause of continuing bladder function loss is a deteriorated bladder microvasculature. Incorporating this aspect into the clinical diagnostic toolbox may improve treatment results. Recent developments in the field of optical spectroscopy now allow for non-invasive measurement of microvascular blood oxygen saturation in living tissue. We have recently reported pre-clinical data that show that this marker can be successfully measured in an animal bladder. In the animal model the marker differentiated bladders with loss of function from those with normal function. In the present paper, we report on the first in vivo measurement of this marker in the human bladder, as proof of principle, in the muscle of bladders with a normal function.

Temporal diabetes and diuresis-induced alteration of nerves and vasculature of the urinary bladder in the rat

OBJECTIVE

• To characterize the temporal changes of the nerves and vasculature of the bladder in diabetic rats.

MATERIALS AND METHODS

• A total of 36 Sprague-Dawley rats were divided into three groups: streptozotocin-induced diabetics, 5% sucrose-induced diuretics and age-matched controls. • The characteristics of the nerves and vasculature in the equatorial cross-sectional areas of the bladder were examined by immunofluorescence staining of their specific markers, neurofilament 200 (NF200) and CD31, at 1, 9 or 20 weeks after induction. • The distributions of the nerves and blood vessels were observed and the densities were quantified.

RESULTS

• Diabetes caused a significant reduction in body weight. Bladder weight increased in diabetic and diuretic rats, but not in controls. • The total cross-sectional wall area and detrusor muscle area at the equatorial midline were greater in bladders of diabetic and diuretic rats than in controls. • Neurofilament 200-immunoreactive (NF200-IR) nerves were mainly distributed in the detrusor muscle. CD31-immunoreactive blood vessels were mainly distributed in the mucosa/submucosa. • There were no significant differences in the NF200-IR nerve terminal area among control, diabetic and diuretic groups. However nerve density was decreased at 9 and 20 weeks in the muscle, and at 20 weeks in the mucosa/submucosa in diabetic and diuretic animals. • Blood vessel density decreased in the diabetic and diuretic groups at 20 weeks in the muscle.

CONCLUSIONS

• Diabetes induced time-dependent changes in the density of the nerves and vasculature in the bladder tissues. • Diabetes-related polyuria plays an important role in these changes.

Role of angiogenesis in bladder response to partial outlet obstruction

Benign prostatic hyperplasia (BPH) is a disease that has its etiology in the abnormal growth of the adult human prostate gland that accompanies the aging process in men. The symptomatic presentation of this disease, however, is related largely to degenerative changes in the bladder that occur as a result of the increasing urethral resistance and partial bladder outlet obstruction (PBOO) caused by the growing prostate gland. BPH is characterized by bladder hypertrophy, significant decreases in urinary flow and compliance, presence of residual urine after voiding, voiding urgency and incontinence (). Obstructed bladder dysfunction secondary to BPH is a slow, progressive disease that is so strongly associated with human aging that it is an expected occurrence of the male aging process. Although the symptoms of BPH are usually not life threatening, they effect an extremely negative quality of life for men who suffer from them. However, many men delay seeking medical treatment for early BPH since bladder function can remain relatively normal as the hypertrophying bladder initially compensates for the progressive increase in urethral resistance caused by prostatic obstruction. The limited changes in micturition pressure and flow characteristics that occur during compensated function are not usually disabling enough to motivate seeking medical attention, which, often, is not sought until the symptoms become typical of advanced disease. Recent advances in detection methods enable identification of patients with significant BPH during compensation before the bladder becomes dysfunctional (decompensated). A more complete understanding of the disease processes that underlie the loss of bladder function associated with BPH might enable the development of treatments that better protect these early-stage BPH patients from the more debilitating aspects of the disease. This review updates the understanding of obstructive bladder dysfunction via the use of animal models.

Differential expression of vascular endothelial growth factor, and angiopoietin 1 and 2 in functionally divergent experimental rabbit models of bladder hypertrophy

PURPOSE

Partial bladder outlet obstruction or ovariectomy with subsequent estrogen replenishment induces bladder hypertrophy in rabbits and yet the functional outcomes of these procedures differ. We investigated whether these models might be distinguished by differential expression of the genes controlling angiogenesis.

MATERIALS AND METHODS

Groups of male rabbits underwent sham surgery or partial bladder outlet obstruction for 1 or 2 weeks. Groups of females underwent sham surgery, ovariectomy or ovariectomy plus estrogen for 1 or 2 weeks. Bladders from each group were weighed and assayed for the contractile response, smooth muscle content and vascular density. Mucosa and muscle layers were separated and RNA from the fractions was assayed by quantitative real-time polymerase chain reaction to measure the relative expression of vascular endothelial growth factor, and angiopoietin 1 and 2 mRNA.

RESULTS

Male bladders with partial outlet obstruction had attributes that typified hypertrophy with a loss of contractile function. Vascular endothelial growth factor expression was up-regulated in the mucosa and muscle layers but the effect was most pronounced in mucosa. Angiopoietin 1 expression was significantly up-regulated in muscle. Female bladders with ovariectomy plus estrogen had attributes that typified bladder hypertrophy with increased contractile function. Vascular endothelial growth factor expression was up-regulated early in mucosa but more highly and consistently increased in muscle. Angiopoietin 1 and 2 expression was not significantly affected.

CONCLUSIONS

Although these models have similar outcomes with regard to bladder hypertrophy, they have opposite functional outcomes that coincide with compartmental differences in the expression of genes involved in the regulation of angiogenesis. The disparity in gene expression might explain the difference in the functional outcomes.

Bladder outlet obstruction accelerates bladder carcinogenesis

OBJECTIVE

To examine the correlation between partial bladder outlet obstruction (PBOO) and bladder carcinogenesis.

MATERIALS AND METHODS

Female Wistar rats (6 weeks old) were divided into three groups of 10 each: group 1 was exposed to n-butyl-n-butanol nitrosamine (BBN, a carcinogen) in drinking water for 8 weeks; group 2 had PBOO induced surgically after exposure to BBN for 8 weeks; group 3 had a sham operation and the rats drank normal water (control group). After 20 weeks, all of the rats were killed humanely and their bladders analysed.

RESULTS

There were no significant differences in body weight among the groups. The bladder weight of group 2 was significantly greater than either group 1 or group 3. Histopathologically, bladder smooth muscle hypertrophy was the major cause of the increased bladder weight for group 2. In group 2 there were increases in bladder wall thickness and many nipple-shaped urothelial tumours. Basic fibroblast growth factor and hypoxia-inducible factor-1alpha expression were significantly greater in group 2 than in groups 1 and 3.

CONCLUSIONS

Exposure of the bladder to carcinogens during bladder hyperplasia and hypertrophy induced by PBOO results in a greater incidence of superficial bladder carcinoma.

Mechanical strain activates a program of genes functionally involved in paracrine signaling of angiogenesis

Studies were performed to examine the extent to which mechanical stimuli mediate control of angiogenesis in bladder cells both in vitro and in vivo. Differential gene expression between control nonstretched and cyclically stretched bladder smooth muscle cells was assessed using oligonucleotide microarrays and pathway analysis by the web tool Fast Assignment and Transference of Information (FatiGO). Data showed that a substantial proportion (33 of 86) of mechanically responsive genes were angiogenesis-related and include cytokines, growth-related factors, adhesion proteins, and matricellular, signal transduction, extracellular matrix (ECM), and inflammatory molecules. Integrative knowledge of protein-protein interactions revealed that 12 mechano-sensitive gene-encoded proteins have interacting partner(s) in the vascular system confirming their potential role in paracrine regulation of angiogenesis. Angiogenic genes include matricellular proteins such as Cyr61/CCN1, CTGF/CCN2 and tenascin C, components of the VEGF and IGF systems, ECM proteins such as type I collagen and proteoglycans, and matrix metalloproteinases. In an in vivo model of bladder overdistension, 5 of 11 mechano-responsive angiogenic genes, independently tested by real-time PCR, were upregulated as a result of pressure overload including Cyr61/CCN1, CTGF/CCN2, MCP-1, VEGF-A, MMP-1, and midkine. Meanwhile, the molecular anatomy of angiogenic gene promoters reveals the presence of GA box-binding for the myc-associated zinc finger protein, MAZ, often found adjacent to binding sites for mechano-responsive transcription factors (e.g., NF-kappaB), suggesting that the coordinated activity of these factors may induce selective angiogenic gene transcription. These data suggest that mechanical control of angiogenic genes is an integral part of the adaptive and plasticity responses to mechanical overload.

Preliminary report on analysis of bladder-wall vasculature using conjunctival microvascular analysis in patients with and without transitional-cell carcinoma

PURPOSE

To develop a technique to analyze the bladder microvasculature during cystoscopy to assess the conjuctival microvascular morphology at the capillary level. This technique could be an adjunct to visual examination of the bladder during cystoscopy for diseases that are presumed to affect the vasculature.

PATIENTS AND METHODS

Subjects with transitional-cell carcinoma (TCC) were chosen because of their frequency of cystoscopy. A total of 12 male patients, ages 45 to 80 years, underwent cystoscopy: four without TCC and eight with TCC by bladder biopsy. The images were digitally recorded and enhanced using a custom image-analysis system. The blood vessel length (VL) and diameter (VD) and blood vessel volume (BVV) were measured.

RESULTS

The VD was significantly greater in TCC than in non-TCC patients only in the lower-order vessels. The VL was significantly longer in TCC than in non-TCC, again in the lower-order vessels. In the higherorder vessels, the VL was significantly shorter in TCC than in non-TCC. The BVV in the lower-order vessels was significantly greater in TCC than in non-TCC patients.

CONCLUSIONS

Differences exist in the morphology of surface microvessels between TCC and non-TCC bladders. Using the current technique, capillaries (VD < 10 microm) are not visible, so refinement of imaging and recording technologies is required to measure capillaries in order to simulate microvascular morphometry in the conjuctiva.

EFFECT OF AGE ON RABBIT BLADDER FUNCTION AND STRUCTURE FOLLOWING PARTIAL OUTLET OBSTRUCTION

PURPOSE

We determined whether young and old rabbits respond differently to partial bladder outlet obstruction.

MATERIALS AND METHODS

A total of 16 male New Zealand White rabbits were separated into 2 groups of 8 each. Group 1 consisted of young rabbits (age 7 weeks) and group 2 consisted of old rabbits (age 2 years). Four rabbits per group underwent partial outlet obstructions and 4 underwent sham operation. Four weeks following surgery individual bladder strips were used for contractile studies and the remaining tissue was examined histologically.

RESULTS

Contractile responses to all forms of stimulation between the young and old sham operated groups were similar. Contractile responses to all forms of stimulation were significantly decreased to the same degree in the 2 obstructed groups. However, the rate of tension generation to field stimulation was decreased to a significantly greater degree in young vs old bladders. Although young and old bladders showed smooth muscle hypertrophy, older rabbits showed significantly greater thickening of the serosa than young rabbits. Young rabbits showed significant inflammation, hemorrhage and expansion of the lamina propria, whereas old rabbits showed none of these characteristics.

CONCLUSIONS

Although there were only minor differences in the physiological response of young and old bladders to obstruction, young rabbits showed a significantly greater degree of histological damage. This may have been due to the thinner wall and greater sensitivity to distention.

Regional differences in responses of rabbit detrusor to electrical and adrenergic stimulation: influence of outlet obstruction

OBJECTIVE

To examine regional responses of control and obstructed rabbit detrusor strips to electrical and adrenergic stimulation, and determine whether outlet obstruction causes regional variations in blood flow throughout the detrusor, as the detrusor smooth muscle of the bladder body has previously been considered homogeneous in its pharmacological properties.

MATERIALS AND METHODS

Fourteen male rabbits had the bladder outlet surgically obstructed for 2 weeks and were compared with 10 unoperated control rabbits. Blood flow was measured with the bladder empty and at capacity, using fluorescent microspheres. Paired dorsal and ventral strips were harvested from the midline equatorial detrusor and electrically and adrenergically stimulated.

RESULTS

Obstructed rabbits had significantly higher bladder capacities and bladder weights than control rabbits. Dorsal strips from both control and obstructed rabbits contracted in response to noradrenaline, whereas ventral strips relaxed. The addition of prazosin, a nonselective alpha1-adrenergic-receptor blocker, completely blocked the contraction in dorsal strips, but had no effect on responses of ventral strips. There was also a regional difference in response to electrical stimulation, with ventral strips generating significantly more tension than dorsal strips in both control and obstructed rabbits. There were no regional differences in detrusor blood flow. Obstruction resulted in significantly lower responses to all forms of stimulation, and significantly less blood flow throughout the detrusor.

CONCLUSION

There are regional differences in adrenergic receptor function and response to electrical-field stimulation throughout control and obstructed rabbit detrusor, a region that was previously thought to be functionally homogeneous. These differences must be recognized and acknowledged to obtain accurate and reproducible data from in vitro studies of the bladder.

Hypoxia inhibits human bladder smooth muscle cell proliferation: a potential mechanism of bladder dysfunction

AIMS

Recent animal studies have suggested that bladder outflow obstruction causes bladder wall hypoxia during both the filling and the voiding phases of the micturition cycle. We have previously demonstrated that mechanical deformation of human detrusor leads to smooth muscle (SM) cell hypertrophy and hyperplasia, which may then contribute to hypoxia in the dysfunctional bladder. We hypothesise that the detrusor's response to a hypoxic environment contributes to bladder dysfunction. The aim of this study was to evaluate the effect of hypoxia on detrusor cell survival and growth.

METHODS

Normal human detrusor muscle was obtained at radical cystectomy and primary cultures were established. Cells were then cultured in the presence of 1% oxygen in a hypoxic chamber for different times. Apoptosis was assessed by propidium iodide DNA staining and flow cytometry. Proliferation was assessed by radiolabelled thymidine incorporation. Cell supernatants were retained for growth factor estimation by enzyme linked immuno-sorbent assay (ELISA), and total cell and nuclear extracts were isolated for Western blotting.

RESULTS

SM cells responded to the presence of hypoxia through significant upregulation of survival factors hypoxia inducible factor (HIF 1alpha) and vascular endothelial growth factor (VEGF) in a time-dependent manner. Hypoxia did not induce cell death, but significantly reduced the rate of proliferation over time, associated with an increase in the cell cycle inhibitor p27kip1.

CONCLUSIONS

In an in vitro human detrusor cell culture model, cells demonstrate a resistance to hypoxia-induced apoptosis but proliferation is inhibited. We suggest that the anti-proliferative effects of hypoxia may limit the ability of detrusor cells to respond to, and compensate for, alterations in their environment contributing to bladder dysfunction.

THE MOLECULAR GENETIC BASIS OF MITOCHONDRIAL MALFUNCTION IN BLADDER TISSUE FOLLOWING OUTLET OBSTRUCTION

PURPOSE

Bladder dysfunction following partial outlet obstruction is a frequent consequence of benign prostatic hyperplasia and an increasingly common problem given the aging of the general population. Recent studies from this and other groups have begun to elucidate the molecular bases for the well described physiological malfunctions that characterize this clinical entity. We summarized and synthesized that information.

MATERIALS AND METHODS

Using modern methods of molecular genetics, including real-time polymerase chain reaction, real-time reverse transcriptase-polymerase chain reaction and others, as well as traditional experimental techniques such as electron microscopy we and others examined the transcriptional profile, morphology, etc of bladder smooth muscle mitochondria in experimental models of outlet obstruction.

RESULTS

Data from many studies have demonstrated that aberrant gene expression in the mitochondrial and mitochondria related nuclear genetic systems underlies the loss of compliance and other attributes of bladder dysfunction following outlet obstruction. Such aberrant transcriptional characteristics engender loss of function in the electron transport and oxidative phosphorylation systems. Morphological studies of mitochondria in the animal model systems support this conclusion.

CONCLUSIONS

In large part the loss of function in bladder smooth muscle following outlet obstruction results from the attenuation of mitochondrial energy production. In this article we reviewed and synthesized all available experimental observations relevant to this problem and we suggest future lines of inquiry that should prove fruitful in developing new strategies to treat the condition.

Structural and vascular response of normal and obstructed rabbit whole bladders to distension

OBJECTIVES

To investigate the structural and morphologic effect of distension after partial outlet obstruction in rabbits.

METHODS

Thirty male New Zealand white rabbits were separated into two groups: control (sham) and partial outlet obstruction (3 weeks). Three rabbits from each group were distended to 5%, 25%, 50%, 100%, and 125% of capacity. Each bladder was fixed at the volume in buffered formalin for 6 to 8 hours. Sections of dorsal and ventral bladder were blocked, and cross sections were evaluated. Quantitative morphometry was performed, and CD31 immunohistochemistry was used to characterize the vascularity.

RESULTS

Partial outlet obstruction resulted in increased bladder weight and capacity and increased thickness of the mucosa, submucosa, detrusor, and serosa. In the control bladder, the greatest thinning was seen between 5% and 25% capacity, and in the obstructed group, the greatest thinning occurred between 25% and 50%. The level of vascular collapse was significantly greater for the control bladders than for the obstructed bladders at all levels of distension. Finally, the obstructed bladders showed a significantly greater level of vascularity in the submucosa than the control bladders.

CONCLUSIONS

Normal bladder distension resulted in significant morphologic changes when the bladder was distended to 25% of capacity but changed relatively little between 25% and 125%. However, distension of the obstructed bladder resulted in significant morphologic changes when the bladder was distended from 25% to 50% of capacity but changed relatively little between 50% and 125%.

Focal hypoxia of the obstructed rabbit bladder wall correlates with intermediate decompensation

AIMS

We showed that partial obstruction of the rabbit bladder outlet caused decreases in detrusor blood flow that were directly proportional to the level of decompensation present. Bladder decompensation is characterized by decreases in detrusor contractility, mitochondrial function, and sarco/endoplasmic reticulum calcium ATPase (SERCA) activity in obstructed rabbits. The current study was designed to create bladder decompensation and to relate its characteristic dysfunctions to the presence or absence of hypoxia in the obstructed rabbit bladder wall. Tissue hypoxia was visualized immunohistochemically after administration of a hypoxia probe in vivo.

METHODS

Twelve New Zealand White rabbits were separated into two groups. The rabbits in group 1 received sham operations; the rabbits in group 2 received partial outlet obstructions by standard methods. Four weeks after surgery, each rabbit received an intraperitoneal injection of aqueous Hypoxyprobe-1, which forms protein adducts in cells having O(2) concentrations less than 14 microM. Two hours after injection, the rabbit was anesthetized and the bladder exposed through a midline incision. One full-thickness bladder strip was cut and immediately placed in fixative for immunohistochemical recognition and visualization of Hypoxyprobe-1-protein adducts. The remaining bladder was then excised, and three additional strips were cut for contractility studies. The remainder of the bladder was frozen for biochemical and slot-blot analyses.

RESULTS

Bladder weight was increased fourfold after obstruction, and significant contractile and biochemical dysfunctions were observed that indicated an intermediate level of decompensation. Immunohistochemical visualization revealed focal areas of moderate to severe hypoxia in the detrusor smooth muscle (SM) and subserosal regions of these bladders. No hypoxia was observed in the obstructed bladder mucosa, consistent with the absence of biochemical dysfunction in this compartment, or in unobstructed bladders. Slot-blot analyses confirmed the presence of significant Hypoxyprobe-1-protein adducts in the detrusor of the obstructed bladder, whereas none were present in the control bladder detrusors.

CONCLUSIONS

Partial outlet obstruction of rabbit bladders resulted in focal areas of moderate to severe hypoxia in the detrusor SM and subserosal regions concomitant with increased bladder mass, decreased contractile function, and selective metabolic dysfunctions of the SM consistent with an intermediate stage of decompensation. The metabolic characteristics of the normoxic mucosa were normal a were those of unobstructed bladders.

Acute intravesical infusion of a cobalt solution stimulates a hypoxia response, growth and angiogenesis in the rat bladder

PURPOSE

Experimental partial bladder outlet obstruction of rats induces a bladder growth and remodeling process similar to that in humans with benign prostatic hyperplasia. Previously we have proposed that bladder hypoxia associated with partial bladder outlet obstruction is a stimulus of this bladder growth process. We report our results of testing the acute effects of a simple chemical agent (cobaltous ion) known to mimic hypoxia in the rat bladder. We measured its ability to effect bladder gene expression, angiogenesis and growth processes.

MATERIALS AND METHODS

Adult rats were divided into 2 groups. One group (controls) received intravesical saline 3 times for 30 minutes in 6 days and the other received intravesical saline with 100 microM. CoCl(2) at the same times. All animals also received continuous infusion of BrdU for the 6-day period through an implanted osmotic pump. Portions of the bladders from these rats were fixed, sectioned, stained for microscopic analysis and immunohistochemically stained to identify BrdU positive cells and vascular elements via factor VIII staining. Other portions were frozen, extracted for proteins and the proteins were comparatively analyzed for the expression of hypoxia inducible factor-1alpha and vascular endothelial growth factor on Western blots.

RESULTS

Bladders infused with CoCl(2) showed extensive expansion of the submucosal region, which was significant compared with that in saline infused bladders. Cells in this expanded region as well as cells within the urothelium were found to be extensively labeled with BrdU, in contrast to control bladders, which had rare BrdU labeled cells in any region. Immunohistochemical analysis for factor VIII showed that the submucosal region of cobalt treated rats contained numerous small vessels and microvessels that were not apparent in controls. These cellular changes were consistent with our finding of increased hypoxia inducible factor-1alpha and vascular endothelial growth factor protein expression in cobalt treated bladders compared with controls.

CONCLUSIONS

Acute intravesical instillation of cobalt ion solution into the rat bladder initiated a hypoxia response accompanied by increased bladder angiogenesis and growth. This finding supports the idea that hypoxia is a stimulus for bladder growth subsequent to partial bladder outlet obstruction.

Regional differences in bladder enlargement and in vitro contractility after outlet obstruction in the rabbit

PURPOSE

Bladder outlet obstruction leads to bladder enlargement and subsequent decreases in contractile function in vivo and in vitro. We determined whether there were regional differences in bladder wall properties and in vitro contractile responses after 2 weeks of bladder outlet obstruction.

MATERIALS AND METHODS

Male rabbits underwent cystometry. The bladder was then filled to 40 ml. and the surface was marked with 2-zero silk knots placed approximately 1 cm. apart. The distance between the knots was measured at 20, 40 and 80 ml. The animals then underwent the creation of surgical obstruction. After 2 weeks the obstruction was removed. Cystometry and measurements were repeated and strips were obtained from defined dorsal and ventral areas. Contractile responses to electrical field stimulation, adenosine triphosphate, carbachol and KCl were determined and compared with strips from unobstructed controls.

RESULTS

In vivo expansion during bladder filling occurred evenly throughout the bladder wall in controls and the contractile response to all stimuli was similar in ventral and dorsal strips. After 2 weeks of bladder outlet obstruction the upper dome expanded to a significantly higher degree than the lower bladder body. The response to all stimuli was significantly reduced after bladder outlet obstruction and there was a significantly decreased response to all stimuli in dorsal compared with ventral strips. Strips from the dorsal midline showed a relaxation response to electrical field stimulation at low frequencies, whereas all ventral strips contracted.

CONCLUSIONS

Functional remodeling after bladder outlet obstruction is a process that does not occur to the same extent throughout the bladder. The obstructed bladder is an inhomogeneous organ with significant regional differences in mechanical and pharmacological properties.

Hypoxia and an angiogenic response in the partially obstructed rat bladder

Previous molecular and blood flow studies performed on animal models of partial bladder outlet obstruction (PBOO) caused us to propose that bladder hypoxia/ischemia was a significant effector of the cellular and functional changes that occur in the bladder as a result of this condition. To confirm the occurrence of hypoxia in the partially obstructed bladder, we obtained rat bladders at increasing intervals following PBOO and measured biomarkers of hypoxia (intracellular formation of hypoxyprobe-1 adducts and expression of hypoxia inducible factor-1 alpha [HIF-1 alpha] protein) and whether such hypoxia might elicit an angiogenic response in the tissue. Rats receiving PBOO or controls were treated with hypoxyprobe-1 at increasing intervals subsequent to surgery and their bladders were sectioned and immunostained using an antibody that detects hypoxyprobe-1 adducts. Control rat bladders were unstained, whereas intense, but regionally restricted, hypoxyprobe-1 immunostaining was detected in all obstructed bladders in a unique pattern that changed over time. Proteins were extracted from bladders removed from similarly treated rats and were analyzed for the expression of the HIF-1 alpha protein as well as for expression of angiogenic regulatory factors (vascular endothelial growth factor, angiopoietin-1, and endostatin) using Western blotting techniques. HIF-1 alpha protein was not expressed in control bladders, however, the protein was highly up-regulated over the 2-week period after PBOO. Likewise, the expression of vascular endothelial growth factor (a downstream target of HIF-1 alpha action) and angiopoietin-1 was also up-regulated in obstructed bladders confirming an angiogenic response to this hypoxia. Enigmatically, however, expression of the antiangiogenic molecule endostatin was also up-regulated by chronic PBOO. These results further support the concept that hypoxia is involved in the cellular remodeling as well as in the progressive functional impairment exhibited by the urinary bladder after PBOO.

Effect of doxazosin on rat urinary bladder function after partial outlet obstruction

Hypoxia induced by partial outlet obstruction is believed to play a major role in both the hypertrophic and degenerative effects of partial outlet obstruction. Doxazosin (dox) is a clinically effective alpha-adrenergic antagonist used in the treatment of symptomatic benign prostatic hyperplasia (BPH). Although the major therapeutic effect of the agent is believed to occur on the smooth muscle components of the prostate by reducing prostatic urethral resistance and thus improving emptying, dox may have part of its clinical action via effects mediated by other actions, including via spinal alpha-adrenergic receptors or direct effects on the bladder, possibly via inhibition of vascular alpha receptors. The specific aim of the current study was to determine whether dox pretreatment on rats affects blood flow to the bladder and reduces the level of bladder dysfunction induced by partial outlet obstruction. In part 1, eight rats were separated into two groups of four rats each. Group 1 received oral administration of dox (30 mg/kg) for 4 weeks; group 2 received vehicle (5% dimethyl sulfoxide). After 4 weeks of treatment, blood flow studies were performed using fluorescent microspheres and the bladders excised, frozen, and submitted to Interactive Medical Technologies (IMT) for blood flow analysis. In part 2, 32 adult male rats were separated into four groups of eight rats each. Groups 1 and 2 received oral administration of dox (30 mg/kg) for 4 weeks, groups 3 and 4 received vehicle (5% dimethyl sulfoxide). At 4 weeks, the rats in groups 1 and 3 received partial outlet obstructions and treatment continued for an additional 2 weeks. After 6 weeks of treatment (total), each rat was anesthetized, the bladder excised, weighed, and isolated strips mounted and contractility studies performed. 1) Four weeks pretreatment of rats with dox increased blood flow to the bladder in both the control and obstructed groups. 2) Partial outlet obstruction induced a mild decrease in blood flow. 3) The magnitude of the increased bladder weight in the vehicle-treated obstructed group was significantly greater than in the dox-treated obstructed group. 4) Partial outlet obstruction resulted in significant decreases in the contractile response to field stimulation in both treated and non-treated rats. The magnitude of the decreased response was significantly greater in the non-treated rats. 5) The response to potassium chloride was significantly reduced by partial outlet obstruction in the vehicle-treated group but not in the dox-treated group. 6) The time to maximal tension was significantly increased in response to carbachol, adenosine triphosphate, and potassium chloride. However, the magnitude of the increase was significantly greater for the vehicle-treated obstructed groups stimulated by potassium chloride than for the dox-treated groups. Dox treatment of rats increased blood flow to the bladder and reduced the severity of the response to partial outlet obstruction. These beneficial effects would be due to pharmacological effects on alpha-adrenergic systems outside those present in the prostate. These include effects on blood flow to the bladder, effects on the micturition centers of the central nervous system, spinal reflexes, and alpha-adrenergic receptors in the urethra and bladder.

Effects of chronic partial outlet obstruction on blood flow and oxygenation of the rat bladder

PURPOSE

Experimental partial bladder outlet obstruction in rats and rabbits drives the bladder through 3 sequential responses, referred to as hypertrophy, compensation and decompensation. The hypertrophy phase, which is a period of rapid bladder growth, has previously been shown to be accompanied by a significant increase in bladder blood flow in rats and rabbits in a manner that likely supports the bladder cell growth process. However, chronic periods of obstruction in the rabbit have been shown to reduce significantly bladder blood flow, especially to the detrusor smooth muscle, corresponding with a loss of bladder contractile function or decompensation in these animals. We determined the effects of chronic 1 to 4-week partial outlet obstruction on rat bladder blood flow and directly correlated them with hypoxia in the rat bladder.

MATERIALS AND METHODS

Rats underwent surgical partial bladder outlet obstruction under anesthesia. At weekly intervals after surgery relative blood flow to the bladder and spleen was measured by a fluorescent microsphere infusion technique. Sham operated rats were also studied 2 and 4 weeks following surgery. In a second experiment groups of similarly obstructed rats were treated with Hypoxyprobe-1 (Natural Pharmacia International, Inc., Research Triangle Park, North Carolina), a chemical probe for hypoxia, 3 days, 1 and 2 weeks after partial bladder outlet obstruction. The bladders were subsequently fixed and immunostained using a monoclonal antibody that detects Hypoxyprobe-1 adducts that are selectively formed in hypoxic cells.

RESULTS

Neither bladder weight nor bladder relative blood flow was affected by sham surgery. Likewise, control and sham obstructed rat bladders were found to be free of Hypoxyprobe-1 reactive areas. In contrast, obstructed rats had significantly increased bladder weight at all time points. Relative weight of the obstructed rat bladders indicates the response to mild-moderate obstruction. Bladder relative blood flow in obstructed rats was significantly elevated 1 and 2 weeks after partial bladder outlet obstruction but it returned to almost control levels by 3 and 4 weeks. Hypoxyprobe-1 staining demonstrated a sequential transition of hypoxia from bladder mucosa and submucosal regions at 3 days to muscularis and serosal fibroblasts 1 week and finally to smooth muscle cells by 2 weeks after obstruction.

CONCLUSIONS

In contrast to the rabbit model, global blood flow in the mild-moderate chronically obstructed rat bladder was found to be higher or nearly equivalent to blood flow in unobstructed control rat bladders. However, even in the presence of normal or above normal blood flow focal regions of hypoxia were still observed in obstructed rat bladders and these regions changed with time. These results provide a reason to understand better why rats are more resistant to the onset of bladder decompensation than rabbits and support the concept that hypoxia is involved in bladder remodeling as well as in progressive functional impairment of the bladder after partial bladder outlet obstruction.

Aspirin treatment improves bladder function after outlet obstruction in rabbits

OBJECTIVES

To examine whether bladder smooth muscle dysfunction after outlet obstruction could be altered by treatment with aspirin. Long-term outlet obstruction causes contractile and metabolic dysfunction of the bladder in vivo and in vitro. The evidence is growing that a decrease in bladder perfusion is an important cause of this phenomenon. The platelet aggregation inhibitor, acetylsalicylic acid (aspirin), has been used to improve perfusion of the heart for decades.

METHODS

Ten male New Zealand white rabbits were obstructed for 4 weeks. Five rabbits received no further treatment (Obs), and 5 rabbits received 2 mg/kg/day aspirin (Obs+aspirin), administered by an osmotic pump implanted subcutaneously 1 week before the surgical obstruction. The bleeding time was measured to confirm the effectiveness of the aspirin treatment. Three different control groups were created: sham-operated rabbits, unobstructed rabbits with pumps containing DMSO (vehicle), and unobstructed rabbits with pumps containing aspirin. The contractile responses of bladder strips to field stimulation, adenosine triphosphate, carbachol, and KCl were determined. A section of each detrusor tissue was fixed in formalin and used to determine the smooth muscle and collagen (connective tissue) volume fraction.

RESULTS

No differences were found in the bladder weights or responses to stimuli in the different control groups, which were therefore combined. Partial bladder outlet obstruction caused significant increases in the bladder weight of the obstructed animals (Obs+aspirin, 10.15 +/- 0.87 g; Obs, 10.17 +/- 0.88 g; and controls, 2.87 +/- 0.21 g). The aspirin treatment increased the bleeding time from 1.7 +/- 0.3 minutes to 3.3 +/- 0.1 minutes. The responses to field stimulation were significantly reduced in all of the obstructed rabbits. However, the responses of the bladder strips from the Obs rabbits to field stimulation were impaired to a significantly greater degree than were those from the Obs+aspirin rabbits. The response to 32-Hz stimulation was reduced by 86% in the Obs group but by only 64% in the Obs+aspirin group. The responses to carbachol were significantly reduced by 62% in the strips from the Obs rabbits, but the responses of the strips from the Obs+aspirin rabbits were similar to the responses of the strips from the controls. The responses to KCl and adenosine triphosphate were reduced, although they just failed to achieve statistical significance using Bonferroni's analysis. The ratio of smooth muscle and connective tissue shifted slightly toward smooth muscle after 4 weeks of obstruction, but no difference was found with or without aspirin treatment.

CONCLUSIONS

Low-dose aspirin has a small but significant protective effect on the contractile dysfunction induced by bladder outlet obstruction in rabbits, although the increase in bladder mass was not altered. Bladders of the same weight showed improved responses to all forms of stimulation after pretreatment with aspirin. Already used by millions of patients with heart diseases, aspirin could be a useful protection against contractile dysfunction of the obstructed bladder.

Vascular response of the rabbit bladder to chronic partial outlet obstruction

Partial outlet obstruction of the rabbit urinary bladder results, initially, in a rapid increase in bladder mass and remodeling of the bladder wall. Previously, it was shown that this response was characterized by serosal growth (thickening) which was apparent after 1 day of obstruction, before any visible vascularization was observed. After 1 week of obstruction, significant microvessel formation was seen in the transition region between the detrusor smooth muscle and the thickening serosa; after 2 weeks the entire serosa was vascularized. In this study we investigated the effect of chronic (4 week) partial outlet obstruction on microvessel density and distribution in the bladder wall immunohistochemically using CD31 as a marker for vascular endothelium. Transverse sections of bladder wall were examined after 4 weeks of no surgery, sham surgery or partial obstruction. The microvessel density of the obstructed rabbit bladder mucosa and detrusor smooth muscle increased relative to augmentation of these compartments while new vessels appeared in the thickening serosa. Although vessel density did not change with obstruction a significant shift in mean vessel circumference to the left occurred indicating a significant increase in the number of microvessels and small vessels consistent with angiogenesis.

Effect of chronic bladder outlet obstruction on blood flow of the rabbit bladder

PURPOSE

Previous studies have shown that the initial reaction of the rabbit bladder to partial bladder outlet obstruction is increased blood flow at day 1 and a return to baseline blood flow at 1 week. Mucosal and muscle blood flow followed this pattern but mucosal blood flow was always 4 to 5-fold greater. In this study we examined the effect of 4 weeks of outlet obstruction on bladder blood flow and correlated it with the severity of bladder contractile dysfunction.

MATERIALS AND METHODS

A total of 14 male New Zealand White rabbits underwent partial outlet obstruction creation by standard methods. After 4 weeks the rabbits were anesthetized, and blood flow to the muscle and mucosa was determined by standard fluorescent microsphere technique. A section of each detrusor was used for in vitro contractility studies. Contractile responses to field stimulation, carbachol and potassium chloride were determined. A section of each detrusor tissue was fixed in formalin and used to determine the smooth muscle volume fraction.

RESULTS

Four weeks of partial bladder outlet obstruction caused a significant and variable increase in bladder weight and a decrease in blood flow to bladder muscle without changes in the blood flow to mucosa. There was a clear correlation between the severity of contractile dysfunction, bladder weight and the magnitude of the decrease in blood flow in muscle. The smooth muscle volume fraction remained stable at approximately 40%.

CONCLUSIONS

Bladder decompensation was associated with decreased blood flow to bladder smooth muscle. Because compensated obstructed bladders with relatively normal contractile function are also hypertrophied but have normal blood flow, decreased blood flow in decompensated bladders is not simply a response to bladder hypertrophy. From this study we hypothesize that decreased blood flow to bladder smooth muscle is an etiological factor in bladder contractile dysfunction (bladder decompensation) secondary to partial outlet obstruction.