Bladder Exstrophy-epispadias Complex Patients Research Articles

Bladder exstrophy–epispadias complex: The effect of urotherapy on incontinence

IntroductionAchieving urinary continence is a key goal in children born with the bladder exstrophy-epispadias complex (BEEC). Unfortunately, this goal is only moderately achieved despite sometimes extensive surgical treatment. Undergoing repeated hospitalization and operations may consequently have a negative impact on quality of life. We therefore believe that other, conservative treatment options should be explored in an earlier stage of incontinence treatment in BEEC patients. As part of this, an intensive urotherapy program based on was offered to patients with persistent incontinence after reconstructive surgery for BEEC. ObjectiveThe aim of this study is to evaluate the benefits of intensive urotherapy on incontinence after reconstructive surgery in children with BEEC. Study designA retrospective chart study was performed including all children who were enrolled in an intensive urotherapy program because of persistent incontinence after reconstructive surgery for BEEC. Urotherapy consisted of a ten-day inpatient training program based on cognitive behavioral therapy, with intensive follow-up by experienced urotherapists. Main outcome measurement was continence, expressed as the percentage of children that achieved complete continence (good result; 100% dry) or 50-99% decrease of wet days a week (improved result) after treatment. ResultsData of 33 patients with a mean age of 10.6 years were analyzed. In 61% of cases (20/33) an improved or good result was reported on incontinence after urotherapy. Children with classic bladder exstrophy more often achieved a good or improved result (13/16; 81%), compared to children with epispadias (6/16; 38%). The only patient with a cloacal exstrophy completed treatment with an improved result. From the group of patients with persistent incontinence, 75% (12/16) reported that the complaints were socially acceptable at the end of follow-up. DiscussionBy following our intensive urotherapy program the majority of patients achieved complete continence or improved incontinence. In addition, our results show that the inpatient training program has a positive impact on acceptance in cases of persistent incontinence. The urotherapists offer individualized care and clear guidance, which we deem essential elements of successful treatment. Considering that repeated surgery may impede progress and offers no guarantee of continence, we recommend giving preference to conservative treatment options ConclusionOur results show that 37% (12/33) of patients with BEEC who were enrolled in our intensive urotherapy program because of persistent incontinence after reconstructive surgery, achieved complete continence after urotherapy and 63% (21/33) still experienced some degree of incontinence. 75% of patients who did not achieve complete continence, described the remaining incontinence as socially acceptable. These findings strongly support counselling patients with BEEC to consider conservative treatment before opting for further surgery.

EDITORIAL COMMENT

The authors are to be commended in their maintenance of a database of their bladder exstrophy-epispadias complex patients which has served as a valuable tool for assessing outcomes and the evolution of care of exstrophy patients over time. The authors have a large referral population, but because most patients who seek care at a referral center following closure elsewhere do so because of complications or being dissatisfied with their care, the outcomes data of patients treated initially at an outside institution tend to be biased. Thus, the authors have carefully omitted any comparison between outcomes at their institution vs those done at an outside facility. The real strength and impact of this study comes from looking at how trends at the authors institution, a high-volume center of excellence, have changed over time.

Global surgical collaboration to treat bladder exstrophy-epispadias in India led to a larger geographical catchment area

Background A gap of care exists in low- and middle-income countries (LMICs) for patients with complex urogenital abnormalities, such as bladder exstrophy-epispadias complex (BEEC). A successful primary surgical repair is critical for optimal long-term outcomes for BEEC, but the availability of such a complex procedure is limited by the expertise needed to deliver a successful initial repair. We hypothesize that a long-term, multi-institutional collaboration based at a tertiary institution in a LMIC may improve outcomes for BEEC by encouraging earlier referrals for the first repair, rather than after failed repairs, and also increase the geographical catchment area by encouraging more distant referrals, once the availability of care becomes widely known. Methods A long-term collaboration between two US academic research centers and the Civil Hospital in Ahmedabad, Gujarat, India was formed in 2009. This collaboration expanded later to include another US and one Middle Eastern hospital system. The entire post-operative cohort of the collaboration was recalled in 2019 and 2020, when epidemiology and demographic surveys were obtained from 82 patients. Results Since 2009, the collaboration has grown overall. The geographical catchment area for referrals and distance traveled by patients to reach the collaboration site has increased to include nine states in India and surrounding countries in Southeast Asia (P = 0.044). Patients traveling from farther distances tended to be of higher socioeconomic status than local referrals (P = 0.041). Conclusions The success of the International Bladder Exstrophy Consortium to improve the care for BEEC patients in India and Southeast Asia is visible from its changing demographics. Patients, some even from families of a higher socioeconomic status, are traveling farther to receive care at a government-funded tertiary hospital. While not all positive benefits of a global surgery collaboration regarding earlier and primary referrals have been achieved, the collaboration is seeing benefits that align with a staged process of referrals. The continued commitment to creating a center of excellence is a model for sustained success for global surgery collaborations.

The Role of Bladder Neck Injection in the Quest for Continence

The Role of Bladder Neck Injection in the Quest for Continence

The exstrophy experience: A national survey assessing urinary continence, bladder management, and oncologic outcomes in adults

The bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of congenital genitourinary malformations with an incidence of 1:10,000 to 1:50,000. Advances in reconstructive surgical techniques have improved clinical outcomes, but there is a paucity in data about disease sequela in adulthood. This is the largest survey to date in the United States exploring the urinary continence, bladder management, and oncologic outcomes in adults with BEEC. Respondents were over the age of 18 with a diagnosis of bladder exstrophy, cloacal exstrophy, or epispadias. They were treated at the authors' institution, included in the Association for the Bladder Exstrophy Community (A-BE-C) mailing list, and/or engaged in A-BE-C social media. A survey was created using uniquely designed questions and questionnaires. Survey responses between May 2020 and July 2020 were processed using Research Electronic Data Capture (REDCap). Quantitative and qualitative statistics were used to analyze the data with significance at p<0.05. A total of 165 patients completed the survey. The median age was 31.5 years (IQR 25.9-45.9). Many patients considered themselves continent of urine, with a median satisfaction score of 74 (IQR 50-97) on a scale from 0 (consider themselves to be completely incontinent) to 100 (consider themselves to be completely continent). There was less leakage among those with a continent urinary diversion compared to those who void or catheterize per urethra (p=0.003). Patients with intestinal-urinary tract reconstruction, such as augmentation cystoplasty or neobladder creation, were more likely to perform bladder irrigations (p=0.03). Patients with continent channels were more likely to report UTI than all other forms of bladder management (89.0% vs. 66.2%, p=0.003). Three (1.9%) patients were diagnosed with bladder cancer. A small portion of patients (27.2%) were given bladder cancer surveillance recommendations by a physician. Most patients achieved a satisfactory level of urinary continence, with the highest continence rates in those with a continent urinary diversion. Those with intestinal-urinary tract reconstruction were more likely to perform bladder irrigations, perhaps to avoid complications from intestinal mucous production. The rates of self-reported UTI and were higher in patients with continent channels, but recurrent UTIs were not affected by the type of genitourinary reconstruction. Bladder cancer exists in this population, highlighting the need for long-term follow-up. Most BEEC patients achieve a satisfactory level of urinary continence, with the best outcomes in those with a continent urinary diversion. This population requires long-term follow-up with a transitional urologist to ensure adequate oncologic care.

Bladder Herniation as an Auto-Augmentation Technique in Bladder Exstrophy: Initial Experience in Patients with Small Bladder Plate

ObjectiveTo present our long-term experience of bladder plate herniation technique in patients with bladder exstrophy epispadias complex (BEEC) and inadequate bladder plate. MethodsTen BEEC patients with inadequate bladder plates were referred. The bladder underlying fascia was opened and the exstrophic bladder was fixed above the peritoneal cavity to herniate the peritoneal contents beneath the bladder plate so that the abdominal pressure would be directly transferred to the posterior bladder wall; causing gradual bladder expansion and auto-augmentation. In 5 patients, the inguinal hernia was fixed to increase the pressure transferred to the exstrophic bladder. The bladder capacity was measured while the patient was crying and when the bladder was enlarged. Cystometry and voiding cystourethrogram were performed before the application of this technique and during the next 6 to 8 months, to determine the bladder capacity for further primary bladder closure. ResultsThe bladder was enlarged during straining/crying without any complications. The average bladder capacity was increased about 2.5 to 3 times after 8 months of follow-up so that it was suitable for undergoing primary closure. None of the children needed bladder augmentation following the single-stage total BEEC reconstruction. ConclusionThis technique seems to be safe, effective, and feasible in patients with small-sized bladder and may be performed before the primary closure to increase the success rate. This technique may be effective in increasing the bladder capacity for staged bladder closure and bladder neck reconstruction without further need for bladder augmentation.

Health-related quality of life among children, adolescents, and adults with bladder exstrophy-epispadias complex: a systematic review of the literature and recommendations for future research.

Bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of genitourinary malformations. Children risk long-term urinary and genital dysfunctions. To achieve a comprehensive understanding, this study aimed to review the literature on generic and disease-specific health-related quality of life (HRQOL) in BEEC patients, and methodologies used. A literature search was conducted in Pubmed/CINAHL/Embase/PsycINFO/Cochrane, from inception to May 2018. A meta-analysis of HRQOL in BEEC patients compared to healthy references was performed. Twenty-one articles (published 1994-2018), describing HRQOL of children and adolescents (n = 5) and adults only (n = 5), or integrated age populations (n = 11), were identified (median sample size 24, loss to follow-up 43%, response rate 84%). Overall HRQOL was reduced in BEEC patients compared to healthy references in 4/4 studies. Impaired physical or general health in BEEC patients has been described in 9 articles, diminished mental health in 11, restricted social health in 10, and sexual health/functioning or body perception impairments in 13 articles. Urinary incontinence was the most common factor related to worse HRQOL (12 studies). In six studies, HRQOL was better than healthy norms. In eligible studies (n = 5), the pooled estimate of the effect of BEEC indicated worse HRQOL for children and adults (0 > effect sizes < 0.5). Thirty-six HRQOL assessments were used, none developed and validated for BEEC. HRQOL in BEEC patients may be negatively impacted, particularly considering mental and social HRQOL. Sexual health/functioning or body perception impairments may be present in adolescents and adults. However, HRQOL is heterogeneously assessed and subsequent findings are differently reported. Additional research is warranted and can be improved.

Genetics of Bladder-Exstrophy-Epispadias Complex (BEEC): Systematic Elucidation of Mendelian and Multifactorial Phenotypes.

The Bladder-Exstrophy-Epispadias Complex (BEEC) represents the severe end of the uro-rectal malformation spectrum, and has a profound impact on continence, and on sexual and renal function. While previous reports of familial occurrence, in-creased recurrence among first-degree relatives, high concordance rates among monozygotic twins, and chromosomal aberra-tions were suggestive of causative genetic factors, the recent identification of copy number variations (CNVs), susceptibility regions and genes through the systematic application of array based analysis, candidate gene and genome-wide association studies (GWAS) provide strong evidence. These findings in human BEEC cohorts are underscored by the recent description of BEEC(-like) murine knock-out models. Here, we discuss the current knowledge of the potential molecular mechanisms, mediating abnormal uro-rectal development leading to the BEEC, demonstrating the importance of ISL1-pathway in human and mouse and propose SLC20A1 and CELSR3 as the first BEEC candidate genes, identified through systematic whole-exome sequencing (WES) in BEEC patients.

No TAP63 promoter mutation is detected in bladder exstrophy–epispadias complex patients

Background/PurposeBladder exstrophy–epispadias complex (BEEC) is thought to have a genetic component in its pathogenesis. Previously we found that p63−/− mice show increased ventral apoptosis and develop a BEEC phenotype. Down-regulation of the anti-apoptotic ΔNP63 and an up-regulation of pro-apoptotic TAP63 isoforms have been demonstrated in BEEC patient bladder tissues. We have previously shown that insertion/deletion polymorphisms of the ΔNp63 promoter are associated with an increased risk of BEEC. In this study, we specifically examined the TAP63 promoter to see if any sequence changes might lead to up-regulation of TAP63 and exaggerated apoptosis in BEEC patients. Methodsi) Bioinformatic analysis of the TAP63 promoter was performed to identify putative regulatory regions. ii) High-resolution Melt and Sanger sequencing was used to screen targeted regions in 112 BEEC patient DNA samples for potential sequence variants. iii) Sequence variation was analysed for significance against normal population frequency data. Resultsi) We identified multiple epigenetic markers of transcriptional regulation within highly conserved areas of the TAP63 promoter sequence. ii) Of the 112 buccal swab DNA samples, adequate and successful screening ranged between 48 and 67 for each region. iii) No novel sequence variation or mutation was uncovered. iv) Two known SNPs were identified. However, allele frequency analysis was not statistically significant. ConclusionOur data do not associate genetic variation within the TAP63 promoter region with an increased risk of BEEC. Our data so far suggests that only ΔNP63 promoter aberration is involved in BEEC pathogenesis.

Candidate gene association study implicates p63 in the etiology of nonsyndromic bladder‐exstrophy‐epispadias complex

Bladder-exstrophy-epispadias complex (BEEC) is a severe congenital anomaly that represents a spectrum of urological abnormalities where parts or all of the distal urinary tract fail to close during development. Multiple lines of evidence strongly suggested p63 as a plausible candidate gene. We conducted a candidate gene association study to further investigate the role of p63 in human BEEC. We conducted a family-based association study of p63 using 154 Caucasian patients with nonsyndromic BEEC and their unaffected parents. High throughput single nucleotide polymorphism (SNP) genotyping was carried out using Illumina's Golden Gate Assay for 109 selected tagging SNPs localized within p63 with a minor allele frequency > 0.01. Individual and haplotype SNP transmission disequilibrium tests were conducted using Plink and Haploview, respectively. We also examined parent-of-origin effects using paternal asymmetry tests implemented in FAMHAP (http://famhap.meb.uni-bonn.de/index.html). Nominally significant associations were identified between BEEC and six SNPs (rs17447782, rs1913720, rs6790167, rs9865857, rs1543969, rs4687100), and four haplotype blocks including or near these significant SNPs. Analysis of parent-of-origin effects showed significant results for seven SNPs (rs4118375, rs12696596, rs6779677, rs13091309, rs7642420, rs1913721, and rs1399774). None of these results remained significant after multiple testing correction. The altered transmission of p63 variants in nonsyndromic BEEC patients may be suggestive of its involvement in the disease etiology. Further and large multi-institutional collaborative studies are required to elucidate the role of p63 in nonsyndromic BEEC.

Insertion/Deletion Polymorphisms in the ΔNp63 Promoter Are a Risk Factor for Bladder Exstrophy Epispadias Complex

Bladder exstrophy epispadias complex (BEEC) is a severe congenital anomaly; however, the genetic and molecular mechanisms underlying the formation of BEEC remain unclear. TP63, a member of TP53 tumor suppressor gene family, is expressed in bladder urothelium and skin over the external genitalia during mammalian development. It plays a role in bladder development. We have previously shown that p63−/− mouse embryos developed a bladder exstrophy phenotype identical to human BEEC. We hypothesised that TP63 is involved in human BEEC pathogenesis. RNA was extracted from BEEC foreskin specimens and, as in mice, ΔNp63 was the predominant p63 isoform. ΔNp63 expression in the foreskin and bladder epithelium of BEEC patients was reduced. DNA was sequenced from 163 BEEC patients and 285 ethnicity-matched controls. No exon mutations were detected. Sequencing of the ΔNp63 promoter showed 7 single nucleotide polymorphisms and 4 insertion/deletion (indel) polymorphisms. Indel polymorphisms were associated with an increased risk of BEEC. Significantly the sites of indel polymorphisms differed between Caucasian and non-Caucasian populations. A 12-base-pair deletion was associated with an increased risk with only Caucasian patients (p = 0.0052 Odds Ratio (OR) = 18.33), whereas a 4-base-pair insertion was only associated with non-Caucasian patients (p = 0.0259 OR = 4.583). We found a consistent and statistically significant reduction in transcriptional efficiencies of the promoter sequences containing indel polymorphisms in luciferase assays. These findings suggest that indel polymorphisms of the ΔNp63 promoter lead to a reduction in p63 expression, which could lead to BEEC.

Pregnancy management in women within the bladder–exstrophy–epispadias complex (BEEC) after continent urinary diversion

Management of operative delivery in pregnant women after reconstruction of the bladder-exstrophy-epispadias complex (BEEC) using bowel segments remains a challenge. We report urological history, pregnancy and delivery course of two BEEC patients after previous abdominal bowel surgeries. One had an ileocecal pouch after previously failed reconstruction, and the other had an ileum augmentation and a catheterizable Mitrofanoff stoma after functional reconstruction of the exstrophic bladder. Frequent bacteriuria and hydronephrosis warranted low-dose prophylaxis throughout pregnancy in one female, bilateral mild upper tract dilatation sonographic monitoring in both patients. Both were successfully delivered by cesarean section. No complications or clinical and sonographic signs for prolapse occurred. However, our operative experience revealed the importance of the abdominal incision type after different reconstructed reservoirs. Though care should be intense in pregnant BEEC individuals, patients should not be discouraged to have own children. To facilitate successful pregnancy outcome operative delivery should be done as a interdisciplinary team work and emergency situations should be avoided by meticulous planning and counseling of the BEEC patients.

P63 (TP73L) a key player in embryonic urogential development with significant dysregulation in human bladder exstrophy tissue

Human bladder exstrophy-epispadias complex (BEEC) comprises a spectrum of urogenital anomalies in which part or all of the distal urinary tract fails to close. Several lines of evidence implicate genetic factors in the formation of BEEC. Among them a murine p63+/+ knockout model showed the full picture of classic exstrophy of the bladder and other urogenital defects within the BEEC spectrum. This led us to study in depth the role of p63 in urogenital development in mice and investigate the implication of p63 in human BEEC. Whole mount in situ analysis in mice was carried out to investigate the ventro-caudal expression of the p63 transcript at gestational days (GD) 9.5-12.5, the equivalent of human gestational weeks 4-6 (postulated time of BEEC organogenesis in humans). In addition, p63 expression analysis was performed in human blood and bladder derived samples of 15 BEEC newborns accompanied by sequencing analysis of their genomic DNA. We also conducted sequencing analysis of genomic DNA in additional 22 BEEC patients. In mouse embryos, p63 expression was detected at days 9.5-12.5 in the cloacal membrane and urethral epithelium, supporting its role in the morphogenesis of the external genitalia and the bladder. Tissue-specific expression of a novel and already-known mRNA isoforms were established and a reproducible dysregulation of variable p63 isoforms was observed in 11 of 15 patients indicating altered gene expression. However, no obvious p63 gene mutations were identified in any of the patients. Our findings strongly suggest that p63 is not only involved in embryonic formation of the urogenital and ventrocaudal anatomy but is also highly dysregulated in human BEEC bladder tissue. Since p63 has been shown to self-regulate its expression through a balance of its isoforms, the dysregulation observed may contribute to the formation of BEEC.

Long-term follow-up of male patients after reconstruction of the bladder–exstrophy–epispadias complex: Psychosocial status, continence, renal and genital function

There is a paucity of knowledge about long-term outcome issues in the bladder-exstrophy-epispadias complex (BEEC). Adult male BEEC patients were investigated in respect of bladder and renal function, fertility, genital function and psychosocial facts. In a cross-sectional study, 17 adult male BEEC patients (mean age 23.4 years) from a single centre were evaluated with a questionnaire, renal and bladder ultrasound, blood tests, hormonal profile and semen analysis. Phenotypically one patient had complete epispadias and 16 had classical bladder exstrophy. Five patients underwent a one-stage functional reconstruction as a primary and 12 as a redo procedure. After a mean follow-up of 19.4 years, 15 bladders were preserved with 12 voiding per urethram and 3 performing intermittent catheterization; 2 were secondarily diverted. Significant residual urine was present in 10; kidneys were normal in 14 patients. Sixteen patients proved ejaculations, 3 had normospermia, 7 oligoasthenospermia and 6 azospermia. In patients with only one single bladder neck procedure normospermia was statistically significant. After functional BEEC reconstruction, long-term bladder function is preserved with mostly normal renal function. The number of bladder neck attempts has a significant influence on andrologic outcome. Detailed analysis may detect multifactorial pathogenesis from the impaired sperm quality in the BEEC.

Biometry of the pubovisceral muscle and levator hiatus assessed by three‐dimensional ultrasound in females with bladder exstrophy–epispadias complex after functional reconstruction

The congenital bony and musculoskeletal defect of the pelvis in bladder exstrophy-epispadias complex (BEEC) highly predisposes females to uterine prolapse. There is a paucity of knowledge on the anatomy of the pelvic soft tissue structures following surgery. The aim of this study was to investigate with transperineal three-dimensional (3D) ultrasound the pubovisceral muscle in females with BEEC who had undergone surgical reconstruction in childhood. In a cross-sectional observational study we examined 12 Caucasian female BEEC patients, mean age 19.9 (range, 15.5-27.4) years, from a single center after a single-stage functional reconstruction with closure of the anterior pelvic ring. As a control group we used 13 Caucasian nulligravidae. 3D transperineal ultrasound volumes were acquired with the patient at rest in the supine position and with an empty bladder, and established pelvic floor parameters were measured. Analysis was conducted offline by two independent investigators. No statistical difference between the BEEC patients and the control group was observed in the anteroposterior diameter or the area of the levator hiatus, or in the maximal thickness of the levator muscle. However, significantly greater values were observed in BEEC patients in the transverse diameter of the levator hiatus (mean, 4.31 vs. 3.81 cm, P = 0.046) and in the levator angle (mean, 80.1 vs. 70.0 degrees, P = 0.040). The measurements obtained in the control group were consistent with those previously reported in the literature. This is the first study showing that transperineal 3D ultrasound can be used for the assessment of BEEC patients after functional reconstruction. Biometric pelvic floor parameters may be useful in the long-term follow-up of BEEC patients.

Diagnostic and therapeutic effects of a low-dose human chorionic gonadotropin (HCG) stimulation test in incontinent boys with bladder exstrophy/epispadias complex (BEEC)

Purpose To evaluate the effects of a low dose HCG test on structural changes of the lower urinary tract and urinary incontinence in boys with a history of complete reconstruction of the BEEC. Material and methods From April 2000 to March 2005, 11 pre-pubertal boys with a mean age of 7.5 years (range 5-11 years) were included in our study. All patients underwent bladder neck reconstruction due to bladder exstrophy (n=7) or classical epispadiais (n=4). All boys had grade I-II incontinence following surgery and received 12 intramuscular injections of 250IU HCG during a 4 week-period. The prostate size, bladder capacity, and bladder neck diameter were estimated using 3D-sonography or pelvic MRI prior to and after injections. The structural changes, uroflowmetric studies, and incontinence scores were compared before and after the HCG test. Results The patients were followed up for 1.5 to 6 (mean 4) years. The total prostate size and bladder capacity increased and the bladder neck diameter decreased in all patients. In all children, the incontinence score improved; 6 boys became continent for a period of 3-6 weeks and 3 boys became continent in long-term follow-up through the puberty. No major side effect was found following treatment. All patients were treated with a combination of anticholinergic, alpha adrenergic, and imipramine or minimally-invasive endoscopic injection of a bulking agent. No patient required open surgical reconstruction of the bladder neck. Conclusions Our preliminary results suggest that the low dose HCG test is a safe and a valuable modality in the treatment and prognostic evaluation of boys with BEEC who suffer from low grade incontinence. The data also reveal the role of prostate enlargement following puberty in the improvement of urinary incontinence in BEEC patients. Moreover, chronic treatment of boys with HCG increases bladder capacity that may facilitate future reconstructive surgery. However no test-responder patients of the present series required open surgical intervention. To evaluate the effects of a low dose HCG test on structural changes of the lower urinary tract and urinary incontinence in boys with a history of complete reconstruction of the BEEC. From April 2000 to March 2005, 11 pre-pubertal boys with a mean age of 7.5 years (range 5-11 years) were included in our study. All patients underwent bladder neck reconstruction due to bladder exstrophy (n=7) or classical epispadiais (n=4). All boys had grade I-II incontinence following surgery and received 12 intramuscular injections of 250IU HCG during a 4 week-period. The prostate size, bladder capacity, and bladder neck diameter were estimated using 3D-sonography or pelvic MRI prior to and after injections. The structural changes, uroflowmetric studies, and incontinence scores were compared before and after the HCG test. The patients were followed up for 1.5 to 6 (mean 4) years. The total prostate size and bladder capacity increased and the bladder neck diameter decreased in all patients. In all children, the incontinence score improved; 6 boys became continent for a period of 3-6 weeks and 3 boys became continent in long-term follow-up through the puberty. No major side effect was found following treatment. All patients were treated with a combination of anticholinergic, alpha adrenergic, and imipramine or minimally-invasive endoscopic injection of a bulking agent. No patient required open surgical reconstruction of the bladder neck. Our preliminary results suggest that the low dose HCG test is a safe and a valuable modality in the treatment and prognostic evaluation of boys with BEEC who suffer from low grade incontinence. The data also reveal the role of prostate enlargement following puberty in the improvement of urinary incontinence in BEEC patients. Moreover, chronic treatment of boys with HCG increases bladder capacity that may facilitate future reconstructive surgery. However no test-responder patients of the present series required open surgical intervention.

Bladder exstrophy–epispadias complex: Investigation of suppressor of variegation, enhancer of zeste and Trithorax (SET) as a candidate gene in a large cohort of patients

The bladder exstrophy-epispadias complex (BEEC) describes a rare anterior midline defect with variable expression involving the infra-umbilical abdominal wall, including the pelvis, urinary tract and external genitalia. It is assumed that the underlying cause of BEEC is a multifactorial mode of inheritance; however, its aetiology remains unknown. Only a few BEEC patients with distinctive cytogenetic features such as numeric or structural chromosomal abnormalities have been reported. The observation of translocations concerning the region of chromosome 9q32-q34.1 in two patients implies that this region bears a candidate gene which, during early blastogenesis, governs the development of this primary field. In this context, we considered the suppressor of variegation, enhancer of zeste and Trithorax (SET) gene, located at chromosome 9q34, to be a good candidate, as the protein encoded is involved in the regulation of cell proliferation and differentiation. Moreover, SET expression was detected in embryonic kidney. A total of 33 patients affected with BEEC were analysed for mutations in the SET gene. SET analysis did not reveal either a mutation or the presence of four single-nucleotide polymorphisms (dbSNP124) already described in the database. The data obtained in this study most likely exclude the SET gene as a possible genetic cause of BEEC. Hence, other genes in this region may contribute to the development of this midline defect.