Evaluation of the ISL1 gene in the pathogenesis of bladder exstrophy in a Swedish cohort

Bladder exstrophy is a congenital closure defect of the urinary bladder with a profound effect on morbidity. Although the malformation is usually sporadic, a genetic background is supported by an increased recurrence risk in relatives, higher concordance rates in monozygotic twins and several associated chromosomal aberrations. Recently, the ISL1 gene was presented as a candidate gene for bladder exstrophy and epispadias complex (BEEC) development in two different studies. In our study, we screened for genetic variants in the ISL1 gene in DNA from 125 Swedish patients using Sanger sequencing and array-CGH analysis. In addition, we evaluated ISL1 expression in RNA of human bladder during embryonic and fetal weeks 5–10 relative to that in lung tissue (week 9). In total, 21 single-nucleotide variants were identified, including a potentially novel missense variant, c.137C>G p.(Ala46Gly), substituting a conserved amino acid. This variant was inherited from an unaffected mother. No structural variants were identified. RNA sequencing revealed ISL1 mRNA expression during the critical time frame of human bladder development. In conclusion, we did not detect any known or likely pathogenic variants in the ISL1 gene in 125 Swedish BEEC patients, indicating that variation in the ISL1 gene is not a common genetic mechanism of BEEC development in the Swedish population.

Genome-wide association study and mouse expression data identify a highly conserved 32 kb intergenic region between WNT3 and WNT9b as possible susceptibility locus for isolated classic exstrophy of the bladder

Bladder exstrophy-epispadias complex (BEEC), the severe end of the urorectal malformation spectrum, has a profound impact on continence as well as sexual and renal functions. It is widely accepted that for the majority of cases the genetic basis appears to be multifactorial. Here, we report the first study which utilizes genome-wide association methods to analyze a cohort comprising patients presenting the most common BEEC form, classic bladder exstrophy (CBE), to identify common variation associated with risk for isolated CBE. We employed discovery and follow-up samples comprising 218 cases/865 controls and 78 trios in total, all of European descent. Our discovery sample identified a marker near SALL1, showing genome-wide significant association with CBE. However, analyses performed on follow-up samples did not add further support to these findings. We were also able to identify an association with CBE across our study samples (discovery: P = 8.88 × 10(-5); follow-up: P = 0.0025; combined: 1.09 × 10(-6)) in a highly conserved 32 kb intergenic region containing regulatory elements between WNT3 and WNT9B. Subsequent analyses in mice revealed expression for both genes in the genital region during stages relevant to the development of CBE in humans. Unfortunately, we were not able to replicate the suggestive signal for WNT3 and WNT9B in a sample that was enriched for non-CBE BEEC cases (P = 0.51). Our suggestive findings support the hypothesis that larger samples are warranted to identify association of common variation with CBE.

Paediatric robotic surgery in clinical practice: a cost analysis

BACKGROUND

Since 2006 we have used robotic assistance when performing minimally invasive laparoscopic fundoplications in children. We compared the costs of robotic surgery with the costs for open and laparoscopic surgery to test our hypothesis that the increased costs of the new technology are acceptable.

METHOD

Costs were calculated using the regional hospital prices for our first 14 fundoplications in children, performed with the aid of the da Vinci Surgical System from Intuitive Surgical. We compared these costs with those of our ten latest fundoplications performed using open and laparoscopic surgery, respectively. There were no differences in the demographic data, work-up or indications for surgery between the three groups of children.

RESULTS

The mean cost of robotic surgical fundoplications (EUR 9 584) was 7% higher than the mean cost of laparoscopic surgery (EUR 8 982) and 9% lower than the mean costs for open surgical procedures (EUR 10 521). These differences can be explained by the increased cost of robotic instruments (EUR 2 081 per operation). The duration of the operation and the duration of in-hospital stay are comparable to those of laparoscopic surgical interventions. The time required for the operative intervention was considerably longer than for the open surgical procedure; the duration of the in-hospital stay was only half of that of the open surgical procedure. The patients seemed to benefit from the use of robotic instruments with less morphine (as a marker of less postoperative pain) and a shorter hospital stay.

CONCLUSION

The introduction of robotic assistance into surgical practice involves increased in-hospital costs, mainly because of the cost of the new instruments. This increase in cost can be offset by the shorter hospital stay compared to open surgery. After laparoscopic surgery the hospital stay is about the same as after operations performed with robotic assistance. Cheaper instruments and shorter operating time will make robotic surgery cost efficient in the future. The benefit for the patients is less trauma due to the use of minimally invasive surgery and a shorter hospital stay. Thus, the higher initial costs may be considered worthwhile.

Bladder exstrophy: psychological impact during childhood

PURPOSE

We describe the impact of bladder exstrophy on the behavior, self-esteem and quality of life of children as well as on the parents, and analyze the need for psychological intervention.

MATERIALS AND METHODS

All 7 boys and 8 girls 3 to 18 years old (median age 11) under treatment at a tertiary pediatric surgery clinic were included in our followup study. Medical and psychological evaluations were performed. Behavior was assessed using the semistructured Höök-Cederblad Child Behavior Interview and the Child Behavior Checklist questionnaire. Self-esteem was assessed by the self-rating I Think I Am questionnaire. Children and parents were interviewed separately. Quality of life was estimated using the Multiattribute Health Status Mark II classification system.

RESULTS

After repeat operations and hospitalization 10 children were dry, although 9 required catheterization. Four children had some behavioral problems, which were manifest in 2. All but 1 male adolescent had good or very good self-esteem. Quality of life was decreased in most cases due to limited self-care, although emotional problems were few. All mothers had experienced the birth as a traumatic event and 5 parents had had psychiatric symptoms.

CONCLUSIONS

Self-esteem may be maintained despite multiple operations, urinary leakage and deviant genitalia but the abnormality had a great impact on children and on the lives of the families. Parents and children required individual intervention from a multidisciplinary team during different stages of childhood.

Bladder exstrophy in Sweden--a long-term follow-up study

A retrospective review of all new cases of bladder exstrophy in Sweden in 1970 through 1989 is presented. The aim was to evaluate management of the malformation in Sweden and possibly identify factors that might improve the outlook. The incidence was 1:33,500 births. Records were reviewed of the 61 children (37 males and 24 females) treated at Sweden's four specialist centers of pediatric surgery. There was one perinatal death. Primary management was mainly early bladder closure (within 72 hours), late closure or perinatal urinary diversion. Subsequent measures included augmentation cystoplasty, bladder neck reconstruction, provision of continent urinary reservoir and penile reconstruction. The follow-up time was 4-19 years. In 15 cases renal scarring developed, though with impairment of total function in only three. Ten patients achieved continence, defined as 3-hour dry intervals, of whom four had urinary reservoirs with continent stoma. Urinary tract infections were recorded during follow-up in 43% of the surviving patients, though the true incidence of infection presumably was higher. To improve management of bladder exstrophy in sparsely populated Sweden, a nation-wide strategy of ongoing interhospital collaboration has been adopted. Results will be continuously presented.