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Bioengineering of bladder tissue, particularly for those patients who have advanced bladder disease, requires a source of urothelium that is healthy, capable of significant proliferation in vitro and immunologically tolerated upon transplant. As pluripotent stem cells have the potential to fulfill such criteria, they provide a critical cell source from which urothelium might be derived in vitro and used clinically. Herein, we describe the in vitro differentiation of urothelium from the H9 human embryonic stem cell (hESC) line through the definitive endoderm (DE) phase via selective culture techniques. The protocol can be used to derive urothelium from other hESCs or human-induced pluripotent stem cells.

As bladder reconstruction strategies evolve, a feasible and safe source of transplantable urothelium becomes a major consideration for patients with advanced bladder disease, particularly cancer. Pluripotent stem cells, such as embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs), are attractive candidates from which to derive urothelium as they renew and proliferate indefinitely in vitro and fulfill the non-autologous and/or non-urologic criteria, respectively, that is required for many patients. This review presents the latest advancements in differentiating urothelium from pluripotent stem cells in vitro in the context of current bladder tissue engineering strategies.

In vitro generation of human urothelium from stem cells would be a major advancement in the regenerative medicine field, providing alternate nonurologic and/or nonautologous tissue sources for bladder grafts. Such a model would also help decipher the mechanisms of urothelial differentiation and would facilitate investigation of deviated differentiation of normal progenitors into urothelial cancer stem cells, perhaps elucidating areas of intervention for improved treatments. Thus far, in vitro derivation of urothelium from human embryonic stem cells (hESCs) or human induced pluripotent stem (hiPS) cells has not been reported. The goal of this work was to develop an efficient in vitro protocol for the induction of hESCs into urothelium through an intermediary definitive endoderm step and free of matrices and cell contact. During directed differentiation in a urothelial-specific medium ("Uromedium"), hESCs produced up to 60% urothelium, as determined by uroplakin expression; subsequent propagation selected for 90% urothelium. Alteration of the epithelial and mesenchymal cell signaling contribution through noncell contact coculture or conditioned media did not enhance the production of urothelium. Temporospatial evaluation of transcription factors known to be involved in urothelial specification showed association of IRF1, GET1, and GATA4 with uroplakin expression. Additional hESC and hiPS cell lines could also be induced into urothelium using this in vitro system. These results demonstrate that derivation and propagation of urothelium from hESCs and hiPS cells can be efficiently accomplished in vitro in the absence of matrices, cell contact, or adult cell signaling and that the induction process appears to mimic normal differentiation.

Purpose: Most patients who need a bioengineered bladder wall have bladder cancer. A graft made with autologous urothelium would not be safe. To investigate the feasibility of providing bioengineered tissue for patients with partial cystectomy we evaluated the host and graft response after transplanting an epithelium-free graft., Materials and Methods: De-epithelialized bladder wall grafts from male rats were transplanted on syngeneic female rat bladders after partial cystectomy. Urothelial morphology, vessel density, inflammation, stromal thickness and uroplakin expression were evaluated 1, 3, 6 and 9 months after surgery. Cell gender was distinguished by fluorescent in situ hybridization using unique X and Y chromosome probes., Results: There was no significant graft contraction at any time. Male graft urothelial morphology and uroplakin expression were similar to those of controls at all time points. The donor bladder had decreased vessel density at early time points while the host had increased vascularity, which normalized in each by 6 months. Graft inflammation and edema normalized by 9 months. There was no muscular hypertrophy. Fluorescence in situ hybridization revealed early ingrowth of host female urothelium and a small fraction of male urothelial cells, which appeared between 1 and 3 months., Conclusions: Within 9 months de-epithelialized grafts appeared histologically as normal bladder, surprisingly faster than an equivalent model with full-thickness grafts. The safety and function of an epithelium-free graft must be determined in a large animal model. These early data in a small animal model substantiate the feasibility and equivalency of using grafts without epithelium, which would allow application in patients with cancer., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Similar to other epithelia, urothelium in vivo has a hierarchal organization of cells each with specific gradients of differentiation. While distinct cell types have been described as important in bladder cancer in vitro, clonal and proliferative capacities of normal urothelial cells have not been characterized., Materials and Methods: Three cell types and colony types were identified from primary porcine urothelial culture. Proliferative activity, patterns of apoptosis and differentiation, colony forming efficiency and ability to change phenotype with passage were determined and compared., Results: Small, T-I colonies with large flattened (type-1) cells had low levels of proliferation and high levels of apoptosis. Large T-III colonies had a central area of small (type-3) cells surrounded by type-1 and type-2 cells. Proliferation and apoptosis were asymmetrically distributed in the periphery of T-II and T-III colonies. T-III colonies proved to be significantly more clonogenic and proliferative. With appropriate induction, type-1 cells were able to proliferate upon passage and form type-3 cells, yet long-term culture demonstrated that progeny of type-1 cells appeared to have inherited a clonogenic handicap., Conclusions: Type-3 cells in the centre of T-III colonies appear to harbour stem-like qualities with a relatively low proliferative and apoptotic index at homeostasis and the ability to become highly proliferative upon passage. This study demonstrates that distinct urothelial cell types with differing clonal capacities can be isolated from the bladder and these cells may have implications for tissue engineering and carcinogenesis.

Adult tissue stem cells replicate infrequently, retaining DNA nucleotide label (BrdU) for much longer periods than mature, dividing cells in which the label is diluted during a chase period. Those "label-retaining cells" (LRCs) have been identified as the tissue stem cells in skin, cornea, intestine, and prostate. However, in the urinary tract uroepithelial stem cells have not yet been identified. In this study, BrdU administration identified urothelial LRCs in the rat bladder with 9% of the epithelial basal cells retaining BrdU label 1 yr after its administration. Markers for stem cells in other tissues, Bcl, p63, cytokeratin 14, and beta1 integrin, were immunolocalized in the basal bladder epithelium in or near urothelial LRCs, but not uniquely limited to these cells. Flow cytometry demonstrated that urothelial LRCs were small, had low granularity, and were uniquely beta4 integrin bright. Urothelium from long-term labeled bladders was cultured and LRCs were found to be significantly more clonogenic and proliferative, characteristics of stem cells, than unlabeled urothelial cells. Thus, this work demonstrates that LRCs in the bladder localize to the basal layer, are small, low granularity, uniquely beta4 integrin rich, slowly cycling and demonstrate superior clonogenic and proliferative ability compared with unlabeled epithelial cells. We propose that LRCs represent putative urothelial stem cells.

Objectives: Because the trigone is a unique region in the caudal bladder with a higher risk of neoplasia, we hypothesized that this area would have a high proportion of progenitor cells. As yet there is no marker nor methodology to specifically isolate urothelial stem cells, and thus demonstrate multi-potential differentiation and self-renewal. Here, our goal was to evaluate the distribution of progenitor cells that carry two general major attributes of stem cells: clonogenicity and proliferative capacity., Materials and Methods: The bladders of Fisher rats were divided into caudal and cephalic segments and primary cultures were established from the harvested urothelial cells., Results: We found that colony-forming efficiency was almost 2-fold higher for cells from the caudal bladder compared to the cephalic bladder. Doubling time was significantly faster for cells harvested from the caudal bladder at initial plating. This suggested that the caudal bladder harbours a higher density of urothelial progenitor cells. With passage to p4, the differences between the upper and lower bladder were lost, suggesting selection of proliferative cells with serial passage. Based on Ki-67 staining, there was no geographical difference in cell proliferation under normal homeostatic in vivo conditions., Conclusions: These results demonstrate geographical sequestration of urothelial progenitor cells to the area of the bladder that encompasses the bladder neck and trigone, which may be a factor in pathological disparities between the trigone and remaining bladder.

With a lack of distinct stem cell markers, isolation of tissue-specific stem cells for tissue engineering and gene therapy is a great challenge. Beta (beta)(1) integrin expression has been used as a way of enriching for putative epithelial stem cells through rapid adhesion to collagen IV or flow cytometry. This is a first report of enrichment of putative urothelial stem cells using rapid adhesion and flow cytometric methods. We assessed our success by determining the clonogenic and proliferative potential of the isolated cells. We demonstrated that enrichment based on beta(1) integrin expression with flow cytometry yields highly clonogenic and proliferative urothelial cells, whereas the rapid adhesion method is not as efficient, possibly because of the unique nature of urothelium, a transitional epithelium, compared to results reported in stratified and columnar epithelia.

Purpose: The rat has been a cost-effective model for the evaluation of bladder development, cancer and stromal-epithelial interactions. Serial cultivation of rat urothelium has been difficult. We developed a reliable protocol for the harvest, serial cultivation and cryopreservation of rat urothelium. We investigated the differentiation markers of in vivo bladder urothelium compared with cells reconstituted onto an acellular bladder matrix., Materials and Methods: Epithelial harvest techniques using trypsin and collagenase were compared. Medium and conditions were optimized for serial culture and growth characteristics were calculated. Cultured cells were cryopreserved, and then recovered and grown on acellular bladder matrices. Morphology and markers of differentiation were compared between normal bladder and engineered grafts using scanning electron microscopy (SEM) and immunohistochemistry., Results: Atraumatic enzymatic removal of urothelium with trypsin yielded more cells with greater viability than collagenase. Cells could be reliably grown beyond 10 passages using fibroblast conditioned medium and a 3T3 feeder layer during initial passages. Cryopreserved cells were successfully recovered and incorporated onto acellular matrices. Immunostaining and SEM of engineered grafts demonstrated early markers of differentiation, such as surface microvilli and cytokeratin 17, on polygonal cells with typical tight junctions., Conclusions: Rat urothelium can be reliably grown using fibroblast conditioned medium and a 3T3 feeder layer during primary culture. Serially passaged cells can survive cryopreservation and they are able to reconstitute epithelium on an acellular bladder matrix. Cells that are incorporated into the matrix express markers of early differentiation and demonstrate typical morphological characteristics by SEM. These culture techniques and this in vitro organoid model should facilitate the use of rat urothelium.