A Quantitative Histological Analysis of the Bladder in Classical Bladder Exstrophy in Various Stages of Reconstruction Utilizing Color Morphometry

  • Dennis S. Peppas
  • Marie-Blanche Tchetgen
  • Benjamin R. Lee
  • Robert D. Jeffs
  • John P. Gearhart



The use of color image analysis to evaluate the contribution of collagen and smooth muscle in a given organ has been well described. We have recently reported on the subtypes of collagen found in normal neonatal bladders and in bladders of newborn exstrophy patients. Much debate continues in the Pediatric Urologic literature regarding the quality of the bladder in exstrophy patients. Despite what is believed to be adequate reconstruction in the exstrophy or epispadias patient, some children fail to attain a capacity required for the development of a satisfactory continence interval. The authors attempt to quantify using color morphometry, the relative amounts of collagen and smooth muscle in the exstrophic bladder at various stages of reconstruction and in newborn normal bladders

Materials and Methods

Bladder biopsies were obtained from the area just above the trigone in fifteen patients with classic bladder exstrophy and compared to sections obtained from nine neonatal bladders. All specimens were stained with Masson’s Trichrome technique, highlighting the extracellular matrix as blue and smooth muscle as red. All specimens were then analyzed using color image analysis system.


The collagen/smooth muscle ratio in control bladders was 0.36 ± 0.06. In those patients closed within one week of birth, the collagen/smooth muscle ratio was found to be 0.83 ± 0.46. In late closure and failed initial closure patients, the collagen smooth muscle ratio was 3.66 ± 2.3. In patients with undergoing bladder neck reconstruction the tissue/matrix ratio was 0.87 ± 0.39. These results indicate that compared with control bladder specimens, the bladder in exstrophy has an increased collagen to smooth muscle ratio. Delay in closure or failed initial closure is associated with a markedly increased COLL:SM ratio. However, once the bladder is successfully closed, the ratio returns to that level found at early closure prior to bladder neck reconstruction or augmentation.


Multiple factors are involved in the successful reconstruction of the exstrophy patient. Should dehiscence, chronic infections, multiple repairs (bladder closures and bladder neck reconstructions) etc. be minimized, their role determining which children will develop a satisfactory continence level may be eliminated. Therefore, the long term outcome in children born with classic bladder exstrophy may correlate most with the organization of smooth muscle and collagen as well as the type of collagen, rather than the relative amounts.


Bladder Neck Bladder Exstrophy Bladder Compliance Bladder Calculus Muscle Ratio 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Hollowell, J.G., Ransley, P.G.: Surgical management of incontinence in bladder exstrophy. Brit J. Urol., 68: 543, 1991.CrossRefGoogle Scholar
  2. 2.
    Hollowell, J.G., Hill, P.D., Duffy, P.G., Ransley, P.G.: Bladder function and dysfunction in exstrophy and epispadias. Lancet 338: 926, 1991.PubMedCrossRefGoogle Scholar
  3. 3.
    Peppas, D.S., Gearhart, J.P., Jeffs, R.D.: Genitourinary reconstruction in classic bladder exstrophy: Results of a seventeen year experience in a single institution. J Urol (submitted)Google Scholar
  4. 4.
    Husmann, D.A., McLorie, G.A., Churchill, B.M.: Closure of the exstrophic bladder: An evaluation of factors leading to its success and its importance on urinary continence. J Urol., 142: 522, 1989.PubMedGoogle Scholar
  5. 5.
    Shapiro, E., Jeffs, R.D., Gearhart, J.P., Lepor, H.: Muscarinic cholinergic receptors in bladder exstrophy: insights into surgical management. J Urol 134: 308, 1985.PubMedGoogle Scholar
  6. 6.
    Jeffs, R.D., Charrois, R., Many, M., Juriansz, A.R.: Primary closure of the exstrophied bladder. Current controversies in Urologic Management. Edited by R. Scott. Philadelphia: W.B. Saunders Co., pp. 226-242, 1972.Google Scholar
  7. 7.
    Gearhart, J.P.: Failed bladder exstrophy repair - Evaluation and Management. Urol Clin North Amer. 18: 4, 1991.Google Scholar
  8. 8.
    Gearhart, J.P.: Bladder neck reconstruction in the incontinent child. Dialogues Pediatr Urol. 10 October 1997.Google Scholar
  9. 9.
    Lais, A., Padiocci, N., Ferro, F., Bosman, C., Boldrini, R., Caione, R: The fate of smooth muscle in exstrophy-epispadias. Abstract American Academy of Pediatrics Urology Section, San Francisco, CA Oct 15 1995.Google Scholar
  10. 10.
    Kim K., Kogan, B., Massad, C., Huang, Y-C.: Collagen and Elastin in the normal fetal bladder. J Urol., 146: 524, 1991.PubMedGoogle Scholar
  11. 11.
    Culp, D.: The histology of the exstrophied bladder. J Urol. 91: 5, 1964.Google Scholar
  12. 12.
    Engel, R., Wilkinson, H.: Bladder Exstrophy. J Urol. 104: 699, 1970.PubMedGoogle Scholar
  13. 13.
    Rudin, L., Tannenbaum, M., Lattimer, J.: Histologic analysis of the exstrophied bladder after anatomical closure. J Urol. 108:802, 1972,Google Scholar
  14. 14.
    Shapiro, E., Becich, M. Perlman, E., Lepor, H.: Bladder wall abnormalities in myelodysplastic bladders: a computer assisted morphometric analysis. J Urol. 145: 1024, 1991.PubMedGoogle Scholar
  15. 15.
    Ewalt, D., Howard, P., Blyth, B., Snyder, III, H., Duckett, J., Levin, R., Macarak, E.: Is lamina propria matrix responsible for normal bladder compliance? J Urol. 148: 544, 1992.PubMedGoogle Scholar
  16. 16.
    Kim, K., Kogan, B., Massad, C., Huang, Y-C.: Collagen and elastin in the obstructed fetal bladder. J Urol. 146: 528, 1991.PubMedGoogle Scholar
  17. 17.
    Lais, A., Paolocci, N., Ferro, F., Bosman, C., Boldrini, R., Caione, P.: Morphometric analysis of smooth muscle in the exstrophy-epispadias complex. J Urol., 156: 819, 1996.PubMedCrossRefGoogle Scholar
  18. 18.
    Lee, B.R., Perlman, E.J., Partin, A.W., Jeffs, R.D., Gearhart, J.P.: Evaluation of smooth muscle and colla-gen subtypes in the normal and bladder exstrophy patient. J Urol., 156: 2034, 1996.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1999

Authors and Affiliations

  • Dennis S. Peppas
    • 1
  • Marie-Blanche Tchetgen
    • 1
  • Benjamin R. Lee
    • 1
  • Robert D. Jeffs
    • 1
  • John P. Gearhart
    • 1
  1. 1.The James Buchanan Brady Urological Institute Department of Urology Division of Pediatric UrologyThe Johns Hopkins Hospital The Johns Hopkins University School of MedicineBaltimoreUSA

Personalised recommendations