Publications by authors named "Tom F Lue"

267 Publications

Mineralized Peyronie's plaque has a phenotypic resemblance to bone.

Acta Biomater 2021 Nov 21. Epub 2021 Nov 21.

Division of Biomaterials and Bioengineering, Department of Preventative and Restorative Dental Sciences, School of Dentistry, University of California San Francisco, California, United States of America; Department of Urology, School of Medicine, University of California, San Francisco, California, United States of America. Electronic address:

Mineralized Peyronie's plaque (MPP) impairs penile function. The association, colocalization, and dynamic interplay between organic and inorganic constituents can provide insights into biomineralization of Peyronie's plaque. Human MPPs (n = 11) were surgically excised, and the organic and inorganic constituents were spatially mapped using multiple high-resolution imaging techniques. Multiscale image analyses resulted in spatial colocalization of elements within a highly porous material with heterogenous composition, lamellae, and osteocytic lacuna-like features with a morphological resemblance to bone. The lower (520 ±179 mg/cc) and higher (1024 ± 155 mg/cc) mineral density regions were associated with higher (11%) and lower (7%) porosities in MPP. Energy dispersive X-ray and micro-X-ray fluorescent spectroscopic maps in the higher mineral density regions of MPP revealed higher counts of calcium (Ca) and phosphorus (P), and a Ca/P ratio of 1.48 ± 0.06 similar to bone. More importantly, higher counts of zinc (Zn) were localized at the interface between softer (more organic to inorganic ratio) and harder (less organic to inorganic ratio) tissue regions of MPP and adjacent softer matrix, indicating the involvement of Zn-related proteins and/or pathways in the formation of MPP. In particular, dentin matrix protein-1 (DMP-1) was colocalized in a matrix rich in proteoglycans and collagen that contained osteocytic lacuna-like features. This combined materials science and biochemical with correlative microspectroscopic approach provided insights into the plausible cellular and biochemical pathways that incite mineralization of an existing fibrous Peyronie's plaque. STATEMENT OF SIGNIFICANCE: Aberrant human penile mineralization is known as mineralized Peyronie's plaque (MPP) and often results in a loss of form and function. This study focuses on investigating the spatial association of matrix proteins and elemental composition of MPP by colocalizing calcium, phosphorus, and trace metal zinc with dentin matrix protein 1 (DMP-1), acidic proteoglycans, and fibrillar collagen along with the cellular components using high resolution correlative microspectroscopic techniques. Spatial maps provided insights into cellular and biochemical pathways that incite mineralization of fibrous Peyronie's plaque in humans.
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http://dx.doi.org/10.1016/j.actbio.2021.11.025DOI Listing
November 2021

Microenergy acoustic pulses promotes muscle regeneration through in situ activation of muscle stem cells.

J Orthop Res 2021 Oct 17. Epub 2021 Oct 17.

Department of Orthopaedic Surgery, San Francisco Veterans Affair Health Care System, San Francisco, California, USA.

Microenergy acoustic pulses (MAP) is a modified low-intensity extracorporeal shock wave therapy that currently used for treating musculoskeletal disorders. However, its function on muscle regeneration after ischemia-reperfusion injury (IRI) remains unknown. This study aimed to explore the effect of MAP on muscle injury after IRI and its underlying mechanisms. Ten-week-old C57BL/6J mice underwent unilateral hindlimb IRI followed with or without MAP treatment. Wet weight of tibialis anterior muscles at both injury and contralateral sides were measured followed with histology analysis at 3 weeks after IRI. In in vitro study, the myoblasts, endothelial cells and fibro-adipogenic progenitors (FAP) were treated with MAP. Cell proliferation and differentiation were assessed, and related gene expressions were measured by real-time PCR. Our results showed that MAP significantly increased the muscle weight and centrally nucleated regenerating muscle fiber size along with a trend in activating satellite cells. In vitro data indicated that MAP promoted myoblast proliferation and differentiation and endothelial cells migration. MAP also induced FAP brown/beige adipogenesis, a promyogenic phenotype of FAPs. Our findings demonstrate the beneficial function of MAP in promoting muscle regeneration after IR injury by inducing muscle stem cells proliferation and differentiation.
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http://dx.doi.org/10.1002/jor.25184DOI Listing
October 2021

Managing Sexual Dysfunction in 2021 and Beyond.

Urol Clin North Am 2021 Nov;48(4):xv-xvi

Department of Urology, University of California, San Francisco, 400 Parnassus Avenue, Suite A-610, San Francisco, CA 94143-0739, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ucl.2021.07.004DOI Listing
November 2021

Penile Fractures: Evaluation and Management.

Urol Clin North Am 2021 Nov 21;48(4):557-563. Epub 2021 Aug 21.

Department of Urology, University of California San Francisco, San Francisco, CA, USA. Electronic address:

Penile fracture is a urologic injury with an etiology that varies based on the cultural milieu. Diagnosis can be made based on history and physical examination alone. Patients should be evaluated with RUG or cystoscopy when urethral injury is suspected. Ultrasound or MRI is a helpful adjunct when the diagnosis is unclear, and can assist in identifying the location of the rupture. Surgical management is favored over conservative measures to improve outcomes. Delayed surgical repair may not be inferior to immediate intervention.
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http://dx.doi.org/10.1016/j.ucl.2021.06.011DOI Listing
November 2021

Corrigendum to "Physicochemical and biochemical spatiotemporal maps of a mouse penis". [J. Biomech. 101 (2020) 109637].

J Biomech 2021 Aug 25;125:110563. Epub 2021 Jun 25.

Division of Biomaterials and Bioengineering, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA, United States; Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, United States. Electronic address:

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http://dx.doi.org/10.1016/j.jbiomech.2021.110563DOI Listing
August 2021

Low-intensity pulsed ultrasound stimulates proliferation of stem/progenitor cells: what we need to know to translate basic science research into clinical applications.

Asian J Androl 2021 Nov-Dec;23(6):602-610

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA 94143, USA.

Low-intensity pulsed ultrasound (LIPUS) is a promising therapy that has been increasingly explored in basic research and clinical applications. LIPUS is an appealing therapeutic option as it is a noninvasive treatment that has many advantages, including no risk of infection or tissue damage and no known adverse reactions. LIPUS has been shown to have many benefits including promotion of tissue healing, angiogenesis, and tissue regeneration; inhibition of inflammation and pain relief; and stimulation of cell proliferation and differentiation. The biophysical mechanisms of LIPUS remain unclear and the studies are ongoing. In recent years, more and more research has focused on the relationship between LIPUS and stem/progenitor cells. A comprehensive search of the PubMed and Embase databases to July 2020 was performed. LIPUS has many effects on stem cells. Studies show that LIPUS can stimulate stem cells in vitro; promote stem cell proliferation, differentiation, and migration; maintain stem cell activity; alleviate the problems of insufficient seed cell source, differentiation, and maturation; and circumvent the low efficiency of stem cell transplantation. The mechanisms involved in the effects of LIPUS are not fully understood, but the effects demonstrated in studies thus far have been favorable. Much additional research is needed before LIPUS can progress from basic science research to large-scale clinical dissemination and application.
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http://dx.doi.org/10.4103/aja.aja_25_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8577250PMC
April 2021

Regenerating Urethral Striated Muscle by CRISPRi/dCas9-KRAB-Mediated Myostatin Silencing for Obesity-Associated Stress Urinary Incontinence.

CRISPR J 2020 12;3(6):562-572

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, California, USA; Department of Chemical and Systems Biology, ChEM-H, Stanford University, Stanford, California, USA.

Overweight females are prone to obesity-associated stress urinary incontinence (OA-SUI), and there are no definitive medical therapies for this common urologic condition. This study was designed to test the hypothesis that regenerative therapy to restore urethral striated muscle (stM) and pelvic floor muscles might represent a valuable therapeutic approach. For the experiment, single-guide RNAs targeting myostatin () were used for CRISPRi/dCas9-Kruppel associated box (KRAB)-mediated gene silencing. For the experiment, a total of 14 female lean ZUC-Lepr 186 and 14 fatty ZUC-Lepr 185 rats were used as control and CRISPRi-MSTN treated groups, respectively. The results indicated that lentivirus-mediated expression of MSTN CRISPRi/dCas9-KRAB caused sustained downregulation of MSTN in rat L6 myoblast cells and significantly enhanced myogenesis . , the urethral sphincter injection of lentiviral-MSTN sgRNA and lentiviral-dCas9-KRAB significantly increased the leak point pressure, the thickness of the stM layer, the ratio of stM to smooth muscle, and the number of neuromuscular junctions. Downregulation of with CRISPRi/dCas9-KRAB-mediated gene silencing significantly enhanced myogenesis and It also improved urethral continence in the OA-SUI rat model.
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http://dx.doi.org/10.1089/crispr.2020.0077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757699PMC
December 2020

Molecular mechanism of action of low-intensity extracorporeal shockwave therapy for regenerating penile and peripheral nerves.

Turk J Urol 2020 Oct 9. Epub 2020 Oct 9.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, USA.

Sufficient functional repair of damaged peripheral nerves is a big clinical challenge in terms of long-lasting morbidity, disability, and economic costs. Nerve damage after radical prostatectomy is the most common cause of erectile dysfunction (ED). In recent years, low-intensity extracorporeal shockwave therapy (Li-ESWT) has been explored to improve the outcomes of peripheral nerve repair and regeneration. Research indicated that application of Li-ESWT after nerve surgery promoted nerve regeneration and improved the functional outcomes, underlined the mechanisms related to increase of neurotrophic factors, Schwann cells activation, and cellular signaling activation for cell activation and mitosis induced by Li-ESWT. We searched PubMed for articles related to research on these topics in both in vitro and in vivo animal models and found numerous studies suggesting that the application Li-ESWT could be a novel treatment for ED induced by nerve injury and other disease related to nerve injury.
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http://dx.doi.org/10.5152/tud.2020.20419DOI Listing
October 2020

Clinical Outcomes of Periprocedural Antithrombotic Therapy in Ischemic Priapism Management.

J Sex Med 2020 11 14;17(11):2260-2266. Epub 2020 Aug 14.

Department of Urology, University of California - San Francisco, San Francisco, CA, USA; Department of Biostatistics and Epidemiology, University of California - San Francisco, San Francisco, CA, USA. Electronic address:

Background: Priapism is a urologic emergency consisting of a painful erection lasting greater than 4 hours; antithrombotic therapy (ATT) have recently been recommended as an adjunct in the treatment of ischemic priapism.

Aim: To determine the short- and long-term outcomes of periprocedural ATT in the management of acute ischemic priapism.

Methods: A retrospective review of patients seen at the University of California, San Francisco, from 2008 to 2019 was carried out to identify those evaluated for acute priapism. Information regarding duration of priapism, etiology, treatment, periprocedural and postprocedural ATT type and dose, and follow-up data was collected.

Outcomes: ATT use was the exposure of interest; outcome variables included priapism resolution, repeat episodes, long-term complications, and follow-up.

Results: 70 patients with at least 1 detailed record of an acute priapism episode between 2008 and 2019 were identified. Of the 70 patients who underwent management for an acute episode of priapism, 59 (84%) received intracavernous injection of phenylephrine with or without corporal aspiration. Of the 4 patients who received ATT at the same time as intracavernous injection, none had additional priapism episodes. In the 55 patients who did not receive immediate ATT, 22 (40%) required at least 1 shunting procedure. The 9 patients who received ATT concurrently with shunting experienced less recurrence than the 13 patients who did not receive ATT (11% vs 69%, respectively P = .012). There were no significant differences in long-term erectile dysfunction (P = .627), fibrosis (P = .118), genitourinary pain (P = .474), and urinary issues (P = .158) between those who received ATT and those who did not.

Clinical Implications: Our findings suggest that ATT has a role in preventing priapism recurrence; we observed that long-term repeat priapism episodes are less frequent in those who received periprocedural ATT compared with those who did not and that ATT may especially reduce recurrence in cases when shunting was required STRENGTHS & LIMITATIONS: This is the first study looking at the clinical outcomes of periprocedural ATT in the management of ischemic priapism. It is limited by the fact that it is a single-center study, types of ATT were heterogenous, and the exact timing of priapism management could not be measured for everyone.

Conclusion: In spite of its limitations, these preliminary findings are promising and warrant further exploration of the use of ATT in the management of ischemic priapism. Ramstein JJ, Lee A, Cohen AJ, et al. Clinical Outcomes of Periprocedural Antithrombotic Therapy in Ischemic Priapism Management. J Sex Med 2020;17:2260-2266.
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http://dx.doi.org/10.1016/j.jsxm.2020.07.013DOI Listing
November 2020

Exosome Released From Schwann Cells May Be Involved in Microenergy Acoustic Pulse-Associated Cavernous Nerve Regeneration.

J Sex Med 2020 09 12;17(9):1618-1628. Epub 2020 Jul 12.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA. Electronic address:

Background: Neurogenic erectile dysfunction (ED) is often refractory to treatment because of insufficient functional nerve recovery after injury or insult. Noninvasive mechano-biological intervention, such as microenergy acoustic pulse (MAP), low-intensity pulsed ultrasound, and low-intensity extracorporeal shockwave treatment, is an optimal approach to stimulate nerve regeneration.

Aim: To establish a new model in vitro to simulate nerve injury in neurogenic ED and to explore the mechanisms of MAP in vitro.

Methods: Sprague-Dawley rats were used to isolate Schwann cells (SCs), major pelvic ganglion (MPG), and cavernous nerve with MPG (CN/MPG). SCs were then treated with MAP (0.033 mJ/mm, 1 Hz, 100 pulses), and SC exosomes were isolated. The MPG and CN/MPG were treated with MAP (0.033 mJ/mm, 1 Hz) at different dosages (25, 50, 100, 200, or 300 pulses) or exosomes derived from MAP-treated SCs in vitro.

Outcomes: Neurite growth from the MPG fragments and CN was photographed and measured. Expression of neurotropic factors (brain-derived neurotrophic factor, nerve growth factor, and neurotrophin-3) was checked.

Results: Neurite outgrowth from MPG and CN/MPG was enhanced by MAP in a dosage response manner, peaking at 100 pulses. MAP promoted SC proliferation, neurotropic factor (brain-derived neurotrophic factor, nerve growth factor, and neurotrophin-3) expression, and exosome secretion. SC-derived exosomes significantly enhanced neurite outgrowth from MPG in vitro.

Clinical Implications: MAP may have utility in the treatment of neurogenic ED by SC-derived exosomes.

Strength & Limitations: We confirmed that MAP enhances penile nerve regeneration through exsomes. Limitations of this study include that our study did not explore the exact mechanisms of how MAP increases SC exosome secretion nor whether MAP modulates the content of exosomes.

Conclusion: This study revealed that neurite outgrowth from MPG was enhanced by MAP and by SC-derived exosomes which were isolated after MAP treatment. Our findings indicate that one mechanism by which MAP induces nerve regeneration is by stimulation of SCs to secrete exosomes. Peng D, Reed-Maldonado AB, Zhou F, et al. Exosome Released From Schwann Cells May Be Involved in Microenergy Acoustic Pulse-Associated Cavernous Nerve Regeneration. J Sex Med 2020;17:1618-1628.
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http://dx.doi.org/10.1016/j.jsxm.2020.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483773PMC
September 2020

Delayed Treatment With Low-intensity Extracorporeal Shock Wave Therapy in an Irreversible Rat Model of Stress Urinary Incontinence.

Urology 2020 Jul 10;141:187.e1-187.e7. Epub 2020 Apr 10.

Department of Urology, Knuppe Molecular Urology Laboratory, School of Medicine, University of California, San Francisco, CA. Electronic address:

Objective: To determine the outcomes and mechanisms of delayed low-intensity extracorporeal shock wave therapy (Li-ESWT) in a rat model of irreversible stress urinary incontinence (SUI).

Materials And Methods: Twenty-four female Sprague-Dawley rats were randomly assigned into 3 groups: sham control, vaginal balloon dilation + β-aminopropionitrile (BAPN; SUI group), and vaginal balloon dilation + BAPN + treatment with Li-ESWT (SUI-Li-ESWT group). An irreversible SUI model was developed by inhibiting the urethral structural recovery with BAPN daily for 5 weeks. Thereafter, in the SUI-Li-ESWT group, Li-ESWT was administered twice per week for 2 weeks. After a 1-week washout, all 24 rats were evaluated with functional and histologic studies at 17 weeks of age. Endogenous progenitor cells were detected via the EdU-labeling method.

Results: Functional analysis with leak point pressure testing showed that the SUI-Li-ESWT group had significantly higher leak point pressures compared with untreated rats. Increased urethral and vaginal smooth and striated muscle content and increased thickness of the vaginal wall were noted in the SUI-Li-ESWT group. The SUI group had significantly decreased neuronal nitric oxide /tyrosine hydroxylase positive nerves ratio in the smooth muscle layers of the urethra, while the SUI-Li-ESWT group had neuronal nitric oxide/tyrosine hydroxylase+ nerves ratio similar to that of the control group. The continuality of urothelial cell lining was also improved in the SUI-Li-ESWT group. In addition, there were significantly increased EdU-positive cells in the SUI-Li-ESWT group.

Conclusion: Li-ESWT appears to increase smooth muscle content in the urethra and the vagina, increase the thickness of urethral wall, improve striated muscle content and neuromuscular junctions, restore the integrity of the urothelium, and increase the number of EdU-retaining progenitor cells in the urethral wall.
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http://dx.doi.org/10.1016/j.urology.2020.03.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7321915PMC
July 2020

The future of penile prostheses for the treatment of erectile dysfunction.

Transl Androl Urol 2020 Mar;9(Suppl 2):S244-S251

University of California, San Francisco, CA, USA.

Penile prostheses (both inflatable and malleable) are standard care in the management of erectile dysfunction (ED). Introduced over 45 years ago, modern penile implants have evolved greatly during that period of time and now represent the cutting edge in materials science and function. Despite the introduction of highly effective oral pharmacotherapy for ED, these devices have remained relevant and will almost certainly remain so for the foreseeable future. Despite their high degree of efficacy, there is always potential for further improvements in both implants themselves and the surgical techniques and processes used for their placement. In this manuscript we speculate on the future of penile implants, based in large part on the historical perspective and recent developments in the implant surgery space. We include recommendations on future technical innovations, post-operative management, and novel implant designs that may revolutionize the future management of ED.
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http://dx.doi.org/10.21037/tau.2019.09.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108986PMC
March 2020

Microenergy acoustic pulses induced myogenesis of urethral striated muscle stem/progenitor cells.

Transl Androl Urol 2019 Oct;8(5):489-500

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA.

Background: Stress urinary incontinence (SUI) is a common disorder with high prevalence in women across their life span, but there are no non-surgical curative options for the condition. Stem cell-based therapy, especially endogenous stem cell therapy may be a potential treatment method for SUI. The aims of this study are to identify, isolate, and assay the function of urethral striated muscle derived stem/progenitor cells (uMDSCs) and to assess uMDSC response to microenergy acoustic pulses (MAP).

Methods: Urethral striated muscle was identified utilizing 3D imaging of solvent organs (3DISCO) and immunofluorescence (IF). uMDSCs were isolated and purified from Zucker Lean (ZL) (ZUC-LEAN) (ZUC-Leprfa 186) rats, with magnetic-activated cell sorting (MACS) and pre-plating methods. The stemness and differentiation potential of the uMDSCs were measured by cell proliferation, EdU, flow cytometry, IF, and Western blot.

Results: Comparison of the cell proliferation assays between MACS and pre-plating reveals the advantage of MACS over pre-plating. In addition, the study reveals that uMDSCs form myotubes when treated with MAP.

Conclusions: The uMDSCs within female rat urethral striated muscle could be a therapeutic target of MAP in managing SUI.
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http://dx.doi.org/10.21037/tau.2019.08.18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842786PMC
October 2019

What Is Shockwave Therapy?

J Sex Med 2020 04 7;17(4):565-569. Epub 2020 Feb 7.

Department of Urology, Memorial Sloan Kettering Cancer Center, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jsxm.2020.01.004DOI Listing
April 2020

Physicochemical and biochemical spatiotemporal maps of a mouse penis.

J Biomech 2020 03 16;101:109637. Epub 2020 Jan 16.

Division of Biomaterials and Bioengineering, Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA, United States; Department of Urology, School of Medicine, University of California San Francisco, San Francisco, CA, United States. Electronic address:

Spatiotemporal mechanobiology resulting in penile pathologies continues to be investigated using small scale animals models such as mice. However, species-dependent functional biomechanics of a mouse penis, is not known. In this study, spatial mapping of a mechanosensitive transcription factor, scleraxis (Scx), at ages 4, 5, 6 weeks, and 1 year were generated to identify mechanoactive regions within penile tissues. Reconstructed volumes of baculum collected using micro X-ray computed tomography illustrated significantly increased baculum length with decreased porosity, and increased mineral density (p < 0.05) with age. The bony-baculum was held centrally in the Scx positive corpus cavernosum glandis (CCG), indicating mechanoactivity within the struts in a 6 week old mouse. The struts also were stained positive for fibrillar proteins including collagen and elastin, and globular proteins including protein gene product 9.5, and α-smooth muscle actin. The corpus cavernosum penis (CCP) contained significantly (p < 0.05) more collagen than CCG within the same penis, and both regions contained blood vessels with equivalent innervation at any given age. Comparison of volumes of flaccid and erect penile forms revealed functional characteristics of the CCP. Results of this study provided insights into biomechanical function of the CCG; in that, it is a high-pressure chamber that stiffens the penis and is similar to the human corpus cavernosum.
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http://dx.doi.org/10.1016/j.jbiomech.2020.109637DOI Listing
March 2020

Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model.

J Sex Med 2020 03 27;17(3):400-411. Epub 2020 Jan 27.

Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA. Electronic address:

Introduction: The human placenta provides a bountiful and noncontroversial source of stem cells which have the potential for regeneration of injured tissue. These cells may restore erectile function after neurovascular tissue injury such as that seen in radical pelvic surgeries and pelvic trauma.

Aim: To determine the effect of human placenta-derived stem cells on erectile function recovery and histological changes at various time points in a cavernous nerve injury rat model and to study the fate of injected stem cells throughout the regenerative process.

Methods: Human placental stem cells (PSCs) were dual labeled with monomeric Katushka far red fluorescent protein (mKATE)-renLUC using a lentivirus vector. A pelvic neurovascular injury-induced erectile dysfunction model was established in male, athymic rats by crushing the cavernous nerves and ligating the internal pudendal neurovascular bundles, bilaterally. At the time of defect creation, nonlabeled PSCs were injected into the corpus cavernosum at a concentration of 2.5 × 10 cells/0.2 mL. The phosphate-buffered saline-treated group served as the negative control group, and age-matched rats (age-matched controls) were used as the control group. Erectile function, histomorphological analyses, and Western blot were assessed at 1, 6, and 12 weeks after model creation. The distribution of implanted, dual-labeled PSCs was monitored using an in vivo imaging system (IVIS). Implanted cells were further tracked by detection of mKATE fluorescence in histological sections.

Main Outcome Measure: The main outcome measure includes intracavernous pressure/mean arterial pressure ratio, neural, endothelial, smooth muscle cell regeneration, mKATE fluorescence, and IVIS imaging.

Results: The ratio of intracavernous pressure to mean arterial pressure significantly increased in PSC-injected rats compared with phosphate-buffered saline controls (P < 0.05) at the 6- and 12-week time points, reaching 72% and 68% of the age-matched control group, respectively. Immunofluorescence staining and Western blot analysis showed significant increases in markers of neurons (84.3%), endothelial cells (70.2%), and smooth muscle cells (70.3%) by 6 weeks in treatment groups compared with negative controls. These results were maintained through 12 weeks. IVIS analysis showed luminescence of implanted PSCs in the injected corpora immediately after injection and migration of cells to the sites of injury, including the incision site and periprostatic vasculature by day 1. mKATE fluorescence data revealed the presence of PSCs in the penile corpora and major pelvic ganglion at 1 and 3 days postoperatively. At 7 days, immunofluorescence of penile PSCs had disappeared and was diminished in the major pelvic ganglion.

Clinical Implications: Placenta-derived stem cells may represent a future "off-the-shelf" treatment to mitigate against development of erectile dysfunction after radical prostatectomy or other forms of pelvic injury.

Strength & Limitations: Single dose injection of PSCs after injury resulted in maximal functional recovery and tissue regeneration at 6 weeks, and the results were maintained through 12 weeks. Strategies to optimize adult stem cell therapy might achieve more effective outcomes for human clinical trials.

Conclusion: Human PSC therapy effectively restores the erectile tissue and function in this animal model. Thus, PSC therapy may provide an attractive modality to lessen the incidence of erectile dysfunction after pelvic neurovascular injury. Further improvement in tissue regeneration and functional recovery may be possible using multiple injections or systemic introduction of stem cells. Gu X, Thakker PU, Matz EL, et al. Dynamic Changes in Erectile Function and Histological Architecture After Intracorporal Injection of Human Placental Stem Cells in a Pelvic Neurovascular Injury Rat Model. J Sex Med 2020;17:400-411.
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http://dx.doi.org/10.1016/j.jsxm.2019.12.002DOI Listing
March 2020

Development of Male External Urethral Sphincter and Tissue-Resident Stem/Progenitor Cells in Rats.

Stem Cells Dev 2020 02 6;29(3):133-143. Epub 2020 Jan 6.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, California.

Stress urinary incontinence (SUI) after prostate surgery is primarily caused by urethral sphincter damage. There are few effective therapeutic approaches for male SUI due to both insufficient study of the structure of the external urethral sphincter (EUS) and incomplete understanding of the resident EUS stem/progenitor cells. The goals of this study were to localize and to determine the distribution of tissue-resident stem/progenitor cells in the male EUS throughout EUS development and to understand the anatomic temporal patterns of the EUS. Newborn Sprague Dawley rats were intraperitoneally injected with the thymidine analogue, 5-ethynyl-2-deoxyuridine (EdU), and the EUS was harvested at five time points (1, 2, 3, 4, and 8 weeks postinjection). The tissue was then processed for EdU staining and immunofluorescence staining for stem cell markers Ki67 and proliferating cell nuclear antigen. We counted the EdU+ label-retaining cells (LRCs) at each time point and colocalized with each stem cell marker, also we isolated and cultured the cells in vitro. The results revealed that the number of EdU+ LRCs in each EUS cross-section decreased over time and that the LRCs were located immediately under the basal membrane of laminin, densely adherent to the muscle fibers. In addition, the thickness of the striated muscle layer developed much faster than the smooth muscle layer during EUS development. By 4 weeks, the structure of the EUS layers was well differentiated. The EUS resident stem/progenitor cells were isolated with MACS MicroBeads system, and myogenesis was confirmed. In this study, we defined both the time-course development of the EUS and the distribution of resident stem/progenitor cells. This information is crucial for forthcoming studies regarding male micturition and for development of novel therapeutic approaches for postoperative male SUI.
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http://dx.doi.org/10.1089/scd.2019.0241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6987740PMC
February 2020

Smooth Muscle Differentiation of Penile Stem/Progenitor Cells Induced by Microenergy Acoustic Pulses In Vitro.

J Sex Med 2019 12 1;16(12):1874-1884. Epub 2019 Oct 1.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA. Electronic address:

Introduction: Modulating tissue-resident stem and progenitor cells with a non-invasive, mechanobiological intervention is an optimal approach for tissue regeneration. Stem cell antigen-1 (Sca-1) has been identified as a stem cell marker within many organs but never within the penis.

Aim: To localize and isolate penile stem/progenitor cells (PSPCs) and to evaluate cellular differentiation after exposure to induction medium and microenergy acoustic pulse (MAP) therapy.

Methods: Six male Sprague-Dawley rats were used to isolate PSPCs. Isolation was followed by stem cell characterization and differentiation assays. The PSPCs were then treated with MAP (0.033 mJ/mm, 1 Hz) at various dosages (25, 50, 100, and 200 pulses) and for different durations (1, 2, 4, 6, or 8 hours) in vitro.

Main Outcome Measure: The PSPCs (Sca-1-positive cells) were isolated using the magnetic-activated cell sorting system. PSPC cellular differentiation was assessed after induction with induction medium and with MAP in vitro. Wnt/β-catenin signaling was also assayed.

Results: The PSPCs were successfully localized within the penile subtunic and perisinusoidal spaces, and they were successfully isolated using magnetic-activated cell sorting. The stemness of the cells was confirmed by stem cell marker characterization and by multiple differentiation into smooth muscle cells, endothelial cells, adipocytes, and neurons. MAP-induced PSPCs differentiated into smooth muscle cells by activating the Wnt/β-catenin signaling pathway in a time- and dosage-dependent manner.

Clinical Implications: By modulating resident PSPCs, MAP may have utility in the treatment of erectile dysfunction (ED).

Strengths & Limitations: This study provides solid evidence in support of microenergy therapies, including both MAP and low-intensity extracorporeal shock wave therapy, for the treatment of ED. Additional studies are needed and should include additional stem cells markers. Furthermore, studies exploring the underling mechanisms for PSPC activation and differentiation are required.

Conclusion: PSPCs were successfully identified, localized, and isolated. Additionally, MAP provoked PSPCs to differentiate into smooth muscle cells via the Wnt/β-catenin signaling pathway. As such, MAP provides a novel method for activating endogenous tissue-resident stem/progenitor cells and might facilitate stem cell regenerative therapy targeting ED. Peng D, Yuan H, Liu T, et al. Smooth Muscle Differentiation of Penile Stem/Progenitor Cells Induced by Microenergy Acoustic Pulses In Vitro. J Sex Med 2019; 16:1874-1884.
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http://dx.doi.org/10.1016/j.jsxm.2019.08.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885549PMC
December 2019

Low-intensity pulsed ultrasound for regenerating peripheral nerves: potential for penile nerve.

Asian J Androl 2020 Jul-Aug;22(4):335-341

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA 94143, USA.

Peripheral nerve damage, such as that found after surgery or trauma, is a substantial clinical challenge. Much research continues in attempts to improve outcomes after peripheral nerve damage and to promote nerve repair after injury. In recent years, low-intensity pulsed ultrasound (LIPUS) has been studied as a potential method of stimulating peripheral nerve regeneration. In this review, the physiology of peripheral nerve regeneration is reviewed, and the experiments employing LIPUS to improve peripheral nerve regeneration are discussed. Application of LIPUS following nerve surgery may promote nerve regeneration and improve functional outcomes through a variety of proposed mechanisms. These include an increase of neurotrophic factors, Schwann cell (SC) activation, cellular signaling activations, and induction of mitosis. We searched PubMed for articles related to these topics in both in vitro and in vivo animal research models. We found numerous studies, suggesting that LIPUS following nerve surgery promotes nerve regeneration and improves functional outcomes. Based on these findings, LIPUS could be a novel and valuable treatment for nerve injury-induced erectile dysfunction.
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http://dx.doi.org/10.4103/aja.aja_95_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406088PMC
June 2021

The effects of microenergy acoustic pulses on an animal model of obesity-associated stress urinary incontinence. Part 1: Functional and histologic studies.

Neurourol Urodyn 2019 11 4;38(8):2130-2139. Epub 2019 Sep 4.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, California.

Aim: Obesity is a strong independent risk factor for urinary incontinence. Effective therapeutic approaches for obesity-associated stress urinary incontinence (OA-SUI) are lacking as the mechanisms remain unclear. The aim of our study is to explore the impacts of microenergy acoustic pulse (MAP) therapy on urethral and pelvic floor muscle structure and function in female lean and fatty rats.

Methods: A total 24 Zucker fatty (ZF) and 24 Zucker lean (ZL) female 24-week-old rats were grouped into four groups: ZL control, ZLMAP, ZF control, and ZFMAP. For MAP treatment, 500 pulses were delivered at an energy level of 0.033 mJ/mm and a frequency of 3 Hz and were applied twice a week for 4 weeks. After a 1-week washout, all rats underwent conscious cystometry and leak-point pressure (LPP) measurements followed by ex vivo organ-bath assay and histological study.

Results: ZF rats had lower LPP as compared to ZL rats, and MAP treatment significantly improved LPP in ZF rats (P < .05). Impaired muscle contractile activity (MCA) in organ-bath study was noted in ZF rats. MAP treatment significantly increased MCA in ZF rats (P < .05) and also increased the thickness of the striated muscle layer and the number of neuromuscular junctions (NMJs). In situ, MAP activated muscle satellite cells significantly (P < .05).

Conclusions: Obesity impairs the function of both the urethral sphincter and the pelvic floor and leads to atrophy and distortion of the striated muscle in obese female rats. These issues contribute to OA-SUI. MAP improves continence by stimulating muscle regeneration and nerve innervation as well as by activating satellite cells.
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http://dx.doi.org/10.1002/nau.24160DOI Listing
November 2019

The effects of microenergy acoustic pulses on animal model of obesity-associated stress urinary incontinence. Part 2: In situ activation of pelvic floor and urethral striated muscle progenitor cells.

Neurourol Urodyn 2019 11 27;38(8):2140-2150. Epub 2019 Aug 27.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, California.

Aim: To investigate the possibility and mechanism of microenergy acoustic pulses (MAP) for activating tissue resident stem/progenitor cells within pelvic and urethral muscle and possible mechanism.

Methods: The female Zucker Lean and Zucker Fatty rats were randomly divided into four groups: ZL control, ZLMAP, ZF control, and ZFMAP. MAP was applied at 0.033 mJ/mm , 3 Hz for 500 pulses, and the urethra and pelvic floor muscles of each rat was then harvested for cell isolation and flow cytometry assay. Freshly isolated cells were analyzed by flow cytometry for Pax-7, Int-7α, H3P, and EdU expression. Meanwhile, pelvic floor muscle-derived stem cells (MDSCs) were harvested through magnetic-activated cell sorting, MAP was then applied to MDSCs to assess the mechanism of stem cell activation.

Results: Obesity reduced EdU-label-retaining cells and satellite cells in both pelvic floor muscle and urethra, while MAP activated those cells and enhanced cell proliferation, which promoted regeneration of striated muscle cells of the pelvic floor and urethral sphincter. Activation of focal adhesion kinase (FAK)/AMP-activated protein kinase (AMPK) /Wnt/β-catenin signaling pathways by MAP is the potential mechanism.

Conclusions: MAP treatment activated tissue resident stem cells within pelvic floor and urethral muscle in situ via activating FAK-AMPK and Wnt/β-catenin signaling pathway.
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http://dx.doi.org/10.1002/nau.24152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6801020PMC
November 2019

Cellular signaling pathways modulated by low-intensity extracorporeal shock wave therapy.

Int J Impot Res 2019 May 22;31(3):170-176. Epub 2019 Jan 22.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, 94143, USA.

Low-intensity extracorporeal shock wave therapy (Li-ESWT) is a form of energy transfer that is of lower intensity (<0.2mJ/mm) relative to traditional Extracorporeal Shock Wave Lithotripsy (ESWL) used for management of urinary stones. At this intensity and at appropriate dosing energy transfer is thought to induce beneficial effects in human tissues. The proposed therapeutic mechanisms of action for Li-ESWT include neovascularization, tissue regeneration, and reduction of inflammation. These effects are thought to be mediated by enhanced expression of vascular endothelial growth factor, endothelial nitric oxide synthase, and proliferating cell nuclear antigen. Upregulation of chemoattractant factors and recruitment/activation of stem/progenitor cells may also play a role. Li-ESWT has been studied for management of musculoskeletal disease, ischemic cardiovascular disorders, Peyronie's Disease, and more recently erectile dysfunction (ED). The underlying mechanism of Li-ESWT for treatment of ED is incompletely understood. We summarize the current evidence basis by which Li-ESWT is thought to enhance penile hemodynamics with an intention of outlining the fundamental mechanisms by which this therapy may help manage ED.
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http://dx.doi.org/10.1038/s41443-019-0113-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587965PMC
May 2019

Delayed Low-Intensity Extracorporeal Shock Wave Therapy Ameliorates Impaired Penile Hemodynamics in Rats Subjected to Pelvic Neurovascular Injury.

J Sex Med 2019 Jan 1;16(1):17-26. Epub 2018 Dec 1.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA. Electronic address:

Background: Erectile dysfunction (ED) caused by pelvic neurovascular injury (PNVI) is often refractory to treatment. In many cases, erectogenic therapy is administered in a delayed fashion.

Aim: To evaluate penile hemodynamic effects and histologic changes associated with delayed low-intensity extracorporeal shock wave therapy (Li-ESWT) after PNVI ED in a rat model. We visualized images using immunofluorescence and 3-dimensional imaging of solvent-cleared organs (3DISCO), a novel imaging technique.

Methods: A total of 32 Sprague-Dawley male rats aged 12 weeks were divided equally into 4 groups: sham surgery as normal controls (NC), PNVI controls (PC), PNVI with very-low-energy Li-ESWT (PVL), and PNVI with low-energy Li-ESWT (PL). Bilateral cavernous nerve crush and internal pudendal bundle ligation were performed in the 3 PNVI groups. Li-ESWT was administered twice a week for 4 weeks in the PL and PVL groups starting at 4 weeks after PNVI.

Outcomes: Intracavernous pressure (ICP) studies (normalized to mean arterial pressure [MAP]) were conducted in all subject animals. After testing, tissue was harvested for immunofluorescence staining and 3DISCO analysis.

Results: Mean ICP/MAP was lower in PC animals compared with NC animals (0.37 ± 0.03 vs 0.91 ± 0.03, respectively; P = .001). The ICP/MAP ratio was significantly higher in PVL and PL animals (0.66 ± 0.07 and 0.82 ± 0.05, respectively) compared with PC animals (P = .002 and .001, respectively). Detailed microstructures and trajectories of nerves and vessels were identified with immunofluorescence and 3DISCO. The PC group had lower density of nerves, axons, neuronal nitric oxide synthase-positive nerves, and Schwann cells in the dorsal penis. Animals in the PL group had significantly higher expression of all of these markers compared with PC animals.

Clinical Implications: Li-EWST may have utility in the management of severe ED related to PNVI from severe pelvic injury or radical pelvic surgeries, even when administered in a delayed fashion.

Strength & Limitations: This study of a severe ED phenotype involved treatment administered in a delayed fashion, which is more consistent with how therapy likely would be delivered in a real-world clinical context. Moreover, because the treatment commenced at 4 weeks after injury, when nerve and tissue atrophy have already occurred, the results imply that Li-ESWT can be used for regenerative therapy. Additional studies on dose optimization and treatment interval are needed to inform the design of human clinical trials.

Conclusion: Li-ESWT ameliorates the negative functional and histologic effects of severe pelvic neurovascular injury in a rat model system. 3DISCO provides high-resolution images of neuroanatomy and neural regeneration. Wang HS, Ruan Y, Banie L, et al. Delayed Low-Intensity Extracorporeal Shock Wave Therapy Ameliorates Impaired Penile Hemodynamics in Rats Subjected to Pelvic Neurovascular Injury. J Sex Med 2019;16:17-26.
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http://dx.doi.org/10.1016/j.jsxm.2018.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326879PMC
January 2019

Five Things I Wish I Would Have Known Earlier in My Career: Lessons Learned in Peyronie's Disease Surgery.

J Sex Med 2018 Aug 31;15(8):1070-1072. Epub 2018 May 31.

Department of Urology, University of California-San Francisco, San Francisco, CA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jsxm.2018.04.645DOI Listing
August 2018

Treatment of stress urinary incontinence with low-intensity extracorporeal shock wave therapy in a vaginal balloon dilation induced rat model.

Transl Androl Urol 2018 Mar;7(Suppl 1):S7-S16

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA.

Background: To investigate the outcomes and mechanisms of low-intensity extracorporeal shock wave therapy (Li-ESWT) on stress urinary incontinence (SUI) in a vaginal balloon dilation (VBD) rat model.

Methods: Thirty Sprague-Dawley rats were randomly grouped into normal controls, VBD only, and VBD with Li-ESWT. Li-ESWT was administered twice per week for 3 weeks. Afterward, all 30 rats were assessed with functional and histological studies. To explore the acute effect of Li-ESWT, another 25 rats, given intraperitoneal 5-ethynyl-2-deoxyuridine (EdU) at birth, were treated with Li-ESWT followed by assessment of vascular endothelial growth factor (VEGF) expression and endogenous progenitor cells distribution at 24 hours or 1 week after the last Li-ESWT therapy. Additionally, rat myoblast L6 cells were used for myotube formation assay .

Results: Functional analysis with leak-point pressure (LPP) testing showed that rats treated with Li-ESWT following VBD had significantly higher LPP relative to those receiving VBD only (44.8±3.2 versus 27.0±2.9 cmHO, P<0.01). Histological examinations showed increased urethral sphincter regeneration in Li-ESWT group. The rats treated with Li-ESWT also had increased vascularity, which was confirmed by immunohistochemistry of rat endothelial cell antigen, while reverse-transcriptase polymerase chain reaction (RT-PCR) showed VEGF expression was significantly enhanced. Additionally, there were significantly increased EdU+ cells in Li-ESWT treated rats at 24 hours. , Li-ESWT promoted myotube formation from L6 cells.

Conclusions: Li-ESWT ameliorated SUI by promoting angiogenesis, progenitor cell recruitment, and urethral sphincter regeneration in a rat model induced by VBD. Li-ESWT represents a potential novel non-invasive therapy for SUI.
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http://dx.doi.org/10.21037/tau.2017.12.36DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881209PMC
March 2018

The extra-tunical grafting procedure for Peyronie's disease hourglass and indent deformities.

Transl Androl Urol 2018 Mar;7(Suppl 1):S1-S6

Department of Urology, University of California, San Francisco, CA, USA.

Background: To describe a novel, tunica-sparing surgical technique-extra-tunical grafting (ETG)-for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure.

Methods: An IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The dissection is continued to the level between Dartos and Bucks fascia, circumferentially for HG deformity and focally for indent deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend (Coloplast, Minneapolis, MN, USA). The graft is sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired penile shaft contour. The urethra is excluded from the graft.

Results: From October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow-up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea (TA). Follow-up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being "very satisfied" and six reported being "satisfied" with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again.

Conclusions: The ETG procedure is a straightforward approach to HG and indent deformities to correct the penile deformity and to provide structural support to prevent penile buckling during intercourse. The procedure does not violate the TA and does not require dissection of the NVB. Thus, ETG carries a very low risk of impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.
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http://dx.doi.org/10.21037/tau.2017.12.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881200PMC
March 2018

Low-intensity extracorporeal shockwave therapy ameliorates diabetic underactive bladder in streptozotocin-induced diabetic rats.

BJU Int 2018 09 20;122(3):490-500. Epub 2018 Apr 20.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA.

Objectives: To evaluate the therapeutic effect of once-weekly low-intensity extracorporeal shock wave therapy (Li-ESWT) on underactive bladder (UAB) in the streptozotocin (STZ)-induced diabetic rat model.

Materials And Methods: In all, 36 female Sprague-Dawley rats were divided into three groups: normal control (NC), diabetes mellitus control (DMC), and DM with Li-ESWT (DM Li-ESWT). The two DM groups received an intraperitoneal 60 mg/kg STZ injection to induce DM. The Li-ESWT was applied toward the pelvis of the rats starting 4 weeks after STZ administration and lasting for 4 weeks. The Li-ESWT was given once weekly, with an energy flux density of 0.02 mJ/mm at 3 Hz for 400 pulses. All rats underwent conscious cystometry, leak-point pressure (LPP) assessment, ex vivo organ-bath study, histology, immunofluorescence, and Western Blot analysis.

Results: Conscious cystometry revealed voiding dysfunction in the DMC group, whereas the DM Li-ESWT group showed significantly improved voiding function, reflected in a reduced post-void residual urine volume and increased LPP compared to the DMC group. Ex vivo organ-bath studies showed that Li-ESWT enhanced muscle contractile activity of the bladder and urethra during electrical-field stimulation and drug stimulation. Histologically, Li-ESWT significantly restored bladder morphology, reflected by a reduction in the intravesical lumen area and increased muscle proportion of the bladder wall. Western Blot analysis showed higher smooth muscle actin expression in the bladder wall in the DM Li-ESWT group compared to the DMC group. Immunofluorescence showed decreased nerve-ending distribution, and destroyed and shortened nerve fibres in the DMC group, and recovery of neuronal integrity and innervation in the DM Li-ESWT group.

Conclusions: In conclusion, Li-ESWT ameliorated UAB and urinary incontinence in the diabetic UAB rat model. The improvement appears to be the result of restoration of bladder and urethral structure and function by Li-ESWT. Li-ESWT is non-invasive and may become a better alternative therapy for UAB. Further investigations are warranted.
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http://dx.doi.org/10.1111/bju.14216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6158099PMC
September 2018

The effect of low-intensity extracorporeal shockwave therapy in an obesity-associated erectile dysfunction rat model.

BJU Int 2018 07 17;122(1):133-142. Epub 2018 Apr 17.

Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, CA, USA.

Objectives: To investigate the feasibility of the Zucker fatty (ZF) rat as a model for research in to obesity-associated erectile dysfunction (OAED) and to determine the effect of low-intensity extracorporeal shockwave therapy (Li-ESWT) on penile tissue and function in these rats.

Materials And Methods: Eight new-born male Zucker lean (ZL group) rats (ZUC-Lepr 186) and 16 new-born male ZF rats (ZUC-Lepr 185) were injected with 5-ethynyl-2'-deoxyuridine (EdU) at birth to identify and monitor endogenous stem cells. Insulin tolerance testing was performed at 10 weeks of age. Beginning at 12 weeks of age, eight ZF rats were kept as controls, and the remaining eight ZF rats were treated with Li-ESWT (0.02 mJ/mm , 3 Hz, 500 pulses; ZF + SW group) twice a week for 4 weeks. Following a 1-week washout period, erectile function was evaluated by measuring intracavernosal pressure (ICP) and mean arterial pressure (MAP). Penile tissues were then harvested for histological study to assess smooth muscle/collagen content and endothelium content in the corpora cavernosum. LipidTOX™ staining was used to evaluate lipid accumulation. EdU, as a marker of cell activation, and phosphorylated histone 3 (H3P), as a marker of cell mitosis, were also assessed.

Results: The ICP/MAP indicated that erectile function was severely impaired in the ZF group as compared with the ZL group. In the ZF + SW group, erectile function was significantly improved (P < 0.05). Muscle atrophy was seen in the ZF group, while Li-ESWT increased the muscle content in ZF + SW group. Moreover, the penile endothelium was damaged in the ZF group, and Li-ESWT enhanced the regeneration of endothelial cells (P < 0.01) in the ZF + SW group. Lipid accumulation was seen in the penile tissue of ZF rats. Li-ESWT significantly reduced both the amount and the distribution pattern of LipidTOX, suggesting decreased overall lipid infiltration. Furthermore, Li-ESWT increased EdU-positive cells and markedly enhanced the phosphorylation level of H3P at Ser-10 in the ZF + SW group. Most H3P-positive cells were located within smooth muscle cells, with some located in the endothelium suggesting that these tissues are the reservoirs of penile stem/progenitor cells.

Conclusion: ZF rats can serve as an animal model in which to study OAED. This study reveals that obesity impairs erectile function by causing smooth muscle atrophy, endothelial dysfunction, and lipid accumulation in the corpus cavernosum. Li-ESWT restored penile haemodynamic parameters in the ZF rats by restoring smooth muscle and endothelium content and reducing lipid accumulation. The underlying mechanism of Li-ESWT appears to be activation of stem/progenitor cells, which prompts cellular proliferation and accelerates penile tissue regeneration. Our findings are of interest, not just as a validation of this emerging treatment for erectile dysfunction, but also as a novel and potentially significant method to modulate endogenous stem/progenitor cells in other disease processes.
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http://dx.doi.org/10.1111/bju.14202DOI Listing
July 2018

Suspected penile fracture: to operate or not to operate?

Transl Androl Urol 2017 Oct;6(5):981-986

Department of Urology, University of California at San Francisco, San Francisco, CA, USA.

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http://dx.doi.org/10.21037/tau.2017.07.25DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673800PMC
October 2017

In Situ Activation and Preservation of Penile Progenitor Cells Using Icariside II in an Obesity-Associated Erectile Dysfunction Rat Model.

Stem Cells Dev 2018 02 22;27(3):207-215. Epub 2018 Jan 22.

1 Knuppe Molecular Urology Laboratory, Department of Urology, School of Medicine, University of California, San Francisco, San Francisco, California.

Obesity-associated erectile dysfunction (ED) involves pathologic change that may be related to deficit of the penile endogenous stem/progenitor cells. Therefore, an in-depth study of the penile stem/progenitor cells in the pathogenesis of ED is warranted. For this study, eight Zucker Lean (ZUC-Lepr 186; ZL group) and 16 Zucker Fatty (ZUC-Lepr 185; ZF) male rats received an intraperitoneal injection of 5-ethynyl-2-deoxyuridine (EdU) to track endogenous stem cells. Twelve weeks later, the ZF rats were randomized to gavage feeding with 1.5 mg/kg/day of icariside II (ZF + ICA II group) or the solvent (ZF group). Treatment lasted 4 weeks and was followed by a 1-week washout period. ZF rats had impaired erectile function with related pathologic changes compared with ZL rats. ICA II treatment restored erectile function and prevented smooth muscle atrophy, endothelial dysfunction, and lipid accumulation compared with no treatment. EdU label-retaining cell levels were higher in the ZF + ICA II group compared with the ZF group. Histone 3 phosphorylation at Ser 10, a specific mitotic cell marker, was additionally used to identify dividing cells. ICA II activated more penile stem cells to proliferate in ZF rats compared with ZL rats. These results suggest that ZF rats can be used as a model for obesity-associated ED and that ICA II improves erectile function and pathologic changes through endogenous progenitor cell preservation and proliferation.
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http://dx.doi.org/10.1089/scd.2017.0220DOI Listing
February 2018
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