PART

III Pediatric Urology

SECTION A  Development and Prenatal Urology

20  Embryology of the Genitourinary Tract

Laurence S. Baskin, MD, and Gerald Cunha, PhD

T
he human urogenital system can be divided into the urinary in Fig. 20.5. Cellular proliferation (documented by the expression
and reproductive systems. These systems are closely interrelated, of Ki67) is abundant in the canalizing urethral plate (see Fig. 20.5),
especially early in development, which begins in the first trimester and apoptosis was not detected (based on the lack of expression of
and is mostly complete by the end of the second trimester. The Carnegie caspase 3; see Fig. 20.5C). The penile urethra forms as a result of
collection of embryos depicts human development from the time of complex fusion of the medial edges of the urethral folds (see Figs.
fertilization to the indifferent stage at approximately 8 to 9 weeks’ 20.6 and 20.7). As development progresses, the epithelial edges of
gestation (Fig. 20.1; Mall and Meyer, 1921; Smith, 2016). Subsequently, the urethral groove begin to fuse to form the midline penile raphe
under the influence of androgens, differentiation of the male and (closing zipper). By 11 to 12 weeks’ gestation, the coronal sulcus
female urogenital structures becomes apparent (Blaschko et al., 2012; is evident separating the penile glans from the shaft. By 16 weeks,
Fig. 20.2). In this chapter, we review the development of the human the urethral folds have completely fused in the ventral midline of
urogenital tract by organ system: external genitalia, prostate, gonads, the penile shaft (see Fig. 20.3). The normal ventral penile curva-
uterus, vagina, bladder, ureters, and kidneys. Understanding normal ture, or chordee, that occurs during development resolves by the
development is essential for understanding abnormal development 20th week.
or urologic congenital anomalies and is the first step in planning The glanular urethra forms via a mechanism entirely different
treatment and surgical reconstruction if indicated. from urethral fold fusion, which occurs within the penile shaft (Liu
et al., 2018). Current evidence supports the view that the glanular
urethra forms from UGS epithelium (Kurzrock et al., 1999). The
DEVELOPMENT OF THE EXTERNAL GENITALIA glanular urethra forms as a result of direct canalization of the urethra
plate with epithelial remodeling within the glans (Baskin et al., 2018;
At 8 to 9 weeks’ gestation, the external genitalia consist of an indif- Liu et al., 2018). By 18 weeks’ gestation, penile and urethral develop-
ferent genital tubercle (Fig. 20.3). Sexual differentiation of the external ment is essentially complete (Fig. 20.8).
genitalia is dependent on prior differentiation of the gonads. The Anatomic and immunohistochemical studies suggest that epi-
process of normal gonadal sexual differentiation is determined thelium of the entire urethra is derived from endoderm of the UGS
by the SRY region on the short arm of the Y chromosome (Larney (Kurzrock et al., 1999). The entire male urethra, including the majority
et al., 2014; Ohnesorg et al., 2014). The gene products of the SRY of the glanular urethra, is formed from the endodermal urethral
genetic cascade direct testicular development (Windley and Wilhelm, plate within the genital tubercle as a result of urethral fold fusion
2015). Additional genetic information required for development of within the shaft and direct canalization of the urethral plate within
male and female accessory sexual structures is located on the X the glans. This is in contrast with the outdated ectodermal extrusion
chromosome and on the autosomes (Blaschko et al., 2012). theory of Glenister, which hypothesized that the glanular urethra
At approximately 9 weeks’ gestation, the Leydig cells appear in formed by skin (ectodermal intrusion) growing into the glans and
the testis and begin to secrete testosterone (Blaschko et al., 2012; meeting the endodermally derived urethra (Glenister, 1954).
Dufau, 1988). Testosterone or the more potent androgen, dihydrotes- The future prepuce forms at the same time as the glanular urethra
tosterone (DHT), masculinize the genital tubercle, Wolffian duct and is dependent on normal urethral development as described
(WD), and urogenital sinus (UGS). Metabolic conversion of tes- earlier. At about 8 weeks’ gestation, low preputial folds appear on
tosterone to DHT is mediated by type 2 5α-reductase, is expressed both sides of the penile shaft, which join dorsally to form a flat
within the UGS and the genital tubercle, and is required for normal preputial ridge at the proximal edge of the corona. The preputial
penile and prostatic development (Blaschko et al., 2012; Wilson ridge initially does not entirely encircle the glans because it is blocked
et al., 1993; Wilson, 2001). ventrally by incomplete development of the glanular urethra. With
Masculinization of the external genitalia takes place under the further development, the bilateral preputial folds (ventrolateral edges
influence of androgens. One of the first signs of masculinization of the preputial ridge) extend distally to eventually cover most of
is an increase in the distance between the anus and the genital the glans. At the same time, the bilateral preputial folds (foreskin)
structures (known as anogenital distance), followed by elongation of grow ventrally and fuse together in the ventral midline. During this
the genital tubercle and formation of a urethral plate (Fig. 20.4). The process of distal and ventral growth of the prepuce, the epithelial
male genital tubercle, future penis, and clitoris contain tissue derived preputial lamina is laid down, which separates the mesenchymal
from all three germ layers. Ectoderm gives rise to the skin of the core of the glans from the mesenchyme of the prepuce, whose outer
phallus. Mesoderm gives rise to the corporal bodies/erectile tissue. surface is covered with epidermis (see Fig. 20.3). Postnatally, the
Endoderm gives rise to the urethra (see Fig. 20.4) and vestibular preputial lamina delaminates creating the preputial space, thus
plate. The urethral plate (derived from endoderm) extends from allowing retraction of the prepuce. Clearly the development of the
the “pelvic urethra” into the future glans penis, terminating just prepuce is linked to development of the urethra, because in
before the distal tip of the future glans (Fig. 20.5). The urethral plate hypospadias, preputial tissue is absent ventrally and excessive
canalizes from proximal to distal to form a wide, diamond-shaped dorsally (classic dorsal hooded foreskin; Baskin, 2017).
urethral groove within the penile shaft (opening zipper; Figs. 20.6 The origin of the nerve supply of the penis may be traced to
and 20.7). The canalization process is seen in the histologic sections week 5 of gestation, when neural crest cells differentiate into the

305
306 PART III  Pediatric Urology

Fig. 20.1.  Whole-mount photographs of developing human embryos from the Carnegie collection. Note
the increasing size and morphologic complexity with developmental stage. (Image courtesy of Dr. Brad
Smith, University of Michigan, from http://embryo.soad.umich.edu/carnStages/carnStages.html; NIH award
N01-HD-6-3257 P/G F003637.)

peripheral and autonomic nervous systems. The somatic innerva- with glanular hypospadias with the classic ectopic meatus and dorsal
tion of the penis comes principally from spinal nerves S2 to S4 hooded foreskin and the other with persistent penile curvature second-
by way of the pudendal nerve (Lue et al., 1984). After passing under ary to penile scrotal webbing. The anatomy of the hypospadiac penis
the sacrospinous ligament and over the sacrotuberous ligament and is exactly like a normal penis except for abnormalities in the develop-
through Alcock’s canal (pudendal canal), the pudendal nerve passes ment of the urethra and overlying skin and a ventrally deficient
through the transverse perineal muscle to course onto the dorsum prepuce (Baskin et al., 1998). The abortive elements of the urethra
of the penis as the dorsal nerve of the penis (Fig. 20.9; Breza et al., and urethral spongiosum such as epithelium, connective tissue,
1989). The autonomic innervation of the penis arises from the vesical smooth muscle, and blood vessels can be found in the adjacent
and prostatic plexi, which are composed of sympathetic nerves from tissue consistent with the hypospadias being an arrest in development
L1 and L2, and parasympathetic nerves from S2 to S4. The bilateral and not a deformation anomaly (Baskin et al., 1998).
cavernous nerves leaves the pelvis between the transverse perineal In the overwhelming majority of cases, the etiology of hypospadias
muscles and the membranous urethra before passing beneath the arch remains unknown. A reasonable hypothesis is that hypospadias is
of the pubis to supply each corpus cavernosum (Paick et al., 1993). caused by genetic susceptibility and maternal exposure to endocrine
The dorsal penile nerve bundles exist not only in the 11 and 1 disruptors (Baskin et al., 2001). Rarely, a known genetic defect is
o’clock positions, but extend around the tunica to the junction of present to explain the hypospadias. For example, a defect in the
the corpus spongiosum and corpora cavernosa. Note the nerve-free enzyme 5α-reductase type 2 (which converts testosterone to DHT)
zone at the 12 o’clock position (see Fig. 20.9; Baskin et al., 1998). leads to severe hypospadias. 5α-reductase type 2 is expressed at the
site of urethral fold fusion along the penile shaft and appears necessary
Clinical Correlation: Hypospadias for normal urethral development (Kim et al., 2002). Severe hypo-
spadias is a consistent finding in patients without the 5α-reductase
Hypospadias occurs in approximately 1 : 250 newborn males (Baskin, enzyme who lack the ability to properly fuse the edges of the urethral
2017). Hypospadias can be defined as (1) ectopic location of the groove (see Fig. 20.13).
urethral meatus, (2) incomplete development of the prepuce (dorsal
hooded foreskin), and (3) ventral skin deficiency/penile curvature. Clinical Correlation: Correction of Penile Curvature
The most common location of the ectopic urethral meatus is at
the junction of the penile shaft and glans penis (Baskin, 2017). Anatomic studies of penile innervation have allowed for strategic
This is consistent with the different mechanisms of urethral forma- design of penile straightening procedures for ventral curvature
tion between the shaft of the penis and the glans (urethral fold associated with hypospadias and congenital penile curvature without
fusion in the shaft and direct canalization of the urethral plate hypospadias (Baskin et al., 1996, 1998, 2000). Along the penile
with the glans). Fig. 20.10 shows two human fetal specimens, one shaft, the nerves course along the tunica albuginea and extend ventrally
 Chapter 20  Embryology of the Genitourinary Tract 307

Fig. 20.2.  Gross ontogeny of the human fetal pelvis from 9 weeks’ gestation (end of indifferent stage) to
16 weeks’ gestation. Note the divergent development after 9 weeks’ gestation, especially with respect
to orientation of the external genitalia with the penis clearly visible at an approximately 90-degree angle
from the body and the clitoris recessed close to the body wall.

Fig. 20.3.  Representative examples of human male (top row) and female (bottom row) external genitalia
(8 to 16 weeks’ gestation). Note the morphologic differences between the male and female genitalia after
the indifferent stage (8 to 9 weeks’ gestation), with lack of urethral fusion in the female specimens.
308 PART III  Pediatric Urology

Fig. 20.4.  A 9-week human male genital tubercle/future human penis. Note the urethral plate in the gross
specimen. In the corresponding histologic cross-section, the three embryonic layers of external genitalia
development are labeled: ectoderm (future skin and prepuce), mesoderm (erectile tissue) and endoderm
(urethral plate and future urethra).

Fig. 20.5.  Optical projection tomography (OPT) of male urethral development from 6.5 to 10.5 weeks’
fetal age. Note the urethral plate (blue arrows) that ends within the glans. Note the progression of the
urethral meatus (green arrows) from the level of the scrotal folds at 6.5 weeks to the proximal penile
shaft at 10.5 weeks. The wide open urethral groove (red arrows) is best seen from 9.5 to 10.5 weeks,
with clear progression of proximal to distal fusion of the edges of the urethral groove to form the tubular
urethra (yellow arrows). The epithelial tag, which is of unknown significance, is marked by the light blue
arrow. Corresponding serial immunohistochemical sections localizing the proliferation marker Ki67 are
labeled with arrows in the OPT specimens A to G, with the exception of C, which illustrates no staining
for the apoptotic marker Caspase 3. (From Li Y, Sinclair A, Cao M, et al. Canalization of the urethral
plate precedes fusion of the urethral folds during male penile urethral development: the double zipper
hypothesis. J Urol. 193(4);2015:1353–1359.)
 Chapter 20  Embryology of the Genitourinary Tract 309

Fig. 20.6.  Lightsheet fluorescence

microscopy images demonstrating
development of the penile urethra at
the ambisexual stage (left, 7.5 weeks),
during active urethral canalization and
fusion to form the urethra in the penile
shaft (middle, 11 weeks), and during
canalization to form the mature urethra
in the glans penis (right, 16 weeks).
E-cadherin is expressed at epithelial
surfaces in development, Cytokeratin
6 is expressed in the urethral plate
and epidermis, and Cytokeratin 7 is
expressed in urothelium.

Fig. 20.7.  (A to F) Scanning electron microscopy ontogeny of the developing human fetal penis from 7.5
to 13 weeks’ gestation in ventral view. White arrowheads indicate the junction of the penile shaft to glans,
red arrowheads indicate the distal epithelial tag, and blue arrowheads indicate the median penile raphe.
(From Shen J, Overland M, Sinclair A, et al. Complex epithelial remodeling underlie the fusion event in
early fetal development of the human penile urethra. Differentiation. 92(4);2016:169–182.)
310 PART III  Pediatric Urology

to completely surround the cavernous bodies up to the ventral junction position is where the tunica albuginea is thickest, facilitating anchoring
with the spongiosum. From the glans to the crural bodies, where of the plication suture (Baskin et al., 1998).
the bilateral corporal bodies (crura) separate to attach to the ventral
pubic rami, the nerves are grouped into tight bundles at the 11 and Clinical Correlation: Duplicated Urethra
1 o’clock positions. The 12 o’clock position is a nerve-free zone
amendable to placement of dorsal plication sutures in mild to Duplication anomalies of the urethra are extremely rare with both
moderate degrees of curvature (Fig. 20.11). Also, the 12 o’clock hypospadiac and epispadiac variations (Coleman et al., 2010). These
are best explained embryologically by splitting of the urethral plate
at the bladder to form complete duplication or splitting along the
shaft of the genital tubercle to form a Y duplication. Sonic hedgehog
appears to be an important genetic pathway controlling this process
(Seifert et al., 2009).

DEVELOPMENT OF THE FEMALE EXTERNAL GENITALIA

The clitoris forms in an analogous fashion to the penis except for
lack of formation of the urethra (Overland et al., 2016; see Figs.
20.3 and 20.12). As in males, a urethral plate (properly called the
vestibular plate in females) undergoes canalization to form a wide
diamond-shaped vestibular groove (opening zipper, homologous to
the urethral groove of males). Because formation of the vestibular
groove and its subsequent canalization occurs in females (and in
males), this process is androgen independent (Shen et al., 2016).
In contrast with penile formation, fusion of the urethral groove
(closing zipper) does not take place, resulting in an open vestibular
groove (Overland et al., 2016; Figs. 20.12 and 20.13). Similar to the
glans penis, the glans clitoris forms a cap on top of the distal end
Fig. 20.8.  Sagittal section of an 18-week human fetal penis. Note the of the narrowed bilateral corporal (clitoral) bodies. Fusion of these
remodeling of the distal aspect of the urethra. The glans, prepuce, corporal clitoral bodies is manifest as a midline septum starting on the ventral
cavernosa, urethra, and meatus are labeled. aspect and extending about halfway into the glans. Large bundles

Fig. 20.9.  (A to H) Multiple views of three-

dimensional reconstruction of human fetal penis
dorsal nerve neuroanatomy at 17.5 weeks’
gestation with respective layers removed for
selective visualization. Blue areas represent pubic
arch. Yellow areas represent nerves and glans.
Light blue areas represent urethra. Pink areas
represent corporeal bodies. Brown areas rep-
resent penile skin.

Fig. 20.10.  A 24-week human fetal penis with

classic distal hypospadias (A) and a 23-week
human fetal specimen with chordee without
hypospadias and penile webbing (B).
 Chapter 20  Embryology of the Genitourinary Tract 311

of nerves course along the clitoral bodies with the highest density
dorsally (Fig. 20.14) in a fashion analogous to the penis (Baskin
et al., 1999). No nerves are noted at the 12 o’clock position, but
nerves extend ventrolaterally completely around the tunica similar
to that seen in the fetal penis. Like in the male, innervation of the
glans clitoris occurs via multiple perforating branches that enter at the
dorsal junction of the corporal body and the glans. The lowest density
of nerves in the glans is on the ventral aspect in juxtaposition to
the glans septum (Baskin et al., 1999).

Clinical Correlation: Congenital Adrenal Hyperplasia

Patients with congenital adrenal hyperplasia, an autosomal recessive
disorder characterized by impaired cortisol synthesis, undergo varying
degrees of virilization leading to genital atypia at birth (Auchus
et al., 2010). These patients can be confused with patients with
hypospadias (albeit with bilateral nonpalpable testis). Unlike normal
female development, the vestibular groove undergoes varying degrees
of closure forming a clitoral shaft urethra that is anatomically
indistinguishable from a normal male urethra (Baskin, 2017). In
the most severe cases, the clitoris looks exactly like a penis with a
normal terminal urethral meatus, glans, and foreskin (Baskin, 2017).
The only feature that distinguishes the male from the female is lack
of palpable gonads (testes) and excess pigmentation.

DEVELOPMENT OF THE HUMAN PROSTATE

Fig. 20.11.  Schematic of penile straightening technique using plication sutures
The human prostate and seminal vesicles develop at the base of the
at the 12 o’clock position, where there is a paucity of nerves, thereby avoiding
bladder at 10 to 12 weeks’ gestation (Fig. 20.15). Information on
nerve injury.

Fig. 20.12.  Optical projection tomography showing fetal ontogeny of human clitoris from 8 to 19 weeks’
gestation. Note the opening zipper, which facilitates vestibular plate opening to form the vestibular groove,
and lack of a closing zipper with the vestibular groove remaining open.
312 PART III  Pediatric Urology

Fig. 20.13.  Lightsheet fluorescence microscopy images of an 11-week human fetal penis (left) and clitoris
(right). Cytokeratin 6 (blue) is expressed in the urethral plate and epidermis, and Cytokeratin 7 (red) is
expressed in urothelium and the dorsal aspect of the vestibular groove. Proximal to distal canalization of
the male urethral plate and the female vestibular plate has produced an open urethral groove in the penis
and an open vestibular groove in the clitoris (opening zipper). Proximal to distal fusion of the urethral folds
has produced the tubular urethral in the shaft of the male specimen only (closing zipper). In the clitoris,
fusion does not occur, resulting in the mature open vestibular groove. Note the epithelial tag on both
specimens.

KEY POINTS: EXTERNAL GENITALIA review the contribution of animal studies to our understanding of
human prostatic development will be noted.
• Androgens differentiate the ambisexual human genital Human and mouse prostatic development can be subdivided
tubercle at 7 to 8 weeks’ gestation into the penis. into the following stages: (1) prebud UGS, (2) emergence of solid
• The penile urethra is formed by an opening zipper epithelial buds from urogenital sinus epithelium (UGE), (3) bud
(canalization of the urethral plate) followed by fusion of elongation and branching, (4) canalization of the solid epithelial
the urethral folds (closing zipper). “ducts,” (5) differentiation of luminal and basal epithelial cells, and
• The epithelium of the entire male urethra is of urogenital (6) secretory cytodifferentiation. The human and mouse prostate
sinus origin. develop below the urinary bladder (Fig. 20.16) from FOXA1-positive
• The clitoris forms in an analogous fashion to the penis UGE. FOXA1 is a marker of the endodermal lineage (Besnard et al.,
except for lack of formation of the urethra within the 2004; Diez-Roux et al., 2011; Robboy et al., 2017). A unique feature
clitoris. of human prostatic development is formation of the verumontanum,
• Anatomy of the hypospadiac penis is exactly like a normal a hillock elongated craniocaudally on the dorsal wall of the UGS
penis except for abnormalities in development of the (Fig. 20.17). The mesonephric (Wolffian) ducts and the fused Mül-
urethra, surrounding spongiosum, overlying skin, and a lerian ducts (MDs; prostatic utricle) join the UGE on the apex of
ventrally deficient prepuce. the verumontanum. Thus, the verumontanum represents an interface
• A nerve-free zone is present at the 12 o’clock position on between the mesodermal epithelia of the WDs and the prostatic
the penile and clitoral tunica that is amendable to utricle with endodermal UGE (see Fig. 20.17).
placement of dorsal plication sutures in mild to moderate The initial event in prostatic development is outgrowth of solid
degrees of curvature and other surgical procedures. epithelial buds from the UGE into the surrounding mesenchyme
during weeks 9 to 10. Because of the inherent difficulty of estimating
specimen age, various investigators have reported initiation of human
prostatic bud formation over a range of ages: 9.5 weeks (Dauge
development of the human prostate is based on sparse literature on et al., 1986) to 10 weeks (Kellokumpu-Lehtonen et al., 1980; Zondek
human fetal prostate coupled with extensive literature on prostatic and Zondek, 1979). Most of the prostatic buds emerge from the
development in laboratory animals in which detailed endocrinologic UGE in the gutters, lateral to the verumontanum (Fig. 20.18). The
and mechanistic studies are possible. For example, the importance craniocaudal extent of the verumontanum and the location of
of androgens in prostatic development was originally determined emergent prostatic buds are best appreciated through examination
through animal studies carried out by Alfred Jost (Jost, 1953) and of the adult prostate gland (Fig. 20.19).
Dorothy Price (Price and Ortiz, 1965) and then subsequently Based on studies in mice, prostatic bud initiation is stochastic
confirmed in humans (Wilson et al., 1981). Accordingly, in this with cords of UGE cells emerging into the mesenchyme and receding
Fig. 20.14.  Computer-generated three-dimensional reconstruction of normal human
fetal clitoris at 24 weeks’ gestation. Red areas represent nerve pathway with a
paucity of nerves at the bottom and top midline of the clitoris. Purple areas represent
a tunica of corporeal bodies. Yellow areas represent the interior of corporeal bodies.
Green areas represent the glans clitoris. Dark green and yellow areas represent the
clitoral hood. (A) Dorsal front view. (B) Dorsal back view. (C) Back ventral view. (D)
Ventral view. (From Baskin LS, Erol A, Li YW, et al. Anatomical studies of the human
clitoris. J Urol. 162(3 Pt 2);1999:1015–1020.)

Fig. 20.15.  Whole-mount photographs of human fetal bladder and prostate (10 to 21 weeks’ gestation).
Note the presence of the vas deferens medial to the ureters on the posterior aspect of the majority of
specimens. The fetal testes and epididymis can be seen in the 13- and 14-week specimens. The fetal
prostate is seen as a bulge of tissue just below the insertion of ureters and increases in size over time.
314 PART III  Pediatric Urology

throughout the budding process. This appears to also apply to branch point. In the rat and mouse prostate, this distance is short for
human prostatic development as ventral prostatic buds reported the ventral prostate and many-fold longer for the dorsal and lateral
in the human fetal prostate (Lowsley, 1912) are not represented prostates (Hayashi et al., 1991; Sugimura et al., 1986a). We suspect
in the adult prostate (McNeal, 1981). Prostatic bud growth and that this is also true for the human prostate. Measurements from
subsequent branching morphogenesis occur from approximately 11 serial sections of the distance from the human fetal prostatic urethra
weeks onward in a specific spatial pattern that eventually establishes to the first branch point is short in some areas (~250 µm; see Fig.
the zonal subdivisions of the mature mouse, rat, and human prostate 21.19A). Thick (0.5-mm) coronal sections of human fetal prostate
(Hayashi et al., 1991; Sugimura et al., 1986a; Timms, 2008; Timms reveal ducts with an initial branch point approximately 1000 µm
and Hofkamp, 2011). The mouse and rat prostate are organized into from their origin from the urethra (see Fig. 21.19B; Cunha et al.,
anterior, lateral, dorsal, and ventral lobes, and ductal branching 2018a). This approximately fourfold difference in ductal length to the
patterns differ greatly among lobes (Hayashi et al., 1991, Sugimura
et al., 1986a). One manifestation of differences in ductal branching
patterns is the distance from the prostatic urethra to the first ductal

WD Utricle

Urachus
Vas deferens
Prostate Ureter

Genital
tubercle Bladder

Seminal
vesicle

Bulbourethral UGS
gland
Rectum

Fig. 20.16.  Diagram of developing male urogenital organs. The bladder, 0.1mm
urachus, prostate, urethra, and bulbourethral glands are derived from Foxa1
endodermal urogenital sinus epithelium (yellow). The ureter, vas deferens,
and seminal vesicle are derived from the mesodermal mesonephric (Wolffian) Fig. 20.17.  Section of a prebud 9-week human fetal urogenital sinus (UGS)
ducts (purple). (Modified from Shen J, Cunha G, Sinclair A, et al. (2018). in the region of the verumontanum, a dorsal hillock projecting into the UGS
Macroscopic whole-mounts of the developing human fetal urogenital-genital (dotted line). The Wolffian ducts (WDs) flank the Müllerian-derived prostatic
tract: indifferent stage to male and female differentiation. Differentiation. pii: utricle, and both open into the UGS at/near the apex of the verumontanum.
S0301-4681(18)30098-7. [Epub ahead of print].) The section is immunostained for FOXA1, an endodermal marker.

SV Lateral views
Bladder
Utricle
Utricle Ecad Ureter
Ejd
Urethra

Human
B fetus Anterior Posterior
Dorsal
view

Human fetal prostate Ejd

A 13 weeks C

Fig. 20.18.  (A) Dorsal view of a 13-week male human fetal prostate showing the prostatic utricle (white)
in the dorsal midline and prostatic ductal outgrowths (green) emerging from the lateral aspects of the
verumontanum. (B) Lateral view of specimen (A). (C) Light sheetthree-dimensional reconstruction of a
12-week human fetal prostate in lateral view immunostained for E-cadherin (red) to display epithelium.
Note that prostatic ducts have emerged from the posterior-lateral aspects of the urethra. Ejd, Ejaculatory
duct. (A and B modified from Timms, 2008 and Timms and Hofkamp, 2011. From Cunha GR, Vezina CM,
Isaacson D, et al. New insights in the development of the human prostate. Differentiation. 103:24–45, 2018.)
 Chapter 20  Embryology of the Genitourinary Tract 315

TABLE 20.1 Marker Expression Profiles in Urogenital

Bladder Sinus Epithelium, Solid “Ducts,” and
Adult Human Prostate

ADULT ADULT
PREBUD SOLID LUMINAL BASAL
Verumontanum MARKERS UGE “DUCTS” CELLS CELLS

TP63 + + – +
KRT5 + + – +
Utricle
KRT8 + + + –
KRT14 + + – +
Ejaculatory KRT18 + + + –
duct
KRT19 + + – +
GSTpi + + – +
A Urethra
UGE, Urogenital sinus epithelium.
Modified from Wang Y, Hayward S, Cao M, et al. Cell differentiation lineage
Ejaculatory in the prostate. Differentiation. 2001;68(4–5):270–279.
duct
Utricle

The endocrinology of prostatic development emerged initially

from animal studies (Jost, 1953; Price and Ortiz, 1965). Androgens
Urethra
produced by fetal testes play a critical role in development of the
prostate. Morphogenetic/differentiation responses to androgens are
mediated by nuclear androgen receptors (ARs) that are activated
Mucosal
glands by either testosterone or DHT. The requirement of androgens in
prostatic development comes primarily from the absence of prostate
B in mice and humans lacking functional ARs (Wilson et al., 1983) and
Fig. 20.19.  Drawings of adult human prostate. (A) Anterior wall of the urethra from the development of the prostate in the female UGS exposed
has been removed to visualize the verumontanum (green) and the posterior to androgens (Cunha, 1975). Although testosterone can activate
and lateral walls of the prostatic urethra. Note the distribution of openings ARs in the UGS by directly binding to the AR, the more potent
of the prostatic ducts in the “gutters” lateral to the verumontanum as described androgen, DHT, plays a critical role in prostatic development. DHT
previously (Timms, 1997). (B) Drawing of a transverse section through the is produced within the developing UGS by 5α-reductase 2 (5αR2;
verumontanum of an adult human prostate showing the prostatic utricle and Russell et al., 1993; Russell and Wilson, 1994). DHT has a 10-fold
ejaculatory ducts joining the prostatic urethra. The prostatic ducts emerge greater affinity for the AR than testosterone (Deslypere et al., 1992).
from the urethra in the gutters lateral to the verumontanum. Mucosal glands 5αR2 plays an important role in prostate and male external genitalia
emerge from the ventral aspect of the urethra. (From Cunha GR, Vezina CM, development (Andersson et al., 1991; Russell and Wilson, 1994)
Isaacson D, et al. New insights in the development of the human prostate. insofar as prostates of patients with 5αR2 deficiency are rudimentary
Differentiation 103:24–45, 2018.) (Imperato-McGinley and Zhu, 2002; Radmayr et al., 2008). Likewise,
transgenic mice lacking steroid 5αR1 and 5αR2 have smaller prostates
and seminal vesicles than controls (Mahendroo et al., 2001). 5αR2 is
predominantly expressed in prostatic mesenchyme (Radmayr et al.,
2008). The function of 5αR1 in urogenital development remains
first branch point is consistent with the idea that ductal branching unclear as cloning and genetic studies demonstrate that the 5αR1 gene
patterns in the human prostate may be lobe specific, as is the case is normal in patients with 5αR2 deficiency (Andersson et al., 1991).
for mice and rats. Mesenchymal-epithelial interactions play a fundamental role
The solid prostatic “ducts” subsequently canalize from their in development of the prostate, even though the overall develop-
proximal urethral connections, distally toward the ductal tips. “Ductal” mental process is elicited by androgens via the AR. Under the
canalization is associated with the differentiation of luminal and influence of androgens, UGM induces and specifies prostatic develop-
basal cells each expressing its unique profile of differentiation markers ment in the epithelium. Indeed, UGM can instructively induce
(Table 20.1) (Wang et al., 2001). The prebud UGE and “solid prostatic prostatic development in embryonic and adult bladder epithelium
ducts” (before canalization) coexpress markers characteristic of both of rodent and human origin (Aboseif et al., 1999; Cunha et al.,
luminal and basal epithelial cells (see Table 20.1). Accordingly, it 1980, 1983). Mesenchymal-epithelial interactions in the developing
appears that epithelial cells destined to become luminal cells maintain prostate are reciprocal. The presence of prostate epithelium plays a
luminal cell markers while losing basal cell markers, and epithelial critical role in the differentiation of UGS mesenchyme into the
cells destined to become basal cells preserve basal cell markers while periductal prostatic smooth muscle cells (Cunha et al., 1992; Hayward
losing luminal cell markers (Wang et al., 2001; see Table 20.1). et al., 1998).
While prostatic ducts are elongating and undergoing branching, The role of mesenchymal versus epithelial AR in prostatic develop-
prostatic mesenchyme (UGM) differentiates into smooth muscle, ment was determined through use of tissue recombinants prepared
and eventually adult prostatic stroma is mostly composed of with epithelium and mesenchyme from wild-type and AR-negative
smooth muscle (McNeal, 1983). Differentiation of UGM into smooth testicular feminization (Tfm) mice (wt-UGM+Tfm-UGE; Cunha and
muscle occurs initially in ventral UGM, with smooth muscle dif- Lung, 1978). Analysis of chimeric prostates composed of AR-positive
ferentiation subsequently spreading into lateral and dorsal areas wild-type mesenchyme plus Tfm epithelium has demonstrated that
(Fig. 20.20). It is perhaps worth noting that at 19 weeks ductal AR-deficient Tfm epithelium (UGE or bladder epithelium) can undergo
branching is most intense near the prostatic capsule, where smooth androgen-dependent ductal morphogenesis, epithelial proliferation,
muscle is particularly abundant (Fig. 20.21; Cunha, et al., 2018b). and columnar cytodifferentiation (Cunha and Lung, 1978; Shannon
Does this mean that prostatic smooth muscle plays a role in ductal and Cunha, 1984; Sugimura et al., 1986b). The fact that mesenchymal
branching morphogenesis? (but not epithelial) ARs are required for prostatic ductal growth,
316 PART III  Pediatric Urology

14wks 17wks

0.2mm
1mm
A B

Fig. 20.20.  (A) Section of human fetal prostate at 14 weeks’ gestation. The red dots indicate the proximal
origin of a prostatic duct from the urethra and the first branch point, respectively. The distance between
these two points is approximately 250 µm. (B) Thick (0.5 mm) coronal section of a 17-week human fetal
prostate photographed with transmitted light. Red dots are placed on three prostatic ducts depicting
ductal length to the first branch point. In all three cases, the distance is approximately 1000 µm. The thin
white line in (B) representing one of the three white lines above is approximately 1000 µm. (From Cunha
GR, Vezina CM, Isaacson D, et al. New insights in the development of the human prostate. Differentiation
103:24–45, 2018.)

Fig. 20.21.  Transverse sections of developing human prostate immunostained for smooth muscle α-actin.
(A) Section through the verumontanum of a 9-week prebud UGS in which sparse α-actin–positive cells
(white arrowheads) are seen in ventrolateral UGM. In contrast, α-actin–positive cells are abundant in the
wall of the rectum. (B) Section of a human fetal prostate exhibiting smooth muscle bundles in ventral UGM
at 15 weeks’ gestation, with minimal α-actin positivity in the dorsal position. (C) Section of a human fetal
prostate at 19 weeks’ gestation showing α-actin–positive smooth muscle around the periphery, where
solid “ducts” are branching. EJD, Ejaculatory ducts; UGS, urogenital sinus; Ur, urethra; WD, Wolffian duct.

branching, and columnar cytodifferentiation suggests that paracrine estrogen receptor beta (ESR2) knockout mice, but not in estrogen
signals from UGM mediate the action of androgens on the epithelium. receptor alpha (ESR1) null mice (Risbridger et al., 2001b), suggesting
However, it is notable that in wt-UGM+Tfm bladder epithelium that prostatic squamous metaplasia is elicited via ESR1. The roles
tissue recombinants, the AR-negative Tfm epithelium failed to express of epithelial (E) versus stromal (S) ESR1 in DES-induced prostatic
prostatic secretory proteins (Donjacour and Cunha, 1993). Therefore, squamous metaplasia were assessed as indicated in Table 20.2.
ductal growth and branching morphogenesis is dependent on Prostatic epithelial squamous metaplasia only occurred in wt-S+wt-E
paracrine signals from AR-positive mesenchyme, and expression of tissue recombinants. Thus, prostatic squamous metaplasia requires
secretory proteins requires epithelial AR. ESR1 simultaneously in both the epithelium and stroma.
Prostate development/differentiation is adversely affected by Several candidate genes have been implicated in prostatic develop-
estrogenic compounds (Prins et al., 2006; Risbridger et al., 2001a; ment. Stimulation of prostatic ductal growth and branching has
Timms et al., 2005; vom Saal et al., 1997). One acute effect of been attributed to a variety of growth factors and growth factor
exogenous estrogen on prostatic development is squamous metaplasia, regulators. Fibroblast growth factor-7 (FGF7 and FGF10, both of
which is elicited by diethylstilbestrol (DES) in wild-type mice and which play an important role in prostatic development, are produced
 Chapter 20  Embryology of the Genitourinary Tract 317

TABLE 20.2 Squamous Metaplasia in Tissue innervation of the human fetal seminal vesicles was initially detected
Recombinants Composed of Wild-Type by immunohistochemistry in the muscle coat of fetal seminal vesicles
(Wt) and ESR1-Null Prostatic Epithelium at 13 weeks’ gestation (Jen et al., 1995). Malformation and malignancy
and Mesenchyme of human seminal vesicles are extremely rare and include rare cases
of seminal vesicle cyst.
MESENCHYME EPITHELIUM SQUAMOUS METAPLASIA

Wt Wt + KEY POINTS: PROSTATE DEVELOPMENT

Wt ESR1 null –
• Androgens produced by fetal testes play a critical role in
ESR1 null Wt –
development of the prostate.
ESR1 null ESR1 null –
• Mesenchymal-epithelial interactions play a fundamental
role in development of the prostate, even though the
overall developmental process is elicited by androgens via
by UGM and signal through receptors in developing prostatic epi- the AR.
thelium (FGFR2-IIIb) to stimulate growth and branching of prostatic
ducts (Donjacour et al., 2003; Finch et al., 1995, Sugimura et al.,
1996; Thomson and Cunha, 1999). Activin-A and its antagonist, DEVELOPMENT OF THE GONADS
follistatin, also play a role in regulating prostate epithelial develop-
ment (Cancilla et al., 2001; Risbridger and Cancilla, 2000). In vitro The gonads differentiate into testes or ovaries and ultimately produce
studies showed that activin-A inhibits prostatic ductal branching sperm or oocytes, respectively. They develop in a bilateral pair of
and growth, and follistatin increases ductal branching (Cancilla et al., longitudinal ridges (gonadal ridges) composed of coelomic epithelium
2001). Thus, prostatic ductal growth and branching may result from and underlying condensed mesenchyme. During the third week of
a balanced interplay between activin-A and its antagonist follistatin. gestation, primordial germ cells arise in the yolk sac and migrate
Other TGFβ family members, bone morphogenetic proteins 4 and from along the dorsal mesentery to populate the gonadal ridges
7 (BMP4 and BMP7), restrict ductal branching in developing prostate located in the lower thoracic and upper lumbar levels (Fig. 20.22).
(Grishina et al., 2005; Lamm et al., 2001). Another growth factor If primordial germ cells fail to reach the gonadal ridges, the
implicated in prostatic development is insulin-like growth factor-1 gonads fail to develop. During the sixth week of gestation, the
(Ruan and Kleinberg, 1999; Ruan et al., 1999). surface epithelial cells of the genital ridge invade the mesenchyme
The homeobox gene, Nkx3.1, is one of the earliest markers of of the gonadal ridges to form the primitive sex cords. The elongated
developing and adult prostatic epithelium in mice (Bhatia-Gaur indifferent gonads within the genital ridge at 7 to 8 weeks are
et al., 1999; Tanaka et al., 2000) and in adult human prostate macroscopically indistinguishable in males and females (Fig. 20.23).
(Ornstein et al., 2001). Hox homeobox genes are also involved in In the course of development, the testes will become more spherical
differentiation of male accessory sex glands (Podlasek et al., 1997, in shape, and the ovaries will remain oblong. Morphometrics analysis
1999). Hoxa-13 and Hoxd-13 are expressed in the embryonic UGS, shows that the length of the developing ovary is greater than that
and loss of function of these genes in mice results in bulbourethral of the testis (Shen et al., 2018a).
gland agenesis and defective prostate and seminal vesicle development
(Podlasek et al., 1997, 1999). p63 is a marker expressed in embryonic Testicular Formation
UGE and later in prostatic basal cells and is required for normal
prostatic development and postnatal response to androgen deprivation Under the influence of SRY gene products, cells in the medullary
and androgen replacement (Kurita et al., 2004; Signoretti et al., 2000). region will form testicular epithelial cords in which Sertoli cells
Fucosyltransferase-1 has also been implicated in prostatic develop- differentiate in association with primordial germ cells that migrate
ment. A fucosyltransferase-1–binding monoclonal antibody defines into these cords (Fig. 20.24; Larney et al., 2014). Sertoli cell differentia-
a unique expression pattern in the developing prostate and inhibits tion only occurs if SRY protein is present; otherwise the sex cords
growth and ductal branching in explants of neonate rat prostate will form ovarian follicles. These primitive testicular cords containing
(Marker et al., 2001). In the prebud stage in mice, androgens stimulate germ cells eventually will canalize and differentiate into seminiferous
bands of Edar, Nkx3-1, and Wnt10b mRNAs to appear in anterior, tubules in which sperm production will occur. Direct cell-to-cell
ventral, and dorsolateral prostatic budding zones. These mRNAs are contact between developing Sertoli cells and primordial germ cells
later focally restricted during bud initiation and elongation to nascent is thought to play a key role in the proper development of male
prostatic bud tips (Bieberich et al., 1996; Keil et al., 2014a; Sciavolino gametes. This interaction occurs shortly after the arrival of the pri-
et al., 1997). In response to androgens, selected buds are stabilized mordial germ cells in the presumptive genital ridge. The testicular
as a result of activating WNT beta-catenin, which subsequently permits cords distal to the presumptive seminiferous tubules also develop
elongation of buds within prostatic budding zones while inhibiting lumen and differentiate into a set of thin-walled ducts called the
buds elsewhere (Allgeier et al., 2010; Mehta et al., 2013). DNA rete testis. Just medial to the developing gonad, the tubules of rete
methylation status of E-cadherin plays an important role in prostatic testis connect with 5 to 12 residual mesonephric tubules that will
bud elongation. DNA methylation of the E-cadherin promoter during form the efferent ductules that will convey sperm to the head of the
the prebud stage and continuing through bud initiation reduces epididymis. The epididymis and the vas deferens develop from the
E-cadherin transcription and increases bud epithelial cell motility Wolffian (mesonephric) duct. During the course of development,
(Keil et al., 2014b). the shape of the testis changes from oblong to relatively round,
reducing its area of contact with the surrounding mesonephros (see
Fig. 20.23). As the testis continues to develop, the tunica albuginea,
DEVELOPMENT OF THE HUMAN SEMINAL VESICLE a thick connective tissue capsule subadjacent to its mesothelial surface,
lines the testis.
Development of the human seminal vesicle is so sparsely represented As the developing Sertoli cells begin their differentiation in
in the literature that a PubMed search on “seminal vesicle, human response to the SRY protein, they also begin to secrete a glycoprotein
and development” reveals only two papers. Aumuller and Riva (1992) hormone called Müllerian-inhibiting substance (MIS; Behringer et al.,
is the most informative literature. Human seminal vesicle appears 1994). MIS causes the paramesonephric (Müllerian) ducts to regress
as a diverticulum of the WD at about the 10th to the 12th week of rapidly between the 8th and 10th weeks of gestation. Small MD
gestation. The diverticulum elongates and folds back on itself, thus remnants can be detected in males as a small epithelial cysts at the
forming a “hooklike duct” with extensive “side ducts forming during superior pole of the testis, called the appendix testis. The prostatic
months 4 to 5 of pregnancy” (Aumuller and Riva, 1992). Autonomic utricle is a small pouching opening on the apex of the verumontanum
318 PART III  Pediatric Urology

Mesonephros
Genital
ridges

Hindgut Cloaca

Primordial
germ cells

Foregut

Heart

Yolk sac
A B

Fig. 20.22.  (A) Site of the primordial germ cell origin in the wall of the yolk sac in a 3-week-old embryo.
(B) Migratory path of the primordial germ cells along the wall of the yolk sac and dorsal mesentery into
the developing genital ridges. (Modified from Sadler TW. Langman’s medical embryology. Baltimore, MD:
Williams & Wilkins; 1985.)

Fig. 20.23.  Whole-mount photographs of human fetal gonadal ontogeny. Testis ontogeny (top row) and
ovarian ontogeny (bottom row) are shown. The testis have a more spherical shape in contrast with the
oblong shape of the ovaries. Note the epididymal attachments in many testis specimens.

in the prostatic urethra and is also an MD remnant. In female embryos, Ovarian Formation
MIS is absent; therefore the MDs do not regress and instead form
most of the female internal genitalia. Table 20.3 summarizes the Female embryos lacking a Y chromosome do not elaborate SRY
embryologic origin of urogenital structures. protein and therefore do not differentiate cords containing Sertoli
During the 9th and 10th weeks, Leydig cells differentiate from cells. In the absence of Sertoli cells and SRY protein, MIS synthesis,
mesenchymal cells of the genital ridge in response to the SRY protein Leydig cell differentiation, and androgen production do not occur.
(Turner et al., 1995). These endocrine cells produce testosterone. At Consequently, masculinization of the genital ducts and accessory
an early stage of development, testosterone secretion is regulated glands is not stimulated, and instead female development ensues.
by placental chorionic gonadotropin, but eventually fetal pituitary In females, the primitive sex cords break up into irregular cluster
gonadotropins assume control of androgen production. Between into which the germ cells migrate to form ovarian follicles. The germ
the 8th and 12th weeks, testosterone secretion by Leydig cells cells differentiate into oogonia and enter the first meiotic division
stimulates the mesonephric (Wolffian) ducts to transform into as primary oocytes during fetal life. The follicle cells then arrest
the paired epididymis, vas deferens, and seminal vesicle. The cranial further germ cell development until puberty, at which point individual
portions of the mesonephric ducts degenerate, leaving a small cystic oocytes resume gametogenesis in response to a monthly surge of
remnant called the appendix epididymis. During the ninth week, five gonadotropins.
to twelve mesonephric tubules in the region of the epididymis make
contact with the developing rete testis. It is not until the third month, Gonadal Descent
however, that communication is established among the developing
seminiferous tubules, rete testis, efferent ductules, and the epididymis. Morphologically, the human urogenital ridge is identical in both
Meanwhile, mesonephric tubules near the inferior pole of the sexes at 7 to 8 weeks’ gestation. Before gonadal differentiation, the
developing testis degenerate, sometimes leaving epithelial remnants, testis lies near the developing kidney in the upper lumbar region,
called the paradidymis (see Table 20.3). loosely held in place by two ligamentous structures. The cranial
 Chapter 20  Embryology of the Genitourinary Tract 319

Male Female

Paramesonephric duct Paramesonephric duct

degenerating developing
Mesonephric
Mesonephric duct
tubules
degenerating

Medullary
Cortical sex
sex cords
cords (derived
from secondary
sex cords)

Mesonephric
duct

Appendix epididymis
Fimbria
Appendix testis

Testis cords (future

seminiferous tubules)
Oogonium
Rete testis
Follicle cells
Tunica albuginea

Oviduct Epoöphoron
Paradidymis Paroöphoron
Epididymis
Vas deferens

Allantois

Prostatic utricle
Gartner
(remnant of
cyst
paramesonephric duct)
(remnant of
mesonephric duct)

Fig. 20.24.  Male and female gonad and genital development. The male and female genital structures are
virtually identical through the seventh week. In males, SRY protein produced by the Sertoli cells causes
the medullary sex cords to become presumptive seminiferous tubules and causes the cortical sex cords
to regress. Müllerian-inhibiting substance (MIS), a glycoprotein hormone produced by the Sertoli cells,
then causes the paramesonephric ducts to regress, leaving behind appendix testis and prostatic utricle
as remnants. Appendix epididymis and paradidymis arise from the mesonephric ducts. In females, cortical
sex cords invest the primordial germ cells and become the ovarian follicles. In the absence of MIS, the
mesonephric ducts degenerate and the paramesonephric ducts give rise to the fallopian tubes, uterus,
and upper vagina. The remnants of the mesonephric ducts are found in the ovarian mesentery as the
epoöphoron and paroöphoron, and in the anterolateral vaginal wall as the Gartner duct cysts. (Modified
from Larsen WJ. Human embryology. New York, NY: Churchill Livingstone; 1997.)
320 PART III  Pediatric Urology

TABLE 20.3  Embryologic Origin of Urogenital Structures

MALE EMBRYONIC STRUCTURE FEMALE

Testis Indifferent gonad Ovary

Seminiferous tubules Cortex Ovarian follicles
Rete testis (an anastomosing network of Medulla Rete ovarii (Hilus in which nerves and blood
delicate tubules located in the hilum of vessels enter the ovary (analogous to rete testis)
the testicle [mediastinum testis])
Gubernaculum testis (testicular descent into Gubernaculum Ovarian ligament (descend and support ovary)
scrotum) Round ligament of uterus (support uterus in pelvis)
Efferent ductules of testis Mesonephric tubules Epoöphroon
Paradidymis (a small group of vestigial tubules (mesonephros [second Paroöphoron (both nonfunctional structures
located above the epididymis) kidney]) located between the ovary and fallopian tube)
Appendix of epididymis Wolffian duct (mesonephric Gartner duct (anterior superior vaginal wall)
Ductus deferens duct) Ureter, pelvis, calices, and collecting tubules
Ejaculatory duct and seminal vesicle Stalk of ureteric bud
Ureter, pelvis, calices, and collecting tubules (Wolffian)
Kidney (metanephros) Intermediate mesoderm Kidney (metanephros)
Nephrons (consists of the glomerulus, proximal (metanephric blastema/ Nephrons (consists of the glomerulus, proximal
tubule, loop of Henle, and distal tubule) mesenchyme) tubule, loop of Henle, and distal tubule)
Appendix of testis Müllerian duct Paratubal cyst (benign paraovarion cyst)
(paramesonephric duct) Uterine tube (fallopian tube)
Uterus
Cervix
Bladder and trigone Urogenital sinus Bladder and trigone
Urethra Urethra
Prostate Vagina, hymen
Verumontanum (seminal colliculus) Urethral glands (Skene’s glands [lesser vestibular
Prostatic utricle glands])
Urethral (Peri) glands (Littre glands) Urethral glands
Bulbourethral glands (Cowper’s glands) Greater vestibular glands (Bartholin glands)
Penis Genital tubercle Clitoris
Glans penis Glans clitoris
Corpora cavernosa of penis Corpora cavernosa of clitoris
Corpus spongiosum of penis Bulb of vestibule (clitoral bulbs)
Ventral aspect of penis Urethral folds/vestibular folds Labia minora
Scrotum Labia scrotal swellings Labia majora

ligament is referred to as the cranial suspensory ligament (CSL), whereas cord appears to shorten during this process as it becomes incorporated
the caudal ligament later develops into the gubernaculum (Fig. 20.25). into the enlarging bulb (Wensing, 1986). Shortening of the cord
Between 10 and 15 weeks, the testis has descended to the future may be an important mechanism to position the testis over the
inguinal region during the enlargement of the abdominal cavity, inguinal ring to permit abdominal pressure to push the testis out
and the ovary only descends into the pelvis. The testis is anchored of the abdomen (Attah and Hutson, 1993; Husmann and Levy,
near the inguinal region by enlargement of the gubernaculum and 1995; Quinlan et al., 1988). Transection of the gubernacular cord
regression of the CSL. As early as the 1700s, enlargement of the can lead to either accidental testicular descent into the contralateral
gubernaculum in males was observed to tether the testis near the inguinal canal or an aberrant intra-abdominal location (Attah and
groin while the kidney migrated cranially (Wyndham, 1943; van Hutson, 1993; Beasley and Hutson, 1988; Frey and Rajfer, 1984).
der Schoot, 1993). In females, the CSL continues to develop, keeping The role of intra-abdominal pressure is controversial during the
the ovary close to the kidney while the gubernaculum remains initial transabdominal descent but is thought to be important during
rudimentary. In males, androgen induces resorption of the CSL, and transit through the inguinal canal and the subsequent scrotal migration
the gubernaculum enlarges to become a plump ligamentous body, (see Fig. 20.25). Androgens act mostly indirectly via the genitofemoral
“holding” the testis in the inguinal region. Starting in the seventh nerve, which produces calcitonin gene–related peptide (CGRP) to control
month, the gubernaculum begins to bulge beyond the external the direction of migration of the testis (Hutson and Donahoe, 1986).
inguinal ring and extends into the scrotal location, and simultaneously Inguinoscrotal descent requires migration of the gubernaculum
it is hollowed out by the evaginating peritoneal diverticulum called over a considerable distance, along with an increase in length of the
the processus vaginalis (Heyns, 1987). The processus vaginalis allows processus vaginalis. The force for movement may come from
the intra-abdominal testis to exit the abdominal cavity. The bulky the intra-abdominal pressure, transmitted directly and indirectly to
distal end of the gubernaculum (known as the bulb) is resorbed in the testis via the lumen of the processus vaginalis and the gubernacular
humans after completion of inguinoscrotal migration. cord, respectively.
Caudal enlargement of the gubernaculum during the early relative Although patients with defective androgen production or androgen
transabdominal movement of the testis is known as the swelling metabolism show varied manifestations of cryptorchidism, the exact
reaction or gubernacular outgrowth (see Fig. 20.25). The gubernacular role of androgen in testicular descent still remains unclear. During
 Chapter 20  Embryology of the Genitourinary Tract 321

CSL

WD
MD

A CGRP
B
C

Fig. 20.25.  The two stages of testicular descent. (A) Before descent, the developing testis is held in the
urogenital ridge by the cranial suspensory ligament (CSL) cranially and the gubernaculum (G) caudally.
The adjacent Wolffian duct (WD) forms the epididymis and vas deferens in the male, and the Müllerian
duct (MD) forms the uterus and tubes in the female. (B) At the end of the transabdominal phase (*15
weeks), the testis is held near the future inguinal ring by the swelling reaction in the gubernaculum. The
skin just beyond the gubernaculum is over the future external inguinal ring, as the scrotum is remote in
the perineum of humans. (C) The inguinoscrotal phase requires the gubernaculum to elongate to the
scrotum, under control of androgens and calcitonin gene–related peptide (CGRP) released from the
genitofemoral nerve (GFN). After migration is complete, the peritoneum of the processus vaginalis (PV)
closes and then completely involutes and disappears. (Modified from Hutson JM, Li R, Southwell BR,
et al. Regulation of testicular descent. Pediatr Surg Int. 2015;31[4]:317–325).

intra-abdominal testicular descent, androgen appears to play a role gubernaculum becomes divided into two parts: (1) the segment
in the regression of the CSL (van der Schoot, 1992). Gubernacular that extends from the ovary to the uterus called the ligament of the
enlargement, in contrast, seems to occur independent of androgen ovary and (2) the segment that extends from the uterus through the
activity, based on the fact that it occurs in androgen-resistant mice inguinal canal and into the labia majora called the round ligament of
and humans (Hutson and Donahoe, 1986). The second migratory the uterus. As in males, the processes vaginalis within the inguinal
step—the inguinoscrotal phase—is thought to be androgen dependent. canal is normally obliterated, but occasionally it remains patent to
Migration of the gubernaculum beyond the inguinal region is absent become an indirect inguinal hernia (Fig. 20.26).
in gonadotropin-deficient mice (Grocock et al., 1988) and those with
complete androgen resistance (Hutson, 1986). Regression of the guber- Clinical Correlation: Cryptorchidism
nacular bulb after the completion of scrotal descent also appears to
be androgen dependent because the gubernaculum remains enlarged Cryptorchidism occurs in approximately 3% of newborn males (Fig.
in humans with androgen resistance (Hutson and Donahoe, 1986). 20.27AB; Gurney et al., 2017). Hydroceles and hernia are even more
INSL3 was identified as a novel gene product of the Leydig common (Chan et al., 2016). An understanding of the mechanism
cells in 1993 (Adham et al., 1993). INSL3 is similar in structure to of testicular descent affected or regulated via the CSL, gubernaculum,
the peptide hormones relaxin or insulin and is expressed in both and processes vaginalis can explain the embryology of undescended
fetal and adult Leydig cells in a differentiation-dependent manner testis, hydrocele, hernia, and acquired cryptorchidism (see Fig. 20.26).
(Balvers et al., 1998) Mice lacking a functional Insl3 gene demonstrate In the case of abnormal retention of the cranial suspensory liga-
intra-abdominal cryptorchidism but otherwise no obvious defects ment, the undescended testis is likely to be found in the abdomen
in other male reproductive organs. Of more importance, early (see Fig. 20.27AB). Abnormalities in the gubernacular attachment
surgical correction of the cryptorchidism in these mice can restore are likely to result in undescended testis located in the inguinal
normal fertility potential (Nef and Parada, 1999; Zimmermann canal area or externally if the gubernacular attachment is ectopic
et al., 1999). These are important findings because they reflect the in the perineum, femoral area, or near the penis. Abnormalities in
phenotype most commonly observed in classic cryptorchidism in closure of the processes vaginalis can result in hydrocele or hernia,
humans. and lack of complete involution of the processus vaginalis can
The ovaries also descend and become suspended within the result in acquired cryptorchidism (see Fig. 20.26C; Hutson and
broad ligament of the uterus. As in males, the female embryos Donahoe, 1986).
develop a gubernaculum-like structure extending initially from
the inferior pole of the ovary into the subcutaneous fascia of the Clinical Correlation: Streak Gonad
presumptive labioscrotal folds. This “female gubernaculum” later
penetrates the abdominal wall as part of a fully formed inguinal Streak gonads typically occur with three genotypes (see Fig. 20.27D):
canal and becomes the round ligament of the uterus. In females, (1) 45,XO (Turners syndrome; Hook and Warburton, 2014); (2)
although the gubernaculum does not shorten like that in males, 46,XX (gonadal dysgenesis; Lee, Nordenstrom et al., 2016; Mouriquand
it still causes the ovaries to descend during the third gestational et al., 2016); or (3) 46,XY (gonadal dysgenesis; Massanyi et al., 2013).
month (by anchoring the ovaries in the pelvis) and places them The condition results if there is an absence of both MIS and testos-
attached to the peritoneal fold (the broad ligament of the uterus). terone. The absence of testosterone results in regression of WD, and
This translocation of ovaries appears to occur during the seventh hence normal male internal reproductive tracts will not develop.
week, when the gubernaculum becomes attached to the developing The absence of MIS allows the MDs to differentiate into the fallopian
paramesonephric (Müllerian) ducts. As the paramesonephric ducts tubes, uterus, cervix, and upper vagina (see Fig. 20.27E). These patients
fuse to form the midline uterovaginal canal, the female gubernaculum have female-like internal and external genitalia and will require
becomes tethered to the developing uterus. In this fashion, the female hormonal replacement for the nonfunctional streak gonad for
322 PART III  Pediatric Urology

A B C

Gubernaculum

Scrotum

Hyrdocele Hernia Acquired

cryptorchidism

Fig. 20.26.  Schematic depicting inguinoscrotal testicular descent and embryology explanation for congenital
cryptorchidism, hydrocele, hernia, and acquired cryptorchidism (ascending testis [T]). At the end of the
transabdominal phase, the enlarged gubernaculum occupies the future inguinal canal, and must migrate 3
to 5 cm to the scrotum (A, step 1), taking the testis inside the processus vaginalis, which elongates inside
the gubernaculum. Failure of this first step causes congenital cryptorchidism. After migration is complete,
the processus vaginalis closes (B, step 2), and failure of this causes inguinal hernia or hydrocele. The final
process (C, step 3) is complete involution of the processus vaginalis remnant, allowing the spermatic cord
to elongate after birth. Failure of this step is the likely cause of acquired cryptorchidism, as the fibrous
remnant of the processus vaginalis prevents the spermatic cord growing normally. (Modified from Hutson
JM, Li R, Southwell BR, et al. Regulation of testicular descent. Pediatr Surg Int. 2015;31[4]:317–325).

development of secondary sex characteristics. Patients with 46, XY sensitivity of fetal Müllerian structures to MIS, which normally
genotype are at risk for gonadoblastoma and subsequent malig- acts between 9 and 13 weeks’ gestation.
nancy and therefore typically have the streak gonads removed
(Cools, 2014).
KEY POINTS: GONADAL DEVELOPMENT
Clinical Correlation: Ovotesticular Syndrome • Under the influence of the SRY gene, the indifferent
gonads of the ambisexual embryo differentiate into a
The presence of both ovaries and testis (Ovotestis) in humans is
testis.
an extremely rare condition in which the gonad differentiates
• Androgens from the Leydig cell of the fetal testis drive
into both testicular and ovarian tissue (see Fig. 20.27E; Lee et al.,
male genital differentiation including prostatic
2016; Mouriquand et al., 2016). During fetal development and
development.
postnatally, both the testicular and ovarian tissue can function
• MIS from Sertoli cells of the testis causes degeneration of
hormonally, although in contrast with potential female fertility with
female Müllerian ductal structures (uterus and fallopian
normal oocytes, functioning spermatogenesis in adulthood has not
tube).
been reported. During fetal development, internal duct development
• Both gonads descend to pelvic location by the third
usually corresponds to that of the adjacent gonad. MD structures
month of gestation, but the testis descends into the
typically develop on the gonad side(s) not containing testicular tissue.
scrotum with the aid of the gubernaculum at about the
WD structures tend to be observed on the gonadal side(s) containing
seventh month.
functioning testicular tissue. Patients born with ovotesticular syndrome
often have atypical genitalia.

Clinical Correlation: Persistent Müllerian Duct Syndrome MÜLLERIAN STRUCTURES (FEMALE

INTERNAL GENITALIA)
Rarely, genetic males (XY) may have persistent MD structures (uterus
and fallopian tubes), a condition known as hernia uteri inguinale The Müllerian structures are not present in normal males secondary
(see Fig. 20.27F; Salehi et al., 2012). This typically results from to the secretion of MIS from the testis (Behringer et al., 1994). In
abnormalities in the MIS receptor, thus eliminating MIS action and females, who lack testosterone, WDs resorb (Blaschko et al., 2012)
retained female internal genitalia in the setting of a relatively normal and MDs are retained and develop into the uterine body, uterine
male phenotype. Clinically this can be found in patients undergoing cervix, and fallopian (uterine) tubes (Fig. 20.28). Note that in the
exploration for bilateral abdominal testis. Retained Müllerian whole-mount specimens it is impossible to differentiate the uterine
structures can also result from immature development of the body from the cervix and vagina. As expected, the size of the uterine
testis in which the timing of MIS production is out of phase with body increases over time (see Fig. 20.28).
 Chapter 20  Embryology of the Genitourinary Tract 323

Fig. 20.27.  Human intraoperative photographs (A) Intraabdominal testis at internal ring. (B) High intraabdominal
testis. (C) Normal ovary. (D) Streak gonads in a patient with XY gonadal dysgenesis. (E) Ovotestis in
ovotesticular syndrome. (F), Retained Müllerian structures in gonadal dysgenesis (orange testis syndrome).

Fig. 20.28.  Whole-mount photographs of developing human fetal female internal genitalia at 9 to 20
weeks’ gestation. Note the increase in size and morphologic complexity with time, and that landmarks
distinguishing the uterine corpus, cervix, and vagina are nonexistent. Specimens photographed with
transmitted light (11, 12, and 16 weeks) permit visualization of internal (epithelial) organization in regions not
too thick (note the epithelium defining the lumen of the uterine tube and the epithelium lining the uterus).
324 PART III  Pediatric Urology

Müllerian duct
Mesonephric
tubule
Wolffian duct
Mesonephric
(Wolffian) duct

Paramesonephric
(Müllerian) duct

Gut
A
A
A
B
C B

Fimbria
C
Fig. 20.30.  Diagrammatic representation of the caudal migration of the
Müllerian duct using the Wolffian duct as a “guidewire.” Note (A), the mes-
Ep enchyme intervening between the Müllerian and Wolffian ducts, (B) contact
Ovarian of the basement membranes of the Müllerian and Wolffian ducts, and (C)
MD folicles direct contact of the epithelia of the Müllerian and Wolffian ducts. (From
MD Robboy SJ, Kurita T, Baskin L, Cunha GR. New insights into human female
Par
WD reproductive tract development. Differentiation. 2017;97:9–22.)
B C
Fig. 20.29.  Drawings depicting the formation and development of the Müllerian
duct (MD). (A) Drawing of the urogenital ridge containing a mesonephric Kidney
tubule (green), the mesonephric (Wolffian) duct (purple), and the coelomic
invagination (orange) forming the MD. Note also migrating primordial germ
cells (red). (B) The MD (orange) is located lateral to the mesonephros and
Wolffian duct (WD, purple). (C) Later stage showing fimbria and degenerated
mesonephric structures (purple) (epoöphoron [Ep] and paroöphoron [Par]).

Ovary
Development of the Human Female Reproductive Tract WD
MD
At the start of week 5 in human female and male embryos, the
coelomic epithelium invaginates on the lateral surface of the paired Mesonephros
urogenital ridges to initiate MD development (Fig. 20.29; O’Rahilly, Bladder
1973). The infoldings later become the tubal ostia of the Müllerian
(paramesonephric) ducts. The paired MDs grow caudally within the Ureter
urogenital ridges using the WDs as “guidewires.” Indeed, the WD is
requisite for caudal MD migration to the UGS (Gruenwald, 1941; Uterovaginal
Kobayashi et al., 2005). Subsequently, the WDs of female fetuses canal
degenerate, leaving vestigial remnants (epoöphoron and paroöphoron)
usually found within the broad ligament of the uterus and Gartner’s
duct within the fibromuscular wall of the vagina (Moore and Persaud, Fig. 20.31.  Diagram of rudiments of human female internal genitalia in the
2003; see Table 20.3). During MD migration, the mesenchyme initially indifferent, bisexual stage (approximately 54 days’ gestation, Carnegie stage
separates the MDs and the WDs (Fig. 20.30). More caudally, the 22). Müllerian derivatives are orange, and Wolffian derivatives are purple. Note
conjoined basement membranes of the MDs and WDs are in contact the changing anatomic relationships between the Müllerian ducts (MD) and
without intervening mesenchyme. Even more caudally, the tip of Wolffian ducts (WD). Note the mesonephros (second primitive kidney) that
the MD is in direct contact with WD (see Fig. 20.30), which led to is dissolving in cranial to caudal fashion lateral to the WD. (Modified from
the idea that the WD may contribute cells to the MD or vice versa Robboy SJ, Kurita T, Baskin L, Cunha GR. New insights into human female
(Frutiger, 1969). However, recent cell-lineage tracing experiments in reproductive tract development. Differentiation. 2017.97:9–22.)
mice do not support this contention (Kurita, 2010).
The WDs and MDs exhibit two gentle curves in route to the
UGS that define horizontal and vertical portions, as seen in frontal by a midline epithelial septum, which disappears in the ninth week
view (Fig. 20.31). The point of contact of the MDs with the UGS is (Hunter, 1930; Koff, 1933; see Fig. 20.32, inset).
called the Müllerian tubercle, which is poorly described and minimally
illustrated in the literature and thus is a term of limited value. During Uterine Tube
the seventh to eighth weeks, the right and left MDs lie between the
two WDs as these ducts approach and join the UGS. In the eighth The uterine tubes, originally called the fallopian tubes, develop from
week, the paired MDs fuse in the midline to form the uterovaginal the paired cranial portions of the MDs retained after the caudal
canal (Fig. 20.32). During fusion, the paired MDs become separated segments fuse to form the midline uterovaginal canal (see Fig. 20.32).
 Chapter 20  Embryology of the Genitourinary Tract 325

Fimbria develop from the irregular ostia of the MDs (see Fig. 20.29). malformations (see later). The cranial aspect of the uterovaginal
At 8 weeks, the uterine tubes are narrow, and the epithelium defines canal forms the uterine corpus and uterine cervix (Fig. 20.34), and
a circular tubular profile. In the ensuing months, two noticeable the caudal portion of uterovaginal canal is involved in vaginal
changes occur: (1) The mucosa becomes highly folded, most promi- development. The Müllerian epithelium lining of the cranial aspect
nently in the infundibulum and ampulla, and (2) the loose mes- of the uterovaginal canal remains simple columnar and eventually
enchyme surrounding the epithelial tube differentiates into an inner forms uterine and cervical glands that penetrate into the endometrial
stromal layer associated with the epithelium and outer layer of smooth stroma. Cervical epithelium remains simple columnar and glandular
muscle (Fig. 20.33). cranially in the endocervix, but near the external os of the cervix
the Müllerian epithelium differentiates into a stratified squamous
Uterus Corpus and Cervix epithelium that also covers the exocervix projecting into the vagina.
The mesenchymal wall of the uterovaginal canal differentiates into
The uterine corpus develops from the cranial portion of the midline endometrial stroma containing uterine and cervical glands. The
uterovaginal canal, which formed as a result of fusion of the MDs endometrial stroma is in turn surrounded by a thick smooth muscle
(see Fig. 20.32). Initially a midline epithelial septum represents layer, the myometrium, which also differentiates from mesenchyme
the zone of fusion of paired MDs that is subsequently eliminated. of the uterovaginal canal.
Failure of regression of the septum can lead to a variety of
Vagina
The origin of human vaginal epithelium has been debated for decades.
Various investigators have proposed that vaginal epithelium receives
contributions from epithelia of the UGS, MDs or WDs alone, or in
combination (Koff, 1933; Bulmer, 1957; O’Rahilly, 1977; Forsberg,
1978). The two most popular views on derivation of human vaginal
epithelium were advanced by Koff in 1933 and Bulmer in 1957
MD

WD Uterine tube 21 weeks

α-actin
Mesonphros

Fusing MDs
Uterovaginal
canal
Septum
UV canal

SV bulb

UGS

Fig. 20.32.  Light sheet microscopy of a human female reproductive tract at

9.5 weeks (indifferent stage) stained with an antibody to E-cadherin that
allows visualization of epithelium. The mesonephros and Wolffian ducts (WD)
are present at this stage. Cranially, the unfused Müllerian ducts (MD) are
destined to form the uterine tubes. Midline fusion of the MDs has created
the uterovaginal canal that terminates caudally by joining the urogenital sinus 0.125mm
(UGS). Inset depicts MD fusion to form the uterovaginal canal (UV canal) and 0.25mm
9 weeks
the septum. Note the sinovaginal bulb (SV bulb, green), which is a UGS
derivative. (From Cunha GR, Vezina CM, Isaacson D, et al. New insights in Fig. 20.33.  Section of the ampulla of the human uterine tube at 21 weeks
the development of the human prostate. Differentiation. 2018. pii: S0301- stained with an antibody to α-actin. Note the highly folded epithelium. Inset
4681(18)30099-9. [Epub ahead of print].) is the uterine tube at 9 weeks’ gestation.

Uterine
Fig. 20.34.  Drawings depicting (A) fusion of the Müllerian ducts corpus
to form the uterovaginal canal and contact of the Müllerian
epithelium of the uterovaginal canal with the sinovaginal bulb
Uterine
derived from urogenital sinus epithelium (UGE). In (B) the cervix
solid vaginal plate has formed from both UGE and Müllerian
epithelium. In (C), the UGE has replaced the Müllerian epithelium Septum Vagina
up to the level of the exocervix.
Uterovaginal
canal Vaginal
plate Hymen
Sinovaginal
A bulb B C
326 PART III  Pediatric Urology

MD

PAX2
UVC

0.05mm
0.25mm
A B

Fig. 20.35.  PAX2 immunostaining of the (A) Müllerian duct (MD) and (B) uterovaginal canal (UVC) at 9 weeks.

(Koff, 1933; Bulmer, 1957). Koff proposed that human vaginal

epithelium derives from both Müllerian and endodermal epithelium Bladder Introitus
of the UGS that forms the so-called sinovaginal bulbs (Koff, 1933).
Koff maintained that Müllerian epithelium predominated in human
vaginal epithelial development. In contrast, Bulmer proposed that Urethra
UGS epithelial upgrowth “forms the whole of (the vaginal) epithelial Uterus
lining.” The conclusions from both studies are based solely on
hematoxylin and eosin (H&E)-stained sections.
We have utilized immunohistochemistry to explore the question of A 1mm
the relative contribution of Müllerian versus UGE to human vaginal PAX2
epithelium. PAX2 is a protein expressed in Müllerian epithelium
(Cunha et al., 2018; Kurita, 2010), and FOXA1 is a protein expressed
in endodermal UGE and its derivatives (Besnard et al., 2004; Diez-
Roux et al., 2011; Robboy et al., 2017). PAX2 immunostaining was
observed in the 8- to 9-week MD and in the uterovaginal canal Vaginal plate
(Fig. 20.35).
The uterovaginal canal initially has a lumen throughout its
entire length, but caudally the epithelium of the uterovaginal canal
B 0.1mm
proliferates to form the solid vaginal plate that caudally abuts the
endodermal UGS-derived epithelium of the sinovaginal bulbs (see
Fig. 20.34). This is illustrated particularly well at 12 weeks, when
the cranial (uterine) end of the uterovaginal canal is in continuity
with the solid vaginal plate (Fig. 20.36). Both the solid vaginal plate
and the uterovaginal canal are PAX2-reactive (see Fig. 20.36AB). In
contrast, the caudal portion of the vaginal plate (sinovaginal bulb)
is FOXA1-reactive as is the epithelium of the urethra and bladder
(see Fig. 20.36CD). During the next several weeks (14 to 21 weeks),
the solid vaginal plate increases in extent, and the areas of PAX2 and
FOLXA1 reactivity change dramatically consistent with substantial Vaginal plate
replacement of PAX2-positive Müllerian epithelium by FOXA1-UGE. C
Canalization of the solid vaginal plate is initiated in approximately FOXA1
the 15th week and is mostly complete by 18 to 19 weeks (Koff, 1933),
when vaginal fornices are well defined with the exocervix projecting Bladder
Introitus
into the vaginal vault. At this stage, PAX2 reactivity was seen continu-
ously from the uterine tube to the upper vagina, and FOXA1-positive
epithelium had extended cranially to the mid-vagina. At 21 weeks, Uterus
the vaginal epithelium was many cell layers thick and glycogenated Urethra
(likely caused by endogenous estrogen; Fig. 20.37AB). Epithelial
PAX2 immunostaining was observed in epithelium of the uterine
tube, the uterus (see Fig. 20.37D), and the cervix (see Fig. 20.37C). D
Epithelial FOXA1 staining was observed from the vaginal introitus
to the cervix. The abrupt change in FOXA1/PAX2 staining occurred
at the same point at the vaginal/cervical junction (see Fig. 20.37EF). Fig. 20.36.  Sagittal sections of a 12-week human female fetal reproductive
These immunohistochemical data support Bulmer’s proposal that tract immunostained with PAX2 (A and B) and FOXA1 (C and D). PAX2-reactive
the entire human vaginal epithelium is derived from UGE, which epithelial cells extend to near the junction with the introitus/urethra (A and
is depicted in Fig. 20.34. The most caudal segment of the vagina B). FOXA1-reactive epithelial cells extend only a short distance into the solid
at the introitus is FOXA1 positive, and thus the presumption is that vaginal plate (C and D). Scale bar in (A) also refers to (D). Scale bar in (D)
the epithelium of the hymen is derived from UGE. also refers to (C).
It is important to recognize that derivation of vaginal epithelium
in the mouse is entirely different from that in the human as is the
 Chapter 20  Embryology of the Genitourinary Tract 327

by imperforate hymen, which is the most common cause of vaginal

obstruction (Fig. 20.38).

Clinical Correlation: Uterus Didelphys

Vagina
Uterus didelphys results from failure of the fusion of the caudal
2mm aspects of the Müllerian (paramesonephric) ducts. A unicornuate
A Introitus
uterus develops when one of the MDs fails to develop.
Uterine corpus
Clinical Correlation: Obstructed Hemivagina
Vagina Cervix
and Unilateral Renal Anomalies
Obstructed hemivagina and ipsilateral renal agenesis (OHVIRA)
B syndrome is a rare congenital anomaly that involves Müllerian and
urinary tract anomalies. OHVIRA syndrome usually presents after
Uterus menarche with symptoms such as cyclic abdominal pain and vaginal
Vaginal epithelium
discharge but can present more dramatically with an acute abdomen
0.1mm and tubo-ovarian abscess. More recently, there have been reports of
OHVIRA syndrome with ipsilateral dysplastic kidneys or ectopic
ureters (Schlomer et al., 2015). OHVIRA syndrome is thought to be
PAX2
0.25mm caused by abnormal development of the MDs and the WDs (Capito
et al., 2008). True renal agenesis can occur because of an absence
in WD formation, ureteric bud formation, or metanephric blastemal
Cervical epithelium D formation. Findings in females with true renal agenesis also include
C an absent ipsilateral bladder hemitrigone. Prior studies suggest the
reason the ipsilateral kidney is not visualized on imaging in OHVIRA
syndrome is not because of true renal agenesis from an absence of
WD formation but secondary to renal dysplasia and atrophy caused
by abnormal WD formation associated with abnormal ipsilateral
MD formation (Kiechl-Kohlendorfer et al., 2011). Usually the distinc-
tion between true agenesis versus dysplasia and atrophy does not
.05mm
have clinical implications. However, in cases of OHVIRA syndrome
FOXA1 in which the ipsilateral dysplastic and atrophic kidney can lead to
persistent vaginal leakage after resection of vaginal septum, we believe
that it is important not to assume that renal agenesis is present in
OHVIRA syndrome. Hence, we accept the new terminology that
E F OHVIRA syndrome should stand for obstructed hemivagina and
ipsilateral renal anomalies (Fig. 20.39; Schlomer et al., 2015).
Fig. 20.37.  Sagittal sections of a 21-week human female reproductive tract.
Because of section orientation, (A) depicts the lower portion of the specimen
(the introitus to the upper vagina), and (B) depicts the upper portion of the
specimen (vagina, cervix, and uterus) (H&E stain). The vaginal epithelium is
many layers thick as a result of estrogenic stimulation (A and B). In (B), note KEY POINTS: MÜLLERIAN DEVELOPMENT
the abrupt transition in epithelial differentiation at the vaginal/cervical border
(*). PAX2 staining of the vaginal/cervical border (C) shows prominent PAX2 • Immunohistochemical data support Bulmer’s proposal
immunostaining (indicative of Müllerian duct origin) of stratified but relatively that the entire human vaginal epithelium is derived from
thin cervical epithelium and PAX2-negative vaginal epithelium (C). Epithelium UGE (without Müllerian or Wolffian cell origin).
of the uterine corpus (D) is strongly PAX2-reactive. FOXA1 immunostaining • A midline epithelial septum represents the zone of fusion
was seen uniformly throughout the entire vagina, and FOXA1 immunostaining of paired MDs that is subsequently eliminated. Failure of
abruptly stopped at the vaginal/cervical border (E and F) in mirror image to regression of the septum can lead to uterine obstruction/
PAX2 immunostaining (C). (*) denotes the interface between vaginal and duplication.
cervical epithelium in (B), (C), and (E). • Failure of the inferior end of the vaginal canal to open can
be caused by imperforate hymen, which is the most
common cause of vaginal obstruction.

terminology. In the newborn mouse, the upper (cranial) portion of

the vagina (called the Müllerian vagina) is lined by PAX2-positive
Müllerian epithelium that abuts on the solid endodermal “sinus Bladder: Ureteral Development
vagina.” Elegant lineage tracing experiments have shown that post-
natally the Müllerian vaginal epithelium completely replaces the Both the bladder and ureters consist of a urothelial-lined lumen, a
endodermal sinus vaginal epithelium (Kurita, 2010). lamina propria consisting of extracellular matrix with unorganized
smooth muscle, an outer layer of thick bundles of smooth muscle,
Clinical Correlation: Vaginal Agenesis and a serosal surface. The ureters and bladders of human males and
and Imperforate Hymen females develop in similar fashion without differences in size. In
contrast, in males the prostate develops below the insertion of the
Failure of canalization of the vaginal canal results in atresia or blockage ureters into the trigone (see Fig. 20.15). Thus, in males the prostatic
of the vagina. This occurs in approximately 1 : 80,000 women and urethra is clearly larger in size than the homologous region in females
is called a transverse vaginal septum. The septum is typically located (Fig. 20.40). The ureterovesical junction inserts into the bladder
at the junction of the middle and superior third of the vagina. Failure trigone in exactly the same fashion in both the male and female
of the inferior end of the vaginal canal to open may be caused fetuses (see Figs. 20.15 and 20.40).
328 PART III  Pediatric Urology

Fig. 20.38.  (A) Gross photograph of bulging imperforate hymen in an 11-year-old female patient with
cyclic abdominal pain. (B) Sonographic images of the same patient with dilated vagina and uterus.

Obstructed hemivagina ipsilateral pelvic renal nubbin The Wolffian (mesonephric) ducts fuse with the cloaca just before
its subdivision by the urorectal septum (Moore et al., 2016; see Table
20.3). The entrance of the mesonephric ducts into the primitive
Healthy kidney UGS serves as a landmark distinguishing the cephalad vesicourethral
and ureter canal from the caudal UGS. The vesicourethral canal gives rise to
Atrophic the bladder and pelvic urethra. Early in development, the bladder
dysplastic is continuous with the allantois. The caudal portion of the UGS
kidney forms the phallic urethra in males and urethra and vaginal vestibule
Septated uteri in females (Moore et al., 2016).

Formation of Trigone
Also, at approximately the fifth or sixth week of gestation, the common
excretory ducts (the portion of mesonephric ducts distal to the origin
of ureteric buds) dilate and connect to the UGS. The formation of
these final connections involves apoptosis, which enables the ureters
to disconnect from the mesonephric ducts and fuse to the bladder
Bladder (Batourina et al., 2005). With use of cell-lineage studies (in mice),
Ectopic the fibromuscular wall of the trigone was found to form mostly
ureter from bladder smooth muscle cells with only a minor contribution
from mesenchymal cells associated with the ureters (Viana et al.,
2007). This is in contrast with the classic hypothesis in which the
trigone is formed from an extension of the ureteral development
into the trigone of the bladder (Weiss, 1988). The ureteral orifices
Obstructed incorporate into the bladder and migrate in a cranial and lateral
hemivagina
direction within the base of the bladder.
The embryonic pattern of ureteral orifice incorporation into the
Fig. 20.39.  Schematic of obstructed hemivagina and unilateral renal anomaly. developing bladder is inferred primarily from clinical observations
In this case, the ectopic ureter from a left pelvic dysplastic renal nubbin of duplex kidneys with two ureters joining the bladder on the same
inserts into the left obstructed hemivagina. side. The upper-pole ureteral orifice rotates dorsally relative to the
lower-pole orifice and assumes a more caudal and medial position.
Weigert and Meyer recognized the regularity of this relationship
between upper- and lower-pole ureteral orifices, which has come
Formation of Urogenital Sinus to be known as the Weigert-Meyer rule (Weigert, 1877; Meyer,
1907). According to this concept, an abnormally laterally placed
At the fifth to sixth week of gestation, the urorectal septum sepa- lower-pole ureteral orifice may result from a ureteric bud arising
rates the cloacal into the dorsal anorectal canal and ventral UGS too low on the mesonephric duct, therefore resulting in premature
(Fig. 20.41) based on the historic observations of Rathke and Tourneux incorporation and migration within the developing bladder. In
(Rathke, 1832; Tourneux, 1888). Abnormalities in the cloacal membrane such an abnormal ureteral orifice, vesicoureteral reflux is more likely
(and not the urorectal septum) are thought to lead to anorectal mal- to occur because of an inadequate intramural tunnel. In contrast,
formations (Fig. 20.42; Nievelstein et al., 1998). Ultimately, the UGS the abnormally caudal upper-pole ureteral orifice may result from
and its diverticulum, the allantois, form the bladder and urethra with a ureteric bud arising too high on the mesonephric duct. It may
the allantois being the embryologic precursor of the urachal remnant. drain at the bladder neck and verumontanum or remain connected
 Chapter 20  Embryology of the Genitourinary Tract 329

Fig. 20.40.  Whole-mount photographs of human female fetal bladders (9 to 21 weeks’ gestation). Compare
to the male ontogeny (see Fig. 20.15), and note the lack of prostate tissue and vas deferens. Note that
the male and female bladder sizes are similar at each gestational age.

to mesonephric (Wolffian) duct derivatives such as the vas deferens pathway with the Shh expressing urothelium necessary for induction
in males (Mackie and Stephens, 1977; Schwarz and Stephens, 1978). of bladder smooth muscle (Cao et al., 2010). Interestingly, smooth
In females, the ectopic upper-pole ureter may insert into the muscle differentiation occurs in subserosal bladder mesenchyme,
remnants of the mesonephric ducts (e.g., Gartner duct cyst) or implying a concentration gradient with higher levels of Shh inhibiting
the vaginal vestibule (Fig. 20.43; Glassberg et al., 1984). smooth muscle differentiation near the epithelium and lower levels
Anomalous development of the WD may lead to an ectopic vas inducing smooth muscle differentiation in more distant positions.
deferens. In certain clinical situations, the vas deferens is connected A number of genes have been implicated in congenital ureteral
to the ureter rather than the verumontanum so that both the ureter anomalies (Table 20.4). A mutation of the PAX2 gene has been
and vas deferens drain into the prostatic urethra via a common duct. identified in a human family carrying renal coloboma syndrome,
This situation may occur when the ureteric bud arises too high on a rare autosomal dominant syndrome characterized by optic nerve
the mesonephric duct and the subsequent common excretory duct coloboma, renal anomalies, and vesicoureteral reflux (Sanyanusin
becomes too long, resulting in incomplete absorption into the devel- et al., 1996). EYA1 is mutated in patients with the dominantly
oping bladder (Schwarz and Stephens, 1978). This anomaly, although inherited disorder, branchio-oto-renal syndrome, which includes a
extremely rare, should be kept in mind when evaluating males with duplex collecting system, renal hypoplasia and dysplasia, and renal
recurrent epididymitis and ipsilateral hydroureteronephrosis. agenesis (Abdelhak et al., 1997a). Pax2 is required for the growth and
elongation of the mesonephric ducts before ureteric bud formation,
whereas Eya1 appears to regulate the GDNF expression, which is a
DEVELOPMENT OF THE URETER prerequisite for ureteric bud outgrowth. Bmp4 and FoxC1 appear to
play a suppressive role in the ureteric bud outgrowth. Evidence suggests
At approximately 5 weeks’ gestation, the stalk of the ureteric bud that BMPs control formation of smooth muscle in the proximal
elongates to become the ureter. Morphologically, the ureter begins ureter and pelvis (Haraguchi et al., 2012). BMP4, expressed in the
as a simple epithelial tube lined with cuboidal cells and surrounded caudal mesenchyme cells, induces ureteral morphogenesis including
by loose mesenchyme. The epithelium attains transitional differentia- smooth muscle and urothelial differentiation (Brenner-Anantharam
tion by 14 weeks, whereas urine production has already started at et al., 2007). Consistent with such a role, Bmp4- and Bmp5-mutant
approximately 12 weeks’ gestation. The first signs of ureteral mus- mice display hydronephrosis and hydroureter (Miyazaki et al., 2003).
cularization and development of elastic fibers are seen at 12 weeks’
gestation. Smooth muscle differentiation is first detected in the Development of the Bladder and Continence Mechanism
subserosal region of the bladder dome and extends toward the bladder
base and urethra, whereas smooth muscle differentiation in the By the 10th week of gestation, the human bladder is a cylindrical
ureter occurs later within the subepithelial region of the ureterovesical tube lined by a single layer of cuboidal cells surrounded by loose
junction, ascending toward the intrarenal collecting system (Baker mesenchymal tissue. The allantois becomes the urachus that connects
and Gomez, 1998). During embryonic ureteral and bladder develop- the fetal bladder to the yolk sac, which is rudimentary in humans
ment, epithelial-mesenchymal interactions are necessary for the and probably nonfunctional. The apex of the bladder ultimately
induction of smooth muscle (Baskin et al., 1996a; Fig. 20.44). The tapers as the urachus, and by the 12th week the urachus involutes
sonic hedgehog (Shh) pathway is thought to be the key molecular to become a fibrous cord, the median umbilical ligament. The bladder
330 PART III  Pediatric Urology

et al., 1991). During gestation, bladder wall musculature increases

in thickness and relative collagen content decreases. The ratio of
thick-to-thin collagen fibers also decreases, whereas the amount of
elastic fibers increases. These changes in compliance seem to coincide
with the time of fetal urine production at approximately 10 weeks’
gestation, suggesting a possible role for mechanical distention (Baskin
et al., 1994). In organ cultures of fetal mouse bladders, distention
promoted a more orderly development of collagen fiber bundles
within the lamina propria in comparison with decompressed bladder
explants, suggesting that mechanical factors from accumulating urine
may play a role during bladder development (Beauboeuf et al., 1998).
Allantois No functional study has been done to assess human fetal conti-
nence mechanisms. Only a handful of ontogenic descriptions are
available using human fetal specimens, providing a basis for specula-
tive theories (Tanagho and Meyers, 1969; Yucel and Baskin, 2004).
Cloaca A mesenchymal condensation forms around the caudal end of the
UGS after division of the cloaca and rupture of the cloacal membrane.
Striated muscle fibers can be seen clearly by the 15th week. At this
time, the smooth muscle layer becomes thicker at the level of bladder
neck and forms the inner part of the urethral sphincter, which is
composed of smooth muscle fibers centrally and striated muscle
fibers peripherally (Bourdelat et al., 1992). Subsequently, sexual
dimorphism comes into play with the formation of the prostate
gland in males and the vagina in females (Tichy, 1989). The urethral
sphincter muscle fibers extend posteriorly, projecting to the lateral
wall of the prostate or to the lateral wall of the vagina.

Clinical Correlation: Vesico-ureteral Reflux

Vesicoureteral reflux occurs in 1 : 500 to 1 : 1000 births. The majority
of vesicoureteral reflux is of no clinical consequence. More severe
reflux in the setting of urinary tract infection is a risk factor for
pyelonephritis (RIVUR Trial Investigators et al., 2014). The mechanism
of reflux is a relatively short intramural ureteral tunnel that lacks
Future bladder sufficient muscle to facilitate the normal unidirectional passage of
urine from the kidneys into the bladder. During normal bladder
growth, ureteral valves often gain additional musculature, hence the
Urogenital sinus high rate of spontaneous resolution of moderate and low grades of
vesicoureteral reflux (Tanagho and Hutch, 1965). In higher grades
of reflux, the abnormal ureteral bud inappropriately signals the
Anorectal canal metanephric mesenchyme leading to renal dysplasia with reflux
most likely an associated but noncausal phenomenon (Mackie
and Stephens, 1977).
Fig. 20.41.  Development of the urogenital sinus. Between the fourth and
sixth weeks, the cloaca is divided into an anterior urogenital sinus and a
posterior anorectal canal. The superior part of the urogenital sinus, continuous
Clinical Correlation: Bladder Exstrophy
with the allantois, forms the bladder. The constricted narrowing at the base Bladder exstrophy occurs in approximately 1 : 30.000 live births,
of the urogenital sinus forms the pelvic urethra. The distal expansion of the with cloacal exstrophy being even less common at approximately
urogenital sinus forms the vestibule of the vagina in females and the penile 1 : 300,000 newborns (1987). Exstrophy of the bladder is character-
urethra in males. (Modified from Larsen WJ. Human embryology. New York ized by a lower abdominal wall defect and separation of the pubic
NY: Churchill Livingstone; 1997.) symphysis in which the anterior aspect of the bladder is open to
the environment along with an open prostatic urethra and dorsal
aspect of the penis (epispadias; Beaudoin et al., 1997). The trigone
epithelium consists of bilayered cuboidal cells between the 7th and of the bladder and verumontanum in the prostate are visible on
12th weeks and acquires mature urothelial characteristics between physical examination and the hemicorporal bodies. Embryologically,
weeks 13 and 17. By the 21st week, bladder epithelium becomes exstrophy of the bladder is caused by incomplete closure of the inferior
four to five cell layers thick and demonstrates ultrastructural features aspect of the anterior abdominal wall and anterior bladder wall.
similar to fully differentiated urothelium. Between the 7th and 12th Exstrophy of the bladder is thought to be secondary to failure of
weeks, the surrounding connective tissues condense, and smooth mesechymal cells to migrate between the ectoderm of the abdomen
muscle fibers begin to appear, first at the region of the bladder dome and endoderm of the cloaca during the fourth week of gestation. This
and later proceeding toward the bladder base. Collagen fibers first results in absence of the inferior parts of the rectus abdominis muscle,
appear in the lamina propria and then later extend into the deeper external and internal oblique muscles, and transverse abdominis muscles.
fibromuscular wall between the muscle fibers (Newman and Antona- The thin epidermis and anterior wall of the bladder rupture, causing
kopoulos, 1989). an open anterior bladder wall defect (Ambrose and O’Brien, 1974).
Bladder compliance is thought to change during development.
When studied in whole-organ preparations of fetal sheep bladders, Clinical Correlation: Urachal Anomalies
bladder compliance is very low during early gestation and increases
gradually thereafter (Coplen et al., 1994). The mechanism of these In the adult, the urachus becomes a thick fibrous cord called the
changes in bladder compliance may involve alterations in both median umbilical ligament. If any remnant of the urachal lumen persists,
smooth muscle tone and connective tissue composition. This anomalies of the urachus can occur such as a cyst (which often
phenomenon is also observed in developing human bladders (Kim presents with infection), sinus (patency with the bladder), or fistula
 Urogenital sinus

Anorectal canal

Rectoprostatic fistula

Abnormal development
of the cloacal membrane

Cloacal malformation

Fig. 20.42.  Abnormal development of the cloacal membrane results in characteristic anomalies of the
urogenital and lower gastrointestinal tract. (Modified from Larsen WJ. Human embryology. New York, NY:
Churchill Livingstone; 1997.)

The ureters invert their

positions as they fuse with The original lower
urogenital sinus ureter opens normally
(the Weigert-Meyer rule) into the bladder

The original upper Uterus

ureter crosses under
Future vestibule the lower one to open
of vagina at an abnormally low Vagina
position

Two ureteric buds grow from a

single mesonephric duct to induce Paramesonephric
metanephric mesenchyme duct

Fig. 20.43.  Embryologic schematic of the Weigert-Meyer rule, in which two ureteric buds grow from a
single mesonephric duct to induce the metanephric mesenchyme. The ureters invert their positions as
they fuse with the urogenital sinus. The upper-pole ureter crosses under the lower ureter and when ectopic
can open into an abnormally low position such as draining into the vagina as illustrated. (Modified from
Larsen WJ. Human embryology. New York, NY: Churchill Livingstone; 1997.)
 Epithelial-mesenchymal signaling
Inducing bladder smooth muscle differentiation

Epithelium
Fig. 20.44.  Bladder smooth muscle differentiation is dependent on signaling from
the urothelium to the bladder mesenchyme through the Sonic Hedgehog pathway.
(Modified from Baskin LS, Hayward SW, Young P, Cunha GR. Role of mesenchymal-
Mesenchyme
epithelial interactions in normal bladder development. J Urol. 1996;156(5):1820–1827.)

Smooth
muscle

TABLE 20.4.  Clinical Correlation: Selected Gene Mutations Associated With CAKUT Syndromes

SYNDROME GENE INHERITANCE RENAL PHENOTYPES

Alagille JAG1 Autosomal Dominant Agenesis, hypoplasia, cystic dysplasia,

(Notch signaling pathway) UPJ obstruction, VUR
Aniridia-Wilms tumor (WAGR) WT1 Autosomal Dominant Tumor, nephromegaly
ATR-X ATRX X-linked Hypoplasia, agenesis, VUR,
hydronephrosis
Branchio-oto-renal EYA1, SIX1 Autosomal Dominant Hypoplasia, VUR
Caudal regression VANGL1 Autosomal Dominant Agenesis, ectopic kidney, hypoplasia,
Autosomal Recessive hydronephrosis, VUR
CHARGE CHD7 Autosomal Dominant Agenesis, hypodysplasia,
hydronephrosis, hydroureter
Cornelia de Lange NIPBL Autosomal Dominant Hypoplasia, VUR, pelvic dilation, renal
ectopia
Fraser FRAS1, FREM2 Autosomal Recessive Renal agenesis, cystic dysplasia,
hypoplasia, hydronephrosis, bladder
agenesis
Hypoparathyroidism-deafness-renal GATA3 Autosomal Dominant Agenesis, hypodysplasia, VUR
Kallmann KAL1, KAL2 X-linked or Autosomal Unilateral renal agenesis, VUR, cystic
Dominant dysplasia
Maturity-onset diabetes of the HNF1 Autosomal Dominant Cystic dysplasia, hypoplasia,
young type V glomerulocystic disease, agenesis,
oligomeganephronia
Meckel-Gruber MKS1–4 Autosomal Recessive Cystic dysplasia, hypoplasia
Noonan NS1 Autosomal Dominant Cystic dysplasia, duplication,
hydronephrosis
Okihiro (aero-renal- ocular) SALL4 Autosomal Dominant Pelvic or horseshoe kidney,
hypoplasia, VUR
Pallister-Hall GL/3 Autosomal Dominant Agenesis, hydronephrosis, hydroureter,
(Sonic hedgehog renal ectopia, horseshoe kidney
signaling pathway)
Renal coloboma PAX2 Autosomal Dominant Hypoplasia, VUR, UPJ obstruction
Renal-hepatic-pancreatic dysplasia EVC, EVC2 Autosomal Recessive Cystic dysplasia
Rubinstein-Taybi CBP EP300 Autosomal Dominant Unilateral agenesis, cystic
hypodysplasia, urethral defects
Roberts ESC02 Autosomal Recessive Agenesis, hypodysplasia,
hydronephrosis
Silverman (dyssegmental dwarfism) HSPG2 Uncertain Hydronephrosis
Simpson-Golabi-Behmel GPC-3 X-linked Medullary cystic dysplasia
Smith-Lemli-Opitz DHCR7 Autosomal Recessive UPJ obstruction, hydronephrosis,
VUR, cystic dysplasia
Townes-Brocks SALL1 Autosomal Dominant Agenesis, hypoplasia, PUV, VUR,
meatal stenosis
Zellweger PEX Autosomal Recessive Cystic dysplasia, hydronephrosis

CAKUT, Congenital anomalies of the kidney and urinary tract; PUV, posterior urethral valves; UPJ, ureteropelvic junction; VUR, vesicoureteric reflux.
Data from Uy N, Reidy K. Developmental genetics and congenital anomalies of the kidney and urinary tract. J Pediatr Genet. 2016;5(1):51–60.
 Chapter 20  Embryology of the Genitourinary Tract 333

(complete patency with urine draining from the umbilicus). Treatment Clinical Correlation: Ureterocele
consists of excising retained patent structures (Mesrobian et al., 1997).
Prophylactic excision of an incidentally found urachal anomaly does Ureteroceles are saclike structures or diverticula of the distal ureter
not appear warranted because the risk for malignancy later in life that can obstruct the flow of urine from the kidney to the bladder
is remote and a large number of urachal anomalies would need to (Tanagho, 1972; Coplen and Duckett, 1995). They are most common
be removed to prevent a single case of urachal adenocarcinoma in duplex systems affecting the upper-pole ureter but can also occur
(Gleason et al., 2015). in single systems. It is possible that ureteroceles are a continuum
with ectopic ureters, with pseudo-ureterocele being in between. The
Clinical Correlation: Duplication Anomalies embryologic explanation of a ureterocele is controversial but thought
to be secondary to a transient obstruction (Tanagho, 1972).
The ureter arises during the fourth week of embryonic development
from the mesonephric, or Wolffian, duct. In ureteral duplication,
the ureteric bud divides into two ureters resulting in two separate KEY POINTS: BLADDER/URETERAL DEVELOPMENT
collecting systems for the kidney (Tanagho, 1976). This occurs in • The bladder and urethra develop from the endodermal
approximately 1% of the population, and most of the time the urogenital sinus, which derives from the ventral portion of
ureteral duplication is of no clinical consequence with both ureters the cloaca after it becomes subdivided by the urorectal
either entering the bladder in their normal position in the trigone septum.
or connecting outside the bladder, the so-called Y duplication. Ureteral • Cell lineage studies have shown that the fibromusculature
duplication can be an issue when the upper-pole ureter does not wall of the trigone is formed from bladder smooth muscle
insert into the bladder but instead into an ectopic site (see later) cells with only a minor contribution from ureteric smooth
or the upper-pole ureter is blocked by a diverticulum within the muscle.
bladder, a so-called ureterocele (see later). • According to the Weigert and Meyer rule, the upper-pole
ureteral orifice rotates dorsally relative to the lower-pole
Clinical Correlation: Ectopic Ureter orifice and assumes a more caudal and medial position
with less chance of reflux.
An ectopic ureter is defined as opening anywhere except into the • Ureteral duplication can be an issue when the upper-pole
trigone of the urinary bladder. In males, an ectopic ureter usually ureter does not insert into the bladder but instead in an
inserts into bladder neck or prostatic urethra but may also may ectopic site, or the upper-pole ureter is blocked by a
insert into the vas deferens or seminal vesicle. In females, an ectopic diverticulum within the bladder, a so-called ureterocele.
ureter may insert into the bladder neck, the urethra, or the Gartner’s • In females, ectopic ureters may insert into the bladder
duct and vaginal vestibule. In the latter two cases, these girls may neck, urethra, or vaginal vestibule. In the latter two cases,
present with persistent incontinence (Williams, 1954). Embryologi- these girls may present with persistent incontinence.
cally, an ectopic ureter results from the ureter not being incorporated
into the posterior part of the urinary bladder. Instead it is carried
caudally with the mesonephric duct and is incorporated into the KIDNEYS
caudal portion of the UGS. The caudal portion of the UGS becomes
the prostatic urethra in males and the vagina in females, hence the The kidneys develop in identical fashion regardless of sex
explanation for the typical location of ectopic ureters. (Fig. 20.45). Fetal lobulations are prominent as development

Fig. 20.45.  Whole-mount photographs of human fetal kidneys (8 to 19 weeks’ gestation). Note the progressive
increase in renal size over time and well-visualized fetal lobulations (starting at 12 weeks’ gestation). The
adrenal gland can be seen capping the upper pole of the fetal kidney in the 8- to 13-week specimens.
Relative sizes of specimens are not exact, but increase with age.
334 PART III  Pediatric Urology

progresses (Fig. 20.46). Note the increase in length and width of Ryan et al., 2018). The embryonic kidneys are, in order of their
the fetal kidneys over time. The kidney shows a bifid ureter at 14 appearance, the pronephros, the mesonephros, and the metanephros.
weeks’ gestation, a variation of normal development in which the The first two kidneys regress completely (pronephros) or partially
upper and lower poles have separate ureters that connect into a single (mesonephros) in utero, and the third becomes the permanent kidney.
ureter, in this case at the lower pole of the kidney (Moore et al., Embryologically, all three kidneys develop from the intermediate
2016). In humans, multiple normal variations of normal ureteral mesoderm. As the notochord and neural tube develop, the mesoderm
development have been described with bifid ureters as seen in Fig. located on either side of the midline segregates into three subdivisions:
20.45 and complete ureteral duplication. paraxial (somites), intermediate, and lateral plate mesoderm. As the
embryo undergoes transverse folding, the intermediate mesoderm
Early Events in Kidney Development separates from the paraxial mesoderm and migrates ventrally to the
dorsal wall of the intraembryonic coelom (the future abdominal
Mammals develop three sets of kidneys in the course of intrauterine cavity). At this time, there is a progressive craniocaudal development
life (Fanos et al., 2015; Moore et al., 2016; Pietila and Vainio, 2014; of the bilateral longitudinal mesodermal masses, called nephrogenic
cords. Each cord bulges from the posterior wall of the coelomic cavity,
producing the paired urogenital ridges. The gonadal ridge, discussed
earlier, is located on the medial aspect of the urogenital ridge.

Pronephros and Mesonephros

The mammalian pronephros is a transitory, nonfunctional kidney
analogous to that of primitive fish. In humans, the first evidence of
the pronephros is seen late in the third week, and it completely
degenerates by the start of the fifth week. Development of the
pronephric tubules/vesicles starts at the cranial end of the nephrogenic
cord in the thoracic region and progresses caudally. This craniocaudal
wave of pronephric tubule/vesicle formation is followed immediately
by craniocaudal degeneration of the pronephric tubules (Fig. 20.47A).
Formation of pronephric tubule/vesicle formation involves a
mesenchymal-to-epithelial conversion. The significance of the
pronephros is the generation of the pronephric duct that grows
caudally within the urogenital ridge. As the pronephric tubules
degenerate, the retained pronephric duct becomes the mesonephric
duct as it grows caudally into the domain of mesonephric tubule
Fig. 20.46.  An 11-week human fetal kidney stained for metanephric mes- development. This simply involves a name change.
enchyme-expressed HoxA11 (green) and E-cadherin (red) imaged using The second kidney, the metanephros, is also transient, but in
lightsheet fluorescence microscopy. Individual optical sections (left) are higher vertebrates the metanephros serves as an excretory organ for
reconstructed into full three-dimensional volume (right). the embryo while the definitive kidney, the metanephros, begins its

Pronephros
Mesonephric ducts
Intermediate
mesoderm

Mesonephros

Cloaca

A. 24 days B. 25 days C. 26 days

Fig. 20.47.  Development of pronephros and mesonephros. (A) Pronephros develops in each of five to
seven cervical segments, but this primitive renal structure degenerates quickly during the fourth week.
The mesonephric ducts first appear on day 24. (B and C) Mesonephric vesicles and tubules form in a
craniocaudal direction throughout the thoracic and lumbar regions. The cranial pairs degenerate as caudal
pairs develop, and the definitive mesonephros contains about 20 pairs confined to the first three lumbar
segments. (Modified from Larsen WJ. Human embryology. New York, NY: Churchill Livingstone; 1997.)
 Chapter 20  Embryology of the Genitourinary Tract 335

development (see Fig. 20.47BC). As the bilateral mesonephric ducts Metanephros

(also called Wolffian ducts) extend caudally into the mesonephric
mesenchyme within the urogenital ridge, mesonephric tubules are The definitive kidney, or the metanephros, initially forms in the sacral
induced that join the paired mesonephric ducts. In total, approxi- region as ureteric buds sprout from the caudal portion of the meso-
mately 40 mesonephric tubules form (see Fig. 20.31). The mesonephric nephric duct and come in contact with condensing (metanephric
(Wolffian) ducts extend caudally and eventually terminate by joining mesenchyme) at about the 4 weeks’ gestation (Fig. 20.48). The ureteric
with the epithelium of the cloaca. bud elongates cranially into the metanephric mesenchyme and begins
Formation of mesonephric tubules begins in the fourth week and to branch dichotomously. The tip of the branching ureteric bud,
involves the condensation of mesenchyme to form dense aggregates called the ampulla, induces the metanephric mesenchyme to condense
that in turn convert into epithelial vesicles. These vesicles subsequently and to convert into epithelial vesicles. As the ureteric bud divides
elongate to form tortuous (initially S-shaped) tubules that join the and branches, each new ampulla acquires a caplike condensation
mesonephric ducts. The formation of mesonephric tubules progresses of metanephric mesenchyme that undergoes a mesenchymal-to-
from cranial to caudal and results in the formation of approximately epithelial transition (see Fig. 20.45).
40 pairs of mesonephric tubules. Only a maximum of approximately The ureteric bud and metanephric mesenchyme exert reciprocal
30 pairs of mesonephric tubules are seen at any one time as cranially inductive effects on each other, and proper differentiation of these
tubules start to degenerate starting at about the fifth week before primordial structures depends on these reciprocal inductive signals
the most caudal tubules form (see Fig. 20.31). By the fourth month, (Fanos et al., 2015; McMahon, 2016; Pietila and Vainio, 2014; Reidy
the human mesonephros has degenerated, except for a few elements and Rosenblum, 2009; Uy and Reidy, 2016). The metanephric
that persist into maturity as part of the male reproductive tract. In mesenchyme induces the ureteric bud to elongate and branch
males, some of the cranially located mesonephric tubules become (Cebrian et al., 2004), and in turn the ureteric bud induces the
the efferent ducts of the testes. The paradidymis consists of retained metanephric mesenchyme to condense and undergo mesenchymal-
mesonephric tubules near the head of the epididymis. In females, epithelial conversion to form metaphoric tubules that will dif-
remnants of cranial and caudal mesonephric tubules form small, ferentiate into nephrons. The initially induced epithelial vesicles
nonfunctional epithelial cysts residing within the broad ligament elongate and in turn form S-shaped structures, and further growth
of the uterus, termed the epoöphoron and paroöphoron (see Table 20.3). and elongation generates the complex elements of the nephron (the
As discussed earlier, residual segments of the mesonephric (Wolffian) glomerulus, proximal convoluted tubule, loop of Henle, and distal
duct are frequently found within the fibromuscular wall of the vagina. convoluted tubule), all of which are derived from the metanephric

WD
WD WD
MM
MM
MM
Sited 1
Cap
UB Bmp4
RV
Gdnf
Ret UB
Gfra1 Pax2
Wnt11, -6 Wt1
Pax2 Eya1
Six2
Sall1

A
B C

Mesangial
cells
Distal
domain
Glomerulus
Proximal tubule
Proximal Henle’s loop
domain Distal tubule
Connecting tubule
Endothelial Collecting duct
Comma-shaped body S-shaped body cells
Migration of mesangial
and endothelial cells Mature nephron
D
Fig. 20.48.  Development of the metanephros (kidney). (A) Key factors in kidney development involve
interplay between secreted signals and transcription factors both in the ureteral bud (UB) that is derived
from the Wolffian duct (WD) and the kidney metanephric mesenchyme (MM). (B) The ureteral bud enters
the kidney mesenchyme and makes the first t-type branch. At the same time, the ureteral bud induces
the condensation of metanephric mesenchyme cells to form a cap of mesenchyme. Cap metanephric
mesenchyme cells contain the progenitors/stem cells of the nephrons. (C) The sequential and reciprocal
tissue interactions between the ureteral bud and the metanephric mesenchyme advance kidney morpho-
genesis–inducing nephrons. (D) The nephron becomes segmented into the glomerulus, proximal tubules,
loop of Henle, distal tubule, connecting tubule, and collecting duct. The collecting duct drains the concentrated
urine to the renal pelvis and from there via the ureter to the bladder. (Modified from Pietila I, Vainio SJ.
Kidney development: an overview. Nephron Exp Nephrol. 2014;126[2]:40.)
336 PART III  Pediatric Urology

mesenchyme. The urine collecting system, consisting of collecting ducts in the inner medulla to form the renal pyramids and papilla that
ducts, calyces, pelvis, and ureter, is formed from the ureteric bud project into the minor calyces. Two to three minor calyces converge to
(see Fig. 20.48). Urine production by the metanephric kidney begins form three to four major calyces that in turn empty into the renal
in the 10th week of gestation. pelvis. Distinct morphologic differences emerge between collecting
All metanephric nephrons are formed in the same way, and the ducts located in the medulla compared with those located in the
overall process involves fairly well-defined developmental stages renal cortex. Medullary collecting ducts are organized into elongated
(Larson et al., 1983; Saxen and Sariola, 1987). The metanephric linear arrays that converge centrally in a region devoid of glomeruli. In
mesenchyme first condenses to form a four- to five-cell layered dense contrast, collecting ducts located in the renal cortex continue to branch
mesenchymal condensate around the ampulla of the advancing and induce metanephric mesenchyme. The most central segments
ureteric bud. Near the interface of the ampulla and its adjacent of the collecting system, formed from the first five generations of
ureteric branch, a cluster of cells separates from a mesenchymal ureteric bud branching, undergo remodeling by increased growth
condensate and forms an oval mass called a pretubular aggregate and dilation of these tubules to form the calyces and renal pelvis.
that undergoes mesenchymal-to-epithelial conversion. An internal cavity
forms within the epithelializing pretubular aggregate, at which point Molecular Mechanisms of Kidney Development
the structure is called the epithelial renal vesicle (stage I). Cells of
the stage I renal vesicles are tall columnar and are stabilized by The details of inductive interactions among metanephric mesenchyme,
attachment to a newly formed basement membrane. The renal vesicles the branching ureteric bud, and more recently the stroma are becom-
elongate to form a comma-shaped body that is in turn converted to ing clearer and provide insight into the complex regulatory mecha-
an S-shaped body, one end of which establishes connection with nisms underlying renal development (Bekheirnia et al., 2017; Capone
the distal tip of a ureteric branch. Multipotential precursors residing et al., 2017; Uy and Reidy, 2016). Formation of renal tubules and
within renal vesicles ultimately give rise to all epithelial cell types the collecting system occurs sequentially and requires dynamic
of the nephron (Herzlinger et al., 1992). Nephron segmentation interactions among epithelial, mesenchymal, and stromal cells. Many
into glomerular and tubular domains is initiated by the sequential of the early events in embryonic kidney development were first
formation of two clefts within the renal vesicle (stage II; upper and elucidated by manipulating lower vertebrate embryos and by using
lower clefts). Creation of a lower cleft, termed the vascular cleft, an in vitro organ culture system. Grobstein’s pioneering work in the
precedes formation of a comma-shaped body. Generation of an 1950s led to an organ culture technique (Grobstein, 1956) whereby
upper cleft in the comma-shaped body precedes formation of an the metanephric mesenchyme is separated from the ureteric bud
S-shaped body. At this stage, the cup-shaped glomerular capsule is during the early part of kidney development and grown in vitro on
recognized in the lowest limb of the S-shaped tubule. Epithelial cells a filter. An inducer tissue, such as ureter or spinal cord, cultured on
lining the inner wall of this cup will compose the visceral glomerular the opposite side of the filter provided the inductive signal. This
epithelium, or podocyte layer. Cells lining the outer wall of the cup ingenious experimental approach has established the kidney as a
will form parietal glomerular epithelium, which lines the Bowman model system for studying the role of epithelial-mesenchymal
capsule. The glomerular capillary tuft is formed via recruitment interaction in organogenesis. The development of many other organs,
and proliferation of endothelial and mesangial cell precursors. The including lung, salivary glands, mammary glands, gonads, prostate,
rest of the S-shaped tubule develops into the proximal convoluted and bladder, also require epithelial-mesenchymal interactions for
tubule, the loop of Henle, and the distal convoluted tubule. When the controlled differentiation and proliferation of tissues (Baskin
the cup-shaped glomerular capsule matures into an oval structure, et al., 1996a; Cunha, 1985).
the nephron has now passed into stage III of development. Now
the nephron can be divided into identifiable proximal and distal Formation of Nephric Ducts
convoluted tubules. The stage IV nephron is characterized by a round
glomerulus that closely resembles the mature renal corpuscle. The The first recognizable event in renal development is formation of
morphology of the proximal convoluted tubule resembles that of pronephric ducts within the intermediate mesoderm. The early
a mature nephron, whereas the distal segments are still primitive. intermediate mesoderm destined to become nephric ducts is distin-
In humans, all nephrons at birth are in varying steps of stage IV. guished by expression of the transcription factors LIM1, PAX2, and
Mesenchymal cells that do not become tubular epithelium give SIM1, but only LIM1 appears to be absolutely essential for nephric
rise to interstitial stromal cells, which differentiate into a diverse duct formation (Shawlot and Behringer, 1995). PAX2 may be
population including fibroblasts, lymphocyte-like cells, and pericytes. important for maintaining other marker gene expression in the
Overall, these events are reiterated throughout the growing kidney nephric ducts (Torres et al., 1995). Available data suggest a model
so that older, more differentiated nephrons are located in the inner in which few opposing secreted factors from the surrounding tissues
part of the kidney near the juxtamedullary region and newer, less cumulatively restrict LIM1 expression to the intermediate mesoderm.
differentiated nephrons are found at the cortex. In humans, although LIM1 then activates PAX2 expression to further orchestrate the forma-
renal maturation continues to take place postnatally, nephrogenesis is tion of nephric ducts.
essentially complete before birth at around 32 to 34 weeks’ gestation
(Pietila and Vainio, 2014; McMahon, 2016). Ureteric Bud Outgrowth Into Metanephric Mesenchyme
Collecting System The outgrowth of the ureteric bud from the mesonephric duct and
its invasion into the condensing blastema of metanephric mesenchyme
The dichotomous branching of the ureteric bud determines the is a crucial initiating event in the development of the adult kidney
eventual pelvicalyceal patterns and their corresponding renal lobules (metanephros). Many candidate genes have been identified to play a
(Cebrian et al., 2004; see Fig. 20.48). In humans, the first nine branch critical role in this process (Brunskill et al., 2008; McMahon, 2016;
generations are formed by approximately 15 weeks’ gestation. By 20 to Pietila and Vainio, 2014). In particular, several lines of evidence have
22 weeks, ureteric bud branching is completed. Thereafter, collecting revealed a crucial role of the RET-GDNF-GFRα1 pathway in the
duct development occurs by extension of peripheral branch segments. ureteric bud outgrowth. Glial cell line–derived neurotrophic factor
Between 22 and 24 weeks’ fetal gestation in humans, the peripheral (GDNF) is a secreted peptide expressed in the metanephric mesen-
(cortical) and central (medullary) domains of the developing kidney chyme that activates the RET receptor, which is expressed in the
are established. The renal cortex, which represents 70% of total mesonephric duct. GDNF activation of RET requires the glycosylphos-
kidney volume at birth, becomes organized as a relatively compact, phatidylinositol (GPI)-linked protein GFRα1, which is expressed in
circumferential rim of tissue on the periphery of the kidney. The renal both metanephric mesenchyme and the mesonephric duct (see Fig.
medulla, which represents 30% of total kidney volume at birth, has 20.48). Gene knockout mutations in Ret, GDNF (Moore et al., 1996;
a modified cone shape with a broad base contiguous with cortical Pichel et al., 1996; Pietila and Vainio, 2014), and GFRα1 (Cacalano
tissue. The apex of the cone is formed by convergence of collecting et al., 1998) inhibit ureteric bud outgrowth. In organ culture systems,
 Chapter 20  Embryology of the Genitourinary Tract 337

recombinant GDNF is sufficient to induce ectopic ureteric bud Hox11

outgrowth (Sainio et al., 1997). However, the competence of the Eya1
mesonephric duct to respond to GDNF is restricted along its antero- Cap mesenchyme
Pax2
posterior axis. This anteroposterior restriction might be mediated Six1
by suppressors of RET signaling within the surrounding tissue, such Six2
as bone morphogenetic protein-4 (BMP4). In organ culture, BMP4 Osr1 Pretubular aggregate
can suppress the activity of GDNF to induce ectopic ureteric bud Sall1
formation (Brophy et al., 2001). Proper location of ureteric bud Renal vesicle
formation is also controlled by the localized expression of GDNF
within the metanephric mesenchyme. Both positive and negative Wnt
Ureteric bud
regulators have been described for GDNF localization. Homozygous
mutation of transcription factor Eya1 causes failure of ureteric bud
outgrowth and a resultant lack of GDNF expression in metanephric
mesenchyme, suggesting that Eya1 regulates GDNF expression (Xu
et al., 1999). In humans, haploinsufficiency of Eya1 results in a Comma
dominantly inherited disorder called branchio-oto-renal syndrome, HNF1B
which involves kidney and urinary tract anomalies (Abdelhak et al.,
1997b; Brophy et al., 2001). Expression of PAX2 in the metanephric
mesenchyme is also required for GDNF activation (Brophy et al.,
2001). GDNF expression is also suppressed at the anterior boundary
of the metanephric mesenchyme through the concerted action of
Notch2/
the FoxC1 and FoxC2 transcription factors (Kume et al., 2000). Jag1
Mutations in either Fox gene result in an expansion of GDNF expres-
sion and the formation of ectopic ureteric buds. Most FoxC1
homozygous mutants have duplex kidneys, in which the upper ureter S-shaped body
is dilated and connects aberrantly to mesonephric duct derivatives
in males such as seminal vesicles and vas deferens. In the developing Nephron
kidneys, Slit2 is primarily expressed in the mesonephric duct, whereas
Robo2 is expressed in the metanephric mesenchyme (Piper et al., Fig. 20.49.  Congenital abnormalities of the kidney and urinary tract (CAKUT)
2000). Mice deficient in Slit2 or Robo2 exhibit ectopic ureteric bud are associated with mutations in transcription factors (including Hox11, Eya1,
formation, multiple ureters and hydroureter, and anterior expansion Pax2, Six1, Six2, Osr1, and Sall1) that regulate the balance between differentia-
of GDNF expression (Grieshammer et al., 2004). SPRY1 negatively tion and maintenance of the nephron progenitors. Multiple gene pathways
regulates GDNF-RET signaling. Loss of Spry1 function in mice results such as Wnt signaling are also required for differentiation into the renal vesicle.
in renal malformations, including multiple ureters, duplex kidneys HNF1B and Notch signaling contribute to the specification of the proximal
and hydroureter, and increased expression of GDNF in the meta- tubules and terminal nephron differentiation. (Modified from Uy N, Reidy K.
nephric mesenchyme (Basson et al., 2006). The data therefore suggest Developmental genetics and congenital anomalies of the kidney and urinary
that multiple factors regulate, both positively and negatively, the tract. J Pediatr Genet. 2016;5[1]:51–60.)
precise timing and localization of GDNF, which then functions as
a guidance cue to activate RET, which is required for proper develop-
ment and patterning of the metanephric kidney. decreased number of ureteric bud branches and diminished expression
In humans (and mice), congenital anomalies of the kidney of Ret (Batourina et al., 2001). Certain markers such as Wnt11 might
and urinary tract (CAKUT) are associated with mutations in these already be compartmentalized to opposing poles of the dilated
transcription factors and signaling pathways that are required for ureteric bud tips, even before a morphologic branch point is evident
normal nephron differentiation (Takasato and Little, 2015; Uy (Pepicelli et al., 1997). In mice deficient for the homeobox gene
and Reidy, 2016; Marciano, 2017). For example, multiple transcription Emx2 (Miyamoto et al., 1997), ureteric bud outgrowth into the
factors (including Hox11, Eya1, Pax2, Six1, Six2, Osr1, and Sall1) metanephric mesenchyme appears normal, but the leading edge of
regulate the balance between differentiation and maintenance of the ureteric bud never dilates and branching is suppressed. Thus,
the nephron progenitors. Wnt signaling is also required for differentia- ureteric development is arrested before the first branching event,
tion into the renal vesicle. HNF1B and Notch signaling contribute and the resulting metanephric mesenchyme does not express markers
to the specification of the proximal tubules and terminal nephron indicative of induction. Similarly, mice with mutation of Sall1 exhibit
differentiation (Fig. 20.49). developmental arrest just after ureteric bud outgrowth and before
dilation of the leading edge of the ureteric bud (Nishinakamura
Ureteric Bud Branching et al., 2001). In normal murine embryos, Sall1 is expressed in
metanephric mesenchyme. Thus, Sall1 might control mesenchyme-
Once the ureteric bud has contacted the metanephric mesenchyme, derived signals that are necessary for ureteric bud dilation and branch
it undergoes a dichotomous branching morphogenesis (Cebrian point determination. Clearly, the pattern of ureteric bud branching
et al., 2004; Costantini and Kopan, 2010). Many of the same factors and the expression of ureteric bud–specific genes are influenced by
that regulate the initial outgrowth of the ureteric bud also appear the metanephric mesenchyme. Indeed, heterologous mesenchyme
to be essential for the subsequent branching of the ureteric bud. derived from lung primordia cannot change the pattern of ureteric
Ureteric bud branching is positively regulated by genetic and nutri- bud branching to that of lung epithelia or induce the ureteric bud
tional factors. PAX2, a paired-box–type transcription factor that is to express lung-specific genes (Lin et al., 2001). Studies have dem-
mutated in humans with renal coloboma syndrome, is a positive onstrated that BMP/activin-like kinase-3 (ALK3) signaling negatively
regulator of ureteric bud branching. During renal development, Pax2 regulates early ureteric bud branching in vivo (Hartwig et al., 2008).
is expressed in the mesonephric duct, ureteric bud, and metanephric The cell surface receptor ALK3 binds BMP2 and BMP4 with high
mesenchymal aggregates induced by ureteric bud branch tips (see affinity and is expressed in the mesonephric duct. Inactivation of
Fig. 20.48). Mice with a Pax2 mutation exhibit decreased ureteric ALK3 changes the pattern of primary ureteric bud branching from
bud branching and renal hypoplasia (Porteous et al., 2000). Ureteric bifid to trifid and increases the number of first- and second-generation
bud branching is also positively regulated by vitamin A and its retinoic branches. These defects are associated with decreased formation of
acid receptor signaling, which promote Ret expression. Rarα and subsequent branch generations, resulting in a decreased complement
Rarβ2 are expressed in stromal cells surrounding Ret-expressing of collecting ducts. These observations suggest that the pattern of
ureteric bud branch tips. Mice deficient in these receptors exhibit a early ureteric bud branching is a critical determinant of subsequent
338 PART III  Pediatric Urology

branching morphogenesis. Thus, ureteric bud epithelial branching Mesenchymal-Epithelial Conversion

morphogenesis is controlled by both intrinsic and extrinsic factors
working in concert to generate a kidney-specific branching pattern The inductive signals emanating from the ureteric bud promote
(see Table 20.4). condensation of the metanephric mesenchymal cells around the
ureteric bud tips and subsequent tubulogenesis (Uy and Reidy, 2016).
Tubulogenesis Mice with null mutations of Pax2 or Wt1 fail to exhibit ureteric
bud outgrowth, and in both cases the metanephric mesenchyme
Classic tissue recombination experiments focused almost exclusively does not respond to induction even when recombined with strong
on the relationship between metanephric mesenchymal cells and inducers in vitro (Brophy et al., 2001; Kreidberg et al., 1993). The
ureteric bud epithelial cells. It is now clear that at least three cell establishment of glomerular versus tubular cell fates is dependent
types are involved in the control of renal development: the ureteric on negative feedback between Wt1 and Pax2 (Ryan et al., 1995).
bud tip cells, the condensed metanephrogenic mesenchymal cells, During early kidney development, the expression domain of Pax2 is
and the stromal or interstitial mesenchymal cells. Once induced by complementary to that of Wt1 in S-shaped bodies. Wt1 expression is
the ureteric bud, the metanephric mesenchyme patterns itself into at restricted to glomerular epithelial precursors (Buckler et al., 1991),
least two different cell populations, a tubular one and a stromal one. whereas Pax2 expression is restricted to the portion that gives rise
The tubular cell population is thought to derive from mesenchymal to tubular epithelial precursors of the proximal and distal nephron
cells in direct contact with the ureteric bud ampulla (Stark et al., segments and later repressed in differentiated tubular epithelium
1994; Torres et al., 1995; Vainio et al., 1989), whereas the stromal (Dressler and Douglass, 1992). Evidence in support of Wnt proteins
cell population surrounds the tubular cells (Hatini et al., 1996). Once as mesenchyme inducers has been gained from in vitro induction
the mesenchyme has been patterned, these cells in the tubular zone assays using Wnt-expressing cell lines (Herzlinger et al., 1994; Kispert
undergo morphogenesis to become renal tubular epithelial cells. There et al., 1998). Of the Wnt mutants examined to date, only Wnt4, which
is evidence that this process is dependent not only on signals from is expressed in the mesenchyme and not the ureteric bud, is crucial
the ureteric bud but also on signals from the mesenchyme itself. One for propagation of the inductive signals. Although Wnt4 mutant
of these autocrine signals may be Wnt4, whose expression is induced mesenchyme is able to aggregate in response to ureteric bud contact,
in cells of the tubular zone after interaction with the ureteric bud. In these mutant aggregates do not form polarized epithelia. Rat ureteric
Wnt4 gene knockout mice, the ureteric bud forms and invades the bud cells secrete tubulogenic factors, such as leukocyte-inhibitory
metanephric mesenchyme, but subsequent development of epithelial factor, which, together with FGF2, appears to stimulate growth and
tubules is abolished (Stark et al., 1994). This suggests that two signals tubulogenesis in vitro (Plisov et al., 2001). Once induced to form
are essential for renal tubule formation—initial ureteric bud–derived aggregates, metanephric mesenchyme becomes polarized into an early
signals activating Wnt4 expression in the metanephric mesenchyme renal vesicle. This vesicle is closely associated with the branching
and Wnt4 itself as a mesenchymal autocrine signal. Signals from the ureteric bud and will eventually connect to the ureteric bud epithelium
stromal cell population also contribute to tubule formation, because to form a continuous tubule. Profound changes take place in the
tubulogenesis is perturbed in Bf2 gene knockout mice (Hatini et al., expression of cell adhesion molecules such as cadherins. Shortly after
1996). The discovery that Wnt4 acts as a downstream signal during induction, metanephric mesenchyme expresses R-cadherin, cadherin-6,
the induction cascade leading to renal tubulogenesis leads to the and E-cadherin, along with suppression of the mesenchyme-specific
question regarding the nature of the initial ureteric bud–derived cadherin-11. Both R-cadherin and cadherin-6 mutants show defects
signals. In vitro data suggest a role for FGF2 and other uncharacter- in the rate of mesenchymal condensation and polarization (Dahl
ized factors secreted by the ureteric bud (Karavanova et al., 1996). et al., 2002; Mah et al., 2000). Some renal vesicles in cadherin-6
Candidate molecules that may cooperate with FGF2 are Wnt11 and mutants also fail to fuse to the ureteric bud epithelia, resulting in
BMP7 (Kispert et al., 1996; Vukicevic et al., 1996). Localization of “dead-end” tubules and a subsequent loss of nephrons.
RET protein to the ureteric bud tips is reinforced by both GDNF
(Pepicelli et al., 1997) and signals emanating from surrounding Renal Vascular Development
stromal cells. For example, retinoic acid receptors are expressed
in the stromal cells and are required for stromal cell–mediated The origin of intrarenal vasculature is not completely understood.
signaling to maintain high levels of RET expression in the bud tips Until recently, it was thought that renal vasculature derived exclusively
(Batourina et al., 2001; Mendelsohn et al., 1999). Consistent with from branches off the aorta and other preexisting extrarenal vessels
the role of retinoic acid receptors in maintaining RET expression (“angiogenic” hypothesis). There is evidence, however, that the renal
in the dividing ureteric bud, rats with vitamin A deficiency have vessels may originate in situ, within the embryonic metanephric
smaller kidneys and fewer nephrons (Merlet-Benichou et al., 1999). mesenchyme from vascular progenitor cells (“vasculogenic” hypoth-
The cellular cross-talk among stromal, mesenchymal, and ureteric esis; Loughna et al., 1996; Tufro et al., 1999). Using antibodies to
bud cells is further highlighted by gain- and loss-of-function experi- Flk-1, a vascular endothelial growth factor (VEGF) receptor present
ments involving FGFs and BMPs. Fgf7-null mutant mice have fewer in angioblasts and mature endothelial cells, it was demonstrated that
branch points and correspondingly fewer nephrons, whereas ectopic endothelial cell precursors were already present in the prevascular
FGF7 in organ culture can stimulate branching (Qiao et al., 1999a, rodent metanephric mesenchyme before any vessels were discern-
1999b). FGF1 and FGF10 affect elongation of the ureteric bud stalk ible from a morphologic standpoint. When embryonic kidneys are
before the branch-point decision is made (Qiao et al., 1999a). Null cultured at the usual atmospheric oxygen concentration, vessels do not
mutations in Bmp7 are associated with even more severe phenotypic develop. However, if the explants are cultured in a hypoxic atmosphere
anomalies, exhibiting limited ureteric bud branching morphogenesis containing 5% oxygen, capillary sprouts develop within and outside
and complete renal developmental arrest. Yet it is difficult to assess the glomeruli, an effect that is inhibited by anti-VEGF antibodies
how FGFs and BMPs exert their collective effects on branching given (Tufro-McReddie et al., 1997). Depending on the developmental
the interplay among all the cell types present in the early kidney potential of the cells involved, both angiogenesis and vasculogenesis
(Dudley et al., 1999). In addition to the proteins just mentioned, a may play a role in the development of renal vasculature (Abrahamson
growing list of growth factors, secreted peptides, and their receptors et al., 1998).
have been implicated in the control of branching morphogenesis,
most by using a variety of in vitro model systems (Pohl et al., 2000). Clinical Correlation: Vascular Anomalies
For many of these factors, however, genetic studies have not proved
conclusive in assigning specific functional roles during ureteric As the kidneys migrate from their origin in the pelvis cranially into
bud branching in vivo, either because of potential redundancies the upper lumbar region, they are vascularized by a succession of
or embryonic lethalities before the onset of kidney development. transient aortic sprouts that arise at progressively higher levels.
Nevertheless, the role of these factors in renal development must be These arteries do not elongate to follow the ascending kidneys but
considered. instead degenerate and are replaced by successive new arteries. The
 Chapter 20  Embryology of the Genitourinary Tract 339

Inferior mesenteric artery

A 6th week B Normal C Pelvic kidney D Horseshoe

kidney

Fig. 20.50.  Normal and abnormal ascent of the kidneys. (A and B) The metanephros normally ascends
from the sacral region to its definitive lumbar location between the sixth and ninth weeks. (C) Rarely, a
kidney may fail to ascend, resulting in a pelvic kidney. (D) If the inferior poles of the kidneys fuse before
ascent, the resulting horseshoe kidney does not ascend to a normal position because of entrapment
by the inferior mesenteric artery. (Modified from Larsen WJ. Human embryology. New York: Churchill
Livingstone; 1997.)

final pair of arteries forms in the upper lumbar region and becomes the dialysis and subsequent renal/liver transplantation has allowed survival
definitive renal arteries. Occasionally, a more inferior pair of arteries (Chandar et al., 2015).
persists as accessory lower-pole arteries. These lower-pole arteries
cross ventral to the ureter and can cause intermittent ureteropelvic Clinical Correlation: Multicystic Dysplastic Kidneys
junction obstruction requiring repositioning of the ureter behind
the accessory lower-pole renal artery. The common variation in Multicystic dysplastic kidneys occur in approximately 1 : 2400 to 1 : 4800
blood supply to the kidney is a reflection of the continually changing newborns. In the majority of cases, this is a unilateral process with the
embryonic renal vasculature. This is reflected in that 25% of adult nonaffected kidney exhibiting compensatory hypertrophy (Gaither et al.,
kidneys have two or more renal arteries (Moore et al., 2016). 2018). Multicystic dysplastic kidneys are characterized by nonfunctional
renal tissue without recognizable glomeruli. The malformed tissue
Clinical Correlation: Ascent Anomalies
Between the sixth and ninth weeks, the kidneys ascend to the upper
lumbar region just below the adrenal glands (Fig. 20.50). The precise KEY POINTS: KIDNEY DEVELOPMENT
mechanism responsible for renal ascent is not known, but it is • The urinary system begins its development before genital
speculated that differential growth of the lumbar and sacral regions system development becomes evident. With the formation
of the embryo plays a major role. When the kidney fails to ascend of mesonephric ducts, embryonic kidneys develop
properly, its location becomes ectopic. If its ascent fails completely, sequentially in the order of pronephros (completely
it remains as a pelvic kidney. The inferior poles of the kidneys may reabsorbed), mesonephros (partially reabsorbed), and
also fuse, forming a horseshoe kidney (incidence ~1 : 500) that metanephros (permanent kidney).
crosses ventral to the aorta. During ascent, the fused lower pole • The metanephros develops as a result of inductive
is arrested by the inferior mesenteric artery and thus does not interactions involving the ureteric bud (an outgrowth of
reach its normal site. Typically, the horseshoe kidney produces no mesonephric duct), condensing blastema of metanephric
symptoms but can be associated with a slight increase in ureteropelvic- mesenchyme, and stromal cells.
junction obstruction and renal calculi. Rarely, the kidney fuses to • Renal tubulogenesis occurs via mesenchymal-epithelial
the contralateral one and ascends to the opposite side, resulting in conversion, whereas dichotomous branching of the
a cross-fused ectopy. ureteric bud leads to the formation of the collecting
system.
Clinical Correlation: Cystic Renal Disease • Selected gene mutations are associated with congenital
anomalies of the kidney and urinary tract.
Autosomal recessive polycystic kidney disease occurs in approximately • As the kidneys migrate from the pelvis, they are
1 : 20,000 live births. Most cases have a mutation in the PKHD1 gene vascularized by a succession of transient aortic sprouts that
that results in microscopic cystic kidney disease and congenital hepatic arise at progressively higher levels. The final pair of arteries
fibrosis (Guay-Woodford et al., 2014). The severe renal disease often forms in the upper lumbar region and becomes the
results in pulmonary hypoplasia causing neonatal death. In patients definitive renal arteries.
with nonlethal pulmonary status, early renal replacement by peritoneal
340 PART III  Pediatric Urology

consists of noncommunicating cysts of various sizes with dysplastic Cunha G, Robboy SJ, Kurita T, et al: Development of the human female
tubular epithelium (Rojas et al., 2011). The etiology is not known but reproductive tract, Differentiation 103:45–65, 2018.
is thought to be related to abnormal signaling between the ureteral Cunha GR, Kurita T, Cao M, et al: Molecular mechanisms of development
bud and the metanephric blastema. Treatment consist of documenting of the human fetal female reproductive tract, Differentiation 97:54–72,
2017.
that the contralateral kidney remains healthy and compensates for the Cunha GR, Vezina C, Isaacson D, et al: Development of the human prostate,
lack of function of the multicystic dysplastic kidney. The multicystic Differentiation 103:24–45, 2018.
dysplastic kidney will typically involute over time and is not at risk for Isaacson D, Shen J, Overland M, et al: Three-dimensional imaging of the
cancer or hypertension (Gaither et al., 2018). Renal agenesis may be developing human fetal lower urogenital-genital tract: indifferent stage to
a nonrecognizable form of multicystic dysplastic kidney in which male and female differentiation, Differentiation 103:14–23, 2018.
the involution occurs early in gestation before the abnormal renal McMahon AP: Development of the mammalian kidney, Curr Top Dev Biol
development can be detected by prenatal sonogram. 117:31–64, 2016.
Pietila I, Vainio SJ: Kidney development: an overview, Nephron Exp Nephrol
126(2):40, 2014.
Shen J, Cunha GR, Sinclair A, et al: Macroscopic whole-mounts of the
ACKNOWLEDGMENT developing human fetal urogenital-genital tract: Indifferent stage to male
and female differentiation, Differentiation 103:5–13, 2018.
The authors would like to acknowledge the work of Dr. John Park, Viana R, Batourina E, Huang H, et al: The development of the bladder trigone,
author of this chapter in the previous edition. the center of the anti-reflux mechanism, Development 134(20):3763–3769,
2007.

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