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Congenital ureter anomalies, including hydroureter, affect up to 1% of the newborn children. Despite the prevalence of these developmental abnormalities in young children, the underlying molecular causes are only poorly understood. Here, we show that the high mobility group domain transcription factor Sox9 plays an important role in ureter development in the mouse. Transient  Sox9  expression was detected in the undifferentiated ureteric mesenchyme and inactivation of  Sox9  in this domain resulted in strong proximal hydroureter formation due to functional obstruction. Loss of  Sox9  did not affect condensation, proliferation and apoptosis of the undifferentiated mesenchyme, but perturbed cyto-differentiation into smooth muscle cells (SMCs). Expression of genes encoding extracellular matrix (ECM) components was strongly reduced, suggesting that deficiency in ECM composition and/or signaling may underlie the observed defects. Prolonged expression of  Sox9  in the ureteric mesenchyme led to increased deposition of ECM components and SMC dispersal. Furthermore,  Sox9  genetically interacts with the T-box transcription factor 18 gene ( Tbx18)  during ureter development at two levels—as a downstream mediator of  Tbx18  function and in a converging pathway. Together, our results argue that obstructive uropathies in campomelic dysplasia patients that are heterozygous for mutations in and around  SOX9  arise from a primary requirement of  Sox9  in the development of the ureteric mesenchyme.

Hydroureternephrosis due to loss of Sox9- regulated smooth muscle cell differentiation of the ureteric mesenchyme