Purpose: Enhanced recovery after surgery protocols aim to improve recovery following urological augmentation and diversion surgery. Based on the positive experiences in adult patients, we evaluated safety and outcomes after implementation of an enhanced recovery after surgery protocol in children undergoing urological augmentation and diversion using small bowel. Materials and Methods: Complications, time to stool, time to flatus and total hospital stay of 15 consecutive patients (group 2) were recorded and compared to the data of 15 consecutive patients before the changes in protocol were effective (group 1). The groups were comparable in age (mean 10.93 vs 9.267 years, p = 0.33), gender (p = 0.71) and operative times (387.9 vs 336.5 minutes, p = 0.19). Results: Compared to the previous protocol involving a mean +/- SD of 7.9 +/- 1.38 enhanced recovery after surgery items per patient, 15.9 +/- 0.26 items per patient were implemented in the new protocol. In group 2 mild bowel related complications were less frequent (1 vs 5, p = 0.168). Time to stool was significantly shorter in group 2 (3.33 vs 5.53 days, p = 0.002), as was time to flatus (2.8 vs 4.73 days, p = 0.002). Total hospital stay in group 2 was 11.93 days, compared to 19.87 days in group 1 (p <0.001), mainly due to more rapid convalescence, although influenced by associated changes in the postoperative protocol as well. Conclusions: In pediatric augmentation and diversion surgery using small bowel the implementation of an enhanced recovery after surgery protocol is safe and effective, reinforcing faster bowel recovery. We did not observe complications or problems after introducing the new protocol.

INTRODUCTION:In up to 20% of patients presenting with undescended testes, one or both are non-palpable. Whereas the most reliable means to exclude an abdominal testis is laparoscopy, there has been a lot of debate about the role of inguinal ultrasound (US) in detecting non-palpable inguinal testis. While we do not aim to add another paper claiming the benefits of US, we wanted to determine the excess capability of US to determine the correct surgical approach - inguinal or laparoscopy. In the light of avoiding unnecessary diagnostic laparoscopies, even the cost-effectiveness raised in many current papers might be called into question. PATIENTS AND METHODS:Of a total of 684 boys who underwent surgery for undescended testes at our department between 2011 and 2014, in 58 (8.5%), one or both testes were neither palpable preoperatively nor under general anesthesia. These boys were examined by two experienced pediatric urologists clinically as well as by US. Besides the size of the contralateral testis, the presence of a testis in the inguinal channel was investigated. The additional impact of US over clinical exam and consideration of the size of the contralateral testis was assessed by means of intra-individual comparisons using Cochran-Q as well as McNemar tests. RESULTS:Clinical exam without considering the size of the contralateral testis had a sensitivity of 9% (95% CI 2-24%) and a specificity of 100% (95% CI 86-100%) to accurately predict the surgical approach deemed appropriate postoperatively. The consideration of the size of the contralateral testis - taken as an isolated factor - accurately predicted the surgical approach with a sensitivity of 21% (95% CI 9-38%) and a specificity of 88% (95% CI 68-97%). Ultrasound accounted for a sensitivity of 53% (95% CI 35-70%) and a specificity of 100% (95% CI 86-100%). The addition of US increased the sensitivity to correctly predict an inguinal incision from 29% to 71% and specificity slightly increased from 88% to 92%. This difference is significant (p = 0.008) in the bilateral McNemar test (Figure). CONCLUSION:Inguinal US of non-palpable testes and measurement of the contralateral testis are synergistic in predicting the surgical approach. The addition of ultrasound to a clinical exam, performed also under general anesthesia and by an experienced pediatric urologist significantly increases the prediction of the correct surgical approach. Our results translate into five boys needing an US of the NPT to prevent one laparoscopy. Whereas cost-effectiveness of US might be debatable in regard to different healthcare systems, it is proven to be an effective, non-harmful tool to avoid unnecessary diagnostic laparoscopies.

Objective and introduction Cowper's syringocele is a cystic dilation of the bulbourethral gland duct, initially defined by Maizels et al. in 1983. Although obstructive and non-obstructive types of this rare anomaly are described, clinical symptoms are highly unspecific. Therefore, we report 12 cases of children and young adults diagnosed with Cowper's syringocele to further clarify clinical course, comorbidity and treatment strategies.Study design We retrospectively collected clinical data of 12 children and young adults from birth to 18.5 years (median 7.2 years) who had been treated in four different institutes during a period of 16 years. The primary specific diagnostic work-up consisted of ultrasound, cystourethrography, and cystoscopy.Results 3Older patients with a median age of 11.8 years clinically presented with obstructive voiding pattern or gross hematuria; infants with a median age of 0.6 years presented with febrile urinary tract infections (UTIs). After cystoscopic confirmation in all patients, endoscopic treatment was possible in nine; open surgical resection was necessary in three patients. Because of intrauterine megacystis and chronic renal failure, one boy underwent suprapubic diversion with a cystostomy soon after birth. Owing to urological comorbidity or later complications, additional procedures were necessary, for example, resection of minor urethral valves, prophylactic circumcision for UTI, endoscopic or open antireflux procedures, and occasionally complex bladder reconstructions in the long term.Discussion According to our data, the initial clinical symptoms of Cowper's syringocele were related to presenting age rather than the previously described type of syringocele according to Maizels et al. Infants presented with febrile UTIs; however, older boys and young adults had mainly voiding problems or nocturnal enuresis. Therefore, the clinical significance of the described syringocele types must be questioned. Eighty-three percent of our patients showed additional urological pathology such as vesicoureterorenal reflux, ureteropelvic junction obstruction, megaureter, or minor urethral valves. Thus, Cowper's syringocele hardly seems to be an isolated pathology.Conclusion Although rare, Cowper's syringoceles should be considered in differential diagnosis of infravesical obstruction in boys and young adults. Diagnostics are usually justified by presenting symptoms such as UTI or urinary flow impairment, which seem to be age dependent. Despite modern diagnostic tools, diagnosis is usually made by cystourethrography and sometimes accidentally by cystoscopy. Considerable urological comorbidities and consecutive bladder dysfunction need long-term follow-up.[GRAPHICS]

IntroductionAlthough cross-trigonal ureteral reimplantation (Cohen) is a commonly used technique in children, it represents a non-physiological transfer of the ureteral orifices and may prove challenging with regard to endoscopic ureteral operations in later life. In 1964, Mathisen described an alternative method of ureteral reimplantation with lateralization of the neohiatus, creating an orthotopic course of the submucosal ureter. We have evaluated success and complication rates of both techniques that were applied sequentially at our departments.MethodsForty-eight consecutive patients (83 ureters, 24 males/24 females) following Mathisen reimplantation were compared with 53 consecutive patients (98 ureters, 30 males/23 females) following Cohen reimplantation. Inclusion criteria were primary vesicoureteral reflux (VUR) and no previous intervention. Reflux grades (Mathisen 58 ureters/69.9% VUR >= III; Cohen 66 ureters/66.7% VUR >= III) and the occurence of other complicating factors (ureteroceles, megaureters, posterior urethral valves) in both groups were comparable.ResultsAfter Cohen's reimplantation there were no immediate complications requiring intervention; during follow-up (mean 28.2 months) three patients (5.6%) suffered febrile urinary tract infections (UTIs), of which one (1.8%) was diagnosed with a persisting VUR. Persistent hydronephroses (>= II SFU) were recorded in six patients (13.2%). After reimplantation using Mathisen's technique, two patients (4.1%) suffered significant intravesical bleeding; during follow-up (mean 23.06 months) four patients (8.3%) suffered febrile UTIs, and seven patients (14.5%) were diagnosed with persisting VUR after a mean follow-up of 10.8 months. The patients with persistent VUR had more commonly high-grade (IV and V) VUR initially, compared to the whole group. Two patients (4.1%) had persistent hydronephroses (>= II SFU). Mathisen's technique for ureteral reimplantation yielded a significantly (p = 0.0256 patients, p = 0.006 ureterorenal units) lower success rate (85.5% patients, 89.2% ureterorenal units) in comparison with Cohen's technique (98.2% patients, 99% ureterorenal units). Although there was no intervention for obstruction, persistent hydronephrosis was more common in the Cohen group (13.2% vs. 4.1%, n.s.).ConclusionsDespite the advantages of an orthotopic ureteral orifice close to the bladder neck, as achieved by Mathisen's reimplantation, cross-trigonal ureteral reimplantation proved more reliable for VUR correction. As regards optimizing the results, patient selection for either technique could prove essential. Nevertheless, as regards the difficulties with ectopic ureteral orifices in the Cohen technique in the long-term follow-up, the concept of anatomic, orthotopic ureteral reimplantation should be pursued and the technique should be further refined.

INTRODUCTION:As there is only scarce information on the parents' view of the cosmetic outcome after hypospadias surgery we aimed to evaluate whether the results of the hypospadias objective penile evaluation (HOPE) score are transferable to parents satisfaction as measured by the pediatric penile perception score (PPPS).PATIENTS:42 patients after hypospadias correction were included (2 (6.9%) glandular, 20 (68.9%) coronal, 6 (20.6%) penile and 1 (3.4%) scrotal hypospadias, median age 15.0 months). Two surgeons independently assessed HOPE score; the PPPS score as well as 4 questions specifically designed by a psychologist were completed by fathers and mothers. 29 (69.9%) full datasets were available for evaluation.RESULTS:Parents' assessment of the cosmetic results was worse than surgeons' assessment (81.13% [PPPS] vs. 92.81% [HOPE] of the respectively possible highest score, P < 0.0001). All 58 parents (100%) were convinced that surgery led to a better cosmetic aspect of their sons' genitalia although both, mothers and fathers, perceived the operation as a major encumbrance (fathers 3.62 vs. mothers 3.97 on a scale from 0-6, P = 0.22).CONCLUSION:Parents can be encouraged preoperatively that a hypospadias operation, seen from their point of view will be a major amendment to the cosmetic appearance of their sons' genitalia even if the operation itself is perceived as a major psychological burden. In direct comparison of the highest possible score of either tool (HOPE or PPPS), the cosmetic results were judged significantly more optimistic by surgeons as compared to parents using validated tools. HOPE score results therefore may not be transferred uncritically to the parents view on the cosmetic results.

We report on a 11 year old boy who was treated for bilateral vesicoureteral reflux grade II at our department by the age of 12 months by bilateral endoscopic injection with dextranomer / hyaluronic acid (Deflux). Because of reflux persistence on the right side an open antireflux surgery (Lich Gregoir) was performed. 10 years after initial treatment he developed serious deterioration of the left kidney function after three febrile urinary tract infections within one month. Diagnostic re-evaluation revealed bilateral recurrence of grade II reflux, which was corrected consequently by open bilateral ureteral reimplantation (Cohen technique). We discuss the available literature as to renal scarring in older children and adults after initial reflux therapy in childhood and conclude that there is no age limit to possible scar formation and that there are possible implications on follow up after “curative” therapy of vesicoureteral reflux in childhood. key words: paediatric urology, vesicoureteral reflux, endoscopic reflux therapy, Deflux, renal scarring

INTRODUCTION:There is no well-defined follow-up scheme available to reliably detect persistent or recurrent vesicoureteric reflux (VUR) after endoscopic therapy (ET), but also to reduce postoperative invasive diagnostics in these children. Our aim was the evaluation of possible predictors of persistence and recurrence of VUR, in order to elaborate and test a risk-adapted follow-up regimen.MATERIAL AND METHODS:92 patients (85/92%f, 7/8%m, age 2.99y) underwent direct isotope cystography (DIC) three months after ET. Persistent or recurrent VUR, scarring on dimercaptosuccinic acid (DMSA) scans and further fUTIs after therapy (follow-up 24.6 m) were documented and analysed.RESULTS:VUR persistence 3 months after ET was found in 11 (11.9%) patients; recurrent VUR in 4 (4.3%) patients. Scarring on preoperative DMSA and dilating VUR (°III and °IV) were significantly associated with recurrent VUR. If only children with preoperative positive DMSA scan or dilating VUR would have undergone DIC, only 58/92 DICs (64%) would have been necessary. Only 45.5% of otherwise detected VURs would have been identified using this risk-adapted strategy.CONCLUSIONS:Limiting invasive follow-up diagnostics (VCUG) and, therewith, the radiation burden in a predefined group of patients at risk for persistence or recurrence of VUR is not recommended, due to the significant chance of missing persistent or new onset contralateral VUR. Therefore, we recommend a routine follow-up VCUG after ET. Further prospective scientific efforts to evaluate new, alternative factors influencing persistence and recurrence of VUR, in order to establish an effective follow-up strategy, are warranted.

Introduction Both, fluoroscopic voiding cystourethrography (fVCUG) and direct isotope cystography (DIC) are diagnostic tools commonly used in pediatric urology. Both methods can detect vesicoureteral reflux (VUR) with a high sensitivity. Whilst the possibility to depict anatomical details and important structures as for instance the urethra in boys or the detailed calyceal anatomy are advantages of fVCUG, a lower radiation burden is thought to be the main advantage of DIC. In the last decade, however, a rapid technical evolution has occurred in fluoroscopy by implementing digital grid-controlled, variable rate, pulsed acquisition technique. As documented in literature this led to a substantial decrease in radiation burden conferred during fVCUGs. Objective To question the common belief that direct isotope cystography confers less radiation burden compared to state of the art fluoroscopic voiding cystography. Study design Radiation burden of direct isotope cystography in 92 children and in additional 7 children after an adaption of protocol was compared to radiation burden of fluoroscopic voiding cystourethrography in 51. The examinations were performed according to institutional protocols. For calculation of mean effective radiation dose [mSv] for either method published physical models correcting for age and sex were used. For DIC the model published by Stabin et al., 1998 was applied, for fVCUG two different physical models were used (Schultz et al., 1999, Lee et al., 2009). Results The radiation burden conferred by direct isotope cystography was significantly higher as for fluoroscopic voiding cystourethrography. The mean effective radiation dose for direct isotope cystography accounted to 0.23 mSv (±0.34 m, median 0.085 mSv) compared to 0.015 mSv (±0.013, median 0.008 mSv, model by Schultz et al.) - 0.024 mSv (±0.018, median 0.018 mSv, model by Lee et al.) for fluoroscopic voiding cystourethrography. After a protocol adaption to correct for a longer examination time in DIC that was caused by filling until calculated bladder capacity, mean radiation burden accounted to .07 mSv (median 0.07 mSv) and the values were less scattered. Discussion As it had to be expected from literature, radiation dose from fVCUG, if modern image acquisition techniques are used, is even less than from DIC. In our protocol, according to nuclear medicine standards, bladders were filled until calculated capacity. This resulted in a longer examination time for the patients with a higher functional capacity, resulting in relatively higher radiation burden. However, also if the protocol is changed or only the patients with relatively fast bladder emptying are considered, radiation burden conferred by DIC is higher (at least × 2.9, comparing the "worst" case for fVCUG with the "best" case for DIC). Absolute radiation burden conferred by either exam is extremely low compared to other medical radiation exposures as well as to environmental radiation. Consequently it is most probably not relevant for the individual childs future risk for cancer or other radiation damage. However, because of repeated investigations with correspondingly higher radiation burden in this patient group the ALARA (as low as reasonably achievable) principle should lead to a optimized use of fVCUG rather than an uncritical use of DIC, given that modern acquisition standards are available and radiation measurement is performed. Also, fVCUG provides more information concerning anatomical details compared to DIC. Conclusion Contrary to common beliefs, effective radiation dose conferred during fluoroscopic voiding cystourethrography is significantly lower than during direct isotope cystography. The prerequisite for our findings, however, is the use of modern image acquisition tools and an optimized protocol. Both exams confer low radiation doses probably only relevant to children undergoing repeated radiation exposure. Nevertheless, this findings should be considered in indication for either exam in order to reduce the radiation burden to a minimum whilst optimizing the information yield.

Objective: Positioning irrigation of contrast (PIC) cystography identifies occult or PIC vesicoureteral reflux (PIC-VUR) in children with recurrent febrile urinary tract infections (UTI) but no vesicoureteric reflux (VUR) on standard voiding cystourethrogram (VCUG). We sought to identify the relationship between PIC-VUR and renal scarring in technetium-99m dimercaptosuccinic acid (DMSA) scans.Patients and methods: We retrospectively analysed PIC cystograms and DMSA scans for 154 kidneys in 81 children (65 girls; 16 boys; median age, 4.7 years; range, 0.9-15.2). Renal scarring was graded on a scale of 0-3. DMSA scans were pathologic in 66 patients (81%). Children had experienced mean 3.8 febrile UTI (range 1-25). Forty-seven (58%) children had a history of reflux, including 15 (19%) with previous anti-reflux operations. Indications for PIC cystography were recurrence of febrile UTI after either bilateral negative VCUG (66 children) or unilateral VUR (15 children) with contralateral/bilateral scarring or reflux that had changed sides in subsequent VCUGs.Results: PIC-VUR was bilateral in 63, unilateral in 12, and absent in 6 children. Statistically significant associations between PIC-VUR grade and severity of renal scarring were identified in inter-individual (n = 77, p = 0.017) and intra-individual (refluxing vs. nonrefluxing kidney; n = 12, p = 0.008) analyses. After excluding patients with history of VUR, statistical significance was maintained in inter-individual analysis (n = 49; p = 0.018).Conclusion: The data suggest an association between PIC-VUR and severity of renal scarring, and legitimise the use of PIC cystography in children with renal scarring due to recurrent febrile UTI but negative findings on VCUG. (C) 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Purpose To prove the long-term efficacy of BTX-A injection in the management of children with neurogenic detrusor hyperactivity. Materials and methods 28 out of 145 children with neurogenic bladder (15 male and 13 female, mean age 10.7 years) who were treated between 2002 and 2010 and became non-responders to conservative treatment were included into the retrospective study. We injected 10-12 U/kg of BTX-A (Botox®) into the detrusor at 20-30 sites, sparing the trigone. The mean follow-up was 48 months (range 6-84 months). Results Group 1. 14 patients had a single injection of BTX-A. Five of them were successful. Mean bladder reflex volume increased (from 62.9 to 117.5 ml), maximum detrusor pressure decreased (from 59 to 37.5 cm H2O), detrusor compliance increased (from 4.8 to 9.5 ml/cm H2O), and leak-point-pressure decreased (from 46.5 to 24.2 cm H2O). Four patients did not respond and were treated by ileocystoplasty. Another five were lost to follow-up. Group 2. 14 patients had repeated (mean 2.5) injections of BTX-A with a mean interval of 13.7 months. In thirteen patients, urodynamic parameters of the first and last injection were similar to those obtained in Group 1, showing a good response. One patient received an ileocystoplasty. Conclusion BTX-A is a safe alternative in the treatment of detrusor hyperactivity in children with myelomeningocele (MMC). The efficacy lasted a mean of 12 months and urodynamic response was unchanged even after several injections. In our series, 21.7% of children with severe low-compliance bladders were non-responders.

Aim: To compare the outcomes of patients with abdominal testes undergoing single-stage Fowler-Stephens (FSI) vs. two-stage (FSII) procedures. Patients and Methods: Between 01/1993 and 06/2009, a total of 41 children (median age 24.5 months) with 50 abdominal testes were treated. Orchidopexy was performed according to the surgeon's choice, resulting in 33 FSI and 17 FSII open procedures. In this retrospective study the charts of all children followed in our outpatient department at one, three and 12 months postoperatively and afterwards annually by the use of volumetry and color Doppler-sonography were reveiwed. Data regarding testicular position, size (consistency), and atrophy were recorded. Results: In FSI, the overall success rate was 79%: 64% (21/33) were of normal size with a normal scrotal position; 15% (5/33) were not at the deepest scrotal point, and 21% (7/33) developed testicular atrophy. In FSII, the overall success rate was 82%: 76% (13/17) were found to be of normal size and 6% (1/17) were not at the deepest point of the scrotum, and 18% (3/17) developed testicular atrophy. Conclusions: In this consecutive series there were no significant differences observed between the two procedures with regard to size, blood supply, position, or atrophy rate of the testes.

Introduction. In the ongoing debate for an optimal management, cost effectiveness has become an important factor. Independent of the different health care systems, treatment efficacies versus their expenses is vocalized worldwide. To determine the cost-benefit ratio between the different types of open surgeries, we performed a retrospective single institution analysis. To compare the clinical outcomes and costs of different operative techniques in children with vesicoureterorenal reflux grade 3 (VUR G3).Patients and methods. We retrospectively reviewed the medical records of 401 patients [514 RU ( renal units)] previously treated conservatively, but unsuccessfully elsewhere and therefore admitted to our institution. Three therapeutic options were offered and, according to parents' decisions, the patients were subdivided in three groups: group 1 - transvesical ureter reimplantation (Politano or Cohen), group 2 - extravesical technique (Lich-Gregoir), and group 3 - endoscopic injection. The average costs of the treatments and re-interventions were calculated according to the initial diagnosis, hospital stay, operating theater, and controls.Results. Group 1 procedures were performed successfully in 98 children (152 RU) and no re-interventions occurred. In Group 2, 132 children (136 RU) underwent extravesical surgery with one re-intervention (0.7%). In Group 3, 171 children (226 RU) underwent endoscopic injection. After the first injection, 69% (157/226) were successfully treated. In 12 RU, a second injection was applied and the cure rate increased to 167/226RU (74%). In the 59 remaining refluxive RUs, open reconstruction was now performed and was successful in: 36 RU by the Lich-Gregoir-, 16 RU by the Cohen-, and 7RU by the Politano- Leadbetter technique.Conclusions. For counseled parents who consented that their children be treated for VUR G3 by open surgery, despite being more expensive, benefited from a significantly higher cure rate than endoscopic injection.

Purpose In order to the cure rates and cost-effectiveness of different antirefluxiv surgeries in children with VUR (vesicorenal reflux) Grade 3. Material and Methods We reviewed retrospectively the medical records of 401 patients (514 renal units (RU) who got admitted to our institution for treatment of primary VUR 3 between 1993 and 2009. Three different therapeutic options (Group 1: intravesical; Group 2: extravesical; Group 3: endoscopic) were offered to parents. The average costs of different surgeries and re-interventions. were calculated according to the hospital stay with operation theatre (OR), ultrasound (US) and standard laboratory examinations (LA). Results Intravesical re-implantation (group 1) were performed in 98 children (n=152 RU). There was no re- intervention necessary. In group 2 132 children (n= 136 RU) underwent an extravesical surgery. In 4% a second intervention was necessary and of these six patients treated, one subsequently required surgery.In group 3 171 patients (n= 226 RU) underwent endoscopic injection (Deflux®). After the first injection 157 RU (69%) were cured, 9 RU required a second, 2 RU a third injection and 58 RU required surgical reimplantation. Mean cost/patient in group 1, 2 and 3 were 16,293€, 10,365€ and 5,659 €, respectively. Mean total (surgery + redo surgery) cost/patient in group 1, 2 and 3 after one year were 16.471€, 19.633 € and 17.925€, respectively. Conclusions For each child with VUR grade 3 open ureteral reimplantation (intra- or extravesical) conveys a higher initial success rate than endoscopic correction. The long-term cost-effectiveness is higher in group 1 than in group 3, where initially surgery costs less. In order to the cure rates and cost-effectiveness of different antirefluxiv surgeries in children with VUR (vesicorenal reflux) Grade 3. We reviewed retrospectively the medical records of 401 patients (514 renal units (RU) who got admitted to our institution for treatment of primary VUR 3 between 1993 and 2009. Three different therapeutic options (Group 1: intravesical; Group 2: extravesical; Group 3: endoscopic) were offered to parents. The average costs of different surgeries and re-interventions. were calculated according to the hospital stay with operation theatre (OR), ultrasound (US) and standard laboratory examinations (LA). Intravesical re-implantation (group 1) were performed in 98 children (n=152 RU). There was no re- intervention necessary. In group 2 132 children (n= 136 RU) underwent an extravesical surgery. In 4% a second intervention was necessary and of these six patients treated, one subsequently required surgery.In group 3 171 patients (n= 226 RU) underwent endoscopic injection (Deflux®). After the first injection 157 RU (69%) were cured, 9 RU required a second, 2 RU a third injection and 58 RU required surgical reimplantation. Mean cost/patient in group 1, 2 and 3 were 16,293€, 10,365€ and 5,659 €, respectively. Mean total (surgery + redo surgery) cost/patient in group 1, 2 and 3 after one year were 16.471€, 19.633 € and 17.925€, respectively. For each child with VUR grade 3 open ureteral reimplantation (intra- or extravesical) conveys a higher initial success rate than endoscopic correction. The long-term cost-effectiveness is higher in group 1 than in group 3, where initially surgery costs less.

Introduction: We evaluated the potential and outcome of preoperative percutaneous nephrostomy (PCN) in infants and children with severe hydronephrosis (Society for Fetal Urology grade IV) due to ureteropelvic junction obstruction. We focused on pre- and post-operative renal split function (RSF), histological findings of the renal pelvis and the reop-eration rate. Patients and Methods: The medical records of 249 patients (254 renal units) who underwent pyeloplasty for ureteropelvic junction obstruction between 1992 and 2009 were retrospectively reviewed. In 24 patients (group 1), PCN was performed before the pyeloplasty for various reasons. Renal split function was investigated using diuretic renogra-phy before PCN or pyeloplasty and 1 year after surgery. His-tological findings and reoperation rates were compared in patients with (group 1) and without (group 2) PCN. Results: Of the 254 renal units, 24 patients with a median age of 80 days (1 day to 11 years) received a PCN before pyeloplasty. The initial median RSF was 43% (4-58%) preoperatively and 45% (21-67%) 1 year postoperatively in group 1 and 47% (11-71%) preoperatively and 47% (0-74%) postoperatively in group 2. Histology revealed chronic inflammation of the renal pelvis in 60% of the PCN patients compared to 21% in group 2. The reoperation rate was 12.5% (3/24) in group 1 and 4% (9/230) in group 2. Conclusions: Preoperative PCN in severe hydronephrosis results in little or no improvement in RSF, causes a high percentage of chronic inflammation of the renal pelvis and increases the risk of reoperation.

OBJECTIVE:The need for surgical correction of vesicoureteral reflux (VUR) is increased in duplicated systems. The aim of this study was to evaluate the outcome of the Lich-Gregoir procedure (LG) with regard to VUR persistence, contralateral de-novo VUR, hydronephrosis, preservation of split renal function, urinary tract infections (UTI) and postoperative side effects.PATIENTS AND METHODS:Between 1993 and 2007, 45 children (mean age 3.2 years) underwent a unilateral common sheath LG. A combined number of at least 75 episodes of febrile UTI had occurred in 39 children prior to surgery. VUR grades I to V were present in two, nine, 16, 16 and two children, respectively. Hydronephrosis was present in 18 children. Mean split renal function was 44.03% (range 15-63%). Indications for surgery were febrile breakthrough UTI in 11 children and abscessing pyelonephritis in two. The remainder underwent surgery due to renal scars, reduced split renal function (<45%), VUR persistence and/or parental desire.RESULTS:Persistent ipsilateral and de-novo contralateral VUR were detected in three children (ipsilateral in one, contralateral in one, bilateral in one), resulting in a 4.4% rate of persistent ipsilateral VUR. One year post surgery, low-grade hydronephrosis persisted in six patients without impact on split renal function. Mean split renal function remained stable at 44.06% (range 15-68%). During follow up (mean 41 months), six febrile UTIs occurred in five girls (92.4% risk reduction, P<0.00000005). Neither urinary retention nor any other side effect was observed.CONCLUSION:Performed unilaterally, common sheath LG is a safe and effective technique to cure VUR, prevent febrile UTI and maintain split renal function in duplicated systems with otherwise uncomplicated anatomy.

Purpose To analyse and compare the efficacy of two stage vs one stage Fowler Stephens orchidopexy (FSO) in the operative management of abdominal testes in a single institution. Material and methods Between 1/93 and 12/05 a total of 25 children with 32 abdominal testes and a mean age of 3.9 years (range 1-13.5 years) underwent two or one stage FSO. In group one 14 children had 17 staged FSO. The time between the two staged operations was mean 4.5 months (range 3-8.8 months). The spermatic artery was clipped laparascopically in 4/14 patients. In group two 12 children had 15 single staged FSO via a standard inguinal oblique incision following a diagnostic laparoscopy. All children were followed at 1, 3 and 12 months including volumetry and color Doppler sonography. The mean follow-up in group one is 5.2 years and in group two 2.6 years. Results In group one (two stage FSO) 12/17 testes (71%) have a normal scrotal position, normal size and growth. One testis is in a correct position but has so far had no catch up growth. 4/17 children had a testis in a high scrotal or inguinal position. Two of them have been reoperated on successfully in the meantime. We observed no testicular atrophy in this group. In group two (single stage FSO) 11/15 testes (73%) are normal sized and in adequate position. Again 1 testis with normal perfusion and position remained rather small. 2/15 children developed a high scrotal or inguinal position, one was reoperated on successfully. One testis became atrophic and has been removed. Conclusions Comparison of the two groups revealed no significant differences concerning viability, catch up growth and adequate position of the testis. Therefore we recommend the single stage procedure in the operative management of an abdominal testis. To analyse and compare the efficacy of two stage vs one stage Fowler Stephens orchidopexy (FSO) in the operative management of abdominal testes in a single institution. Between 1/93 and 12/05 a total of 25 children with 32 abdominal testes and a mean age of 3.9 years (range 1-13.5 years) underwent two or one stage FSO. In group one 14 children had 17 staged FSO. The time between the two staged operations was mean 4.5 months (range 3-8.8 months). The spermatic artery was clipped laparascopically in 4/14 patients. In group two 12 children had 15 single staged FSO via a standard inguinal oblique incision following a diagnostic laparoscopy. All children were followed at 1, 3 and 12 months including volumetry and color Doppler sonography. The mean follow-up in group one is 5.2 years and in group two 2.6 years. In group one (two stage FSO) 12/17 testes (71%) have a normal scrotal position, normal size and growth. One testis is in a correct position but has so far had no catch up growth. 4/17 children had a testis in a high scrotal or inguinal position. Two of them have been reoperated on successfully in the meantime. We observed no testicular atrophy in this group. In group two (single stage FSO) 11/15 testes (73%) are normal sized and in adequate position. Again 1 testis with normal perfusion and position remained rather small. 2/15 children developed a high scrotal or inguinal position, one was reoperated on successfully. One testis became atrophic and has been removed. Comparison of the two groups revealed no significant differences concerning viability, catch up growth and adequate position of the testis. Therefore we recommend the single stage procedure in the operative management of an abdominal testis.