Ureterocele is a cystic dilatation of the intravesical ureter that is most commonly observed in females and children, and usually affects the upper moiety of a complete pyeloureteral duplication. According to their position, ureteroceles are divided into intravesical, when the ureterocele is completely contained inside the bladder, and extravesical when part of the cyst extends to the urethra or bladder neck. Most ureteroceles are diagnosed in utero or immediately after birth during an echographic screening of renal malformations. Severe, febrile urinary tract infection is the most common postnatal presentation of ureteroceles, but they may, rarely, prolapse and acutely obstruct the bladder outlet. Once an ureterocele is identified sonographically, a voiding cystourethrogram to detect vesicoureteral reflux (VUR) and a 99m-technetium dimercapto-succinic acid renal scan to evaluate the function of the different portions of the kidney are mandatory. VUR in the lower pole is observed in 50% of cases and in the contralateral kidney in 25%. Simple endoscopic puncture of the ureterocele has recently been advocated as an emergency therapy for infected or obstructing ureteroceles and as an elective therapy for intravesical ureteroceles. The rate of additional surgery after elective endoscopic puncture of an orthotopic ureterocele ranges from 7 to 23%. Treatment of ectopic ureteroceles is more challenging and both endoscopic puncture and upper pole partial nephrectomy frequently require additional surgery at the bladder level. The reoperation rate after endoscopic treatment varies from 48 to 100%. It is 15 to 20% after upper pole partial nephrectomy if VUR was absent before the operation, but is as high as 50-100% when VUR was present. Thus, endoscopic incision is appropriate as an emergency treatment or when dealing with a completely intravesical ureterocele. Upper pole partial nephrectomy is the elective treatment for an ectopic ureterocele without preoperative VUR. In an ectopic ureterocele with VUR, no matter which type of primary therapy has been chosen, a secondary procedure at the bladder level, involving ureterocele removal and reimplantation of the ureter(s), should be anticipated.

Opposite gender should not be assigned in patients affected by penile agenesis, who are better raised according to their karyotype and hormonal production. Definitive phalloplasty in adults may achieve good results. Nevertheless, this procedure is generally performed in postpubertal boys and it is not easily available everywhere. Therefore, we believe that social and psychological concerns justified this type of phalloplasty as a palliative preliminary procedure in 3 of our patients. In those countries where definitive forearm phalloplasty is not available our method may also be justified in older children (as in 1 of our patients) as an attempt at a definitive procedure.

Our data show a close relationship between acute epididymitis in infants for both UTIs and genitourinary malformations. Every infant presenting with epididymitis would undergo a complete evaluation including abdominal ultrasound and voiding cystourethrography. In older children the need for imaging should be dictated by clinical history and physical findings.

A retrospective co-operative study was conducted among 6 Italian paediatric surgical departments to assess the results of different forms of treatment of vesicoureteric reflux in patients with neurogenic bladder. Between January 1980 and December 1989 we studied 641 neurogenic bladders in children, mainly due to spina bifida; reflux was detected in 199 patients with 263 refluxing ureters. Details of treatment were available for only 170 patients and they were divided into 2 main groups: conservative medical treatment (n = 127) and primary surgical treatment (n = 43). Medical treatment consisted mainly of clean intermittent catheterisation and the administration of appropriate drugs. In the surgical group 36 reimplantations, 6 cystostomies and 1 STING were performed. Fifteen patients underwent surgery as a secondary procedure. The results showed that approximately 50% of patients with reflux were cured by clean intermittent catheterisation and drug therapy. Ureteric reimplantation can be safely performed in patients with neurogenic bladder provided that a normally compliant, non-hyper-reflexic bladder can be achieved by means of drugs or by bladder augmentation with bowel.

Transperitoneal robotic pyeloplasty is an excellent minimally invasive choice for the treatment of UPJO in HSK pediatric patients. The pediatric setting should prompt attention to every detail to avoid unfortunate complications.