Ipsilateral ureteroureterostomy in the surgical management of the severely dilated ureter in ureteral duplication.

PURPOSE: Ipsilateral ureteroureterostomy for the surgical management of severely dilated ureter in ureteral duplication is well supported in the surgical literature but often not done. We evaluated our institutional experience with ureteroureterostomy in duplication anomalies to assess the feasibility and success of this procedure. MATERIALS AND METHODS: An 8-year retrospective review of the records of all patients with complete renal duplex anomalies was evaluated. Anatomical presentations, and operative and nonoperative treatment of these patients were evaluated. RESULTS: A total of 193 patients were identified with complete renal duplication. Associated anomalies included ureterocele in 24 patients, ectopic ureter in 38 and vesicoureteral reflux in 57. Of 193 patients 160 (83%) with duplex anomalies underwent surgical intervention with a total of 41 ureteroureterostomies performed in 39 patients with dilated donor ureters. A total of 11 ureteroureterostomies were performed primarily and 30 were performed in conjunction with ipsilateral ureteral reimplantation of the distal common segment below the ureteroureterostomy. Ten of the 39 patients had the contralateral side reimplanted for vesicoureteral reflux. In all children with ureteroureterostomy the anastomosis between the 2 ureters remained patent. Two of the 11 children who underwent ureteroureterostomy alone had de novo ipsilateral vesicoureteral reflux (1), which was treated with ureteral reimplantation, and subureteral injection (1). Two children who underwent concomitant ureteroureterostomy and reimplantation without indwelling stents had transient postoperative urinomas that required subsequent drainage. Additionally, 3 patients had persistent ipsilateral vesicoureteral reflux, which was treated with subureteral injection in 1 and observation in 2. One patient presented with transient ipsilateral urinary obstruction, which required percutaneous drainage and resolved spontaneously. CONCLUSIONS: In cases of ureteral duplication with a severely dilated ureter requiring surgical intervention ipsilateral ureteroureterostomy is a viable option for reflux and/or obstruction. The procedure is rapid and technically feasible, and it offers excellent cosmesis. In addition, ureteroureterostomy has minimal morbidity and it facilitates early hospital discharge.

Minimally invasive open renal surgery.

PURPOSE: Improved pediatric laparoscopic techniques and instruments have led to the increased popularity of laparoscopic pyeloplasty and nephrectomy at some centers. The recent trend has compared laparoscopic to open techniques to draw parallel conclusions from the adult literature that laparoscopic surgery in children offers the same advantages. Historically open renal surgery in the pediatric population has been done successfully but usually through more traumatic incisions. We present our experience with minimally invasive open renal surgery. MATERIALS AND METHODS: A retrospective review of the last 6 years was performed of consecutive open pyeloplasties for ureteropelvic junction obstruction and open nephrectomy for multicystic dysplastic kidneys and renal duplication anomalies at a tertiary hospital for children. Parameters evaluated were patient age at surgery, surgical incision size, operative time, hospital stay and the need for postoperative narcotics. RESULTS: A total of 135 patients underwent open renal surgery using an open retroperitoneal flank incision, including 66 younger than 1, 32 who were 1 to 5, 11 who were 5 to 10 and 26 who were older than 10 years. Mean +/- SD operative time was 101.4 +/- 44.7 minutes in patients younger than 1 year, 87.7 +/- 39.3 minutes in those 1 to 5 years old, 127.1 +/- 62.7 minutes in those 5 to 10 years old and 127.8 +/- 38.4 minutes in those older than 10 years. Incision size for the groups was 1.9 +/- 0.61, 1.9 +/- 0.72, 3.0 +/- 1.3 and 3.8 +/- 1.6 cm, respectively. The last 20 patients younger than 1 year who underwent open pyeloplasty had an incision of between 1 and 1.5 cm. Most incisions were performed through a posterior, subcostal muscle splitting approach. All patients received postoperative ketorolac. Supplemental narcotics were not required in any patients younger than 10 years. Of the patients 90% were discharged home in less than 23 hours. CONCLUSIONS: The minimally invasive approach to open renal surgery is a safe and effective treatment choice in pediatric urology. The procedure can be easily performed through a small incision with minimal morbidity, comparable operative time and excellent cosmesis without excessive postoperative pain issues, allowing early discharge home. Perhaps this refined open surgery technique should be the benchmark for comparing new techniques.

Betamethasone cream for the treatment of pre-pubertal labial adhesions.

PURPOSE: We evaluated the efficacy of 0.05% betamethasone cream for the treatment of pre-pubertal labial adhesions. METHODS: We retrospectively reviewed the records of 19 children with labial adhesions who were treated with betamethasone cream from 6/2001 to 3/2003. Children were treated with 1 to 3 courses of twice-daily 0.05% betamethasone cream for 4 to 6 weeks. Successful lysis of adhesions was assessed by clinical exam or parental phone contact and outcomes were defined as: (1) success--complete separation of labia, (2) partial success--greater than 75% separation, (3) progression to surgical lysis, and (4) lost to follow-up. RESULTS: Nineteen patients with an average age of 58 months (range 12 to 132 months) were treated. Four of the 19 patients had never been treated previously and 1 had been treated previously with surgical lysis of adhesions only. Fourteen of the 19 patients had been previously treated with conjugated estrogen (Premarin) cream. Two of these fourteen patients had also undergone surgical lysis of adhesions. Severity of adhesions ranged from 33% to 99% labial closure. Betamethasone cream was successful in treating 13/19 (68%) pre-pubertal labial adhesions. Eleven (85%) of these 13 patients had complete resolution of labial adhesions with 1 course of treatment, 1 (7.5%) had resolution with 2 courses of treatment and 1 (7.5%) had resolution with 3 courses of treatment. One patient had a partial success with 3 courses of betamethasone cream. Two (11%) patients underwent surgical lysis of adhesion after 1 and 2 courses of betamethasone cream respectively. Three (16%) patients were lost to follow-up. Average follow-up was 7 months (range 1-24 months). No adverse outcomes or untoward effects were noted in any of the patients treated. CONCLUSIONS: Betamethasone 0.05% cream appears to be a safe and effective treatment of pre-pubertal labial adhesions as primary therapy or in patients that have failed previous therapies and it may avoid the undesirable side effects of breast budding and hyperpigmentation that can be associated with Estrogen creams.

Presentation of fused vas deferens.

Transverse testicular ectopia is a rare condition that usually presents as a unilateral nonpalpable testis and a contralateral descended testis with an associated hernia. Currently, with the use of diagnostic laparoscopy, transverse testicular ectopia is found before groin exploration. We reviewed 2 cases that were referred to our institution. Both patients had a common vas deferens with proximal fusion. To our knowledge, a fused vas deferens has only been reported three other times in published reports. Our second case is unique in that this is the first time a common vas deferens has been reported outside of transverse testicular ectopia.

Gonadoblastoma and Turner syndrome.

PURPOSE: The presence of a Y chromosome in the extrascrotal gonad of patients with intersex disorders has been associated with a high risk of GB and, potentially, GCT. Recently, modern sophisticated genotyping has revealed a subgroup of TS cases with a mosaic karyotype expressing a Y chromosome. We sought to evaluate this group of patients and address their risk of gonadoblastoma. MATERIALS AND METHODS: We reviewed the records and genotyping of all females newly diagnosed with TS between 1990 and 2002 at Children's Hospital in Denver. All patients with TS and Y chromosome mosaicism underwent gonadectomy, and the specimens were evaluated for the presence of gonadoblastoma on histological analysis and to identify Y chromosome on genotyping. RESULTS: A total of 192 girls with a clinical diagnosis of TS were identified between January 1990 and December 2002. Seven records were unavailable and 19 patients did not have karyotypic analyses available in the hospital charts. Of the remaining 166 patients 67 exhibited mosaic cell lines, of whom 8 had 45,X0/46,XY mosaic pattern and 59 had mosaic patterns without Y chromosomal elements. All 8 patients with Y mosaicism underwent uneventful laparoscopic gonadectomy on an outpatient basis. One patient observed to have bilateral dysgenetic gonads after gonadectomy was excluded from the study. Gonadoblastoma (bilateral 2 patients, unilateral 1) was detected in 3 of 7 patients (43%) with Y mosaicism. CONCLUSIONS: In our series 4.8% of evaluable patients with TS carried a 45,X0/46,XY karyotype. Gonadoblastoma can be evident even at an early age in streak gonads with Y mosaicism and may be bilateral. We recommend prophylactic laparoscopic gonadectomy of streak gonads in patients with TS who carry a Y mosaic genotype, because fertility is not an issue, surgical morbidity is minor and there may be a high potential for malignant transformation of gonadoblastomas in this population.

Xanthogranulomatous pyelonephritis.

Xanthogranulomatous pyelonephritis is a rare condition in children. A 7-year-old boy developed right flank pain and tenderness 1 month after an appendectomy. Abdominal computed tomography scan documented a right renal mass. A right nephrectomy was performed. The pathological report documents xanthogranulomatous pyelonephritis. He experienced an uneventful recovery. Xanthogranulomatous pyelonephritis should be included in the differential diagnosis of children with fever, weight loss, flank tenderness, and a renal mass.

The minimally invasive open pyeloplasty.

BACKGROUND: The dismembered pyeloplasty is the operation of choice for ureteropelvic junction obstruction (UPJO). Recently, with the advent of improved minimally invasive techniques and equipment, laparoscopic dismembered pyeloplasty has gained popularity. We present our experience with a minimally invasive open pyeloplasty. MATERIALS AND METHODS: A retrospective review of the last 5 years of consecutive open pyeloplasties was performed with regard to age, surgical operative time, length of hospital stay, need for postoperative narcotics and surgical success. RESULTS: Seventy-four patients had a dismembered pyeloplasty using an open flank incision: 34 patients (<1 year), 13 (1-5 years), 7 (5-10 years) and 20 (>10 years). Mean surgical time for patients according to age was: <1 year, 109.4+/-36.4 min; 1-5 years, 105.5+/-37.4 min; 5-10 years, 131.1+/-76.4 min; >10 years, 134+/-37.8 min. Mean incision sizes for the respective groups were 2.01+/-0.50 cm, 1.93+/-0.73 cm, 2.71+/-1.55 cm and 3.5+/-1.58 cm. The last 20 patients under 1 year of age had incisions of 1-1.5 cm. The majority of incisions were via a posterior subcostal muscle splitting approach. All patients received postoperative ketorolac and acetaminophen. Supplemental narcotics were not required in any patient less than 10 years old. All patients were discharged in <23 h. Radiologic and/or symptomatic improvement was seen in 70/74 (95%) patients after surgery. CONCLUSION: The minimally invasive approach to open pyeloplasty is a safe and effective treatment choice for UPJO. In small children our technique can be easily performed through a small incision without excessive postoperative pain allowing for early discharge. Our results with a refined open surgical technique challenge the current trend in the literature that laparoscopic pyeloplasty techniques are superior with regard to cosmesis, length of stay and postoperative narcotic use.

Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas.

OBJECTIVE: To evaluate the impact of various factors that might ultimately influence the stoma complication rate associated with the construction of a continent catheterizable urinary (CCU) and Malone antegrade colonic enema (MACE) stoma in children. PATIENTS AND METHODS: Retrospectively, we reviewed our experience in patients who had a CCU and/or MACE stoma reconstructed at our institution from 1992 to 2003. Diagnosis, type of stoma constructed (CCU vs MACE), single vs dual stomas, stomal site, conduit material (appendix, split appendix, Monti-Yang or ureter), sex, age, patient mobility and body mass index, race and concomitant surgery (e.g. bladder augmentation with or without bladder neck reconstruction) were evaluated for stoma-related complications. In all, 109 patients (64 males and 45 female), with a mean (sd, range) age of 8.6 (5.7, 2-37) years, had 151 stomas constructed during the period of analysis, comprising 56 CCU only, 11 MACE only and 42 (84 stomas) both simultaneously. RESULTS: The mean (range) follow-up was 48 (6-144) months. The primary diagnoses were neurogenic bladder in 60 (55%), bladder exstrophy/epispadias in 17 (16%) and posterior urethral valves in 11 (9%) patients. The umbilicus was the primary site for the CCU stoma in 88 of 98 (90%) cases, while the right lower quadrant was the primary site for MACE in 46 of 53 (87%). After surgery complete stomal continence was provided in 95 of 98 (97%) CCU stoma, whereas the MACE was successful in 52 of 53 (99%). The stoma-related complications included stenosis in 27, leakage in eight, false passage in four, atrophy in two, keloid in one, and breakdown of the stoma in two. Individually, only greater age and a primary diagnosis of neurogenic bladder were independent risk factors associated with an increased rate of stomal complications and higher incidence of revision (P < 0.05). CONCLUSION: Stomal complications are extremely common whether CCU or MACE stomas are constructed individually or together. Nevertheless, despite the need for revision, the high stoma continence rate supports their use. Greater age at surgery and a primary diagnosis of neurogenic bladder were associated with a significant increase in the stoma-related complications and the need for revision.

Laparoscopic Palomo varicocele ligation in children and adolescents: results of 103 cases.

PURPOSE: We evaluate our experience using the laparoscopic Palomo varicocele ligation (LPV) technique in male children and adolescents with varicoceles. MATERIALS AND METHODS: Between September 1994 and September 2002, 122 varicoceles were treated using LPV with either mass cord vascular clip application (68) or LigaSure (Valleylab, Boulder, Colorado) vascular sealing (54). All procedures were performed as day surgery cases and patients were allowed to return to normal activities as soon as they could tolerate them. Followup was scheduled for 6 to 12 weeks and 1 year postoperatively. Testicular size was evaluated using a Prader orchidometer. RESULTS: Of the 122 patients 103 were evaluable at the initial postoperative visit and 96 at 1-year followup. Patient ages ranged from 9 to 19 years (mean 14.6). Operating time was 9 to 52 minutes (mean 28), although in the last 2 years (28 cases) mean operative time has decreased to 14.6 minutes. Indications for surgery included ipsilateral testicular hypotrophy in 84 cases, symptoms in 3 and parental choice in 16. At followup only 1 recurrent varicocele (vascular sealant group) was identified which was subsequently re-treated successfully using vascular sealant LPV. At 1 year 64 of 78 testes (82%) demonstrated catch-up growth and there was no evidence of testicular loss or persistent hypotrophy in the others. Reactive hydroceles were identified in 6 patients equally distributed between the 2 LPV techniques. Surgery was required on 2 of these hydroceles due to size, and the other 4 are small and are being observed. Temporary scrotal emphysema occurred in the vast majority of patients and 1 patient required laparoscopic closure of a small sigmoid serosal tear. No patients required narcotic medications for greater than 48 hours. CONCLUSIONS: LPV is a highly successful method to correct varicoceles in young males with catch-up growth similar to series using other accepted standard techniques. LPV can be performed safely and rapidly as an outpatient and allows early return to activity. As with the open Palomo technique, hydrocele is a bothersome complication that may require a second surgical procedure if correction is warranted.

Laparoscopic varicocele ligation: are there advantages compared with the microscopic subinguinal approach?

OBJECTIVES: To compare the operative time, outcome, complications, and patient costs between laparoscopic varicocele ligation (LVL) and subinguinal microscopic varicocelectomy (SMV) in two patient cohorts. Varicocele therapy is a controversial issue, with no single approach adopted as the best therapeutic option. LVL has been considered more expensive and of no proven benefit compared with SMV. METHODS: We compared two groups of patients who underwent surgical correction of varicocele at our institutions during a 6-year period. Group 1 included postpubertal adolescents who underwent LVL and group 2 included adults seen at an infertility practice who underwent SMV. The outcome measures selected included operative time, direct hospital costs to the patient, and negative outcomes. RESULTS: We identified a total of 72 patients, 36 (mean age 13.8 years) in group 1 and 36 (mean age 34.1 years) in group 2. Group 1 had no persistent or recurrent varicoceles compared with 4 patients in group 2. Three men in group 2 required emergency room evaluation and no patient did so in group 1. No hydroceles developed in group 2, but three developed in group 1. CONCLUSIONS: LVL resulted in shorter operative times and fewer negative outcomes compared with SMV. This translated into lower direct patient costs for LVL. For those who have mastered laparoscopic techniques, LVL should be considered a safe, cost-effective option in the correction of varicoceles.

Vaginal construction using sigmoid colon in children and young adults.

OBJECTIVE: To evaluate the age at which patients who required vaginal replacement (an uncommon procedure in children) were diagnosed, and the cause of their anomaly, and to relate these variables to the surgical outcome. PATIENTS AND METHODS: Patients who had vaginal replacement at the author's institution between 1990 and 2002 were reviewed retrospectively. Depending on the age at reconstructive surgery, patients were divided into pre- and postpubertal groups. RESULTS: A neovagina was constructed in 23 patients during the study period; sigmoid colon was used in 20 but not in two patients with cloacal exstrophy and in one with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS). These cases were excluded from the analysis of outcomes and complications. Group 1 comprised patients diagnosed and treated before puberty and group 2 those diagnosed and/or treated afterward. In group 1 the presenting diagnoses included androgen insensitivity syndrome (AIS) in six patients, MRKHS in two, cloacal exstrophy in two, vaginal tumour in one, Müllerian duct renal aplasia cervicothoracic somite dysplasia, vertebral abnormalities, anal atresia, cardiac anomalies, tracheo-oesophageal fistula, and/or oesophageal atresia, renal abnormalities and limb defects syndromes in one each. In group 2 the presenting diagnoses included MRKHS in seven, AIS in two, and congenital adrenal hyperplasia in one. Complications included superficial wound infection (two patients), recurrent introital stenosis, and blind loop mucocele, complete stenosis of perineal neovaginal opening (one each) and dyspareunia in three. Neither age nor pelvic habitus (android vs gynaecoid) influenced the outcome, and the cosmetic results were excellent in all the patients. CONCLUSION: Isolated sigmoid neovaginal construction appears to be applicable to many diagnoses and in patients at any age. Although an android pelvis can present technical challenges, in this experience it was not associated with a greater complication rate. The long-term satisfaction with the sigmoid neovagina for intercourse, especially in those constructed before puberty, still requires long-term evaluation.

Torsion of an indirect hernia sac causing acute scrotum.

A 6-year-old boy presented with an acute scrotum and was found at surgical exploration to have torsion and infarction of an indirect hernia sac. This represents the sixth reported case of this entity in the literature. The pediatric surgical specialist and those in the acute care setting should be aware of this consideration in the differential diagnosis of the acute scrotum.

Pediatric urinary tract infections: the role of fluoroquinolones.

Infections of the urinary tract (UTI) occur commonly in the pediatric population. Because of the high association of pediatric UTI with congenital structural anomalies of the urinary tract and with dysfunctional elimination syndromes, it is far more common for children to be categorized as having complicated UTI than their adult counterparts. And for children more intensive therapy is often required. Early and effective treatment of UTIs in the pediatric patient is considered essential to prevent long term morbidity and potential mortality from end stage renal disease. An oral antimicrobial is more convenient than parenteral therapy and is preferable as long as clinical efficacy and safety can be assured. Oral fluoroquinolones are an attractive alternative for the treatment of complicated UTI in children, and safety must always be a factor in considering their use in this population. Although the role of fluoroquinolones in pediatric UTI is still under investigation, the limited data available demonstrate a likelihood of efficacy and safety.

Successful hypospadias repair with ventral based vascular dartos pedicle for urethral coverage.

PURPOSE: We describe an easy technique to reliably harvest a vascularized dartos pedicle for urethral coverage at the time of urethroplasty in hypospadias surgery. The complication of urethrocutaneous fistula in hypospadias surgery as a result of using this technique is also evaluated. MATERIALS AND METHODS: A retrospective review (July 1999 to September 2002) identified 180 pediatric patients who had undergone primary hypospadias surgery by a single surgeon. A modified technique of harvesting a vascularized dartos pedicle was incorporated in 111 hypospadias repairs. A ventral based vascularized dartos pedicle of tissue was used to cover a modified urethroplasty as described by Snodgrass. RESULTS: The intraoperative meatal position before urethroplasty was subcoronal in 95 cases, penile/midshaft in 11 and penoscrotal in 5. The majority of patients (90 of 111) were younger than 12 months at surgery. Ages ranged from 5 months to 16 years (mean 21.1 months). Of the 111 patients reconstruction using the ventral based vascularized dartos pedicle to cover the urethroplasty was successful in 109 (98.2%), and at followup they have an acceptable cosmetic result with no evidence of urethrocutaneous fistula. In 1 patient with distal hypospadias a urethrocutaneous fistula developed, which was recognized 20 months postoperatively. Another patient with penoscrotal hypospadias had a proximal fistula at 6 months. There were no recognized intraoperative urethral injuries or complications. Followup ranged from 3 to 38 months (mean 19.1). CONCLUSIONS: The ventral based vascularized dartos pedicle urethral coverage procedure is an easy and reliable technique to harvest adequate vascularized tissue to cover a hypospadias urethroplasty. In this small single surgeon series, this technique appears to have contributed to a low rate of urethrocutaneous fistulas after hypospadias repair.

Males with Down's syndrome and nonneurogenic neurogenic bladder.

PURPOSE: We assessed the relationship of trisomy 21 with the most severe dysfunctional elimination syndrome, nonneurogenic neurogenic bladder or the Hinman-Allen syndrome. MATERIALS AND METHODS: We retrospectively reviewed our experience with children with Down's syndrome (trisomy 21) in a 10-year period and identified a subset who presented for the evaluation and treatment of urinary tract infections associated with severe disorders of urinary and fecal elimination. RESULTS: Four males 9 months, 14 years, 18 years and 21 years old met the criteria for review. All patients underwent radiological and urodynamic evaluation, and were diagnosed with hydronephrosis and prostatic urethral dilatation with pelvic floor spasticity. Renal function studies showed a creatinine of 0.7 mg./dl. in the 9-month-old, 1.2 mg./dl. in the 14-year-old, 1.9 mg./dl. in the 18-year-old and 2.2 mg./dl. in the 21-year-old patient. Three patients underwent surgical treatment to protect the upper urinary tract, including bladder augmentation cystoplasty and an appendiceal Mitrofanoff stoma in 2, and vesicostomy in 1. The remaining patient was treated conservatively with a behavioral modification program that included timed voiding and a bowel regimen. CONCLUSIONS: Boys with trisomy 21 may be at risk for the Hinman-Allen syndrome. Surgical intervention and clean intermittent catheterization for renal preservation and continence can be performed in this population despite intellectual impairment. Further evaluation is necessary to determine whether this relationship is more common than appreciated and whether this syndrome occurs in females with trisomy 21.

Snodgrass hypospadias repair with vascularized dartos flap: the perfect repair for virgin cases of hypospadias?

PURPOSE: Since its introduction, the Snodgrass hypospadias repair has been applied to virtually all forms of hypospadias repair. However, fistula rates have still been reported to be as high as 5% from large center, multiple surgeon studies and 16% from smaller center studies. We report on the use of the Snodgrass repair in conjunction with routine use of a vascularized dartos flap and 2-layer closure of the neourethra from multiple institutions. MATERIALS AND METHODS: Records of patients who underwent a primary 1-stage hypospadias repair with the Snodgrass technique in conjunction with vascularized dartos flap coverage were reviewed. Nearly identical surgical technique was used by all 6 surgeons in each case, which included a 2-layer closure of the neourethra, preservation of the well vascularized periurethral tissue and routine use of vascularized dartos flap coverage. A total of 514 cases were identified, including 414 with distal and 100 with midshaft or proximal hypospadias. Stents were used in 292 of the 514 repairs. RESULTS: Of the 414 distal cases there were no fistulas and 1 case of meatal stenosis. Of the 100 proximal cases there were 3 fistulas and 1 case of meatal stenosis. The overall complication rate was less than 1% for all cases combined. CONCLUSIONS: This series represents the largest reported multi-institutional experience with the Snodgrass technique. When used in conjunction with vascularized dartos flap coverage, 2-layer closure of the neourethra and special attention to preservation of the periurethral vascular supply, this repair can be performed with a near 0 complication rate. We believe that this is the optimal repair for routine cases of hypospadias.

Use of small intestinal submucosa for corporal body grafting in cases of severe penile curvature.

PURPOSE: Small intestinal submucosa is a unique biomaterial that has been found to promote tissue specific regeneration in the urinary tract. We present our experimental and clinical experience with small intestinal submucosa (SurgiSis, Cook Biotech, Spencer, Indiana) for pediatric corporal body reconstruction. MATERIAL AND METHODS: A total of 20 Fischer rats underwent implantation of a 7 x 3 mm. small intestinal submucosa graft following excision of an ellipse of tunica albuginea and 14 control animals underwent tunical excision with reimplantation of this autologous segment. The animals were euthanized, and the penis was sectioned and histologically studied at intervals of 1, 2, 4, 6, 16 and 24 weeks. In 15 pediatric patients small intestinal submucosa was used for corporal body grafting. The grafting procedure was performed along the ventral (hypospadias cases) or dorsal (epispadias cases) surface of the corporal bodies. The tunica albuginea was incised full thickness at the point of maximal curvature down to the cavernosal tissue and the defect was filled with a single layer of small intestinal submucosa. RESULTS: Measurements of the animal small intestinal submucosa grafts did not reveal significant graft contraction through 6 months. There was no graft expansion or ballooning after pharmacological induction of an artificial erection. Histologically, marked inflammation at 1 week precipitously decreased to a normal appearing tunica albuginea at 3 and 6 months. In all clinical cases small intestinal submucosa was found to be technically easy to handle. Mean followup is 14 months (range 5 to 26). All patients have a straight phallus as documented by observation of spontaneous erections or artificial erection at the time of stage 2 hypospadias repair. No complications occurred. CONCLUSIONS: Small intestinal submucosa demonstrates tissue specific regeneration properties in the rat and human tunica albuginea. It is an off-the-shelf material that is safe, technically easy to use and readily available.