Can endoscopic balloon dilation for primary obstructive megaureter be effective in a long-term follow-up?

BACKGROUND: Ureteral tapering and reimplantation is an established treatment for persistent or progressive primary obstructive megaureter (POM) but may result in complications and morbidity. Use of a less invasive technique involving endoscopic balloon dilation appears very interesting. OBJECTIVE: The objective of this report is to determine if endoscopic balloon dilation for POM is effective in the long term as well as to assess complications of the procedure. MATERIAL AND METHODS: A retrospective review was done on 19 patients and 20 ureters treated with the endoscopic balloon dilation by POM from June 2000 to February 2010. Surgery was performed solely in those cases in which there was persistence of obstruction in the renogram along with one or all of the following conditions: impairment of the differential renal function <40%, worsening of the renal pelvic dilation, febrile UTI in spite of antibiotic prophylaxis or renal calculi. The patients comprised 16 boys and 3 girls with a mean age at surgery of 17 months (range 1-44 months). Ten cases were left sided, eight right sided, and one bilateral. Under endoscopic and fluoroscopic guidance, a 3-5 Fr dilating balloon was inflated to 12-14 atm, or until disappearance of the stenotic obstructive area. A double J stent was positioned and withdrawn 2 months later. Follow-up recorded the presence of symptoms, number of reintervention procedures registered, and included renal ultrasound and MAG-3 renogram. RESULTS: There were no perioperative complications. Eighteen ureters showed a non-obstructive pattern on MAG-3 renogram after the first endoscopic dilation, representing a 90% success rate. One case required a second dilation, which proved successful and two cases of recurrent lithiasis required ureterotomy without instances of obstruction. 2 patients had a febrile UTI and a vesicoureteral reflux was diagnosed in one. Renal function was preserved in 95% of patients. The mean follow-up was 6.9 years (range 3.9-13.3 years). One patient was lost after the procedure. DISCUSSION: In an era of minimally invasive techniques, the search for less invasive procedures for treatment of POM has resulted in a variety of surgical options. Angulo et al., in 1998 and our group described the first POM treatment with endoscopic balloon dilation, which is believed to be a definitive, less invasive, and safe treatment. Furthermore, should an endoscopic approach fail, reimplant surgery can be performed. Few publications have reported short series with good results in the short and medium term. Torino et al. presented five cases in children aged less than 1 year, none of these showed evidence of obstruction. García-Aparicio et al. presented a series of 13 patients treated with a success rate of 84.6%. Christman et al. added laser incision in cases of narrowed ureteral segment 2-3 cm long and used double stenting. Good outcomes were presented in 71%. Romero et al. reported improvement of drainage within the first 18 months after treatment in 69% of patients. The potential de novo onset of vesicoureteral reflux may be the source of some controversy. We consider that dilation does not significantly alter the antireflux mechanism. In VCUG is not systematically performed because it is an invasive test. This restricts the conclusions that can be drawn from our findings. Nevertheless, some groups continue to systematically perform VCUG. CONCLUSIONS: Endoscopic balloon dilation for POM is a safe, feasible, and less invasive procedure that shows good outcomes on long-term follow-up. However, multicenter studies and prospective trials should be encouraged to provide more definitive evidence on its benefits.

Tumores testiculares en la infancia / Testicular Tumours in Infancy and children

Introducción: los tumores testiculares prepuberales son distintos a los que se presentan en la edad adulta. Tradicionalmente han sido considerados malignos, pero realmente los tumores testiculares benignos son más frecuentes en esta edad. Material y métodos: revisamos nuestra experiencia en el tratamiento de los tumores testiculares en niños ≤ 13 años con intención de evaluar el empleo de orquiectomía parcial. Desde 1984 hasta 2008 hemos diagnosticado y tratado en nuestro centro 15 tumores testiculares en edad pediátrica. Se revisa la actitud terapéutica empleada con énfasis en la posibilidad de preservación testicular en pacientes seleccionados y se evalúan los resultados. Resultados: la forma de presentación clínica en el 80% de los casos fue aumento del tamaño testicular con masa palpable. Se realizaron 4 orquiectomías radicales (27%) y 11 tumorectomías (73%). Todas las lesiones benignas en la anatomía patológica definitiva fueron tratadas con tumorectomía: cuatro quistes epidermoides, un hemangioma, un lipoma, un hamartoma fibroso, un tumor de la granulosa juvenil y una fusión espleno-gonadal. También fueron tratados con éxito de forma conservadora dos casos de teratoma. Los casos tratados de manera radical fueron un caso de tumor de saco vitelino (estadio I), dos tumores germinales mixtos y un gonadoblastoma. Conclusiones: los tumores testiculares en la edad prepuberal benignos predominan sobre los malignos. Ante una masa testicular palpable con marcadores tumorales negativos se puede plantear un tratamiento conservador mediante tumorectomía. No obstante, la lesión debe ser completamente extirpada para evitar recurrencias (AU)

Introduction: prepubertal testicular tumours are different from those that appear during adulthood. Traditionally, they were considered to be malignant, however benign testicular tumours are actually more frequent at this age. Materials and methods: we analysed our experience in the treatment of testicular tumours in children ≤ 13, with the intention of evaluating the use of partial orchiectomy. From 1984 to 2008, we diagnosed and treated 15 testicular tumours in children at our centre. We examined the therapeutic approach employed, underlining the possibility of testicular conservation in selected patients and we have analysed the results. Results: the clinical presentation in 80% of the cases was an increase in testicle size with palpable mass. We performed 4 radical orchiectomies (27%) and 11 tumourectomies (73%). All the benign lesions in the final pathological anatomy were treated with tumourectomy: four epidermoid cysts, one hemangioma, one lipoma, one fibrous hamartoma, one juvenile granulosa tumour and one splenogonadal fusion. We also successfully and conservatively treated two cases of teratoma. The cases that received radical treatment were a yolk sac tumour (Stage I), two mixed germ cell tumours and one gonadoblastoma. Conclusions: there are more cases of benign testicular tumours than malignant tumours during puberty. In the event of a palpable testicular mass with negative tumour markers, conservative treatment by means of a tumourectomy may be considered. However, the lesion must be removed completely to prevent recurrence (AU)

[Testicular tumours in infancy and children]. / Tumores testiculares en la infancia.

INTRODUCTION: prepubertal testicular tumours are different from those that appear during adulthood. Traditionally, they were considered to be malignant, however benign testicular tumours are actually more frequent at this age. MATERIALS AND METHODS: we analysed our experience in the treatment of testicular tumours in children ≤ 13, with the intention of evaluating the use of partial orchiectomy. From 1984 to 2008, we diagnosed and treated 15 testicular tumours in children at our centre. We examined the therapeutic approach employed, underlining the possibility of testicular conservation in selected patients and we have analysed the results. RESULTS: the clinical presentation in 80% of the cases was an increase in testicle size with palpable mass. We performed 4 radical orchiectomies (27%) and 11 tumourectomies (73%). All the benign lesions in the final pathological anatomy were treated with tumourectomy: four epidermoid cysts, one hemangioma, one lipoma, one fibrous hamartoma, one juvenile granulosa tumour and one splenogonadal fusion. We also successfully and conservatively treated two cases of teratoma. The cases that received radical treatment were a yolk sac tumour (Stage I), two mixed germ cell tumours and one gonadoblastoma. CONCLUSIONS: there are more cases of benign testicular tumours than malignant tumours during puberty. In the event of a palpable testicular mass with negative tumour markers, conservative treatment by means of a tumourectomy may be considered. However, the lesion must be removed completely to prevent recurrence.

Further insights into the role of T222P variant of RXFP2 in non-syndromic cryptorchidism in two Mediterranean populations.

The aetiopathogenesis of isolated cryptorchidism remains largely unknown. Mutation screenings in the most relevant candidate genes for testicular maldescent lead to controversial data in the literature. In particular, the role of the T222P genetic variant of the RXFP2 gene is still debated. Given the controversies, the aim of this study was to provide further data on this genetic variant in two Mediterranean populations. A total of 577 subjects from Spain and 550 from Italy (with and without a history of cryptorchidism) were analysed. The T222P substitution was found in both unilateral and bilateral cases and in a total of 12 controls. These data exclude a clear-cut cause-effect relationship between T222P variant and testicular maldescent. The T222P variant was found at a similar frequency in both cases and controls in the Spanish population, whereas in Italy, the frequency of T222P resulted significantly higher in the cryptorchid group (p = 0.031). The observed difference between the two countries and the highly variable phenotypic expression of the T222P variant may depend on the genetic background or on environmental conditions. The haplotype analysis of the RXFP2 gene in T222P carriers and their parents showed that this variant is linked to the previously inferred C-C-G-A-13 haplotype and consequently provides further support to the 'founder effect' hypothesis. In conclusion, our data indicate that T222P is a frequent variant in the Spanish population with no pathogenic effect. Although in Italy it seems to confer a mild risk (odds ratio = 3.17, 95% confidence interval: 1.07-9.34) to cryptorchidism, the screening for this variant for diagnostic purposes is not advised because of the relatively high frequency of control carriers (1.4% of Italian men without a history of cryptorchidism).

Ectasia piélica en diagnóstico prenata / Pyelic ectasia in prenatal diagnosis

La ecografía gestacional demuestra que el 1,4% de los fetos presentan algún grado de hidronefrosis, aunque en el 50%, dicha ectasia habrá desaparecido en el nacimiento. El desconocimiento que aún existe con respecto a las diferentes etapas del desarrollo fetal hace que sea difícil distinguir entre aquellas situaciones fisiológicas y las que son patológicas. La medición de los diámetros de la pelvis renal a lo largo de la gestación y la cantidad de líquido amniótico son datos importantes para establecer un pronóstico. Las válvulas de uretra posterior son las responsables de un buen número de casos de hidronefrosis gestacional significativa. Es importante diagnosticarlas y proceder a su tratamiento para evitar daño renal. Se presenta un caso clínico y se realiza una revisión sobre el tema proponiendo un algoritmo de actuación clínica (AU)

Gestational ultrasound shows that 1.4% of the fetuses have some degree of hydronephrosis, although in 50% renal ectasia will have disappeared at birth. The ignorance that still exists in the different stages of fetal development makes it difficult to distinguish between those situations that are physiological or pathological condition. Measuring the diameter of the renal pelvis throughout pregnancy and amniotic fluid are important data for establishing a prognosis. Posterior urethral valves are responsible for a number of significant cases of gestational hydronephrosis. It is important to diagnose it and provide treatment to prevent kidney damage. We present a case report and a review is made on the issue and we propos an algorithm for clinical intervention (AU)

Persistencia del seno urogenital: técnica quirúrgica mediante genitoplastia / Persistance of the urogenital sinus: surgical technique using genitoplasty

Las anomalías del seno urogenital (genitales ambiguos) consisten en la comunicación persistente de la vagina con el aparato urinario. Esta persistencia se observa en los recién nacidos con estados intersexuales, a los que actualmente se denomina desordenes de la diferenciación sexual (DDS). El tratamiento es quirúrgico. Presentamos un caso clínico de una niña de 4 años que presentaba un seno urogenital bajo, que fue tratada mediante genitoplastia (AU)

Eurogential sinus abnormalities (ambiguous genitalia) consist in the communication of the vagine with the urinary tract. This sinus persistence is observed in new borns with intersex states, which is now called disorders of sexual differentiation (DSD). The treatment is surgical. We present a case of a 4 year old girl who bad a low urogenital sinus, which was treated by genitoplasty (AU)

Persistencia del conducto peritoneo vaginal: revisión conceptual a propósito de un caso clínico / Persistence of the conduit vaginal peritoneum: conceptual review about a clinical case

La persistencia del conducto peritoneo-vaginal escrotal se debe a una falta de cierre del trayecto que, durante las etapas de desarrollo fetal, separan la cavidad peritoneal del escroto. Factores como la prematuridad o el bajo peso al nacer predisponen a esta alteración. Se presenta de diversas maneras: persistencia completa, parcial en forma de quiste de cordón e hidrocele con conducto cerrado. Es posible la asociación a hernia inguinal. Se puede producir su cierre espontánea en los 2 primeros años de vida. El tratamiento es quirúrgico, generalmente vía inguinal. Presentamos un caso clínico y una revisión sobre los aspectos básicos de esta entidad (AU)

The persistence e of the scrotum peritoneal-vaginal duct due to a lack of closure of the journey, during fetal development stages, separating the peritoneal cavity of the scrotum. Factors such as prematurity or low birth weight predispose to this disorder. It comes in different ways: full persistence, partly in the form of hydrocele and cord cyst with duct closed. Possible association with inguinal hernia is possible. Closure can occur spontaneously in the first 2 years of life. Treatment is surgical, usually transinguinal We present a case report and a review on the basic aspects of this entity (AU)

Disfunciones no neuropáticas del aparato urinario inferior en la infancia. A propósito de un caso / Non neuropathic dysfunctions of the low urinary system in childhood: one clinical case

Las disfunciones del aparato urinario inferior en la infancia (DNNTI.I) es un campo con gran confusión semántica. No existe una terminología común entre los diferentes grupos, usando distintas definiciones para describir lo mismo. Esta confusión refleja la investigación moderna, que en las últimas décadas nos ha hecho cambiar radicalmente nuestra visión sobre el tema, considerando que los niños son individuos en crecimiento, distintos a los adultos. La ICCS (International Children´s Continence Society), ha publicad las guías para intentar esclarecer esta confusión. Presentamos un caso clínico de hiperactividad del detrusor, y seguidamente un intento de clasificación de las DNNTI-I sin causa orgánica o neurológica (AU)

Lower urinary tract function and malfunction in children is a field rife with semantic confusion. Different groups use different definitions of commonly used terms. This confusion partly reflects modern research, which has radically changed our views of these conditions during the last decades, and partly the fact that children are growing individuals who differ from adults. The ICCS (International Children´s Continence Society), has published guidelines trying to clear-up this confusion. We present a clinical case of detrusor hyperactivity, and afterward an attempt to classify different lower urinary tract dysfunctions without organic or neurogenic cause (AU)

Bone response to different strength orthodontic forces in animals with periodontitis.

BACKGROUND: Occlusal alterations resulting from tooth movements caused by periodontitis-related bone loss are often corrected with orthodontic treatments. Although the outcome is usually satisfactory, a quantitative histomorphometric study of bone response would contribute to improving treatment planning and optimizing results. METHODS AND RESULTS: This study is a histomorphometric analysis of alveolar bone response to 51 and 75-g orthodontic forces applied to rat molars subjected to experimental periodontitis by placing a ligature around the neck of the molar during 48 h. The orthodontic device consisted of two bands with a tube welded to their palatine aspect, through which the arms of a helicoidal spring were threaded so as to exert force toward palatine. The device was placed immediately and 48 h after removing the ligatures. When applied 48 h post-removal of the ligature, both orthodontic forces caused an increase in bone volume in the periodontitis group. CONCLUSIONS: Our study shows that application of orthodontic forces once periodontal infection has been controlled contributes to increasing alveolar bone volume, consequently improving bone quality.

[Use of ureterocalicostomy in child]. / Uso de la ureterocalicostomía en la edad pediátrica.

INTRODUCTION: There are many clinical situations in wich it may be difficult to perform appropriately an anastomosis between the renal pelvis and the proximal portion of the uretersafely. Preservation of the organ depens upon the availability of surgical resources. In fact, that principle becomes particularipy significant when dealing with children. OBJECTIVES: To describe different clinical and surgical situations in wich the successful performance of ureterocalicostomy has enable us to maintain three renal units with function from child patients and without complications. METHOD AND PATIENTS: Three children aged 8, 4 and 1 year were submitted to surgery because of pyelocaliceal lithiasis in the first case and secundary ureteropelvic stenosis in the remaning two cases. RESULTS: With a median follow-up of 12 months, all three renal units were preserved and, according to the isotopic study, functionality was improved in the two cases of ureteropelvic obstruction and the normal preoperative function was preserved in the first case. No complications occurred either during the immediate postoperative period or up to the date of this review. CONCLUSION: Ureterocalicostomy should be considered a suitable alternative in different clinical situations in wich the ureteropelvic continuity could be compromised, or in cases of indundibulopelvic stenosis.

Prevention of vesicoureteral reflux at the time of complete primary repair of the exstrophy-epispadias complex.

INTRODUCTION: With Mitchell's technique it is possible to perform bladder closure, reconstruction of epispadias and the bladder neck in one single procedure in an exstrophy patient. However the most common postoperative complication is pyelonephritis secondary to vesicouretral reflux. Reflux is closely linked to bladder exstrophy due to an abnormal anatomic development of the distal ureteral segment and to a pathologic bladder disposition. This problem is normally solved in subsequent surgical procedures. TECHNICAL CONSIDERATIONS: We decided to apply the technique described by Gil-Vernet as a first step of a bladder exstrophy repair following the Mitchell's technique. This ureteral advancement by means of trigonoplasty is a simple surgical procedure for vesicouretral reflux that preserves the intrinsic and extrinsic periureteral musculature. It is quite a short procedure that has yielded rates of success over 90%. CONCLUSIONS: The realization of this antireflux technique together with the primary closure could avoid later surgical correction in patients whose have had multiple operations.

[Surgical treatment of the extrophy-epispadias complex. Review and current concepts]. / Tratamiento quirúrgico del complejo extrofia-epispadias. Revisión y conceptos actuales.

Since earlier descriptions the surgical management of the bladder exstrophy and epispadias complex (BEEC) has experimented gradual changes in the search for good aesthetic and functional results. The initial urinary diversion and bladder plate removal has evolved under various authors either by improving or supplementing the above described advances, until reaching the staged functional closure and more recently the complete primary BEEC closure. These later techniques allow to obtain encouraging continence indexes and successful aesthetic results; the low incidence and complexity of this condition however, advises both in terms of early management and later complications that this should be managed in reference centres. Sharing on this spirit of technique combination in search for a satisfactory result for exstrophic newborns and inspired by Leadbetter's contribution to Young-Dees's procedure for vesicoureteral reflux (VUR) correction, we have added a new step to the complete primary BEEC closure known as the Mitchell's technique by performing Gil-Vernet's trigonoplasty to prevent VUR, closely associated to bladder exstrophy. We believe VUR can be prevented right from the first surgical approach in the exstrophic newborn.

Tratamiento endoscópico del reflujo vesicoureteral / clinical case: endoscopic treatment of the vesicoureteral reflux

Este artículo presenta un caso clínico de reflujo vesicoureteral diagnosticado en una niña de 4 años (AU)

Uréter ectópico en duplicidad de vías / Ectopic ureter in double in a case of ureteric duplication

Se evalúan los criterios y métodos diagnósticos y terapéuticos de la duplicidad ureteral (AU)

Embriología urogenital: bases genéticas y ecografía prenatal / Urogenital embriology, genetic basis and prenatal ecography

Introducción:El 20 por ciento aproximadamente, de las anomalías fetales detectadas por ecografia prenatal afectan al sistema genitourinario. Hasta en un 1 por ciento de los embarazos puede sospecharse una malformación urogenital.Embriogénesís del aparato urogenital:El conducto de Wolff participa de la formación del tramo urinario superior, la vía seminal y el conducto de Müller, actuando como organizador de todos ellos. La vejiga se origina del endodermo en íntima relación con el ano, recto y el tramo genital inferior. Exceptuando el trígono, que se origina en el conducto mesonéfrico, la porción uretral del seno urogenital da origen a la uretra supramontanal en el hombre y a la totalidad de la uretra en la mujer. El sexo gonadal y el desarrollo de los genitales internos dependen de la presencia o ausencia del cromosoma "Y". Su presencia produce la transformación testicular de la gónada primitiva; su ausencia, la diferenciación pasiva de la gónada primitiva en ovario.La testosterona de las células de Leydig estimula localmente la diferenciación del conducto de Wolff en deferente, vesículas seminales, epididimo y eyaculadores. La falta de cromosoma "Y" desarrolla los genitales internos femeninos, aún en ausencia de los ovarios. Los genitales externos en el varón dependen de la presencia sistémica de dihidrotestosterona (DHT). La ausencia de DHT en la mujer determina la formación del clítoris y labios menores.Bases genéticas y moleculares de la embriogénesis:Existen una serie de mediadores moleculares y factores relacionados con la división de la yema ureteral y la nefrogénesis que abarca una compleja interacción entre factores de transcripción, factores de crecimiento locales y composición de la matriz extracelular. El principal mecanismo molecular depende del "Glial ceil line-derived neutrophic factor" (GDNF) que es secretado por el metanefros y estimula el receptor CRET del conducto mesonéfrico. El sistema Renina- Angiotensina (RAS) es importante en el crecimiento y diferenciación renal así como también en la regulación de la tensión arterria. La determinación y la diferenciación sexual son procesos secuenciales que se inician con la fertilización, al establecer el sexo cromosómico y continúan con el desarrollo del sexo gonadal y fenotípico. Aunque están involucrados más de 19 genes, el más importante es el gen SRY (Sex Region Y) que se halla en el brazo corto del cromosoma "Y".Embriogénesis y ecograjia prenatal:En condiciones normales el riñon fetal puede visualizarse a la semana 14, crece durante toda la gestación y especialmente entre la semana 13 y la 24. La nefrogénesis se completa en la semana 36. Los cálices y uréteres no son visibles por ecografía. La vejiga se puede ver a partir de la semana 13 (transvaginal) y 14 (transabdominal). La ecografia tiene una sensibilidad diagnóstica del 78 por ciento para detectar malformaciones urogenitales. En todos los estudios prenatales se debe evaluar: líquido amniótico, localización y características de los riñones, vejiga, sexo fetal y buscar anomalías congénitas asociadas. (AU)

Conservative treatment of phimosis in children using a topical steroid.

OBJECTIVES: From 1997 through 1998, we conducted a prospective study to evaluate the long-term outcome of using topical steroids in the treatment of childhood phimosis. METHODS: Both the parents and their children were instructed to apply 0.05% betamethasone cream topically twice a day for 1 month and to retract the prepuce after the fifth day of treatment. Results were evaluated at the end of the treatment and 6 months later. RESULTS: One hundred thirty-seven boys were evaluated. The median age was 5.4 years. At initial presentation, 61 boys had a phimotic but retractable prepuce, 37 had a nonretractable phimotic ring, and 39 had a pinpoint opening. Patients with a history of previous forcible foreskin retractions were considered to have secondary phimosis. By 6 months following treatment, 90% (124 children) had an easily retractable prepuce without a phimotic ring. No differences were seen in the response rate between those with primary and secondary phimosis. In all cases, the treatment was well tolerated without local or systemic side effects. All the patients with persistent or recurrent phimosis were found to be noncompliant with the suggested daily foreskin care. CONCLUSIONS: Topical steroid for the treatment of phimosis is a safe, simple, and inexpensive procedure that avoids surgery and its associated risks. It is effective both in primary and in secondary phimosis. We emphasize the importance of proper and regular foreskin care and hypothesize on the mechanism of action of the steroids.

[Treatment of staghorn calculi by extracorporeal shock-wave lithotripsy in children]. / Traitement des calculs coralliformes par lithotritie extra-corporelle par ondes de choc chez l'enfant.

UNLABELLED: To evaluate the efficacy of monotherapy with extracorporeal shock-wave lithotripsy (ESWL) for staghorn calculi in children. MATERIAL AND METHODS: Between September 1987 and December 1998, 27 children (18 boys and 9 girls) with a mean age of 5.2 years (9 months to 147 years) were managed in our department for staghorn or pseudo-staghorn calculi. They were treated with a Lithostar Siemens-Ultra lithotriptor ith ultrasound detection. The "Puigvert method", which starts with low energy which is then gradually increased, allows satisfactory painless fragmentation, avoiding the need for general anaesthesia. RESULTS: the success rate was 70% with two sessions (37% with a single session). In one case, lithotripsy was not indicated and percutaneous nephrolithotomy was necessary. Two cystine stones ina girl (probably longstanding stones) could not be fragmented and open surgery was required. The other five systine staghorn calculi ere treated successfully. Ureteral catheterization was not required and only one double J stent was placed preventively in a girl with a solitary kidney. No major complication was detected. CONCLUSION: ESWL with the Siemens-Ultra lithotriptor is a safe and effective first-line method for the treatment of staghron calculi in children.

Staghorn calculi in children: treatment with monotherapy extracorporeal shock wave lithotripsy.

PURPOSE: We evaluated the effectiveness of monotherapy extracorporeal shock wave lithotripsy (ESWLT) for treating children with staghorn calculi. MATERIALS AND METHODS: From February 1992 to December 1997, 11 boys and 4 girls 14 months to 13 years old (median age 4 years) presented to our institution with staghorn calculi. In these patients ESWL was performed using a Siemens Lithostar-ULTRA with ultrasound stone localization and with intravenous sedation or without anesthesia. Using the Puigvert method the frequency and energy of the shock waves delivered were increased progressively to desensitize cutaneous nerve receptors, making the procedure less painful and improving stone fragmentation. RESULTS: Overall stones resolved in 11 of the 15 patients (73.3%) after an average of 2 ESWL sessions. Of the 11 patients 7 were stone-free after only 1 session, 2 with fragments less than 5 mm. required no further intervention, and 2 required additional surgery, including percutaneous nephrolithotomy to remove large residual stone fragments in 1 and open renal surgery to remove a cystine staghorn calculus in 1. Ureteral stents were not required in any patients. One case of post-ESWL fever resolved promptly with antibiotics. CONCLUSIONS: ESWL using the Siemens Lithostar-ULTRA is simple, effective and safe primary treatment in children with staghorn calculi.