Permanent cutaneous vesicostomy: a pragmatic approach to safely manage lower urinary tract dysfunction in pediatric patients with chronic and life-limiting conditions and neuropathic bladders.

Introduction: Lower urinary tract dysfunction (LUTD) in cerebral palsy (CP) and other neuromuscular diseases can present with chronic retention that leads to hydronephrosis, recurrent urinary tract infections (UTI), and stone formation. Whenever the conservative treatment of LUTD fails for any reason, it is considered to be complicated LUTD, in which a surgical approach is warranted. Cutaneous vesicostomy (CV) is a simple, well-tolerated, and potentially reversible procedure that protects the upper tracts. We describe our experience using CV for this complex population. Materials and methods: Children with CP and other neuromuscular diseases admitted to pediatric long-term care units for palliative care between 2015 and 2019 were included in the study. They present multi-system involvement, polypharmacy, and Gross Motor Function Classification System levels of 4 or 5. We retrospectively studied this population's indications and results of CV. Results: Of the 52 admitted patients, 18 presented LUTD with UTI (n:18; 100%), stones (n:5; 28%), progressive hydroureteronephrosis (n:3; 17%), or stones (n:2; 11%). Conservative initial management (catheterizations, prophylaxis antibiotics) was effective in half the cases. The remaining nine were defined as complicated LUTD and underwent CV. After a mean follow-up of 11.3 months, the follow-up showed improved hydronephrosis in all nine (100%) patients. Recurrent UTIs were no longer seen in eight of nine patients, although three patients required bladder irrigations; bladder stones did not recur after CV; the kidney stones needed further intervention. Revision of the CV was required in two (11%) cases at 12 and 24 months postoperatively due to stoma stenosis. Conclusion: CV is a relatively simple and effective procedure representing a pragmatic solution for managing complicated LUTD in complex long-term institutionalized pediatric palliative care patients with neuropathic bladders.

Redo surgery to improve urinary function, sexual function and cosmesis in male patients with exstrophy-epispadias complex complications. Technical principles and pearls based on case scenarios.

The bladder exstrophy-epispadias complex includes some of the most challenging conditions treated by pediatric urologists. They are associated with the need for multiple intricate reconstructive procedures, aimed at restoring the anatomy and function of the bladder, urethra and external genitalia. These patients often endure multiple redo reconstructive procedures to improve urinary function, sexual function and cosmesis throughout the first two decades of life. In this article, we present the 30-year experience of a single surgeon performing redo surgery for males born with epispadias and bladder exstrophy. Through detailed documentation of 6 clinical cases, we highlight technical aspects that may contribute to a successful surgical reconstruction in these patients. The article is focused specifically on patients undergoing redo epispadias repair with or without concomitant continence procedures. We make the case for complete penile disassembly with external rotation of the corpora to correct recurrent dorsal curvature; this approach also allows the surgeon to have access to the proximal urethra and bladder neck after opening the intersymphiseal scar/band. This is useful when additional procedures on the bladder, such as bladder neck tailoring, are necessary. We also highlight the importance of avoiding reverse Byars' flaps when performing skin closure, due to the resulting midline scar. Besides being associated with a poor cosmetic outcome, it can also contribute to recurrent dorsal curvature. The authors advocate for rotational skin flaps to cover the penile shaft. Correction of dorsal curvature and improved cosmesis obtained with complete penile disassembly sometimes comes at the expense of the urethra being left as a hypospadias (figure). This will require further surgeries (usually a 2-stage buccal mucosa graft), much like the treatment of proximal hypospadias. Redo epispadias surgery in males remains a challenge. The systematic approach offered by the case scenarios may help guide surgeons dealing with this difficult condition. Patient with complications after repair of classic bladder exstrophy. A) Stone retrieved from posterior urethra after complete penile disassembly. B) After opening the inter-symphiseal scar, the bladder has been opened and the bladder neck tailored. C) Complete penile disassembly has been completed with corporal bodies and urethra individualized. D,E,F) Final appearance of the repair; abdominal wall was closed with anterior rectus sheath flaps, penile skin was closed with rotational flaps and urethra ended up as a hypospadias.

Kidney function outcomes in patients after complete primary repair of bladder exstrophy and penopubic epispadias: Results from the international bladder exstrophy consortium.

INTRODUCTION: Historically, repair of bladder exstrophy (BE) is associated with compromise to the upper tracts; the single stage repair of BE was considered to exacerbate risks of kidney impairment. OBJECTIVE: We aim to evaluate the risk of upper urinary tract deterioration or chronic kidney disease after the complete primary repair of exstrophy (CPRE). STUDY DESIGN: As part of the U.S.-India Multi-institutional Bladder Exstrophy Collaboration, we prospectively performed data collection on all patients managed at the Civil Hospital, Ahmedabad from 2010 to 2020. All patients who underwent primary or redo BE or primary penopubic epispadias (PE) repair using CPRE were included. Data on annual VCUG and DMSA, serum creatinine and cystatin-C, urinary albumin, and creatinine were aggregated. RESULTS: 72/104 patients who underwent CPRE at a median age of 1.7 years (IQR: 1.1-4.6) were included: 43(60%) patients with primary BE, 17(24%) with redo BE, and 12(17%) with primary PE. At a median follow-up of 4 years (IQR: 3-6), the overall median eGFR was 105 for BE, and 128 ml/min for PE. 14(19%) patients had eGFR<90, and 22(31%) had microalbuminuria. 21(30%) patients had kidney scarring in DMSA and 31(44%) had VUR. Multivariate analysis showed that neither kidney scarring nor VUR could predict the presence of eGFR<90 or microalbuminuria. Of 72 patients, 2 (3%) patients had dry intervals >3 h, 9 (13%) patients have dry intervals of 1-3 h and 44 (61%) patients had dry intervals <1 h during follow-up. We found that kidney function outcomes (i.e., eGFR and microalbuminuria) were not associated with continence status (p = 0.3). DISCUSSION: In this series, we report a 5% incidence of CKD stage 2 or above that was not impacted by continence status. Furthermore, a 40% incidence of VUR and a 30% incidence of kidney scarring during follow-up was observed within this cohort, neither of which had a significant impact on renal function deterioration (i.e, decline in eGFR), but underscores the need for close kidney surveillance in children that have undergone bladder exstrophy repair. CONCLUSIONS: Modern CPRE technique for the repair of BE may increase the risk of kidney scarring in the intermediate-term follow-up, however, this finding does not correlate with low eGFR and presence of albuminuria inpatients. Therefore, close follow-up with serial kidney function measurements is warranted and necessary after CPRE.

Caregiver distress: A mixed methods evaluation of the mental health burden of caring for children with bladder exstrophy.

Introduction: Caring for children with bladder exstrophy-epispadias complex (BEEC) exacts a long-term emotional toll on caregivers. Previous studies leave a gap in understanding the impact that caring for a child with BEEC has on caregivers in low- and middle-income countries (LMIC). We hypothesize that families and caregivers experience psychological distress that has long gone unaddressed. Materials and methods: From 2018 to 2020, researchers conducted a multi-method evaluation of caregiver distress with participants recruited as part of the annual International Bladder Exstrophy Collaboration based in Ahmedabad, Gujarat, India. In 2018, pilot data was collected through cognitive interviews. In 2019, researchers conducted structured interviews predicated on themes from the previous year, which subsequently prompted formal mental health screenings in 2020. Caregivers who reported suicidal thoughts were immediately referred for intervention. Results: In 2018, caregivers described the primary source of stigma arose from their village (n = 9, 26.5%). Caregivers also identified long-term concerns (n = 18, 52.9%), including future fertility and marital prospects, as sources of anxiety. In 2019, caregivers substantiated preliminary findings with the primary source of anticipated (n = 9, 31%) and experienced (n = 19, 65.5%) stigma again stemming from their communities. Both cohorts identified the collaboration as a positive source of support (n = 23, 36.5%). In 2020, caregivers stated decreased emotional wellbeing as number of subsequent repairs increased (n = 54, 75%, p = 0.002). Caregivers of children who underwent initial surgery within 5 years of screening reported higher anxiety (n = 46, 63.8%) and this was exacerbated as the number of subsequent repairs increased (p = 0.043). Conclusion: Complex, long-term course of care, including additional surgeries, significantly impacts caregiver distress in the LMIC setting. Screening for caregivers of children with complex congenital anomalies, like BEEC, should be an essential element of any comprehensive effort to alleviate the global burden of disease.

Orchio-Septopexy: A new technique to cover and fix detorsed testis undergoing fasciotomy of tunica albuginea

ABSTRACT Purpose Compartment Syndrome (CS) has been recognized as a potential factor that worsens testicular viability after detorsion, especially in borderline cases of prolonged ischemia. Fasciotomy of the testicular tunica albuginea to relieve the pressure associated with CS has been proposed to accommodate edema after detorsion, embracing the raw fasciotomy area with tunica vaginalis flap (TVF) or graft. Fashioning the TVF can be tedious in cases of severe scrotal edema. Herein we present a technique that facilitates and expedites the procedure, maintaining the fasciotomy area decompressed. Materials and Methods In testicular torsion, where the testis remains with dark coloration and questionable viability after detorsion a longitudinal releasing incision is made in the tunica albuginea (fasciotomy) to decrease compartmental pressure. If signs of parenchymal recovery (bleeding points, better color) are seen an orchio-septopexy is performed, suturing the incised albuginea's edges to the septum with a running suture, avoiding CS as well as re-torsion. Results Orchio-septopexy was performed in 11 cases with a mean age of 11.9 years (3-17). All cases had clinic follow-up and testicular Doppler US with a mean of 9.5 months (6-24). 6/11 cases (54%) were salvaged, with good vascularity in the Doppler US and maintained more than 50% testicular volume compared to the contralateral side. Conclusion Orchio-septopexy after testicular fasciotomy is a simple and fast technique that can be utilized in cases of prolonged testicular ischemia and questionable viability. More than half of the testes recovered, encouraging us to propose its utilization as well as its validation by other surgeons.

Orchio-Septopexy: A new technique to cover and fix detorsed testis undergoing fasciotomy of tunica albuginea.

PURPOSE: Compartment Syndrome (CS) has been recognized as a potential factor that worsens testicular viability after detorsion, especially in borderline cases of prolonged ischemia. Fasciotomy of the testicular tunica albuginea to relieve the pressure associated with CS has been proposed to accommodate edema after detorsion, embracing the raw fasciotomy area with tunica vaginalis flap (TVF) or graft. Fashioning the TVF can be tedious in cases of severe scrotal edema. Herein we present a technique that facilitates and expedites the procedure, maintaining the fasciotomy area decompressed. MATERIALS AND METHODS: In testicular torsion, where the testis remains with dark coloration and questionable viability after detorsion a longitudinal releasing incision is made in the tunica albuginea (fasciotomy) to decrease compartmental pressure. If signs of parenchymal recovery (bleeding points, better color) are seen an orchio-septopexy is performed, suturing the incised albuginea's edges to the septum with a running suture, avoiding CS as well as re-torsion. RESULTS: Orchio-septopexy was performed in 11 cases with a mean age of 11.9 years (3-17). All cases had clinic follow-up and testicular Doppler US with a mean of 9.5 months (6-24). 6/11 cases (54%) were salvaged, with good vascularity in the Doppler US and maintained more than 50% testicular volume compared to the contralateral side. CONCLUSION: Orchio-septopexy after testicular fasciotomy is a simple and fast technique that can be utilized in cases of prolonged testicular ischemia and questionable viability. More than half of the testes recovered, encouraging us to propose its utilization as well as its validation by other surgeons.

Bladder exstrophy: We need to improve. A lot.

INTRODUCTION: Bladder exstrophy (BE) affects continence and sexual function, impacting on social life and mental health. Long-term data from the patients' point of view are needed to get a real-life perspective on the problem. STUDY DESIGN: A self-developed questionnaire concerning sexual, psychosexual and psychosocial outcomes was sent to the adult members of the Brazilian Exstrophy Group. RESULTS: Fifty out of 67 adults from the group (74.5%) responded to the questionnaire. Failure of initial bladder closure attained 62%. Almost ¾ of the patients had augmentation cystoplasty. Bladder lithiasis was common. Esthetic procedures were frequently done. Repetitive UTI (n = 32, 64%) and kidney scars/disease (n = 20, 40%) were frequent. Most (88%) patients either depend on CIC or remain incontinent. Sexual problems predominated in males. Surgery for continence often failed, requiring re-operations, but the prognosis without these procedures was comparatively worse. Continent patients underwent more surgeries (mean 18, 13 and 9 procedures in continent, imperfectly continent and incontinent patients, respectively). Augmented patients more frequently achieved dryness (p = 0.0035). Two-thirds of the women underwent vaginoplasties, but dyspareunia/feeling of "tight" vagina still affected a quarter of them. Four women (15.4%) delivered healthy children. 91.7% of the males reported "normal" erections, but sexual inhibition was common due to feeling of having a small penis (n = 18, 75%). Persistent dorsal curvature and abnormal ejaculation were common (58.3% and 77.1%, respectively). Patients' comments related mainly to mental health issues/need for specialized care, limitations of medicine to cure/treat their disease, unavailability of experts, especially adult specialists, embarrassment over deformities and insufficient information about disease/treatment/prognosis. DISCUSSION: Most BE patients are well-integrated into society, but feelings of sadness and low self-esteem are common. Most welcome procedures to become dry, despite self-catheterization. The results of bladder neck reconstruction are far from perfect, despite multiple attempts and bladder augmentation was often necessary. Volitional voiding is uncommon. Sexual problems are worse for males, and sexual avoidance is common. Sexual function and self-image are inter-related. It seems reasonable to offer selective esthetic procedures to improve social/sexual interaction. Obstetric complications are common, especially UTI, need for ureteral and/or conduit stenting, abnormal fetal positioning, uterine prolapse, technical problems during surgical deliveries and prematurity. CONCLUSION: Continence/dryness in BE was mostly eventually achieved, usually depending on multiple interventions, bladder augmentation and self-catheterization. Despite multiple surgeries many adults remain incontinent. Sexual problems and avoidance are the rule in males, due to the feelings of penile inadequacy. Pregnant females deserve expert obstetric care.

Variant of Bladder Exstrophy With an Intact Penis: Surgical Options and Approach.

Variants of bladder exstrophy are a rare but diverse spectrum of bladder exstrophy-epispadias complex. This case series describes a group of 4 unique exstrophy variant cases who had an intact phallus, but a completely open bladder plate. These patients underwent exstrophy repair and concomitant umbilicoplasty at the Civil Hospital, Ahmedabad as part of the US-India Multi-institutional Bladder Exstrophy Collaboration and were followed at the same institution. We believe that a detailed assessment of bladder neck prior to reconstructive repair and bladder closure would be beneficial in these cases as the extent of bladder neck involvement would affect reconstructive approach.

Digital Pattern Recognition for the Identification and Classification of Hypospadias Using Artificial Intelligence vs Experienced Pediatric Urologist.

OBJECTIVE: To improve hypospadias classification system, we hereby, show the use of machine learning/image recognition to increase objectivity of hypospadias recognition and classification. Hypospadias anatomical variables such as meatal location, quality of urethral plate, glans size, and ventral curvature have been identified as predictors for postoperative outcomes but there is still significant subjectivity between evaluators. MATERIALS AND METHODS: A hypospadias image database with 1169 anonymized images (837 distal and 332 proximal) was used. Images were standardized (ventral aspect of the penis including the glans, shaft, and scrotum) and classified into distal or proximal and uploaded for training with TensorFlow. Data from the training were outputted to TensorBoard, to assess for the loss function. The model was then run on a set of 29 "Test" images randomly selected. Same set of images were distributed among expert clinicians in pediatric urology. Inter- and intrarater analyses were performed using Fleiss Kappa statistical analysis using the same 29 images shown to the algorithm. RESULTS: After training with 627 images, detection accuracy was 60%. With1169 images, accuracy increased to 90%. Inter-rater analysis among expert pediatric urologists was k= 0.86 and intrarater 0.74. Image recognition model emulates the almost perfect inter-rater agreement between experts. CONCLUSION: Our model emulates expert human classification of patients with distal/proximal hypospadias. Future applicability will be on standardizing the use of these technologies and their clinical applicability. The ability of using variables different than only anatomical will feed deep learning algorithms and possibly better assessments and predictions for surgical outcomes.

Upper lip graft (ULG) for redo urethroplasties in children. A step by step video.

PURPOSE: Lower lip and cheek are commonly used sources of buccal mucosa grafts for urethroplasty. In recent years, aiming to improve the donor site morbidity, our preference changed to the use (ULG). The aim of this video is to illustrate the technical details of the ULG harvesting for children. MATERIAL AND METHODS: The inner surface of the upper lip is exposed by two stay sutures. The frenulum is spared, the mucosa to be harvested is marked and local submucosal infiltration is done with a solution of bupivacaine plus epinephrine. The edges are incised ant the submucosa plane created with a scissor. The graft is detached, defatted, and applied with quilting stitches over the recipient site with the standard technique. Hemostasis is secured and the donor site is left open. RESULTS: From 2015 to 2018, 25 ULG harvests were done in 24 patients. Only one (5%) presented local pain associated to the procedure in the first 24 h. After minimum 2 months after surgery, none of the patients presented perioral nubmness, difficulty with mouth opening, contraction of the donor site or changes in salivation. CONCLUSIONS: ULG harvest is easy and a suitable alternative source of oral mucosa for urethroplasty in children.

Long-term fate of the incised urethral plate in Snodgrass procedure; A real concern does exist.

We present here a case of a patient post tabularized incised plate urethroplasty for distal hypospadias without chordee who developed urethral stenosis and acquired curvature along the territory of the incised plate necessitating a redo surgery. The histological analysis of the incised urethral plate revealed absence of smooth muscles, vessels and elastin fibers within the area of the incised plate which could explain the poor compliance of this segment and the development of the curvature. To our knowledge, this case is the first in humans displaying the long-term histological findings of healing post tabularized incised plate urethroplasty.

A Model for Sustained Collaboration to Address the Unmet Global Burden of Bladder Exstrophy-Epispadias Complex and Penopubic Epispadias: The International Bladder Exstrophy Consortium.

Importance: International collaboration to alleviate the massive burden of surgical disease is recognized by World Health Organization as an urgent need, yet the surgical mission model to treat reconstructive surgical challenges is often constrained in ensuring adequate patient follow-up, optimal outcomes, and sustainability. Objective: To determine whether a collaboration predicated on long-term commitment by surgeons returning to the same institution annually combined with an experienced host surgical team and infrastructure to ensure sustained patient follow-up could provide surgical care with acceptable outcomes to treat bladder exstrophy-epispadias complex (BE) and penopubic epispadias (PE). Design, Setting, and Participants: In this prospective, observational study, long-term collaboration was created and based at a public hospital in Ahmedabad, India, between January 2009 and January 2015. The entire postoperative cohort was recalled in January 2016 for comprehensive examination, measurement of continence outcomes, and assessment of surgical complications. Seventy-six percent of patients (n = 57) who underwent complete primary repair of exstrophy during the study interval returned for annual follow-up in 2016 and formed the study cohort: 23 patients with primary BE, 19 patients with redo BE, and 11 patients with PE repair. Main Outcomes and Measures: Demographics, operative techniques, and perioperative complications were recorded. A postoperative protocol outlining procedures to ensure monitoring of study participants was followed including removal of ureteral stents, urethral catheter, external fixators, imaging, and patient discharge. Results: Of the 57 patients, 4 were excluded because they underwent ureterosigmoidostomy. Median age at time of surgery was 3 years (primary BE), 7 years (redo BE), and 10 years (PE), with median follow-up of 3 years, 5 years and 3 years, respectively; boys made up more than 70% of each cohort (n = 17 for primary BE, n = 15 for redo BE, and n = 9 for PE). All BE and 3 PE repairs (27%) were completed with concurrent anterior pubic osteotomies. Seventeen of 53 patients (32%) experienced complications. Only 1 patient with BE (4%) had a bladder dehiscence and was repaired the following year. Conclusions and Relevance: A unique surgical mission model consisting of an international collaborative focused on treating the complex diagnoses of BE and PE offers outcomes comparable with those in high-income countries, demonstrating a significant patient retention rate and an opportunity to rigorously study outcomes over an accelerated interval owing to the high burden of disease in India. Postoperative care following a systematized algorithm and rigorous follow-up is mandatory to ensure safety and optimal outcomes.

Update on the surgical approach for reconstruction of the male genitalia.

The majority of patients with DSD will be found to carry an XY karyotype and be assigned male gender. From a phenotypical standpoint, most will present with proximal hypospadias ± cryptorchidism. In this review article, the authors present the current status of reconstruction of the male genitalia in this setting. The report addresses the following topics: surgical input in the evaluation of the newborn with an undervirilized external genitalia, including gender assignment considerations; controversies surrounding timing and indication for hypospadias surgery in proximal cases as well as use of testosterone; surgical techniques and decision-making process for one- vs. two-stage repairs; complications of hypospadias surgery based on technique used for repair; and long-term follow-up. The high complication rates observed in the treatment of proximal hypospadias attest to its challenging nature. Concentration of experience, tracking carefully identified patient-centered outcomes and long-term follow-up of this patient population are recommended.

Application of the STROBE statement to the hypospadias literature: Report of the international pediatric urology task force on hypospadias.

INTRODUCTION: Observational studies, particularly case series, represent the majority of the current hypospadias research. As a result, this literature lacks standardization of surgical techniques, uniform definitions of hypospadias complications, and consistency of outcome reporting, which may make it difficult to compare results across studies. A modified version of the STROBE statement, containing 20 items, was presented at the International Pediatric Urology Task Force on Hypospadias meeting to assist with clear and transparent reporting of hypospadias studies. The adoption and implementation of this modified tool will allow investigators and health care providers to critically evaluate quality and identify bias within the literature. In addition this instrument will ensure consistency of reporting, improving objective comparisons between studies, unification of results, and development of evidence-based clinical guidelines. METHODS: In this article, we have applied the modified STROBE statement to the hypospadias literature, aiming to create a guide on study reporting for pediatric urologists, and ultimately improve the quality of research in our field. We present itemized recommendations for adequate reporting of hypospadias studies and case series, ranging from drafting the abstract to addressing biases and potential sources of confounding. Included with each item is a brief explanation of its importance and potential effect on the study, as well as pertinent examples of hypospadias articles. RESULTS: A modified STROBE summary table containing 20 items is presented in (Supplementary Table 1). CONCLUSIONS: If properly conducted and reported, hypospadias studies have the potential to provide useful information to clinicians and surgeons. However, authors should recognize the inherent limitations of these observational studies, especially in the form of bias, which may introduce invalid data or limit generalizability. Thus, we expect that the use of this guiding tool will not only improve transparency of hypospadias reporting, but also improve its methodological quality, allowing proper comparison and interpretation of data across different institutions.

Measurement of Differential Renal Function by Scintigraphy in Hydronephrotic Kidneys: Importance of Conjugate Views for Accurate Evaluation.

PURPOSE: Traditionally a single posterior view is used to measure differential renal function during nuclear renal scintigraphy. Nevertheless, experimental data show important variation in this measurement in the setting of significant hydronephrosis. To date, the impact of degree of hydronephrosis on the accuracy of differential renal function determination has not been addressed. We evaluated the discrepancy between function measured by anterior and posterior views, and the relationship to varying degrees of hydronephrosis. MATERIALS AND METHODS: We retrospectively reviewed consecutive mercaptoacetyltriglycine renal scans from 2009 to 2011. Ultrasounds were reviewed and degree of hydronephrosis was recorded using anteroposterior pelvic diameter. Absolute percent difference in differential renal function between each view (anterior minus posterior) was calculated and correlated to anteroposterior pelvic diameter. Patients were stratified into 4 groups according to anteroposterior pelvic diameter, ie less than 10 mm, greater than 10 mm, greater than 15 mm and greater than 25 mm. RESULTS: A total of 519 scans with corresponding ultrasounds were analyzed. Median patient age was 2.26 years. Kidneys with a larger anteroposterior pelvic diameter had a greater discrepancy in function on anterior and posterior views. There was a meaningful discrepancy for anteroposterior pelvic diameter greater than 10 mm (p = 0.034) and greater than 25 mm (p = 0.032). Several statistical models were used to identify a meaningful cut point of 15 mm, where the discrepancy in anterior and posterior views became significant (p = 0.001). CONCLUSIONS: The use of single views during nuclear renography for grossly hydronephrotic kidneys is often inaccurate. The discrepancy in differential renal function obtained on the anterior and posterior views is adversely impacted especially as anteroposterior pelvic diameter increases beyond 15 mm. Therefore, we suggest incorporation of conjugate views for estimating differential renal function in patients with hydronephrosis.

Impact of drainage technique on pediatric pyeloplasty: Comparative analysis of externalized uretero-pyelostomy versus double-J internal stents.

INTRODUCTION: Pediatric pyeloplasty with double J (DJ) stent drainage requires manipulation of the uretero-vesical junction (UVJ) and a second anesthetic for removal. Externalized uretero-pyelostomy (EUP) stents avoid these issues. We report outcomes of laparoscopic and open pyeloplasty with EUP compared to DJ stents in children. METHODS: We retrospectively reviewed 76 consecutive children who underwent pyeloplasty for ureteropelvic junction (UPJ) obstruction over a 1-year period by 5 pediatric urologists at a single institution. The exclusion criteria included patients with concomitant urological procedures, other urinary drainage strategies, "stentless" pyeloplasty or patients without follow-up data. Based on surgeon preference, 24 patients had a EUP stent and 38 had a DJ stent placed. RESULTS: The mean follow-up was 23.8 ± 10.9 months and 21.1 ± 11.1 months for the EUP and DJ stent groups, respectively (p = 0.32). The mean age was 40 ± 54 months and 80 ± 78 months for the EUP and DJ groups, respectively (p = 0.04). The EUP group had a greater proportion of open pyeloplasties (n = 17, 71%) versus the DJ group (n = 16, 42%; p = 0.04). There were no statistically significant differences in operative time, length of stay, and overall complication rate between groups. Complications were divided by timing of complication (intraoperative, before and after 3 months) and according to the Clavien Classification system. There were no statistically significant differences between these subgroups. The limitations of this study include small sample size, potential selection bias, and heterogeneity between both study groups. CONCLUSIONS: Pyeloplasty using EUP stents does not incur prolonged operative time, longer length of stay or higher complication rate when compared to DJ stents. Within the limitations of this study, EUP stents may be a safe alternative to DJ stents.