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Hypospadias is the most frequent genital variation in male newborns with an incidence of 1:200-300. The variation within this anomaly is very high, from isolated distal hypospadias to very complex penoscrotal cases with accompanying genital or nongenital anomalies, genetic anomalies or even disorders of sexual differentiation. In the literature one can find up to 250 different surgical techniques for hypospadias repair. The goal of the new S2k guideline on hypospadias (AWMF registry no. 006-026), developed by the German Association of Urology (DGU) and the German Association of Pediatric Surgery (DGKCH), was a certain standardisation of the preoperative diagnostic workup, the surgical management and the postoperative care of patients with distal, middle or proximal hypospadias. In this article, the most important facts of the guideline are presented using a fictional case of an infant with distal hypospadias. For further reading, we refer to the S2k guideline, which can be easily accessed by scanning the pictured QR code., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra., Objectives: To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction., Materials and Methods: The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity., Results: The general rules of reconstruction that should be applied in each particular situation are described., Conclusions: Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

Background: Primary urethral cancer in males is a rare entity with only approximately 800 cases described, which is why it is difficult to formulate evidence-based guidelines for treatment. For tumors in the pT2 stage with a localization distal to the membranous urethra, a penis-preserving operation can be carried out., Methods: In the period from November 2006 to February 2014 a total of 4 patients with primary urethral cancer underwent a penis-preserving urethral resection. The tumor characteristics and treatment results were collated retrospectively., Results: Of the four patients one had a transitional cell carcinoma of the mid-penile urethra in stage pT2 G2. In two out of the four patients a squamous cell carcinoma (PEC) was present in the mid-penile urethra in stages pT2 G2 and pT2 G3, respectively, with concomitant carcinoma in situ (CIS). The fourth patient had a PEC of the fossa terminalis in stage pT2 G2. Initially all patients underwent a penis-preserving resection. In one case, despite an initial R0 resection a local recurrence occurred and a complete penectomy was performed. Irradiation and lymphadenectomy were not carried out. At a mean follow-up of 37 months all patients are currently in complete remission., Conclusion: Primary penile urethral cancer can be treated by a penis-preserving operation. Close follow-up is essential because recurrence can arise despite an initial R0 resection.

The severity of secondary hypospadias can range from a mild cosmetic problem to severe functional impairment. Accordingly, surgical management of the defect can be either simple or extremely demanding. During the operation the penis should always be regarded as a functional unit so that the treatment goal of a good cosmetic and functional result can be achieved. In addition, the surgeon should have an extensive repertoire of operative techniques at his disposal and should be well versed in skin grafting methods so that he is able to adapt the procedure optimally to the intraoperative findings as necessary. If certain do's and don'ts of hypospadias correction are additionally observed good results can usually be obtained even in complicated hypospadias patients with multiple previous operations. Unreflected treatment, on the other hand, usually leads to further worsening of the problem resulting in the so-called hypospadias cripple.

For a long time the standard treatment of an ectopic ureterocele, combined with a double collection system, was an upper-pole resection with or without ureter resection. Between 1980 and 1992, 27 children were treated initially with an endoscopic incision of the ureterocele. Twenty-four of these children were followed up. In 11 of 24 cases the endoscopic incision was sufficient and in 5 of 24 other children a reflux operation had to be performed afterwards, so that in 66% of the children the upper-pole resection was not necessary. We presume that the endoscopic incision of an ectopic ureterocele must be the first step in operative planning.

Between January 1985 and December 1990, a total of 40 patients aged 2-40 years underwent surgical reconstruction for complicated failure of hypospadias repair. These included 19 patients with multiple previous operations, severely scarred skin, penile deviation, long urethral defects and scarred or cleft glans, who were classified as hypospadias cripples (group I). The remaining 21 patients had distal urethral defects and a scarred or cleft glans but better skin condition; this group was classified as having defects of the distal urethra and glans (group II). Island flaps were used in 17 patients, and transversal or axial random penile skin flaps in 18. In 4 patients the urethra was reconstructed with mesh graft and in 1 case, with a bladder mucosa graft. With the designed single-session procedure primary treatment was successful and free of complications in 52% of the patients in group I and 67% in group II. In each of 3 patients three further operations were required. In 15 patients revision surgery was confined to simple fistula closure, stricture incision or correction of scarred skin. Follow-up examination at 7-72 months showed that treatment had been successful in all patients.

Congenital urinary tract malformations are frequently the cause of urinary transport disturbances. However, not all the malformations or obstructions presenting sonographically as hydronephrosis have to be treated surgically. The Whitaker test, an invasive diagnostic procedure to establish the urodynamic relevance of an obstruction, does not provide a reliable estimate of prognosis; spontaneous cures in cases of obstruction have been reported. Diuresis renography offers several advantages as compared with the Whitaker test, for example a more physiological basis, less observer dependency, better reproducibility and--last but not least--non-invasiveness. However, diuresis renography has to be carried out according to a strictly standardized protocol. Sufficient hydration (20 mg/kg body weight) and bladder catheterization (to rule our reflectory transport disturbances) are mandatory. Today, 123I-OIH or 99mTc-MAG3 are the radiopharmaceuticals of choice; the activity for children has to be reduced in relation to body surface. To stimulate diuresis, furosemide (0.5-1 mg/kg of body weight) has to be given. For the evaluation of diuresis renography, sequential scintigrams as well as functional curves have to be used. It is strongly recommended that diuresis renography be combined with clearance determinations separately for the two kidneys. The interpretation of diuresis renography should not rely only on quantitative curve parameters but--above all--on visual analysis of the functional curves. However, in cases of proven obstruction, diuresis renography--like the Whitaker test--cannot accurately predict the prognosis in any individual case. If renal function is normal and there is no difference between the left and the right kidney, a wait-and-see attitude seems to be justified.(ABSTRACT TRUNCATED AT 250 WORDS)

Bladder exstrophy is seen in 1 of 30,000-40,000 live births, and is seldom treated in many urological departments. Treatment options for children with exstrophy are upper urinary tract diversion or reconstruction of the bladder and plastic surgery of the bladder neck to gain urinary continence by the age of 4-7 years. Historical reviews report continence rates of 10-30% after a staged approach with primary reconstruction and secondary bladder neck repair. This formerly meant upper urinary tract diversion as a third stage in 70-90%. Multiple operative procedures could be avoided when primary diversion was done. The best results were reported following antirefluxive implantation of ureters into the sigmoid colon (ureterosigmoidostomy). In boys, the base of the bladder was removed, leaving a small residual bladder which together with the reconstructed epispadias served as a "seminal tract". Total removal of the bladder was performed in girls. Long-term follow up of upper urinary tract diversion showed disturbances of serum electrolytes, urinary tract infections and stone formation, and after ureterosigmoidostomies an increased rate of colon carcinomas was documented. These results led to renewed interest in reconstruction. The technique of bladder neck reconstruction was changed, resulting in a higher rate of late urinary continence: augmentation cystoplasties, clean intermittent catheterization and the artificial sphincter help to achieve a continence rate of more than 90%. This goal was reached only after multiple operations and without knowledge of the long-term sequelae of augmentation cystoplasties. The years to come will show whether new concepts of ureterosigmoidotomies, such as the sigma-rectum pouch, will be preferable, or a late urinary tract diversion after failed reconstruction. Most centers are now agreed that primary reconstruction of bladder exstrophy should be attempted in the newborn child.

Fibroepithelial polyps are rare benign tumours that can cause obstruction of the urethra. Most such polyps occur during childhood. We present two patients, one is a child, the second an adult male. The problematic diagnosis is emphasized.

The treatment of hypospadias has developed over the years from a disabling intervention to a surgical procedure devised with due consideration for the needs of paediatric patient. The operation is timed to fit in with the child's psychological development, being performed early in life before it becomes too traumatic for the child. Resection of the chordee and creation of the neourethra in a single session is increasingly superseding the two-stage procedure usual earlier, especially for distal and medial hypospadias. However, when the surgeon is sufficiently experienced even proximal hypospadias can be corrected in a single session, for example by a combination of a Thiersch and a free island flap or by free bladder mucosal flaps or grafts. The use of suitably fine instruments and suture material should be a matter of course, as should the use of magnifying lenses. Urinary diversion is still obligatory in most centres, and, like the sort of dressing used, it depends on the individual experience and judgement of the surgeon. The incidence of postoperative complications should be below 10% regardless of the degree of hypospadias.

From 1976 to 1983 23 boys with posterior urethral valves were seen. Two boys died during early infancy from terminal renal failure. One boy is submitted to a chronic peritoneal dialysis program. Of the remaining 20 patients ten show signs of compensated renal failure (creatinine greater than 1.5 mg/dl), ten boys show normal renal function. Four out of 46 kidneys were removed. Vesicoureteral reflux was primarily present in 14 renal units (30.4%). Three of these kidneys were removed. Reflux ceased spontaneously after valve ablation in ten renal units, ureterocystoneostomy was done in one. Ureterovesical obstruction was seen in three renal units and treated by resection and neoimplantation. Renal hypoplasia and -dysplasia together with urinary tract infections determine the degree of renal function impairment in boys with posterior urethral valves. Surgical intervention of the upper urinary tract is seldom needed. Antenatal diagnosis of obstructive uropathy is helpful to avoid septic obstruction in the neonate. Percutaneous nephrostomy is the treatment of choice in critically ill children presenting with dilatation of the upper tracts.