Background: Total excision of pediatric posterior fossa tumors is by farthe best line of management. Pediatric posterior fossa tumor surgerychallenges neurosurgeons due to the unique anatomy of this region.Objective: Evaluation of the possible benefits and outcome of telovelarapproach to fourth ventricular tumors in children. Methods: This study wasconducted between June 2009 and December 2011 on 25 patients withfourth ventricular tumors presented to Children’s Cancer Hospital-Egypt(CCHE-57357). All cases were operated through the telovelar approach inprone position. Surgery was guided with navigated intra-operativeultrasound (IOUS). We utilized the integration of IGSonic intra-operativeultrasound technology into BrainLab-Kolibri™ neuronavigation system.Results: Total tumor excision was accomplished in 10 medulloblastomacases out of 13 cases (76.9%), in 3 out of 4 (75%) ependymoma cases, and5 out of 8 (62.5) astrocytoma cases (brainstem attachment). Cerebellarmutism occurred in 4 (16%) patients 3 of whom were medulloblastomas (2cases of transient mutism subtype and 2 cases of classic PF syndrome).Clinical outcome 3 weeks after surgery was excellent and good in 22 (88%)cases, fair in 3 (12%) cases with no mortalities. Conclusion: The standardtelovelar approach allows excellent exposure to fourth ventricular tumors.Navigated intraoperative ultrasonography (IOUS) is of great help in tumorswith cystic components and those in the lateral recesses. Safe and maximaltumor excision is achievable especially when telovelar approach is guidedby navigated intraoperative ultrasonography (IOUS).