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Paediatric Urology
Surgical Complications on the development of the central nervous system. Surgical
Surgical complication rates obviously depend on the chosen complications have been shown to increase with patient age at
procedure, and include urethrocutaneous fistula, meatal stenosis, repair, again supporting the benefits of early repair.
23
urethral strictures, urethral diverticula, complete breakdown, skin
necrosis, residual or recurrent curvature and hypospadiac cripple (a Follow-up
term describing patients who have undergone multiple unsuccessful The necessity for long-term follow-up has been stated by several
hypospadias repair attempts).
20
authors. Mureau
19
found a large proportion of young adult patients
who desired functional or cosmetic penile improvement. Outcome
Psychological Sequelae measurements are needed for quality control, although functional
Common sense dictates that children with any malformation may outcome is difficult to assess. An in-depth personal history
develop more psychological stress and are at increased risk of including assessment of pain (dysuria), urinary tract infections,
impaired QoL. More specifically, the emotional trauma of genital frequency and time for voiding, straining, use of abdominal wall
surgery and growing up with a cosmetically and functionally musculature to empty the bladder in due time and dribbling are
imperfect penis may lead to abnormal psychosexual development. necessary. US to assess bladder-wall thickness and residual urine
Hypothetically, the factors leading to undermasculinisation of the can be used, as can uroflowmetry.
external genitalia may also affect the development of masculine
gender characteristics and behaviour. In animal studies, pre-natal Cosmetic outcome in the form of appraisal by the treating team alone
androgen exposure of the foetal brain is related to post-natal sex- is insufficient; uninvolved specialists and subjective appraisal by
typed behaviour. This hypothesis in the most common forms of patients and parents are equally important.
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Not only do assessment
hypospadias remains speculative; therefore, in modern societies it is of HRQoL and psychosocial outcomes need to be monitored, but
most likely irrelevant. known risk factors for non-optimal outcomes such as pure patients
knowledge also need to be addressed.
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In more recent studies, psychosocial adjustment seems to be normal,
whereas normal psychosexual development is hampered by negative Ethics
genital appraisal and sexual inhibition. Further studies are needed to According to the principles of ‘good clinical practice’, in most cases
clarify these findings, but it appears that medical factors have only a repair of hypospadias creates an ethical problem. In the majority of
limited influence on psychosexual outcome.
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cases, parents/care-givers agree for a baby to undergo cosmetic
surgical intervention. Of course, they consult paediatric urologists for
Ideal Age their recommendations and in many cases follow this professional
The American Academy of Pediatrics (AAP) recommendation that advice, which in practice can almost never be unequivocal. Therefore,
the ideal age for genital surgery is between six and 12 months we as surgical professionals are actively involved in this decision-
intuitively makes sense, but strictly speaking is not evidence-based. making process. Although this repair is designed to allow normal
Using the window of genital unawareness of the young child is psychosexual development for the patients, there is no clear-cut
supposed to minimise fears related to genital surgery and allow for evidence to support this. Self-help groups claim that early surgery
normal psychosexual development. Better pain control, limited violated their right to make a decision for themselves and created
numbers of operations,
22
minimising separation from parents and significant personal problems. Solving this ethical dilemma between the
optimising post-operative care by better quality dressings and principles of attempting to do the right thing for the patient versus the
catheters certainly intuitively support better psychological patient’s right to autonomy will be possible only by better psychological
outcomes. However, a recent comprehensive systematic review on outcome studies, most importantly including untreated patients. n
psychosocial and psychosexual development and HRQoL failed to
reveal any positive effects of corrective surgery, nor to support the
Rita Gobet is Head of the Division of Paediatric Urology
hypothesis that an earlier time- point of corrective surgery may lead
at University Children’s Hospital, Zürich. She is a board
to better psychological adjustment.
21
Risk of anaesthetic sequelae
member of the European Society of Pediatric Urology
need to be taken into consideration. Generally speaking, the risk of
and a founding member and first President of the Swiss
Pediatric Urology Group. Dr Gobet was a Fellow of the
anaesthetic complications in a paediatric environment is not
European Academy of Pediatric Urology in 2005 and
elevated after six months of life; however, certainly in the
gained her medical doctorate at the School of Medicine,
experimental literature there are hints that there may be more
University of Zurich in 1986.
subtle but nevertheless concerning side effects of anaesthetic drugs
1. Wang MH, Baskin LS, J Androl, 2008;29:499. 1999;64:115. 19. Mureau MA, Slijper FM, Nijman RJ, et al., J Urol,
2. Kurzrock EA, Karpman E, Pediatr Endocrinol Rev, 2004;1:288. 12. Retik AB, Borer JG, Hypospadias. In: Retik AB, Vaughan ED, 1995;154:1902.
3. Jones K, Philadelphia: WB Saunders, 835;1997. Wein AJ, et al. (eds), Campbell’s urology. 8th ed., Philadelphia: 20. Horton CE, Devine CJ Jr, Plast Reconstr Surg, 1970;45:425.
4. Baskin LS, J Pediatr Urol, 2007;3:420. Saunders, 2002;2291–2. 21. Schonbucher VB, Weber DM, Landolt MA,J Pediatr Psychol,
5. Paulozzi LJ, Environ Health Perspect, 1999;107:297. 13. Retik AB (ed.), Proximal hypospadias, Philadelphia: WB 2008;33:520.
6. Dolk H, Vrijheid M, Scott JE, et al., Environ Health Perspect, Saunders, 1996;977–84. 22. Sandberg DE, Meyer-Bahlburg HF, Hensle TW, et al.,
2004;112:398. 14. Borer JG, Bauer SB, Peters CA, et al., J Urol, 2001;165:581. J Pediatr Psychol, 2001;26:465.
7. Skakkebaek NE, Rajpert-De Meyts E, Main KM, Hum Reprod, 15. Cox MJ, Coplen DE, Austin PF, J Urol, 2008;180:2649. 23. Hensle TW, Tennenbaum SY, Reiley EA, Pollard J, J Urol,
2001;16:972. 16. Milla SS, Chow JS, Lebowitz RL, Pediatr Radiol, 2008;38:202. 2001;165:77.
8. Sharpe RM, Skakkebaek NE, Fertil Steril, 2008;89:e33. 17. Baskin LS, Kogan BA, Duckett JW, Handbook of Pediatric 24. Mureau MA, Slijper FM, Slob AK, et al., J Urol, 1996;155:703.
9. Bauer SB, Bull MJ, Retik AB, J Urol, 1979;121:474. Urology, second ed, Philadelphia: Lippincott, Williams and 25. Schonbucher VB, Landolt MA, Gobet R, et al., J Pediatr,
10. Silver RI, Rodriguez R, Chang TS, Gearhart JP, J Urol, Wilkins, 2005;12. 2008;152:865.
1999;161:1954. 18. Schonbucher VB, Landolt MA, Gobet R, Weber DM,
11. Kurzrock EA, Baskin LS, Cunha GR, Differentiation, J Pediatr, 2008;152:865.
84 EUROPEAN UROLOGICAL REVIEW
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