Genitourinary and Anorectal Surgery in Children
Antenatal hydronephrosis
Grade hydronephrosis by Society for Fetal Urology criteria; most mild cases resolve. Ureteropelvic junction obstruction is confirmed with a Lasix renogram. Vesicoureteric reflux is graded I-V, with antibiotic prophylaxis for high grades and surgical referral for breakthrough febrile infections. Posterior urethral valves present in a male infant with a thick-walled bladder, bilateral hydroureteronephrosis and a keyhole sign; initial management is catheter drainage, then valve ablation, and renal failure may already be established.
Hypospadias: do not circumcise the neonate, because the prepuce is needed for urethroplasty. If a non-palpable testis or bifid scrotum accompanies hypospadias, evaluate for a disorder of sex development before any surgery.
Undescended testis: orchidopexy between 6 and 12 months reduces infertility and malignancy risk; retractile testes need no operation.
The acute scrotum
Testicular torsion involves the bell-clapper deformity, a high-riding transverse testis and an absent cremasteric reflex. If suspicion is high, do not delay for imaging - explore and fix both testes. Torsion of the appendix testis gives the blue dot sign.
Anorectal malformations
Imperforate anus is classified by the level of the fistula: low lesions may be treated by anoplasty, high lesions need a divided colostomy followed by posterior sagittal anorectoplasty. Hirschsprung disease presents with delayed meconium and enterocolitis, shows a transition zone on contrast enema and is confirmed by suction rectal biopsy.
Worked example
A 3-year-old has four hours of acute scrotal pain and vomiting. Rule of thumb: salvage is best within six hours, so go to theatre rather than to ultrasound.