Most urologic procedures are simple surgical repairs in healthy children and are performed on an outpatient basis. Some children require complex repairs, and it helps to understand the repair to tailor the anesthetic technique.
Circumcision
Children beyond the newborn period may present for circumcision under general anesthesia as an elective procedure for cosmetic reasons, or as a treatment for recurrent phimosis.
Preoperative assessment should include assessment for sedative premedication. An oral analgesic agent such as acetaminophen 15 mg/kg or ibuprofen 10 mg/kg may also be included. Most children undergo inhalational induction and maintenance with sevoflurane. Airway management is provided by face mask or supraglottic airway. Tracheal intubation is usually reserved for small children in whom a supraglottic airway may not be suitable because of the imperfect fit, and because the child may be situated further down the operating room (OR) table where the airway is not readily accessible. Regional analgesia should be provided by a penile block, caudal epidural block (see Chapter 20 ), or pudendal block. Postoperative fever is very common after circumcision, especially in children with preexisting phimosis.
Hypospadias Repair
Hypospadias is a congenital defect that consists of an abnormal positioning of the penile meatus. It occurs in approximately 1 out of every 350 male births. It ranges from a very mild defect, in which the urethral opening is located along the underside (ventral aspect) of the penis, to a severe defect where the opening is located on the underside of the scrotum. The severity of the lesion will determine the type of surgical procedure. Surgery is necessary to allow normal urination, to correct the deformation for cosmetic reasons, and to ensure normal sexual functioning in the case of a severe chordee. Repair is often performed during the first year of life.
There are several types of surgical procedures, depending on the severity of the lesion. In general, the more severe the lesion, the longer and more extensive the surgery. Preoperative assessment is routine and includes screening for other congenital anomalies, and optimizing coexisting medical conditions. Laboratory studies are not indicated. Anxiolytic premedication should be ordered if the child is older than 10 or 11 months, and an oral analgesic may be included. Induction and maintenance of general anesthesia are provided by inhalational agents. Airway management consists of a supraglottic airway or tracheal intubation, depending on the age of the child and the length of the procedure. Regional anesthesia with a caudal epidural block or pudendal block is standard pain management, especially because the more involved repair is expected to cause prolonged pain and analgesic needs. Systemic analgesics may also be necessary.
Over the past several years there has been a controversy brewing about whether the inclusion of caudal anesthesia increases the chances that the child will develop a postoperative urethral fistula. There is no plausible mechanism, and at this point, no convincing evidence that there is an association.
Testicular Torsion Repair
Testicular torsion manifests as acute scrotal pain and results from a twisting of the spermatic cord with vascular compromise of the testicle. If the problem is not surgically corrected within about 6 to 8 hours, testicular ischemia can result. This is generally considered a surgical emergency. Temporizing treatment involves manual detorsion; this may alleviate ischemia but orchidopexy is still required.
Preoperatively, the patient should be prepared for emergency surgery. An intravenous (IV) catheter should be inserted to provide hydration and to prepare for a rapid sequence induction of general anesthesia. Adolescents may be offered spinal anesthesia with sedation. Intraoperative analgesia is provided by local infiltration at the surgical site and small doses of opioids. Postoperative concerns include pain and nausea/vomiting, which are treated by standard therapies.
Orchidopexy
Orchidopexy (also known as orchiopexy) is performed to repair cryptorchidism (also known as undescended testicle ). During fetal development, the testicles develop in the abdomen and descend into the scrotum during the last trimester. In a small percentage of newborns (3%), one or both testicles fail to descend. Approximately half then descend within the first year of life. The remaining must undergo surgical intervention because of the increased risk for infertility and malignancy in testicles that remain undescended within the abdominal cavity during childhood.
Children with undescended testicles are usually healthy, although there is a higher incidence of prematurity. A number of congenital syndromes are assoicated with undescended testicles and include Noonan’s and Prader-Willi syndromes, among many others. Prune-belly syndrome consists of undescended testicles, absent anterior abdominal musculature, and dilatation of parts of the urinary tract. This rare syndrome may be accompanied by impaired renal function.
Preoperative assessment is routine and will depend on any coexisting medical conditions. Induction and maintenance of general anesthesia are routine. Airway management consists of a supraglottic airway or tracheal intubation. The procedure consists of two incisions: one in the lower groin to retrieve the testicle, and the other at the bottom of the scrotum to anchor the testicle. Blood and insensible fluid losses are minimal. Regional analgesia is provided by an ilioinguinal block (with surgical local infiltration of the scrotal incision) or caudal epidural block (see Chapter 20 ). Postoperative concerns include pain and nausea/vomiting.
The pudendal nerve block has been used for many applications in adults, and more recently has emerged as a regional technique for analgesia in pediatric urologic surgery. Pudendal blocks can offer notable advantages over traditional caudal blocks. Adverse effects associated with caudal blocks such as lower extremity motor blockade, are avoided by specifically targeting the innervation of the perineal space. Contraindications to neuraxial techniques may be circumvented. In terms of pain control, pudendal blocks have been shown to confer analgesia of better quality and longer duration compared with caudal block, when used for hypospadias repairr.
The pudendal nerve provides sensory innervation to the external genitalia and perineal space, and motor innervation to the transverse perineal muscles and rectal and urethral sphincters. After originating from the anterior rami of S2 through S4, the pudendal nerve courses through the pudendal canal alongside the internal pudendal artery and vein. Its distal branches land within the ischioanal fossa, a fat-filled space between the rectum and ischium ( Fig. 29.1 ). The transperineal approach is a field block that relies on the spread of local anesthetic within the ischioanal fossa to reach to branches of the pudendal nerve.
