Psychological Preparation

Perhaps the most demanding task of preoperative surgical preparation for the pediatric population is managing the stress of the patient and parents or other caregivers. While commonly underestimated by the surgeon, operatively induced anxiety can have long-term effects, including nightmares, separation anxiety, eating problems, and increased fear of physicians and health-care institutions. Often the key to reducing stress is to allay the fears of the caregiver, as parental anxiety is known to be transferred to the child. Surgical education begins with the parent or parents. Confronting parents’ fears begins with a comprehensive understanding of the nature, risks, and benefits of the surgical procedure. Reduced anxiety among parents diminishes the patients’ anxiety. Depending on the age of the patient, the physician should offer patients the opportunity to speak privately, away from their parents, to address the concerns that the patient may have but is embarrassed to discuss in front of the parents. Additionally, it is imperative to ask appropriately aged children if they have any questions or concerns. Providing age-appropriate reading materials to patients has also been shown to help reduce anxiety.

Preoperative hospital visits provide invaluable educational opportunities for both patients and parents. Arranging for families to meet the anesthesia team preoperatively allows for an introduction to the multidisciplinary approach to modern-day surgery. It also facilitates addressing parental concerns regarding anesthesia as well as patient anxiety surrounding pain control and induction of anesthesia. In addition, many children’s hospitals offer behavioral preparation programs run by child life specialists, which have been shown to help reduce perioperative stress levels if conducted 5–7 days prior to surgery. Familiarizing families with the facilities, staff, and surgical process preoperatively helps to alleviate some of the stress associated with the procedure.

Methods to help distract or calm patients on the day of surgery, including video games, music, and sedative premedication, have been shown to be effective in reducing stress levels surrounding surgery. However, the most stressful aspect of surgery is the induction of anesthesia. In an effort to ease anxiety, many hospitals allow a parent to accompany the patient into the operating room to be present during induction. While the anxiolytic effect of this intervention on the patient is controversial, parents who accompany their children have been found to have less stress associated with the separation process and have a higher satisfaction level with the overall care provided during the surgical encounter.

Many factors outside of our control affect perioperative stress, including previous hospitalizations, patient personalities, and severity of disease. However, there are many programs in place to help ameliorate family anxiety both at the time of preoperative discussion, in the days leading up to the surgery, and also on the day of surgery itself. By optimizing these interventions we not only allow for a smoother day of surgery, but also improve overall satisfaction with the surgical process and decrease postoperative behavioral complications.

Preoperative WorkUp

Important Medical Considerations

Premature infants have higher risks when undergoing anesthesia, principally with postoperative apnea. The presence of anemia, specifically with a hematocrit <30%, significantly increases the risk of apneic episodes and elective surgery should be delayed until anemia resolves. The postconceptual age (PCA) is also an important factor in postanesthesia risk. Among patients undergoing herniorrhaphy, former premature infants who have a PCA of >60 weeks had a <5% incidence of apnea. There is some evidence that using spinal anesthesia instead of general anesthesia decreases rates of postoperative apnea in premature infants and allows for outpatient procedures.

Asthma is another common medical condition in patients undergoing elective procedures. Severity of asthma can often be confused with how well controlled the disease is; mild asthma if not well controlled can appear worse than well-controlled severe asthma. Medical management should be optimized prior to any elective procedure, and, as much as possible, patients should strive to be compliant with all medications preoperatively. All asthma medications should be taken the day of surgery, including inhaled agonists or leukotriene inhibitors. Intraoperatively endotracheal intubation is felt to induce more respiratory complications than a laryngeal mask airway (LMA), and for short procedures standard mask anesthesia is preferred if feasible. Patients may require inhaled agonists intraoperatively to treat bronchospasms or, if on chronic oral or inhaled steroids, may require stress dose steroids to prevent adrenal crisis.

Obesity is an increasing disease among children and has an impact on surgical care. Obese patients are more likely to have comorbidities that affect anesthesia care, including hypertension, type 2 diabetes, and bronchial asthma. Preoperative evaluation should be comprehensive enough to screen for these underlying conditions. Office physical exams may be less accurate at defining true testicular position in obese patients and may lead to use of anesthesia to facilitate exams. Additionally, obese patients are more likely to have anesthesia complications such as difficult intubation, postanesthesia care unit (PACU) upper airway obstruction, and prolonged PACU stays.

Other medical conditions that require special recognition are sickle cell anemia, Down syndrome, and diabetes. Sickling conditions can cause acute chest syndrome, stroke, and myocardial infarction when red blood cells form sludge in vasculature during the perioperative period. Historically it has been recommended to give perioperative transfusions to reduce the Hgb S levels to less than 40%; however, more recent evidence suggests that oral hydration may be sufficient to avoid serious complications after minor, elective surgical procedures. Patients with Down syndrome have a 10–30% risk of having atlantoaxial instability, which can put them at risk for cervical subluxation or dislocation during general anesthesia when the neck is maximally extended for intubation. While routine screening is not generally performed, a plain film of the cervical spine is sufficient to diagnose the condition. Along with the increase in obesity, type 2 diabetes is becoming more prevalent in the pediatric population. Diabetics should have cases scheduled early in the day, and crystalloid fluid containing 5% glucose should be started upon establishment of intravenous access. Half of the patient’s morning insulin should be given, and glucose levels should be monitored intraoperatively and in the PACU.

Bowel Preparation

Preoperative bowel preparation serves two roles: For urinary tract reconstruction involving the gastrointestinal tract it reduces gross spillage of enteric contents that theoretically decrease bacterial load if there is a violation of the bowel, and it reduces intraabdominal fecal mass to increase work space in laparoscopic cases. As laparoscopy becomes more prevalent among the pediatric urologic population, bowel preparation becomes an important consideration. A porcine model showed significant increases in intraabdominal volume following bowel preparation, space that can be important in the already cramped confines of a pediatric peritoneum. However, studies examining augmentation cystoplasties in children both via open as well as robotic-assisted laparoscopic approaches have shown no increased operative complications, similar hospital stays, and equivalent results when done without a bowel prep as compared to with a bowel prep.

Preferred bowel preparations vary by institution; however, a light mechanical bowel preparation for a laparoscopic case typically involves clear liquids for ≥24 hours preoperatively and a weight-adjusted dose of magnesium citrate (0.5 mL/kg, usually not >200 mL in total dose). More aggressive regimens, including GoLYTELY solution and possible oral antibiotics, can be used in surgeries requiring manipulation of bowel.

Often patients are admitted preoperatively to undergo bowel preparations. This allows for careful monitoring of electrolytes and individual titration of regimen to ensure the bowel is clean. Magnesium citrate can cause hyper­magnesemia while Phospho soda-based bowel regimens can lead to hyperphosphatemia and hypocalcemia. Furthermore, patients with chronic kidney disease or neuropathic bowel require special consideration as they are at higher risk for electrolyte compromise.

Preoperative Fasting

The goal of preoperative fasting is to reduce the volume and acidity of gastric contents to lower the risk of aspiration events during anesthesia and postoperatively. However, there is no literature linking higher gastric volumes to increased aspiration events. In children there is a fine balance between anesthesia risks and risks of dehydration and hypoglycemia. Current guidelines recommend fasting periods of 2 hours for clear liquids, 4 hours for breast milk, and 6 hours for formula, solids, or nonhuman milk ( Table 54.1 ). Studies show that periods of fasting are often longer than recommended, leading to significant preoperative discomfort. In addition, time of fasting does not correlate well with gastric volume. Despite this, aspiration events can have serious consequences and fasting times, if violated, will most likely lead to postponement of elective procedures.

Robotic and Laparoscopic Considerations

Mirroring trends in adult urologic surgery, laparoscopic and increasingly robotic-assisted laparoscopic procedures are becoming more common. Potential advantages to minimally invasive techniques include better cosmesis, improved visualization of anatomic structures, reduced postoperative pain, and shorter hospital stays. While surgical outcomes have generally been found to be equivalent, these results come out of large-volume centers and are likely not reproducible by surgeons with inadequate training in robotic technique.

There are aspects of pediatric physiology that lead to special considerations when utilizing laparoscopy in children. Children have higher incidences of right to left cardiac shunts, high chest wall compliance, rate-dependent cardiac output, and diaphragmatic respirations, all of which could be negatively affected by CO ₂ insufflation. While various hemodynamic and respiratory variables have been seen to change significantly following insufflation for both intra- and extraperitoneal procedures, conscientious anesthesiologists have been able to safely manage patients without complications.

The size of the patient also effects aspects of laparoscopic surgery. The smaller surface area for surgery requires more precise port placement to decrease the likelihood of trocar collisions. Foley decompression during intraperitoneal surgery is essential as the bladder commands a more abdominal position in children. Additionally, a child’s abdominal wall is more compliant so lower pressures are used to create adequate working space. Infants (0–2 years), children (2–10 years), and adolescents (>10 years) require pressures of 8–10 mm Hg, 10–12 mm Hg, and 15 mm Hg, respectively. Patients are at higher risk of developing fluid overload due to less insensible losses than with open procedures and reduced glomerular filtration due to increased abdominal pressures.

Latex Precautions

Latex is produced from the sap of Hevea brasilinesis , a rubber tree. In the 1980s the rise of transmittable diseases prompted increased use of latex products, and the 1990s saw a rise in latex allergies caused by type I immediate anaphylactic-type reactions as well as type IV delayed-type hypersensitivity reactions in sensitized patients. Pediatric urologists need to be cognizant of latex allergies, as spina bifida patients in particular are the highest-risk population. Historically, up to 60% of spina bifida patients have been found to carry the allergy, with the major risk factor being number of surgical procedures. Latex allergies can be life threatening if children develop intraoperative anaphylaxis, a condition that can be difficult to detect early as warning signs are hidden under surgical drapes. As latex has become a well-recognized allergen, it has increasingly been removed from contact with high-risk patients. Performing latex-free operations on spina bifida patients has shown a decrease in latex sensitization and allergies, with one study finding a decrease in symptoms from 55% to 5%. As latex substitutes become functionally equivalent to latex products, it is prudent to avoid using latex around all high-risk patients.

Perioperative Antibiotics

Currently there are no guidelines for perioperative antibiotic prophylaxis in pediatric urologic procedures. The goal of prophylaxis is to reduce postoperative infections while not exposing the patient to undue harm in the form of allergic reactions, side effects, or resistant organisms. Colonization with “superbugs” is a major concern among our patient population, especially since many have anatomic abnormalities that predispose them to forming UTIs. Perioperative antibiotics are best administered within 60 minutes of the start of a procedure and should end within 24 hours of the procedure.

A recent survey of pediatric urologists revealed that >75% would give antibiotics before open pyeloplasty, hypospadias repair with anticipation of indwelling catheter, reconstructive bladder surgery, endoscopic procedures, and open ureteral reimplantation; most would not give perioperative antibiotics for orchidopexies, circumcisions, simple chordee repairs, or hernia/hydrocele repairs. There is evidence to suggest that the risk of infection is related to the wound class of the procedure. Regardless of procedure site, wound class 2 procedures (clean contaminated) had a 6.7-fold higher rate of infections compared to wound class 1 procedures (clean), suggesting that prophylaxis should be targeted at higher wound class surgeries.

Without any formal recommendations, surgeon judgment should be used when deciding to use antibiotic prophylaxis. In our institution, we use prophylaxis for procedures involving skin incisions in the genital region in pubertal children, in addition to the common procedures listed above. Perioperative antibiotics are also given to children undergoing endoscopic manipulations who take daily prophylaxis.

Anesthesia

The fear of anesthesia looms large when parents are considering surgery for their children, often overshadowing concern for the procedure itself. Preoperative hospital visits that allow the parents and patient to meet with the anesthesia team are a powerful tool to reduce anxiety. Often recognition that the anesthesiologists are specially trained to take care of pediatric patients can reassure parents.

Risks associated with pediatric anesthesia have decreased dramatically as the medical field has recognized that child physiology is different from the adult’s. Modern anesthesia has proven to be very safe. A single center observational study of pediatric surgeries over a 30-month period showed a perioperative adverse event rate of 79 : 1000 anesthetics. The majority of intraoperative events were respiratory involving children <1 year of age while 77% of the PACU events comprised vomiting among older patients. There were no anesthesia-related deaths. Despite the overall safety, independent of ASA score, age <1 year predicted adverse events; therefore, all procedures in this population should involve a specialist provider. A recent systematic review confirmed the safety of pediatric anesthesia, finding that the risk of acute severe complications of anesthesia, defined as “an unexpected perioperative event in a pediatric patient which without intervention by the anesthesiologist within 30 minutes may lead to disability or death,” was <1%.

Recently there has been some concern over pediatric anesthetics and neurocognitive development. Rodent models have shown early anesthesia can impair synaptogenesis, causing neuronal apoptosis and subsequent learning and behavioral problems. Overall, observational studies have shown mixed results in the human population. There is evidence suggesting anesthesia, either as a single or multiple exposure(s) during childhood, increases the likelihood of developing a learning or behavioral disability. Bartels et al. conducted a twin study that compared anesthesia exposures prior to age 3 to educational achievement and cognitive problems at age 12. They concluded that anesthesia is a marker for later cognitive impairment, but anesthesia itself is not causal. Currently, more data are needed to determine the effect, if any, of early childhood anesthesia on cognitive development.

Hypothermia

Intraoperative hypothermia of as little as 1.5–2°C is known to have adverse outcomes, including increased wound infection risk, morbid myocardial outcomes, coagulopathy and need for transfusion, and prolonged recovery and hospital stays. Infants are at high risk for hypothermia due to their thin skin, increased body surface area to weight ratio, and decreased ability to thermoregulate. The most influential factors for decreasing intraoperative body temperature in infants and neonates are OR temperature less than 23°C and major versus minor surgery.

The ideal temperature in the operating room varies by patient age; however, it should approximate the temperature at which the child’s oxygen consumption and metabolic rate are minimal. This corresponds to 24–26°C in a newborn or small infant and 21°C in a child. Methods used to maintain the patient’s temperature include overhead radiant heat or heated room, warmed blankets and air blankets, prewarmed skin-preparation fluids, warmed IV fluids, and waterproof drapes.

Complications of Circumcision

Approximately one in three men worldwide are circumcised, with regional prevalence ranging from 75% in the United States to 6% in the UK. Complications occur in approximately 1.5% of these procedures. Complication rates vary depending on how old the patient is when the surgery is completed and whether the procedure is being done as part of a religious ceremony or by a medical practitioner.

Early complications include bleeding, infection, and penile or urethral injury. By far the most common complication is bleeding. Circumcisions performed with a Gomco clamp usually bleed from the frenulum and can be stopped with pressure or with a frenular stitch. If bleeding is coming from a cut skin edge, a hemostatic agent such as silver nitrate can be applied to the area. If there is a large surface area that is oozing with no apparent bleeding vessel, epinephrine-soaked gauze can be used as a compressive dressing to help achieve hemostasis. Often continued bleeding can be due to removal of too much penile shaft skin. The shaft will eventually re-epithelize and no skin grafting is needed but the patient will likely need close follow-up for local wound management for 1–2 weeks. Bleeding that is refractory to the above management, or that results in a large peri-penile hematoma may require surgical exploration.

Infection is a rare early complication. While the penile skin can be difficult to keep clean, the robust blood supply to the organ likely contributes to a low rate of infection.

Although rare, the most serious complications are partial or full-thickness excision of the glans, penile necrosis, urethral injury, or penile amputation. Necrosis typically occurs when “excessive” electrocautery is utilized during the circumcision or if it comes into contact with a metal Mogen or Gomco clamp. It is prudent to use bipolar cautery if needed for hemostasis. Excision of glans tissue is most common with a Mogen clamp when glans tissue is inadvertently pulled into the clamp with the foreskin. Inadequate lysis of adhesions or a high frenular attachment is often the underlying cause of this complication. Proximal migration of the Plastibell plastic ring can occur when it is retained for too long and can cause necrosis of the penis and erosion into the urethra. Additionally, in religious circumcisions the foreskin is often pulled up and pinched between the fingers, which can cause entrapment of the glans tissue. If the glans is amputated it should be wrapped in soaked gauze and placed on ice. Reattachment of the amputated tissue can be successful within 8 hours, and microsurgical technique is usually not needed.

Late complications include meatal stenosis, urethrocutaneous fistulas, skin bridges, and trapped penises. Meatal stenosis can develop in the setting of subclinical inflammation of the meatus unprotected by the foreskin. It has also been hypothesized that ligation of the frenular artery may contribute to stenosis. Stenosis, if symptomatic, requires surgical correction.

Urethrocutaneous fistulas likely develop after crush injuries to the ventral surface of the penis or excessive mobilization of the urethra during freehand circumcisions. Repair is delayed to allow for maturation of the fistula and growth of the penis to facilitate tissue handling.

Penile adhesions following circumcisions are common and do not always require treatment. If symptomatic, adhesions can be managed with a topical steroid cream; however, if they are refractory they may require a circumcision revision. If adhesions become epithelialized they form skin bridges, which will not respond to steroid cream or physical manipulation. Skin bridges require division.

A concealed or trapped penis can develop when the circumcision heals abnormally. A concealed penis occurs in the presence of a prominent suprapubic fat pad that subsumes the penile shaft resulting in deficient shaft skin. A hidden penis typically occurs when too much shaft skin is removed causing inward telescoping of the glans with subsequent scarring of the peri-penile skin over the glans, which may lead to secondary phimosis. This is more likely to occur if there is a preexisting ventral skin deficiency (penoscrotal webbing) that is unrecognized prior to circumcision. Conservative management with betamethasone cream to the scarred skin is effective in 79% of children, the remainder of whom require surgical intervention. If surgery is required, the penis should be degloved and the skin fixed to Buck’s fascia to prevent recurrence.

Certain anatomic abnormalities make neonatal circumcisions riskier and should be deferred. The presence of penoscrotal webbing, abnormal urethral meatus, including hypospadias or epispadias, micropenis, or buried penis all warrant a neonatal urology consult ( Fig. 54.1 ). Typically circumcision for these patients is deferred until after 6 months of age and is completed under general anesthesia.

Contraindications to neonatal circumcision. A, Buried penis; B, penoscrotal webbing; C, epispadias; D, micropenis.

(With permission from Anthony Caldamone.)

Complications of Inguinal Surgery

Complications of Pyeloplasty

Ureteroplevic junction obstruction (UPJO) is a congenital condition caused by a variety of possible etiologies, including intrinsic stenosis, abnormal insertion, aperistaltic segment, and extrinsic crossing vessels or fibrous bands. In the era of prenatal imaging most UPJOs are diagnosed at an early age; however, some children present later with flank pain, flank mass, and UTIs. Indications for repair include symptoms, impaired renal function, or progressive renal loss. In this section we will discuss open and laparoscopic pyeloplasty.

Choice of surgical approach depends on severity of disease, age of the child, and experience of the provider. The most common technique is the Anderson-Hynes dismembered pyeloplasty, with the spiral pyeloplasty typically reserved for long-segment stenosis. Laparoscopic and robotic pyeloplasty are increasingly utilized, with data showing a steeper learning curve versus open procedures; however, experienced surgeons have similar complication rates. Robotic or laparoscopic procedures may have an advantage over open procedures, especially in older children where smaller incisions offer better cosmesis and less pain; however, this is in exchange for higher costs and longer operative times.

The most common complications of pyeloplasty are UTIs and urinary leak. Postoperative UTIs can cause inflammation at the site of the surgery leading to fibrosis and subsequent failure. Preoperative urine cultures should be checked and the urine should be sterile when starting the procedure. Tal et al. found a 12.6% rate of positive urine cultures postoperatively, with a higher rate, although not statistically significant, among stented patients. Infection rates vary widely in the literature depending on definition, with Mufarrij et al. quoting a 2.9% rate of febrile UTI.

Persistent urinary leakage is usually identified by sustained high output from the Penrose drain, which is placed at the site of anastomosis intraoperatively. Other symptoms include pain refractory to typical analgesic regimen, prolonged postoperative fever or ileus, and flank mass. Urinary leaks can be managed conservatively, by retaining the Penrose drain for 5–7 days, but if leakage persists, drainage of the kidney may be required either via a double J ureteral stent or nephrostomy tube. Like UTIs, leaks can cause inflammation and fibrosis at the site of anastomosis and thus may increase failure rates. Ozayar et al. found that early intervention at a median of 4.5 days postoperatively with placement of a nephrostomy tube achieved the same rates of radiographic and symptomatic success as patients who did not have a complication. The incidence of urinary leaks likely varies depending on the procedure, with one review of the literature finding a 3% rate of leak among stented pyeloplasties versus 8% among unstented pyeloplasty. However, this series found a higher rate of UTIs among stented patients, suggesting there is a trade off when leaving a stent. Stented patients also require a second anesthesia for stent removal. Additionally, proximal migration or breaking of stents can further complicate this procedure. A more recent case series of 367 pyeloplasties found no difference in complication or failure rates between stented and unstented procedures, with the only statistically significant differences being a longer length of stay for stented patients of 0.5 day and a longer period for drains of 6 days in unstented patients.

Pyeloplasty failure is defined by persistent or delayed obstruction. Early obstruction often presents as urinary leak and can be managed conservatively as described above. However, persistent or delayed onset of worsening hydronephrosis or symptoms requires more aggressive treatment. Failure rates are low at 4% and are thought to occur due to fibrosis and restenosis at the anastomosis. Acute complications of UTIs and urinary leak might contribute to fibrosis, along with poor tissue handling, ischemia to the ureter, missed crossing vessels, and tension at the anastomosis. While avoiding an open reoperation for correction is tempting, endopyelotomy and endoscopic balloon dilation have had low success rates when compared to open, laparoscopic, or robotic reoperation. Redo operations may require a spiral technique to traverse a large segment or a ureterocalicostomy if there is a dependent calyx. Salvage rates approach 100% but can require more than one additional procedure. Refractory obstruction in the setting of poor renal function may require nephrectomy.