Pediatric urology has become an important discipline within the specialties of pediatrics and pediatric surgery. The enormous attention paid to urologie conditions unique to the pediatric age group, primarily congenital and developmental abnormalities; the development of more exacting and safer diagnostic methods; and the superb skill of the urologie surgeon with special training and experience with children have dramatically transformed the approach to management and the prognosis in infants and children with urologie disorders. A close working relationship has developed between the pediatric urologist and the pediatric nephrologist, merging the surgical and medical skills of these highly specialized disciplines.
This issue of Pediatric Annals deals with four of the most important urologie problems encountered by the pediatrician, nephrologist, and urologist. Elder and Duckett review the progress in the last few years in the prenatal diagnosis of urologie abnormalities of the fetus, with particular attention to the obstructive lesions that result in hydronephrosis. In many parts of the world, maternal ultrasonography is performed routinely to detect unsuspected fetal anomalies, about 20% of which are genitourinary. Prenatal diagnosis makes it possible to deliver the infant in a tertiary care center, for prompt evaluation, with the pediatric urologist prepared for surgical intervention of obstructive lesions, if necessary, soon after birth. There is now, in addition, a limited experience with fetal surgery for obstructive lesions, although the benefit of intervention prior to birth is uncertain, and fetal surgery for urologie abnormalities is rarely performed.
The undescended testis is one of the most common urologie abnormalities encountered by the pediatrician. Koyle, Raj fer, and Ehrlich review the embryology, pathogenesis, and pathophysiology of this disorder and discuss their current approach to management. The pediatrician should be able to differentiate the truly undescended testis from the normal testis that is not found in the scrotum because of a hyperactive cremasteric reflex. Early correction of the undescended testis is indicated in order to improve fertility. Koyle and coworkers discuss the role of hormonal therapy in children with cryptorchidism and the timing of surgical intervention. Most authors report poor results with hormonal therapy. In the opinion of this writer, descent occurs after treatment with gonadotrophin when the diagnosis is retractile testis and rarely, if ever, with true cryptorchidism. Although it is now recognized that many undescended testes are abnormal and that placing the testis into the scrotum does not assure normal spermatogenesis, cosmetic and psychologic improvement, as well as the enhanced ability to detect the development of tumors, warrant early intervention.
In the next article in this issue, Hulbett and Duckett review our current understanding of the embryology, diagnosis, and management of posterior urethral valves, the most common cause of bladder outlet obstruction in children. Prenatal and postnatal diagnosis has led to the detection of this condition in the absence of clinical symptomatology. Early diagnosis is important to avoid the consequences of obstructive voiding on the upper urinary tract. The diagnosis is suspected in the newborn on the basis of an inadequate urinary stream and a palpably enlarged bladder or following screening with ultrasound; the diagnosis is confirmed with voiding cystourethrography. Although surgical correction of posterior urethral valves usually proceeds without complication, ureterovesical reflux is encountered in approximately 50%, urinary incontinence may be a problem, and renal function may be seriously impaired, particularly if surgical correction is delayed.
The diagnosis of hypospadias and its correction are recorded in antiquity. The dysfunctional urination and sexual inadequacy that may result from this condition are well described by Levitt and Reda in their comprehensive review of this common condition. They review the genetics and point out the importance of investigation for associated genitourinary abnormalities and recommend performance of renal and bladder ultrasonography. The psychologic consequences of hypospadias, even following successful repair, are discussed. With modern techniques, surgical correction of hypospadias can be anticipated to result in an excellent cosmetic and functional outcome.
A careful review of the articles in this issue will bring the pediatrician up to date on some of the most important developments of recent years in the diagnosis and management of common urologie disorders in children. It is essential that the pediatrician be familiar with these conditions to ensure their early recognition and close collaboration with the pediatric nephrologist and pediatric urologist. In this way, the infant and young child will he assured the benefits of the extraordinary advances in this field.