Timing of Elective Surgery on the Genitalia of Male Children With Particular Reference to the Risks, Benefits, and Psychological Effects of Surgery and Anesthesia

Abstract

Technical considerations are no longer the major limiting factors in determining the timing for the surgery of undescended testes or hypospadias, because experienced pediatric urologic surgeons can perform these operations on young children safely and reliably. Important theoretical considerations suggest that early orchidopexy is preferable, particularly in minimizing the histologic injury that occurs with increasing age. There does not seem to be an increased risk when orchidopexy is performed in children 6 to 12 months of age, compared with the risk in older children, provided that it is performed by surgeons, nurses, and anesthesiologists with pediatric training and experience. Emotional, cognitive, and body image development may be affected profoundly by both the genital deformity and the reconstructive surgery. These psychological factors are of considerable importance, in that a child's reaction to both the surgery and the anesthetic trauma varies dramatically with age. Postoperative behavioral problems such as aggressive or regressive behavior, night terrors, and anxiety may be more common at certain ages, particularly at 1 to 3 years of age. The period from 6 weeks to 15 months is a relatively good time for surgery from the viewpoint of emotional development, provided parentchild separation is minimized; this period has the additional advantage that the child's "defective status" within the family is not prolonged. The importance of the care giver's attitude toward the child may be of particular importance to the child's developing body image. Superimposed on all of these factors is the developing sexual identity of the individual, which again suggests that, in the absence of any other health factors, successful early genital surgery minimizes disturbances in the patient's psychological development. The best time for surgery for hypospadias is between 6 and 12 months of age. Orchidopexy should be performed at or near 1 year of age. If the improved risk-to-benefit ratio for this early genital surgery is to be achieved, it is essential that children undergoing this surgery be cared for at facilities with experienced pediatric support personnel, particularly in the areas of anesthesia, urology, and nursing, who are sensitive to the special needs of children.