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INTRODUCTION

FOCUS POINTS

  1. Pediatric patients undergo a wide variety of genitourinary procedures, which can range from isolated outpatient surgeries to complex reconstructions.

  2. Most urological procedures are elective in nature, and majority of these patients are healthy or with stable chronic medical conditions.

  3. Latex-free precautions during perioperative management are highly recommended in patients with chronic urological conditions due to concerns of hypersensitivity after repeated latex exposure.

  4. Regional anesthesia and analgesia are excellent alternative/complementary techniques for genitourinary procedures with minimal risk when performed in asleep patients.

  5. Perioperative medications should be reviewed in advance and administration or discontinuation discussed [chronic steroids or other immunosuppressants, antihypertensive medications such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs)].

  6. Renally excreted medications should be adjusted perioperatively to decrease the risk of further renal impairment.

  7. End-stage renal disease (ESRD) patients on dialysis should be particularly reviewed for fluid status and symptoms between dialysis sessions.

The genitourinary system has been described to have the highest percentage of congenital anomalies. A study of antenatal ultrasounds reported a frequency of 21% for urinary tract abnormalities;1 this is supported by a review that estimated the screening sensitivity of urogenital anomalies to be almost 88%.2 In the newborn period, ultrasonography is the preferable diagnostic tool for initial evaluation of abdominal masses; almost 55% of these have been shown to be of renal origin.3 It is important to remember that nephrogenesis continues to progress until 36 weeks of postconceptual age. At birth, there is a significant decrease in renal vascular resistance with an associated increase in glomerular filtration rate.

Children undergoing urological procedures may be prone to emotional disturbances because of repeated interventions. In addition, patients with obstructive uropathy and chronic renal insufficiency are susceptible to frequent urinary tract infections (UTIs). Therefore, special attention to their psychological well-being and to the risk of septicemia is warranted in the perioperative period.4

This chapter highlights key surgical conditions involving the genitourinary system, and provides a brief overview of the anesthetic management for this diverse population of surgical patients.

KEY SURGICAL CONDITIONS

External Genitalia and Urethra

Circumcision

Circumcision, which involves surgical removal of foreskin of the penis, is a common outpatient operation in healthy male children. Besides religious and sociocultural reasons, medical indications include phimosis, balanitis, and urine outlet obstruction.

Neonatal circumcision has a low complication rate and is usually performed in the nursery under local anesthesia. In infants and children, circumcision is performed under general anesthesia, using face mask, laryngeal mask airway (LMA), or endotracheal tube.5 While a caudal block may be performed for postoperative analgesia, a multimodal regimen using acetaminophen (10 to 15 mg/kg IV) and topical anesthesia (lidocaine-prilocaine) or a dorsal penile block is equally effective.

Two major complications of circumcision include infection and bleeding.

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