Although prenatal intervention is extremely unusual, The Mount Sinai Medical Center's Department of Obstetrics has a good deal of experience with this rare procedure. Often, however, hydronephrosis in the prenatal stage can frequently be resolved with observation. Moderate to severe hydronephrosis may represent a significant urinary tract disorder.There are many diagnostic tools and methods to distinquish which a patient is suffering from and to determine the best therapeutic remedy for it.

A detailed evaluation in conjunction with pediatric nephrology (the study of kidneys) is necessary. Using shock wave lithotripsy or endoscopy the stone can be disintegrated without the need for surgical incisions. Less commonly, the stones need to be treated with open surgery.

The goals of treatment in reflux are to prevent infected urine from reaching the kidney which can cause pyelonephritis (kidney infection), scarring, hypertension, proteinuria and even end stage renal disease. Because of this many of these children are placed on daily low-dose antibiotics. In the case of high grade reflux or if the the condition is associated with a concomitant condition that makes resolution unlikely, surgical repair is an appropriate option.

The testes are usually able to be brought into the scrotum and the abdominal wall defect can be surgically repaired so that it has a less wrinkled appearance. Reflux is corrected if it does not resolve. While the bladder is large, it generally does not need surgery to reduce its size.

Traditional treatment is to reconfigure the bladder as a sphere in the first 48 hours of life and to bring the widened pubic bones together. At a later date construction of the bladder neck as well as the correction of reflux should be performed. In the third stage the penile abnormality is repaired.

This is technically demanding surgery and requires dedicated commitment to follow-up by both the treating physician and the family. At times, several of these procedures can be combined under the same anesthesia, and in fact in many instances the exstrophy and epispadias are repaired together in one surgery in the first 2 days of life. The ultimate goals are creation of a normally functioning bladder (including adequate volume, lack of reflux, and dryness) and a normally appearing and functioning penis. Some of the patients require augmentation (enlargement) of the bladder with a portion of the intestines.

In rare cases, a combined obstetrical/urologic team needs to intervene prior to delivery to protect the development of the kidneys and lungs. Posterior urethral valves can be treated in the first few days after birth in almost all infants. A cystoscope is introduced in the urethra, and through the scope, a small wire is used to burn away the valves. In many cases, long-term follow-up with the urologist is necessary.

The goals of treatment for a child with myelodysplasia are a normal capacity bladder that stores urine at a low pressure and does so in a continent fashion. In addition we hope to preserve the function of the kidneys and decrease the amount of infections that the child has.

A great advance in this has been the common usage of clean intermittent catheterization as well as pharmacologic agents and urodynamic studies which help clarify the function of the bladder. If these conservative measures do not assist in controlling bladder function other surgical procedures can restore the bladder towards normal function.

The majority of procedures to correct hypospadias are done on an ambulatory basis under general anesthesia and are extremely successful. The foreskin, which is present only on the dorsal side, should not be removed prior to the reconstructive surgery as often this skin will be used in the repair. However due to advances and newer techniques, certain types hypospadias can be repaired even in the absence of the foreskin. This type of surgery, as with all of these congenital anomalies requires a good deal of experience and should be done only by those who deal with these problems on a regular basis.

Episadias can be corrected by creating a new urethra and rotating the corporal bodies to give the penis its more normal orientation.

Correction of this abnormality can usually be done on an ambulatory basis by surgically resecting the offending chordee tissue and/or placing placating sutures in the penis.

Many of these conditions can be treated by surgical means and ultimately sexual and fertility potential established. These disorders require close and immediate consultation between the pediatric urologist, pediatric endocrinologist, geneticist and neonatal intensive care physician to determine what possible abnormalities are seen in the genes, hormones, and anatomy.

If the testis has not descended by the first 6-12 months of life it is unlikely to do so. In addition, the testis, which functions and grows better in its scrotal position, begins to undergo damage as early as one year of life if left outside of the scrotum. We therefore recommend surgical correction of undescended testes at 6 to 12 months of age.

A non-palpable testis represents one of three scenarios: 

•  the testis is actually in the inguinal canal and for one reason or another cannot be palpated 
• the testis is inside the abdomen 
• the testis does not exist on that side

Our preference to differentiate between these three possibilities is to perform laporoscopy followed by the appropriate procedure (i.e. orchidopexy vs removal of testicular remnant) in the same sitting. Many of the intra-abdominal testes can be brought down into the scrotum via laporoscopy alone. If cryptorchidism is corrected, fertility potential should approach that of the general population. Frequent testicular examinations are required to check for possible testis tumors.

Inguinal hernias are treated by closing the patency with a surgical procedure. The recurrence rate is minimal. This surgery is done under general anesthesia on an ambulatory basis.

Like a hernia, hydroceles are very easily treated by simply closing the patency via surgery and the recurrence rate is minimal. This surgery also can be done under general anesthesia on an ambulatory basis.