At Mount Sinai, our pediatric urology specialists, including Jeffrey A. Stock, MD, Fernando A. Ferrer, MD, and Neha Malhotra, MD are dedicated to providing personalized and comprehensive family-centered care offering evaluation, medical treatment, and surgery for newborns, infants, children, and adolescents. Our multidisciplinary team approach uses the extensive knowledge and experience of the health system’s obstetricians, perinatologists, neonatologists, and pediatric urologists to manage prenatally detected genitourinary anomalies.
Conditions We Treat
We treat a wide variety of perinatal conditions, including hydronephrosis, posterior urethral valves, ureteropelvic junction obstruction, vesicoureteral reflux, and multicystic dysplastic kidneys. We routinely perform surgical repairs of common genitourinary anomalies such as hydroceles, undescended testis, hypospadias, and chordee during the first year of life. Whenever possible, we offer this advanced care on an outpatient basis. The most common conditions we treat are:
Hydronephrosis refers to extra urinary fluid in the kidney. It is not a separate disease, but a physical phenomenon that occurs with certain diseases. Its symptoms, treatment, and prognosis are those of the disease that caused it. Typically, if this occurs prenatally, it resolves itself on its own. Moderate to severe hydronephrosis may need intervention.
Tumors of the kidney require surgical excision as well as combined management with pediatric oncology. Wilms tumor is the most common example; other conditions we see frequently are mesoblastic nephroma and neuroblastoma (found commonly on the adrenal gland, but can be located anywhere along the sympathetic nervous system). Signs/symptoms of kidney tumors include abdominal pain, abdominal mass, blood in the urine, vomiting, and failure to thrive. The prognosis for these tumors has improved greatly with the combination of surgery, chemotherapy, and radiation.
Kidney stones are much more common in adults than in children. Nonetheless, the condition does happen. When it does, the first step in treatment is to find out what type of kidney stone is present. Kidney stone types include calcium oxalate, uric acid, cystine stones, and struvite stones. Once we have determined what type of kidney stones your child has, we must determine the cause of the condition. Kidney stones are frequently caused by abnormal function of the metabolism, reflux, and obstruction. Collaborating with our colleagues in the Department of Nephrology, we often use shock wave lithotripsy or endoscopy to disintegrate the stone without surgery.
Urinary tract infections (UTI) are often the first sign of a congenital bladder or kidney anomaly. These UTIs may go undiagnosed without a proper examination of the urine. If a true UTI exists, we may perform a renal and bladder ultrasound as well as a voiding cystourethrogram to rule out any kidney or bladder anomalies. Between 30 percent and 40 percent of children with a UTI accompanied by a high fever have some type of urological anomaly from birth. Signs and symptoms of a UTI are: dysuria (burning on urination); frequent and urgent urination; foul smelling, cloudy urine; incontinence (bed wetting episodes); and fever.
Vesicoureteral reflux (VUR) is an abnormal movement of urine back from the bladder into the kidneys. We rank the severity of VUR on a scale of 1 to 5, with 1 being the mildest and 5 the most severe. Most children develop grades 1 or 2, which generally resolve themselves over time. Grade 3 resolves itself about half the time. Grades 4 and 5 generally require surgical intervention. To treat Grades 4 and 5, we lengthen the path of the ureter as it travels from the kidney into the bladder. The surgery is successful approximately 98 percent of the time.
The goals of VUR treatment is to prevent infected urine from reaching the kidney, which can cause infection (pyelonephritis), scarring, hypertension, proteinuria, and even end-stage renal disease. Often, we place children with VUR on daily low-dose antibiotics. If the VUR is high-grade or the child has another condition that complicates matters, we may opt for surgical repair.
Prune belly syndrome is a highly unusual condition. It occurs in males who have a wrinkled abdominal wall as a result of insufficient stomach muscles, bilaterally undescended testes, and other urinary tract anomalies. We diagnose prune belly syndrome at birth. To treat this condition, we typically use surgery to bring the testes into the scrotum and correct the abdominal wall defects. Often, these efforts also address reflux.
Exstrophy is an uncommon congenital bladder anomaly that happens when the tissue of the abdominal wall is deficient and the bladder becomes flat along the abdominal wall, instead of being a sphere inside the pelvis. As a result of the condition, urine leaks out of the abdominal wall from the exposed ureteral orifices. This is associated with pubic separation and epispadias, which is a severe congenital curvature and foreshortening of the penis.
Traditional treatment for exstrophy is to reconfigure the bladder as a sphere in the first 48 hours of life and to bring the widened pubic bones together. Then, later on, we construct a bladder neck and reflux correction will be performed. The third step is repairing the penile abnormality. Sometimes we can do one or more of these procedures during the same surgical session. The goal is to create a normally functioning bladder (with adequate volume, lack of reflux, and dryness) and a normal-looking and functioning penis. Some patients require augmentation of the bladder with a portion of the intestines.
Posterior urethral valves are wisps of tissue in the prostatic urethra (the tube running through the prostate), preventing the release of urine out of the bladder. These valves cause an obstruction that can be anywhere from mild to severe (severe problems can result in renal failure, bladder dysfunction, or even death). We diagnose this condition by prenatal ultrasound. When we see it, we need to destroy the valves using cytoscopy within the first week of life. Physicians will direct attention to possible electrolyte abnormalities and pulmonary hypoplasia (underdevelopment of the lungs) that can develop secondary to the decrease in amniotic fluid (oligohydramnios). Generally, we can treat this condition during the first few days after birth, using a cystoscope that we place into the urethra to remove the valves. Sometimes we need to intervene before the baby is born, to protect the developing kidneys and lungs.
Neural tube defects occur when the bones of the spine do not form correctly, causing the spinal cord and its nerves and coverings to protrude through the skin or lie just beneath it. Since we have begun using prenatal vitamins, including folate, we have seen far less of these defects. However, many children still suffer from myelodysplasia (which includes myelomeningocele and occult spina bifida). Since the bladder and the urinary sphincters function under neurologic control from the spinal cord, damage can result in lower urinary tract dysfunction which, if untreated, can lead to kidney damage. Symptoms of the condition are frequent infections, incontinence, and urination.
The treatment goal is a normal capacity bladder with continence. We also hope to preserve kidney function and decrease the incidence of infections. Recent advances in catheterization, medicine, and urodynamic studies help considerably. When these do not work, we can perform a surgical procedure to restore the bladder toward normal function.