Pediatric Urology
Most problems of a child's kidneys, bladder and genitals are present from birth and are corrected with planned surgery. For several of them, the age at operation matters as much as the operation itself.
Pediatric urology covers undescended testes, hypospadias, hernias and hydroceles, tight foreskins, urine flowing back from the bladder to the kidneys, and blockages where the kidney meets its drainage tube. Most are diagnosed in the first months of life and treated in a day case or a short stay. Timing is important. A Swedish randomized trial found that undescended testes moved at nine months grew better than those moved at three years, and a national study found that operating before puberty halved the later risk of testicular cancer compared with operating after. Send us your child's ultrasound, scans and reports, and a pediatric urologist will tell you what the plan should be and when to come.
6 to 18 months
Recommended age for undescended testis surgery
2.23 vs 5.40
Relative risk of testicular cancer, surgery before or after age 13
1 to 3 days
In Istanbul for most planned operations
Free
Pediatric urologist's review of your file
Free consultation
One team for the whole urinary tract
A pediatric urologist works with pediatric anesthetists, radiologists, nephrologists and nurses trained in the care of small children. Many conditions are linked, an undescended testis with a hernia, reflux with bladder habits, so one team looking at the whole child avoids separate visits and repeated anesthesia.
Testicular torsion is an emergency
Sudden severe pain in the scrotum, often with vomiting, can mean a twisted testis. The testis can be saved only if it is untwisted within hours, so a child with these symptoms needs the nearest emergency department at once.
Why does timing matter, and what does the evidence show?
The Swedish timing trial
In Stockholm, 155 boys with one undescended testis were randomized to surgery at nine months or at three years, and the size of the testis was measured by ultrasound up to age four. After early surgery the testis grew and caught up partly with the normal side. After later surgery it did not grow, and the gap widened. Since testicular volume broadly reflects sperm-producing tissue, the result supports operating in the first year.
Surgical treatment at 9 months resulted in partial catch-up of testicular growth until at least age 4 years compared to surgery at 3 years, clearly indicating that early surgery has a beneficial effect on testicular growth.
Randomized trial of 155 boys, Journal of Urology, 2007
1
Before surgery
A pediatric anesthetist meets the family. Light milk is allowed until six hours before, clear fluids until one hour.
2
The operation
Under general anesthesia with a nerve block for pain relief, 30 to 90 minutes for most operations. A parent stays until the child is asleep.
3
Home
Most children go home the same day or the next morning, with pain relief and a check a week later.
Hypospadias
Hypospadias is repaired by straightening the penis if it curves, building a new urethra to the tip and reshaping the foreskin or removing it, depending on the family's wishes and the anatomy. Mild forms need one operation. Severe forms may need two stages six months apart. A thin catheter drains urine for several days. The commonest complications are a small leak, called a fistula, and narrowing of the new opening, which a minor second operation corrects.
Treatment for undescended testis before puberty decreases the risk of testicular cancer.
Swedish national cohort of 16,983 men, New England Journal of Medicine, 2007
Reflux of urine to the kidneys
Many young children with a urinary infection and fever turn out to have vesicoureteral reflux. The RIVUR trial randomized 607 children aged 2 to 71 months with reflux to daily low-dose antibiotics or placebo for two years. Antibiotics halved recurrent infections, from 72 to 39 children. Kidney scarring stayed the same, 11.9 against 10.2 percent. Bacteria became more resistant.
A follow-up analysis found new scars mostly in older children, those with a second infection before the trial and those with high-grade reflux. Surgery, either an injection of a bulking gel through a cystoscope or reimplantation of the ureter, is kept for children with repeated infections despite treatment, high-grade reflux or worsening kidney scans.
- Treat bladder and bowel problems, constipation and holding urine, which drive infections.
- Decide on daily antibiotics with the family, weighing fewer infections against resistance.
- Repeat kidney scans to watch for scarring.
- Offer endoscopic injection or open or robotic reimplantation when infections continue or reflux is severe.
1
Diagnosis
Ultrasound of the kidneys and bladder, a bladder X-ray study called a voiding cystourethrogram, and a DMSA kidney scan when scarring is suspected.
2
Treatment plan
The urologist and nephrologist agree on watching, antibiotics or surgery, according to the grade of reflux, infections and scans.
3
Follow-up
Ultrasound and urine tests at intervals, and a repeat scan after any surgery to confirm the reflux has gone.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
RIVUR trial, 607 children with reflux, two years
| Outcome |
Daily antibiotic |
Placebo |
| Recurrent urinary infection |
39 of 302 |
72 of 305 |
| Kidney scarring |
11.9 percent |
10.2 percent |
| Resistant E. coli at first recurrence |
63 percent |
19 percent |
Kidney blockage
Ureteropelvic junction obstruction
Many blockages show on scans before birth and improve without surgery. Doctors watch them with ultrasound and kidney function scans. When the kidney swells more, loses function or causes pain or infections, a pyeloplasty removes the narrow segment and rejoins the kidney to the ureter, by open, laparoscopic or robotic surgery. Success rates exceed nine in ten in experienced hands.
Hernia and hydrocele
Groin and scrotal swellings
An inguinal hernia in a child is repaired soon after diagnosis, since the bowel can become trapped. A hydrocele disappears by age one or two in many children. Surgery follows if it persists or changes size during the day, and both operations are day cases done through a small groin cut or by laparoscopy, with the child home by evening.
Anesthesia in small children
Parents worry most about the anesthetic.
Pediatric anesthetists adjust every drug and dose to the child's weight and age. A nerve block given while the child is asleep numbs the area for hours, so most children wake comfortable and need only paracetamol and ibuprofen at home. Operations are timed so that young infants have short fasts, and premature babies, who need longer monitoring after anesthesia, have surgery planned with that in mind. Questions on long-term effects of anesthesia in early childhood come up in many families. The team discusses them openly.
How many days in Istanbul, and what decides the cost?
Planning the trip
- Ultrasound reports and images, and any kidney scans or bladder studies.
- The child's weight, medicines, allergies and any previous operations or anesthesia.
- Photographs where useful, for example of hypospadias or a swelling.
Most trips are short.
Most planned operations need one to three days in Istanbul, a week for hypospadias with a catheter, and longer for kidney or bladder reconstruction. Children fly comfortably once they eat, drink and play as before and the surgeon has checked the wound, two to five days after a day-case operation.
Cost depends on the operation, the anesthesia, the hospital stay and any scans. Your own figure follows the free review of your child's file.
A coordinator who works with families every day plans the visit, from the visa invitation letter sent ten days ahead to the transfer and a family hotel near the hospital. One parent stays with the child throughout, and both parents stay until the child falls asleep. The team speaks seven languages, halal, vegetarian and diabetic meals are served, a prayer room is available, and a female doctor is assigned on request when the schedule allows. Back home, the same WhatsApp number reaches the coordinator, and the urologist reviews follow-up ultrasounds and photographs sent by your pediatrician, with a clear schedule of when each check is due, because many of these conditions, an undescended testis brought down at one year or a reflux that may resolve as the child grows, need watching for years after the operation itself is long forgotten by the child.
Pediatric urology FAQ
When should an undescended testis be operated on?
Between six and eighteen months of age. A randomized trial showed better testicular growth after surgery at nine months than at three years.
Does surgery for an undescended testis prevent cancer?
It lowers the risk but does not remove it. In a Swedish study, surgery before age 13 was linked to half the cancer risk of surgery afterward.
Does my child with reflux need surgery?
Most do not. Antibiotics halved infections in the RIVUR trial, and surgery is kept for repeated infections, severe reflux or worsening kidney scans.
At what age is hypospadias repaired?
Between 6 and 18 months, in one stage for mild forms and two stages for severe forms.
How long will we stay in Istanbul?
One to three days for most operations, around a week for hypospadias repair.
Can both parents be with the child?
Yes. Both parents can stay until the child is asleep, and one parent stays throughout the hospital stay.
References
- Kolon TF, Herndon CD, Baker LA, et al. Evaluation and treatment of cryptorchidism: AUA guideline. Journal of Urology. 2014;192(2):337-345.
- Kollin C, Karpe B, Hesser U, Granholm T, Ritzén EM. Surgical treatment of unilaterally undescended testes: testicular growth after randomization to orchiopexy at age 9 months or 3 years. Journal of Urology. 2007;178(4 Pt 2):1589-1593.
- Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at surgery for undescended testis and risk of testicular cancer. New England Journal of Medicine. 2007;356(18):1835-1841.
- RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. New England Journal of Medicine. 2014;370(25):2367-2376.
- Mattoo TK, Chesney RW, Greenfield SP, et al. Renal Scarring in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) Trial. Clinical Journal of the American Society of Nephrology. 2016;11(1):54-61.
