AMERICAN ACADEMY OF PEDIATRICS

590 PEDIATRICS Vol. 97 No. 4 April 1996

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

Surgery and Anesthesia

Section on Urology

In 1975 an action committee of the American Acad-emy of Pediatrics (AAP) Section on Urology pub-lished its recommendations for the timing of electivesurgery on the genitalia of male children.’ The com-mittee concluded at that time that “the ideal age fororchiopexy is after age 4 and before age 6 unless asymptomatic hernia is present.” Hypospadias sur-gery was best performed sometime after the child’sthird birthday.

In the years since that report, the approach to thesecommon childhood problems has been modified sig-nificantly as a result of a combination of factors,particularly the following: an improved understand-ing of the psychological implications of genital sur-gery in children; improvements in the technical as-pects of surgery for hypospadias; clarification of thenatural history of undescended testes; and advancesin pediatric anesthesia. These changes have resultedin the AAP requesting that a committee reevaluatethe previous recommendations for the timing ofmale genital surgery. The Action Committee onSurgery has considered the age-related anestheticand/or surgical risks and benefits in relation to thepsychological impact of these procedures during thevarious stages of the child’s development.

PSYCHOLOGICAL FACTORS

Emotional Development

Several studies2” have demonstrated that duringthe first year of life, opportunities for establishing astrong and stable mother-father-infant relationshipmust be fostered. The quality of this attachment willbe affected by many variables; one of these, congen-ital birth defects, may influence the mother’s attitudetoward the child.

From the viewpoint of emotional development, theperiod from 6 weeks to approximately 15 months ofage generally seems to be a relatively less-difficultpsychologic developmental period for surgery if pa-rental separation is limited. The period from 24 to 36months of age also may be a time when the trauma ofsurgery is relatively less difficult. However, that pe-nod has the disadvantage of potentially prolonging

The recommendations in this statement do not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, taking into

account individual circumstances, may be appropriate.

PEDiATRICS (ISSN 0031 4005). Copyright © 1996 by the American Acad-

emy of Pediatrics.

the child’s “defective” status and crystallizing anydisruption in family relationships that the child’scondition may have produced.

Body Image and Sexual Development

In large part, the body image of a child is derivedfrom the soda! interactions with the primary caregivers and peers. A child with an external birth do-fect, including hypospadias, is at risk of developingdistortions of body image that reflect other people’ssubtly communicated evaluations of the child’sbody. Given the early development of body imageand the importance of parental response, the impli-cation for repair of hypospadias is that the earlier therepair can be achieved, the more likely the child wifiachieve a psychologically healthy perspective ofbody image.

A specific area in which social feedback affectsbody image is sexual development. Research on chil-dren with ambiguous genitalia has shown that sex-ual identity is a function of social learning throughdifferential responses of multiple individuals in theenvironment.46 For example, children whose genetic

sexes are not clearly reflected in external genitalia (ie,hermaphroditism) can be raised successfully asmembers of either sex if the process begins before theage of 2#{189}years. Therefore, a person’s sexual bodyimage is largely a function of socialization.

School-aged boys with hypospadias are morelikely to have behavior that is gender atypical whencompared with that of boys without hypospadias.7The severity of the anomaly does not predict thedegree of feminine behavior. The repair of hypospa-dias before 30 months of age seems optimal for thefollowing reasons: (1) awareness of the differentsexes as well as the presence of a physical deformityoccur at that time; (2) socialization of boys of that agecreates situations in which comparison of genitaliaoccurs-nursery schools often provide this opportu-nity, and boys who sit to urinate or who have readilyvisible penile defects will be exposed to the socialresponses of peers; and (3) from the age of 30 monthsto at least 5#{189}years, the boys’ fears of physical harmare significant and may be exacerbated by surgery.8’9These older boys facing repair of hypospadias needreassurance that their sex will not be altered in anyway and that they are already completely male.

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AMERICAN ACADEMY OF PEDIATRICS 591

Cognitive Development

Cognitive aspects of the preparation of a childyounger than 18 months old for surgery are neces-sarily limited. Children nearly 2 years of age, how-ever, can comprehend that they will be in a strangeenvironment and receive treatment. Between theages of 2 and 7 years,’#{176}children can understand moreinformation and still will require simple, consistent,and concrete explanations of what they will experi-ence and how long they will be away from home,who will be with them, and when and where theywill feel pain. Such children are egocentric in theirsview of the world and, therefore, need clear, consis-tent statements of negative causality, such as, “youroperation is not your fault or a punishment.”Thought may be illogical during this period and,unless one is careful, a child may later have misun-derstandings. A child who has attained the capacityfor operational thought (7 years of age or older) willbe able to understand causality in a more adult-likefashion but still may unconsciously associate surgerywith punishment.

Psychological Effects of Surgery and Anesthesia

In 1945, Levy” published the first study to addressspecifically the question of the psychological effectsof surgery on children. He noted that the highestincidence of postoperative emotional disturbancewas seen in children between the ages of I and 3years. Characteristic types of problems were pro-longed night terrors (children between 1 and 2years), negativism (children older than 4 years), andvarious fears (including phobias, hysterical reac-tions, and anxiety reactions) in all age groups. Levyreasoned that surgery represented a greater emo-tional hazard to the 1- to 3-year-olds because of theirpoorer comprehension, increased dependency ontheir mothers, decreased social contacts outside thehome, and decreased facility to handle anxiety.

Jackso&2 examined emotional trauma in childrenwho underwent tonsillectomies. Thirteen (9%) of the140 children had postoperative behavior changesthat were thought to be indicative of emotionaltrauma. Again, children between the ages of I and 3years were at increased risk for postoperative behav-ioral changes.

Vernon and associates” examined the psychologi-cal response to anesthesia and surgery in 22 children2 to 6 years of age. The factors that increased suscep-tibility to postoperative emotional stress were age,length of hospitalization, and the particular anesthe-siologist involved. Factors not considered significantby the authors included birth order, gender, priorhospitalization, the preoperative behavior of thechild, characteristics of the illness or treatment, thedegree of pain during hospitalization, or the pres-ence or absence of the mother during induction ofanesthesia. They suggested that reducing the child’sunfamiliarity with the hospital environment may re-duce the incidence of distress after surgery.

Inadequate preoperative sedation in young chil-dren may result in excessive preoperative fear andanxiety in addition to postoperative emotional dis-

turbances.’4 Deliberate falsehoods and deceptions in-crease the potential for postoperative emotional dis-turbances in older children, because, ultimately, thechildren are confronted with the truth. Davenportand Werry’5 compared the behavior of 145 childrenundergoing tonsillectomies to that of siblings andhealthy control children and concluded that briefhospitalization, minor surgical pain, and skillful an-esthesia produce no residual behavioral effects in themajority of children.

The definitive study of the psychological risks ofthe surgery and anesthetic will never be done, be-cause it is difficult to isolate the psychological stressinflicted by hospitalization, anesthesia, and surgery.Existing data, however, suggest that certain groupsof children may be at increased risk of postoperativebehavioral sequelae. An individual anesthetist’s rap-port with a child can lessen the incidence of stormyinductions. Older children benefit from clear andhonest explanations of anesthesia, surgery, and hos-pitalization; a familiarity with the hospital and sur-

gical environment is also helpful.

Anesthetic Considerations

Pediatric anesthesia has come of age during thelast 10 to 15 years, with a number of dramatic im-provements. Perioperative monitoring has improvedconsiderably with the use of pulse oximetry to re-duce both intraoperative and postoperative hypox-emia in infants and children, and this technology isnow routine in pediatric centers. Advances in phar-macology have produced shorter-acting syntheticnarcotics and muscle relaxants, resulting in safer andmore-stable anesthesia. An improved understandingof the unique physiologic responses of neonates, in-fants, and children to anesthesia has resulted in im-proved management of respiratory problems, cardio-vascular responses, and fluid and electrolyte balance,as well as temperature regulation. Caudal anesthesiahas been used with increasing frequency for postop-erative analgesia in the pediatric population, as wellas to reduce requirements for intraoperative anesthe-sia. In addition, pediatric anesthesiologists have ac-quired an improved understanding of the importantpsychological differences between children of differ-ent ages, as well as an increased awareness of theimportance of minimizing the period of parent-childseparation.

Most studies of anesthetic risk are not stratified byage and American Society of Anesthesia (ASA) class,and therefore, it is difficult to determine the preciseanesthetic mortality rate for ASA class I patientsbetween 6 and 12 months of age. Furthermore, moststudies do not consider relative surgical magnitudes;however, it is reasonable to assume that the anes-thetic risk for the repair of hypospadias and orchio-pexy is probably less than that for major intra-abdominal or cardiac procedures.

Tiret et aP6 reported a mortality rate of I in 40 000in a prospective survey of anesthesia-related mortal-ity and morbidity in infants and children in 440institutions chosen at random in France. Smith’7 re-ported no deaths in 37 000 cases of tonsillectomy andonly 1 anesthetic death in 29 000 procedures of all

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592 TIMING OF ELECTIVE SURGERY ON THE GENITALIA OF MALE CHILDREN

types. Mayhew and Guiness’8 reviewed a total of33 636 pediatric patents undergoing anesthesia andfound only 2 incidents of cardiac arrest in ASA classI patients, an incidence of cardiac arrest of I in 16:800. Both of these children recovered without inci-dent. Patel and Hannallah’9 confirmed the safety ofped iatric outpatient anesthesia.

Roy and Lerman2#{176}found an increased risk of la-ryngospasm in infants between I and 3 months of

age. The incidence remains fairly constant betweenthe ages of 6 months and 9 years. It is difficult todocument an increased incidence of laryngospasm inchildren between 6 and 12 months of age when com-pared with older children. There is an increased riskof postoperative hypoxemia in young children thatmay persist for several hours even after uncompli-cated anesthesia. The recommendation for supple-mentary oxygen in the recovery room has reducedthis potential problem significantly. With the routineuse of a pulse oxirneter as well as other intraopera-tive and postoperative monitors, undetected hypox-emia should be rare. Other significant complicationsof anesthesia, including aspiration of gastric con-tents, hypotension, malignant hypothermia, and hal-othane-associated hepatitis, do not seem related toage.

These data suggest that after the first 4 to 5 monthsof life, age alone is not the major risk factor, as longas the anesthetic is administered by an anesthesiolo-gist with significant pediatric experience and appro-priate monitoring is used.

Undescended Testes

Recognition of the changes in the treatment ofcryptorchidism during the last decade are best un-derstood by contrasting current practices with theoutdated recommendations from the last AAP Sec-tion on Urology Action Committee report in 1975. Atthat time it had been indicated that:

1. Primary dysgenesis (a congenital lesion) waspresent in 20% to 100% of cryptorchid testes;

2. The critical timing of histological deterioration oc-curred between 4 and 10 years of age, althoughsome testes were suspected to be affected as earlyas I year; and

3. Little evidence for spontaneous descent after Iyear was found. The report concluded that orchi-dopexy should be performed after the fourthbirthday, although there were indications that ear-lier orchidopexy might be beneficial. The chal-lenge was issued that it would be “. . . the respon-sibility of those that promote . . . earlyorchidopexy to prove . . . the efficacy of such anapproach.”

In the intervening period, the challenge to provethe efficacy of early orchidopexy has been met. Theoverwhelming impetus for earlier surgery has beenthe clear-cut documentation that histologic deterio-ration in cryptorchid testes begins during the secondyear of life. Studies indicate that between 0 and 6months, virtually all cryptorchid testes examinedhistologically appear normal.2’ At I year, although

there is some variation in germ cell numbers, withsome cryptorchid testes having lower counts thannormal, mean values do not deviate from normal.22By 2 years, 30% to 40% of testes are aspermato-genic.21”� Further germ cell deterioration occurs pro-gressively with increasing age. In addition to thesequantitative changes, qualitative changes in the germcells (increased nuclear size and increased DNA con-tent) have been demonstrated in older boys, 6 to 18years of age, possibly representing premalignantcells or those qualitative changes relating to fertilityreduction later in life.24 Although the germ cells arethe target regarding fertility, significant histologicchanges in other cells, especially Leydig’s cells, occurearly. Abnormal hormonal correlates of these histo-logic abnormalities have been demonstrated even ininfancy, with a reduction in the response of luteiniz-ing hormone to gonadotropin-releasing hormonestimulation.� Subsequent infertility correlates ofthese abnormalities exist. A direct relation has beenshown between prepubertal germ cell counts in cryp-torchid biopsies and sperm counts in the semen anal-ysis of the same patients in adulthood.26 To date,

only one study relates fertility to the age at whichorchidopexy was performed. In this study, 90% ofmen were fertile when orchidopexy had been per-formed when they were between 0 and 2 years; 50%were fertile when it had been performed between 3and 4 years; and 30% were fertile when it had beenperformed between 9 and 12 years.27

These studies suggest that damage in cryptorchidtestes is not congenital, and that the associated tes-ticular deterioration should be considered a diseaseprocess, not a congenital malformation. Primary dys-genesis is seldom identifiable as a cause of theseobserved histologic abnormalities. Timely interven-tion in relocating these testes to the scrotum is likelyto prevent histologic deterioration. As with othergenital procedures, improved surgical technologyhas lowered the age at which successful orchidopexycan be performed. Miniaturized instrumentation,fine suture materials, optical magnification, andimproved surgical techniques now allow orchi-dopexy to be performed safely in children I year ofage. The complication rate for orchidopexy per-formed by pediatric subspecialists is not greaterfor young children than it is for older patients.28Whereas orchidopexy in 1955 was associated withan 8-day inpatient stay,29 virtually all orchido-pexies for palpable testes are now performed on anambulatory basis.

In summary, there are strong indications that do-terioration of cryptorchid testes begins around 1 year

of age. These deteriorative changes may be irrevers-ible and may correlate ultimately with poor semenquality. Because spontaneous testis descent after6 months of age is unlikely, the need for treatmentafter that time is evident. Because orchidopexy at1 year of age can be done safely in experiencedhands, we recommend it at that age or soon thereaf-ter as the optimal current treatment for children withcryptorchid testes.

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AMERICAN ACADEMY OF PEDIATRICS 593

Hypospadias

In the previous report of the action committee,reconstructive surgery for hypospadias was recom-mended for patients when they were at an age whenthe potential for an excellent functional and cosmeticresult was thought to be optimal. Technical consid-erations were thought to have the greatest influenceon the timing of surgery. At the time of that report,multistage reconstructive techniques with indepen-dent chordee correction and the urethral reconstruc-tion separated by an interval of 6 to 12 months werethe rule. Children frequently remained in the hospi-tal for 5 to 14 days after each surgical procedure, andparental rooming in was not routine in all centers.

Today, experienced surgeons who perform recon-structive surgery for hypospadias can accomplishthe vast majority of repairs of hypospadias with asingle-stage procedure; multistage repair is reservedfor only the most severe malformations. Despite thefact that more complex and time-consuming single-stage reconstructions are commonly performed,many surgeons are regularly performing surgery forhypospadias when children are 6 months of age.�#{176}’�The routine use of optical magnification, microin-strumentation, and delicate suture material hasmade surgery for hypospadias in small infants tech-nically feasible,32’�’ and experienced surgeons canperform early reconstructive surgery with cosmeticand functional results at least equal to those achievedin older children.M��5 However, not all institutionshave individuals on their staffs who are experiencedand comfortable with the complexities of surgery forhypospadias in young infants, and under these cir-cumstances, the surgical risks may be increased.

Paradoxically, as more complex reconstructiveprocedures are performed in much younger chil-dren, the requirement for postoperative hospitaliza-lion has been reduced dramatically. Currently, themajority of operations for hypospadias are now per-formed as outpatient procedures or with only over-night hospital stays, thereby minimizing the periodof potential parent-child separation and, theoreti-cally, much of the emotional trauma associated withthe surgery. When a hospital stay is required, mostcenters take great care to minimize the time ofparent-child separation; rooming in is routine inmost pediatric centers. When a child is cared for in ahospital where the above criteria can be met, surgeryfor hypospadias optimally should be performedwhen the child is 6 to 12 months of age.

SUMMARY

Technical considerations are no longer the majorlimiting factors in determining the timing for thesurgery of undescended testes or hypospadias, be-cause experienced pediatric urologic surgeons canperform these operations on young children safelyand reliably. Important theoretical considerationssuggest that early orchidopexy is preferable, partic-ularly in minimizing the histologic injury that occurswith increasing age. There does not seem to be anincreased risk when orchidopexy is performed inchildren 6 to 12 months of age, compared with the

risk in older children, provided that it is performedby surgeons, nurses, and anesthesiologists with pe-diatric training and experience.

Emotional, cognitive, and body image develop-ment may be affected profoundly by both the genitaldeformity and the reconstructive surgery. These psy-chological factors are of considerable importance, inthat a child’s reaction to both the surgery and theanesthetic trauma varies dramatically with age. Post-

operative behavioral problems such as aggressive orregressive behavior, night terrors, and anxiety maybe more common at certain ages, particularly at I to3 years of age. The period from 6 weeks to 15 months

is a relatively good time for surgery from the view-point of emotional development, provided parent-child separation is minimized; this period has theadditional advantage that the child’s “defective sta-tus” within the family is not prolonged. The impor-tance of the care giver’s attitude toward the childmay be of particular importance to the child’s devel-oping body image. Superimposed on all of thesefactors is the developing sexual identity of the indi-vidual, which again suggests that, in the absence ofany other health factors, successful early genital sur-gery minimizes disturbances in the patient’s psycho-logical development.

The best time for surgery for hypospadias isbetween 6 and 12 months of age. Orchidopexyshould be performed at or near 1 year of age. If theimproved risk-to-benefit ratio for this early genitalsurgery is to be achieved, it is essential that chil-dren undergoing this surgery be cared for at facil-ities with experienced pediatric support personnel,particularly in the areas of anesthesia, urology,and nursing, who are sensitive to the special needsof children.

ACTION COMMITTEE FOR DETERMINING TIMING OF

ELECTIVE SURGERY ON THE GENITALIA OF MALE

CHILDREN

Evan Kass, MD, Chairperson

COMMITTEE MEMBERS

Stanley J. Kogan, MDCharles Manley, MDJeffrey A. Wacksman, MDWilliam M. Klykylo, MDAnthony Meza, MDJanet Schultz, PhDEugene Wiener, MD

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1996;97;590Pediatrics Section on Urology

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

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1996;97;590Pediatrics Section on Urology

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

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