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Objective: To present the importance of searching for the surgical causes of pharmacologically resistant hypertension in the neonatal population., Study Design: A case report and discussion are provided., Results: Severe hypertension in the neonatal period is uncommon and almost always has a secondary cause. Although a majority of hypertensive neonates can be successfully managed with medical therapy, some cases are resistant to pharmacological treatment. We report three hypertensive neonates who failed to respond to intensive multidrug therapy. This led to further evaluation and identification of obstructive uropathies in two neonates and renovascular disease that necessitated surgical intervention. Subsequently, all patients had prompt resolution of hypertension and normalization of renal function. All are now off antihypertensive medications and have normal renal function at 12 months of follow-up., Conclusion: Our report exemplifies the importance of the consideration of surgical etiologies for differential diagnosis in neonates with severe hypertension that is unresponsive to pharmacological therapy. Early diagnosis and prudent management of these etiologies reduce morbidity and mortality and preserve of renal function.