ABSTRACT. Objective. Fetal intervention for obstructive uropathy was first performed at the University of California, San Francisco in 1981. Indications for treatment were bilateral hydronephrosis with oligohydramnios. Preintervention criteria included fetal urinary electrolytes with ␤-microglobulin levels, karyotyping, and detailed sonography specifically looking for renal cortical cysts. We reviewed the outcomes of children who underwent fetal intervention with specific long-term follow-up in patients who were found postnatally to have posterior urethral valves.

In children the outcome of stented pyeloplasty is similar to that of nonstented repair. In contrast to previous reports, using a stent for drainage should not necessitate a longer hospital stay.

IntroductionStudies have demonstrated that variables other than duration of symptoms can affect outcomes in children with acute testicular torsion. We examined demographic and logistical factors, including inter-hospital transfer, which may affect outcomes at a tertiary pediatric referral center.MethodsWe reviewed charts of all pediatric patients with acute testicular torsion during a five-year period. Data were collected regarding age, insurance type, socioeconomic status, duration of symptoms prior to presentation, transfer status, time of day, time to surgical exploration, and testicular salvage.ResultsOur study included 114 patients. Testicular salvage was possible in 55.3% of patients. Thirty-one percent of patients included in the study were transferred from another facility. Inter-hospital transfer did not affect testicular salvage rate. Time to surgery and duration of pain were higher among patients who underwent orchiectomy versus orchidopexy. Patients older than eight years of age were more likely to undergo orchidopexy than those younger than eight (61.5% vs. 30.4%, p=0.01). Ethnicity, insurance type, or time of day did not affect the testicular salvage rates. On multivariate analysis, only duration of symptoms less than six hours predicted testicular salvage (OR 22.5, p<0.001).ConclusionEven though inter-hospital transfer delays definitive surgical management, it may not affect testicular salvage rates. Time to presentation is the most important factor in predicting outcomes in children with acute testicular torsion.

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Patients with spinal bifida treated in utero appear to have the same changes in urodynamic parameters and anatomical abnormalities in the urinary tract as other children with spinal defects who have undergone standard postnatal care. In utero treatment of spinal bifida may expose the newborn to the effects of prematurity. The long-term effects on bladder function in the fetus after in utero repair of myelomeningocele remain unknown. A randomized controlled trial is necessary to evaluate long-term bladder function as well as other outcome variables in this experimental approach to patients with myelomeningocele.

OBJECTIVE: To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges. METHODS: This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children’s hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan–do–study–act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies. RESULTS: Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P &lt; .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P &lt; .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05). CONCLUSIONS: Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non–children’s hospital settings.

Formation of the male urethra requires the synthesis of testosterone, its activation to dihydrotestosterone (DHT) in genital skin, and binding of DHT to the androgen receptor. Defects in any of those steps can cause hypospadias. To determine whether defects exist in the production of androgens in individuals with hypospadias, we examined enzymatic function of 3beta-hydroxysteroid dehydrogenase (3betaHSD), P450c17 (17alpha-hydroxylase and 17,20 lyase activity), and type 3 17betaHSD. Sixty-eight subjects participated in the study: 48 patients had hypospadias, and 20 had normal male genitalia. Subjects were stratified into groups based on age and severity of hypospadias, as defined by location of the urethral meatus after correction of penile curvature. Hormonal values in boys with hypospadias were compared by nonparametric analysis with those in age-matched controls. Controls excluded individuals with cryptorchidism, micropenis, known endocrine defects, or receiving steroid supplementation. Morning fasting serum levels of pregnenolone, progesterone, 11-deoxycorticosterone, 17-hydroxypregnenolone, 17-hydroxyprogesterone, 11-deoxycortisol, cortisol, dehydroepiandrosterone, androstenedione, androstenediol, testosterone, and DHT were determined. To focus on the proximal steps in androgen biosynthesis, 12 individuals with hypospadias underwent standard ACTH stimulation. No significant differences in the androgen precursors and metabolites were found between controls and individuals with hypospadias. The response to ACTH was variable without a significant difference between the patients with different degrees of hypospadias and/or published controls. These data indicate that enzymatic defects in the steroidogenic steps from cholesterol to DHT are not a common etiology of hypospadias. Routine abnormalities in the androgen biosynthetic pathway are an unlikely cause of any degree of hypospadias in boys without accompanying cryptorchidism or genital malformations.

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