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Presentamos el caso clínico de un paciente varón de 6 años de edad con antecedente de caída desde su propia altura un mes antes de su valoración en consulta, en donde se identifica una tumoración pulsátil en región hipotenar de mano derecha, no dolorosa y no fija a planos profundos. El ultrasonido doppler informa de una tumoración con pared definida, heterogénea, con flujo sanguíneo a través de la misma. En base a los antecedentes y a los resultados del ultrasonido se decide intervenir quirúrgicamente para evitar posibles complicaciones, encontrando un aneurisma de la arteria cubital de 3 x 3 cm de diámetro, no trombosado, que resecamos, practicando reconstrucción mediante injerto venoso término-terminal. El paciente evolucionó sin complicaciones.

Los lipomas suponen el 16 % de los tumores de tejidos blandos que se originan en la mano. Tienen una presentación clínica particular debido a la complejidad anatomofuncional de la zona. Analizamos 14 pacientes con diagnóstico clínico de lipoma en mano, 64.3 % de ellos de sexo femenino, con edad promedio de 44.1 años. La localización fue: en la vaina flexora digital 33.3 %, medio palmar (musculatura tenar principalmente) 40 %, muñeca dorsal (incluido interóseo) 20 % y antebraquial 6.7 %. La disminución de la función de la mano y/o de la muñeca fue la principal sintomatología de los pacientes (66.7 %). Las alteraciones funcionales producidas incluyeron: dedo en gatillo, alteraciones de la flexión y de la pinza, seguidos de dolor en 26.7 % y alteraciones de la sensibilidad en 26.7 %. Síndrome de túnel del carpo en 20 %. En 26.7 % la queja fue cosmética. La escisión resolvió la sintomatología en todos los casos. El seguimiento promedio fue de 15.8 meses, sin ningún caso de recurrencia y solamente se presentó una complicación menor. El estudio por imagen solo fue necesario en 1 caso de esta serie; la certeza mediante diagnóstico clínico fue del 93 %.Lipomas account for the 16 % of all the soft tissue hand tumors. Their clinical presentation is particular, due to the anatomical and functional complexity of the hand. We analyze 14 patients with the clinical diagnosis of hand lipoma, 64.3 % female, with medium age 44.1 years old. The localization was: digital flexor sheath 33.3 %, midpalmar (thenar muscles mainly) 40 %, dorsal wrist (including interosseus muscle) 20 % and antebrachial 6.7 %. The decrease in hand or wrist function was the main symptom (66.7 %). The functional impairments include: trigger finger, flexion and grip impairment, followed by pain, sensitivity alterations and cosmesis in 26.7 %. The carpal tunnel syndrome presented in 20 %. The surgical excision solved the symptoms in all cases. The mean follow-up was 15.8 months. None recurrence was observed and only 1 minor complication presented. We used an image study to make the diagnosis in 1 case, having a clinical diagnosis accuracy of 93 %.

En la enfermedad de De Quervain, la cirugía es la indicación estándar como procedimiento terapéutico y consiste en la liberación de los tendones abductor pollicis longus (APL) y extensor pollicis brevis (EPB) del primer compartimento de la mano. Está documentada la presencia de un septum dentro del compartimento entre los tendones del extensor corto y del abductor largo del pulgar. La importancia que tiene describir y hallar este subcompartimento radica en que la falta de conocimiento del mismo provoca el fallo en su liberación completa en los pacientes con enfermedad de De Quervain, por lo que los síntomas pueden persistir en el postoperatorio inmediato y tardío. El objetivo de este trabajo es determinar la presencia de un subcompartimento en el primer compartimento extensor de la mano en la población mexicana. Realizamos en el Hospital General Dr. Manuel Gea González de México DF un total de 32 liberaciones del primer compartimento extensor en 30 pacientes, todas secundarias a enfermedad de De Quervain con seguimiento promedio postoperatorio de 7,5 meses. La presencia de este subcompartimento se encontró en 21 pacientes (65,6 % de los casos), conteniendo en el 100 % el tendón EPB. El APL presentó 3 fascículos en el 31,25 % de casos, 2 fascículos en el 53,12 % y 1 fascículo en el 15,6 %. El EPB presentó 2 fascículos en el 6,25 % de los casos y 1 fascículo en el 93,75 % del total. En el seguimiento, ningún paciente presentó recidiva de la enfermedad. Proponemos la falta de identificación de un subcompartimento en el primer compartimento extensor de la mano como la principal causa de recidiva de enfermedad de De Quervain en nuestro medio.Surgical release of the first compartment of the hand containing abductor pollicis longus tendon (APL) and extensor pollicis brevis (EPB) is the gold standard treatment for De Quervain's disease. It´s well known that a septum commonly exists between these two tendons. The importance of this septum has been addressed in current literature. Knowledge of this anatomy and its prevalence is important as failure to address first compartment as two subcompartments could lead to treatment failure and persistent symptoms. The aim of this study is to determine the prevalence of subcompartments in the first hand extensor compartment in mexicans. We performed 32 releases of the first extensor compartment in 30 patients at the Hospital General Dr. Manuel Gez González in México DF, all of them with De Quervain disease. Median follow up was 7,5 months. We found and released the described subcompartment in 21 patients (65,6 %), with EPB in the subcompartment in 100 % of the cases. The APL presented 3 bundles in 31,25 %, 2 bundles in 53,12 % and 1 bundle in 15,6 %. The EPB presented 2 bundles in 6,25 % and 1 bundle in 93,75 %. No patients experienced recurrence of De Quervain disease symptoms. We hypothesize that the rate of recurrence may be due to failure in identifying and releasing the subcompartments.

Los tumores glómicos fueron descritos en 1924; están formados por elementos vasculares, musculares y nerviosos por debajo de la uña y pueden afectar la regulación de la irrigación de la punta del dedo con el frío. Constituyen el 1-2% de los tumores de la mano. Aunque no se trata de una patología frecuente, el cirujano plástico debe estar familiarizado con ella para un diagnóstico y tratamiento adecuados. Presentamos la experiencia en tumores glómicos de la clínica de mano del Hospital Dr. Manuel Gea González; reportamos los hallazgos clínicos y el manejo en cada caso mediante resección quirúrgica y enfatizamos sobre la importancia de una exposición adecuada durante la cirugía para resecar el tumor completamente y evitar recidivas.Glomus tumors were described in 1924; they involve vascular, muscle and nerve elements under the nail and can affect vascular supply of the finger tip. It represents 1-2% of hand tumors. Although it is not a common pathology, plastic surgeons must be familiarized to be able to diagnose and treat it properly. We present the experience of glomus tumor in our hand clinic at Hospital Dr. Manuel Gea González, reporting the clinical presentation and the surgical excision. We emphasize the importance of a good exposition of the tumor in the surgery for a complete excision and to avoid recurrences.

En la enfermedad de De Quervain, la cirugía es la indicación estándar como procedimiento terapéutico y consiste en la liberación de los tendones abductor pollicis longus (APL) y extensor pollicis brevis (EPB) del primer compartimento de la mano. Está documentada la presencia de un septum dentro del compartimento entre los tendones del extensor corto y del abductor largo del pulgar. La importancia que tiene describir y hallar este subcompartimento radica en que la falta de conocimiento del mismo provoca el fallo en su liberación completa en los pacientes con enfermedad de De Quervain, por lo que los síntomas pueden persistir en el postoperatorio inmediato y tardío. El objetivo de este trabajo es determinar la presencia de un subcompartimento en el primer compartimento extensor de la mano en la población mexicana. Realizamos en el Hospital General Dr. Manuel Gea González de México DF un total de 32 liberaciones del primer compartimento extensor en 30 pacientes, todas secundarias a enfermedad de De Quervain con seguimiento promedio postoperatorio de 7,5 meses. La presencia de este subcompartimento se encontró en 21 pacientes (65,6 % de los casos), conteniendo en el 100 % el tendón EPB. El APL presentó 3 fascículos en el 31,25 % de casos, 2 fascículos en el 53,12 % y 1 fascículo en el 15,6 %. El EPB presentó 2 fascículos en el 6,25 % de los casos y 1 fascículo en el 93,75 % del total. En el seguimiento, ningún paciente presentó recidiva de la enfermedad. Proponemos la falta de identificación de un subcompartimento en el primer compartimento extensor de la mano como la principal causa de recidiva de enfermedad de De Quervain en nuestro medio.

Abstract: Objective: Clitoroplasty is a procedure usually performed in young children, but its long-term psychosexual importance is controversial. We present two adult women from different cultural backgrounds who desired surgery for clitoromegaly. Methods: A similar clitoroplasty procedure with preservation of the neurovascular bundle was performed on both patients. Preoperative and postoperative interviews were conducted by an independent observer to learn about the effects of the condition and the surgery. Results: The Icelandic patient had bilateral ovarian dysgerminomas and a gonadoblastoma. The Bolivian patient had a 17β-hydroxysteroid oxidoreductase deficiency. Both patients reported normal libido but sexual inactivity because they felt ‘embarrassed’. Postoperatively, our patients reported normal clitoral sensation and that they were sexually active. They differed in their opinion regarding the optimal timing of clitoroplasty – one suggesting surgery soon after birth and the other recommending deferral until informed consent by the patient is possible. Conclusions: Regardless of cultural background patients are affected by clitoromegaly. This is demonstrated in these cases by the reported feelings of discomfort, distress, and sexual inactivity due to embarrassment. The long-term significance of clitoromegaly and the value of clitoroplasty for young patients with disorders of sexual differentiation remain controversial. [Copyright &y& Elsevier]

ABSTRACT: Purpose:: Complete primary repair of bladder exstrophy (CPRE) represents a paradigm shift from the staged approach for surgical management. We present early clinical outcomes in our patients following CPRE. Materials and Methods:: From 1996 to 2004 all newborns with bladder exstrophy were treated with CPRE within 48 hours of birth. We reviewed parameters including transfusions (packed red blood cells), urethral meatal position, complications, findings on renal ultrasound and renal scan, and post-CPRE procedures and infections. Results:: A total of 16 boys and 7 girls were treated with CPRE. Followup ranged from 8 to 96 months. Twelve boys (75%) and 2 girls (29%) received packed red blood cells at CPRE (p = 0.066). The tubularized urethral plate could not be brought to the penile tip, resulting in hypospadias in 9 of 11 boys (82%) with the running suture technique and only 1 of 5 boys (20%) with the interrupted technique (p = 0.036). Of the 23 patients 6 had a total of 8 complications after CPRE. Vesicoureteral reflux was present in 17 of 23 patients. After CPRE a total of 93 endoscopic/surgical procedures (median 4, range 0 to 16 per patient) were performed. Five patients had 1 to 4 episodes of pyelonephritis, 16 of 23 had 1 or more episodes of asymptomatic bacteriuria and 5 had cortical defects on renal scan. Conclusions:: We recommend that urethral closure during CPRE be performed with interrupted suture technique to prevent hypospadias. An aggressive approach should be taken toward reflux in the setting of urinary infection. Consideration should be given for repair of all aspects of the defect during CPRE, including bilateral ureteral reimplantation. [Copyright &y& Elsevier]

ABSTRACT: Purpose:: We assessed bladder growth and dynamics following complete primary repair of bladder exstrophy (CPRE) compared to the staged approach. Materials and Methods:: We reviewed the records of 16 boys and 7 girls who underwent CPRE within 3 days of life from 1996 to 2004 and compared them to the records of 8 boys and 6 girls treated with a staged repair from 1979 to 1996. Screening methods included voiding cystourethrogram, radionuclide cystogram and urodynamic study. We estimated growth curves for bladder capacity following repair in each group, and compared percent predicted bladder capacity (PPBC), compliance and detrusor overactivity between the CPRE and staged repair groups following bladder neck reconstruction. Results:: Bladder capacity in the staged repair group was 69.8 ml (95% CI 46.7–104.4) immediately after bladder neck reconstruction and increased by 15.0% per year thereafter (95% CI 6.2–24.5, p = 0.002). In the CPRE group bladder capacity was 29.0 ml (95% CI 21.3–39.5) initially and increased by 28.9% per year thereafter (95% CI 17.4–41.5, p <0.001). PPBC started at 45.6% (95% CI 35.7–55.5) and increased 1.2% per year (95% CI −1.1–3.5, p = 0.29) following repair for all genders and surgery groups. Compliance was 124.4% (95% CI 22.6–310.7, p = 0.01) greater in the CPRE group at all times following repair. Detrusor overactivity was present in 0 of 19 patients in the CPRE group and 6 of 13 (46%) in the staged group (exact p = 0.002). Conclusions:: Within the CPRE group bladder stability was universal, and sphincter electromyography was normal suggesting no neuromuscular compromise of the pelvic floor. At early followup, our results suggest that PPBC is equivalent irrespective of gender or management. Further objective evaluation is needed in both groups. [Copyright &y& Elsevier]

Summary Introduction Open ureteroneocystostomy (UNC) is the gold standard for surgical correction of vesicoureteral reflux (VUR). Beyond single-center reports, there are few published data on outcomes of minimally-invasive (MIS) UNC. Our objective was to compare postoperative outcomes of open and MIS UNC using national, population-level data. Method We reviewed the 1998–2012 Nationwide Inpatient Sample to identify pediatric (≤18 years) VUR patients who underwent either open or MIS UNC. Demographics, National Surgical Quality Improvement Program (NSQIP) complications, length of stay (LOS), and cost data were extracted. Statistical analysis was performed using weighted, hierarchical multivariate logistic regression (complications) and negative binomial regression (LOS, cost). Results We identified 780 MIS and 75,976 open UNC admissions. Compared with patients undergoing open UNC, patients who underwent MIS UNC were likely to be older (6.2 versus 4.8 years, p < 0.001), publically insured (43 versus 26%, p < 0.001), and treated in recent years (90 versus 46% after 2005, p < 0.001). MIS admissions were associated with a significantly shorter length of stay (1.0 versus 1.8 days, p < 0.001) and higher cost ($9230 versus $6,304, p = 0.002). After adjusting for patient-level confounders (age, gender, insurance, treatment year, and comorbidity), and hospital-level factors (region, bedsize, and teaching status), MIS UNC was associated with a significantly higher rate of postoperative urinary complications such as UTIs, urinary retention, and renal injury (OR 3.1, p = 0.02), shorter LOS (RR 0.8, p = 0.02), and higher cost (RR 1.4, p = 0.008). Discussion Strengths of this study are its large cohort size, long time horizon, national estimation, and cost data. Most prior studies are case-series limited to the size of the institutional cohort. Our analysis of 76,756 operative encounters revealed that open UNC continues to be performed at far greater frequency than MIS UNC, outpacing the latter modality by nearly 100:1. Children treated with MIS UNC had three times greater odds of developing postoperative urinary complications, and MIS UNC patients incurred average costs per admission that were nearly 1.5 times higher than those of children who underwent open UNC. These children were also likely to be older, publically insured, and treated in more recent years. On the other hand, patients treated with MIS UNC required substantially shorter postoperative hospitalization, with an average LOS roughly half that of open UNC cases. Limitations include the retrospective nature of the administrative database, lack of detailed patient-level data, and no available long-term postoperative outcomes. Compared with open surgery, MIS UNC was associated with shorter LOS but higher costs and possibly higher urinary complication rates. Table Bivariate/multivariate analysis of postoperative complications for MIS UNC. NSQIP complications a Unadjusted OR (95% CI) Adjusted OR b (95% CI) p value b UTI 1.00 (0.37–2.72) 0.99 (0.40–2.44) 0.98 Urinary complications 2.63 (1.00–6.91) 3.13 (1.17–8.40) 0.02 All complications 1.15 (0.48–2.78) 1.27 (0.57–2.85) 0.56 a Using open UNC as reference. b After adjusting for age, gender, insurance, year, comorbidity, teaching status, hospital region, and hospital size. [ABSTRACT FROM AUTHOR]