Abordaje mínimamente invasivo del tumor de Wilms unilateral: un reporte de caso y revisión de la literatura / Minimally invasive approach to unilateral Wilms tumor: a case report and literature review

Introducción. El tumor de Wilms es la neoplasia abdominal más común en pacientes pediátricos. En la mayoría de los casos se presenta como una masa unilateral indolora en el abdomen. El objetivo de este artículo fue presentar el caso de una paciente de 4 años con tumor de Wilms unilateral derecho manejado con cirugía mínimamente invasiva en el Hospital Universitario del Valle. Métodos. Revisión de la historia clínica e imágenes de la paciente, descripción de la técnica quirúrgica y revisión de la literatura del manejo de tumor de Wilms unilateral. Caso clínico. Paciente femenina de 4 años quien consultó en abril de 2019 por un cuadro clínico de dolor abdominal y sensación de masa en flanco derecho. Se realizó ecografía abdominal donde se encontró imagen nodular heterogénea de contornos definidos en riñón derecho, con riñón izquierdo normal. Se hizo diagnóstico de tumor de Wilms unilateral y se llevó a cirugía mediante abordaje mínimamente invasivo, con buena evolución postoperatoria. Conclusión. La cirugía es el pilar del manejo, y la nefrectomía mediante abordaje laparoscópico para casos seleccionados, en manos entrenadas, tiene la suficiente eficacia, seguridad y cumplimiento de los principios quirúrgicos y oncológicos que provee la cirugía abierta.

Introduction. Wilms tumor is the most common abdominal neoplasm in pediatric patients. In most cases it presents as a painless unilateral mass in the abdomen. The objective of this article was to present the case of a 4-year-old patient with right unilateral Wilms tumor managed with minimally invasive surgery at the Hospital Universitario del Valle. Methods. Review of the patient's clinical history and images, description of the surgical technique and review of the literature on the management of unilateral Wilms tumor.Clinical case. A 4-year-old female patient who consulted on April 4, 2019 with a clinical presentation of abdominal pain and sensation of mass in the right flank. Abdominal ultrasound was performed where a heterogeneous nodular image of defined contours was found in the right kidney, with a normal left kidney. A diagnosis of unilateral Wilms tumor was made and surgery was carried out using a minimally invasive approach, with good postoperative evolution. Conclusion. Wilms tumor is the most common abdominal neoplasm in pediatric patients. The most common presentation is a painless palpable mass. Surgery is the mainstay of management, and nephrectomy using a laparoscopic approach for selected cases, in trained hands, has sufficient efficacy, safety, and compliance with surgical and oncological principles that open surgery provides.

Manejo quirúrgico de prolapso uretral en pediatría: Reporte de caso / Surgical management of urethral prolapse in pediatrics: A case report

Introducción. El prolapso uretral es una entidad poco común, con una incidencia estimada de 1 en 3000 mujeres. Se presenta cuando la mucosa uretral sobresale espontáneamente más allá del meato uretral. Es una patología poco diagnosticada dada su baja frecuencia y de allí la importancia de conocer sobre su presentación, diagnóstico y tratamiento. El objetivo de este artículo fue presentar el caso de una paciente de 10 años con diagnóstico de prolapso uretral y su manejo quirúrgico. Caso clínico. Paciente femenina de 10 años, que consultó por cuadro clínico de 1 año de evolución consistente en dolor en región urogenital, que se irradiaba a hipogastrio, asociado a pujo y disuria, a quien se le diagnosticó prolapso uretral y se realizó corrección quirúrgica de mucosa uretral prolapsada mediante técnica de Kelly-Burnham modificada. Conclusión. El prolapso uretral es una entidad que con frecuencia es diagnosticada erróneamente pues su diagnóstico es eminentemente clínico. Si bien se ha descrito el tratamiento médico en primera instancia, éste tiene una alta tasa de recurrencia, por lo que en estos casos se prefiere la resección quirúrgica del tejido prolapsado.

Introduction. Urethral prolapse is a rare entity, with an estimated incidence of 1 in 3,000 women. It occurs when the urethral mucosa spontaneously protrudes beyond the urethral meatus. It is a poorly diagnosed pathology given its low frequency and hence the importance of knowing about its presentation, diagnosis and treatment. The objective of this article was to present the case of a 10-year-old patient with a diagnosis of urethral prolapse and its surgical management. Clinical case. A 10-year-old female patient, who consulted for a 1-year clinical picture consisting of pain in the urogenital region, radiating to the hypogastrium, associated with pushing and dysuria, who was diagnosed with urethral prolapse and a surgical correction of the urethral mucosa was performed prolapsed by modified Kelly-Burnham technique. Conclusion. Urethral prolapse is an entity that is frequently misdiagnosed because its diagnosis is eminently clinical. Although medical treatment has been described in the first instance, it has a high recurrence rate, so surgical resection of the prolapsed tissue is preferred in these cases.

Three-dimensional characterization of trabecular bone mineral density of the proximal ulna using quantitative computed tomography.

BACKGROUND: Although previous studies have measured general proximal forearm bone mineral density (BMD), no study has systematically mapped the 3-dimensional trabecular BMD of the proximal ulna. The aim of this study was to describe the 3-dimensional distribution of the trabecular bone density of the proximal ulna. We hypothesize a variable distribution of proximal ulna trabecular BMD depending on the region of interest (ROI). METHODS: Computed tomographic (CT) scans of 9 fresh-frozen cadaveric proximal ulna specimens with a mean age of 59.3 ± 8.1 years were studied. Each CT file was converted from DICOM to a QCT file that could be analyzed using QCT software (QCT Pro Version 6.1, Model 4 CT Calibration Phantom; MindWays Software Inc, Austin, TX, USA). The ROIs were defined as spheres of trabecular bone 3 mm in diameter located throughout the proximal ulna. RESULTS: ROIs proximal to the trochlear notch demonstrated higher BMD than ROIs distal to the trochlear notch. Furthermore, volar ROIs adjacent to the ulnohumeral joint tended to have higher BMD than dorsal ROIs. The highest BMD was found in the tip of the olecranon. CONCLUSION: Hardware in fixation constructs for proximal ulnar fractures should be directed toward ROIs with the highest BMD to maximize purchase. Hardware should approach the ulnohumeral joint without penetrating the joint to capture trabecular bone with the highest BMD. The most important fixation in such a construct will be that which captures trabecular bone with maximum BMD proximal to the trochlear notch (eg, the tip of the olecranon).

Three-Dimensional Characterization of Trabecular Bone Mineral Density of the Distal Radius Utilizing Quantitative Computed Tomography.

Background: Distal radius (DR) fractures demonstrate patterns of predictable fragments. Bone mineral density (BMD) measurements of these regions of interest (ROIs) may guide more precise treatment. Methods: Computed tomography (CT) scans of the DR of 42 healthy volunteers (23 female) were analyzed using quantitative CT software, measuring BMD within trabecular bone. Seven ROIs were described by alignment with the distal (volar ulnar distal [VUD], dorsal ulnar distal [DUD], volar radial distal [VRD], and dorsal radial distal [DRD]) or proximal (middle ulnar proximal [MUP], middle proximal [MP], and middle radial proximal [MRP]) sigmoid notch. Additional ROIs were the radial styloid (RS) and metadiaphysis (MD). A general estimation equation assessed subject's BMDs with predictive factors of gender, ROI, and age. The interaction between gender, ROI, and age was included in the model to allow for differences in ROI to vary with gender and/or age. Results: Comparing ROIs within the same gender and, separately, within the same age group revealed significantly higher BMD adjacent to the radioulnar and radiocarpal joints. Male and female individuals aged ≥50 years (mean: 172.7 mg/cm3 ± 6.1) had significantly lower BMD than those aged <50 years (mean: 202.7 mg/cm3 ± 5.8) when all ROIs were considered. Males had higher mean BMD at each ROI compared with females; these differences were significant in 5 of the 9 ROIs: VUD, DUD, DRD, RS, MUP. Conclusions: Trabecular BMD of the DR is highest adjacent to the radioulnar and radiocarpal joints. Female patients and those ≥50 years have lower trabecular BMD.

Utility of Prolotherapy for Upper Extremity Pathology.

Prolotherapy is a method of treatment of painful musculoskeletal conditions whereby a sclerosing agent is injected into an area of tendinosis or osteoarthritis to strengthen and repair painful connective tissue. It is a safe, effective, and relatively inexpensive nonsurgical treatment modality. This article provides a history of prolotherapy, discusses its proposed mechanisms of action, and provides a review of the existing literature on prolotherapy as a treatment for upper extremity pathologies, specifically, hand osteoarthritis, lateral epicondylitis, and rotator cuff disease.

Snapping at the Lateral Aspect of the Elbow: A Case Report and Review of the Literature.

CASE: A 59-year-old man presented with snapping at the lateral aspect of the elbow and associated pain. Magnetic resonance imaging demonstrated extensor tendinopathy and thickening of the radial collateral ligament. Ultrasonography showed entrapment of a synovial fold in the radiohumeral joint. Initial arthroscopic debridement did not alleviate the snapping. Three months later, the patient underwent open excision of a thickened and partially torn annular ligament; subsequently, all of the symptoms resolved. CONCLUSION: Snapping elbow is a phenomenon that often coincides with pain and limited function. Accurate diagnosis is critical because misdiagnosis has been demonstrated to have serious consequences, including the need for repeat surgery.

Ulnar Styloid Base Fractures Cause Distal Radioulnar Joint Instability in a Cadaveric Model.

BACKGROUND: The deep portion of the distal radioulnar ligaments (DRUL) inserts on the ulnar fovea and is the most important stabilizer of the distal radioulnar joint (DRUJ). Ulnar styloid base fractures that include the ulnar fovea may cause DRUJ instability. METHODS: DRUJ stability in pronosupination was evaluated in 12 fresh-frozen upper extremities (4 female) aged 52 to 68 years (mean: 58.8 years) using a custom fixture, which allowed free rotation of the radius around the fixed ulna. Optical motion capture was used to record rotation of the radius with respect to the ulna. Each specimen was subjected to 3 N m of torque in both supination and pronation under 4 conditions: intact, ulnar styloid osteotomy with disruption of the foveal insertion of the DRUL, ulnar styloid fixation, and DRUL transection. Group differences were compared using a 1-way repeated-measures analysis of variance and Tukey multiple comparison post hoc tests. RESULTS: When compared with the intact condition, both ulnar styloid osteotomy and DRUL transection significantly increased mean pronation (by 9.40° and 15.21°, respectively) and supination (by 9.05° and 17.42°, respectively) of the forearm. Screw fixation only significantly reduced pronation compared with osteotomy (by 2.62°). Screw fixation did not significantly affect supination. CONCLUSIONS: Ulnar styloid fractures that disrupt the fovea cause instability of the DRUJ in pronation and supination under 3 N m of torque in a cadaveric model. Screw fixation of ulnar styloid base fractures achieves anatomic reduction; however, it only partially returns rotational stability acutely to the DRUJ and only during pronation.

Hand and arm pain: A pictorial guide to injections.

This article, with illustrative figures, will help you get to the cause of your patient's pain and guide your administration of corticosteroid injections.

Evaluation of Ulnar-sided Wrist Pain.

Determining the etiology of ulnar-sided wrist pain is often challenging. The condition may be acute or chronic, and differential diagnoses include injuries to the ulnar carpal bones, ligament tears, tendinitis, vascular conditions, osteoarthritis and systemic arthritis, and ulnar nerve compression. An anatomically based, methodical physical examination coupled with provocative maneuvers, including piano key, ulnar impaction, shuck, foveal stress, and extensor carpi ulnaris synergy tests, further defines the differential diagnosis. Diagnostic imaging used in the evaluation of ulnar-sided wrist pain includes plain radiographs and MRI with or without arthrography. Wrist arthroscopy is becoming increasingly important in the diagnosis and management of ulnar-sided intra-articular wrist pathology.

A Review of Anatomical Placement of Corticosteroid Injections for Uncommon Hand, Wrist, and Elbow Pathologies.

Corticosteroid injections are a common nonsurgical treatment of intersection syndrome, flexor carpi radialis tendonitis, flexor carpi ulnaris tendonitis, and medial epicondylitis. The benefits of corticosteroid injections for these conditions have been well studied and documented in the medical literature. Patients with less common upper extremity complaints usually first present to their primary care provider. A correct anatomical diagnosis will help with early definitive treatment, as the injection must be in the proper location for maximal benefit to the patient. The following review on uncommon upper extremity complaints provides information for a correct diagnosis and treatment plan, followed by a possible injection. This review will hopefully provide high quality care while also cutting health care costs by making the correct diagnosis at the initial presentation. [Full article available at http://rimed.org/rimedicaljournal-2017-03.asp].

Patient Comprehension of Carpal Tunnel Surgery: An Investigation of Health Literacy.

Background: Health literacy is the ability of a patient to understand their medical condition. The purpose of this investigation is to determine whether patients are able to obtain an elementary understanding of the fundamental principles of carpal tunnel release and the postoperative instructions after going through the process of informed consent and being provided an additional standardized postoperative instruction document. Our hypothesis is that patients will lack an understanding of these principles and, therefore, will be at risk for being noncompliant in their postoperative care. Methods: Fifty patients with a diagnosis of carpal tunnel surgery who elected to undergo carpal tunnel release alone were enrolled. A standardized education process was performed. Patients completed the questionnaire at their postoperative visit. Results: The average percentage of correct answers was 75.8% (8.34 out of 11 correct). Fisher exact test analysis demonstrated that patients with a lower education level were less likely to know how long it takes for their preoperative symptoms to resolve (P = .0071), and they were less likely to correctly choose all of the important elements of postoperative care during the first week after surgery (P = .022). Conclusions: Although we made efforts to help patients achieve health literacy in carpal tunnel surgery, we found that patients continued to lack comprehension of pertinent components of carpal tunnel surgery, particularly understanding the involved anatomy.

An Anatomic Evaluation of Arthroscopic Access to the Radial Head.

PURPOSE: To determine the area of the radial head accessible for visualization and screw placement from the standard anteromedial and anterolateral portals used in elbow arthroscopy. METHODS: Five cadaveric elbows were arthroscopically evaluated using standard anteromedial and anterolateral portals. Markers (pins) were placed into the accessible portions of the radial head at maximal pronation and supination. Specimens were then evaluated by computed tomography, and the arc of the radial head accessible from each portal was determined. RESULTS: A continuous 220.04° ± 37.58° arc of the radial head was accessible from the combination of the anterolateral and anteromedial portals. From the anteromedial portal, the arc obtained measured 147.96° ± 21.81°, and from the anterolateral portal, the arc obtained measured 156.02° ± 33.32°. Using the radial styloid as a marker for 0°, the mean total arc ranged from 92.3° ± 34.06° dorsal to 127.74° ± 23.65° volar relative to the radial styloid. CONCLUSIONS: Standard anteromedial and anterolateral portals used for elbow arthroscopy allow access to an average 220° area of the radial head. CLINICAL RELEVANCE: This study defines the area of the radial head that can be contacted using commonly used, safe, and simple portals.

Trends in Revision Elbow Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers.

PURPOSE: To determine the frequency of revision elbow ulnar collateral ligament (UCL) reconstruction in professional baseball pitchers. METHODS: Data were collected on 271 professional baseball pitchers who underwent primary UCL reconstruction. Each player was evaluated retrospectively for occurrence of revision UCL reconstructive surgery to treat failed primary reconstruction. Data on players who underwent revision UCL reconstruction were compiled to determine total surgical revision incidence and revision rate by year. The incidence of early revision was analyzed for trends. Average career length after primary UCL reconstruction was calculated and compared with that of players who underwent revision surgery. Logistic regression analysis was performed to assess risk factors for revision including handedness, pitching role, and age at the time of primary reconstruction. RESULTS: Between 1974 and 2014, the annual incidence of primary UCL reconstructions among professional pitchers increased, while the proportion of cases being revised per year decreased. Of the 271 pitchers included in the study, 40 (15%) required at least 1 revision procedure during their playing career. Three cases required a second UCL revision reconstruction. The average time from primary surgery to revision was 5.2 ± 3.2 years (range, 1-13 years). The average length of career following primary reconstruction for all players was 4.9 ± 4.3 years (range, 0-22 years). The average length of career following revision UCL reconstruction was 2.5 ± 2.4 years (range, 0-8 years). No risk factors for needing revision UCL reconstruction were identified. CONCLUSIONS: The incidence of primary UCL reconstructions among professional pitchers is increasing; however, the rate of primary reconstructions requiring revision is decreasing. Explanations for the decreased revision rate may include improved surgical technique and improved rehabilitation protocols. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dual-camera technique for arthroscopic rotator cuff repair.

An all-arthroscopic rotator cuff repair demands a high level of technical skill and is associated with a steep learning curve. It is well accepted that small rotator cuff tears or partial tears can be more difficult than large or even massive tears to repair. Part of the reason is the difficulty in visualizing the tear, as well as important surrounding structures, during repair. To improve visibility during the repair process, we have introduced a second arthroscopic camera. Two cameras allow the surgeon to observe the rotator cuff from both the articular and bursal sides. We find this technique has merit in small or partial-thickness rotator cuff tears; however, there may be other applications.

Volar wrist ganglion excision through the flexor carpi radialis sheath.

Volar wrist ganglions are much less frequent than their dorsal counterparts but provide much more surgical trepidation due to their proximity to the radial artery. With the majority arising from the radiocarpal joint, we have found that entering the flexor carpi radialis sheath and accessing the ganglion through the floor of the sheath allows for a relatively safe excision of these benign hand tumors.

Magnetic manipulation and optical imaging of an active plasmonic single-particle Fe-Au nanorod.

Superparamagnetic microbeads play an important role in a number of scientific and biotechnology applications including single-molecule force measurements, affinity separation, and in vivo and in vitro diagnostics. Magneto-optically active nanorods composed of single-crystalline Au and polycrystalline Fe segments were synthesized with diameters of 60 or 295 nm using templated electrodeposition. The Fe section was magnetically soft and had a saturation magnetization of approximately 200 emu/g, resulting in a 10-fold increase in magnetization relative to that iron oxide nanoparticles. The strong plasmonic response of the Au segment of the rod in both the longitudinal and transverse directions made it possible to detect the orientation of a single rod in a polarized light microscope with nanometer resolution. These nanorods provide significantly improved physical properties over iron oxide superparamagnetic beads, making it possible to simultaneously manipulate and monitor the orientation of biomolecules with well-defined forces at the nanometer scale.

Methylene blue-enhanced arthroscopic resection of dorsal wrist ganglions.

The ganglion is the most common soft tissue mass of the hand and wrist. Over the past 10 to 15 years, there has been a growing interest in arthroscopic treatment of dorsal wrist ganglions. Proposed advantages of arthroscopy include greater motion (particularly wrist flexion), improved cosmesis, and potential to identify/treat other intra-articular pathology. Despite the documented clinical success of arthroscopic ganglion excision, limitations include inconsistent identification of the ganglion stalk. Our described technique offers a means by which to improve visualization of the ganglion stalk intra-articularly to produce a more effective and efficient arthroscopic ganglion excision. During the procedure, a small volume of methylene blue solution is injected into the cyst. Its communication with the joint is apparent arthroscopically, thus identifying the location of the stalk. With the ability to precisely identify the ganglion stalk using an injection of methylene blue, the surgeon can direct the arthroscopic debridement toward the appropriate pathologic tissue. Unnecessary debridement of uninvolved tissue can be avoided with the technique. This also allows for optimal portal placement and, in particular, indicates whether a midcarpal portal should be employed. This should result in fewer recurrences, decreased operative time, and less iatrogenic injury.