The Management of Upper Urinary Tract Obstruction in Resource-Poor Settings

Objective: The management of upper urinary tract obstruction in the absence of modern facilities presents a major challenge to Urologic practice in developing countries. The aim of this study was to describe the etiology; presentation and treatment of upper urinary tract obstruction at the Jos University Teaching Hospital; Nigeria. Patients and Methods : This is a prospective analysis of 37 consecutive patients (18 males; 19 females) with a mean age of 35.5 years (range 3-55) who were managed for upper urinary tract obstruction at our department between January 2001 and December 2005. Two of them presented with a second pathology; so that we treated 39 pathologies in total. Flank pain was the most common clinical feature; being present in 35 patients (94.6). Other clinical features were gross hematuria in 12 (32.4); an enlarged kidney in 5 (13.5); renal impairment in 4 (10.8) and hypertension in 3 (8.1) patients. Diagnostic work-up consisted of plain radiography; abdominal ultrasound scan; intravenous urography and retrograde pyelography. Renal pelvic stones were the leading cause of obstruction (13 patients; 35.1); while congenital pelvi-ureteric junction (PUJ) obstruction was found in 7 (18.9) and ureteric stricture and vesical schistosomiasis in 4 (10.8) and 3 (8.1) patients; respectively. Two patients had bilateral obstruction from two different causes.Results: Twenty-nine open surgical procedures were carried out. They consisted of pyelolithotomy (n=12); pyeloplasty (n=6); ureteroureterostomy (n=4); ureteroneocystostomy (n=3); nephrectomy (n=2) and ureterolithotomy (n=2). Eight patients were treated non-surgically. Two patients are awaiting definitive surgical treatment. A total of 4 (13.8) complications following 29 operative procedures were encountered: two cases of migration of double-J ureteric stents ; one case of prolonged urine leakage and another case of wound infection. Conclusion : Upper urinary tract obstruction is not uncommon in our environment. In the absence of modern facilities; open surgery remains our main option of treatment; and it is relatively safe

Posterior urethral valves in childhood : experience in a center with scarce facilities

Objective: Posterior urethral valves (PUV) are the most common congenital causes of lower urinary tract obstruction in male children; but few cases have been reported from Nigeria. In this study we describe our 7-year experience of management of PUV in children in order to increase the awareness of this condition in our environment. Patients and Methods : This is a report of 41 consecutive children with PUV who were managed at the Jos University Teaching Hospitals (JUTH); Jos; Nigeria; from June 2000 to April 2006. Their age at presentation ranged from 2 days to 15 years (mean: 2.5 years). The relevant clinical; laboratory and radiological data were entered into a database and analyzed.Results: Twenty-eight patients presented with a condition highly suspicious of PUV; while 7 patients presented with other urological conditions. Six patients presented with non-urological symptoms which caused a delay in diagnosis and institution of treatment. Voiding cystourethrography was diagnostic in all cases. In the majority of patients (n=31); management consisted of transurethral balloon avulsion of the valves yielding a satisfactory outcome in over 80. Conclusion : Although this study was restricted to one hospital; there appears to be a high incidence of PUV in children in North Central Nigeria. An increased awareness of varied clinical features; a high index of suspicion and simple conservative treatment by balloon avulsion of PUV would improve the outcome.of the patients. Urethral stricture was the main complication (which responded to serial dilatation) and occurred in 3 patients. The postoperative mortality rate was 2.6

Urologic day-care surgery : scope and problems in a developing country

Objective Due to the numerous economic and social benefits associated with the practice of day-care surgery; it is gaining widespread acceptance worldwide and across all specialties. We therefore determined the spectrum of procedures and the difficulties faced during implementation of day-care urologic surgery in a tertiary-care center in Nigeria. Patients and Methods This was a prospective study of all consecutive urologic day cases seen at the urology unit of Jos University Teaching Hospital; Nigeria; from January 2003 to December 2004. A total of 270 patients aged between 2 weeks and 100 years (median 55 years) with a male to female ratio of 14:1 were seen during the study period. The parameters studied were the presenting symptoms; diagnosis; treatment modalities; anesthesia; complications and whether or not the patients were converted to be in-patients or readmitted after discharge as well as the reasons for such conversion or readmission. The statistical analysis was done using the Epi-info 2004 system; version 3.2.2. Results The main conditions seen were urethral stricture in 89 (32.5) patients; benign prostatic hyperplasia in 86 (31.8); carcinoma of the prostate in 26 (9.6); carcinoma of bladder in 15 (5.6) and male infertility in 10 (3.7) patients. The procedures carried out were mainly urethroscopy/ urethrocystoscopy in 103 (38.2) patients; visual internal urethrotomy in 48 (17.8) and trucut prostatic biopsy in 33 (12.2) patients. Sedation was used in 142 (52.9); sedation and local anesthesia in 53 (19.7); local anesthesia alone in 9 (3.3); general anesthesia in 22 (8.1) and other combinations or omissions in entry in 41 (15.2) patients. Circumcision was performed on 3 neonates (1.1) without anesthesia. There was a cancellation rate of 15.6(n=42) mainly due to the inability of the patients to come (24 patients; 57.1); inadequate materials in the theatre (9 patients; 21.4); power failure (4 patients; 9.5); strike action (3 patients; 7.1) and financial difficulties (2 patients; 4.8). We had a conversion rate to in-patients of 1.9(n=5) for various reasons. No further complications or readmissions after discharge were encountered. Conclusion Urethrocystoscopy is the most frequently performed procedure and urethral stricture the most common diagnosis in our day practice. Cancellation of cases and conversion to in-patients remain our major challenges. The education of patients and physicians; as well as the provision of adequate material and infrastructure are recommended in order to provide the maximum benefit from urologic day-surgery practice