Rural surgery; experience at rural and backward desert region of Pakistan

To study the pattern of Urological and Non-Urological cases and their management at rural hospital. Descriptive and case series study. All surgical patients managed at civil hospital Mithi, from 3rd June 2009 to 3rd June 2012. In this study 4657 patients were enrolled. All patients presented with symptoms suggesting surgical disease and managed as surgical cases were included in the study. These patients were either admitted via outpatient department [OPD], emergency department or operated as OPD cases. The patients who received 1st aid medication and referred to tertiary care were not included. The variables noted and analyzed were patient's demographic data, provisional and final diagnosis, disease pattern, presentation, mode of admission, mode of treatment, nature of operation, complications and final outcome. All the data was analyzed by SPSS version-16 on computer. During three year study period, 4657 patients were managed either conservatively or operated upon. Out of total, 2591[55.6%] were emergency and 2066[44.36%] were elective admissions. The male female ratio was 4:1 .The mean age of patients was 36.5 Years. Urinary tract diseases were responsible for 1638 [35.17%], alimentary tract diseases 1242 [26.6%], trauma 932 [20.01%], soft tissue infections 546 [26.9%], superficial lumps 367 [18.13%] admission. Most common operative procedures for urinary tract diseases 409 [20.20%], soft tissue infections 546 [26.9%]. superficial lumps 367[18.13%], alimentary tract diseases [15.06%] 305, trauma [soft tissue repair and fractures 14.9%[303], were major bulk for operations. Regarding procedures Abscesses incision and drainage in 197 [22.6%] patients, cystolithotomy in 153 [17.6%], Hernioraphy [130] 14.9%, appendecectomy 105 [12.09%], haemorrhoidectomy 51[5.8%],breast abscess 38 [4.3%] breast lump [fibroadenoma] 25 [3.6%], hydrocele23 [2.6%], Ureterolithotomy 22 [2.5%] laparotomy 15 [1.7%], pyelolithotomy12, [1.3%] fissure in ano 13, [1.4%] undecended testis 12 [1.3%] Orchidectomy11 [1.3%] and abscesses psoas, perinal, scrotal 13 [1.4%], 18 [2.07%], 12 [1.3%] respectively. The concluded that the most common cause of seeking surgical care at back ward rural Tharparker was urinary tract diseases. Presence of surgical specialist at remote and back ward region Tharparker is candle in the dark. Main reason of patient referral to tertiary care was deficient in skill medical and surgical professionals, paramedic staff and medical equipments

Simultaneous repair for complicated/ complex vesicovaginal fistula

To determine the outcomes of repair of complicated/complex vesicovaginal fistulae [VVF] by simultaneously abdominal and vaginal approach. Prospective descriptive study. This study was conducted at PUMHS, Nawabshah from Jan. 2008 to Dec. 2012. After routine clinical examination and investigation, patients having complicated/complex vesicovaginal fistulae were selected for repair. The patients having associated with colonic involvement or with preexisting malignant pelvic pathology were excluded from the study. Follow up was carried out weekly basis for 03 to 06 months. Our study comprises of only 12 cases having complicated/complex VVF. The mean age was 35 SD +/- 3.5 years. The mean size of fistula was 3.9 SD +/- 1.2 cm. The ureter and urethra were adjunct with fistula in 03 [25%] and 02[%] cases respectively. all cases were treated with aforementioned method and auto-cystoplasty was carried in 08 [66.5%] cases. The uni-lateral and bilateral ureteric re-implantation was attempted in 01 [8.5%] and 02 [16.5%] cases respectively and double J stent were kept in all these cases. The success was achieved in 09 [75%] cases. The short and long term complications like frequency/dysuia/urgency of micturation, urinary stress incontinence and dyspareunia that had occurred in 04 [33.5%], 02 [16.5%] and 05[41.5%] cases respectively. Simultaneously abdominal and vaginal approach should be considered as complementary add-on to improve the access in difficult instances from 02 sides. It authorizes the surgeon to excise the fistulous tract

out come of transvaginal repair in 50 cases of vesico-vaginal fistula

To see the out come of transvaginal repair of vesico-vaginal fistula. A consecutive case series study. This study was conducted in the department of Urology and Dialysis Unit Peoples Medical College Nawab Shah, from Jan 2007 to the Dec 2009. Patients were collected from the urology out patient department and the department of gynecology People's Medical College Nawab shah. Total 50 females were operated for the vesico-vaginal fistula trans-vaginally. After the admission care full history and examination were done to demonstrate the incontinence subjectively and objectively. Before surgery all subjects were diagnosed by the cystoscpic examination. All subjects were operated transvaginally. The total 50 females were operated for the vesico-vaginal fistula trans-vaginally. In 35 cases obstructed and prolonged labour and in 15 cases pelvic surgery was the cause of vesico-vaginal fistula. Cystoscopically all fifty fistulae were divided according to their site in the bladder. Supra trigonal 07, trigonal 35 and Marginal 08. All were repaired transvaginally. After two weeks catheter was removed, the leakage occurs in four [04] cases in supra-trigonal cases. In trigonal variety of vesico-vaginal fistula all thirty five [35] cases only three [03] fistulae were leaked. In third variety of vesico-vaginal fistula was marginal variety. Total eight [08] fistulae were and three [03] out of eight fistulae were leaked. We conclude that transvaginal is an excellent approach for the vesico-vaginal fistula, especially in trigonal, solitary and smaller i.e. <4cm variety of fistulae. Careful selection of the patient and the time of repair are the important mile stones for the successful out come.

Polycystic ovarian syndrome: response to metformin therapy

To determine the response of polycystic ovarian syndrome [PCOS] to metformin therapy. This study was conducted from January 2006 to December 2007 at Peoples Medical College Hospital Nawabshah. All the patients presenting with infertility, menstrual irregularity and increase body mass index [BMI] were included. Diagnosis was confirmed by clinical presentation and ultrasound finding. Patients diagnosed with PCOS were given metformin for six months, the clomiphene was added for three months if the patients did not conceive. Later metformin alone was continued and patients were re-evaluated after one year. Total 63 patients, mean age of PCO was 24.49 +/- 4.87 years and married were 52 [82.53%] cases, 44 [69.83%] cases were present with menstrual irregularity, 31-74% were overweight, 6.34% obese. 52 cases with infertility in which 39 [74.98%] cases had conceived. Metformin significantly increase ovulation and conception rate

comparative role of optical urethrotomy with and without clean intermittent self catheterization [CISC] in urethral stricture

To assess the comparative role of optical urethrotomy in urethral strictures with [CISC] clean intermittent self catheterization and with out CISC. Comparative cross sectional. This study was conducted at the Department of Urology Peoples University of Medical and health Sciences for Women. Nawabshan. Sind from July 2008 to June 2010. The patients were thoroughly evaluated. All patients were subjectively examined pre-operatively by detailed history and complete clinical examination. Patient's satisfaction from his urinary stream and the sense of satisfactorily emptying of bladder were the main subjective tool. While the Uro-Flow Metry and Post-voiding residual urine were the main objective tools in both pre and post operative period. Under the spinal anesthesia optical internal urethrotomy was done. After removal of catheter all patients were divided equally in two groups. Group A. Patients without clean intermittent self Catheterization [CISC]. Group B. Patients on clean intermittent self catheterization [CISC]. All hundred [100] subjects were divided in two groups. Group A and B. Fifty [50] in each group. After third month seven [07] patients of group A, showed decline uro-flow Metry. Two [02] subjects in fifth month were submitted for the second session of optical urethrotomy. In Seventh month three [03] patients presented acute retention of urine all three were submitted for second session of optical urethrotomy. In 12th month five patients more submitted for the repeat session of optical urethrotomy regarding the group B patients. In the seventh month [05] patients presented with disturbed flow metry. In tenth month two [02] while in twelth month three [03] patients were needed to the second and third sessions of urethrotomy respectively. we conclude that optical urethrotomy with CISC is more effective treatment modality for the urethral strictures than the optical urethrotomy without CISC