Genito-urinary reconstruction in southern Nigeria.

BACKGROUND: Urologic cases constitute about 25% of a busy surgical practice in Nigeria with up to 50% of these cases being genito-urinary abnormalities in adults and children. As most urologic surgery in Nigeria is done by general surgeons, a knowledge of the disease pattern and effective techniques in management would be helpful in surgical training. OBJECTIVE: To describe the disease pattern and surgical outcomes in patients undergoing genito-urinary reconstruction in southern Nigeria METHODS: We retrospectively reviewed the medical records of patients who underwent genito-urinary reconstructive procedures by two urologists and one paediatric surgeon over a 7-year (1991-1998) period at two tertiary referral centres in southern Nigeria. We extracted data such as age, sex, nature of pathology, surgical therapy and outcomes. Patients with a follow up of 12 months were excluded. The pattern of genito-urinary disease, type and outcome of surgical therapy, and complications were determined. RESULTS: Two hundred and twenty seven patients (121 men, 39 women, and 67 children) underwent genito-urinary reconstruction during the seven years spanning 1991-1998. The study population consisted of 160 adults and 67 children (< 15 years old). Mean patient age was 43 years with a range of 18-87 years for adults and three years (range 18 months-13 years) for children. Mean follow up duration was 15 months, (range--13 months-seven years). Urethral abnormalities comprised 69% (98/ 227) of the lesions. The most common abnormality was urethral stricture in 98 (43%) patients. Urethral strictures were reconstructed as follows; primary anastomosis 83 (84.6%), pedicled penile skin island 6 (6.1%), Blandy 2 stage, 4 (4%), meatoplasty three (3%) and meatotomy, two (2%). The overall complication rate for repair of urethral strictures was 4.08%. There were 79 (35%) congenital lesions, including hypospadias 62 (27%), pelvi-ureteric junction obstruction 13 (6%), bladder exstrophy 2 (0.8%), chordee without hypospadias, 2 (0.9%), and concealed penis 1 (0.4%). These were managed using the following techniques; MAGPI, 30 (48.3%), urethroplasty, 22 (10%) single stage 10 (45%), two-stage 12 (55%), and urethral mobilization 10 (16%). Vesico-vaginal fistula complicating obstructed labour and pelvic surgery was the main cause of urinary fistulae. Ten patients underwent microsurgical epididymo-vasostomy for obstructive azoospermia resulting in three pregnancies. CONCLUSION: Lower urinary tract reconstruction represents a major proportion of urologic surgery in southern Nigeria. Management by urologic specialists results in good outcomes, therefore urologic training in this area should include a large component of lower urinary tract reconstruction.

Anaesthesia for ambulatory paediatric surgery: common techniques and complications.

BACKGROUND: Ambulatory surgical care accounts for over 70% of elective procedures in Northern America. Ambulatory paediatric surgical practice is not widespread in Nigeria. This report examined clinical indicators for quality care in paediatric ambulatory surgery using common outcomes after day case procedures as benchmark. METHODS: This was a cross-sectional study of children who were presented for ambulatory surgical care in the University of Benin Teaching Hospital. A standardized questionnaire was employed to record the age, gender, indication for surgery, type of anaesthesia, timelines for the surgery and associated complications. RESULTS: A total of 93 patients had surgical procedures on ambulatory basis. The mean age of the patients was 4.1(4.0) yr and duration of surgical procedure 31.3(12.1) min. The male to female ratio was 3:1, and herniotomy was the most frequent procedure on ambulatory paediatric surgical care 60 (64.5%). The common anaesthetic techniques employed in the paediatric ambulatory setting were spontaneous respiration with face mask 40 (43%), Inhalation technique with tracheal intubations 31 (33.3%), general anaesthesia with relaxant technique five (5.4%), local infiltration with or without sedation eight (8.6%), GA plus caudal block eight(8.6%), and subarachnoid block one(1.1%). The indicators of quality care were unanticipated admission (5.4%), repeat hospital visit (4.3%), readmission (2.2%) and delayed discharge (21.5%). CONCLUSION: The practices of paediatric surgery on ambulatory services are feasible in our setting. The observable complications are within acceptable limits. The timelines in the scheduling and discharge appear not to be optimal for an effective ambulatory service.

Paediatric intussusception in Benin city, Nigeria

Intussusception is one of the leading causes of intestinal obstruction in children. This study reports our experience in the management of intussusception in Benin City; Nigeria. This was a 10-year retrospective review of intussusception in children at the University of Benin Teaching Hospital from January; 1997 to December; 2006. Twenty four children were admitted with intussusception (M: F = 1:1.4) within the period. Only three patients (12.5) presented within 24 hours of onset of illness. Ten (41.6) presented between one and four days; seven (29.2) between five and 10 days; while four (16.6) presented between 11and14 days. Abdominal pain; irritability; blood in stools; vomiting; abdominal distension and palpablemass in various combinations were the clinical features. All the patients; except one (4); were below the age of one year. There was much delay before presentation of infantswith intussusception; with high attendant mortality

Spontaneous Neonatal Gastrointestinal Perforation : Surgical or Conservatisme Management

B a c k g r o u n d : S p o n t a n e o u s n e o n a t a l gastrointestinal perforation occurs without any primary lesion of the gastrointestinal tract. It is a rare surgical emergency that may be caused by shunting of blood from renal; peripheral and mesenteric vascular bed to vital organs such as heart and brain during periods of perinatal stress.Aim: To report three neonates with spontaneous gastrointestinal perforation. Results: Between 2001 and 2005; we managed three cases of spontaneous gastrointestinal perforation in neonates at the University of Benin Teaching Hospital; Benin City. The perinatal stress factors were caesarian delivery; prematurity and fetal distress due to prolonged obstructed labour. Two had exploratory laparotomy and their perforations were closed in 2 layers while one was managed conservatively. They survived and were discharged after ten; thirty-six and eight days on admission and remained well during one year of follow up.Conclusion: Early diagnosis; adequate resuscitation and timed surgical intervention resulted to encouraging outcome

Altered osmotic thresholds for arginine vasopressin secretion and thirst during superovulation and in the ovarian hyperstimulation syndrome (OHSS): relevance to the pathophysiology of OHSS.

OBJECTIVE: To test the hypothesis that decreases in and maintenance of a new steady state in plasma osmolality and sodium level in ovarian hyperstimulation syndrome (OHSS) are due to altered osmoregulation of arginine vasopressin secretion and thirst. DESIGN: Prospective study. SETTING: IVF-ET program in a university-based assisted reproductive treatment center. PATIENT(S): Eight women undergoing superovulation for IVF-ET and five women with normal menstrual cycles. INTERVENTION(S): Two-hour infusion of 5% saline on day 3 or 4 after hCG administration in patients undergoing IVF or in the early luteal phase in controls. A 5% saline infusion test was done on day 10 after hCG administration in one patient with OHSS and one patient without OHSS, both of whom were undergoing IVF. MAIN OUTCOME MEASURE(S): Comparison of changes in thresholds for thirst and plasma vasopressin to plasma osmolality. Changes in urine osmolality, plasma electrolytes, hemoglobin level, and hematocrit were assessed at baseline and during infusion of 5% saline. RESULT(S): The sensitivity of the changes in arginine vasopressin secretion and thirst after 5% saline infusion was similar in IVF patients on day 3 or 4 after hCG and controls. However, the osmotic threshold was significantly lower by 6 mOsm/kg in IVF patients. By day 10 after hCG, the lower osmotic thresholds for arginine vasopressin secretion and thirst persisted in OHSS, although the sensitivity to arginine vasopressin secretion was markedly reduced. CONCLUSION(S): The osmotic thresholds for arginine vasopressin secretion and thirst are reset to lower plasma osmolality during superovulation for IVF-ET. This new lower body tonicity is maintained until at least day 10 after hCG in OHSS. Decreases in plasma osmolality and plasma sodium levels in OHSS are due to altered osmoregulation rather than electrolyte losses; correction of apparent "electrolyte imbalance" in OHSS is therefore inappropriate.

Congenital peritoneal encapsulation of small intestine: a case report.

Congenital peritonel encapsulation of the small intestine is a rare malformation. It is associated with clinical features which may cause diagnostic difficulties and more often it is recognised only at exploratory laparotomy. We present a case in a 15 year old female, who was treated and she had a good result. Embryological explanation for the pathology is also considered. It is a disease entity which should be recognised, especially when encountered at laparotomy and treated appropriately.

Coexistent hemoconcentration and hypoosmolality during superovulation and in severe ovarian hyperstimulation syndrome: a volume homeostasis paradox.

OBJECTIVE: To investigate the concomitant time courses of the changes in osmolality and calculated blood volume during the genesis of ovarian hyperstimulation syndrome (OHSS). DESIGN: Prospective longitudinal study. SETTING: IVF-ET program in a university-based assisted reproductive technology center. PATIENT(S): Thirty women undergoing superovulation for IVF-ET. INTERVENTION(S): Blood and urine samples were obtained on seven occasions from the start of FSH stimulation until a pregnancy test. Five women with severe OHSS had daily blood and urine tests during hospitalization. MAIN OUTCOME MEASURE(S): Changes in serum and urine osmolality, serum electrolytes, albumin, hemoglobin, and hematocrit. RESULT(S): Blood volume in women with OHSS decreased significantly by 20% from days hCG +2 to +4, followed by a sustained increase of 30% above baseline from days hCG +8 to +12. There was no statistically significant change in blood volume in women without OHSS. There was a sharp decrease in serum osmolality in women without OHSS between days 0 and hCG +2, which recovered toward baseline from day 4 after hCG. In women with OHSS, there was an unexpected increase in osmolality of 6 mOsm/kg between days hCG -2 and 0, followed by a decrease of 8 mOsm/kg by day hCG +2; this was sustained until day hCG +12. Patients with OHSS demonstrated a concentration and dilution of their urine during the acute and recovery phases of the syndrome, respectively, despite persistence of the hypoosmolar state. CONCLUSION(S): Decreased osmolality in severe OHSS is maintained despite significant decreases and increases in blood volume, suggestive of fundamental alterations in osmoregulation.

One hundred and three concurrent IVF successes for donors and recipients who shared eggs: ethical and practical benefits of egg sharing to society.

Egg sharing is a form of egg donation where complete strangers can collaborate anonymously to overcome their involuntary childlessness. In a retrospective analysis, results of egg sharing treatments were analysed in 37 consecutive donors and 39 recipients who had achieved concurrent success following IVF treatment. The interval between being accepted onto the programme and receiving treatment was less than 6 months for most patients. Births of 103 infants are expected. Multiple pregnancy rates were high and equivalent in both the groups (donors 32.4%, recipients 25.6%) despite the original number of eggs available being halved at egg collection and equal numbers being allocated to donors and recipients. On average fewer than six eggs were required for the birth of each baby. More successes are expected in time as 33 couples (43.4%) have their excess embryos stored for future use. The programme avoided the need to advertise for donors. This had particular significance for members of minority ethnic groups. It is surmised that promotion of concurrent treatment of egg sharers and recipients will attract funds from insurance providers or health boards who are unimpressed by IVF treatments with indifferent success rates and runaway costs. In the event of such funds materializing, meagre NHS resources for IVF treatment could be better focused. Overall, the benefit derived from applying the simultaneous treatment of anonymous donors and recipients is so compelling as to make it the preferred IVF option for qualifying couples.

Severe haemophilia following use of donor eggs: implications for screening of prospective donors.

Oocyte donation has become a common treatment modality for a range of infertility conditions. The Shared Egg Donation (SED) scheme is one of various strategies that now exist to try and overcome shortages, that have invariably occurred from the very success of oocyte donation procedures. Despite a reassuring positive profile that has been demonstrated, some residual concerns still exist with regard to the SED programme. We report the first case of severe haemophilia following use of donor eggs in the SED scheme. The case has not only illustrated potential problems that can occur with egg donation schemes, but also suggested a plausible model on which to base future management of similar cases. The case furthermore illustrates that there is no substitute for 'good practice' in ensuring those risks and concerns of egg donation programmes are kept to acceptable limits.

Severe ovarian hyperstimulation syndrome following salvage of empty follicle syndrome.

We report a case of severe ovarian hyperstimulation syndrome (OHSS) following a rescue of empty follicle syndrome (EFS). This suggests that the risk of developing OHSS remains unaltered even in the presence of EFS. The case supports the possibility of obtaining oocytes that fertilize and cleave normally after a second dose of human chorionic gonadotrophin (HCG) and a repeat oocyte retrieval. It supports the suggestion that the follicles are not necessarily empty in EFS. It demonstrates further that OHSS cannot be prevented by aspiration of follicular fluid and patients with large numbers of follicles and EFS must be warned of this potential complication.

The posterior urethral valve uropathy: results of treatment.

Nineteen children treated for posterior urethral obstruction due to congenital valve in the University of Benin Teaching Hospital, Benin City, Nigeria, over a 9-year period have been analysed. Their ages ranged from birth to 12 years. Results show that associated kidney pathology may be irreversible even after successful excision of the valve. This determines the final prognosis, which is worse the younger the child at presentation.

Management of peritonitis in perforated appendicitis in children.

A prospective study on the management of severe acute appendicitis with gangrene and perforation was carried out using protocols that included schematized treatment. The schemes emphasized adequate preoperative treatment, meticulous operative technique of peritoneal toileting, generous use of appropriate antibiotics in combinations, and early graded patient's ambulation in the postoperative period. The average hospital stay was seven days, wound infection was of mild degree and less than 1%, and there was a low morbidity. Follow-up has shown no serious complications.

The herniotomy spoon.

At the time of ligation of the hernial sac in an inguinal hernia repair, particularly in infants and young children, the spermatic cord structures need to be protected, and the grooved spoon is useful at this stage. This paper reaffirms the usefulness of the spoon, and describes a structural modification necessary to improve its effective use.

Chronic non-strangulating incompletely obstructing intussusception: with case report of a seven and a half year old Nigerian boy.

One case of chronic intussusception (ileo-ileo colic) is reported. A seven and a half year old male had presented with colicky abdominal pain, vomiting, a palpable abdominal mass, infrequent passage of mucus or blood with stools and weight loss over a period of six weeks. There was delay in diagnosis due to unusual presentation and a low index of suspicion. The patient had been admitted to a peripheral general hospital for four weeks where he was treated for amoebic dysentery without improvement, before his transfer to our hospital where the diagnostic problem continued, until the paediatric surgical unit was called in.

Skin closure during appendicectomy: a controlled clinical trial of subcuticular and interrupted transdermal suture techniques.

Over an 18-month period, 100 consecutive patients who underwent appendicectomy were randomly allocated to have skin closure either by interrupted transdermal or subcuticular techniques. Ninety cases were performed as emergencies within 6 h of admission. Only cases of acute uncomplicated appendicitis were included. Complications arising from the method of wound closure used were assessed. It was noted that the mean wound closure time and cost of material were significantly reduced in the group using the subcuticular technique (P less than 0.025). The wound infection rate was the same in both groups, but when all wound complications were taken together, there was a significantly higher incidence with the interrupted method. The results from this trial indicate that subcuticular wound closure during appendicectomy--an operation with a high risk of infection--is not associated with an increase in the incidence of wound complications and offers a cost and time-saving advantage.

Familial occurrence of cryptorchidism.

A case of Cryptorchidism involving a father and all his four sons who are product of a nonconsanguineous marriage has been described. From a review of the literature, as well as evidence derived from the family history, it is suggested that the mode of inheritance may be autosomal dominant with incomplete penetrance or multifactorial.

Incidence of undescended testis in a population of children at Benin City

One thousand; eight hundred and ninety-six children aged 6 to 12 years were examined for undescended testis. The incidence was found to be 0.8in the 6 year olds; and also in the 7 and 8 years groups. The overall incidence was 0.4. A differential intrascrotal descent rate was also discovered between the right and left testes; by observations of position of testis in scrotum in each age group: thus while at the age of 6 years 9.4of the left testes and 6of the right testes had touched the base of the scrotum; at the age of 12 years 88.3of the left testes but 95.7of the right testes lay in the base of the scrotum