Surgery in rural Nigeria--problems, challenges and recommendations.

A review of 1,645 major and intermediate operations performed in a 20-bed rural hospital over a period of 4 years was undertaken to highlight the problems associated with rural surgical practice. Despite such problems as lack of essential facilities, poorly trained paramedical and support staff, a commendable measure of success was achieved in terms of low rates of mortality and morbidity. This was possible through hard work, meticulous surgical technique and sound judgement. Interestingly, all the cases comprising 271 major and 1,374 intermediate operations were performed using local, regional, light general anaesthesia or combinations thereof, without the help of an anaesthetist. Our surgical training programmes should include rotations through rural surgical units, because of the particular situations involved.

Management of unrepairable urinary vaginal fistulae in a developing country.

Thirty-eight out of 44 patients with unrepairable urinary and rectal vaginal fistulae obtained good to excellent results from diverting the urine by uretero-colic anastomosis. The patients who hitherto were regarded as social outcasts became integrated into society once again. Intestinal conduits are generally not employed for urinary diversion, because of the social dislike for colostomies and ileostomies, coupled with the lack of availability of the necessary external appliances, in Nigeria. In spite of the good results recorded, it is felt that urinary diversion by uretero-colic anastomosis for vesico-vaginal fistulae should be regarded as the last resort; there are well-known adverse complications from the operation, coupled with psychological trauma to the patients because of their inability to micturate in the normal fashion.

Effect of continuous irrigation with normal saline after prostatectomy.

Normal saline solution is often used for continuous irrigation of the bladder following prostatectomy in order to prevent clot retention. There is usually a concern for possible sodium reabsorption and consequent fluid retention. Considering the harmful cardiovascular effect in elderly patients who usually come for prostatectomy, fluid retention could be detrimental. Therefore we have hitherto given daily lasix injections routinely during continuous irrigation of the bladder with normal saline solution. This study is designed to find out if the amount of sodium reabsorbed is significant enough to justify the practice. The amount reabsorbed is indeed not significant (p > 0.05). A plea is therefore made to give lasix injection following prostatectomy only if there is a clinical indication for it.

New approach to the management of Fournier's gangrene.

A new method of treating Fournier's gangrene is described in 13 patients. There was no mortality and the average hospital stay was 10 days. Considerable gain in man-hours and expense was recorded when compared with the old method of treatment with antibiotics and wound debridement.

Ureteral injury in obstetric and gynecologic operations in Nigeria.

Forty-eight cases of ureteral injuries resulting from obstetric gynecologic surgery were treated at the University of Nigeria Teaching Hospital between January 1978 and December 1987. Cesarean sections and cesarean hysterectomies were the leading causes of injury, being responsible for 18 (38%) and 12 (25%) of the cases, respectively. Ureteral transection was the commonest lesion observed, being noted in 29 (60%) of the patients. Attempt was made to reimplant the ureter into the bladder whenever possible, thus ureteroneocystostomy was performed in 27 (56%) cases while only 3 cases of end to end anastomosis were done. There was a case of mortality recorded from one of the referred patients. Forty patients recovered normal renal function after repair. Repair of ureteric injury as soon as the patient is fit for surgery is recommended.

Complications of treatment of urethral stricture in our practice.

Bleeding is the most common early postoperative complication of the treatment of urethral stricture, while recurrent stricture is the most common late postoperative complication irrespective of the method of treatment applied. The different sophisticated methods of urethroplasty make it possible today to treat successfully complicated urethral strictures. The results of such treatment, however, have been associated with a variety of complications (impotence, incontinence and urethrocutaneous fistula), especially when simple methods such as bouginage are used. Although bouginage is associated with a greater recurrence rate of urethral stricture than is urethroplasty, the former should be encouraged in centres where facilities and trained urologists are limited, as it often occurs in the developing countries, since the method is simple and can be used as emergency without prior urethrogram.

Treatment of urethral strictures in University of Nigeria Teaching Hospital.

A review of 150 patients with urethral strictures treated over a period of seven years at the University of Nigeria Teaching Hospital, Enugu, showed that 83 per cent of the patients were treated with a form of bouginage. Recurrence rate among this group was 65 per cent as opposed to 44 per cent among the group treated with urethroplasty. About 40 per cent of the patients obtained good to excellent results, 26 per cent rather poor results, and the rest achieved fair results. Even though urethroplasty afforded the best results, bouginage, in spite of the high recurrence rate, should be encouraged in centers with limited facilities for urethroplasty.

Management of urethral injuries in University of Nigeria Teaching Hospital.

A plea is made for diversion of urine by suprapubic cystostomy as initial treatment in clinically established urethral injury. When early retrograde urethrography is not possible this study should be done between 3 and 6 weeks after injury, when infection or extravasation of urine at the injured site might have cleared. The quality of x-ray at this time is good and helps to determine the definitive treatment of the resultant stricture, if any. Good results were achieved in 32 patients treated along these guidelines. Poor results were achieved in 13 additional patients treated initially with interlocking sounds, even though the nature of the injury could have contributed partly to the bad result.