The Utility of Digital Rectal Examination in Estimating Prostate Volume in a Rural Hospital Setting.

OBJECTIVES: To determine the correlation between prostate volume estimated by digital rectal examination (DRE) and that estimated by abdominal ultrasound in the same patients. PATIENTS AND METHODS: Men who presented to our urology outpatient clinic with lower urinary tract symptoms were recruited in this study. We estimated the prostate size by digital rectal examination using the sliding scale as a guide and subsequently measured the prostate volume by transabdominal ultrasound. RESULTS: A total of 100 patients completed this study. The mean age was 65.6 ± 9.84 years. The Kappa's reliability test comparing the prostate size estimated by DRE and the prostate size measured by transabdominal ultrasound was 0.579832, the Kappa's standard error was 0.097768 and Kappa's t value was 5.93. The Kappa's reliability test fell into good agreement range (0.4-0.75). This is further validated by the Pearson's correlation test ascertaining correlation between Ultrasound and DRE and generated a correlation coefficient(®) of 0.59 (P = 0.00). This implies a high positive correlation between ultrasound estimated prostate volume and that estimated by DRE that is statistically significant (P < 0.01). CONCLUSION: Estimation of prostate volume by digital rectal examination is reliable. This is very important in an environment where esoteric laboratory facilities are not readily available, and the clinician has to depend mainly on his clinical acumen.

Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

The value of international prostate symptom scoring system in the management of BPH in Jos, Nigeria.

OBJECTIVE: To determine the value of international prostate symptom scoring (IPSS) system in management of patients with benign prostatic hyperplasia (BPH) in Jos, Nigeria. MATERIALS AND METHODS: This was a prospective study of 104 newly diagnosed patients with BPH from June 2006 to July 2007. Patients' symptoms were initially evaluated by administering a pretreatment IPSS/Quality of Life Score (QOLS). This categorized patients into mild, moderate, and severe symptom groups. The mild symptom group had watchful waiting as mode of management. The moderate symptom group received doxazosin, an alpha blocker, while the severe symptom group had prostatectomy. A post-treatment IPSS/QOLS was administered 3 months after. Mean changes in IPSS/QOLS was calculated and subjected to paired student's t- test for significance in changes. Spearman's correlation coefficient was used to test significance between correlations. RESULTS: Mean age of patients was 64.3 years. 3 patients (2.9%), 53 patients (51.0%), and 48 patients (46.1%) fell into the minor, moderate, and severe symptom categories, respectively. The QOLS correlated with IPSS. There was a mean change in symptom scores of +2.3 for the minor symptom category, -8.1 (P < 0.001) for IPSS and -1.7 (P < 0.001) for QOLS in the moderate symptom category, and -24.6 (P < 0.001) for IPSS and -4.0 (P < 0.05) for QOLS in the severe symptom category. CONCLUSION: The study has shown that IPSS is a valuable tool in management of patients with BPH.

Has the creation of a urology residency programme translated in to more surgical exposure for final year residents?

BACKGROUND: Surgical residency programmes are supposed to enhance resident operative experience. The impact of urology residency was assessed at our institution before and after establishing a structured urology training programme in 2006. MATERIALS/METHODS: Log books of final year Urological residents presented for the West African College of Surgeons (WACS) and National Postgraduate Medical College (NPMC) final part II exams from January 2007 to December 2011 at Jos University Teaching Hospital (JUTH) were reviewed. All residents had completed mandatory 3 years of urology training. The records of surgeries performed by residents were extracted. These surgeries were categorized as Endoscopic procedures, open kidney/ureter surgeries, open bladder surgeries, open prostate surgeries, open urethral and open testicular/penile sugeries. The records were compared with records of operated cases in the same category before the commencement of Urology residency training from January 2001 to December 2005. Results were presented as tables and charts. The Students unpaired t-test was used to assess significance. P value of < 0.05 was taken as significant. RESULTS: There was an overall increase in absolute number of operative cases performed by final year residents in the period after the commencement of the Urology residency programme (n = 596) compared to the period before the training began (n = 381) this however, was not statisically significant (p = 0.3). There was a decline in endoscopic surgeries done by residents after the training begun compared to the era before the training. CONCLUSION: Whereas creation of the urology training programme in JUTH has resulted in more operative cases done by trainee urologists, the exposure to endosopic surgeries has declined. This will not augur well for the training programme in the long run. Periodic rieiew of the data should be performed to maintain consistent, positive experiences for residency training.

The management of prostatic haematuria.

BACKGROUND: Prostatic haematuria is a common clinical problem. In this report, we have reviewed the incidence, precipitating/co morbid factors, treatment and outcome of haematuria in patients with benign prostatic hyperplasia and prostate cancer METHODS: A two year prospective review of 37 patients who presented with haematuria associated with benign prostatic hyperplasia and prostate cancer Each patient had full clinical assessment, including any associated precipitating or co morbid factors. All patients had urethral catheterization; and cystoscopy to exclude bladder tumours or bladder stones. Subsequent management depended on severity of bleeding; and consisted of one of the following: observation only, irrigation only, irrigation and blood transfusion and emergency prostatectomy. Upon stabilization, the definitive treatment in each patient was based on primary pathology. RESULTS: A total of 134 patients who had either benign prostatic hyperplasia or prostate cancer were treated. Thirty seven (27.6%) patients presented with haematuria. The incidences of haematuria in benign prostatic hyperplasia and prostate cancer were 26.7% and 29.2% respectively. Haematuria was precipitated in 17 (45.9%) patients; while nine (24.3%) patients had 12 associated co morbidities. Seventeen (45.9%) patients had blood transfusion. A total of 34 (91.8%) patients were managed conservatively. There were four (10.8%) deaths. CONCLUSION: Prostatic haematuria is a common urologic challenge. In most cases conservative management is the key In the absence of modern facilities, emergency open prostatectomy may be needed to control bleeding, in those in whom conservative approach has failed; or when specifically indicated based on the individual patient or as dictated by other local factors.

Thyroidectomy under local anaesthesia: how safe?

BACKGROUND: In order to compliment the inadequate health facilities in the rural areas in Nigeria, nongovernmental organisations provide adhoc outreach health camps that offer treatment in various medical specialties including surgery. SETTING: Rural outreach health camps. OBJECTIVE: To evaluate the safety of thyroidectomy under local anaesthesia at rural outreach setting with inadequate facilities for general anaesthesia. PATIENTS AND METHODS: This was a prospective descriptive study of 33 consecutive cases of thyroidectomy performed using field block with 1% lignocaine and adrenaline 1: 200,000 dilution during two free medical outreaches that held at Jos, Nigeria in March and October 2005 respectively, lasting two weeks each. RESULTS: A total of 33 primary thyroid operations were performed consisting of 30 subtotal thyroidectomies (91%), 2 lobectomies (6%) and one total thyroidectomy (3%), The patients were aged between 23 and 62 years with a mean age of 45.8 years. There were 3 males and 30 females with a male: female ratio of 1:10. There was no mortality but morbidity was 2/33 (6%) Two complications were recorded in 2 patients and were superficial surgical site infection (3%) and reactionary haemorrhage (3%). CONCLUSION: We conclude that thyroidectomy under local anaesthesia is a safe procedure in experienced hands at rural settings with inadequate facilities for general anaesthesia.

Outcome of urethroplasty for urethral stricture at Jos Universitry Teaching Hospital.

BACKGROUND: The treatment of urethral stricture disease has remained a challenge over the years. The outcome has also been varied, with recurrent stricture being a major concern. We determined the outcome of urethroplasty with particular reference to the complications. METHODOLOGY: This was a retrospective study over 10 years (1995 to 2005) done at the Jos University Teaching Hospital, a tertiary health institution in the middle belt region of Nigeria. RESULTS: There were a total of 32 patients whose ages ranged from 0.06 to 75 years (mean 25 yrs, SD 18.8 yrs,). Eleven patients had had one form of stricture treatment or the other. Stricture aetiology was traumatic in 21 (66%) and inflammatory in 6 (19%) patients. Of the 24 patients in whom the stricture length at operation was specified, six, 11 and seven were <2 cm, 2-4 cm and >4 cm respectively. The stricture was located in the anterior urethra in 18 (58.1%), posterior urethra in 2 (6.4%) and bulbomembranous in 11 (35.5%) of patients (unspecified in one). The bulbar urethra was the single most involved region, occurring in 12 (38.7%) patients. Resection and end to end anastomosis was done in 16 patients and replacement urethroplasty in 16 others (Quarteys in 12, Swinney in 3 and Orandi in 1). Complications observed were urinary tract infection in 12 (37.5%) patients, recurrent stricture 11 (34.4%) wound infection 10 (31.3%), oedema of genitalia 7 (21.9%), urethrocutaneous fistula 4 (12.5%), impotence 3 (9.4%), wound haematoma 2 (6.3%) and urinary incontinence in 1 (3.1%) patient(s). CONCLUSION: Urinary tract infection, recurrence of the stricture and wound infection remain our major challenges. We recommend that in order to improve outcome, surgeons should regularly audit their practice and make necessary adjustments. In addition, urethroplasty should preferably be carried out by those with the cognate experience, while not compromising the need to teach younger colleagues.

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

The acute scrotum: aetiology, management and early outcome-preliminary report.

BACKGROUND: Most patients with acute scrotal pain may require urgent exploration. We determined the aetiological factors, treatment and early complications in such patients. METHODS: This was a prospective study of consecutive patients presenting with the acute scrotum at Jos University Teaching Hospital, Nigeria from January 2001 to December 2002. RESULTS: Twenty-nine patients were studied with a mean age of 29.4 years (range 12 days to 80 years). Seventeen (58.6%) were 11 to 30 years old. The clinical diagnostic accuracy for testicular torsion was 75% because out of the 24 patients initially thought to have testicular torsion, 18 (62.1%), four (14.8%) and two (6.9%) had testicular torsion, epididymoorchitis and torsion of appendix testis respectively at exploration. The diagnosis in other patients was intrascrotral abscess in two (6.9%), Fournier's gangrene in one (3.4%) and haematocoele in one (3.4%). Only four (13.9%) patients presented within the first 24 hours of illness (all explored within 6 hours) and 14 (48.3%) in one to five days. Thirteen (44.6%) patients had orchidopexy while seven (24.2%) had orchidectomy as a result of testicular torsion (five) and intrascrotal abscesses (two). Testicular exploration only, with antibiotics was the treatment for patients eventually found to have epididymoorchitis, with good response. Testicular salvage rate was 72% in patients with testicular torsion. Postoperative complications observed in three patients were wound infection (two) and wound dehiscence (two). CONCLUSION: We conclude that testicular torsion is the most common cause of acute scrotum in our environment. Majority of our patients with acute scrotum present to hospital late. Health education of the public and attending physicians is required in order to reduce delay in presentation, improve diagnostic skills, testicular salvage rate and prognosis.

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

Testicular torsion on the Jos Plateau.

In order to determine the pattern and the factors that influenced outcome, we retrospectively studied fifty-seven patients with torsion of the testis admitted to the Jos University Teaching hospital between August 1993 and July 2001. The age ranged from 2 to 55 years with a mean of 22.7 years. Majority (79%) of the patients were in the second and third decades of life. The main suspected precipitating factors in this study were cold weather and scrotal trauma: in 28% of the cases no cause could be ascertained. Eight (14%) patients presented within 4 hours and 35 (61%) presented after 24 hours of the onset of symptoms. Both sides were equally affected. Testicular pain, retraction and scrotal swelling were the most common presenting complaints. The highest incidence 65%) occurred between November and February when the weather on the Jos plateau is coldest. At surgery, 34 (60%) patients were found to have associated congenital anomalies; in 22 (39%) patients, the testis was non-viable. There was no mortality in this series and the complications were superficial wound infection (14%), testicular atrophy (7%) and sub-fertility (16%). High index of suspicion in a patient with acute scrotum, prompt and effective surgery will improve testicular salvage.

Surgical experience with management of vascular injuries.

UNLABELLED: To highlight the problems that are associated with the causes, diagnosis and management of vascular injuries. MATERIALS AND METHODS: A retrospective study of 52 cases of vascular injuries managed at the Jos University Teaching Hospital (JUTH) during a ten year period. RESULTS: The sex ratio M:F was 6:1 and the mean age at presentation was 23 years. The most common causes of vascular injuries were road traffic accidents in 44 per cent, iatrogenic 27 per cent and industrial in 13 per cent. These resulted in 50 cases (96 percent) of penetrating vascular injuries and 2 (4 percent) of blunt injury to vessels. Fifty-four percent of patients presented in shock. Active bleeding was recorded in 81 percent, pulse deficit in 65 percent and frank gangrene in 16 per cent. Aneurysms of various types occurred in 14 percent. Associated injuries were fractures in 60 percent, soft tissue injuries in 56 per cent and peripheral nerve injuries in 10 per cent. Overall, 52 arteries and 51 veins were injured, resulting in 15 lacerations, 74 complete transactions and 2 vascular blunt injuries with intimal tears and intraluminal thrombosis. Direct lateral suture of vessels was employed in 13 vessels, anastomosis in 12 vessels, graft interposition in 4 cases, ligation in 49 cases and aneurysmectomy in 3 cases. Three primary amputations were performed versus 7 secondary amputations. Hospital mortality was 16 percent and was mainly due to hypovolaemic shock, acute renal failure and sepsis.

Pyogenic thyroiditis and HIV infection.

Infective thyroiditis remain rare disease entity. Six patients were seen in Jos, Nigeria in the last five years. All of them were HIV positive. The presentation and management of these patients are high-lighted. The clinical features and bacteriology were similar to those previously documented for infective thyroiditis.

Adult intussusception: the Jos experience.

Twenty two consecutive cases of adult intussusception managed between January 1990 and December 1998 at Jos University Teaching Hospital formed the basis of this study. Thirteen (59.1%) of the patients were males and 9(40.9%) females, with a male to female ratio of 1:4:1 and a mean age of 49.6 years. Most patients were referred late to our service as a result of poor index of suspicion and misdiagnosis. Laparotomy was done in all the cases and in 5(22.7%) patients no cause could be found, but in the remaining 17(77.3%) definite causes were identified which were mainly polyps in 7(31.8%) patients and colonic malignancies in 4(18%). The ileocolic intussusception was the commonest variety. Sixteen (72.7%) patients had bowel resection for colonic carcinoma, gangrenous bowel and irreducibility of the intussusception while manual reduction was successful in the other 6(27.3%) patients. The morbidity rate was 22.7% and the complications were wound infection and adhesive intestinal obstruction. Two deaths were recorded with a mortality rate of 9.1%. The pattern of adult intussusception as seen in the western world was observed in this tropical highland.

Childhood intussusception: a 9-year review.

Sixty-four consecutive cases of intussusception in 48 infants and 16 older children managed at Jos University Teaching Hospital between January 1990 and December 1998 are reviewed. The age range was between 3 months and 15 years (mean 2.2 years) and the male to female ratio was 3.6:1. The quartet of abdominal pain, bloody mucoid stools, abdominal mass and palpable rectal mass was present in 70% compared with the classical triad (abdominal pain, bloody mucoid stools and abdominal mass) which occurred in only 32%. All the children had surgery. In 26 (41%) of the children, no associated cause was found, in three polyps formed the lead point and in five children a buried appendicectomy stump formed the lead point. In 30 (47%) other children, mesenteric lymphadenopathy and inflamed Peyer's patches were noted. Ileo-colic intussusception occurred in 32 (50%) children. Manual reduction was successful in 67%. Bowel resection for gangrene, irreducibility and an iatrogenic colonic tear was done in 30% of patients. Two (3%) had spontaneous reductions. There were four deaths. The commonest complications were wound infection and adhesive intestinal obstruction.

Safety of daycare hernia repair in Jos, Nigeria.

OBJECTIVE: To evaluate the safety of day surgery for inguinal hernia. DESIGN: A randomised prospective study of patients presenting for elective inguinal hernia repair. SETTING: Jos University Teaching, Jos, Nigeria. SUBJECTS: One hundred and twenty one patients who completed a six-week follow up period. INTERVENTIONS: Sixty one patients had elective hernia repair as daycares while 60 patients were treated as inpatients. Forty six herniotomies and seventy five herniorrhaphies were performed under local or general anaesthesia. MAIN OUTCOME MEASURES: Early post-operative complications, including wound complications were evaluated. RESULTS: Early post-operative complications occurred in two of the 61 daycares and 15 of 60 inpatients (p=0.002). There were twelve and ten wound complications in daycares and inpatients respectively (p=0.668). There was no mortality. CONCLUSION: Outpatient elective inguinal hernia repair in carefully selected patients is relatively safe in our environment.

An unusual chest impalement.

We present the case of a 49-year old farmer, a combatant in communal clash over a piece of farmland on the Jos Plateau, who was impaled on his chest by a 13.5 cm long metal arrow, 56 hours prior to presentation. The arrow hit him tangentially on the left side of the chest and disappeared completely into his chest traversing the chest wall and lacerating the superior lingula segment of the lung but the tip of the arrow was only about 1.5 cm short of the pericardium. We are not aware of any report in literature on a patient in the West African sub-region who sustained and survived such serious chest impalement by a rigid object for more than two days before hospitalisation. Sustained public education and enforced legislature against the use of such lethal weapons will go a long way in preventing serious injuries of this nature.