Clinical characteristics and outcome of management of Fournier's gangrene at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria.

BACKGROUND: Fournier's gangrene (FG) though a rare condition can be associated with significant mortality. There are few reports in our environment documenting the outcome of management of the condition. The aim of the following study was to describe the clinical characteristics and outcome of management of patients with FG in a tertiary hospital in Southwest Nigeria. PATIENTS AND METHODS: The clinical records of patients who presented with FG at a tertriary hospital over a 5 year period were reviewed. RESULTS: A total of 11 cases were reviewed and all patients were male. The scrotum alone was the most common site of involvement (54.5%). Late presentation was common with 9.6 days (range 1-21 days) being the average duration between the onset of symptoms and presentation at the hospital. Most of the patients (63.6%) did not have any identifiable systemic predisposing factor. There was no mortality or testicular loss recorded. CONCLUSION: Patients with FG still present late in our environment. However, appropriate aggressive treatment can help ameliorate the associated mortality and morbidity even in a resource poor setting.

Urethrocutaneous fistula complicating circumcision in children.

INTRODUCTION: Urethrocutaneous fistula is an unusual but preventable complication following circumcision. We describe our experience with the management of this potentially challenging condition. MATERIALS AND METHODS: We reviewed all patients who had surgical repair of post-circumcision urethrocutaneous fistula from September 2008 to September 2011 in our institution. RESULTS: Thirty-one cases presenting at age 4 weeks to 12 years were managed. Twenty-six (84%) had had circumcision in the neonatal period. Most circumcisions (81%) were carried out by nurses using the dissection method and without anesthesia. In 30 (97%) patients, the fistula was single. The fistula size ranged from 1.5 to 12 mm in the widest diameter. Modified Mathieu's flap procedure was used in the repair of 18 (56%) fistulae and 9 (28%) fistulae were by simple closure. Recurrence of the fistula was seen in 8 (25%) patients with large fistulae > 5 mm in diameter. The recurrent fistulae were small and were repaired by simple closure. CONCLUSION: Urethrocutaneous fistula post-circumcision is frequently seen in our practice and the surgical repair is challenging and associated with high recurrence rate in large fistulae. This preventable condition may be avoided by proper education and training of circumcisers.

Urologic daycase surgery: a five year experience.

BACKGROUND: Expectedly, daycase surgery (DCS) is today witnessing a boom in developing countries as a reasonable option in the face of global economic recession, although with limited scope. AIM: The aim of this study was to describe the urologic day surgery experience at the Lagos State University Teaching Hospital, Ikeja. MATERIALS AND METHODS: All day-case urologic surgeries done between January 2006 and December 2010 were retrospectively studied. Data obtained were patients' personal details, diagnoses, procedures performed, mode of anesthesia, and surgical complications as well as admission rate. RESULTS: A total of 1070 operations were performed. The patients were aged 7 days to 92 years. Local anesthesia was employed in 42.2% while general anesthesia was used in 1.7% of patients, mostly pediatric cases. Caudal block anesthesia (55.8%) was administered for transrectal prostate biopsy and urethrocystoscopic procedures. The diagnostic and therapeutic urologic procedures in adults were mainly prostate biopsy (n = 344, 32.1%), urethrocystoscopy (n = 218, 20.4%), varicocelectomy (n = 143, 13.4%), and orchidectomy (n = 93, 8.7%). Mohan's valvotomy was the most common pediatric operation (n = 19, 1.8%). Postoperative morbidities that warranted hospital admission were observed in 17 (1.6%) cases. CONCLUSION: Urologic day surgery is feasible with minimal morbidities. The provisions of a dedicated day-case unit or a mobile DCS service may further improve on the volume of cases that can be operated on a day-case basis and has the potential of further reducing the waiting time for surgery.

Effect of obesity on serum prostate-specific antigen in Nigerian men.

OBJECTIVE: Lower serum total prostate-specific antigen (PSA) levels (tPSA) have been reported in obese men. It has not been confirmed if this association truly exists in all ethnic groups. Thus, we evaluated the relationship between tPSA and obesity among Nigerian men. METHODS: Men aged ≥ 40 years with tPSA <20 ng/ml and no known prostatic disease were involved. Obesity was defined using the body mass index (BMI) and waist to hip ratio (WHR). Multivariate linear regression was used to investigate the relationship between tPSA and either BMI or WHR. The odds of having abnormal tPSA were estimated using logistic regression. RESULTS: A total of 3,191 men participated, and 3,049 (95.6%) were eligible for analysis. A BMI ≥ 25.0 and a WHR ≥ 0.9 were found in 47.7 and 64.6%, respectively. tPSA was significantly associated with age (p < 0.001) and digital rectal examination status (p < 0.001). Multivariate linear regression analysis showed no relationship between tPSA and obesity (BMI, p = 0.581; WHR, p = 0.160). Adjusting for age and digital rectal examination status, logistic regression showed no significantly observable trend of having a tPSA level greater than thresholds for men with a BMI ≥ 25 or a WHR ≥ 0.9 when compared with normal BMI or WHR, respectively. CONCLUSION: Although overweight and obesity were common among healthy Nigerian men, there was no associated tendency towards lower serum tPSA.

Mohan's valvotome for the ablation of posterior urethral valves.

INTRODUCTION: Treatment of posterior urethral valves (PUV) is now most commonly by endoscopic valve ablation, but this is not readily available in our environment. We describe our experience with Mohan's valvotome for the ablation of PUV. MATERIALS AND METHODS: All patients with PUV who underwent Mohan's valvotomy over a 28-month period from June 2006 were reviewed. RESULTS: There were 35 patients. The median age was 1.5 years (mean age 3.0 years, range 11 days to 14 years). Eleven (31.4%) and 24 (68.6%) patients received the treatment under local and general anaesthesia, respectively. Adequate relief of obstruction was achieved in all patients with marked improvement in the urinary stream. Complications were recorded in two (5.7%) patients; one was re-operated because of recurrent urinary retention, and the other had urinary incontinence which resolved after 3 months. At follow-up of 1-28 months (median 14 months), three (8.6%) patients had died from sepsis and malnutrition. The 32 (91.4%) surviving have good urinary stream, normal renal function (serum creatinine level <1.5mg/dl) and resolution of hydronephrosis as demonstrated on ultrasound. There was no mortality resulting directly from the use of Mohan's valvotomy. CONCLUSION: Mohan's valvotome is an effective instrument for the ablation of PUV. It is invaluable in the developing world where paediatric endoscopes are not readily available.

Retrograde pericatheter urethrogram for the post-operative evaluation of the urethra.

Pericatheter urethrogram (PUG) has been found to be a useful assessment tool after endoscopic urethral realignment or open urethroplasty prior to removal of the urethral catheter. Very little is known in the English literatures of the procedure of PUG in the evaluation of the urethra post-operatively. We aim to describe our technique of PUG and its usefulness in the evaluation of the urethra. We reviewed 22 patients who underwent PUG after endoscopic urethral realignment or urethroplasty over an 18 month period in our institution. The indications, procedure and success of PUG were noted. The radiological findings were also documented. The mean age of the patient was 31.9 years. Seventeen (77.3%) and 5 (22.7%) patients had PUG at least 3 weeks after endoscopic realignment of the urethra and urethroplasty for urethral strictures respectively. PUG was successful in all the patients and no complication arising from the procedure was recorded. The radiographs showed satisfactory urethral healing in 15 (68.2%), urethral stenosis in 2 (9.1%), contrast media extravasations in 8 (36.4%). We concluded that PUG allows for adequate urethral assessment and healing before the indwelling catheter is removed.

Association between erectile dysfunction and lower urinary tract symptoms due to benign prostatic hyperplasia in Nigerian men.

BACKGROUND: Erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) are highly prevalent in aging men. It is also necessary to evaluate ED before and subsequent to treatment intervention, when a patient presents with BPH. Current evidence suggests that there is an association between these two clinical conditions independent of age and comorbidities. No study from our environment has looked at this possible association which is therefore the aim of this study. MATERIALS AND METHOD: 132 patients who presented to our urology clinic for evaluation of LUTS/BPH were requested to complete the International Prostate Symptoms Score (IPSS) and International Index for Erectile Function-5 (IIEF-5) questionnaires. Their comorbidities were also noted. Data were evaluated with SPPS 14.0 software and a p value <0.05 was considered significant. RESULTS: The mean age of the patients was 64.8 (range 46-84) years. ED and LUTS/BPH significantly correlated with the age of the patients. ED was present in 71% of the patients. The second question in the IIEF-5 questionnaire (How would you rate your ability to have an erection hard enough for penetration?) showed a significant correlation with total IPSS score (p = 0.022) while the total ED score and other questions showed only weak correlations that did not reach significant levels. However, the sum of the obstructive symptoms scores (p < 0.001), unlike the sum of the irritative symptoms scores (p = 0.202), showed a significant correlation with ED scores. In addition, there was a significant correlation between the quality of life (QOL) due to urinary symptoms and ED scores. CONCLUSION: ED is highly prevalent and related to LUTS/BPH among our patients. The high prevalence may be due to the obstructive urinary symptoms therefore providing a possible link between BPH and ED through the increased alpha-adrenergic outflow from the pelvis. The poor QOL associated with LUTS/BPH may also result in ED. It is hoped that this study would form groundwork for further research in this area in our environment.

Clinical and radiological characteristics of Nigerian boys with posterior urethral valves.

Posterior urethral valve (PUV) obstruction is the most common cause of bladder outlet obstruction in boys. Currently, the diagnosis of PUV is commonly made prenatally. In our environment, however, prenatal diagnosis is rare and the diagnosis is usually made postnatally from the clinical and radiological features. This study therefore examines the clinical and radiological spectrum of boys with PUV in our environment. We examined the clinical presentations, ultrasonographic and the micturating cystourethrographic (MCUG) features of boys with PUV in our institution over a 22-month period from June 2006. There were 28 patients with PUV over this period. The age at presentation ranged from 11 days to 11 years (mean age = 2.7 years). Although prenatal ultrasound scan was done in 23 (82.1%) patients, no prenatal diagnosis was made in any of the patients. The diagnosis was made after infancy in 16 (57.1%) patients. Recurrent urinary tract infection (UTI) was the most common mode of presentation occurring in 14 (50.0%) patients with 7 (50.0%) of the patients with UTI presenting with septicaemia. Voiding dysfunctions, which occurred in all the patients, were the primary mode of presentation in 12 (42.9%) patients. Three (10.7%) patients presented with renal insufficiency, which was significantly associated with the age at presentation (P = 0.026). Ultrasound scan done in the postnatal period strongly suggested the diagnosis of posterior urethral valves in 22 (78.6%) patients in whom the posterior urethra was found to be dilated, associated with thick-walled urinary bladder and bilateral hydronephrosis. Trabeculations of the bladder was a constant feature on MCUG. Other features on MCUG included dilatation of the posterior urethra in 26 (92.8%), bladder diverticuli in 15 (53.6%) and unilateral and bilateral vesicoureteric reflux in 3 (10.7%) and 1 (3.6%) patient(s), respectively. The diagnosis of PUV obstruction which is often made late in our environment, is mainly by clinical, sonographic and MCUG features in the postnatal period. A majority of patients present late, with recurrent UTI.

Multiple neurofibrosarcoma in a patient with Neurofibromatosis-1 : a case report

Neurofibromatosis-1 is a multi-systemic; genetic and progressive disease. The patients have an increased risk of malignant transformation. Neurofibrosarcoma is rare but when it occurs; may pursue an aggressive course. This case report is of a 30-year-old female patient who first presented at the University of Calabar Teaching Hospital in November 2004 with a neurofibrosarcoma of the right foot complicating a neurofibroma of the same foot first noticed 27 years earlier. She had a right below knee amputation. Fourteen months later she presented with a huge tumour involving the right lower and middle lobes for which a right lower and middle lobectomy was done. The histology of the specimen confirmed neurofibrosarcoma. In the developing world late presentation is common with increased risk of malignant transformation. Early diagnosis and follow-up; genetic coun- selling of patients and relations on early presentation would improve outcome

Angiomyolipoma : a report of two cases

Objective: We report two cases of unusual renal tumours in two Nigerian adults. The first case was in a 45 year old female; who presented with an insidious onset of right upper abdominal pain with right abdominal swelling. The second case was a 33 year old pregnant lady; presenting with three week history of right lumbar pain and an accompanying mass. The various modes of radiological investigations and their significance in making a prompt diagnosis are highlighted. Method: Abdominal ultrasound scan; intravenous urography and CT scan confirmed the presence of renal masses in both cases and the suspicion of renal malignancies were raised clinically. They both had nephrectomy. Results : Histology report of the masses revealed angiomyolipoma (AML). Conclusions: In a period of three years; out of twenty four solid renal tumours operated upon in the Lagos State University Teaching Hospital (LASUTH); two were unusual. All the others were renal cell carcinoma. All diagnosis were confirmed histologically

Relationship between haemorrhoids and prostatism: results of a prospective study.

Haemorrhoids are less prevalent in Africans than their European counterparts due to consumption of high-residue diet and bulky stools resulting in less straining at stooling. Bowesman felt that most cases of haemorrhoids in the African were due to lower urinary obstruction. This study was carried out to find any cause and effect relationship between benign prostatic hypertrophy and haemorrhoids. Sixty-two elderly patients with benign prostatic hypertrophy were screened for haemorrhoids before and after prostatectomy. Twenty-five patients had haemorrhoids before operation. In 20 patients (80%) the haemorrhoids had regressed spontaneously 3 months after surgery. It is therefore important to recognise that the presence of haemorrhoids in elderly males may be due to prostatism.

Suprapubic prostatectomy without suprapubic tube and without bladder irrigation.

Forty consecutive patients who presented with benign prostatic hypertrophy had suprapubic prostatectomy without the use of suprapubic tube or bladder irrigation. Instead they had 'autoirrigation' by giving each patient 6 litres of intravenous fluids in 24 h and using intravenous Lasix to induce steady diuresis. Compared with 40 other patients who had the conventional suprapubic prostatectomy with postoperative bladder irrigation, these patients experienced no adverse effects. Rather the cost of treatment, the duration of hospitalization and the morbidity of treatment were reduced in these patients.

Synchronous suprapubic prostatectomy and inguinal herniorrhaphy.

Synchronous suprapubic prostatectomy and inguinal herniorrhaphy were performed on 12 patients who presented with benign prostatic hypertrophy and concurrent inguinal hernia(s). The results of these were compared with those of 12 other (control) patients, matched for age, who presented with benign prostatic hypertrophy only and who had suprapubic prostatectomy by the same surgical team under similar operative conditions. The results showed that while the additional herniorrhaphy increased the operating time by 30 min and increased the mean blood loss by 250 ml, it did not carry any other significant morbidity. This approach eliminates multiple hospitalisation and operations, multiple anaesthesia and prolonged catheterisation, and lowers the high cost of hospitalisation.

Paratesticular rhabdomyosarcoma in adolescents.

Paratesticular rhabdomyosarcoma is a rare tumour which occurs mostly in children and adolescents. Unlike other paratesticular sarcomas, it is associated with a much poorer prognosis. Therefore a multidisciplinary approach in the management of this condition is advocated in an effort to improve the results of treatment. In this paper we report the first 2 cases managed at this hospital.

The rarity of urinary calculus in Nigeria.

An epidemiological survey of urinary calculous disease has been carried out in Nigeria. This involved the use of questionnaires, personal interview of doctors and clinical and autopsy reviews in several large medical centres in the country. It is evident that urinary calculi are rare among Nigerians in spite of the high temperature and high carbohydrate diet. There does not appear to be any particular tribe or geographical location that is more predisposed to stone formation than the others. It is possible that the low calcium content of Nigerian waters, the minimal consumption of dairy products, the physically active life and some other unknown factors protect Nigerians against urinary calculus formation.

Recanalization rate following methods of vasectomy using interposition of fascial sheath of vas deferens.

A small but definite recanalization rate has followed the vas ligation method of partial vasectomy for sterilization. Interposition of the fascial sheath between the divided ends of the vas reduced the recanalization rate to 0. Fulguration of the lumen of the cut vas ends was used but was not the significant factor in this zero recanalization rate.

Air cystometrography and sphincter electromyography in patients with bladder outlet obstruction.

38 patients with infravesical obstruction secondary to benign prostatic hypertrophy had CO2 cystometrography (CMG) and sphincter electromyography (EMG) at onset of retension and 6 weeks after intermittent bladder drainage. Neurological diseases were excluded in these patients. Three patterns of CMG tracings were obtained and were called, normal, 'compensating' and 'decompensating' on the basis of the volume: pressure ratio of the curves. By strict definition, no abnormal detrusor contractions were seen in any of these patients who also all had normal sphincter electromyography. It is questionable therefore if infravesical obstruction, in the absence of neurological deficits can account for the uninhibited detrusor contractions described in the literature. Rather it is possible to explain the above CMG tracings on the effects of obstruction on the bladder smooth muscle and collagen fibers which have been shown to be non-neural dependent.

Radical surgery for renal cell carcinoma.

A modified radical nephrectomy to cope with renal carcinoma presenting at advanced stages, is evaluated. A total of 50 cases were treated in this hospital from 1962 to 1976. The poor results from treatment of renal cell carcinoma in the earlier years, have prompted the modification of the conventional radical nephrectomy to cope with this disease which is still frequently seen at advanced stages. The modification includes exclusion of distant metastasis. The adherent segment of colon is resected along with the tumour. The renal vessels are then isolated. If the IVC is involved by a right-sided tumour, it is resected along with the tumour. The ureter is then ligated and the tumour with the adrenal gland, the resected colon segment, regional lymph nodes and the IVC are removed in one block. 2 such patients who otherwise would have been considered inoperable have survived for over 3 years.