Mayer-rokitansky-kuster-hauser syndrome: surgical management of two cases.

The Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome is a rare anomaly characterized by congenital aplasia of the uterus and vagina in women showing normal development of secondary sexual characters and normal 44 XX karyotype. We report our experience in the management of two patients with congenital absence of the vagina due to the MRKH syndrome. The first case was a 24-year-old student, who presented with primary amenorrhea, uterovaginal agenesis, right pelvi-ureteric junction obstruction, and left renal agenesis. The second patient was a 24-year-old housewife, who presented with primary amenorrhea and inability to achieve penetrative sexual intercourse. She had vaginal atresia and a grossly hypoplastic uterus. Both had successful sigmoid colovaginoplasty and are sexually active. Vaginal reconstruction using the sigmoid colon saw an immediate and satisfactory outcome in both patients.

Surgical trainees' understanding of Dukes' staging in rectal cancer.

BACKGROUND: This study was conducted to determine the understanding of Dukes' Staging of Rectal Cancer by surgical trainees. METHODS: At a West African College of Surgeons' revision course, questionnaires were distributed asking questions related to staging of Rectal Carcinoma with special emphasis on Dukes' staging, the results were analyzed using SPSS Version 10.0. RESULTS: We had sixty-one (61) respondents, one (1) questionnaire was incompletely filled and sixty were therefore analyzed. They were all males. Majority of respondents 53 (88.3%) were between 30 and 39 years of age. Fifty (83.3%) were junior residents, while 10 (16.7%) were senior residents. Exactly 71.1% of the residents have had more than 6 months of general surgery posting. Forty-nine (81.7%) had staged rectal cancer in practice. Fifty-four (90%) knew no other staging system apart from Dukes'. Only 11 (18.3%) were able to outline Dukes' staging correctly. Fourteen (23%), 12 (20%), and 25 (41%) were able to correctly get Stage A, B and C of Dukes' Classification. CONCLUSION: Adequate comparison of outcome of treatments will be difficult if there is confusion in staging. The 1932 Dukes' Staging should be uniformly adopted for its simplicity Alternatively, proformas of the TNM Staging can be introduced in clinical practice to decrease the reliance on memory.

Oral mucosa grafts for urethral reconstruction.

BACKGROUND: Urethral reconstruction has continued to present formidable and enormous challenges for urologic, paediatric and plastic surgeons as diverse opinions have been expressed on the quality and type of ideal substitution material. This literature review is aimed at drawing attention of surgeons to the versatile nature of oral mucosal grafts. METHODS: A review of the utilization of oral mucosa in urethral reconstruction was made. Structured Medline search was performed looking at all aspects of utilization of oral mucosa including mucosal harvest, donor site morbidity and outcome. RESULTS: The unique demands of the urethra set a high standard for autogenous graft substitutes; hence literature reports reveal that split and full thickness skin grafts from the scrotum, penis, extragenital sites (ureter, saphenous vein, appendix, colon, medial upper arm, neck, lateral chest, abdomen, bladder mucosa) and more recently oral mucosa have been used. Unlike other tissues, oral mucosa grafts are flexible, easy to harvest and trim and have an excellent microvasculature favorable for graft-taking. Furthermore, the natural moist location of the oral mucosa in the oral environment favours its easy adaptability in the urethral passage thus giving good long-term results. However, there are reports of complications at the donor site with the commonest being anaesthesia or paraesthesia of the cheek or lips. Regional variations of the oral mucosa, length of the graft required, the decision to close or leave donor site open and harvesting technique are some of the factors suggested to account for differences in donor site morbidity. CONCLUSION: Oral mucosal graft is a versatile urethral substitute with excellent outcome. It is becoming the gold standard for urethral substitution.

Urinary bladder cancer and schistosomiasis in North-Western Nigeria.

BACKGROUND: An unusually high prevalence of bladder cancer was noticed by clinicians and in the cancer registry of Usmanu Danfodiyo University Teaching Hospital, Sokoto. Several areas of this region were also known to be endemic for urinary schistosomiasis. OBJECTIVE: To determine the epidemiological characteristics of bladder cancer in the region and to assess the impact of schistosomiasis on these cases. METHOD: Retrospective review of clinical and histopathogical records of bladder cancer cases seen at Usmanu Danfodiyo University Teaching Hospital, Sokoto from January 1999 to December 2004. RESULT: One hundred and thirty three cases satisfied our criteria for inclusion. There was a 4.7 fold rise in the number of bladder cancer cases between 1999 and 2004. The male to female ratio was 11.1:1.0. The mean age was 46.0 years and ranged from 20 to 82 years. Majority, 107 (80.5%) were farmers and fishermen from regions of the distribution of surrounding river or their smaller tributaries. Squamous Cell Carcinoma comprised 65.1% of histologically verified cases and in 50% of Squamous Cell Carcinoma; there was histological evidence of chronic urinary schistosomiasis. CONCLUSION: Bladder cancer is a common malignancy in Sokoto, North-Western Nigeria. The association with chronic urinary schistosomiasis is very strong and the hospital incidence appears to be rising.

Management of "watering-can" perineum.

OBJECTIVES: To review the management of watering-can perineum (WCP) in a Nigerian centre and to outline challenges of its management. DESIGN: A retrospective review of cases of watering-can perineum over a seven-year period. SETTING: Usmanu Danfodiyo University Teaching Hospital, Sokoto, a Nigerian tertiary health centre. SUBJECTS: Forty one patients with the diagnosis of watering-can perineum managed from January 1997 to December, 2003. RESULTS: There were 41 cases of watering-can perineum. The mean age at presentation was 46.0 years (range: 7 to 80). Characteristically, all the patients had long standing neglected urethral stricture. Eighteen (43.9%) presented with single active fistulae while eight (19.5%) had more than four (9.8%) active external openings. Fistulae were located in the perineum (58.5%), scrotum (41.6%), penis (14.6%), penoscrotal junction (9.8%) and thigh (49%). The strictures were post inflammatory in 73% of patients. Bulbar strictures constituted 63.4% of cases. At presentation, patients were in general planned for initial suprapubic cystostomy (SPC) followed by assessment of stricture and finally urethroplasty in six months. Patients who could not afford urethroplasty were offered dilatation. The immediate outcome of urethroplasty was satisfactory in 70.6% of patients. CONCLUSION: Watering-can perineum was a common sequel of long standing neglected inflammatory urethral stricture. SPC followed by urethroplasty gave the best results. Prevention and adequate treatment of urethritis, prompt treatment of urethral stricture, and affordable and accessible reconstructive urologic service are recommended to reduce the incidence of WCP and suffering of the patients.

Quality surgical care for rural dwellers: the visiting option.

Although the majority of Africans live in rural areas, the existing surgical infrastructure and expertise are concentrated in urban centres. Many rural dwellers dislike visiting urban hospitals due to poverty, ignorance, fear, distance or unpleasant city experience. Trained personnel are unwilling to work in rural areas because of poor infrastructure and lack of incentive. The best means of bringing surgical care to rural dwellers is yet to be determined. We explored the visiting surgeon option. For three days every 4-6 weeks, a general surgeon visited a rural health centre in the Maiyama Local Government area of Kebbi State, Nigeria, and operated on selected surgical cases. In total, 111 patients had 125 surgical procedures during 18 visits (January 2001-May 2003). These represented 66.7% of all surgical cases seen during the visits. There were 22 (17.6%) paediatric surgical, 90 (72%) general surgical and 13 (10.4%) obstetric and gynaecological (O&G) cases. Fourteen (11.2%) procedures were performed as emergencies. The most common operation was inguinal herniorraphy, which constituted 36% of cases. The morbidity rate was 1.6% with no operative mortality. Easily treatable but potentially fatal surgical conditions are common among poor, rural dwellers. A visiting service can offer this population sustainable, cheap, good-quality care in a friendly environment.

A review of appendicectomy in Sokoto, North-western Nigeria.

BACKGROUND: Acute appendicitis is a common surgical emergency in developed countries. There is a strorng evidence of a rising trend in the developing world. METHODS: We present a retrospective review of appendicectomy as performed at Usmanu Danfodiyo University Teaching Hospital, Sokoto over a six year period (January 1997 to December, 2002) RESULTS: The diagnosis of appendicitis was made in 38.9% of surgical abdominal emergencies. The peak age group was 20 to 29 years with a male to female ratio of 1.4:1. The negative appendicectomy rate was 15.9% There was associated Schistosoma haematobium in 4.44% of cases. Appendicectomy had a morbidity rate of 13.3% and a mortality of 0.9%. CONCLUSIONS: Appendicitis was the commonest surgical emergency in Sokoto. The negative appendicectomy, morbidity and mortality rates were within the range widely quoted in the literature. The need to avoid negative exploration is imperative in this poor community.

Paediatric urolithiasis in northern Nigeria

Background. The incidence of paediatric urolithiasis varies according to geographic areas. In Nigeria, there is paucity of literature on urinary stone diseases in childhood. Materials and Methods. In the period between January 1993 and December 2003, 67 Nigerian children with urinary stones were retrospectively reviewed. Results. There were 63 (94.0%) boys and 4 (6.0%) girls. The mean age at presentation was 6.9 years. Thirty one (46.3%) were in the age group less than 5 years. The commonest presenting symptoms were dysuria 42 (62.7%) and abdominal pain in 30 (44.8%). Pulling on the penis is characteristically present in 26 (38.8%) patients. The stones were located in the lower tract in 57 (85.1%) cases. Anatomic obstruction along the urinary tract was responsible for stone formation in 12 (17.9%) patients. Sixteen (23.9%) patients had associated urinary tract infection. All the stones analyzed were mixed and 75% contained urate. In 7 (10.4%) patients the stones were passed spontaneously. Open surgical technique was employed in the remaining 60 patients. There was no death recorded. Post-operative complications occurred in 15 (25.0%) of the operated patients. The commonest complications were wound infection 3 (5.0%) and vesicocutaneous fistula in 3 (5.0%) patients. The average duration of hospital stay was 16.0 days. Conclusion. In our practice lower tract stones are common and congenital urinary tract obstruction is the commonest identifiable cause for stones. The age and sex distribution and chemical composition are in keeping with historic and endemic stones. Early detection and treatment of urinary tract obstruction will further reduce the durden of stones disease

Childhood burn injuries in north western Nigeria.

This 2-Year (1999-2000) prospective study was undertaken to determine the pattern and outcome of childhood burns at the Usmanu Danfodio University Teaching Hospital Sokoto, North Western Nigeria. A total of 108 children, 15 years and below, were seen. There were 67 males and 41 females giving a male to female ratio of 1.6:1. Domestic accidents were responsible for 100 (92.6%) cases. Hot liquids as the agents of injuries were recorded in 72 (66.7%) children. The mortality rate was 6.5% (7 cases), all males. Petrol explosion was responsible for 4 deaths. Another case is made for the reduction in the incidence, morbidity and mortality of burns by elevating the socio economic status of the community.

Gangrenous bowel in Nigerians.

OBJECTIVE: This study is to critically examine gangrenous bowel as seen in a developing country to identify factors associated with mortality and to reappraise the problems in our environment. We also looked at mortality associated factors not considered by other studies from the subregion. DESIGN: We retrospectively reviewed the records of all patients who had gangrenous bowel over a 10 year period (1986 to 1995) at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. SETTING: University of Ilorin Teaching Hospital, Ilorin, Nigeria. SUBJECTS: All patients with gangrenous bowel seen at the University of Ilorin Teaching Hospital, Ilorin Nigeria from January 1986 to December 1995 were included is this study. RESULTS: Ninety five patients were seen with a male to female ratio of 2:1. A high prevalence at age zero to five (17.9%) was noted due to childhood intussusception. The average duration of symptoms before surgery was 5.6 days. External hernia were responsible for 42.1%, intussusception for 22.1% and adhesions for 12.9% of cases. Other rarer and unusual causes of gangrene are also presented. Ileal gangrene was seen in 80.9% of cases. The overall mortality was 35.8% with no significant age and sex differences. Mortality varied directly with the length of gangrenous bowel irrespective of the cause and with the delay in operative intervention up to eight days. Peritonitis and involvement of the colon were also associated with high mortality. CONCLUSION: As a result of late presentation allowing for high diagnostic accuracy, elaborate investigations to determine bowel viability have little role in our setting at present. Improvement in socio-economic status, health education, elective repair of hernia and early operative intervention are recommended to bring down the mortality from gangrenous bowel.