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.

Managing many patients with a urethral stricture: a cost-benefit analysis of treatment options.

OBJECTIVES: To report a management method in a community where there are many patients with urethral stricture and where the short-term goal of providing some treatment to most may override the sometimes conflicting long-term aim of minimizing recurrence rates. PATIENTS AND METHODS: Over a 3-year period, using optical urethrotomy in 76 patients followed by intermittent self-dilatation (ISD) in 29, urethroplasty in 28 and dilatation in three, 92 of 134 patients with a urethral stricture were treated and the outcome compared. RESULTS: The overall recurrence rate was 22%; a combination of urethrotomy plus ISD had a recurrence rate of 17% and gave a mean duration of follow-up without recurrence similar to that after urethroplasty. ISD significantly increased both the time before recurrence and the duration of follow-up without recurrence after urethrotomy. In addition to providing lasting treatment to many patients, urethrotomy was also 10 times cheaper, 10 times faster to perform and offered the surgeon better protection from infection with human immunodeficiency virus than did urethroplasty. CONCLUSION: Because wrongly selecting urethrotomy (resulting in a failed procedure) wastes valuable operating time and resources, the pre-operative recognition of strictures unsuitable for urethrotomy and their treatment by urethroplasty is important for overall efficiency.

The impact of renal impairment on the management of patients with lower urinary tract obstruction.

One hundred patients with lower urinary tract obstruction (LUTO) seen over a 10-month period were prospectively studied. Nineteen (19%) had an elevated serum creatinine (> 125 mumol/l); 13% had benign prostatic hyperplasia (BPH); 4% had urethral strictures; and two had congenital anomalies. Though urethral strictures are more common than BPH they cause less renal impairment, probably because the patients are younger and also because a urinary fistula may form proximal to the stricture when the intravesical pressure rises very high. Eighty per cent of the patients with renal impairment had a urinary tract infection (UTI), and in these the reduction in serum creatinine following relief of obstruction was slow and erratic. In three patients who did not have UTI the serum creatinine dropped steadily at a rate which varied from 6.8-845 mumol/l/week following continuous bladder drainage and appropriate supportive management. All patients with elevated serum creatinine had delayed surgery and required prolonged preoperative hospitalization, with a resultant sharp increase in the cost of their treatment.

alpha-receptor blockade for benign prostatic hyperplasia: uses and problems in a developing country.

OBJECTIVE: To evaluate the use and problems of alpha-receptor blockade with prazosin among patients in Nigeria with benign prostatic hyperplasia (BPH) who face a prolonged wait for a prostatectomy. PATIENTS AND METHODS: The study comprised 31 patients (mean age 64.4 years, range 55-89) facing a prolonged wait for prostatectomy: in group 1, 14 patients presented in acute urinary retention and had an indwelling urethral catheter; in group 2, six patients had indwelling catheters but removal was deemed necessary to control urinary tract infection: in group 3, 11 patients had troublesome symptoms from BPH but no retention. Some of the patients were also hypertensive. After receiving I mg of prazosin twice daily, the catheters were removed at various intervals and the effect on symptom scores and residual urine volume determined after one week and 2 months. RESULTS: Prazosin allowed the catheters to be removed, improved the symptoms of prostatism and/or controlled high blood pressure in seven, five and nine patients in each group, respectively. CONCLUSION: The use of this alpha blocker for BPH in the absence of facilities to measure urinary flow rate, intravesical pressure and serum prostate specific antigen can be justified for short periods. However, a large default rate among these patients raises additional questions about long-term safety and underlines the importance of selecting patients carefully.

Another look at acute appendicitis in tropical Africa: and the value of laparoscopy in diagnosis.

Acute appendicitis is believed to be one of the commonest causes of the acute abdomen in tropical Africa. Negative appendicectomy rates are usually above 20%, which is now considered unacceptably high because of increased risk to patients and the availability of diagnostic facilities to aid clinical decision-making. Our negative appendicectomy rate over a 4-year retrospective period was 29.7% in males, and 47% in females. These reduced to 11% and 10%, respectively, after the introduction of laparoscopy for doubtful cases of acute abdominal pain.

Laparoscopy in developing countries in the management of patients with an acute abdomen.

Surgeons in developing countries see a need to improve diagnosis and decision making in patients with an acute abdomen. Without the benefit of diagnostic aids such as computers and high-resolution ultrasonography, the rate of unnecessary laparotomy is often unacceptably high. The laparoscope is usually available in a developing country and its use easily acquired. Using laparoscopy in doubtful situations the unnecessary laparotomy rate was significantly reduced from 14.0 to 6 per cent (P < 0.05). Laparoscopy achieved a diagnostic accuracy of 86 per cent and prevented unnecessary laparotomy in 57 per cent of those in whom it was used.