Transurethral Resection of Prostate (TURP) and Vesicolithotomy for Large Bladder Stone in Single Session: The Third World Perspective.

OBJECTIVE: To study the effectiveness and safety of combined transurethral resection of prostate (TURP) and open vesicolithotomy in patients with benign prostatic hyperplasia and massive vesical calculi in a single session. METHODS: A descriptive study conducted at the Institute of Kidney and Diseases, Peshawar Pakistan from March 2013 till December 2019. In total, 43 patients were selected by nonprobability conventional sampling. We included patients with occluding enlarged prostate size of 30-60g and bladder stones of more than 35 mm which was not amenable to cystolitholapaxy or cystolithotripsy. Conventional TURP followed by formal vesicolithotomy was performed in all patients in a single session. All the preoperative, perioperative and postoperative data were documented on structured Proforma. The data analysis was done on SPSS. RESULTS: The average age of the patients included was 65 ±7.5 years. Mean size of prostate was 45.5±6.8 g and mean stone size was 38.4±4.2 mm. The majority of patients [60.4% (n=26)] presented with refractory urinary retention. On average the operation time was 66.3±5.5 minutes. The mean resected volume of prostate was 23.5±6.8g and the average hospital stay was 5.5±1.2 days. Mean trial of removal of catheter was 5±0.6 days. The trial of removal of catheter was successful in all patients. Significant improvement in maximum flow and average flow was recorded in all patients (p = 0.001). On average, the complication rate noted was 6.9% (n = 3). There was no need for blood transfusion. No mortality was recorded in the study. CONCLUSION: The combined TURP and open vesicolithotomy in a single session is an efficacious, safe and viable treatment modality for large bladder calculi secondary to moderately enlarged prostate.

Effectiveness of Direct Observation of Procedural Skills (DOPS) in Postgraduate Training in Urology at Institute of Kidney Diseases, Peshawar.

OBJECTIVE: To determine the effectiveness of direct observation of procedural skills (DOPS) in the assessment and improving operative skills of postgraduate residents in urology. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Department of Urology, Institute of Kidney Diseases (IKD), Hayatabad Medical Complex, Peshawar, from March till December 2016. METHODOLOGY: Twenty postgraduate residents in urology were assessed for three commonly performed procedures in urology with structured proforma, specially designed for DOPS, using Likert scale from 1 to 5. Formative feedback was given to all the residents highlighting their strengths and weaknesses. During second phase, all the three procedures were performed by four consultants respectively with residents as learner in the second phase of DOPS. During the third phase, a repeat assessment of e-residents was performed to study the overall improvement in operative skills, respectively. RESULTS: In pre-DOPS assessment, only 7 (35%) out of 20 residents, passed in skill of cystoscopy, 6 (30%) residents passed in transurethral resection of prostate (TURP), while 3 (15%) residents passed in skills of uretero-renoscopy (URS). The mean score of overall ability to perform procedure during first phase of DOPS were 2.7 ±1.3 for cystoscopy, 2.1 ±0.97 for TURP, and 2.5 ±1.1 for ureterorenoscopy. Significant improvement (p 0.04) in passing was observed in third phase with 17 (85%), 14 (70%), and 14 (70%) residents were declared passed in cystoscopy, TURP and URS, respectively. The mean score of overall ability to perform procedure during the third phase was 4.7 ±0.7 for cystoscopy, 4.5 ±0.94 for TURP, and 4.7 ±0.94 for ureteroscopy. CONCLUSION: DOPS is effective tool for assessing and improving the skills of postgraduate residents in urology.

An audit of patients' satisfaction after adult day-case surgery at Ayub Teaching Hospital, Abbottabad.

BACKGROUND: Day-case surgery has become an important component in the provision of surgical care in the Western countries. This study was done to introduce the concept of day-case surgery and assess the patients' satisfaction after day case general surgery in our set up with vast rural communities lacking medical facilities and no day-case surgery units in the hospitals. METHODS: All those patients suitable for day-case surgery and who accepted day-case surgery for general surgical procedures in General Surgical 'A' unit of Ayub Teaching Hospital, Abbottabad were interviewed after the operation on follow up visits. Questions were asked about their satisfaction with day-case surgery. If they were not satisfied, the reasons for dissatisfaction were noted. Direct admissions and re-admissions after day-case surgery were recorded. Any complications in the postoperative period were also noted. The patient's preference for a similar procedure as day-case in future was also recorded. RESULTS: There were 122 patients in this study. 60(49%) were operated under general anesthesia and 62(51%) under local anesthesia. Fourty Nine (40%) patients were satisfied while 73(60%) were not satisfied with day-case surgery. Six (5%) patients were admitted directly after day-case surgery while 7(5.7%) patients were admitted after discharge. Complications occurred in 41(33.6%) patients at home. Wound complications and pain were the most common morbidity encountered by the patients. Twenty eight (23%) patients contacted a hospital or a doctor in the early postoperative period. Sixty two (51%) patients would prefer operation as in-patient while 74 (60.6 %) would prefer an overnight stay after the operation next time. CONCLUSIONS: Patients' satisfaction with day-case surgery in Ayub Teaching Hospital is not high. Short-stay surgery would be more appropriate in our set up.

Efficacy of mitomycin C in reducing recurrence of anterior urethral stricture after internal optical urethrotomy.

PURPOSE: To determine the efficacy of mitomycin C in reducing the recurrence of anterior urethral stricture after internal optical urethrotomy (IOU). MATERIALS AND METHODS: This was a randomized controlled trial conducted in the Department of Urology at the Institute of Kidney Diseases Peshawar from March 2011 to December 2013. A total of 151 patients who completed the study were divided into two groups by the lottery method. Group A (cases) comprised 78 patients in whom mitomycin C 0.1% was injected submucosally in the stricture after conventional IOU. Group B (controls) comprised 73 patients in whom IOU only was performed. Self-clean intermittent catheterization was not offered in either group. All patients were regularly followed up for 18 months. Recurrence was diagnosed by use of retrograde urethrogram in all patients and flexible urethroscopy in selected cases. Data were collected on a structured pro forma sheet and were analyzed by SPSS. RESULTS: The mean age of the patients in group A was 37.31±10.1 years and that in group B was 40.1±11.4 years. Recurrence of urethral stricture was recorded in 11 patients (14.1%) in group A and in 27 patients (36.9%) in group B (p=0.002). The mitomycin group also showed a delay in recurrence compared with the control group (p=0.002). CONCLUSIONS: Recurrence of urethral stricture is high after optical urethrotomy. Mitomycin C was found to be highly effective in preventing the recurrence of urethral stricture after IOU.

Gastrointestinal perforation in children due to blunt abdominal trauma in Hazara, Northern Pakistan.

A retrospective study of 25 children with gastrointestinal perforation due to blunt abdominal trauma in a single region of Pakistan is presented. The age, sex, aetiology, site of perforation, abdominal and X-ray findings, associated injuries, surgical procedures and outcome were analysed. There were 20 boys and 5 girls: mean age was 10 years. The injuries were the result of road traffic accidents 12 (48%), falls 11 (44%) and 'struck by animals' two (8%). Associated injuries occurred in 19 (76%). On admission 20 (80%) patients had peritonitis while 18 (72%) had pneumoperitoneum. Mean time from trauma to admission was 10 hours and admission to operation was 5 hours. Ileum was the most common site of perforation. Simple closure was the most common surgical procedure. Complications occurred in nine (36%) patients--six (24%) died. Delay in presentation and operation was associated with increased morbidity and mortality. Frequent evaluation of the child and abdominal X-rays are still the important tools for early diagnosis of gastrointestinal perforation following blunt abdominal trauma.

Trans urethral electric vaporisation of prostate as an alternate to trans urethral resection in benign prostatic hyperplasia.

BACKGROUND: There is an impression that trans urethral electric vaporisation of prostate (TUEVP) is a relatively safe surgical procedure for obstructing benign prostates, however before considering it an alternative to Trans urethral resection (TURP) in our setting. we conducted this study to assess its safety. convenience and especially cost effectiveness in our practice. METHODS: Fifty patients with signs of benign prostatic enlargement causing acute urinary retention were selected and divided into two equal groups A and B. Patients of group A underwent TURP while the group B patients had TUEVP. Postoperative follow up to assess the results of the surgeries, including noting the complication rate, began 24 hour after the catheter was removed, continuing during postoperative visits of the patient at 2 weeks, 3 months and finally 6 months. RESULTS: For approximately same size prostate, the mean operation time was less for TUEVP as compared to the TURP. The mean volume of irrigating fluid used and the number of blood transfusions required was also less in the TUEVP patients. In addition. TURP patients were also noted to have slight postoperative hyponatraemia. Clot retention was more frequent in the TURP group than the TUEVP group. Urethral catheters were required for longer duration (mean duration 74.88 hrs vs 24hrs, p=0.0001) and so was the hospital stay (mean duration 6.25 days vs 4.4 days. p=0.0046) in the TURP group patients. Total mean cost of treatment was also higher in the patients undergoing TURP. Among the complications, only the peroperative blood transfusion rate was higher in the TURP patients as noted above. CONCLUSIONS: The TURP has slightly higher morbidity and is costlier than TUEVP but its results in terms of relieving outflow obstruction are significantly better than TUEVP. It is therefore concluded that TURP is a more effective procedure but TUEVP with lesser morbidity and cost, is more suitable for relatively lesser obstructions in our setting.

Screening for biochemical abnormalities in urolithiasis patients.

BACKGROUND: The significance of biochemical screening in stone formers has been a debated topic. This study was conducted to investigate the frequency of biochemical abnormalities in our urolithiasis patients and to compare the abnormality between the first time and recurrent stone formers so that this information would help in assessing the value of biochemical screening in our practice. METHODS: Over a twenty-one month period, new and recurrent stone disease patients had one random blood specimen and two random 24-hour urine collections analysed for biochemical abnormalities. Serum was checked for calcium, urate, phosphate and creatinine. The urines were measured for volumes, calcium, oxalate, urate, citrate, cystine and pH. RESULTS: Out of total of 113 patients, 83 (73%) had some urinary or blood abnormality. Highest number of abnormalities were in urine. Low volume 33 (39.76%), hypercalciuria 33 (39.76%) and hyperoxaluria 20 (24.1%) were the main urinary abnormalities. Elevated serum creatinine in 10 (12.05%) was commonest blood abnormality. Females had significantly higher frequencies of low urinary volume (48% vs 21%, p=0.001), hyperoxaluria (38% vs 11%, p=0.002) and hypocitraturia (37% vs 0%, p<0.001). There was no significant difference of abnormality rate between first time and recurrent stone formers. CONCLUSION: A high frequency of urinary biochemical abnormality and equal abnormality frequencies among first time and recurrent stone formers highlights the significance of biochemical screening even in cases of initial stone presentation. We feel such diagnostic evaluation would help in providing precise treatment and efficient prophylaxis.