Place of urolithiasis in the spectrum of urological pathologies, practices and use of endourological procedures in the management of calculi of the upper urinary tract: results of a survey of referral centres in Africa.

Our aim was to determine the current trend of endourology in the management of upper urinary tract calculi in Africa reference centres. We conducted an online multiple-choice questionnaire survey involving 46 centres from 27 countries using a structured well-designed Google Form (®) questionnaire. The questionnaires were distributed to the head of service through their emails. The questions collected demographic data about the centre, the epidemiology of urolithiasis, diagnostic means and management of upper urolithiasis, especially access to endourology procedures and their practices. Descriptive analyses were performed. The participation rate was 77.9%. Urinary lithiasis was one of the three main pathologies encountered in 42/46 centres. 33 centres had easy access to CT scanners and 34 had operating theatres equipped with endo-urological surgery equipment. Of these 34 centres, 30 perform endourology for the management of upper urinary tract stones. Rigid ureteroscopy is the main technique used by the centres. It is the only endourology technique used for stone management by 12 centres (40%). 7/30 (23.3%) have the option of performing rigid ureteroscopy, flexible ureteroscopy and percutaneous nephrolithotomy. The frequency of procedures varies widely, with 43.3% rarely performing endourological surgery. Seventeen centres have their operating theatre equipped with a fluoroscope and 6/42 centres have extracorporeal lithotripsy. Open surgery is still used in 29/42 centres (69.1%). Laparoscopy is available in 50% of centres, but none reported performing laparoscopic lithotomy. In Africa, urinary lithiasis plays an important role in the activities of referral centres. Modern management techniques are used to varying degrees (not all centres have them) and with very variable frequency. Open surgery is still widely performed as a management. Rigid ureteroscopy is the main endourological technique. It is essential to develop the practice of modern urology in Africa, mainly endourology.

Multidisciplinary approach to cancer care in Rwanda: the role of tumour board meetings.

Introduction: Cancer treatment is complex and necessitates a multidisciplinary approach. Tumour Board Meetings (TBMs) provide a multidisciplinary platform for health care providers to communicate about treatment plans for patients. TBMs improve patient care, treatment outcomes and, ultimately, patient satisfaction by facilitating information exchange and regular communication among all parties involved in a patient's treatment. This study describes the current status of case conference meetings in Rwanda including their structure, process and outcomes. Methods: The study included four hospitals providing cancer care in Rwanda. Data gathered included patients' diagnosis, number of attendance and pre-TBM treatment plan, as well as changes made during TBMs, including diagnostic and management plan changes. Results: From 128 meetings that took place at the time of the study, Rwanda Military Hospital hosted 45 (35%) meetings, King Faisal Hospital had 32 (25%), Butare University Teaching Hospital (CHUB) had 32 (25%) and Kigali University Teaching Hospital (CHUK) had 19 (15%). In all hospitals, General Surgery 69 (29%) was the leading speciality in presenting cases. The top three most presented disease site were head and neck 58 (24%), gastrointestinal 28 (16%) and cervix 28 (12%). Most (85% (202/239)) presented cases sought inputs from TBMs on management plan. On average, two oncologists, two general surgeons, one pathologist and one radiologist attended each meeting. Conclusion: TBMs in Rwanda are increasingly getting recognised by clinicians. To influence the quality of cancer care provided to Rwandans, it is crucial to build on this enthusiasm and enhance TBMs conduct and efficiency.

Diagnosis of advanced prostate cancer at the community level in Rwanda.

BACKGROUND: Prostate cancer is the second most common cancer in men and sixth leading cause of mortality. If not recognized early, patients with advanced prostate cancer can experience debilitating complications which can otherwise be prevented by early androgen deprivation therapy. This research intends to define clear diagnostic tools that will guide practitioners in the rural community setting toward early management of advanced prostate cancer. METHODS: We conducted a cross-sectional observational study at three referral hospitals in Kigali, Rwanda on patients who presented with clinical suspicion of advanced prostate cancer over a period of 6 months. All patients underwent prostate biopsy as well as metastatic work up (CT or MRI), for those who were eligible. Statistical analysis was done using STATA 14.2. RESULTS: 114 patients were included in the study. The median age was 70 years (interquartile range: 65-79 years). In total 14 (12.3%) patients were found to have benign disease, while 100 (87.7%) patients were found to have cancer. Among those who had cancer, 85 (85%) had advanced prostate cancer. 110/114 (96.5%) were symptomatic at presentation. Common presenting symptoms were lower urinary tract symptoms (80.7%), back pain (54.4%), and urinary retention (36.8%). Abnormal digital rectal examination (DRE) was a strong risk factor for both cancer and advanced disease. Prostate cancer was found in 92.2% of those with abnormal DRE compared to 41.7% in those with normal DRE (p = 0.001). Also, cancer was found in 96.1% of those with multinodular prostate on DRE (p = 0.02) and had high odds (OR 14.6; CI 3.41-62.25) of having advanced prostate cancer (p < 0.001). The mean (± SD) PSA was 643.3 ± 1829.8 ng/ml and the median (range) was 100 ng/ml (9.05-10,000 ng/ml) for the whole study population. All patients with prostatic-specific antigen (PSA) of 100 ng/ml or above had advanced prostate cancer. CONCLUSION: The results show that there is a significant correlation between clinical findings and advanced prostate cancer. All patients with abnormal DRE and PSA above 100 ng/ml had advanced prostate cancer. Diagnosis of advanced prostate cancer is possible at the community level if PSA testing is utilized and practitioners are well trained.

Introducing a Morbidity and Mortality Conference in Rwanda.

OBJECTIVES: To assess the structure, format, and educational features of a morbidity and mortality (M&M) conference in Rwanda. To determine factors associated with adverse events and to define opportunities for improvement. DESIGN: Retrospective, descriptive study of all cases presented at a surgical M&M conference over a 1-year period. Cases were reviewed for factors associated with adverse events and opportunities for improvement. Factors were characterized as delays in presentation, delays in diagnosis, delays in the operating room, errors in judgment, technical errors, advanced disease, and missing resources or malnutrition. Opportunities for improvement were categorized at the physician or hospital level. SETTING: University Teaching Hospital of Kigali, a tertiary referral hospital in Rwanda. PARTICIPANTS: Cases presented at the surgical M&M conference over a 1-year period. RESULTS: Over a 1-year period, there were a total of 2231 operations with 131 in-hospital mortalities. There were 62 patients discussed at M&M conference. Of those discussed, there were 34 (55%) in-hospital deaths and 32 (52%) unplanned reoperations. Common diagnostic categories included 30 (48%) gastrointestinal, 15 (24%) trauma, and 10 (16%) neoplasm. Delays were commonly cited factors affecting outcomes. There were 22 (35%) delays in presentation, 23 (37%) delays in diagnosis or management, and 20 (32%) delays to the operating room. Errors in judgment occurred in 15 (24%) cases and technical errors occurred in 18 (29%) cases. Twenty-three (37%) patients had a critical resource missing and 17 (27%) patients had advanced disease. Malnutrition was associated with 11 (18%) adverse events. Participants identified opportunities for improvement in 48 (77%) cases. CONCLUSION: M&M conference can be used in a low-resource setting as an educational tool to address core competencies of practice-based learning and improvement and systems-based practice. It can define factors associated with surgical adverse events and opportunities for improvement at the physician and hospital levels.