Paediatric urology in Sub-Saharan Africa: challenges and opportunities.

The need for paediatric urological care in low- and middle-income countries in sub-Saharan Africa (SSA) is enormous due to a burgeoning paediatric-aged population and a disproportionate burden of congenital malformations. There are formidable challenges in the provision of a skilled workforce and appropriate infrastructure, resulting in a huge unmet need with consequent effects on the long-term health and prosperity of the population. Constraints of funding, geography, culture, surgical and anaesthetic skills, and instrumentation means that many conditions present late and with complications that could have been avoided by an earlier attendance. It also means that the management of congenital malformations, e.g., bladder exstrophy and congenital obstructive posterior urethral membrane, differ substantially from that seen in the developed world, with the outlook for children with renal failure being particularly bleak. Collaborations between paediatric urologists from high- and low-income countries are beginning to help with the development of a surgical infrastructure customised to paediatric care, and with the training of specific paediatric urological knowledge and skills. These collaborations, whilst welcome, still require substantial expansion to achieve more equitable access to appropriate paediatric urological care for children in SSA. Future efforts have to focus on the creation of sustainable and equal partnerships between urologists from low- and high-income healthcare environments, with an emphasis on providing sustainable management, appropriate to local need and available resources. The provision of shared learning, utilising the benefits of global digital communication, will improve mutual understanding of needs in a resource-poor environment and the involvement of trainees from both income settings can help perpetuate long-term collaborations.

Hirschsprung disease managed with one-stage transanal endorectal pullthrough in a low-resource setting without frozen section.

BACKGROUND: Over the past few decades, surgery for Hirschsprung's disease (HD) has evolved into a minimally invasive, single-stage procedure with excellent outcomes. Intraoperative frozen section biopsy is critical for this procedure to avoid the potential risk of leaving a retained aganglionic segment. However, this facility is not available in most low-income countries. Therefore, a two-stage procedure with an initial colostomy is still practiced in the developing world. We aimed to evaluate the outcome of single-stage transanal pullthrough performed in a facility without frozen section biopsy. METHODS: A retrospective review of all patients who underwent transanal pullthrough in two teaching hospitals over a 6-year period (2015-2020). RESULTS: Forty-seven children underwent transanal endorectal pullthrough (TERPT). Age at surgery ranged from 2 months to 6 years and mean weight was 8.7 kg. Barium enema did not show transition zone in 6 patients (12.8%) while others demonstrated short segment HD. Intraoperatively, the transition zone was visualized in 40 patients (85%). TERPT alone was performed in 35 (74.5%), TERPT with laparotomy to visualize transition zone in 9 (26.7%) and TERPT with transabdominal mobilization was required in 3 (6.4%). Definitive histopathologic examination revealed aganglionic segment pullthrough in 4 (8.5%) and transitional zone pullthrough in another 4 (8.5%). However, with long term follow up all eight children remained asymptomatic and no intervention was required. CONCLUSIONS: Transanal pullthrough offers reduced number of surgeries and faster recovery. We have also observed a good functional outcome despite a discrepancy with pathology results. Overall, our data suggests it is a safe and viable option for the treatment of short segment HD in facilities where frozen section is not available.

Outcome of PUV Patients Following Ablation in a Tertiary Teaching Hospital in Addis Ababa, Ethiopia.

BACKGROUND: Posterior urethral valve  (PUV) is the most common cause of congenital lower urinary tract obstruction in boys. It is considered that early diagnosis and intervention have good outcomes in terms of renal function, though the varying extent of embryological insult requires these boys to remain in extended follow-up and care. OBJECTIVE: To assess the renal outcome of patients following PUV ablation. METHODS: This was a descriptive retrospective study. Data were collected from the operation logbooks of patients from 2015 to 2019 that had been admitted to the Tikur Anbessa Specialized Hospital pediatric surgery unit with a working diagnosis of PUV and had ablation done primarily or following diversion. Data were collected from January to April 2020 and analyzed using SPSS 25. P value≤0.05 was considered significant. RESULTS: Seventy patients were analyzed and followed for 3 years for the development of postoperative chronic kidney disease (CKD) after PUV ablation. Postoperative CKD was found in 52.9% of patients and end-stage renal disease in 2.9%. Risk factors associated with postoperative CKD were the presence of preoperative and postoperative proteinuria, postoperative hypertension, and elevated nadir serum creatinine. Results also showed that a delay between the development of vesicostomy and ablation had a significant correlation with renal outcome. Elevated nadir serum creatinine, postoperative proteinuria, and delay between the development of vesicostomy and ablation were found to be independent risk factors of development of CKD. CONCLUSION: There was a high rate of CKD development in patients who had had ablation for PUV, which was comparable to other studies. Three variables were found to be independent risk factors for the progression of CKD, unlike other findings seen in low- and middle-income countries.

Incidence and Risk Factors of Thrombocytopenia in Neonates Admitted with Surgical Disorders to Neonatal Intensive Care Unit of Tikur Anbessa Specialized Hospital: A One-Year Observational Prospective Cohort Study from a Low-Income Country.

BACKGROUND: Thrombocytopenia is one of the most common hematologic disorders affecting neonates admitted to the neonatal intensive care unit. The aim of this study was to determine the incidence and associated risk factors of neonatal thrombocytopenia in neonates admitted with surgical disorders. METHODS: An observational prospective cohort study was conducted and all neonates admitted to neonatal intensive care unit of Tikur Anbessa Specialized Hospital with surgical disorders were included. Data were collected using a checklist and analyzed by SPSS version 23. Chi square test and independent sample t- test were used to assess the association among different variables. RESULTS: A total of 210 neonates were included in the study, out of which 56.2% were males. The incidence of thrombocytopenia was 55.8%. Among neonates with thrombocytopenia, 90.9% had late onset thrombocytopenia and half were in the severe range (<50,000/µL). The presence of sepsis (P = 0.000) and atresia (P = 0.000) were found to be significantly associated with the development of thrombocytopenia. The mean non feeding hours were found to be significantly longer for patients with thrombocytopenia (t [199], 5.81, P = 0.000). CONCLUSION: The incidence of thrombocytopenia is high in our institution. Prevention methods towards neonatal sepsis should be given due emphasis.

Hypospadias Repair in Ethiopia: A Five Year Review.

BACKGROUND: Hypospadias repair is one of the problematic issues in pediatric surgery. As a result of the multiple complications following the procedure, a variety of techniques have been used and newer methods continue to emerge. There is still controversy regarding the best method of repair. We aimed to determine the outcome of surgery and factors contributing to unfavorable outcomes in children with hypospadias. MATERIALS AND METHODS: This is a retrospective review undertaken from September 2009 to August 2014. The research was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All children who underwent hypospadias repair and had regular follow-up were included in the study. RESULTS: A total of 202 boys aged less than 13 years were assessed. Most surgeries (80.3%) were performed in children older than 18 months. Transverse incised plate urethroplasty (TIP) was frequently performed for distal hypospadias (71.2 %), while transverse ventral preputal flap (TVPF) was the most common procedure done for proximal hypospadias (62.8 %). Overall success rate for first surgery was 55.9 %. There was a high rate of major post-operative complications (44.1%) of which urethrocutaneous fistula (UCF) was the most common (31.2%) followed by meatal stenosis and glans breakdown (7.4 % each). These complications were found to be higher in those who were operated at a later age and those with proximal hypospadias (p=0.03 and p=0.01 respectively). There was also a significant difference among the type of procedures with TIP and TVPF having the least complications (p<0.01). CONCLUSION: From our experience, we found TIP a relatively safe and reliable method of repair for distal hypospadias while TVPF single stage repair was superior in the proximal ones. The high rate of complications in our institution was associated with higher burden of severe hypospadias and older age at surgery.

FOREIGN BODY INDUCED TRACHEOESOPHAGEAL FISTULA IN A PEDIATRIC PATIENT WITH A MISDIAGNOSIS: CASE REPORT AND REVIEW OF LITERATURE.

Acquired tracheoesophageal fistulae can be diagnosed clinically by features such as cough elicited by swallowing but symptoms can be mild. Here, we report a case of a foreign body induced trachea-esophageal fistula in a 2 year and 6 months old male child with a chronic cough who had long been misdiagnosed and mismanaged.