Recall of consent information by day care prostate biopsy patients: An assessment of the role of a third-party check.

BACKGROUND: To evaluate the extent of recall of consent information by daycare prostate biopsy patients in our low-literacy setting. And to evaluate the role of a 3rd party check on patient's recall of consent information. SUBJECTS AND METHODS: As part of our standard of care, a formal informed consent session for day care prostate biopsy takes place 3 days prior to the procedure. For this study, before leaving the outpatient clinic the same day, the patient acknowledged before a third-party that his concerns were or were not satisfactorily addressed. The extent of recall of consent information was assessed on the morning of the procedure using a researcher-administered questionnaire. Consecutive patients participated in this cross-sectional study for day care prostate biopsy at a tertiary hospital in southeast Nigeria from February to November 2015 after obtaining due consent. RESULTS: The recall of the risks associated with the planned procedure was poorer than the recall of the nature of the disease condition or the nature of the planned procedure. However, it was observed that aggregate recall was significantly poorer among patients who negatively attested to a satisfying consent session (OR 0.125; P < 0.0005). CONCLUSION: The use of a third-party in determining patient satisfaction after a consent session may be a better indicator of patient comprehension and subsequent recall of consent information, especially in low-literacy settings. Using a third-party, in this manner, may assist in checking paternalism inherent in the patient-doctor relationship.

Learning transurethral resection of the prostate: A comparison of the weight of resected specimen to the weight of enucleated specimen in open prostatectomy.

BACKGROUND: Minimally invasive procedures in the surgical management of benign prostate enlargement (BPE) are of limited use in the resource-poor settings due to nonavailability of the requisite facilities and skills. It has been observed that teaching uroendoscopy inclusive of transurethral resection of the prostate (TURP) can be challenging in the resource-poor settings where the traditional master-apprentice (Halstedian) approach has remained the prevalent training technique. PATIENTS AND METHODS: We aimed in this retrospective study to assess completeness of resection in TURP by comparing the proportion of prostate tissue resected to the proportion enucleated in open retropubic prostatectomy (ORP). We included all BPE patients on urethral catheter managed in the first 18 months after Halstedian training in TURP. The analysis was done using SPSS® 20 and VassarStats® online software. RESULTS: Twenty patients' files for TURP and twenty-eight patients' files for ORP met the inclusion criteria. Patients in the 2 treatment arms were similar in age (P = 0.22), body mass index (P = 0.45), proportion of prostate tissue extirpated (P = 0.38), and International Prostate Symptom Score 12-month postprocedure (P = 0.06). However, larger prostates were treated with ORP (P < 0.0005). The correlation of the weight of resected specimen to preoperative prostate volume (PV) (r = 0.78; P < 0.001) was similar to that of enucleated specimen to preoperative PV (r = 0.89; P < 0.001). Similarly, the proportion of extirpated specimen correlated positively with the preoperative PVs for both TURP (r = 0.23; P = 0.33) and ORP (r = 0.292; P = 0.13), with no evidence of any difference between the 2 correlation values (P = 0.84). CONCLUSION: With appropriate patient selection, especially as a newly trained Surgeon, resections in TURP are as complete as enucleations in ORP.

Acute and intermittent testicular torsion: Analysis of presentation, management, and outcome in South East, Nigeria.

BACKGROUND: Testicular torsion compromises the blood supply to the testes and may result in testicular loss or damage if not dealt with promptly. It can occur either as acute testicular torsion (ATT) or intermittent testicular torsion (ITT). This study examines the presentation, management, and outcome of adult testicular torsion. PATIENTS AND METHODS: During the period January 1999 and December 2009, 34 out of 59 patients treated for testicular torsion, who had complete records, were evaluated. Operating theater and urology ward admission registers were used to identify patients. RESULTS: Age range was 16-50 years. Of the 34 patients, 11 (32.4%) were between 26 and 30 years old, while 16 (47.1%) were between 16 and 25 years old. Mean age was 27 years. Scrotal pain of varying severity was noted in all patients; there was associated vomiting in 21% of cases and abdominal pain in 38% of cases. Clinical diagnosis was ATT in 12 (35.3%) patients and ITT in 22 (64.7%) patients. In the ATT group, only one patient (8.3%) presented within 6 h of onset of symptoms. In the ITT group, 3 patients (13.6%) presented within 1 month of onset of symptoms while 7 (31.8%) of patients presented between 1 and 6 months after the onset of symptoms. Testicular salvage rate was 58.3% for ATT. Surgical intervention occurred within 3 h in the ATT group in 7 patients (58.3%) and in 5 patients (41.7%) within 3-6 h of onset of symptoms. In the patients with ITT, 12 patients (54.5%) were operated upon within 1 month of presentation. Preoperative external manual detorsion was performed in 1 patient. CONCLUSION: Late presentation was observed, especially in the intermittent variety. Delay occurred both at pre- and intra-hospital phases. Testicular salvage rate may be improved by physician/health worker and community enlightenment. Adoption of local anesthetic may reduce intrahospital delay.

Ischemic priapism in South-East Nigeria: Presentation, management challenges, and aftermath issues.

CONTEXT: Ischemic priapism is the more common variety of priapism and often presents late. Outcome is largely dependent on the duration of ischemia. AIMS: To determine the etiology, presentation, management, and outcome of ischemic priapism. SETTINGS AND DESIGN: Retrospective analysis of consecutive cases presenting to three hospitals offering specialist urological services in South-East Nigeria from January 2000 to December 2010. PATIENTS AND METHODS: Fifteen patients were assessed for clinical data and outcome. STATISTICAL ANALYSIS USED: The data were analyzed descriptively and inferentially using Statistical Package for Social Sciences (SPSS version 16, SPSS Inc., Chicago IL, USA) with P < 0.05. RESULTS: Mean age was 30.5 years (standard deviation [SD] =1.63), range: 14-79 years. Onset to presentation interval ranged from 6 h to 28 days. Eight patients (53.3%) had sickle cell disease (SCD). Four patients (26.7%) had unidentified causes. The 8 SCD patients had stuttering priapism on several occasions previously. Six patients (40%) had taken oral herbal medications as treatment prior to presentation. Initial resuscitative measures were intravenous hydration, aspiration, and irrigation with normal saline in 13 patients. Glanulo-cavernous shunt (Al-Ghorab) was performed in all the patients. Detumescence was immediate in 14 and delayed in 1 patient. Three patients had transient recurrence of tumescence, while one had to be reshunted. Erectile dysfunction (ED) occurred in 7 patients (46.7%). Occurrence of ED increased significantly in patients presenting 24 h after onset of symptoms ([P = 0.032] Fishers exact test). Mean duration of follow-up was 21.9 weeks (SD = 4.1), range: 3-156 weeks. CONCLUSIONS: Low flow priapism is common in our environment, and approximately half will occur in SCD patients who have had stuttering priapism previously. Timely diagnosis and treatment will reduce the probability of severe ED. In our experience, the Al-Ghorab shunt provides rapid relief. Enlightenment is vital in reducing ischemia time. Emphasis on preventive measures in SCD patients is vital.

Ischemic Priapism in South-East Nigeria: Presentation; Management Challenges; and Aftermath Issues

Context: Ischemic priapism is the more common variety of priapism and often presents late. Outcome is largely dependent on the duration of ischemia. Aims: To determine the etiology; presentation; management; and outcome of ischemic priapism. Settings and Design: Retrospective analysis of consecutive cases presenting to three hospitals offering specialist urological services in South-East Nigeria from January 2000 to December 2010. Patients and Methods: Fifteen patients were assessed for clinical data and outcome. Statistical Analysis Used: The data were analyzed descriptively and inferentially using Statistical Package for Social Sciences (SPSS version 16; SPSS Inc.; Chicago IL; USA) with P 0.05. Results: Mean age was 30.5 years (standard deviation [SD]

Transvesical prostatectomy in the management of benign prostatic hyperplasia in a developing country.

CONTEXT: The surgical management of benign prostatic hyperplasia (BPH) is evolving away from open surgery. In developing countries however majority of cases are managed by transvesical prostatectomy (TP). AIMS: This study aims to describe our experience regarding the efficacy, complication profile and outcome of TP in the management of BPH in Nigeria. SETTINGS AND DESIGN: A descriptive, retrospective study carried out in three tertiary centers. SUBJECTS AND METHODS: Two hundred and ninety-seven patients were studied. Parameters examined included age, clinical features, investigations, type of postoperative bladder irrigation, prostate gland volume, duration of hospital stay, complications and outcome. STATISTICAL ANALYSIS USED: Simple means and percentages with SPSS 16. RESULTS: Mean age was 65.2 ± 6.8 years (range 47-93 years). Presentation with severe lower urinary tract symptoms only occurred in 76 patients (25.7%); acute urinary retention was seen in 106 patients (35.7%). Chronic urinary retention, impaired renal function and haematuria occurred in 47 (15.8%), 37 (12.5%), and 31 patients (10.4%) respectively. On comorbidity, 63 patients (21.2%) were hypertensive and 24 patients (8.1%) had diabetes mellitus. Two hundred and twenty three patients (75%) had indwelling catheters at the time of surgery. Preoperative urinary catheter duration was 1 week-35 months. Mean duration of hospital stay was 8.8 days. Complications were transient urinary incontinence 33 patients (11.1%), urinary tract infection 38 patients (12.7%), and acute epididymoorchitis 15 patients (5.1%). Clot retention occurred in 40 patients (13.5%). Mortality rate was 1%. CONCLUSIONS: TP remains useful in developing climes. There is a need to emphasize effective preoperative workup so as to limit morbidity. Emphasis on variety of techniques for hemostasis is necessary.

Undergraduate surgery clerkship and the choice of surgery as a career: perspective from a developing country.

BACKGROUND: There are concerns regarding a possible decline in the proportion of students choosing surgery as a career in some countries in sub-Saharan Africa. Published works indicate that most students choose their ultimate career during undergraduate training. The present study was undertaken to assess the medical student's perception of the surgery clerkship and determine its influence in the choice of surgery as a career. METHODS: The study involved a cross-sectional survey of 2009 and 2010 graduating medical classes of the University of Nigeria based on self-administered questionnaires. The clerkship evaluation was assessed on a 3-point Likert scale (1 = poor; 3 = excellent). RESULTS: The response rate was 70.3 % (275/391); 179 (65.1 %) of the students were males and 96 (34.9 %), females. Sixty-one (22.2 %) rated the overall quality of their surgery clerkship as excellent (mean rating = 2). Compared with the other three major clerkships, surgery has the lowest rating for overall quality (mean rating: surgery = 2; others = 2.2). Aspects of the clerkship experience that contributed to the overall lower rating of surgery include quality of opportunity to participate in direct patient care; clarity of posting goals and objectives; experience in learning history taking skills, basic physical examination skills, and interpretation of laboratory data; accessibility of faculty; and students' perception that they were treated in a respectful manner. The major suggestions to improve clerkship quality were these: (1) more involvement in direct patient care (n = 154; 56 %), and (2) improvement in student-faculty interaction (n = 9 1; 33.1 %). Overall, 96 (34.9 %) students selected surgery as a specialty, and 39.3 % (108/275) selected the other three major specialties. Surgery was selected by 17/48 (35.4 %), 59/166 (35.5 %), and 20/61 (32.8 %) students who rated the surgery clerkship as "poor," "just right," and "excellent," respectively (p = 0.876). Factors indicated as major influences in the choice of surgical specialty included personal satisfaction 41.7 % (40/96), clerkship experience 36.4 % (35/96), and diligence of faculty 13.5 % (13/96). CONCLUSIONS: Periodic assessment of the satisfaction of medical students regarding their surgical clerkship experience is important. In our setting, we have identified aspects of the surgical clerkship that could be improved to enhance the quality of the experience, ensure the attractiveness of the field to the most qualified candidates, and boost interest in surgery as a career.

Fournier's gangrene -- analysis of management and outcome in south-eastern Nigeria.

BACKGROUND: Fournier's gangrene is a necrotising fasciitis of the genitalia and perineum, with associated polymicrobial infection and risk of organ failure or death. The purpose of this study was to determine the presentation, systemic and local predisposing factors, management challenges and outcome in south-eastern Nigeria. PATIENTS AND METHODS: We studied 28 out of 34 consecutive male patients with complete case notes seen in two centres (the University of Nigeria Teaching Hospital and St Mary's Hospital) between January 1995 and December 2008. Operating theatre registers and urology ward admission registers were used to identify patients. RESULTS: The mean patient age was 48.3 years (range 28 - 66 years), with a peak age incidence of 50 - 59 years. The majority of patients were farmers, manual labourers and artisans. The site of gangrene was scrotal in 22 patients (78.6%), penoscrotal in 3 (10.7%), abdominoscrotal in 2 (7.1%) and scroto-perianal in 1 (3.6%). The mean interval between onset of symptoms and presentation was 7.2 days (range 3 - 14 days). Systemic predisposing factors identified were diabetes mellitus in 6 patients (21.4%), filariasis in 2 (7.2%), congestive cardiac failure in 1 (3.6%) and HIV infection in 1 (3.6%). In 18 patients (64.3%) no systemic factor was identified. Local predisposing factors identified were chronic scrotal skin itching in 16 patients (57.1%), scrotal thorn injury in 2 (7.1%) and urethral catheterisation in 2 (7.1%). Scrotal carbuncle and scrotal surgery each accounted for 2 patients (7.1%), and zipper injury and ischiorectal abscess occurred in 1 patient each (3.6%). No local predisposing factor was identified in 1 patient (3.6%). The common clinical features were fever, scrotal swelling/pain, and later a malodorous painless wound. Treatment involved fluid administration, correction of electrolyte imbalance, antibiotics, debridement and daily wound inspection/dressing with hydrogen peroxide soaks and sodium hypochlorite. The mean duration of hospital stay was 37.1.days (range 21 - 84 days). One patient died (3.6%). CONCLUSION: Fournier's gangrene is a challenging surgical problem, with significant morbidity. Diabetes mellitus is a significant systemic risk factor. In the majority of our cases, no systemic predisposing factor was identified. Local risk factors, especially chronic scrotal itching, were contributory. With proper management, mortality is low.

Testicular cancer: Management challenges in an African developing country.

BACKGROUND: Advances in oncology have greatly improved the prognosis of testicular cancer. In developing countries, however, the outcome is still poor. PATIENTS AND METHODS: Twenty-four patients managed for testicular cancer at two centres (University of Nigeria Teaching Hospital, Enugu, Nigeria, and JAMA Urological Clinic, Enugu) between April 1984 and March 2003 were prospectively studied. Histopathological data were obtained in all cases. RESULTS: Peak age incidence was 20 - 29 years. Testicular swelling was the principal complaint in 23 patients. The mean interval between onset of symptoms and presentation was 5.3 months. Two patients (8.3%) presented with stage 1 disease, 7 (29.2%) with stage 2, 7 (29.2%) with stage 3, and 8 (33.3%) with stage 4. Seventy-five per cent of tumours were right-sided, and 25% were left-sided. Treatment consisted of radical orchidectomy in all patients and cisplatin-based chemotherapy and radiotherapy in some patients. One patient with a tumour in an intra-abdominal testis underwent laparotomy. The most common histological types were seminoma and embryonal carcinoma. A fifth of the patients died, while half were lost to follow-up. The mean follow-up period was 9 months. CONCLUSION: Morbidity and mortality of testicular cancer is high in developing countries. Late presentation, poverty, paucity of resources and the high cost of newer imaging modalities and treatment are major challenges to management. Better health funding and education regarding testicular self-examination is essential.

Giant Seminoma following ipsilateral orchidectomy: a rare finding. Case report.

Giant intrascrotal recurrent seminomas are rare in the surgical literature, probably due to widespread information about self-detection. A recent European study has reported a reduction in the primary tumour size at presentation. These findings are at variance with the situation in sub-Saharan Africa. We present a 32-year-old patient who presented with an 8-month history of progressive, painless left hemiscrotal swelling, no lower urinary tract symptoms and no evidence of metastatic disease. The patient had undergone a left inguinal orchidectomy 2 years prior to the onset of the current swelling, on account of a suspected testicular tumour. Histology was, however, returned as 'sections of testis showing haemorrhagic necrosis with areas of fibrosis. No malignancy seen. Diagnosis consistent with long standing torsion'. The patient had excision of the mass via an inguinoscrotal incision, with primary wound closure and drainage, and had good post-operative recovery. Histopathology subsequently reported seminoma. We discuss a rare case of giant intrascrotal recurrent seminoma in a young African patient and comment on the surprising absence of metastatic symptoms and the management in the absence of new imaging techniques. We emphasize the value of extirpation in such cases and the need for thorough sectioning of histopathological specimens. We also note that seminoma should be considered in the differential diagnosis of scrotal swelling even in the absence of the testes (after orchidectomy).