|Year : 2019 | Volume
| Issue : 4 | Page : 214-218
Urologic day-care surgery in a Tertiary Hospital in Nigeria: A 4-year review
Abubakar Sadiq Muhammad, Abdulwahab-Ahmed Abdullahi, Ngwobia Peter Agwu, Ismaila Arzika Mungadi
Urology Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Submission||25-Jan-2018|
|Date of Acceptance||25-Jun-2018|
|Date of Web Publication||29-Nov-2019|
Dr. Abubakar Sadiq Muhammad
Urology Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto
Background: Day-care surgery is associated with economic, social, and health benefits to the patients. The increasing pressure on hospital bed and theater space serves as impetus for renewed interest in day-care surgery in our facility. Objective: To report our experience in day-care surgery in the past 4 years. Materials and Methods: This is a retrospective review of patients who had urologic day-care procedures in our facility, from January 2014 to December 2017. Data were collected through pro forma and analyzed using SPSS version 20.0 for windows. Results: There were 502 patients who had day-care procedures within the study period which accounted for 43.5% of elective procedures. The patients' age ranged from 1 to 90 years. There were 494 males (98.4%) and 8 females (1.6%). The procedures were diagnostic in 89.6%, therapeutic in 9.8%, and both diagnostic and therapeutic in 0.6% of the patients. The procedures included transrectal ultrasound (TRUS)-guided prostatic biopsy (74.5%), urethrocystoscopy ± biopsy and double J stent retrieval (16.7%), varicocoelectomy (2.8%), circumcision (1.4%), meatoplasty (0.6%), excisional biopsy (0.6%), and others (3.4%). Two patients (0.4%) had a conversion to inpatient admission due to persistent hematuria following urethrocystoscopy and biopsy. There were three re-admissions (0.6%) for postprostatic biopsy infection (0.4%) and surgical site infection (0.2%) following varicocoelectomy in an obese patient. Conclusion: TRUS-guided biopsy, urethrocystoscopy, and varicocoelectomy are the most common day-care procedures in our facility. The morbidity, conversion, and re-admission rates were acceptable.
Keywords: Day-care urology, outcome, prostate biopsy, urethrocystoscopy, varicocoelectomy
|How to cite this article:|
Muhammad AS, Abdullahi AA, Agwu NP, Mungadi IA. Urologic day-care surgery in a Tertiary Hospital in Nigeria: A 4-year review. Sahel Med J 2019;22:214-8
|How to cite this URL:|
Muhammad AS, Abdullahi AA, Agwu NP, Mungadi IA. Urologic day-care surgery in a Tertiary Hospital in Nigeria: A 4-year review. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:214-8. Available from: http://www.smjonline.org/text.asp?2019/22/4/214/272145
| Introduction|| |
Surgery subspecialty day-care surgery has been evolving over the years after the introduction of day-care surgery by James Nicoll in 1909., It has been popularized in the United Kingdom and United States where it is called ambulatory surgery with over 60% of elective surgeries carried out as day-care surgery. The day-care surgery has been popularized as a result of developments in anesthesia, perioperative pain management, minimally invasive procedures, changing attitude toward recovery and concept of enhanced recovery after surgery. In urology, it initially covers minor and intermediate surgeries but now select major urologic surgeries both open and endoscopic are carried out as day-care surgeries. The major surgeries currently reported include laparoscopic robotically assisted radical retropubic prostatectomy, ureteroscopy ± lithotripsy, and transurethral resection of the prostate and bladder tumor.,,, The impetus to this trend in day-care surgery is due to its twin benefits of convenience and cost-effectiveness. There is minimal disruption of patients' normal life and more bed spaces are released for inpatient care., There is avoidance of diseases related to hospitalization such as nosocomial infection and deep venous thrombosis.,
The main problem of day-care surgery in the developing countries like Nigeria is the initial cost of setting up a standard day-care unit with its own separate theater, recovery, staff, and anesthetist as in the developed world., There are no organized family physicians or community nurses to continue the care of the patients at home. Therefore, the burden of care is borne by family members and caregivers. The limitation of theater spaces for all surgical subspecialties including urology serve as impetus to organize our minor theater which has all the requirements into day-care unit to cater for our day-care procedures.
The aim of this study is to document our experience in urologic day-care surgery in our facility.
| Materials and Methods|| |
This is a retrospective study of all the patients that had day-care procedures by the urology unit of our hospital from January 2014 to December 2017. Health Ethics and Research Committee of Usmanu Danfodiyo University Teaching Hospital, Sokoto approved the study (protocol no UDUTH.HERC/2012 NO 38) dated July 9, 2012. The procedures were carried out in the urology procedure room, main theater, and day-care unit initially, but in the past 2 years, urology procedure room is used for transrectal ultrasound (TRUS)-guided biopsy and day-care unit for other procedures. The day-care facility has two theaters, reception, scrubbing area, recovery room, parking space, and dedicated staff. After the patient is counseled, the intended procedure explained to them, verbal and written consent will be obtained. Intravenous access will be obtained; intravenous prophylactic antibiotics will be given using 1 g ceftriaxone. The procedures were carried out under local anesthesia (LA), ketamine, and sedation. Postoperatively, the patient will be taken to the recovery room on intravenous fluid (normal saline), intramuscular pentazocine. If there is nausea and vomiting, intramuscular metoclopramide or promethazine is given. For the patients that had urethrocystoscopy and biopsy, a size 20 Fr 3-way Foley's catheter will be passed and bladder irrigated with normal saline until urine is clear or pinkish before removal. After the recovery, the patient is discharged to the relatives on oral medications that include diclofenac and ciprofloxacin. Regional and full general anesthesia was not used the due absence of dedicated anesthesia team in the facility.
Data were collected from operation lists, procedure registers, and case folders through a pro forma. The data included biodata, diagnosis, type of procedure, type of anesthesia, complications, conversion, and re-admission and cancellation rates. Data analysis was done using Statistical Package for the Social Sciences (SPSS) 20.0 version (2011) for Windows (SPSS Incorporation, IBM, Chicago, IL, USA). The results were reported in percentages and mean ± standard deviation.
| Results|| |
A total number of 562 patients were scheduled for day-care procedures, but only 502 cases were done due to cancellation or failure to show up by 60 patients (11%). The patients' age ranged from 1 to 90 years, with a mean of 60.7 ± 15.8 years. There were 494 males (98.4%) and 8 females (1.6%).
The most common diagnoses of the patients were benign prostatic hyperplasia (BPH) and cancer of the prostate (caP) in 53.6% and 22.9% of the patients, respectively. The patients had abnormal digital rectal examination findings, high prostatic-specific antigen or hematuria, and thus the need to exclude prostate or bladder cancer. Other details of the diagnosis are shown in [Table 1].
The procedures were diagnostic in 89.6%, therapeutic in 9.8%, and both diagnostic and therapeutic in 0.6% of the patients. The procedures were carried out by residents in 67.3% of the cases and consultants in 32.7%. Local anaesthesia was used in adults ± parenteral analgesia and general anesthesia (ketamine) was used in children. Xylocaine + adrenaline in the form of gel were instilled into the urethra and rectum to provide local analgesia for urethrocystoscopy and prostate biopsy. The most common procedures were TRUS-guided prostatic biopsy (74.8%) and urethrocystoscopy + biopsy ± double J (DJ) stent removal (16.7%). Other types of day-care procedures carried out are shown in [Table 2].
Out of 652 patients scheduled for day-care procedures, 60 were cancelled (11.0%) due to ability of the patients to come to the theater, power failure, the inability of the patients to procure complete materials in time, inadequate sterile drapes in the time, and nonpayments of operation fee.
Three patients (0.6%) were converted to inpatient admission due to persistent hematuria following urethrocystoscopy and three patients (0.6%) also were re-admitted for postprocedural infections, 2 patients (0.4%) following prostatic biopsy, and an obese patient (0.2%) following bilateral varicocoelectomy. The patients were treated with appropriate antibiotics and wound dressed using 10% povidone iodine for the patient who had surgical site infection.
| Discussion|| |
Day-care surgery in urology is fast growing with procedures such as transurethral resection of the prostate and bladder, laparoscopic robotic-assisted radical prostatectomy, and ureteroscopic lithotripsy done as day cases.,,, Within the study period, 1115 elective urological procedures were carried out for which day-care urological procedures accounted for 43.5% of the cases. This is >30.4% reported by a study in Nigeria but lower than 51%–62% reported by most of the previous studies.,, Royal College of Surgeons  and British Association of Urological surgeons  proposed that day-care surgeries should be 65% and 75% of elective cases, respectively. We are presently limited by full anesthesia cover due to the absence of dedicated anesthetic team. Propofol and regional anesthesia were not used. Increasing the spectrum therapeutic cases in select patients including those that can be done under total intravenous anesthesia using propofol will achieve these targets. Provision of dedicated anesthesia team and necessary equipments in the day-care unit will facilitate the enrollment of more intermediate and select major urological procedures as day cases.
The age range of patients in this study was 1–90 years, which is in line with studies done in Lagos  and Ibadan  but higher than that of Ife. The wide age range of the patients was due circumcision and TRUS guided carried out in children and elderly patients with phimosis and prostatic diseases, respectively. On average, the patients were middle age with a mean age of 60.7 years due to the fact that the most common diagnoses were BPH, caP, and bladder cancer which are found in such age groups. There were few females in this study as reported by the previous studies.,, This is due to the fact that the most common diseases of our patients were BPH and caP which are found only in males.
The finding of BPH and caP as the most common diagnoses in the present study is in line with previous studies in Nigeria.,, The procedures carried out in this study were mainly diagnostic as reported in Lagos. This is contrary to the findings by some previous studies in Nigeria where therapeutic procedures predominate., The spectrum of therapeutic cases in our study is limited by lack of full anesthetic cover. Prostate biopsy, urethrocystoscopy, and varicocoelectomy were the most common diagnostic and therapeutic procedures carried out in this study as reported by previous studies.,, This reflects the high prevalence of BPH, caP, bladder cancer, and varicocele in our environment.
As reported in Jos and Ife, local and general anesthesias were primarily used for adults and children, respectively., Xylocaine + adrenaline gel was instilled into the rectum and urethra for prostatic biopsy and urethrocystoscopy. This is contrary to what was reported in Lagos where caudal block was used prostatic biopsy and urethrocystoscopy. Some of the patients who did not tolerate LA alone were augmented with some forms of analgesia such as pentazocine. Local anaesthesia is preferred in day-care surgery in adults due to relative safety and minimal postoperative nausea and vomiting which facilitate faster discharge from the hospital., Significant number (67%) of the procedures were carried out by residents as reported by the previous studies in Nigeria., This enhances the training of our residents as they do these procedures under supervision.
Postoperative morbidities leading to hospital admission were found in 1.2% of the patients which is lower than 1.6% that was reported in Lagos. The conversion and re-admission rates of 0.6% recorded in this study are comparable to the findings of the studies in Lagos  and Ife  but lower than that of the study in Jos. This is due to strict selection criteria such as enrollment of only patients with American Society of Anesthesiology Class I and II. The causes of re-admission and conversion to inpatient admission were similar to the findings in previous studies in Nigeria., These include postprostatic biopsy infection and urethral bleeding. This also is keeping with a study done in India. Our re-admission rate (0.6%) is below the cutoff rate of 2.4% suggested in the Western world. This is partly due to the selection criteria, generous use of LA, patients' counseling. Some studies in the Western world recorded re-admission rate of 9.3% due to increased workload and technical difficulties of the procedures carried out in the West. More major procedures are carried out under general anesthesia and some may exceed the 1 h duration limit recommended for day-care procedures., As spectrum of major cases increase, our readmission rate may increase as it was observed in the Western world. The cancellation rate in this study of 11.0% is lower than 15.6% that was reported in Jos, but the reasons for the cancellations were similar., These included mainly inability of patient to come to the theater, inadequate operation materials, power failure, and inadequate sterile drapes. Adequate patient counseling, adequate information, communication, dedicated source of power to the theater, and sending of operation list to laundry and provision of theater materials by the hospital may reduce these problems. In developed countries, use of community nurses was shown to reduce patient-related cancellations. We do not have enough personnel to adopt this strategy. Effective communications using telephones will go a long way in reducing some of these cancellations as reported by a previous study. The challenges of the urologic day-care surgery include sharing of the facility in the same day with general surgery. The two theater spaces we have for the day-care surgery are competed with general surgery on first come first served basis. This delays the commencement of urologic cases and the consumables may also be exhausted which may lead to cancellation of some cases. We presently commenced operations very early to finish our cases as planned. Dedicated unit for only urology as obtainable in the new Urology Institute will eliminate this competition and its attendant problems. At present, as the cases of day-care surgery are lumped during the urology outpatient clinic with other cases, the patients do not get the necessary attention, scrutiny, and preparations. Problems will spill to the day of surgery. This brings a lot of hardship and anxiety to the patients and managing team. Dedication of a team in the clinic to cater for day-care patients will reduce these problems. Patients come along with operation materials and consumables on the day of surgery with many items missing. Provision of these materials by the hospital as is done for the main theater or verification of the materials at outpatient clinic on another day will reduce the problem. In terms of the full anesthesia coverage, we are hopeful in the increase in the availability of consultant anesthesiologists in the hospital and the day-care facility will be fully covered in personnel and equipment. This will increase the spectrum of the day-care cases in our hospital.
Initially, the day-care cases are lumped with major cases. This limited the number of major cases that can be done and maximum of two day-care surgeries can be done. With the organization of the day-care unit, all the day-care cases except TRUS-guided prostate biopsy were done at the unit and up to 7 cases can be done. This is due to collaborative effort with the other staff of the unit, commencement of the list early and use of 2 teams, in which a consultant urologist and at least a senior registrar operate in the other theater.
| Conclusion|| |
Transurethral ultrasound-guided prostate biopsy, urethrocystoscopy ± biopsy, DJ stent retrieval, and varicocoelectomy were the most common diagnostic and therapeutic day-care urological procedures carried out in our facility. The morbidity, conversion, and re-admission rates were acceptable. The major limitation of this work is its retrospective design. There might have been missing data. However the number of cases is large enough to allow generalization of our results.
Prof. Aminu Mode, Head of Department, Department of Modern European Languages and Linguistics, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria.
Financial support and sponsorship
This study was self-funded.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]