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Reports
Urological training
COST Africa Bsc UROLOGICAL TRAINING Jan-Feb 2015 REPORT
Subject: Urology, BPH prostatectomy surgical techniques and postop management.
Trainer: Gert Jan Montagne, urological consultant.
MULANJE DISTRICT HOSPITAL
Dates |
12 – 16 Jan 2015 |
Subjects covered |
BPH prostatectomy surgical techniques and postop management |
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Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis. |
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Lectures on urinary retention, SP catheter placement, emergency issues in urology, bladder ca, prostate ca. |
Trainees Cost Africa |
Mr Martin Malunga, senior CO,
Mss Hilda Dauti, CO Mr Sam Matandala, CO |
Others attending |
Mr Morris Chalusa CO Mr Manyozo Dawa anaesthetic CO Dr Jane Jere MO nursing staff male ward |
People met |
Dr Khuliena Kabwere DHO Hospital Matron Hospital Administrator |
Programm |
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Mon 12th morning |
wellcome, introduction hospital, meet DHO, rounds male/female/paed wards, preview prostatectomy candidates (x10) at OPD clinic lecture on prostatectomy techniques and postop management. |
Mon 12th afternoon |
1 x prostatectomy transvesical by senior CO Malunga + Monta |
Tue 13th morning |
lecture on urinary retention / SP catheter placement and postop management after prostatectomy to complete surgical staff
1 x prostatectomy retropubic by trainer Monta + Malunga |
Wed 14th morning |
1x prostatectomy transvesical by trainer + Dauti/Morris visit to Mulanje Mission Hosp to find surgical gowns |
Wed 14th afternoon |
theatre session cancelled b/o power/water shortage lectures surg CO team on variety of urological subjects |
Thur 15th |
Public Holiday ; assessment flood damage Tuchilla Health Centre with hospital team |
Fri 16th morning |
2 x prostatectomy retropubic by Malunga / Monta and Matandala / Monta |
Fri 16th afternoon |
evaluation with CA trainees |
Evaluation |
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Preparation |
very good, daily surgery |
Patients selection |
very good : 10 – 12 patients selected |
Hospital |
well organised wards / theatre with enthusiastic / dedicated staff |
Special problems |
frequent powercuts due to the continuous heavy rains |
CA trainees |
Enthusiasm / interest high. Surgical skill is average - good. |
Prostatectomy done |
yes, transvesical P (CH22 two way + SPcath) |
The high volume of iv fluids required for postoperative continuous bladder irrigation keeps this team from doing more than 3-4 prostatectomies a month. The demonstrated technique of postop bladder irrigation by forced diuresis was therefore warmly wellcomed |
Ultrasound |
yes, routinely used in urological patients. |
Blood |
MBTS – Blantyre (in emergency: Mulanje Mission H) |
Procedures done |
5 |
Prostatectomy faesible |
yes |
Needs |
largesize hematuria catheters ch22-24; suturematerial |
NSANJE DISTRICT HOSPITAL
Dates |
19 – 22 Jan 2015 |
Subjects covered |
BPH prostatectomy surgical techniques and postop management |
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Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis. |
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Lectures on urinary retention, SP catheter placement, BPH, emergency issues in urology, bladder ca, prostate ca. |
Trainees Cost Africa |
Mr Laston Nthukutu CO, Mr Joseph January CO |
Others attending |
nursing staff male ward, nurses tutor |
People met |
Dr Chijuwa DHO Dr Mastala DMO Mr Chanyuka aneasth CO Mr Chabuka anaesth CO Mr Chawawa in charge OR |
Programm |
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Mon 19th morning |
wellcome, introduction hospital, DHO and DMO; preview prostatectomy candidates; lecture on prostatectomy techniques and postop management for CA trainees. |
Mon 19th afternoon |
1 x prostatectomy transvesical by CO Nthukutu + Monta |
Tue 20th morning |
lecture on BPH 1 x prostatectomy retropubic by trainer + Thukutu |
Tue 20th afternoon |
1 x transvesical prostatectomy by January + trainer ; 3d prostatectomy patient cancelled b/o insufficient preop information |
Wed 21th morning |
ward rounds postop patients male ward, 1x prostatectomy retropubic by Thukutu + trainer (January ass); 2d case cancelled b/o hypertension |
Wed 21th afternoon |
lecture CA trainees + nursing staff male ward + tutor student nurses on urinary retention + postoperative management after prostatetcomy; lecture CA trainees on variety of urological subjects |
Thur 22th |
ward round male ward seeing postop patients. OR patient cancelled b/o persisting hypertension; lecture on emergeny issues in urology and urological oncology; evaluation training with CA trainees |
Fri 23th |
cancelled, no candidates for surgery |
Evaluation |
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Preparation |
hospital preparation good, daily surgery |
Patients selection |
selection could be much better |
Unfortunately the prostatectomy candidates were selected by a junior intern CO because both CA trainees had their holiday in December 2014. This resulted in incomplete preop work-up (hypertension not noted) and incorrect indications (mild-moderate voiding complaints but no catheter and very small prostate volume). As a consequence there were not enough patients for a whole week of surgery. |
Hospital |
well organised wards/theatre with enthusiastic/dedicated staff |
Special problems |
infrequent powercuts, covered by hospital generator |
CA trainees |
Enthusiasm / interest high. Surgical skill varies. |
Surgical skill/experience is good (lNt) – average (JJ). The young CA trainees’ primary interest was in surgical technical aspects of the procedures. This left room for teaching on the importance of preop work-up and intensive postoperative care in this type of patients. |
Prostatectomy done |
yes, transvesical P (CH22 two way + SPcath + prostate cavity packing) |
Ultrasound |
yes, routinely used in urological patients. |
Blood |
MBTS – Blantyre |
Procedures done |
4 |
Prostatectomy faesible |
yes |
Needs |
large-size hematuria catheters ch22-24; suturematerial |
MANGOCHI DISTRICT HOSPITAL
Dates |
26 – 30 Jan 2015 |
Subjects covered |
BPH prostatectomy surgical techniques and postop management |
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Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis. |
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Lectures on urinary retention, SP catheter placement, BPH, emergency issues in urology, bladder ca, prostate ca. |
Trainees Cost Africa |
Mr Calistus Chiumia CO Mr Aubrey Filimoni CO |
Others attending |
nurses male ward |
People met |
Dr Phoya MO Dr Peno DHO |
Programm |
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Mon 26th morning and afternoon |
1 trainee was abscent on Monday. Wellcome, introduction hospital, DHO; preview 3 prostatectomy candidates: one was unfit for surgery (HT, cardiac failure, old age) the other is not well indicated (mild-moderate symptoms without catheter). 3d pt did not show up. |
Tue 27th morning |
surgery is cancelled. Lecture on management of urinary retention and on postop management of prostatectomy patients for nurses of male ward. Lecture on prostatectomy techniques and postop management for CA trainees. Lecture on BPH management. Consultation on child with pelvic tumor in paediatric ward. |
Tue 27th afternoon |
lectures on bladderca, prostate ca and on emergency issues in urology for CA trainees. Preview of three prostatectomy candidates for Wedn: one case with dubio indication (no cath, moderate symptoms, inguinal hernia). |
Wed 28th morning |
1x prostatectomy transvesical by Filimon + trainer (Chiuma present); (1 trainee abscent after 1st case) |
Wed 28th afternoon |
1 x transvesical prostatectomy by Chiuma + trainer. 3d OR case cancelled b/o dubio indication. Evaluation training programm with CA trainees. |
Thur 29th |
ward round male ward seeing postop patients. Evaluation |
Fri 30th |
cancelled, no candidates for surgery / no OR time. |
Evaluation |
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Preparation |
patient selection could be better; no daily surgery, poor anaesthetic cooperation |
Patients selection |
5 patients selected - some had to be cancelled |
Hospital |
only 2 days for surgery, anaesthetic staf not very motivated to assist. |
Special problems |
Mangochi DH suffers from frequent power and water cuts. |
CA trainees |
one of the CO´s was abscent on Monday, Wednesday and Thursday. |
Following better patient selection both quantatively and qualatively and with a higher attendance the CA trainees would have had much greater benefit of this urological training.
Hospital management could have done a little better in arranging the anaesthetic service for this week
The surgical skill of the CA trainees is good (AF) to average (CC). In view of the cancelled patients the importance of a proper preop work-up was underlined.
(transvesical) Prostectomies are done on a weekly base at Mangochi DH since the arrival of CO’s Filimoni and Chiumia. The use of continuous bladder irrigation somewhat limits the numbers. The information on irrigation by forced diuresis was therefore wellcomed. |
Procedures done |
2 |
Prostatectomy faesible |
yes |
US at Mangochi DH |
yes, routinely used in urological pts |
Blood |
MBTS, Balaka branch |
Needs |
large-hole hematuria catheters ch22-24 |
MWANZA DISTRICT HOSPITAL
Dates |
2 – 6 Feb 2015 |
Subjects covered |
BPH prostatectomy surgical techniques and postop management |
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Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis. |
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Lectures on urinary retention, SP catheter placement, BPH, emergency issues in urology, bladder ca, prostate ca. |
Trainees Cost Africa |
Mss Michelle Kamwendo CO Mr Ken Namuku CO |
Others attending |
nurses male ward |
People met |
Mr Raphael Piringu DHO Dr Benson Khobidi DMO Mrs Ennet Nasangwe ic theatre Mr Collins Noniwa anaesth CO Mr Feliciano Mkomaludzu anaesth CO Mrs Maureen Mkwesa ic male ward |
Programm |
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Mon 2d morning |
Wellcome by CA trainees, meeting the DHO, DMO, theatre staff and male ward staff. Review of 12 selected patients including instruction CA trainees in US studies kidneys and bladder. |
Mon 2d afternoon |
Prostatectomy case cancelled b/o urethral stricture. Tutorial on prostatectomy techniques and postop care / irrigation. Completing preop review patients |
Tue 3d morning |
8.00 am lecture to male ward nursing staff on postop care including irrigation. 1 x (retropubic) prostatectomy by trainer / trainees. |
Tue 3d afternoon |
surgery (1x child with urethral trauma and 1 prostatectomy patient) was cancelled b/o blackout and 3 emergencies from maternity. Tutorial on SP catheter placement, BPH management and PSA |
Wed 4th morning |
follow-up male ward postop patient SP placement + wound inspection in youth with urethral trauma 1 x (transvesical) prostatectomy trainer + trainees |
Wed 4th afternoon |
1 x (transvesical) prostatectomy trainees + trainer Tutorial with trainees on urological cancers. Preview of three prostatectomy candidates for Thursday |
Thur 5th morning |
ward round male ward checking postop patients. Tutorial postop care / irrigation with male ward nursing staff. 1 x transvesical prostatectomy by trainee Mich + trainer / Ken |
Thur 5th afternoon |
1 x transvesical prostatectomy by trainee Ken + trainer / Mich tutotorial on urethral stricture disease |
Fri 6th morning |
ward round male ward checking postop patients ; 1 x transvesical prostatectomy by Mich + Ken with trainer present ; evaluation |
Evaluation |
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Preparation |
very good |
Patients selection |
very good: 12 patients selected, most had good indications and were fit for surgery. |
Hospital |
enthousiastic DHO and DMO, dedicated / interested theatre staff and male ward staff, all eager to introduce this procedure. Allowing daily surgery and providing all necessary material. Apart from inguinal hernia and scrotal surgery the theatre list in Mwanza DH is dominated by frequent Caesarean sections and evacuations. Up to date prostectomies were not done at Mwanza DH. |
CA trainees |
The surgical skill of the CA trainees reflects a lack of exposure to major abdominal/pelvic procedures. However, both trainees absorbed all new information with interest and were very eager to be instructed in doing prostatectomies. The importance of intensive postoperative care in prostatectomy patients was underlined. Both trainees and male ward nursing staff were instructed in the use of irrigation by forced diuresis. |
Blood |
MBTS or using blood donated by guardians locally. |
Ultrasound |
yes, routinely used in urological patients. |
Procedures done |
6 |
Prostatectomy faesible |
+/- yes |
Needs |
large-hole hematuria catheters ch22-24 |
With some hesitance I could trust the two trainees to start doing this procedure in Mwanza. However, early follow-up by a visiting surgeon is necessary. |
DEDZA DISTRICT HOSPITAL
Dates |
9 – 12 Feb 2015 |
Subjects covered |
BPH prostatectomy surgical techniques and postop management |
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Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis. |
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Lectures on urinary retention, SP catheter placement, BPH, emergency issues in urology, bladder ca, prostate ca. |
Trainees Cost Africa |
Mr Kenneth Murreno CO, Dedza Mr Martin Kapito CO, Dedza Mr Chancy Tembo CO, Mchinji Mr Gregory Khwimani CO, Mchinji |
Others attending |
nurses male ward |
People met |
Dr Banda, DMO Dr Jere, DHO Mr Joel Moyo anaesthetic CO Mr Lameck Matapira anaesthetic CO Mr Bernard Jali anaesthetic CO |
Programm |
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Mon 9th morning |
Wellcome by CA trainees, meeting, DMO, theatre staff and male ward staff. Review of six selected patients planned 1st prostatectomy cancelled b/o lack of anaesthetic staff. Tutorial on BPH management, urinary retention and on prostatectomy techniques - postop care / irrigation. |
Mon 9th afternoon |
1 x transvesical prostatectomy by trainer + Kapito / Tembo . 2d prostatectomy case cancelled b/o lack of aneasth staff. Completing preop review patients |
Tue 10th morning |
8.00 am lecture to male ward nursing staff on postop care / irrigation. Follow-up yesterdays patient while other team starts up theatre. 1 x transvesical prostatectomy by trainer + Murreno / Khwimani and 2d transvesical prostatectomy by trainer + Kapito / Tembo |
Tue 10th afternoon |
preview of preop patient, cancelled b/o HT – adipositas – U stricture? tutorial on urological cancers (while waiting for emergency caesarean) and 1 prostatectomy patient by Murreno + Khwimani + trainer |
Wed 11th morning |
follow-up male ward postop patients while other team starts up in theatre: 1 x transvesical prostatectomy by the two teams supervised by trainer. Introduction ultrasound urinary tract in radiol dept. |
Wed 11th afternoon |
1 x (transvesical) prostatectomy was cancelled b/o hypertension. Tutorial with trainees on emergency issues. Joint discussion on the standard procedure orders |
Thur 12th morning |
ward round male ward checking postop patients. One patient was cancelled b/o signs of UTI. Tutorial on urethral stricture disease and another session on US handson training. |
Thur 12th afternoon |
evaluation |
Fri 13th morning |
programm cancelled b/o lack of patients |
Evaluation |
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For programm reasons the CO’s of Mchinji and Dedza were combined in the 5th week. |
Preparation |
very good |
The Dedza DH management had prepared the CA prostatectomy training well allowing daily surgery and providing all necessary material. The Introduction of this new procedure was wellcomed by theatre staff, anaesthesists and male ward staff with enthusiasm and interest. |
Patients selection |
very good: 12 patients selected, most had good indications and were fit for surgery. Unfortunately the rains (?) prevented some of the booked patients from showing up. |
Hospital |
Up to date prostectomies are not done in Dedza nor in Mchinji DH. |
CA trainees |
The surgical skill of these CA trainees varies and reflects talent, experience and the extent of exposure to major abdominal / pelvic procedures. In Mchinji DH hysterectomies and laparotomies are done, not in Dedza DH. However, all trainees absorbed all new information with interest and young as they are were very eager to be instructed in doing prostatectomies. The importance of intensive postoperative care in prostatectomy patients was underlined. |
Blood |
MBTS, local donors |
Ultrasound |
yes, routinely used in uro pts |
Procedures done |
5 |
Prostatectomy faesible |
+/- yes |
Needs |
large-size hematuria catheters ch22-24 |
These young trainees are eager and enthousiastic enough to assist each other in doing this procedure. No information on Mchinji DH organisation. Short term follow-up by a visiting surgeon is necessary. |
NKHOTA KOTA DISTRICT HOSPITAL
Dates |
16 - 20 Feb 2015 |
Subjects covered |
BPH prostatectomy surgical techniques and postop management |
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Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis. |
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Lectures on urinary retention, SP catheter placement, BPH, emergency issues in urology, bladder ca, prostate ca. |
Trainees Cost Africa |
Mrs Chimwemwe Mojeza Kana CO Nkhota Kota DH Mr Gideon Nyasulu CO Nkhota Kota DH Mr Francisco Nkhoma CO Dowa DH Mr Maxwell Yambeni CO Dowa DH |
Others attending |
nurses male ward |
People met |
Dr Sosten Lankhulani DHO Mr Noel Ng’oma anaesth CO Mr Limbani Luwe anaesth CO |
Programm |
|
Mon 16th morning |
Wellcome by CA trainees, meeting theatre staff, anaesth CO’s and male ward staff. Review of 11 selected patients, 8 cancelled b/o HT, anemia, U stricture or aspecific symptoms |
Mon 16th afternoon |
surgery cancelled b/o incomplete preop work-up candidates Tutorial on BPH management, urinary retention and on prostatectomy techniques - postop care / irrigation |
Tue 17th morning |
8.00 am wellcome at handover followed by lecture to male ward nursing staff on postop care / irrigation. 1 x transvesical prostatectomy by trainer + Chimwemwe / Francisco 1 x transvesical prostatectomy by trainer + Gideon / Maxwell |
Tue 17th afternoon |
no surgery b/o lack of anaesthetic staff tutorial on urological cancers and 1 |
Wed 18th morning |
check on male ward postop patients ; preop review 1 x new patient who was planned for Thu. 1 x transvesical prostatectomy by Francisco / Chimwemwe supervised by trainer. |
Wed 18th afternoon |
surgery was cancelled b/o 3 maternity emergency cases. Tutorial with trainees on emergency issues and urethral stricture disease. |
Thur 19th morning |
ward round male ward checking postop patients. 1 x transvesical prostatectomy by Gideon / Maxwell and trainer standby |
Thur 19th afternoon |
1 x transvesical prostatectomy by Chimwemwe /Gideon and trainer standby. Programme evaluation |
Fri 20th morning |
ward round male ward checking postop patients and bedside handover to non CA clinical officers who will do postop care. |
Evaluation |
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For programm reasons the CO’s of Nkhota Kota and Dowa DH were combined in the 6th week. |
Preparation |
patient selection and hospital preperation could be better |
The Dedza DH management had prepared the CA prostatectomy training well allowing daily surgery and providing all necessary material. The Introduction of this new procedure was wellcomed by theatre staff, anaesthesists and male ward staff with enthusiasm and interest. |
Patients selection |
The trainees had selected 12 patients but most of these (eight!) had clear contra-indications or were otherwise not fit for surgery. |
Hospital |
The new (2008) Nkhota Kota DH is perfect looking. However, some essentials were missing like Hb reagent (!), anaesthetic drugs, large-size catheters and bladder syringes. Daily surgery was allowed, the anaesthetic staff was very cooperative and interested and so were the nurses of male ward. Up to date prostectomies are not done in Nkhota Kota DH nor in Dowa DH. |
CA trainees |
The surgical skill of these CA trainees varies and reflects talent, experience and the extent of exposure to major abdominal / pelvic procedures. Major abdominal surgery or hysterectomies are incidently done at Nkhota Kota nor at Dowa DH. There certainly is potential (FN) among these trainees. |
Blood |
MBTS, local donors |
Ultrasound |
yes, routinely used in uro pts |
Procedures done |
5 |
Prostatectomy faesible |
not yet, more training needed. |
OFF NOTE |
it was considered very unfortunate that the postoperative care of the Nkhota Kota patients was necessarely left in hands of non CA clinical officers not involved in the training. Reason fort his was that the CA trainees had to leave for Blantyre to do their exams. There was a proper handover. |
In conclusion, the idea of performing prostatectomies in the District Hopsitals was strongly supported by the CA trainees and all Hospital management / staff. It was generally felt however that 1 week is insufficient for the training of Clinical Officers of variable surgical experience in performing a new surgical technique. The tutorials on various urological subjects, the hands-on introduction on ultrasound of the urological tract and the standard orders of procedure were very much appreciated. The Mulanje, Nsanje and Mangochi District Hospital organisation is good and these CA trainees are to be encouraged to continue doing these procedures. Mwanza and Dedza DH did (very) well and with some hesitance the CA’s trainees of Mwanza, Dedza and Mchinji DH can be trusted to start doing this procedure. There is no information on Mchinji DH organisation. The need of early follow-up by a visiting surgeon was generally felt. Hospitals like Nkhota Kota DH need assistance in the preparation of such a training programme. With additional training the CO’s of Nkhota Kota and Dowa can be expected to perform prostatectomy in future. Any surgical training programme should include adequate time for postoperative care of all operated patients.
Gert J Montagne, Blantyre, 22 February 2015
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