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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
  Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis.
  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  
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  
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
  Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis.
  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  
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  
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
  Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis.
  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  
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  
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
  Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis.
  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  
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  
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
  Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis.
  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  
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  
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
  Postoperative irrigation techniques: continuous bladder irrigation, bladder irrigation by forced diuresis.
  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  
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