Post-Circumcision Urethro-Cutaneous Fistula: The Key to Successful Reconstruction.

Background: Routine circumcision of boys is a common practice in Tanzania. Because sometimes it is performed by persons with no surgical training, complications, including urethro-cutaneous fistula (UCF), are not uncommon.Methods: Five boys whose ages ranged between 4 and 12 years with UCF were seen at four Dar es Salaam hospitals between 2002 and 2005. Personal particulars, the personnel doing the circumcision, description of the repair and follow up were recorded on a data sheet. Intravenous Augmentin was given at induction of anaesthesia for the fistula repair. A urethral catheter was inserted, and then a tourniquet was applied at the base of the penis. After incision and development of skin flaps the urethra was closed, a layer of dartos fascia interposed, followed by closure of the skin, all with 6/0 Vicryl. A compression dressing was applied, and the catheter was left in for 5-7 days.Results: The boys ranged in age between 5 and 12 years, and had undergone circumcision at age 2 to 12 years. All patients were circumcised by paramedical personnel or a traditional practitioner. Urine leakage commenced 2 days to 2 weeks after circumcision. Four boys had coronal while one had a glandular UCF. No post repair complication was reported after follow up of 3 to 20 weeks.Conclusion: Use of fine synthetic absorbable sutures and careful closure of the fistula with interposition of a pedicles dartos graft, are the main prerequisites for success. Attention to details of surgical technique can produce consistently good results in repair of UCF

Prevalence and clinical presentation of HIV infection among newly hospitalised surgical patients at Muhimbili National Hospital, Dar Es Salaam, Tanzania

Background: In Tanzania information is lacking on the prevalence of HIV infection in surgical patients in tertiary care facilities, in whom there are many points of special interest. Objective: To determine the prevalence of HIV infection and associated clinical and demographic features among hospitalised surgical patients at Muhimbili National Hospital (MNH). Setting: Muhimbili National Hospital. Materials and Methods: Consecutive newly admitted patients were tested for HIV antibodies after pre-test counselling. Sera were tested using a dual ELISA algorithm. The data were analysed to determine the prevalence of HIV infection and relationships of serostatus with clinical and socio-demographic characteristics. Results: Of 1,534 patients admitted during the study, 1,031(67.2%) consented to HIV testing following pre-test counselling. The prevalence of AlDS-related clinical features in patients who declined to be HIV tested was similar to that of seronegative patients, but significantly lower than that of seropositive patients. The overall age-adjusted HIV prevalence was 10.5% (95% Cl=9.9-14.0). The highest age-specific HIV prevalence was in the age group 35-44 years at 27.9%. No one was infected in the age group 0-4 years (n=111). Differences in prevalence between age groups were statistically significant (

Treatment Options and Outcomes of Urethral Stricture in Dar Es Salaam,Tanzania. Have we utilized all the Options?

Background: The historical management of urethral strictures constituted regular dilations of the scar tissue but this inevitably failed for long strictures or subjected to secondary trauma, ischemia, scarring and further reduction of luminal caliber. A urethral stricture would best be managed bytaking into account its etiology, site, length and caliber as well as applying the right procedure. Length, patient’s age and co morbid factors play significant roles in the choice of treatment. Therefore this study was set to document treatment options and early treatment outcomes of urethralstricture among patients seeking urological services in Dar es Salaam.Methodology: This was a hospital based descriptive, prospective study which involved all patients presenting to urology clinics confirmed to have urethral strictures during the period of study from March 2011 to December2011.Results: A total of 111 patients with urethral strictures were recruited into the study, all were male with age range of 10 – 97 years with a mean of 52.7. DVU was the most performed procedure accounting for 73 (65.8%) of all patients followed by primary urethroplasty at 31 (27.9%) and multistage urethroplasty at 7 (6.3%). DVU was the commonest procedure in all age groups.Conclusions: Three treatment options of urethral stricture DVIU, primary urethroplasty, multistage urethroplasty including clean intermittent catheterization (cic) were adopted as modes of treatment of patients with urethral stricture seeking urological services at Muhimbili National hospital and Tumaini hospital in Dar es Salaam, DVIU being the commonest mode treatment. Primary urethroplasty and DVIU had better treatment outcome during the follow up of 3months.Key words: Treatment options, urethral stricture, outcome

Elective Abdominal Ultrasonography by Surgeons at MNH, Dar-Es-Salaam, Tanzania.

Background: Ultrasound scanning (USS) is an important diagnostic tool in most specialties of surgery. The abdomen is the most commonly scanned region and learning and practicing abdominal USS is the most rewarding. This study was aimed at sharing our experience of elective abdominal ultrasound scanning (USS) done by surgeons at the Department of Surgery, Muhimbili National Hospital (MNH).Methods: This is a retrospective audit of indications and sonographic findings in 1782 elective scannings done over a 42-month period. All scanning was done by surgeons using Aloka SSD 500scanner with a 3.5 MHz probe. Average patient scanning time was 5-10 minutes.Results: The most frequent indications for abdominal ultrasound scanning were abdominal pain (27%), urinary tract symptoms (25%) and abdominal swelling / mass (13%). Overall 47 % of all scanned patients and 58% of those with abdominal pain had normal findings. Of all the patients with abnormal USS findings 42% had abdominal mass. Stone disease was infrequent, seen in 49 (2.7% of all scanned) patients.Conclusion: Pain is the most frequent reason for requesting abdominal ultrasound scanning but it has a low yield of sonographic findings. Scanning for abdominal swelling/mass gave the highest proportion of abnormal findings. USS of a surgical patient done by surgeons expedites diagnostic workup, shortens hospitalization, facilitates biopsy and may help to avoid diagnostic laparotomy

Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa

Rapid Resuscitation with Small Volume Hypertonic Saline Solution for Patients in Traumatic Haemorrhagic Shock

Background: Haemorrhagic shock is a major cause of morbidity and mortality worldwide. Trauma and its complications account for one in ten deaths worldwide and are the leading cause of death in those below 45 years of age in developed countries. Survival of the shocked patient is influenced by the speed and efficiency with which resuscitation is carried out. Rapid infusion of a small volume of 7.5% hypertonic saline (HSS) has been shown to result in immediate restoration of circulating volume and tissue perfusion but results of investigation of its use remain inconclusive. The objective of this study was to determine the clinical outcomes of infusing locally made 7.5% HSS in patients with haemorrhagic shock.Methods: During a six-month period, all adult trauma patients coming to the casualty with haemorrhagic shock were enrolled into the study. A detailed clinical assessment was performed, and respiratory and cardiovascular vital signs were recorded. Five millilitres of venous blood was drawn for determination of Haematocrit, haemoglobin, serum electrolytes and creatinine. A rapid infusion of 250mls of HSS was given intravenously followed three to five minutes later by recording the vital signs again and drawing another 5 mls of blood for a repeat of the laboratory tests. Recovery from shock was followed by standard fluid infusion. Additional or alternative resuscitation and other therapeutic measures were taken as indicated. Recording of the vital signs was continued at four hourly intervals for 24 hours. The data were entered into a computer data base and analysed.Results: Forty five patients were enrolled and resuscitated with 250 mls 7.5% HSS. Among the studied patients, 88.9% recovered from shock immediately after being infused with 7.5% HSS. Of patients with a single injury, 96.6% recovered from shock whereas only 75% of those with multiple injuries recovered. Eighty percent of patients survived beyond 24 hours post resuscitation. While 93.1% of patients with a single injury survived beyond 24 hours, only 56.3% of those who sustained multiple injuries did so.Conclusion: Rapid resuscitation with HSS has demonstrated clinical benefits in initial treatment of traumatic hemorrhagic shock in patients admitted to the emergency room. Further investigation of the effects of HSS resuscitation is warranted

Teachers\' and Students\' Perceptions of the Learning Environment in Clinical Departments at the School of Medicine, MuhimbilI University College of Health Sciences

Background: The School of Medicine at Muhimbili is the main doctor-training institution in the country. It runs a five-year MD programme taking 200 students annually. As for many schools in low-income countries, the majority of teachers have no formal training in educational theory Objective: To describe the physical and psychosocial learning environment from teachers' and students' perspectives, describe the perceptions of teachers and students of each other, and propose ways of improving the learning environment. Methods: Fourth year students of the 2005 graduating) class and selected clinical teachers took part in a survey to document their perceptions of the school's learning environment, and the perceptions of teachers and students of each other. Structured questionnaires designed by the authors were used for recording the required information from teachers and from students for analysis. Findings: The availability of ward patients suitable for clinical training was considered adequate by 84% of the students. However, less than 50% of students thought the wards, clinics, library and operating rooms provided a conducive learning environment. Only a third of the students said they used the Internet to access learning material. Two thirds of students said it was difficult to access teachers for consultation outside of scheduled classes. While 63% of students said teachers regularly showed them how to elicit physical signs on patients, a modest 58% of students perceived their teachers as professional role models. Only 13% of students felt that teachers avoided intimidating them during clinical teaching. Seventy one per cent of teachers provided feedback to students after clinical assessment, but only 21% of the teachers believed feedback to students should be directed towards identifying students' strengths and reinforcing them rather than seeking their weaknesses for correction. Conclusion: The learning environment at the school has some strengths that should to be amplified, and numerous weaknesses that need to be corrected in order to make the environment more conducive to teaching and learning. Tanzania Medical Journal Vol. 22 (1) 2007: pp. 9-1

Elective abdominal ultrasonography by surgeons at MNH, Dar-Es-Salaam, Tanzania.

Background: Ultrasound scanning (USS) is an important diagnostic tool in most specialties of surgery. The abdomen is the most commonly scanned region and learning and practicing abdominal USS is the most rewarding. This study was aimed at sharing our experience of elective abdominal ultrasound scanning (USS) done by surgeons at the Department of Surgery, Muhimbili National Hospital (MNH). Methods: This is a retrospective audit of indications and sonographic findings in 1782 elective scannings done over a 42-month period. All scanning was done by surgeons using Aloka SSD 500 scanner with a 3.5 MHz probe. Average patient scanning time was 5-10 minutes. Results: The most frequent indications for abdominal ultrasound scanning were abdominal pain (27%), urinary tract symptoms (25%) and abdominal swelling / mass (13%). Overall 47 % of all scanned patients and 58% of those with abdominal pain had normal findings. Of all the patients with abnormal USS findings 42% had abdominal mass. Stone disease was infrequent, seen in 49 (2.7% of all scanned) patients. Conclusion: Pain is the most frequent reason for requesting abdominal ultrasound scanning but it has a low yield of sonographic findings. Scanning for abdominal swelling/mass gave the highest proportion of abnormal findings. USS of a surgical patient done by surgeons expedites diagnostic workup, shortens hospitalization, facilitates biopsy and may help to avoid diagnostic laparotomy

Post-circumcision urethro-cutaneous fistula: the key to successful reconstruction.

Background: Routine circumcision of boys is a common practice in Tanzania. Because sometimes it is performed by persons with no surgical training, complications, including urethro-cutaneous fistula (UCF), are not uncommon. Methods: Five boys whose ages ranged between 4 and 12 years with UCF were seen at four Dar es Salaam hospitals between 2002 and 2005. Personal particulars, the personnel doing the circumcision, description of the repair and follow up were recorded on a data sheet. Intravenous Augmentin was given at induction of anaesthesia for the fistula repair. A urethral catheter was inserted, and then a tourniquet was applied at the base of the penis. After incision and development of skin flaps the urethra was closed, a layer of dartos fascia interposed, followed by closure of the skin, all with 6/0 Vicryl. A compression dressing was applied, and the catheter was left in for 5-7 days. Results: The boys ranged in age between 5 and 12 years, and had undergone circumcision at age 2 to 12 years. All patients were circumcised by paramedical personnel or a traditional practitioner. Urine leakage commenced 2 days to 2 weeks after circumcision. Four boys had coronal while one had a glandular UCF. No post repair complication was reported after follow up of 3 to 20 weeks. Conclusion: Use of fine synthetic absorbable sutures and careful closure of the fistula with interposition of a pedicles dartos graft, are the main prerequisites for success. Attention to details of surgical technique can produce consistently good results in repair of UCF