Indications, outcome and complications of ureteroscopy, at Gezira Hospital for renal diseases and surgery, Sudan: a seven years ‘experience

Background: Ureteroscopy (rigid and flexible) with irrigating and working channels have expanded the capability of the urologist to diagnose and treat most abnormalities of the upper tracts.Objective: This study was conducted as a part of holistic auditing to the services provided by Gezira Hospital for Renal Disease and Surgery (GHRD&S), and specifically to evaluate ureteroscopy done in GHRD&S with emphasis on the indications, outcome and complications.Methods: Across-sectional- hospital-based study was adopted. All patients who underwent ureteroscopy since the inauguration of the hospital from 2005-2011 were included.Results: The total number of patients satisfying the inclusion criteria was 472 with a mean age of 40.6 years. Male to female ratio was 1.46:1. The mean hospital stay was 2.74 days.The commonest indication for ureteroscopy was ureteric stone amounting (74%) to a tangible share of ureteric stenting or removal as indication were found in (56.8%) . and therapeutic ureteroscopy for (92.3%). Ureteric stricture was not uncommon (24%). The success rate of therapeutic ureteroscopy was (93.7%) with definite correlation to the site of pathology been (91.75%), (92.3 %) and (87.5%) for the lower, mid and upper ureter respectively. The complications recorded were bleeding (3.3%), penetration (2.5 %), post-operative colic (13%) and infection (0.4%). Mortality rate was zeroConclusion: Because the experience of ureteroscopy in GHRD&S was auspiced by regular training from the SIU the outcome is really comparable to the literature.Keywords: Ureteroscopy, Gezira Hospital for Renal Disease and Surgery, Wad Medani, Success and safet

CHOLEDOCHAL CYST DIAGNOSTIC AND OPERATIVE CHALLENGE

The variations in the morphological characteristics of the extra-hepatic biliary system are numerous. It has been stated that the extra-hepatic biliary system has more anomalies in one cubic centimeter of the space around the region of the cystic duct than any other part of the body (1,2). The incidence of congenital anomalies of the extra-hepatic biliary system varies between 0.58% and 47.2% (3).One such rare anomaly is Choledochal cyst ( CDC), also known as congenital common bile duct cyst (BDC), is a rare type of bile duct cyst of uncertain origin. The majority of cases reported are young women and children of Asian descent. In North America, its incidence is estimated to be 1/150 000(2), but it is increasing in Western adults. The most common symptoms of CDC are abdominal pain, jaundice and abdominal mass.(4

Urine Cytology for Detection of Bladder Carcinoma: Experience of Gezira Hospital for Renal Disease and Surgery(GHRDS)

Background: Urine cytology has been and remains the standard in the initial evaluation of lower urinary tract lesions to rule out bladder cancer. Objectives:  To evaluate the significance of urine cytology as a diagnostic tool for bladder cancer and a to assess the cytological pattern in voided and washed urine. Methodology: This was a cross-sectional descriptive hospital-based study. A total of 43 patients who were suspected to have bladder tumors based on both clinical and radiological findings. Pre-cystoscopy voided urine specimens and post-cystoscopy bladder wash specimens were collected. Three stains were used in preparation of cytological smears Hematoxylin / Eosin, Diff-Quik and May-Grünwald Giemsa, whenever possible equivalent histopathological diagnosis was obtained. Results: This study included 86 urine cytology specimens obtained from a total of 43 cases of suspected bladder cancer. Muscle invasive cases had the higher percentage (37.2%) with more prominent features of malignancy in cytology than the earliest stages. In 30.2% of voided urine specimens were excellent, while 79.1% of bladder wash specimens had excellent quality with more cellularity and preservation of cells in cytological smears. Conclusion: Urine cytology is a reliable method in the diagnosis of bladder cancer. The quality of washed urine is better than voided urine in cytological results

Surgical Complications of Arteriovenous Fistula as Permanent Vascular Access in Patients with End Stage Renal Disease at Gezira Hospital for Renal Disease and Surgery. Revisited

Background: Vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. Objectives: To evaluate the surgical complications of AV fistula as permanent vascular access in a patient of end stage renal disease (ESRDS) at Gezira hospital for renal diseases and surgery (GHRDS). Methods: Retrospective, prospective cross sectional hospital based study, done in 237 patients with end stage renal disease who underwent arteriovenous fistula.In 206 patients of the study sample done retrospectively and 31 patients of the study sample done prospectively,and they were followed for 1year. Study was conducted from September 2010 to September 2016. Data was collected using questionnaire.  Results: Sixty eight percent of study sample were males, with 42% above 50 years and 0.8% less than 10 years. Most of the patients (52.3%) were diagnosed as ESRD from the first presentation, 43.5% were diagnosed as chronic renal failure (CRF) on regular followup, while the minor rest of the patients were due to acute renal failure(ARF) which progressed to end stage renal disease.The complications rate was 32.8% (n=82), perioperative complications were 9.3% (n=22) represented as infections 3.8% (n=9), bleeding 3.0% (n=7), stenosis 1.7% (n=4), thrombosis 0.8% (n=2). The late complications were 23.18% (n= 60) the commonest was pseudo aneurysmal 19.4% (n=46) followed by venous HTN 0.8% (n=2) and steal syndrome 0.4%(n=1), skin necrosis 0.4%(n=1), idiopathic stop function 2.1% (n=5), thrombosis 0.4% (n=1). Conclusion: Permanent arteriovenous fistula is the best option for haemodialysis in patients with end stage renal disease. The commonest complication was puncture site pseudo aneurysm

Quality of life of Sudanese Patients with Benigan Prostatic Hyperplasia. The Oblivious Problem

Background: Although the IPSS and QOL index are universally used, they can only quantify the severity of lower urinary tract symptoms suggestive of benign prostate hyperplasia (BPH) and evaluate treatment efficacy, but cannot fully reflect the overall quality of life. Moreover, because QOL scale depends on the culture background, it is necessary to develop a Sudanese version of the scale. Objective: To evaluate the impact of BPH on the quality of life by assessing the physical, mental and stress states among patients of BPH. Methodology: This study was conducted on 424 patients with BPH in Gezira Hospital for Renal Disease and Surgery (GHRDS), Sudan. The study was cross-sectional, prospective small-scale hospital based study using simple random sampling technique. The subjects were limited to the Sudanese patients, who could hear and answer the questions of the questionnaire independently and that was done for accuracy and privacy. Taking the patient's educational level into account, all items were expressed in spoken language. The data collection tool was a questionnaire which was modified to twelve items from the BPH Quality of Life Index. Results: The majority 386 patients, 91% were physically fit. The pattern of urination was bothering to their daily life of around 320 patients/75.5%, 225 patients/53.1% of patients were worried about the outcome of the disease, 259 patients/61.1% were not concerned of having prostate cancer and 332 patients/78.2% were satisfied with their sleep. The sexual life had been affected in 201 patients/47.4%. The physical state was assessed by the ability of the patient to pray Friday Jomaa at the mosque which was 85.8% and also by attending important Sudanese obliging social activities like condolence which was (91.9%) of the patients. Conclusion: The impact of BPH on quality of life was obviously significant in the three domains; physical, mental and stress state among patients of BPH in GHRD&S.There should be a validated scale for the BPH Quality of Life Index addressing the traditional strata for Sudanese patients.           &nbsp

Primary Fibrosarcoma of the Testicle with Puzzling Post-surgery Presentation: Mimicking Recurrence

Sarcomas of the testis are extremely rare tumors, their incidence being difficult to assess accurately. The authors report a case of a 21-year-old male, presented with painless scrotal swelling that increased in size insidiously within three months. The examination revealed a 10 cm right testicular swelling—hard, not tender and oval in shape. Testicular ultrasound revealed right heterogenous testicular mass. Tumor markers (Human chorionic gonadotrophin (HCG) and alpha fetoprotein) were normal. CT chest and abdomen were normal. Radical orchidectomy was done through an inguinal approach. Histopathology showed testicular fibrosarcoma with spindle cells. After one month, the patient noticed reappearance of a swelling in the right hemiscrotum. Right inguinal exploration with massive resection of the recurrent scrotal mass was done. Histopathology revealed inflammatory process dominated by stitch granuloma. In conclusion, the recurrence rate of testicular sarcomas is high following radical orchidectomy, but still there was a place of non-malignant massthat looks like recurrence; it might occur like nonspecific inflammatory mass and stich granuloma

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation.

OBJECTIVES: To provide an accurate, web-based tool for stratifying patients with atrial fibrillation to facilitate decisions on the potential benefits/risks of anticoagulation, based on mortality, stroke and bleeding risks. DESIGN: The new tool was developed, using stepwise regression, for all and then applied to lower risk patients. C-statistics were compared with CHA2DS2-VASc using 30-fold cross-validation to control for overfitting. External validation was undertaken in an independent dataset, Outcome Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). PARTICIPANTS: Data from 39 898 patients enrolled in the prospective GARFIELD-AF registry provided the basis for deriving and validating an integrated risk tool to predict stroke risk, mortality and bleeding risk. RESULTS: The discriminatory value of the GARFIELD-AF risk model was superior to CHA2DS2-VASc for patients with or without anticoagulation. C-statistics (95% CI) for all-cause mortality, ischaemic stroke/systemic embolism and haemorrhagic stroke/major bleeding (treated patients) were: 0.77 (0.76 to 0.78), 0.69 (0.67 to 0.71) and 0.66 (0.62 to 0.69), respectively, for the GARFIELD-AF risk models, and 0.66 (0.64-0.67), 0.64 (0.61-0.66) and 0.64 (0.61-0.68), respectively, for CHA2DS2-VASc (or HAS-BLED for bleeding). In very low to low risk patients (CHA2DS2-VASc 0 or 1 (men) and 1 or 2 (women)), the CHA2DS2-VASc and HAS-BLED (for bleeding) scores offered weak discriminatory value for mortality, stroke/systemic embolism and major bleeding. C-statistics for the GARFIELD-AF risk tool were 0.69 (0.64 to 0.75), 0.65 (0.56 to 0.73) and 0.60 (0.47 to 0.73) for each end point, respectively, versus 0.50 (0.45 to 0.55), 0.59 (0.50 to 0.67) and 0.55 (0.53 to 0.56) for CHA2DS2-VASc (or HAS-BLED for bleeding). Upon validation in the ORBIT-AF population, C-statistics showed that the GARFIELD-AF risk tool was effective for predicting 1-year all-cause mortality using the full and simplified model for all-cause mortality: C-statistics 0.75 (0.73 to 0.77) and 0.75 (0.73 to 0.77), respectively, and for predicting for any stroke or systemic embolism over 1 year, C-statistics 0.68 (0.62 to 0.74). CONCLUSIONS: Performance of the GARFIELD-AF risk tool was superior to CHA2DS2-VASc in predicting stroke and mortality and superior to HAS-BLED for bleeding, overall and in lower risk patients. The GARFIELD-AF tool has the potential for incorporation in routine electronic systems, and for the first time, permits simultaneous evaluation of ischaemic stroke, mortality and bleeding risks. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier for GARFIELD-AF (NCT01090362) and for ORBIT-AF (NCT01165710)