Table 7 shows the distribution of patients among the various treatment modalities in the emergency period. Essentially the main aim of treatment at this stage was to relieve the retention. The indication for a suprapubic cystotomy was the inability to relieve the urine retention via the urethal route, and when urethral dialatation cannot be carried out immediately.
functional obstructions due to central nervous system disorders; 7(58.3%) were patients who had spinal cord injuries from road traffic accidents, while the other 5(41.7%) were hypertensive patients who had strokes (cerebrovascular accidents). Three of these five patients had palpably enlarged but clinically benign prostates, but were however, managed for their CNS problem since the primary cause of their obstruction was not due to the prostatic disease. These patients were catheterized for a period varying from 2-12 weeks.
TABLE 8: DEFINITIVE TREATMENT MODALITIES
MODALITY FREQUENCY (%)
1. PROSTATECTOMY 45 (31.7)
2 URETHROPLASTY 20 (14.1)
3. ORCHIDECTOMY ALONE 20 (14.1) 4. ORCHIDECTOMY + ANTIANDROGEN 15 (10.6) 5. INDWELLING URETHRAL CATHETER 12 (8.5) 6. ANTIBIOTICS + ANALGESTICS 9 (6.3) 7. ANTIANDROGEN/OR LHRH 6 (4.2) 8. INTERVAL BOUGINAGE 6 (4.2) 9. CLOTH EVACUATION + IUC 4 (2.8)
10. VALVECTOMY 2 (1.4)
11. VESICOLITHOTOMY 1 (0.7)
12. BLADDER NERVE RESECTION 1 (0.7)
13. ANALGESICS 1 (0.7)
(n = 142) (91.6)
LUTO. Clot retention and epidymo-orchitis was seen only in patients that had prostatectomy, 21 out of the 32 anaemic patients also belong to this group.
Three patients who had orchidectomy became psychologically depressed. Six (60.0%) of the 10 wound infections were mainly suprapubic wounds created during the emergency suprapubic catherterization. Microscopy showed growth of mainly skin commensals sensitive to either 3rd generation cephalosporin or a quinolone. Six transurethral catheters were retained in patients who kept their catheter usually >4 weeks. They were removed by over inflating and rupturing the ballons, two patients who had bilateral orchidectomy plus flutamide 250mg 8 hourly developed gynaecomastia within 6-10 weeks of treatment. One patient who had anastomatic and the only patient who had substitutional urethroplasty developed postoperative urethral stenosis. These were managed by interval dialatation, the later patient also developed a urehtrocutaneous fistula when the urethral catheter was removed on 14th postoperative day. The catheter was repassed and left insitu for 14 more days. On rremoval, the fistula had closed.
Postoperative bleeding (4.2%), clot retention (3.5%), anaemia (22.5%) was common among prostatectomy patients. Pyuria (9.9%) and urethritis (8.5%) was seen in patients who were catheterized for ≥4 weeks. Most postoperative fevers did not exceed 380c and were considered response to surgical trauma in the absence of any obvious infection.
TABLE 9: FREQUENCY DISTRIBUTION OF COMPLICATIONS RESULTING FROM THE TREATTMENT OF LUTO TYPE OF COMPLICATION FREQUENCY(%)
ANAEMIA 32 (22.5)
POSTOPERATIVE FEVER 30 2(21.1) POSTOPERATIVE COUGH 25 (17.6)
PYURIA 14 (9.9)
URETHRITIS 12 (8.5)
WOUND INFECTIO 10 (7.4) POSTOPERATIVE HEMORRHAGE 6 (4.2) CLOT RETENTION 5 (3.5) EPIDIDYMO-ORCHITIS 4 (2.9)
DEPRESSION 3 (2.1)
GYMAECOMASTIA 2 (1.4) POST OPERATIVE URETHRAL STENOSIS 2 (1.4) URETHROCUTANEOUS FISTULA 1 (0.7)
this patients were referred from other health institutions around the location of UCTH. Typically, these patients were completely unabe to perform their essential investigations from the beginning
TABLE 10: DISTRIBUTION OF PATIENTS LOST TO FOLLOWUP
FREQUENCY (%)
BPH 11(84.6)
HYPOSPADIAS 1(7.6)
BLADDER CALCULUS 1(7.6)
TOTAL = 13(8.4%)
DISCUSSION
A total of seventy thousand, one hundred and thirty nine (70,139) new patients were during the period covered by the study. Of this number, three thousand, six hundred and fifty two patients (3,652) or 5.2% attended the Surgical Out Patient Department (SOPD). Urology unit saw one thousand six hundred and forty two patients (1,642) representing 45.0% of total SOPD attendances and 2.3% of all hospital attendances. A total of one hundred and fifty five patients were diagnosed both in the Accident and Emergency Department and the SOPD as having LUTO. This figure represents 0.22% of the total hospital attendances over the period giving an incidence rate of LUTO in UCTH as 221/105.
One hundred and fifty two patients (98.1%) were males with age ranging from 4-95 years, mean 56.53±17.92, ad three (1.9%) were females whose ages ranged from 15-42 ears with a mean of 27.33±SD13.65. This gives a male: female ratio of approximately 50:1. Making LUTO a predominantly male diseases.These figures indicate that advanced age and sex are pre-disposing factors to LUTO as earlier observed by Tu et al30 and Patel et al76. However, the work of these two teams and that of William53 reveals a critical deficiency of this study: in today’s urological practice, LUTO is not just defined by clinical evidence of obstruction alone but by urodynamic assessment. Findings such as postvoid urine of >200ml or bladder pressure greater than 20cm H2O at the peak of micturation is equally defined as obstruction.30,53,75-77.
In such urological centres/clinics, patients with LUTS are urodynamically assessed, and those found to have large postvoid urine or high intravesical pressure at peak of micturation are classified as having LUTO. The implication of this is that, many men presenting in the early stages of BPH, CaP and stricture were probably being treated for lower urinary tract infections, more so as the screening tests for these diseases are not routinely done for patients with LUTS.
It is thus reasonable or logical for one to say that if these facilities (urodynamics) were to be available, the incidence of LUTO would have been higher than stated in this study.
Ninety nine (63.9%) of the patients in this study were patients in the 6-8th decades of life, and BPH, CaP and strictures accounted for 79.4% of all the cases of LUTO. This agrees with the documented study of Yeboah5 and a previously retrospective data shown in table 2 of cases of LUTO in this centre between 1980-1985. In both data, CaP represented a major aetiological factor (26.5%, Table 2). This is in agreement with reports by other workers; Ukoli22, Roger et al40, Yeboah50 and Alan et al39. In Ekwere’s study 78 56.0% of CaP patients presented with obstructive uropathy. Jackson et al79 reported a higher incidence of CaP among black Americans, and often at a younger age with a more aggressive disease.
to racial differences rather than environmental factors.
The distribution of patients among various aetiological factors in this study, (Table 2) varies significantly from that of Choong’s3 study (one of the most comprehensive study encountered during the literature review). In Choong’s study, BPH accounted for 53.0% versus 36.1% CaP, was 7.0% versus 26.5% and functional obstructions from neurological disease of the CNS was 2.0% versus 7.7% in this study. These variations in patients distribution is quite understandable; Choong’s study was on acute lower urinary tract obstruction while this study is a combination of all the three basic types; acute, chronic and acute-on-chronic.
The comparison between the current and the previous 1980-1985 study as shown on Table 2 indicates that there is a six-fold increase in CaP which agrees with report from many centres that the incidence of CaP is on the increase worldwide including Nigeria which was previously considered a low incidence area20,23,39,50,78.
Table 6 shows the various investigations done. Ninety seven patients (62.6%) did PSA (BPH patients 56, CaP 41) and in 67.6% of BPH patient, the PSA was found to be more than 4.0ng/ml, the upper limit of te universally quoted normal,43,44,47 with the mean PSA for BPH being 17.90±21.3. This high PSA in elderly patients has been noted by Ukoli et al22 who screened men in a rural
out that the mean PSA in the elderly was 13.75(4.45). In western societies, these elderly patients in Ukoli’s study will be subject to further tests such as transrectal ultrasonography and ultrasound guided biopsy of the prostate, creating a state of anxiety in these patients.
In this study, the chi-square and the p-value of PSA were calculated at two levels: 0-20ng/ml and at >20ng/ml. At 0-20ng/ml these values were 1.06 and 0.302 while at >20ng/ml they were 5.80 and 0.016, p-value being statistically significant. The significant of this finding on a wider dimension cannot be substantiated by this study but at least it shows that many patients in this study with being prostatic disease secreted a higher amount of PSA making the call by Iya et al80 for a population specific reference range of PSA for African men very appropriate and urgent.
Of the 97 patients who had BPH and CaP, 94 had digitally guided biopsy based on suspicious findings on DRE and PSA levels. The practice of multiple biopsies suggested by Mohammed et al20 and Figueiredo et al54 was adopted.
Forty one cases of CaP were diagnosed in patients who had earlier been suspected based on findings of DRE and PSA level. This high degree of clinico-pathologic correlation is probably because most of these patients presented at an advanced state of the disease. In those patients whom acid phosphatase was requested for and performed and it was found to be raised in most of the cases of advanced CaP. The phenomenon of raised acid phosphatase in patients with
acid phosphatase as an assessment of patients with CaP almost irrelevant. As it will normally not rise in early disease except in diseases that are clinically advanced often with mestatases to the bones40,78
Two previously non-diabetic patients were found to have high blood sugar level from the result of fasting blood sugar (FBS). This finding makes the suggestion by Badoe41 that a FBS should be done for elderly patients who are likely to undergo surgery relevant in view of the high morbidity/mortality that may result from operating on a patient with undetected diabetes.
The explanation for this asymptomatic hyperglycaemia in elderly patients according to Ganong15 is that, physiologically elderly patients have a higher transport maximum (Tmax) in the kidneys, such that they could have hyperglycaemia without glycosuria.
The histopathology of all the 45 prostatectomy specimens revealed only one (2.2%) incidental adeno-carcinoma of the prostate. This patient remains clinically stabled throughout the period of the follow-up. This incidence of incidental carcinoma of the prostate as noted in this study is statistically low when compared with figures from multi-centre studies by Jackson79 (11.8%), Magoha81 (80% Lagos, and 79.2% Nairobi) and Mandong82. This wide variation may be related to the total number of specimen processed (few in this study), the number of slides prepared from a single specimen, as well as the experience of
be accounted for by the fact that most of the patients presented at an advanced stage such that the possibility of missing a carcinoma on digitally rectal examination was minimal.
The treatment of the 142 patients who completed this study followed the basic principles recommended by the Suffolk consensus group75 on the management of patients with lower urinary tract obstruction. This guideline requires that a detailed clinical examination be followed by urodynamics assessments and other essential investigations (classified into basic, screening and diagnostic). Men wth BPH could be initially treated with α-blocker or 5α-reductase inhibitor followed by prostatectomy 1-2 weeks later. Another aspect of this guideline is the concept of catheterizing patients and sending them home to be reviewed 24-72 hours later for further assessment. The use of antibiotics prior to catheterization is equally not encouraged.
In this study, urodynamics were not employed because these facilities do not exist in this centre. Also α-blockers, 5α-reductase inhibitors were very difficult to be obtained by patients and so could not be prescribed. Patients in this study presented at a late and complicated state of LUTO with anaemia sepsis or septicaemia, so it was necessary to use antibiotics pre-catheterization and not to send them home because from experience, patients in this environment rarely attend follow-up clinics. However, Choong3 noted a 57.0% decrease in LUTO among men who were on 5α-reductase inhibitor over a 4-year period and a
catheterized and sent home.
Preoperatively, patients were given between 500 to 1000mg of either a quinolone or a 3rd generation cephalosporin plus metronidazole. This regimen probably accounted for the low incidence of wound infection in this study (7.4%
Table 9) judged against the background that many of the operations were on septic patients or were potentially contaminated84 as a result of obstructive uropathy. Awojobi83 used a single dose of intravenous 120mg of gentamycin and 2g of intrarectal metronidazole and noted a 72% reduction in postoperative wound infection. While this regimen is cheap and was effective; our sensitivity pattern, and the fact that many of these elderly patients had renal decompensation, makes the use of high dose gentamycin risky in view of its nephrotoxicity41.
Transurethral resection of the prostate is regarded as a goal standard for the treatment of BPH. It is known to reduce morbidity, mortality and hospital stay by up to 25-30%50-53,85. Also other minimally invasive procedures21,40,50,52,61 in the management of LUTO were not employed in the study due to the lack of such facilities in this centre. However, a recent report by Akporiaye (Baptist Medical Centre Sapele)90 that transurethral vaporization of the prostate is very effective for the treatment of obstructive prostatic diseases with minimal morbidity is encouraging. In many established centres, minimally invasive procedures are of first choice in the treatment of LUTO, because many of these elderly patients often have other co-morbid conditions such as cardiovascular,
CaP was treated with antiandrogens (bicalutamide and flutamide) or luteinizing hormone releasing hormone agonist, goserelin (4.2%), castration (14.1%), and castration plus antiandrogen (10.6%). These are current chemotherapies in the management of advanced CaP39. The choice of any was guided by the patients own wishes after a full explanation of the advantages and disadvantages.
Stilboestrol was used only sparingly for 1-2 weeks often in patients who could not afford their antiandrogen immediately. It was not use routinely because of its recognized cardiovascular effects (myocardial infarction, fluid retention and hypertension)39,70,86. The only long term complication resulting from the treatment of these patients was gynaecomastia in an elderly patient who had castration plus flutamide. Other long term effects like hot flushes, fluid retention, deep vein thrombosis, myocardial infarction, hormone resistance were not noted probably because of the short period of this study.
Of the 20 urethroplasties, 95.0% (19) were anastomotic while one was substitutional using the scrotal skin. Two (1.1%) had post repair stenosis while the patient who had substitutional urethroplasty developed urethrocutaneous fistula on the 14th postoperative day following the removal of the urethral catheter. Aghaji et al67 reported 10.3% and 3.5% respectively of the above complications while Nwofor et al56 reported a 16.7% of restonosis in 12 cases.
These two studies were retrospective covering a period up to 5 years compared to this study. Generally, the complication rate following urethroplasty depends on the experience of the surgeon, the method of urethroplasty
urethroplasty and shorter strictures having lower complication rate21,61,64. To reduce long term complication from substtution urethroplasty, emphasis today is on the use of bladder and buccal mucosa tissues for replacement21,61,64. Only long term followup can tell the rate of recurrence in this study.
Interval dilatation of urethral stricture is a temporal measure21, because apart from creating false passages which can lead to post dialatation haemmorrhage, it has a higher recurrence rate, Attah et al65 observed a 65.0% recurrent rate in less than 2 years. Interval dialation in this study was offered to patients who could not immediately afford the cost of their surgery.
In the absence of a paediatric resectoscope valvectomy was done using a modified catheter method. This involves creating a sizable knot at the tip of a nasogastric tube passed via a suprapubic cystotomy. The tube was then pulled antegradely to engage the valves with the knot which were then avulsed. Two patients were treated with this method (Table 8) and the immediate postoperative period was uneventful with good voiding. However, only long term follow-up and randomized clinical trial will appraise this method. Indwelling urethral catheterization was passed on 12 patients who had functional obstructions and hypertension related strokes. The standard management of this patients ought to be intermittent self catheterization3,75. This was however not practiced because of the fear of possible self contamination and the induction of septicaemia.
favourably with those noted in previous studies 50, 67, 83, 87-89. For example Aghaji recorded a 3.5% urethral fistula and 10.4% restructure in about a hundred patients following urethroplasty, while Awojobi did not record any incidence of wound infection, clot retention, nor epididymo-orchitis from 18 prostatectomies.
The possible reasons are that many of these studies were retrospective and long term, or only dealt with a specific aetiological aspect of LUTO. Seven (4.9%) mortalities were recorded. Six of them had central nervous system diseases and died due to CNS related complications rather than from the direct effect of LUTO. Only one of these patients (0.6 %) died from severe haemorrhage due to BPH can be attributable to LUTO, making the mortality rate in this study very low judged against the background of our environment, the perculiar nature of our patients and the associated complications and co-morbidities.
In conclusion, I will say that the incidence of LUTO in UCTH is high (221/105) and is most likely to increase as more people live long enough to enter the 6th to the 8th decades of life. The clinical manpower appeared adequate but the basic facilities are still lacking.
A few observations made during the course of this study will now be put forward as suggestions to enable the urology unit and the hospital authority plan ahead for effective and efficient management of LUTO in the future.
I. The medical management of Cap in this study involves the use of flutamide, bicalutamide, goserelin and occasionally stilboestrol. These are
have recommend the policy of 1st and 2nd line drugs, pulsatile chemotherapy and an initial orchidectomoy alone, to avoid multiple wide spread hormone resistant. These strategies are worth considering in this centre to avoid uncontrolled and wide spread drug resistance cancers.
II. The policy of catheterizing and sending a patient home to be reviewed within 48-72hrs for further investigation on an out patient basis suggested by choong et al36 is worth trying on a selective basis. The advantages is that it will avoid the prolonged admission following relieve of obstruction, make for effective usee of hospital beds, and prevent patients from acquiring hospital microflora that are multi-resistant to antimicrobials.
III. The urology unit saw 2.3% of 70,139 hospital attendances, and yet has only one operation day in a week. Even in the best of times, not more than 2-3 major operations can be done in a week. One will suggest that a functional endoscopic theatre, and second theatre slot in a week be allotted to the unit to enhance the efficiency of this unit and hence the speedy disposal of patients.
IV. The medical Records Department urgently needs a reorganization to prevent the frequent misplacement of patients’ folders and essential clinical notes. One way may be the computerization of this department in line with modern information principles.
V. Lower urinary tract obstruction is now largely preventable by the use of finasteride3. However this can only be done if patients present early, at the
period of LUTS. Choong et al noted a 57% reductin of LUTO in men having finasteride over a 4 year period, compared to a matched group having placebo. Finasteride is also currently being investigated as a prophylxis in the prevention of familial CaP91. Also Omega-3 fatty acids which are anticarcinogens are associated with a reduced risk of CaP, while Omega-6 increases the risk of developing CaP92. The role of trace elements like selenium, copper and vitamins A, D and C in the pathogenesis of CaP is still controversial and under investigation 92,93. All these relevant information about the aetiopathogenesis of CaP need to be communicated to the patients during routine clinical work and the general public.
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