Urological Endoscopy: Results of the First 15 Months, in Kara (Togo) ()
1. Introduction
The advent of endoscopic techniques has revolutionized the management of urological pathologies, both diagnostically and therapeutically in the world. In our sub-Saharan countries, urological pathologies were treated by open surgery, for a very long time, with high morbidity and mortality and postoperative hospital stay [1]. While hospitals in African capitals are equipped with endoscopic equipment in order to offer the population better care [2] [3], hospitals in other distant cities often lag behind. In Kara, a semi-urban town, located 400 km north of Lomé, the capital of Togo, the urology department of the Kara teaching Hospital was equipped with endoscopic equipment at the beginning of 2021. Before this date, urological pathologies were treated only by open surgery, with high morbidity [1]; endoscopic techniques had never been used. The aim of our study was to report the results of the first 15 months of urological endoscopy practice at the Kara Teaching Hospital.
2. Patients and Methods
This was a retrospective and descriptive study, which took place in the urology department of the Kara Teaching Hospital, from February 2021 to April 2022, i.e. a period of 15 months. The register of operative reports and patient records were used for data collection, including any patient who underwent an endoscopic urological intervention in the urology department of kara teaching hospital, and whose file was usable. The following parameters were studied: age, sex, diagnosis, indication, diagnostic or therapeutic nature of the procedure, and results.
Data processing was done by Word, Excel and the EPI Info statistical software.
3. Results
A total of 102 urological procedures (endoscopic and non-endoscopic) were performed during the study period; of the 102 interventions, 62 were endoscopic urological interventions, i.e. 60.7% of the interventions. The average age of operated was 55.5 years (±16.4) with extremes ranging from 28 to 87 years. Figure 1 shows the number of endoscopic procedures performed per year. Figure 2 shows the distribution of operated patients according to sex. In our study, 40.3% of endoscopic interventions had been performed for prostatic hypertrophy, followed by interventions for the removal of ureteral endoprostheses in 17.7% of cases..
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Figure 1. Distribution of endoscopic procedures by year.
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Figure 2. Distribution of patients according to sex. F: Feminine; M: Male.
Bladder tumours, and ureteral stones come next, with 9.6% of cases each. Table 1 shows the various pathologies diagnosed and which required endoscopic urologic intervention. TURP is the most used endoscopic intervention in our study with 43.5% of cases followed by the removal of JJ probes in 17.4% of cases. Table 2 shows the various indications requiring endoscopic intervention. The endoscopic intervention was performed for diagnostic purposes in 17.4% (11) of cases, and for therapeutic purposes in 82.2% (51) of cases. The various endoscopic interventions resulted in success in 96.7% of cases. About the patients with whom we had failures, it was about two patients who had a lumbar lithiasis, and in whom we had proposed a ureteroscopy. During their treatment, the stone moved up into the kidney; not having a flexible ureteroscope, we had just put in place a JJ probe.
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Table 1. Pathologies requiring endoscopic intervention.
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Table 2. Indications requiring an endoscopic intervention.
4. Discussion
Endoscopy in urology consists of using minimally invasive techniques to explore and treat certain pathologies of the urinary system using optical equipment called an endoscope [2]. Endoscopic procedures are the most performed procedures in urology in the West, with a rate of around 80% [4] [5]. In our sub-Saharan countries, this rate barely exceeds 50% [6] [7] [8]. Difficulties, especially financial, would prevent the acquisition of adequate equipment for carrying out endoscopic interventions. However, at home in Kara, nearly 60% of our interventions were endoscopic in 15 months of endoscopic practice. This difference with our sub-Saharan colleagues could be explained by the fact that the urology department of the Kara Teaching Hospital had endoscopic equipment from the outset, allowing not only diagnostic exploration, but also the therapeutic management of pathologies. many hospitals in black Africa, when acquiring their endoscopic equipment, only had what was necessary for endoscopic exploration (urethrocystoscopy, removal of the JJ probe, etc.). It was only afterwards that equipment was acquired to perform prostate or bladder resections, or even equipment to allow the management of urinary stones by rigid or flexible ureteroscopy [9].
We note in our study that transurethral resection of the prostate (TURP), was the most performed endoscopic intervention in 43.5% of cases. TURP is considered the gold standard in the surgical management of benign prostatic hyperplasia, with a significant reduction in morbidity and mortality and postoperative stay [10] [11]. Halidou in Niger had found at 0.96% in 2022 [2], and Kambou, 8% in 2006 in Burkina Faso [12]. We note that the figures differ depending on the year and the country. Halidou had noticed in his study that few hospitals had a resector; which explained the low performance rate of TURP; as for Kambou, its figures dating from 2006, it is very likely that the rate of realization of TURP is higher today. Prostatic pathology, being also the most encountered in a urology department, it is easy to see that TURP is the most performed intervention in our study. This rate would be even higher in our study if the available resection material allowed TURP to be performed for more than one hour. This constraint forces us to choose only patients whose prostate volume did not exceed 60 to 80 cc for TURP. Patients with a larger prostate volume benefited from a prostatic adenomectomy via the upper route. In the future, we plan to acquire equipment allowing prostatic resection for more than an hour.
Rigid ureteroscopy, for the management of ureteral stones, represented 6.4% of our endoscopic procedures. Preferred to open surgery, it has the advantage of considerably reducing the length of hospital stay. The rate of realization of this endoscopic technique is low in our study, because the diagnosis of ureteral stones is not often made in the department. It should also be noted that some patients treated for renal lithiasis had undergone open surgery, since we do not yet have a flexible ureteroscope. We agree with Niang [13] that the routine practice of ureteroscopy in sub-Saharan Africa remains a challenge for African urologists. When we know that the type of diet plays an important role in the occurrence of urolithiasis on the one hand, and that our diet is more and more modeled on the Western model on the other hand, it is inevitable that we will be increasingly faced with cases of urinary lithiasis. We must therefore fight to have the complete equipment necessary for the management of urolithiasis by endoscopic route.
The success rate of our endoscopic procedures was 96.7%. Halidou had also found a success rate of around 100% [2]. These figures prove that, despite the recent nature of the acquisition of endoscopic equipment, in our African health structures, there are already urologists trained in its use; most acquired this skill during their specialization in certain countries of the sub-region, where urological endoscopy is already highly developed; or during internships in Western hospitals. It would be a shame if, after having acquired such skills, often at the cost of many sacrifices, to lose them for lack of an adequate technical platform; It is therefore urgent that, on the political level, the necessary is done, in order to remedy this situation, which does not help either the urologist who will lose his skills, nor the population who will not benefit from the best care.
5. Conclusion
Urology nowadays cannot be done without endoscopy. At the Kara Teaching Hospital, the results are already promising after less than 24 months of endoscopic practice in urology, with a technology platform that was still incomplete until then. The financial cost of acquiring such equipment prevents many sub-Saharan urologists from being comfortable in their daily desire to give the best possible care to their patients. Advocacy must be made for political decision-makers, so that the situation improves, for the good of both urologists and patients.