Annals of African Medicine

ORIGINAL ARTICLE
Year
: 2012  |  Volume : 11  |  Issue : 3  |  Page : 146--151

Skills acquisition for trainee urologists: Are the Federal Medical Centers in Nigeria suitable?


Abdulwahab Akanbi Ajape1, Mustapha M Kura2, Emmanuel O Ojo2, Ahmed Gadam Ibrahim2, Sunday Kelvin Obiano2,  
1 Division of Urology, Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Surgery, Federal Medical Centre, Gombe, Nigeria

Correspondence Address:
Abdulwahab Akanbi Ajape
P.O. Box 4850, Ilorin. Kwara State
Nigeria

Abstract

Background: Surgical training involves acquisition of knowledge and skills. The district hospitals are known to play complementary role in surgical training in many parts of the world; it is time to evaluate for the possible role Federal Medical Centers (FMC) in Nigeria can play to complement the training of urologists. Against this background, we retrospectively reviewed the relative frequency of urologic procedures performed in one of the FMC as a case study. Materials and Methods: Hospital data were retrospectively reviewed from January 2007 to June 2010 and records of urologic procedures were extracted for analysis. The total numbers of operations done within same period were also recorded. Result: Urological procedures formed 24.6% of the surgical operation in the hospital during the study period. Uncomplicated prepuce, bladder outflow obstruction, uro-oncology and congenital urological lesion topped the list and accounted for 31.3%, 22.7%, 11.9%, and 11.0% of the cases, respectively. The most frequently performed urological operation in the center was circumcision. Nephrectomy, ureteroneocystostomy, pyeloplasty, cystectomy, and urinary diversion were other procedures performed. Conclusion: The varieties and volume of urologic cases recorded in this centre is comparable with those documented in other established training institutions and thus, it is recommended that the trainees should find time to visit some of these centers and acquaint themselves with hands-on surgical exposure.



How to cite this article:
Ajape AA, Kura MM, Ojo EO, Ibrahim AG, Obiano SK. Skills acquisition for trainee urologists: Are the Federal Medical Centers in Nigeria suitable?.Ann Afr Med 2012;11:146-151


How to cite this URL:
Ajape AA, Kura MM, Ojo EO, Ibrahim AG, Obiano SK. Skills acquisition for trainee urologists: Are the Federal Medical Centers in Nigeria suitable?. Ann Afr Med [serial online] 2012 [cited 2020 Nov 24 ];11:146-151
Available from: https://www.annalsafrmed.org/text.asp?2012/11/3/146/96872


Full Text

 Introduction



Surgical training involves not only the acquisition of theoretical basis of clinical practice but also adequate surgical skills in an environment of adequate caseloads and dedicated supervision. [1] The training is believed to be optimal when the number and variety of cases go pari passu a dedicated and appropriate supervision. [2] In keeping with the rapid pace of development in medicine in the rest of the world and in attempts to meet the health needs of a fast-growing population, Nigeria has been making efforts to meet the demand for specialist care through training.

An era of surgical sub-specialization was recently noted in the surgical training in Nigeria and this was not without its merit and limitations (personal communication). One of the major limitations is the inadequate number of fully accredited training institutions with respect to urology training. The perceived surge in the number of trainees, with an average of two new urology-trainees per year in each of the accredited surgical training centers (personal communication), has continuously strained available training institutions, which unfortunately are not being expanded to cope with the present reality. The resultant effect may, in the authors' opinion, affect the quality of the trainee negatively.

The exposure to academic and theoretical basis of clinical urologic practice may perhaps be adequate. However, considering the patients load in relation to the number of trainee and the expected training period, couple with the incessant health workers' strikes, the exposure of the trainees to surgical skill may be insufficient. The expected progressive boost in the trainee's confidence to the point of independence, which is one of the main objectives of the training programme, may be lacking or take longer period to achieve. [1],[2]

Although skill acquisition is a continuous process, [1] the continuity, under a dedicated supervision, is often broken after the exit examination of either the West African College of Surgeons or the National Post graduate College, which are the two colleges that statutorily govern postgraduate medical training in Nigeria and the sub-region, when the trainee is expected to leave the training institution and take appointment somewhere else where his/her responsibilities will include making major final decisions on patients' management.

The Federal Medical Centers (FMC) were established in all states of the federation, where federal university teaching hospital or other federal tertiary health institution is not present, to complement the role of the secondary health institution in the states. A total number of 21 FMC were accredited by the Medical and Dental Council of Nigeria (MDCN) for internship training. Of the 38 West African College of Surgeons-accredited postgraduate surgical training centers in Nigeria only 9 of the FMC were inclusive. Only 15 centers were accredited for urology training and two third of them had partial accreditation for training; among which are 2 of the FMC. [3],[4],[5] In many developed nations, such as Taunton and Readings in England and Drogheda in Ireland, the district hospitals are developed to play a significant complementary role in surgical training. [5],[6],[7] This appeared to be the trend in the past when many teaching hospitals had an outpost where surgical trainees have hands-on and boost their confidence to the point of independence.

With the advent of the FMC in Nigeria it is time to look at the possible role, or otherwise, these FMC could play to complement the skill acquisition by trainees in terms of caseloads and varieties of surgical pathology seen in such centers.

Against this background, we retrospectively review the relative frequency of urologic procedures performed in one of the FMC as a case study.

Setting

The Federal Medical Centre, Gombe (FMCG) is a 288-bed capacity referral hospital in the North-Eastern part of Nigeria serving a population of over two million people. The catchment area extended to the neighboring states of Bauchi, Jigawa, Yobe, and Borno. The department of surgery has partial accreditation for training resident doctors. It is manned by seven consultant surgeons consisting of two general surgeons, two each of plastic and orthopedic surgeons, and a urological surgeon. In addition, there are over half-a-dozen visiting surgeons at different times round the year. There are presently about a dozen of surgical trainees at different levels of their respective training.

 Materials and Methods



Patients' data were retrospectively reviewed from January 2007 to June 2010. Data were retrieved from the hospital data base. The urologic procedures/operations records were extracted and the patients' age, sex, diagnosis and operations were analyzed using SPSS version 14.0. The total number of operation done within the same period was also recorded.

 Results



There were 2848 procedures carried out during the period under review. Of these operations, 706 (24.8%) were urologic procedures. The gender distribution was in a ratio of 1:15 and in favor of the male gender. The ages ranged from 10 days to 90 years and the age group distribution is as shown in [Table 1]. {Table 1}

There were variety of urological diseases seen; the uncomplicated intact neonatal or childhood prepuce, bladder outflow obstruction, uro-oncology, and congenital urological lesion topped the list, these accounted for 31.3%, 22.7%, 11.9%, and 11.0% of the cases, respectively [Table 2]. {Table 2}

The pediatric patients (age 15 years or less) accounted for a total of 326 (46.2%) of the caseloads. The common diagnoses among the children were expectedly congenital anomalies which are mainly in the form of prepuce related conditions, patent processus vaginalis (PPV) and hypospadias among others [Table 2]. It is noteworthy that the only two cases of pelvi-ureteric junction obstruction (PUJO) presented beyond the pediatric age group.

Benign prostate hypertrophy (BPH), urethral stricture disease (USD), and bladder neck stenosis/stricture (BNS) were the major causes of bladder outflow obstruction (BOO) in the adult population and accounted for 47.5%, 43.8%, and 6.9%, respectively of the causes of BOO. All cases of BOO in the pediatric age were caused by posterior urethral valve except one case of urethral stricture. Genito-urinary trauma constituted 1.3% of the caseloads and more than on half of them involved the urethra. Urolithiasis was another common urological diagnosis at the center and these were twice as common in the upper urinary tract as compared with the lower urinary tract.

Uro-genital cancer accounted for 11.9% of the total caseload; of these, suspected bladder cancer represented 56% follow closely by cancer of the prostate. The entire malignant lesions seen in the pediatric age within the study period were wilm's tumor [Table 2].

Of the nine patients with urinary fistula, eight were in the pediatric age group, including those with obstetric fistula, this could be explained by the fact that many of them may not actually know their exact age. Four of the patients with urinary fistula (44.4%) developed urethra-cutaneous fistula (UCF) following hypospadias repair; there was one each of congenital UCF, uretero-vaginal fistula (UVF), and vesico-cutaneous fistula (VCF).

The most frequently performed urological operation in the center was circumcision, it accounted for 32.9% of the total caseloads [Table 3]. Other operations were open prostatectomy, urethrocystoscopy, herniotomy, and urethroplasty. Other major urological procedures performed included nephrectomy, ureteroneocystostomy, pyeloplasty, cystectomy and urinary diversion, partial cystectomy, partial penectomy, and various open stone surgeries.{Table 3}

Open prostatectomy was done for 71 (93.4%) of the 76 patients with BPH, the other patients had wedge excision of the bladder neck for fibrotic prostate. Urethroplasty was performed on 31 occasions; these were among the 70 patients with diagnosis of urethral stricture diseases (USD), the other patients with USD either had urethral dilatation or suprapubic cystostomy (SPC) to relieve urinary retention or divert urine away from urethrocutaneous fistula [Table 2] and [Table 3]. Diagnostic urethrocystoscopy was performed on 53 occasions for patients with lower urinary tract symptoms (LUTS), hematuria and suspected bladder carcinoma.

Nephrectomy was performed on 14 out of the 17 occasions for malignant renal disease. Open urinary stone surgeries were undertaken on 50 occasions; it is noteworthy that no ablative surgery was done on account of stone disease. Radical cystectomy with urinary diversion was possible in six of the bladder cancer patients who presented with operable T 3 N 1-2 M x bladder tumor (one of them had in-situ diversion). Urethrectomy and diversion were done for the patient with urethra carcinoma. Orchidectomy was performed on 17 occasions and was indicated for hormone manipulation for locally advanced/metastatic prostate cancer in 15 of the 17 occasions; the remaining indications resulted from complication of neglected torsion of the testes.

The "repair" procedure was used to encompass patients who had repair for bladder injury, epispadias, bladder exstrophy, hypospadias, and fistulae [Table 3].

A majority of those who presented with infertility had testicular biopsy done; however, epididymo-vasostomy was performed on two of those who had features of normal volume obstructive azoospermia. Vasovasostomy was done for a patient with iatrogenic injury to the spermatic cord.

 Discussion



Urology has been an evolving specialty since the time of Hippocrates; this evolution has become established in the latter half of the 20th century but the essential facilities, such as interventional uro-radiology, endo-urology and uro-laparoscopy facilities, for such modern urological practice are lacking in Nigeria. [8],[9],[10] This study has shown that the caseloads encountered in the FMCG are similar, in both quantum and variety, with findings from established urology training centers in Nigeria. [9],[10]

The most commonly performed major urological operation was open prostatectomy in 10.1% of the caseloads which was closely followed by urethroplasty for urethral stricture. These findings agreed with report from other centers. [9],[10],[11] About 10.8% of the urological procedures involved the upper urinary tracts in the present review and this was majorly accounted for by the burden of urolithiasis and ureteric stricture probably from schistosomal infestation which was believed to be endemic in this region. [12]

It was noted that pediatric urological procedures were equally remarkable; it constituted 46.2% of the caseloads. Circumcisions were high on the list of pediatric caseloads; however, reconstructive procedures of many congenital anomalies were equally done. This is particularly important because many of the training centers are competing with the pediatric surgeons for pediatric urological procedures and this limit the exposure of the trainees to the bulk of their training requirement and subsequent practice. The preponderance of urological procedure in male was also noted in the study and several reasons have been adduced for similar findings in earlier reports. [9],[10],[11]

The common denominator in all the procedures was that they were of sizeable number relative to the report from other teaching hospitals where training was already established. Thus, it will be beneficial for trainees to visit such similar centers across the country to sharpen their acquired skills before exiting from the training programme. During such a "teaching practice," the trainees should be able to boost their surgical skill and confidence in decision making since the usual "tension" and the psychological effect that is often associated with the presence of the trainers and other trainees will be eliminated. In addition, the competition for performing procedure among the trainee will be less compared to the established centers.

With an average of 4.2 urology-cases per week, and a tendency of actually increasing this volume whenever a visiting urologist or a specialist resident (urology senior registrar) is around, the FMCG and the other FMC should be able to complement the training of the urology trainee in acquiring and boosting their surgical skill. Aside from boosting their respective surgical skill, the trainee would have provided services to the respective FMC, they will interact with the other residents and/or medical officers, nurse anesthetist, and perioperative nurses, thereby correcting their misconception, if any, and also learn from them.

The FMC provide a good spectrum and volume of pathologies essential for core urologic training. It is therefore recommended that the surgical trainees should avail themselves of the rare opportunities available in the FMC in terms of ample patients' load in an environment devoid of the stiff competition for hands-on surgeries that characterizes established training centers. Trainees should therefore find time to visit some of these centers especially during their annual leave. Better still, both the National postgraduate and the West African College of Surgeons could incorporate this form of exposure to the curriculum of their training. Since the Federal government of Nigeria is involved in the training programme, a policy could also be formulated to encourage such visit before exiting from the training programme; this, the authors believe, will bridge the gap between the fairly qualitative medical services available in the urban centers where the established training institutes are located as compared with the rural places where many of the FMC are located.

 Conclusion



The varieties and volume of urologic cases recorded in this center is comparable with those documented in other established training institutions and thus, it is recommended that the trainees should find time to visit some of these centers and acquaint themselves with hands-on surgical exposure.

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