The morbidity and mortality of surgically treated urological patients in a tertiary centre in western Kenya
Author: Musau P, MBChB, Mmed (Surg), MSc (Urol), Moi University, School of medicine P.O. Box 5455-30100, Eldoret-Kenya E
Objective: To determine the morbidity and mortality of surgically treated urological patients at Moi Teaching and Referral Hospital (MTRH) and compare them with those of other tertiary centres.
Design: A five year hospital based, retrospective study reviewing files of patients who underwent surgery for urological problems in MTRH for the period 1st January, 2005 to 31st December, 2009.
Setting: The records department of Moi Teaching and Referral Hospital, a 750 bed capacity hospital in the Western region of Kenya.
Subjects: Four hundred and twenty patients whose files were complete for the sought data.
Main outcome measures: The primary outcome measures were the morbidity and mortality rates. Morbidity was depicted by the postopera-tive complications and hospital length of stay. The secondary outcome measures were patient demography, the type of surgery and the duration of surgery.
Results: The male to female ratio was 13.5:1 with 49% of all the patients being older than 50 years. Seventy-seven patients (18.3%) had co morbid diseases with hypertension (22.5%), diabetes mellitus (14.3%) and Human Immunodeficiency Virus (HIV) infection [7.8%] as the top three conditions. The top three procedures were prostate, urethral and bladder surgeries. The morbidity and mortality rates were 5.5% and 1.2% respectively.
Conclusion: While prostate disease remains the leading urological problem, urethral strictures are significantly higher than in the other reviewed regions. Co morbidities amenable to preoperative interventions and a relatively younger population make our morbidity and mortality rates acceptably low compared to other tertiary centres.
Surgical audit is a prerequisite in the care of patients in that it helps the surgical team to learn from its past and incorporate the experiences into the better care of pa-tients (1). The treatment of particular diseases using available op-tions may be audited to bring out the outcomes of man-agement (2-3) and cost-effectiveness of curative thera-pies (4). Even with the knowledge that an audit of our surgical urological procedures can yield information of benefit to the hospital, country or the greater global village, there is a glaring deficit of this data.
The present study audits the morbidity and mortality of surgically treated urological patients at Moi Teaching and Referral Hospital, a tertiary 750 bed facility in the Western Kenya region that is the training ground for the School of Medicine, Moi University. were retrieved from the Health Records Department and complete files of these patients were examined for data extraction as per a pre-designed data sheet in line with the objectives for the study. The extracted data was assessed for completeness before coding, entry into a spread sheet and transfer into a computer for analysis using Statistical Package for Social Sciences (SPSS) ver-sion 17.0.
The primary outcome measures were the morbidity and mortality rates. Morbidity was depicted by the postop-erative complications and hospital length of stay. The secondary outcome measures were the patient demog-raphy, the type of surgery and the duration of surgery.
Gathered data were analysed in line with the outcome measures for descriptive statistics for central tendencies, spread and correlation. Inferential statistics assumed a 95% confidence interval and a test significance value at ≤0.05.
Materials and Methods
Patients who underwent surgery for urological problems were identified from the theatre registry. Relevant files
Five hundred and one relevant files were retrieved from the records department out of which 420 files found complete for the sought data were analysed. There were 391 males and 29 females, giving a male to female ratio of 13.5:1.The age ranged from six months to 92 years giving a mean ± Standard Deviation of 47.7±24.5 years. The majority (49%) of the patients were older than 50 years (Table 1).
Seventy-seven patients (18.3%) had co morbid diseases with hypertension (22.5%), diabetes mellitus (14.3%) and Human Immunodefiency Virus (HIV) infection [7.8%] as the top three conditions. Presence of co mor-bid diseases was positively correlated with hospital length of stay and outcome of treatment (both p <0.001) but was not significantly correlated with postoperative complications (p=0.123). Prostate surgery accounted for 26.9% of the surgeries with 81 Transurethral Resections of the Prostate (TURPs) and 32 open prostatectomies. There were 72 urethroplasties and 51 diagnostic endo-scopic procedures. The rest are as shown in table 2.
Table 3 shows the significant variables when subjected to both univariate and multivariate analysis for predic-tive values. The duration of surgery ranged from under one hour to over four hours with majority of the procedures (47.9%) being between one and two hours (table 4). The type of surgery was predictive of time taken (p<0.001) with urethroplasties accounting for 51.9% of the procedures lasting longer than 3 hours.
Twenty three patients (5.5%) developed postoperative complications. Wound sepsis and dehiscence accounted for 52.2% of the complications while the rest included clot formations in the urinary bladder, urine retention and urine leak around catheters.
Hospital length of stay ranged from one to sixty-nine days. The majority (43.1%) stayed less than a week while 7.9% stayed longer than 4 weeks. The duration of stay was positively correlated with postoperative complica-tions and presence of co morbidities (both p <0.001). When subjected to multivariate analysis, co morbidity had a greater predictive value than presence of postoper-ative complications for the length of hospital stay (0.003 vs. 0.008)
Five patients died, giving a mortality rate of 1.2%. The death rate among females was 10 times that of males and 80% of all deaths occurred in those with co morbidi-ties. On multivariate analysis, co morbidity had a greater predictive value on outcome than gender (p value 0.001 vs. 0.008).
A surgical audit gives a glimpse into and provides hind-sight based on past surgical experiences. It can help in the formulation of future practices aimed at better surgi-cal care. Urological surgical audits are rare globally and most of the statistics address specific urological proce-dures. This study found that 93.1% of our patients were males. It compares well with Eke and colleagues’ 98.5% (1) and confirms a universal understanding that urology is predominantly a care for males. The majority of these patients fall in the sixth decade and above, suggesting an older population due to prostate disease as the leading urological problem.
As the study ascertained, co morbidities rise with an ag-ing population and as such, it is understandable that up to 18.3% of the study group had co morbid factors. The co morbid disorders seem to vary with regions but are all largely lifestyle based (2-3). HIV was the third co mor-bidity after hypertension and diabetes mellitus and this may point to the significance of HIV in surgical practice in developing countries.
Prostate disease and its treatment remains the lead-ing urological practice with TURP as the gold standard mode of intervention (4-6). The use of open prostatecto-my may be dictated by the prostate size or institutional limitations (1, 2, 7). In the Kenyan setting, it is noted that the 71.7% TURP rate in this study is significantly higher than the only other tertiary institution’s (Kenyatta National Hospital) 19% (2, 8) and could be an indicator of institutional peculiarities that may play a role in pa-tient management. It would be interesting to explore the reasons behind such a major difference in mode of treat-ment even with institutional aspirations towards TURP as the treatment mode of choice.
Post operative complications were a determinant of length of hospital stay. Hampshire and others found the duration of surgery was a determinant of sepsis develop-ment (9) and this can be seen in line with the current finding that surgeries lasting longer than 2 hours led to more postoperative complications. In the study, pre-ex-isting medical conditions were significant determinants of outcome. This is in keeping with studies done else-where (10-11) but our co morbidities that are amenable to preoperative control and a younger population com-pared to the other studies make our morbidity and mor-tality rates acceptably low.
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In keeping with world trends, prostate disease remains the leading urological problem in our setup even though urethral strictures are significantly higher than in the other reviewed regions. Co morbidities amenable to pre-operative interventions and a relatively younger popula-tion make our morbidity and mortality rates acceptably low.
I am grateful to Henry Mwangi for the concerted efforts to retrieve relevant files from the records department against many odds.
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