|Year : 2020 | Volume
| Issue : 2 | Page : 132-135
Overview of paediatric urology practice in lagos state university teaching hospital, Ikeja, Lagos, Nigeria
Abimbola Ayodeji Abolarinwa1, Olufemi O Ojewuyi2, Adaobi U Solarin3
1 Department of Surgery, College of Medicine, Lagos State University, Ikeja, Lagos State, Nigeria
2 Department of Surgery, Ladoke Akintola University Teaching Hospital, Osogbo, Osun State, Nigeria
3 Department of Surgery; Department of Paediatrics, College of Medicine, Lagos State University, Ikeja, Lagos State, Nigeria
|Date of Submission||20-Nov-2019|
|Date of Decision||15-Jan-2019|
|Date of Acceptance||17-Feb-2020|
|Date of Web Publication||11-Apr-2020|
Dr. Abimbola Ayodeji Abolarinwa
Department of Surgery, College of Medicine, Lagos State University, PMB 21266, Ikeja, Lagos State
Source of Support: None, Conflict of Interest: None
Introduction: Paediatric urology is one of the subspecialities of urology, and in most climes, it is practised by the urologists and paediatric surgeons, and likewise in the Lagos State University Teaching Hospital (LASUTH). The urologists see and manage most of these cases in LASUTH. There has been no formal training in this subspeciality. However, both the urologists and paediatric surgeons in LASUTH have acquired some measure of skill and experience over time by virtue of the relatively high volume of the cases seen. This study is aimed at reviewing the practice of paediatric urology in the urology division of LASUTH and to advocate for formal training in an otherwise rare but direly needed subspeciality. Patients and Methods: The ports of entry of paediatric patients with urologic conditions were assessed retrospectively over a 5-year period (2014–2018). The paediatric age range based on the Lagos State Government policy for health care is from birth to 12 years old. The ports of entry included the urologic outpatient department, paediatric and the adult surgical emergency units and the paediatric wards. Patients referred to and managed by the paediatric surgery division were excluded from this study. Results: The total paediatric urology cases seen and managed by the urologist in LASUTH within the period of review were 421. A total of 363 paediatric urology cases were seen during the period under review, making up 7.96% of the urology cases seen at the surgical outpatient department. The most common cases managed were hypospadias, posterior urethral valves and hydronephrosis. A variety of other cases include priapism, circumcision and post-circumcision injuries, urethral prolapse, testicular torsion, cystic renal dysplasia, disorder of sexual differentiation and several others. Three hundred and seven surgical procedures were done in the period of review on 272 (64.6%) patients. Conclusion: There is a need for subspecialisation in paediatric urology to harness more specialists with a specific focus, training and interest in children and their urological conditions.
Keywords: Paediatric, specialisation, urology
|How to cite this article:|
Abolarinwa AA, Ojewuyi OO, Solarin AU. Overview of paediatric urology practice in lagos state university teaching hospital, Ikeja, Lagos, Nigeria. Niger Postgrad Med J 2020;27:132-5
|How to cite this URL:|
Abolarinwa AA, Ojewuyi OO, Solarin AU. Overview of paediatric urology practice in lagos state university teaching hospital, Ikeja, Lagos, Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 May 25];27:132-5. Available from: http://www.npmj.org/text.asp?2020/27/2/132/282316
| Introduction|| |
Paediatric urology is traditionally considered among urologists as the true child of the field of adult urology. It has become a subspeciality practised by paediatric surgeons in some countries, whereas it is still a subject of heated debate in others. In the United States, paediatric urology is fully practised by urologists as they possess sufficient workforce of paediatric urologists. Whereas, in most European countries, the issue of who takes care of the paediatric age group with urological conditions is still a subject of controversy. In some of these countries, who does what, depends on the personalities involved and their level of influence in their various institutions.
In Nigeria, the urologists and the paediatric surgeons practise paediatric urology to varying degrees, depending on the skill and the experience of the surgeon. Only a few have subspecialised.
It is globally accepted that the best paediatric practice has to be exclusive. Mixing children care with adult practice produces unfavourable reports.
The variety of the cases that require expertise include posterior urethral valves, prune belly syndrome, bladder exstrophy/cloaca, proximal hypospadias, ureteric malformations/malfunctions and other complex disorders that clearly demand skill and experience. Common paediatric urologic procedures such as orchidopexy, circumcision and other scrotal pathologies are performed by most surgeons and even non-specialists.
In this review, we sought to look at our experience over the past 5 years and recommend the way forward for the standard practice of paediatric urology in Nigeria.
| Patients and Methods|| |
We retrospectively reviewed the hospital records of patients with urologic conditions from birth to 12 years old over a 5-year period (2014–2018). The paediatric age range based on the Lagos State Government policy for health care is from birth to 12 years old. This group of children are offered subsidised health care at all Lagos state government-owned health facilities. Records from the ports of entry of paediatric patients with urologic conditions were studied. These ports included urology surgical outpatient department, paediatric emergency department and wards and the surgical emergency department. Patients referred to and managed by the paediatric surgeons were excluded from the study.
| Results|| |
The total paediatric urology cases seen and managed by the urologist in Lagos State University Teaching Hospital (LASUTH) within the period of review were 421.
Paediatric urologic conditions seen at the urology outpatient department were 363 cases, which accounted for 7.96% of the total urologic cases seen from this portal of entry during the period of study [Figure 1]. Fifty-nine cases were reviewed based on consults from the paediatric emergency and wards, whereas 13 cases were seen at the surgical emergency department [Table 1].
|Figure 1: Total and paediatric cases from the urology outpatient department|
Click here to view
|Table 1: Paediatric urologic cases that presented via the ports of entry to Lagos State University Teaching Hospital|
Click here to view
Of the total cases, the most common conditions were hypospadias (119; 28.3%), posterior urethral valves (87; 20.7%), hydronephrosis (50; 11.9%), priapism (37; 8.8%) and circumcision injuries (30; 7.1%).
A variety of other cases seen include congenital anomalies such as prune belly syndrome, ectopic kidney and cystic renal dysplasias. Some emergencies such as acute urinary retention, testicular torsions and urogenital traumas were also managed. An interesting case of absence of penile tumescence from birth in a 6yearold boy was also seen, as well as other clinical cases listed [Table 2].
|Table 2: Paediatric urologic cases managed in Lagos State University Teaching Hospital from 2014 to 2018|
Click here to view
Three hundred and seven surgical procedures were done in the period of review on 272 (64.6%) patients. The variety of operative procedures included nephrectomies, pyeloplasties, ureteroneocystostomies, bladder surgeries, corrective external genitalia surgeries, penile and testicular surgeries and lower tract diagnostic endoscopies among others [Table 3]. Others were managed non-operatively, awaiting surgery or were lost to follow-up.
|Table 3: Paediatric urologic cases operated in Lagos State University Teaching Hospital from 2014 to 2018|
Click here to view
| Discussion|| |
The wide gap in paediatric urologic practice between developing and developed world is a major concern. While prenatal detection of severe malformations and foetal surgery has revolutionised the clinical science and practice of these problems substantially in the developed world, we are still grappling with the basics in our environment. Moreover, there are only few facilities fully dedicated to the care of children in Nigeria and most are privately owned with the attendant high cost of care. The aforementioned are the few factors which may have hampered the practice of paediatric urology in our environment. Most prenatal ultrasound scans in our environment still focus on confirmation of cyesis, gestational age and determination of foetal gender, though it suffices to say some of the cases of hydronephrosis seen in our study were detected from prenatal ultrasound scan.
The annual rise in paediatric urology cases seen in our study could be attributed to the introduction of a vibrant paediatric nephrology unit in LASUTH, with direct referral of cases to the urologists. There is also a strong collaboration between the units and the assurance of long-term follow-up of the patients till they outgrow childhood.
In some studies, male neonates requiring circumcision were reported as the most common paediatric urologic condition seen by the general urologist.,, This is in contrast to our findings where hypospadias was the most common case seen. Most circumcisions are done shortly after delivery by trained midwives and younger doctors; hence, it is not a clinical condition that necessarily requires referral to a tertiary centre as LASUTH. In a study by Ikuerowo et al., Mohan's valvotomy was reported as the most common day case paediatric urologic procedure. This is similar to our findings in this study.
While about 90% of the patients from our study had open surgeries, there has been a shift from open procedures to mostly endoscopic procedures in the developed world over the past two decades.
The extent to which paediatric urological procedures should be performed by the general urologists has not been agreed upon, and it is unlikely that this will be resolved in the nearest future. Some have suggested that a general urologist who understands paediatric urology, and can patiently assume the seamless follow-up of children up to puberty, makes a far greater contribution to care than one who performs the occasional complex procedure. In LASUTH, all the urologists are general urologists. Paediatric surgeons also practice paediatric urology. They manage the common groin conditions such as hernias and hydroceles, some hypospadias, epispadias, posterior urethral valves, routine circumcisions and their complications. The paediatric surgery unit also exclusively manage Wilms' tumours and now advocating for community screening. This is the reason why some of these clinical cases were not represented in our data.
We believe neither general urologist nor paediatric surgeons can do adequate justice to paediatric urology in our environment. It requires dedicated training to understand the complexities and the embryology of the urogenital system as well as the variations of neonatal and paediatric pathophysiology.
Nigeria is a densely populated country with a 2019 estimated population of 201,748,560 persons, with a density of 218.4/km. With only about 130 registered urologists as at 2016, and who are mostly general urologists practicing in Nigeria, it may be seen as a luxury to encourage subspecialisation in paediatric urology. More so, the population of children is <10% of the volume of the urologic cases managed as observed in our study in the Urology Outpatient Department in LASUTH. However, this small subset of patients does not erode the value and luxury of having good paediatric urologic health care available. In a nationwide, population-based cohort study by Calderon-Margalit et al. in Israel, it was observed that an increased risk of end-stage renal diseases in adulthood was associated with clinically evident kidney disease in childhood.
Management of these urologic issues in children are likely to be long term, even into adulthood. It is necessary to provide uninterrupted, comprehensive urologic follow-up and health care for paediatric urology patients who will require further urologic care as adults. This is usually done by transitional urologists in the developed world. Post-surgery referral back to paediatric nephrologist is also important in improving long-term outcomes. Fortunately, this privilege is available at LASUTH.
It is, therefore, important that these children are managed by paediatric urologists from onset to improve a better future outcome.
We advocate that subspecialisation of paediatric urology should be encouraged. More investment in special equipment for children and developing centres of excellence that are accessible and affordable will drive further interest in this field.
Our study represents an actual lower figure of the paediatric urology cases seen and managed in LASUTH, as patients managed by the paediatric surgeons were excluded from this study. A future prospective is being considered which would include all children with urologic issues managed in LASUTH, irrespective of the managing team.
| Conclusion|| |
There is a need for establishing a subspeciality in paediatric urology in LASUTH and in Nigeria.
This would involve training, investment in paediatric equipment, collaboration within all specialities involved in the care of these children and will power from the government and society.
The ultimate goal is to establish centres of excellence, fully dedicated to the immediate and long-term care of children with paediatric urologic pathology.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bloom DA. State-of-the section address: American academy of pediatrics, section on urology. The origin of a species: Pediatric urology. J Urol 2003;170:1488-92.
Arul GS, Spicer RD. Where should paediatric surgery be performed? Arch Dis Child 1998;79:65-70.
Rushton HG. Subspecialty certification in pediatric urology. J Urol 2005;173:1845-6.
Dewan P. How to develop the subspecialty of pediatric urology? Indian J Urol 2007;23:387-9.
] [Full text]
Solarin AU, Oladimeji AB, Ikuerowo SO, Abolarinwa AA, Kayode-Awe OM, Nwankpele TO, et al
. Spectrum of congenital anomalies of the kidney and urinary tract as seen at the Lagos state university teaching hospital, Ikeja. Ann Clin Sci 2019;4:1-5.
Takure AO, Shittu OB, Okeke LI, Olapade-Olaopa OE, Adebayo SA. Daycase urology at Ibadan, Nigeria: A ten year review. Pan Afr Med J 2010;6:13.
Ojo EO. Day case surgery and developing countries: A review. Niger J Clin Pract 2010;13:459-66.
] [Full text]
Sowande O, Takure A, Salako A, Badmus T, Olajide A, Banjo O, et al
. Day case urology in a dedicated day case surgery unit in a Nigerian teaching hospital. J Ambul Surg 2009;15:3-11.
Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006;6:21.
Ikuerowo SO, Bioku MJ, Omisanjo OA, Esho JO. Urologic daycase surgery: A five year experience. Niger J Clin Pract 2013;16:28-30.
] [Full text]
Marberger M. Should we be concerned about losing urology territory to other specialties? Indian J Urol 2009;25:221-4.
] [Full text]
Woodhouse CR. Which pediatric urological conditions can be handled by adult urologists? Nat Clin Pract Urol 2005;2:152-3.
Osuoji R, Williams O, Ajai O, Idika OC, Abolarinwa AA, Bankole MA. Wilms' tumour: Experience in a developing tertiary center in Nigeria. East Cent Afr J surg 2011;16:51-7.
Osuoji R, AbdulSalam M, Akinola R. Advocating periodic ultrasound scan screening for early detection of Wilms' tumour in Nigerian children. J Med Clin Stud 2019;2:230-8.
Calderon-Margalit R, Golan E, Twig G, Leiba A, Tzur D, Afek A, et al
. History of Childhood kidney disease and risk of adult end-stage renal disease. N
Engl J Med 2018;378:428-38.
Kovell RC, Skokan AJ, Wood DN. Transitional urology. Urol Clin North Am 2018;45:601-10.
[Table 1], [Table 2], [Table 3]