The role of international partnerships in improving urethral reconstruction in low- and middle-income countries

As of 2010, the Global Burden of Disease (GBD) project estimated that benign urologic conditions accounted for 13.5 million disability-adjusted life years (DALYs) [1‐3]. As the global burden of disease comprises a growing proportion of cases that require surgical care, the number of surgical mission trips has grown significantly [1]. Urethral strictures comprise one such disease that has been increasing in relation to trauma in low- and middle-income countries (LMICs) and requires dedicated urological care [4, 5]. The development of in-country permanent surgical centers in many parts of the world is leading to a paradigm shift where sustainability and local capacity building are increasingly more important than having visiting surgeons perform high-volume, short-duration surgical trips [6]. The task of focusing more on strengthening health systems is a daunting one made even more difficult by the lack of local health data and poor record collection systems in many LMICs [7]. As a result, urologic care in many parts of the world is still delivered in archaic forms that have historically high rates of morbidity and mortality [8]. While the most well-intentioned foreign surgeons attempt to address this surgical gap, the importance of data collection, outcome tracking, and quality of care has been neglected. We believe that the most sustainable approach to urethral stricture care and surgery in general in LMICs is a comprehensive one which includes:

Without all of the above factors, a surgical program lacks accountability and is unlikely to lead to lasting improvements in care.

This study employed both qualitative and quantitative methods, and was approved by the local hospital ethics board and the IRB at the University of Washington. The Hôpital General de Grand Yoff (HOGGY) in Dakar, Senegal is a major referral center in West Africa and was chosen as the site of study based on their 10-year relationship with IVUmed and hospital record keeping system which allowed for a retrospective review of data going back 11 years.

The relationship between IVUmed providers and the local urologists at the HOGGY was observed during a male reconstructive workshop in July 2017. This was the fifth dedicated male reconstructive workshop held since August 2013. Once the IVUmed team left, the host urologist was observed doing a variety of stricture repairs independently. Attention was paid to whether the teaching points from the workshop were being employed, and whether the technical skills employed during surgery seemed to have changed after the workshop.

Informal interviews were conducted with visiting urologists in attendance at the workshops to gain insight into the perceived value of the workshops and how or if they shape their practices. We did not include these qualitative results in our manuscript; however, it informed our understanding of how the program worked and helped contextualize our findings.

A retrospective review was performed on all urological surgical cases performed between January 1st 2006 and July 31st 2017 to evaluate the number and types of surgeries performed to treat urethral strictures. Medical records belonging to all patients who underwent urethroplasty were then reviewed for data extraction on demographics, etiology, prior treatments, stricture characteristics, diagnostic workup, surgical technique used, postoperative course, and whether or not IVUmed was involved. Outcomes were then compared before and after August 2013 when IVUmed’s reconstructive workshops began. Non-operative management was not assessed.

Surgical success was defined as a minimum of 6 months of follow-up over which there was no need for further intervention and the patient reported satisfaction with his urinary symptoms. The 6-month timeframe was used to determine success, because patients were not asked to return for follow-up if they were found to be doing well at their postoperative visit.

Failure was defined by patient report of difficulty urinating, recurrent stricture seen on cystoscopy, or posturethroplasty intervention.

The workshop started with joint evaluation of all scheduled patients by the IVUmed provider and the staff urologist at the HOGGY. Their records were reviewed, and in any case with an inadequate preoperative workup, the IVUmed provider reviewed the necessary components of a complete and relevant workup or tailored the surgical plan accordingly. A total of 20 patients were seen and 7 urethroplasties were performed in 3 days. During surgery, the IVUmed provider guided the staff urologist where necessary and honed in on reconstructive principles that are not typically emphasized in general urology training. The dynamic between the two surgeons was collegial and mutually respectful. Notably, the IVUmed provider made a point of using only the available instruments, so that the skills and techniques being taught could be reproduced after the workshop.

Due to the absence of clinic records, the overall number of patients seeking care at the HOGGY for urethral strictures is unknown. Between January 1st 2006 and July 31st 2017, a total of 774 surgical procedures were performed to treat urethral strictures on 569 patients. Of these procedures, there were 539 direct vision internal urethrotomies (DVIU), 185 urethroplasties, 32 suprapubic tube placements (SPT), and 18 urethral dilations. Procedures performed in the ER and clinic were not captured. Figure 1 shows the types of surgical interventions performed by year.

Over the last 11 years, 115 patients met inclusion criteria for this study, and collectively, they underwent 145 urethroplasties. Table 1 shows demographic information on the 115 patients that were included in this study. Patients’ educational level and socioeconomic status were not noted in the medical records.

Most patients undergoing urethroplasty were young and otherwise healthy. The modal age at the time of surgery was 30. Many patients who presented to the HOGGY had been initially worked up elsewhere and, in most cases, had undergone some prior treatment for their stricture. Table 2 lists the proportion of patients who had undergone some prior surgical treatment for their strictures and describes the nature of the intervention.

Many of the patients who underwent urethroplasty at the HOGGY presented with long, complicated strictures. The most common documented causes of strictures were pelvic fracture urethral injury (PFUI) and infection (26.1% and 24.4%, respectively). Strictures caused by PFUI led primarily to bulbo-membranous strictures (28 of 30), of various lengths (40% < 2 cm, 23% > 2 cm, 37% undocumented length). In most cases, there was no etiology documented in the medical record. The vast majority of strictures were located in the distal urethra (82.6%). A smaller percentage was proximal (13%), and in 4.3% of cases, there was no documentation of stricture location and no accompanying X-rays that could be used to make the determination. Table 3 lists stricture characteristics documented in the medical records.

Excision and primary anastomosis (EPA) was the most common urethroplasty technique used (62% of urethroplasties). Seventeen percent of urethroplasties were performed using a flap or graft and the remaining 21% employed some other or unspecified technique.

The approach to international partnerships that focuses more on training and less on case volumes is relatively new in the global health landscape. Few organizations track or present their data. While there is clearly room for improvement, the fact that urethroplasty outcomes improved after training workshops is all the more reassuring given the small number of procedures that were actually performed by IVUmed providers. Because of the 6 months of follow-up needed to determine success, the cases included in the outcomes analysis encompassed only 3 IVUmed workshops. As there has been no change in the complexity of disease presenting to the HOGGY or the mismanagement by referring providers, the decrease in failure rates suggests that the surgical decision-making and technical skills taught during the workshops may gradually be manifesting through better patient outcomes. As the number of workshops increases and providers gain more experience, we hope to see continued improvement.

These data support the argument that teaching local providers about the principles of reconstructive urology has a more sustainable impact on patient outcomes than simply conducting a high-volume surgical trip. Having said that, the failure rates are still unacceptably high and there are many different factors that may be responsible for this in and outside of the operating room.

We believe, where possible, that it is best to have a dedicated local urologist engaged in multiple workshops until he or she is comfortable not only performing the procedure independently but teaching those techniques to their colleagues and trainees. As a result of this discussion, a provider from the HOGGY has been assigned to assume the role of reconstructionist and will be participating in all subsequent workshops.

There were multiple occasions on which a patient was found to have a worse stricture intra-operatively than was anticipated based on improperly performed X-rays. This sometimes led to an inappropriate surgical technique being applied to certain strictures or surgeons having to perform much more technically challenging procedures than they were prepared for. Based on this experience, the local urologist arranged for a training session for radiologists on how to properly perform the diagnostic X-rays needed for urethral strictures.

We also discussed several non-operative issues that arose from making observations during surgery. Sterile technique was not strictly followed. This was due in part to the paucity and expense of certain ‘single-use’ instruments which were reused multiple times and could not be fully sterilized. Many of the surgical instruments were in poor condition and affect tissue handling adversely.

Postoperative care for urethroplasties requires diligent wound care and the HOGGY did not have specialized wound care supplies for urethroplasties that employ grafts. This certainly could have contributed to the poor success rate of those procedures and the SSI rate. Due to the nature of the health care system and the lack of resources in general, patients are not closely attended to by nursing staff and there are few protections for fresh surgical wounds. This increases the risk of postoperative tissue trauma which can seriously hinder wound healing.

Other factors identified during the study that could contribute to poor patient outcomes and are difficult to address within our framework include late presentation by patients who live in rural areas, mismanagement elsewhere, and high rates of urethritis causing long and complex strictures.

Outcomes for urethroplasty improved significantly after only three surgical workshops that were aimed at improving not only technical skills but knowledge of surgical principles and peri-operative management. In attempting to assess outcomes before and after dedicated training sessions, we aim to take a responsible approach to global health and hope to encourage other groups to do the same. International surgical organizations should focus on empowering local providers and promoting the independent practice of safe surgical care rather than fostering a reliance on visiting surgeons. Creating a set of management guidelines in collaboration with local providers can be an invaluable step forward in this process.