Supplement

Difficulties of surgery in the developing world: a personal view

Commercial cystostomy kits/trocars are not always readily available in regions with insufficient funding. Open suprapubic cystostomy procedures are yet prevalent. This paper presents a simplified percutaneous suprapubic cystostomy technique that utilizes specially selected surgical blades in the place of commercial trocars.

Eighty-nine male patients with acute urinary retention underwent puncturing of the visibly and palpably distended bladder with surgical blade size 20 (7 mm diameter), 21 or 22 (9 mm diameter) to allow resistance-free placement of Foley catheter size 18 Fr (maximum diameter of 6 mm) or size 20 (maximum diameter of 6.7 mm) respectively under local anesthesia along the mid abdominal line in a sagittal direction – two finger breadths above the pubic symphysis. The main outcome measures were to determine the success rate and the encountered complications.

Successful bladder puncture and insertion of the Foley catheter of choice was possible in all cases. There was no mortality and no adjacent visceral injury. There were two cases of catheter blockage with clots that were easily flushed out.

Emergency cystostomy can be safely achieved through direct puncture of the visibly and palpably distended bladder with appropriately selected surgical blades that will subsequently allow resistance-free placement of sizable Foley catheters.

The global burden of surgical disease is estimated as being 11% of the total global burden of disease. In this article we discuss the portion of this burden which could be ameliorated with plastic surgical expertise. Although not necessarily seen as a major player in issues related to global health, plastic surgeons are uniquely qualified to decrease the burden of surgical disease afflicting people in the developing world. Burns, traumatic injuries, and congenital anomalies are some of the areas where the presence of plastic surgical expertise can make a significant difference in patient outcomes and thereby decrease the years of life lost due to disability due to these highly treatable conditions. In light of the severe shortage of plastic surgeons throughout the developing world, it falls to those concentrated in the developed world to harness their skills and address the vast unmet needs of the developing world so as to enhance global health.

To determine whether postoperative bladder irrigation can be safely eliminated in the context of a modification to surgical technique. Post-operative irrigation is routinely used following suprapubic prostatectomy for benign prostatic hyperplasia (BPH).

Single center retrospective study of 82 patients who underwent suprapubic prostatectomy for BPH comparing complications in those treated with irrigation to patients treated with surgical modification and no irrigation. These consecutive patients were divided into 2 groups: group 1 consisted of 43 patients who underwent suprapubic prostatectomy before June 2006 with post operative bladder irrigation and standard method of surgical hemostasis. Group 2 consisted of 39 patients who underwent suprapubic prostatectomy after June 2006 with no post operative irrigation and a modified bladder neck repair performed with the intent of improving hemostasis. The modified bladder neck repair is described.

Patient characteristics and prostate specimen weights are comparable in both groups. Clot retention was more common in the group 1 patients (11 patients in group 1 vs 2 patients in group 2, P = .01), and 2 patients with disruption of the anterior bladder wall closure were in group 1.

Suprapubic prostatectomy can be safely performed without the use of postoperative irrigation. The elimination of postoperative irrigation significantly reduces the economic burden on patients in our locality.

Purpose: To provide recommendations for the implementation of high dose rate (HDR) ¹⁹²Ir brachytherapy technology in developing countries.

Methods: An Advisory Group Meeting of the International Atomic Energy Agency (IAEA) met to address the implementation of HDR ¹⁹²Ir brachytherapy technology in developing countries. These recommendations reflect only the personal opinions of the authors and do not necessarily represent the opinion of the IAEA.

Results: An HDR treatment system should be purchased as a complete unit that includes the ¹⁹²Ir radioactive source, source loading unit, applicators, treatment planning system, and control console. Infrastructure support may require additional or improved buildings and procurement of or access to new imaging facilities. A supportive budget is needed for quarterly source replacement and the annual maintenance necessary to keep the system operational. The radiation oncologist, medical physicist, and technologist should be specially trained before HDR can be introduced. Training for the oncologist and medical physicist is an ongoing process as new techniques or sites of treatment are introduced. Procedures for quality assurance (QA) of patient treatment, and the planning system must be introduced. Emergency procedures with adequate training of all associated personnel must be in place.

Conclusions: The decision to select HDR in preference to alternate methods of brachytherapy is influenced by the ability of the machine to treat a wide variety of clinical sites. In departments with personnel and budgetary resources to support this equipment appropriately, economic advantage becomes evident only if large numbers of patients are treated. Intangible benefits of source safety, personnel safety, and easy adaptation to fluctuating demand for treatments also require consideration when evaluating the need to introduce this treatment system.