Urethral Reconstruction and Percutaneous Nephrolithotomy Workshop – March, 2017

Project Haiti Urology:
Urethral Reconstruction and Percutaneous Nephrolithotomy Workshop,
Hopital St. Francois de Sales, Port-au-Prince, Haiti
March 4-11, 2017

Team members:
Henri Lanctin, MD (Watertown, SD)
Frank Burks, MD (Royal Oaks, MI)
Dan Rosenstein, MD (San Francisco, CA)
John Denstedt, MD (London, Ont, Canada)
Bob Marcovich, MD (Miami, FL)
Keegan Maxwell, MD (St. Cloud, MN)
Maxx Gallegos, MD (Reconstructive fellow, Detroit, MI)
Desmond Adamu, MD (Urology resident, Miami, FL)
Will Sikes, CRNA (Plainwell, MI)
Megan Cleland, BN (San Francisco, CA)

The team arrived by air on Mar.4 and checked in to Le Plaza Hotel, near Hopital St. Francois de Sales (HSFDS) in downtown Port-au-Prince. A team dinner/meeting with Haitian urology colleagues was held that evening.

The next day we visited HSFDS, toured the facility and OR’s. Time was spent organizing equipment, meeting staff and seeing pre-op patients.

Drs. Burks and Rosenstein, working with Dr. Santucci’s fellow Dr. Maxx Gallegos performed, taught and proctored a total of 7 urethral reconstruction procedures. 2 were repeat procedures. There were 4 excision and primary anastomosis cases, 1 buccal mucosal graft, and 2 pelvic fracture urethral injuries. Two of the patients were pediatric (7 and 11 years). Application procedure for Peyronies disease was also completed. There were no complications encountered at the time of team departure from Haiti. Average estimated blood loss was 160 cc. With these cases, this team has now taught and performed 69 urethral stricture cases in Haiti. Haitian urologists, particularly Dr. Youry Dreux, continue to improve in their ability to do cases independently. Accordingly, workshops tend to have a higher number of either repeat procedures or a greater level of difficulty.

Concurrent with the reconstruction workshop, in a second room, a total of 16 stone procedures were performed on 11 patients. This was led by Dr. John Denstedt, who on this trip performed the first percutaneous nephrolithotomy (PCNL) in Haiti. The team also included endourologists Dr. Bob Marcovich and Dr. Keegan Maxwell as well as general urologist, Dr. Henri Lanctin. A total of 13 PCNL’s, 3 semi-rigid ureteroscopic procedures and a percutaneous removal of bladder calculus were performed.

Despite significant pre-planning, technical difficulties were encountered, including the absence of ultrasonic lithotripsy probes, mechanical problems with the backup pneumatic lithotripsy device and an underpowered laser unit which frequently overheated and required cooling and rebooting. These technical issues were compounded by lack of adequate pre-op imaging (CT scans or IVP) and a high level of complexity (large, multiple, dense stones with complex anatomy). There was only 1 case that a solitary stone could be removed without fragmentation.

Because of the above factors, 5 “second look” procedures were performed: 1 large staghorn due to mechanical problems with the pneumatic lithotripter, 2 due to complex intrarenal anatomy (1 with scarring from previous surgery, 1 with blown out calyx and scarred infundibulum), and 2 large, dense midureteral calculi which were embedded in the urothelium.

Despite the above issues and complexities, no complications were encountered by the time of team departure and all cases were either completely stone free by fluoroscopy or the offending calculus was removed. In all cases there was a Haitian urologist scrubbed and assisting.

Both the reconstructive and stone workshops were facilitated by pre-workshop teleconferences with team physicians and Haitian colleagues which included didactic lectures, Q&A sessions and presentation of proposed surgical patients by the Haitian team. This proved to be extremely effective and improved pre-workshop planning and scheduling of cases.

A great deal of time was spent planning next steps for the successful development of the stone treatment center at HSFDS and it is the hope that a young urologist or senior resident will be able to successfully apply for an Endourological Society fellowship for hands on training at a high volume center, such as currently exists in India. Dr. Christian Valme (4th year resident) was invited by Dr. Denstedt to apply to the financial committee of the ES.

The technical and equipment issues were discussed and plans devised to hopefully deal with them. It is anticipated that a second PCNL / URS workshop may be held as soon as late fall 2017, perhaps to coincide with GASHU annual meeting.

Funding for the PCNL / ureteroscopic workshop as well as procurement of equipment and supplies for the stone center was provided by the Endourological Society, a grant from Cook (Canada), Storz Urology, Project Haiti and Project Haiti team members, their hospitals, and various other equipment representatives.

Mr. Chris Gleason from NextMed, LLC who has partnered with Dornier to donate a Dornier ESWL unit joined us to tour HSFDS, meet with team members and hospital administration and develop a time line for implementation of the project. He also outlined the stone treatment decision engine that has been developed and our requirement to participate in outcome tracking and analysis. It was decided and arrangements were made to ship the unit now. Discussions occurred regarding who to send for training in Tucson, AZ with the GPC funded nurse and this was deferred to Haitian urology leadership for final decision. The 2 urologists who will be trained on the ESWL unit will be Drs. Bernard Brutus and Reginald Valme and they will be trained at a NextMed site in West Palm Beach. The dates for the first cases have tentatively been set for May19-21, 2017.

Preliminary discussions were held with an international radiology group, Rad-Aid regarding CT scanning and support at HSFDS as well as radiology resident and technician training. Contacts and introductions were made with further follow up planned.

It is the hope of the team that over time, when word spreads that minimally invasive treatment options are being competently performed at HSFDS, Haitian patients with symptomatic stone disease will present earlier. This will mean smaller, less dense stones which can be more easily treated and, more importantly, lead to less suffering. With our efforts Haitians from all socioeconomic backgrounds will have equal access to these treatment options.

Henri P. Lanctin MD, FACS
March 16, 2017

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