Practice of Endo-Urology in the Centre of Ivory Coast: Overview and Results ()
1. Introduction
Endoscopy in urology brings together all the minimally invasive techniques used to explore and treat certain pathologies of the urinary tract by means of optical equipment called an endoscope. It dominates the practice of urology in developed countries. Endoscopic exploration and treatment of disorders of the urinary tract, whether by retrograde, percutaneous or laparoscopic route, defines endo-urology [1] . Endo-urology has revolutionised the practice of urology, as it allows operations to be carried out through natural passages without opening the walls, under the control of a device called an endoscope. Endoscopic surgery is a minimally invasive, elegant and attractive technique, with many undeniable advantages for the patient. It is less invasive than laparotomy, can be performed at any age, requires no incision, causes less cosmetic damage, has a low risk of adhesion, reduces the length of hospital stay, is comfortable post-operatively, allows patients to return to work quickly and reduces morbidity and mortality [2] [3] [4] . It was introduced into the therapeutic armoury of urologists in Côte d’Ivoire in 1982 by Dje et al. [5] , but in Bouaké the practice of endo-urology is recent. To this end, we conducted a preliminary study with the aim of reporting the various explorations and/or endoscopic procedures performed and the results in Bouaké.
2. Patients and Methods
Study design and approval
After obtaining the approval of the ethics committee of the private facility and the university hospital of Bouaké (Ivory Coast), we conducted a cross-sectional and descriptive study of the medical records of patients followed and having undergone exploration and/or endoscopic surgery. This study was conducted in a private facility in Bouaké for two years, from 01 January 2021 to December 2022.
Inclusion and non-inclusion criteria
All patients who underwent endoscopic exploration and/or surgery were included in the present study. Patients who underwent any other means of exploration or open surgery were excluded from our study. All endoscopies were performed on sterile urine. Patients who underwent endoscopic surgery were systematically subjected to a preoperative work-up consisting of: haemogram, partial thromboplastin time (PTT), prothrombin rate (PT), uremia, creatinemia, electrocardiogram, pulmonary radigraphy, and urine cytobacteriological examination (UCE).
The endo-urological equipment consisted of:
• A urethrotome
• A CH 21 cystoscope
• Sheath resector 26CH
• 30 degree optics
• Monopolar electric current
• A continuous irrigation system using glycine with cut/coagulation set at 130/70 W
• ELLIK bulb for recovery of swarf after resection
• A cold light source
Data were collected using a survey form containing the parameters studied and entered using Word software. EPI-Infos 7 software was used to analyze the data.
The parameters studied were: Age, sex, reason for consultation, pre and per operative diagnosis, endoscopic procedure performed, duration of operation, outcome of operations, duration of post operative drainage and mortality.
3. Results
During our study period, 157 patients underwent endoscopic exploration and/or endoscopic intervention, the results are as follows.
3.1. Epidemiological Data
3.1.1. Age
The mean age of the patients was 58.9 years, ranging from 28 to 90 years.
The most represented age group was 61 - 70 years in 58.5% (n = 92), Table 1.
3.1.2. Sex
In our series, men represented the majority of patients with 96.1% (n = 151), Table 2.
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Table 1. Distribution of patients by age group.
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Table 2. Distribution of patients by sex.
3.2. Clinical Data
Reason for Consultation
Acute retention of urine was the most frequent reason for consultation with 55.41% (n = 87), followed by dysuria 25.47% (n = 40) and haematuria 9.55% (n = 15), Table 3.
3.3. History and Comorbidity
The majority of patients had no urological history 61.78% (n = 97). 15 patients had hypertension and 9 had diabetes as comorbidities. These represented 9.55% and 5.73% respectively.
3.4. Diagnosis
3.4.1. Pre-Operative Diagnosis
The diagnosis of benign prostatic hyperplasia (BPH) predominated in 22.92% (n = 36), Table 4.
3.4.2. Intraoperative Diagnosis
The intraoperative diagnosis was dominated by benign prostatic hyperplasia with 33.12% (n = 52), Table 5.
3.5. Endoscopic Procedures
Urethrocystoscopy was the most common endoscopic procedure with 33.12% (n = 52) followed by TURP 22.92% (n = 36), Table 6.
3.5.1. Associated Procedures
We performed procedures associated with endoscopy in 49 patients, and dilatation with a benique was most often associated with endoscopy 15.92% (n = 25), Table 7.
3.5.2. Duration of Procedure
Procedures lasting between 21 and 35 minutes were the most common, 55.41% (n = 87), Table 8.
3.5.3. Anatomopathology
Adenomyofibroma of the prostate accounted for 52.17% (n = 36) of the 69 pathological findings.
3.5.4. Operative Follow-Up
Post-operative follow-up was straightforward in 93.63% (n = 147) of cases.
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Table 3. Breakdown of patients by reason for consultation.
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Table 4. Distribution of patients according to preoperative diagnosis.
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Table 5. Breakdown of patients by intraoperative diagnosis.
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Table 6. Distribution of patients according to endoscopic procedure performed.
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Table 7. Distribution of patients according to the procedure associated with endoscopy.
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Table 8. Distribution of patients according to length of procedure.
3.5.5. Morbidity
Morbidity was dominated by urinary tract infections in general 3.82% (n = 6); Table 9.
3.5.6. Germs Found on Antibiotic Susceptibility Testing
The most frequent germ was E. coli, accounting for 66.66% of cases.
3.5.7. Length of Hospital Stay
The average length of hospital stay was 4.7 days, with extremes of 1 to 7 days.
3.5.8. Outcome of Endoscopic Procedures
Out of 157 endoscopies performed, only 1.9% resulted in failure of the procedure (n = 3).
3.5.9. Average Post-Operative Drainage Time
The average duration of post-operative drainage was:
Average of 5.5 days, with extremes of 4 to 6 days for patients who had undergone TURP, TURB and endoscopic resection of secondary sclerosis of the cervix.
Average of 21.6 days, with extremes ranging from 14 to 30 days, for patients who underwent EIU.
3.5.10. Mortality
Mortality was 1.27% (n = 2) in our series.
4. Discussion
Endo-urology has revolutionised the practice of urology, both in exploration for aetiology and in surgical management, and its introduction into our therapeutic arsenal has reduced the major complication of open surgery such as surgical site infections in our practice. In our series, the average age of patients was 58.9 years. This result, which shows an age greater than 50 years, is in line with that reported by MAHAMAT in his study in N’DJAMERA, who reported an average age of 53.54 years [1] . Other authors such as DIAKITE [6] in MALI and OFOHA [7] in NIGERIA reported an average age of 62 and 63.8 years respectively. However, cases of patients under 50 years of age were reported by COULIBALY and colleagues in Côte d’Ivoire in their study of prostatic adenomectomy in twins [8] . Our result could be explained by the prevalence of
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Table 9. Distribution of patients according to morbidity.
cervicoprostatic pathologies, which increases from the age of fifty (50), and also by physiological ageing. Male patients predominated in our study (95.5%). The same observation has been made in the literature [3] [4] [5] . Our result could be due to the high frequency of urogenital pathologies in men, as opposed to women. We found that acute retention of urine was the most frequent reason for consultation, at 55.41%. This finding was made by MAHAMAT [1] , LOTTERSTATTER [3] and DIALLO [9] . The high frequency of urinary retention in our series reflects the long evolution of the pathologies and also the delay in patient consultation.
From a diagnostic point of view, benign prostatic hyperplasia was the most frequent pathology with 22.92%. This is consistent with studies by SAHIN [10] , WANG [11] and SHABBIR [12] in which benign prostatic hyperplasia was the urogenital disease with the highest frequency. Our results confirm the thesis that adenomyofibromatous hyperplasia of the prostate is the most frequent benign pathology in men over fifty (50) years of age. In our study, we found that urethrocystoscopy was the most frequently performed endoscopic procedure (33.12%). This result is close to that of other authors. It was 36.3% in the MAHAMAT study in N’Djamena [1] . The common practice of urethrosystoscopy in urology consultations could justify our results.
The exploration and surgical treatment of pathologies of the upper urinary tract require appropriate endoscopic tools such as rigid or flexible urethroscopy for diagnostic urethroscopy and interventional urethroscopy for stone fragmentation [13] . As we did not have this equipment, we mainly used double J endoprostheses, i.e. 5.73%. This is much lower than the results reported by ZAKOU in SENEGAL [14] and PEDJA in Morocco [15] , which were 54.55% and 30.12% respectively.
Transurethral resection of the prostate accounted for 22.92% of endoscopic procedures performed. Our rate is lower than that of DIAKITE in MALI [6] , LOUSAIEF in TUNISIA [16] and NOURI in MOROCCO [17] which were respectively 57.7%, 58% and 52.18%. But higher than the rates reported by other authors such as KANE in SENEGAL [18] , KAMBOU [19] and ZONGO [20] in BURKINA FASSO who noted respectively 18.5%, 10% and 8.11%. Our results show the importance of trans-urethral resection in the surgical management of benign prostatic hyperplasia.
We performed 23 endoscopic resections of the bladder neck, i.e. 14.64%. This was the second most common endoscopic procedure in our series. It was used to treat secondary sclerosis of the bladder neck by removing the sclerotic and fibrous tissue stenosing the bladder neck. In 2000, XAVIER GAME et al. [21] experimented with this technique for the treatment of chronic retention of urine after urinary incontinence. These spectacular results led him to describe the technique as effective, quick to perform, minimally invasive and without morbidity or mortality.
Endoscopic internal urethrotomy (EIU) accounted for 9.55% of endoscopic procedures performed during the study period. It alone accounted for 28.7% in the series by MAHAMAT [1] . EIU is a simple technique, which can be repeated, with simple postoperative follow-up and a shorter hospital stay. In our series, it was the third most common endoscopic procedure. It was indicated for short, simple strictures. Complicated or complex forms of urethral stricture were reserved for uretroplasty.
Trans-urethral resection of the bladder (TURB) accounted for 6.34% in our study. This result is close to that of MAHAMAT [1] in N’Djamena, who reported 7% of TUR in his study. TUR remains an essential examination for the diagnosis of bladder tumours on the one hand, and on the other hand occupies a place of choice in the initial treatment of these tumours. The low number of trans-ureteral bladder resections could be explained by the unavailability of endo-urological equipment in our public centres. 55.41% of operations last less than 1 hour. MAHAMAT et al. [1] reported average times of 23.2 minutes for UIE and 45.98 minutes for RTUP. In 2016, DIAKITE in MALI reported an average duration of 40 minutes [6] . These short endoscopic times reflect the skill and experience of the surgeon and the quality of the endoscopic equipment.
The post-operative course was simple in 93.63% of cases. However, we observed 3.8% complications, mainly urinary tract infections with Escherichia coli as the main germ. DIAKITE reported 5% complications [6] , MAHAMAT [1] , 27.3% haemorrhagic complications. Other authors have reported cases of bladder explosions during endoscopic manipulations [22] . This low complication rate in our study could be explained by the mastery of the different procedures and the scrupulous respect of the different endoscopic intervention times.
The average length of hospital stay was 4.7 days. DIAKITE [6] reported 3 days, DJE [5] 12.53 hours. These different lengths of hospital stay confirm the thesis that endo-urology has a short hospital stay.98.08% of operations were successful. Three (3) procedures (1.9%) were unsuccessful. This low failure rate has been noted by several authors in the literature [5] - [10] .
Our study finds its strength in the rigorous methodology, the first carried out to our knowledge in Bouaké in the center of the Ivory Coast. It lifted the veil on the panorama of endoscopic explorations and/or interventions over two years of practice of endourology. However, it has its limits. It is a cross-sectional and descriptive study therefore these results deserve external validation with an independent and larger sample. It would be helpful if future studies with a larger sample size were done to substantively judge our results. We believe, however, that these results are clinically relevant due to their strong characterization in the real-life context.
5. Conclusion
The results of our study have enabled us to assess the extent of endoscopic procedures performed in Bouaké. The results show that uretrocystoscopy and trans-ureteral resection of the prostate are the most common endoscopic procedures, both in terms of diagnostic exploration and surgical management. The reduced intervention time, the reduction in morbidity and mortality, and the short length of stay all bear out the reliability of endo-urology.
Authors’ Contributions
AVION Kouassi Patrice, AKASSIMADOU N’diamoi, AGUIA Brice: statistical analysis and re-reading of the article as well as its drafting.
ZOUAN Freddy, ALLOKA Venance, KAMARA Sadia, DJE Koffi: documentary research and editing of the work.
Ethical Considerations
We have protected the confidentiality of the information gathered during the survey. Thus, an anonymity number was assigned to each survey form with authorisation obtained from the administrative and health authorities.