IVUmed / Project Haiti Urethral Reconstructive and General Urology Workshop, Pignon, Haiti March 16-20, 2015

US/Canada team members: Henri Lanctin MD, Frank Burks MD, Dan Rosenstein MD, Dan
Stein MD, Stuart Anderson MD, Justin Linhardt CRNA, Claudie Williams RN, Pat Lanctin, Chris
Lanctin

Haitian physicians; Urologists – Youry Dreux MD, Gaby Nelson MD and Jory Desir MD. Drs.
Jean-Marie Aubourg and Harold Hosty audited the workshop for several days. Urology
residents- Kedex Joseph MD, Marc-Aurele Osiris MD, Dieusiel Codio MD, and Noelsaint
Beavoir MD

We arrived in Port-au-Prince early afternoon Mar.14 and took the small bus to Pignon. After a 4
1/4 hour trip we arrived in time for a late dinner. We then settled into the dorm, hung our
mosquito netting and set the work schedule and duties for the week.

Sunday morning was spent at Hopital Bienfaisance de Pignon organizing our instruments and
supplies in the OR, evaluating the anesthesia equipment and preparing for the week of surgery.
In the afternoon we did 2 clinics with Drs.Rosenstein, Burks and Stein evaluating 11 and
scheduling 9 patients for urethral reconstruction. The patients came from urologists in Les
Cayes, Cap Haitien and Port-au-Prince and the majority presented with well performed
radiological studies, a benefit of our previous workshops. Contrast availability and cost
continues to be problematic and several retrograde urethrograms and cystograms had to be
performed. A concurrent general urology clinic was run evaluating 21 patients and scheduling16
for surgery / procedures. Most of these patients were from the Pignon area.

Monday we began to operate with 4 urethral reconstruction cases being completed utilizing both
OR’s. Starting Tuesday, general urology cases were done in Room 2 and urethral cases were
performed in Room 1.

Anesthesia provided by Dr.Anderson and Justin CRNA was fortunately very uneventful. A
Haitian anesthesia resident from Port-au-Prince worked with them and she had, in her words, “a
beautiful experience”. She worked on her spinal technique under the patient tutelage of
Dr.Anderson and was introduced to the Glide Scope (which was donated by IVUmed 2 years
ago to HBP) during a difficult intubation. She adapted to it quickly and was delighted by the
manner in which it made a difficult procedure relatively easy.

We utilized primarily Haitian OR staff, especially for scrub tech and room prep. We are fortunate
to have Claudie on our team as she is a urology OR circulating nurse from Detroit, who happens
to be Haitian and speaks Creole. She has a wonderful personality and is a tremendous asset to
the team. Circulating and turning over of our flexible cystoscope was accomplished by Pat and
Chris who never stopped running. They were attentive to our needs and showed ingenuity when
requested items were not available. PACU care was provided by HBP nursing staff under our
watchful eyes.

There were 9 urethral reconstructive cases; 4 redo pelvic fracture urethral injuries (1 for the 4th
time, none previously operated at IVUmed workshops), 4 primary pelvic fracture urethral injuries
(one requiring an open cystotomy for large bladder calculi), and 1 anastomotic urethroplasty for
a straddle injury stricture. Drs. Rosenstein and Burks have now completed a series of 46
urethral reconstruction cases in Haiti, with a large percentage being complicated, redo cases.
They are tracking their outcomes.

We completed 9 TURPs, 7 for urinary retention with indwelling SP or urethral catheters and 2 for
obstructive symptoms. We also did 4 cystoscopes and 2 circumcisions. A very challenging
pyelolithotomy was performed for a large calculus. After extensive dissection in the renal hilum,
we encountered a very small renal pelvis and despite an elongated pyelo/ureterotomy we were
unable to completely extract the bulk of the stone. We were successful fragmenting the leading
edge which was felt to be the obstructing element, but the main stone was too hard to fragment
and remove. Unfortunately we had a miscommunication and were led to believe that blood was
available for the patient pre-op, however intraoperatively when considering a nephrotomy
incision we were informed that was not the case and we elected not to proceed with that
approach in the absence of available blood. Consideration for nephrectomy was abandoned as
the kidney had normal parenchymal thickness. We elected to leave a double J stent indwelling
for 6 weeks and follow expectantly if his pain does not recur from the debulking that was
accomplished. He was discharged on PO Day 3 with no post operative problems.

At the time of departure, all urethroplasty patients were discharged except for the last one
performed and discharge was planned for the following day. No immediate postoperative
complications were encountered. Five of the 9 TURPs had catheters removed and were either
discharged or voiding well upon team departure. Several were discharged with catheters due to
the distance from hospital that they had to travel and several remained hospitalized with plans
to remove the following day. No immediate complications occurred except for a call to evaluate
post op pain during the night following surgery on one patient. It was determined that he was
having spasms and he settled with no further treatment other than reassurance. All remaining
inpatients were left under the care of the in house general surgeon with telephone back up from
Dr. Dreux in Port-au-Prince. He will also follow them post op, including the several with high
PSA’s that were sent for pathological evaluation.

Once again, after patient care, our primary goal was teaching the Haitian physicians. They were
actively involved in the urethroplasty cases with a Haitian physician scrubbing as first assist and
encouraged to perform up to their level of expertise. This occurred in 7/9 cases. With some
complex redo cases it was necessary to have 2 experienced reconstructive surgeons for optimal
patient outcomes as that takes priority over teaching. Visualization of the procedure is
significantly facilitated by the in-light camera and 3 monitors providing excellent teaching for the
physicians not actively operating. The more workshops that we do and the more cases the
Haitian physicians are completing when we are not present, the more we find that they are able
to do. The Haitian physicians performed a portion of all the TURPs that were done, once again
facilitated by the camera/monitor system. Several demonstrated substantial improvement in
technique and they were all very engaged in learning from watching others operating. The
Haitian residents and young urologists were invaluable in pre/post operative patient education,
obtaining histories and in overall patient care. Ward rounds were efficient, productive and
educational. This is a tribute to their current training but there is still significant room for
improvement.

A classroom session was held on Thursday afternoon to discuss post op care and principals of
urethral reconstruction. This was conducted primarily in French by Dr. Rosenstein.
Nevertheless, improved English language skills was noted among several of the residents who
have been studying English and this was encouraged. We now have had a total of 18 Haitian
urologists/residents attend IVUmed/Project Haiti workshops in Pignon, 8 of them multiple times.
Three have been to 3 or more workshops and Dr.Dreux has been to 7. We continue to work to
optimize the learning experience of the attendees to make the investment of the week in Pignon
more worthwhile. The high number of attendees dilutes the operating time of each individual
and impedes our assessment of the skill level of the individual participants. Overall feedback
however continues to be positive. Tentatively, the next male urethral reconstruction workshop is
scheduled for the first week of March 2016.

One highlight of the week was a reception on the patio of Dr Guy Theodore’s home that
included our team, the Haitian physicians, hospital administration, gynecologist Dr. Jean-
Jumeau Batsch, cardiologist Dr. Omer Shedd and several internal medicine physicians from Les
Cayes. It was a wonderful meal and the opportunity to visit with our colleagues in a more
relaxed venue was appreciated by all attendees. Workshop certificates acknowledging their
hard work and efforts were handed out to the Haitian physicians.