FIRST FORMAL FEMALE UROLOGY AND VOIDING DYSFUNCTION WORKSHOP IN CAP HAITIEN RESIDENCY PROGRAM:
July 27-28, 2017
Logistics: On July 27 & 28, 2017, I visited the University Justinien Hospital. I drove from Port-au-Prince to Cap Haitien in a large size SUV I rented at the Port-au-Prince International Airport. I do not currently recommend the drive unless you enjoy “off-road” driving’ like I do. I stayed in Cap Haitien at a nice boutique Hotel called Habitation Jouissaint. The Hotel was recommended to me by Dr Geto Dube (Chief of Urology and Chief administrator of the Hospital). I was very pleased with the Hotel. It had friendly staff, great AC, excellent food, beautiful ocean and mountain views.
Workshop Participants: I had the opportunity to meet with the residents and evaluate the outpatient clinic, inpatient facilities, and operating room. The Urology service includes two fulltime attending urologists – Dr. Geto Dube – Chief of Service and Residency Program Director and Dr. Jory Desir, Assistant Chief. Dr. Desir is very involved in residency teaching and well respected by the residents. Currently, the residency program has 3 residents in training. Two PGY 3 and one PGY4 (graduating in 6 months). There is no PGY1 or PGY2. I understand that this was planned because of the diminished caseload and frequent strikes in the Hospital, which is a national and governmental dilemma. The Residents include: Robens Dorsainvi PGY 4, Jesena Samson PGY 3, and Jolius Thelusme PGY 3.
Female Urology Workshop Structure: The female urology and voiding dysfunction session consisted of a two -hour lecture in the Chief of Urology’s Office and Conference room. The entire service attended the lecture including all the residents and attending urologists. The subjects discussed included:
Surgical Management of Stress Urinary Incontinence
- Epidemiology and pathophysiology of stress urinary incontinence
- Relevant Anatomy of female stress urinary incontinence
- Appraisal of different techniques used to treat stress urinary incontinence
- Complications rates associated with various techniques currently used to treat stress urinary incontinence
- Technical details of various Stress urinary incontinence operations
- Indications for surgery
- Management of complications associated with midurethral sling placement
Evaluation and management of Overactive Bladder (OAB)
1-Definition of OAB –dry without urge incontinence) and OAB –wet (with urge incontinence)
2-Evaluation of OAB – ie UA, PVR, Exam etc
3- Appraisal of the current AUA/SUFU OAB Guidelines
4- Medical management of OAB – Drugs available in Haiti and side effect
5- Appraisal of Third line OAB Therapies: Sacral Nerve Stimulation (Interstim), Posterior tibial nerve stimulation, Bladder Botox (Chemodenervation)
6- Mechanism of action and side effects of Chemodenervation
Operating Room Session at Hospital Justinien Cap Haitien
A 49 yo Haitian female, multiparous, with mixed (Balanced) urinary incontinence. She had a grade II Cystocele and grade I rectocele and no uterine prolapse. Vaginal tissue was well estrogenized. Pre-operative evaluation revealed minimal post void residual and cough stress test demonstrated stress urinary incontinence associated with rotational descent of the urethra. Dr. Dube had previously performed a positive Q Tip test. Her outcome expectations were counseled for her diagnosis of mixed urinary incontinence. The procedure was performed under general anesthesia. I examined and counseled the patient pre-operatively with the residents.
The patient was placed in the lithotomy position. The OR table was in very poor state of disrepair. The stirrups were metallic poorly padded with a” make-shift” tubing holding them. The size of the OR was adequate. The anesthesia team of the Hospital was competent, friendly and very skilled. Two attendings and one senior resident who had just graduated scrubbed the case. The Haitian urologists and resident participated in all steps of the surgery. Teaching points included:
- Vaginal Exposure
- Pearls of obtaining vaginal access for vaginal surgery
- Techniques of vaginal wall flap dissection
- Techniques for safe Passage of retropubic/Suprapubic trochars
- Importance and pearls during intraoperative cystoscopy to rule out bladder or urethral perforation
- Technical pearls for tensioning the suburethral sling
- Proper techniques for anterior vaginal wall closure
Generous Donation by Caldera Medical
The Sling Technique used was the Caldera Desara- Blue with the Re-usable Caldera retropubic suprapubic trochars that can be easily re-used and re-sterilized in any third world country including Haiti. This is also very cost effective. Two sets of trochars were generously donated by Caldera Medical. A special thanks to Lavinia Kandy and Jody Stephens, my Caldera Medical territory manager.
In addition, Caldera Medical donated 6 retropubic suburethral Desara-Blue synthetic meshes for midurethral sling placement. We used one and the team has 5 others remaining for subsequent cases. We are grateful to Caldera Medical for their support of the Female Urology Workshop in Cap Haitien. Caldera has a designated philanthropic arm, which supports such medical missions.
Thank you again Caldera Medical for your philanthropy.
The urology facilities in Cap Haitien are in a severe state of disrepair at Justinien Hospital. The Faculty, the chief of service and residents are very enthusiastic and eager to improve the program. The inpatient facility is in disrepair with an old setting and inadequate monitoring of post-op patients. The patient beds are very old and the sanitary conditions vastly inadequate. The ultrasound equipment essentially does not work and is an old B&K. Gousse Urology LLC donated a Cook Biopsy Gun during the visit and accessories to the service in order to start a prostate biopsy program in Cap Haitien, but the ultrasound equipment is non-functional.
The service is in need of a flexible cystoscope. The Storz equipment that was donated a year ago remains in very good condition in Dr Dube’s (Chief of Service) office. The Storz Pack with video is missing a “video camera head “to be fully functional. Perhaps Storz can also donate a flexible cystoscope. I did not get a sense that many TURPS were currently being performed in Cap Haitien. They are lacking the stone disease equipment we currently have a St Francois Hospital in Port-au- Prince.
The chief of Service and Dr Desir are very interested in Urodynamic Testing. For many years they have shown a great interest in Urodynamics. In fact, they have performed a few studies with old equipment in the past. I have contacted Laborie in order to see if they would be willing to donate new Urodynamic equipment to the service. Dr Chris Gomez and I would be willing to teach Urodynamic testing at the service. In addition, perhaps the AUA/ SIU / Laborie can help pay for a graduating resident and a junior attending to participate in an AUA or Laborie Urodynamic course.
Finally, I am hoping that this year the Cap Program will resume accepting new residents in order to maintain the viability of this noble Urology teaching institution. Of note, Justinien Hospital serves as the sole facility which services a large segment of the national population including major surrounding cities such as Milot, Port-de-Paix, Fort Liberte, Limonade, Limbe, Grande Riviere du Nord, and even Gonaives etc. A donor has been identified who is willing to help renovate the physical facilities of the Urology Service of Justinien Hospital but wants the commitment of GASHU in order to obtain the necessary urologic equipments.
It was a true delight to have the honor and the opportunity to visit the Urology Department of University Justinien Hospital.
Angelo E. Gousse M.D.
Voluntary – Professor of Urology – University of Miami – Miller School of Medicine
Fellowship Director: Female Pelvic Medicine, Urodynmaics and Reconstructive Urology
American Urologic Association – Representative to Haiti
Executive Board Member – Chair Resident Education Committee– Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction (SUFU)
Global Association for the Support of Haitian Urology (GASHU) – Member