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Year : 2021  |  Volume : 24  |  Issue : 9  |  Page : 1380-1384

Urologic Day Case Surgery at a Nigerian Tertiary Hospital: A 5-Year Experience

1 Department of Surgery, Faculty of Clinical Sciences, College of Medicine of University of Lagos and Urology Unit, Lagos University Teaching Hospital, Idi-Araba, Surulere, Nigeria
2 Department of Surgery, Urology Unit, Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, Nigeria

Date of Submission05-Dec-2020
Date of Acceptance17-Jun-2021
Date of Web Publication16-Sep-2021

Correspondence Address:
Dr. R W Ojewola
Department of Surgery, Faculty of Clinical Sciences, College of Medicine of University of Lagos, Idi-Araba, Surulere, Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_671_20

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Background: Nowadays, the practice of day case surgery (DCS) is an attractive and appealing one with widespread acceptability because of numerous benefits. Aim: This study aimed at presenting our experience with urologic DCS in a tertiary healthcare center. Patients and Methods: A 5-year review of all day-case urologic surgeries at our tertiary healthcare center was carried out. Data on patients' biodata including age and sex, diagnoses, indications and procedures performed, types of anesthesia, complications, admission and re-admission history were obtained from theatre records and patients' case notes. Data were analyzed using PASW Statistics version 18.0 and results presented in table and charts. Results: A total number of 1277 of the 1825 urologic surgeries which took place during the study period were performed as day cases giving a proportion of 67.8%. The age range was 11 days to 94 years. The most commonly performed DCS are prostate biopsy, cystoscopy and varicocelectomy in 368 (28.8%), 165 (12.9%) and 163 (12.8%) patients respectively. Local anesthesia with or without sedation was the most commonly used in 981 (76.8%) cases. Twenty-four (1.9%) patients required unplanned admission for complications, 18 (1.4%), delayed completion of surgery, 4 (0.3%) and delayed recovery from anesthesia, 2 (0.16%). Three (0.2%) of these patients were re-admitted for management of sepsis following prostate biopsy. Conclusion: This study like numerous others demonstrated the feasibility, effectiveness and safety of DCS. To meet up with the global trends in DCS in Nigeria, there is need for investment in infrastructure and adoption of minimally invasive techniques to allow incorporation of more complex cases in the range of procedures offered as DCS.

Keywords: Anesthesia, day case surgery, procedures, urologic

How to cite this article:
Ogunjimi M A, Ojewola R W, Fatuga A L, Tijani K H, Jeje E A, Okeke C J, Oladimeji A T. Urologic Day Case Surgery at a Nigerian Tertiary Hospital: A 5-Year Experience. Niger J Clin Pract 2021;24:1380-4

How to cite this URL:
Ogunjimi M A, Ojewola R W, Fatuga A L, Tijani K H, Jeje E A, Okeke C J, Oladimeji A T. Urologic Day Case Surgery at a Nigerian Tertiary Hospital: A 5-Year Experience. Niger J Clin Pract [serial online] 2021 [cited 2022 Nov 29];24:1380-4. Available from:

   Introduction Top

Day case surgery (DCS) is defined as admission of patients for investigation or operation on a planned, non-resident basis with provision of adequate facilities for recovery in a ward or unit set aside for this purpose. Specifically, it means that patients for DCS are discharged home the same calendar day of their procedure. This typically incorporates a short post-operative stay of about 4 to 6 hours, but with more complex surgical procedures, longer hospital stays may be required. More important in the concept of DCS is that the procedure must have been planned and booked as a day case before the patient's admission to the hospital. On the contrary, patients who are planned as inpatients but were consequently discharged home on the day of surgery count as inpatients with zero length of stay rather than day cases.[1]

DCS is widely accepted worldwide and should further be promoted due to several benefits it offers including cost reduction, reduction in patient waiting time for surgeries, lower incidence of nosocomial infections, convenience, less risk of cancellation of the surgery, and a quicker return to normal activities.[2] Interest in DCS as well as the complexity of the procedures has increased in recent years with a wider range of patients now considered suitable under this concept.[3] In the United Kingdom (UK), over 50% and in United States of America and Canada, about 60% cases of all elective surgeries are carried out as day cases.[4] Though DCS is increasingly being practiced all over the world, there is still disparity in the utility of this concept between developed and developing world.[5]

In Nigeria, the concept of DCS is being practiced with reports cutting across different surgical specialties.[6],[7] The scope is however different from other parts of the world where there is increasing number of more complex procedures being performed as day cases. This study aimed at documenting our local experience with urologic DCS in a tertiary healthcare center over a five-year period.

   Patients and Methods Top

Ethical approval for this study was obtained from the Health Research and Ethics Committee of our hospital. A 5-year review of all day-case urologic surgeries from January 2015 to December 2019 at our tertiary healthcare center was carried out. The required information was obtained from theatre registers as well as the patients case notes using a structured pro forma. Data obtained were patients' biodata including age and sex, diagnoses, date of surgery, procedures performed, indications for surgery, types of anesthesia administered, complications, admission and re-admission history.

Records were obtained from both dedicated day-case as well as major theatres where the day case procedures were performed. Typically, the patients were observed in a dedicated recovery room for 1-4 hours and occasionally for a longer duration from where they were discharged home. Reasons or indications for admission in patients who could not be discharged on the day of surgery as well as those discharged but were re-admitted were duly noted. All minor and intermediate cases that were not planned ab initio as day cases were excluded even when they were discharged same day. The data obtained were collated, imputed and analyzed using PASW Statistics version 18.0 (IBM Co., Armonk, NY, USA). Results were displayed using simple proportions in tables and charts for categorical data whereas mean, median and range were used for continuous data.

   Results Top

A total of 1277 day-case urologic surgeries were performed during the five-year study period from January 2015 to December 2019. The age range was 11 days to 94 years, with a median of 64 years. [Figure 1] shows the age distribution of patients. Majority, 1184 (92.7%) were males whereas 93 (7.3%) were females with a male-to-female ratio of 12.7:1. Majority, 1162 (91.0%) of the patients were adults, while the children below the age of 15 years were 115 (9.0%).
Figure 1: Age distribution of patients

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There were a total of 1825 urological cases performed over the study period giving a proportion of 67.8% for DCS. The most commonly performed DCS procedures during the study period are prostate biopsy, cystoscopy and varicocelectomy in 368 (28.8%), 165 (12.9%) and 163 (12.8%) patients respectively. The least performed procedures as day cases were secondary wound closure (3), wedge-biopsy of penile ulcer (2), closure of vesicostomy (2), wound debridement (2) excision of bladder papilloma (1), and penile fracture (1) which were grouped as others. [Table 1] gives the details of the procedures performed in these patients.
Table 1: Distribution of day case surgery

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Local anesthesia with or without sedation was the most commonly used anesthesia in 981 (76.8%) cases. This was mainly in form of local infiltration of operation sites for various scrotal and groin surgeries and intra-rectal lignocaine lubrication mainly for prostate biopsy. Some patients required general and spinal anesthesia as depicted in the [Figure 2] below while seven male neonates had circumcision without anesthesia. General anesthesia was utilized in just 5.4% of all cases; majorly in children, 51 (73.9%) compared with 18 (26.1%) adults who had general anesthesia.
Figure 2: Mode of anesthesia

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Of the 1277 patients planned as day case surgery, a total of twenty-four (1.9%) required unplanned admission. Complications from procedures, 18 (1.4%), delayed completion of surgery, 4 (0.3%) and delayed recovery from anesthesia, 2 (0.16%) necessitating overnight stay were the reasons for admissions in this category of patients. Morbidity that required unplanned admission were hemorrhage in form of hematuria and or hematochezia in 15 (1.2%) following prostate biopsy and one patient following cystoscopy plus biopsy. Others were one patient each with severe post-operative pain following varicocelectomy and herniorrhaphy. Three of the DCS patients were re-admitted within few days of discharge for management of sepsis from prostate biopsy making the re-admission rate to be 0.2%. No mortality was recorded in these cohorts of patients who had DCS over the study period.

   Discussion Top

The practice of DCS is today an attractive and an appealing one with increased spread to many specialties and many regions of the world.[5] It is now established practice with rates still increasing around the world and has greatly evolved since the early days of the specialty which saw minor procedures carried out on fit patients. Nowadays, due to advances in anesthesia and surgical techniques, DCS is the standard pathway of care for many complex patients and procedures traditionally treated through inpatient pathways.[8],[9],[10] In Nigeria, DCS is being practiced by many hospitals to a great extent including our institution which has three theatre suites dedicated for DCS.[5],[6] This is particularly true for our urology unit which channels a significant percentage of patients through the DCS pathway.

In this study, the sex distribution in favor of males is not surprising as most of our patients in urology are males and age distribution with preponderance of elderly patients is also consistent with known facts that the prevalence of urological problems increases with age. This is in agreement with other studies on urology DCS in Nigeria and elsewhere.[6],[11]

The overall rate of urology DCS remains variable in Nigeria.[12] In this study, day case procedures accounted for 66.8% of all urologic procedures performed during the study period covering various investigative and therapeutic procedures. This is slightly higher than proportions reported previously in our sub-region which may suggest an increasing utilization of DCS in recent times.[6],[11] Despite this increase, it has however yet to meet the proportion reported in the developed countries where the trend of DCS is increasing rapidly and it is still far below the three quarter target set by the UK department of health about a decade ago in order to address the problem of long waiting list occasioned by lack of bedspace for admission following surgery.[13] This low utilization of DCS in developing world may not be unconnected with inadequate infrastructure, poor funding, inadequate manpower and poor organization.[14] Lack of dedicated day care services is a major obstacle in optimal utilization of DCS. Unlike reported in some centers in Nigeria where there are no dedicated day case theatres with DCS taking place in the same theatre for inpatient surgery thereby interfering with smooth running of DCS, the day cases in our center were performed on scheduled days, in the minor operation theatres, which has three suites located in the Accident and Emergency complex of the hospital.[14] To actualize the global trend of increasing the quantum and proportion of DCS, dedicated DCS theatre is desirable as well as significant investment in day-case surgery as practiced in Europe and America.

The findings of this study revealed that day cases offered in our center were mainly for minor and intermediate surgeries. Like many other centers in our subregion, there are no major cases being part of DCS.[6],[15] This is in contrast to what obtains in the developed world where many major cases that meet the requirements are being offered DCS.[3] This is not unconnected with advancement in technology and surgical techniques resulting in adoption of minimally invasive techniques for hitherto openly performed surgeries which require prolonged admission for wound care and pain control. This is particularly true in the field of urology where endoscopic treatments are the gold standard in the management of many lower and upper urinary tract problems like transurethral resection of the prostate (TURP) for benign prostatic hyperplasia and ureteroscopies for stone treatment. In addition, more and more urological problems are also being sorted out by other minimally invasive laparoscopic and robotic surgeries. On account of this, complexity and scope of DCS has changed dramatically in the last decade. The scope of urologic procedures depends on the peculiarity of the environments. Prostate biopsies, scrotal surgeries and varicocelectomies are the most commonly performed procedures as DCS in our environment. Though a fifth of these patients had endoscopic procedures, this was largely urethrocystoscopies and few internal urethrotomies. This is in big contrast to a wider spectrum of endoscopic procedures being incorporated as DCS in advanced countries. The scope and complexity of urological procedures have expanded to include many urological procedures recently as many authors have demonstrated feasibility of DCS for laparoscopic nephrectomy and transurethral resection of the prostate.[9],[16] Among modern urologists, there is a growing recognition that many well-established urological procedures may be performed in an ambulatory setting.[17] To align with this global trend of increasing the complexity of urologic cases done as DCS, there is need to do more of endoscopic and laparoscopic treatment of major urological diseases in Nigeria.

Local anesthesia (LA) was the most commonly used anesthesia in about 76.9% of all cases in this study. Local anesthesia is desirable and practical in almost all minor and most intermediate cases for day procedures in adults. This is due to its relative safety and minimal postoperative complication thereby facilitating faster discharge from hospital which is the goal of DCS. Addition of sedation to LA has been proven to improve pain control and patient's satisfaction because of the dissociative effect of these agents.[18] As the scope of DCS however expands to incorporate more complex procedures, there will be increasing need for more complex anesthesia. General anesthesia is more suitable for laparoscopic and upper tract endoscopic procedures. This is reflected in reports on day case surgery from the advanced countries.[9],[10],[16] Furthermore, local anesthesia may not be appropriate in children even for minor procedures. Hence, the utilization of more of general anesthesia for children in this study.

The definition of DCS entails discharge on the same calendar day of surgery. It should be noted that there were some minor and intermediate as well as few major operations which actually qualified to be DCS during the study period but were excluded because patients were either discharged on days other than the day of surgery or not planned as DCS ab initio. DCS is therefore not about complexities of procedure but about concept of safely operating and discharging patient on the same day of surgery.

Adverse effects of surgery and anesthesia are not uncommon in surgical practice and are major cause of prolonged admission and re-admission following surgical procedures. Their occurrence is largely dependent on many factors including the diagnosis, complexity of surgery, associated morbidities, duration of surgery and type of anesthesia. The general guideline is that procedures to qualify for DCS should not carry a significant risk of serious postoperative complications requiring immediate medical attention, for example, hemorrhage or cardiovascular instability and postoperative symptoms, such as pain and nausea, must be controllable by the use of a combination of oral medication and local anesthetic techniques.[19] The key to successful DCS is therefore appropriate selection of patients. The admission and re-admission rates of 1.6% and 0.3% respectively were consistent with reports from other centers in Nigeria. It may be due to composition of surgeries in this study being mainly minor and intermediate surgeries which did not carry significant risk as stipulated in the guideline for selection of patients for DCS. This finding is also comparable with results published elsewhere and translates to the levels of safety achieved in DCS even with inclusion of more complex cases. Higher rates may suggest that more inappropriate patients are being treated as day cases; therefore, careful patient selection is sine qua non for a successful outcome in day case surgery.

   Conclusion Top

DCS has several advantages and should therefore be embraced because of the numerous benefits it offers. This study like numerous others, demonstrated the feasibility, effectiveness and safety of DCS even in our setting. Though, it is being practiced in developing countries like Nigeria, there is need to increase the volume and proportion of surgeries undertaken as DCS. To accomplish this, there is need to invest in infrastructure and training as well as better organization of DCS services in our hospitals. This will allow incorporation of more complex cases currently performed as inpatient open surgery in the range of procedures offered as DCS to our patients in this subregion.

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   References Top

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