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© 2021 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Open Surgery for Urinary Stones in a Resource  
Poor Setting: A Look at Dalhatu Araf Specialist 
Hospital, Lafia, Nigeria
Christian A. Agbo 

Institution-Dalhatu Araf Specialist Hospital, Lafia, Nigeria

Soc Int Urol J.2021;2(2):79–81

DOI: https://10.48083/KFQZ6048

Dalhatu Araf Specialist Hospital
The Dalhatu Araf Specialist Hospital is a tertiary 
multispecia lt y public hospita l located in Laf ia, a 
northern part of Nigeria, which, because of the climate, 
has a high incidence of urologic stones even in children 
as young as one year old. Within the state, which has a 
population of about 2 million, there is another tertiary 
institute (in Keffi) that has 2 urologists. Further afield, 
there are bigger hospitals in Abuja, Jos, and Lagos that 
can undertake other procedures. Some patients are 
referred to Abuja, but it is a 3-hour drive from Lafia, and 
we can refer only those who can afford to pay—about 
90% cannot.

Management of Urinary Stones  
in Our Environment
The Dalhatu Araf Specialist Hospital has X-ray and 
ultrasound equipment, and CT is available at a nearby 
centre. The hospital also has video equipment, but 
there is no funding for instruments. I have, therefore, 
purchased 2 cystoscopes, but they are rigid, rather 
than flexible, representing technology from the 1960s 
or 1970s, and they do not provide the same view as the 
more modern flexible scopes. The lack of technology 
is particularly frustrating because I spent 6 months in 
India training in the endoscopic management of stones, 
so I have the skill to undertake minimally invasive 
procedures if the equipment were available.

TABLE 1

Overview of the open surgery done for urinary stones seen at Dalhatu Araf specialist hospital,  
Lafia, Nigeria within a 2-year period

Location of stone n % Types of open surgery 

Renal

Single 6 21.4
Anatrophic nephrolithotomy 

Extended pyelolithotomy

Staghorn 3 10.7
Anatrophic nephrolithotomy

Extended pyelolithotomy

Ureter 5 17.9 Ureterolithotomy

Bladder 11 39.3 Cystolithotomy

Urethral 3 10.7 Urethrolithotomy

Total 28 100.0

Introduction

Urinary stone disease has aff licted humankind since antiquity[1]. It remains a common urological condition 
worldwide, including in our environment[2]. Although open surgery was previously the main option for stone 
removal, advances in technology mean that treatment is now largely through minimally invasive surgery, as 
recommended by a number of urological guidelines[3,4]. Unfortunately, at our centre, we still treat urinary stones 
solely through open surgery, mostly because we lack  endoscopic equipment. In addition, most of our patients, even if 
referred to facilities where endoscopic management is possible, cannot afford the cost of treatment. 

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UROLOGY AROUND THE WORLD

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Urinary stones account for about 30% of my case-
load as the hospital’s single urologist. In the last 
2 years, 28 open surgeries for urinary stones were 
underta ken at the hospita l (Table 1), including 
anatrophic nephrolithotomy, extended pyelolithotomy, 
ureterolithotomy, cystolithotomy (Figure 1), and 
urethrolithotomy. Patients with urinary stones are 
referred here from other smaller centres within the state. 
A good proportion (55.4%) of the patients are managed 
non-surgically, in accordance with the European 
Association of Urology guidelines. These are patients 
who are asymptomatic or non-obstructing and those 
that have medical expulsive therapy for lower ureteric 
stone.

The patients are financially responsible for their 
health care but at a very subsidized rate because of the 
low socioeconomic status of the people, many of whom 
are subsistence farmers, growing rice and yams. Cost is 
therefore a major consideration in treatment. If patients 
come in for surgery, they pay the hospital US$100 for 
stone management (more if there are complications). For 
a lot of patients, this is more than one month’s salary, 
and about 2/3 of patients are still managed without 
surgery.

The commonest indication for surgery is persistent 
pain (61.2%) followed by obstruction. All patients who 
meet the indication for surgery are managed by open 
surgeries. Although open surgery still has a role in stone 
management in cases of complex stone, Hippocrates 
discouraged open surgeries for stone. His oath reads: 

‘I will not cut persons labouring under the stone, 
but will leave this to be done by practitioners of this 
work’[5]. The majority of urinary stones can be managed 
endoscopically[6]. In the near future, we hope to manage 
stones endoscopically, which will require additional 
training and equipment.

When surgery is required, patients are admitted a 
day before the procedure. The average hospital stay is 
5 days. Both external and internal stents are used here 
depending on the availability and affordability at time of 
surgery. When patients undergo pyelolithotomy, stents 
are usually put in, which can entail a hospital stay of  
up to 5 to 7 days (when external stent is used),  depending 
on drainage. In some cases (when internal stent is used), 
they stay 2 to 3 days, and then come back for removal at 
6 weeks post-procedure. When an external stent is used, 
it is passed through the kidney, as with nephrostomy. 
Instead of a single J stent, we use a feeding tube, which is 
far less expensive and works just as well.

As the sole urologist at the centre, I am also respon-
sible for the patient’s postoperative care, which can be 
quite challenging. Although we do have residents in 
general surgery, who assist me, as well as residents doing 
a three-month rotation in urology and subspecialties, 
there are no urology residents—and as the hospital does 
not have accreditation, we do not have visiting residents 
from Abuja or Lagos.

Postoperatively, the patient’s family is responsible for 
a lot of the care, including provision and preparation of 
food. Pain medications are provided while the patient 
is in hospital, but at discharge, the patient assumes 
responsibility and must obtain needed drugs from the 
nurses or the pharmacy within the hospital.

The hospital also sees a lot of benign prostatic 
hyperplasia. Currently, it is not possible to do anything 
but retropubic simple prostatectomy because the hospital 
does not yet have the equipment to permit transurethral 
resection of prostate. We are looking forward to getting 
equipment. Many patients cannot afford medical 
therapy, so they undergo simple prostatectomy, which 
I do here (probably 2 a month). Postoperatively, patients 
are catheter-dependent for 7 to 10 days for transvesical 
prostatectomy, and most are comfortable with that.

Difficulty in getting to the centre or concerns about 
the cost of treatment means that patients with bladder 
cancer often present at an advanced stage. Once the 
diagnosis has been confirmed by cystoscopy, patients 
are referred to a higher-level centre for transurethral 
resection of bladder tumour. Chemotherapy is also 
available if patients can afford it. Otherwise, radical 
cystectomy is performed at our centre. Regardless, 
patients are often lost to follow-up.

FIGURE 1. 

A stone from the urinary bladder via open cystolithotomy

80 SIUJ  •  Volume 2, Number 2  •  March 2021 SIUJ.ORG

UROLOGY AROUND THE WORLD

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Conclusion
Although open surgery still has a role in complex 
stone disease and in patients with anatomical and 
physiological anomalies, the majority of urinary stones 
can be managed by minimally invasive surgeries. To 
date, attempts to secure funding (from government 
bodies and from private foundations) for equipment 

that would allow stones to be managed endoscopically 
have been unsuccessful. We continue to seek support 
and funding for training and provision of endoscopic 
equipment that will enable us to meet the global 
standard of care.

References
1. Tefekli A, Cezayirli F. The history of urinary stones: in parallel with 

civilization.  Scientific World Journal.2013;Article ID 423964. doi.
org/10.1155/2013/423964

2. Çakici ÖU, Ener K, Keske M, Altinova S, Canda AE, Aldemir M, et 
al. Open stone surgery: a still-in-use approach for complex stone 
burden. Cent European J Urol.2017;70(2):179–184.

3. Tzelves L, Türk C, Skolarikos A. European Association of Urology 
Urolithiasis Guidelines: Where Are We Going? Eur Urol Focus. 
2020;S2405–4569(20):30270-30274. doi: 10.1016/j.euf.2020.09.011.

4. Zumstein V, Betschart P, Abt D, Schmid HP, Panje CM, Putora PM. 
Surgical management of urolithiasis – a systematic analysis of 
available guidelines. BMC Urol.2018 Apr 10;18(1):25.

5. Buchholz N, Elhowairis ME, Bach C, Moraitis K, Masood J. From 
‘stone cutting’ to high-technology methods: The changing face of 
stone surgery. Arab J Urol.2011 Mar;9(1):25–27.

6. El-Husseiny T, Buchholz N. The role of open stone surgery. Arab J 
Urol.2012;10(3):284–288.

81SIUJ.ORG SIUJ  •  Volume 2, Number 2  •  March 2021

Open Surgery for Urinary Stones in a Resource Poor Setting

https://doi.org/10.1155/2013/423964
https://doi.org/10.1155/2013/423964
http://www.siuj.org

