First Laparoscopic Nephrectomy in Rwanda and More

Well, we completed the first laparoscopic radical nephrectomy ever to be done in the country of Rwanda. It was a bit of shit show, but we got it done using only hook cautery, a suction device and one staple load with a single use stapler that we reused. I did the case and then following week we did another one and I took Dr. Emmanuel through the second one. He did the whole case himself having only seen one laparoscopic nephrectomy in his life. See one, do one, teach one. Usually, though, it is see 50, do 50, then start teaching. Here in Kigali at CHUK, we are on the accelerated program. The patients did quite well and now we hope to build on that by acquiring better and more sophisticated equipment. The hook cautery is SO 1990’s!! My project is to help build on the laparoscopic program that is in place and I may ask for YOUR help at some point. :).

In the video below, Dr. Emmanuel, who has only seen one laparoscopic nephrectomy (kidney removal) the week before, is seen here using a stapler to cut and close off the renal artery and vein, which is the most significant portion of the operation. And for the urologists reading this, yes, you can take them both at the same time, especially if there are limited staple loads available! NO worries about fistula, especially since we dissected the artery and vein separately. If it does not staple properly, then the bleeding can be brisk, so there is always a little bit of tension in the room. Right after the video ended, everyone clapped for Emmanuel. It was very cute.

My first radical cystoprostatectomy experience at King Faisal Hospital, the private hospital

A lot of private paying patients come from the DRC, Democratic Republic of Congo, known as Congo around here. There is another country called the Republic of Congo, whose capital is Brazzaville, also known as Congo, but let’s stick to the larger DRC. The DRC whose population is 80 million has only one urologist in the whole country and he is in Kinshasa, which might as well be the moon for people living in the resource-rich, unstable eastern Congo which borders Rwanda. With the development of the medical profession here in Rwanda, the word is out that there are good doctors and specialists here, so people come from neighboring countries, Congo, Burundi, Uganda, and even Tanzania to be seen by the urologists here. Last week I did a radical cystoprostatectomy with my co-surgeon, Dr. Afrika at the private hospital. That surgery involves bladder and prostate removal and taking a piece of bowel, plugging the ureters into that segment and attaching segment to the skin like a colostomy except it is urine coming out, not feces. It’s a big surgery obviously and this one was particularly difficult due to the patient’s extremely narrow pelvis (black men tend to have more narrow pelvises) and he had had previous bladder surgery. There were several surgeons and residents in the room to see how this surgery is done. It started with me explaining the steps to everyone, having Dr. Afrika do half the case and then 4 hours later it devolved into a situation where the patient was bleeding, hypotensive, the blood was not being brought up fast enough, and I could not see the prostatic apex due to the patient’s anatomy, so I had to go full commando, and use the force by cutting blindly by feel and just get this thing out before the patient bleeds to death on the table. That’s the thing about surgery here in Rwanda, and much of Africa in general. YOU are it. There is no backup, there are no layers of support. That’s the big difference from Africa to North America. The urologists here tell me that as well, that every procedure they do is with not backup and also no backup equipment. At home, if I can’t access the upper urinary tract with one wire, I have 6 other options to try. Here the urologist is using one wire and if that doesn’t work, then you are up the creek with the only paddle. I was fully on my own at that point, and if I don’t figure this out soon, bad things are to happen to this patient, and there are all these folks in the room watching. Well, we got the bladder out and the patient actually did just fine and discharged home postoperative day 7. Unfortunately for me, I was coming down with a serious bacterial stomach infection during the case. That experience was something else. The patient’s total bill for the surgery? 3.8 million Rwandan francs (4,300 US) and had to pay 1.6 million upfront to get in the hospital door.

The patient is going to stick around here is Kigali for the next month and then will be seen in postoperative clinic in 3-4 weeks when we hopefully give him the green light to go home back to the DRC.