Medical Research Council of South Africa.

Background Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0•7 per 100 000 population (IQR 0•2-2•0). Maternal mortality was 20 (0•5%) of 3684 patients (95% CI 0•3-0•8). Complications occurred in 633 (17•4%) of 3636 mothers (16•2-18•6), which were predominantly severe intraoperative and postoperative bleeding (136 [3•8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4•47 [95% CI 1•46-13•65]), and perioperative severe obstetric haemorrhage (5•87 [1•99-17•34]) or anaesthesia complications (11•47 (1•20-109•20]). Neonatal mortality was 153 (4•4%) of 3506 infants (95% CI 3•7-5•0). Interpretation Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa.

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration: NCT03044899.

Background: Urethral strictures cause malfunction of the urethra. Urethroplasty is a cost-effective treatment option. Its success rate is greater than 90% where excision and primary anastomosis(EPA)is performed and 80-85% following substitution urethroplasty. Definitive treatment for recurrent urethral strictures after urethroplasty is not defined. Repeat urethroplasty is a viable option with unknown efficacy.Method: Retrospective analysis of patients who underwent revision urethroplasty for unsuccessful urethroplasty at KNH from 2015 to 2018 was performed. Patients’ age, demographic data, stricture length, location, aetiology, comorbidities and type of urethroplasty was evaluated from records with complete data. Male patients aged 13 to 80years were evaluated. Comparison of urethroplasty outcome between two patient cohorts was made: Fresh urethroplasty patients versus failed urethroplasty who underwent revision so as to determine efficacy of the later. Principal outcome measure was urethral patency, while Subsidiary outcome measures were associated complications. Outcomes were compared using statistical package SPSS version 23.0.Result: 235 patients who met inclusion criteria underwent urethroplasty, 71.5% (n=168) had a successful outcome, while28.5% (n=67) failed and were subjected to revision urethroplasty. Another 58% were successful upon revision but experienced significant morbidity. Majority of urethral strictures were bulbomembranous. Trauma was the leading cause of urethral strictures followed by idiopathic strictures. EPA was the commonest surgery while Tissue transfer featured prominently in revision urethroplasty. A significant correlation was evident between stricture length, prior surgery, and procedure choice and urethroplasty outcome.Conclusion: Revision urethroplasty is feasible after failed urethroplasty but less efficacious. Stricture length, number of prior surgeries and procedure choice affected outcome.EPA and Tissue Transfer techniques are essential surgical armamentarium in revision setting.