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PROCEEDINGSOFTHEFIRSTJOINTHAITIANAMERICANUROLOGYCONFERENCE

NOVEMBER14-15,2013HOTELOASISINTERNATIONAL,PETIONVILLE,HAITI

HistoryofUrologyinHaiti(PierreBoncy,MD)UrologyinHaiticametoberecognizedasaspecialtyinHaitisome50yearsago.Aseverywhereelse,itwasoriginallyperformedbygeneralsurgeonswhoeventuallylimitedtheirpracticetotheuro-genitaltract.ChristianValme,MDwhopracticedinthe1960sisconsideredthetruepioneerinUrologyattheStateUniversityHospitalofHaiti.WealsohavetorecognizethelateDr.ConstantPierre-LouiswhoorganizedtheServiceofUrologyatthesamehospital.Aroundthesameperiod,Dr.ConstantAndrepracticedurologyinthecityofCap-HaitienafterashorttrainingperiodwithDr.ConstantPierre-LouisinPort-au-Prince.Heperformedcircumcisions,hydrocelectomies,cystostomiesandpenileamputations.HebecamethemedicaldirectoratHopitalJustinienin1957andretiredin1969.The1970-1980decadeisconsideredthegoldeneraofHaitianurologyasagroupofyoungurologists,mostofthemtrainedintheUSAattheHomerJ.PhillipsMedicalcenterinSaint-Louis,MOreturnedhometopracticetheirskills.TheyincludedDecatrelMirville,MD,RogerValme,PierreNazon,MD,AnthonyCamilleMD,RaymondRemy,MDandDr.Benjamin.Mostofthemhavesincediedorretired.Thebatonwaspassedtothethirdgenerationofyoungurologistsinthe1980s,amidstserioussocio-politicalupheavalandseriousdifficultiesincludinganobsoleteandinadequateequipment.Between1980and2000,thisgroupwasmadeofPierreBoncy,MD,Dr.Barthelemy,BernardBrutus,MD,Pierre-AlixNazon,MDandJacquesGraciaMedilien,MD.ThisbringsustocontemporarytimesandthecurrentstaffattheStateUniversityHospitalthatincludesinadditiontothepreviouslymentionedgroup,Georges-EricBrisson,MD,ClaudePaultre,MD,RogerValme,MD,MiletotClervilandG.Alexis,MD.EverysinglememberoftheteamhascompletedaresidencytraininginUrologyattheStateUniversityHospitalandisthuscertifiedbytheMinistryofHealth.Inaddition,theyhaveacquiredadditionaltrainingeitherintheUSA,inFranceorintheFrenchAntilles.Mostoftheseurologistspracticeinthe“RepublicofPort-au-Prince”eitherinthepublicsettingattheStateUniversityhospitalorintheprivatesector,betweentheHopitalduCanape-Vert,l’AsileFrançais,theHopitalSaint-FrancoisdeSales,theCliniqueRoger-EmmanuelandtheBaptistMissionofFermathe.TheevolutionofHaitianUrologyismirroredbytheevolutionofprostatectomythatwentthroughthestagesof

- Trans-VesicalAdenomectomywithsupra-pubicPezzerCatheter- Trans-VesicalAdenomectomywithcontrolofbleeding- Trans-VesicalAdenomectomywithFoleycatheter- Trans-VesicalAdenomectomywithbloodtransfusioninlessthan50%ofthecases- Finally,Trans-UrethralResectionofProstate

ProgressinthefieldofUrologyinHaitiwillrequirenotonlyanequipmentupgrade,butalsostrongleadershipandtheunificationofallinvolvedinthepracticeofurologyandinthetrainingofthenextgenerationinordertostandardizetheresidencyrequirementsandimprovetheskillsoftheurologistsAnInventoryofHumanResourcesinUrologyinHaiti(ClaudePaultre,MD)ThefirstMedicalSchoolinHaitiwasestablishedin1820.Sincethen,ithasbecomeincorporatedintheStateUniversityofHaitiastheFacultedeMedecineetdePharmacie.Themedicaldegreeisobtained

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afterasix-yearcyclethatfollowsthesatisfactorycompletionofthesecondaryschoolcurriculum.Thatsix-yearcycleincludestwoyearsofBasicSciences,threeyearsofClinicalSciencesandoneyearofrotatinginternship.

• Subsequently,threeadditionalprivatemedicalschoolswereadded:UniversityofQuisqueyain1988,UniversityLumierein1993andUniversityofNotre-Damein1995,whichisaseven-yearprogram.Thus,therearecurrentlyfourrecognizedmedicalschools.Moreschoolsareintheprocessofseekingrecognition.Withinthosemedicalschools,UrologycoursesareprovidedtotheFifth-Yearstudentsbyfiveprofessors:Dr.R.ValméandDr.M.ClervilattheStateUniversity,Dr.R.ValméandDr.J.M.AubourgatNotre-Dame,Dr.P.BoncyatQuisqueyaandDr.C.PaultreatLumière.ThemedicalstudentsreceivetheirfirstclinicalexposuretoUrologyintheirfifthyearofeducationunderthedirectionoffourClinicalInstructors:DrP-A.NazonandDrG.AlexisattheStateUniversity,Dr.J.M.AubourgatNotre-DameandDr.J.GanthieratLumière.ThesecondclinicalexperienceinUrlogyisprovidedasaone-monthrotationinUrologyduringthefinalyearofrotatingInternship,whichtakesplaceattheStateUniversityHospital(HoppitalGeneralinPort-au-Prince)fortheStateUniversityStudents,attheHôpitalUniversitaireJustinieninCap-HaitienforthestudentsfromNotreDameandQuisqueyaandatHôpitalImmaculéeConceptioninLesCayesforthestudentsfromLumière.AtthePost-Graduatelevel,theresidentsreceivetheirspecialtytraininginUrologyattheStateUniversityHospitalinPort-au-PrinceandatHopitalUniversitaireJustinieninCap-Haitien.InPort-au-prince,theFacultyincludes:Dr.P.Boncy,HeadofDepartment,Dr.G.E.Brisson,AssistantHead,Dr.C.Paultre,ProgramDirectorandastaffofseven:Dr.B.Brutus,Dr.D.Barthelemy,Dr.J.G.Médilien,Dr.G.Alexis,Dr.P-A.Nazon,Dr.M.ClervilandDr.R.Valmé.In2013,thefour-yearprogramcounts12residents:3atthethirdyearlevel,sixatthesecondyearleveland3atthefirstyearlevel.Therearecurrentlynofourthyearresidentssincetherewasnograduationin2010,becauseoftheJanuary12,2010Earthquake.TheServiceofUrologyattheHôpitaluniversitaireJustinienofCap-HaïtienisdirectedbyDr.JeanGetoDubé,whoisalsothechiefAdministratoroftheInstitution,aidedbyhislonestaffmemberDr.JoryDésir.Fiveresidentsarenowintraining,twoatthesecondyearlevelandthreefirstyearresidents.ThroughvarioustrainingopportunitiesofferedinEuropeandinNorthAmerica,someofthestaffmembershaveacquiredaspecialexpertiseinspecificareas.InEndourology,Dr.Pierre-AlixNazonisthemostversedinUrethrocystoscopy,InternalUrethrotomy,TURPs,TURBTs,Resectionofposteriorurethralvalves,ureteroscopyandshockwavelithotripsy,whileDr.ClervilhasspecialskillsinfemaleurologyandurologiconcologyasheisthemostfacilewithColporrhaphyandcolpopexy,aswellasRadicalProstatectomiesandCystectomies.Finally,Dr.JacquesJeudyhasbeenpioneeringarenaltransplantprogram,whichisstillinitsinfancy.BesidesthetwotrainingcentersinPort-au-PrinceandCap-Haitien,UrologicproceduresarealsoperformedinLesCayes,Petit-Goave,St-MarcandJacmel.Inconclusion,overthepast20years,24physicianshavebeentrainedinUrology.Currently,thereareatotalof26urologistsinHaiti:20inPort-au-Princeand6fortherestofthecountry,whichrepresentsaratioof1:>300,000population.Thisnumberislikelytogrowsoonthankstothetwoaccreditedsitesofresidency.UROLOGICSURGERYINAPRIVATESETTINGINPORT-AU-PRINCE–Pierre-AlixNazon,MD

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MyassignmentwastopresentalistofthemostcommonurologicpathologiesencounteredinHaiti.Suchdatahasnotbeencompiledatthenationallevel.Inlieuofnationalstatistics,Ithoughtthatasurveyoftheproceduresperformedoveratwo-yearperiodatasingleinstitutionwouldgiveanidea,albeitabiasedone,oftheurologicconditionsseeninHaiti.ThispresentationisbasedonareviewofthesurgicalinterventionscarriedoutfromJanuary2010toJanuary2013attheCliniqueRogerEmmanuel,whichisasmallprivateambulatorycenterlocatedonAvenueJohnBrowninPort-au-PrinceanddedicatedtoUrologicProcedures.ItconsistsofoneOperatingroom,threepatientroomsandonelithotripsysuite.ThreehundredthirtyUrologicprocedureswererecordedoverthisperiodandcanbeenumeratedbyorderoffrequency.TURP 133Ureteroscopy 36Circumcision 32Varicocelectomy 31InternalOpticUrethrotomy 24Hydrocelectomy 22SurgeryforKidneyStones10

Bilateralorchiectomy 10SurgeryforBladderstones9Cryptorchidycorrection8Prostatectomy7PosteriorUrethralvalveablation4Vasectomy 2 RadicalProstatectomy1

Theycanalsobelistedbyanatomicsiteasfollows:150Prostateoperations(or45.45%),63scrotalprocedures(19.09%),55interventionsforstonedisease(16.66%),32circumcisions(9.69%),24urethraloperations(7.27%)andtwootherprocedures(0.60%).Breakingeachcategorydown,wefindthat113prostaticproceduresweredoneforbenignprostatichypertrophy(106-TURPand7opentrans-vesical)and37foradenocarcinoma(27TURP+Orchiectomy,10orchiectomiesand1radicalprostatectomy).Sixty-threecases(19.09%)wereclassifiedasScrotalproceduresandincluded31varicocelectomies,22hydrocelectomies,eightundescendedtestesandtwovasectomies.Fifty-fiveinterventions(16.66%)werecarriedoutforstonediseases:36forureteralstonesextractedbysemi-rigidureteroscopywithorwithoutintra-corporealpneumaticlithotripsy,10openpyeloornephro-lithotomiesandnineforopenorendoscopicremovalofbladderstones.Undertheheadingofforeskinprocedures(9.69%),welisted32circumcisions–6ofthemforchildrenlessthanfouryearsofage.InthegroupingofUrethralProcedures,wecounted24internalopticurehrotomyandfourposteriorurethralvalvefulgurations,foratotalof28proceduresor7.7%.Finally,twoadditionalurologicprocedureswereclassifiedasothers,includingoneunsuccessfulrepairofavesico-vaginalfistulaandacaverno-spongialshuntforpriapisminapatientdiagnosedwithsicklecellanemia.

Conclusions:BenignProstaticHypertrophyandProstaticcarcinomaremainthemostcommoncasesseeninourpractice.Bladderoutletobstructionrepresentsanenormousburdenforthemalepopulationsincetheyspendoftenmonths,evenyearswithindwellingbladdercatheters.MostpatientsinourseriesweretreatedwithTransUrethralResections,whichisnotwidelypracticedinHaiti.WorkshopsandadditionaltraininginthisareawouldbebeneficialformostofHaitianUrologists.Astotheprostaticcarcinomas,theyweremostoftendiagnosedinadvancedstages,onlyonepatientqualifyingforaradicalprostatectomy.Theonlyoptionforthemajorityofthe

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caseswashormonaltherapy,whichconsistedinasurgicalcastration.Fortunately,itwouldappearthatthehighgradeprostaticadenocarcinomareportedintherelativelyyoungmalesintheAfricanAmericanpopulationandotherCaribbeancountriesisnotseenasfrequentlyinHaiti.Itiscuriousthatinacountryknownforitsoverpopulation,wetreatedmoremenforinfertilitywith24varicocelectomiesagainstonly2vasectomies.ThisshouldbefoodforthoughtfortheMinistryofHealthandPopulation.Asfarasdealingwithstonedisease,wehavebecomequitefacilewiththesemi-rigiduteroscopebutwehavenoexperiencewiththeflexibledevice.ThehighcostoftheLaserequipmentanditsfragilityrepresentmajorobstaclestotheuseofthattechnologyinHaiti,butwehopesoontobeabletoperformpercutaneousnephrolithotomies,sincewealreadyhavetheC-armfluoroscopycapability.OurcasesofUrethralStenosisweretreatedbyOpticalUrethrotomyandourresultsweresimilartothosereportedintheliterature.However,recentworkshopsinReconstructiveurologicsurgeryhavechangeddramaticallytheoutcomeforourpatients.UrethroplastywithorwithoutgraftasthebestapproachfordifficultstricturesconstitutesamajorimprovementinurologicpracticeinHaiti.InthefieldofPediatricurology,circumcisionsandtesticulardescent+fixationareregularlydoneWedonothaveapediatriccystoscopyset,soweusetheureteroscopeforposteriorurethralvalvefulgurations(4patients)Finally,asfarasfemaleUrology,mostofthepatientspresentedwithrenalorureteralstones.WealsohadonecaseoffailedVesico-VaginalFistularepair,whichhassubsequentlysuccessfullyrepairedsincethenbyDr.AngeloGousseduringoneofhisrecentvisitstoourinstitution.Thissurveyhascertainlymanylimitations,butourpurposewastopresentthestatusofHaitianUrologyinordertohelpourgrouptoimplementprojects,findstrategiesandmeanstoreachwhatshouldbethegoalofthiscollaborationbetweenHaitianandAmericanUrologists,whichisto:“AchieveanappreciablestandardofcarefortheHaitianUrologicpatients.”HaitianResidencytraininginUrology–ObstaclesandLimitationsbyJoryDesir,MDandYouryDreux.Fiftyyearsago,aresidencyprograminUrologywasinitiatedattheGeneralHospitalinPort-au-PrincewhichsincehasbecometheStateUniversityofHaitiHospital(HUEH).TheUrologyResidencyprogramstartedinCap-HaitienattheJustinienUniversityHospital(HUJ)in2006.ThesetwoinstitutionsconstitutetheonlytwotrainingvenuesinUrologyinHaitiandtodate,theyhavegraduated26urologistsoverthepast20years:24inPort-au-Princeand2inCap-Haitien.ThefacilityattheHUEHincludes

• 2consultationsroomsforoutpatientvisits∗ 9inpatientbeds:4foremergencycasesand5forelectiveones∗ 1roomforarchives∗ 1roomforminorsurgery∗ 1treatmentroomforFoleycatheterinsertionsandreplacements

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∗ 1conferenceroom∗ ThreeofficesfortheChefofUrology,theHeadNurseandtheSecretary.

TheUrologyServiceatHUJconsistsof∗ 1outpatientconsultationroom∗ 11inpatientbeds:6forelectiveandemergencycases,1forisolationand4forprivate

patients∗ 1roomforminorsurgery,whichisalsousedforendoscopicexploration∗ 1treatmentroomforFoleycatheterinsertionsandreplacementsandnursingcare∗ Twooffices:onefortheUrologyChiefandonefortheheadnurse.–Thereisnobudget

forasecretaryinUrology∗ IroomforMedicalRecords∗ Noformalconferenceroom

AttheHUEH,thestaffandpersonnelaremadeof11urologists(10active),12residents(three3rdyear,six2ndyearandthreeFirstyearresidents,10Nurses,seveninterns,fivenursingstudentsandeighthousekeepers.Incomparison,theServiceofUrologyatHUJcountstwoattendings,threeresidents(twosecond-yearandonefirstyearresidents),eightnurses(1headnurse+7staffnurses),12Interns,5NursingStudentsand3housekeepers.TheresidentsarerecruitedfromallthefourmedicalschoolsbutpredominantlyfromNotreDameandQuisqueya,throughanationalcontest.Theresidencycurriculumstretchesoverafour-yearperiodandconsistsofatheoreticaldidacticcomponent,aclinicalcomponentandanoperativecomponent.However,thespecificrequirements,suchasthegoalsandobjectivesofthatCurriculumremainvagueandoftenignored.Indeed,thestandardsareilldefined.Thereisnosystemofaccreditationoftheresidencyprogramsandthereisnoassessmentoftheleveloftechnicalexpertiseachievedbytheresidentattheendofhisorhertraining.Someresidentscompletetheirtrainingwithlimitedexposuretocertainproceduresornonewhatsoever.Eveniftherewasamandatoryquotaofprocedures,howcanitbeenforced?Additionalobstaclestothepropertrainingofaurologyresidentresultfromthephysicaldeficienciesofthehospitalfacilityandtheinadequatesupervisionoftheseresidents,dueinparttothesalarystructureandintrinsicfailuresintheresidencystructure.Indeed,thesefacilitieslackofproperequipment.Theinstrumentsareoftenobsoleteandwhenbroken,itisimpossibletohavethemservicedorreplaced.Onesensesthatboththeresidentsandtheattendingstaffshowalackofmotivationorworkethics.Thesalarystructureispartlyresponsible,sincetheyaretraditionallylow(<US$200/monthforaresidentand<US$650fortheattendingstaff)andtheyarepaidirregularly.Therefore,tomeettheirdailyexpenses,theattendingstaffmustearnadditionalincomefromprivatepractice,whichpreventsthemfrombeingphysicallypresentatthehospitalstosupervisetheresidentsormoreactivelyparticipateintheirformationbyprovidinglecturesandotherdidacticactivities.Thereisalackofanup-to-datelibrarywithappropriateaudio-visualeducationalmaterial.Althoughthereisanabundanceofurologicpathologyinthepopulation,despitethefactthatmedicalcareissupposedtobefreelyavailable,alargepercentageofthepopulationcannotaffordaconsultation,thetestsnecessaryorthecostsofoperationsandhospitalization.Therefore,thenumberofcasesavailableforthetrainingoftheresidentsislimited.Thenumber

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ofinpatientbedsislimited.Adequateimagingstudiesarelackingmostofthetimes.Theequipmentintheemergencyserviceorintheoperatingroomislimitedanddoesnotincludewhatwouldbeconsideredbasicinamoreadvancedsystem,suchasendoscopy,laparoscopy,lasertechnology.Forexample,theemergencyroomlackoftenthefollowingtoolsandmaterials:catheters(coude,rigid…),anultrasoundmachine,aBladderscan,trocarforsupra-pubiccystostomy,Filiformsandfollowers,Cystoscopeset,sterileGauzeandglovesorevenanadequateUrologicTable.Theoperatingsuiteateitherinstitutiononlyhastwoworkingoperatingroomsforsixsurgicalservices.TheUrologyServicehasaccesstotheoperatingroomsonlytwodaysaweek.Theylackofproperurologictables,workingelectro-cautery,suctionmachines,endoscopictowerswithlightsource,overheadlightsetc…Thereisnopossibilityforfrozensections.Evenregularpathologyisverycostlytothepatientsandthereisalongwaitingperiodforthepathologyresultsevenwhenthepatientcanaffordtohavethetestdone.Althoughseveralattendinghavehadshortperiodsoftrainingabroad,cantheyreallybeconsideredspecialists?Cantheyoffersub-specialtytrainingtothefinishingresidents?Arethereanyprogramsofcontinuingmedicaleducationtokeeptheattendingphysiciansup-to-date?ThereisnoexchangebetweentheHUEHandtheHUJprograms.TherearenopossibilitiesforclinicalorlaboratoryresearchandnourologicpublicationsinHaiti.ShortperiodsoftraininginFranceortheFrenchAntillesarerareandunpredictable.Tostarttoremedytoalltheseproblems,wehumblysubmitthefollowingrecommendations:1- Firstweneedarevisionofthecurriculumwithgoalsandobjectiveswell-definedtakingintoaccounttheevolutionoftraininginurologyintheworldandadaptedtotheHaitianreality2- ContinuingMedicaleducationandopportunitiestoincreasetheirskillsandlevelofexpertiseanddefinestandardsofcareforallstaffinvolvedinthetrainingofurologyresidents.3-ExchangebetweenHUEHandJUHtosynchronizethetrainingofurologyresidents:clinicalrotations,videoconferencing,commonresearchprojects,writtenandoraltestsattheendoftheresidencyforbothsitesinlieuofboardcertification.4-EstablishanacademicenvironmentforpropereducationinUrology–Opportunitiestopublishcasereports,caseseries,reviewarticlesorpresentatlocal,nationalorinternationalurologicconferences5-Encouragethefacultymemberstoobtainsub-specialtytraining6-Offertheresidentstheopportunitiestorotateinthesedifferentsub-specialtiespriortotheirgraduationortoobtainthemselvessub-specialtyqualificationaftergraduation.UrologyisanessentialpartofamedicalschoolCurriculumanditcontributestothemultidisciplinaryculture,byplayinganactiveroleinthecrosstrainingofalltheresidents.UrologyResidencyTraining–TheFutureofUrologiccareinHaiti–AngeloGousse,MDTheLanguageforMinimumProgramRequirementswasApprovedbytheACGME,September28,1999EducationalProgram.Itstatesthattheresidencyprogrammustrequireitsresidentstoobtaincompetenciesinthe6areastothelevelexpectedofanewpractitioner.Towardthisend,programsmustdefinethespecificknowledge,skills,andattitudesrequiredandprovideeducationalexperiencesasneededinorderfortheirresidentstodemonstrate:

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• PatientCarethatiscompassionate,appropriate,andeffectiveforthetreatmentofhealthproblemsandthepromotionofhealth

• MedicalKnowledgeaboutestablishedandevolvingbiomedical,clinical,andcognate(e.g.epidemiologicalandsocial-behavioral)sciencesandtheapplicationofthisknowledgetopatientcare

• Practice-BasedLearningandImprovementthatinvolvesinvestigationandevaluationoftheirownpatientcare,appraisalandassimilationofscientificevidence,andimprovementsinpatientcare

• InterpersonalandCommunicationSkillsthatresultineffectiveinformationexchangeandteamingwithpatients,theirfamilies,andotherhealthprofessionals

• Professionalism,asmanifestedthroughacommitmenttocarryingoutprofessionalresponsibilities,adherencetoethicalprinciples,andsensitivitytoadiversepatientpopulation

• Systems-BasedPractice,asmanifestedbyactionsthatdemonstrateanawarenessofandresponsivenesstothelargercontextandsystemofhealthcareandtheabilitytoeffectivelycallonsystemresourcestoprovidecarethatisofoptimalvalue

Theresidencyprogrammustdemonstratethatithasaneffectiveplanforassessingresidentperformancethroughouttheprogramandforutilizingassessmentresultstoimproveresidentperformance.Thisplanshouldinclude:

• Useofdependablemeasurestoassessresidents'competenceinpatientcare,medicalknowledge,practice-basedlearningandimprovement,interpersonalandcommunicationskills,professionalism,andsystems-basedpractice

• Mechanismsforprovidingregularandtimelyperformancefeedbacktoresidents• Aprocessinvolvinguseofassessmentresultstoachieveprogressiveimprovementsin

residents'competenceandperformance.Theresidencyprogramshoulduseresidentperformanceandoutcomeassessmentresultsintheirevaluationoftheeducationaleffectivenessoftheresidencyprogram.Itshouldhaveinplaceaprocessforusingresidentandperformanceassessmentresultstogetherwithotherprogramevaluationresultstoimprovetheresidencyprogram.Overallgoalsandobjectivesmustbedefinedfortheentireresidencyprogramandforeachpost-graduatelevel.TheoverallgoalsshouldfocusonCompetencybasedevaluations–assessingsurgicalskillandjudgment.Thefirstyearresidentshouldlearn:Endoscopicprocedures,Minoropenurologicprocedures-penile&scrotalsurgeryandsurgicaltechniquesforcomplexmajorcasesthroughobservationintheOR.Thesecondyearresidentwillgainresearchskills,understandandfunctionasthe'consult'resident,attempttomasterthemorecomplexsurgicalprocedures,improveendoscopicandresectionskills(i.e.,TURP,TURBT)andmastertransrectalultrasoundbiopsytechniqueaswellasreadingUrodynamicstudies.TheThird-YearresidentwillfocusonPediatricUrologicprocedures,acquireEnhancedknowledgeofrenalphysiologyandvascularsurgeryskillsandmanagetheconsultservice.Inaddition,hewillactasprimarysurgeononmanyofthemajorcasesandasaTeachingAssistanttojuniorresidentsontheminoropenandendoscopiccases.

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TheFourth-YearResidentwillmasterorganizationandmanagementofthepatient’ssurgicaltreatment,inpatientandoutpatientcareandorganizationandoperationofanefficientservice.Thedidacticaspectoftheresidencytrainingshouldbeinclusiveofthefollowingactivities:

– CaseDiscussion/IVP(Uro-radiology)– Pathology/TumorBoard– QualityAssurance/MorbidityandMortality– MultidisciplinaryOncologyConference– Didactics/”Campbell’s”Club– Evidence-BasedMedicine–JournalClub– PediatricUrology–Nephrology– Research– Urodynamics– VisitingProfessorships– Tele-MedicineConferences– WebBasedEducation

Thepurposeofthesedidacticactivitiesistosecureacoreknowledgethatwillinclude:. BPH,LTOS• Cancer:Prostate,Bladder,Penile,Renal• UrinaryIncontinence–MaleandFemale• Urolithiasis• PediatricUrologicDisorders• ErectileDysfunction,MaleInfertility• GUInfections• TraumaandUrethralStrictureDisease

Aspartofhisadministrativeduties,theChiefResidentshallorganizetheCallschedules,managetheDutyhours,beresponsibleforDisciplinaryaction,providecounselingwhenneededandparticipateintheappraisaloftheperformanceofJuniorresidentsandfacultymembers.Tomeettheirresearchrequirements,theResidentsareencouragedtobeinvolvedinclinical/chartreviewresearchthroughouttheirresidency.Theyarealsoencouragedtopresenttheirclinicalresearchfindingsatscheduledlocal,nationalandinternationalconferences.ThereisanurgentneedforUrologyCertificationinHaiti.SuchprocessshouldimplicatetheMedicalSchools,theDepartmentofEducation,theRectoroftheUniversityandtheHaitianSocietyofUrology.ThereisalsoaneedforVerificationofthecredentialsandExpertiseofUrologyVolunteersworkinginHaiti.BoththesecertificationswouldbebestservedbyaCentralizedProcessandwithsupportandinputfromAmericanUrologicAssociation,theSociétéInternationaled’Urologie,theIVUmed,IndividualUrologistsandotherInterestedOrganizations.Meanwhile,thereisagreatneedfor- BasicSupplies:Catheters,stents,wires,sutures,GUtrays- EndoscopicInstruments:rigid,flexiblescopes- UltrasoundEquipment- UrodynamicEquipments

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- OperatingRooms:staffandequipments- Computers-ForEducationWebBased,DVDs,Audio-visuals,etc.- TeachingModels–Animals/ManikinsObstaclestothePracticeofUrologyinHaiti–AnAnalysisofNeeds–JeanGetoDube,MD,MscThisfirstJointHaitianAmericanUrologyConferencewastriggeredbyDr.Ziegelbaum’sinitiale-mailfollowedbytheimmediatechainreactionofalltheAmericanurologists,whointhepasthavevolunteeredinHaiti.IamspeakingofDrs.Lanctin,DeVries,AngeloGousse,Dale,Peterson,SamBroaddus,etc…UndertheleadershipofDr.Louis-JosephAugusteandhispartnersoftheAMHE,thediscussioncontinuedandeventuallywaschanneledtoresultinthisfirstjointmeetingoftheseHaitianandAmericanAssociations.Ithankallofyouforyourenthusiasm.IwilldiscusstodaytheobstaclestothepracticeofUrologyinHaiti,whilepresentingananalysisoftheneedsofHaitianUrologists.TheultimategoalistheadvancementofHaitianUrology,throughthisfrankdiscussionbetweenourHaitianandAmericancolleaguesaboutwhatneedstobedone,particularlyintheareaofformation.Wecanapproachthistopicintwoways:eitherbydiscussingtheneedsinCap-HaitienandseparatelytheneedsattheStateUniversityofHaitiHospitalinPort-au-Prince,orbylookingattheproblemmorebroadlyfromanationalstandpoint.Weelectedtopursuethesecondapproach,becauseUrologyisnotpracticedonlyattheHUEHandHUJ,butalsoinprivatepracticesettings,incertainphilanthropiccenterswhereurologyservicesareofferedandfinallyincertaingovernmentalmedicalcenterswhereurologiccareisprovideddailyorsporadicallyeitherbyHaitianUrologistsorvolunteersfromabroad,suchasBonneFinHospital,ImmaculateConceptionHospital,BienfaisanceHospitalofPignon,etc...Aneedisthedifferencebetweenwhatonehasandwhatonewishesforandthereasonswhytheseneedscannotbefulfilledrepresenttheobstacles.Withthisinmind,weaskedourselvesthreequestions:

- Whatisthecurrentsituation?- Whatshouldbethecurrentsituationandwhatwecandotoachieveit?- Whycan’tweachieveityet?

Thesequestionswereintegratedinasurvey,whichwassenttoalltheurologiststrainedateithertheHUEHortheHUJ.Weinsistedthatallquestionsbeanswered.Ahospitaladministratoraswellasthemedicaldirectorofahospitalwasalsoaskedwhytheirhospitalsdonotbuycertainurologicequipment.Certainly,oursurveyhadseverallimitations.First,thenumberofindividualsinterviewedwassmall.Second,giventheshortperiodoftimeallottedforthestudy,wedidnothavethetimetosubmitthecompiledanswerstotheintervieweesinordertoverifyiftheconclusionstrulycorrespondedtotheiropinions.Theselimitationshowevershouldnotinvalidatetheresultsofourstudythatweintendtosubmittothecriticalreviewoftheurologistsinattendancetodayandwhoforsomepracticalreasonsdidnottakepartinthestudy.Fromtoday’sdiscussionwillemergeadditionalinformationwhichwillfurtherourknowledgeoftherealneedsinHaitianUrology.Thismeetingrepresentsthereforean

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importanttoolfordatacollectionandasignificantstepintheassessmentofourneedsandtheobstaclestothepracticeofUrologyinHaiti.RESULTS:OBSTACLES-Asfarasthetypesofsurgicalproceduresperformed,theyconsistpredominantlyofopen,breadandbuttercases,althoughwehaveseenatimidprogressintheformofafewradicalprostatectomies,tworenaltransplants,someurethralinterventionsandsomeendoscopicprocedures,particularlyintheprivatehospitalsettings.Fromatechnicalpointofview,theurologistwhowantstoperformagivenprocedure,hastobringhisownequipment,rangingfromelectrocauterytoendoscopicinstruments.Imagingstudiessuchasasonographyorevenassimpleasanintra-venouspyelographyareeasilyobtainableintheprivateinstitutionsbutextremelydifficulttogetinthepublicinstitutions.ACTscanispossiblebutbeyondthereachoftheclientsofthepublichospitals.Itisdifficulttoobtainbloodtests,suchasfreeorboundPSAanditmaytakemonthstoobtaintheresultsofabiopsy.ThemedicaldirectorthatweinterviewedcouldnotseetheneedtopurchasesophisticatedurologicequipmentbecausetheyareveryexpensiveandtheORcasesarerare.Itisthereforenotclearthatonewillgetadecentreturnontheinvestment.Thegovernmentshouldabsorbthecostoftheseinstrumentstomakethemavailabletothepublic.Mostoftheresponderstothesurveyfeltthattherewasalackofasenseofresponsibilityregardingtheequipmentinthepublicsetting.Themaintenancesysteminthepublicinstitutionsisinadequateordownrightinexistent.Thusthehalf-lifeoftheinstrumentsintheprivatesettingismuchlongerthaninthepubliccenters.Thereisalsoaproblemofindividualism,sincetheurologistswillseldominvesttogethertopurchasetheveryexpensiveitems.Thetrainingoftheresidentsremainsadilemma,sinceitisnotstandardizedandwehavenotfigureouttomeasuretheircompetencybeforegraduation.Someofthemareluckytoreceiveadditionalformationabroad,butthisisinconsistentandsomegraduatefromourtrainingprogramshavedifficultyperformingtransurethralresectionwhileelsewhereintheworld,theyarealreadyintheeraoflaparoscopyandroboticsurgery.Inaddition,theancillaryhelpmaynotbeverydependableandsomeurologistsworryaboutthequalityofpost-operativecarethatthenurseswillprovidetotheirpatientsintheprivatesector.Needs:Itisimperativetokeepthebasicinstrumentsofurologyavailable.However,atthesametime,asenseofresponsibilitytowardtheequipmentmustbeinstilledintheusersandamaintenanceservicemustbeestablished:Teachthephysicianshowtousethemandthepersonnelhowtocareforthem.Opportunitiesshouldbeprovidedforthepracticingurologiststoupdatehisorherknowledgeandtoparticipateincontinuingmedicaleducationprograms.Wemustalsoencouragetheyoungphysicianstoacquiresub-specialtytraining,particularlythoseworkingatauniversitycenter.Whyareweinthatsituation?Thereisanoveralllackofinvestmentsinthearea.Thereisroomforinvolvementbytheprivatesectors,butthegovernmentshouldpurchaseandmakethebasictoolsavailable.Thereisalackofvision–Wedonotknowwherewearegoingorhowtogetthere.Manyurologistshavelostallconfidence–Whyshouldwetry?Wearesofarbehindandwewillnevergetthere.Thereisalsoalackofleadership.TheHaitianSocietyofUrologyismoribund.Wearetooindividualisticanddonotwanttoworktogethertomakethingsbetter.Thereisnoregulatorysystemforthespecialty.Theeconomyisinbadshapeformostofthepopulation.Thepopulationdoesnotunderstandthevalueandtheroleofurology

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asaspecialty.Otherhealthcareprofessionalsdonotappreciateurologyeither.Thepracticeofurologyislimitedtojustafewcentersacrossthecountry.However,thereseemstobeasilverlininginthecloud.Thankstoindividualeffortandmotivation,weareseeingmoretransurethralprocedures,acoupleofrenaltransplantsandafewradicalprostatectomiesaswellasafewurethralinterventions.Atthesametime,weseemtodiscernabeginningofchangeintheattitudeofthepopulation,sincemenarenowwillingtobeoperatedforvaricoceles.Myrecommendationswouldbetoseizethisopportunitytoadoptastrategicplanforthegrowthofourspecialty.Seizetheopportunitytoreinforceourstructuresandimproveourarmamentarium.Seizethisopportunitytoestablishasystemofcontinuingeducationforthepracticingphysiciansaswellastheresidentsintraining,inpartnershipwithourAmericanColleagues.Wehavetoestablishabettersystemtomanageandmaintaintheequipmentaswellasasenseofpersonalresponsibilityamongtheusersofthisequipment.TheHaitianSocietyofUrologyshouldassumeitsroleasaleadertounifyalltheurologistsaroundcommongoals.GroupsofUrologistsshouldcometogetherandseekthirdpartyfinancingfortheacquisitionofcostlyequipment.Mypersonalwishisthatmeetingssuchasthisonecontinueinthefuturetokeepusfocusedonthegoal,whichistostirtheUrologyspecialtyforwardforthewelfareoftheHaitianpopulationingeneral.KonbitSante–SamuelBroaddus,MD,FACSMynameisSamBroaddus,MD,aStaffurologistattheMaineMedicalcenterofPortlandsince1984andIagreethatthisFirstJointHaitianAmericanUrologyConferencehasahistoricsignificance.YouwillallowmetoexpressmyheartfeltthankstoourHaitianhostsfortheircollegialandcollaborativespirit.Thiseffortisbothaspirationalandinspirationalforme.IhavebeenworkinginHaitiasavolunteersince1994,firstattheAlbertSchweitzerHospitalinDeschapellesandlateroninCap-HaitienattheJustinienUniversityHospital,undertheauspicesofKonbitSante,alsocalledCap-HaitienHealthPartnership.ThislatterorganizationwasfoundedinMainein2000.Fromtheonset,ourGoalandmissionwastodevelopapartnershipwiththeHaitianMinistryofHealthinordertobuildcapacityofthepublichealthcaresysteminNorthernHaitiwithmaximumlocaldirection.WechosetodesignateourorganizationbythesetwoCreolewords:“Konbit”whichistheTraditionalHaitianmethodofworkingtogethertogetthejobdonebetterandquickerand“Sante”,meaningHealth.KonbitSanteisalegallyrecognizedNGO,thatemploys40Haitians,includingphysicians.Italsoincludes120clinicalandpublichealthvolunteersandmorethan20infrastructurevolunteers.ThroughapartnershipbetweenpeoplewithexpertiseandinterestintheUSandourHaitiancolleagues,weseektobuildlong-termcapacity.Ourworkhasbeencenteredattwopublichealthinstitutions-JustinienUniversityHospitalandFortSt.MichelHealthCenter.TheyarebothstaffedandmanagedbytheHaitianMinistryofHealth.Ourroleisthatofasupportingpartner.Weworktogetherwiththeadministrationandstaffattheseinstitutionstoidentifytheprevailingneedsandpriorities,thenseektheresourcesnecessarytojointlyimplementappropriate

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interventions.ThestaffweemployareembeddedwithintheseinstitutionsandseveralareMinistryofHealthemployeesaswellasourown.OureffortshavebeenfocusedoncertainClinicalInitiatives,suchasWomen’shealth,ChildrenHealth,CommunityOutreachandotherformsofcollaboration.In2008,weconductedabaselineassessmentoftheSurgicalServicesatJustinienHospital,intheformofaSWOTGapanalysisthatlookedatissuesofStaffing,thephysicalstructureandcapacityoftheSurgicalwardandtheOperatingRooms.WealsolookedattheClinicalCaseMix,DifferentQualityInitiatives,OpportunitiesforSurgicalEducationandResearch,theprovisionandmaintenanceofSurgicalEquipmentandMaterials,aswellasotherSurgicalSupportServices.Armedwiththesedata,weundertookseveralSupportprogramsfortheinfrastructuresoftheinstitutions,byrebuildingsomeofthehospitaltoiletfacilities,byimprovingtheHospitalelectricgridandbysupplyingsturdyandhighcapacityelectricwashingmachinesinordertoreplacethearchaicsystemofwashingthelaundrybyhand.ThroughacooperationwithUSAID,wearepresentlyengagedinaprojecttoexpandandupgradethePediatricPavilionattheHospital.OursupporttotheHospitalhasalsoincludedtheregularcollectionandshippingofdonatedmaterialsandequipmenttotheinstitutionandsupportasalarylineforamanagertoorganizeandkeepaninventoryofthestocksinthedepotofthehospital.Ourcommitmenttothisprogramisforthelongrunanditembodiestheconceptofaccompaniment.Personallong-termrelationshipsnotonlymatter,buttheymatteralot.Toaccompanysomeoneistogosomewherewithhimorher,tobreakbreadtogether,tobepresentonajourneywithabeginningandanend.Thereisanelementofmystery,ofopenness,inaccompaniment:Iwillgowithyouandsupportyouonyourjourneywhereveritleads.Iwillkeepyoucompanyandshareyourfateforawhile.Andby"awhile,"Idon'tmeanalittlewhile.Accompanimentismuchmoreoftenaboutstickingwithataskuntilitisdeemedcompletedbythepersonorpeoplebeingaccompanied,ratherthanbytheaccompagnateur.ThisfirstJointHaitianAmericanurologyConferenceisagroundbreakingevent.Totheextentthatothersurgeonsindevelopingcountriesfacethesamechallengesandobstaclesthatwehavemetandarestillmeeting,weareencouragedbytheAmericanCollegeofSurgeonstopublicizeourattempttobringHaitianandAmericanurologiststogetherandraisethebarofurologyinHaiti.ProjectHaiti/IVUmedCollaborationinHaiti–HenriLanctin,MD,FACSSinceitsinceptionin1989,ProjectHaitiincollaborationwithIVUmedhasbenefitedfromthegenerouscontributionsofmorethan600volunteers–medicalandothersfromallwalksoflife.Theprojecthascontributed10,000-20,000lbsdonatedsuppliesannually.IthasdesignedandbuiltHopitalBienfaisanceexpansions,completedmissionarydormitoryfacility,constructedtheinternationalairportofPignon,builtandsupportedaprimaryschoolfor300students,helpeddevelopandfundthefirst“Mother’sClubs”,helpedDr.GuyTheodoretoestablishPignonRotaryClub(votedbestinCarribeanandDr.GuyisHaiti’sfirstGovernor).Wealsodevelopedsolar/batteryenergystorageaswellasasewagesystemforthehospital.Wehavebrought

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surgeonprofessorstoteachforthepast17years.WehaveachievedallianceswithindustryanddonatedtwoEndo-suitesandthecapabilitytoperformsatellitebasedtelesurgery.Wewouldlikeheretoacknowledgeallthecorporationsthathaveaidedusinthisjourney:

• StrykerEndoscopyandCommunications

• ThelenHeating• SellHardware• Gary’sPainting• BrainerdGlass• HoffmanElectric• MultipleConceptInteriors• Fastenal• ToolCriboftheNorth• CuyunaRegionalMedicalCenter• LarsonAllen

• BerchtoldCorporation• JordanArchitects• RiverwoodHealthCareCenter• Stor-MorShipping• Nelson,Inc.• ChristianCoalitionforHaiti• USSurgicalCorp• LakeStatesLumber• LundbergPlumbing• Nor-sonConstruction• GeneralElectric• EthiconEndosurgery

OneofthemostremarkablejointendeavorsofIVUmedandProjectHaitiwastheMultidisciplinaryPublic-PrivatePartnershiptoTrainHaitianPelvicSurgeonsinVesicovaginalFistulaRepair.FromNovember2011-2012,3week-onlyworkshopswereconductedattheHopitalBienfaisanceinPignon.Itinvolvedthepublic,private,non-governmentalandeducationalsectors.Thecoursewastaughtby2USfellowshiptrainedurologistsandtheAttendeesincludedHaitiangynecologists&urologists,aswellasHaitian&USresidents.21patientsbenefitedfromthisprogram,whichwassuccessfulin81%ofthecases,atthesametimethattwogynecologistsandaurologistweretrainedinthecorrectionofVesico-VaginalFistulas.FuturedirectionsofthiscooperationwillincludethecontinuationoftheSupportforHopitalBienfaisancedePignon,thecontinuationofVVFandUrethralReconstructionWorkshops,Supportforurologistsinotherareas,assistancewithHaitiappropriateresidentcurriculumandtraining,thedevelopmentofanEMRsystemasproposedbyDr.FranSchneckandtheUroHaiti.orgwebsiteaswellasthesupportforparticipationintheSIU/AUAtrainingcoursesandSupportforthetrainingcourseattendees.UrologyinHaiti:CurrentObservationsandFutureHopes–MichaelZiegelbaum,MDTheGoalofthisFirstJointHaitianAmericanUrologyConferenceistocoordinatetheeffortsofAmericanUrologistsinterestedinprovidingphysicianseducationanddirectpatientcare.ThisinteractionwithourHaitianColleagueswillrequireapartnershipwiththem,aswellastheirguidanceinordertofulfilltheirmandates.Industryinvolvement,governmentalsupportaswellasadditionalpartnershipswillbecrucialtothesuccessofsuchendeavorandweseizethisopportunitytosaluteandexpressourgratitudetoalltheentitieswhohaveallowedthisconferencetobecomeareality:AMHE,AUA,IVUmed,HaitianSocietyofUrology,representativesoftheindustrysuchasKarl-Storz,Stryker,MedShare,Sonosite,Zeissandindividualfriendsandcolleagues.

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Thereasonsformypersonalinvolvementisthisprogramstandfrommylonghistoryofgivingbacktothelessfortunate,mypersonaldesiretoexpandmyhorizonsandseetheWorld,theJudaicprincipleofTIKKUMOLAM(repairingtheWorld)andmypersonalfriendshipwithDr.LouisJAuguste.ThegeneralguidelinesofmyinvolvementinHaitiarethefollowing:

! Tocooperatewiththelocalmedicalworkforceanditsresources! Tosupportlocalhealthcarewithlearningmaterial,medications,suppliesand

equipment! Toprovideourexperienceandworktoelevatethelevelofcare! ToempowertheHaitianhealthcareprofessionaltopracticebettermedicineand

explorewaystoprovidesustainableimprovementsintheirhealthcaredeliveryInotherwords,ourgoalistoteachourHaitiancolleagueshowtofish,ratherthangivingthemtheproverbialfish.Inthisactofaltruism,letusnotforgetthatwewillfindsomethingforusaswell.Thisprogramoffersustheopportunitytogroundoneselfandtohaveabettersenseoftheworld,atthesametimethatitwillallowustoconnectonewithhis/hertrueclinicalabilitiesandjudgment,despitethelackoftechnology.Itwillprovideourresidentswithavaluablehumanexperienceaswellasasenseofaccomplishmentandforallofus,AmericansandHaitians,abondingexperience.

WewillrememberthatHaitiwasoncetherichestFrenchcolonywithaneconomybasedonslaveexploitation.Thisuntenablesituationledtotheslaverevolution,whichwascrowned,withsuccessin1804,attheendofalongstruggle.Sincethatmoment,wehavewitnessed200yearsofhamperedleadership,non-acceptancebytheInternationalcommunityasanequal,economicpredationbywesterngovernmentsandcorporations.Allthesefactors,coupledwithrecurrentandfrequentnaturaldisasters,haveresultedinmakingthatoncesorichislandintothepoorestcountryinthewesternhemisphere.Thelossofthecountry’sagriculturalbasemixedinwithoverpopulation,atrickledowneconomy,diversionoffundsatthehighestlevel,isarecipefordisaster.Theimpactofthissituationisthat80%ofthepopulationlivesbelowthepovertylevel,earninglessthan$200/year.Only50%ofthepopulationhaveaccesstocleanwater;60%ofthepopulationhasnoaccesstoheathcareand20%haveadifficulttimeaccessinghealthcare,sincetheyhavetowalkover5kilometerstoreachahealthcarefacility.Healthcareexpenditureamountstoabout$83percapitaperyear.Thus,itisnotsurprisingthatLifeexpectancyismerely54years.TheHaitianHealthCaresystemfacesstaffingissues,equipmentissues,energyissues,issueswithcleanwater,alongwithissuesofpatient’scomfortandsafety.AnimportantpartofthehealthcaresystemistheJustinienUniversityHospital,a250-bedinstitutionerectedin1890,renovatedin1920duringtheUSOccupationofHaiti.However,sincethen,severalrenovationsunfortunatelyhavenotkeptpacewithmodernstandardsofcare.Thus,itstillhasliterallywide-openwardswitharchaicsanitaryfacilities.JustinienHospitalnolongerprovidesfoodorlaundryservicesandtheinfrastructureisfortheleastobsolete.Atmylastvisit,theOperatingSuitewascomprisedoftwofunctioningOperatingRoomswithinadequatelightingandcooling.Theanesthesiamachinesoftenmissedpartsandthelimitedavailabilityofblood,intravenoussolutionsandoxygenmadeitariskyundertaking,nottosayanadventure,everytimesurgerywasperformed.Theequipmentisscarceandpoorly

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maintained.Thissituationisfurthercomplicatedbyalackof,aswellasmismanagementof,economicresources.Thereisnoaccountabilityandthehierarchyisunderminedbytheoverarchingdominanceofthegovernmentalbureaucracy.Salariesarepaidirregularly,makingitdifficulttomakedemandsoftheemployees.Informationtechnologyisinitsinfancy.BasicmeasuresassimpleasproperidentificationofthepersonnelwithIDbadgesorasecuritysystemforthefacilityarenotimplemented.Yet,thisMedicalCenteristhereceivinghospitalforthe200,000populationofCap-Haitien,aswellasalloftheNorthernDepartment,aswellastheHaitianpopulationofthenorthwesternareasoftheDominicanRepublicandtheIslandsofBahamas,sincetheHaitianlivingillegallyinthesecountriesaredeniedaccesstoanylevelofmedicalcare.JustinienHospitalprovidetrainingforover60residentsinthespecialtiesofSurgery,InternalandFamilyMedicine,Urology,Orthopedics,Pediatrics,ObstetricsandGynecology,OphthalmologyandOto-Laryngology.AsfarastheUrologyspecialtyisconcerned,intheUS,itisrapidlymovingrapidlytowardslaparoscopicandendoscopicapproaches,whileadvancedimagingtechnologiesandscreeningprotocolsallowearlierandearlierdetectionofdiseasesandbettersurveillanceofpatientsaftertreatmentfortheirmalignancies.Bycontrast,inHaiti,thediseasesarediagnosedlateandmostofurologicproceduresarecarriedoutinanopenmanner,withoutthebenefitofpathologyservices.Thisnascenteffortforcooperationbetweenallthesocietiesinvolvedinthisfirstjointconferencecanplayalargeroleinsolvingthisuntenablesituation.Beyondthesupplyofmaterialandothertechnologicalsupport,itwillrequirealocalwillforimprovement,tomakeorganizationalchangesandagreatersenseofhonesty,accountabilityandresponsibilitytowardthepopulation.ItwillrequirethatallforeignassistanceorganizationsoperatinginHaitilookbeyondtheirpersonalagendasorinterests,rejecttheprospectofperpetualdependencyandaccepttheconceptofgreaterconcertationofefforts,solelyfortheadvancementofthecountrytowardself-reliance.Thesolutiontothissituationwillalsorequirethecooperationofmultiplesectorsofhealthcare,suchasnursing,administrationandsocialwork,aswellasthebusinessandtheindustrysectorsthatcanatlastbecomeinterestedintheupgradingandmaintenanceofamoremodernarmamentarium.Then,ourrolewillbetoworkwiththeMinistriesofEducationandHealthtodesignandimplementabettercurriculumforthetrainingofthenewgenerationsofphysiciansandurologistsandoffertothepracticingurologistsopportunitiesforcontinuingmedicaleducationandintegrationofnewtechnologies.Intheinterim,areliablebroadbandinternetsystemwillmakeavailableTele-Pathology,Tele-RadiologyandTele-Conferencing,thatcanbridgethegapcausedbydeficienciesintheseservices.ItisourhopeandexpectationthatthisconcertedeffortwillleadtotheimprovementoftheurologichealthofthegeneralpopulationofHaiti.ItcanalsoprovideanenrichingexperienceforourUSurologyresidents,sincewiththedisappearanceofphysicalborders,theworldhasbecomemoreandmoreaglobalvillage.WorkingsidebysidewiththeirHaitiancolleagues,theycanbroadentheirhorizonsandletthemselvesbechallengedwithdifferentpathologiesandformsofpresentation.Finally,onamoreselfishnote,IhopethatwhenIcomefora

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vacationinPort-Morgan,Moulin-sur-MerorLabadiewithmyfamily,IwouldreceiveinHaitithesameexcellentlevelofcarethatIwouldexpectanywhereelse.DevelopmentofanIntegrated,OpenSourceElectronicHealthRecords–FrancisSchneck,MDOutofthethousandsofNGOoperatinginHaiti,atleast40ofthemhavefocusedondiverseaspectsofhealthcare.Thishasresultedinalackofcoordinationofresources,withlimitedabilityforinformationexchangebetweenprovidersandorganizations,duplication of efforts, limited consistent follow-up, lack of outcome and effectiveness analysis, limited integrated data for reporting requirements and limited transfer of health information from paper to electronic. In an attempt to solve these problems, we have sought primarily to create an integrated health care record encompassing medical, environmental, social, and cultural information and as a secondary goal, we wanted to create a low cost electronic solution for patient records, create a system designed specifically for geographical need that can evolve over time and increase collaboration between volunteer organizations. Presently, the Electronic Medical Record is a compilation of demographic data, vital signs, progress notes, radiologic images, laboratory values and developmental information. EMR is expected to evolve in the near future and to reflect the social, cultural and environmental context of the individual or the population. An integrated comprehensive electronic health record would provide an invaluable tool for all these organizations to coordinate their efforts. The characteristics of this system should be:

- Open source, i-e Lowcost,allowingbroadcontributionbyhealthprovidersandacademicpersonnelandvolunteers.

- Crowdsourcing:inotherwords,acceptingdesigninputfromusers,fieldexperts,healthprovidersandtechnicalexperts.

- Integrated: i-e able to communicate with other systems used by multiple organizations- Inclusive:i-eaholisticsystemcapableofevaluatingtheinteractionsbetweenmedical,

environmental,socialandculturalfactorsimpactingoutcomes- Evolving:meaningthatitbeabletogrowandchangewithgeographicalandtemporal

needsandthatitbeadaptabletoeachuniquepopulation.Thus, input received from different hospital networks could be stored in each individual server and sent via satellite to the “cloud” as a backup. In turn, the information so accumulated could be released to involved hospitals and medical clinics, departments of health, Volunteer organizations and funding entities with reporting contingencies. A prototype for this device has been created as a small suitcase, almost like a laptop by the VECNA® company and is essentially a Portable Electronic Health Record and Network in a Box. It is ready to be piloted and IVUmed will bring it down on its next training visit to Haiti. All screened patients will be entered into the electronic health record system. The patient processing and system data elements will be evaluated for feasibility. Patients who receive surgery will have a more detailed information input into the health record. Staff/providers will be asked for input on current practices and feedback and they may be asked to join crowd-sourcing site to provide feedback online if interested. The suitcase system will return to IVUmed after the visit. The pilot will include 5-10 sites and will include repeat visits to these sites. Logins will be given to appropriate individuals, such as Visiting Health Workers and Local Health Workers in order to access the Web-based system. The users will be identified by Names, Birthdates and Biometrics (e-g. fingerprints). The system is very user friendly and information can be entered

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by clicking on consecutive menus or by using a touch-sensitive keyboard. It will also suggest options for treatment based on best Evidence-based medicine recommendations. It will also allow compilation of data for studying different pathology entities or population cohorts as well as preparation of appropriate reports. Following the satisfactory completion of the pilot project and the site study, the timeline for the development of the project will move to a regional evaluation before finally a mass deployment. IVUmed will keep all interested individuals abreast of the different phases of this very promising project. OnlineCoordinationofUrologyEffortsinHaiti–JoshWoodTheMissionofIVUis:ToMakequalityurologicalcareavailabletopeopleworldwideandourMottois:TeachOne,ReachMany.Althoughitwasofficiallyfoundedin1995,IVUmedstartedoperatingin1992.ItrepresentstheLeadingindependentNGOdedicatedtourologicalcareandteaching.Throughouttheyears,ithasexperimentedwithdiversesettingsandprogramsandhasservedcommunitiesinAfrica,Asia,CentralAmerica,Caribbean,SouthAmericaandtheUS.TheprogramsofIVUmedhadincluded:

" PediatricUrology:21years(3w/Interplast)

" GeneralUrology:14years" ResidentScholars:14years" FemaleUrology:9years

" ReconstructiveUrologyandLF:9years

" DomesticUSProgram:5years" IVUmedFellowships(2fellows)" IVUmedSeniorFellows(6fellows)

WiththesupportoftheAmericanUrologicalAssociationandtheSocieteInternationaled’Urologie,IVUhasbeeninvolvedinmultipleprogramsthathavetakenplaceinPort-au-Prince,Leogane,Deschapelles,PignonandCap-Haitien,throughpartnershipswiththeUniversitéofNotreDamecommittedtotheeliminationoffilariasisinHaitibytheyear2020andProjectHaitidevotedtoimprovingthequalityoflifeofthepeopleofHaiti,byprovidingmedicaleducationtoHaiti’sownhealthcareproviders.Tocoordinatealltheseefforts,IVUmedhascreatedaWebsiteentitled:www.UroHaiti.org.Inaddition,thiswebsitewillallowtoCommunicateneeds/wantsofurologistsinHaiti,Educatepotentialparticipants,Shareanddiscussbestpractices,PostcurriculumandothermaterialsandFacilitatecommunication.Individualsororganizationsinterestedinsponsoringaworkshoporothereducationalprogramcanpostthedate,thesite,thefocusoftheeventandpossiblyrequesttheparticipationofvolunteersinwhatevercapacity.Moreover,itcanbeavaluablesupporttotheeducationalprograms,byListingneedsoftrainingmaterials,Postingcurriculum,educationalmaterialsandlinkstousefulresourcesonline,CoordinatingawidearrayofresourcesandInformingothersofcurrenttrainingactivities.ThewebsitewillprovideageneralorientationtopotentialparticipantsintheeffortsbyofferinganOverviewofurologyinHaiti,Matchingpotentialvolunteerstoparticipatingorganizations,informingthepotentialvolunteers/visitingprofessorsasto“Whattoexpect”andfinallyallowthemtoJoinacollaborativeeffort.

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UroHaiti.orgwillallowtosharebestpracticesbyPostingactivities,goals,results,askquestionsthroughaBlogoradiscussionforum,toplanstrategiesandseekpartnerstoaddresschallenges.Viceversa,thewebsitewillallowthelocalentitiestocommunicatetheirneedsinanyspecificareaofEducationandtraining,Equipmentandsupplies,anySite-specificinput,Inputfromnursing,anesthesia,etc.andRecruitsupportfromAUA,industry,etc.Whilewesharecommongoalsandcommitment,wecanharnessouruniquestrengths,shareouruniqueperspectives,ourexpertisebasedonvariousdegreesofexperienceandtakeadvantageofourpersonalpartnershipsandcontacts.FinallythewebsitecanopentodoortomultipleinnovationssuchasTelehealth,Digitaleducationmodules,Increasedopportunityforacquiringskills,ElectronichealthrecordsandOutcomesmeasures.Itcanalsoopenthedoortoregionalpartnershipswithforexample,theCaribbeanUrologicalAssociation(CURA),Pan-AfricanUrologicalSurgeon’sAssociation(PAUSA)andtheSociétéInternationaled’Urologie(SIU),invarioussub-specialtiessuchasGeneralUrology,ReconstructiveUrology,UrologicOncology,FemaleUrology,PediatricUrologyandorEndourology.Inturn,thesepartnershipscanleadtoResearch,Internationalcollaborativeefforts,Publications,ScholarshipsandfurtherrecruitmentofVolunteers.PleasevisittheUroHaiti.orgwebsiteandmakeityourwebsite.EPILOGUEDear Colleagues: If you were not present at this First Joint Haitian American Urology Conference, you missed an opportunity to be part of history or to watch history in the making. This meeting that was sparked by Mike Ziegelbaum's query after his first trip to Cap-Haitien, was eagerly supported by the AUA, the IVUmed, the Haitian Society of Urology, the Haitian Medical Association and the Association of Haitian Physicians Abroad. The latter group played a key role in organizing this conference with the support of the Haitian Society of Urology and Dr. Margarett Osselyn-Abraham. Most of the Urologists who have been involved in Haiti in the past responded to the call. So did 13 of the 26 urologists practicing in Haiti. Altogether, there were 28 participants. The conference went on as scheduled and allowed both the Haitian and the American sides to consider the many aspects of the situation, which have brought it to the level of a crisis and an inventory of the resources available both locally and from the organizations involved in support missions to the different medical centers of the country. The discussion was frank, albeit at times uncomfortable. At the end, we all came out completely convinced that such meeting of the minds was overdue and a sine qua non to proceed forward. If specific solutions were not elaborated, steps to bring about changes at all levels were taken. At the end of the meeting that concluded exactly on time, the following motions were made and approved: 1- The entire group including both the American and the Haitian Urologists would meet again next November in Haiti at a specific date to be determined. There will also be an interim focused gathering of the minds at the Annual AUA conference in Orlando, FL next May 2014. 2- The assembly elected a team of nine individuals to organize the subsequent joint activities. It included: - Angelo Gousse, MD_ representing both the AUA and the AMHE - Samuel Broaddus, MD - Pierre Boncy, MD - Frank Burks, MD - Geto Dube, MD - Henri Lanctin, MD

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- Claude Paultre, MD - Francis Schneck, MD - Michael Ziegelbaum, MD with the administrative support of Josh Wood and Ellen Molino. 3- The group will elaborate a calendar of activities, workshops and other educational opportunities over the coming 3 or 4 years, to allow individuals to arrange their schedules accordingly. Although the website www.urohaiti.org is not completely ready, it is agreed that it will play a major role in the programming of these activities. It is worth noting that the participants were able to acquire up to 6 CME credits for the event. In addition to being a working conference, it was also an enjoyable occasion to have personal interaction with this incredible bunch of "nice people." As for me, it was a lot of fun (and a lot of work) to help make this meeting a reality. Now I am happy to pass the baton to Dr. Gousse. Thank you for having given me the opportunity to serve the people of Haiti.

Louis Joseph Auguste, MD Surgical Oncology/General Surgery Associate Clinical Professor of Surgery Hofstra North Shore/LIJ School of Medicine Clinical Director of Department of Surgery/A-Service – Long Island Jewish Medical Center President of the Long Island Jewish Medical Center Staff Society Assistant Secretary of the Central Executive Committee of the AMHE Coordinator of the AMHE/Justinien University Hospital Project Co-Chair of the First Joint Haitian American Urology Conference

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FirstJointHaitianAmericanUrologyConferenceHotelOasisInternational

November15,2013

RosterofparticipantsandContactInformation

Name Specialty Organization Title Emailaddress/telephone

Badlani,Gopal,MD

Urologist AmericanUrologicalAssociation

Secretary/AUA gbadlani@wakehealth.edu/336-716-4310

Beauvoir,NoelSaint,MD

Urology HôpitalUniversitaireJustinienCap-Haitien,Haiti

Resident

Black,Derrick Vendor Takeda Vendor Derrick.black@takeda.comBoncy,Pierre,MD Urologist StateUniversityHospital Chiefof

UrologyTpboncy99@yahoo.com/509-3401-8534

Brisson,Georges-Eric,MD

Urologist Port-au-Prince,Haiti Brissongeb@yahoo.com/509-3710-9708

Broaddus,Samuel,MD

Urologist MaineMedicalCenterPortland,Maine

BROADS@mmc.org/1-207-415-6106

Brutus,Bernard,MD

Urologist Port-au-Prince,Haiti Bentus9@yahoo.com/509-3708-6849

Burks,Frank,MD Urologist ComprehensiveUrologyRoyalOak,MI

fburks@urologist.org/248-336-0123cell:248-310-7267

Cadet,Jean-Claude,MD

ENT StateUniversitySchoolofMedicine

Dean cadethaiti@yahoo.fr509-3602-2460

Clervil,Mitelot,MD

Urologist Port-au-Prince,Haiti Mitelot@hotmail.com/509-3455-4880

Codio,Dieusel,MD

Urology HopitalUniversitaireJustinienCap-Haitien,Haiti

Resident

Coles,Maxime,MD

Orthopedist AMHE President maxime@colesmd.com203-395-1934

Desir,Jory,MD Urologist JustinienUniversityHospitalCap-Haitien,Haiti

A.I.ChiefofService

Desirj.urology@gmail.com/509-3670-2438

DeVries,Catherine,MD

IVUPresident

Dreux,Youry,MD Urologist StateUniversityHospital dyoury@yahoo.fr/509-3758-1116

Dube,Jean-Geto,MD

Urologist JustinienUniversityHospital

ChiefAdministrator

getodubb@yahoo.fr/509-3688-9355

Edelstein,Robert,MD

Urologist MerrimackUrologyAssoc.31 Village Square Chelmsford, MA 01824

Rob.edelstein@gmail.com(978) 256-9507

Ellison,Lars,MD Urologist PenobscotBayUrology larsellison@gmail.com/

21

Rockport,Maine 207-593-5400Gousse,Angelo,MD

Urologist FloridaInternationalUniversity-AMHE

FellowshipDirector

agousse@aol.com/786-200-3447

Carvajal,Hortensia

KarlStorz Hortensia.Carvajal@karlstorz.com

Jeudy,Jacques,MD

TransplantSurgeon/Urologist

jacquesjeudy@aol.com

Lanctin,HenriP.,MD

Urologist PrairieLakesHealthCareSystem

hplanctin@gmail.com

Loubeau,Jean-Michel,MD

GeneralandVascularSurgeon

Larchmont,NewYork Dr.loubeau@verizon.net914-374-7030

Medilien,JacquesGracia,MD

Urologist 97RueOswaldDurandPort-au-Prince,Haiti

Molino,Ellen AmericanUrologicalAssociation

InternationalCoordinator

emolino@auanet.org410-689-3771

Myril,Sahmonde,MD

Urologist Cayes,Haiti sahmondem@yahoo.fr/509-4472-5313

Nazon,Pierre-Alix,MD

Urologist StateUniversityHospital panuro@yahoo.com/509-3448-0842

Paul-Blanc,Raymond,MD

Urologist 16CreedenStreetMansfield,MA02048-AMHE

raypb@comcast.net/508-801-7332

Paultre,Claude,MD

Urologist StateUniversityHospital/SocieteHaitienned’Urologie

President uropaultre@yahoo.com/509-3711-1307

Peterson,Curtis,MD

PediatricAnesthesiologist

PrimaryChildren'sHospitalAnesthesiology100NMarioCapecchiDriveSaltLakeCity,UT84113

801-662-3577

Rosenstein,Daniel,MD

ReconstructiveUrologist

StanfordUniversityHospitalSystemPaloAlto,CA

AssociateChiefofUrology

danielrosenstein@gmail.com

Schneck,Fran,MD

PediatricUrologist

UniversityofPittsburgMedicalCenter

schneck@upmc.org/412-692-5260

Surena,Claude,MD

Pediatrician MinistèredelaSantePubliqueetdelaPopulationPort-au-Prince,Haiti

CoordonateurCommissionNationalepourlaRepriseduSecteurSante

csurena@gmail.com/509-3702-1578

Theodore,Guy,MD

GeneralSurgeon HopitalBienfaisancedePignon,Haiti

Founder/GeneralDirector

Noukafel.prdh@gmail.com/509-4890-7172

Valme,Roger,MD Urologist StateUniversityHospitalPort-au-Prince,Haiti

Wood,Josh IVUmed josh@ivumed.orgZiegelbaum,Michael,MD

Urologist IntegratedMedicalProfessionalsLakeSuccess,NY

ziegelbaum@gmail.com/516-437-4228

KaribeInternationalHotel

JuvenatPetionville,Haiti

www.karibehotel.com509-2812-7000

22

HotelOasisInternational

115RuePan-AmericainePetionville,Haiti

509-2248-1105

ProceedingsoftheFirstJointHaitianAmericanUrologyConference

November14–15,2013Petionville,Haiti

TableofContents

HistoryofUrologyinHaiti-PierreBoncy,MD……………………………………………………………………………..1AnInventoryofHumanResourcesinUrologyinHaiti-ClaudePaultre,MD.……………………………….1UrologicSurgeryinaprivatesettinginPort-au-Prince–Pierre-AlixNazon,MD…….……….…………...2HaitianResidencytraininginUrology–ObstaclesandLimitations-JoryDesir,MDandYouryDreux……………………………………………………...………..4UrologyResidencyTraining–TheFutureofUrologiccareinHaiti–AngeloGousse,MD,FACS...6ObstaclestothePracticeofUrologyinHaiti/AnAnalysisofNeeds–JeanGetoDube,MD,Msc.…9KonbitSante–SamuelBroaddus,MD,FACS………………………………………………………………………………11ProjectHaiti/IVUmedCollaborationinHaiti–HenriLanctin,MD,FACS……………………………………..12UrologyinHaiti:CurrentObservationsandFutureHopes–MichaelZiegelbaum,MD………………..13DevelopmentofanIntegrated,OpenSourceElectronicHealthRecords–FrancisSchneck,MD….16OnlineCoordinationofUrologyEffortsinHaiti–JoshWood………………………………………………………17Epilogue–LouisJAuguste,MD,FACS………………………………………………………………………………………….18RosterofParticipantsandContactInformation…………………………………………………………………………..20TableofContents………………………………………………………………………………………………………………………..22