I was delighted to have been accepted to visit and work in the urology unit at Mansoura. Professor Ahmed Shokeir, a true gentleman, confirmed my visit details, and made me feel very welcome and part of the team.
This was not my first fellowship; I had previously worked in St. Augustine, in the robotic unit at Bordeaux, with Richard Gaston and Thierry Piechaud, and had visited Professor Gill’s department in Los Angeles on a robotic preceptorship. I am currently working with Peter Wiklund in Karolinska, doing robotic-assisted radical cystectomies with intracorporeal neobladders. This exposure to centres of excellence had confirmed to me the simple fact that good robotic surgery closely replicates the principles of open surgery, and I had been informed by senior colleagues that there is no better place in the world to observe the honed skills of open pelvic oncology and reconstructive surgery than in Mansoura. To achieve excellence in complex surgery needs a combination of excellent surgical technique and a sufficient volume of workload to master the procedure. The pelvic oncology team in Mansoura has abundant skills and very many patients who need their expertise.
Mansoura University Hospital is one of the largest Urology Departments in the world. The Urology and Nephrology Center consists of a main building with 120 beds, 80 for Urology and 40 for Nephrology. In addition, there are 12 beds for haemodialysis and eight more for intensive care. The in-patient service is incorporated under the same roof, with all the supporting and complementary facilities. In the main building there is an operating room suite that consists of three rooms for open surgery and one for endoscopy.
The Urology and Nephrology Center was officially opened in May 1983. Mansoura is close to the new faculty of Medicine and is a University Hospital. As the city is located in the centre of the Delta region, where most of the population work as farmers, historically they saw a high proportion of patients with an infestation of Bilharzia. In the past Bilharzia was endemic in 40% of the local population. Mansoura developed the expertise and a reputation for major pelvic oncological surgery and reconstructive surgery, specialising in open radical cystectomy and orthotopic neobladder formation. Mansoura has helped to pioneer neobladder construction and developed the Abol-Enein-Ghoneim anti-refluxing pouch. Currently Bilharzia is endemic in less than 1% of the population, and due to several ongoing factors, including smoking and environmental pollutants, most patients requiring radical cystectomy now present with transitional cell carcinoma rather than squamous carcinoma. The number of patients requiring major surgery therefore continues unabated.
I was introduced to Ahmed Harraz, an Associate Professor who is also a very gifted surgeon. He guided and assisted me throughout my time at Mansoura in a very friendly and highly competent manner. We had many interesting discussions about surgery and the current changes occurring in Egypt. He showed patience and kindness, and I am pleased to call him my friend.
On a typical day ward the rounds commenced around 7.30 am before the team met at 8.30 am to discuss inpatient care of complex patients and emergency admissions. Then interesting articles from journals were presented and their relevance to patient care debated under the guidance of Professor Ahmed Shokeir, who was always able to expertly draw out the important points and clarify the findings. We were then allocated our daily roles in theatre. At least one open radical cystectomy was listed for each day, with more than 90% of male patients and over 80% of female patients receiving orthotopic neobladders. I had the chance to observe and participate in radical cystectomies, extended lymph node dissections and neobladder formation. It was an honour to be part of such an expert team, and a privilege to receive such amazing exposure to high-volume surgery, whilst I was made to feel welcome to ‘scrub in’ and participate in the surgery under the guidance of senior surgeons.
Mansoura has a magnificent pedigree and has long been recognised as a centre of excellence with an international reputation. It was the site of the first robotic cystectomy, performed as part of a collaboration with Professor Menon, and the results from the series of 17 patients were published in 2003. The team at Mansoura is currently assessing the re-introduction of robotic surgery, and I strongly hope they are successful in this venture, as with their combined expertise, volume of cystectomies and scientific approach, they will certainly help to make further progress in radical pelvic surgery, to the benefit of patients all over the world.
Mansoura is a unique combination of art and science. There is great artistry in the way they construct neobladders, and whereas the books describe making an incision in the antimesenteric border to detubularise the ileum, the surgeons have a fantastic attention to detail, describing precisely where to go closer to the mesentery to optimise the position of the neobladder dome and the spherical shape of the bladder. They are like masters of origami in their approach. Whilst they have great artistic ability the surgeons are also undoubtedly scientific in their approach to medical issues, continually re-assessing and questioning things, whilst striving for perfection in all they do and often, in my opinion, achieving it. They have an excellent onsite animal laboratory where they do everything from stem cell research to training courses, and where I spent many happy and productive hours under the close guidance of Professor Abol-Enein and Ahmed Harraz learning about the intricacies of orthotopic neobladders.
As well as generously sharing their skills and insight we discussed possible collaborative research projects. In the future we are planning to set up a multi-institutional working group to examine various aspects of neobladders, with the aim of improving outcomes and minimising complications for our patients.
My experience in Mansoura was a wholly positive one and I would recommend a visit to Mansoura to anyone who wishes to learn about open radical cystectomy and reconstructive surgery. Mansoura has many gifted trainers as well as gifted surgeons. I have lots of fond memories and have left behind good friends that I look forward to collaborating with on projects, and I hope to visit again soon.
Dr. Justin W Collins
Notes
Peer review under responsibility of Arab Association of Urology.