Kathmandu Model Hospital Research Articles

Experience of Hydatid Cyst Management in a Tertiary Care Center in Kathmandu Nepal

Introduction Hydatid cyst is a common disease in Asian subcontinent produced by the larval stage of Echinococcus granulosus. The most common site of involvement is the liver. The mode of presentation can vary. The management of hydatid cyst includes medical treatment with albendazole, ultrasound guided aspiration and instillation of scolicidal agents as well as surgical treatment. Surgery can be perfomed by open or laparoscopic approach. The aim of this study is to analyze the cases of hydatid cyst of liver managed in our set up.
 MethodsThis is a retrospective study of 45 patients with hydatid cyst managed in Kathmandu Model Hospital over the last five years. Data were collected from the patients hospital records. Demographic parameters, chief complains, radiological findings, anti echinococcal immunglobulin findings, mode of management,complications of surgery were evaluated.
 ResultsMajority of our patients were female (66.7%). Mean age of the patients were 39±17.2 years (16 to 89 years).Most common symptom of presentation was pain in right upper quadrant of abdomen.Most common site of involvement was liver (93.33%)followed by spleen (4.4%). There was one case of ruptured pulmonary hydatid cyst which was referred.Operative management was done in patients (17.77%) out of which five patients (62.5%) underwent laparoscopic partial pericystectomy and omentoplasty.No major complications were encountered in any of the cases managed surgically.
 ConclusionMajority of cases occured in liver. Most cases were managed conservatively. Laparoscopic management of hydatid cyst is effective.

Assessment of Caesarean Section Rates at Kathmandu Model Hospital Using the Robson's Ten Group Classification System.

Aims of this study was to assess the caesarean section rate and identify the indications contributing to the same using the Robson's Ten Group Classification System at Kathmandu Model Hospital. This was a retrospective study conducted at Kathmandu Model Hospital among women who underwent caesarean section from 1 January to 31 December, 2018 and were grouped according to Ten Group Classification System. The overall caesarean section rate and the contribution of each group was calculated. The overall caesarean section rate was 66.1% (494 among 747 total deliveries) in 2018. Nullipara, singleton cephalic, >= 37 weeks, spontaneous labor (Group 1) was the major (24.2%) contributor to the overall caesarean section rate followed by previous caesarean section, singleton cephalic, >=37 weeks (Group 5, 22.6%) and nullipara, singleton cephalic, >=37 weeks, induced or caesarean section before labor (Group 2, 18.8%). Also, the caesarean section rate was 49.5% in nullipara, thus increasing the trend of caesarean section for previous caesarean section in future. Efforts must be focused more on Group 1, 2 and 5 to decrease the increasing trend of caesarean section Promoting vaginal delivery in nullipara and facilitating vaginal birth after caesarean are the most relevant areas of intervention.

Study of Cleft Lip and Palate in Kathmandu Model Hospital, Nepal

Introduction: Cleft lip and/or palate is a congenitally persistent space affecting orofacial region. It is generally divided into cleft lip (CL), cleft palate (CP) and cleft lip with cleft palate (CLP). The objective of the study was to evaluate distribution of patterns of orofacial clefts according to sex and laterality; predisposing factors and other congenital anomalies associated with cleft lip and/or palate.
 Materials & Method: A cross-sectional descriptive type of study was carried out using in 268 patients having cleft lip and/or palate. Types of clefts, predominance of sex and laterality, familial history, associated anomalies and drug and disease history of mother were recorded.
 Result: The results revealed 23.51% CL, 54.85% CLP and 21.64% CP. There were 58.21% males and 41.79% females. Positive family history of cleft was present in 28.0% and associated anomalies were observed in 3.7% of the cleft subjects. Mothers of 6.0% of the total patients were exposed to teratogenic agents during first trimester of pregnancy.
 Conclusion: It was concluded that among the three types of cleft (CL, CP and CLP), CLP is the most common type. The males are affected more with cleft lip and/or palate than the females. Clefts also have risks of associated congenital anomalies. Exposure to teratogenic agents in first trimester of pregnancy is also associated with orofacial cleft.

Semi-rigid Ureteroscopy for the Management of Ureteric Calculi: Our Experience and Complication Encountered.

Semi-rigid ureteroscopy lithotripsy have become standard of treatment for ureteral calculi. The aim of this study isto review outcome of Semi-rigidureteroscopy lithotripsy and to report the complications encountered. After approval from institutional committee of Public Health Concern Trust Nepal,we retrospectively reviewed the chart of all patients of ureteral stone who underwent ureteroscopy and pneumatic lithotripsy at Kathmandu Model Hospital between January 2013 and September 2017. Patient characteristics, stone size, success rate and complications were assessed. Intraoperative complications were graded using modified Satava classification system and the postoperative complications graded according to modified Clavien classification system. The success rate was based on stone free status after primary semi-rigid ureteroscopy lithotripsy, without the need of any other secondary procedures. Total 232 patients underwent semi-rigidureteroscopy lithotripsy. Mean age was 46 (16-76) years, with 128 males and 104 females. Size of the stone ranges from 5-18mm. The success rate of primary semi-rigidureteroscopy lithotripsy was in218 (93.9%) cases.Most intraoperative complications were modified Satava grade I (41.7%) andII(3.87%).Four(1.7%) patient had grade III complication, requiring conversion to open surgery. Ureteral avulsion was seen in 1(0.43%) patient, requiring ureteral reimplantation.The postoperative complication were modified Clavien grade I(10.7%), grade II(5.17%), grade III (4.6%) and grade IV(0.43%). Double J stents were inserted in all the patients postoperatively.The mean hospital stay was 2.2(1-14)days. Semi-rigid ureteroscopy lithotripsy for the management of ureteral stones is efficacious and have a lesser major complications.

Evaluation of Abnormal Cervix with Visual Inspection under Acetic Acid and Colposcopy

Background: Cervical cancer is a major public health problem especially in developing countries. It can be prevented through implementation of routine screening program. There are different screening methods but their efficacy are still questionable. So the purpose of this study is to evaluate the efficacy of visual inspection of cervix with acetic acid and colposcopy to detect precancerous lesion in women with clinically unhealthy or abnormal cervix.Methods: Forty patients with abnormal cervix (35) and abnormal pap smear results (5) were enrolled for the study in outpatient department of Kathmandu Model Hospital. Patients were evaluated with visual inspection of cervix with acetic acid and colposcopy in the same sitting. Cervical punch biopsy were taken from suspected lesion or from four quadrant if colposcopy findings were normal and sent for histopathological examination. The finding of visual inspection of cervix with acetic acid and colposcopy were correlated with histopathological finding and compared with each other.Results: The age of participants ranged from 24 to 68 years with mean age of 38.17 years and mean parity of 2.25. visual inspection of cervix with acetic acid and colposcopy were positive in eight (20%) and ten (25%) respectively. There were five (12.5%) cases of histopathologically proven lesion. The sensitivity of visual inspection of cervix with acetic acid and colposcopy were 80% and 100 % respectively and that of specificity were 88.5% and 85.5%.Conclusions: visual inspection of cervix with acetic acid is an effective screening tool with comparable sensitivity and specificity. It can be used as alternative screening methods especially in low income resource countries where the burden of disease is high.Keywords: Cervical cancer; Colposcopy; screening; VIA.

Evaluation of Abnormal Cervix with Visual Inspection under Acetic Acid and Colposcopy.

Cervical cancer is a major public health problem especially in developing countries. It can be prevented through implementation of routine screening program. There are different screening methods but their efficacy are still questionable. So the purpose of this study is to evaluate the efficacy of visual inspection of cervix with acetic acid and colposcopy to detect precancerous lesion in women with clinically unhealthy or abnormal cervix. Forty patients with abnormal cervix (35) and abnormal pap smear results (5) were enrolled for the study in outpatient department of Kathmandu Model Hospital. Patients were evaluated with visual inspection of cervix with acetic acid and colposcopy in the same sitting. Cervical punch biopsy were taken from suspected lesion or from four quadrant if colposcopy findings were normal and sent for histopathological examination. The finding of visual inspection of cervix with acetic acid and colposcopy were correlated with histopathological finding and compared with each other. The age of participants ranged from 24 to 68 years with mean age of 38.17 years and mean parity of 2.25. visual inspection of cervix with acetic acid and colposcopy were positive in eight (20%) and ten (25%) respectively. There were five (12.5%) cases of histopathologically proven lesion. The sensitivity of visual inspection of cervix with acetic acid and colposcopy were 80% and 100 % respectively and that of specificity were 88.5% and 85.5%. visual inspection of cervix with acetic acid is an effective screening tool with comparable sensitivity and specificity. It can be used as alternative screening methods especially in low income resource countries where the burden of disease is high.

Endourological management of forgotten double J stents: case series

Putting ureteral stents are an integral part of urological practice. However, stents that fragment or are forgotten for a long time pose a management challenge and also legal dilemma. Our series consists of a review of five patients with forgotten double J stents. All these cases were managed at Kathmandu Model Hospital and all the forgotten stents were retrieved endourologically. Management of such complicated ureteral stents requires a multimodal therapeutic approach incorporating the latest ESWL and endourological techniques. Proper counseling to the patient with reference from post-operative KUB X-ray may prevent this urological tragedy.

Epidemiology of multi drug resistant gram negative bacteria in Kathmandu, Nepal

Purpose: Multi drug resistant (MDR) bacterial infections are considered to be hospital-acquired in high income countries. Little data are available regarding the epidemiology of MDR bacteria in low and middle-income countries. Our study looked at the epidemiology of gram negative bacterial infections in Kathmandu, Nepal. Methods & Materials: Kathmandu Model Hospital is a 125 bed tertiary care hospital, in Kathmandu, Nepal. All patients hospitalized with MDR bacterial infections over a 12 month period were retrospectively evaluated. MDR bacteria included those with extended spectrum beta lactamase (ESBL), carbapenem (CRE) or colistin resistance. Age matched controls of patients with clinical infection but negative cultures were selected during the same time period. Water surveillance was performed to identify a potential source of environmental exposure. 55 vials were filled from various drinking water sources in Kathmandu; including bottled water, home reservoirs, and community taps. Water samples were analyzed by centrifugation and conventional culture techniques. Results: No significant differences in patient characteristics were noted between the groups (Table 1). Among the cases, 73% had E. coli, 15% had Acinetobacter sp (ACBC), and 12% had K. pneumoniae. The majority of infections in both groups were community acquired. 5 water samples from 4 locations were found to have ACBC.Tabled 1CasesControlsAge years mean (range)54 (23-95)54 (18-89)Sex Male13 (32%)17 (43%) Female27 (68%)23 (57%)Admission Diagnosis Respiratory7 (18%)18 (45%) Genitourinary17 (43%)5 (13%) Skin and Soft Tissue4 (10%)0 (0%) Abdominal9 (22%)5 (13%) Unknown source3 (7%)12 (29%)Comorbidities Cardiac1211 Respiratory213 Renal52 Endocrine135 Other83Hospital Ward Medicine25 (64%)27 (68%) Surgery9 (23%)10 (25%) Gynecology5 (13%)3 (7%)Organism E. coli290 K. pneumoniae50 ACBC60 No growth040Community Acquired3936Hospital Acquired14 Open table in a new tab Conclusion: Gram negative bacterial resistance is a prevalent concern in low and middle-income countries. Our study demonstrated gram negative bacteria in the drinking water in various locations throughout Kathmandu. This is a possible source of community acquired MDR bacterial infection.

Prevalence of helicobacter pylori infection in patients with peptic ulcer disease at Kathmandu Model Hospital

Introduction: Endoscopic rapid urease test is a simple and most widely used test to detect the presence of urease in the gastric mucosa. Many studies have reported prevalence of H. pylori infection in relation to age, gender and site of ulcer. Therefore, this study was designed to determine the prevalence and significance of H. pylori in peptic ulcer disease. 
 Methods: A retrospective review was carried out for patients with peptic ulcer disease who had undergone upper GI endoscopy in Department of Internal Medicine at Kathmandu Model Hos­pital. The records from January 2013 to December 2017 were analyzed. Any patient with previously diagnosed peptic ulcer, history of active bleeding, cancer and incomplete records were excluded. Peptic ulcer associated with H. pylori was diagnosed on the basis of endoscopic rapid urease test. 
 Results: Among the 418 diagnosed case of peptic ulcer disease by upper GI endoscopy from Jan 2013 to Dec 2017, 213 tested positive for H. pylori by rapid urease test. Among the positive cases, over a half were males patients. Majority (23.9%) of the patients were in the age group of 35-44 years. Prevalence of H. pylori in duodenal ulcer was 51.6% followed by combined gastro-duodenal ulcer (26.8%) and gastric ulcer (21.6%). H. pylori was significantly associated with duodenal ulcer (p<0.0001). 
 Conclusion: This study demonstrated relatively high prevalence of H. pylori infection in patients with duodenal ulcer who had undergone upper GI endoscopy.

Profile of Obstetric and Iatrogenic Fistula Surgeries At Kathmandu Model Hospital

Aims: To find out the pattern of urogenital fistula.
 Methods: This was a retrospective study of 222 patients who underwent fistula surgery during the period of January 2012 to March 2018 in Kathmandu Model Hospital. The data were collected from the hospital records. The fistulae were classified according Goh system. Patients’ demography, obstetric characteristics and surgical outcome were reviewed. The primary outcome was in terms of urinary continence.
 Results: Among 222 cases, majority of the patients had fistula due to obstetrical cause, contributing 58% (n=127) and 42% (n=95) had fistula after gyanaecological surgery. The age ranged from 15 to 65 years. Most of the patients had fistula of type 1a, contributing 38% (n=84) and only 0.01% (n=3) of type 3c and 4b according to Goh’s classification. Hundred (78.7%) cases of obstetric fistula patients were dry and continent after surgery, whereas 95(89.4%) cases of fistula after gynecological surgery were successfully repaired. Eighteen patients with obstetric fistula and 6 patients with fistula after gynecological surgery had failed repair.
 Conclusions: Our study showed obstructed and prolonged labor was the major cause of obstetric fistula, but fistula resulting after gynecological surgery should not be overlooked.
 Keywords: fistula, iatrogenic, labour

Using GOFER to Digitize Patient Records in Kathmandu Model Hospital

Aim: To collect and digitalize data of patients who underwent fistula repair at Kathmandu Model Hospital.
 Methods: Operation Fistula built a digital version of Model Hospital’s Surgery Log, using a mobile data collection tool (Commcare). Researchers were trained on the data collection tool and provided with a tablet which hosted the application. Once data is collected, tableau dashboard will be built to visualize the collected data and to share key insights. Model Hospital then proceeded to input patient records, and provided Operation Fistula with key feedback to continue improving this process.
 Results: The results of this process have been threefold: Facilitation of data collection, Creation of an accurate database, and Provision of clear insights with access to data visualization dashboards.
 Conclusions: This study has shown the benefits of digitizing historical patient records using GOFER. By creating an online database, this has the potential to be used in future for academic research.

Experience of Managing Ureterovaginal Fistulas following Obstetric and Gynecological Surgeries

Aims: Iatrogenic ureteric injuries leading to fistula are rare but devastating complications of obstetric and gynecological surgeries.The aim of the study is to review the demography of ureterovaginal fistula (UVF) and its surgical outcome in the starting phase of fistula surgery.
 Methods: This is a retrospective review of 15 patients of ureterovaginal fistula who were referred to department of Obstetrics and Gynaecology of Kathmandu Model Hospital from Feb 2014 to Sept 2017. The study reviewed the demography, causes and surgical outcome of ureterovaginal fistula (UVF). Ten patients who had complete blind end at the distal ureter undergone Lich-Gregoir extravesicalur enteroneocystostomy. In other 5 patients, guide wire was successfully negotiated beyond the fistula site, however retrograde double J stenting could be done in only 4 patients.
 Results: All the patients had distal ureteric injury close to vesicoureteric junction leading to ureterovaginal fistula. Among them, majority were due to post hysterectomy 60% (n=9) followed by obstetrics procedures (caesarean section) 40% (n=6). Fourteen patients (93%) had successful closure of the fistula with complete preservation of renal function till date. Retrograde double J stenting was possible in patients who were referred earlier within two weeks of the onset of injury.
 Conclusions: In our short review, iatrogenic injury to the distal ureter during Obstetrics/Gynaecologic surgery was found to be the leading cause for the formation of ureterovaginal fistula. Endoscopic management with ureteric stents is still possible if the patients are referred earlier following primary surgery.

Profile of Obstetric and Iatrogenic Fistula Surgeries at Kathmandu Model Hospital

Aims: Vesico-vaginal fistula (VVF) is an abnormal fistulous communication between the bladder and/or urethra and the vagina that allows continuous involuntary discharge of urine into the vaginal vault affecting patients’ medical, physical, mental, social and sexual life. The aim of this study was to review and deliver a profile, their demography and outcome in the early phase of fistula surgery performed in our institute.
 Methods: This was a retrospective study of 222 patients who underwent fistula surgery during the period of January 2012 to March 2018 in Kathmandu Model Hospital. The fistula were classified according to Goh`s system. Patients’ demography, obstetric characteristics and fistula repair outcomes were reviewed. The primary outcome was in terms of urinary continence.
 Results: A total of 222 women aged between 10 to 65 years with a mean age of 31.4 were included. Majority of the patients had fistula due to obstetrical cause, contributing 58% (n=127) and in 42 % (n=95) of patients had fistula of gynecological etiology. Most of the patients had fistula of type 1a, contributing 38% (n=84) and only 0.01% (n=3) of type 3c and 4b according to Goh’s classification. Among 127 fistulas repaired of obstetric etiology100 (78.7%) patients and 85 (89.4%) out of 95 fistula patients of gynecological cause were continent and dry.
 Conclusions: Our study showed obstructed and prolonged labor was the major cause of obstetric fistula, however iatrogenic fistula was also becoming common. Majority of our cases had successful outcome with some degree of stress in some patients.

Using The Global Obstetric Fistula Electronic Registry to Digitalize Patient Records in Kathmandu Model Hospital

Aim: The aim of the study was to collect and digitalize data of patients who underwent fistula repair at Kathmandu Model Hospital. Once data were collected, a Tableau dashboard was built to visualize the collected data and to share key insights.
 Methods: Operation Fistula built a digital version of Kathmandu Model Hospital’s Surgery Log, using a mobile data collection tool (CommCare). Researchers were trained on the data collection tool and provided with an electronic tablet device which hosted the application. Kathmandu Model Hospital then proceeded to input patient records, meanwhile providing Operation Fistula with key feedback to continue improving this process.
 Results: The results of this process have been threefold: facilitation of data collection, creation of an accurate database and provision of clear insights with access to data visualization dashboards.
 Conclusions: This study has shown the benefits of digitizing historical patient records using Operation Fistula’s Global Obstetric Fistula Electronic Registry (GOFER) platform. By creating an online database, this has the potential to be used for future academic research.

Ureteral Obstruction in Endometriosis

Aim: Endometriosis is defined as functional endometrial glands and stroma that occur outside the uterine cavity. It is an estrogen dependent, benign, inflammatory disease that affects women during premenarcheal, reproductive and postmenopausal hormonal stages.
 Methods: This is a retrospective review of six cases with diagnosis of ureteral endometriosis. All the patients were referred to Department of Surgery, Kathmandu Model Hospital and the study period was from September 2015 to August 2018.
 Results: In our study all the patients had involvement of the ureter. All the patients who had undergone open surgery had extrinsic involvement of the ureter. Two patients who had mild distal ureteric stenosis only were managed by diagnostic URS and retrograde DJ stenting. Another two patients with right distal ureteric stenosis were managed initially with retrograde DJ stenting but after removal of ureteric stent and in subsequent follow up the degree of hydroureteronephrosis increased in both the cases. These two patients were finally undergone right Lich Gregoir ureteroneocystostomy. In the remaining two patients, ureterorenoscopy (URS) guided double J stenting were attempted but failed to insert the stent due to stenosed ureter so they underwent open abdominal hysterectomy with excision endometriotic cyst with ureterolysis and double J stenting.
 Conclusions: Ureteral endometriosis is a rare disease presenting most commonly with nonspecific symptoms and signs and thus making preoperative diagnosis often difficult for the clinicians. Treatment of ureteral endometriosis is primarily surgical. The surgical procedures which are usually performed are excision of all endometriosis lesion, ureterolysis, ureterectomy with ureteroureteral anastomosis and ureteroneocystomy.

Isolation of Organism and its Drug Sensitivity Pattern in Patients with Urinary Tract Infection at Kathmandu Model Hospital

Introduction: Lack of compliance and unjustified antibiotic prescriptions has resulted in increasing bacterial resistance and is proving as a major challenge in the management of infections. Knowing the commonly isolated uropathogens and their antimicrobial susceptibility is beneficial in planning treatment protocols.Methods: A retrospective review of records of patients with urinary tract infection from January 2012 to December 2016 was conducted at Kathmandu Model Hospital. All patients who were diagnosed as having culture positive urinary tract infection in medical ward of Kathmandu Model Hospital during 5 years period were analyzed for demographic data, prevalence of organism and antibiotic susceptibility patterns.Results: A total of 315 samples were culture positive. The majority of bugs were gram negative E.coli (48.57%) followed by multi-drug resistant E.coli (28.89%). The other major pathogens were E. faecalis (6.03%), S. epidermidis (4.44%), K. pneumoniae (4.13%), respectively. The highest level of sensitivity in first line antibiotics was seen in nitrofurantoin (84.9%), whereas least sensitivity was shown by amoxicillin/clavulanic acid (21%). Similarly, in second line antibiotics, highest sensitivity was seen in tetracycline (100%), imipenem (91.9%) and least to meropenem (49.2%). Ceftazidime is mostly (93.3%) resistant antibiotics among uropathogens. All the third line antibiotics such as polymyxin B, tigecycline and colistin were 100% sensitive to all our isolates.Conclusions: Nitrofurantoin may be an appropriate choice for initial empirical therapy of urinary tract infection. Similarly, the multi-drug resistant E.coli is increasing but it can be tailored if antibiotics are used appropriately on the basis of susceptibility data.

Creation of Functional Neo-vagina in Vaginal Atresia

Vaginal atresia is one of the common congenital anomalies of the female lower genital tract due to incomplete canalization of Mullerian ducts. It mostly presents as primary amenorrhoea with attacks of severe lower abdominal pain at monthly interval in presence of appropriate Tanner staging secondary sex characteristics. It is diagnosed by clinical presentation, examination and imaging, usually Ultrasound scan and Magnetic Resonance Imaging. There are conservative non-surgical as well as surgical methods to correct it. A 13 years pubertal girl presented at Kathmandu Model Hospital with complaints of cyclic severe lower abdominal pain since one year with presence of appropriate secondary sexual characteristics. Ultrasound showed features suggestive of hematometra. She underwent drainage of hematocolpos with neo-vaginoplasty followed by intravaginal mould placement. She also underwent dilatation of neovagina thrice under IVA to maintain the vaginal length and function. We present here a case of isolated vaginal atresia, who underwent Mc Indoe Vaginoplasty followed by serial dilatation.

Outcome of Sacrospinous Ligament Fixation of the Vault during Repair of Pelvic Organ Prolapse

Pelvic organ prolapse includes descent of anterior/ posterior wall and apical (vault) prolapse with significant morbidity. In this study we evaluated the outcome of sacrospinous ligament fixation of vault through vaginal approach as part of the repair for massive uterovaginal (pelvic organ prolapse stage III and stage IV) and vault prolapse. This study on sacrospinous ligament fixation along with repair for Pelvic organ prolapse at Kathmandu Model Hospital from November 2016 to April 2018 was done to assess the outcome in terms of early (during hospital stay) and delayed (six months) post-operative complications and need of removal of sacrospinous fixation suture and recurrence of vault prolapse. Out of 95 Pelvic organ prolapse patients, 80 (84%) were post-menopausal, 28 (29.4%) were in the age group of 70-79 years. There were 61 (64%) POPQ stage III. The post-operative complications during post-operative hospital stay were pain over right buttock in 42 (44%), urinary retention in 7 (7%) and UTI in7 (7%). Sacrospinous suture was released in two patients for severe pain over right buttock. At one-week follow-up, 35 (36%) had right buttock pain of moderate severity and 8 (8%) had vaginal cuff infection. Sacrospinous suture was removed in one patient for neuropraxia two weeks following surgery. At four weeks follow-up, 25 (26%) patients had mild right buttock pain relieved by oral NSAIDs on need. At six months follow-up, five had occasional buttock pain, six had some recurrences and two had some vault prolapse and one each had short vagina and stress incontinence. Sacrospinous ligament fixation is a good procedure for the management of Pelvic organ prolapse with better long-term outcome if performed with good surgical expertise.

Outcome of Sacrospinous Ligament Fixation of the Vault during Repair of Pelvic Organ Prolapse

Background: Pelvic organ prolapse includes descent of anterior/ posterior wall and apical (vault) prolapse with significant morbidity. In this study we evaluated the outcome of sacrospinous ligament fixation of vault through vaginal approach as part of the repair for massive uterovaginal (pelvic organ prolapse stage III and stage IV) and vault prolapse. Methods: This study on sacrospinous ligament fixation along with repair for pelvic organ prolapse at Kathmandu Model Hospital from November 2016 to April 2018 was done to assess the outcome in terms of early (during hospital stay) and delayed (six months) post-operative complications, need of removal of sacrospinous fixation suture and recurrence of prolapse. Results: Out of 95 pelvic organ prolapse patients, 80 (84%) were post-menopausal, 28 (29.4%) were in the age group of 70-79 years. There were 61 (64%) POPQ stage III. The post-operative complications during post-operative hospital stay were pain over right buttock in 42 (44%), urinary retention in 7 (7%) and UTI in 7 (7%). Sacrospinous suture was released in two patients for severe pain over right buttock. At one-week follow-up, 35 (36%) had right buttock pain of moderate severity and 8 (8%) had vaginal cuff infection. Sacrospinous suture was removed in one patient for neuropraxia two weeks following surgery. At four weeks follow-up, 25 (26%) patients had mild right buttock pain relieved by oral NSAIDs on need. At six months follow-up, five had occasional buttock pain, six had some recurrences and two had some vault prolapse and one each had short vagina and stress incontinence. Conclusions: Sacrospinous ligament fixation is a good procedure for the management of pelvic organ prolapse with better long-term outcome if performed with good surgical expertise. Keywords: Prolapse; repair; sacrospinous fixation; vaginal hysterectomy.

In-Vitro Biofilm Detection among Uropathogens and their Antibiogram Profile

Objectives: The study was carried out in Kathmandu Model Hospital, Kathmandu with the aim of in- vitro biofilm detection among uropathogens and its correlation with antibiotic resistance.
 Methods: Uropathogens (n=234) were isolated, and identified with standard microbiological techniques and further subjected to Modified Congo Red Agar Method for the biofilm detection in-vitro; antimicrobial susceptibility testing (10 antibiotics) was performed by Modified Kirby Bauer disc diffusion method. The MIC and MBEC values of Levofloxacin were determined by agar dilution for planktonic forms and by microdilution method for biofilm phase respectively.
 Results: Among 234 urine isolates, 134(57%) were positive for in-vitro biofilm production and 88(37.6%) were multidrug resistant (MDR). E. coli was the predominant biofilm forming uropathogens. The incidence of biofilm producers was found to be independent of age-wise, gender wise and indoor-outdoor distribution of patients. The association between biofilm production and multidrug resistance among uropathogens was found statistically non-significant (p-value>0.05). The MBEC values of biofilm phase of growth were found to be greater than the MIC values for their planktonic counterparts. The MBEC values ranged from 4 to more than1024 μg/ml whereas the MIC values ranged from 0.003-16 μg/ml.
 Conclusion: The results of the present study suggest that biofilm detection is a critical step to fight against biofilm-involved infections. However, further studies are needed for the development of effective preventive and treatment strategies of biofilm associated UTIs to avoid recurrence and persistence.