Urology Practice in Low- to Middle-Income Countries

The global burden of urological diseases is rising, particularly in low- and middle-income countries (LMICs) undergoing rapid demographic and epidemiological changes. However, comprehensive data on the challenges and dynamics of urology practice in these regions are lacking, underscoring the urgent need to evaluate various aspects of urological care in areas that account for half of the world’s population. In this thematic issue of the Société Internationale d’Urologie Journal, we aim to illuminate in LMICs the burden of urological diseases, the challenges faced by practitioners, and potential opportunities for improving care.

In the first article, Almusafer et al. (Contribution 1) reviewed the burden of nephrolithiasis in LMICs, highlighting that this condition presents a significant healthcare challenge. They found interregional variability in prevalence linked to socioeconomic status, gender, and risk factors such as diet and pollution. Despite advances in treatment, open surgery remains common due to limited access to advanced endourological techniques, compounded by inadequate healthcare infrastructure and training. The authors call for region-specific strategies and sustainable healthcare solutions to address these gaps.

Cassell et al. (Contribution 2) assessed the burden of benign prostatic hyperplasia (BPH) in Sub-Saharan Africa, noting that lower urinary tract symptoms (LUTSs) significantly impact the quality of life for many men. This issue is exacerbated by a lack of awareness and limited access to both pharmacological treatments and modern surgical interventions. The authors urged policymakers to integrate BPH management into broader healthcare initiatives in these regions.

Kidney transplantation (KT) is the preferred treatment for end-stage renal disease (ESRD), due to its better long-term survival and cost-effectiveness compared to dialysis. Duong et al. (Contribution 3) found that access remains limited in LMICs, with disparities in kidney replacement therapy (KRT) rates. Higher-income LMICs demonstrate greater KT prevalence, while barriers like inadequate healthcare infrastructure and limited organ donation frameworks hinder access. These findings underscore the need for targeted interventions and international collaboration to enhance donor transplants and incorporate KT into healthcare planning.

For genitourinary (GU) malignancies, Shete et al. (Contribution 4) highlighted the disparities in the incidence of prostate, bladder, and kidney cancer in low- and middle-income countries (LMICs). The authors also addressed the inequities in access to surgical care, radiation therapy, and clinical trials for patients with these malignancies in LMICs. In the same vein, Majdalani et al. (Contribution 5) explored the challenges in urologic oncology care delivery in these regions, identifying inadequate health education, limited screening, and restricted access to treatment options as significant barriers. The lack of gold-standard treatments available in high-income countries, combined with poorer socioeconomic conditions, often results in more advanced disease stages at diagnosis and higher mortality rates. They emphasized the need for comprehensive data to better understand the factors contributing to mortality associated with urologic cancers.

In developed countries, access to innovative systemic treatments for GU malignancies is influenced by factors such as race, socioeconomic status, and healthcare structure, with high medication costs leading to financial distress. In contrast, LMICs face even more complex challenges, including limited healthcare infrastructure and a shortage of trained professionals. Galloway et al. (Contribution 6) highlighted the difficulties in treating metastatic prostate cancer in Asia and bladder cancer in Brazil and the Middle East, advocating for the development of resource-limited guidelines by organizations like the World Health Organization to standardize treatment regimens and ensure equitable access.

Improving outcomes for urological patients in LMICs is closely tied to the quality of postgraduate urology training. Baqain et al. (Contribution 7) noted that many training programs rely on outdated curricula and traditional methods, with significant variability in residency duration, research requirements, and resident salaries. Limited fellowship opportunities and few programs achieving international accreditation emphasize the urgent need for standardized training frameworks. Future initiatives should focus on enhancing training opportunities to ensure equitable access to advanced urological care and education globally.

Considering urology practices around the world, El Anzaoui et al. from Morrocco provide a glimpse of hope for establishing patient access to robotic surgery in a middle-income country as part of an ambitious initiative to improve the health system in Morocco.

The disparities in urological disease treatment across countries are particularly pronounced in LMICs, which is worsened by a shortage of healthcare professionals and the migration of doctors to higher-income nations. Factors such as insufficient funding, challenges in negotiating drug prices, and limited education and training opportunities significantly affect care quality. We advocate for the implementation of comprehensive initiatives by international organizations, including the World Health Organization, to address the various challenges faced by healthcare systems in LMICs.