Observations and Reflections from Sub-Saharan Africa. Comment on Shahait, M. Urology Practice in Low- to Middle-Income Countries. Soc. Int. Urol. J. 2024, 5, 374–375

Shahait’s article on “Urology Practice in Low- to Middle-Income Countries” [1] was read with great interest. It is an editorial reviewing a number of articles published in Soc. Int. Urol. J., Volume 5, Issue 5, which focused on the various aspects of urological practice in low- and middle-income countries. On the basis of their publication, we proposed to write the present commentary for the following three main reasons: (i) to further support the arguments on urological surgical practice in sub-Saharan Africa with a focus on endourology and (ii) to propose axes to improve urological surgical practice, while the third reason (iii) concerns the journal itself, which can be a forum for sharing and advocacy.

In an attempt to establish the state of urological surgery in a referral center in Nigeria, while seeking to define the proportion of open surgery and the endourological techniques used, Okeke et al. [2] reported alarming figures and gave a very precise conclusion, ‘‘Open surgeries accounted for the majority of these cases done with prostate-related procedures being the most common procedures. Few endourological procedures were performed’’. This observation contrasts with that which had been made by Watson et al. [3]. For these authors, in developed countries, the surgical management of urological diseases is largely based on endoscopy. In Africa, however, open surgery continues to be the main modality. Today, there is a wide range of treatment modalities for urolithiasis, with minimally invasive techniques predominating. However, given the lack of endo-urological equipment and expertise in most parts of sub-Saharan Africa, most urological centers in these regions still practice open surgery for the management of upper urinary tract calculi [4]. The same applies to prostate surgery, which is still mostly performed open [5]. According to Kifle et al. in Ethiopia [6], the reasons for this practice may be due to the lack of essential endourology equipment and the shortage of qualified professionals.

Following this argument based on the main urological pathologies and their management, it is important to make a plea for the practice of endourology in Africa. Endourology offers significant advantages in the treatment of urological conditions. These include the following: reduced surgical complications (endourology is generally less invasive than traditional surgical procedures, reducing the risk of post-operative complications); shorter recovery times (endourological procedures often enable faster recovery, which is crucial in regions where patients often have significant economic and family responsibilities); saving medical resources (by avoiding heavier surgical procedures, endourology can help save valuable medical resources such as hospital beds, nursing staff and medical supplies); treating widespread conditions (promoting endourological techniques can help solve major health problems in the region); and increased accessibility to care (some endourological procedures can often be performed on an outpatient basis, improving accessibility to care for patients living in remote areas). In addition to these main points, other advantages can be cited as follows: constantly evolving technology; international collaboration; promotion of research; and improved quality of life. In short, promoting the practice of endourology in Africa offers significant advantages in terms of public health, efficiency of care, and medical resources. Such advocacy could help raise awareness among medical authorities and political decision-makers of the importance of developing this specialty in the region. The training of specialized personnel is an important part of this advocacy to promote the practice of endourology in Africa, because this strengthens local skills and improves the quality of urological care available.

The third reason relates to the accessibility and impact of the journal on the practice of urology worldwide and, particularly, in low- and middle-income countries. We believe that beyond the informative aspect and the sharing of experiences, this journal can be a place for questioning and advocacy seeking to improve the practice of surgery.