Endourologists have pioneered minimally invasive techniques in urology and have been leaders of all surgical specialties in procedural innovation. The percutaneous nephrolithotomy and robotic prostatectomy, for example, have made what were once large open procedures with substantial morbidity now come-and-go procedures or procedures with 1 night of hospitalization. This has been a benefit to patients from all walks of life, reducing complications, convalescence, and pain.¹

However, inequities in treatment for urological conditions, from prostate cancer to stone disease, exist. Disparities in timely diagnosis, appropriate treatment, and oncologic outcomes have been well documented for decades. Although prostate cancer mortality has decreased over time, the disproportionate burden of disease based on factors such as race and socioeconomic status persist. Unfortunately, these patterns of disparity and differential outcomes are not unique to prostate cancer. Originally thought to be predominantly a disease in men of European descent, kidney stones are increasing in prevalence in all races and sexes.^2,3 Outcomes for kidney stone disease treatment, however, are disparate along social, racial, and economic lines as patients who are underinsured, African American, or Hispanic are more likely to present multiple times to the emergency department and wait longer for surgical treatment of their stone disease.⁴

For many patients, having a urologist who looks like them provides a level of comfort and trust that cannot be disregarded. Treatment for their urological conditions remains impacted not only by patient-level factors, but also shared decision-making between the patient and their urologist. This is not an indictment of how we practice medicine, but rather an acknowledgement that the patient’s perception of the care they receive is important.⁵ Representation within urology and urology training, as a whole, has long been an area in great need of attention. Over recent years, there have been increased efforts dedicated to improving representation, both in terms of gender and race, within the urology workforce. Steady increases in the number of women in urology (now reported as 10.9% of the workforce based on 2021 AUA Census data) have not yet been mirrored in the number of those from underrepresented groups within medicine (4.4% Hispanic, 2.4% African American/Black, 1.4% other races including multiple races). We see that these observations vary across different urological subspecialties, but entry into the field of urology remains the crucial first step in the pipeline for endourology. Less than 10% of the workforce (6.9%) report fellowship training in endourology, and 4.4% report endourology as their primary subspecialty area. Compounding this is the imbalance in representation among endourologists. In order to improve representation within endourology we must first address the barriers to entry into the urology workforce as a whole. Addressing these barriers necessitates the need for an introspective, critical assessment of how our field trains, mentors, supports, and retains trainees from diverse backgrounds. Understanding how to improve the process of recruiting and training a broader demographic of trainees will not only change the face of urology within the United States, but also provide a roadmap of how to approach these issues globally.

Minimally invasive surgery is a luxury in many low- and middle-income countries where urologists often do not have access to robotics, flexible ureteroscopes, or laser technology.⁶ As we pursue new innovations to improve care for our patients and as we take steps to reduce inequity in our field, we must keep in mind that we treat urological disease in the context of the global burden of disease. There are exciting opportunities to improve care delivery in traditionally resource-limited settings as technology becomes more readily available and at lower cost.⁷ Endourologists can be at the forefront of these efforts to advance equity in urological care internationally, working with colleagues in low- and middle-income countries to deliver gold standard urological care to all populations that suffer with these diseases. It is therefore also necessary to increase representation of providers from these countries in endourology research, leadership, and innovation.

Intentional, long-term, coordinated, and supported efforts are needed to create durable change over time to improve diversity, inclusion, and gender equity in endourology. This will require input and effort from our field, and it will falter if left to siloes of individuals with duplicative efforts. It is not sufficient to leave these efforts as the sole responsibility of designated faculty, or to publish the occasional paper on disparities in care outcomes. Our support for our patients and colleagues from underrepresented and historically disenfranchised groups must be thorough and holistic to improve our pipeline of potential future endourologists and improve our care for our patients.