Introduction and Background

There are more than 120 million people in Ethiopia. We only have 3 urology programs (2 in the capital city Addis Ababa and 1 in Bahirdar City). The are 60 urologists out of which only three are female. We don’t have urology subspecialists. There is no endourology service in most hospitals outside of Addis Ababa. There are few endourology equipment and supply companies. With regard to the caseloads, disease burden and distribution, and cost of urologic procedures, data are lacking. This could be a fertile ground for scientific research for the practicing urologists in Ethiopia and affiliated professionals.¹

Urological Disease Burden and Distribution Data From One Tertiary Center in Ethiopia

In one tertiary center in Ethiopia, urological stone disease comprised 30% of urological admissions with a male-to-female ratio of 2:1. The majority of the patients had upper tract stones. Renal stones constituted 51.6%. The treatments instituted were endoscopic approach in 51%, open approach in 43.6%, and combined in 5%. Nephrectomy was performed in 7.4% of the cases.²

Gaps Identified in Urological Care in the Country

There is not a single pediatric urologist in the country. In addition, we don’t have dedicated pediatric endourological facilities. There are challenges with equipment availability and supply management systems.³

There is a huge load of patients with urological cancers primarily of bladder and prostate origin. The diagnosis is often made based on clinical examination, cystoscopic evaluation, and biopsy. Clinical staging of cases depends mainly on conventional contrast enhanced CT scan and, at times, MRI. The former is widely available in the public hospitals while the latter is not.

A finger-guided transrectal needle biopsy of the prostate is regularly performed in few hospitals in the capital city. Transperineal fusion (image-guided biopsy) has never been performed in the country. Urological cancer treatment in our hospitals is currently dependent on open surgical procedures, which are limited to the kidney and ureters. Both open radical nephrectomy and nephroureterectomy are performed with good clinical outcome. Patients with locally advanced and metastatic disease who are not eligible for surgical intervention are transferred to the clinical oncology unit, and urologists are not directly involved in the therapy.

Lack of expertise in uro-oncology significantly affects patient care. Currently there is no uro-oncologist in Ethiopia. The following operative procedures are currently not being performed in public as well as private hospitals anywhere in the country.

Open radical cystectomy and urinary diversion

Open radical prostatectomy with pelvic lymph node dissection

Retroperitoneal lymph node dissection

Pediatric ureteroscopy

Mini-/micro-percutaneous nephrolithotomy

Pediatric extracorporeal shock wave lithotripsy

Minimally invasive benign prostatic hyperplasia (BPH) surgeries such as holmium laser enucleation of the prostate, thulium laser enucleation of the prostate, transurethral incision of the prostate, UroLift, etc (only performed in 1 private Chinese hospital: Silk Road Hospital)

Robotic surgeries

Patients diagnosed with urinary bladder cancer, regardless of the disease stage, are treated by repeated sessions of transurethral resection of bladder tumor in the hospitals where a urology program is available. Though suboptimal treatment, repeated sessions of transurethral resection of bladder tumor are not available in other hospitals in the country. Intravesical chemotherapy agents are not widely available and patients are sent to the clinical oncology unit for possible systemic therapy.

Action Plan for Optimal Urological Service

This huge burden of urological disease can be seen as the single most important indicator of the need for a well-organized and efficient urological service. This action plan is prepared based on lessons learned during a 2-month–long clinical visit conducted at the University Hospital of Cologne, Germany.⁴ The visit was focused primarily on uro-oncologic care, including open and minimally invasive treatment of cancers of the entire urinary tract. The basic organization of the uro-oncology department at this university is taken as a reference in the preparation of this document. Moreover, valuable suggestions forwarded by the chief uro-oncologist, who is actively engaged in the implementation of the visiting professor program in various European countries, are also included.

The visiting professor program

The visiting professor program in urology is a clinical visit conducted by a surgical team led by a professor in urology or its specialties from international associations or hospitals. Depending on the circumstances, the team might comprise junior doctors, well-trained nurses, and anesthesia care professionals.

Accordingly, the Urology Society of Ethiopia (USE) can significantly benefit from the experience of the visiting professor in terms of knowledge and skill transfer as well as collaborative clinical research. The visiting professor program can be conducted 2-3 times per year and will include the following activities:

In order to conduct the visit effectively, short training can be given to interested operation theater nurses and anesthesia team professionals. This can be conducted either virtually or in person on the first visit. The trained nursing and anesthesia staff will be active participants of the urology specialty team on each subsequent visit afterwards.

Establishment of a multidisciplinary treatment team

In 2022, the European Association of Urology–European Urological Scholarship Program granted a Clinical Visit Scholarship for 3 postgraduate year–5 urology residents from Ethiopia at University Hospital Cologne, Germany. One of the lessons learned from the clinical visit at the university hospital of Cologne is the treatment of urological cancers by a team of experts comprised of clinical oncologists, radiologists, pathologists, and uro-oncologists. Individual patient cases are discussed on a weekly tumor board session and an integrated treatment plan is devised. This kind of treatment approach is advocated by all international cancer and urological societies in order to achieve the desired outcomes.

The treatment of uro-oncologic cases in Ethiopia can be reorganized in such a manner by involving pathology, clinical oncology, and the radiology departments in each tertiary center. The professional opinion of each discipline can be incorporated into the treatment plan and the visiting professor can be a point person in the process.

Further assistance on the organization of the team can be obtained from the visiting professor and an experience-sharing discussion session may be arranged.

The multidisciplinary treatment team members can gather on the first day of each visit by the professor and cases can be discussed before proceeding to surgical procedures. This proposed meeting can also be conducted virtually based on need a few weeks prior to the arrival of the visiting professor. We believe these discussion sessions will create a suitable teaching environment for resident doctors in the urology unit.

E-learning and resident exchange

The establishment of an e-learning platform that focuses on specific topics within the scope of uro-oncology can be an efficient way of knowledge exchange. The visiting professor can conduct a short teaching lecture session virtually to be followed by an elaboration of discussion points raised by residents and urologists. These virtual sessions can be conducted based on need or regularly in defined time intervals. Newer diagnostic methods, treatment algorithms, and research findings can be discussed at the sessions.

The urological treatment service in Ethiopia is mainly based on open surgical procedures. There is especially a significant flow of patients with kidney stones and BPH. Large numbers of open kidney stone surgeries and transvesical prostatectomies are performed annually. A urology resident exchange program can be arranged between the professional associations and university hospitals in which urology residents from Western hospitals can visit Ethiopian hospitals and vice versa. They can participate in open stone and BPH surgeries. These procedures are not commonly performed in the developed world due to the relatively lower disease prevalence and the presence of more advance treatment modalities.

The postgraduate specialty training in urology uses a national harmonized training curriculum where residents are engaged in a 5-year training program. According to this curriculum, final year urology residents are expected to participate in a short clinical attachment at a foreign urology teaching institution. The primary aim of the visit will be to expose residents to advanced diagnostic and therapeutic modalities, which are not available in low-income countries like Ethiopia. Accordingly, we recommend university hospitals in developed countries via their respective associations to be the center of choice as they are well equipped with the newest diagnostic and treatment technologies. We believe that the Western perspective of urological care and the fast-growing innovations in the field can be easily witnessed in this center. Moreover, such a visit will surely motivate young residents from Ethiopia to initiate innovative research ideas when they get back to their home country.

Hence, a continuous educational collaboration between local and international societies shall be established with regard to virtual learning and resident exchange primarily to benefit the young urologists in training.

Collaborative clinical research

Clinical research in the field of urology in Ethiopia is at its premature stage. Multiple research areas are untouched because of lack of initiative among urologists, lack of research grants, and lack of a suitable working environment. Clinical research collaboration in the field of urology between USE and other associations like the AUA, American College of Surgeons, European Association of Urology, or Canadian Urological Association will be a golden opportunity for urologists and residents to develop initiatives, widen their scope of clinical perspectives, and translate the findings of a Western study into an Ethiopian context.

Strengthening USE

USE was inaugurated in 2021 and is the first professional association of urology in Ethiopia. USE has successfully conducted its first and second annual general meetings in May 2022 and May 2023, respectively. It is currently making efforts to create strong links with regional and international urological associations. At the second annual general meeting of USE, a lot of scientific work was presented, including original research papers and unique urological cases.

The USE General Assembly has appreciated the work of the past members of the executive committee and voted in new members to serve the next term on May 26, 2023.

New executive committee members (Figures 1 and 2):

Figure 1. Seid Mohammed Hassen, MD, Assistant Professor of Urology, Program Director of Urology Program at St Paul’s Hospital Millennium Medical College, new President of the Urology Society of Ethiopia.

Figure 2. New executive committee members of the Urology Society of Ethiopia. Left to right: Dr Gebrehiwot, Dr Gedfe, Dr Teferi, Dr Hassen, Dr Lemma, and Dr Issack.

Fitsum Gebreegziabher Gebrehiwot, MD, Assistant Professor of Urology at SPHMMC: General Secretary

We express our gratitude to the following guests, who are Professors of Urology, for joining us and giving state-of-the-art lectures on important and practice-changing topics of urological surgery during the annual conference of USE in May, 2023:

We believe that the establishment and implementation of a visiting professor program in urology and its specialties between USE and other associations will be the foundation to strengthen urological services nationwide. The collaboration can be translated in USE and a consideration should be given for regular scientific lectures by visiting professors from other international professional associations like the AUA, American College of Surgeons, European Association of Urology, Canadian Urological Association, etc. This will be an important step to increase the visibility of USE internationally and the opportunity can be used to devise a more integrated regional collaboration by inviting other urological societies in Eastern and Central Africa to the sessions. State-of-the-art lectures can be given by the visiting professors to share their profound success in patient care and clinical research.

A second opinion forum can also be organized by the USE in which each member urologist shares clinical cases that might require a second opinion from a more experienced urologist locally or abroad for maximal patient benefit.

Since its inception in 2002, the Residents and Fellows Committee has represented the voice of trainee members of the AUA. The Committee’s mission is to address the educational and professional needs of urology residents and fellows, and promote engagement between residents and fellows and the AUA. The Committee welcomes your input and feedback! To contact the Committee, or to inquire about ways to get more involved, please email rescommittee@AUAnet.org.