For this special Humanitarian Issue of AUANews, I will share 2 experiences from my 18 years with feet on the ground in Sub-Saharan Africa (SSA) and an example from Kenya.

During my residency in general surgery, the sum of my formal urology training was a 1-month internship at the Brady Urological Institute in Baltimore. Postresidency, my first position was at the Baptist Medical Centre (BMC), Ogbomoso, Nigeria. I was at BMC for 12 years between 1978 and 1993, with each fourth year back in Baltimore at the Loch Raven VA. In Nigeria, urology was about a fifth of my practice. The most frequent diagnoses were benign prostatic hyperplasia, presenting often in acute retention, urethral stricture from gonococcal urethritis and trauma, prostate cancer, torsion of the cord/testis, but rarely urolithiasis. Fortunately, there was an experienced surgeon at BMC who taught me his way of dealing with many of these–for me–challenges. In the early 1980s, a community urologist from Kerrville, Texas, Dr Theron Hawkins, who passed in 2020, visited my colleague Dr Don Meier and me for 2 weeks. We depended on visitors staying for 2 weeks to help us upscale our practice on many fronts–orthopedics, pediatric surgery, plastic surgery, anesthesia, etc. Dr Hawkins was one of the most important visitors during my 12 years in southwestern Nigeria. We requested that he help us become better at cystoscopy and, hopefully, bring us a rigid urethroscope. During his first 2-week visit, Dr Hawkins observed our practices across many genitourinary fronts, but most importantly for open, transvesical prostatectomy with postop continuous bladder irrigation and van Buren sound or filiform and follower dilatations for most patients with urethral strictures. In the course of that fortnight and a second visit a year later, he reflected on what we might do to improve patient care. He then taught us how to perform a prostatectomy using a Malament suture to eliminate the need for continuous bladder irrigation and how to perform direct vision internal urethrotomy, thus moving the quality of our urologic practice up 2 logs. He even repaired our autoclave! Subsequent to his investment of time and personal expense, we presented our experiences with the Malament technique and with direct vision internal urethrotomy to 2 clinical congresses of the West African College of Surgeons. A publication ensued with 4 of our Nigerian trainees in the authorship along with Dr Hawkins and Dr John D. McConnell: “The outcome of suprapubic prostatectomy: a contemporary series in the developing world”.¹ To this day, in many hospitals in West Africa, open prostatectomy with the Malament suture is used to essentially eliminate the need for both continuous irrigation and transfusions.

Figure 1. Trainers and trainees (left to right): Dr Erik Hansen, pediatric surgeon; Dr Amon M. Ngongola, consultant pediatric surgeon, University Teaching Hospital, Zambia; Alain Jules Ndibanje, consultant pediatric surgeon, University of Rwanda, Kigali, Rwanda; Dr Yves Mpongo, attending pediatric surgeon, SIM Galmi Hospital, Niger; Dr Ron Sutherland, pediatric urologist, Hawaii.

Figure 2. Genitourinary Team Kijabe 2023: David Muchiri, medical assistant; Dr Irungu Juma, attending urologist; Dr Paul Shu, a visiting G/S resident from Mbingo, Cameroon.

Figure 3. Dr Jack Barasa, attending urologist and chief of surgery, AIC Kijabe Hospital, Kenya.

Figure 4. Dr Irungu Juma, attending urologist, AIC Kijabe Hospital, Kenya.

After 23 years at the Nashville VA (1993-2016) and about 20 years as program director for general surgery, with annual visits to SSA to “water friendships” and take specialist colleagues along to improve skills, my wife and I returned to SSA for an additional 5 years (1 year each in Kenya and Rwanda and 3 years in Botswana). In Kijabe, Kenya, I worked with Dr Erik Hansen, pediatric surgeon at BethanyKids at Kijabe Hospital in the Central Highlands (Figure 1).

Dr Erik Hansen writes:
The vast majority of pediatric urology was outside the scope of my pediatric surgical training in the United States but made up 40% of my practice in Kenya. Like other expat surgeons working in low- and middle-income country hospitals, I had the opportunity to learn to do operations and care for children with conditions that were new to me. I’m indebted to pediatric urologists like Ron Sutherland and Lynn Teague who invested in our patients, the pediatric surgical trainees, and me to advance and improve the urologic care we provided. Through repeated visits to Kijabe and generous gifts of equipment, they graciously and patiently ‘taught the trainer’ and equipped me and the program so that we could continue to teach the fellows increasingly complex pediatric urology. Their impact is immense, and they have expanded pediatric urologic care through skills and knowledge passed on to pediatric surgical graduates practicing across SSA.

The College of Surgeons of East, Central, and Southern Africa (COSECSA) started in 1999 to address the education of surgeons for the subregion, where there was 1 surgeon per 200,000 persons amongst the 12 countries in COSECSA as of 2017. In Kenya, currently there are approximately 45 urologists for a population of 55 million (1:1,200,000). The University of Nairobi is the only urology residency program in Kenya. Kijabe Hospital, with 2 Kenyan urologists, is launching a residency program in urology (Figure 2). Dr Jack Barasa trained initially as a general surgeon and is chief of surgery at Kijabe (Figure 3). He completed a 2-year urology fellowship in Liverpool, United Kingdom and returned to Kenya. Dr Irungu Juma trained at the Kilimanjaro Christian Medical Centre in Moshi, Tanzania, which has trained urologists for the subregion since the 1970s (Figure 4). With 2 urologists on faculty, the program can be approved by COSECSA and will be part of the capacity-building initiative of the Pan-African Academy of Christian Surgeons (PAACS), a faith-based nongovernmental organization which launched its first program in 1997. The Kijabe genitourinary program will be the first PAACS urology training program. Currently, PAACS has training programs (general surgery, orthopedic surgery, pediatric surgery, anesthesiology, Ob/Gyn, neurosurgery, plastic surgery, and fellowships in head and neck surgery and cardiothoracic surgery) in 19 hospitals spread across 11 countries with 150 residents and fellows.

PAACS and other SSA training programs depend on volunteers to help upscale, broaden, and modernize their curriculum, scope of practice, efficiency, and especially their safety and quality. Nigh every specialty in the broad tent of surgery in SSA needs more providers. Urology is one of the areas needing more providers for male and female adults and children, and those with differences in sex development.

Note: The late Professor John Kwateboi Marmon Quartey of Korle Bu in Accra, Ghana, befriended Dr Meier and me. He taught us his vascularized penile/preputial skin flap open urethroplasty.² Learning and teaching were and are bilateral.

Websites for those interested:

Pan-African Academy of Christian Surgeons (https://paacs.net/)

Kenya Association of Urological Surgeons (https://www.kaus.or.ke)

Pan African Urological Surgeon Association (https://pausaafrica.org)

Prof. J.K.M Quartey & Others- My Tribute (modernghana.com)

J Lester Eshleman (1921-2009)-Find a Grave Memorial (https://www.findagrave.com/memorial/33152862/j-lester-eshleman)