Figure 1. International Volunteers in Urology team and Komfo Anoyke Teaching Hospital urology department. Front, red jacket: Dr Kwaku Addai Arhin Appiah, department chair.

Figure 2. International Volunteers in Urology team. Left to right: Patrick Probst (Kansas City Urology Care), Daisy Obiora (University of Pittsburgh Medical Center), Bradley Mason (Georgetown), Keith Kowalczyk (Georgetown), and Ben Davies (University of Pittsburgh Medical Center).

Figure 3. Operating rooms at Komfo Anoyke Teaching Hospital.

Figure 4. Canopy walk in Kakum National Forest.

Urologic missions abroad play a crucial role in addressing health care disparities, advancing medical research, and providing direct clinical care to underserved regions. International Volunteers in Urology (IVU) is a nonprofit organization led by urologists to provide medical and surgical education to doctors and nurses in resource-poor areas with the goal of improving urologic care around the world.¹ The motto “Teach one, reach many” is embodied by the surgical teaching workshops, virtual visiting professorships, and lecture series offered in over 30 countries. IVU has recently focused on invigorating a urologic oncology workshop in Kumasi, Ghana, with the urology department at the Komfo Anoyke Teaching Hospital (appropriately named KATH) in October 2023 led by Dr Kwaku Addai Arhin Appiah (Figure 1), and made significant strides in creating lasting relationships in the region and providing durable patient care. This 5-day workshop, led by Drs Ben Davies (University of Pittsburgh Medical Center) and Keith Kowalczyk (MedStar Georgetown), served as an additional brick in a mutually beneficial relationship for both parties (Figure 2). Another IVU team with Drs Michael Poch (Moffitt Cancer Center) and Sunil Patel (Johns Hopkins) have been going biannually for the past 2 years; however, there is a need for additional workshops, which was addressed with this trip.

The workshop consisted of an intake clinic where the team reviewed histories, labs, and scans of patients who were proposed for surgery in the upcoming week. Cases were presented by local residents, and imaging was reviewed with the group as an educational experience. Operative days consisted of 1 to 2 major cases done in the trauma operating room (Figure 3), as the urology theater was under renovation. There were a total of 3 radical cystectomies with ileal conduits, 1 radical nephrectomy, 1 radical prostatectomy, and bilateral testicular implant for an unfortunate patient who had a history of bilateral testicular torsion. After the operative portion of the workshop, Drs Davies and Kowalcyzk ran a lecture series for the KATH urology department on testicular and prostate cancer.

Culturally, the team dove into the local cuisine and history, and learned about the founding of the hospital and its deep roots in the Ashanti tribe. The hospital itself was founded on the Komfo Anoyke Sword Site, the location where the founding of the Ashante Nation took place in 1695. This site was predicted to be a place of healing by Okomfo Anoyke, the king’s chief advisor and priest. To symbolize this, he placed a sword into the ground, which has not been able to be removed since.² The hospitality and friendliness of the KATH team was incredibly welcoming, and the IVU team was introduced to Ghanaian dishes including banku, jollof rice, and palm wine. After the workshop, the team explored the Kakum National Forest and participated in a forest canopy walk and birdwatching (Figure 4).

New Initiatives

During the intake clinic, there was a surprising proportion of women presenting with bladder cancer without traditionally described exposures. Using an Institutional Review Board–approved database of pathology reports at KATH from 2018 to 2023, we found a significant proportion of women with bladder cancer (64%).

Most patients were traders or farmers without additional exposures or family history of malignancy. Fifty-two percent of women had Schistosoma exposure, though none had a smoking history. Many patients presented with advanced disease (22% cT3, 41% cT4), and 6/21 (29%) female patients had squamous cell carcinoma. Most women (17/21, 81%) had high grade disease, and few (4/21, 19%) had concomitant carcinoma in situ. Seven of 21 (33%) female patients were node positive at the time of cystectomy.

This enigmatic presentation suggests there may be additional unidentified exposures in the community or genetic predispositions in this population, which are currently under investigation. This new project was undertaken by a collaboration between the KATH urology department and the IVU participants, and the findings will be fully presented at the AUA Annual Meeting in May 2024.

In another advancement, we implemented a pilot electronic medical record during this clinic to provide continuity of care between missions. We plan to optimize history taking, postoperative rounds, and case logs with this new tool, which will help facilitate our research arm.

Understanding the Need for Urologic Missions Abroad

The importance of IVU in this region is highlighted with a new urologic oncology workshop and a budding research initiative, fostering further collaboration between IVU and the local faculty. Ultimately, the goal is to establish a meaningful, long-term presence at KATH between both the University of Pittsburgh Medical Center/Georgetown and the Hopkins/Moffitt teams to cement an educational initiative that has a profound and lasting effect in the region. Urologic conditions, especially oncological pathologies, often pose a significant challenge in low-resource settings where access to specialized health care is limited, causing delayed presentations and complex pathology that requires expertise to manage. This was underscored in 2 major ways in Kumasi especially, where patients have poor access to care.³ There is a significant lack of prostate cancer screening in this population. Many patients have delayed presentations due to this; our singular patient had an initial presentation of urinary retention and a PSA of 60 ng/mL. Anecdotally, many undergo radiation treatment due to cost restrictions and lack of local experience in radical prostatectomy.

The lack of resources is seen especially in advanced bladder cancer patients, who most often undergo neobladder creation by the local faculty for urinary diversion, as they are unable to routinely afford ostomy supplies. During our workshop, no patients were deemed to be neobladder candidates due to advanced disease or other clinicopathologic characteristics. Prostate and bladder cancer management are both areas in which IVU can provide a direct benefit to patients. Further missions can help bridge this gap by bringing together expertise, resources, and local knowledge of the region’s population to improve patient care in Ghana.